[Senate Hearing 114-681] [From the U.S. Government Publishing Office] S. Hrg. 114-681 OPIOID CRISIS ======================================================================= FIELD HEARING before the COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS UNITED STATES SENATE ONE HUNDRED FOURTEENTH CONGRESS SECOND SESSION ---------- BORDER SECURITY AND AMERICA'S HEROIN EPIDEMIC: THE IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND PRESCRIPTION OPIOIDS IN WISCONSIN, APRIL 15, 2016 EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO, APRIL 22, 2016 ---------- Available via the World Wide Web: http://www.fdsys.gov/ Printed for the use of the Committee on Homeland Security and Governmental Affairs [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] OPIOID CRISIS--2016 S. Hrg. 114-681 OPIOID CRISIS ======================================================================= FIELD HEARING before the COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS UNITED STATES SENATE ONE HUNDRED FOURTEENTH CONGRESS SECOND SESSION __________ BORDER SECURITY AND AMERICA'S HEROIN EPIDEMIC: THE IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND PRESCRIPTION OPIOIDS IN WISCONSIN, APRIL 15, 2016 EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO, APRIL 22, 2016 __________ Available via the World Wide Web: http://www.fdsys.gov/ Printed for the use of the Committee on Homeland Security and Governmental Affairs [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] U.S. GOVERNMENT PUBLISHING OFFICE 22-773 PDF WASHINGTON : 2017 ____________________________________________________________________ For sale by the Superintendent of Documents, U.S. Government Publishing Office, Internet:bookstore.gpo.gov. Phone:toll free (866)512-1800;DC area (202)512-1800 Fax:(202) 512-2104 Mail:Stop IDCC,Washington,DC 20402-001 COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS RON JOHNSON, Wisconsin Chairman JOHN McCAIN, Arizona THOMAS R. CARPER, Delaware ROB PORTMAN, Ohio CLAIRE McCASKILL, Missouri RAND PAUL, Kentucky JON TESTER, Montana JAMES LANKFORD, Oklahoma TAMMY BALDWIN, Wisconsin MICHAEL B. ENZI, Wyoming HEIDI HEITKAMP, North Dakota KELLY AYOTTE, New Hampshire CORY A. BOOKER, New Jersey JONI ERNST, Iowa GARY C. PETERS, Michigan BEN SASSE, Nebraska Christopher R. Hixon, Staff Director Brooke N. Ericson, Deputy Chief Counsel for Homeland Security Megan Harrington, Legislative Assistant, Office of Senator Portman Gabrielle A. Batkin, Minority Staff Director John P. Kilvington, Minority Deputy Staff Director Holly A. Idelson, Minority Senior Counsel Marianna L. Boyd, Minority Staff Director, Subcommittee on Federal Spending Oversight and Emergency Management Laura W. Kilbride, Chief Clerk Benjamin C. Grazda, Hearing Clerk C O N T E N T S ------ Page FRIDAY, APRIL 15, 2016 Opening statements: Page Senator Johnson.............................................. 1 Senator Baldwin.............................................. 3 Prepared statements: Senator Johnson.............................................. 47 Senator Baldwin.............................................. 49 Senator Ayotte............................................... 51 WITNESS James F. Bohn, Director, Wisconsin HIDTA, Office of National Drug Control Policy................................................. 5 Tim Westlake, M.D., Vice Chairman, State of Wisconsin Medical Examining Board and Chairman, Controlled Substance Committee... 7 Tyler Lybert; Accompanied by Ashleigh Nowakowski, Your Choice- Live, Hartland, Wisconsin...................................... 9 Ashley Nowakowski................................................ 11 Lauri Badura, Mother of Archie Badura, Oconomowoc, Wisconsin..... 12 Hon. R. Gil Kerlikowske, Commissioner, U.S. Customs and Border Protection, Department of Homeland Security.................... 24 Hon. Brad Schimel, Attorney General, Department of Justice, State of Wisconson................................................... 25 Hon. Jon Erpenbach, State Senator, District 27, State of Wisconsin...................................................... 28 Hon. John Nygren, State Represenatative, District 89, State of Wisconsin...................................................... 31 Alphabetical List of Witnesses Badura, Lauri: Testimony.................................................... 12 Prepared statement........................................... 74 Bohn, James F.: Testimony.................................................... 5 Prepared statement........................................... 53 Erpenbach, Hon. Jon: Testimony.................................................... 28 Prepared statement........................................... 86 Lybert, Tyler: Testimony.................................................... 9 Prepared statement........................................... 70 Kerlikowske, Hon. R. Gil: Testimony.................................................... 24 Prepared statement........................................... 76 Nowakowski, Ashley: Testimony.................................................... 11 Nygren, Hon. John: Testimony.................................................... 31 Prepared statement........................................... 91 Schimel, Hon. Brad: Testimony.................................................... 25 Westlake, Tim: Testimony.................................................... 7 Prepared statement........................................... 61 FRIDAY, APRIL 22, 2016 Opening statements: Page Senator Portman.............................................. 93 Senator Brown................................................ 97 Prepared statements: Senator Portman.............................................. 139 Senator Brown................................................ 142 Senator Johnson.............................................. 145 Senator Ayotte............................................... 146 WITNESS Dan Simon, President of University Hospitals Case Medical Center. 93 Hon. R. Michael DeWine, Attorney General, State of Ohio.......... 100 Carole S. Rendon, Acting U.S. Attorney, Northern District of Ohio, United States Attorney's Office, U.S. Department of Justice........................................................ 104 Tracy J. Plouck, Director, Ohio Department of Mental Health and Addiction Services............................................. 107 Michele Walsh, M.D., Division Chief, Neonatology, UH Case Medical Center, UH Rainbow Babies and Children's Hospital.............. 119 Nancy K. Young, Ph.D., Director, Children and Family Futures, Inc............................................................ 121 Margaret Kotz, D.O., Director, Addiction Recovery Services, UH Case Medical Center, University Hospitals...................... 123 Emily Metz, Program Coordinator, Project DAWN,................... 125 Rob Brandt, Founder, Robby's Voice............................... 127 Alphabetical List of Witnesses Brandt, Rob: Testimony.................................................... 127 Prepared statement........................................... 214 DeWine, Hon. R. Michael: Testimony.................................................... 100 Prepared statement........................................... 148 Kotz, Margaret D.O.: Testimony.................................................... 123 Prepared statement with attachment........................... 201 Metz, Emily: Testimony.................................................... 125 Prepared statement........................................... 211 Plouck, Tracy J.: Testimony.................................................... 107 Prepared statement with attachment........................... 157 Rendon, Carole S.: Testimony.................................................... 104 Prepared statement........................................... 151 Simon, Dan: Testimony.................................................... 93 Walsh, Michele M.D.: Testimony.................................................... 119 Prepared statement........................................... 170 Young, Nancy K.: Testimony.................................................... 121 Prepared statement with attachment........................... 173 APPENDIX Akron Beacon Journal article, submitted by Senator Brown..... 233 Statement of Cleveland Clinic, Dr. Jason Jerry, M.D.......... 234 BORDER SECURITY AND AMERICA'S HEROIN EPIDEMIC: THE IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND PRESCRIPTION OPIOIDS IN WISCONSIN ---------- FRIDAY, APRIL 15, 2016 U.S. Senate, Committee on Homeland Security and Governmental Affairs, Pewaukee, Wisconsin The Committee met, pursuant to notice, at 2:30 p.m., in the RTA Conference Room, Waukesha County Technical College, Hon. Ron Johnson, Chairman of the Committee, presiding. Present: Senators Ron Johnson and Tammy Baldwin. OPENING STATEMENT OF CHAIRMAN JOHNSON Chairman Johnson. This hearing of the Senate Homeland Security and Governmental Affairs Committee will come to order. I want to first thank Senator Baldwin for making this a very nice bipartisan effort and getting us a little bit closer here. [Applause.] Totally off topic. The Senate is actually a very collegial place. We actually get along quite well together. We serve on a couple of Senate Committees together. So, I think that is actually an area of hope for our country. We really do get along, so I really do appreciate you understanding what an important issue this is and participating in this today. I want to thank our witnesses. I will be thanking them in greater detail a little bit later as I start introducing them, but, particularly, those that have suffered. This takes real courage, and we certainly appreciate you coming here and sharing your story because if we are going to solve this problem, we need to understand it, we need to understand that the use and abuse of drugs, there is nothing glamorous about it. It ends in squalor and death and broken lives and broken families. So, we truly appreciate you coming here. Now, I have a written opening statement, which I never read, I just enter them into the record.\1\ So, with consent, I would ask that that occur. --------------------------------------------------------------------------- \1\ The prepared statement of Senator Johnson appears in the Appendix on page 47. --------------------------------------------------------------------------- I also do want to add a--I have been requested by Senator Ayotte to enter her statement in the record as well.\2\ And, in that, by the way, she thanks Commissioner Kerlikowske, with the U.S. Customs and Border Protection (CBP). The commissioner has been extremely helpful, and he has attended not only this hearing. We held a field hearing down in Arizona. We held a field hearing in New Hampshire on this issue. He is going to be going to a field hearing in Ohio. --------------------------------------------------------------------------- \2\ The prepared statement of Senator Ayotte appears in the Appendix on page 51. --------------------------------------------------------------------------- And, it really is these hearings, rather than in Washington, D.C., when we come into our communities, that can really impact and highlight these problems so that we can hopefully develop a consensus on how to start solving some very difficult issues. As part of this committee, as a matter of fact, our first field hearing was in Tomah, Wisconsin. In many ways, a very related hearing, the tragedies that occurred because of opioid overprescription at the Tomah Veterans Affairs (VA) health care facility. We also held a field hearing in Milwaukee on school choice, one up in Stevens Point on ``Waters of the United States,'' and now this one here today in Pewaukee. So, again, I want to thank the witnesses. I want to thank all of the members of the community for coming out here. I hope you will find this as informative as Senator Baldwin and I will. Let me just kind of speak from the heart in terms of how this journey to Pewaukee and this hearing really began. When I took over the Chairmanship of the Committee, we first established a mission statement. It is pretty simple: To enhance the economic and national security of America. And then, we established four priorities on the homeland security side: border security, cyber security, protecting our critical infrastructure, and combating Islamic terrorists. The first one we addressed--border security, we have held 15 hearings on border security. We have issued an approximately 100-page report, and it is right here--I would recommend you going online or getting a copy of it--laying out the findings of our hearings. You might ask, well, how does border security relate to a hearing here in Wisconsin on the effect of heroin and the use and abuse and the overdoses here in Wisconsin. Well, certainly, my conclusion, as well as I think a number of our committee Members is, among many causes of our unsecure border, I place at the top of the list America's insatiable demand for drugs. Now, that maybe is not readily apparent, but let me explain why I believe that. The fact that we have this demand for drugs, the flow is always going to meet the demand, the supply will meet the demand. General Kelly, formerly the Commissioner of U.S. Southern Command (SOUTHCOM) provided that information on a hearing we had in Washington, D.C., on Tuesday. Because of our demand, we have created these drug cartels, some of the most evil people on the planet. The drug cartels control whatever part of the Mexican side of the border they wish to control. They are destroying public institutions in Mexico and Central America. As a result, we have porous borders. If you want a metric on that, by the way, we only interdict between 5 and 10 percent of illegal drugs coming through the southwest border. Evidence that we are not reducing the supply is in 1981, in inflation-adjusted dollars, the cost of heroin, a little more than 30 years ago, was $3,260 per gram. Today, you can buy a gram of heroin for about $100 a gram. There is ten doses in a gram. So basically, one dose, one hit of heroin, costs $10, which is roughly the equivalent of a nice craft beer in a fancy restaurant. Unfortunately, this is a very affordable addiction, and it is an affordable addiction that is destroying people's lives. In early January, I also did a national security swing through Wisconsin. And, every public safety official I spoke to, local, State, and Federal, when I asked them what is the number one problem you are dealing with, they responded that is drug abuse, because the crime it is creating, it is the broken families, the broken lives, the overdoses. So, you combine the fact that every public safety official is saying drugs is the biggest problem, with what we found out with our border security hearings, that drug demand is the root cause of our unsecured border, which, by the way, threatens our national security, public health and safety, and really prevents us from fixing the illegal immigration problem, you start realizing our insatiable demand for drugs, the abuse of drugs, is fueling all these enormous problems that we face today in America. So, that is something we need to take to heart, and it is a problem we have to lay out the reality of, and that is, quite honestly, the purpose behind every one of these hearings of this committee: to lay out the reality so that the people attending the hearing, both senators at the dais here, or people in the audience, walk away from that hearing having taken the first step in solving any problem, which is admitting you have one and understanding the depth of it. So, again, I just want to thank everybody for coming here. I am looking forward to the testimony. Again, I thank the witnesses for having the courage to share your stories and also for, the dedication as public safety officials trying to solve a problem. With that, I will turn it over to Senator Baldwin. OPENING STATEMENT OF SENATOR BALDWIN Senator Baldwin. Thank you, Chairman Johnson, for convening us here in our home State. I will also go through the formality of asking that my written opening statement be made a part of the record\1\ and follow your lead in speaking from the heart. --------------------------------------------------------------------------- \1\ The prepared statement of Senator Baldwin appears in the Appendix on page 49. --------------------------------------------------------------------------- We had a chance to talk between our formal meetings, just about how this impacts everybody, sometimes very immediately in one's own family--sometimes coworkers, neighbors, and fellow congregants--just as it affects everyone across our State and affects everyone across our Nation and, regrettably, has not gotten the policy attention that it really has needed until recent years. I think part of that has to do with something we have struggled with as a nation over the years of stigmatizing issues and making it more difficult for individuals and family members to come forward and tell their stories, be vocal, be visible, but if we only realized we can solve problems when we do that. And so, I want to add my words to Senator Johnson's in thanking the witnesses who sit before us right now, and we will have a second panel, and I want to greatly thank the second panel of witnesses in advance for being leaders and helping us sort of charge right through that stigma. I do not want anybody here to feel sorry for us in terms of the jurisdiction of our Committees. So, I am going to actually speak a little bit beyond the jurisdiction of the Homeland Security and Governmental Affairs Committee (HSGAC), because both Senator Johnson and I have the ability to serve on a couple of different Committees, and epidemics, crises, and tragedies do not fit neatly into necessarily one Committee's jurisdiction. And so, I want to just add that in terms of addiction, the supplier is not always a drug cartel many miles away. Sometimes it is a medicine cabinet that has been left with unused pills. And, sometimes it is a prescriber who has been trained and takes an oath to care for our health and well-being, but yet well-meaning, has overprescribed or is overrelying on prescription drugs. And, the pathway to the tragedy and epidemic that we are seeing right now, I guess I will say there is several pathways, and we, as policymakers at the Federal level, and we will be joined by some amazing leaders at the State level in our next panel, can not be limited just by this this committee's jurisdiction and not the other. We have to work together and put together comprehensive problems, because when, in 2014, 28,000 Americans lost their lives to either prescription opiates or illegal opiates, such as heroin and fentanyl, it demands that we work together and form those solutions. Recently, the Senate took a really significant step forward with the passage of an act called the Comprehensive Addiction and Receovery Act (CARA), and I think it is going to be a policy step forward. Resources need to come too. Because all of the treatment programs in the world unfunded will not provide the care and support that people need to lick an addiction and to stay sober and to partake in lifelong recovery. And so, the Federal Government is a partner, one partner of many, that need to come together to solve this issue, to strengthen our communities, but that is what needs to be done. And again, thank you, Chairman Johnson, for convening us here, and I so look forward to hearing from our witnesses, putting a face on those unspeakable statistics, in terms of overdose deaths and people in need. Chairman Johnson. Thank you, Senator Baldwin. It is the tradition of this Committee to swear in witnesses, so if you will all rise and raise your right hand. Do you swear the testimony you will give before this Committee will be the truth, the whole truth, and nothing but the truth, so help you, God. Please be seated. Our first witness is James Bohn. Mr. Bohn is the Director of the Wisconsin High Intensity Drug Trafficking Area (HIDTA), within the Office of National Drug Control Policy (ONDCP), a position he has held since February 2015. Prior to this, Mr. Bohn worked for the U.S. Drug Enforcement Administration (DEA), for almost 30 years, 15 on which was spent serving as a special agent in charge of the DEA Milwaukee District Office. Mr. Bohn. TESTIMONY OF JAMES F. BOHN,\1\ DIRECTOR, WISCONSIN HIDTA, OFFICE OF NATIONAL DRUG CONTROL POLICY Mr. Bohn. Chairman Johnson, Senator Baldwin, and distinguished Members of the Committee, it is my privilege to address you on behalf of the Executive Board of the Wisconsin High Intensity Drug Trafficking Areas program concerning the statewide drug threat assessment of Wisconsin, and in particular, the HIDTA-designated region. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Bohn appears in the Appendix on page 53. --------------------------------------------------------------------------- My name is James F. Bohn, and I have been the Director of the Wisconsin HIDTA since February 2015. The HIDTA-designated counties in Wisconsin incorporate approximately 46 percent of the State's population. The HIDTA program is designed to support and encourage Federal, State, local, and tribal law enforcement agencies to work together in task force situations to target identified drug threats in the local HIDTA-designated areas. Each year the Wisconsin HIDTA Investigative Support Center conducts a comprehensive assessment of the drug threats in our area to identify and prioritize any new and continuing trends or threats affecting Wisconsin. Wisconsin can best be described as a destination State for illegal drugs and drug activity. By ``destination'' state, I am referring to the fact that in most instances, once illegal drugs enter Wisconsin's borders, they are almost always going to be used and/or resold within the State. Wisconsin's proximity to the major source cities of Chicago and Minneapolis has a direct and significant impact on the presence of illegal drugs and drug activity in Wisconsin. Within Wisconsin, Milwaukee is considered a source area for illegal drugs for other parts of the State. Now, while Wisconsin is geographically located on the Northern border, our investigations and intelligence reports of any significant seizures being sourced by drug trafficking organizations on the Northern border from the Northern border, which are relatively few, confirm that their initial entry into this country occurred via some other Northern border location, such as Detroit or one of the more western States, or by shipped parcel, prior to making its way into Wisconsin. The Wisconsin HIDTA Drug Threat Assessment has consistently found that the vast majority of drugs entering Wisconsin are via passenger vehicle on one of the major highways intersecting the State. Preliminary indications of the 2016-17 Drug Threat Assessment are confirming some notable differences from last year's threat assessment. However, what is the same is that opioid abuse, including both heroin and prescription drug abuse, remain the number one drug threat in Wisconsin. And, while Wisconsin has historically experienced relatively low levels of methamphetamine (meth)-related activity, methamphetamine is now beginning to show a much greater presence all around the State as well. For years, most of the methamphetamine activity in Wisconsin was concentrated along the western portions of the State due to its proximity to Minneapolis. However, within the past year, much larger quantities of methamphetamine are showing up all around the State. Most of the seizures have been directly linked to groups out of Minneapolis and, at times, Chicago. Minneapolis continues to be a distribution center for large amounts of Mexican-produced methamphetamine coming directly from the southwest border by Mexican drug trafficking organizations bringing it into the Minneapolis area. Much of the heroin abuse in Wisconsin stems from users transitioning from prescription opioid drugs to heroin. Last year, 100 percent of the Wisconsin survey respondents listed heroin as their number one drug threat. For 2015, Milwaukee County alone reported 109 heroin-related overdose deaths, with the vast majority of the heroin in Wisconsin being sourced from Chicago-based traffickers with connections to the southwest border and Mexican cartels. Over the course of the past 2 to 3 years, the majority of heroin present in Wisconsin is one of the several types of high purity Mexican heroin, as opposed to the high purity South American heroin that was routinely seen for the decade or more prior to that. In addition, the growing heroin problem has led to increased violence and challenges for law enforcement, especially in the Milwaukee area, not only by the ever- increasing number of overdoses and deaths, but also due to changes in the retail distribution market. In Milwaukee, for example, mobile drug houses have become commonplace and have presented law enforcement with new and more dangerous challenges. These opportunistic traffickers travel around the city in stolen vehicles, usually with multiple violators and weapons inside the vehicle, posing an increased level of danger not only for law enforcement, but also to the public. Of growing concern during 2015 and continuing into 2016 is the increased presence of fentanyl. This most recent increase in fentanyl abuse appears to stem from the importation of fentanyl that is most likely clandestinely produced in Mexico and mixed in with quantities of heroin being smuggled into Wisconsin. In response to Wisconsin's identified drug threats, the Wisconsin HIDTA program uses a multi-faceted approach to address the identified threats and is committed to facilitating cooperation among Federal, State, local, and tribal law enforcement and prevention efforts through the sharing of intelligence, and by providing support to coordinated law enforcement efforts toward identified drug threats. Thank you for the opportunity, and I would be happy to answer any questions that you may have. Chairman Johnson. Thank you, Mr. Bohn. Our next witness is Dr. Timothy Westlake. Dr. Westlake is the Vice Chairman of the State of Wisconsin Medical Examining Board and Chairman of the Controlled Substance Committee. Dr. Westlake also serves on numerous boards designed to combat against the heroin and opiate epidemic, including as the Wisconsin State Coalition for Prescription Drug Abuse Reduction Chairman. For his day job, Dr. Westlake works as an emergency physician at the Oconomowoc Memorial Hospital. Dr. Westlake. TESTIMONY OF TIM WESTLAKE,\1\ M.D. VICE CHAIRMAN, STATE OF WISCONSIN MEDICAL EXAMINING BOARD AND CHAIRMAN, CONTROLLED SUBSTANCE COMMITTEE Dr. Westlake. Thank you. I would like to take this time to thank Chairman Johnson and Senator Baldwin for holding this hearing. I am grateful for the opportunity to testify and share my experiences. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Westlake appears in the Appendix on page 61. --------------------------------------------------------------------------- My name is Tim Westlake. I am a full-time emergency physician at Oconomowoc Memorial Hospital, and I have been practicing there for 15 years. In my role as an emergency physician, I have witnessed firsthand the evolution of this crisis. This past week alone, I treated two heroin overdoses. One of them survived, and one did not. I later found out that the patient we could not save was the fourth person from his high school class to die of an overdose. The coroner that slipped him into the body bag said he has recently been seeing on average two opioid overdose deaths per day taken down to the Milwaukee County Medical Examiner. What can be said to comfort those who have lost a loved one in this way? Sometimes I feel like all I can do is sit there with the family and bear witness to the unimaginable pain and suffering that they experience. I wish I was making this next part up, but, while I was writing out the testimony, my wife received a text about the tragic news of another overdose death of a child in our area. He was at my daughter's high school last year. He took a single pill. How dangerous could one single pill be? It was very dangerous. It was a highly potent, long-acting opioid and suppressed his respiration so much, his heart stopped and he's brain-dead. And, I believe right now his organs are being harvested. And, tragedies like this play out every day once every 24 minutes in America, and it is truly the public health crisis of our time. But, there is hope. Awareness is increasing, and I applaud the efforts being made to address this issue. It is critical to remember that the lion's share of healthcare regulation occurs at the State and local level, and as such, most of the responsibility for addressing the prescription drug epidemic will come from the State's hospital systems and physicians themselves. The Federal Government has a limited, but useful, role, and there are small areas really only where that best solution involves Federal legislative change. The opioid crisis did not exist in epidemic proportions until the last 15 years. That was mainly due to a shift in the opioid prescriptive practices in the late 1990s. It was directly related to the premise that pain was being undertreated and that patients had a right to have their pain treated. And, people know this as the pain scale that we see every time you go into the doctor's office, several times usually. This originated with the Federal Government as a probably well-intentioned program through the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs, and then it quickly was reinforced by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and embedded into the culture of the practice of medicine. It is now embedded, literally, in every single doctor-patient relationship, and it has been and continues to be a driving, causative factor in overprescription that is occurring. Earlier this week, I was working a night shift and woke up and got an e-mail and text saying that I could not believe how excited I was that Senator Johnson's released a bill that will eliminate the pain scale, effectively. It is called the Pressure to Reduce Overprescribed Painkillers (PROP Act). It will make the Federal Government unable to tie medical reimbursement to pain outcome measures and will help take the government out of the doctor-patient relationship. It is already gained broad bipartisan support and backing from the medical community and recovery community. Senator Johnson, thank you. You really do not have an idea how much impact this will have in eliminating the pain scale. Perhaps as far as what you could do for regulation of prescribers, it is the single-most important piece of Federal legislative reform that you could do. It is very important. Another area of Federal legislative reform that was useful is the area of reform for prescriptive practices within the VA system, and legislation in this area was recently authored and released by Senator Baldwin, and I applaud her for the two bills. The Jason Simcakoski Memorial Opioid Safety Act models the reforms in the VA system after the best practices that the States are doing, and it applies them at the Federal level. Now, she also has another bill that passed some Senate hearings as well, the Heroin and Prescription Drug Abuse Prevention Act, and then there are good pieces that cover expanding access to Suboxone, increase the availability of Narcan, and access expansion for treatment, which is important. There are over 9 billion--with a B--Vicodin pills prescribed in the United States every year. It is estimated that between one-to two-thirds of these are not taken and are available lying around as leftovers. That is an excess supply every year of three to six billion pills. Fifty to 70 percent of the adolescents and young adults that abuse prescription drugs start by taking these leftovers. As the person becomes opioid dependent, tolerance develops, they need more pills, the cost of taking the increasing amounts of pills becomes too great, and the next step is, almost invariably, a switch to heroin use. As the chairman said, it is $10 a day or $10 a dose, so much cheaper than buying pills. In fact, 80 percent of heroin use starts with prescription opioids first. With the relatively cheap cost of heroin trafficked over the porous Southern border, along with drugs such as fentanyl and other synthetic opioids coming in over the border and through mail order, Wisconsin is awash in opioids. And, any bill that would encourage a change in this prescriptive practice, thus decreasing the amount of the excess opioid pills, would go a long way in addressing the current epidemic. We are actually currently working on a bill, fleshing an idea for a bill with Senator Johnson that would do exactly that, decrease that excess leftover supply. It is a small-volume, time-limited refill of a short-acting pain medication used for acute pain. Right now you cannot do refills on any medications. I want to go into a lot more detail to explain it, but I do not have the time. I had to cut some stuff. Chairman Johnson. We will give you some time. Dr. Westlake. Excellent. So, at the State level here in Wisconsin, we have been blessed with the available leadership of Representative Nygren and Attorney General (AG) Schimel, who have thoroughly explored the best paths looking forward and what works and what does not in other States and truly listening to and involving all stakeholders in the process. In fact, we just came from a coalition meeting that had all the major health systems from the State in Madison, just like literally an hour ago, and that the purpose is to try to prepare the health systems unifying the best practices across the systems. They are really leading the country in establishing the ways that State government can best position the State and the community resources to address the epidemic. Thank you again, Chairman Johnson and Senator Baldwin, for the opportunity to testify, and thank you especially for your leadership on this issue in the battle against the scourge of prescription drug abuse. The bills you have both introduced will really help best position the State and our country to move forward, and it makes me proud to be from Wisconsin to see you guys both up there. Thank you. Chairman Johnson. Thank you, Dr. Westlake. And, we will give you some time in that question-and-answer period to expand on some of those points you made. Our next two witnesses are a brother and sister, but they are also joined by their parents, Rick and Sandi Scott. And, again, I just want to thank you as a family for your courage coming forward. This is not an easy thing to talk about. It is not, you are laying your life out there, you're subjecting yourself to real scrutiny here, but you are doing it to save other lives. So, we really do appreciate that. So, we have Tyler Lybert and his sister, Ashleigh Nowakowski. Tyler is a recovering heroin addict and will share his personal experience with addiction and recovery. He is accompanied today by his sister, Ashleigh, who will provide her perspective as the sister of an addict for 11 years. Both Tyler and Ashleigh serve as public speakers for Your Choice to Live, Inc., a drug and alcohol awareness program created by their family to provide Wisconsin youth with the knowledge and skills to remain substance free. Again, Tyler and Ashleigh, thank you for sharing your story, and we are looking forward to hearing it. Tyler. TESTIMONY OF TYLER LYBERT\1\, ACCOMPANIED BY ASHLEIGH NOWAKOWSKI, YOUR CHOICE-LIVE, HARTLAND, WISCONSIN Mr. Lybert. Thank you for having us. This is a real honor. We are honored that you guys asked us to come. I mean, we do this all of the time, and, honestly, I am nervous