senator grassley: the procedure

will be that i'll make an opening statement. senator leahy will. d then we'll go to the order that we have established as you see people sitting at the table there. i'll introduce the senators and senator leahy will introduce the governor. america is experiencing an historic epidemic of drug overdose deaths. over 47,000 died from overdoses in 2014. that's an all-time high. to put this in perspective, it's more deaths that resulted from either car crashes or gun violence. addiction to opioids, primarily prescription painkillers, and heroin, is driving this epidemic. it is destroying lives, families and the fabric of entire communities. it's something that i'm hearing

about in iowa. of course, other parts of the country have been hit even harder. at today's hearing, the committee will learn more about this terrible epidemic, what's being done to address it and how congress can help. the committee looks forward to learning more about the comprehensive addiction and recovery act, which is the result of the leaderships of senators whitehouse, portman, colin powell char, ayotte -- klobuchar, ayotte and over the years, doctors have prescribed opioids to help thashe patients manage pain. for many, these medicines have been the answer to their prayers, but for others they have led to a nightmare, a nightmare of addiction. the new england journal of medicine estimated that over 10 million persons reported

abusing prescription opioids at some point in 2014. the emergency room visits involving the misuse of the prescription opioids increased over 150% between 2004 and 2011. treatment admissions linked to them more than quadrupled etween 2002, 10 years later, 2012. the use of heroin has also spiked sharply. the national survey on drug use and health reports over 900,000 americans used heroin in 2014, nearly a 35% increase from the previous year. heroin deaths more than tripled between 2010 and 2014. in 2007, only 8% of state and

local law enforcement officials across the country identified heroin as the greatest drug threat. now, this year -- last year that number rose to 38%, more than any other drug. according to numerous studies, prescription opioids addiction is a strong risk factor for heroin addiction. in some cases, those addicted to painkillers turn to heroin to get a similar high because recently it's become cheaper and more easily available. now, very important question -- why has cheap heroin begun flooding into our communities? well, mexican cartels are expanding into territory because the administration hasn't secured the border. indeed, heroin seizures at the border have more than doubled

since 2010. the senate caucus on international narcotics control, joined by our colleague senator ayotte, sought accountability for this alarming development at a hearing in november. so this is a complex crisis requiring a multifaceted solution. the first and most important head ust be prevention to off addiction before it can even begin. prevention includes educating the public about the dangers of these substances, including through the important work of anti-drug coalitions. it also includes educating doctors, taking a hard look at perverse incentives that may lead to overprescribing. for example, a few weeks ago, senator feinstein, ayotte and i wrote to h.h.s. to seek a progress report on a federal review exploring whether patient satisfaction surveys

linked to higher medicare payments actually encourage doctors to prescribe opioids. many people who abuse prescription drugs get them from friends or relatives. so prevention always -- also involves support for initiatives that allows patients to safely dispose of old or unused medications. so that brings me back to something i was involved in to have -- to help start these takeback programs by working with senators klobuchar and cornyn in 2010 to pass a secure and responsible drug disposal act. and i was pleased when d.e.a. acting administrator rosenberg voiced his support for them very recently. at the same time, it's concerning that this administration is muddling prevention efforts by sending mixed signals to young people about the danger of addiction

to marijuana. the president has even excused smoking marijuana as just another bad habit, and the department of justice continues to decline enforcing our federal drug laws in this area. but young people don't need increasing access to another potential pathway to addiction. according to c.d.c. report, a person who is addicted to marijuana is three times more likely to be addicted to heroin. another part of the solution needs to include better treatment options for those who become addicted. the use of medication assisted treatment appears to show promise, so along that line, overdose deaths may be reduced by the more widespread use of naloxin, a drug proven highly effective in reversing

overdoses. and finally, law enforcement will play a very critical role. we can't arrest our way out of this epidemic, but we can continue to crack down on unlawful prescribing practices, enforce our border with mexico and target the violent cartels that are trafficking heroin in this country. so i get back to something else a member of this committee and i have been involved in. senator feinstein and i introduced the transnational drug trafficking act of 2015. our bill would make it easier for the department of justice to prosecute cartels who harm our communities from abroad by trafficking heroin, other drugs and precursor chemicals, the ultimate delivery for -- for ultimate delivery here in the united states. in october, our bill passed the

senate for the third straight congress by unanimous consent but hasn't found success in the house, so it's critical that the representatives finally pass this legislation which will help protect our communities from transnational drug trafficking threats. so i'm finished. i welcome our guests, and i'll introduce them. i now turn to senator leahy. senator leahy: well, thank you very much, mr. chairman. i think you look around this committee, republicans and democrats, from representing all parts of the country, we know in our communities, whether they're urban or local, no matter what their size, they're grabbling with the tragic effects of the epidemic of heroin and prescription opioid abuse. we've all see the statistics. i tell you one thing about the dramatic rise in overdose

deaths, particularly among young people, but go behind the numbers, as i have, governor shum lynn and our state has, eric miller, our u.s. attorney has. and behind the numbers you see the human impact of this epidemic. families trying to find the treatment for a loved one hooked on painkillers, children neglected or left behind by an addicted parent, victims of crime fueled by addiction, law enforcement community officials overwhelmed by the flood of opioids and cheap heroin. my wife is a retired registered nurse. she and i sat around some of the kitchen tables in vermont, and our governor knows some of these locations. some of them are very affluent areas and some of them are very poor areas. but the stories we have heard from families and parents --

and we've gone there just ourselves. no press, nobody else. just wanted to talk to these people. we had a couple times we have driven away, we were both in tears what we heard. these are human stories. go way beyond the statistics. so it's not a question of whether there is an epidemic. the question is, what do we do about it? like many other states, we have not been immune to the scourge in vermont, but in following what we normally do in vermont, we rallied together to tackle the problem head on to community-based and comprehensive strategies. that makes me proud to be a vermonter. we heard testimony about a number of these innovative approaches during a series of field hearings. i convened during the past several years in vermont. in one city, in rutland they went to the mayor, strong republican, i might say, and they said, do we want to talk

about this in our cities? and we said, we want to talk about it. and we had to keep changing the venue because more and more people wanted to come. we had city officials, their project vision, city officials, law enforcement, residents and we heard from all of them knowing that this is not just a law enforcement and it's not just a medical profession. we had the faith community, parents, educators, they're all in it together. the boys and girls clubs throughout vermont are working with schools and public health officials to help children who re swept up by this. from all of my conversations with vermonters from law enforcement down through, we cannot arrest or jail our way out of this problem. we've lost the war on drugs because we relied primarily on unnecessarily harsh sentencing laws. can't repeat these mistakes

of the past. we have to work on the demand. we can close everything -- let's assume we can close everything coming from mexico. if we have demand in this country, it will come from somewhere else. the -- so long as we have people who spend the money who want to buy the opioids, who want to buy the heroin, it will come here. i don't care which border we close, it will come here. so we've got to stop the demand. we have to identify and support effective prevention treatment and recovery programs, and we can't just pay lip service to our communities. after the field hearing i convened in rutland, i asked for a new federal grant program for treatments of heroin and opioid abuse and help to get more funding for law enforcement to go after the drug traffickers in vermont we've seen an 65% increase in the number of vermonters getting treatment for their addiction in the last couple years, and governor, i thank

you for that. it's great progress, but we know on any given days, there are hundreds more that find themselves on waiting lists. other patients of rural corners of my state travel hours just to get their medication. so i see senator shaheen. i co-sponsored her supplemental appropriations bill to fund additional public health outreach and treatment and recovery and law enforcement efforts. i'm proud to co-sponsor the comprehensive recovery act. the committee will report that bill soon. we can talk about it, we can have bills, we can have the tions, let's spend money. spend the money for things outside of -- let's not spend the money for things outside our country. we should spend money within our country. this is dangerous. i will close and thank governor shumlin. he's been a national local leader on this issue.

and a lot of people want to pretend we didn't have the problem. the governor gave in his state of the state address in the past -- instead of saying everything is great, as most do, he talked about this problem. that was his whole issue. boy, the reaction around our state and around the country was saying, it's about time. it's about time somebody speaks up. senator grassley, i thank you for convening this hearing, but we have to find comprehensive and enduring solutions. the federal government will do its part to provide the resources to support it. that's important. but we have to act. we're not going to arrest our way out of this. everybody in law enforcement knows that. we're not going to do it simply by saying, let's close a source from one country because it will come from another country. we've got to attack and work and do all the comprehensive programs in the faith

community, the educators, law enforcement, parents, medical facilities to stop the demand. until you stop the demand, we'll always have the problem. thank you. senator grassley: why don't you continue your introduction of the governor, if there's anything else you want to say at this point. senator leahy: go ahead. and i will introduce him. senator grassley: obviously when you're introducing colleagues like i'm doing, you know an awful lot about them that ought to be said. you have to kind of keep -- senator leahy: can't do that. senator grassley: so -- but i can say all of them are extremely dedicated to fighting the opioid epidemic sweeping their communities, and i'm grateful that they're all interested in this and that they've been asking me to move along with this hearing and i think from initial discussions with members we believe both

from a cost standpoint and from a substance standpoint we might be able to move ahead. at least i hope that's the outcome after i talk to all my members. our first witness is senator ayotte of new hampshire. she is co-author and original co-sponsor of this bill, s. 524, the comprehensive addiction and recovery act. she's a former prosecutor and attorney general, was one of the leading voices in congress seeking solutions to opioid epidemic. our second witness, senator shaheen, also from new hampshire, she is also co-sponsor of kara and have been highly effective leader on the issue. new hampshire's fortunate, obviously, to have two senators working across the aisle on this very important crisis issue. next, senator rob portman from hio co-author and lead

republican sponsor of cara. he's worked in bringing awareness to this epidemic throughout the state and has long been a champion of the anti-drug initiative, including the drug-free community act, and also probably 20 years ago came to my state to help me with a nonprofit organization that i started in had my state as well. so our relationship on this issue goes back a long, long time. and now it's your opportunity on the governor. senator leahy: well, peter shumlin has served as governor of vermont since 2010. a small business owner, public servant, father of two from put knee, vermont. two wonderful young women. he's a committed entrepreneur. he's a longtime code director, along with his brother, of put knee student travel national geographic student expeditions. your brother told me at the opening of the session, he's

counting the days to get you back there in the company. the company sends students on educational programs and service projects across the globe. partner with several real estate companies to provide space. southeast vermont. i've known him forever, it seems. his public service began 30 years ago at the age of 24. in 1990, governor appointed him to fill an empty seat in the vermont house of representatives. he served for eight years. he was elected by his colleagues, rrps and democrats alike, to lead the senate as president pro term. he's the 81st governor of vermont and is a very close personal friend. senator grassley: thank you, all, very much. and we'll do it in the order that i introduced you. so it will be senator ayotte, senator shaheen, senator

portman and then governor shumlin. go ahead, proceed. senator ayotte: thank you, chairman grassley, leab leahy, members of this committee -- ranking member leahy, members of the committee. thank you for having this hearing today, because it's the most urgent public health and safety crisis facing my home state of new hampshire. and having served as the attorney general of our state, i can assure you i have never seen anything like this in terms of the epidemic that we are facing. so the timing of this hearing could not be more important. i'm very honored to be here with my colleague, senator shaheen. in the fall we held a hearing, a field hearing of the homeland security committee and heard from people in new hampshire, but we also heard from director ticelli, who has worked with new hampshire. i want to thank senator shaheen. i'm very honored to be here with governor shumlin who has

been a real leader in vermont, a neighbor of our state, and had an important keen work on this issue. and senator portman has been a leader on the comprehensive addiction act. he started his anti-drug coalition in ohio. he's also led the effort when he was in the house of representatives to pass the drug-free communities act, and now working with senators klobuchar and whitehouse, i was proud in september, 2014, to introduce the comprehensive addiction and recovery act. i want to thank the members of this committee who are sponsoring this act. certainly ranking member leahy, senator hatch. i know senators blumenthal and i also want to thank senator donnelly for the work we have done on legislation together on this important issue. today you will hear in the third panel from the police chief, nick willard from

manchester, new hampshire. he'll talk about the epidemic facing our state, how we can address this together, both law enforcement working with those in prevention, treatment and recovery. and i had the preverage of doing a wide -- privilege of doing a ride-along with the manchester police department and i also did one with the manchester fire department. i was there an hour and a half, we went to two heroin overdoses within an hour and a half. i can assure you, this is hitting every family in some way in new hampshire. i watched our first responders bring people back to life with narcan. but for them being here and having this life-saving drug, they would have died. and it's just really struck me how devastating this is because one of the cases i went to, there was a baby in a crib in the corner. so when we think about this, this is not just the impact of those struggling with addiction. it's the impact on all of our quality of lives and, of course, on the future for our

children. in new hampshire in 2014 we had 320 drug overdose deaths. that was a 60% increase from the year before. this year our chief medical 148 ner tells us that 385, of those deaths are also attributed to a devastating drug called fentanyl which d.e.a. tells us is 50 times more powerful than heroin and that's an issue which i believe needs to be addressed by this committee as well. solving this crisis requires a wholeistic approach and the comprehensive addiction and recovery act that so many members -- and i really appreciate the leadership on this committee on this act -- is critical i believe. we brought together over 120 stakeholder groups around the country to put this legislation together. those who are on the front line in every aspect.

