recognize we have the most dynamic economic engine the world has ever known right here in america. we need to use it again. we cannot work it when the time. it does not work when you have high taxation rates. which are absurd. we have the highest corporate tax rates in the world. and yet some of our officials sit there and wonder why people do work overseas. they obviously do not understand business. people do not go into business to support the government. they go into business to make money. [applause] dr. carson: we obviously have to create an environment that is conducive to them making money. that means lowering the

corporate tax rate, making it competitive. if we were really smart, we would do another big stimulus. you are saying, what? what did he just say? remember that big stimulus that we were supposed to have at the beginning of the obama administration? whatever happened to that? i know where we could get a big stimulus. there is $2 trillion of offshore money because they will not bring it back because it will be taxed at 35%. what if we give them a tax holiday and let them bring it back, repatriate that money? it won't cost us a dime. [applause] dr. carson: that is the kind of thing we have to start thinking about. if you go to the financial advisor and you are in trouble they will tell you there are a few -- they will ask you for questions.

what do you own? what do you know? -- owe? well, we only a lot -- owe a lot. what do we own? we own a lot, also. just in terms of land and the mineral rights for it, we are probably at least $50 trillion. we own dams. we own levees. we own railroads. the government owns 900,000 buildings. 77,000 of which are being not utilized or underutilized. think about that. at the same time, the government is leasing over 500 million square feet from the private sector, using your taxpayer money. it is totally horrendous when

you look under the hood. you just want to shut it back down. [laughter] dr. carson: it is that bad. i want to tell you what we are going to do. if god ordains that we end up in the white house. i will to you what we are going to do. we are going to change the government into something that looks more like a well-run business than a behemoth of inefficiency. [applause] dr. carson: when i say we, i am talking about our team. when i started this endeavor, i am familiar with a man who has started over 30 companies, is extraordinarily successful. i asked him to put together the rest of the team in order to be able to do this. his name is terry giles. where are you? [applause]

dr. carson: now that we are transitioning from, you know, an exploratory committee, i have asked terry if he would take the lead in helping to select the people who will be able, who have had enormous experience with business and with making things work, so that we can transition our government from this inefficient thing that we have into something that really works and something that works the way it is supposed to, according to our constitution. [applause] we also have a great team. we have our -- who do we have?

[laughter] dr. carson: we have our chairman , barry bennett. who never wears a tie but you will get used to seeing him. he does a terrific job. [applause] dr. carson: and, we have our director of communications, doug watts. who does wear a tie. [applause] dr. carson: and we have our treasurer and finance director logan delaney. [applause] dr. carson: and we have our national spokesperson, dana bass. [applause] dr. carson: we are going to be doing different things that you have seen before because it is

not political. there are people who say, you cannot do this area you don't have experience. let me tell you something. i don't have a lot of experience busting budgets and doing the kinds of things that i've gotten us into all the trouble we are in now. i do have a lot of experience in solving problems. complex surgical problems that i've never been done by anybody before. [applause] dr. carson: i do have corporate board experience with 18 years with kellogg's. 16 years with cosco as well as a biotech company. kandi and i have experience starting a national nonprofit scholars fund. nine out of 10 of those fail. ours is thriving in all 50 states and has launched several

national awards. [applause] dr. carson: the point being that you can gain experience in other ways. it does not have to be just in politics. i can name a lot of people and politics with been there all their lives and you probably would not want them to polish your shoe. we need to be smart enough to think for ourselves. to listen for ourselves and in terms of a pedigree that we need -- i have to tell you, everybody has been telling me, are you ready for this. they're going to come after you with everything under the sun. they are going to try to say you are a horrible dr.. everything you can imagine. i know that. i expect that. it is ok. don't worry, just listen to what is being said. i'm not even asking everyone to vote for me. i'm just asking people to listen to what i am saying and listen

to what politicians are saying and make an intelligent decision based on your intellect. the real pedigree that we need to help to heal this country, to revive this country. someone who believes in our constitution and is willing to put it on the top shelf. [applause] dr. carson: someone who believes in their fellow man and loves this nation and is compassionate. somebody who believes in what we have learned since we were in kindergarten. that is, that we are one nation, under god, indivisible with liberty and justice for all. god bless you and god bless the united states of america. [applause]

♪ glory, glory hallelujah glory, glory hallelujah glory, glory hallelujah his truth is marching on ♪ [applause] [cheers]

[captions copyright national cable satellite corp. 2015] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> if you want to watch this again, we will have it online at www.c-span.org. at 8:00 eastern time. take a look at carly fiorina who also announced today. she asked her announcement of the video on youtube. >> i am running for president. our founders never intended us to have a professional political class.

they believe citizens and leaders need to step forward. we know the only way to reimagine our government is to reimagine who is leading it. i am carly fiorina and i'm running for president. if you are tired of the soundbites, the victory all, the pettiness, the egos, the corruption if you believe it is time to declare the end of identity politics, if you believe it is time to declare the end of lowered expectations, if you believe that it is time for citizens to stand up to the political class and say enough, then join us. it is time for us to empower our citizens, to give them a voice in our government, to come together to fix what has been broken about our politics and government for too long. because we can do this together. >> both carly fiorina and then

carson's announcements at 8:00 here on c-span. tomorrow former governor mike huckabee expected to announce he is getting into the race. we will have his announcement live on c-span from hope arkansas tomorrow at 11:00 eastern. >> tonight on "the communicators" we speak with three members of congress with shared interests in communication. al franken, bob goodlatte, and doris matsui. >> i firmly believe comcast and time warner cable would have been too big, anticompetitive, not in the public interest would have led to higher prices for consumers, less choice. if it's even possible with the state of your companies, worse service. >> we are also working on technology companies, dealing with people's privacy and protection of civil liberties.

that is legislation dealing with the nsa and the fisa court dealing with the revelations about a gathering of telephone metadata. this bill, which passed the house with a bipartisan vote in the last congress, about to bring it up again, bans metadata collection and storage from the government. >> if you saw the net neutrality debate also, that was unbelievable in the sense that people understand that the internet should be free. there should not be people who get faster access or not. when that occurred, that energy that happened with that, when chairman wheeler, a cousin of the overturning of the open internet order, when he had to have a new proposal out there

he hinted there might be pay prioritization. that means the internet provider to the end-user, which is the customer, that they may have to pay for faster speeds or whatever. 4 million comments? that is unheard of. >> remarkable partnerships iconic women. their stories in "first ladies." >> she saved the portrait of washington which is one of the things that endeared her to the nation. >> who ever find out where francis was staying, what she looked like, who she was seeing, that would help to sell papers. >> she takes over a radio station and starts running it. >> she exerted enormous

influence because she would move a mountain to make sure that her husband was protected. >> "first ladies" now a book. looking into the personal life of every first lady in american history based on original interviews from c-span's original series. filled with lively stories of fascinating women who survived the scrutiny of the white house, sometimes at a great personal cost, often changing history. "first ladies" is an entertaining and illuminating read, now available as a hardcover or e-book. host: each year since 2006 c-span has invited students to participate in our studentcam competition.

they asked it is to join in on the debate over today's public policy issues by producing a documentary on a specific theme. "the three branches and you." contestants tell a story about a policy, law, or action by one of the three branches. entries came from 45 states. overall, 150 student prizes were awarded him a totaling $100,000. a team of 8th graders were net the grand prize winners for 2015 for their video on minimum wage. their cable provider in lexington is time warner cable. let me introduce you to our three grand prize-winning

students. anna gilligan, katie demos, and michael lozovoy. welcome to all of you. tell me about your school. anna: we go to the school for the creative and performing arts. we are the 8th grade. i am an art major, katie is a band major and michael is also an art host: how do you get to go to the school? katie: you could audition through a process. basically if you are into art, you submit a portfolio. if you are in band, you play an audition. they select a few students to go into that category for next year. host: what is it like going to school there? michael: very interesting. it is a smaller school to the

normal public schools in lexington. if you come in in the fourth grade and you leave in the 8th grade, you have spent five years with the same people. usually people stay there. when you audition, there's a lot of a petition to get into the school. it is very interesting experience. all of the teachers are friendly. most have been teaching there a longtime. they like it a lot. host: sounds like you might be making friends for life. michael: yeah. anna: oh great, i get to work with my friends. anna: i started in piano.