now. --------------------------------------------------------------------------- \1\ The joint prepared statement of the Lybert family appears in the Appendix on page 70. --------------------------------------------------------------------------- But, like you said, I am a recovering heroin addict. I started really young. I started experimenting in sixth grade. It was introduced to me by older people. And, when I was younger, I was chubby and hyper, so it was a bad combination and I did not have many friends. Parents did not want me coming over because I was too hyper and stuff like that. So, alcohol was introduced to me by older people and I saw that as my golden ticket to popularity. I thought, ``Yes, I can finally have friends now. All these old people want me to drink with them.'' And so, I started drinking in sixth grade and I started smoking pot in seventh grade. I was doing pills by 15 and I was doing heroin by 16 or 17 years old. And, I never planned on this. I did not wake up and say, ``My goodness, when I grow up, I cannot wait to be a heroin addict.'' It started with that first small steppingstone. It started with drinking, it started with smoking pot, and it increased. And so, I chose drugs over everything else in my life. In going through high school, I got expelled from high schools, I got arrested all of the time, and I was in and out of jail. And, after high school, it just gave me more time to do whatever I wanted to. So, after high school, I worked every day, and I looked for drugs every night--and that was my entire life for 10 years. And, before drugs and alcohol, I was this hyper, fun-loving kid that was always in a good mood, always laughing, always smiling, always joking around. But, the farther I got into drugs and the more I got in trouble and the more that drugs mattered to me, the less I became who I was, and instead of being this hyper, fun-loving, little chubby kid, I was an angry, violent monster. I was never in a good mood. I did not laugh anymore. I did not know what smiling was. I did not know what life was anymore. And, the only thing that mattered to me was drugs. That was it. Just as long as I was getting high, that was the only thing that mattered. And, in the midst of it, I did not see what I was doing to everybody around me. While I was in it, the only thing that was important were, like I said, drugs. So, I did not care what was happening to my family, I did not care what was happening around me, and I did not really see what kind of damage I was doing until I got into treatment and I got sober. And, in my family, I have my sister and my mom and my dad. From each of them, I looked for something else. My mom--I am a mama's boy, I can admit that. I looked for her support and her love. She was always there for me and she was always in my corner. From my dad, I just wanted his approval. And, from my sister--yes, she was my sister, so---- Chairman Johnson. Your older sister. Mr. Lybert. Yes, my older sister. But, because of what I was doing, because I was getting arrested and going to jail and getting expelled, because I was making really bad choices all the time, I never got any of that from them. My sister wanted nothing to do with me, my mom cried every day because of what I was doing, and my dad and I fought like it was World War II every single day. And, I would wake up every morning terrified of what I did the night before, because I could usually never remember. And, I would wake up every morning terrified to go downstairs because I did not want to have to face my family. And, I hated it. I hated my life. I hated everything about it. And, we had tried multiple different treatments. We had tried inpatient and outpatient, Suboxone, methadone, everything under the sun, but nothing was working. So, I started to come to the conclusion that I was never going to be sober. And, coming to the conclusion that I was never going to be sober and hating the way my life was going, I drew one ultimate conclusion from that, that I did not think I should be here anymore. And, I figured that maybe if I die, maybe my family can finally get some peace and maybe if I die, maybe my family can finally lead the lives they were supposed to lead without me having to drag them down anymore. And, in the mornings, instead of wondering what I did the night before, I would start wondering, ``Why am I still here? '' And, instead of being terrified to go downstairs, I would pray that I would not wake up the next day. There was nothing good in my life, there was nothing positive, and I could not stop what I was doing. And so, it eventually came to the point where my family came to the--well, they did not come to the same conclusion, but they came to the conclusion where they had tried everything they possibly could, but nothing was working. And so, they kicked me out, and I went down and I lived in Milwaukee, and I had given up on life completely. I was on the verge of taking my own life when I got a phone call from my mom. And, my mom goes, ``You have two options, and these are the last two options we will ever give you. You can keep doing what you are doing, but we never want to see you again. You are not welcome to our house, you are not welcome to call us, you are not welcome to talk to us. If you choose this, you are no longer our son and we never want to see you again. Or you can get help, and we will support you 100 percent.'' And so, I went into treatment again and learned more in treatment than I ever had in the past because this time I wanted to be sober. And so, I got out of treatment. I have been sober for a little over 7 years now and, hands down, it has been the best-- -- [Applause.] Thank you. It means a lot. But, obviously, my family is still here supporting me. And so, that is my story. I will let Ashleigh talk. Chairman Johnson. Thank you, Tyler. Before Ashleigh begins, normally Rick, Sandi, and Ashleigh all chime in and tell us stories. For time, we are going to let Ashleigh speak for herself and for her parents. But, again, thank you for sharing this and we look forward to your testimony. TESTIMONY OF ASHLEIGH NOWAKOWSKI Ms. Nowakowski. OK. So, my name is Ashleigh. I am Tyler's older sister. I am 3 years older than him. And, on behalf of my parents and myself, Tyler's drug use deeply impacted all of us. We hurt 10 times more than he did because we were watching someone we love destroy his life. My mom cried all the time and blamed herself for his problems, my dad was always angry, and I hated him for what he was doing to our family. When we should have been making childhood memories by going on vacations and spending time together, we were fighting, crying, and living in fear that we would get the phone call that Tyler was never coming home again. I could not even have him stand up in my wedding because I did not think he would be alive for it, and I did not want to have to explain to my wedding guests why there was a missing groomsman. My mom even had his funeral planned. There were times when I thought, ``God, if you are going to take him,'' just take him. He was suffering, we were suffering, and we did not know that there was a way out. When Tyler went into treatment, I did not think it was going to work. But, after many therapy sessions--and as a family we had family sessions--we were able to repair some of the broken pieces in our relationship. Today, I cannot put into words what the past 7 years of having Tyler clean and sober has brought to our family. Tyler is not only my little brother, but my best friend and someone I can look up to. We know that he can go back at any day and start using again, and that is a fear we will have to live with for the rest of our lives. And, we also have survivor's guilt because we know so many families that are not as fortunate as us and do not get to experience what it is like to get their loved ones back. So, thank you. [Applause.] Chairman Johnson. Thank you for sharing that. I know that was not easy. Our final witness on this panel is Lauri Badura. Lauri lost her son Archie Andrew Badura to an overdose at age 19 in 2014. As a result, the foundation Saving Others for Archie (SOFA) was founded. Ms. Badura is a resource to Wisconsinites across the State of Wisconsin in sharing her story and offering hope to many. Today she is here to share this incredibly personal experience. Lauri. TESTIMONY OF LAURI BADURA,\1\ MOTHER OF ARCHIE BADURA, OCONOMOWOC, WISCONSIN Ms. Badura. Good afternoon. My name is Lauri Badura, and I am a wife, a mother, and a dedicated businesswoman. I want to thank my family, my husband behind me, my two sisters, and my two very best friends, Bill and Kelly, who are on my board, and all of the countless other people--there are several people that have lost children that came here today--or have children in detox today. So, I just wanted to share that before I start. --------------------------------------------------------------------------- \1\ The prepared statement of Ms. Badura appears in the Appendix on page 74. --------------------------------------------------------------------------- I want to thank you, first off, for listening. Second, I wish to thank you both for your past and future commitment to stemming the raging tide of this epidemic. In 2014, the year that my son Archie died, in our country, we lost over 47,000 people. My statistic was quoted from the Centers for Disease Control (CDC). That is right, you heard it correctly. The figure was not a mistake. 47,000 people perished in this Nation due to drug addiction in one year alone! Those of us who have lost loved ones to an opiate epidemic, those of us who advocate for more attention to this issue, please understand what we certainly understand, why the latest news reports center upon the gravity of worldwide incidents across the globe, where a dozen of people might be killed by terrorists, or where 25 or 68 people perish in a single suicide bomber attack, but we all defiantly cannot understand the importance of these news stories, with 47,000 compared to that. But, for moms and dads like us, we have lost our children to this opiate addiction and this epidemic. The lack of attention on this ridiculously large numbers of deaths, 47,000 in a single year, we do not always understand this lack of attention and outrage. That is why today is monumental. Because of your listening today and the scheduling of this hearing, you have changed the contours of this entire conversation. On behalf of the survivors here today, I applaud your leadership and express my deepest gratitude to each of you for the gift of your time and your talent. I was invited to speak to you because my son Archie died from a heroin overdose on May 15, 2014. And, I hope you have read my biography. I brought it along. You will read about the harrowing details of our family's personal hell. You will learn about Archie's cousin, who, while remaining alive, now lives with a debilitating traumatic brain injury at age 44. He will continue to require 24-hour, around-the-clock medical care for the rest of his life. Over the course of the past 2 years, I have told our story, a story of survival, to countless audiences of all ages, shapes, and sizes. But, today I want to talk to you about another aspect of my life. You see, every week I get calls from across southeastern Wisconsin, mostly from people who, like me, are coping with the pain of the death of a child. These people, many of them survivors of this opiate epidemic, are referred to me. Who refers them? You name it. I receive referrals from psychiatrists, psychologists, nurses, priests, and business professionals--even my boss. And, this is not an exaggeration--I receive referrals from funeral homes. I have the Kleenex to prove it. That is right, funeral homes. The directors give my name out now. My commitment to all of these people is unwavering. I talk to each and every person who calls me seeking help. Each person is suffering with and struggling with the horrors of substance abuse addiction, and I am one who can empathize, identify, and relate to their experience. What does my inner drive to serve others come from? I am not entirely sure. No doubt my faith of God sustains me. There is also no doubt that my son Archie motivates me. I refuse to allow his life to be taken in vain. I make sure that his memory will live on, even if, through the efforts of his mom to help others cope with their pain and suffering, it is my mission to ensure that Archie's life story will continue to serve as an agent of change and transformation to saving others for Archie. So, what you might ask, is my life like today? Well, I just want to share that, 10 days ago, when I received your invitation to the hearing--I want to recount a few details of what these days are like, similar to Dr. Westlake. I think we get the same texts, possibly. I hope you will gain a little bit of vision of what it is like in my life today. On April 5, a mother called me. Her teenage son had died, and she wanted to know if her hell would ever be put away or will ever go away. Two days later, on April 7, another mother called. She got my name from a funeral director who buried her child, and she told me she does not know how she will ever get out of bed and get a break from her personal grief. She is just devastated. On April 8, I learned of a young man who knew both of our sons from childhood who died of a heroin overdose this weekend. I cooked dinner, brought it to their family, and we all sobbed in each other's arms as we looked at their Catholic school grade pictures. There were no words of comfort to offer. I sat in silence. This boy had carried my son's casket. It made no sense. That young man's funeral happened this past Saturday. I attended. The wounds reopened. I cried some more. Out of the blue a week ago, a psychologist called me. He asked permission to give my personal cell number to a patient, a woman that he feels he cannot reach. The psychologist has worked with this mother for a full year after she lost her 28- year-old daughter. This past weekend, a mother reached out to me with her 38- year-old son, who was turned away at the emergency room (ER) for a detoxer treatment. She had found him with a needle in his arm and did not know what to do. So, I made sure that she was armed with Narcan. She tried to call a hospital to get in, it would not be until next week, and she went to bed that night with the Narcan sleeping next to him. For two nights, that is how it was. The third morning, he was not there. He is still not home. The system let this mother and son down. I am not done, though. My son Augie called me from the University of Wisconsin (UW)-Eau Claire Sunday evening. Another freshman student in his dorm overdosed on opiates. Augie, who serves as a public speaker and knows more than anyone should at his age about drug addiction--it was Augie who was the first responder to this UW-Eau Claire student and called 911. The fellow student did survive and was grateful for Augie's quick thinking. So, you see, it is all over. There are several more messages on my phone looking for help, several that I have not even returned as of yet today. But, why me? Why do they call me? Why do psychologists, business professionals, and funeral directors call me? Sometimes I feel like I am not quite sure, because I have terrible days. You know what I am talking about, these days when you can barely get out of bed. The heaviness of the grief is insurmountable. In other venues, it may look like I have it all together. I enjoy a good deal of success as a business marketing executive. I feel quite natural serving clients across the Nation from the East Coast to California. In this realm, I am comfortable and I am confident. But, here in this realm, there is no business school for parents whose children are addicted to opiates, like heroin. In this realm, there is no textbook or guidebook to follow when you learn that your child has an addiction, no. But, people continue to reach out to me. I believe it is because I am raw, living-proof knowledge of this addiction storm. I lived it day after day with my son, Archie, and then I buried my own son. I am not embarrassed, nor do I apologize. I do not wallow in shame, nor do I blame others. Instead, I seek to find resources--resources which will build knowledge, create understanding, and help counsel others through this nightmare. Besides being a seeker, I am also waiting. I am waiting for leaders like you. It may be too late for my Archie and our family, but can we work together to save others? This hope is why I came today. I wanted to briefly share some urgent needs that I think are important from all the telephone calls and what I have heard from across the State, for not only our State, but our Nation. First, the medical treatment model needs reworking. Think diabetes: Lifelong care; lifelong approach. Addiction: Lifelong care; lifelong approach. We need to change the way we use healthcare in our Nation when it comes to opiate addiction. We need a treatment model because true opiate addiction needs medication. And, also, treatment needs to be uninterrupted by insurance companies. Addicts need to be able to focus on the recovery and not whether or not their insurance company is going to deny or end their coverage. Second, the window to get treatment is so narrow, and these families are being turned away each day they come to an ER to get help. HFS-75 opiate detox, in general, is urgently needed to stabilize a person and is part of a treatment-oriented system of care. Traditional opiate detox is not generally covered by health insurance. The need for some type of detox facility remains in communities, and alternatives to traditional opiate detox are being explored by the private sector, such as ambulatory detox, rapid, home-based programs, and even visiting nurses. Third, step up the medically assisted treatment to aid the opiate epidemic. Use medical-assisted treatment for opiate users in a recovery program and in drug courts as part of the law. We must provide Vivitrol for those incarcerated and for those newly released. Fourth, restricting access to drugs not just from Mexico, but from all our borders and boundaries and professional responsibility. Tighten up education to drug companies and better educate physicians, oral surgeons about the how-to's of writing an opiate script. Lastly, look into the data on those that have survived opiate overdose and the suffered brain trauma that are now wards of our State, like my nephew, that will need 24-hour care for the rest of his life and is unable to give back to society. Harnessing all of our stories together and looking at the hard facts for policymakers, this is the other side of the epidemic that nobody wants to speak about. So, I close with these five important unmet needs, and I hope my perspective provides you with insight so they may be reality for future policy changes. I thank you for your time, and hopefully together we can save lives. Thank you. [Applause.] Chairman Johnson. Thank you, Lauri. Obviously, our sincere condolences to you and your family. Our sincere thanks for your commitment to help others turn your tragedy and the loss of Archie to something positive, trying to help others, and just for your courage for testifying here today. Tyler, I want to go to you, because you said you tried different types of treatments--different types of medications to get you off of heroin, and then finally one worked. Can you describe what did not work and why it did not work and what finally worked with you? Mr. Lybert. I think the biggest part of why treatment did not work for me is because, at the first six treatments, I did not really want to be sober yet. I think that is the most crucial part to anyone getting sober is wanting to be sober. And, for everybody it is different. Methadone may not have worked for me, but it has worked for plenty of other people. Vivitrol may work for somebody else--it may not work--it is different for everybody. But, I think the key thing is, is that person has to be at a State where they are willing to change. Chairman Johnson. So, in your testimony, you described yourself pretty low stages for quite some time. Mr. Lybert. Yes. Chairman Johnson. But, I mean, we always hear hitting rock bottom. I mean, it really was when your parents kicked you out of the house, you were living in some situation, and then it was when your mom called? I mean, what--describe rock--I hate to say this, but describe rock bottom, and what was different about it than what you were describing, which sounded pretty rock bottom while you were in the house as well every morning waking up. What is the difference? Then, Lauri, I am going to come to you, because I want to hear how that relates in terms of your situation. Mr. Lybert. Well, I think the biggest thing is, is the last time that, every time that I hit rock bottom before that, I was like, well, this is just a fluke. This will not happen again. I will not get this low again. I will make sure of it. I will be better this time. I will be a better addict this time. The last time that I went in was the final realization that this just is not working anymore and that rock bottom was--I had a knife. I was ready to end everything. I was done. I could not take the burden anymore. Chairman Johnson. Ashleigh, real quick, did you and your parents, did you recognize rock bottom? Did you see something different about it this time? Ms. Nowakowski. Not at first we did not. When my parents kicked him out of the house, I had moved out of the house, but they had called me and said, we have kicked him out, and this is the ultimatum. If he calls you, do not answer his phone calls. And so, they were the ones that went to go pick him up and take him to treatment. But, it took a little bit for us to realize that he wanted to get help. So, at first, I did not know if we noticed a change in him or anything like that, but he felt it. Chairman Johnson. Other than that attitude of now I really hit rock bottom, was there a difference in the treatment or was it strictly just the attitude? Ms. Nowakowski. I think a big thing that helped him was we changed as a family. So, we had to go to family sessions and-- because throughout all the other treatments, my parents would take him, drop him off, pick him up, he was fixed. Like, you fix him, and he will come back into our house. And, that was not working. So, when we went to the final treatment, we actually had to go to family sessions and work on changing dynamics within the entire family. Chairman Johnson. So, you were with Tyler. So, now you went through treatment, to a certain extent, together. Ms. Nowakowski. Right, exactly. Chairman Johnson. And, that was the first time that happened. And, Tyler, was that--I mean, in addition to hitting rock bottom, was that family treatment, was that also key? Mr. Lybert. Yes, I think that was a huge part, because family was--no matter how much I did that was wrong to them and how much I said I hated them, they were still the most important thing to me. So, knowing--like seeing their support and, seeing my dad tell the counselor that, well, I work every day, and I am not going to be there because you cannot set a meeting early enough, and the counselor saying, hey, tough luck, you are coming. And, for all of us to be in the same room and to be able to share, what we were feeling to each other, that was the first time that has ever happened. So, yes, I think that was a major part. Chairman Johnson. Lauri, I hate to even ask, because I hate to have you go through this process again, but were there attempts to put Archie in treatment? Did those work, did they not work, or--and/or can you talk about because you are helping so many other people, can you relate to this? Can you kind of---- Ms. Badura. Yes, I can. And, I do not feel guilty, Tyler. We love you, and we are so glad you made it. But, Tyler is an anomaly. There is not a lot of them that make it out, there really is not. I wish there was a lot of Tylers. I wish I knew them; I do not. So, I am so glad. I mean, our families are close. We know each other well. They knew Archie. I guess, I have my sisters and husband, and it was 4 years of hell. It was marijuana. So, everybody says, oh, heroin. That was not even introduced before 2 months before he died. So, I guess rock bottom? There were so many rock bottoms. We kept thinking, this is it, this is it. But, if you look on the last page, when you walk into an ER and see that your kid ingested an opiate patch, and the physician said most kids ingest a spoonful, he ate the entire patch and was foaming at the mouth. This is his first overdose. He should have died that day, January 3; he did not. If anybody wants to see it back there. There were several times. And, just like any addict, they do not want to die. They are off trying to get to a high of feeling better, but this drug owns them. They are in a jail of something that none of us can understand. I cannot tell you how many people said to me, how in the world could that boy carry your casket and then he overdose this weekend? I said, because you do not get it, you really do not get it. People who say that, ``Oh, they can just stop''-- they cannot. You cannot. And, it does, it starts with the pills. It starts with the pills, and then it goes, as you said, $10. Chairman Johnson. Tyler, when we were in the back and I asked Neal what he knows about the percentage of successful treatment. About 1 in 10 is what he said. That actually surprised me as being high. By the way, Rick and Sandi, if you would not mind, at the end of the panel, I will have you come forward if you wanted to just say a couple words or if there is something that you want to express here. That may be powerful. I do want to go to Mr. Bohn and Dr. Westlake. Anything you can kind of chime in on the treatment aspect of this? Things that you know, that we understand. Obviously, Dr. Westlake, you treat the emergency side of this equation. But Mr. Bohn? Mr. Bohn. One of the things we have learned from law enforcement over the years is the fact that it is going to take treatment to get people, otherwise we are going to see them again and again in the criminal justice system. We have now got an entire generation of addicted people out there. We focus on the people that bring it in. We focus on the people that deal in this stuff. But, I can tell you, the high level violators that bring this stuff in are smart enough to know not to use it, because they know how dangerous it is. So, it will take a lot of prevention, it will take a lot of rehabilitation, but law enforcement has a duty as well to keep it out as much as possible. Chairman Johnson. Could you just kind of speak to what we know about the success rate of treatment? Then I will turn it over to Senator Baldwin to ask questions. Dr. Westlake. So, yes, I mean, my area of expertise really is more in emergency medicine, some of the policy areas, but it is abyssmal results. I mean, once someone gets addicted, it is, one out of 20, one out of ten tops. So, there is a lot of different drugs that are addictive. Alcohol, you are an alcohol addict, and you have maybe 50 years of drinking before you die. You get too drunk, you pass out, you throw up, maybe a car accident if it is that horrible. You take too much heroin one time, you take one pill, like this kid last week, and you are dead. And so, there is just no room for error. And, the biggest thing, we just had this coalition meeting, we asked the health systems, how can we partner together? We brought States together, the Department of Homeland Security (DHS) and all kinds of players at that level, and the shortfall is in the treatment. So, there is not enough treatment fighters. If we could get all the addicts, 168,000 opioid addicts, if we could get them into treatment now, we do not have, so that is an important piece. I believe in limited government, that the funds really need to be justified to be spent, but I think the return on investment for getting people clean is huge, and it is well worth the cost. Chairman Johnson. What was shocking, before I turn it over to Senator Baldwin, in the testimony, I think you said the average beginning age was 11. Eleven years old. You were in sixth grade--11 or 12? Mr. Lybert. Eleven, yes. Chairman Johnson. Nothing glamorous about that, is there? Mr. Lybert. No. Chairman Johnson. Senator Baldwin. Senator Baldwin. Thank you all again for your amazing and powerful testimony. I want to just pursue a number of the issues that each of you raised a little more deeply. Lauri Badura, if I can start with you. You just described your last few weeks. You are like the key resource for people who have your cell number and people who give out your cell number. We have an epidemic, and it strikes me that people have no idea where to turn, what to do. It does not sound like an emergency response to an epidemic at all. Tell me, what is out there for parents? When you talk to them, of course, you are doing some personal counseling. You are sharing your experience, hugging them. What sort of formal resources are out there, especially if you are hearing from parents who have not lost their children yet? Ms. Badura. Absolutely. I am so glad you are asking. I am on the Alcohol and Other Drug Abuse (AODA) advisory committee for Waukesha County, and there are several wonderful things that are out there, but there are many--it is hard getting the word out there. They are doing great things, but no one really--I call it connecting the dots. That is if you look up my name--most people Google ``heroin mom,'' and my name comes up. So, I call it connecting the dots in the State because each county is doing fabulous. I mean, I have worked with Milwaukee. No one is talking to each other. Why redo each other's work? But, what I would tell somebody that would call is there is something called 211, which is--you know what that is, right? Senator Baldwin. Of course. Ms. Badura. OK, the 211. And then, a lot of people do not know it. So, they are just comforted with that fact. If they cannot, most of the problem is a lot of these people, the resources are tapped, there is no more insurance, they have done treatments, most of them, I would say, have done three, under their family's insurance, and they are tapped out. So, then they go to a county, and the county it takes 4 or 5 days on a good day. That is what my friend was waiting for this past weekend when the boy--they were trying to wait to get him in, and that is just because they are so backed up. But, I know so besides that, it is arming--if you are living with somebody with an addiction and they are using opiates, you have to have the Narcan, and the public does not know about that. There is great resources here that are training, they are handing out needles, they are doing things here, but they just need help getting the word out. There is also the Addiction Resource Council (ARC), they are doing fabulous things, but we do not even have counselors. The counselors are going to age out soon, and there is not enough counselors to counsel people. Because, really, Archie was 77 days clean. He wanted to be clean. That is the most dangerous time. You can get them through treatment, but they still need--that is why I am saying, ``We need the care like diabetes, where for life, you are getting looked at, you are getting to see a doctor and saying, `OK, how is it going? Well, maybe you need to go do this again.' '' So, those are the steps. And, there is also--I give several different numbers of private homes, that care that will take the people, and then public places, but there is not many beds. Senator Baldwin. About those beds. Just in terms of your own knowledge and your own experience, is it because of lack of professionals to staff them or lack of local resources, State resources, national resources to fund them, lack of insurance coverage, all of the above? Ms. Badura. It is really all the above. Senator Baldwin. I think I know the answer to the question, but I want to hear you---- Ms. Badura. No, but it is a great question. Like Lutheran Social Services (LSS) is one I can tell you in Waukesha County who has been pushed around because they cannot get a building. Nobody wants them. And, they have the funds, they are ready to have a building, and I know they are working on that, so--but people do not want a hospital full of addicts maybe in their neighborhood, I do not know. I know that is one problem. I think that they are definitely limited on doctors. I think we do not have the physicians as many as possible. I know we do not have the counselors. I absolutely know that. But, I think our resources for what the epidemic has done. Because I joined this advisory group when Archie was alive, I came to this meeting saying, please help, my son is so sick, please help, I do not know what to do. And, I wanted to educate myself. I can tell you, in those 2 years, these people that are working in their daily job--it is not my daily job--they are tapped. There is nothing. They are not getting any more help. I mean, we really need more people, more resources, more help. And, I am thinking almost like hospice care, where it is, it is in your home, and people come. I am not sure, because I know it is expensive. But, we have to save lives. Senator Baldwin. That is right. Tyler and Ashleigh, before I ask the question, I also want to give you permission to plug the prevention work that you have done through Your Choice to Live. We will get a series of public service announcements as I go across and ask questions, so if you want to say anything about that as a precursor. But, Tyler, I want to ask you about the impact of your interactions with the criminal justice system. You talked about several arrests, I think several incarcerations at the local level. And, I understand that everybody's path is different. Were those experiences helpful or motivational for you to actually make the decision to ultimately seek treatment? How did that play out in the path that your addiction took? Mr. Lybert. Well, I think one of the things, and we talk about this quite a bit, but, back 10 years ago, when I was using or--yes, it is--wow, it was 10 years ago, when I was 18, when I was 19, when I was 20, things like that, there was not the problem there is now. So, the--the--oh, my gosh. Ms. Nowakowski. Criminal system? Mr. Lybert. That is it. The criminal system did not have the resources they did either. So, when I was arrested for driving under the influence (DUI)--or whatever I was arrested for--I was never offered classes, I was never offered anything like that. So, for me to say it helped me, not necessarily, because I would blame the system every time. Now, a lot of different things are put into place for people that do get arrested and things like that, like the 180 Diversion Program. I went through the alcohol treatment court in Waukesha County after my third DUI. And so, in that respect, it did help, because that gave me a year after I was already sober to be held accountable. So, I think that the criminal system is getting better and doing better at trying to help addicts rather than lock them up. Especially in our community in Waukesha County, Oconomowoc specifically, when kids get in trouble for underage drinking or paraphernalia or possession or anything like that, their first offenses, Judge Kay in Oconomowoc, he refers them to our program, to our detour class, so they can take a 12-hour class on--all about risk taking and choices and making better decisions and stuff like that. So, I think that the justice system and criminal system together is starting to see a need for help rather than sentencing. Senator Baldwin. Dr. Westlake, I have a question for you, but before, you just heard Ms. Badura say that too few people even