circles this morning are not going to come to pass because democrats and attorney generals are going to be able to challenge the trump administration and i fully expect democratic challenges will succeed. that is actually our system working, whether or not you have the supreme court ruling on the decision. >> one question back here. >> i'm a phd student. i was just going to ask, maybe an area of potential bipartisan cooperation but there's a lot of talk about restricting access to telephones in classrooms and i'm wondering where you guys see all of that going? >> i think it has a lot of traction with parents we now

have new evidence that there are

there is yellow or red, a lot of neurological function. well, what does a brain look like that has been addicted to cocaine? and is now 10 days sober? you don't have to be a brain scientist to see that there ain't much yellow or red in those pictures. that means that the neural function is not functioning in

a normal way. very importantly, if you ask people who have just completed detox, 3 to 5 days into a detoxification facility, you asked them how they feel. they feel a lot better. they say, i've learned my lesson. and they mean it, but as you can see from this picture, they're not playing with a full deck. they don't have full control, and they are not able. it is not that they lost total control, but their control of their behaviors is diminished. does it ever get better? how about if we see france 100 days sober? there is more return of function there. it is not, quote, normal, and we don't know if it ever gets to be normal. i think this is the longest period this brain has been

imaged. we also don't know if these individuals started that way, but we know two things. when you see changes of this nature, you are talking about medical condition. two, you know that if you see the changes of this nature and they don't correct in a fairly short period of time, you are dealing with a longer-term problem, and that leads to the next part of this talk. if you think that you've got a character disorder, you treat a person a certain way. if you think you have a chronic illness, something where you have got long-term functional problems, diabetes, hypertension, asthma, chronic pain, rheumatoid arthritis, lots of chronic illness, you treat them different. let's look at it. here is a traditional model of

how you get treated in a rehab facility. the 30 day treatment programs. or it could be a 60 day outpatient program or a 90 day outpatient. you start with a substance use disorder patient who enters shady acres treatment program. in that box, there is a fixed program of care. everyone gets the same thing. the idea is to get them to complete. and when they complete, they should have learned that they have a problem, accepted it. realized new ways of dealing with it, the kinds of craving issues they are going to confront when they get discharged, and as you can see, this is a nice fixed box there, right at the lower part of that, there is a discharge ceremony. everyone is hugging and crying and wishing johnny the very best. six months, or 12 months later, tom mcclelland -- mcclellan

comes around to see if the treatment worked. if it doesn't, the patient wasn't ready, or the treatment was bad. that is very traditional, but it is different than if you thought this condition was a continuing care kind of problem, like ib disorder, hypertension, or asthma. where you don't have a cure, but you can manage. it is a different kind of problem. it starts with primary care. because the physician and the nurses in a primary care team have all been trained in the course of their education to diagnose and handle chronic illnesses, and because they have an array of medications and behavioral therapies and support services, they can often handle a chronic illness right in the least intrusive

type of care available. primary care setting. sometimes, that doesn't work. the symptoms get out of control. and what do you do? well, you transfer, and it is usually with the touch of a button on your health record, you transfer. you have people that are specialized with medical devices and the goal of specialty care is not to cure. there isn't a cure for diabetes or arthritis or anything. it is to reduce the symptoms, increase the function, and then send them back to primary care, where they can continue now at a level of severity that is manageable in the outpatient center. a couple of points here. one, you don't want to let the patient out of care. you know that the effects of

any of this care are only going to last as long as the patient is involved actively in the course of care. to my knowledge, they do not have 30 day diabetes programs, for example. two, evaluation is a clinical activity. because they don't have diabetes or hypertension programs. they have tailored types of care, and the evaluation, like blood pressure, if you have a test for whether your glucose -- hemoglobin a-1 c is below 6%, that has two functions. one, to evaluate whether whatever has occurred before that test has worked, and two, it is designed to guide what happens, and in the next days and weeks ahead, that is very important. the idea in chronic care is to tailor care to the specific constellation of problems that a patient has.

okay. i think we can skip this slide here. we basically covered it. at this point, you can probably tell why the original system failed. it never fit what later, the developing science taught us about what some of the underlying causes of addictions are. two, it was segregated. i hope this is the last vestige of segregation that is in our system. but it was purposefully segregated from the rest of mainstream healthcare. to this day, less than 30% of american medical and nursing schools have a single course in addiction. it was never insured until about 2010, with the affordable care act, so it didn't have insurance dollars to fund it. even the information collected

in the course of addiction treatment was not allowed to be shared with the rest of medicine, which created many dangers. there were no systems, as in the rest of medicine. whether you like pharma or you don't like pharma, there is lot of money to be made in a pharmaceutical company if they can develop a better medication or medical device for condition. there aren't any of those incentives in the addiction treatment field, and unlike illnesses where they have the american cancer society or american diabetes association, there are no advocates informing for better and more care. so does that mean there is nothing that can be done? not at all. and these are coupled -- there are many issues that state policymakers are making --

