[Senate Hearing 114-681]
[From the U.S. Government Publishing Office]
S. Hrg. 114-681
OPIOID CRISIS
=======================================================================
FIELD HEARING
before the
COMMITTEE ON
HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
----------
BORDER SECURITY AND AMERICA'S HEROIN EPIDEMIC: THE
IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND
PRESCRIPTION OPIOIDS IN WISCONSIN, APRIL 15, 2016
EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO,
APRIL 22, 2016
----------
Available via the World Wide Web: http://www.fdsys.gov/
Printed for the use of the
Committee on Homeland Security and Governmental Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
OPIOID CRISIS--2016
S. Hrg. 114-681
OPIOID CRISIS
=======================================================================
FIELD HEARING
before the
COMMITTEE ON
HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
BORDER SECURITY AND AMERICA'S HEROIN EPIDEMIC: THE
IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND
PRESCRIPTION OPIOIDS IN WISCONSIN, APRIL 15, 2016
EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO,
APRIL 22, 2016
__________
Available via the World Wide Web: http://www.fdsys.gov/
Printed for the use of the
Committee on Homeland Security and Governmental Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
U.S. GOVERNMENT PUBLISHING OFFICE
22-773 PDF WASHINGTON : 2017
____________________________________________________________________
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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
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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.
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\1\ The prepared statement of Senator Johnson appears in the
Appendix on page 47.
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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.
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\2\ The prepared statement of Senator Ayotte appears in the
Appendix on page 51.
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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.
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\1\ The prepared statement of Senator Baldwin appears in the
Appendix on page 49.
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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.
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\1\ The prepared statement of Mr. Bohn appears in the Appendix on
page 53.
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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.
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\1\ The prepared statement of Dr. Westlake appears in the Appendix
on page 61.
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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.
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\1\ The prepared statement of Senator Erpenbach appears in the
Appendix on page 86.
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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.
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\1\ The prepared statement of Representative Nygren appears in the
Appendix on page 91.
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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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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO
----------
FRIDAY, APRIL 22, 2016
U.S. Senate,
Committee on Homeland Security
and Governmental Affairs,
Cleveland, OH.
The Committee met at 10:13 a.m. in the Ruhlman Conference
Center, University Hospitals of Cleveland, 11100 Euclid Avenue,
Cleveland, Ohio. Senator Rob Portman presiding.
OPENING STATEMENT OF DR. SIMON, PRESIDENT OF UNIVERSITY
HOSPITALS CASE MEDICAL CENTER
Dr. Simon. Good morning. My name is Dr. Dan Simon. I am the
president of University Hospitals (UH) Case Medical Center.
Welcome to Ohio and to the flagship hospital of the University
Hospitals system.
On behalf of our Chief Executive Officer (CEO) Tom Zenty,
our senior leaders, our 26,000 doctors, nurses and employees
and the community we serve, we are honored to host this
important hearing.
We are grateful to the U.S. Senate Committee on Homeland
Security and Governmental Affairs (HSGAC) for confronting the
opioid crisis.
I would like to thank Chairman Johnson and Ranking Member
Carper for their leadership on the Committee and their staffs
for being here this morning.
I would also like to thank our fine Ohio Senators Sherrod
Brown and Rob Portman for honorably representing Ohioans in
Washington.
We were privileged to host Senator Portman for a round
table event last January to discuss his legislation, the
Comprehensive Addiction and Recovery Act (CARA). We are pleased
that it passed the Senate and hope for speedy consideration in
the House.
Thank you for your strong leadership on a very complicated
issue.
Now I would like to turn things over to Senator Portman.
OPENING STATEMENT OF SENATOR PORTMAN\1\
Senator Portman. Dan, thank you very much. I appreciate
that. And, I am now going to officially call this hearing to
order.
---------------------------------------------------------------------------
\1\ The prepared statement of Senator Portman appears in the
Appendix on page 139.