i do not know what i want to do in the future. i learned a lot of skills that have helped me with this project and putting it together and other things along the way. katie: i auditioned for contemporary dance and switched majors. i changed my major to creative writing and band. for the future, i'm thinking i want to go into some sort of health care. i was thinking i might want to be some sort of a doctor or pediatrician or surgeon. host: how will your art study help you with that goal? katie: i feel it is less about the art study. i have been given so many different experiences. i'm so thankful on how to work with a team and know people and how to work together. host: basic life skills.

what about yourself, michael? michael: i was in art. i auditioned for art. i have been an art major. when you are in sixth or seventh grade, you're allowed to have a minor's class. it is a second category you could take a class in. you do not have to audition for it. you are already doing your major. i did creative writing/literary arts. that is what it is also called. i switched to drama. i liked them both. you have lots of options when considering what you want to do. i feel i multi talented.

i wanted to do different things. my future career i want to do is something related to technology and also having world traveling -- it was an enhancing experience. at the same time with majors and minors, we also have electives we could take. we have options there i had video production. that really help in both situations. host: let's talk about this project. when did you first hear about the company mission? katie: we have two social studies classes.

the teacher discovered the studies classes. c-span competition and introduced it. let's do this as a class project. make it a grade. after the great, we have the option of committing it to the c-span competition. we look into it. we had done the project. why not submit it? so we did. the outcome was amazing. [laughter] host: there were several teams in your class. how many decided to enter the contest? anna: i think about half of them. some didn't complete it by the due date. i think half ended up entering. host: how did you become a team? michael: when we learned about the assignment, i wasn't really enthusiastic about it.

great. another assignment thing. but then once i learned more about it, as we learned more about it, we got more interested. we decided to take it seriously. we have the skills. we decided to come together. each of us contributed a huge part to the video. that would make a tri-force as our classmates called us. host: if you were the technical part, what were the roles that the two of you had? katie: i was the researcher. i looked at all of the sources and gather the information that

was necessary to be the substance of our video. anna was the reporter. anna: i talked to the interviewees and did some camera shots. michael: i helped with that. anna: use that shot. i like the facial expressions. host: was this a first-time experience for you? anna: me and katie, yes. katie: that was his field. michael: my dad makes a lot of videos. he used his own business. he used good time video. he filmed events like weddings or shows scapa. as i was growing up as a child i was surrounded by all of these equipments and things. it was something i was actually

interested in. host: what kind of equipment did you use? michael: anna had a camera that was an old camera. they wanted to use it. it was convenient for them. there are going to travel to do some interviews. when she gave it to me, i looked. made sure it worked. it was tape. it was old. [laughter] you do not need the most high quality camera to do a video. host: a winning video, no less. [laughter] michael: another thing i realized is the camera alone isn't going to help in the interviews. you need a microphone. i was so frustrated with editing. sometimes it didn't have any audio.

host: quite a learning experience. michael: we used the microphone. microphones always has better audio than the camera. we used adobe pro. it is a pretty professional editing software. that gave me a lot of options. we used a tripod. we didn't use much more than that. that was the materials and resources that we had available to us to make the video. it wasn't really something that you need to invest a lot of money into. we didn't invest any money. it was something we already had. lots of people have cameras. sometimes people do not use them. if you want to do something with

it, you pick up the camera and learn how to use it. host: that is a good message. now we know how you did it. how did you choose this topic? anna: i'll take that. i love the idea of the project. i was so excited about it. i know you had to use some c-span clips. i looked at the options available on your website. i saw some things about the minimum wage and people were protesting. there were two very different point of use. there was no middle ground. human rights. rights for workers. that is what we are going to do. human rights, i'm passionate about that. this is what is going to happen. host: did the topic work with

what you are studying in school? katie: it sort of was a new area to explore. we have been doing world history and geography. we were just starting on the u.s. this year. as we explored more modern current events that were happening, i feel we learned a lot about social studies and history itself. we went back to learn about things about the minimum wage. the experience, the topic was different from what we were learning. host: now that we have learned how you did it and what the topic was, let's show the audience your winning video. we will come back and talk more after everyone sees it. [video clip] >> the federal government created the minimum wage in 1938 at the height of the great

depression. it was designed to keep america's workers out of poverty and increase consumer purchasing power in order to stimulate the economy. >> it has been increased 22 >> it has been increased 22 times in order to keep up with inflation, including seven times in the past five years. >> some say, it's time to do it again. but is that really in the best interest of our communities? sidney jones is a single mother with a four-year-old child. she has to make tough choices each week, since she has to make ends meet on a minimum wage job $7.25 per hour. she says it's isn't enough to get by >> sometimes it's hard and i have to decide if my son needs underwear i'm going to have to be late on a bill, or i'm going to have to ask to borrow money. so it is hard sometimes.

>> sydni is not alone. according to the bureau of labor statistics, 3.3 million americans make minimum wage or below. that is 2.6% of all u.s. workers most are employed in fields like food service, retail sales, or personal care, such as daycare. rosemarie gray makes minimum wage as a custodian. rosemarie: we have to pay for ourselves, our bills and housing and stuff and you just cannot do that on minimum wage. you just can't. so you have all of these programs like food stamps. it's like, why do you need food stamps? because you've got to eat and you don't make enough to feed yourself and pay all your bills you just don't. >> this push is on to raise the minimum wage federally from

$7.25 per hour to maybe $10.10 per hour, which would provide a little over $21,000 per year if the individual works 40 hours per week. it has been six years and the minimum wage was raised. some in congress say this now the time to raise it again. >> things are getting better but the problem is, they are only getting better for some. corporate profits had continued to break records while americans are working harder and getting paid less. >> but some like kentucky congressman andy barr said raising minimum wage will cost jobs citing a study by the cbo. >> we would lose 500,000 to $1 million jobs immediately, those low income jobs. -- two one million jobs immediately, those low income jobs.

>> the representative said more education and improving training are the keys, not an artificial wage. >> what we need to focus on again our policies for economic growth so that workers in lower wage jobs moving to higher wage jobs. those jobs within the open to new workers who come in that are currently unemployed to backfill those jobs and move up the ladder of success that way. >> many business owners agree. markel started a metals company 20 years ago. he believes a wage hike hurts the bottom-line, forcing companies to ways -- raise prices. >> if there's a mandate for a higher minimum wage, it will force companies to raise their

prices in the marketplace. >> vice president joe biden said increasing minimum wage will help all workers earn more and spend more. >> folks, it is long past due to increased minimum wage that would lift millions out of poverty, and presentable effect to boost wages for the middle class and spur economic growth for the u.s. >> and some minimum wage workers say extra money will make them less dependent on government benefits, saving taxpayers millions. >> the city help me get my apartment, paid the first month and the deposit. they are broke, because everybody is meeting money so badly that they don't have any money anymore. this is the opportunity to be on my own will stop if i had my own money, i could have a the

deposit, the first and last month, whatever. but i couldn't because of the situation i was in. >> but even some minimum-wage workers believe mandating a pay hike will cost them and everyone else in the long run. >> if they raise minimum wage, everything else has to go up as well. the government is pressing for $10.10 and then the employee will have to pay more money because prices will go up. and it also makes our money worth less than it is now. >> minimum-wage jobs should be considered entry-level jobs. >> congress should not mandate higher wages. rather, invest in programs that help workers advance to higher skilled and higher pay jobs.

