so that nobody is going into the convention with the majority of delegates, the moment you show gerald ford calling ronald reagan's down to the stage as a signal of the unity of the party, that's crucial. >> can be positive for the party to have democracy flourishing in public. for theinsberg republican national committee. thank you for explaining all of this. [captions copyright national cable satellite corp. 2016] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] students produce documentaries telling us about the issues they want candidates to discuss. students told us that the economy, equality, education, and immigration or top issues. thank you to everyone who competed this year.

in april, one of the top 21 entries will air on c-span. all winning entries is available for viewing online at student cam.org. >> white house national drug policy director michael botticelli testified tuesday on the federal government's efforts to combat heroine and prescription opioid addictions. this hearing is about three hours.

>> i'd like to call the hearing to order. without objection, the chair is authorized to declare recess at any time. the order of business this morning will be as follows. we will begin the hearing with opening statements from myself, the ranking member, and other members are welcome to submit opening statements, and with mr. coming's support we will leave the record open for -- five days, legislative days, for additional comments or statements. without objection, so ordered. when we complete the opening statements, we will turn to our panel of witnesses. the have five distinguish witnesses today, three at the

federal level, one at the state and one of the local, for our hearing. we'll swear those witnesses in and we will hear their testimony, and proceed with questions. that will be the order of business. so, again, welcome, and i will start with my opening statement. unfortunately, the united states is experiencing an historic epidemic of drug overdose deaths. today, drug overdose is the leading cause of accidental death in the united states. in 2014 -- i don't have the 2015 figures yet -- in 2014, 47,055 deaths caused by drug overdose.

that means that this hearing -- if this hearing last for two hours, 10 people will die from drug overdose death. this is a chart showing the increase of 1999. i chaired the criminal justice drug policy oversight subcommittee from 19981999, and we thought we had an epidemic back in 1999 with 16,000. i can show you some of the headlines from my local newspapers, where many people were dying over a weekend. unfortunately that is what we are seeing in my community and across the united states. unfortunately, more americans have died from drug-related overdoses in one year than all

that were killed in the link the korean war. if the current trend continues, the annual death rate could climb beyond those killed in vietnam over that multiyear struggle, in one year. the graph from "the washington post" illustrates the disturbing rise in drug overdoses between 1999 and 2014. of the 47,000, more than 10,000 americans died of heroine-related overdoses. heroin use is increasing at a faster rate -- you want to talk about a war on hand war on young people, the heroin cancer killing women at twice the rate of men.

unfortunately, we have seen, according to the centers for disease control and prevention, that with heroin deaths among our youth between 18-25 of the past decade have soared. again, leaving the deadly statistics. across all demographics, the rate of heroin-related overdose deaths has increased 286%. while the exact cause is up for debate, many experts believe that the use of other drugs is also a driving factor. they could potentially open the door to the epidemic. those already addicted turned to

hair when because it is cheaper and more readily available. mexican drug cartels have established heroin trafficking routes here in the united states and coming across our borders. now we see increased supplies in recent years. i had a chance to talk with my police chief in law enforcement folks in the district, dea folks, and we are seeing an incredible supply, and we will have some questions about where that is, specifically, coming from. we know a lot of it is coming

across the mexican border. the impact, unfortunately, is felt in communities across the nation. just a few weeks ago, i met with all the local officials, and we have one of my local officials who we will hear from in a few minutes, teresa jacobs. our county mayor in orange county, who has been forced to deal with the heroin epidemic in central florida. orange county alone -- you will hear more about this -- we have had 475 related heroin bookings in 2013. by the end of 2015, we had 840. the majority of those arrested were between the ages of 18 and 44. the obama administration, unfortunately, i believe, has been sending mixed signals about the use of substances such as marijuana, which is one of the gateway drugs. talk to anyone who was in counseling, treatment, rehabilitation, and you will find out that marijuana is a gateway drug, and many of the

heroin abusers start there and work their way up the chain of deadly drugs. according to the national institute on drug abuse, listened to this, for high school seniors are now using marijuana than cigarettes. a policy that has been adopted, unfortunately, has consequences. the just say no drug policy, championed by the late first lady nancy reagan, has turned into a just say ok policy, and now we are seeing the consequences. while improving treatment is a key, enforcement is in the must remain an essential part of combating heroin epidemics. when i saw the numbers in our locale, i said, "well, it looks like you have been able to keep

the lid on some of this, although it is now at epidemic proportions." they told me, "mr. micah," he said, "this is only because we have now antidotes that can bring these people back. the only reason we aren't seeing double or triple the deaths is because our law enforcement and first responders can bring these people back, if they can get to them in time." not only are illegal immigrants flowing over the mexican border, but also illegal drugs. we know that is the main source of the supply of heroin, cocaine, marijuana, and a host of other deadly narcotics. stopping deadly drugs from entering the united states is a federal responsibility and we will hear from some of the officials engaged in that war. new statistics show federal drug prosecutions are down 6% in the last year. this comes after a 14% drop since the beginning of the obama administration, so-called smart on crime initiative. our front-line law enforcement officers, if we are going to

save these kids and others who are overdosing, they should be equipped with the resources to prevent and save them from overdose death, not just our emergency medical officers. the ems people usually get there after the first responders, and it may be too late. this is something else we have learned from our local task force and law enforcement officials. one of the police chiefs in my district informed me that just

within the last month or so, we had one student who had to be revised from overdosing three times in one week. that's astounding. it's astounding, because he is still alive and we were able to catch it. speaker ryan announced addressing this current epidemic as a priority, and we have acted on some legislation. i believe that this is absolutely critical, that this whole drug situation, including the heroin epidemic becomes a priority for this congress. i look forward to hearing from our witnesses today as we examine how to protect our communities from this fast-growing and skyrocketing national epidemic. i am now pleased to yield to our ranking member, mr. cummings. mr. cummings, as my ranking member, we together led the effort from 1998 to 2000. i remember going into baltimore with him and conducting hearings when people were dying on the streets in huge numbers.

but we're back, unfortunately, backsliding, and here we are today. that he did a great job trying to save people in his community, and he is now the ranking member of our full committee. mr. cummings. >> thank you, mr. chairman. i want to thank the people holding the hearing on america's heroin and opioid epidemic. i want to take a moment before i start to extend our prayers to the people of brussels, belgium. >> i would join you. and i would ask everyone for a moment of silence, if we could. thank you, mr. cummings. >> thank you, mr. chairman. today's hearing is about a national public health emergency, and we need to treat it like one.

people are dying in baltimore, orlando, salt lake city, manchester, and cities all across our nation. we can no longer ignore this public health emergency. congress needs to put its money where its mouth is and actually help, help our state funded treatment programs to stop this epidemic in its tracks. drug treatment facilities without adequate funding are like firemen trying to put out a raging inferno without enough water. last week, leader pelosi sent a letter urging speaker ryan to schedule a vote on $600 million in emergency funding to help states address this epidemic before this recess. our colleague from connecticut

is already introduced this bill, and senator sheen has been pressing it in the senate. congress will not leave town until we take emergency actions to increase funding to help states combat this epidemic. we also must fully found president obama's request for $1.1 billion in 2017. this crisis will not end in a day. it will take our sustained commitment, and every one of us owes it to our constituents to make them a priority. they want us to take action, and

they want us to take action now. let me tell you why federal funding is so important. in my hometown of baltimore, i witnessed with my own eyes, in my own neighborhood, the destruction drug addiction inflicts on our communities. the first time i ever heard of a drug overdose death was 55 years ago from heroin. 55 years ago. i didn't understand it, the young man in our neighborhood who we looked up to, who turned to heroin. i will never be confused about what this was about. i have seen neighborhoods and hard-working families and communities destroyed -- in baltimore, where many of the victims were poor and black, this went on for decades. it was treated like a war rather than health emergency. we incarcerated them rather giving them the help they needed.

now things are changing. between 2006 in 2013, the number of first-time care when users nearly doubled -- first-time heroin users nearly doubled. nearly half of them were white. this epidemic has become a runaway train propelling through every family and every community in its path. it has no respect for barriers. it is now responsible for the deaths of 78 americans every single day. every single day. why is this happening? in part, as a result of doctors overprescribing pain medication and drug companies leading them on so they can make massive profits. i'd like to enter into the record an op-ed by -- that appeared in "the baltimore sun." >> without objection, so ordered.