---------------------------------------------------------------------------
I appreciate everybody being here. This is a distinguished
group of Cleveland area citizens and a really distinguished
panel, two panels, in fact. We look forward to hearing from
them in a moment.
This is a critical hearing, because it is an opportunity to
draw attention to an issue that all of us face in the State and
in our country, which is this epidemic of opioid addiction and
overdose prescription drugs and heroin.
It has devastated communities here in Ohio. It has torn
families apart. But, this is happening all over the country.
And, as we will talk about in a moment, the fact that our
legislation called the Comprehensive Addiction and Recovery Act
passed with a 94 to 1 vote in the United States Senate, which
never happens, which is evidence of that. I do look forward to
the expert testimony we are going to receive today.
And, Dan is right, I was here in this very room in a round
table discussion where I learned about some of the expertise
that resides right here at University Hospital and also at our
other great medical institutions in town. And so, we thought
this would be an appropriate place to hold this hearing.
It also happens to be a beautiful room for a hearing. You
may find many Congressional hearings now coming to this room.
[Laughter.]
The staff is here from the offices of Chairman and Ranking
Member and they are equally impressed. So, I think they may
want to come back, if you will offer it for free. [Laughter.]
I want to thank Sherrod for being here. Senator Brown and I
have worked on this issue together, as we have on so many other
issues for the good of Ohio.
And, this is one that crosses every line. There is no zip
code that is immune from it. It also crosses every party line.
We have really tried with the CARA legislation over the
last 3 years, as we developed it, to make it not just
bipartisan, but nonpartisan. It is not caring where the ideas
come from, but if they are good ideas, to try to promote them.
And, it is urgent. Every day we lose 120 Americans to drug
overdoses. Think about that. 120 people lost every day. The
rate of overdose over the last 14 years has doubled, leaving
about a half a million Americans dead from overdoses.
And, the tragedy of a death from overdose, as terrible as
it is, tells only part of the story. And, many people in this
room are working on this issue every day and understand what
that means.
But, it is about the families being torn apart. It is about
that drug being more important than anything, whether it is
family, work or faith. It is about communities being impacted
dramatically.
When I talk to prosecutors in Ohio, they think by far most
of the crime in their communities are connected directly to
this issue. It is about individuals getting off track and not
being able to pursue their God given purpose in life.
So, it is horrible that people are dying from drug
overdoses. But, sometimes I think we forget this broader issue
that is affecting everybody.
It is hitting us especially hard here in Ohio
unfortunately. We are probably they say one of the top five
States in the country, maybe the top State now, in fentanyl, at
least heroin overdoses.
So, it is something that is appropriate for a hearing, to
raise the visibility of it, and you get extra testimony.
I do not think it is getting better. And, we will hear from
witnesses today about this. But, there is a troubling report
this last week about a survey that was taken. It is called the
Ohio Issues Poll. In 2014, they reported that two out of every
10 Ohioans knew someone who was abusing prescription drugs. In
the latest poll, it is 3 out of 10. And, out of those 3 out of
10, 4 in 10 know someone who had overdosed.
Sherrod and I were talking earlier at a town hall meeting.
I asked how many people have been affected, friends or family,
and half the hands in the room go up. And, people look around,
and they cannot believe it. They cannot believe that others are
experiencing it, too.
Because there is not enough discussion about it. There is
too much stigma attached to addiction. And, it is a disease.
And, it is treatable. And, one of the problems in getting
people into treatment is to break down that stigma, which I
think is part of the reason this hearing is important.
By the way, about 5 of those 120 persons dying every day
are dying in Ohio.
As Sherrod talked about earlier, drug overdoses have killed
more Ohioans than car accidents, actually every year in Ohio
since 2007. Overdose deaths have tripled from 99 to 2010.
We were told that 200,000 Ohioans now are addicted to
opioids. 200,000. That is roughly the size of the city of
Akron. We do have 20,000 overdoses a year. Several thousands
will probably lose their lives again this year.
So, I do not think it is slowing down. I do not think we
have any time to waste.