facing right now. we are going to get new dollars. what are we going to do? the easiest thing to do would be to buy more of what we have. we have existing contracts. is that a good idea? or could we do better? could we use the power of state block grants, new dollars, and contracting to improve things? so let's examine the first. it is not a bad idea, especially if we know we don't have enough treatment available for everybody, it wouldn't be a bad idea to trite more of the same, as long as what we have is pretty good, and we have good reason to think that, you know, more money will incentivize others to come in. but working with the nonprofit shatterproof, they have been doing something that is very kin to a consumer's report. and i'm going to show you the evidence in this chart. along the top, this is actual

data, by the way. 12 addiction treatment programs for adolescents. outpatient adolescent treatment programs in the city of philadelphia, and the programs are along the top. if you read a consumer report and you are interested in buying a lawnmower, if the lawnmower is along the top and along the sides are the quality dimensions that are important for determining the outcome of addiction treatment. now, you get a green sticker if you got a lot of evidence-based practices in certain dimension. you get a yellow if you have a few, and read if you have none. here is program one, and if you look at it, not too bad. lots of evidence-based practices. when i say evidence-based, i mean medications, behavioral therapies, recovery support services, where research has shown them to be important and

effective at effecting better outcomes. as you can see, program a has quite a number. they don't do program evaluation. that is why they are red. they are not paid to do it, and they don't do it, but not bad. -- too bad. here are the rest of the programs. i repeat, this is actual data. so what you are seeing there is very little evidence-based practice going on in contemporary outpatient addiction care. you can characterize it primarily as group counseling, and when that doesn't work, well, you get group counseling. and if that doesn't work, you get group counseling, because that is what they are paid. so two points here. one, you are paying -- as a

state agency responsible for licensing and regulating care, you are buying this stuff. and two, you can know what you are buying. so, where i to be in charge of these new dollars and if they were going for new care, i would insist that the programs admit to external evaluation and publication of what they are providing. that is one way a state can use their money in a new way. and here, very quickly, is the last one. it is one of my favorite studies of all time. it was done in delaware. in around 2001, delaware had an influx of money, much like the money you are seeing now. it came out of nowhere, but it was a 9% increase, and then state director jack hepp said,

i'm not going to use the additional money. we have a contract for, let's say, 100 treatment slots, and the best they are doing is 40% occupancy. so, that is telling me that the program is not very attractive. it's not getting people in, and that's not providing value to the citizens of delaware, so what he said was, to the 16 programs in operation, i'll tell you what. i have bad knees and goodness. the bad news is starting in 2001, you are only going to get 90% of what you had last year. now, before you start screaming, you can make 109% of what you had last year, and i will pay you every month, but, i'm not going to pay you for doing the same old thing. i want to see more patients in

treatment. if you can do that, that is valuable to the state of delaware. if you can't, i don't want to pay you for it. here's the results of that. this is the year before the contract went in, and this is the census for programs in delaware. at that point, it was 40% what they were paying. the first year, the contract is in yellow because it wasn't fully implemented, but you can see the senses went up, and here is the first, second, third, fourth, fifth years after the contract. it tripled the number of patients in the care of the program. i have a similar graph with length of stay for 30, 60, and 90 days. double the length of stay. point, states are marketmakers in the addiction treatment field. they have tremendous power. they can contract to get value

for their citizens. so, with that, i will close and turn it over to the panel. i hope it has set the stage for some discussion of things that could happen in the future. >> thank you so much, tom. after our panel discussion, we will have a chance to have audience questions, including from our vast online audience, and those can be directed to, do i have that right -- hadar.zeevi.aei@aei.org. hadar.zeevi.aei@aei.org. think about your questions before this. let me ask you, tom, are there new mistakes being made?

we are seeing recreational marijuana being legalized across the country. we are seeing harm reduction centers where addicted persons are allowed to inject drugs under medical supervision. are those meeting people where they are and understanding that this is a new approach, or are these new mistakes that we might be making? >> i don't know. i will give you my opinions. i don't have factual data of studies to support it. but a, it is my opinion that it is a bad idea to legalize marijuana. if you go back to that pyramid, what you are going to do by legalizing is you are going to broaden the base of users, and for every substance you can think of, when you increase the number of users, 30%, roughly,

are going to develop harmful use. they are going to get into a car accident or have interpersonal violence or something that is a problem associated with the harmful use of the substance, and 10% are going to have an addiction. i don't -- my personal view is decriminalization is the way to go with marijuana. it is crazy to put someone in jail and ruined their livelihoods for the rest of their lives based on marijuana possession, but to sanction is, in my opinion, wrong. it is hard to argue against something as nice sounding as harm reduction. who is for harm production? i don't think anybody, but for me, i draw the line -- i am for

any harm reduction procedure that also reduces substance use, because i think it is a fact that most substance use, and certainly harmful use, is not good. i like lots of the things that they talk about, but safe injection sites have not demonstrated that they would get more people into treatment. they are very expensive. they are dangerous. i don't think they are warranted. >> so, we are seeing new potential. let's integrate this into the health system, but we are also seeing maybe new false paths in your opinion. okay, i want to turn to somebody covering this on the front lines. aneri pattani for health news. what are you seeing at the state, local, and county level in terms of how these monies are dispersed. you have some news about that that you can show desperate