>> these actions would benefit our community, because more people making more money would create more tax revenues for governments, which would result in people being able to invest more in positive community changes. >> there you have it, the 2015 grand prize came documentary the artificial wage. among the requirements for this contest is to explore alternative points of view and to use c-span video. people can see that you did both. what was interesting when we were judging this is that you did not just explore the point of view. as documentarians, you came to a conclusion and presented that to your viewers. i got the impression your view shifted over the course of the project. how does that happen intellectually? >> well, we started out inking, you know let's raise the minimum wage. it's the human thing to do.

you want these people to make more money so they can pay for more things, get us out of poverty. it seems like the operators -- the obvious choice. once you are doing it, that was our pro-side. then we looked at the con side and there was so much more evidence on the con side for why we should not raise the minimum wage. and we looked at the long-term effect, it did not seem to help. short-term effect, it would help. but long-term is the more important. in the end, our conclusion was more the con side. >> michael, did you get into a big debate about this, or was it apparent to all of you? >> we had different opinions, but i approached it from a neutral standpoint, because if there are two documents -- arguments for raising the minimum wage, there have to inherit -- have to be merits for

both sides. i came at it from a neutral standpoint and did not make up my mind until we kept doing some research. it's all very political. people have lots of opinions. we just try to find a conclusion that would make sense for both sides. and what our conclusion essentially was, was that minimum-wage jobs should be considered entry-level jobs. where you do a minimum-wage job and then programs that the government will invest in will lift them out of the minimum-wage jobs and make them move up. we thought that the government should invest in programs that help people move out and move up into higher-paying jobs. and that ultimately would make

things better, because more people would be getting into their higher-paying jobs and people who don't have jobs are then employed, because minimum-wage jobs are open. that would benefit our economy we think. >> and just to clarify, your position is that the federal government should not raise the minimum wage, but you are ok with states raising them individually? >> i have not looked into that. we did discuss in our video more the federal government raising. i know in our own community we are definitely about raising the minimum wage. i personally, that is not my point of view. i think we should all consider the long-term effects and look at where that will put these workers. and if these jobs are worth that much money. are they doing as much work? how much are they making

compared to how much money they are getting paid? >> what was the process you used to interview people who are actually making minimum wage? >> a wonderful program called jubilee jobs. my dad had done some work with them. we thought is there a way that we can interview some of them hear their story, what they thought about it and have happen ? >> and my mom also works with a charity called "dress for success," which is connected with jubilee jobs. there were opportunities there so it was easy for a slowly picked the topic because we have those options. >> how did you connect with the congressman? >> that was more on anna's part. >> my dad used to work on state government with congressman barr.

we were able to coordinate that interview based on where he was on a certain day. >> you went to the office? >> i did not go. i was busy that day. >> it was the two of you that went? who ran the camera? >> my dad. i would say, hey, let's to this angle and he did in over the shoulder shot and could get me in there. >> what was it like in the congressman's office that day? >> it was pretty relaxed, a lot like this. just the conversation, you know, to hear his point of view and i would say, oh have you considered this? and he would say, yes, here's what i think about that. it was interesting to think about who is representing me what he had to say. >> where were you when you got the news that this video had won the big prize? >> it was about two days for the public announcement came out to stop we were -- came out. we were in one of the rooms in our school.

our principal and our social studies teacher were there. when the phone came on, when we heard that we were the grand prize winners, we were ecstatic with joy. it was unbelievable. i can't really put it into words how it felt to hear those words. the first thing i did was, just i cried. >> embry looked at each other -- [indiscernible] >> you are the cool customer in the group, i can tell. you are first-time documentarians. or you surprised that you made it into the grand prize? or did you feel that it was really well done? >> at the time that we made it come out we knew we could get something. >> you knew. he was very confident. katie and i were very -- >> humble.

>> and mike was like, we worked really hard. there's definitely a possibility. and i thought, i don't know maybe. i mean, just for next year's entry to the contest. never shall -- sell yourself short. you don't know what you are capable of congressman -- of accomplishing. >> inviting folks down and doing a presentation, but was that like having that happen at your school? >> that was pretty interesting. >> we were in our schools multipurpose room and we basically sat down on the stage. >> did the whole school come? >> yes, every class was invited and everyone was there for the their money. it was really sort of advertising us. [laughter] once we got there, the principal took us up and she would say a little blurb about each of us that was sort of personal. and then we sat back down. our social studies teachers gave

different speakers -- speeches about social studies in the classroom. in the c-span people came and presented us with the award. i like to think of that ceremony as less of something for us as it was for everyone in our class who had entered into the competition. we cannot forget about them. christ and the other people for the future. >> i felt like we were not just recognizing our team's efforts, but everyone's. >> why do you mean for the future? what are you thinking? >> i think the future classes the seventh graders and so on that will do that competition, i think it inspired them to know that it's definitely possible.

>> it is an achievable goal. >> yes, when somebody you know who you spent years at our school with accomplish something and you know that, somebody from your school did that, i think it gives hope to other people that they can achieve the same goal as well. and it's not like some 12th grader in high school who had a bunch of money and capability to do that, and connections with, i don't know, some crazy thing that would give them a huge opportunity to help them make an outstanding video. no, without mike was just normal -- with us it was just normal people from the school who worked really hard and were able to produce something with the same opportunities that people at our school have. >> clearly another part of

being grand prize winners is coming to washington. and not just on this program. what are you doing also here? >> i love coming to pc we're learning -- to d.c. were learning about everything that has happened here in the past. and one my favorite parts is the arlington national cemetery. the changing of the guard, you see it on youtube and then you see is in person -- see it in person, and it was just amazing. the precision and everything, i admire that so much. >> and what was today like? you started out with the capital tour? x yes, we did. -- >> yes, we did. we started out with a person from c-span on a tour and we walked around the capital. i think i had been there before on some other trips to washington but there is so much you can learn from theirre, things

that you miss. i recommend that anybody who comes to d.c., they should take a tour and stop by the congress building. you get a sense of american pride when you go in there because it is so established, so beautiful, and you get to see democracy where it is. >> we will finish of the day today by going back to the capital club flex -- capitol complex. what is the remainder of the day like? >> we will be going back to the capital to meet mitch mcconnell the majority senate leader which will be amazing. that makes me feel like, as kentuckians -- there are 50 states but as kentuckians, we can come together to meet some

more that someone really special. and then we will get ready to fly back to lexington. collects a busy 24 hours for you. what do you plan to say to -- >> a busy 24 hours for you. what do you plan to a two mitch mcconnell? >> we actually got a letter from him when we had won. and it was very personal and interesting, and he said he was proud to represent kentuckians like us. i will thank him for that. >> when you and i talked on the phone, it was announced today and we were ordered over a short -- we recorded over a short interview to tell you that you had one. and there was also prize money. it was too early for you to have thought about that. have you all talked about or thought about how much you will -- how you will spend your prize

money? how much will you be getting? >> we will that the 5000 between us. we will each get about $1500. i'm going to take about $250 to $500 and donate that to a couple of charities. i initially thought i would give some to jubilee jobs for letting us come there and get those interviews. and then another have, i was thinking, maybe a gift to my school or maybe another charity that i'm passionate about. >> and a little bit for you at the end. >> and the rest is going to my college fund. >> how about you? >> i plan on saving it. when you are younger you usually do not make the best decisions as you would when you do later. i plan on keeping it, and maybe if i'm doing what katie is

doing, i will donate them to the school, or charity. lots of people are joking, well, you have $2000 now, why don't you just buy this? and if i -- i would want to keep it for them a i don't know maybe an emergency. or something that show. >> congratulations. you are only in middle school, so there are more opportunities for you to continue to enter the student can, and we hope you will. thank you for sharing your views with all of the c-span viewers. we hope the young people of their watching this will think about entering the contest in the future as well. we will announce the new contest

the september of this year. you can keep checking back c-span's website. we will keep making the announcement on the screen. it will be a different theme from the new year. that is that student cam.org. >> on capitol hill today working on a presidential override of a veto. and more work on the iran nuclear oversight bill. also, 2016 budget resolution negotiated by the house and in it. house is out this. they would back for legislative is on may 12, a tuesday. you can see live coverage here on c-span. >> the new congressional directory is a handy guide for to the 114th -- handy guide to the 114th congress. it has bio and contact

information, twitter handles, a foldout district map and capitol hill map and congressional committees and more. order your copy today. it is $13 and five cents plus shipping and handling, through the c-span.org store. >> another candidate about to seek the republican nomination. ormer arkansas governor and talkshow host mike huckabee expected to announce his candidacy from hope, arkansas. we will have live coverage right here on seas and will stop -- on c-span. >> tonight on the communicators we spoke with members of congress on shared issues in legislation. >> i firmly believe that comcast were allowed to buy time warner cable that they would be a too big a company and it would not have been in the public

interest. it would have led to higher prices for consumers, less choice, and if it is even possible with the two companies, worse service. >> we are also working on giving with people's privacy and protection of civil liberties. and that is legislation dealing with the nsa and a five the court, the foreign intelligence surveillance act court, dealing with revelations about the gathering of telephone metadata. this bill, which passed the house with a big bipartisan vote in the last congress, and we are about to bring it up again bands metadata collection and storage by the government. class if you saw the net neutrality debate also, that woman was -- that one was unbelievable in that people understand the internet should be free. and there should not be people who get faster access or not.