The U.S. Senate response has been this Comprehensive
Addiction and Recovery Act--again it passed by an overwhelming
vote. I think it is a critical step in the right direction. It
was not just 3 years in the making. We had five conferences in
Washington.
A number of the experts you will hear from today actually
came and testified or talked to us on this legislation. I want
to thank them for that.
Local Ohio happens to have a lot of smart people who are
experts in this area. We also just have a big problem here in
our State.
We made it bicameral from the start. So, it was not just
not partisan, it was the House and the Senate working together.
We actually introduced identical legislation.
And, the House bill, the CARA legislation in the House, has
120 plus cosponsors. So, the one reason that we believe that
the House can act quickly is because they have been working
with us for 3 years. We did not just take Senate ideas. We took
House and Senate ideas and more importantly ideas from experts
around the country. And, they do have over 120 cosponsors.
So, we are urging them to simply pass that legislation, get
it to the president who will sign it and get it to our
communities where it will begin to help immediately.
Are there other things we should do? Of course. And, we
will hear some about that today. And, should they pass
additional legislation? Of course. Should there be more
funding? Of course.
All of these things can and should happen. But meanwhile,
let us get this specific response, it has passed the Senate,
through to our communities.
The House did move on some small bills earlier this week,
and I applaud them for that.
By the way, 3 of the 12 bills are identical to CARA,
language identical that is in the CARA legislation. So, again,
we can work with the House on additional ideas. Well, let us
pass CARA now.
Cleveland is one of the regions in Ohio that has been hard
hit. The statistics are heartbreaking, and they are a call to
action for all of us.
There is some city council members here. The city medical
director is here. There are members of the Cuyahoga County Task
Force who are here. You all have been in the middle of this.
But, as some of you know very well, from March 10, the day
that the Senate passed CARA, March 10, until March 27, 29
people died of overdoses. That is one 17 day period in one
city. One long weekend, 12 people died, fentanyl-laced heroin.
And, we will hear some about that later today.
Attorney General (AG) DeWine has been involved in this
issue as well with regard to fentanyl. And, I know the Drug
Enforcement Administration (DEA) is here with us today. We
appreciate you all being here. We have other law enforcement
folks from the High Intensity Drug Trafficking Area (HIDTA)
folks. And, we had a hearing on fentanyl this week in
Washington. It is one of those issues that has unfortunately
really hit Cleveland hard.
By the way, of the 12 people who died, they ranged in age
from 21 years old to 64 years old, white, African-American,
rich, poor. This knows no boundaries and certainly no zip code.
As we talked about, it is not just a Cleveland inner-city
problem. This is a problem in our suburbs and our rural areas.
In fact, per capita use in the rural areas may be greater.
Fentanyl, again it is 100 times more potent than heroin.
And, depending on the dose of fentanyl and how it is produced--
it is a synthetic drug.
We had five people die in Cleveland from fentanyl in 2013.
A 700 percent increase in 2014. More than doubled the next
year. This year, probably doubling again.
So, we are just on a steep climb. I am looking at the
medical director who has to deal with this every single day.
Last month, as some of you know, in Fairview Park, not far
from here, you had a man overdose at McDonald's. And, it was of
course immediately online and went viral.
Luckily, someone was there administering Narcan to save his
life. But, there were kids there. And, this is increasingly
happening in public places and in broad daylight.
We have learned a lot here in Cleveland over the last few
years, again speaking with advocates, doctors, patients. I have
had an opportunity to tour Rainbow Babies and Children's
Hospital here and see the incredible work that doctors and
nurses are doing. What compassion they have for these kids who
are born with addiction.
750 percent increase in babies born with addiction in the
last 12 years in our State. Whether it is at St. Rita's
Hospital in Lima or whether it has been nationwide or
Cincinnati Children's Hospital, it is the same story.
And, we will hear about that today from some real experts,
talking about how we can ensure that this Neonatal Abstinence
Syndrome (NAS) can be addressed both in terms of prevention,
education, but also with effective treatment.