>> today is the perfect timing for this panel. my colleagues at kff health news and shatterproof -- spoke it is a national nonprofit that works on addiction issues and advocacy. our three organizations have been collaborating for a year trying to answer the question that howard posed, how is this money spent? we looked at records at state, county, and city levels across the country. we built a database of 7000 ways that governments used this money in the first few years

that they were receiving it, so 2022 and 2023, and just, big picture, there's a lot we can get into, but we found that during those two years, 2022 and 2023, state and local governments received about $6 billion in opioid settlement funds. of that, roughly 1/3 they spent or committed to spending on a variety of initiatives. another third, they basically set aside and said, we are going to use this in future years. we have not sent it yet. the final third we could not track because there were no public reports about that money, and so it is not clear if they spent it, didn't spend it, or how it is being used. >> right. so let's drill down on that. dr. mcclellan was talking about treatment. is there any way to know what kind of treatment programs this is going for? he has pretty strong and seemingly informed views about what works and what doesn't. >> yeah, so, we found more than $416 million of the opioid settlements went to treatment broadly. >> that is a pretty small number out of the whole big number, isn't it? >> it is the largest chunk, i would say of the expenditures we found. it is the largest chunk.

so, funding treatment was clearly a priority, but then, to your question, that can mean a lot of things, and so, we made the database available to the public. everyone can see it on our website. all 7000+ lines of it if you want to go through it. you can see that some of the treatments are things that experts generally .2. medications for opioid use disorder. residential facilities with counseling. some are abstinence-based or, you know, group therapy only, the varied approaches that dr. mcclellan pointed out, are all being funded with this money. just because it is going to treatment doesn't mean that it is going to evidence-based treatment. >> or he was talking about what we call performance-based contracts, and that may or may not be a thing. >> that is correct. i think the opioid settlement

money -- they quite -- haven't quite gotten to yet. >> haven't quite gotten to. those are chilling words. i want to turn to theresa miller because teresa is with the legal aid center, but she previously had important roles in state government, including as director of human services in pennsylvania. imagine for us that you were tasked with that. what kind of tension would it be for a government official faced with that choice? >> thanks for that question. >> we look at money coming to government as, what a great thing. you have all this money, and now you can go spend it. to your point, i think it is a lot harder than it sounds like.

you have so many different interest groups. you have people and entities that have not had funding, and those that have funding, all trying to get a piece of that pie. and from the legal action centers perspective, we have advocated, along with other organizations, for these dollars to go to evidence-based practices and really going to approaches that save lives and help connect people to care and that make communities work better. >> in terms of these others, what would you, putting on your old hat at health and human services, what would you define as evidence-based? >> i would define it just like dr. mcclellan. looking at the evidence, what does the evidence show? does it show that putting money into x or y place, does that produce better outcomes or not? we've had 50+ year drug war,

where we have arrested people and put them in jail. we know that's not helping. we know that is not evidence- based. and dr. mcclellan's presentation did a beautiful job of talking about how we know this is a chronic health condition, so locking people up is not, as we've seen, is not an effective way of addressing that, getting people connected to evidence-based, proven care, care that saves lives and gets people connected to the services and support they need, making communities healthier, that is where we should be spending these dollars. if i were still in state government or local government, one of the things we advocated for that i would hope i would do is look to the communities that have been most impacted come and look to the community- based organizations, this people that have been on the ground, doing the hard work of making sure people are getting the services they need, and

find the gaps in the continuum of care that dr. mcclellan talked about. find those gaps because there are entities within the current system that have existing funding mechanisms, and there are those that don't, and i would argue a lot of community- based organizations are in that category. they do a lot of amazing work with very little money, and i think the opioid settlement funds are a great opportunity to get that funding to those entities. >> are they just doing good stuff and we should fund them because we have money? >> treatment is one piece of the continuum of care, but we advocated for things like wraparound support, housing services, harm reduction. i know dr. mcclellan talked about views about overdose prevention centers. but there's no locks on and things like that that are saving lives. overdose prevention centers do that. it is about finding out from the communities that we are serving, what they need, where

are the gaps, and how do we help fill it with this newfound money? >> since you are in pennsylvania, is there a community that comes to mind when you are talking about this? a specific place that you once served, once visited, that you could describe in terms of the impact of the opioid wave and how the organizations deal with it. >> i think philadelphia comes to mind. and, you know, this is where it is hard not to bring up race

and the impact that race has had in this country, and certainly the role it has played in the war on drugs, but when you look at philadelphia, that is a place that has been very hard hit, and i think they are getting very creative about how to address these issues. also, the thing about harm reduction that i think is really important is harm reduction was created for and by people with lived experience, and it is sort of a ground-up approach, making sure it is addressing the needs of the community, and i think that is important. they are doing good work in philadelphia. >> right. i'm going to move on in a minute, but tom, are you okay with what she just said? >> there are a range of things that are labeled harm reduction. i am okay with almost everything she said. there are things that i don't think of as true harm reduction, that i wouldn't spend my money on, like safe injection sites. i just don't think there is evidence for them -- that. i don't want to cast too broad brush here. i think, like everything else, follow the evidence. if it does what it is supposed to and you can measure it, spend money, and go that way. >> we spent a lot of money for a lot of years on ideology. things that people have in their minds that ought to work. well, they often don't, but you

can know what does work and you ought to put your money where that evidence is. >> irma esparza diggs was helping the council make decisions. national league of cities, so philadelphia i'm sure is part of the national league of cities. what are you hearing from your members about this? or most of them aware that this money is even coming? >> short answer, yes. and what we are hearing is that it is personal. >> that it's what? >> personal, in the sense that they know the families's children are overdosing in their public school bathrooms. they themselves have been impacted by it, and so, to the point that was made, you are spot on. it is having solutions that are really from the ground up. what is working?