know about Narcan or naloxone. So, for people in this room who might not know, for people who might be hearing about this hearing by watching the nightly news, can you give us one minute on what the heck those two drugs--or what that one drug with two different names is, what it does, and why people need to know about it? Dr. Westlake. Sure, yes. Narcan, or naloxone is the drug name for it, is an opioid reversal agent. So, what happens when you take opiates is they sedate your respirations, they fill these chemical receptors in your brain, and eventually it suppresses your respirations so much, you stop breathing, it lowers your oxygen level, and your heart stops after that. What the Narcan does, if you can get it in before that whole cycle is completed, is it kicks off all the opioid chemical analogs, and so it clears it, just immediately, literally takes them off. I have given it to patients where they come in and they are breathing at two breaths a minute and they are blue, I give it to them, and if you give a little too much, sometimes they are wide awake and they are angry as heck right away. I mean, it is just like turning a switch, if you can get it in the patient in time. Chairman Johnson. Just real quick, is there any danger to having that in the general population? Is there any abuse of that drug? Dr. Westlake. No. The theoretical risk would be, well, are you motivating people to feel safer using? And, initially, I kind of thought that maybe 10 years ago, until I had some insight into it. And absolutely, those people are going to be using. When you are an addict, that is what you do, is you use. And then, I think Attorney General Schimel is going to talk about it, he is pushing to possibly go the Food and Drug Administration (FDA) with no prescription necessary. And, I think--I mean, the only issue I would have would be that we have to make sure the supply is enough that we can get it in the ambulance services. I would not want it to just disappear, and all of a sudden there is shortages, because there are drug shortages on a lot of different things. So, but apart from that, there is no--other than, you feel a lot of pain if you give it to someone. Chairman Johnson. Is it injected, or how is it---- Dr. Westlake. You can shoot it in someone's nose. So, there is a nasal atomizer that you can use. You can inject it. Chairman Johnson. Sorry to take your time. Senator Baldwin. No, I absolutely wanted this to be a public service announcement on this topic. I have a question too, but---- Dr. Westlake. Yes, it is a great message. Senator Baldwin [continuing.] No, I think it is a really important question. And, not unlike the distribution of clean needles to prevent other deaths related to people who shoot drugs, this does have that side debate, but it reverses an overdose. So, my question for you actually relates to the recently released Centers for Disease Control safe prescribing guidelines. I think they went through a fairly long process trying to look at the latest evidence on appropriate and safe use of opioid pain medications. I would like to ask you, in terms of educating your peers in the medical community about safe and appropriate prescribing, sort of what is the most important piece of information that this guidance should include to support prescribers in preventing adverse outcomes of addiction and recognizing addiction in their practices? Dr. Westlake. Yes, the guideline piece is--we actually just pushed and Representative Nygren had a bill that went through that we just signed that gave the Medical Exam Board the ability to promulgate guidelines. We actually--Mike McNett is a doc that I work with who would come--modified the CDC guidelines and put them into our language. The thing that is important is to get the changes to come from underneath within. So, you have to get the providers, which I think there is an awareness now, to understand that there is inappropriate prescription. So, it cannot just be another Federal mandate like, you got to do this and it needs to come from underneath within the health systems and from within the doctors. And so, what we are trying to do at the State level, through the controlled substances committee, which is what promulgates the guidelines, is to have input from the stakeholders. So, then when we come out with these guidelines, the systems can then say, OK, these are reasonable guidelines, they are good guidelines. And, when you get buy-in from the providers in the systems, then it can be incorporated into the culture of the practice, and education is important with that as well. It has to be limited, though. Because, again, we have a crisis now, so there is a huge opioid epidemic. The problem I have with legislation, State and especially Federal, is once it is in place, it is never going to get repealed. There is never going to be enough will to repeal it. So, if you put something in place--there is a great piece of legislation that had, continuing medical education (CME)--4 years of opioid CME per year for the DEA. The problem with that is in 20 years, hopefully, the culture will have changed that it will not be a problem, but I will still be stuck doing 4 hours of opiate CME. And so, that is the thing is, that Representative Nygren used sunsetting. So, after three years, the restrictions on checking the prescription database will go away. And then, hopefully by then, the culture of prescriptive practice will have changed. So, that is the wisdom of the legislation. Senator Baldwin. Yes. But, and you raise a great point. I remember reading an article about how sometimes change in the medical community is slow, and it was Dr. Gawande talking about how a recipe change in New York City was adopted universally in all the certain type of restaurant in 7 days, but it took 7 years to change a protocol at the medical profession. So, we obviously need to put a huge exclamation point behind these new guidelines. Dr. Westlake. And, have the systems within own their part of the guidelines. Senator Baldwin. Yes, exactly. One last question of this panel from me for you, Mr. Bohn. So, you have the rather unique role of overseeing the coordination among so many different levels of the Federal, State, and local law enforcement efforts to combat drug trafficking. And, I guess I just want to--from that unique perspective, I want to know how you believe it Is working and what more we can be doing at the Federal level in Congress to support coordination to more effectively combat the flow of heroin and other illegal opioids into this community. Mr. Bohn. It is just that the support is both funding for training, for enforcement, and for prevention methods. In HIDTA, we have a heroin-specific task force that we have just beefed up by about 50 percent with more manpower, but at the same time, we are always doing costly training out there. We are training law enforcement, because in a lot of the communities, this is something relatively new to, on how to handle overdose investigations and--because it is in every community. At the same time, we do a lot of public awareness training to go out and just let people know that this is out there. And, we have participated in countless heroin summits around the-- and opioid summits around the State to raise awareness both within law enforcement and within the public in general. We are working hard to get the intelligence sharing that needs to be done at the law enforcement level so that all the agencies that are participating in these share intelligence so that we can make connections and close those intelligence gaps as well. So, there is several levels to the problem, several levels to the solution, and it is not going to be one thing; it is going to be a multifaceted solution. Senator Baldwin. Thank you. Chairman Johnson. Thank you, Senator Baldwin. I do not want to put too much pressure on Rick or Sandi. Would you like to make any comments before we seat the next panel? Do you think Ashleigh did a pretty good job for you? Ms. Scott. I do. Chairman Johnson. OK. I think she did as well. Mr. Lybert. Are you sure, mom? [Laughter.] Ms. Scott. Yes. Chairman Johnson. Thank you all for your powerful testimony. This is not the last hearing on this, trust me. So, thank you, and we will seat the next panel with that. [A recess was taken from 3:42 p.m. to 3:46 p.m.] Chairman Johnson. As I mentioned to the earlier panel, it is our tradition to swear in witnesses, so if you all rise and raise your right hand. Do you swear the testimony you will give before this Committee will be the truth, the whole truth, and nothing but the truth, so help you, God. Please be seated. Our first witness is Commissioner Gil Kerlikowske, and we know you have a hard stop at 4:30, so when we get done with the testimony, we will come to you and ask you the questions, and then, feel free to, I guess, probably catch your plane, right? Commissioner Kerlikowske. Thank you, Senator. I appreciate it. Chairman Johnson. So, Commissioner Gil Kerlikowske is our first witness. He is the Commissioner of the U.S. Customs and Border Protection at the U.S. Department of Homeland Security. Commissioner Kerlikowske is also the former director of the Office of National Drug Control Policy. Mr. Kerlikowske has four decades of law enforcement and drug policy experience. And, again, I just want to express our--this committee's thanks for all the traveling you have done to participate in these similar types of hearings in the States which are being affected by this tragedy. Commissioner. TESTIMONY OF THE HONORABLE R. GIL KERLIKOWSKE,\1\ COMMISSIONER, U.S. CUSTOMS AND BORDER PROTECTION, DEPARTMENT OF HOMELAND SECURITY Commissioner Kerlikowske. Thank you. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Kerlikowske appears in the Appendix on page 76. --------------------------------------------------------------------------- Chairman Johnson and Senator Baldwin, thank you so much for the opportunity to appear today and to be here to discuss this significant abuse and addiction issue of heroin. It is an important discussion about a complex, difficult challenge that our Nation faces. Customs and Border Protection has a critical role in the effort to keep heroin and other dangerous drugs out of communities. We seize nearly 4 tons of illegal drugs every single day, and it is a variety of drugs. Our seizures of heroin increased 22 percent in the last fiscal year (FY). While the vast majority of the seizures still occur along the southwest border, we interdict heroin in all modes, air, land and sea, in both the travel and the cargo environments. Add in between the ports of entry (POE), our frontline officers and agents use a variety of technology and assets, everything from canine to large x-radiation (x-ray) equipment, etc., along with intelligence and information sharing with our State, local, and Federal partners. Continued efforts to intercept drugs at the border are a key aspect of addressing the crisis, but I think we all know and recognize that interdiction and arrests alone will not solve this problem. President Obama conveyed just a couple weeks ago at the National Prescription Drug Abuse and Heroin Summit in Atlanta that we need to focus efforts on prevention and treatment in conjunction with the deterrence of drug trafficking via criminal organizations. And, we need to better integrate our efforts and share information. I am pleased to support the Department of Justice (DOJ) and the Office of National Drug Control Policy on the National Heroin Task Force, which fosters a collaborative relationship between public health and law enforcement across all levels of government. Law enforcement at all levels is committed to security, but also in protecting the health and safety of the public. And, for Customs and Border Protection, this is especially important because nationwide we encounter nearly 1 million people every day that come into our country through our ports of entry. And, we were the first Federal law enforcement agency to initiate naloxone training for our officers who may encounter someone experiencing an overdose. I want to acknowledge the significant strides that we have made with Mexico and that they have taken in recent years to address transnational organized crime, and narcotic smuggling specifically. The relationship with our Mexican counterparts is stronger today than it ever has been, and while more can be done, we know that we receive information from Mexican authorities on a daily basis. They sit with us in some of our targeting centers, we work closely with them, and I think the recognition that we are all very much in this together is clear. So, thank you for holding this important hearing, and I am happy to answer your questions at the appropriate time. Thank you. Chairman Johnson. Thank you, Commissioner. Our next witness is Attorney General Brad Schimel. Attorney General Schimel was elected as the Wisconsin Attorney General on November 4, 2014. A front-line prosecutor, first elected Waukesha County District Attorney in 2006, Schimel has pledged as attorney general to put public safety over politics and continue to fight against heroin and human traffickers. General Schimel. TESTIMONY OF THE HONORABLE BRAD SCHIMEL, ATTORNEY GENERAL, DEPARTMENT OF JUSTICE, STATE OF WISCONSIN Mr. Schimel. Good afternoon. And, thank you, Chairman Johnson and Senator Baldwin, for the opportunity to testify, and thank you for both of your commitment too. Thank you for your commitment to finding bipartisan ways to address this opiate epidemic that we are facing. Some of the legislation that you have both proposed will make a difference in this battle for us. And, Senator Baldwin, you asked whether--in the question- and-answer (Q&A) period earlier, whether this was an--this sounded like an emergency response to a crisis, and it does not. And, many of the people in this room have been on kind of the speaking circuit together for a long time, and we have been asking for a long time, after we talk about the nature of the problem, we are asking people what are we prepared to do about this? We have seen in the course of a little over a decade, opiate overdose deaths more than quadruple. And, if we saw that kind of a change in traffic crash deaths, we would put a roundabout every 200 feet. We would lower speed limits to 15. We would not let people get their driver's license till they are 30. We would do things that sound crazy. And yet, as to this, we are still kind of struggling for awareness. So, I appreciate your committee's willingness to help raise this awareness. I do not want to repeat things that others said, but I will reiterate what Mr. Bohn said. This is also driving virtually every other kind of crime in our nation. Dr. Westlake, he has had enough in the emergency department. Me, I have had enough. There have been years in Waukesha County where we have had close to 50 overdose deaths, right in this one county while I was the district attorney (DA). I have met now all along the way, hundreds of parents who have buried their children. I have had enough. I am tired of this. The law enforcement officers and emergency medical services (EMS) that are in this room today, they have had enough, of often going back over and over to the same house, to the same person, who was saved recently and just went right back to using, because we do not have enough help for them. And, they are often, as Tyler Lybert said, they are often not ready to get help. And, the Lyberts and Mrs. Badura, we have spoken together dozens of times, and still, every time any of them talk, I still get choked up and get teary-eyed, because their story does not get any better no matter how many times you hear it. So, ask any law enforcement officer here in this room or anywhere, what is the worst problem we have seen in the last quarter century, this is it, this is the one. And, now, you have heard a lot about how this devastates people in many ways. There is one way that has not been mentioned yet, and that is employers. It is affecting our economy. Four out of five employers in a survey conducted in Indiana, which is not so different from Wisconsin, four out of five employers in that survey had to address opiate abuse and addiction in their workplace. Conservative estimates suggest that opiate abuse is costing employers nationwide over $26 billion annually. This is affecting our economy. And, I do not want to repeat all the things that have been said about the issue on the border, but any discussion about this problem has to include a discussion about our Nation's international borders. In years past, heroin came to America from southeast and southwest Asia. Because it was so hard to get it here, it had to be cut drastically in order to be profitable. In the 1980s, the average heroin purity on the street was about 5 percent. We do not see 5 percent anymore, because it is so easy to get it into our country, they do not have to cut it to make it profitable. Instead, they are competing with each other for who has the most potent heroin. And so, now we find heroin between 20 percent and all the way up to close to 80 percent pure. And, when you look at it in your hand, you do not know what you have. That is part of why we are seeing so many overdoses, because a young person, or even a middle-aged person, using that has no idea. So, it is going to be necessary in this to address the border security as part of this problem. And, I want to mention methamphetamine. Mr. Bohn mentioned it briefly. Wisconsin and many other States took drastic steps to make it harder to produce methamphetamine here in America. So, we made it harder to buy the necessary ingredients to make it, and we have cut down domestic production. Unfortunately, the production shifted to Mexico. Our problem with methamphetamine is worse than it was before, and it is growing, and it is spread to parts of our State that did not use to have the problem. So, we do have to address the border in this issue. And, in terms of how we are going to solve this problem, it has been said as well today that this is an all-hands-on-deck answer that we need to have. Law enforcement will not do this alone, treatment will not do it alone, and prevention will not do it alone, but they all three have to be as a part of this. One of the challenges is that unlike investigating an armed robbery that happens at one place and one point in time, the drug trafficking does not respect any municipal or State boundaries. It is moving everywhere. And, it is necessary for law enforcement to be able to work across jurisdictions together. One of the ways they have been able to do that over the years is through the assistance of the Byrne Justice Assistance Grants. Those grants have been shrinking over the years, and it is making it harder for the local, municipal police departments and the metropolitan drug enforcement groups to do their work. And, it has been years ago already now in Waukesha County, and I am a little bit reluctant to even say this out loud, but years ago we stopped focusing on marijuana at all with our metropolitan drug enforcement group because the opiate problem is consuming so much of our efforts. Narcan has also been mentioned today, and I just want to echo the comments. There is no reason to take it unless you need to reverse an opiate overdose. You do not get high off of it, it does not do anything to you, it has no harmful effects. Still, it requires a prescription. I am hoping we can see that change. Also, medication assisted treatment has been mentioned. And, you heard from Mrs. Badura about the concerns that oftentimes, a person who has been confined, be it a jail, a prison, or inpatient treatment, oftentimes the most dangerous time for them is right after their release. Relapse is a very common phenomenon, and their tolerance is now lower, and frequently they try to use at the same level they did before they were confined, and we are seeing so many of the overdose deaths happen at that time frame. Medication-assisted treatment (MAT) can help with this. We should fund having this available to people who are about to get out of jail or prison, people who are going to get out of a treatment setting, so that they can have assistance in resisting those urges that result in relapse. And, then one of the wisest things we have done in the criminal justice system--and that was also mentioned by Tyler Lybert--have been treatment courts. And, we have now treatments courts in about half of the counties in Wisconsin. Most of the counties that did that, like Waukesha County, when we started up our drug treatment court, we did so with Federal grant assistance, a startup grant. That is invaluable. You cannot get your county board to pony up the money to start it until you can demonstrate that it is doing something, that those startup grants are critical. You can start them up and you can show your county board the graduates and how your county is becoming healthier as a result, and then they will continue to fund it. So, please continue to support those grants to startup treatment courts. It is the wisest thing we have done, because we have started as a criminal justice system to treat addiction not as a felony, but as the disease it is, and it is a real opportunity for us. And, I also encourage making available more competitive grants. There are innovative ideas out there, in law enforcement, in social services, in nongovernmental groups. The only problem is, they are expensive, and, again, they have to demonstrate success before they can get that outside funding. Start-up grants, a competitive process, administered by the Office of Justice Assistance or the National Association of Attorneys General (NAAG), you name it, they can make a difference in finding new ways to approach this problem. So, I appreciate very much the committee's interest in tackling this Nation's opiate epidemic, and thank you, Chairman Johnson and Senator Baldwin, for the opportunity to testify today and for your work. Chairman Johnson. Thank you, General Schimel. Our next witness is Senator Jon Erpenbach. Senator Erpenbach was elected to represent the 27th Senate District in November 1998. His Senate colleagues elected him Senate Democrat leader in December 2002 through 2004. Currently, Senator Erpenbach is a member of the Joint Committee on Finance of the Wisconsin Legislator's Budget Writing Committee. Senator Erpenbach. TESTIMONY OF THE HONORABLE JON ERPENBACH,\1\ STATE SENATOR, DISTRICT 27, STATE OF WISCONSIN Senator Erpenbach. Thank you, Mr. Chairman. --------------------------------------------------------------------------- \1\ The prepared statement of Senator Erpenbach appears in the Appendix on page 86. --------------------------------------------------------------------------- First, I would like to commend Brad and John for their work on this issue. They say Democrats and Republicans in Madison cannot get along. We have on this issue. And, especially John with his work on this has been great, and you too as well, Mr. Chairman and Senator Baldwin. I really truly appreciate what you have done. The problem we are talking about today is well documented. I do not need to spend a whole lot of time on statistics other than to say, we would not be here if it was not the urgent problem that it is. The State of Wisconsin and the Federal Government need to partner together if we are going to be successful in the fight against this epidemic. In my testimony today, I will talk about a couple of different ways that we can partner together, the local, State, and Federal Governments, to combat the epidemic that brings us all here today. I am proud to represent Sauk County in my Senate District. Sauk County is home to the Community Activated Recovery Enhancement (CARE) program. This is a program that could, potentially, be a statewide or even a nationwide model. There are several things we can do to help it be even better. In Sauk County in 2010, law enforcement and the medical community started noticing a growing problem. There were 20 heroin and opiate deaths in a 2-year period. Ambulance companies and first responders reported over 80 uses of Narcan, an opiate that--we have talked about that already. Law enforcement and the medical and legal community and local businesses--this is important, local businesses--joined together to address what they saw as a community crisis. They had the foresight to recognize that this problem could not be solved by law enforcement alone, and they knew they needed a more comprehensive approach, so they developed the CARE program. CARE is an integrated system, putting the individual at the center of their treatment, which empowers the individual to make better life choices. CARE recognizes that addiction can be treated and overcome using an integrated, multidisciplinary approach that requires medical treatment, mental health services, social services, and healthy support systems. It is a program that recognizes addiction is a disease, as the attorney general said. A lot of us used to see it the other way around, as somebody just choosing to do this. It is a disease, and as a speaker said earlier, it needs to be treated throughout the lifetime. It is an important piece of the CARE program is Vivitrol, a drug that we have heard about already, injected monthly and blocks the receptors in the brain responsible for an opiate high. Vivitrol is expensive. The average cost of a monthly shot is about 1,200 bucks. St. Vincent de Paul was the first to step in in Sauk Prairie to cover the cost for the drug for inmates who agreed to the program, but they could not afford it much longer. While enrolling inmates in the CARE program, Sauk County realized that Medicaid-eligible inmates leaving jail were experiencing a gap in coverage, jeopardizing their ability to continue to receive the shots. Wisconsin is a State that chooses to terminate rather than suspend Medicaid coverage for those who are incarcerated, and that needs to change. With us here, by the way, in the audience tonight from the UW-Extension is a member of the CARE team in Sauk County, Dr. Morgan McArthur, and he is a great resource for anybody on your committee who has any questions about the CARE program and how it is worked to this point. According to the National Conference of State Legislatures, at least 18 States currently suspend rather than terminate Medicaid coverage for people who are incarcerated. The suspension approach yields administrative savings related to reapplication eligibility determination process, which can take as long as 45 to 90 days. I would be remiss if I did not take this opportunity, Mr. Chairman, to advocate for Wisconsin to take the Federal Medicaid Expansion dollars that have available to it through the Affordable Care Act (ACA). Our Legislative Fiscal Bureau estimates that Wisconsin is losing about $320 million over the biennium. 13.4 percent of the people in Wisconsin that would qualify for this Medicaid expansion have substance abuse disorders, 13.4 percent. So, needless to say, they could be helped by this. Mr. Chairman, in order to confront this horrible epidemic head-on, in order to begin to win this fight, we must break down the barriers, we must change the way we look at addiction, and, again, treat it as a disease. And, on a personal note, we heard from Tyler and Ashleigh. Growing up in my family, my sisters, Mary and Kim, and I were Ashleigh. My brother, Will, was Tyler. We lost Will in January. He was 53 years old--lifelong battle with addiction. He used up until the day he died. He did not die of a single overdose. He just died of a lifetime of abuse. He was a brother, he was a son, and most importantly, he was a father. And, even being a father could not help him overcome this. And, I remember, Ashleigh talked about counseling. I remember the Erpenbachs going to family counseling in middle school and high school, and back then I had no idea why I was there. I was angry. I was really upset with my brother. I just wanted him to knock it off. And, there were days, in fact even months, when he would not use. But, when we would not see him for 2 or 3 days, or 2 or 3 weeks, or 2 or 3 months, we knew what was going on. I saw what it has done to my mom and dad. And, the one picture I will remember on the day he died, which was this past January, were two people approaching 80 years old, being married together probably close to 60 years now, hugging in a hallway of the hospital, turning and walking out. I am a dad. I cannot imagine that. I cannot imagine that whatsoever. We have a real serious problem, and it is threefold. It is the border issue, which is way above my pay grade, but it is also an issue how society sees drugs and addiction. And, it is not just drugs. It is addiction, period. It is gambling. Addiction takes on many forms, but the results are the same. It tears the individual apart, tears the family apart, tears the community apart, tears society apart. If you want to look at it as a dollars and cents figure-- and this is the last thing I will say, and then I will be happy to answer questions--the amount of money taxpayers could save if we do this right would be tremendous, not only in Wisconsin, but certainly nationally. Thank you. Chairman Johnson. Thank you, Senator Erpenbach. Sorry for your loss and thank you for sharing that. Our final witness is Representative John Nygren. Representative Nygren was elected as a Wisconsin State Representative from the 89th Assembly District in November 2006. Representative Nygren has made addressing the heroin-opiate epidemic in Wisconsin a major priority, leading the way in the passage of 17 bills by the Wisconsin legislature, 16 of which have been signed into law. And, again, a person of real courage to kind of lay bare your story for public scrutiny. So, we certainly appreciate your willingness to do so. Representative Nygren. TESTIMONY OF THE HONORABLE JOHN NYGREN,\1\ STATE REPRESENTATIVE, DISTRICT 89, STATE OF WISCONSIN Representative Nygren. Thank you, Senator Johnson and Senator Baldwin, for having a hearing today on the impact of trafficking and abuse of heroin and prescription opiates in Wisconsin. --------------------------------------------------------------------------- \1\ The prepared statement of Representative Nygren appears in the Appendix on page 91. --------------------------------------------------------------------------- It is already been said, our country is currently facing a prescription opiate and heroin epidemic. This problem knows no boundaries. All demographics of people are affected in one way or another, no matter their income, no matter their race, no matter whether they are from an urban community or a rural community. And, Senators, no matter if you are Republican, no matter if you are a Democrat. Many of us know too well that Wisconsin is not exempt from this epidemic. As mentioned, I have a daughter, Cassie, who is now 27 years old, who, unfortunately, to this day, is still struggling with addiction. Hers began with an illegally obtained prescription. We had a doctor selling prescriptions of OxyContin that, unfortunately, she got access to. When that supply dried up, she moved onto heroin, like many others. So, my family is no different--my community is no different. The county of Marinette led the State in overdose deaths per capita a couple years in a row. Initially, as an elected official--initially as a parent--we dealt with this problem, privately, like most would. But, when I began to read the obituaries of my friends' and neighbors' children, it was a call to action, and it was for that reason that I am very proud of the steps that the legislature in Wisconsin has taken over the past 3 years to combat this devastating problem in our State. In 2013, we laid the foundation of what was to become the Heroin Opiate Prevention and Education Agenda (HOPE). This foundation was laid with seven bills that aimed to fight heroin's use and addiction in our State. We expanded access to drug treatment opportunities; made opiate antagonists, like Narcan, more readily available to first responders; and enacted a Good Samaritan law. However, after the session ended, it was very clear that there was much more work to be done to combat our problem in Wisconsin. As this session began, we continued our work to build on the HOPE Agenda. Instead of specifically targeting heroin-- heroin gets a lot of headlines, it is very dramatic and oftentimes has been talked about in the news, but it starts much more innocently in most cases. The root problem of our situation in Wisconsin has been readily agreed by many experts lies with prescription opiate misuse, abuse, and addiction. Studies show that in most cases, heroin addicts begin with an addiction to prescription painkillers. Whether these medications are obtained legally or not, we need to do our best to curtail the illegal use of these dangerous medications. As a continuation of the HOPE agenda, this session we passed 10 additional bills--9 of which have already been signed into law by Governor Walker. These bills continue to expand access to opiate antagonists to reduce incidents of overdose deaths, further expands access to treatment and diversion programs so people addicted to opiates can get the help they need in lieu of incarceration. And, we have expanded the use of Wisconsin's Prescription Drug Monitoring Program (PDMP), so instances of overprescribing become less common. It is our hope that these important pieces of legislation will reduce the number of people who become addicted to legal prescription opiates, and in turn, reduce the number of people who eventually turn to heroin and other dangerous substances. here are 17 HOPE Agenda bills total, and all of them were approved unanimously by both houses of the Wisconsin State Legislature. Governor Walker has signed 16 of these proposals into law, and we are expecting the 17th to be signed very soon. Once again, it is important to note, this is not a Republican issue, this is not a Democrat issue. When people contact my office to bare their soul about their personal stories, we never ask what their party affiliation is; but rather, this is a public health and safety issue. I am proud that there has been such widespread support for these pieces of legislation from people throughout our State, including the medical community, law enforcement, my colleagues in the legislature, the Governor, attorney general, and countless addiction advocates. Now it is time to start combating this devastating problem. I am proud that Wisconsin is leading the way with efforts like the HOPE Agenda and confident that other States will begin to look to us for guidance as far as what can be done. The laws that make up the HOPE Agenda are not a silver bullet that will solve this epidemic, but each proposal is an important step in the right direction. With that, I look forward to continuing our work to further build upon the HOPE Agenda in the future. Future efforts look to reduce current barriers to treatment, as well as provide additional access to treatment. I appreciate the opportunity to testify before your Committee today on the HOPE Agenda and the State of Wisconsin's efforts, and I hope to be able to be a resource for your work as we continue to address this problem nationally. Thank you. Chairman Johnson. Thank you, Representative Nygren. We do have---- [Applause.] We do have about 15 minutes with the Commissioner, so let me start asking questions, then I will turn it over to you, Senator Baldwin, for the Commissioner, and then we will move on to the rest of the panel. Commissioner, on Tuesday, when we held a hearing in D.C., we had the former head of Southern Command, General John Kelly, testify before the Committee, and in previous testimony, the other 15 hearings we have had, and