when that occurred and that whole energy that happened with that when chairman wheeler because of the overturning of the open internet order, when he had to have a new proposal out there, when he just hinted that there might be paid prioritization in which that means the internet provider to the end-user, which is the customer, that they may have to pay for faster speeds or whatever, that was unheard of. >> tonight at 8:00 p.m. eastern on the communicators on c-span two. >> a house subcommittee recently examined the efforts of federal agents is to fight specific -- prescription drug abuse, specifically opioids.

the hearing is chaired by congressman tim murphy of pennsylvania. it is about two hours. chairman murphy: good morning and welcome. it is mental health month, so it is fitting we are here on this issue. third in a series of hearings involving a growing problem of prescription drugs and heroin addiction that is ravaging our country. this is our nation's single biggest public health concern. over the past five weeks, a

subcommittee has heard from addiction experts working with local communities and our leading academic and research centers. dr. robert dupont, former drug control policy and director of the national drug abuse testified that federal programs lack direction and standards on treating addiction as a chronic addiction and note whadt is being done to prevent relapse. he challenges us to ask the most fundamental question, what is rediscovery? -- recovery? dr. anna lemke provided critical testimony on how we must revise our health care quality measures to reduce overprescribing, reform privacy regulations and incentivize the ooze of -- of the use of prescription drug monitoring programs. we know that those addiction disorders need a broad treatment options that many with substance abuse disorders have a psychiatric disorder. we need to tear down federal policy and funding barriers that keep us from treating both simultaneously. about three weeks ago, one of today's witnesses, mr. michael

botticelli, presented a slide. i'm going to show it here at the national summit on major causes of death from injury from 1999 to 2013. quite a revealing slide. while the trends of other major cause of death, such as auto accidents went down, drug poisoning goes up 21% from 2008 until 2013. in many states, these numbers are soaring at high double-digit rate increases. as the doctor has indicated to me at the summit, we must do better and we have much work to do. today, we will hear from federal agencies charged with providing guide guidance and leadership to the opioid epidemic. the department of health and human services, or hhs, and its substance abuse and mental health administration, also known as samha regulates our countries 1300.

-- 1300 opioid treatment programs, and is responsible for certifying the 26,000 physicians who prescribe the most common medication, epinephrine. according to testimony provided in april of last year, there were nearly 1.5 million people treated with these opiate medication with a five-fold increase in the last ten years. has samhsa defined the role of -- the goal of recovery for what these treatment programs are supposed to accomplish? are they collecting data at an individualized level that would hold individuals responsible for the results? so far the answers indicate that it is no. when you don't define where you are going, every road you take leaves you lost. we are hoping that we can get some direction today. the numbers indicate we are failing as a nation.

we darn well better come to terms with that. the 43,000 lives lost year, the thousands of babies born addicted to opiates tell us the terrible toll that this epidemic has taken. you heard my thoughts about the addiction maintenance and i've referred to heroin helper, not because it's altogether lacking but rather because infrastructure the federal government has used for this highly potent medication is not fully working and, worse yet, in many cases it's contributing to the growing problem. this has to be fixed and i hope we'll find solutions and that's what we need to discuss today openly, honestly, and humbly. if we do not reverse the current trend, where is this going to end? how many millions of citizens do we want to have on opiate maintenance? how many more must die and how many more lives and dreams must be shattered before we recognize the depth of this. -- this national scourge. i don't believe better living through dependency. this is not a general indictment

of opiate maintenance. for some people it's the bridge treatment and there should be no shame or stigma associated with it. but it should not be the only thing offered and it's not the only goal. what patients can be successfully transition off of these medications or protocols best for effecting this transition. what are the best practices for prevention of relapse for those patients who end opiate maintenance treatment you? there are nonaddictive medications approved for this use but are the medications widely available and how well do they work? the diversion for illicit nonmedical use is how the opiate addiction can be spread. where is the call to modernize existing treatment system tone sure the right patient gets the -- to ensure the right patient gets the right treatment at the right time? why aren't we hearing about expanding access to nonnarcotic

treatments? these are all incredibly important tools and we want to make sure hhs talks more about these. last week dr. wesley clark, the former director of samhsa center and who oversaw the growth over the last decade declared before the american society of addiction medicine that many you been at for an -- eupenephrine practices have become pill mills where doctors and dealers were increasingly indistinguishable laboratory fraud prevailed. the problem is not with upineprine, however. and this is what we need to discuss. i consider this as a bridge to cross over in the recovery process. as i said, it's not a final destination. we seek to lay out a recovery that is an option. for cancer, diabetes, aids, we want people to be free of the diseases, not just learn to live with it. we need to commit the same sorts of things to research and clinical efforts that boldly

declare what we must change here. i thank our witnesses for being here and i recognize ranking member of the subcommittee, mrs. degette from colorado for five minutes. >> thank you, mr. chairman. i think it's really important to hear from our witnesses about the work that the federal government is doing to address this serious public health issue and i know all of the agencies represented before us do critical work to prevent and treat this ep depidemic. in march, i applaud the department's actions and i'm gratified to hear that this is one of the secretary's top priorities. i want to hear more about this initiative today and how all the agencies before us are working together to accomplish its goals. but at the same time, i have some hard questions about our approach to caring for those who have substance abuse disorders. last week we heard from a panel

of medical experts who have vast experience in treating opioid addiction. unfortunately, as the chairman said, they gave us a fairly bleak view of the opioid treatment landscape in this country. for example, one witness, a psychiatrist as columbia university and a research scientist at the new york state psychiatric institute, told the committee that the majority of patients being treated for opioid addiction received treatment that is both, quote, outdated and, quote, mostly ineffective. he described this approach of rapid detoxification followed by an absence only method without the use of important treatment medications. the doctor added that this is potentially dangerous because it raises the risk of an overdose if a patient relapses. as troubling as this testimony from our last hearing was, today we have dr. volkow on our panel, one of the world's top experts

on addiction research. and she notes, i'm sure you'll talk more about this, doctor, in her written testimony that quote, existing evidence-based prevention and treatment strategies are highly underutilized across the united states. why is that, mr. chairman? why do we have experts week after week telling us that the bulk of the treatment that americans are receiving for this devastating disease are ineffective, outdated and not evidence-based? we need to be asking ourselves some tough questions. for example, the president of the american academy of addiction addiction said that you addiction psychiatry told us last week that patients and their families need to know that detoxification treatment and drug-free counseling are associated with a very high risk of relapse. are patients enrolled in treatment getting sufficient data so they can make medley informed choices? -- medically informed choices?

are family and loved ones being told what approaches have high failure rates before choosing an approach to treatment? frankly, this is not a decision that should be taken lightly. getting ineffective treatment may not only be financially costly but it may result in a fatal relapse. finally, mr. chairman, recent testimony, including some i saw in the written statements for today, raises important questions about whether taxpayer dollars should fund certain approaches for combating this opioid epidemic over others. this is an issue i've been talking about week after week. we all agree we need the most effective treatment. and our experts agree that this treatment needs to be a broad menu of options that is different from patient to patient. so we might not have a silver bullet to cure opioid addiction at this point but we know what treatment works better than

others. evidence tells us and all of the experts agree, that for most patients, a combination of medication-assisted treatment and behavioral treatment, such as counseling and other supportive services, is the most effective way to treat opioid addiction. if that's the case, we should pursue more policies that encourage this approach as a clear option and steer away from any efforts that are not evidence-based. it's costly and it's dangerous to the patient. so i hope we can all work together to fight this epidemic. and i do look forward to hearing from all of our witnesses. i'm glad secretary burwell and the department are devoting serious attention to both the prevention and treatment sides of this problem. mr. chairman, this has been a really great series. i'm happy to have a whole investigation like this in this committee. there is one group that we haven't heard from yet. i'm hoping -- >> we will. >> good. we haven't heard from the states yet.