it has the endorsement of the national district of attorney -- attorneys association, the major county this was association, the community anti-drug coalitions of america and the national associations of attorney general. i would note, by the way, my attorney general from new hampshire has endorsed it. the iowa attorney general has endorsed it. the vermont attorney general has endorsed it, and many of the attorney generals have said, please pass this legislation. it expands opioid abuse and prevention and education efforts. the chairman is right, we've got to get into the schools. we got to get the prevention focused on opioids, prescription drugs and also heroin. expands the availability of narcan to first responders and law enforcement. supports additional resources to identify and treatment incarcerated individuals so we can end the reinvolving door we see in our prisons -- revolving

doors in our prisons. disposal of unused prescriptions. strengthens prescription drug monitoring programs. and we can administer narcan and our first responders are doing an amazing job of bringing people back to life, but if we don't get the support of those dealing with addiction and deal with the underlying issues, we are not going to solve this problem. and as the chairman -- and you'll hear from chief willard today, we cannot arrest our way out of this problem. this is not just about statistics. this is about real people dying. real people like courtney griffin from new hampshire who was 20 years old and had such a promising life before her. real people like the grandmother who told me the other day as she waited on me in the store, i lost my granddaughter. we can make a difference in the senate and in this committee by passing the comprehensive

addiction and recovery act by working together to not only support our first responders but to make sure we're focusing on prevention, make sure that those who are struggling with addiction that we get them support for treatment and recovery. most of all, i want you to know that we can turn this around because i've also heard the redeeming stories, people like eric spofford, who was addicted to heroin and now has established treatment facilities in new hampshire and is turning this around. but we need to act immediately. this is a crisis. i'm so glad that you're holding this hearing today. i thank all of my colleagues who are working on this issue, and i thank this committee for its leadership and i look forward to working with you. thank you. senator grassley: thank you, senator ayotte. and now senator shaheen. senator shaheen: thank you, chairman grassley, and ranking member leahy, and the members of this committee for giving me the opportunity to testify this morning. i'm a co-sponsor of the

comprehensive addiction and recovery act, and i appreciate the leadership of my colleague, senators ayotte and whitehouse and klobuchar and those working on this legislation. i am actually here to testify, however, not on that bill, but on two bills that i've introduced -- the opioid and heroin epidemic emergency supplemental appropriations act. that's a mouthful, but what the bill would do is allocate $600 million in emergency funding to address this national crisis. the second bill is the combat heroin epidemic and backlog act, which would authorize a grant program to help reduce the chronic backlog of heroin and fentanyl cases at state police crime labs. and mr. chairman, you and senator leahy and my colleague, senator ayotte, talked eloquently about the statistics that affect this epidemic, but the fact is i believe what we have now is a pandemic.

it's affecting young and old, it's affecting urban and rural, rich and poor, white, minorities and it's spreading to every state in this country, including alaska and hawaii. in new hampshire, we're losing more than a person a day to drug overdoses. last year three times as many people lost to drug overdoses as traffic accidents. and we just had a study come out on mortality rates in this country that show that mortality rates among middle-aged white americans are actually increasing for the first time in decades rather than decreasing, and that was attributed primarily to the rising substance abuse disorders. those enator leahy said, statistics don't adequately describe the devastation to families who have lost loved ones and who are still struggling with trying to get loved ones into treatment. but despite all these

statistics, despite the stories that senator ayotte and i have heard in new hampshire and that all of you have heard in your home states, public health and law enforcement agencies at all levels lack the resources to mount an effective response to the heroin and opioid epidemic. and nationwide in 2013, nearly nine out of 10 people who needed drug treatment did not receive it. this is tragic and it's unacceptable, and we need to mobilize a national response. you know, my legislation proposes $600 million. specifically it provides an additional $200 million under the edward byrne memorial justice assistant grant system to fund state and local efforts including law enforcement, prosecution and court programs, drug treatment and enforcement programs as well as prevention and education. and unless you think $600 million is too much, remember

that last year congress passed $5.4 billion in emergency funding to combat the ebola outbreak and we lost only one person in the united states to ebola. in 2009, congress passed nearly $2 billion in emergency funding just to fight a swine flu epidemic. so we need better coordination and we need more resources and i'll think you will hear from chief willard, the challenges they're hearing in new hampshire because they don't have the resources they need. and i want to talk about the backlog act which is designed to help drug labs across this country, crime labs across this country as they analyze drugs. this bill is modeled on what we id in 2005 to combat methamphetamines, and what we're seeing in new hampshire and across this country is that state police forensic

laboratories have accumulated backlogs of heroin and fentanyl cases because they don't have the resources to do the testing. in new hampshire, the state forensic lab receives about 750 testing requests each month, but it can only process 450. and the growing backlogs result from an increase in heroin cases and a dramatic surge in fentanyl cases. and just to give you some idea of senator ayotte touched on this but in new hampshire, according to our chief medical xaminer, in 2013, we had 193 overdose deaths. 18 of those were fentanyl related. 326 4, we had 1 -- overdose deaths. 145 of those were fentanyl related. and in 2015, we had 385 deaths from overdoses, 253 were fentanyl related.

we have got to act with a sense of urgency because delays in processing drug samples have disrupted every stage of the policing and judicial processes. we are no longer able to identify combination and sight, drugs by undercover law enforcement are forced to wait before continuing investigations and prosecutors and judges are less likely to offer plea deals without lab confirmation of a drug's authenticity. so put simple, these backlogs are keeping us from putting dangerous criminals and drug traffickers back in jail and getting them off the streets. so mr. chairman, there's obviously a lot of work that we need to do to address this pandemic. i believe it's something that working together we can overcome, but it's going to take a multifaceted approach, as you said, and we got to act now before things get even

worse. thank you very much. senator grassley: thank you, senator shaheen. now, senator portman. senator portman: thank you, chairman grassley, ranking member leahy, and members of the committee for letting us come before you talking about a critical issue we face in every single one of our states and every community in this country and that's the epidemic of heroin and opioid abuse. senator ayotte talked about s. 524, which is a comprehensive addiction and recovery act, cara. it's a bipartisan bill that addresses this issue head on. and it does so in a comprehensive way, through treatment, prevention, recovery. it's one i had the privilege to work on with my colleague and co-author, sheldon whitehouse, who's on this committee. along with senators ayotte and klobuchar. we've been working on this for a few years now. we brought in experts from all around the country to give us their best advice. this committee's done some good work already.

i was very encouraged, mr. chairman, by your comments earlier and by the ranking member's comments about the importance of addressing this issue in a comprehensive way and about the importance of moving this legislation forward. again, i thank you for that. i think it's the appropriate federal response to this growing epidemic. i also want to thank those experts out in the field from every area, prevention all the way through recovery who have worked with us over the past few years in putting this together and participated in about a half dozen forums we had here in washington, d.c., where they've come in and given us their input. we've all been back home getting input. no matter where i go in my home state of ohio i hear from the same story. i hear it from mothers, fathers, brothers, sisters, friends. i hear heartbreaking stories how addiction is ruining lives. tearing apart families, devastating communities. this epidemic is striking very close to home. and i know you're hearing that too as you go home. last year 2,482 ohioans died

from a drug overdose. that should demonstrate to all of us how difficult it is to break through this addiction, the binds of addiction are so strong. hospital in s at a cleveland, looking at the care they give to addicted babies. i had a chance to talk to some mothers who continued to use during their pregnancy. that's how strong these bonds of addiction are. thousands more, of course, are surviving these overdoses but they're still struggling. they're struggling to hold a job, they're struggling to take care of their familieses. economists tell us that addiction cost this country $700 billion per year. that's loss productivity, expensive health care, it's happening in our emergency rooms, it's more crimes, it's the cost of incarceration, it's the cost of policing. that's a lot of money.

but, of course, it doesn't tell the true cost in human lives. and you all talked about that this morning. it's the cost in dreams that are never fulfilled. i think this hearing will be very effective in helping bring awareness to the severity of the problem, and we've heard it already this morning. but i think it's just as important we talk this morning about the reasons for hope, that there are alternatives out there, there are ways to address this. there are ways we can make progress in combating this ep demeanoric and lives can be -- epidemic and lives can be saved. senator grassley and senator leahy has been at this for a couple decades, as was mentioned. i worked on prevention strategies that actually work and we have spawned more than 200 community coalitions together with the drug-free communities act. we need to do more and focus more on not just the prevention and education but treatment and recovery. i've seen some amazing people who lead programs in my state that actually work.

i visited with a lot of men and women who struggle way diction and have the courage to seek treatment and get on the road to recovery. i've also been fortunate enough to get to know ohioans who have taken their personal tragedy and channeled their grief into something constructive. they used their story to help others avoid addiction. or help others break the stigma of addiction. you're going to hear from one of those women here this morning. tonda dare, i first met last fall. she came here for the rally on the mall against addiction and she told her story to me. and her story is one that breaks your heart. her daughter, holly, was 21 years old when she died of a heroin overdose. now, to the outside world, holly didn't fit the

and have the courage to seek treatment and get on the road to recovery. i've also been fortunate enough to get to know ohioans who have taken their personal tragedy and channeled their grief into something constructive. they used their story to help others avoid addiction. or help others break the stigma of addiction. you're going to hear from one of those women here this morning.