you have participated in a number of those as well, we certainly found that the vast majority of drugs that move into America through the southwest border actually come through our ports of entry. I believe that is true, I will let you comment on that, but General Kelly, I was surprised when he said we have visibility of about 90 percent of the flow of illegal drugs. We have visibility of it--we just, simply, cannot interdict it. Is that kind of your understanding? I understand you are Customs and Border Protection at the border. General Kelly is Southern Command in Central America, but I know DHS is cooperative down there as well. Can you just kind of lay out what the reality is in terms of our visibility of the flow, our inability to interdict, and just the problem we have. These drug traffickers are very sophisticated in their use, and I have been to the border, the use of dogs, the use of imaging technology, it is extensive, and yet, according to testimony with former drug Czar General Barry McCaffrey we only interdict between 5 and 10 percent of illegal drugs coming in through the southwest border. So, just can you speak to that, the difficult nature of the task? Commissioner Kerlikowske. Sure, Mr. Chairman. I would separate out two things that General Kelly said. One is certainly the drugs that come across through the waterways in the Caribbean, et cetera. I think he is very clear that we have a lot more visibility on that than we have ever had, for a variety of reasons. Customs and Border Protection flies the Airborne Warning and Control System (AWACS). We do that in conjunction with our partners in the Coast Guard. We have an incredible center in the Joint Interagency Taskforce (JIATF) South in Key West, Florida and we have a lot of information, a lot of visibility, et cetera. What we do not have are the assets to go after that. Now, what we are talking about here mostly is cocaine, either destined for the United States, but frankly, given the appetite that Europe and Africa and others have for cocaine, this is cocaine going all the way across. It would be like when I was a police chief and we had a call of a robbery at a 7- Eleven, and I would say thank you for the information, but I do not have anybody to send. We could actually use more assets to be able to respond because we do have very good information, both technology and also informant information. On the other hand, the drugs that flow, and we are talking here mostly heroin, the drugs that flow into the United States from Mexico, again, speaking about heroin, is almost always interdicted through our ports of entry. We do not see many backpackers or others coming between the ports of entry, and when we do interdict drugs, it is almost always marijuana being done in those backpacks. So, it is coming through the ports of entry, whether it is John F. Kennedy International Airport (JFK) or the San Ysidro POE, and it is people that are carrying it on their person, it is people that have swallowed it, and it is hidden inside of vehicles, and of course our best deterrence to that has been able to interdict. I will tell you that I look at a lot of data, and I have seen that testimony and heard that testimony from General McCaffrey, who is a friend and a colleague and a mentor, but I would be very reluctant to cite to you the percentage of drugs that we either seize or do not seize. That being said, if we seized 50 percent or 70 percent, your earlier statement in the opening about our appetite for drugs and the fact that this is such a high profit area is going to make it extremely difficult if we seized 80 percent. Chairman Johnson. I mean, the percentage is neither here nor there. The supply is meeting the demand and then some. To have the prices go from $3,000 a gram to $100 a gram, there is a real problem. Oftentimes we hear that the use of drugs is a victimless crime, and I think we have heard in testimony there is no such thing, the broken families, the broken lives. Again, these are the drug cartels, they are businesses. They expand their product line into human trafficking and sex trafficking. I do want you to speak to the brutality of these drug cartels, but I do want to talk a little bit about what we saw in Guatemala, where we visited a shelter--no address on it because they are trying to protect themselves from the drug cartels--the sex traffickers, but a shelter for sex-trafficked little girls. The youngest was 11, the oldest was probably about 16--average age is about 14--and they have cribs because they, obviously, get pregnant. So, anybody who thinks this is a victimless crime, go down to Guatemala and see just one sliver of that type of victimhood. But, again, you are on the front lines. You see the brutality. General Kelly was talking about anybody in public safety that would even begin to think of going up against the drug cartels, they get a little compact disc (CD) with their pictures of their family and their little girls. I mean, can you speak to what you know of why there is such impunity on the part of drug cartels, because they are simply untouchable because they are so brutal? Commissioner Kerlikowske. And, I think we are talking mostly then about Central America, because I have visited Guatamala. We certainly know the statistics in those three Central American countries, Honduras, El Salvador---- Chairman Johnson. Well, Mexico is quite bad as well, is it not? Commissioner Kerlikowske. Well, although, actually, in the last year of President Calderon and continuing through President Pena, we have seen a decrease in their violent crime. It is still significantly higher than that of the United States. But, in those visits and in looking at that data, the level of violence, Honduras and El Salvador have homicide rates that oftentime top the world in the per capita killings, and I think that is what we have seen in the number of unaccompanied children (UAC) and others that have come across the border. But, it is driven by gang violence. And, I would go back and say that as much as the work that has been done by the Department of State (DOS), International Narcotics and Law Enforcement to provide rule of law training, to provide technology, to provide training for professional law enforcement, until, as Secretary John Kerry mentioned, in Davos, Switzerland, recently, until the corruption issue is addressed in these countries, you are not going to find people that are going to want to pick up and go to a local law enforcement official and say, I want to report something, I need help. So, I would say corruption drives part of this. Chairman Johnson. But, can you talk about specifically the techniques the drug cartels use to gain the impunity with which they operate? Commissioner Kerlikowske. Well, I think they are going---- Chairman Johnson. This is not just gang violence. I mean, this is a very dedicated effort on their part to be incredibly brutal against the family members of public safety officials, beheadings, those types of things. Commissioner Kerlikowske. Yes, we have seen time after time after time, and including in Mexico, very high level law enforcement officials, many of whom have reputations that have been brought in to essentially improve things, to do public safety, they have been killed, their families have been killed. The mayor, just outside of the city of Mexico City, within the State of Mexico, was murdered only several days after her election. The intimidation and the threats to prosecutors, to law enforcement officials, et cetera. Which often then comes back to why in the United States we have not seen anywhere near that level of intimidation or violence. And, that is because, quite frankly, we have law enforcement officials that are not corrupt, we have prosecutors that will not back off from prosecuting, at the greatest and most severe level, people that would do that type of intimidation or threats. But, you are absolutely correct. The better things that would improve in those countries for safety, security, etc., the better we would be when it comes to our drug issue. Chairman Johnson. So, my final point, and I will turn it over to Senator Baldwin, the breakdown of those public safety institutions, that impunity, that is driven by our insatiable demand for drugs, and it is important for us to recognize that. Senator Baldwin. Senator Baldwin. Thank you. Commissioner, I want to hear you elaborate a little bit more about the pilot with regard to training your officers to administer naloxone. As I understand it, the beginning of Phase II implementation of that pilot is going to begin in the next couple of months. I would like to hear about when the initial pilot project will be complete and your thoughts about whether this pilot needs to be further expanded. Commissioner Kerlikowske. We should actually---- Senator Baldwin. Perhaps describe it, because many in the audience might not be familiar with it. Commissioner Kerlikowske. When I served as the president's drug policy adviser starting in 2009, the issue of prescription drugs was known in the medical community; it was basically unknown anywhere else, unless people had been adversely affected. They knew about it, but frankly, you could count on one hand the number of articles about prescription drug overdoses. It is on the tip of everyone's tongue. It is knowledgeable. It is the subject of these hearings and many others. And so, one of the things that we saw very clearly was that if we can save people's lives, and, frankly, the first responders are often law enforcement, although the medical community does respond very quickly, the use of naloxone can reverse overdose. I think when the doctor testified about the concern that, well, naloxone is only going to encourage someone because they know they are not taking the chance, I also heard from the young woman at the end of the panel when she talked about, look, people cannot stop. If they could make a decision and say, you know what, I am going to quit, by heaven, I think they would have made that decision and quit. So, we wanted to see naloxone in the hands of every local law enforcement, State troopers, deputy sheriffs, and police officers, but we also wanted to see it in the hands of our people because we deal with a million people a day coming into the country. And, when I was in Boston this morning, they talked about people who were overdosing in the restroom of Boston Logan International Airport, and the State troopers there have naloxone and are able to use it. We need the same thing. I can assure you, Senator, that when the pilot is over, we will make sure that naloxone is at every one of our ports of entry. Senator Baldwin. Thank you. Chairman Johnson. Again, Commissioner, thank you for your service to the country and thank you for coming again. Your dedication to these hearings on a local basis is really much appreciated, and thank you. Commissioner Kerlikowske. Thank you. [Applause.] Chairman Johnson. So, it is down to three. General Schimel, you talked a little bit about the problem businesses are having. Coming from a manufacturing background myself, I can tell you that we have been drug testing, and as I have traveled around the State now and talked to manufacturers, who, cannot hire enough people, not one, for a variety of reasons. One of the reasons is that so many drug tests, 50 percent of people that come in for an application do not show up for the drug test--and these are just basic anecdotal percentages-- another 50 percent that actually take it, fail. So, this is an enormously difficult problem. You talked a little bit about the purity. Does anybody on the panel really understand the issue of fentanyl now? Is that being blended with heroin? I mean, this is kind of a new drug on the scene in the last year and a half, correct? Mr. Schimel. Well, it is gained a lot more attention. It has been working its way through for some time now, but fentanyl is extraordinarily frightening because it is exponentially more powerful than heroin and exponentially more deadly, and when it is laced in with heroin, the user may not have any idea that it is in there. Chairman Johnson. What is the pricing of fentanyl? Mr. Schimel. I do not know the answer on that. I am sorry. Chairman Johnson. Why would they lace that into heroin? If you are saying heroin now is so cheap, it can be so pure, why would they blend? Anybody know? Mr. Schimel. There is a competition for who has the best heroin, who has the drug that gets you the most high, that you can use the smallest amount to get to where you want to be. That is actually not a fair way to put it. I do not think they want to be there, but the place they need to be. As I have heard, many people who are in recovery from addiction--or are still struggling--talk about this, and once they progress very far into their addiction, they no longer get high. They simply are taking the drug to not get sick. There is not even the joy of feeling good from using it anymore. There is no joy left in their lives. So, by making the drug more powerful, they can maybe shoot past getting around being sick and still have some joy. It is incredibly dangerous, and we are seeing really shocking numbers of deaths from fentanyl. Chairman Johnson. Do people take it on their own? And, is this injectable, is this snortable, or how is fentanyl administered? Mr. Schimel. Like the more potent heroin, you can take it in all the different manners now. That is one of the major differences, is several decades ago, with the 5 percent pure heroin, the only way to really get high was to shoot it up. Now, with the higher purity heroin, you can start by smoking it or snorting it, and that is less frightening a move than strapping a tourniquet around your arm and searching for a vein. Chairman Johnson. You talked about methamphetamine. I think in your testimony you talked about it is really prevalent more on the western side of the State. Is that just simply a supply issue, that it is just more readily available through markets in Minneapolis or Minnesota? Mr. Schimel. It used to be very much a northwest phenomenon in our State. That has changed, and the southwestern part of our State is--law enforcement there is howling for help. Treatment providers there are very concerned about what they are seeing. Southeastern Wisconsin avoided it because there had always been a steady supply of cheap crack cocaine from the Chicago area, and that seemed to offset that demand. But, methamphetamine is on the move, and it is moving across our State. It will be everywhere soon. Chairman Johnson. But, again, we used to manufacture here. You shut down those meth labs, and now it is just coming in, again, flowing freely into the United States from Mexico. Mr. Schimel. The only kind of labs we have in the State anymore are what--we call them ``one pots,'' and it will be an individual who is cooking up enough for themselves and maybe a girlfriend or boyfriend, but that is it. No more commercial manufacturing. Chairman Johnson. OK. Senator Erpenbach, you mentioned the drug Nivitrol. Can you tell me a little bit more what you know about that? You said the price is high. If it was more widely-- -- So, if we administered more of it, would that price come down? I mean, could you just---- Senator Erpenbach. That I do not know. Not being a pharmacist, I can tell you that I have read that it blocks certain receptors that lead to the high. It is expensive because the pharmaceutical companies can make it that way, I guess. They can charge whatever it is they choose to charge. But, the point is, if somebody really, truly wants to make that step and has truly decided that, yes, I am done with drugs, we, as a community, need to be there for them. And, one of the ways we can be there is to try and make Vivitrol as prevalent as we possibly can to those who do need it. And, again, in the situation in Sauk County when they are identifying inmates who want to be part of this program and we have that gap coverage where Medicaid shuts off for people that we incarcerate in jails and then there is a wait to get back on, if they can get back on at all, that Vivitrol, that shot of Vivitrol, once they are out and they have made that decision to change their life, has to be available to them. Because if it is not, shortly after they are out, if they do not get the support they need, the help they need, and the community is not behind them and government is not behind them, they are going to end up right back in jail because they ended up stealing something because they needed the money to go out and buy some heroin or do whatever. I mean, that was the case with my brother. Senator Baldwin. Can I just---- Chairman Johnson. Sure. Senator Baldwin. So, I am one of those people who just learned a little bit more about this issue recently, and so, dangerous with the knowledge, but I had a chance to visit with participants in a Vivitrol program in Dane County, seven or eight people who were quite successfully being treated on the drug. It is particularly useful in that hand-off between jail and the community, because you have had to--and doctor, you can let me know if I have said anything incorrectly--but you had to have been free of opioid use for about 14 days beforehand. And so, reaching that 14 days is extremely challenging for addicts in the community. But, when you are in jail---- Senator Erpenbach. It is there. In my brother's situation, whether it was a county jail, Waupun, Green Bay, or Oshkosh--whatever prison he happened to be in, services, things that he needed, they were available. When he was out, they were not. And, it got to the point where, much like Tyler and Ashleigh's mom and dad basically saying to Tyler, you are out of here. I mean, we went through that process with my brother, Will. But, at the same time, you are still always holding out hope. So, as a community and as a government, whether we are State government officials or Federal Government officials, if there is funding available to help somebody who, again, has made that decision and they are transitioning out of a county jail, and we are saying, sorry, you do not qualify for this shot, good luck out there on the streets, we are going to see them right back there again. And, I ended my comments by saying, you want to talk dollars and cents, because a lot of us talk tough on taxes, you want to save money, you start investing in programs that work, and we will be saving a tremendous amount of money here in Wisconsin and nationally. Chairman Johnson. Let us face it, it costs somewhere between $30,000 and $50,000 per year to incarcerate somebody. But, talking to the Lyberts, they thought that the one treatment for Tyler was about $78,000 worth. Senator Erpenbach. About how much? Chairman Johnson. About $78,000. And, when you hear the other--I do not know what the exact stats are, but one in 20, one in ten. I mean, that is part of the problem, is this is enormously expensive, unfortunately. So, 10 percent or 5 percent effective. I mean, it is one of those problems we have to be honest with, in terms of what is actually going to work. That is why something like Vivitrol, if it really blocks those receptors---- Senator Erpenbach. Yes. And, I know it is expensive, and I saw my parents write checks when I was growing up once insurance ran out, and I have seen other families go through it as well. But, again, there are programs out there that work, and that is what we need to invest in. Chairman Johnson. And, that is what we need to explore, which is why I have the hearing. Representative Nygren, you did not really mention Cassie-- other than just the name--in your testimony. You have talked about her. Would you be willing to share a little bit more of that experience before I turn it over to Senator Baldwin? Because it is these examples--it is that courage. And, by the way, my nephew overdosed a couple months ago--and the family wants to keep that private--I have a buddy that I played softball with, his daughter has been struggling with heroin for 5 years. He heard about this hearing, texted me, and said, ``Boy, use that as an example anonymously.'' So, I mean, I understand the problem and the pain, and this is very hard to make public, but, we have to address the demand side, we have to take the glamour out of it, and the way you take the glamour out of it is this kind of testimony--it is so powerful. So, if you do not want to, just tell me, I will turn it over to Senator Baldwin, but if you are willing to share, it is helpful and it is very powerful. Representative Nygren. Well, we have talked about it before. As I said, initially, families typically deal with this privately, especially when you are a little bit more in the spotlight--and besides, it was a private, personal issue, family issue. But, Cassie's involvement with drugs began with probably--I should not say probably, I know it first began with alcohol, then marijuana, and---- Chairman Johnson. Just at what age? Representative Nygren. Well, I would say alcohol, probably, but she did not like alcohol. That started probably around 13 and 14. Marijuana started around 15 or 16 and prescription drugs started around 17. Now, I mean, we have not really talked about the legalization of marijuana. That is one of those movements that is out there, and I know the attorney general has talked about this before, but there is people that will argue that marijuana is not a gateway drug, but I would argue that each of those are gateway drugs for some people. I grew up in the generation where a lot of people probably smoked marijuana, and those are the people in decisionmaking positions today, and they think, well, it did not affect us, so it would be OK to legalize it. But, as the attorney general, who has more knowledge on this, has talked about, we are talking about marijuana that is probably six or seven times stronger than what it was back in the 1970s. Chairman Johnson. I think it is more than that, isn't it? Representative Nygren. So, I mean, this is not your daddy's marijuana we are talking about, but---- So, that was kind of her progression. And, as a family, we went through all the--if you sat somebody--Lauri Badura or, somebody else who has had a loved one with an addiction right next to me, we could probably tell a pretty similar story. Tell you a story about robberies in your home, or break-ins in your home, missing dollars, missing valuables, those type of things, things that began to disappear. All those things were difficult as a family. Seeing somebody who was once a straight-A student not graduate from high school was difficult. Seeing her eventually, in orange in county jail or eventually prison was difficult. But, the most difficult thing as a parent was when they are in active addiction, waiting for that phone call to come. That phone call came for me. I got there, was able to try to help her breathe until the paramedics arrived and administered Narcan. If it would have been the basic-level emergency medical technicians (EMTs) in Marinette, they could not administer Narcan at that point in time; we have changed that. But, waiting for that to happen. She has an opportunity today to lead the life that we dreamed for her. Unfortunately, she is still struggling. But, Tyler mentioned it earlier, there is a certain amount of guilt when you talk about this, because it is difficult for me to talk to--dramatically about the challenges my family has faced when I know of so many others who their children do not have that opportunity for hope. Chairman Johnson. They are gone. Representative Nygren. They are gone. So, I try to be that voice for them. There is so many people working very hard on this issue throughout our State. It was talked earlier that we all need to work together, and we do. We tried to create a website recently to try and bring all those different links, all those different resources together, HOPE Agenda website, but there is so many people trying, and I do believe we are making progress, but there is so much more work that needs to be, and for Cassie there is a lot of work that needs to be done as well. Chairman Johnson. God bless you and her, and we, obviously, are praying for her. First of all, thank you for sharing that, and thank you for all your efforts. And, with that, Senator Baldwin. Senator Baldwin. Thank you. Attorney General, I would like to hear your thoughts on the most pressing gaps that still exist. Your testimony you talked about--well, you gave a real strong voice to the need to have, basically, a seamless interaction between law enforcement and public health systems in order to tackle this emergency. Your expertise, of course, is on the law enforcement side, but you have seen both. You talked about the fact that the Edward Byrne Memorial Justice Assistance Grants (JAG) program keeps shrinking, you talked about the treatment courts and the fact that new counties are unlikely to start them if there is not a Federal contribution, and you talked about the importance of innovation that is happening around this State, that competitive grant programs would also be of great importance. As well as I do, about the fiscal constraints we face nationally, statewide, but where do you see the most profound gaps that would benefit from greater Federal attention to better grapple with this emergency and acknowledging it is a crisis and an emergency? Mr. Schimel. The biggest future challenge we face is going to be availability of treatment resources. It is now already. But, as we have great collaboration with our medical community in Wisconsin, and as a result, combining that with some law changes, we are going to see prescribing of opioids decrease, and probably dramatically. That is going to limit the amount of prescription narcotics that are available for diversion and abuse, and those who are already addicted are going to turn to heroin then. Numbers from 2013 already suggested then 163,000 people in Wisconsin were abusing opiates in some manner. We cannot treat those. We cannot treat that many. We cannot even come close. We are going to have to be prepared for that. It is something that I am very proud of our medical community in Wisconsin, because they get this, and they are working on it. They are working to change education for doctors, they are working to change the conversation between doctors and patients, and they are working to make sure there are more Suboxone providers. One of the things we could do is address right now what many assert is an artificial limit for the number of patients that a Suboxone-certified doctor can see. Senator Baldwin. Yes. Mr. Schimel. They can see more, and many recommend that we eliminate those artificial limits, or at least raise them, because Suboxone will be--and as Tyler Lybert described, not every kind of treatment works for everybody, it is all different, but we need to have it available, and that does work for many people as a support while they are also getting treatment. These are medication-assisted treatment; it is important to remember that. It still will always circle back. But, we can stretch our treatment capabilities if we have the medication assisting someone in getting through treatment as well. I believe treatment providers can serve more people if their patients are stabilized with some kind of medication assistance. And, prevention dollars are so important. And, I want to expand a little bit on drug treatment courts. In Waukesha County, our drug treatment court costs about $2,700 a year to have an individual in that court. That included all of their treatment, drug testing, case management, constant trips to court. Did I say drug testing? I meant to. Everything. They did not have to come up with any money to be in the program. $2,700, I cannot keep somebody in the county jail for 3 months. $2,700, I cannot keep them in the State prison for one month. $2,700 will not pay for an autopsy and the toxicology reports that are necessary. All of the people that enter into the drug treatment courts in our State are coming there with two destinations that were awaiting them otherwise. They were either going to overdose and die, or they were heading to prison, and drug treatment courts are interfering with that path, and it is the best thing we're doing. Senator Baldwin. One quick additional question. As you have taken a journey from being the head law enforcement official in this county, to a statewide perspective, I have also gone from representing a part of the State to representing the whole State, are there any geographical gaps that you would want to bring to my attention? I know I get calls from constituents who talk about the distances that they need to travel to seek treatment, to seek support, to seek help. Mr. Schimel. Treatment resources are taxed severely everywhere, but in the more rural communities, it is most profound. People sometimes have to travel a hundred miles or more to get to a treatment provider, and many of these individuals do not have money left to have a reliable car. They may have---- Senator Baldwin. They may not have a license. Mr. Schimel [continuing.] Lost their driver's license a long time ago, and there is certainly no bus. We are seeing innovations in the treatment community, where treatment providers are utilizing videoconferencing for it, and I am told by treatment providers that it is demonstrated to be as effective or can be as effective as in-person treatment provided, but it needs to be--the person receiving that videoconferencing should be in some kind of a medical facility where they can get help and advice face-to-face as well. But, these are some of the things that we are attempting to do to expand these resources to meet a demand that, frankly, we hope will become overwhelming. We hope that these tens of thousands of people that need to be in treatment, we are hoping that more and more of them will be ready to accept treatment. Senator Baldwin. Thank you. Senator Erpenbach, I want to continue this discussion about the nexus between law enforcement and public health and care and treatment for those with addiction based on your testimony about the incredible work that is being done in Sauk County. You talked a little bit about some of the treatment that begins in jail and how there are often interruptions when a person leaves and tries to seek that same treatment in the community. I think the Vivitrol example is a key example. How is the treatment funded when it is offered in a jail setting? How is it not being covered when it becomes an issue of community treatment for the profile of people who are needing it? Senator Erpenbach. Well, I do know that in Sauk County, with St. Vincent de Paul, who first stepped up and started paying for it, and, obviously, they cannot afford it, they have had about 30 people who have gone through the CARE program and gone through it successfully. And, obviously, you identify who would be good candidates while people are serving their time in Sauk County Jail. And, again, if we, as a State, decided to suspend, as opposed to terminate, Medicaid services for folks who are sitting in county jails, that would go a long way. That would be a very first good step. The next step, again, would be, in my opinion, to taking the Medicaid expansion, because somebody who is making minimum wage is not eligible for BadgerCare in Wisconsin, and there is 13 percent of those who would be eligible from the 100 percent to the 138, 13 percent of those or so who have addiction- related issues that are costing society and their families and themselves ultimately, in many cases the ultimate in their death, when they die. So, one thing we should do in Wisconsin, and, I am going to talk with Representative Nygren about this at some point when we head into the next session, is what we can do in working with DHS to just suspend, not terminate, those services for those folks who lose their Medicaid eligibility. Senator Baldwin. Thank you. Representative Nygren, I just want to commend you on your work on the HOPE Agenda, the work that we have talked about, in terms of coordinating at the State and Federal level. I would love it if you could spend a few moments further talking about the agenda pieces that improve access to Narcan, or naloxone, and whether you are already hearing any feedback about how those are working in communities across the State. Representative Nygren. Sure. So, you know what, we in Wisconsin, I think we are a true citizen legislature. We all bring different experiences to the table. My background in insurance, finance, the restaurant business, as a small business owner--so I kind of thought that would be my area of expertise, but God had a different plan in addition to that, having a daughter with an addiction. So, a lot of the experiences that I have already went through with Cassie have enabled us to turn some of those experiences into legislation. So, the day that we got that phone call and we found her purple, struggling to breathe, needle in her arm, and I tried to help her breathe until the paramedics arrived--or EMTs. Marinette we have both basic-level EMTs, who are emergency rescue squad, which is all volunteer; and we have paramedics assigned to Bay Area Medical Center. The paramedics showed up first. I did not know the difference, necessarily. But, they administered naloxone and brought her back to life. So, that experience began to get me thinking about it. It is like, well, what happens if I am in a rural area, and it is a police officer that shows up first? At that time, basic-level EMTs, the rescue squad folks, or police and fire, unless they have advanced EMT training, did not have the ability to carry and administer naloxone. So, we changed that. In addition to that, this session we also expanded access to naloxone through what is called a standing order. There are a number of pharmacies, Walgreens, CVS, Aurora in our State that are allowing for naloxone to be purchased with some simple training through what is called a standing order with the local pharmacist. There is not a lot of data yet on that, but I have been kind of pushing my folks in the administration, my staff, to try and get data on that first piece. And, I can tell you that we recently got a graph, actually an outline of the State of Wisconsin, showing the number of administrations of naloxone during the last year. And, the total was, I believe, nearly 4,000. So, you know that oftentimes we pass legislation that we do not necessarily know or have a good idea of what the immediate effects are, but it has been argued by some that putting naloxone into more hands enables that behavior. The objective here is getting more people in recovery so they can be productive, tax-paying citizens living the American dream. Sorry for that, spouting that ideal. Well, they cannot do that, they cannot recover, they cannot get into recovery if they are dead. So, the more access to that, the better. Senator Baldwin. Thank you. Chairman Johnson. Would you like to just do a closing statement, because people have been very patient. So, just have a couple closing comments before we close out the hearing? Senator Baldwin. I just think it has been an extraordinary opportunity to hear from Wisconsinites who tackle this issue from various perspectives, some having faced tragedy. Frankly, even those who were coming to speak because of the office they held--everybody has a personal experience with this. But, we have an extraordinary amount of education due to make everyone aware that this is an epidemic, that this is an emergency. And, I think that the better job we can do of understanding the root causes from cartels in Central America to well-intentioned physicians and prescribers in communities across America, who are just trying to alleviate pain, but are not prescribing in manners that are