>> i just want to read a paragraph in this article. prescription of opioids have been traditionally limited to cancer, pain, and comfort measures, but in the mid-1990's, drug companies began marketing these pills as a solution to a new plethora of ailments. in their efforts to expand the market, producers understated and willfully ignored the powerfully addictive properties of their drugs. the promotion of oxycontin by purdue pharma was the most aggressive marketing of the schedule ii drug ever undertaken by a pharmaceutical company. one family, which owns the stanford connecticut-based purdue pharma, is one of

america's wealthiest families. the richest newcomers to the list are worth an estimated $14 billion. $14 billion. as she explains, the united states has 5% of the world's population, but we consume 80% of the world's painkillers. tweet that. 5%, ladies and gentlemen, of the world's population, but 80% of the world's painkillers we consume. so yes, i believe it was unconscionable that the nation ignored this issue for decades, but now republicans and

democrats are starting to work together. i thank god that this day has finally come, and the stars are starting to align, for meaningful change. we now have people like orrin hatch, chris christie, rob portman, kelly ayote realizing the severity of this crisis and providing more funding to help our cities and states. they are beginning to realize that this is not an urban issue, april issue, a black issue, an hispanic issue, or a white issue. this is an american issue that affects your sisters, your brothers, your sons, and your daughters. here is something else we must do. we can no longer allow drug companies to keep ripping off taxpayers for life-saving medication.

the chairman mentioned just a moment ago the drug naloxone and its life-saving effects. cities all around the country are realizing the need to equip their first responders with naloxone, which can reverse opioid overdoses in a matter of minutes, but their abilities have been directly undermined by corporate greed. as more first responders began using this drug, the company that makes it, amphistar, begin to increase its prices by staggering them out. in may, 2014, it cost the baltimore city health department roughly $190. guess what? today it costs more than $400. for life-saving drugs. despite repeated efforts by my home state of maryland, this company continues to overcharge for this drug. the company also continues to

obstruct congressional oversight by refusing to produce all of the documents i requested last may, last may, about their massive price increases. mr. chairman, today's hearing is really focused on the heroin and opioid epidemic. but i hope the committee will turn next to my request for documents, as well as my request for a hearing, with executives from amphistar. with that, let me welcome our esteemed panel of witnesses. i particularly like to welcome the baltimore city health commissioner, who has done an outstanding job. she is a true national leader in developing and carrying out effective solutions to the opioid crisis. we are very fortunate to have

her heading our health efforts in baltimore, and we are very pleased to have her here today. with that, mr. chairman, i yield back. >> thank you, mr. cummings. we will leave the record for those who came in late for five legislative days. we now want to welcome our witnesses and let me first introduce them, and then we will swear you in. i'm pleased to welcome the honorable michael botticelli, the director of office of national drug control policy at the white house. we have -- the assistant director of the version control at dea, the drug enforcement administration at the department of justice. then we have -- and she is the principal deputy administrator of substance abuse and mental

health services administration at the u.s. department of health and human services. then we have -- she's the health commissioner for baltimore city health department. i'd also like to welcome my requested witness, the honorable tracy jacobs, mayor of orange county, florida. some of you have been before us, some of you haven't. we ask that you limit your statements to approximately five minutes. you will see a little monitor. you can also request additional statements or information be added to the record, so if you have a statement you want to summarize, you are welcome to do that. since this is an oversight and

investigations panel of congress, i'd like you to stand now and be sworn. raise your right hand. did you sell only or affirm that the testimony you are about to give before this committee and congress is the whole truth and nothing but the truth. all the witnesses have answered in the affirmative. we will let the record reflects that. we first turn to our own ondcp representative, the director of the office of national drug control policy from the white house. welcome. you're recognized. >> chairman mica, ranking member cummings, members of the committee, thank you for the opportunity to appear here today to discuss the issues surrounding opioid drugs, including heroin, in the united states and our federal response.

during his state of the union address, president obama specifically mentioned addressing heroin use is a priority in an opportunity to work with congress in a bipartisan manner on this issue that transcends party, income level, gender, race, and geography. we reduce the national drug control strategy, which is the nations blueprint for producing consequences for drug use. as a coordinator of federal drug control agencies, in 2011 the administration released a plan to address the sharp rise in prescription opioid drug misuse that coincided with the surge in opioid drug prescribing at the beginning of the century. as this crisis has evolved, with an increase in heroin and fentanyl use, the administration continues to put forward new initiatives to help deal with emerging issues. for example, in october, the administration announced a series of steps it took with partners, as well as federal agencies, aimed at addressing this epidemic. opioids are having an unimaginable impact across the united states.

57 people die each day from opioids in 2010, and by 2014, it was up to 78. the number of drug overdose deaths involving synthetic drugs has more than doubled since 2012. is overdose rates are harrowing, however we are making some progress. nonmedical use of opioids for those 12 and under reduced significantly. unfortunately, this process has been counteracted by the availability and use of heroin. heroin purity has risen while prices remain low. the crisis is compounded by the reemergence of sentinel, a powerful synthetic opioid which is sometimes added to heroin to increase its potency, or used unsuspectingly on its own.

its use increases risk of overdose death. while prescription opioid use forest surpassed -- a recent review article concluded that this transition appears to be a part of the transition of addiction among those with frequent user dependence rather than a response to the reduction in availability of prescription medications, as some have speculated. graduate medical education programs do not provide a comprehensive focus on the identification or treatment of opioid use disorders. a startling evaluation of health care claims data found that the majority of nonfatal opioid overdose victims were receiving an opioid from a prescriber. in response last year, president obama issued a presidential memorandum requiring all federal agencies to provide training on

the appropriate and effective prescribing of medications as part of their federal duties. just last week, the centers for disease control issued recommendations for primary care clinicians on the prescribing opioids. they also obtained commitments by more than 40 provider groups at more than 500,000 health care providers. the administration continues to work with congress to make mandatory prescriber education part of their controlled substance licensure. the administration has also focused on several key areas to prevent opioid overdoses, including increased education, increasing third-party and first responder access to the opioid overdose reversal medication, promoting good samaritan laws, and connecting overdose victims

and persons with an opioid overdose to treatment. yet there remains in this country a considerable gap that inhibits many victims of this epidemic from accessing the treatment they so desperately need. therefore, the presidents fy 2017 budget proposes $1 billion in new funding over two years to support cooperative agreements to expand access to medication assisted treatment and to expand access to substance abuse treatment providers in areas across the country most in need of providers. in just a few days ago, the secretary announced $94 million in affordable care act funding to health centers to expand the delivery of substance use services, with a specific focus on medication addicted treatment for opioid use disorders. while we appreciate congress's support, the president's proposal underscores the need

for additional funding to address this epidemic. to address the increase in heroin and illicit fentanyl use, the strategy focuses on identifying, disrupting, and dismantling criminal organizations trafficking drugs, working with the international community to reduce the cultivation of poppy. in addition, last year, ondcp created the national harrow and coordination group, which is a multidisciplinary team of subject matter experts, to lead federal efforts to reduce the supply of heroin and fentanyl in the united states. we have also committed to $.5 million in high-intensity drug trafficking area programs to develop a heroin response strategy. we have also been actively

engaged with the government of mexico on efforts to reduce the flow of heroin and fentanyl into the united states. earlier this month, i met with the mexican attorney general and other interagency representatives. we agreed to further collaborations to disrupt the production of heroin and fentanyl. this bilateral cooperation will be mutually beneficial. we remain committed to working with our partners to reduce and prevent the health and safety consequences of nonmedical prescription opioid heroin and elicit fentanyl use. thank you very much. >> thank you. we will withhold questions until we have heard from everyone. let me recognize -- and welcome him, our dea representative. >> thank you, chairman mica, ranking member cummings, and distinguish members of the committee.