Effectively these nurses and doctors take these babies, of
course, through a withdrawal process. And, the long term
consequences to these children we will hear more about today,
but it is very difficult to know. It is such a new phenomenon.
And, of course, that concerns all of us.
So, I think Cleveland has a lot to teach the country about
how serious this threat is, as well as effective prevention and
treatment ideas. And, that is why this hearing is important.
Again, there is a lot to do in addition to the
Comprehensive Addiction and Recovery Act. And, we should
continue to listen to the experts as we develop our ideas,
because this issue is just too important not to.
I do think today we will hear from some really important
testimony from some really compassionate and gifted people who
work here in this facility and experts in the field. I look
forward to hearing from them.
We also have a statement that I want to enter into the
record from Senator Johnson, who is the chair of this
Committee,\1\ from Senator Ayotte,\2\ and also testimony that
has been submitted by Dr. Jason Jerry, who is with us this
morning from the Cleveland Clinic.
---------------------------------------------------------------------------
\1\ The prepared statement of Senator Johnson appears in the
Appendix on page 145.
\2\ The prepared statement of Senator Ayotte appears in the
Appendix on page 146.
---------------------------------------------------------------------------
Where are you, Doctor? There he is.
Thank you and thank you for the Clinic for being here.
I also want to thank the staff from Senator Johnson and
Senator Carper. Senator Carper is the ranking Democrat on the
Committee--his staff is here as well--for helping not just put
this together, but also for being here and helping us
substantively to pull information out of this hearing to use it
for legislation.
And, again, I want to thank Senator Brown for his
participation in this hearing today and for his passion for
this issue. He has been involved all over the State and had
hearings all over the State or round table discussions all over
the State.
And, again, it is an issue that, as he will talk about,
affects our entire State. And, therefore, we have to work
together to solve it.
Now, I will turn it over to Senator Brown for his opening
statement.
OPENING STATEMENT OF SENATOR BROWN\3\
Senator Brown. Thank you, Rob. Thank you, Senator Portman.
Thank you to UH, Dr. Simon, and all of you.
---------------------------------------------------------------------------
\3\ The prepared statement of Senator Brown appears in the Appendix
on page 142.
---------------------------------------------------------------------------
It took Rob Portman coming to my home town to get to do
something in this room. I have never been in this room.
[Laughter.]
I have been to UH like 25 times, including visiting family
members----
Senator Portman. They never let you in.
Senator Brown [continuing]. Doing hearings and doing
discussions and past conferences. But, it took the other guy to
come in town to get the use of this room. So, thank you, I
appreciate that.
And, I thank Senator Portman to allow me to be at this
hearing. Because I do not sit on this Committee in Washington.
And so, I am kind of an honorary member or something today
sitting in. So, thank you for that.
And, to Senators Carper and Johnson and their staffs, thank
you for arranging this, for the room and the witnesses, and the
second panel especially too.
Rob talked about this upcoming a couple of times. And, if
you look out this window, you will see zip codes that have some
of the highest infant mortality rates in the country, and
certainly in the State and maybe in the country.
You will see some of the highest foreclosure rates in the
country. The zip code my wife and I live in, 44105, south of
Slavic Village, had more foreclosures than any zip code in the
United States of America in 2007.
So, this is a public health crisis--opioid addiction--as so
many of these other things are--and how related they are.
As Senator Portman pointed out, this is not a city problem,
this opioid addiction.
I first started hearing a lot about this when I came to the
Senate in 2007, and especially in places like Adams and Brown
County of the Ohio River. Attorney General DeWine has been
working on this a long time, a lot of us have.
And, it started off with Oxycontin and oxycodone and
Percocet and Vicodin and legally prescribed drugs. And, it has
spread obviously.
And, we know that addiction--when you think about
addiction, and you think about the biases and the prejudices
people have about addiction, years ago addiction, when it was
confined to certain areas and certain cities, look out this
windows, it was considered a character flaw or it was
considered an individual problem. We know it is not.