safe, with the guidance they need, once we understand that, we can do a much better job, and I think we are with these State leaders, we are moving in the right direction. But, boy, this epidemic is far ahead of us right now, and we need to catch up, and we need to do it fast. Thank you again. Thank you to the audience members who sat through--I suspect everyone in here is here because you have a passionate belief in getting this right. So, thank you for that time and attention and any help you can give us to get the job done. And, Chairman Johnson, thank you for having this hearing. Chairman Johnson. Thank you. I am an accountant. I got some numbers. Let me just run a couple numbers by before I do my closing statements. What we are witnessing here, obviously, are tragedies to individuals and to families, and what we are seeing here is, I think, some pretty extraordinary, but I would say probably not uncommon, cooperation at the local and State level, trying to grapple with a very difficult problem. One of the issues we have, when we talk about funding, is there are always limited resources. Just so you understand, on a Federal Government level, for fiscal year 2016, we will spend about $30 billion on the war on drugs, about half of it on the demand side, half of it on the supply side. This hearing is just one in a series, and one of the things we will definitely do is try and delve into that $30 billion that we spend and see if there a better way to deploy it. Are we better off, rather than spending $30,000 or $50,000 per prisoner, looking at using that in terms of treatment? But, again, the treatment costs are high, and we just really do have to really figure out a better way of addressing these problems. It is very complex. There is the supply side, there is the demand side, there is the treatment side. From the Federal Government's standpoint, we do need to concentrate on that supply side, and, the fact that we do not have those secure borders, the fact we have those drug cartels creating such barbarity and evil in the world. I mean, we definitely have to address that. And so, we will do that. But, again, I commend you folks for working together in a very bipartisan fashion. I commend you for taking the time to be here today. Hopefully, the public does take a look at this and go, it is possible, we do do it, we do like each other, we do try and work together, and the approach to be used is try and find areas of agreement. There are plenty of things that divide us. I mean, even in this hearing, there are some differences, no doubt about it, but we are all human beings. There is no one political party that has a monopoly on compassion. We want to solve these problems. If we concentrate on those areas of agreement, it is just a whole lot easier finding common ground. And, if you will indulge me for 2 seconds. I was not going to do this, but prior to this hearing, my wife did reach out to her brother and got a text. And, I did not want to bring in anything like that, but I just have to read some--there is a text with probably about 20 different lines in it. Talking about the autopsy report, ``he could not read it. Too sad. I am still crying. Just tears to me now, big tears''. That is what is affecting people's lives, these tragedies on an individual basis. So, again, Senator Baldwin, thank you for your involvement in this issue, things you are trying to work on. Gentlemen, thank you for what you are doing. Again, the audience members, you are probably here because you have been touched, you have been affected by this. This is not going to end. This is a big problem, it is a complex problem, many components to it. But, if we work together, if we concentrate on areas of agreement, the shared goal of trying to rid this country, quite honestly this world, of this scourge, we just might start finding some commonality. So, with that, let us close it out. The hearing record will remain open for 15 days, until April 30 at 5 p.m., for the submission of statements and questions for the record. Thank you all. This hearing is adjourned. [Applause.] [Whereupon, proceedings were adjourned at 4:57 p.m.] A P P E N D I X ---------- [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO ---------- FRIDAY, APRIL 22, 2016 U.S. Senate, Committee on Homeland Security and Governmental Affairs, Cleveland, OH. The Committee met at 10:13 a.m. in the Ruhlman Conference Center, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio. Senator Rob Portman presiding. OPENING STATEMENT OF DR. SIMON, PRESIDENT OF UNIVERSITY HOSPITALS CASE MEDICAL CENTER Dr. Simon. Good morning. My name is Dr. Dan Simon. I am the president of University Hospitals (UH) Case Medical Center. Welcome to Ohio and to the flagship hospital of the University Hospitals system. On behalf of our Chief Executive Officer (CEO) Tom Zenty, our senior leaders, our 26,000 doctors, nurses and employees and the community we serve, we are honored to host this important hearing. We are grateful to the U.S. Senate Committee on Homeland Security and Governmental Affairs (HSGAC) for confronting the opioid crisis. I would like to thank Chairman Johnson and Ranking Member Carper for their leadership on the Committee and their staffs for being here this morning. I would also like to thank our fine Ohio Senators Sherrod Brown and Rob Portman for honorably representing Ohioans in Washington. We were privileged to host Senator Portman for a round table event last January to discuss his legislation, the Comprehensive Addiction and Recovery Act (CARA). We are pleased that it passed the Senate and hope for speedy consideration in the House. Thank you for your strong leadership on a very complicated issue. Now I would like to turn things over to Senator Portman. OPENING STATEMENT OF SENATOR PORTMAN\1\ Senator Portman. Dan, thank you very much. I appreciate that. And, I am now going to officially call this hearing to order. --------------------------------------------------------------------------- \1\ The prepared statement of Senator Portman appears in the Appendix on page 139. --------------------------------------------------------------------------- I appreciate everybody being here. This is a distinguished group of Cleveland area citizens and a really distinguished panel, two panels, in fact. We look forward to hearing from them in a moment. This is a critical hearing, because it is an opportunity to draw attention to an issue that all of us face in the State and in our country, which is this epidemic of opioid addiction and overdose prescription drugs and heroin. It has devastated communities here in Ohio. It has torn families apart. But, this is happening all over the country. And, as we will talk about in a moment, the fact that our legislation called the Comprehensive Addiction and Recovery Act passed with a 94 to 1 vote in the United States Senate, which never happens, which is evidence of that. I do look forward to the expert testimony we are going to receive today. And, Dan is right, I was here in this very room in a round table discussion where I learned about some of the expertise that resides right here at University Hospital and also at our other great medical institutions in town. And so, we thought this would be an appropriate place to hold this hearing. It also happens to be a beautiful room for a hearing. You may find many Congressional hearings now coming to this room. [Laughter.] The staff is here from the offices of Chairman and Ranking Member and they are equally impressed. So, I think they may want to come back, if you will offer it for free. [Laughter.] I want to thank Sherrod for being here. Senator Brown and I have worked on this issue together, as we have on so many other issues for the good of Ohio. And, this is one that crosses every line. There is no zip code that is immune from it. It also crosses every party line. We have really tried with the CARA legislation over the last 3 years, as we developed it, to make it not just bipartisan, but nonpartisan. It is not caring where the ideas come from, but if they are good ideas, to try to promote them. And, it is urgent. Every day we lose 120 Americans to drug overdoses. Think about that. 120 people lost every day. The rate of overdose over the last 14 years has doubled, leaving about a half a million Americans dead from overdoses. And, the tragedy of a death from overdose, as terrible as it is, tells only part of the story. And, many people in this room are working on this issue every day and understand what that means. But, it is about the families being torn apart. It is about that drug being more important than anything, whether it is family, work or faith. It is about communities being impacted dramatically. When I talk to prosecutors in Ohio, they think by far most of the crime in their communities are connected directly to this issue. It is about individuals getting off track and not being able to pursue their God given purpose in life. So, it is horrible that people are dying from drug overdoses. But, sometimes I think we forget this broader issue that is affecting everybody. It is hitting us especially hard here in Ohio unfortunately. We are probably they say one of the top five States in the country, maybe the top State now, in fentanyl, at least heroin overdoses. So, it is something that is appropriate for a hearing, to raise the visibility of it, and you get extra testimony. I do not think it is getting better. And, we will hear from witnesses today about this. But, there is a troubling report this last week about a survey that was taken. It is called the Ohio Issues Poll. In 2014, they reported that two out of every 10 Ohioans knew someone who was abusing prescription drugs. In the latest poll, it is 3 out of 10. And, out of those 3 out of 10, 4 in 10 know someone who had overdosed. Sherrod and I were talking earlier at a town hall meeting. I asked how many people have been affected, friends or family, and half the hands in the room go up. And, people look around, and they cannot believe it. They cannot believe that others are experiencing it, too. Because there is not enough discussion about it. There is too much stigma attached to addiction. And, it is a disease. And, it is treatable. And, one of the problems in getting people into treatment is to break down that stigma, which I think is part of the reason this hearing is important. By the way, about 5 of those 120 persons dying every day are dying in Ohio. As Sherrod talked about earlier, drug overdoses have killed more Ohioans than car accidents, actually every year in Ohio since 2007. Overdose deaths have tripled from 99 to 2010. We were told that 200,000 Ohioans now are addicted to opioids. 200,000. That is roughly the size of the city of Akron. We do have 20,000 overdoses a year. Several thousands will probably lose their lives again this year. So, I do not think it is slowing down. I do not think we have any time to waste. The U.S. Senate response has been this Comprehensive Addiction and Recovery Act--again it passed by an overwhelming vote. I think it is a critical step in the right direction. It was not just 3 years in the making. We had five conferences in Washington. A number of the experts you will hear from today actually came and testified or talked to us on this legislation. I want to thank them for that. Local Ohio happens to have a lot of smart people who are experts in this area. We also just have a big problem here in our State. We made it bicameral from the start. So, it was not just not partisan, it was the House and the Senate working together. We actually introduced identical legislation. And, the House bill, the CARA legislation in the House, has 120 plus cosponsors. So, the one reason that we believe that the House can act quickly is because they have been working with us for 3 years. We did not just take Senate ideas. We took House and Senate ideas and more importantly ideas from experts around the country. And, they do have over 120 cosponsors. So, we are urging them to simply pass that legislation, get it to the president who will sign it and get it to our communities where it will begin to help immediately. Are there other things we should do? Of course. And, we will hear some about that today. And, should they pass additional legislation? Of course. Should there be more funding? Of course. All of these things can and should happen. But meanwhile, let us get this specific response, it has passed the Senate, through to our communities. The House did move on some small bills earlier this week, and I applaud them for that. By the way, 3 of the 12 bills are identical to CARA, language identical that is in the CARA legislation. So, again, we can work with the House on additional ideas. Well, let us pass CARA now. Cleveland is one of the regions in Ohio that has been hard hit. The statistics are heartbreaking, and they are a call to action for all of us. There is some city council members here. The city medical director is here. There are members of the Cuyahoga County Task Force who are here. You all have been in the middle of this. But, as some of you know very well, from March 10, the day that the Senate passed CARA, March 10, until March 27, 29 people died of overdoses. That is one 17 day period in one city. One long weekend, 12 people died, fentanyl-laced heroin. And, we will hear some about that later today. Attorney General (AG) DeWine has been involved in this issue as well with regard to fentanyl. And, I know the Drug Enforcement Administration (DEA) is here with us today. We appreciate you all being here. We have other law enforcement folks from the High Intensity Drug Trafficking Area (HIDTA) folks. And, we had a hearing on fentanyl this week in Washington. It is one of those issues that has unfortunately really hit Cleveland hard. By the way, of the 12 people who died, they ranged in age from 21 years old to 64 years old, white, African-American, rich, poor. This knows no boundaries and certainly no zip code. As we talked about, it is not just a Cleveland inner-city problem. This is a problem in our suburbs and our rural areas. In fact, per capita use in the rural areas may be greater. Fentanyl, again it is 100 times more potent than heroin. And, depending on the dose of fentanyl and how it is produced-- it is a synthetic drug. We had five people die in Cleveland from fentanyl in 2013. A 700 percent increase in 2014. More than doubled the next year. This year, probably doubling again. So, we are just on a steep climb. I am looking at the medical director who has to deal with this every single day. Last month, as some of you know, in Fairview Park, not far from here, you had a man overdose at McDonald's. And, it was of course immediately online and went viral. Luckily, someone was there administering Narcan to save his life. But, there were kids there. And, this is increasingly happening in public places and in broad daylight. We have learned a lot here in Cleveland over the last few years, again speaking with advocates, doctors, patients. I have had an opportunity to tour Rainbow Babies and Children's Hospital here and see the incredible work that doctors and nurses are doing. What compassion they have for these kids who are born with addiction. 750 percent increase in babies born with addiction in the last 12 years in our State. Whether it is at St. Rita's Hospital in Lima or whether it has been nationwide or Cincinnati Children's Hospital, it is the same story. And, we will hear about that today from some real experts, talking about how we can ensure that this Neonatal Abstinence Syndrome (NAS) can be addressed both in terms of prevention, education, but also with effective treatment. Effectively these nurses and doctors take these babies, of course, through a withdrawal process. And, the long term consequences to these children we will hear more about today, but it is very difficult to know. It is such a new phenomenon. And, of course, that concerns all of us. So, I think Cleveland has a lot to teach the country about how serious this threat is, as well as effective prevention and treatment ideas. And, that is why this hearing is important. Again, there is a lot to do in addition to the Comprehensive Addiction and Recovery Act. And, we should continue to listen to the experts as we develop our ideas, because this issue is just too important not to. I do think today we will hear from some really important testimony from some really compassionate and gifted people who work here in this facility and experts in the field. I look forward to hearing from them. We also have a statement that I want to enter into the record from Senator Johnson, who is the chair of this Committee,\1\ from Senator Ayotte,\2\ and also testimony that has been submitted by Dr. Jason Jerry, who is with us this morning from the Cleveland Clinic. --------------------------------------------------------------------------- \1\ The prepared statement of Senator Johnson appears in the Appendix on page 145. \2\ The prepared statement of Senator Ayotte appears in the Appendix on page 146. --------------------------------------------------------------------------- Where are you, Doctor? There he is. Thank you and thank you for the Clinic for being here. I also want to thank the staff from Senator Johnson and Senator Carper. Senator Carper is the ranking Democrat on the Committee--his staff is here as well--for helping not just put this together, but also for being here and helping us substantively to pull information out of this hearing to use it for legislation. And, again, I want to thank Senator Brown for his participation in this hearing today and for his passion for this issue. He has been involved all over the State and had hearings all over the State or round table discussions all over the State. And, again, it is an issue that, as he will talk about, affects our entire State. And, therefore, we have to work together to solve it. Now, I will turn it over to Senator Brown for his opening statement. OPENING STATEMENT OF SENATOR BROWN\3\ Senator Brown. Thank you, Rob. Thank you, Senator Portman. Thank you to UH, Dr. Simon, and all of you. --------------------------------------------------------------------------- \3\ The prepared statement of Senator Brown appears in the Appendix on page 142. --------------------------------------------------------------------------- It took Rob Portman coming to my home town to get to do something in this room. I have never been in this room. [Laughter.] I have been to UH like 25 times, including visiting family members---- Senator Portman. They never let you in. Senator Brown [continuing]. Doing hearings and doing discussions and past conferences. But, it took the other guy to come in town to get the use of this room. So, thank you, I appreciate that. And, I thank Senator Portman to allow me to be at this hearing. Because I do not sit on this Committee in Washington. And so, I am kind of an honorary member or something today sitting in. So, thank you for that. And, to Senators Carper and Johnson and their staffs, thank you for arranging this, for the room and the witnesses, and the second panel especially too. Rob talked about this upcoming a couple of times. And, if you look out this window, you will see zip codes that have some of the highest infant mortality rates in the country, and certainly in the State and maybe in the country. You will see some of the highest foreclosure rates in the country. The zip code my wife and I live in, 44105, south of Slavic Village, had more foreclosures than any zip code in the United States of America in 2007. So, this is a public health crisis--opioid addiction--as so many of these other things are--and how related they are. As Senator Portman pointed out, this is not a city problem, this opioid addiction. I first started hearing a lot about this when I came to the Senate in 2007, and especially in places like Adams and Brown County of the Ohio River. Attorney General DeWine has been working on this a long time, a lot of us have. And, it started off with Oxycontin and oxycodone and Percocet and Vicodin and legally prescribed drugs. And, it has spread obviously. And, we know that addiction--when you think about addiction, and you think about the biases and the prejudices people have about addiction, years ago addiction, when it was confined to certain areas and certain cities, look out this windows, it was considered a character flaw or it was considered an individual problem. We know it is not. We know addiction is--some people are just more predisposed toward addiction than others. We know it is not a character flaw. It is not a personal problem. It is an illness. And, it is a chronic disease. And, that is why this hearing is so very important. Fundamentally--and I want to thank the people. I did not do this. I thank the people in this room who are some of the best activists, as Rob has pointed out, some of the best activists in our State fighting against this. The numbers are just overwhelming. The availability is amazing. I have done, as Rob said--and he has, too--I have done round tables, town halls all over the State. I remember one in Southern Ohio. I said, how easy is it to get heroin? They said, you know where the McDonald's is out on Route 23? I said, yes. They said, go out there. Walk around for 3 minutes, and you will be able to buy some. We know what a round table I did in the Mahoning Valley-- the Youngstown area. A woman, affluent, she said because of the money her family had, they could keep their son alive. He was addicted at 14, because he went into the--I think, if I recall, they were taking care of their grandmother, as I did with home care and my brothers did some 10 years ago in Mansfield. And, there was morphine in the cabinet, because they were helping her be comfortable in her last months or last weeks and even last days. And, their 12--14 year old son began to take the morphine. And, he has been addicted in and out treatment for 12 years. And, she talked about the family is just turned upside down, because this son has siblings. And, they are not getting the attention that they deserve and they demand and the parents and all the things that happen. So, we know how excruciating this is in every city, county, inner-ring suburb, more far flung suburbs, every county in the State. And, that is the importance of what we do. But, the other thing that really came through to me on this is how every community is crying out for dollars to help us on this. And, we cannot get Congress to--neither the State nor the Federal Government has come up even close to the dollars we need to scale out these programs. Almost every community in the State, people have come together. They are very good, as Rob said earlier today, they are very good not for profits. They are very good county- funded--all the different ways we fund treatment. Those exist. But, none of them can scale up without a lot of help from Columbus and Washington. And, when you think--because nobody predicted this opioid epidemic to explode the way it did. So, no community is prepared to scale out. It just does not have the resources to do that. And, that is where we come in. CARA, the work that Rob has done, is very important and impressive with CARA. We need to get it through the House. He is working on that. We are all working on that. We also though need Senator McConnell to begin to support much better funding. And, we need the Governor and the legislature to support much better funding. You just cannot do this on the cheap. The reason though I am optimistic is, I have seen what our country has done in public health for generations. So, it was our country that led the eradication of small pox, where hundreds of millions of people in the 20th Century died of small pox. It is pretty much eradicated. Look what we did with polio in the 1940s to 1950s--1930s, 1940s, and 1950s to eradicate polio in this country and most places around the world, almost every place. What we did with Ebola 2 years ago. When the alarmists in our country said, ``thousands of people are going to die from Ebola.'' Well, do you know how many people died from Ebola--contracted in the United States and died here? Zero. We are facing the public health threat of the Zika virus now. We are accelerating the research for vaccine and an antiviral for cure, for vaccine and cure. And, this is, at least for us in this State, an even bigger public health threat with opioid addiction. So, we have risen to the occasion as a community, as a Nation. I think we will today. This hearing that Senator Portman called is a step toward that. Thank you. Senator Portman. Thank you, Sherrod, great points. We will now go to our first panel. And, we are going to discuss here the Federal, State and local collaboration to combat opioid addiction. We have three really distinguished panelists. First, we are going to hear from Attorney General Mike DeWine. As I said earlier, Mike DeWine has been a leader on this issue, not just focusing on the law enforcement side of it, which you might expect from an attorney general, but also on the prevention side and the community outreach. He is also going to talk about fentanyl and his effort to prevent drug abuse. Next, we are going to hear from Carole Rendon. Carole is the acting U.S. Attorney for the Northern District of Ohio. She's gone well beyond the call of duty to actually lead the task force here in Cleveland on opioid addiction. And, I thank her for that and her continued passion. She is going to talk about strengthening partnerships across government to address this problem in her role as part of the task force. Finally, we are going to hear from Tracy Plouck. Tracy is the director of the Ohio Department of Mental Health and Addiction Services (MHAS). She was a key resource as we developed CARA, as you can imagine, as one of those people I talked about earlier from Ohio who actually gets it and has a lot of expertise on the ground. She is going to talk about what the State has done to expand addiction treatment, including efforts to respond to the Neonatal Abstinence Syndrome (NAS) we talked about earlier, the addicted babies. So, with that, I would ask all three witnesses if they are willing to stand, please, we can swear you in. Please raise your right hand. Do you swear the testimony you will give before this Committee will be the truth, the whole truth and nothing but the truth, so help you, God? Mr. DeWine. I do. Ms. Rendon. I do. Ms. Plouck. I do. Senator Portman. Excellent. Let the record show that the witnesses all answered in the affirmative. And, with that, again thank all three of you for being here. And, Attorney General DeWine, thank you for your passion and expertise on this issue. We would like to hear from you. TESTIMONY OF THE HONORABLE R. MICHAEL DEWINE,\1\ ATTORNEY GENERAL, STATE OF OHIO Mr. DeWine. Mr. Chairman and Senator Brown, thank you for-- not just for doing this hearing today, but thank you for your long time focus on this particular issue. You have traveled the State, both of you have traveled the State extensively and really I think understand what this problem is all about. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. DeWine appears in the Appendix on page 148. --------------------------------------------------------------------------- You mentioned, Chairman, about fentanyl. There is just one statistic. In 2015, in our crime lab, it was brought in to us and we dealt with, the amount of fentanyl that year was-- exceeded what it was in our labs for five previous years combined. And, this year, 2016, we are seeing it go straight up as well. So, there is absolutely no change in that. The number of deaths, we all cite statistics. I do not think we know exactly how many people we are losing in Ohio. I would simply say this. That if it was not for naloxone and Narcan, those numbers would just be much worse. And, what that tells you though I think is it is not just the deaths. It is the families that are destroyed, the moms and dads who get up every day and worry about their kid all day long, because their child is now in the 22nd day of recovery, and they do not know how long that that is going to last. You are absolutely correct, this is a very different drug epidemic. I started looking at the drug problem when I was an assistant prosecuting attorney in the 1970s. This is very different. It is everywhere. It is the rural areas, cities, and suburbs. The face of heroin is really the face of the State of Ohio. And, it does cover every single demographic group. I do not really know why we are seeing this huge problem. But, I will note two things that I think are significant that have come together. First of all, the marketing of heroin is fundamentally different than it has ever been before. They are much more sophisticated. It is much more user friendly or consumer friendly. Poppies are grown generally in Mexico. The heroin is made, processed in Mexico. It comes across our Southern border. It comes into Ohio and other States. And, the groups that are selling it really use what I call the pizza delivery system. It is very similar. The price is about the same, and you can get it just about as quickly as you can get a pizza. It is $10. It is $15. Sometimes they will give it away, because they want to get someone hooked. It is a perfect business model, because you start off at this level of heroin for $15 a day. In 6 months or a year, you may be clear up here. Some doctors have told me the ratio could be as high as 100 to 1. So, what starts as a $15 a day habit can be a $1,500 a day habit. Thus the comment by almost every law enforcement officer that we see around the State of Ohio, that 80, 90 percent of the crime in the county, every county, is due to this particular problem. The second thing that I think is different today is we have a culture problem. And, I think we can do something about that. When I was a county prosecuting attorney, you would, after a while, you would sort of get to know the drug dealers in your county. You would arrest them. And, some of them you got almost on speaking terms with. And, after we would arrest someone, I would ask them, what drugs are you selling? Or in some cases with the user, what drugs are you using? And, they would mention a number of different things. But, if I would ask, well, what about heroin? The answer would be, no, I am not crazy. I do not do that. That is other people. We do not do that. I do not put that needle in. There was some psychological barrier that was there. That psychological barrier for whatever reason is just down. It is gone. And, we have to culturally resurrect that. We cannot arrest our way out of this problem. What we do in law enforcement--we work with this every day. We have a special heroin unit that works with local law enforcement on the law enforcement side, the investigation side. But, we cannot arrest our way out of this problem. I want to compliment you, Senator Portman, for the CARA Act, and, you, Senator Brown, for your work in support of it. This takes a holistic approach. I think we have to have a holistic approach. We have to have education. We have to have prevention. We have to have treatment. And, we have to have the law enforcement side. Let me just mention a couple things. The bad news is the nature of this problem and how bad it is and how horrible it is. The good news is we are starting to see some maybe not progress in the numbers, but we are starting to see some communities that have figured out how to fight back. When we first started looking at the pain med problem, one of the things I noticed was that the communities that who were starting to make progress in this area--and I think this still is true as well for heroin--are communities that have come together, pulled together. It is usually led by a mom, sometimes a dad, but usually a mom of someone who has died, a boy, girl who has died. And, they sort of rise up in the local community. And, the ones that work involve the business community. They involve the faith based community, the churches. They involve law enforcement. They involve education. And, they have to come together. I was so impressed by this model, that a few years ago we put together a small group in our office. We now have six young ladies who work every single day to work with local communities to try and help them. Not to tell them what to do, not to tell--every community is different. But, rather to share what other communities have done. And so, I always mention that in any group. And, we have many times people who will take us up on it. Again, we do not pretend to be experts. But, what we do know is what is happening in other places in the State and what works. So, I would encourage us to look at this from the local point of view. Those of us at the Federal level and those of us at the State level, we can help. Ultimately, we are not going to solve this problem. We can help. We can help give people resources. We can help give them ideas. But, ultimately, it is going to have to be done at the individual community level, which is why I put this group together. Let me mention a couple other places. Sheriff John Tharp, the Sheriff in Lucas County, has a program that we have partnered with him. He came to me over a year ago and said, ``I have an idea.'' And, I thought he was going to talk about law enforcement. And, he said, ``No, that is not what I am taking about.'' He says that we have to get people into treatment more quickly. And, we have to, once they are in the treatment, make sure they stay in treatment. And so, what the sheriff has done with the help of local-- some local money and some money that we gave him, he has a program that is over a year old now, and we begin to see some real results, where they will go out--if the emergency room is ready, when the emergency room has somebody who comes in and actually survives an overdose, the sheriff is called. The sheriff has a very small unit of dedicated people. They move. They come out. One individual will come and see the family and see the addict and see if maybe that is a teachable moment. See if that addict is ready at that point. And, if they do, that sheriff's deputy becomes really the advocate or the sponsor of that person. I talked to a few of the addicts who were recovering in this program a few weeks ago in Lucas County. One recovering addict pointed over across the room to the sheriff's deputy. He said, ``Do you see that sheriff's deputy over there? '' And, I said, ``Yes.'' He said, ``I call him five or six times a day.'' I said, ``Why do you call him five or six times a day? '' He said, ``I have to in order to get through the day. But, he has always been there for me.'' He said, ``Without him, I would not still be in recovery. I would have relapsed.'' So, there are programs out there. Senator Portman, down in your area, Colerain Township, they have a similar program that is going on. So, I think there is a lot of very good things that are going on. I do not think we can forget education. As a country, we have to do more in the area of prevention and in the area of education. I was on President Reagan's National Commission on Drug- Free Schools when I was in the U.S. House of Representatives in the 1980s. A little different in some ways and in some ways the same--a drug problem. The one that every expert who came in on education and drug prevention said to us is, you have to do something every single year. You have to start in kindergarten. You have to have something that is age appropriate. And, you have to go all the way through the 12th grade. And, if you think you are going to do something in the fifth grade and the ninth grade, and that is all you are going to do, I suppose that is better than nothing. But, it is not going to really get the job