dea views the combined prescription and opioid heroin abuse epidemic is the number one drug threat facing the country. i appreciate the opportunity to appear before you today and talk about what we at the dea are doing to address the threat. prescription opioids are walking users up to heroin's deadly embrace. mexican cartels are in communities throughout our country, exploiting the epidemic and flooding the country with high purity, low-cost heroin. those cartels are forming a toxic business relationship with violent distribution cells. what is the end result? in one year, almost 30,000 of our fellow americans died to prescription opioids are heroin overdose. everyone has acknowledged this is an unimaginable tragedy. dea understands that we need a balance, holistic approach to this epidemic. we stand with our interagency partners, including those represented here today, to embrace prevention and treatment. however, enforcement must be a

key component of our overall strategy. we need to investigate and bring to justice not those suffering from opioid use disorders, but those who are exploiting human frailty for profit. our answer to dealing with this drug threat -- attack supply, reduce demand, and empower the community. there are three prongs to this strategy. law enforcement, divergent control, and community outreach. my comments today focus primarily on the office of the dea that we will be more than happy to follow up with details about operation: rolling thunder. it's a 360 strategy focused on the violent distribution in our communities and the mexican cartels supplying them that is killing so many americans. with 1.6 million dea registrants, we are uniquely positioned to help with this fight. the vast majority of those 1.69 million registrants are law-abiding citizens, either our practitioners, pharmacists,

manufacturers, and distributors working in communities. we investigate the small percentage of those operating outside the law, but yet inflict considerable harm on our country. for example, practitioners not prescribing for a legitimate medical purpose outside the usual course of professional practice. pharmacists not performing their corresponding responsibility to ensure the prescription is valid. manufacturers and distributors not upholding the regulatory obligations. how do we do that? with our tactical diversion squad, are groups, and great federal and state and local counterparts. our tactical diversion squads are specialized units. we have 69 of them nationally. we are going to add 8 within the next six to nine months.

we are creating two mobile tactical diversion squad that can deployed where the need is, giving fluid enforcement capabilities. we have 700 skilled investigators spread across this country. both the tactical diversion squad and the diversion groups work with their respective groups to bring charges against those operating outside the law. where appropriate, they bring administrative actions. dea as order to show cause or immediate suspension orders, potentially revoking their registration. as i said earlier, enforcement will be a key part of the overall strategy, but engaging with that large community and educating them are just as critical. in the last two years, we have conducted more than 300 events, providing education and guidance to thousands of registrants. since 2011, with our great partners at the national association of boards of pharmacy's, we have created 64

pharmacy diversion awareness conference is in 29 states that have had the privilege of interacting with 10,000 employees about the risks of diversion. finally, we will continue engaging with our interagency partners on expanding access to treatment, mandatory prescriber education, and a safe and responsible disposal of unused prescription drugs. early in february, a leading national chain pharmacy said they would put drug-backed kiosks in 39 states and washington, d.c. we see that as a positive step in the right direction. we look forward to the day when those secure kiosks are so commonplace that people can dispose of their unwanted and unused prescriptions frequently, safely, and conveniently. dea will also continue our national takeback initiative, with events every six months. during our september, 2015 take back, we collected more than 370 tons of unwanted, unused prescription drugs. the next national event is april

30, five weeks from now. for almost 20 years, i have had the privilege of working with the great men and women of the dea along with our federal, state, and local, and foreign counterparts. this current drug threat, the subject of this hearing, is unlike anything i have ever seen. we at the dea will do whatever it takes to fight this epidemic. we will attack supply, we will reduce demand, we will do our best to empower communities. i thank you for the opportunity to appear before you and look forward to answering any questions you have. >> thank you. we will get to questions after all of our witnesses. let me recognize the deputy administrator or substance and abuse mental health services at the department of health and human services. welcome, and you are recognized. >> good morning.

members of the committee, my name is -- and i am the principal deputy administrator, honored to have been delegated the authorities by secretary burwell. many thanks to all of you for your leadership to raise awareness and catalyze action on the nation's opioid crisis. as you have noted, this is truly a matter of life or death. i know prescription drugs, heroin, and fentanyl have had devastating consequences in many of your districts. i know this because we have partnered with leaders in your community as we implement life-saving programs for individuals with or at risk of opioid use disorders. the state of maryland and city of baltimore are addressing high rates of opioid related emergency room visits and utilizing peers to recruit patients.

in florida, our monitoring program helped to get critical data to the front lines of the fight to prevent prescription drug abuse. in wyoming, we have seen fantastic progress as the state has implemented our strategic prevention framework, using data and science to focus their efforts. in utah, they are increasing access to residential treatment for pregnant women with substance use disorders. healthy babies are being born and progress is being made. while treatment is increasing, -- as a nation, we will not stem the rising tide if only two out of ten people with the disorder have access to the treatment they need. it wouldn't work for diabetes, it wouldn't work for hiv, and it will not work for addiction. we must join together to ensure that everyone with an opioid use disorder who seeks treatment finds it. toward this end, we are proud to support the president's national drug control strategy and secretary burwell's initiative.

in hhs, are initiative focuses on high-impact areas -- changing prescribing behavior, increasing access to and naloxone -- it is simple. to prevent opioid misuse, we need to reduce the number of pills in people's medicine cabinet. we will encourage the use of timelines in order to chart a safer, more effective course -- dedicated, well-trained professionals. we must give them the tools they need to deliver high-quality, safe, and effective care stop since 2007, we have provided education to 72,000 health care professionals. we also reach local communities to get grants, administered together with ondcp.

they do the yeoman's work to promote health and prevent drug use, including misuse of prescription drugs. the second aim of this initiative is increasing access to naloxone. as you have noted, it can reduce a potentially fatal opioid overdose, but it only works if it is there when you need it. this prevention course, one of the targeted strategies would promote prescribing of naloxone, particularly for patients with high risks of overdose. we also let states now they may use it to block grant funds, to disseminate naloxone and for training and education on its use. soon we will be issuing and announce -- we appreciate your strong support in this area. the third area of the secretary's initiative is expanding use of medication

assisted treatment. research tells us that medication, along with behavioral therapies and recovery support, are important components of an evidence-based treatment plan. however, resources are limited. as the director noted, the president's fy 17 budget requests $1 billion in new mandatory funding which would focused on the continuum of prevention and treatment services, expanding the use -- and building the substance abuse treatment workforce. it also includes $30 million in new mandatory funding to evaluate the effectiveness of medications and treatment programs under different real-world situations. on the discretionary side, we propose to maintain and grow investments made by congress in 2015 in 2016. we are providing for 23 more states with expansion capacity, and we are preserving the behavioral safety net by

maintaining increases to the substance abuse, prevention and treatment bloc. we are also working with doj to clarify and enhance the connections between mat and the criminal justice system. drug courts are the most successful criminal justice response to addiction in our nations history. this year, we will prioritize treatment that is expanded to ensure every state has it fully implemented. with all this new care, who is there to provide it? we must ensure that the substance use workforce is sufficient to meet growing demand. as such, we are requesting $10 million to test the safety and effectiveness of expanding it to nurses and physician assistants, and the administration has requested $20 million for our

colleagues at the house resources and services administration to grow the workforce. finally, we are proposing a new regulation to increase the patient limit for physicians who have a waiver to prescribe. members of the committee, thank you, and i look forward to working with you to ensure that we are using our investment strategically, responsibly, and effectively deliver the greatest possible impact. >> thank you. we now recognize -- with the baltimore health department, city health department. welcome and you are recognized. >> thank you very much. members of the committee, thank you for calling this important hearing. i'm here as an emergency physician who has treated hundreds of patients with opioid addiction. i'm also here is a health commissioner, where i have declared the epidemic to be a public health emergency. last year, baltimore launched our three-pronged approach to fight this on the front lines. first, we have to save lives. that is why we are making the opioid antidote, naloxone, available to every single resident.