and let me just say, municipal governments don't manage their public health systems. that is at the county and state levels, but because of what we saw, and we released our first report with the national league of cities and the national association of counties, and pulled together, convened a task force that worked for that full year because this was putting a strain on their local fire emergency personnel and police in a way that was not sustainable, and community residents were looking to them to solve the problem. so they had to be the ones to roll up their sleeves and convene those advocacy organizations, those public health, nonprofits, at the community level, to not just assess the scope of the problem, but to figure out what

is there to help support, and to the question that was asked about what is working and what is not, some things are just as simple as basic community education campaigns and awareness campaigns, especially if you see a particular population dealing with this more so than others, and having local officials, whether they be a very small community with a population of 1000, or a very large community like the city of philadelphia, being the ones to bring together, convene the different stakeholders that have a vested interest in this, and by stakeholders, those people that either have the solutions or the resources to be able to create a concerted plan to address this in a targeted and meaningful way. >> so if i'm the mayor of mechanicsburg, pennsylvania, where tom mcclellan once lived, or any other municipality, i am tempted to use this money to pay for those firefighters that

were overstretched, to pay for police, because i'm going to tell myself, well, if it's against the law, and the police are out there, disrupting the guys on the corner, i might prevent the start of substance abuse. are those guys wrong? >> no. and it is just as much about prevention as it is about had -- helping people get off of this and not become addicted. just recently, the national league of cities posted a dashboard that delineated how much money municipal governments specifically have coming to them over the next 18 years. >> 18 years. >> correct. so that they can plan accordingly. >> how much money are they

getting? give us the shorthand. >> i don't have the short answer off the top of my head, but included with that is, what are the things that other communities have done from prevention, from a response, but then, also, how do you support the ongoing addiction that has happened? what are those ways in which communities, regardless of size or capacity, have been able to address this? just last year, during our annual legislative conference, her congressional city conference which happens in every march of every year, we convened the state attorney general for the state of alabama. we convene our municipal league director from the state of arkansas, and then, from ohio, we invited the president of the opioid settlement fund, to come and talk about what is working, and how city leaders, given the fact that they don't control their public health systems, what is it they can do, and how can they be really intentional

about using these limited funds to be able to really meet the specific needs of their communities? and what that conversation, when it unfolded -- what it unfolded into is people are dying every day. people we know. our neighbors. and we can't afford to not maximize what is coming to cities, especially because when congress appropriated emergency funding to first deal with this opioid epidemic, most of that money resided with the states and didn't move to local communities expeditiously. now that we have this opportunity and money is coming, how can they adequately plan for that, and the national league of cities is working with the city leaders to write that out and make that available through its education efforts. >> so i want to turn to dr.

sally satel. how do you compute what you have heard so far? i want to make that a broad invitation. >> the first thing is the tensions over what to fund, and i realize most locales are taking a pretty scattershot notion i mean that in a positive way -- they are trying to approach -- take a lot of systems. harm reduction, needle exchange, narcan, but one question is, do you approach this from the standpoint of what is going to help tomorrow, or what could prevent, you

know, the new ablation, or at least try to reduce that. we are talking about younger kids, obviously. or, should the money go in addition that only helping the people that have the drug problem, preventing others from having one, to the damage that addiction has done, and there was an article in the philadelphia inquirer last week in kensington, which is, as you know, probably one of the worst communities with encampments and a lot of open air markets -- a lot of overdoses. they spent -- philadelphia received 20 million in settlement funds in 2023. over a third of that was set aside specifically for kensington, and divided into five areas. one for parks and schools. home repairs, rent relief, and support for small businesses. and, there was outcry from some

of the nonprofits that thought that is not helping people who are addicted. but i think that is a good idea. >> wait a minute. that sounds counterintuitive. explain your position. >> how is that counterintuitive? >> because you're not helping the people directly. >> i think that is a legitimate scope to also pay attention to communities that have been hurt. but more specific, i suppose, i don't have to go that far out into social reform, or spoke -- social repair. there is just another group. i don't know what its name is. it is a coalition of 192 national agencies. i think it is called national seachange coalition. >> it is a group. it doesn't have a single name. >> that's right.