We know addiction is--some people are just more predisposed
toward addiction than others. We know it is not a character
flaw. It is not a personal problem. It is an illness. And, it
is a chronic disease. And, that is why this hearing is so very
important.
Fundamentally--and I want to thank the people. I did not do
this. I thank the people in this room who are some of the best
activists, as Rob has pointed out, some of the best activists
in our State fighting against this.
The numbers are just overwhelming. The availability is
amazing. I have done, as Rob said--and he has, too--I have done
round tables, town halls all over the State.
I remember one in Southern Ohio. I said, how easy is it to
get heroin? They said, you know where the McDonald's is out on
Route 23? I said, yes. They said, go out there. Walk around for
3 minutes, and you will be able to buy some.
We know what a round table I did in the Mahoning Valley--
the Youngstown area. A woman, affluent, she said because of the
money her family had, they could keep their son alive.
He was addicted at 14, because he went into the--I think,
if I recall, they were taking care of their grandmother, as I
did with home care and my brothers did some 10 years ago in
Mansfield. And, there was morphine in the cabinet, because they
were helping her be comfortable in her last months or last
weeks and even last days. And, their 12--14 year old son began
to take the morphine. And, he has been addicted in and out
treatment for 12 years.
And, she talked about the family is just turned upside
down, because this son has siblings. And, they are not getting
the attention that they deserve and they demand and the parents
and all the things that happen.
So, we know how excruciating this is in every city, county,
inner-ring suburb, more far flung suburbs, every county in the
State. And, that is the importance of what we do.
But, the other thing that really came through to me on this
is how every community is crying out for dollars to help us on
this. And, we cannot get Congress to--neither the State nor the
Federal Government has come up even close to the dollars we
need to scale out these programs.
Almost every community in the State, people have come
together. They are very good, as Rob said earlier today, they
are very good not for profits. They are very good county-
funded--all the different ways we fund treatment. Those exist.
But, none of them can scale up without a lot of help from
Columbus and Washington.
And, when you think--because nobody predicted this opioid
epidemic to explode the way it did. So, no community is
prepared to scale out. It just does not have the resources to
do that.
And, that is where we come in. CARA, the work that Rob has
done, is very important and impressive with CARA. We need to
get it through the House. He is working on that. We are all
working on that.
We also though need Senator McConnell to begin to support
much better funding. And, we need the Governor and the
legislature to support much better funding. You just cannot do
this on the cheap.
The reason though I am optimistic is, I have seen what our
country has done in public health for generations. So, it was
our country that led the eradication of small pox, where
hundreds of millions of people in the 20th Century died of
small pox. It is pretty much eradicated.
Look what we did with polio in the 1940s to 1950s--1930s,
1940s, and 1950s to eradicate polio in this country and most
places around the world, almost every place. What we did with
Ebola 2 years ago. When the alarmists in our country said,
``thousands of people are going to die from Ebola.'' Well, do
you know how many people died from Ebola--contracted in the
United States and died here? Zero.
We are facing the public health threat of the Zika virus
now. We are accelerating the research for vaccine and an
antiviral for cure, for vaccine and cure. And, this is, at
least for us in this State, an even bigger public health threat
with opioid addiction.
So, we have risen to the occasion as a community, as a
Nation. I think we will today. This hearing that Senator
Portman called is a step toward that. Thank you.
Senator Portman. Thank you, Sherrod, great points.
We will now go to our first panel. And, we are going to
discuss here the Federal, State and local collaboration to
combat opioid addiction. We have three really distinguished
panelists.
First, we are going to hear from Attorney General Mike
DeWine. As I said earlier, Mike DeWine has been a leader on
this issue, not just focusing on the law enforcement side of
it, which you might expect from an attorney general, but also
on the prevention side and the community outreach. He is also
going to talk about fentanyl and his effort to prevent drug
abuse.