in the er, i have given naloxone to patients who are about to die and have watched them revive within seconds. naloxone should be part of everyone's medicine cabinet. in 2015, we trained 8000 people in the city on how to use it, including our police officers, who within six months have saved 21 citizens. in october, i issued a blanket prescription for naloxone to 620,000 residents of baltimore. but saving a life without connecting it to treatment is just treading water, so our second approach is to increase on-demand prescription treatment. we believe that treating addiction is a crime, is unscientific inhumane, and ineffective. our city's criminal justice and public health teams have partnered on drug treatment court's and on a pilot project were individuals, small amounts of drugs will be offered treatment instead of incarceration.

the science is clear -- addiction recovery requires medication, psychosocial support, and wraparound services, yet nationwide, only 11% of patients with addictions get the treatment they need. imagine if only one in 10 cancer patients got chemotherapy. yet my patients come to the er seeking addiction treatment and i tell them that they must wait weeks or months. i have had patients overdose and die while they are waiting because we failed to get them help at the time that they asked. in baltimore, we have started a 24/7 phone hotline that includes immediate access to an addiction counselor or social worker and a direct connection to make an appointment.

evidence shows what works for treating addiction but we are nowhere near getting everyone treat. when it comes to wraparound services. take housing. 18,000 to railways. for less than 100 recovery pets. addiction treatment reduces crime and seeds society money. we should invest in treating incarcerating it our third approach is to produce addiction through educating the public. we launched a campaign to reduce stigma and encourage treatment. that includes billboard ads and targeted outreach. kindw has its first in the of training so anybody who watches a short video can printout -- prescriptions.

doctors want to do the right thing. we have to give them the tools to do so. guidelines. we are alerting doctors to one in threeds overdose from opioids involves valium or xanax. these are usually prescribed together. i had a petition with other health officials to call for a warning risk communication on opioid and benzodiazepine. there is a lot baltimore has done to emerge as a model of overdose. we further support from congress including expanding funding for our services like housing.

directly funding local jurisdictions on the frontline -- removing regulatory barriers and regulating the escalating aice of naloxone and funding national reduction in pain. the epidemic of opioid addiction is a national public health -- wency in it addiction are all in this together. thank you for calling this hearing. recognizeeased to are my district, then they

of orange county, florida. is the principal city. we have our mayor who started a heroin task force when we were hit with the epidemic. she is accompanied -- but they are not going to testify. george washington or public health director. david segal who lost a daughter to a joke overdose and has turned tragedy into a concerted public effort and caring sessions is a former city commissioner from winter park's. welcome. i recognize mayor jacobs -- welcome. >> thank you. membersmember cummings, of the committee, thank you for calling this hearing and thank you for this opportunity to discuss a serious threat.

county,of orange florida, alameda share a few statistics. i would like to ask that a statement from one of our constituents be added to the record. mr. siegel is president of victoria's voice foundation. >> so ordered. >> thank you print many of you know orange county as the home to orlando and 12 other municipalities. if a population of 1.2 million. we broke a national record for tourism and entertaining more than six to 2 million visitors. many of you do not know that last year we also lost 84 lives to heroin overdoses. probably nobody will know that that was a 600% increase since 2011. four years ago, like so many other counties, we were fighting -- and we were worked hard, we have adopted regulations at

local and state level. we provided resources to break opioid addiction and we were pretty successful. frontline has moved but the battle is tougher than ever. too many prescription drug abusers have found an inexpensive and deadly alternative, era when. despite central florida strong economy and our extraordinary quality of life, heroin has exploded. usersear, 2000 heroin moved through our county jail. many of these -- most of them not possessing, but other offenses. resulting from the debilitating effect that heroin use as. housed 100 expectant mothers attempted to opioids. jail frankly, our county has become the treatment center of last resort for so many people.

do not realize the threat that heroin poses. natalie to the lives of the addicts, but if epic of our community. for the good of our citizens, we .re fighting hard last summer i convened the heroin task force. we have 22 high-ranking officials that serve only task force, from our chief judge to our state attorney, to medical professionals, to our superintendent of public schools, two representatives from our three colleges. i commend the effort of the orlando police department, as well as our metropolitan bureau of investigation. since we fully informed this task force, they have arrested more than 370 heroin related incidents in a six months. last month we concluded our efforts and may 30 seven

recommendations, similar to the comments you heard from my colleagues here. we recommend bond increases for trafficking. we recommend media and social media campaigns morning about the deadly nature of heroin. heroin is the serial killer among our community and so few people recognize it for that. coordinated efforts to avoid fatal overdoses by demanding access to naloxone, i commend the work of my colleague. naloxone as you heard, is a life-saving drug used in severe overdose situations. and also, to look for new opportunities to fight addiction by coupling detox at our jail with addiction treatment programs using the drug the vivitrol. in addition to moving forward, the implementation of these recommendations, we are working with our partners, which has

teamed up with of the national league of cities, as well as with other organizations to implement the best practices. we know there is no single solution, but there are some universally effective approaches. enforcement is absolutely critical to combating heroin use. we must be tireless in educating people that addiction is an illness that requires serious medical treatment. from law enforcement to families, the life-saving drug naloxone needs to be more accessible without a prescription and available at a reasonable cost. and once one point. i want you to know that in orange county through our collaborative effort, we are committed to doing everything we can with the resources we have. here is where we need your help. help stop the influx of drugs across the border. we need you to continue to expand your efforts to stop these deadly drugs before they enter our communities. law enforcement will do their

part, but the federal government must do everything possible to keep this plague from our shores and communities. help us treat more addicts. with a regional population of 2.5 million, we have only 26 beds for the uninsured, and yet 62% of the overdoses in our community are among the uninsured. and help us raise awareness so that more people will choose not to try this deadly drug in the first place. to end this crisis and to save lives, we all need to be engaged. i thank you for your attention to this critical issue. i thank you for your leadership and for your service to this country. >> i thank you, mayor jacobs, for participating today. now, we will turn to questions. i'll lead off. the scope of the problem that we are facing as, i don't think

people are comprehending this. from 16,000 when we chaired the drug, criminal justice drug subcommittee, 16,000 to 47,000. we are approaching 50,000 in one year. heroin is only what? 20% of that, 10,000 deaths. when are the figures coming out? >> we hope to have those by the end of the year. >> by the end of the year? we can't get them until then? >> part of the issue is this data gets reported from county -- >> 47,000 from 2014. count,, folks, the 35,000 automobile deaths in the united states. half of those people have some

kind of substance in their system when they are killing themselves. it used to be that the biggest killer of teens was automobile accidents. now it is drugs. that right? >> that is correct. >> it is killing our youth. we haven't even gotten into firearms. firearms are the tool of the drug trade and they have illegal weapons they are using to commit robberies, mayhem -- again, it is an astounding number. we haven't killed this many in multiple year wars as we are killing in one year. we will lose guys, half a million people in one decade at the rate we are going, or more. every family has been affected by it and now it is just a slaughter out of control. now, we have a lot of responsibility and i am all for treatment.