they reject the idea of any of this money going for law enforcement. and that very much affects people who are addicted because they get arrested, and they go to drug court, and hopefully they can go to drug courts, unless someone committed a significant crime, i don't think anybody thinks that people that have drug problems should be in cells, but they should be under supervision. they should be monitored. this is a therapeutic context. they are then put into treatment. there is some leverage that they can stay there because one thing that tom, if you mentioned it, i apologize, but didn't spend too much time on -- it was a great overview --

your initial question was, why isn't it fulfilling it -- and one answer is no one is staying long enough. the dropout rates are significant. if you are lucky, if half the dose people in a program, like 25%, stadion terrier, that's because, yeah, because the quality of treatment isn't so good. some of that is because frankly, there isn't much leverage, and people are ambivalent about giving up addictions come as much trouble as it causes them, they also used drugs for reasons. it is a dynamic of self- medication in my view. anyway, for it what it's worth, i think that is wrong. i disagree with the coalition. reentry. that is very important when people leave prison or jail. how do they integrate back into their neighborhoods, the places where they got very high before they were arrested, and so they don't overdose? we know that the race of

overdoses, i saw one study that said 100%. in any case, it is large. you are at very high risk when you come out of a program and then go back into your neighborhood, and, so, methadone and sometimes -- are stored in prisons. that's all good. i would disagree with those 192 groups on that. >> you spent some time in southern ohio in your psychiatric practice, dealing with the opioid belt we could call it. how do you feel about money going for the communities rather than them? >> it is part of why people, you know, to some extent, why some people are mired in addiction, because they feel that the communities are

completely devastated. so that does contribute. i would say there's a lot of universality to this problem, and it is true in dc, and it is true in this little town called ironton, there's not enough long-term treatment, even though i said people drop out, you have to remember that every minute someone spends in a treatment program they are not in the emergency room, or they are less like the to show up with an od in the emergency room, to commit crime, to show breakup that is under the table, but at least they're making some money and they are busy and productive, so even when outcomes, if you measure outcomes, that we all want to measure them this way, you know, you finish the program and you're not using drugs anymore, and that does happen for some people, but even when it doesn't, it's always of benefit.

>> so, aneri, does this tension and use of the money -- i have a say in reaction to that dose this could be really good news, billions of dollars, really good news, so we don't want to forget that when we talk about what mistakes we make and all of this. if all these people are not interested to could be directed to treatment, this could be really good news and a really good deal, so let's not lose sight of that, but, aneri, does the tension described in the philadelphia inquirer article about were to use the money , is that echoed in the reporting that you have done at the local level? >> absolutely. i think lots of different tensions have come up in just this group of five folks here. if you look at the money being used in thousands of cities, counties, states across the country, there are lots of those tensions. law enforcement or not, treatment, but what kind of

treatment? primary care prevention and at kids, but is it just say no or mental health resources. i'm a small local government and i have a budget i have to balance, and the arpa dollars are gone, and now i have a hole in the settlement money is coming. can i use that? can i use it to pay for the salary of my health director, and the money that i normally use for their salary, can i use that to fill up potholes while others are saying, hey, you know, the opioid settlement money is here to add new services and expend -- expand what we are doing because what we paid for before is not enough -- attention -- i could spend an entire panel talking to you about the tensions that are true and popping up all over the country around how people want this money spent. >> so these are debates on city council floors? >> absolutely. city councils, county commissioner meetings. i watched a lot of those were people have very differing views about the money. where advocates come. where the sheriff's office comes. folks are asking for the money are talking about it.

and sometimes, the debate doesn't happen until after the decision is made because people may not know tissue up to that meeting. the decision is made. it shows up somewhere and people say, hey, that is not what i wanted that money used for. >> a lot of people compare this to tobacco settlement monies. tom, you are leaning in. >> i just wanted to point out something. sally brought it up, but 50 years, there has been this terrible wrong tension between law enforcement and treatment. like it is one or the other. any good person and treatment knows it is almost impossible to prevent relapse in a community that is overflowing with drug availability, so we need law enforcement to reduce drug availability. from a factual point of view, drug courts, sally mentioned, >> tell us what a drug court is for the uninitiated. >> a drug court is where a person is arrested for a drug- related offense. let's say robbery in the

service of supporting habit. they are offered a choice, very importantly. you can either go and do the sentence, or you can go to the drug court. the drug court will force you to go to treatment and force you to show up every week to show whether treatment is working, you will have to submit urines and all that. if you pass the drug court, and it is usually six months to a year, your charge is expunged. you don't have the charge. if you fail, you have already said you are guilty, so you are going to go to jail, so it is the combination of treatment under conditions where there is, let us say, artificial motivation, and let's go back to the brain stuff. you know, these are brains that are not completely functioning. i can't tell you how many people i have evaluated six months after care, said, thank

god my parole officer forced me into treatment. i wouldn't have gone. it's an unfortunate tension that doesn't have to be. >> so teresa, legal aid center is looking at the legal arm of this. do you agree with tom that forced treatment is necessary in some cases? >> you know, legal action centers leaned away from forced treatment. i think, from our perspective, we have tried to take the law enforcement approach for a very long time. we've tried to have law enforcement be first jail with a chronic health condition does not lead to the best outcomes. from our perspective, and i would encourage local governments thinking about how to spend these dollars to think about crisis response. >> what does that mean? >> crisis response when someone

is in a mental health or substance abuse crisis. if you call 911 with a heart attack, the police do not show up at your door. you have trained paramedic show up at your door. if you call 911 because you are in an s mental health crisis, oftentimes in most cities you have law enforcement responding. law enforcement often agree they are not the best respond to those types of calls. there is discussion now with the new 988 suicide crisis hotline. there is discussion about how can municipalities do a better job of changing the way they respond to crises. instead of sending a law enforcement officer with a gun to a mental health crisis, have someone who is trained to deal with the mental health crisis. and back to the point i made earlier.