it's critical we hear from them because that's where the rubber's hitting the road. we need to hear what the states are doing to address this problem and understand the reasoning between -- behind some of the choices being made. some states are picking effective treatment methods and others are not. so i think we need a multifaceted approach. this is what our research has showed. i know we can work together to continue this important investigation. i just want to add one more note, the witnesses and the audience may see members jumping in and running out. we have another hearing in energy and commerce committee going on down on the first floor. so people will be coming and going. but i know certainly from my side of the aisle, people recognize this as a very serious issue. thank you. >> and i know they'll be calling votes at 9:30. >> i thought it was 11:00. >> i'm here for the duration. so we want to hear from you.

and hopefully the members. now we recognize mr. upton. >> we really are going to have votes at 9:30? >> we are. >> i'm going to submit my statement for the record, then. yield back. >> all right. mr. pallone, five minutes. >> i'll do the same because we both have to go to the other hearing. >> see how much we get along? is there anybody else on either side that needs recognition? >> no, let's go into this. >> wait. mr. kennedy. >> mr. kennedy? >> he wanted a minute. can i -- mr. chairman, can i yield just one minute? >> yes, you can yield your minute to mr. kennedy of massachusetts. >> thank you very much for the consideration. i yield back. >> all right. let me now introduce the witnesses on the panel for today's hearing. we have the honorable michael botticelli, part of the executive office of the president, welcome. dr. frank, secretary for planning evaluation of health and human services dr. volkow

dr. douglas throckmorton, a deputy director of the drug evaluation for the food and drug administration, dr. debra houry, director of the national injury and prevention and control at the centers for disease control and prevention the honorable ms. hyde, and patrick conway, innovation and quality for medicaid and medicare services. welcome. you are aware that the committee is holding an investigative hearing and when doing so has a practice of taking testimony under oath. do you have any objection to testifying under oath? none of the witnesses are -- have objection. the chair advises you under the rules of the house and committee that you're entitled to be advised by counsel.

none of the witnesses say so. so in that case, please rise raise your right hand, i'll swear you in. do you swear that the testimony you're about to give is the truth, the whole truth, and nothing but the truth? >> yes. >> thank you. all witnesses answered in the affirmative. you are now under oath. and subject to the penalties under section 1001 of the united states code. you may all give a five-minute statement. please stick to the five minutes. if you don't have to fill it, that is ok, too. >> thank you, chairman murphy, member degette for the opportunity to provide testimony to you today about the administration's efforts to address the opioid academic in the united states. mr. chairman, as you recognized, in 2013, almost 44,000 died of a drug overdose. that's one death every 12 minutes.

using the rule as the coordinator of the federal drug control agencies, in 2011, we pursued the prevention plan to -- published the administration's prescription drug abuse prevention plan to address the sharp rise in prescription opioid drug misuse in this country since 1999. as you know, the plan consists of action items categorized under four pillars. education of patients and subscribers, increased prescription drug monitoring proper medication disposal and informed law enforcement. with the work of our hhs partners here today and other federal partners as part of the work group convened by ondcp, we have made some strides in each of these areas but there is much more to be done. since time and education programs devoted to the identification of treatment of substance use disorders is rare, we have worked with our federal partners to develop continuing education programs about substantial abuse, managing pain appropriately and treating patients using opioids more safely. many prescribers in federal agencies, including hhs, are receiving this important

training. despite this, a large percentage of prescribers have not availed themselves of this training. therefore, the administration continues to press for mandatory prescriber medication. -- prescriber education tied to can stroll that prescriber education tied to controlled licensure. i am pleased that secretary burwell has expressed her support to set requirements for specific training for opioid prescribers. today, all states but one, missouri, have prescription drug monitoring programs that allow prescribers to check on drug interactions as well as alert them to the signs of dependence on opioids. missouri is working to authorize that program. with all states implementing pdmp's, we are working on state-to-state data sharing within the health record system providers use every day. in october, the drug enforcement administration's final regulation on controlled substances disposal became effective.

ondcp and our federal partners and stakeholders have looked for ways to stimulate more local disposal programs in partnership with pharmacies, local government, community groups and local law enforcement. in the work of our law enforcement partners at the federal, state and local levels is ongoing. those engaged in fraud across the drug control supply chain are being investigated and prosecuted. recent data shows we are seeing an overdose from prescription opioids leveling off in this country but a dramatic 39% increase in heroin overdoses from 2012 to 2013. this is creating an additional need for treatment in a system where a well-known gap between treatment capacity and demand already exists. therefore, we must redouble our efforts to address people who are misusing prescription opioids since we know this is a major risk factor for subsequent heroin use. earlier this week, the administration held the inaugural meeting of a congressionally mandated interagency heroin task force. mary lou leery is one of the

co-chairs for this committee. in addition, the president's fy 16 budget request includes $99 million in additional funds for treatment efforts. we have also been working to increase access to the emergency opioid overdose reversal drug naloxone so witnesses can take steps to help save lives. many police and fire departments have already trained and equipped their personal with that their personnel -- already trained and equipped their personnel with this life-saving drug and loved ones with opioid drug abuse disorders are equipping themselves as well. while law enforcement and other first responders have an important role to play, the medical establishment must become more engaged to identify and treat heroin and opioid prescription disorders. every day these people appear in our emergency departments and other medical settings and more models and interventions are needed to get these individuals engaged their care. we need to extend availability

of evidence-based opioid treatment. medication assisted treatment combined with behavioral and other recovery supports have been shown to be the most effective treatment for opioid disorders. decisions about the most appropriate treatment options and their duration need to be agreed upon by both the patient and treatment provider. we must also provide community support, such as access to housing, employment and education to give patients the functional tools they need to lead healthier lives and integrate into the community as part of their recovery process. while we support multiple pathways to recovery, the literature shows that short-term treatment, such as detoxification alone, is not effective and carries risk of relapse and overdose death.

because of the lack of availability of evidence-based treatments and the strong connection between injection of opioid drugs and infectious disease transmission, we also promote the use of public health strategies that will help prevent the further spread of infectious disease. the hiv and hepatitis c outbreak in indiana is a stark reminder of how it can spread other diseases, how health strategies, such as syringe exchange programs need to be part of the response to the opioid epidemic and how rural communities, that have limited treatment capacities, may have additional public health crises. finally, we're addressing neonatal absence syndrome. research shows that the incidents of nas has grown five-fold between 2000 and 2012 and 81% of the hospital charges for nas were attributed to medicaid.

we must consider that the best interest of babies with nas is often served by best addressing the interests of the mother. therefore, we need to provide safe harbor for pregnant and parenting women seeking prenatal care and treatment. in conclusion, we look forward to, working with congress on the next stage of action to address this epidemic. thank you. >> thank you. dr. frank, we're going to try to get your testimony and then we'll run off and vote and come back. go ahead. dr. frank: chairman murphy ranking member degette and members of the subcommittee, thank you for the opportunity to discuss how the department of health and the department of health and human services is addressing the opioid abuse epidemic. the abuse and misuse of opioids and heroin is a high priority for the hhs leadership team and we're pleased to be with you today. i'd like to give you an overview and describe how we're working to develop a multifaceted solution to this problem. it's going to take a lot of collaboration. addiction to an abuse of opioids, including both prescription painkillers and heroin and the terrible outcomes associated with them are growing

at an alarming rate. just over a third of drug overdoses in 2012 and 2013 were from prescription opioids while heroin-related deaths have spiked dramatically, almost tripling since 2010. the sharp abuse places a burden on the health system. there were 259 million prescriptions filled for opioids in the u.s. in 2012. a large increase over just a few years prior. the medicare program under part d spent $2.7 billion on opioids overall in 2011. $1.9 billion, or 69%, was accounted for the top 5% opioid abusers. the cost of abuse and misuse of opioid shows up in preventable use of very expensive health care. heroin presents an equality troubling but different abuse in overdose pattern.

we saw increases between 2002 and 2009 in a number of people using heroin. but that number has held fairly steady since 2009. the striking new trend is that there's an increasing share of the users that are dying from heroin overdoses. so what i'm telling you is that we have an opioid prescribing problem sitting alongside a drug abuse and misuse problem. secretary burwell has committed to addressing the epidemic. she's driving us towards two main goals. one, reducing opioid overdoses and overdose-related mortality and, two, decreasing prevalence of opioid use disorder. she directed us to use the best science and to focus on the most promising levers that can make a difference for the people who struggle with opioid addiction and their families. hhs agencies have been collaborating on this problem for some time and we hope you will agree after today that the sum is -- that their hold is