treatment is at the end of the process. a have already been addicted. we have got to stop this stuff at our borders. i sat with our police chief. we put in place the -- i had to do that by legislation a number of years ago because they played political games. even the creation of high games we did it years ago. here we are, far beyond where we ever were then. this is out of our newspaper six days ago. these deadlyging substances. mexicant just parallel -- you talked about mexican --

not just illegals are coming across the border. but they are coming across with drugs. isn't that right, mr. maloney? testimony: yes, that's correct. >> i saw the pattern. they are cartels. they are organized. did you all see el chapo? he said he came across the border. it was like a sieve. after the most sought drug dealer and he crosses the border like a holiday visit to the united states. somehow, we've got to get a handle on this. there prosecutions, when we looked at trafficking with illegal weapons is down. and prosecution. i talked to some of my da folks -- they are not going to say this -- but it is hard to make cases on these guys.

a lot of cases are dropped on the traffickers. sir, we have, prosecution. giveuild the case and you them to the district. i am going to demand a meeting with my u.s. attorney in the central district and see why there prosecutions are down. but they are down. did you know that? also seen that the sentences are up and that we are focused on the -- mr. michael: they are telling me that it is hard to make the case. they are bringing deadly substances in. and the trafficking pattern, some is coming through the u.s. mail. they told me the mail is starting to track that down. they get across the border and then they transit it across the united states like some kind of a gift package. is that correct, sir? they were also intent to get the package there on time.

germso get the deadly there on time. so we have to look at every avenue these guys are using. they border -- i was in mexico years ago. i do know if you came with me on that trip, mr. cummings, but -- you can do ada signature. you have looked at the stuff coming across. where is it coming from? >> mexico. representative mica: metalico best mexico where the amateur hours. but now they are dumping the stuff in a community. by the time we get the treatment, it is way too late. downall for them a lot to and having that with our first responders. but i told you the first story

when they've policed chief tony, three times in one week, a student, they had to revive him. they had to trade at the prescription drugs in the cabinet with meloxidone. put the chart up on heroine opioid-- ok, look at the drugs at the top and heroin. we have actually brought that down a little bit. it went. so we have been somewhat effective in cracking down on prescription drugs. but look what is happening with heroine. it is off the charts. it is being replaced with a cheaper and more available -- you verify this from dea. they see the prices down. >> that is correct. why is the price down when the supplies all over the place? baltimore,ust

washington, d.c., orange county, it's every state in the united states we are seeing this. partly, sir? >> that's correct. again, i get a little hot to trot over this, but we deal with -- our job is protecting the citizens of the united states, primarily national defense. we saw what happened with the brussels attack. we are being attacked in our streets, in our schools, in our families with this. again, they killed today 40 people. in thell 50,000 people latest statistics we have, which are more than a year old. and i know tough enforcement works. it worked with mayor giuliani. they stopped the drugs with zero tolerance. now we say may be and i just announced a new federal policy, just say ok, instead of just say no.

>> i would agree that part of our strategy is to focus on primary prevention. that, by delaying when people use, particularly kids use alcohol, marijuana or tobacco, we substantially increase this fact that they will have a life free of drugs aired representative mica -- of drugs. representative mica: and are you aware that high school students are now using marijuana more than cigarettes. i would like to yield now to mr. clay. representative claim. thank you, mr. chair. thank you for your comments on this and the opioid epidemic. let me start with dr. win and i commend you on the

groundbreaking work you are doing in baltimore. you are not just talking the talk when it comes to speaking out on ending the stigma related to addiction. you are walking the walk when it comes to expanding access to treatment for your residence. -- residents. you provide treatment on demand on a 24/7 basis for baltimore residents. i would imagine that insuring someone can access treatment as soon as they present themselves as willing to do so is a powerful tool for making sure that they actually begin treatment. and that your approach will save thousandsf of -- or of lives as a result. true treatment is the medicaid exclusion, which prohibits medicaid from paying for community-based, non-hospital

inpatient residential treatment in a facility of 16 or more beds . unfortunately, the imd exclusion means that, if you are on medicaid, you are treated like a second-class citizen, unable to thess what may be appropriate care for your substance use disorder. residence you are responsible in baltimore, do you agree they should have access to the medically appropriate care they need, whether or not they are on medicaid? >> thank you, commerce and clay. i absolutely agree. thank you for it and that addiction is a disease. if a patient came to the hospital with a heart attack, we would never say wait three weeks and, maybe, if there is a bed available, we will get used in then. is and exclusion appropriate.

the way to move on the federal level would allow us to increase treatment for all of our patients regardless of their medicaid status. : that wouldve clay put us in the same footing as everyone knows, so that we would not be seen as discriminating on en: level of their area dr. w our treatment incapacity is one in 10 nationwide. representative claim: and i want to thank you for the reader today. every city and county should have a commission raising the alarm as forcefully and as a en is, ands dr. w hopefully orange county has. and congress will finally he the call and do something significant about the opioid asdemic, because it seems

though we, as a country, have come together and decided this is a national emergency. we should sit up and pay attention. so let me thank you, too, mayor jacob, for being here and what you do to raise the level of awareness in your community. miss inamoto. you testified about the work that samson does. can you describe that work in additional detail? billionified of the $1 of military funding. why is it important that samson receive these funds?

as you articulated, -- capacity of our treatment the need exceeds the capacity of our treatment today. and it's person that seeks treatment, just as dr. wen has done, 24 hour treatment is necessary. this proposal for 900 $20 million to be infuse across two years, we think that would supercharge the community with the need for individuals seeking treatment will have an open door when they are ready to get that treatment. as we know, the window can be small for some people. and we need to take advantage of that opportunity when they come knocking. representative clay: thank you for your response. i yield back. mica: i recognize

the chairman from ohio. : in my community, i was touring a brand-new hospital. back to a conference room to meet with the leadership of the brand-new hospital and asked them what is their most significant challenge. babies being me born to opiates. a brand-new hospital, out of all of the funding issues they would have, you would not have thought that the use challenge of a brand-new hospital was babies addicted to opiates. mr. bucket shelley, thank you for all of your efforts. a greatyou are doing job and i appreciate your advice to congress s to how we would formula -- as to how we would formulate our response. ms. ms. enomoto, i would like

to put up some of your slides here in the first being " approximately one million americans need, but do not access treatment for an opiate distress to shoulder." when we hold these hearings, we don't do them just merely for increased community awareness. congressional to do list and agency to do list. so that is why i am turning to your budget justification. for example, more than 80% of state prisoners, 72% of federal prisoners, and 82% of jail inmates meet the criteria for

having either a mental health or substance abuse issues. staggering numbers. 72% federal, 82% jail inmates of mental or substance abuse issues. next slide. studies show, your budget ,ustification, ms. enomoto after i left that hospital, i then began the quest to try to find out where are the resources . how can we find the resources to find treatment? in our criminal justice system in our community, i found people strolling to find treatment to those who are incarcerated. and then i was introduced to a prohibition in your agency's

funding that prevents it from being utilized for those who are incarcerated. documents that indicate that the problem -- we have a self sorting, right? we have people who present themselves in the criminal justice system with the problem area we have an understanding that, without treatment, they will not be able to transition and we will, as our chairman has said once again, beep providing assistance to them in either an overdose situation or see them again in the real justice system. funding, therer is an exclusion that prevents communities from using dollars that they receive from you to actually address that for people who are incarcerated. comments, in medicare and medicaid, there are similar exclusions that prevent people who are entitled to receive their treatment from receiving that treatment. , hr 476, that

would eliminate those restrictions, that would say this is funding that is already there and it is not an increase of fun and although i am for increasing the funding, but these are funds that are already there that would allow those people to receive it. , your agency by rule could eliminate that restriction. why don't you? know -- you know, i think the issue you wanted out is important to communities all over the country. we know that people in our jails come in our prisons, are represented with mental illness and substance abuse. at the same time, we strongly support of purchase, such as drug courts and diversion, early diversion. we have made significant concessions --

turner: itive appreciate that. but can you tell me why your agency will not waive never permit and allowed the it could be? ms. enomoto used: i want to give you an accurate answer. i can follow-up with you. representative turner: i appreciate that. and i would encourage members to support sb 476. representing -- representative cummings: dr. wen, i want to thank you for being here. at the beginning of the meeting, we put into the record the effects of opioid over prescription evident in rooms entitled. the op-ed explains we are now seeing the increase of heroin

overdose because prescription painkillers are being overprescribed. i want to be clear feared i am not try to blame the doctors. -- i want to be clear. i am not trying to blend the doctors. , do you believe one reason we are seeing an uptick in overdoses because of the abusive prescription opioids? yes or no? dr. wen yes. representative cummings: the op-ed has a startling statistic. "we are consuming over 80% of the world's painkillers." the op-ed explains that drug companies are actively eroding -- promoting this problem.