>> thinking about the gaps in finding people more appropriate for law enforcement. municipalities around the country are having peers specialists and mental health counselors. people to respond to these types of crises. >> are they trained? >> not always social workers or psychiatrists or they don't always have to be phds. often there are teams of people who are much better prepared to respond to these types of crises. rarely in these calls do you need a law enforcement officer. from our perspective, again because jail is not the best place to treat a health condition. if we think of crisis response differently, that is a whole way to avoid

the jail and incarceration system to get people what they need. maybe not just treatment but social services another care they need. >> and we have drug and mental health problems. >> tom, i want to keep this focused on what local and state government should do. should we hire more first responders of a different sort? very specific. we've heard about community repair that sally was talking about. you have ideas about how to contract and the political context and you referred to this in delaware. if you revoke contracts, there is going to be an outcry. if you think there is a bunch of cities that are spending their money ineffectively saying we are going to defund the treatment facilities, one can expect the back lash. how

do you advise cities to deal with that potential? >> i will say a few words. i thought it was an important point that was made about small communities don't control their healthcare system and that is important. one thing small communities can do and do better than large communities is prevention. this is not my opinion, this is a fact. there are studies done -- large- scale studies on prevention saying you don't need drug prevention and early pregnancy prevention, you need healthy living prevention that is best done at the community level. >> we don't want to prevent healthy living. >> good point. but, it is best done in works best and the results are very impressive. like 40% of reductions in early high school

dropped out and drug use. that is the kind of thing a small community can do. >> what is the meat on the bones ? what form would that take? >> it is generic prevention generic. it doesn't work because all the things that are killing and harming our young have the same generic antecedents. two, it works, like treatment itself, it works if it's chronic. not you get a course in eighth grade saying drugs are bad and then we add prevention, that doesn't work good. chronic prevention does. at best when it is age- appropriate and comes from the entire community. the police have a role in the schools have a role in the clergy has a role and parents learn new skills.

again, i'm not talking about fictitious ideas. this has been tried successfully. washington, iowa and pennsylvania, as a matter of fact. that is one thing that small communities can do. getting back to contracting turning it into treatment, every insurance company, now, wants to see a full continuum of care. most states want to assure the community they are getting a full continuum of care. >> why? >> it is the affordable care act having that continuum. meaning detents detox for patients and most states do that by making separate contracts. they get residential care from our lady of perpetual misery and detox from shady acres, everybody has a contract.

but, those programs are not connected. you cannot go from one to the other. you have to discharge and admit and it's not at all like being in a hospital. it doesn't have to be like that. it's like me having a car and i've got the tires and wheels in my basement and the engine in my spare bedroom and the body in my backyard. i have a car but it does not run. the way the states are securing this is they are saying to these treatment programs, if you can get yourself together -- summer for me nonprofit corporations, that allow them to specifically transfer. then, the state buys something with real value. a true continuum of care and not just pieces. >> you also have different types of licenses to deal with the fact that there is an incumbent advantage.

>> absolutely. the state of arkansas is a good example. they know very well that even if you know for sure that shady acres is doing bad care, they cannot get rid of the program. it is politically impossible, but they can do different levels of licensure. the program that says i proudly want to do group therapy and only group therapy could get a level i license to continue their practice and do as was said earlier, they can do recovery support and continuing care. but, you could, if you joined with the hospital and had a physician and you had an electronic health record and could provide all of the kinds of care that you really need, you could get a level ii license which gives you will not more money because it is worth more money. you're getting the full set of

things that you need to address the illness. i mean, imagine a diabetes program that doesn't use no stinking medications. no, sir, we just do diet. suppose they got a license to do that but did not offer medications or any of the other and it would be preposterous. it would be, you know, malpractice. it's done all the time in addiction because it just grew up that way. i'm sorry, i rambled on too long. >> ascetic your experience in pennsylvania. because the programs were sideload and did not relate to each other? >> i didn't necessarily have a lot of experience on the provider side. at dhs, we contracted with the managed care organizations. one thing that resonates with me is that it is purposely hard

to win contracts. for us it was contracts with managed care organizations and to start new ones. in pennsylvania, when i was there, took years to do reprocurement. some by design because you don't want people to come in and make changes overnight. it means that change is hard. >> so there is an incumbent advantage? >> for sure. >> here is an out of left field question. we see new figures come out that the overdose death rate has declined. i want to ask you, sally, or anybody else. feel feel to jump in and don't feel i need to invite you. is it possible that the crack cocaine that the opioid epidemic is at the peak and somehow on its own? >> yes, that is possible. that is possible. i don't think we know that yet, but there is an

encouraging drop of 15% nationally and 28% in ohio and north carolina is even more. that is definitely encouraging. there is speculation about why from having narcan -- it happened fast and that is what is really interesting and also worrying. it also seems -- we don't know what one thing happened that made it happen so quickly? again, maybe it was a pretty robust ramping up of narcan. >> overdose prevention? >> yeah, overdose prevention. not prevention, they overdose reversal agent. more people got into treatment and actually i don't think it did because it was stable. there are local differences when you talk about

this at this you. i just read something the other day about maybe there is a little less. maybe there is less drug coming in and people thinking there is a drug called cytosine which finds its way into the supply and causes horrific necrotic sores on people's bodies. that may be not only an aversive development that really scares people. it either sends them to treatment or to methamphetamine . also cytosine is very sedating and basically people sleep through most of the day whereas they might have essentially, have it had not been mixed in with their hair when or fentanyl