-- that the whole is greater than the sum of the parts. our action informed by the evidence and discussion with states and other stakeholders fall into three general categories. one, addressing opioid prescribing practices, two expanding the use of naloxone and, three, promoting medication-assisted treatment. let me outline the plan in a bit more detail. first, pdmp's. we're increasing investments in prescription drug monitoring programs among the most promising clinical tools to curb prescription opioid abuse. we're investing through state grants and technical assistance in supporting best practices to maximize the impact of pdmp's. second, naloxone, a life-saving drug that can reverse overdose from both prescription overdoses and heroin. we are working with state and local governments to support training and other measures that get naloxone into the hands of those that are in a position to reverse overdoses.

finally, we have plans to support the appropriate use of medication-assisted treatment, or m.a.t. the enactment of the addiction equity act opens new opportunities to expand access to these evidence-based treatments. we also are working on identifying best practices in primary care settings, increasing access to m.a.t. through grant support and potentially increasing the supply of m.a.t. providers by reviewing the policy and regulations of one of the types of the individuals certified to prescribe. our commitment to halting this complex public health epidemic is set out in the president's 2016 budget that includes a $99 million increase for parts of our initiative. finally, evaluation will help us identify the most effective activities, allow us to continually learn and in order to address this public health concern. in closing, this is critical for hhs and for the nation and with

-- we can't do it alone. we need help. thank you for encouraging an open discussion of this today and we are committed to turning the tide on the opioid epidemic. >> thank you. now, votes are in progress. even though time is running out, only about 20 people voted so far. so this is throwing everybody off and their schedules. i apologize. this is what happens on capitol hill. but we're committed to hear from you. we know how important this is and we value your testimony. so we're probably going to be back in a little under an hour. so we look forward to hearing from you then and getting to the rest of the testimony. thank you.

chairman murphy: all right. thank you for being patient. all right. dr. volkow, you're recognized for five minutes. dr. volkow: good morning chairman murphy, ranking member degette and other members of the subcommittee. i want to thank you for organizing and inviting me to participate in this important hearing. the known use of prescription pain relievers is a public

health challenge and demands solutions on the one happened to -- on the one hand, to prevent their diversions and the misuse while at the same time demands solutions that will not jeopardize access of these medications for those that need them. opioid medications are probably among the most effective painkillers that we have for the management of acute, severe pain. and the proper use can actually save lives. they act by activating opioid receptors that are located in the areas of the brain that persist pain but very high -- that perceive pain, but they have very high concentration of opioid receptors in brain regions and hence the problem. activation of these receptors is what is associated with the addiction potential. there are also high levels of receptors in areas of the brain that regulate breathing, which is why their use is associated also with the high risk of death from overdoses.

we have heard that devastating consequences from the escalation of the abuse of prescription medications in our country, the overdose deaths, the transition to injection of heroin and associated infections with hiv and hepatitis c and increasing numbers that we're seeing on the neonatal abstinence syndrome. the role is to support the research that will help develop solutions to prevent and treat abuse of prescription medications that could be implemented now while at the same time funding research that, in the future, will provide transformative solutions. there are already evidence-based practices that have been shown to be effective in the prevention of overdose deaths. that include the use of medications for opioid addiction and the use of naloxone to reverse opioid overdoses.

there are three medications currently available to treat opioid addiction, methadone and others which when used as a treatment plan have been shown to facilitate abstinence and reduce overdose and hiv infections. also, when coupled to prenatal care pregnant women addicted to opioids, these medications reduce the risk of obstetric and neonatal complications. yet, despite the strong evidence, less than 40% of those receiving treatment for opioid addiction get treated with this medication. the funding research on strategies that facilitate the use of medications for opioid addiction in the health care system. another key component to reduce overdose deaths is to expand the use of naloxone so they have

partnered with pharmaceutical companies to develop user friendly effective delivery systems for naloxone that will facilitate their use by those that have be a loosely no -- absolutely no medical training. in addition, neither supports research on the treatment of pain and on the treatment of opioid addiction, they will offer new solutions for the treatment of these two disorders. examples -- for example, for the management of pain, including the development of drug combinations or new formulations with less addiction potential. the development of analgesics that do not rely on the opioid system. and the development of nonmedication interventions, such as the use of magnetic or electrical brain stimulation for pain management. examples of research on the treatment of opioid addiction includes a development of slow-release formations that need only once or once every six

months dosing that would work with vaccines against heroin which will prevent the delivery of the drug into the brain hence interfering with the rewarding effects and reverse -- adverse consequences. because the epidemic of prescription drug abuse results from a lack of knowledge from health care provider, the importance of developing curriculum to train both in pain and substance abuse disorder is a priority which neither has developed in partnership with the other institutes, nih centers of excellence. there are over 24,000 deaths from opioid overdoses in 2013. 24,000. this highlights the urgency to address this epidemic. solutions are already available. the challenge is the implementation. this requires strong integration of efforts and neither will continue to work closely with other federal agencies

community organizations and private industries to address this complex challenge. >> thank you. dr. throckmorton, five minutes. >> mr. chairman, ranking member degette and members of the subcommittee, thank you for the opportunity to be here today to discuss fda's role in combating opioid abuse. our goal is to find the balance between needing to treat patients with pain, and needing to reduce drug abuse and this work is being done to address other parts of the federal government and we know a successful and sustainable response must include federal and state government, public health officials, opioid subscribers and researchers and -- opioid prescribers, addiction experts, researchers and

manufacturers and patient organizations. for our part, fda plays a central role in the regulation and use of drugs from their discovery and throughout their marketing. for example, when fda reviews a drug for possible marketing, we also approve drug labeling which includes approved uses of the medicine and as well as information about the safety risks. fda also follows drugs after they are marketed carefully, including opioid drugs, when necessary, this enables us to take a variety of actions to improve their safe use, such as changes to approve labeling. the first area of fda activity i'd like to highlight is our work to support the development of abuse that make it is harder or less rewarding to abuse. while this is not a silver bullet that will prevent all abuse, fda believes it can help reduce opioid abuse. to incentivize this, fda issued to meet with sponsors interested in developing them. to date, the fda has received

some 30 investigation new drug applications from manufacturers. in addition, we have approved four opioid drugs with abuse deterrent claims in their labeling. overall, we are in the early stages of their development and i am encouraged by this level of work. fda envisions a day not far in the future where they are an effective abuse-deterrent forms. next, with regard to prescribing opioids, we know they are critical medications and they have to have high-quality education. over the past several years, the fda has done several things to improve educational materials on opioids. for example, we recently finalized required changes to approved labels of the extended release long-acting opioids, changing their indication to inform prescribers that these drugs should only be used for pain severe enough to require daily around-the-clock treatment when alternative treatments would not work. at the same time, fda

strengthened significantly the warnings on these opioids. we want prescribers to use them with care, and today it's among the most restrictive of any drugs that we have in the center and have clear language that calls attention to the potentially life-threatening risks. the fda is working to improve the information available for prescribers in other ways. under certain circumstances, fda can require manufacturers as a part of the risk evaluation and mitigation strategy to address safety concerns such as opioid abuse. in 2012, fda required manufacturers to fund the development of unbiased continuing education programs on opioid prescribing practices for prescribers. in the first year since that program has been in place, approximately 6% of the 320,000 prescribers, around 20,000 prescribers have completed one of those courses. we believe this training for

prescribers is important. we also support mandatory education for prescribers of opioids as called for by the administration in the 2011 prescription drug abuse plan and re-empathized in the 2014 drug-control strategy. finally, fda has been working with many other stakeholders including the agencies here today, to explore the best ways to prevent overdose deaths by the expanded use of naloxone. as others have said, it can and does save lives. fda is working to facilitate the development of naloxone formulations that could be easier used by anyone responding to an overdose. first, fda meets with manufacturers whenever needed and is using whatever tools we can to expedite product development. we approved the formulation of naloxone, which is intended to be a administered by people witnessing an overdose such as family members and caregivers. we've approved this product in 15 weeks. going forward, we will work on

how best to use naloxone, and the fda and many other agencies are planning a public meeting in july to deal with questions of access and state and local best practices. in conclusion, as a society, we face an ongoing challenge and a dual responsibility. we must balance efforts to address opioid drug misuse abuse and addiction against the need for access to appropriate pain management. these are not simple issues and there are no easy answers. the fda is taking important actions we hope will achieve this balance. we welcome the opportunity to work with congress, our federal partners, the medical community, advocacy organizations, and the multitude of interested communities and families to turn the tide on this devastating epidemic. thank you for this opportunity to testify. i look forward to answering any questions that i can. murpchairman murphy: dr. houry.