Next, we are going to hear from Carole Rendon. Carole is
the acting U.S. Attorney for the Northern District of Ohio.
She's gone well beyond the call of duty to actually lead the
task force here in Cleveland on opioid addiction. And, I thank
her for that and her continued passion.
She is going to talk about strengthening partnerships
across government to address this problem in her role as part
of the task force.
Finally, we are going to hear from Tracy Plouck. Tracy is
the director of the Ohio Department of Mental Health and
Addiction Services (MHAS). She was a key resource as we
developed CARA, as you can imagine, as one of those people I
talked about earlier from Ohio who actually gets it and has a
lot of expertise on the ground.
She is going to talk about what the State has done to
expand addiction treatment, including efforts to respond to the
Neonatal Abstinence Syndrome (NAS) we talked about earlier, the
addicted babies.
So, with that, I would ask all three witnesses if they are
willing to stand, please, we can swear you in.
Please raise your right hand. Do you swear the testimony
you will give before this Committee will be the truth, the
whole truth and nothing but the truth, so help you, God?
Mr. DeWine. I do.
Ms. Rendon. I do.
Ms. Plouck. I do.
Senator Portman. Excellent. Let the record show that the
witnesses all answered in the affirmative. And, with that,
again thank all three of you for being here.
And, Attorney General DeWine, thank you for your passion
and expertise on this issue. We would like to hear from you.
TESTIMONY OF THE HONORABLE R. MICHAEL DEWINE,\1\ ATTORNEY
GENERAL, STATE OF OHIO
Mr. DeWine. Mr. Chairman and Senator Brown, thank you for--
not just for doing this hearing today, but thank you for your
long time focus on this particular issue. You have traveled the
State, both of you have traveled the State extensively and
really I think understand what this problem is all about.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. DeWine appears in the Appendix on
page 148.
---------------------------------------------------------------------------
You mentioned, Chairman, about fentanyl. There is just one
statistic. In 2015, in our crime lab, it was brought in to us
and we dealt with, the amount of fentanyl that year was--
exceeded what it was in our labs for five previous years
combined. And, this year, 2016, we are seeing it go straight up
as well. So, there is absolutely no change in that.
The number of deaths, we all cite statistics. I do not
think we know exactly how many people we are losing in Ohio. I
would simply say this. That if it was not for naloxone and
Narcan, those numbers would just be much worse.
And, what that tells you though I think is it is not just
the deaths. It is the families that are destroyed, the moms and
dads who get up every day and worry about their kid all day
long, because their child is now in the 22nd day of recovery,
and they do not know how long that that is going to last.
You are absolutely correct, this is a very different drug
epidemic. I started looking at the drug problem when I was an
assistant prosecuting attorney in the 1970s. This is very
different. It is everywhere. It is the rural areas, cities, and
suburbs. The face of heroin is really the face of the State of
Ohio. And, it does cover every single demographic group.
I do not really know why we are seeing this huge problem.
But, I will note two things that I think are significant that
have come together.
First of all, the marketing of heroin is fundamentally
different than it has ever been before. They are much more
sophisticated. It is much more user friendly or consumer
friendly.
Poppies are grown generally in Mexico. The heroin is made,
processed in Mexico. It comes across our Southern border. It
comes into Ohio and other States.
And, the groups that are selling it really use what I call
the pizza delivery system. It is very similar. The price is
about the same, and you can get it just about as quickly as you
can get a pizza. It is $10. It is $15. Sometimes they will give
it away, because they want to get someone hooked.
It is a perfect business model, because you start off at
this level of heroin for $15 a day. In 6 months or a year, you
may be clear up here. Some doctors have told me the ratio could
be as high as 100 to 1. So, what starts as a $15 a day habit
can be a $1,500 a day habit.
Thus the comment by almost every law enforcement officer
that we see around the State of Ohio, that 80, 90 percent of
the crime in the county, every county, is due to this
particular problem.
The second thing that I think is different today is we have
a culture problem. And, I think we can do something about that.