, they would've been awake for those 8-10 hours and they would've been injecting more. there is less opportunity to overdose because that is keeping you from potentially. >> and then the earn out as you say. younger generation see what is happening to older siblings and parents who are addicted to crack. it is a situation where there is a burnout that is intrinsic to our repulsion see what is happening to people around you. go ahead. >> the fact that overdoses have declined does not mean that addictive behavior has declined? >> in fact, this is an overdose epidemic even more than an addiction epidemic. i don't know that we are seeing fewer addicted people, we are

seeing fewer people who have died. so, that is important. and i will throw in a final complication. it is that carfentanil which is about 100 times as potent as fentanyl. and it is as 100 times as potent as morphine. >> it is a nuclear bomb as is to tnt and -- >> it is for elephants and if that canes momentum, that would be disastrous. also there is a new form of synthetic opioid and is more potent than fentanyl. and it is important to be cautiously optimistic. >> all the more reason to get people into treatment that works so they don't use the

drugs. i know you are a director of fentanyl accuracy for cities, is there something that we need to appreciate? >> absolutely. just to the point of how has it changed or evolved? i have been with the national league of cities for eight years and at first it was about opioids. more and more leaders in the last few years, it is about fentanyl. in our public health professionals that do this work every day, they tell me, irma, you need to reframe this as substance abuse. yes, there is a federal role for this. because of the coordination and frankly the dynamics are different in every state which impacts the localities and what they have to do do. there has to be a connection between what happens at the local, state, and federal level because the

reality is congress -- h administration is going to have tough decisions to make as it relates to budgeting and appropriations. where are those programs that make the most significant impact ? especially when you take into account the fact that we have a mental health crisis. an isolation crisis in this country . what does that really mean for limited public health resources? >> can i -- i wanted to jump in there. you asked about the federal government role and it's a question i get asked a lot from readers and the general public. what is the federal government doing on the opioid settlement money? the answer is not a lot. the settlements are between state

governments in most part in the federal government is not a party to most lawsuits. that does not mean they cannot play a part. there was a bill introduced in congress to legislate how this money could be used at the state level. there were several lawmakers in congress who wrote and said, can you take a more active role in overseeing maybe creating a centralized database where this money could be tracked or best practices could be elevated? that, by and large, has not happened. we have not seen an active governmental role. with the broader landscape of addiction and addiction treatment, all of that, of course the federal government and medicaid is the largest payer for addiction recovery in our country. i have not seen much on the way of opioid settlement money. >> the government could be a market maker versus what it reimburses? >> a lot of folks i have spoken to whether current or

informative roles say there are things the federal government could do to steer state and local governments about how to use this money. they have different levers they can pull, essentially. >> i will turn to the audience. >> and if you are online, you can go to the website. does anybody have a question or a comment? or, a complaint. do we have anything online? nothing online? does anybody else -- everybody gets a final comment. >> i will start. you know, i think what is most important about the opportunity with the settlement funds is for communities, as a whole, to have the flexibility to not

just rapidly respond. but, based on what is happening, tailor the responses and the support and the solutions to what are the specific needs and circumstances on the ground. you all mentioned the decisions of local leaders that they have to make. leaders and councilmembers have to make tough decisions about what the prioritize every day. it is not easy. as you can imagine, everybody has their own ideas for best practices on how those limited dollars should be spent. the reality is there is a housing crisis where they are racing to build infrastructure. there is a mental health crisis and the substance of use crisis . there are so many competing priorities. you cannot address one solution at the expense of another or one issue at the expense of another. it's about coming together. for

those people that do this work each and every day, being the ones to advise and to some port . not just throw stones because we are not going to be able to meet the needs of each respective community as we do it. because, otherwise, people will continue to die. >> you remind us of the website with a great new report. >> you can find it at kffhealthnews.org. my perspective as a reporter covering addiction and mental health issues many years and generally writing about the problems and the harms we have been talking about. as this money is coming in totaling about $50 billion spread out over 18 years, it is an opportunity. a lot of people i talked to see it as an opportunity to build treatment

structure and build recovery services and invest in childhood nutrition. as people look at the tobacco settlement of the 1990s. i think the tensions you see highlighted here are playing out because people care strongly about how this money is used and they want to know how the money is used in track that and evaluate to see in five years if we need to change the strategy and do something different for the final 10 or 15 years. as a reporter, a lot of my job is to figure out where the money is going and there is not a lot of transparency around that. hopefully to make that more transparent and spark conversations. you can check that out at kffhealthnews.org . >> at the risk of being cynical , we know you will have a story to cover for a long time. >> yes. this is a two-year series and i'm sure there will