in the mid-1990's, drug companies have been marketing these pills for a new plethora of ailments in their efforts to expand the market, producers understated and willfully toward the powerfully addictive properties of their drugs." that sounds like drug companies are almost like drug pushers. the op-ed cites several examples, for instance, it says "the promotion of oxycontin by urdu pharma was the most aggressive firm a -- progressive marketing of a schedule 2 drug ever taken by pharmaceutical company." this is big business. combatthe world do we this massive and aggressive effort by drug companies?

makingw, when they are [indiscernible] dr. wen: thank you for asking that question. i appreciate you saying that. doctors want to do the right thing. when we talk to our communities, our youth also recognize -- we if you youths in school, ask whether heroin is good or bad, they will say it is bad. but because of the aggressive marketing of drug companies, we have this expert tatian that there should be a pill prescribed for every pain. change.what we have to we have to make sure that doctors get the resources, the tools they need, including prescription drug monitoring programs, including guidelines that would help with safe prescribing, but also the resources when we are in the ar -- the er. we need the tools to connect their patients to treatment. otherwise, we know that patients need care but we cannot deliver it. cummings: you

talked about guidance sent out. does it also include using painkillers that are not so addictive or not addictive at all? dr. wen: yes. it includes three things. one, the necessity of coke xone withng melo opioids. the second is to be careful of the opioid medications, knowing that they are not first line medications. that they should only be prescribed for severe pain. and the third is the danger of in -- of ben's adapters representative cummings: so it's about profit. achieved the list of america's 50th -- 50 wealthiest families.

that's appalling. i call that blood money. because people are dying big-time. somethinggo back to ms. enomoto and maybe others of you can answer this. yesterday, i was talking to a reporter. and he was saying, cummings, aren't you concerned that, with even more money being requested for treatment and to deal with this problem, because there are intony more people getting opioids and heroin, that money will be spread so thin that it will not have the kind of impact that you are hoping for? botticelli: i think we need to have a conference a response to that. first and foremost, we need to

rein in prescribing behavior and united date. the centers for disease control put out recommendations last week that closely follow the guidelines that dr. wen put out. we know this is a significant driver to the problem. we also know, despite all of our efforts, we still have too many people overdosing and dying, largely because they can't access treatment programs when they need treatment programs. and this is why that the president has put forward a significant proposal to expand treatment capacity in the united states. i hear this wherever i go. i just did a town hall forum in .oledo, ohio i asked the sheriff the wanting the federal government should be doing to address this opioid epidemic? he did not say more police officers. treatment capacity. we are looking at how many people need treatment and adjust the proposal to really focus on making sure that as many people

as possible had access to treatment when they needed it. representative cummings: one more question. dr. wen, what happened? in other words, this was not a problem before -- not as much of a problem. but then something happened. can you tell me what happened? the german that fighter -- and i understand people moving from the opioids what happened but with regard to the opioids to get so many people on them and then for them to move to heroin? do you know? dr. wen: my understanding is that there was aggressive marketing by drug companies. so that the pain scale is something that is asked of every patient of the time in the horse -- the course of their hospital stay. the goal should not be getting to pain-free. the goal should be getting to appropriate treatment. yet this is the expectation put on patients and doctors. doctors are put in a hard place of satisfying those requirements

when all of that does wes for the drug company -- was done for ies' benefit. theesentative cummings: patient as a tool. and then comes in and doesn't the truth. and says i have a 9. does that happen? dr. wen: that definitely happens. and the doctors feel that they have to get the patient's pain to zero. mr. botticelli: we have set up an expectation that opioids are the first line against pain therapy. for we are trying to do is, -- particularly for people with chronic pain, that opioids is not the first line of defense to

really substantially reduce pain. andave to focus on other -- evidence seems to be pretty strong that people who are in crime pain don't have significantly better functioning when they are on opioids. we need to be thinking about things like exercise and diet and cognitive behavioral therapy opioid-based therapies, especially for people with chronic pain. cummings: mr. turner asked a critical question, ms. enomoto, when he talked about -- i guess he was talking about treatment imprisons. is that right? and what stops you from providing treatment in prison? is that what he was asking you? ms. enomoto: yes. representative cummings: there is a regulation that says you can't do that? ms. enomoto: yes. and i want to check into that to give you an accurate answer. representative cummings: thank

you. i wonder if that is something that congress should be dealing with. i do not know if that is in your control or in our control. do you know, mr. botticelli? mr. botticelli: i do not. representative walker: i appreciate this hearing. i appreciate this panel of witnesses being here today. mr. botticelli, you talked about treatment. i think you mentioned the sheriff, that's the one thing the federal government can do. needs -- is good and we need more of it, but that is reactive after the problem exists. is that fair to say? so let's start from the very basis. i am married to the medical community. my wife works at a level one trauma center. the one of the things that i have seen as a minister for two decades is the introduction of marijuana.

we've heard the statistic today that more high school seniors now do we instead of cigarettes. you recently discussed the legalization of marijuana during a 60-minutes profile. you think this could lead to future drug use among the youth? evidence isli: the pretty clear, when you're talking about early drug use by youth, particularly alcohol, tobacco and marijuana, that increases the probability that people are going to have a more significant problem later in life. in the episode i talked about the fact that i and the federal government do not support the legalization of marijuana. look atieve, when you the data in terms of the high levels of marijuana use that we have among youth in the country, and particularly when we have an industry that is quite honestly targeting our youth with things like funny cartoon characters and edibles, that we are in for more significant problems in the united states.

we have been tracking data for the last 40 years. what it has shown is that, when perceive using drugs, particularly marijuana, as less risky, we see an increase in drug use. not only do we have an historically high levels of marijuana use among youth, we are also seeing historically low levels of prescription -- a perception of risk of marijuana use among youth. walker: doese anybody disagree with the findings? is everybody agreed that this marijuana usage is the beginning of what potentially could be a greater problem? record, i am seeing everybody say yes except for dr. wen. dr. wen: it is one contributor.

a lot of people who start using heroin begin with using perception painkillers. walker: sometimes a first introduction is through purchasing marijuana. his effort to say? usingn: and also through other prescription drugs. representative when -- representative walker: i want to make sure that we are not representing doctors as the bad guy. they have learned to become master manipulators, as far as going into doctors offices and emergency rooms. mr. cummings talked about the different pain levels and threshold. obviously, there are scoring systems by customer satisfaction indexes that dr. -- that hospitals have to work with. ? is that the dissent? dr. wen: -- is that fair to say? are triedost doctors

to do the right thing and most patients are getting -- i tried to get the care that they want. amber is my knee and i will have some pain. but that does not mean i should be prescribed an opioid. representative walker: we need to continue to be -- to do better. i think of richard and jennifer in north carolina. they had a son who had no drugs in his system except one thing. he had played if a bug in the night before. he had taken one prescription pain pill from his mother's medicine cabinet and it killed him. message inaken that burlington, north carolina, and traveled through the state to bring that. i am overwhelmingly alarmed at the spike and i would like to see the 2015 numbers as soon as

they are available on where we are going with this heroin epidemic. it is a problem for all of us and we need to do more. mica: let me recognize the gentlewoman from new york, ms. maloney. it isentative maloney: encouraging to hear your testimony and the efforts taken city, state, and federal governments across our country. come in congress, need to put money where our mouth is. in the short term, i urge my colleagues to approve the $600 million in emergency funding, which the professionals are asking for, to combat this epidemic. from what i am hearing from dr. wen and others is, if we hit the treatment level when they are

becoming addicted to the painkillers, then it doesn't get to another level of the opium. i think, if we could fund it, that would be important. the senate recently acted on this crisis. they passed the comprehensive addiction and recovery act of 2016 to help prevent and treat the opioid addiction. but it does not provide any funding. is a program, mayor jacobs, that doesn't provide any funding? does this program help people suffering in your city or your area? jacobs: obviously, congresswoman, funding is a necessary component of any program that we offer. i could and just one thing, because we talked a lot about treatment. we have mentioned that that is on the tail end, that's reactive.