tonda dare, i first met last fall. she came here for the rally on the mall against addiction and she told her story to me. and her story is one that breaks your heart. her daughter, holly, was 21 years old when she died of a heroin overdose. now, to the outside world, holly didn't fit the stereotype of someone who was a heroin addict. she excelled in school, she will a lot of friends. she was selected for homecoming and prom court. she was building a life for herself. she was engaged to be married. then on her 20th birthday at a celebration some friends of hers said, why don't you try this? and they gave her some heroin. she thought she would experiment with it. and she got into the grips of addiction. tonda did, as you'll hear later, what any mom would do. she helped her daughter try to get into treatment. holly went into rehab. she gained a period of sew bright. but then the addiction took over. she has 40 chapters around ohio and around the country and it's in the hopes that other daughters will not follow that similar dangerous path. i commend her. there are so many others who have done the same way. i met in the state of ohio last week, i visited marion, ohio, and i met bethany who has struggled with heroin addiction. she struggled as a teenager, she was a promising athlete, she was going to college, she had a scholarship but she got sidetracked through her addiction. she was an expecting mom and he used. and she says that tearfully now. he was arrested. law enforcement tried to help herp by not putting her in jail -- help by not putting her in jail. she had to deep the opioid addiction because of her kids. she went on to graduate from marion dependency treatment court where they provide resources for mothers facing

substance abuse. after five years of being sober, bethany now leads that specialized docket as the court coordinator to help other mothers in recovery. to my colleagues this story, the -- morning, the story of bethany shows the faith. we've seen it around the country. people can break this grip of addiction and get into treatment and recovery. it's hard. they need our help. listening and learning from these families is what helped us inform our work on cara. every step of the way. as sheldon whitehouse will tell you. from prevention efforts to law enforcement strategies to addressing overdoses and expanding evidence-based treatment to supporting those in recovery, this legislation is comprehensive. it will help communities pursue all of these proven strategies, and we need them all, not just one. i'm complitted to passing this bill and getting to signed into law because i truly believe it can make a difference in the lives of the people i represent and in the families you

represent. i once again want to thank the nine members of this committee who have co-sponsored this legislation. i want to thank those who are willing to work on getting this report out and on the floor for a vote. and, again, i'm encouraged what i heard this morning. i think cara is an investment. it's not inexpensive but it's an investment where communities are desperate for resources. and expertise. it's a small investment for the future. we will know success by empty jail cells, by the number of people who never have to struggle way diction in the first place, by the moms and dads who now can be reunited with their kids. the message is very simple. today, there is something we can do to help. to those who struggle and think they can't overcome to those who believe there is no one out there to help them, you are not alone. we are with you. there is hope. and that hope can be furthered by this committee leading the

way by reporting out this legislation. thank you, mr. chairman. senator grassley: thank you, senator portman. now, governor shumlin. go ahead. governor shumlin: thank you, mr. chair. it's a real honor to be here to share some of vermont's story with you. i got to thank my great friend, senator leahy, for inviting me down and giving me this privilege. i'm glad to have my state's attorney -- my u.s. attorney here with me, eric miller. and maybe before i add to your colleague's extraordinary comments on this crisis, i just have to tell you this. when governors give their state of the states or inaugural addresses, it's kind of a big deal for us. we spend a lot of time on it, and we lay out proposals we think really will make a difference. i made the mistake this year of doing that and halfway through the speech acknowledging two of my favorite people on this earth -- senator leahy and his wonderful wife, marcel. they got the longest, biggest standing ovation of the speech.

and needless to say, the press wrote, senator leahy and marcel get biggest ovation of speech and that's all that vermonters heard about my state of the state. i won't make that mistake again. listen, i was going to share with you many of the stories, the heartbreaking stories that you just heard from your extraordinary colleagues from new hampshire and ohio. so i won't. vermont has the same heartbreaking stories. when i dedicated my state of the state address to this subject, needless to say it was a pretty lonely place for vermont to be. there was a long debate about whether vermont really had that big of problem and should the governor really be spending this much time on this one. so i got to tell you, it gives me a lot of hope to hear from your colleagues as well as to see this committee focusing so intently on this challenge that we're all facing together.

i came into this knowing very little about addiction but i was just listening to vermonters, much like senator leahy has, as he traveled around the state and the heartbreaking stories and i started asking -- so how did we get into this mess, and what do we do to get out of it? and when i started talking to thed a icts, to law enforcement, to -- addicts, to law enforcement, to docs, to nurses, i learned we were doing almost everything wrong. why? first, our criminal justice system was designed to do -- to maximize addicts going to prison and not going to treatment. just plain and simple. i learned that the most likely chance you have to move someone from denial -- and denial with this addiction is extraordinary. it makes denial for alcoholism or other addictions we all face with our family and friends look small. but the most likely chance you're going to get to getting

opioid addict to agree they got a problem and go to treatment is that moment when the blue lights are flashes, the handcuffs are on and they bottom out. i found in vermont we were missing that opportunity every single time. it took four, five months between getting charged and going before the judge to wind your way through a court system. by then they were back using, they were back abusing, they were back addicted, they were back in the streets to feed their habit. i literally fund for every state's attorney in our state assessor, funds a third-party assessor, who every time there's a bust, goes in and makes the determination -- is this person someone we should be scared of? in which case they go through the old system and end up most likely in jail. or is this someone we should have hope for, get into treatment and move back to a

productive life? and all i can tell you is it's working. we're finding the vast majority of folks who are suffering from this disease won't hurt you. they'll just hurt themselves. and removing them to treatment, to recovery, to a comprehensive system, not that there aren't failure, not they don't have setbacks, but it moves them into recovery. it is reduced our incarceration population dramatically. vermont saved $50 million in the last several years not locking folks up but instead getting them into the treatment programs and back into a productive life. as t is working as well one might hope. second, we've expanded treatment like madd. even with tough budget times, we've made tough choices but we're building out our treatment centers as fast as we can. that, too, is having a huge effect. our problem is that as we have removed the stigma, as you are

helping to do right here in this hearing today, mr. chair, we have more and more folks who are willing to come forward to say, i have the disease, i need help. and i know vermont is having the same challenge. we're finding longer and longer waiting lines because there's more and more demand. but we got to keep building out treatment centers. we need help in building out those treatment centers. third, the rescue kits that your colleagues mentioned about the narcan is absolutely critical. this was the first state to get into police hands, law enforcement at every level, municipal, county, to get it into the hands of firefighters. everyone will take it we've saved hundreds and hundreds of lives. this is expensive stuff. we need help saving lives. prescription drug monitoring program that senator shaheen has mentioned she wants to build upon is critical. we had governors from all over new england working together to improve the data where folks are shopping for prescription drugs across state lines.

so without telling you more about what i think we're doing right and what's giving me hope, i want to mention a little bit about what isn't giving me so much hope. listen, we need financial help. the states cannot do this alone. as an example, when senator leahy helped to get us a grant for $3 million, it seems like a small amount of money in washington but it was huge for vermont in allowing us to get it to the howard center, the rutland regional center, the chickland clinic to help us build out our treatment centers. we're scraping together pennies to try and make our treatment centers stand on their own. so financial help from washington is critical. i am encouraged by the bipartisan support here in the senate to help us get the financial resources that every state needs to fight this battle and to win it. so money, huge. second, we got to look at

what's holding us back in treatment and one of the things i got to tell thaw i found in vermont is as we build out treatment centers, particularly this is true of small rural states, where we're having challenges to get enough primary care docs in the medical field to deal with the illnesses we're all facing, with medicaid and medicare underpayments and so forth, we do not have an extra physician force to deal with the magnitude of treatment that is necessary to successfully win this crisis. to get treatment to folks that need it. so you got to ask this question, and this is a federal change i beg to you make. why is it that physician assistance and nurse practitioners can prescribe oxycotin and other drugs that lead to heroin addiction but they won't prescribe the treatment drugs that would allow someone to get off this stuff and get back to normal life? why is that? so i ask you to help us in

expanding the force on the ground that will help us actually be able to treat folks by making it immediately possible for physician assistants and nurse practitioners under the direction of physicians to be able to prescribe the maintenance drugs that allow us to move from addiction. i just want to close by saying this. e do need to ask this question , why are we in this mess? what led us into this mess? why are all 50 states on a bipartisan basis saying we need help? this is everybody that's having this problem. this disease knows no racial boundaries. it knows no income boundaries. it knows no partisan boundaries. everybody's in. and i think we have to have a more honest discussion about what led us into this mess. listen, i know that our instinct is to say, wow, those

folks down in south america and other places are sending us lots of heroin and it's a huge problem. well, of course it is, but i ask you, is that a new problem? has something changed dramatically in the last decade or so that has brought this heroin to america? and i would say no. we've always had this problem of drug dealers trying to get -- support their countries and their wars and everything else by sending illegal drugs to america. so then what did change? and i think it's important for us to have an honest discussion about this. what changed was that we changed our attitudes in america and our practices in america in the late 1990's about how we deal with pain. why aren't we talking about that? listen, this i can tell you. i have a lot of hope for where we're headed. i'm incredibly discouraged we

still have more people signing up for opioid addiction in vermont than we had when we launched this battle two years ago. well, why? listen, the facts matter. when the f.d.a. approved oxycotin, purdue several years later, the manufacture of that drug, pleaded guilty to telling physicians and docs that this painkiller wasn't addictive. they had a $60 million fine in the same year that $11 billion worth of oxy cotin and other painkillers were sold in america. in 2010 we prescribed enough oxycotin in this country to keep every adult in america high for a month. we did. those are just facts. in 2012, we prescribed 250 million prescriptions of oxycotin. now, there's only last time i

checked roughly 250 million people in our country. so that's a prescription for every living american. just a few years ago, the f.d.a. approved zohidro. call it oxycotin on steroids. we're about to do this again, team. they didn't make it tamper resistant so you can snort it, you can shoot it. that's what led us into this mess. listen, this year they approved oxycotin for kids. so you can't make this stuff up. i ask you to pause, take a deep breath and ask this question -- are we willing to have an honest discussion about how we're dealing with pain medication in america? because i can tell you that until we do, all the good work that we're trying to do together will lead to more

tragedy, more loss of life, more of our sons and daughters dying of opioid addiction because that is what has changed. what has changed is that we simply pass out painkillers like candy in america, and we're unwilling to have that conversation. thank you. senator grassley: senator leahy. senator leahy: mr. chairman, i assume our senate colleagues probably have to leave. i've seen the senate schedule is not the house schedule, the senate schedule is pretty busy. [laughter] i ask the senators do be excused. i do have a question for the governor. senator grassley: we can talk any time. and i look forward to continued conversation on this legislation with my colleagues. so you can stay if you want to. go ahead, ask governor shumlin your question. senator leahy: well, thank you,

mr. chairman. you know, governor, you and i talked about this a lot. and i appreciate your passion. i would note for everybody here , this is not just something that governor says publicly. he's talked about a lot privately. i think -- i think it's fair to say you feel the same way i heard from police officers all over the state of vermont, it's not just a law enforcement problem. i think a lot of them certainly tell me both the federal level police, state police, local police, county, they tell me if they could get people into treatment they'd much prefer doing that. is that the same thing you're hearing? governor shumlin: absolutely. i have to say law enforcement is an extraordinary ally in this battle. it's not only true sflerment

but across the country. i was recently on a panel with a police chief in glouster, massachusetts, who literally said, listen, here's my poll circumstances and now vermont and new hampshire law enforcement folks are doing the same thing. if you're addicted to opioids, come to my station. we won't arrest you. we'll get you into treatment. we'll get you into recovery. we're not arresting any more folks who are addicted to this disease and are nonviolent. and, you know, i sometimes think we don't give law enforcement enough credit for being on the front lines of this. for years we said to law enforcement as a nation, this is your problem. go settle it. you know, if i were law enforcement, i'd be a little raw about that. but instead, they've said, hey, we want to partner with the medical community. we want to partner with treatment folks. we want to partner with families to try and solve this problem as a disease, not a crime, and, you know, without them, we would not be where we are. senator leahy: but we also have

to have a place for them to bring this people. to have a diversion program, i think we all agree, you got to then have the people -- governor shumlin: absolutely. and we're literally scraping together the resources to try and pull this off. cannot tell you that vermont -- i think the centers in new hampshire and ohio would say the same thing, we're doing the best we can with the resources we have. senator leahy: senator grassley is saying nurse practitioners. senator grassley: we have a lot of -- you know, nurses, the attitude towards nurses in america, you can't have a nurse unless you have a doctor looking over you. i think we got to change that. but in rural america, we have to make greater use of nurse practitioners. senator leahy: i'm somewhat partial to nurses, as you know. i have a daughter-in-law who's an active nurse practitioners. senator grassley: i guess in the order of durbin and then whitehouse and then klobuchar.