dr. houry: chairman murphy ranking member degette, i'd like to thank you for inviting me here to discuss this very important issue. i'd like to thank the committee for opioid prescription abuse. i'm the director of the national center prevention and control at the cdc. as a trained emergency room physician, i have seen firsthand the devastating impact of opioid addiction on individuals and their families as well as the importance of prevention. together, we have witnessed a deadly epidemic unfolding in states and communities across the country. the overdose epidemic is driven in large part by fundamental changes in the way that health care providers prescribe opioid pain relievers. enough prescriptions were filled in 2012 for every american adult to have their own bottle of pills. as the amount increased, so has the number of deaths. in alignment with the department initiative, i want to highlight cdc's work in developing opioid prescribing guidelines for

chronic pain and providing direct support to states to implement multisector prevention programs. cdc is currently developing guidelines for prescribing of opioids for noncancer pain. this undertaking is responsive to a critical need in the field. these new guidelines will redefine best practices for chronic pain and make important advances in protecting patients. the audience for these guidelines are primary care practitioners, who account for the number of prescriptions for opioids compared to other specialties. the guidelines process is under way and our goal is to share public comment by the end of this year. we have plans in place to encourage uptake and usage of the guidelines among providers which is key for prescribing practices. the second activity i'd like to highlight is our major investment in state level prevention. states are at the front lines of this public health issue. and cdc is committed to

equipping them with the expertise they need to reverse the epidemic and protect their communities. utilizing the newly appropriate $20 million, we recently published a new funding opportunity called prescription drug overdose prevention for states. it builds upon existing cdc-funded state programs and targets states that have a high drug overdose burden and those that demonstrate readiness needed to combat the epidemic. it requires collaboration across sectors for a truly comprehensive response. the goals for this program are to make prescription drug monitoring programs more timely, easier to use and able to communicate with other state pdmp's. to implement medicaid or workers compensation prevention and data driven prevention to the community struggling with the highest rates of drug abuse and overdose, states also will be given the flexibility to use the program to respond to emerging

crises so they know what works to prevent overdose and save lives in their community. the development opioid prescribing guidelines and our state prevention program are two key ways that cdc's broad work contributes to the initiative. we're examining overdose heroin which have more than doubled since 2010 and prescription opioid abuse, a key risk factor for heroin use, has contributed significantly to this rise in heroin use and overdose. we will leverage our scientific expertise to improve public health surveillance of heroin and evaluate effective strategies to prevent future heroin overdoses. addressing this complex problem requires a multifaceted approach and collaboration among a variety of stakeholders. but it can be accomplished. particularly with the ongoing efforts of all of the organizations represented here on this panel. cdc is committed to tracking and

understanding the epidemic supporting states working on the front lines of this crisis and providing the tools and providing the tools and guidance they need. thank you again for the opportunity to be here with you today and for your continued work and support of us protecting the public's health. i look forward to your questions. chairman murphy: thank you doct or. ms. hyde? ms. hyde: good morning, chairman murphy, ranking member degette. thank you for inviting samhsa to be part of this hearing. according to samhsa's national survey, the nonmedical use of prescription opioids is high, approximately 4.5 million individuals in 2013. heroin use is much lower, about 289,000 individuals reporting

past month use, but that's doubled in five years. fortunately, the nonmedical use of pain relievers has decreased some from 2009 to 2013 especially among young people ages 12 to 17. however, as you know, overdoses and overdose-related deaths from prescription drugs and heroin has risen dramatically among all ages. few who need treatment are receiving the community-based services that they need to live free of addiction. samhsa believes recovery is the goal. the data and public education and regulatory efforts are all designed to prevent overdoses help provide the treatment and services needed for people with substance abuse disorders to achieve recovery, support their families, and foster support of communities. samhsa together with six other medical societies funds to train prescribers with the best approach to pain management. the addiction technology

transfer centers provide training and materials on opioid abuse disorders to distribute research-based best practices to the treatment field. to help prevent opioid-related deaths, the funds may be used to purchase and distribute naloxone and increase training on its use. also, in 2014, they updated their opioid overdose prevention tool kit to educate individuals, families and first responders and others about steps to prevent and reverse the effects of opioid overdoses, including the use of naloxone. this tool kit is one of the most downloaded resources on the website. the president's 2016 budget includes $12 million in discretionary grants for states to deliver naloxone in high-risk communities and support education for overdose prevention strategies. as part of a recovery-oriented

care model, medication-assisted treatment is not meant as a stand alone approach but rather is designed to include medication, counseling behavioral therapies and recovery supports. in march 2015, samhsa revised guidelines for opioid treatment programs which highlight the care model and encourage the use of any of the three fda-approved medications for the treatment of opioid abuse disorder based on an assessment of the needs. they are taking an integrated care approach as part of the new 2015 grant program to expand and enhance the availability of medication assisted treatment and other clinically appropriate servcies in states with the highest rates of opioid admissions. the president's 2016 budget proposes to double this program. in collaboration with doj, samhsa added language to the 2015 grant requirements to make sure that drug court clients do not have to stop the prescription as part of a

regulated opioid treatment program. samhsa regulates the treatment programs which are expected to provide a full range of services for their patients. in collaboration with a drug enforcement administration samhsa provides waivers for treatment in a practice setting other than in an opioid treatment program. samhsa funds efforts to help prevent prescription abuse and heroin use. for example, in 2014, samhsa strategic framework partnerships for success program made preventing and reducing heroin use one of its focus areas along with prescription drug misuse and abuse and underage drinking. for 2016, the president has proposed $10 million for the framework rx to help states use data, including pdmp data, to

identify communities and assist the nonuse of drugs. we want to thank you again for taking on this issue and allowing samhsa to share its efforts with you and we look forward to answering your questions. chairman murphy: dr. conway, you're recognized for five minutes. dr. conway: chairman murphy and ranking member degette and members of the subcommittee, thank you for inviting me to discuss the situation preventing prescription drug abuse. as we heard from other witnesses, they have been implicated in drug deaths in the last decade. as a practicing physician, i understand the importance of this issue. cms recognizes our responsibility by ensuring appropriate safeguards are in place to prevent overuse. ensuring they can access needed medications and treatments for substance abuse disorder. since its inception in 2006, medicare part d prescription drug benefit made medicines more available and affordable

leading to improvements in access to prescription drugs. despite these successes, part d is not immune from the nationwide epidemic of opioid abuse. cms has broadened its focus to address potential fraud by making sure they have coverage for drug therapies that meet safety and efficacy standards. we believe that broader reforms will protect beneficiaries of damaging effects associated with prescription drug abuse and to prevent and detect overutilization. the strategy is to monitor part d drug utilization management programs to prevent overutilization of these medications. to accomplish this goal, the medicare part d overutilization monitoring system or oms was implemented in 2013. through this system, cms provides reports to sponsors on

beneficiaries with potential opioid overutilization identified through analysis of prescription drug event data and through beneficiaries for the cms program for integrity. sponsors are expected to utilize various drug utilization monitoring tools to prevent continued overutilization of opioids. from 2011 to 2014, oms has reduced users by 26%. they use medic, charged with investigating fraud and abuse, developing cases for referral to law enforcement agencies. in 2013, cms directed the medic to increase its focus and address drug analysis. creating new tools against problematic prescribers and pharmacies. we finalized a provision that requires providers to enroll or

have an opt-out affidavit on file and establishes revocation authority for abusing prescribing patterns. state medicaid agencies have taken action to attack that epidemic. efforts include expanding medicine benefit to include behavioral health service for those addicted to drugs and pharmacy management review programs. cms are encouraged by states effected strategies tore designing benefits for the population. we launched the accelerator program to provide states with technical assistance and other support to address this important issue. cms, in coordination with cdc and nih, issued informational bulletins on medication assisted treatment for substance abuse disorder in the medicaid program. it outlined that medication and behavioral therapies is the most effective combination of treatment. we issued a similar bulletin focused on these services in pediatric and youth population.