this country came together. it galvanized around tobacco use. and it profoundly changed the way our youth look at that. if this country would come together, if the congress, if the state and local level would come together around the campaign of awareness about how serious heroin use is, opioid drug, painkillers, all of those things, i think we could make a bigger impact at that level and stem the tide of this. representative maloney: i appreciate that point. but that whole efforts stand access to tobacco, access, and it made it more difficult to have access to tobacco. i know the cdc just came out with some guidelines that basically says don't prescribed this so easily. you should have a higher threshold for it, as dr. wen said. when you fall down, you bruise

yourself good you are not always -- you're so. you're going to have some pain sometime. we need to lower the expectation that you are not going to have any pain. have certainly better to pain them become addicted to heroin or something worse. the maybe some concrete thatlines on access to it maybe the scientific community should define what pain level should have access to opioids. and that it should not be something that everyone should expect and be a pain free the whole time they are in a hospital. how would you react to that, dr. wen, to having guidelines that really stand access to very severe pain levels? because what we are doing, for someone to be comfortable for a week, we are turning them into addicts. and it's --

i would say to my colleagues on the other side of the aisle and on my side of the aisle that we shouldn't leave here until we the that $600 million for program. what good is a program if you don't find it? it makes it somewhat we are doing something when we are not really doing something. what they need is the treatment in the field. dr. wen but i would like to askdr. wen, what do you think about reversing it? givingt education, but doctors help but knowing what threshold of pain would be necessary before this very dangerous, addictive drug is allowed? with you thatee doctors need further guidance and tools in order to make the best decisions possible for the patients. and having guidance would also be useful because we don't want to punish doctors who are doing the right thing. currently, when reimbursement is

tied to get in doctor or a getting that patients to become pain-free, that becomes very difficult for the doctor to practice appropriately. i also want to caution that there are appropriate uses for opioid medication, for cancer pain, for surgeries. we don't want to eliminate that altogether. representative maloney: i agree. but direct guidelines. who would do that, the cdc? : the cdc guidelines we agree with and we would hope they would go further and requiring the co-prescribing maloxone and helping us to put further warnings, including box warnings on benzodiazepines and opioids, which are the highest risk recommendation to alert health patients and doctors. representative maloney: my time is up. thank you. chairman mica: let me see. we have mr. buck of colorado. you are recognized. representative thought: thank

you, mr. chairman. in 1970, congress passed the for the cases with children. as part of that, a waser-resistant container developed for that purpose. we are now dealing with the situation where there are a huge number of young people get these opioids from their parents' medicine cabinets. i have been made aware of a product that i am holding right here which costs less than a dollar. it would increase the cost of the prescription less than one dollar. and it is -- it has a combination on it that would require the parents to open a

that. if a child's right to get into this, it would be apparent to the parent that someone tried to open this but did not have the combination. mr. milione: we support anything that would serve that purpose. we are aware of that company and that device. buck: you might also recognize that the company comes from the great state of colorado. mr. milione: we would support the take back kiosks, to get drugs out of the cabinet. that is a part of our overall strategy. that wouldogy prevent those dangerous drugs getting into the hands of children or anyone, we would support. buck: i am not a big proponent of the administrative regulations. but can you, by regulation,

require that dangers grabs be dispensed in packaging like this? can require that the regulation require the disposal. i can take that back and look at it. we've got to navigate somewhat carefully because, if this technology were made widely available, that would be great. but it would have to come from a private entity. not a mandate necessarily. representative buck: we do need an act of congress to require -- obviously, we are not going to a particulary or technology, but would you support opioid to be dispensed in some kind of secure container? mr. milione: it would certainly help preventing it from getting into the hands of children and something that we have to talk to about or follow-up if there was impending legislation. representative buck: i would appreciate that much.

, the federalcelli government dispenses drugs through the v.a. and other agencies. require and it active congress are for the federal government, for purpose is of dispensing drugs to federal employees are veterans use packaging like this without a federal law from congress? mr. botticelli: we would have to go back and look at what kind of authority we would have or if the federal government needs additional authority to do that. of what wethat, part have in trying to do at the federal level, is ensure that every federal prescriber at least at -- has some level of mandatory education. but in terms of mandating a package, i don't know if we have the authority re: -- or if we need additional authority.

representative buck: i look forward to working with you to try to develop in this area. i thank you, chairman. and i yield back. representative lynch: i do want to associate myself with the words of the chairman and the ranking member early on in this issue very there is much we can do on the treatment side. also thent, there is opportunity to reduce the number of people that require treatment. i think we have to double our efforts in that regard. michael botticelli, the to see you again. mike for those who don't know, headed up our efforts in massachusetts for lots of years in i want to thank mr. milione for the dea's help. my state has been overrun can you have assigned the agents working with local police in our area.

we appreciate the help there. that has been an enormous help for us in trying to interdict some of the heroin pipeline coming up into the boss area. cofounded ther of pushing house in boston, a treatment facility. our kids are coming in so young with addictions to both opioids and heroin. we've got basically 24 beds for boys, 20 for girls. but i've got a line out the door and it's happening over and over and over again. and i do want to say, just as a sideline here, as i talk to our young april, and we have put through thiskids through our home. while i don't know if marijuana

is a gateway drug to heroin, but every single kid that i am dealing with that is on opioids and heroin started with marijuana. there is a perfect match. 100%. every kid i am dealing with for heroin and for over a way, when i asked them, what did you start out with, they all say marijuana. so maybe there is some susceptibility there. i'm not sure. it is not anecdotal. it is more than that. it is empirical, over thousands of kids. a point in that direction. it deserves a cautionary note in terms of some of this marijuana legalization. i think we will find ourselves a huge problem. one thing i want to talk about a get your opinion -- we haven't talked about the power of these opioids. i'll give you a couple of examples. district had amy tooth problem. she had an extraction.

they gave her a large prescription of oxycontin. she consumed that. they went back and complain, falsely she tells me now, of continued tooth pain. so she is yanking teeth out of her head just so she could get prescriptions of oxycontin. that is unbelievable. and i talked with some of my doctors in the boston area. and they tell me that the chemical changes in the brain. it overrides -- the oxycontin and the hundred phone -- hydrocodone overrides the endorphin creation in the brain. so it is more powerful than the endorphins that the brain can produce on its own. that, wheny come off they need that, that is why they are going for more oxycontin or heroine, because it's the only thing that can scratch that itch. so we got to think about this. these drug companies are creating customers for life, foromers for life guard --

life. another young father in my district, shoulder pain, same deal. given to much oxycontin prescription -- too much two or three prescriptions later, now he is buying on the street. family, now has fallen into that trap. i think it is a commercial advantage for some of these companies to produce a product that creates a customer for life. we have to think about what we are doing in that regard. that is a huge commercial advantage. governor baker and the mass legislators said, you can only get so many pills. we are not going to let you refill them. it is also part of our drug monitoring peace that we are doing along those lines as well. is there anything on the front end, mike, that we could be doing to stop the number of getle -- because, once they in there, we are having