senator durbin: i want to thank my colleagues for coming. there's no town too small, no suburb too wealthy not to have heroin overdose deaths in the state of illinois. i want to especially thank governor shumlin because i think you pointed to something we need to point to. we can all endorse the legislation that's been described. every single piece of it. i looked at that and said, i'm for that. you go at the heart of our responsibility. the food and drug administration, the pharma industry, the dirty docs. you know, we don't have to go to the border here to see the source of opioids. you go to the pain clinic in the mall. you go to the doctor, you know, just around the corner. you go to the pharmacist who looks the other way. . clearly, i think we have a responsibility here. phrma is making a fortune off this. i'll concede the fact over the last 10 years we have decided to tackle pain directly. i'm glad. for a lot of people it's the

difference in quality of life that we have to readily acknowledge. but with it has come a dramatic abuse. to think that the prescriptions legally written prescriptions, a his country, result in bottle of pills for every single adult american, as you said, to treat them with this drug for at least a month, tells me it's out of control. congress, what are you doing about this? senate, what are you doing about this? the f.d.a. dreaming up new applications for children? and for super opioids? where in the heck is the congress in terms of our responsibility when it comes to this? and the second point i'd like to make is, that police chief in gloster ought to be here today. -- claus cher, ought to be here today. decided after four heroin

overdose deaths in one weekend, they were going to buy into his program. 25 kids came forward, young people came forward. you know what happened? they went into treatment. and you know what happened to the jail? it was empty. the petty crimes, the burglaries, the thefts to sustain these habits started disappearing. but there's a key element here. how did they get into treatment? if they are lucky enough, if they are lucky enough to have health insurance and their families, they have access. if they are lucky enough through the affordable care act to have access to medicaid, then they get into treatment. and we all know we don't have enough resources here to treat these people. we absolutely, positively have to do it. i want to commend, too, we have senators from minnesota here. it was senator well stone and smart domenici in a bipartisan effort that demanded and finally after years succeeded in bringing reform to health insurance so that it now covers mental health counseling. it now covers addiction services.

those who want to repeal the affordable care act, put your hand up if you want to repeal that part of it. it would be disastrous across america when we consider this drug overdose and other things. thank you for turning the spotlight back on us. it's not just all the things we have heard. we have to look at f.d.a., phrma. we have to look at what's going on with the illicit prescription and filling of prescriptions across america. that is our responsibility. thank you. senator grassley: i'll call on cornyn and whitehouse. senator cornyn: i want to take a second to thank our colleagues for your powerful presentation here today. i think what we are seeing in america is that we are reconsidering a lot of our criminal justice policies. this committee's under the leadership of chairman grassley, has passed out, for example, a criminal justice reform bill. something i know that senator portman and others have worked on a lot.

but i hope that we -- as we look at this terrible pandemic as senator shaheen called it, we look at this comprehensively. because i don't know if you can draw any artificial lines between dealing with mental health issues and the criminal justice system and drug addiction issues, because we know from talking to our sheriffs that many of our jails are populated by people with mental health issues for which they self-medicate if they are unable to find other places where they can get help. but i would also like to make a plea of my colleagues on behalf of somebody who represents a state with 1,200 miles of common border with mexico, its demand is a big problem, governor? thank you for your powerful testimony. but we also need to deal with the supply issue as well. i know it's tough. our friends in mexico say, well, we wouldn't have all the drug cartel activity and all the

transportation of drugs into the united states if there wasn't such demand in the united states. so we do have to deal with both of those. i hope as we look at this we won't draw any artificial lines or create any stove pipes and we'll try to find a way to deal with this in a broader, more deliberate way. thank you. senator grassley: senator whitehouse. senator whitehouse: i'll put my statement in the record so we don't go too great length. we have two panels away of us here. i want to thank our colleagues for the terrific work they did as original co-authors of the bill. senator klobuchar and i are very grateful, they were joined by senator kirk and senator koonce as well. i thank them. i also want to particularly thank senator hatch and senator graham who were the first to committee sponsors on the majority side on this bill. they helped to make sure we had this hearing today. i want to make a record of how

important senator hatch and senator graham have been to getting us to this point in addition, of course, to the chairman himself who made the call. thank you very much. whatever else i'll add to the record. senator grassley: senator tillis. senator tillis: thank you for being here and your work on this. senator identify yot, as i have already ex-- ayotte, as i have already expressed to you. caring carolina's black and blue today after your patriots' got eliminated. -- i think it's a great stefment look forward to seeing it move through the process. governor, hi a question for you. i am a personal friend of your speaker. i have known him for five years. having been speaker down in north carolina. to the point that senator cornyn is making -- i do agree to a large extent with what senator

durbin said, but if we focus on, for example, the prescribed painkiller problem, then i think we are going to see an increased uptick in heroin abuse. it's obvious it's happened in north carolina. matter of state policy we did a number of things to crack down on drug shopping and the sorts of things we were seeing in the state. and there's almost a direct correlation between a reduction in those prescribed open yoids and increase tsh -- opioids and increase in heroin abuse. as a matter of state policy -- i'm very struck by the fact that some states there are great disparities between overdoses and deaths. i was shocked to know that ours had gone up 480% over three years. but it's still a fraction of what a state that's got 1.5 million people have versus a state that has 10 million people. what are we doing to address

these specific issues? what risks do we run of federal policy potentially hampering what you think and your speaker and your senate leader need to do to address the things that are unique to some of these states that seem to have disproportionate problems? governor shumlin: that's a great question, senator. i can't tell you why some states are being hit harder than others. but this, i'm convinced of, i don't think that we would have the heroin problem in america if we weren't starting folks out on opiates that are sold over the drug counter stores. irisn't coincidence that our rational exuberance around painkillers is matched by the rising heroin crisis. i am convinced that if we went back to the old policies on pain medicine, which is when someone

has chronic pain treat t. and treat it hard, but don't pass this stuff out as if it's not a problem, which is what we are doing. i'll give you an example, i know we can all tell these stories. the other day i had a reporter come into my office, she just had surgery for carple tunnel, and i said how many did you get? what do you mean? how many objectionies did you get? she said 80. good. how many do you take? she said half of one. so there's 79 1/2 left behind. three weeks later my head of health care -- his daughter comes by, she's a sophomore in college. she had four molars pulled out. i said did they give you any painkillers? she said, yeah. i said what did they give you? she said oxy. how many did you get? she said 40. how many did you take? she said none. so there's 40 more. my point is there is no question that when we made it tamper

resistant folks went to the pure heroin because it's cheap earn easier to get. but we cannot lose sight of the fact that we were not having this problem prior to the invention of objectiony cotton. we just -- oxycotin. we just weren't, as the senator from illinois said eloquently -- mentioned -- when the f.d.a. approves zohydro, it's own advisory panel, 13 members, voted 11-2. f.d.a. do not approve this drug. they did. so my point is there is a correlation if you talk to folks who are addicts would have done. and many, many times, 80%, 90% of the times folks said to me i got in a car accident, hi surgery, this happened to me, knee, whatever it was, that led me into this mess. senator grassley: senator a shaheen wanted to add something.

senator shaheen: we talked about the f.d.a. everybody talked about phrma anti-role of drugs. what we haven't talked about is medical schools and doctors. it's my understanding that most medical schools don't have any courses on prescribing medication on recognizing drug abuse. it seems to me that we have also got to get some attention from medical schools who are turning out doctors who are doing these prescribing practices without the history of what has been raised here at this hearing. senator grassley: senator identify yot. -- ayotte. senator ayotte: we have to engage the medical community on this. for example in new hampshire back when i was attorney general i was fighting for prescription monitoring then, our state was late to the game on it. when we look at this data and getting physicians the information that they can have, that's one of the pieces of this bill is to support the prescription monitoring programs, physicians that can't to do the right thing, it gives

them the data to understand if someone's doctor shopping. it also gives us the focus know if a particular doctor is actually exceeding his or her bounds because it's also focusing on them. so that allows us to address that. we have to engage the medical community. i think samsa, who you'll hear from, will tell you, as i understand t. some of the work they have done nationally, four out of five people started with overusing or misusing prescription drugs. to your point, chairman, that you raised in your opening, we also right now with the patient survey are actually encouraging reimbursement based on how satisfied people are with pain. that has to be addressed as well. i know that c.m.s. is looking at this. but it has to be a priority because we don't -- this was brought to our attention from doctors who are concerned that if they are worried about an addiction issue, they are being judged on a survey that's saying how is your pain satisfaction? that has to be addressed as well.

senator grassley: senator portman and then senator klobuchar. senator portman: i don't disagree with the commends made heemplet we have the drug monitoring programs which are incentivized. to senator tillis' question how the states will respond to this legislation. it doesn't mandate the states to do this. itprovide incentives. every state will be a little different. some states have done some really cutting-edge work. they should be the laboratories of democracy in this. we are helping them on this prescription monitoring program, including across state lines. think about it. in our states we may have a great program, my state of ohio, southern ohio state, west virginia, and kentucky have different programs. you don't know if somebody got a prescription filled in ohio. that's something the federal government can do. we have legislation on that. second, this drug takeback program is incentivizing this legislation. so care focuses on getting some of those drugs off the shelves, which governor shumlin is right. having talked to hundreds of

people who are recovering, who have been addicts because of prescription drugs, i understand that issue very well, including the athlete i talked about earlier, but i will also tell you there are a loft people i talked to who jumped that step and went straight to heroin. i'll use an example of that as we'll hear later from her mom. i think now because heroin is so plentiful, i was with the f.b.i. in ohio yesterday talking about this, the drug cartels from mexico are in ohio. they are in illinois. they are in our states. because it's so plentiful, so cheap, it's not just about prescription drugs anymore. it has been a gateway for a lot of people. but now there is a problem we have directly with heroin. even first use. back in the days when we worked on this issue of cocaine and marijuana back in the 1990's, heroin was not a first use drug. it was a drug that you used after you had other gateway drugs typically. with young people as young as 13, 14, 15 they are using heroin

today. this legislation is comprehensive. it does deal with the prescription side, but also deals directly with the heroin issue which sadly we now have to confront perhaps of this onslaught that came from the overuse of pain medication. but now the heroin is upon us. senator grassley: senator klobuchar. senator klobuchar: thank you very much. i'm proud to be an original co-sponsor of this bill. i just want to get to this point about what we should really be looking at here and what we have some control over in the congress. i'm a former prosecutor. i know these drugs have been coming in as you have stated, senator portman, i think the number one thing that we can do right now, in addition to funding our law enforcement, making sure we have efforts with d.e.a. funded, is really go after what's been happening with prescription drugs. while it is true that there are people that originally get hooked on heroin, the facts are the facts as senator ayotte just said. four out of five, 80%, this is

the last statistic i had, four out of five of these heroin users started with prescription drugs. what the governor has been telling us, senator durbin has been telling us, this is different than it was even when i started as a prosecutor in 1998. this is a different situation. we have these prescription drugs. i bet everyone in this room either has some in their cabinet, has had some in their cabinet, or knows someone in their family where you just took one or two as the governor pointed out, and there's 20 left or there's 30 left. and they are sitting in there. senator cornyn and i passed a prescription drug takeback, we finally got the rules out of d.e.a. so we could get that moving. but that is not going to solve it if it just keeps happening over and over again n this bill are the work that senator identify yot -- ayotte and i did on the prescription drug monitoring. just having come from a state here where it's not just the land of 10,000 lakes but 10,000 treatment certainties, the home of hazelton, bettle ford, i know