be more years of stories to come. >> just to reiterate how important it is that people stay in a treatment program. that is because one of the most enduring facts of drug treatment is that the longer you stay, the better you do. you internalize the values. with abstinence, the first time i said that, doug thought it was sexual abstinence. also the important part of what therapy does which is largely to cultivate a habit of self observation so people understand what it's situations make they are vulnerable. the have to start working and working can pose its own challenges. it is helpful to

talk about that with the counselor. >> how do you do that? >> that is what keeps them there , at least at the beginning. it is important for people to stay and that is my segue to another point that tom made which is this almost false dichotomy between criminal justice or corrections and a treatment program. if i have a patient who is, you know, leverage to to be there under a system of benign paternalism. you have to go where there will be a different consequence. that is so helpful. the one thing you said, teresa, and i guess i disagree with you a little bit on this. we don't want folks in cells but if you commit a crime, there has got to be accountability for that. better drug treatment than the kind of consequence that would befall someone if they were not

addicted and committed the same crime because that is a jail cell. >> teresa. >> i want to go to appoint that was made a little bit ago about what we are seeing now in terms of reduction of overdose deaths. everyone is celebrating and that is wonderful, but it is important to note we are not seeing that across all demographics. that's for white people are definitely going down. >> which were previously disproportionately high and we have seen a reversal. >> in the black and native american population, we are not seeing that same decline and i wanted to point out. the other thing i would urge because this is a forum for local governments and others trying to figure out how to spend these dollars. in this country we have a history of sort of deciding for communities what is going to work for them. i would encourage folks to get on the ground and listen to the people

you are serving. figure out from their perspective. that means including people with lived experience in the dialogue and the discussion and the development of solutions. people actively losing and not just those in long-term recovery. you need multiple perspectives to make sure the solutions you come up with will meet the needs and turn the tide to make sure people are able to get the care they need when they need it . >> thank you so much, they may want to call this guy. ask tom because he seems to be deeply in this. last comment? >> i would just say, look, there is tremendous value at the individual family, community, and national level in recovery. to get more people in recovery, it is the real value. as a guy

who spent his life in addiction. working in addiction treatment, not that's not the point. treatment is the way to real value which is recovery. number one, there are more people today in stable recovery than are addicted. most people don't know that because they look like every other citizen. they are anonymous. don't forget that. this is an illness you can recover from. two, these new dollars offer opportunities that you don't have. yeah, they are competing demands and it is tough to make decisions. but, it is crazy to keep doing things in the good old- fashioned way when that is not the thing providing value to the state or to the country. so, i encourage a time to put evidence into play. try things that might work. use the power that the states and communities

have for the very, very good things they can do. >> thank you panel. [ applause ]. ♪♪ .

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now, government officials testify on president biden's request for nearly $100 billion in disaster relief in the wakes of hurricanes helene and milton with the senate appropriations committee. the buddha job, dan criswell and isabel guzman are among the witnesses. senators john ostroff and tom tillis spoke in front of the committee to share how their home states have been impacted by the recent storms. this is just over three hours. e

am in a divided by hundreds of >> opgood morning. this committ will come to order. today we are holding a hearing to discuss urgent federal funding needs for communities harmed by the recent natural disasters. this is the first hearing since we had the election. it is clear some things will look different next year. one thing that will not change is my commitment to working with senator collins to do the important work of this committee in a bipartisan manner despite any distractions thrown our way. there is too much at stake for families back home for any of us to throw up our hands. we

have to wrap up our fy 25 bills and our effort to work to complete that process as quickly as possible in a manner consistent with bipartisan bills which we have all put so much effort into. back to the subject at hand. we hope will have two panels of witnesses today. first senators also often tillis will speak about the challenges their states are facing. then we will hear from officials at the department of transportation, the small business administration, department of agriculture and the department of housing and urban development. we received an updated emergency supplemental request from the white house which offers a helpful roadmap but it is just the start. we know it will take full time to assess the needs of our communities impacted by hurricanes and other natural disasters and the resources required to recover. i hope we can take what we hear

today and act swiftly in a bipartisan way to provide relief . after all, there is a long history of members coming together quickly in the wake of tragedy. everyone of us knows our states have needed help after disasters before and we will certainly need help again. when disaster strikes, should never matter who is in the white house and who is in the majority in which governor is asking for support or how anyone voted on election or the last bill. as i said before, you don't argue over whether to put out a fire. you don't debate how much water to use or how many people to save. you roll up your sleeves and get to work and get help out the door. as much as is needed and as fast as is possible. right now there are people in our country needing help and yet this is one of the longest times, in my member memory that we have gone without providing help. it's unacceptable and

time to get paid out to people after the many disasters we have faced over the past two years. we have seen devastating wild fires including my home state in washington and in maui. a typhoon in guam which is still in recovery. we've seen historic flooding in vermont and deadly tornadoes in several states. there is an ongoing effort to rebuild after the key bridge collapse in baltimore and of course the two hurricanes that recently tore through the south with catastrophic effect. it is clear that hurricane milton and hurricane healing were devastating. the full extent of the damages still coming into focus. while we can see the road to recovery more clearly, we can see it is a long one and will take serious federal support. there are still communities without power and clean drinking water. there are miles and miles of