cms is dedicated to providing the best care to beneficiaries with opioid addiction. working with state medicare programs to implement safeguards to prevent the abuse and treat them effectively. cms has made progress but there's more work to be done. cms is taking interventions to reduce the addiction and overdoses and medicare and medicaid. previous testimonies i have never had family here or time to thank them. i want to thank my mother, diane conway is here, my son jack who is out of school as well as my wonderful wife, heather, daughters alexa and savannah. and without their love and support, i would not be able to work on issues like this. they're critically important to our nation, so thank you. chairman murphy: thank you, doctor, thank you for recognizing to take your family to testifying day. apparently everybody else didn't get the memo.

i just want to start by saying if talent and dedication alone could solve this crisis, we'd be there with the testimony of today and other days. obviously we still have problems. let me start by asking a few questions. for the director, office of national control policy uses the term recovery, does it mean to include patients with opioid addiction in buprenorphine or methadone treatment program still using heroin or illicit drugs or would you say that's not recovery? dr. botticelli: from our perspective and as a person in recovery, clearly we want to make sure that people are continuing to progress in recovery, free from substances is the ultimate goal of recovery programs. i think everyone would agree on that. we also know that substance use, particularly opioid use disorders, are a significant chronic disorder, and that

oftentimes and even my own experience show me that people often will experience relapse and will often need multiple attempts at treatment to get to that final goal of long term recovery and long term abstinence. we want to make sure we are continuing to engage with patients, that we are moving them toward better health, better recovery, and being free from substance use as part of long term recovery. chairman murphy: >> let me ask this, we heard last week there was not uniform definition of recovery. this is the talent pool, you're the ones that do these. do you all meet on a regular basis to talk about these issues? when was the last time you got together to talk policy issues pam? dr. botticelli: let me start. it is actually part of our statutory authority that we set in conjunction not just with hhs, but all federal agencies that have a role in substance use and opioid use disorders. we have been engaged with dod, v.a., bureau of prisons.

chairman murphy: you meet regularly? dr. botticelli: we do. we have quarterly meetings. chairman murphy: let me move on that, too. that's important. miss hyde, let me ask you in response to our bipartisan letter of march 18th concerning the national registry of evidence based programs you noted that, quote, new submission and review procedures will improve rigor of registry and bring into closer alignment of other evidence based programs in the federal government. prior to entering into the july 2014 contract, did samhsa feel it needed strengthened? yes or no. do you feel it needed to be strengthened? ms. hyde: thank you for the question. we thought the process we used for determining what practices were reviewed needed to be strengthened, and in the process we have also increased the rigor with which we look at them. chairman murphy: can you give us a list of what you consider to

be models in the federal registry we can review as part of that, as evidenced based programs? ms. hyde: certainly. chairman murphy: thank you. your response also indicates an outside contractor will assume role of gate keeper determining which studies and outcomes are reviewed in the screening and review of an intervention with aim of preventing bias in favor of the intervention developers. was samhsa's prior system for selecting interventions prone to any kind of bias or conflict of interest, was that a concern? ms. hyde: yes, mr. murphy, it was a concern. it was pretty much developer driven so a developer had to want their practice to be reviewed. then they had some control over what research we looked at. we changed that with the new contract which began last year and we will help decide priorities together with public input, but the contractor will help us look more objectively at evidence. chairman murphy: thank you.

i just pulled up here -- i got a note, an article, is this one of your constituents from eastern colorado? i don't want to take your colorado thunder, a fascinating article. it made reference to the increase use of emergency departments with opioids. they said that's 10.5 million with this is probably an underestimate, that people go to emergency rooms for treatment for withdrawal, but also many trying to get more opioids. -- opiates. when you have users with prescriptions from more than one physician, they're more likely to be involved in riskier practices. i am wondering if any of you comment on that's an area we are addressing? some of you comment on the issues? dr. volkow: .

>> yes, the article, referring to new england journal of medicine article that shows there's been a very significant quadruple number of cases in intensive care units. this does reflect the fact that there are many women being prescribed opioid medications during the pregnancy itself, and based on another study was estimated 21% of women that are pregnant are going to receive an opiate medication, which again highlights the need to enforce bertha guidelines on management of pain need to be enforced in better ways. there's a study that evaluated the extent that physicians are following guidelines by the main medical organizations as relates to management of pain. that's an area where there needs to be an aggressive increase in education and enforcement of guidelines. chairman murphy: thank you. i am out of time. i ask unanimous consent to

submit this for the record. ms. degette? ms. degette: thank you, mr. chairman. doctor, as i mentioned in opening statement, you're one of the world's top experts on the issue of treating addiction. briefly, what does the body of scientific evidence show regarding effectiveness of methadone and buprenorphine in treatment of opioid abuse disorders? dr. volkow: the research has shown, has shown it not just for methadone and buprenorphine, and naloxone, as part of a comprehensive program for program for treatment of opiate addiction are quite effective and significantly improve outcomes of individuals being able to stay on one hand abstinent from the drug or to decrease likelihood of relapsing, also protects them against adverse outcome such as overdose. ms. degette: so in light of

those studies you also said in your testimony that existing evidence based prevention and treatment strategies are highly underutilized across the united states, and last week we had an expert tell our panel that very few patients with opioid addiction today receive treatments that have been proven most effective. he was talking about this rapid detox, followed by abstinence- based treatment. i wonder if you can help understand this. why do we have a situation where people are not getting evidence based treatment? dr. volkow: it is a complex problem. there are many reasons they're not getting correct treatment, including the fact of education of proper management of substance abuse disorder, including the health care system.

then you have an infrastructure because addiction is sigma -- stigmatized, therefore likelihood of people accessing that care is much lower, then of course there's a difference between states in the way they implement treatment, so all of these factors account for the current situation. ms. degette: dr. frank, do you have anything to add to that? dr. frank: yes, i do. i think one thing that's very important to remember is that overall we treat 10% of the people with these disorders. so it is not surprising that people aren't getting evidence based treatment because they're not getting treatment, period. second part is, why aren't they getting evidence-based treatment among those that do? and i think that there are insurance dynamics that hopefully we are fixing. there are access to trained professionals who are trained in these things, and then in a sense trying to kind of get the systems and infrastructures aligned to support the best

practices. ms. degette: and dr. houry, several of our witnesses including you, mentioned that role of the states in this. can you talk about that for a minute? dr. houry: absolutely. i think states have different populations, different issues, different prescription drug monitoring programs and so tailoring for states, so they can best identify, state medicaid program or other high risk patients, that's why the program at cdc is helpful, we are a higher level view to work across states. ms. degette: and do you think the states have work to do in terms of implementing these programs that are science based and that work? dr. houry: you know, i think we are starting to do that. like our program itself has only been in existence for six months but we are seeing great progress. if you look at policies states are implementing, we are seeing

reductions in doctor shopping, patients going to different doctors because of utilizing prescription drug monitoring programs. although it is early in the stage, i am optimistic we are making progress in the states. ms. degette: dr. volkow, i want to come back to you. another expert last week said patients and their families need to know detox i have indication and drug free counseling are associated with a very high risk of relapse. i am wondering if you can tell us what the science shows. is this type of treatment generally effective or less effective? sniff what is does the research show? dr. volkow: the research has shown that in general it is associated with increased mortality. this reflects the fact that addiction is a chronic disease, and changes in the brain persist months, years after you stop taking the drug. what they do is remove the

physical dependence and assume the addiction is cured and these are two independent processes. as a result, the patient feels they're safe and then they relapse because they're still addicted. ms. degette: thank you. thank you very much, mr. chairman. mr. chairman murphy: i recognize mr. collins for five minutes. >> mr. collins: thank you, mr. chairman. this is truly a fascinating topic we are discussing and it is obvious there's no easy solution. we heard it is a chronic disease, 10% are seeking treatment. i guess my question for miss hyde and samhsa is certainly with pregnant women that may have young kids at home, inpatient treatment might be the preferred, we just can't let perfect be the enemy of good.