from talking to those doctors and experts that we are not really going to change this until we change the way these painkillers are given out. that's why the doctor monitoring, having more limited of dispense of these drugs will make a difference here because i am all in on trying to do everything we can to keep these dangerous drugs out of our towns, but the change here and what we have more control over is how we get these people hooked on drugs in the first place. sometimes they are such innocent. they just have a bad back. no one warns them given their particular makeup if they take these drugs for four days instead of maybe just one day or maybe just one, they are going to get hooked. we are doing this in our country. our policy, not a drug dealer on the corner. that's what i think we need to focus on. that's yim' pleased with this bill. senator grassley: senator session. senator sessions: i think senator klobuchar is correct. a reporter with "the new york times" that's written an online

book that says these pills delay healing. the pain pills, the more you take, the longer you have these problems. a lot of points that we really need to reduce the amount of prescription drugs out there. as a former prosecutor myself, we targeted prescription drugs in mobile, alabama, that most -- it can be the most successful reduction of drugs there is because there are not many sources. only certain doctors, we found really the illegality was coming from drug stores, two drug stores. when you eliminate that, you don't plea-bargain with people until they tell you where they got their pills. you can pretty quickly go right back to the sources that are out there. this is a winnable thing. and it does lead to additional drug use. thank you, mr. chairman. senator grassley: senator koonce. senator koonce: thank you. i just hope the american people notice the striking

bipartisanship this panel has shown. senators and governor, the questions, comments we have heard from members of the judiciary committee, the input we have heard from senators who have worked so hard on this issue for a long time. my home state of delaware, like your states, your states, is also struggling with an opioid addiction challenge that has translated quickly into a heroin epidemic that has penetrated every level of society and background. and i, too, has stories i could share about our local law enforcement and paramedic and first responder community. i'm thrilled to be able to support both cara, a bipartisan bill which lays out the authorizing background for expanding prevention, supporting recovery, and senator shaheen's emergency supplemental to make sure we have the legal framework and financial resources. this is a genuine problem in all of our states. and it's my hope that folks who are watching recognize you have republicans and democrats working together to craft a thoughtful, broad strategy. it's my real hope we'll get these bills moved, thank you, mr. chairman.

thank you, members of the panel. senator grassley: we have had a forceful discussion. very seldom do our colleagues get involved with questions from our colleagues. thank you-all very much for your patience. i'm going to move on to the second panel now. i know that i don't have to tell you that we'll be talking about this in the future because you're going to make sure we do. the second -- while we have commotion, i'm going to call the second panel. our first witness is michael boata chellly. director of drug -- national drug control policy at the white house. he heads the obama administration drug policy efforts and is responsible for creating the annual national drug control strategy. previously he served as director of substance abuse services, massachusetts. he has an under graduate decree from sienna college and masters of education st. lawrence

university. second witness, dr. nora bolcoff director of the national institute of drug abuse. which supports most of the world's research on health aspects of drug abuse addiction. previously she worked at the department of energy's brook haven national laboratory where she held several leadership positions. she got her medical degree at the national university of new mexico. our third witness, akenya anamoto, she serves as the acting administrator of substance abuse mental health services administration. that agency leads public health efforts to advance the behave yorble health in our country. -- behavioral health in our contry. she's worked at samsa since 1998. earned a bachelor's degree and master's degree in psychology from ucla and is also a graduate of harvard kennedy school of

government. r final witness is louis melahone, deputy assistant administrator, office of division and control within the drug enforcement administration. in that position he's responsible for overseeing and coordinating major pharmaceutical and chemical division investigations, drafting, and promull gating regulations. he's been with the d.e.a. in multiple capacities since 1997. and holds a b.a. from villanova university and j.d., rutgers. we'll go with the way that we inter-- introduced you. would you please start out. you appeared before our committee many times. thank you. >> thank you, chairman grassly. members of the committee, thank you for the opportunity to be here today to discuss the issues surrounding opioid drugs, including heroin and fen continue no -- fen continue no

in the united states. this is an important issue for president obama. the president specifically mentioned addressing prescription drug use and heroin as a priority and opportunity to work with congress on an issue that transcends party, income level, gender, and race. mr. botticelli: i also thank the members here for the ongoing leadership for the work in our office on this public safety issue. the office of national drug control policy produces a strategy which is our blueprint for drugpolicy. using our role as coordinator of federal drug control agencies in 2011 the administration released a plan to address the sharp rise in prescription opioid drug use this. plan contains action items, categorized in four areas, many already discussed today. education of prescribers and patients. increase in use of prescription drug monitoring programs, proper medication disposal, and law enforcement efforts.

since this plan was released, this crisis has clearly evolved. within with an increase in heroin use and overdose deaths and the administration has put forward new initiatives to help deal with emerging issues. as all of you know and have all indicated, we need a comprehensive and multifaceted response and coordination at the federal, state, and local levels. opioids are taking a terrific toll on public health and safety in countries across the united states. we all talked about the staggering numbers so i won't repeat them. these numbers are harrowing, however, but we are making some progress in addressing prescription drug misuse. past month nonmedical use of opioids by americans 12 and older was significantly lower during 2014 during its peak in 2009. the number of people initiating nonmedical use of pain relievers in the past year also decreased significantly. this progress, however, has been

counteracted by an increase in the availability and use of heroin. although nonmedical prescription opioid use continues to far surpass heroin use. heroin purity has been rising while prices have remained low. and this heroin crisis has been compounded by the re-emergence of illicit fen continue no sometimes added to heroin to increase its potentcy or used on its own. since it's far more potent than heroin, it has increased risk and increased overdose deaths in the united states. although the transition from nonmedical prescription opioid use to heroin occurs at a very low rate, a recent article concluded that this transition appears to be part of the progression of the disorder among those with frequent nonmedical prescription opioid use or dependence. we all talked about the need for enhanced prescriber education and graduate medical education ograms because they do not

provide a comprehensive focus on identification and treatment of opioid use or safe and effective opioid prescribing. in one of the most jarring studies that i have seen in my 10 years in doing this work, a recent evaluation of health care claims data found that a majority of nonfatal opioid overdose victims were receiving an opioid for a prescriber at the time of their overdose and most alarming 91% of them received an opioid prescription again from a prescriber. 70% of them from their own prescriber before an overdose. in response, last year president obama issued a presidential memorandum requiring all federal agencies to the extent permitted by law to provide training on the appropriate and effective prescription of opioid medications for their staff who prescribe controlled substances. the administration also continues to press and would continue to work with congress to pass mandatory prescriber education tied to controlled substance license sure.

the administration has focused on several key areas to prevent opioid overdoses, including educating the public over overhe dose risk and intervention. increasing third party and first responder access to the opioid reversal medication. working with states to promote good samaritan laws, and connecting overdose victims and persons with an opioid disorder treatment. we appreciate that congress provided more than $400 million in funding in the f.y. 16 appropriation act specifically to address the opioid epidemic and an increase of more than $100 million from 2015. to address emerging rise in heroin use, our strategy focuses on identifying, disrupting and dismantling criminal organization who is traffic in opioid drugs, working with the international community to reduce the cultivation of poppy, identifying labs creating dangerous opioids. and we have also been enhancing our efforts along the nation's

borders and have been actively engaged with government of mexico on supply reduction issues to decrease the flow of these drugs in our country. finally, this past summer ondcp committed $2.5 million to our high intensity drug trafficking area program to develop a strategy to respond to the heroin epidemic providing resources, enforce resources to address heroin threats across 15 states and the district of columbia. this administration continues to work with our federal, state, and local tribal partners and reduce the public health burden and consequences of prescription opioid, heroin, and fentinol and i thank you for your commitment to address this this public health concern. senator grassley: now dr. volkof. push the red button. >> good morning, everyone. i want to thank you-all for giving me the opportunity to participate in this hearing.

what is the nature of the problem? chronic main is among the most prevalent and debilitating medical conditions with over 30% of americans suffering from some orm of chronic pain. the effectiveness for severe acute pain and the limited alternatives for chronic pain have combined to produce an overreliance on opioid pain medications even when the benefits for chronic pain are uestionable. dr. voikow: what is no longer questionable, is opioid medications have been diverted. opioid medications such as objectiony could he continue are diverted and abused because just like heroin they bind to opioid receptors.

opioid receptors are located in regions of the brain that regulate pain which is why they are so potent. but they are concentrated also in brain required regions which is also why they produce addiction. opioid receptors are also located in brain regions that control breathing, which is also why they can produce overdose and death. nydia supported the development of the three medication that is are currently approved for the vehement of opioid addiction, methadone and others. there is strong evidence for the effectiveness of these in the treatment of opioid disorder in the prevention of overdoses, in the prevention of infections such as h.i.v., and improving the object stet trick and neonatal outcomes of opioid addictsed pregnant women. despite the strong evidence,

less than 40% of those being treated for opioid addiction receive these medications. thus, expanding the access to medications for addiction is a critical part of the h.h.s. strategy. towards this end neither funds research to develop implementation strategies for the use of medications in substance abuse treatment frams in the health care system and in criminal justice settings. examples include initiating the emergency room and integrating the mackment of medications, of these medications with an infectious disease clinics. examples in the criminal justice prior to lude drugs the release, once a month injection that blocks the action of heroin or other opioid drugs. thus interfering with relapse and death from overdose.

nydia also funds rich to develop treatment that will improve clines that requires dosing every six months or new transformative solutions such as the development of the heroin vaccine. as a component of this strategy ection spanneding the use of nyloxin. a medication that can rapidly reverse an opioid overdose. o this end nida has funded the development of medication that is do not require injection thus making them easier to use for those that have no medical training. one of these products, was just approved by the f.d.a. last year. finally, since the limited treatment alternatives for the management of severe chronic pain has led to the overreliance on opioid medication, nida also funds development of better and

safer treatments for chronic pain, including others that are less addictive pain medications not relying on the opioid system, and nonmedication interventions. the epidemic of opioid prescription abuse and rising heroin abuse resulted both from a lack of knowledge of health care providers and the management of pain, including appropriate use of opioid medications, as well as the lack of knowledge around identification and management of addition. thus, a fundamental component to reverse this epidemic requires the education of health care providers both in management of pain and in substance disorders. to help address this nida in partnership with n.i.h. institute has created centers of excellence for the development of education curriculum for pain and substance abuse disorders. the urgency to address this

epidemic is highlighted by the nearly 30,000 deaths from opioid overdose that occurred in 2014. the highest ever reported. solutions are already available. the challenge is their implementation. nida will continue to work closely with other federal agencies, community organizations, and private industries to address this omplex challenges. >> thank you for inviting me here today. it's a great honor to talk with you about the real sense of advancing the nation's behavioral health and what we are doing to address the crisis. i want to thank the first panel. for providing great leadership. i know this crisis has had devastating consequences in all of your states, but i agree with you, mr. sessions, this is a winnable battle.

you are already heard we are facing a treatment gap of unacceptable proportions. we will not stem the rising tide of this public health crisis if only two out of 10 people fwet the treatment they need. it wouldn't work for diabetes. it wouldn't work for h.i.v. and it will not work for addiction. but like many other issues we face, closing achievement gap will be a complex effort requiring a multifaceted approach of the the federal government needs to work with preventionists, payers, treatment systems, public health official, states, tribes, law enforcement community organizations, and the recovery community in order to tackle the challenges ahead. as you have heard, addressing substance abuse disorders related to prescription open yoids and others are key priorities for this administration and samsa is proud to support the president's national drug control strategy and secretary burwell's opioid nishtifment the goal of the initiative is to reduce -- changing prescribing behavior.