done. So, I think we have to kind of rethink how we are approaching this. We cannot put all the burden on the schools. But, we have to figure out some way, so that young people are getting the information they need in something that has been tested and we have data behind that it actually works as far as prevention. I was in Boardman a few weeks ago and talked to school officials. They have a program there they are just starting. They took a program basically off the shelf. They bought it, a proprietary program. They have inserted it into kindergarten all the way through 12th grade. And, they are just starting it. They actually put it into their science program. So, they work with their science teachers. So, it is a way maybe to get around the problem that we are always looking to schools to do everything. Well, let us figure out how to put that in. They do it through their science classes. It is basically nine periods a year, in kindergarten all the way through 12th grade. It will be a long time before we have the data. But, I think it looked very promising. And, I think that is something we need to look at in other communities. Again, thank you both very much for holding this hearing. It is very important. We have looked at the members of the panel, and we have looked at the people in the room. Mr. Chairman, as you said, we have a lot of great talent here. So, thank you for giving me the opportunity to talk about what I see, how I see this problem, at least from the Attorney General's view. Thank you. Senator Portman. Thank you, Attorney General DeWine. Acting U.S. Attorney Rendon, we will hear from you. TESTIMONY OF CAROLE S. RENDON,\1\ ACTING U.S. ATTORNEY, NORTHERN DISTRICT OF OHIO, UNITED STATES ATTORNEY'S OFFICE, U.S. DEPARTMENT OF JUSTICE Ms. Rendon. Chairman Portman and Senator Brown, thank you so much for the opportunity to discuss how we here in Northeast Ohio are addressing the heroin, opioid and fentanyl overdose epidemic that we are all experiencing. --------------------------------------------------------------------------- \1\ The prepared statement of Ms. Rendon appears in the Appendix on page 151. --------------------------------------------------------------------------- Here, in Northeast Ohio, we have a really innovative program. It is the Northeast Ohio Heroin and Opioid Task Force. And, if you look out into this room, you will see many members of our task force from all different walks of life, all working together to help to solve this problem. The rise of heroin and fentanyl and the misuse of prescription opioids threatens our communities, our families, our safety. And, these things are all interrelated and they have to be addressed together. And, that is why the Department of Justice (DOJ) and the Administration are working closely with our Federal, our State, our local law enforcement officers to fight this growing epidemic through a combination of enforcement, prevention, education and treatment. It is truly a four legged stool, and without any one of those legs, the stool will not stand. And, this is truly a crisis in Northeast Ohio. We have heard a little bit of some of the statistics. But, let me fill you in on what we are seeing here in Cuyahoga County, and with thank you to our Medical Examiner, who I have to tell you was the first person to sound the alarm on this epidemic here in our county. So, heroin overdose deaths increased in Cuyahoga County by more than 400 percent between 2007 and 2012, when 161 people died of heroin overdoses. But, sadly, the number of heroin overdoses has increased year by year. And, recently, it has gotten dramatically worse with the introduction of fentanyl, which, as you mentioned, Chairman Portman, is incredibly potent and extremely deadly. So, according to the Cuyahoga County Medical Examiner, while there were only five overdose deaths in 2013 attributable to fentanyl, in 2014 that number rose to 37, and last year it was 91--91 overdose deaths attributable to fentanyl or a combination of heroin and fentanyl. And, last year 228 people, just in Cuyahoga County, died of an overdose of either heroin or fentanyl--or a combination of the two. And, this year we have already seen 125 fatal overdoses in Cuyahoga County, and it is only April. So, the devastation that this is wreaking throughout our community cannot be overstated. But, the crisis is not limited to Cuyahoga County. So, as you know, there are 40 counties in the Northern District of Ohio. And, we are seeing waves of overdose deaths everywhere in our district; Lorain, Summit, Stark, Lucas, Marion. It is everywhere throughout the Northern District of Ohio. And so, faced with this crisis, what we did is we assembled this task force. And, it brought together a wide diverse group of stakeholders to identify and implement comprehensive solutions to this growing crisis. And, in 2013, we held a summit to focus on the heroin epidemic. We had more than 700 people at that summit from all walks of life, from all aspects of our community; treatment providers, doctors, parents who had lost children, law enforcement, across the board. The result of that summit was the creation of a heroin and opioid community action plan. And, let me emphasize the word community action plan. This is the plan that guides the work of our task force. And, it addresses the heroin and opioid crisis from four different perspectives; law enforcement, health care policy, education and prevention and treatment. I want to take a minute just to highlight a few of the successes we have had, because the news is all so grim. But, there have been some successes, and they are worth noting. So, law enforcement. We created a heroin involved death investigation team. And, what this is, is a group of dedicated law enforcement officers who roll out to every overdose scene. And, they treat it like what it is, a crime scene, and they are there to gather evidence that we can then use in our criminal prosecutions. To date, the United States Attorney's office has brought nine death specification indictments, which carry a 20 year minimum mandatory term of incarceration for the dealers who are killing people in our community. And, there have been a dozen more manslaughter cases brought in the State court system, because we partner, of course, with the attorney general and all of our local county prosecutors. Health care policy. So, members of the task force, many of whom are sitting in this room, have worked to increase the physicians' use of the Ohio Automated Rx Reporting System (OARRS), which is the statewide prescription drug monitoring program. And, they have helped to develop really important increased training and education for doctors about the dangers and the unintended consequences of over prescribing opioids. And, I will note that a recent Centers for Disease Control (CDC) report showed that the total doses of opioids prescribed in Ohio decreased by 11.6 percent from 2012 to 2015, in no small measure as a result of the work of the members of our task force. Education and prevention. Members of the task force have organized town hall meetings and presentations at schools and with labor unions and community organizations throughout Cuyahoga County. And, through this, task force members have reached literally thousands of people. And, they have also spearheaded two significant media campaigns to raise very importantly awareness of this crisis. And then, finally, last but not least, I am looking at Dr. Jerry, treatment. So, the task force members have led the effort to expand the availability of the opioid overdose reversal drug naloxone to first responders and relatives of those who have substance use disorders. And, that work has literally saved hundreds of lives. And, they are continuing that work, while also addressing what you mentioned, which is the critical shortage of treatment facilities in our District and throughout the United States. These efforts, in my opinion, they are an incredible example of what we always talk about in the Department, a multi-faceted approach, that really is what we mean when we talk about being smart on crime. And, our task force, because of its success, is now a model that is being replicated at U.S. Attorney's offices all across the country. But, while we have had some successes, we are keenly aware that this problem just continues to grow and get worse by the day. And, it is morphed, as we have discussed, from painkillers to heroin to now an incredibly deadly new drug, fentanyl. And, as you have noted, Chairman Portman, we cannot arrest our way out of this problem. But, we have to aggressively prosecute the drug dealers who are bringing this poison into our community. And, we have to find a way to choke off the supplies of the drugs into our community. And, of course, simply getting treatment for everyone who has suffered through addiction, that is not going to solve the problem by itself either. But, given the number of people who we know are already addicted to opioids in our communities, we have to find a way to make treatment readily available to those who need it. And, of course, changing prescribing practices alone, that is not going to curb the problem either. But, we have to start impacting the way that doctors are prescribing opioids. And, we have to address the underlying incentives that cause that to happen in the first place. And, education is critical. And, that is why the Administration is now championing a practice that requires people who are seeking a DEA registration to get specifically trained on prescription opioids and the dangers and the need to carefully prescribe. And then, finally, every one of us has to continue to talk to our children, to our friends, to our colleagues about the dangers of opioids. Because no one is immune from this threat. As you mentioned, Chairman, Senator Brown, opioid addiction knows no boundaries. It is an equal opportunity killer of men and women, young and old, city, suburban, rural, wealthy and poor, white, black and Hispanic. It is everywhere. And, it is killing people in our community every day. We are all at risk. And, you mentioned, Senator Brown, Ebola and the Zika virus--sometimes I wonder if people were dropping dead at this rate of Ebola or Zika, how would we all be responding? And, would it look like the response that we are seeing to this crisis? And, if not, why not? How do we get to the stigma that underlies our failure to address this crisis with every single tool in our tool kit? And so, from my perspective, this is going to take what we have all come to talk about as the ``all of the above'' approach. Everyone has to work together in concert. We have to roll up our sleeves to address what from my perspective, in my little corner of the world, is one of the worst public health crises I have ever seen and one that I hope never to see again. So, thank you. Senator Portman. Thank you, Ms. Rendon. Director Plouck. TESTIMONY OF TRACY PLOUCK,\1\ DIRECTOR, OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES Ms. Plouck. I really appreciate the opportunity to present at this hearing today. --------------------------------------------------------------------------- \1\ The prepared statement of Ms. Plouck appears in the Appendix on page 157. --------------------------------------------------------------------------- And, as you are aware, the opioid epidemic has hit all States. And, Governor John Kasich and his administration has worked tirelessly in the last 5 years with both State, local and Federal partners to curb the tide, and yet the storm just continues to rage. I know you both share the same concerns that the Governor does. And, I would like to talk to you a little bit today about Ohio's overall efforts and where we still have work ahead of us. Unintentional drug overdose deaths in Ohio reached an all time high of 2,482 in 2014, which is the most recent year available. That is 2,482 families that have been affected by a death related to overdose in our State just in one year. Opiate related deaths, which include both heroin and prescription painkillers, peaked at 1,988 deaths in 2014, up from only 296 in 2003. With 502 fentanyl-related drug overdose deaths in this State in 2014, fentanyl was a significant contributor to the rise in drug overdose deaths according to the preliminary data that has been released by the Ohio Department of Health (ODH). By comparison in 2013, just 84 deaths involved fentanyl. As a result, Ohio proactively requested assistance from the Center for Disease Control's EpiAid to better analyze our opiate related deaths. We are currently reviewing the recommendations and determining what should be implemented in Ohio to build on our effort. This continues to be a pressing issue for the State. Governor Kasich has made the fight against opiates a priority and is one of the nation's most outspoken advocates on the issue. Early in his administration, the Governor announced the establishment of the Governor's Cabinet Opiate Action Team (GCOAT) to fight opiate abuse in Ohio. GCOAT is comprised of directors from multiple cabinet agencies that touch the opiate issue. And, it is designed to foster collaboration across public health, treatment, law enforcement, education and other agencies that touch some facet of this complex challenge. I know you understand the importance of taking this issue in a multi-pronged way because of your work on CARA. Senator Portman, I would like to thank you for your sponsorship of the bill, and I would like to thank you, Senator Brown, for your support as well. CARA takes a similarly comprehensive approach and addresses on a national level several things that Ohio has demonstrated we know are working and making some progress. I would like to talk a little bit about some specific areas. And, I am going to start with prescribing practices and prescribing guidelines specifically. In its ongoing efforts to combat drug abuse and save lives, the Governor's Cabinet Opiate Action Team developed comprehensive prescribing guidelines for outpatient management of acute pain this past January. The acute guidelines follow previous prescribing guidelines for emergency departments, which were released in 2012, and the management of chronic pain in 2013. All three of these guidelines were developed in conjunction with clinical professional associations, health care providers, State licensing boards and State agencies. I know that CARA also addresses this issue from a national perspective. And, I applaud efforts to limit the number of opioids prescribed nationally to ensure that these powerful drugs are only used in the course of appropriate medical care. As a result of the prescribing guidelines and the increased utility of OARRS, our prescription drug monitoring system in Ohio, the number of prescriber and pharmacist queries using OARRS increased from 778,000 in 2010 to 9.3 million in 2014. And, Ohio is making further progress. The number of prescription opiates dispensed to Ohio patients in 2014 decreased by more than 40 million doses relative to the previous year. The number of individuals doctor shopping for controlled substances, including opiates, decreased from more than 3,100 in 2009 to approximately 960 in 2014. From 2013 to 2014, there was a nearly 11 percent decline in the number of patients prescribed opiates at a dose higher than the current guidelines that are recommended. Ohio patients receiving prescriptions for opiates and benzodiazepine sedatives at the same time dropped by 8 percent. So, we are seeing some progress related to these interventions. I want to say a little bit about prevention, which has been mentioned by both of the other panelists. In 2014, the Governor and the first lady launched ``Start Talking,'' which is a statewide youth drug prevention initiative based on the premise that youth are up to 50 percent less likely to initiate drug use if an adult who cares about them talks directly with them about this issue and the risks involved. Understanding that this is not an easy discussion to begin, the program aims to help parents and other adults communicate better with kids on these topics. ``Start Talking'' offers three free tools for parents and other youth leaders to approach children and young adults. Nearly 57,000 adults are receiving these biweekly messages via e-mail to help start important conversations. ``Parents360Rx'' is the second component of the program. It is a national program that Partnership for Drug-Free Kids established that is designed to help educate adults about the dangers found in their own medicine cabinets. This is a good topical source for community meetings to help draw attention to some precautions that every household can take in the fight against the opiate epidemic. And then, finally, ``5 Minutes for Life'' is a program that is led by the Ohio State Highway Patrol, the National Guard and local law enforcement in partnership with high schools. Troopers, law enforcement officers and National Guard members talk directly with students, usually student athletes, to encourage them to become ambassadors and lead peer-to-peer conversations about the importance of healthy choices. During this school year alone, over 260 events have been hosted with more than 35,000 students participating. I want to say just a moment about criminal justice initiatives and our support for court involved individuals. Established in 2014, we launched the addiction treatment program. This supports drug courts in establishing a program to provide addiction treatment, including medication assisted treatment, to non-violent adult offenders with dependence on opiates, alcohol or both. The first phase of the program reached 410 men and women, two-thirds of whom also had a co- occurring mental health disorder. According to a Case Western Reserve University evaluation of the program, past months drug use among program participants decreased by almost 70 percent, while crimes committed dipped 86 percent. At the same time, employment increased by 114 percent, while stable housing increased by nearly 29 percent. Among participants, 60 percent had a job, and 91 percent had stable housing upon completion of the program. This program is funded with $11 million over the current biennium in 14 Ohio counties. CARA emphasizes the importance of treatment as an alternative to incarceration, and we are seeing that work here in Ohio is effective in that regard with the drug court model. I want to say just a little bit about expanding the availability and the use of naloxone or Narcan, as has been noted earlier. Our department administers grants for first responders across the State. We know that through State emergency medical services (EMS) data, naloxone was administered to 18,438 patients in 2015. That is more than 18,000 deaths avoided as a result of this lifesaving measure. Without this important overdose antidote, Ohio's already two large number of overdose deaths would be much higher. The most recent State budget included $1 million to purchase naloxone for first responders, including police and fire. A concerted effort has been made to convince local agencies of the importance of carrying naloxone, oftentimes as an overdose victim cannot wait for EMS to arrive. And, we have seen many communities sign on to this. CARA also addresses this issue, and we support your efforts. Naloxone use is critical to saving lives and getting people into treatment. I would like to say a little bit about Neonatal Abstinence Syndrome. In 2013, the Kasich administration launched an effort to address the epidemic among the smallest of Ohioans, babies born to mothers who are addicted to prescription painkillers, opiates and heroin. By engaging expecting mothers in a combination of counseling, medication assisted treatment and case management, the 3-year project is estimated to reduce infant hospital stays by 30 percent among those enrolled moms and babies. One of the goals of CARA is to improve addiction and treatment services for pregnant and postpartum women. And, we believe Ohio is developing a model that can be replicated nationally. Across the State, I continue to hear stories of waiting lists and difficulty accessing treatment, in part due to the Federal Institutions for Mental Disease (IMD) exclusion. Treatment works, but it is not easy. I recently read of a couple who, after multiple relapses, found themselves homeless, involved in criminal justice and lost custody of their young daughter. Through treatment received through extended Medicaid benefits, they have over a year of sobriety. They have regained custody of their daughter, and they are now employed. We know that approximately 400,000 additional Ohioans were able to connect with mental health and/or drug addiction treatment as a result of the Medicaid expansion when it was extended to adults up to 138 percent of poverty. Capacity and workforce continue to be a challenge. And, the IMD exclusion poses a barrier to treatment access. I appreciate that CARA sets up a way to take a serious look at the IMD exclusion and its impact on treatment. Thank you again for inviting me to testify on this very important topic today. I want to commend both of you on your work on this issue. And, I especially commend you, Senator Portman, on your leadership on this issue through your career. Again, as I described in my testimony and at length in my written statement for the record, a number of the provisions in the CARA bill are activities that Ohio is undertaking. And, we fully support the expansion on a more national scale of these efforts. I stand ready to work with you as we move forward. And, we look forward to any questions that you might have. Senator Portman. Great. Thank you, Director Plouck. I appreciate it. And, we will have some questions. I am going to ask Senator Brown to go first. I want to just make one comment that is pretty obvious to everybody in the room. If we can get CARA passed, because of the programs that all three of these panelists talked about, we will be in a good position to access some of these grants, whether it is with regard to prevention, education or treatment, medication assisted treatment or, as you mentioned, the Neonatal Abstinence Syndrome, working with pregnant women. Our veterans, of course, in Ohio are great. And, they are funded in here. So, there is the diversion programs, drug courts. So, there is a lot of opportunity here for Ohio. We play a leading role thanks for the additional help that will come from CARA going forward. I will ask Senator Brown to go first with questions--and I want to ask you some myself. Senator Brown.. Mr. Chairman, thank you. And, Director Plouck, let me start with you. First of all, you were some years ago, in addition to what you are doing now, some years ago you were a Medicaid director in the State, right, so you know this issue pretty well. On March 30, an Akron Beacon Journal editorial discusses the role that Medicaid expansion, when the Governor made his decision as part of the Affordable Care Act (ACA) to expand Medicaid, and discussed in part Ohio's battle of its addiction. I would like, Mr. Chairman, to enter into the record this editorial,\1\ if I could. --------------------------------------------------------------------------- \1\ The editorial submitted by Senator Brown appears in the Appendix on page 233. --------------------------------------------------------------------------- Senator Portman. Yes. No objection. Senator Brown. Folks who have health insurance are better able to access critical mental health, of course, mental health and substance abuse services, including medication assisted therapy, as we talked about. I would like to focus on a different benefit of Medicaid expansion, if I could, because the expansion localities around the State are now able to use money they would have spent on health care for other critical services. For example, Summit County's Alcohol, Drug Addiction & Mental Health (ADM) services board used to rely on a local tax levy to help pay for basic health costs for the disadvantaged. Now, after the expansion of Medicaid, the board can utilize these levy dollars to meet other urgent needs in Summit County. That is funding recovery coaches, Project Deaths Avoided with Naloxone (DAWN), funding detox, both to the local community. Medicaid expansion enabled Summit County to save more than $4 million last year, and is projected to save the county more this year, money that is being used to address other urgent needs. My question is this: The new ``Healthy Ohio'' plan out for comment through the Ohio Department of Medicaid, out for comment from the Senators from Medicare and Medicaid Services, would require nondisabled adults, including some pregnant women, to pay premiums for coverage that is free today, would impose new limits on how many times Ohioans can go to the doctor or get care they need each year, or require patients to pay out of pocket, as I think you know, when they go to the doctor, pick up prescriptions, on top of monthly premiums that they may face. And, additionally, if individuals cannot afford to pay the premium or they get locked out of coverage, they have to again rely on help from local counties. Walk through, if you would, what ``Healthy Ohio,'' if the Medicaid waiver is granted to the State from Center for Medicare, Medicaid services, how ``Healthy Ohio'' would affect folks who rely on Medicaid for addiction treatment? Ms. Plouck. Chairman Portman and Senator Brown, I am not the lead cabinet director on this issue. And, I would want to defer to any clarification that Director McCarthy from Ohio Medicaid would want to bring to this. I think the general philosophy behind ``Healthy Ohio,'' when it was added into the last biannual budget, was a philosophy of personal responsibility for individuals. And, Medicaid is following the law to request the waiver that was stipulated in the budget bill. As far as access to addiction and mental health services, those are named services in the Ohio Medicaid benefit. And if, those would be subject to the same requirements related to call sharing or anything that would be required as a part of ``Healthy Ohio'' waiver. So, I do not believe that addiction treatment is approached any differently than other Medicaid services in that regard. Senator Brown. Understanding you are part of an administration with the legislature that is asking for the waiver. But, does that make sense to you, when dollars that would have been available now may be used for other things, when we know how every community is starved for dollars on treatment programs? Ms. Plouck. The Ohio Department of Medicaid is following the law that was enacted in the budget bill to request the waiver from the Federal Government. Senator Brown. And, I understand they are following the law. I want your opinion of that law. Granted I understand you are part of the administration. Does that make sense to you? If you can step in that other role, and it is probably unfair to ask you to step in the other role. But, can you kind of talk that through? Ms. Plouck. As an advocate for individuals and families that are struggling with mental health and addiction challenges in their lives, I think that we should work to try to overcome any barrier to access to treatment that exists. Senator Brown. OK. Ms. Plouck. I recognize that to an individual, the waiver, if enacted as it has been proposed pursuant to the budget bill, does create some obstacles that would need to be overcome on an individual basis depending on the resources of the individual. Senator Brown. Thank you. And, I ask that in part--I mean, I opposed the waiver pretty obviously. But, I also ask in part, because the Centers for Medicare and Medicaid Services (CMS) in Washington can make a determination to choose parts of that waiver to grant and parts to deny. I think they should deny the entire waiver. I understand they may not. And, I know that hospitals around the State are concerned about the waiver period, because they so applaud it when the Governor expanded under the ACA Medicaid, I will not speak for others. But, the ones that have talked to me think that this is backsliding and particularly with the acute needs we have now. But, thank you for your candor there. I appreciate that. For General DeWine and again U.S. Attorney Rendon, an easier question than I would asked Director Plouck. [Laughter.] Senator Brown. I just really wanted to kind of flush out some of the things you already said. We know that the opioid crisis is not just law enforcement. Senator DeWine, you said you cannot arrest your way out of it. We have all said that. We all understand that. And, we kind of made those mistakes in the war on drugs in the past. You cannot arrest your way entirely out of this, we know. So, we know it is not just the law enforcement. As you said, it is law enforcement, not just law enforcement. It is not just treatment. It is a problem that requires something more comprehensive, as Senator Portman has mentioned many times with CARA overall. But, what can regular people do to help address this crisis? And, we have some of the State's best experts here. We have people that devote much of their workday and beyond that to doing this. Talk more about the general public, what people can do? Mr. DeWine. Chairman and Senator Brown, I think that is an excellent question. Because I truly believe that the success that we have achieved so far and that we can achieve in the future is going to be very much depending on what occurs at the local level. We all have a role. We do what we do. U.S. Attorney does what they do in regard to law enforcement. We try to help with the six individuals who I told you about who will go out and help in the local community. The communities that have started to change the culture, to change how we look at it, communities that have begun to really assist people with not only getting in treatment, but what happens when we get out of treatment, those communities--where we have seen that happen is because the local community got together. I know you had a lot of town hall meetings. Senator Portman has had town hall meetings. I suspect you found what I found when I did this. We did a number of town hall meetings over a year ago. And, to me the interesting thing, but also kind of scary thing was, that we would have a lot of people, a lot of just citizens who came. And, we would have a panel of experts. But, we would have a roomful of citizens. And, we encouraged just a conversation. And, what I found was that you would get someone who would stand up on one end of the room and say, well, in this community we need such and such. We do not have that. Somebody else on the other side of the room stands up and says, yes, we do. So, a lot of it is I think pulling people together and getting people out of their normal area where they work and communities coming together. And, when you have a grass roots effort in the local community, what happens is, people in that community start talking to each other more. That is how we are going to do this. I think the other thing average citizens can do is to say, hey, look, in this community, somehow we have to have education at every grade level. And, we have to work with our schools, who we ask to do all kinds of a million things. And, they are overburdened. But, we have to work with our schools. And, the community has to say to the school, this is very important. If we are going to deal with this problem in the future, if we are going to have some success 5 years, 10 years, or 20 years from now, we have to start in kindergarten. And, we have to work all the way through. So, I am a great believer in the local community and where the local community comes together, where the business community is involved, where the church faith based community is involved. I think we can see some progress. That is what the individual can do. Ms. Rendon. Senator Brown, I think that is an excellent question. Because I think there are things that every single person in our community can do to help with this crisis. And so, what you are doing here today is a huge step, because we all need to be educated about what is happening. And so, the more we get the word out, the more people know that this is out there, the more they can figure out where their piece is, where they can help. But, for the average citizen, what I tell people when I am at these town hall meetings, there is a ton that everyone can do. So, you can start by going home and opening your medicine cabinet and figuring out what is in there that should not be there that you were prescribed a year and-a-half ago. And then, on April 30, you can see my good friends at the DEA on their drug take-back day, and take that medication safely to a drug drop box and get rid of it before somebody accidentally tries it, some young kid who thinks it is safe because it is in a medicine bottle, somebody who happens to be in your home. You can do that on a daily basis in many of our police stations. And, I know some of our pharmacies are now starting to agree to have drug drop boxes in the pharmacy, which I think is phenomenal. So, that is something you can do. You can talk to your kids, to your family, to your friends. My oldest son is here. And, he can tell you, I think maybe because of my career, I have been talking to my children about the dangers of drugs since they were toddlers. So, just as we have taught all of our children to buckle their seat belt and not smoke cigarettes and not drink and drive, we have to have on that list, do not use drugs. You do not know, that first time that you take it, you have no idea how it is going to impact you. And, then we all have to look at ourselves in the mirror and figure out when we became a culture that has to be pain free at all times. Right? So, when I had my wisdom teeth out, I got Tylenol, and I think I got to stay home from school for a day. Now, you take your children to get their wisdom teeth out, and they want to give you Percocet. Percocet. We as parents, we as citizens, need to stand up and say, no. I am not taking that prescription. I do not need that prescription. My husband had his elbow operated on--not removed. We do not need a 60 day supply of Vicodin. I want three. Right? But, I found out you can do the same thing at the pharmacy. So, if they do give you the prescription for 30 Vicodin, you do not have to take 30 Vicodin. You can talk to your pharmacist and say, how many of these do I actually reasonably need to address this problem? And, they will tell you, two, three. And, you can walk home from the pharmacy with just what you need. So, it has to start with each one of us in our homes with the things that we care about, with our commitment to this next generation and the future of our community. And so, there is a role for every single person in our community to help with this. And, getting the word out is the first step. So, thank you. Senator Portman. Thank you. Thank you, Senator Brown. I could not agree you with more. And, tragically, we are going to hear from a witness in a little while about wisdom teeth extraction and the specific issue that you raised and how that led to an addiction and eventual overdose and death. But, and you are right, everybody has a role. One of the things we tried to do in this legislation, drop boxes, for instance, we do provide for them to be at pharmacies and at long term care facilities and in hospitals that have pharmacies. I must tell you, I have a frustration on the prevention and education side, because, 22 years ago, I started this group in Cincinnati. Officially, we were having our 20th year anniversary I think in a couple weeks. I founded it. I chaired it for the first 9 years. I was on the board until I joined the Senate. It is called Coalition for a Drug-Free Greater