terrible, terrible, terrible problem. we have a lot of recidivism, a lot of relapse, a lot of money we are spending for rehab. and we need to do that. i'm not discounting that. but on the front end, to stop these kids from being trapped and other unsuspecting patients from being trapped into this cycle? is there anything else we can do affront to stop that from happening? mr. botticelli: i thank you for that question. i think it is really important. test justst do released guidelines, but they are only guidelines. i agree. the vast majority of physicians are well-meaning. part of what massachusetts has done, 16 other states, there is legislation in congress now, we would love to work with you on mandatory prescriber legislation. this is not about bad doctors. they have gotten a lot of misinformation, largely from drug companies, that these are not addictive medications and that we continue to hand them out. i'm a quitethink ominously, in the middle of an epidemic, it is reasonable to have a prescriber to take a minimal amount of education as

it relates to safe and effective open yard prescribing. -- opioid prescribing. weyou look at the overdoses a direct, there is correlation between the amount of prescriptions we are giving out and overdosed deaths. and that has been going on for 10 years. and i think the medical community has a role to play in that is a good starting point. >> what about liability? these people are unsuspecting and they are getting addicted like that. mr. botticelli: i agree. they have a role to play not only in terms of making sure they are reading the letter of the law on marketing, but also encouraging to turn formulations. -- to workto talk with the da to go after outline who are wantonly ignoring the lawn this. but you're right. we need prescriber education, good prescription drug monitoring programs, so

physicians can identify people who are going from doctor to doctor to do that. are reallynt, if we going to reduce the magnitude of the problem, we've got to scale back on the prescribing and identify people who are starting to develop problem. chairman mike at: mr. lynch, i went into one of the drug programs in my community and talked to every kid i could. the are all youths in treatment program. every kid told me this sand saying. he started with marijuana. then they go on to all the rest of it. we have a very serious situation in this country. mr. wahlberg is next. the gentleman from michigan. representative wahlberg: thank you, mr. chairman. i apologize for being out. rosie the riveter showed up at the capitol and i wanted to say hi to four of them for my district.

interesting issue and it does affect all of us. my district has to minister and is there. i appreciate all the efforts that all of you have shown towards this issue. , how long has the dea been aware of the increased prevalence of sentinel-list of drugs, and howard -- fentanyl -laced drugs. a number of years. we have seen it for the country. we are doing what we do with all of our criminal investigations. we target the worst of the worst , criminal trafficking organizations. a full trick them, track them, and i can -- indict them. it is a multipronged approach. it's definitely something we are concerned about. we are concerned about the unsuspecting users exposed to it when combined with heroin or

when it is put into an exact replica of an opioid pill. there is a whole panoply of different challenges. it also poses a risk to my law-enforcement brothers and sisters that encounter increasingly fentanyl in an enforcement operation. as you know, it can be inhaled, absorbed through your skin with tragic consequences. it is a major problem for us. for users, for the country, and for law enforcement. mr. milione wahlberg -- representative wahlberg: what has the dea learned about fennel when it appears and heroin? mr. milione: the majority of it is coming from mexico with precursors and actual fennel should -- fentanyl shipped from china, particularly if in the northeast. those are the two primary threats. representative wahlberg: it is

my understanding that mexico is a primary source. mr. milione: that is true. wahlberg: how are you working to decrease this traffic? any additional efforts that you can talk about in regards to what is coming across the border? mr. milione: we have a great relationship with our largest office in mexico. we have a great relationship with the counterparts. we keep on working with them on the trafficking situations. the most powerful cartel has an incredible distribution. they are capitalizing on the opioid epidemic. heroin, butusing on they are flooding it with fentanyl. we do with what we do with our state and local counterpart everyday. representative blogger: mr. botticelli, what efforts is the u.s. engaging in to work with governments where heroin is produced to cut off the supply?

involvendly, does this identifying lapses in countries like mexico that involves a trafficking bonanza of heroin and fentanyl in the united states and what is the barrier stopping the? mr. botticelli: having an aggressive approach that reduces supply is particularly important to do that. i was just in mexico a few weeks ago, meeting with the attorney general and high-level folks in the government, calling for enhanced action, particularly as it relates to heroin, looking at enhanced eradication efforts, looking at how we go after both heroine and fentanyl labs, and how we continue to support mutual collaboration in going after the organizations that deal with it. we have also been working with the dea and our high-intensity trafficking areas to magically to look at producing and going after those organizations that

are trafficking heroin and fentanyl domestically. it is important to have a mistake approach and have a robust enforcement response. we have to really look at how we work with our customs and border protection, both to increase the detection of heroin and fentanyl, and to look at our international work with china that often produces these precursor chemicals as it relates to fentanyl production. we were just pleased that china moved to schedule over 130 new substances, including one of the precursors from aceto fentanyl. it is important for us to work with their international partners and working with our domestic law enforcement folks. representative wahlberg: thank you. i yield back. representative cartwright: thank

you, acting chair michael, and thank you to all the witnesses for coming today. i have listened to all of your testimony and it's well taken. i come from pennsylvania. pennsylvania, hospitalization for overdoses due to pain medication increased 225% from 2000 to 2014. drug overdose deaths in panels -- in pennsylvania increased 6.5% compared to a increase nationally. it is a huge problem in pennsylvania. and director botticelli, you mentioned attending a town hall. earlier this year, i did a town hall in my district and school county, pennsylvania. it is a rural place. typically, we get between 30 and 40 people out for a routine town

hall. at this one, we had over 100 people come out and nobody was smiling. every family is touched by this crisis, by this epidemic. the question is what can be done to combat it? in pennsylvania, there is a company, europa pharmaceuticals using nanotechnology and is following the usda erected to use the lowest dose. it is an african-american owned company that is growing by the month of writing not only jobs in pennsylvania, but also a logical solution to our national opioid epidemic. i also believe there are legislative solutions to help 953,ss the issue, like hr the comprehensive addiction and recovery act. this was introduced in the house by representative sensenbrenner of wisconsin.

in the senate, the same bill was introduced by senator whitehouse of rhode island. that bill passed the senate. 10 in the house, i am a cosponsor of 953. it's a bill that would adjust programs that would provide a series of resources and incentives to help health care providers, law enforcement officials, states and local governments expand drug treatment prevention and recovery efforts. and through funding towards those efforts. i wish to urge republican leadership to move it to the house floor for a vote. it is a concrete step we can take in the right direction. my colleague, mr. lynch, talked , and the newland england area has been referred to as "the cradle of the heroin

epidemic" by "the new york times." i see you got here head, mr. milione. you are aware of that for my ticket. mr. milione: yes, i am. cartwright: 63% of law enforcement agencies reported heroin is the greatest drug threat. governor charlie barker signed legislation making massachusetts the first state to pass a statewide cap on first-time opioid prescriptions. my question is, with the rising number of opioid debts, what step has dea taken to collaborate with state and local law permit agencies to reduce opioid debts? mr. milione: they have brought

together all the different elements, state, federal, local, working with the health community to identify where the hotspots are and do community outreach and also the enforcement on the groups that are trafficking in these substances. : how'sntative cartwright the federal government working to support innovative ideas by the states to combat the opioid epidemic? think thereli: i are a number of ways that we are doing that. looking at funding opportunities to provide states with the opportunities to really strategies.ative one of the things that are office does is really look at how do we promote some of these innovative things that are happening at the state levels. whether that law enforcement that are working to get people into treatment or things like the 24-7 triage programs. part of the federal government responses that states and locals have the resources they need to continue to implement programs that address these issues. secretary tennyson in

pennsylvania has demonstrated leadership in the war cap and here. i talked with the secretary just about every day in terms of looking at what my the federal government can continue to do. but it think the largest fraction we have is making sure that states and locals have the resources they need to continue to develop and show leadership on this issue. representative cartwright: a mentor that. i yield back. -- amen to that. i yield back. representative heise: to me, this is especially alarming just for the fact that high school students are using painkiller medication at alarming rates, which makes them 40 times more vulnerable to use heroin.