two, increasing access to nylaxone. today i'll focus specifically often samsa's role in each of these areas. with respect to prescribing behavior, it's an obvious tactic to prevent prescription open yode misuse by reducing the numbers of people's medicine cabinets. to do that, physicians and other providers need to be better educated on proper describing and dispensing open yoids. to manage chronic pain and treat addiction. we understand that the vast majority of physicians and other prescribers are not bad actors. most are dedicated, well trained professionals who are committed to their patient's good health, but they are very busy. and it's hard to find time for elective training. training that's not required. since 2007, samsa's provided clinical support system for opioid therapies has provided continuing education to over 72,000 primary care physicians, dentists, and other health care

professionals. that is tremendous progress, but we have a long way to go. samsa's also addressing the issue of prescribing practices through grants to increase interoperability and and in f.y. 2016 with congress' support of the new grant program, samsa will support states, tribes, and territories to utilize pdnp's to provide communities with the greatest need for prescription drug prevention programming. samsa also reaches local communities to prevent substance misuse and abuse to the drug free community grants we administer. these coalitions do yeoman's work to create university environments that promote health and prevent drug use drug the misuse of prescription drugs, heroin, and fentinol. the secretary aim sin creasing access to nyloxone. it can reverse a potential overdose but only works if you got it when you need it. samsa offers an overdose prevention course for prescribers and pharmacists. one strategy to ensure it is nearby when needed is to

co-prescribe the product with opioid anal geesics, particularly for patients with high risk of overdose. another resource it our opioid overdose tool kit. it is the most downloaded publication on our website. samsa will release a funding announcement and traging -- training to first responders. imagine the livense we'll save. the third aim is expanding the use of medication assisted treatment. there are many pathways to recovery and it is critical to ensure each individual has access to the full continuum of evidence-based services, research tells us that medications along with behavioral health treatment and supports are important opponentents of an evidence-based treatment plan. however it remains significantly underutilized. today there are only a few f.d.a. medications. that's why we are so grateful that in f.y. 2015 and 2016

congress provided new funding for states to expand treatment capacity both through increases to the substance abuse prevention and treatment block grant and discretionary funding specifically for a.m.t. samsa also worked with d.o.j. and others to clarify and enhance the connection between m.a.t. and the criminal justice system. through a drug court grant program. drug courts are the most successful criminal response to addiction in history. supporting lifelong recovery. reuniting families. reducing crime. saving tax dollars. and serving as the foundation of crimes in a justice reform in the states this. year we'll prioritize treatment that's less susceptible to abuse exexpand assistance to ensure it's fully implemented. as the secretary announced in setcht last year, h.h.s. has initiated the rule making process to increase the cap on the number of patients to whom physicians may perfect describe. because we are -- prescribe. because we are in the middle of rule making i look forward to

coming back to talk to you. it wouldn't be a hearing about behavioral health if we didn't talk about the work force. we are expected toing expand coverage to 60 million people. we must act swiftly to make sure we meet the demand. the work force including prescribing and nonprescribing professionals. psychologists, counselors, therapists, and pearce both youth and adult and others. we are grateful for the administration's and congress' support of samsa in this crucial area. members of the committee, thank you for convening this important hearing. you know all too well that substance use disorders come at great cost to society. the impact of untreated or undertreated behavioral conditions on the labor market, the criminal justice system, schools, and communities is tremendous but above all the impact is greatest on individuals and families. samsa's budget accounts for just over 10% of what the nation spends on substance abuse treatment annually.

we are small but mighty. we are steadfastly committed to using our investment strategicically, responsibly, and effectively to deliver the greatest possible impact for the american people. thank you very much. senator grassley: thank you. >> thank you, chairman grassley, ranking member leahy, senators. it's an honor to appear before you today. d.e.a. views the combined prescription opioid and heroin abuse epidemic as the number one rug threat facing our country. i appreciate coming before you to talk about what we are doing to address the threat. we understand we need a balanced approach to this yep. our efforts are designed to ensure patient access to the medications while at the same time preventing the diversion of these highly addictive dangerous drugs. we stand with our interagency partners, including those represented here today. and embrace comprehensive prevention, treatment, and education efforts as critical to our success.

we need to investigate and bring to justice not those suffering from opioid use disorder, but those exploiting human frailty for profit. our answer to this drug threat attack supply, reduce demand, and power communities. d.e.a.'s 360 strategy. there are three prongs to it. law enforcement, divergent control, community outreach. my nish comments today focus primarily on the office of diversion control role in that strategy, but we would be more than happy to follow up on rolling thunder. it's the heroin enforcement prong of the strategy that focuses on the stocksic business relationship between the mexican cartels flooding our country with heroin anti-distribute cells slinging that dope in our communities. milione: -- the vast majority of

those 1.6 million registrants are law-abiding citizens. these are practitioners, pharmacist, manufacturers, distributors spread across this contry. we investigate the very small percentage that are operating outside the law that yet inflict considerable harm on our country. for example, practitioners not prescribing for legitimate medical purpose outside the usual course of professional practice. pharmacists not performing the cordsing responsibility to ensure a prescription is valid. manufacturers and distributors not upholding the regulatory obligation to prevent diversion. how do we do it? with our tactical diversion squads and groups. our tactical diversion squads are specialized units made up of agents, diversion investigators, and intel an alses, we have 69 deployed nationally. we are in the process of creating two mobile tactical diversion squads that give us the ability to deploy where the need is. giving us a fluid enforcement

capability. we have more than 600 skilled diversion investigators spread across this country in our diversion groups, both the tactical diversion squads and groups work with the respective u.s. attorneys' offices to bring criminal and/or civil charges and where appropriate administrative actions. our order is to show causes are immediate suspension orders, potentially revoketting a d.e.a. registrant's registration. in the last two years d.e.a. diversion has conducted more than 300 events, providing education and guidance to thousands of d.e.a. registrants and others. in the coming weeks i'll be meeting with nausm industry leaders to discuss areas of mutual concern. increased dialogue and appropriate collaboration with industry are crucial to our collective efforts. finally, we will continue engaging with our interagency partners on these important initiatives we discussed earlier

today. expanding access to treatment, mandatory prescriber education, and the safe and responsible disposal of unwanted, unused rescription drugs. we look forward today that drop boxes are so common in pharmacist and elsewhere, that people can dispose of their unwanted drugs conveniently, frequently, and safely. ensuring that those pills don't get in the wrong hands and start omeone down the journey toward opioid use distoward. we'll continue our takeback initiative with national events approximately every six months. during our september 26, 2015 take back, we collected 741 tons of unwanted, unused, drugs from 5,202 collection sites. our next one is scheduled for pril 30, 2016. the d.e.a. stands with our interagency partners, embraces a balanced approach that attacks the supply, reduces demand, and empowers communities. for almost 20 years i had the

privilege of working with the brave men and women of the d.e.a. along with our federal, state, local, and foreign counterparts investigating some of the most entrenched, domestic, and threatening our contry. this current prescription opioid and heroin epidemic is unlike anything i have seen. i know statistics have been mentioned, but in the last four years more than 100,000 americans have died, overdosed and died. this is an unimaginable tragedy. we at the d.e.a. will do whatever it takes to engage in this fight. i thank you for the opportunity to appear before you and look forward to answering any questions you have. senator grassley: assuming it's just those of us that are here it will be in this or. i'll speak then senator durbin, then senator sessions, then senator klobuchar unless senator tillis comes back. i'm going to start out with director botticelli.

i refer to the final report of your office and d.o.j. co-chair and the national heroin task force. there are a loft good ideas in there to attack this epidemic from many different directions. but the task force mission statement included among other things creating a framework for efforts to quote-unquote, restrict heroin supply. on this point i have some questions because i think there's a fault in not enough .ttention it didn't mention heroin that's been trafficked into this country by mexican drug cartels. they don't mention that heroin seizures at the border have more than doubled since 2010. they don't even mention that the few weeks before the report was released your office announced that mexican heroin production

jumped an incredible 62% from 13 to 14 years. my question -- how can it be that the national heroin task force didn't even acknowledge these dramatic developments related to the supply part of the heroin problem let alone suggest specific solutions to address it? before you answer that, isn't it at least part of the answer to this epidemic securing the border from mexican cartels? what can we do about that part of the problem? dr. botticelli: i agree with many of the comments here today that focusing on supply reduction has to be part of our comprehensive response. we know part of what we are seeing in the united states is a tremendous increase in very cheap, very pure heroin in many part of the country where we haven't seen it before. as well as an increase in

fentinol. the task force, senator, focused exclusively on what we can do domestically as it relates to both public health and law enforcement. but part of our national drug control strategy, part of our work in general around this issue, has been to focus on one, how can we work with the government of mexico to look at things like enhanced eradication, to look at taking down heroin labs, finding other labs, taking them down. we also in october i formed a national heroin coordination group that's been working in concert with the national security council to look at what additional actions we can take, including those at the border and in other parts of the country, to reduce the flow of heroin into the united states. it has to be part of our comprehensive response to do that. i would agree that we have to focus on our supply reduction efforts as we look at things like prevention treatment and recovery, because we know that that is part of what is really fueling the heroin and

particularly the overdose that is we have seen with fentynol in the united states. senator grassley: i hear you say you are dealing with t i respect that. but it seems to me where you have a central document like the report is, that this aspect of it should have been mentioned. it seems to me that it could be a problem with the administration avoiding at all costs and facing this issue squarely. i'll go to dr. volkow. the relationship between the prescription painkiller crisis and the heroin crisis has been the subject of some specific study and debate. you touch on this in your testimony. we have heard a lot of discussion about this very day. the heart of the question is, to what extent the heroin crisis is attributable to the overprescription of painkillers

and subsequent efforts to reduce diversion that may have led some users to cross over to heroin as opposed to other factors such as the rapid increase in heroin supply over the last few years? so, question, clearly it's not an either/or situation, but could you tell us more about what the studies tell us about how much we should attribute to our roin crisis to experience over the last 20 years with prescription opioids? dr. volkow: it's not an either/or. what happened was a dramatic increase in the number prescriptions that led people to become addicted to them. in parallel there was an increase in the entry of heroin. and the resultant increase in heroin abuse by people addicted to prescriptions and started to use heroin because it was more available. indeed, however, as.

so opioid medications became more difficult to divert, some individuals transitioned to heroin because of that. but we address the problem, the source of the heroin epidemic that we have, is the addiction to prescription opioids. if we want to address it, we need to address the abuse and diversion of prescription opioids. it's the source. it's the origin of the heroin epidemic. senator grassley: a couple other questions i had were answered in your testimony. gi to senator durbin. -- i go to senator durbin. senator durbin: we were just talking, members of my staff, i was trying to remember a 72-hour period in chicago last year, i know there were 74 heroin overdoses or deaths, could have been deaths. it was horrendous. when it came in to the supply there. as i mentioned earlier, i traveled around my state, it isn't a chicago problem.