Cincinnati. Now, it is called Prevention First. And, we are considered a model coalition. I was the author of the Drug Fee Communities Act of 1997. We have spawned 2,000 coalitions throughout the country. As all three of you have acknowledged, we are still not able to persuade so many of our fellow citizens, not just kids, this is not just about young people, of the dangers. And, the best research shows that it is this recognition of the danger that kept those people from trying heroin. In the 1990s when we started our coalition, it was not an issue. Now, we have 13 year old kids in Ohio trying heroin, first time, shooting up. Parents, all the evidence shows parents or other caregivers, when there is not two parents at home--which unfortunately is the case in many of our communities. And, in many situations you do not have a parent who is available, even if the parent is in the family. But, parents make a huge difference. The single largest difference as a parent, when I had three teenagers, well, all three are passed teenagers now barely, you kind of wonder sometimes. But, it is incredibly important, as you say. But, on the issue of community coalitions and this whole issue of prevention and education, we are going to hear from Rob Brandt later, who has become an expert on this by necessity. But, what should we be doing differently? The CARA program starts a national awareness campaign, specifically on this issue of the connection between prescription drugs and opioid addiction, and the fentanyl and the heroin connection. Because four out of five people who are addicted to heroin start on prescription drugs. That is what they say. And, we need to--people do not know that. So, they do not know when they go to have a relatively small procedure that they should not be asking for the Percocet. Instead they should be asking for the Toradol or the Tylenol. So, that specifically is in here. But, what would you say? And, Attorney General DeWine, again you have been active on this, Ms. Rendon and Director Plouck, if you would like to jump in. But, what would you do differently in terms of the prevention and the education side of this, something different and new? Mr. DeWine. No. You go ahead. Ms. Rendon. Well, so one of the things that I think is an example that is really incredible to me from our task force here in Northeast Ohio is the partnership between law enforcement, treatment, education and regular community members, which has allowed us in some respects to get a little bit ahead of the curve. So, I talked earlier about our Medical Examiner (ME) sounding the alarm on this problem as it came on the horizon. So, they were the first to see fentanyl in pill form in our district. They sent out an alert, and it came to us, because we are on this task force. And so, it went immediately to the DEA. And, within weeks, the DEA had made a massive seizure of fentanyl in pill form, just shy of 1,000 pills. And, we were able to charge that individual in Federal court within days and address this problem and get the word out very publicly. And, what was so important about that is the fentanyl pills were shaped and dyed to look like oxycodone. And so, if you are an oxycodone user, and that is what you think you are taking, and it is fentanyl, it is an overdose waiting to happen. I mean, every one of those pills was an overdose waiting to happen. But, we were able, because of this group that we have together and the constant communication that we have, both when we are sitting together in our office and then also on a regular basis by e-mail and phone, we were able to sound a really loud alarm bell and get the word out to the drug using population. Joan Synenberg was here earlier. She is a common pleas court judge. She has one of the drug courts. There she is, back there. She is a member of our task force. And, told us a really heart-breaking story of one of her graduates--I was at the graduation--who 2 days after graduation overdosed and died. And so, that caused us to realize that we have to get to her graduates as they are walking out the door to make sure that they understand how dangerous the world has become while they have been sober. Because the heroin users do not know how deadly and dangerous the fentanyl is. And, when you are taking an illegal drug, unlike a drug that you get at the pharmacy, you have no idea what it is you are about to put in your mouth. And so, unless you can get the word out, really actively, really publicly through the media, through one on one meetings, through this combination of people working at all levels, you cannot impact the problem. But, all of us together, that is why the stool has to have the four legs, all of us together, we can make a difference. And, we are. It is disheartening when it is not going in the direction that you want it to. But, I am telling you every day we are saving lives and will continue to do so. Mr. DeWine. I have a couple of comments. Mr. Chairman, you are absolutely right. There is a natural progression from opiates to heroin. One of the things that we partnered with Governor John Kasich's office, right after he took office and I took office, was to really crack down on doctors who are really nothing more than drug dealers. We have taken, and I say we, because we are the lawyers for the State Medical Board, and we pushed this. But, the State Medical Board has really stepped up. For many years they were not frankly doing what they needed to do. They have taken I believe 70 doctors' licenses in the State of Ohio. I was involved in some of the raids. And, I will not take your time to tell you the horror stories. But, we had one doctor who was on the circuit, basically. He would spend one day--and he had 10 offices around the State. And so, that--if we can stop people from--change the culture regarding an opiate, we are going to see some progress in the heroin as well. Because one flows, one flows from the other. We had a real pendulum swing, in regard to the culture of prescribing pain meds. And, if you recall, 15 years ago or so, the concern was that doctors were not treating pain. And, that was probably a correct comment, that we needed to do a better job, particularly people who have long term retractable pain. But, we went too far the other way. We are now starting to move back. But, I will tell you, I had the same experience as I have experienced with a granddaughter who had her wisdom teeth taken out and was given dozens and dozens of pills. That was what the prescription was. Our daughter, we told her not to take any of them. She did not take any of them. So, we are not there with changing the culture with the medical community. We have come a long way. As to the second thing, I will go back to what I said, Mr. Chairman and Senator Brown, we have not done a very good job in this country in regard to education. I think you have to be--we have to be careful, is what some of the experts will--I do not intend to be an expert. But, will tell me is, there is some things we do--we could be doing that we might think is the right way in education, and it may be exacerbating the problem. So, I think whatever we do, it would have to be evidence based. And, we have to have that tested. But, you all will remember when I was about leaving, and when Senator Brown was about coming, I think, in the Senate, you were in the House, but, killed the national funding. It was not very much in education. But, every school got some of it. Every school got something. And, that just went away. I lost that fight. And, those who were fighting on our side also lost. We lost that. So, I think we have to look at that more and see what the Federal Government can do. I think candidly we have to do something in this State, so that we are doing something with education K through 12 every year. Nothing less than that is acceptable. Nothing less than that is going to begin at least to deal with this problem. We are not doing that. And, I am not blaming anyone. But, we have to start doing that again. Senator Portman. Thank you. I have so many other questions. And, I am going to continue the discussion with all three of you and then with Senator Brown on these issues. But, we do have another panel that is patiently waiting. And, I want to get them up here, too. Thank you to all three of you for not just coming today and sharing your views with this distinguished group of people who are in the trenches, but for what you do every single day to help to save lives and to pull lives back together. So, we look forward to continue to work with you. And, thank you for your testimony. Ms. Rendon. Thank you. Senator Portman. I would now like to call the next panel up, if we could, please. Dr. Michele Walsh, Dr. Kotz, Emily Metz and Rob Brandt. OK. We are on to the next panelists here. I would like to get started. Why do we not start by swearing in the panel, since this is the custom of this Committee to do this. So, please stand and raise your right hand. Do you swear the testimony you will give before this Committee will be the truth, the whole truth and nothing but the truth, so help you, God? Thank you. Let the record show that all the answers were in the affirmative. We appreciate each of you coming today and look forward to the opportunity to hear from you and also to get some questions in. I was probably negligent in not mentioning for the last panel that we are asking for five minute opening statements. And, I know you all know that. But, try to stick to 5 minutes, if you can, because that will give us more time to have interaction between yourselves and we will be able to ask you direct questions. Again, we have an amazing group here. First, is Dr. Michelle Walsh, who is right here. I mentioned earlier the Rainbow Babies and Children's Hospital work. It is incredible. She has given the opportunity to tour it a couple times, I think, maybe a few times, but more recently with regard to this issue of babies who are born with Neonatal Abstinence Syndrome. So, thank you for being here. Dr. Michele Walsh is division chief of neonatology right here at UH. She will talk about that issue. After Dr. Walsh, we will hear from Dr. Nancy Young. Dr. Young is an expert in the issue of substance abuse and its impact on children. She is going to expand on the broader impact of the Neonatal Abstinence Syndrome we mentioned earlier. In particular, Dr. Young is going to discuss the correlation of substance abuse and children entering the child welfare system. Again these are areas that she has testified about before. In fact, she came to our Finance Committee, where Senator Brown both and I serve, and testified before the U.S. Senate. I appreciate her willingness to come here to Cleveland. Dr. Margaret Kotz is here. Dr. Kotz is an addiction expert. She is a specialist right here at University Hospital. And, she told me this in our round table discussion last year. We got to talk to her about some of her work. And, she is going to discuss the merits of medication assisted treatment. That is one we did not get a chance to get into as deeply as I wanted to in the first panel. We look forward to that. Emily Metz is here from project DAWN. She is going to speak about the work in the community to get naloxone out to prevent these overdoses. We talked a lot about that today. I think I am going to be with you later this afternoon and be able to see some of your good work directly at the free clinic. And, also I know you work with MetroHealth, their facility here in Cleveland. So, we look forward to hearing from you. And then, last but not least, Rob Brandt is here with us. And, I was looking at Rob when there was discussion about this issue of prescribing to our kids prescription drugs that are addictive, in the case of a wisdom tooth extraction. And, unfortunately, Rob is an expert. He is a business leader. He got involved with prevention because of his family-- his son, Robby. He has a group called Robby's Voice. They are awesome, because they are out there in the schools. We talked about doing it at young ages. He is there in the elementary schools. And, he works to bring the message of drug education and drug prevention to students and families. So, again, thank you all for being here. And, Dr. Walsh, we look forward to your testimony. TESTIMONY OF MICHELE WALSH, M.D.,\1\ DIVISION CHIEF, NEONATOLOGY, UH CASE MEDICAL CENTER, UH RAINBOW BABIES AND CHILDREN'S HOSPITAL Dr. Walsh. Thank you, Chairman Portman, Senator Brown and distinguished guests. I am Michelle Walsh. I am the Chief of Neonatology here at Rainbow. I thank the Committee for holding this field hearing in Cleveland. And, we are proud to host you at the UH Case Medical Center. I thank the Committee for holding this field hearing in Cleveland. And, we are proud to host you at the UH Case Medical Center. I have been privileged to care for the tiny babies of Northeastern Ohio for over 25 years. And, I appreciate the opportunity to speak on their behalf. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Walsh appears in the Appendix on page 170. --------------------------------------------------------------------------- Never have I seen a public health epidemic of the severity of the current opioid epidemic among our citizens. And, as others have said, Ohio unfortunately has the unfortunate distinction of being among the lead in the entire country. We must focus our efforts on a cohesive national strategy that attacks every facet of this complicated problem. In the same way, as Senator Brown alluded, that we came together as a nation to combat Acquired Immunodeficiency Syndrome (AIDS) and more recently Ebola, the same urgent epidemiologic methods and prevention are needed to combat this scourge. The Comprehensive Addiction and Recovery Act championed by you, Senator Portman, and so many others is exactly the right direction to address the complexities of addiction treatment, the inadequate numbers of programs, inadequate numbers of trained physicians and addiction specialists and the critical shortage of facilities to address this exploding issue. As others have highlighted before me, and I will not repeat, the epidemic is staggering. And, I entered into the record data on the explosive growth from 2001 to 2011 of the number of citizens in Ohio. Which the data from the Ohio multi- agency community report documented that in 2001, there were only eight counties that had a significant problem with opioid addiction. But, by the last available report in 2011, there were only eight counties---- Senator Portman. That will be entered into the record. Dr. Walsh [continuing]. That was not at the highest levels of addiction. The fentanyl problem is exploding. And, unfortunately, the epidemic among adults has led to a corresponding epidemic among newborns. A recent publication from Tennessee analyzing Medicaid data indicated that 27 percent of pregnant women were prescribed one or more opiates during their pregnancy. So, it does have to start with education, not just of our children, but also more education of physicians. And, as has been highlighted here, it is not just physicians. It is dentists. It is emergency room physicians who in the interest of being compassionate are over prescribing these drugs. The tragic occurrence of a newborn addicted to narcotics causes a syndrome similar to what is seen in adults-- jitteriness, fever, diarrhea, poor feeding, and, if not treated, seizures. About half of the babies that are narcotic exposed in the womb require pharmacologic treatment. The problem is that the strategies were largely unstudied. And so, there is huge variation in the amount of drugs used and the duration of the treatment. Governor Kasich challenged Ohio children's hospitals to work together to come up with a better approach to this. And, we were able to publish our research that showed a significant improvement in the treatment of the newborns. Working together, we identified best practices for caring for the family and the infant and improving the integration of care between obstetricians, neonatologists and addiction medicine specialists. From the earliest days of our work in 2011 to today, we have decreased the number of opiate-exposed newborns who received opiate treatment from 60 percent to 45 percent--and decreased the length of their treatment from 25 days to 16 days and the total hospitalization from 31 days to 19 days. As we took that, we moved from the six children's hospitals, and with funding from the Ohio Department of Medicaid, we moved this into our statewide Ohio Perinatal Quality Collaborative (OPQC). And, I am privileged to lead that group. And, we are now active in all 105 maternity hospitals in Ohio. And, in fact, on Monday, we will have our third learning session where over 500 health professionals will meet together to share lessons learned and further improve our treatment course. While embracing the cohesive approach that you have heard from the first panel, we are just beginning to see the tide turn on the amount of narcotics prescribed in Ohio. And, for the first time, the data comparing 2012 to 2014, the amount of opiates prescribed decreased for the first time. And, we hope that this will be a harbinger that as prescribed opiates decrease, the epidemic of addiction will decrease as well. I believe Ohio's approach to be a model for the Nation. And, I respectfully urge additional approaches like the CARA Act to continue efforts to educate physicians and dentists and all other prescribers on appropriate pain treatment, especially the limited role of narcotics in acute pain and the science of addiction. All of the efforts limiting illegal prescribing practices and requiring the mandatory use of our OARRS prescription platform is beginning to make inroads. We do need to create new programs within our opioid maintenance clinics, encouraging mothers to focus on their recovery and consider delaying pregnancy until the mother's health and dependence are improved. We also, as has been emphasized, need to enhance programs that encourage women to seek prenatal care and avoid criminalizing pregnant women with narcotic addiction. Some States have criminalized using opiates during pregnancy. And, what we are seeing, as some of those States are adjacent to us, we are seeing increasing numbers of those women seeking care in Ohio, rather than seeking care in their home State. We need to create incentives for new methadone treatment providers to enter into the field and eliminate barriers to prescribing Suboxone replacement therapy during pregnancy, which will decrease the severity of newborn withdrawal and allow certified providers to increase the number of patients they are treating. Lastly, we need additional residential treatment programs that welcome both the mother and her infant and can comprehensively support the recovery. Pregnancy is a teachable moment, where women are highly motivated to change and improve their lives and the lives of their children. And, among all of those who are treated for addiction, the success rates are higher in pregnancy than they are in other populations. And finally, as was alluded by Senator Brown, we need to fund research at the National Institutes of Health (NIH), as we do not know what the long term consequences to these infants are going to be, and whether there are going to be impacts on their intellectual development in the future or in their vulnerability to addiction themselves in the future. Thank you again for the opportunity to testify. And, I stand ready to support your efforts in any way possible. Thank you. Senator Portman. Thank you, Dr. Walsh, you already have. Dr. Young. TESTIMONY OF NANCY K. YOUNG, M.D.,\1\ DIRECTOR, CHILDREN AND FAMILY FUTURES, INC. Dr. Young: Thank you. And, thank you, Senator Portman and Senator Brown, for having the hearing and your continued support on these issues and the CARA Act. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Young appears in the Appendix on page 173. --------------------------------------------------------------------------- Each year the number of infants who have been prenatally exposed to illicit drugs, binge drinking and heavy alcohol is about 360,000, the population of Butler County, each year. I would like to emphasize four points from my written statement. In the past three decades, our country has experienced at least three major shifts in substances of abuse that have had a dramatic impact on children and families, but particularly on the child welfare system. While the increase of opioid misuse has been described as having the worst effects, unfortunately, as reported in governing just last week, we have to begin to anticipate the synthetics, such as bath salts and spice, which are beginning to kill people in a very different way than the overdose, but are increasingly being manufactured, marketed and used. The point is that irregardless of the drug of the decade, child welfare agencies see some of its worst effects. And, despite the history and the known cost of substance use disorder on child welfare, the response has not been systemic. It has not been with funding changes to adequately address the problem. Instead, we have offered demonstration grants and pilot programs. While worthwhile, to understand what works, we need to be at that systemic level of understanding how to take these initiatives statewide. My second point is that the current opioid crisis, as is all too well-known in Ohio, means that young people are dying at astonishing rates too often leaving young children. Grandparents and other kinship providers are taking in these children--sometimes with little support or assistance. We recently analyzed the Federal Adoption and Foster Care Analysis and Reporting System (AFCARS) data set and found that children who were placed in protective custody, because of their parent's alcohol or drug problem, are most frequently placed in kinship placements, rather than other type of foster care or group homes. Another effect of opioids on child welfare services is the alarming increase in infants who are coming into protective custody. In 2014, 45,000 infants were placed in protective custody, the most recent year that data are available. Specific to opioids, thank you again for your support of protecting our Infants Act. I understand the report to Congress is underway in the administration. But, the Federal law intended to protect these infants, the Child Abuse Prevention and Treatment Act (CAPTA), requires medical providers to notify child protective services of infants identified as affected by prenatal substance exposure. However, it is not consistently implemented. And, child welfare agencies do not have clarity about how best to meet these families' needs. Last week, the Administration on Children, Youth and Families (ACYF) issued program instructions for States to more fully describe their State laws and policies and then procedures for these infants. Clearly a view of the current legislation and funding mechanisms to provide safe care for these infants is now essential. But, we also need to recognize that CAPTA funding for this provision is approximately $25 million nationwide, which in some States, it is about half of one State employee. The response to the effects on these infants is essentially an unfunded mandate that to date has not been implemented and in the wake of increasing NAS no longer seems adequate. The urgent policy issues here are clarifying how to implement the CAPTA law, expanding treatment access by appropriating funds for CARA, for example, and most important, ensuring that child welfare financing is flexible enough to allow keeping infants with their families whenever possible by ensuring treatment access and in-home preventive services. My third topic is the good news on what we know about what works. Federal investments over the past decade have tested collaborative strategies in nearly 100 communities. And, those investments consistently produced better outcomes for these families. To simplify, we have determined that there are seven core common strategies implemented in communities which lead to improved outcomes in five Rs. Recovery. The children remain at home. They reunify. We have dramatic decrease in recurrence and decrease of return to care, about a third of standard services. These positive results are detailed in my written statement. Implementing these priority strategies is underway in Ohio as a result of a grant from the Department of Justice's Office of Juvenile and Delinquency Prevention (OJJDP) as a grant to the Ohio Supreme Court. OJJDP selected five States to show how these ingredients of better practice can be implemented on a larger scale by creating systems change throughout the juvenile court docket. I have been privileged--I feel like Ohio is my second home. I am here about every other month and on the phone every week with a State team that is devoted to expanding these kinds of practices across the State, with 12 communities that have been selected as pilots. And, over this past 18 months, we have been focused on implementing these seven key ingredients and working on the data systems to monitor outcomes. Next spring, Ohio will be one of those five States that will compete for funds for full implementation of the plans that they have made in the last 2 years. Finally knowing that Federal investments have generated a knowledge base of effective approaches and demonstration grants, pilot programs and Title IV-E waivers, we now have clear policy choices. Improving data collection and monitoring. Building on the lessons from the prior Federal investments to take these initiatives to scale in the States. Solve the current gap in timely treatment access. Funding CARA, as you know, is critical, as well as providing child welfare with the resources they need to pay for substance abuse and mental health treatment for parents, including those families with a baby affected by prenatal substance exposure. And, preventing future crises and costs as substance abuse patterns change over time, by providing the flexible funding that is needed by child welfare to meet the needs of families before infants are removed. When we assure timely access to effective treatment, families recover, kids stay safe at home, and we save money. Now, we can and we must move beyond these pilots and demonstrations and take these lessons into systemic changes across agencies for all of our children and families. Thank you so much for your time. Senator Portman: Thank you, Dr. Young. Dr. Kotz. TESTIMONY OF MARGARET KOTZ, D.O.,\1\ DIRECTOR, ADDICTION RECOVERY SERVICES, UH CASE MEDICAL CENTER, UNIVERSITY HOSPITALS Dr. Kotz: Chairman Portman and Senator Brown, thank you for the privilege of being here today. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Kotz appears in the Appendix on page 201. --------------------------------------------------------------------------- I am an addiction psychiatrist at University Hospitals. And, my background is, is that I have been in the field of addiction psychiatry for over 30 years. Recently, I have been heavily involved with national agencies, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), and Center for Substance Abuse Treatment and recently spoke with Agent Jess, and worked with professional organizations to develop regulations and guidelines, as well as policies for treatment of opioid disorders. I share the concerns of all of our previous speakers and legislations that opioid addiction is destroying the lives and communities of many Ohioans. You have heard previously, too, that this disease was previously thought to mainly affect impoverished males in inner-cities. However, the current epidemic affecting suburban women, well to do professionals and adolescents in privileged environments has reminded us that the disease of addiction does not discriminate. I would like to discuss the role of medication assisted treatment. Studies show that when heroin addiction is treated only with abstinence and psychosocial treatment, that most fail. Our 50 years of experience with methadone to treat heroin addiction confirms that counterintuitively the use of a selected opioid to treat opioid addiction results in decreased unemployment, criminality and infectious diseases such as Human Immunodeficiency Virus (HIV) and hepatitis C. However, while effective, methadone is not an option for the overwhelming majority of patients with opioid addiction. It requires daily visits to specially licensed facilities, typically only found in large urban locations. It is completely inaccessible to rural patients and relatively so to those living at a distance in the cities, especially when transportation is limited. The daily visits are a barrier to employment. Since the Drug Addiction Treatment Act of 2000 (DATA 2000), Office Based Opioid Treatment (OBOT), has been available, the partial opioid agonist buprenorphine can be prescribed by qualified primary care providers, by a physician, in the patient's neighborhood, making it significantly more accessible. Daily visits are not needed, so that the patients can work more easily. Research demonstrates that it is as effective as methadone and far safer in case of overdose or child exposure. Even so, access remains severely limited, due to inadequate numbers of physicians prescribing buprenorphine. An alternate medication based strategy for treatment relies not on opioids, but rather an antagonist medication that blocks opioids. Only one--naltrexone--is currently available as a daily pill or a monthly injection. While less acceptable to many patients than buprenorphine, for those willing to take it or who have monitored administration, it can be a valuable tool for increasing long term sobriety. Although opioid agonist and antagonist medications are important additions to our treatment armamentarium, they are not in and of themselves sufficient for successful treatment. This is especially true when a primary care provider has 15 minutes to provide addiction treatment, while also complying with requirements to ensure that other issues, such as vaccinations and colonoscopies are up to date. So, what we need is support for extended office visits and for associated behavioral services to be and to have essential favorable outcomes. It is imperative that we train more doctors to include medication assisted treatment, and that we ensure that there is payment for both medical and behavioral services. In Northeast Ohio, there are simply not enough facilities or behavioral services to treat addiction for those who need it. And, when space is available, insurance often fails to pay for it. Or, perversely, patients are required to fail a level of care or a medication before the appropriate treatment will be considered. In summary, a current epidemic, our current epidemic is having a catastrophic impact on many lives in our communities. We are fortunate that both of our Ohio Senators are taking action to address this scourge. Senator Portman was a co-author of the act. And, Senator Brown has been a ferocious supporter of it. I am a proud member of our Heroin Task Force in Northeast Ohio. However, I also think that it is likely that an approach at the Federal level will be necessary to stem the tide of opioid addiction. Thank you. Senator Portman: Thank you, Dr. Kotz. Ms. Metz. TESTIMONY OF EMILY METZ,\1\ PROGRAM COORDINATOR, PROJECT DAWN Ms. Metz: Senator Brown, Chairman Portman, fellow speakers, and guests, thank you for allowing me to speak to you regarding the opioid epidemic and its devastating impact on Cuyahoga County. The MetroHealth System is an essential hospital system committed to leveraging its expertise, resources, and relationships to respond to this public health crisis. I serve as Program Coordinator for MetroHealth Cuyahoga County Project DAWN, a lifesaving overdose prevention program sponsored by the health system, the Alcohol, Drug Addiction and Mental Health Services Board of Cuyahoga County and the Ohio Department of Health (ODH). I am also speaking to you as a member of the Cuyahoga County Opiate Task Force and our local U.S. Attorney Opiate Action Plan Committee. --------------------------------------------------------------------------- \1\ The prepared statement of Ms. Metz appears in the Appendix on page 211. --------------------------------------------------------------------------- These committees convene many local experts, such as Project DAWN Medical Director, Dr. Joan Papp, the Cleveland Clinic's Dr. Jason Jerry, County Drug Court Judges David Matia and Joan Synenberg, Dr. Gilson, our County Medical Examiner, and even Erin Helms who manages recovery housing in our community and many others in order to address this crisis by collaborating with government, law enforcement, education and prevention and addiction experts. Our country is in the grips of an opiate addiction and overdose epidemic. We are at risk of losing a generation of Americans to disease that devastates lives, families and entire communities. In 2014, 2,482 Ohioans died as a result of a drug overdose, where 80 percent of these fatalities involved an opioid. In large part, our country's epidemic is iatrogenic. Our liberal prescribing of opioids has created a generation of Americans who are addicted to opioids and require help. As a nation, we must mobilize to curb and fix this crisis. At Project DAWN, we work to reduce opioid overdose mortality by helping to expand community access to the opioid overdose antidote naloxone. We train community members on risk factors for overdose, how to recognize an overdose and how to respond to an opioid overdose. The most critical aspect of our program is the free provision of naloxone to our patients. Since Dr. Joan Papp founded our county program in March 2013, we have provided over 3,300 kits to community members resulting in over 430 overdose rescues that we are aware of alone. Ohio's streets are saturated with fentanyl-laced heroin, which has contributed to the loss of 502 Ohioans during 2014, as compared to 84 during 2013. Because fentanyl is an opioid that is up to 50 times stronger than heroin, the dose of naloxone needed to revive the victim must be increased. This development is impacting our intervention efforts and budget because it is increasingly necessary to provide additional take home doses to our patients. We and other alcohol, drug and mental health service providers in our country do not have the adequate resources to meet the emerging needs of communities struggling with substance use disorders. Cuyahoga County Project DAWN is actually considered one of the largest Project DAWN programs in Ohio. We have expanded to include 3 to 4 hour walk-in clinics 3 days a week. And, also, started to provide naloxone kits in other community settings, such as the county jail, MetroHealth emergency departments and the Free Medical Clinic of Greater Cleveland's syringe exchange program. Without these strong community collaborations, we would not be able to save as many lives. Currently Project DAWN's efforts are shouldered by one full-time employee, me. In Ohio, we are one of 37 Project DAWN programs in a State of 88 counties. The reality is that many of these programs do not have full-time staff members, and some are only able to operate once a month. And, often, there are programs that run out of funds to purchase naloxone before the year's end. Project DAWN programs are essential to curbing opioid overdose mortality at the community level, because we equip those most likely to witness an overdose with the proper lifesaving tools. While we strongly support increasing access to naloxone for first responders, including police, fire and EMS, we know that the most likely individuals to witness an overdose are actually drug users, their family and their friends. We strongly support the Comprehensive Addiction and Recovery Act and request funding be considered to help lay responders who are connected to Project DAWN models. This investment will sustain and expand community based naloxone programs that have a proven track record in reaching people in the community before they intersect with the first responder system. We applaud our Congressional leadership for recognizing that increasing naloxone access in our country does not alone fix the opioid epidemic. The CARA legislation is promising, in that it promotes evidence based and innovative strategies, interventions and treatments at the community level. Project DAWN welcomes Federal funding in support of community networks focusing on connecting treatment, housing, education and employment opportunities to those struggling with addiction. Finally, the stigma that is present in our country for individuals, as you have heard from others, is no small issue to tackle. We commend CARA's focus on public awareness campaigns, which would educate the public on the risk of prescription drugs and heroin abuse. We hope these campaigns will also educate the public that addiction is a chronic disease. And, we should support those in recovery, just as we rally behind those who face other diseases. Individuals with substance use disorders are not bad people trying to get good. Instead they are sick people trying to get well. Thank you for your time and allowing me to serve on this panel. Senator Portman. Thank you, Ms. Metz. Mr. Brandt. TESTIMONY OF ROB BRANDT,\1\ FOUNDER, ROBBY'S VOICE Mr. Brandt: So, I want to thank Senator Brown and Senator Portman for the opportunity to present this testimony today, as well as for your work on the CARA legislation. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Brandt appears in the Appendix on page 214. --------------------------------------------------------------------------- On October 20, 2011, my son Robby passed away from a heroin overdose. His addiction started with a prescription for pain medication after he had his wisdom teeth taken out. It grew because of the availability of prescription pain medications in school. And, it ultimately led to his addiction to heroin. As a family, we battled the disease as best we could. But, we lacked information. We lacked education. We lacked awareness to the resources that may have been available that may have helped us save his life. But, our deficit of education really began well before his addiction. And, it began with the lack of education in the schools, to the students, where they do not fear the drugs or that the stigma is not scary, and the lack of awareness at the community level, which allows us as parents to continue to live under the false pretense that it is not going to be our kid. In May 2012, we started Robby's Voice in an effort to raise awareness at schools and efforts to raise awareness in the communities. And, since then, we have spoken to over 75,000 people in the schools, in communities, in rehabs. And, we are currently working on turnkey programs for schools, as well as developing a center for continued recovery for post treatment. But, the reality of it is--it is not why we started Robby's Voice. We started Robby's Voice because it was his dream. We started Robby's Voice because, when we went on this road of addiction, we had no clue. We did not know what to do. We did not know where to turn. We did not know how to deal with it. And, it does split the family. And, the only thing worse than living with an addict is the death of a child. And, you cannot fix that. So, today, I speak to you as a parent who has lived with an addict, as a parent who has lost a child, and as a parent who has been on the front lines for the past 4 years fighting the battle. Robby did not want to be an addict. He said it over and over. He could not escape it. We could not protect him. And, in the end, we lost him. And so, because of that, we believe strongly that prevention is the ultimate answer. Prevention strikes at demand. Law enforcement strikes at supply. Prevention strikes at demand. If there is no buyer, there is no one for the seller to sell to. Prevention means that we have to take a good hard look at causation--things like pain as a vital sign. Pain is subjective. And, pain can be traced back to the beginning of this epidemic. We have to look at things like the Affordable Care Act and the payment structure that promotes prescribing because of patient satisfaction surveys. We have to be able to sever payment from pain. Prevention addresses the concepts of choice and consequence. And, it is going to allow us to escape this epidemic, and it is going to allow us to avoid the next one. To that, education is the cornerstone of a prevention strategy. Education will drive a critical change in culture. And, education will drive the change in the stigma that we deal with every day in society. Education has to be comprehensive. It has to be Kindergarten through 12th grade. It has to expand beyond just science in other classrooms and other curriculums. It has to extend to the teachers. It has to extend to the support staffs. It has to extend to the parents who are the missing link in this. We speak at schools all the time. And, what we hear is, we do not have the time, because we have standardized tests. We do not have the money. We do not have the resource. And, as a result, most of the schools that we speak in do not have comprehensive sustainable education plans. We have to educate across the spectrum. We have to educate in the communities. We have to educate in law enforcement. We still get mixed messages from the police department. Are the police departments in the arrest and prosecute mode or are they in the treatment mode? And, it is mixed in the communities. We only have 46 police departments in the State of Ohio that are carrying Narcan. And, I can tell you it is not because of just the cost. I have had police officers look me in the eye and tell me, we just do not know if we should save these people. We cannot miss our opportunity to educate at the point of origin, whether it is the point that the prescription is written or at the point of dispense at the pharmacy. We also have a 70 to 90 percent failure rate in treatment. And, that frankly is a support issue. As a society, we provide support for chronic diseases like cancer and diabetes and obesity. Yet with addiction, we do not have the necessary resources, nor the necessary funds to provide the support that is needed to sustain sobriety. And, as a result, we unknowingly continue to enable relapse. Support also has to extend beyond the addict to the family. We call addiction a family disease, yet we focus our treatment and our treatment dollars solely on the addict, while the families are at home enabling relapse, enabling addiction. So, the question really becomes is what can the Federal Government do to help us? And, in our opinion, we believe the Federal Government can help us not only create, but employ a comprehensive strategy. This is a national issue. And, you have a national perspective. But, more importantly than that, we believe that the Federal Government can help us move with the sense of urgency, a sense of purpose. The cost of addiction we measure in billions of dollars. But, the cost of addiction is not the dollars. It is the cost of the community, and it is the cost to the fabric of our families. We are going to lose 120 Americans today. We are going to lose 120 Americans every day until we move. And, we measure that statistic as well. See, that is not a statistic. But, those 120, they are moms and dads. They are brothers, they are sisters, and they are sons and daughters. And, that is what has to stop. Thank you. Senator Portman. Thank you, Mr. Brandt. I really appreciate your willingness to be here and channel your grief that you and your family have experienced into something so constructive. I am going to start with a question about these kids. And, Dr. Walsh, you talked about the fact that we need more research into what the long term effects are. Do you agree that we also need more research into how to try to avoid those long terms effects? In other words, although I know your neonatal unit here is at the cutting edge--one of the best in the entire world--I have also been at other hospitals that do not have that expertise, here, in Ohio. And, I know you have been generous to bring in babies from not just this region, but from around the State and, indeed, across State lines. But, what do you think needs to be done in terms of the research, first, to determine what the long term impact is, and, second, how to avoid these impacts? Dr. Walsh. Well, Chairman Portman, as usual you ask the salient question. The babies are the downstream. They are just the tiniest part of this horrible epidemic. And so, prevention is what it is all about. And, moving upstream to have more comprehensive treatment programs is, I think, the appropriate method. And so, using public health language, a primary prevention strategy through education in the schools. But, also then, if a woman has a substance abuse disorder, urging a life planning process, so that they avoid pregnancy while they are seeking treatment and in recovery. The research that we need on the infants, obviously, is long term. So, we need to understand how are they doing in early childhood and at school age. It is not difficult. Sadly, we have way too many babies in Ohio to be able to do this study. In the 18 months that we have been working throughout the State, we have treated over 4,000 newborns with opiates for NAS. And, another 4,000, who we were able to manage without opiate exposure. The bigger question that concerns me is that, if you have a genetic predisposition to addiction--and the baby shares those same genetics as the mom--are these infants then--have they been changed, in the womb, to even enhance that genetic predisposition? And, that is going to take even decades of research to be able to answer that question. Senator Portman. As you say, this is only, not, relatively, a new phenomenon--and it is overwhelming in our neonatal units. But, it is time for us to do this research, immediately, to be able to save these kids. So that they do not have to go to school unable to concentrate or to learn, which is some of what I hear, anecdotally, from some of the teachers--elementary school teachers--who are experiencing these kids coming into their classrooms. And, how do we help with that? Dr. Young, you talked a little about this. And, one of the things that has always concerned me is this coordination you mentioned in your testimony between child protective services and the neonatal abstinence syndrome. Just to be clear, because I am not sure I understand this, are child protective services (CPS) contacted when there is a child who comes out of the hospital and has been diagnosed with neonatal abstinence syndrome? Dr. Young. The Child Abuse Prevention and Treatment Act, it says that they are to. But, we know that there are vast discrepancies in how that is implemented. Last week was the first time that there were program instructions to ask the child welfare agencies to describe what their policies and procedures are once that referral is made. We have six States with the National Center on Substance Abuse and Child Welfare (NCSACW)--six States that we are working with, specifically, on this coordination between hospitals, obstetricians, child welfare agencies, the courts, and treatment agencies. And, we have detailed some of the reasons that obstetricians, in particular, and hospitals tell us, in terms of why those reports are not made. Two States--New Jersey and Virginia--are in the process of surveying all of their birthing hospitals in order to get a better handle on what those issues are, as to why infants are either not detected or not referred or not followed up with. So, there is a host of issues. And, I would be happy to follow up with some of those details from those States that we are working with. Senator Portman. We would love to see that data. CARA, as you know, authorizes and reauthorizes some programs in this area for pregnant women and postpartum women. And, I know you have been supportive of that. And, you have testified about that, and even in the Senate Finance Committee. But, it seems to me, this is an opportunity, I guess, to go past--to not just provide---- Dr. Young. Right. Senator Portman [continuing]. More of those services, but more research into those. Dr. Young. Right. Senator Portman. Because we have a real problem. And, I agree with what Mr. Brandt said about prevention and education. Again, I have been at this for many years. But, we have these kids. Dr. Young. Right. Senator Portman. And, they are moving their way through the system right now. Dr. Young. Correct. Several years ago, we looked at the independent living programs, because we know that these are kids that are at a substantial higher risk of developing their own substance use disorder. And, sadly, we did not find information about addiction, about being the child of a person with a substance use disorder in the independent living programs. So, I think foster youths tell us over and over, first I wish you would have helped my parent. And, second, I did not know what I was dealing with. So, much of what we are looking at when communities come together and actually try and work across these systems is parent/child interventions that address both of those issues. Senator Portman. Try to keep the child in the home, ultimately? Dr. Young. Keep the child in the home. But, also, after unification--or if they are at home--that the parenting class is a two generation program. That it is prevention for the child at the same time that it is a parenting program for the parent. And, if I could just follow up on the long term consequences. It is an area that I looked at pretty extensively, previously. And, most of the research would say that alcohol and tobacco are the two substances that have the most long term developmental consequences, particularly related to alcohol related neurodevelopmental disorders. So, when you hold those things constant, even the things that we thought were going to happen with cocaine and methamphetamine--and the prior research from the prior heroin epidemic in the 60s followed kids up to about 5 and 6 years old. And, when you controlled for those other substances, poverty and change in out of home placement, it does not look like there is an effect of that substance in and of itself. What we have to be mindful of are first substances and the neurodevelopmental effects of alcohol. And, second, what that postnatal environment is, and the continuity of care for the postnatal environment, particularly for kids who are placed in out of home care and the frequent changes in foster care placements. Senator Portman. That data is needed. I have heard this as well. That fetal alcohol syndrome has had more---- Dr. Young. Oh, yes. Senator Portman [continuing.] Evidence of long term---- Dr. Young. Oh, yes. Senator Portman [continuing.] Impacts on brain development. Dr. Young. We know that clearly now---- Senator Portman. Attention span and so on. Dr. Young [continuing.] From all the prenatal exposure studies that were done during the cocaine epidemic, in particular. Senator Portman. That might be a slice of better news, and the ability to really be able to---- Dr. Young. Right. Senator Portman [continuing.] Post-withdrawal to be able to get these kids in the right environment. Dr. Young. Correct. Senator Portman. And, to be able to make their lives full. Dr. Young. Right. Senator Portman. In a lot of bad news, that is the relatively better news. I have a couple other questions. But, I am going to ask Senator Brown if he would want to ask some questions. I know he has another commitment, as do all of you I am sure. But, again, thank you all for being here. I may come back for a second round. Senator Brown. Thank you. And, Ms. Metz, I loved your comment--not bad, not trying to get good, but, simply, trying to get well. Mr. Brandt, I think the real heroes in our society are those who have lost so much, as you have. And, we do not want that to happen to other families. And, you devote much of your life to that, so thank you for that. And, what you said about the satisfaction surveys in the Affordable Care Act, I am hopeful that with the new president next year that we can go back and begin to instead of having votes to repeal the Affordable Care Act or not, whichever side you vote, that we can actually go back and begin to make changes against. Anything that broad obviously has some shortcomings. And, that is, certainly, one of the things that we will look at, the satisfaction surveys and the impact that has on pain medication. Thank you. Mr. Brandt, what do we get wrong in our conversations about addiction? And, as you answer that, elaborate on some of the work you have done to help change that dialogue. Mr. Brandt. I think one of the biggest things we get wrong is this perception. We just had this conversation the other night. When you look at the news coverage of addiction--and it is on every day--what do we see? We see death. We see crime. We see arrests. And, it continues to paint the picture of these addicts as bad people--bad kids. And, they are not. These are good people. These are good kids that are being driven to these actions out of a sense of desperation--driven by a disease that they could not comprehend--that has changed their brain chemistry and that is driving this desperation. So, we create this stigma in society. And, as a result, it drives our perceptions. And, that is, I think, one thing that is critical. Then, the other thing is, again, it is cohesion strategy. It is parent involvement. I was at an event last night in a community of 10,000 people. About 200 plus people showed up-- really good showing. We had Drug Abuse Resistance Education (DARE) officers from multiple communities there. And, you know who was not there? Not one single representative from the schools. Not one. So, we lack some cohesion relative to our strategies. But, I think really one of the biggest deficits we have are the parents. We did a parents event in a community one evening. And, we had two parents show up. The next day we did the high school. And, nine kids went to guidance and asked for help. That is a disconnect. So, we have to do a better job of getting the information out. So, relative to the work we do, we spend a lot of time going into schools--whether it is elementary schools or high schools. And, we have a program for the schools that focuses on choice and consequence and information. We are working on sustainable messaging, because it cannot be one time hits. It cannot be once a year. So, we are developing posters, things that the students can do to have student leadership. We do the same thing with parents organizations. But, really our big focus right now is recognizing that we have a massive relapse rate. We have a massive relapse rate. So, we are in the process of jumping on board with the recovery communities and looking at a center for continued community, where we can allow recovering addicts to have a place to come where they fit, where they feel comfortable. They are not sitting at home alone. Where we can help them with that, secondary education, post secondary education, coping skills, goal setting schools, resume writing, dressing for interviews, interview skills. We want to get down the road to develop sober employees. And so, much of that is just linked to helping communities lift the stigma off through education. Senator Brown. Thank you. Dr. Walsh, thank you for the work you do at Rainbow--one of the great hospitals in the State. You have said something so obvious and so important--that we should avoid criminalizing pregnant women. What do we do to encourage pregnant women to get help? Dr. Walsh. So, through the Ohio Perinatal Quality Collaborative (OPQC), we worked with an advertising firm that only does public health messaging. And, we have created a number of informational pieces that are directed at the pregnant women and encouraging them to seek help. And, we have some messaging that we are partnering with the treatment programs, maintenance treatment programs to have that information there, and say, this is where you are entitled to free prenatal care. This is how you can sign up for Medicaid, for coverage. Because it is Medicaid that covers over 85 percent of these births. And, just reaching out to encourage them to get into care. The States that have made that criminal have seen about a 60 percent drop in the number of women seeking prenatal care. And so, now you have only the hit of substance exposure, but now you do not even have the routine prenatal care and prevention that any pregnant woman would have. And so, those babies are doubly affected. Senator Brown. Thank you. Dr. Kotz, as I have done these round tables around Ohio and listened to the--you heard people talk about the difficulty of getting access to treatment, both on the provider side and from the patient side--and especially the families--I, primarily, hear two things. One is that it is just a dollar figure--they cannot scale up enough. The other I hear is that the limit that Congress put on providers, on the number of patients they could have. That might have made sense a decade and-a-half ago, but does not make sense now. That is what we are trying to do with the Recovery Enhancement for Addiction Treatment (TREAT) Act. We hope we can fix that, particularly, in centers where they have had a history of providing care. And, doctors can go do more than 30 the first year and 100 the second and beyond. But, could you just--if you would give me your thoughts on what more do we do to address treatment options I would appreciate it. Dr. Kotz. I think it is a complex situation. And, I was at the Senate hearing that I think, in 2003, asked that the limit be moved from 30 to 100. The problem is that over half of the physicians in this country, who are waivered and eligible to prescribe, are not. And, that is based on several reasons. One, is that there are not behavioral services that are paid for to go along with it. And, the other thing is, for a primary care physician-- again, as I said, if they are to get involved with medication assisted treatment, like buprenorphine, they have to be able to, one, refer, which is not happening. And, two, they have to be able to be paid for the time that they are taking to do it. So, again, I think addiction treatment is terrifically underfunded. And, that is why there is such a huge barrier to access. My opinion in some of the professional national organizations I am involved with that have been working with the Federal agencies--there has to be a sensible number. The numbers that have been thrown out there, like one physician to be capped at 500, I think is going to lead to a lot more diversion. And, one--even one physician without an infrastructure cannot take care of 100 patients. So, when you are talking about increasing the cap or the limit, currently I think the Department of Health and Human Services (HHS) is--what they are proposing is increasing it to 200. I think that even a tiered approach, where if you are a physician that has an infrastructure with nurse practitioners and with counselors and behavioral services, then you could definitely take care of perhaps more than 100. But, if you do not have that infrastructure, then you are not really going to be providing evidence based care. So, I think there needs to be a reasonable approach to it. Senator Brown. I mean, that is the difficulty in picking a number. But, I mean, I have been to clinics, treatment centers around the State which clearly have the, as you say, the infrastructure to be able to do--if they had the dollars. Some do. Some have more than others. But, to scale up because they have all the ancillary services. And, that is a difficult way to write the law or regulation that way. But, we have to figure it out. Thank you. Senator Portman. Just a quick follow up on that. I think you are right, I think it is a complex issue. I was at a treatment center in Dayton, Ohio on Friday talking about this issue. It was a methadone clinic with some suboxone, so it was not one of these physicians. But, I think there is a concern about diversion. And they, as you know, take very careful steps at these treatment centers, including here in Cleveland, to avoid that diversion. But, there is plenty evidence of that happening. So, we do want to continue that, that discussion with you. And, it is not part of the legislation as a result. We do have a study on the issue of how many beds in a residential treatment center, which is another issue I think that needs to be addressed, and we need to expand that. But, the question is bringing in the extras--and that is something that again needs discussion. On medication-assisted treatment, you did not mention Vivitrol or the difference between, sort of, methadone, Suboxone, and Vivitrol--and what works and what does not work. Do you have thoughts on that? Have you had experience with Vivitrol? We have about 12 pilots around Ohio now. And, some of the drug courts are using it. And, from what they have told me, some have had very good experience. I have also been at round tables with recovering addicts who have acknowledged to me that they have used Vivitrol--and then used other substances--not opioids, but, specifically, cocaine--and it did not work for them. What are your views as an expert? Dr. Kotz. So, when I mentioned agonist, that included methadone and buprenorphine. And, the antagonist I mentioned was naloxone, which is the injectable form of Vivitrol. Senator Portman. Yes. Dr. Kotz. So, I think, Vivitrol is definitely a good alternative to agonist therapy. I think it should be used more widely. Again, a lot of it originally had to do with cost. The cost when I first started giving Vivitrol was $1,500. And, most insurances were not paying for that. And, more recently, payers have said that you have to fail oral naloxone before they will consider giving you Vivitrol. So, the preauthorization hassle is enormous. And, also, even the preauthorization for buprenorphine has gotten to be an enormous burden to prescribers. Senator Portman: Actually, I know that it is still considered more expensive. Although, when it is once a month as an injection--if it works--it could arguably be less expensive. And, the timeframe obviously the average time on methadone, for instance, is much longer than Vivitrol. But, on the other hand, it is new. So, we do not have a lot of experience. I appreciate your input on that. And, Ms. Metz, I know we are going to have a chance to talk about this later, and I look forward to seeing your work firsthand. But, this whole issue of Narcan has been talked about a lot today. And, as you know, naloxone, Narcan is a part of this legislation. In other words, not just the firefighters and our police officers, but your organization would benefit from some of the trainings and some of the grants to provide more immediate assistance to save lives. And, that is important. The one thing that troubles me--and I went to Kroger. They asked me to come for their announcement that Kroger was going to go to over-the-counter. And, all I asked them was, ``Well, what are you doing in terms of the consultation or providing people with some information on treatment options? '' Mr. Brandt talked about frustration he hears from some police officers. And, he did not say this, but I will tell what you they tell me, which is that, sometimes, they are administering it to the same person three, four, or five times. And, their thought is, ``How do you get the person into treatment? '' That, to me, is the good intention here. How do you actually shift from the safety net--we talked about the guy at McDonald's within a few miles from here. How do you get that person motivated to go into a program to get the treatment--to get the long term recovery that is needed? How do you respond to that? Ms. Metz. Sure. So, that is definitely a valid question. With regard to relapse, unfortunately, relapse is a part of addiction. So, if people do not survive their relapse, they could never have the opportunity to get into recovery. From my personal experience with this program for about 3 years, most of my patients actually end up saving their friends, who are also drug users. Sometimes I do see, maybe, some folks who have overdosed multiple times. But, most of my patients, when I see them, they are asking me, ``Where do I go for detox and treatment? '' And, that is information that I have readily available for folks. The problem is, the treatment waiting list for detox--for inpatient are months long. And so, we are going to expect people to continue to have an overdose. We want to make sure that they survive to get to that point. We also see folks who are getting out of inpatient treatment programs and are having a relapse almost immediately after getting out of treatment. Because, as Rob mentioned, some of our programs are failing our patients. The relapse rate from inpatient treatment is 90 percent. Now, that is a very high risk individual for overdose and overdose death, because they have no tolerance anymore. If it is heroin that they are going to have an overdose on--perhaps, it is heroin that they use when they have a relapse--but all too often it ends up being fentanyl. So, that is something that we are continuing to be concerned about. And, unfortunately, as I said, relapse is a part of this disease. With regard to our pharmacies, I was involved in actually training all of our Discount Drug Mart pharmacists, who are now carrying naloxone. It is mandated as part of the law for pharmacists to be able to furnish naloxone, that they go through the training similar to what we do. And so, one of the important things that I emphasize in that training is, you want to have all of these treatment resources available to folks. Because, especially with the syringe exchange patients I see, I might be their first entry into the health care system. They might never have been comfortable with asking someone for help. And, they see someone like myself who sees them as an individual and has that information available to them. So, I think that we are actually going to find more opportunities for folks when they go into the pharmacies to be able to ask for treatment. And so, they should be ready with that information. So, I hope that answered your question. Senator Portman. It does. And, I commend you for that. And, I am glad that in your training that, you help them to find the local treatment and detox center information. And, as you said, one of the big issues we have in Ohio is some of our detox centers do get filled up. Having, ridden with the police officers on this issue, from their perspective, that is their big issue often is that they do not have anyplace to send people. They do not want to arrest our way through this issue. On the other hand, they have to find a place for these people who they pick up who have overdosed. And then, if you are not doing what you are doing, which is to provide these options, I think we are really missing an opportunity. We talked a lot about teachable moments today. That is a teachable moment. And, I have talked to many recovering addicts, who have told me that is when it happened for them--when they overdosed--and two people told me they died. They literally feel like they died. And, I guess in some respects, medically, they might have. One guy told me he saw his father in heaven and came back. And, when he came back, that is when he finally decided he needed to seek treatment. So, I thank you for doing that. And, I hope that we will have a chance to see it today later, but I think that is really important to interact with their pharmacists. I have so many other questions. And, again, I will continue in touch with everybody here. But, just one final one for you, because you have mentioned this. I am not sure everybody picked up on it. But, to use Narcan in its normal dose for fentanyl is not always effective, is that accurate? Ms. Metz. Yes. The problem with fentanyl, because of its extreme potency, the onset of the overdose is quicker. So, overdoses can occur up to 2 hours or so after somebody uses an opioid with fentanyl. You hear of folks, unfortunately when we have lost our community members, you will hear the needle was still in their arm, something like that. That is a case when it is more likely that it is a fentanyl overdose. Because, literally, the person falls out into the overdose immediately. And so, the response time needs to be quicker. All too often in most cases, the dose of the naloxone must be increased. So, typically sometimes we will find that one or two doses of our two milligram intranasal naloxone might revive somebody who is having just a heroin overdose. We have seen people that need 10 doses of this medicine. Now, that is very important for our program, because we are already stretched in our funding. And, I have patients pretty much every day that I have decided this person is an extremely high risk, they should have more doses. We are at risk of running out of funds through our program now. If you think of a rural community, it takes a long time for the ambulance to get there, if a person is even willing to call 911. Because there is that fear of being arrested or being charged with a drug charge or maybe even being charged with manslaughter, that they supplied that drug to their friend or family member. So, it is an increasing concern for us. Senator Portman. Well, it is a new challenge. At least, it is a greater challenge than it used to be--particularly, here in Cleveland--and in other areas that have been specifically targeted with fentanyl. And, again, I thank all the witnesses. This is great information here today. I think we have learned two things. One, the comprehensive approach is the only approach. And, I appreciate the fact that many of you helped us get to this point on this one bill, CARA--into our communities quickly. It will help. It will help Emily. It will help Dr. Kotz and Dr. Walsh with what they are doing. It will certainly help Mr. Brandt in what he is courageously doing. And so, we have to get that done. But, then, there is more to do. And, funding has to follow. We did a good job in sort of providing evidence based grant making. But, now you have to have funding that actually follows it. And, I think that is going to be successful this year. But, we have to just keep the pressure on. And, as with every issue, again, I started working on this many years ago--the substance that is being abused will come and go--as is talked about by the experts here today. We tend to take our eye off of the ball. We will never solve the problem entirely. The tide continues to come in. And, to turn that tide requires consistency. So, I got that today, too. And then, finally, the sense that this is a crisis. This is not just we are talking theoretically about stuff we should be doing. This is stuff we have to do in order to save lives and repair our communities and get families back together. So, thank you very much for your testimony. Thank you University Hospital and all of us who are still here for allowing us to use this beautiful room, which will now become the official hearing room for the United States Congress. Thank you. This hearing record will remain open for 15 days until May 7 at 5 p.m. for the submission of statements and questions for the record. And, the hearing is adjourned. [Whereupon at 12:35 p.m., the Committee was adjourned.] A P P E N D I X ---------- [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]