[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
        
        
        
        
        
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                          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]      






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 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

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          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.
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    \1\ The prepared statement of Mr. Brandt appears in the Appendix on 
page 214.
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    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

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