it's an american problem, sadly. in every town, large and small. that we get into. when i went to dixon, illinois, population 20,000, inspired by the chief of police to have people step up and admission their addiction. they weren't arrested. they were taken to treatment. petty crime in the community disappeared. virtually disappeared as a result. they were saying knee, what are you going to do about treatment? now that they have stepped up, now -- it's an hour and a half drive from dixon, illinois, to the closest treatment facility. if the person who is a user happens to have the good fortune of someone who will pay for it, health insurance plan, medicaid plan, whatever it might be. talk to me for a moment about the treatment side of this. it strikes me that we need to dramatically increase our commitment to mental health counseling and addiction services. i'll just add parenthetically, the fact that this is no longer

an inner city minority problem but an american problem, predominantly a white american problem, i think creates a political force that might see us to the right conclusion. i welcome your comments. anyone who would like to speak to it. >> i would echo the sentiment of many people here we have seen law enforcement step to the table in a dramatic way and acknowledging we can't arrest our way out of the problem. director botticelli: we have law enforcement agencies across the country administering lockdown, when you her r hear about them reversing people's lives it's amazing. we have seen nationally where police are not only saving people's lives but accelerating and i think we need not frustrate them by a look of -- lack of treatment availability. we should capitalize on their good will. despite i think all of the things that we have done

collaboratively to expand treatment, even president obama in west virginia acknowledged the fact we probably have a significant treatment gap here, administrator enomoto talked about only 20% of people get treatment in the united states. that's abysmal. we wouldn't accept that with any other disease. the last thing i'll say is -- we also have to combine that with an increase in the work force. we can put money out to expand treatment. we need more physicians who are able to prescribe these medications. we'd love to work with congress on expanding who can prescribe those, including physician assistants and nurse practitioners. senator durbin: i endorsed this. i have a measure with senator markey to allow physicians to dramatically expand their caseload. there are so few willing to take on these cases. that is a temporary answer. the real answer is to bring in the professionals who in the proper numbers to deal with this epidemic that we are facing.

director botticelli: what we have seen is the speanings into the rural parts of the united states like the governor talked b we have to focus on those strategies that gets some of those resource, some of those folks in rural parts of the country that don't have a dedicate the treatment. senator durbin: going back to the earlier observation about dirty doctors who are rescribing pain clinics that end up being on the street and sold into commerce here, tell me if you can, do i know which one of you wants to. what are we doing working with the medical societies and medical professionals? they are the gate keepers for these prescriptions. senator sessions talks about a couple drug stores a couple drug stores and dozen dirty dogs and now you have a city that's -- dogs -- docs now you have a city

that's under siege. what are we doing tone courage the profession to clean itself up and police the ranks for those abusing it so that they are held accountable in a public way? dr. volkow: i would state fundamental problem in all of this issue if you think about 750 million prescriptions annually in the united states which leads to an enormous amount of diversion. one pick up and take back day, we are overprescribing medications. it's not just drug doctors which are very few, but the practice that is we have in order to treat pain in this country that are the main source of the prescription opioids being diverted and leading to addiction. senator durbin: is there a conversation with the medical profession about this?

director botticelli: we worked with most of the medical societies and got them to commit to train a half million of their prescriptions. from pie perspective it's not enough. when we look at the data. we look data and we are 10 years into this epidemic i don't think it's too much to ask. medical professionals. and medical societies to support a minimal amount of medical education as relights to safe and effective opioid prescribing. dr. volkow: i am ' going to intrude here. one of the issues, many of the guidelines that are currently available for physicians in order to train about the use of prescription opioids have been developed by the pharmaceutical industry. there is a direct conflict. it's coordinated with many to generate kish rick lum not just medical students and physicians but nurses, pharmacies, dentists for the proper management of pain and use of prescription opioids.

again there is also -- we have been working with a different medical agencies, for the development of guidelines for the better management of pain. senator grassically: senator sessions. senator sessions: thank you. very important, senator durbin is correct on many of those points he's paid. association of pain physicians are concerned about this. they know people are coming in and complaining about pain. many of them have other sources, other doctors giving them pain pills. they have supported things such as allowing a physician to check through a computer system other doctors that may be providing the same relief. mr. botticelli, do you agree that would be helpful? and provides good doctors an opportunity to push back and not overprescribe. director botticelli: good monitoring programs that are easy to use and interoperable

across state lines so physicians can have good, accurate information about how many prescriptions one of their clients could be getting. it's a prime part of our strategy and we have seen them work in many states that have implemented and where prescribers actually use the data in the databases. senator sessions: d.e.a. has great power, it seems to me. you can monitor the number of prescriptions that are coming from a certain -- any physician, can you not? as part of your control ability? administrator milione: those are state programs. we support all of our state partners and also the national association. senator sessions: but if you have information that a physician is prescribing extraordinary amounts, you can go and interview that physician, you can examine their records as part of -- you don't need a search warrant, you can just ask for their records. and a drugstore pharmacist can -- you can also examine their

records, is that correct? administrator milione: that's correct. investigations can start in a number of different ways, and patterns of overprescribing and such, information from other sources can lead to an investigation. senator sessions: now, if a doctor is clearly abusing -- and i saw it in my community. we had some doctors and we had some pharmacists, which we didn't expect. the simple deal was the d.e.a. and the local police chief signed a one-page memorandum in my office that nobody would have a plea bargain on a prescription drug until they told where it came from. it came back from a very limited number of sources, and that trial of that particular drug was eliminated in alabama for a while. so if somebody goes to jail, that sends a message to the other doctors and pharmacists, does it not? administrator milione: certainly it does. senator sessions: i think that's important. looking at the new report from

the prestigious new england journal of medicine just a couple of months ago, they conclude there is no consistent evidence of an association between the implementation of policies related to prescription opioids and increases in the rates of heroin use or deaths. although the data is relative sparse. alternative tiffly, heroin market forces -- alternatively, heroin market forces, including increased accessibility, high purity of heroin appeared to be the major drivers of the recent increase rates of heroin use. o you agree with that, mr. milione. administrator milione: it's not a yes or no answer.

senator sessions: it is. mr. botticelli, you are what they used to call the drug czar. do you agree that reduced price, high purity and increased accessibility of heroin are the major drivers of the recent increase in rates of heroin use? director botticelli: sir, this study was undertaken -- a question i had about what we're hearing, does reduced availability of prescription drugs drive people to heroin? there are folks who have said, if you clamp down on heroin -- senator sessions: look, i'm sure some do. i don't dispute that. the question is as i asked you. director botticelli: i would agree that the availability of very cheap, very pure heroin in the united states, as well as unpreeted addiction, has gnificantly increased heroin -- unprecedented addiction, has significantly increased heroin use rates. senator sessions: lack of enforcement at the border is a big part of this. i'll just say this personal story. in the 1970's, i became a --

assistant united states attorney. i was given 17 heroin cases to prosecute. they were small ones. they didn't trust me for anything bigger. it was almost all coming from turkey. president carter was very aggressive in that, and i give him credit. i came back in 1981 as united states attorney and we went several years before we saw a heroin case. supply is important. we can impact supply, and heroin at low prices and high purity on the streets are dangerous, and prosecutions are critical to this. and people need to go to jail o are pushing this kind of addictive power into our community, destroying lives and families and dying of overdose and destroying whole families. so mr. chairman, it's a very important hearing. thank you. we can do better about prescription drugs. taxpayers are paying on their medicaid and medicare bills

often. their insurance rates are higher because of overdoses and overprescription of prescription drugs. it's an important issue. thank you for your leadership. senator grassley: senator white house. -- senator whitehouse. senator whitehouse: my appreciation for you holding this hearing. i think it's an important issue, as the witnesses have said. and i think the comprehensive addiction recovery act provides a means of getting our arms around it. first, mr. botticelli, thank you for being here. congratulations on the terrific 60 minutes appearance. there i was clicking through the channels and next thing i know there you were. it was really wonderful. i have to go to another event for another piece of bipartisan legislation that i'm co-authoring, and so i won't be re when ms. hurley testifies

but i want to welcome linda hurley of rhode island who has been on the ground dealing with this problem for 20 years. will bring a really terrific perspective to this committee. and also tom, my rhode island friend, who is now working at sam is a -- samsa right now. i do want to ask unanimous consent that letters from the national association of attorneys general and the national district attorneys association and 126 organizations that are active in this area be admitted in the record. they're all supporting the comprehensive addiction recovery act. senator grassley: without objection, they will be included. senator whitehouse: thank you, mr. chairman. i assume all of the witnesses on this panel support the comprehensive addiction recovery act. but if you could confirm that for the record, i'd appreciate it. >> there is clear evidence that a comprehensive response, again, multidimensional aspects of this, that are embedded in the cara act are tremendously important. we know we need to do more. director botticelli: i think

all of those components put forward in the bill are critically important to make headway in terms of this epidemic. senator whitehouse: agreed? r. volkow: [inaudible] dministrator enomoto: at sam a, we are ready to implement this which congress appropriated in 2015 and then another increase in 2016 which is very similar to some of the prosecutors that were described in the cara act. i thank you, senator whitehouse, for your leadership on this issue and continued support of our mission. we believe that the public health approach of the cara act is vitally important to moving forward on the issue.

administrator milione: senator whitehouse, happy to work with you or anyone on this legislation that will alleviate the epidemic. senator grassley: senator tillis. senator tillis: thank for being here and for your service. first, i want to go back and say i am happy to see we have a growing consensus around cara and doing what we need to do to address the problems, both in terms of the prescription drug problem and the heroin problem. and i think we also -- i think you, dr. volkow -- did i pronounce that correctly? said something very intreeinging to me. it was a -- intriguing to me. it was a potential heroin vaccine, and the reason i mention that is ironically, part of the solution to the problems with these drugs that are being prescribed is relying on the very communities that

may have created these and they are being dispensed improperly to come up with solutions and treatments so we can resolve the problem. so we need to make sure, as we're trying to fix the problem with educating doctors and being sure they're dispensed properly that we don't disincentivize the very people that we're going to have to rely on the community, the research communities, the pharmacy companies to try and ome up with solutions. i think sometimes in the rhetoric we can demonize people who are actually part of the solution. as we get to the problems. my question for you, actually, milone? on is -- is it governor o'malley: milione. administrator milione: milione. senator tillis: very clear knowledge, we know where these people are, we know when they get up in the morning. a lot of times we know when

boats are leaving the shore and going someplace in mexico and yet we really haven't recognized the death toll of narcoterrorism over the past several years. hundreds of thousands of people in the united states have died as a result of drugs come -- coming to this country. what are your thoughts, first off, some sense of drugs flowing in the country? many people think they're being manufactured and distributed out of mexico. what is the illicit drugs that are coming maybe across the mexican border but their origination is someplace else? administrator milione: i cabot give you an exact percentage. it's bringing it across the southwest border. they are coming from colombia, south america and the source countries but the mexicans have taken over a great deal of that and have great distribution that works throughout our country. senator tillis: do you agree with general kelly that a part of our strategy when we talk

about border security, if we spent more time focusing on the southern border of mexico and some sort of collaboration and providing more interdiction money that that may be a higher benefit to at least reducing the supply chains? administrator milione: senator, my whole career as an agent and what d.e.a. focuses are are targeting networks -- the cartel leaders, the link points, domestically. as far as in the foreign arena, we have a great overseas presence. we work with our foreign counterparts in mexico and elsewhere. it's an ever-evolving threat and we work with them side by side to work those cases and attack the entire network. senator tillis: how would you characterize mexico's cooperation with these efforts? administrator milione: we have a great partnership in mexico. senator tillis: thank you. i will yield time for the next panel. senator grassley: senator klobuchar. senator klobuchar: thank you very much, mr. chairman. i want to start with something i mentioned when i made my opening statements here and that is the drug takeback work

that senator cornyn and i passed in 2010, the secure and responsible drug disposal act, and we took a very long time, as you know, mr. milione, to get those rules done but they're finally done. and it makes it easier for some of the drug takeback programs, especially with assisted care facilities, other places. but what we'd really like to see is the pharmacies start doing this. i think that would make it much more widespread than just having it in police offices and we have in minnesota in libraries. we're pretty ahead of the curb on this. i think it would be good to have them in places where people are buying drugs and bringing back things. what do you think we can do to incentivize this since it hasn't been happening? administrator milione: it's a great question. it's certainly a concern for you. we want to work with our interagency partners in try to find some long-term sustainable solution with private industry.

until that point, like i said in my opening statement it would be great if drop boxes were all over the country. until that, what we'll focus on and continue to do the takeback events. it's an opportunity to get the drugs off the street but also an opportunity to engage the community about the link between prescription opioids and heroin. we'll trying to expand those drop boxes. senator klobuchar: thank you. do you want to add anything, mr. botticelli? director botticelli: we thought once the regulation would pass it would -- we've been working with large pharmacy chains to see what we can do and are there grant possibilities within the federal government. senator klobuchar: it took two years to pass the bill and five years to get the rules. if we need more rules or another law, we can't take six more years as more and more people are addicted and dying. so if that's what the answer is, that the pharmacies say they need more rules or more, you know, forceful regulations, then we should do that. but we better get it done.

and if that's not what they need, i think they can just do it, then they should do it. so i will join with you in trying to get that done. i also want to put on the record, mr. chairman, with your permission, the testimony from hazelton betty ford, one of the leading treatment centers in the country that's based in minnesota. senator grassley: without objection. senator klobuchar: thank you very much. and just talking to dr. marvin, the chief medical officer at hazelton betty ford, he spoke about the mandate of prescription drug monitoring programs. mr. botticelli, as you note in your testimony, a number of states have enacted measures to do this already. that's part of the work that senator ayotte and i did. the bill we introduced that's part of this bill. could you talk about what barriers there are to making this a reality and if the state programs are differing so some are more intense than others and what we can do to move that along? director botticelli: so one of the things we've done, it's not just having those programs. it's how do physicians use

them. and we have looked at and we were happy there were additional resources this year through the department of justice to enhance prescription drug monitoring programs. and we also are looking at how do we accelerate the use of that information in electronic medical records to diminish the burden on a prescriber from checking various databases as well as interstate operability? but, again, i think that what we've seen is relatively -- even with good programs -- relatively low utilization of prescription drug monitoring programs. so part -- senator klobuchar: are you saying we need to make it more mandatory? we can't have this because people don't want to do it and more and more people are getting addicted and dying, it doesn't seem to be working? director botticelli: i agree. i think we've seen success of states implementing mandatory use of these programs. we've seen a decrease in doctor shopping behavior when prescribers access the information. senator klobuchar: so just making it voluntary doesn't appear to be working? director botticelli: i think with the urgency of the

situation that waiting until we get more uptake on these programs is not fast enough. senator klobuchar: ok. my last question of you is the core issue here with the governor of vermont was talking about with making it easier and easier, more of these products out there and getting approved for populations. what do you think needs to be done? do we need to change the standards that f.d.a. uses so they take better consideration of the risks of addiction in terms of approving things? director botticelli: my take on this, quite honestly, is that this is not just about the amount of those medications. but it's really about prescribing behavior. it's really not about the -- are we having these drugs? it's how they're prescribed. i go back to the study. senator klobuchar: and the amounts they're prescribed as well? director botticelli: i go back to the study i cited where this was not about whether or not we had an approved medication. this was about physicians who continue to prescribe in spite

of the fact that someone had an overdose. that's not about how many medications. senator klobuchar: so if you could wave a magic wand, i'm sure you would help with our drug takeback. that's fine. number one is to make these programs more intense, mandatory so that the physicians have more limits and the doctor shopping stops so they can have limits on how much they prescribe and when they're prescribing it? director botticelli: i would absolutely agree with that. senator klobuchar: all right. thank you. senator grassley: senator franken. senator franken: thank you, mr. chairman. sorry i wasn't here. i was at other meetings and was not able to read your testimony. our office didn't get it until late last night or early this morning. this is a subject that's interested me for decades. you're just talking about prescribing overprescription of these. one of the causes -- and senator shaheen mentioned this and i thought it was incredibly important is medical school. medical school, nursing school.

it's been something i have heard about for decades and doesn't seem to get corrected which is that we've had addiction problems in this country for a long time. this is not new. why don't we have in medical instruction to medical doctors or to students, information about what addiction is? because we don't seem to have it. and we should have it at nursing school too. but if you have doctors these drug nd monitoring programs, prescription drug monitoring programs should be mandatory. anytime you're prescribing an opioid, you should be having a look and see what this history is.

because we know now what a serious problem is, but anybody here have a strong view on medical school and training of physicians in this country on what addiction is? dr. volkow: yes. we've actually been funding several investigators for disorders and one of the big challenges for medical students has been that the medical schools say their curriculum is low. we don't have time for more questions. so we have been working to try to convince to have questions on the medical exam that relates to substance abuse disorders because that will incentivize medical schools to train medical students in the management of substance abuse disorders. the same strategy for pain. and we had a researcher that actually evaluated the number of hours that medical students get on education on pain and they found out that veterinary

schools get approximately at least five times more hours of education on how to handle pain in animals than in humans. we have a need on both sides. and so -- senator franken: they spend five times on -- dr. volkow: veterinarians you get more training than if you're a medical student. the amount of time you train and screen and properly manage pain is -- senator franken: that's crazy. if you look at data -- you know, addiction has other health -- causes other health problems too. and a lot of what people come into the doctor's office with is the result of addiction. and if the doctor understood that, we'd be -- this isn't just about o.d.'s. this is about other diseases too. and this is something that has been vecksing me for a long --

vexing me for a long, long time. i just want to touch on a couple of things and i won't have enough time here. we talked about this affecting rural white people. it's also -- in minnesota big time our american indian population. and there is an epidemic. only 2% of minnesota's population is native american but native american babies represent over 28% of babies born addicted to opioids. nd we need to address that and we've seen some good things. hannipen county has a project that has reduced the number of children born in withdraw. i was wondering what strategies anybody has to close this gap that we have between the need in rural communities and in indian communities and the available resources which

brings me to the -- just the other program -- other question that i have which is -- how are we going to gear up treatment when only 20% of people who have addiction can get treatd? dr. volkow: yeah. when we address the problem of neo natal syndrome which is the syndrome of people being born out of women that had been given opioids, we have to distinguish two different sources. one of them are women that are pregnant and they have pain and are prescribed and opioid medication during their pregnancy. in the united states, it's 18% to 24% of pregnant women received an opioid medication during their pregnancy. if they are going in their last trimuster, there is a likelihood they will have a child with neonatal abstinence syndrome. and they have prescription medication that if they are not properly treated will have a

severe case of neat owe natal abstinence syndrome. one of the questions the medical community is having, do you need to have so many prescriptions of opioids in pregnant women? the consensus is you should probably give it under very unique situations and avoid them. the second one is that studies have shown that treatment with either methadone on patients that are addicted to heroin actually improves the outcomes to the mother and to the baby. and third, the other item that is important is regardless of what drives ultimately the neato natal abstinence syndrome, the important of training physicians in order to recognize someone that's at high risk of having an infant with neonatal abstinence syndrome is you intervene. if you don't intervene then that newborn can die. senator grassley: senator colmes. >> let me move, if i might

directly, to a question of director botticelli from the office of national drug control policy. i was very pleased last summer to see my home community of new cassel county, delaware, added to the philadelphia high intensity drug trafficking area and i know you personally visited my state, my county and you recognized it like so many other states and communities is facing a very real challenge in terms of the increased frequency and intensity of prescription drug abuse and heroin addiction. senator coons: in august as part of your heroin response strategy, they received additional funding to place drug intelligence officers and drug policy analysts in pennsylvania and delaware. i would be interested in how they're working in the five regional hidtas and how you see your larger bay of adding additional law enforcement personnel fairing and how this helps state and local law

enforcement have the scales and responsibility and strength they need to tackle this very difficult challenge? director botticelli: thank you for that comment. i was pleased to announce that i think having the resources to look at increasing high drug trafficking areas in the united states is particularly important so we're grateful that we have the resources to do that. but our hidta understand, like the d.e.a., it needs to be part of a comprehensive response and the additional dollars we're able to give, not just with law enforcement intelligence but work in a comprehensive way to diminish the supply and also have that robust community response to be able to do that. i will -- i'm actually -- our hidta folks are in town next week and i'm getting a briefing from them on the response strategy. be happy to provide you with an update in terms of where they are, what measures they've looked at and how we might continue to focus on both the law enforcement and public health aspect to that.

senator coons: i think we need a combined strategy. the cara bill that's been referenced so broadly in this hearing is one i was proud to join as a co-sponsor. i do think we need a comprehensive strategy. i would be interested, mr. milione, and director botticelli, when the d.e.a. has resources to deal with local law enforcement, how do we sustain that overtime? how do we recognize this is not just sort a temporary or transtory problem, it's one we will need both additional public health and law enforcement resources for quite sometime, how could we better support valuable programs like this in congress? mr. milione? administrator milione: well, it's been the bread and butter for decades. we welcome and engage with our tate and local counterparts. we'll continue to do what we've

done. we value those relationships and continue down that path. director botticelli: i think one of the values of having and continuing to build on the hidta infrastructure becomes important. and not just around the heroin and opioid epidemic. one of the things that's impressed me about our n hmbings idta programs is their nimbleness, in terms of being able to focus whatever emerging drug threat is. we're talking about heroin and opioids, but in many parts of the country, meth continues to be a problem. we've had an increase in new psychoactive products. and we've focused on those issues that are important and really be able to move toward those evolving trends. so, you know, and obviously having state and local as part of their board and part of their structure are incredibly important to the hidta management. senator coons: mice question if i might. do we in the public health sector have the same sustained

coordination around public health provisions at the state and account -- county level and what more do we need to do to get to a strategy that will address this for the long term, doctor? dr. volkow: the implementation of public health policies varies by state. for example, the implementation of medication assisted therapy differs enormously. in some states it follows you don't have to have a whole series of roadblocks in order to get the medication. you know, it is very difficult to get the medications and also you are limited to andersen amount of time. -- you are limited to a certain amount of time. it's not very well implemented. the health care system and treatment varies from state to state as well as the involvement of the health care system with individuals that go from the criminal justice system out into the community. so there's not a consensus on ow the states are managing it.

administrator enomoto: i would say in the area of behavioral health know they need to partner with law enforcement, veterans, labor counterparts so throughout ought the samhsa programs and the programs of my fellow h.h.s. divisions are requiring that in order to get the federal funding to miro the collaboration we developed at the federal level, both interagency as well as within the department. we're encouraging our localities to do the same. senator coons: thank you. i'd like to thank the panel both for your testimony and your leadership on in very pressing and difficult issue. and i hope that chief willard of manchester will talk about the vital role that state and local law enforcement plays in sustaining our progress towards reducing america's dependency on opioids and heroin. thank you, mr. chairman. senator grassley: and i, too, thank the panel for your testimony and i'll dismiss you at this point and while you're leaving, i will call -- read

the next panel and final panel. chief nick willard is chief of police, manchester, new hampshire. the largest city in that state. he's made attacking the opioid epidemic a hallmark of his tenure as chief. prior to being named chief last year, he served in various capacities in that department since 1992. prior to that, chief willard served in the u.s. air force as a security policeman. he has a degree in criminal justice from the new hampshire technical institute and is also a graduate of the f.b.i. national academy. the second witness we've heard senator portman speak of two or three times, tonda dare. after losing her daughter, holly, to a heroin overdose in 2014, she founded holly's song