When I was a county prosecuting attorney, you would, after
a while, you would sort of get to know the drug dealers in your
county. You would arrest them. And, some of them you got almost
on speaking terms with.
And, after we would arrest someone, I would ask them, what
drugs are you selling? Or in some cases with the user, what
drugs are you using? And, they would mention a number of
different things.
But, if I would ask, well, what about heroin? The answer
would be, no, I am not crazy. I do not do that. That is other
people. We do not do that. I do not put that needle in.
There was some psychological barrier that was there. That
psychological barrier for whatever reason is just down. It is
gone. And, we have to culturally resurrect that.
We cannot arrest our way out of this problem. What we do in
law enforcement--we work with this every day. We have a special
heroin unit that works with local law enforcement on the law
enforcement side, the investigation side. But, we cannot arrest
our way out of this problem.
I want to compliment you, Senator Portman, for the CARA
Act, and, you, Senator Brown, for your work in support of it.
This takes a holistic approach. I think we have to have a
holistic approach. We have to have education. We have to have
prevention. We have to have treatment. And, we have to have the
law enforcement side.
Let me just mention a couple things. The bad news is the
nature of this problem and how bad it is and how horrible it
is.
The good news is we are starting to see some maybe not
progress in the numbers, but we are starting to see some
communities that have figured out how to fight back.
When we first started looking at the pain med problem, one
of the things I noticed was that the communities that who were
starting to make progress in this area--and I think this still
is true as well for heroin--are communities that have come
together, pulled together.
It is usually led by a mom, sometimes a dad, but usually a
mom of someone who has died, a boy, girl who has died. And,
they sort of rise up in the local community.
And, the ones that work involve the business community.
They involve the faith based community, the churches. They
involve law enforcement. They involve education. And, they have
to come together.
I was so impressed by this model, that a few years ago we
put together a small group in our office. We now have six young
ladies who work every single day to work with local communities
to try and help them. Not to tell them what to do, not to
tell--every community is different. But, rather to share what
other communities have done.
And so, I always mention that in any group. And, we have
many times people who will take us up on it. Again, we do not
pretend to be experts. But, what we do know is what is
happening in other places in the State and what works.
So, I would encourage us to look at this from the local
point of view. Those of us at the Federal level and those of us
at the State level, we can help.
Ultimately, we are not going to solve this problem. We can
help. We can help give people resources. We can help give them
ideas. But, ultimately, it is going to have to be done at the
individual community level, which is why I put this group
together.
Let me mention a couple other places. Sheriff John Tharp,
the Sheriff in Lucas County, has a program that we have
partnered with him. He came to me over a year ago and said, ``I
have an idea.'' And, I thought he was going to talk about law
enforcement. And, he said, ``No, that is not what I am taking
about.''
He says that we have to get people into treatment more
quickly. And, we have to, once they are in the treatment, make
sure they stay in treatment.
And so, what the sheriff has done with the help of local--
some local money and some money that we gave him, he has a
program that is over a year old now, and we begin to see some
real results, where they will go out--if the emergency room is
ready, when the emergency room has somebody who comes in and
actually survives an overdose, the sheriff is called. The
sheriff has a very small unit of dedicated people. They move.
They come out.
One individual will come and see the family and see the
addict and see if maybe that is a teachable moment. See if that
addict is ready at that point. And, if they do, that sheriff's
deputy becomes really the advocate or the sponsor of that
person.
I talked to a few of the addicts who were recovering in
this program a few weeks ago in Lucas County. One recovering
addict pointed over across the room to the sheriff's deputy. He
said, ``Do you see that sheriff's deputy over there? '' And, I
said, ``Yes.'' He said, ``I call him five or six times a day.''
I said, ``Why do you call him five or six times a day? '' He
said, ``I have to in order to get through the day. But, he has
always been there for me.'' He said, ``Without him, I would not
still be in recovery. I would have relapsed.''
So, there are programs out there. Senator Portman, down in
your area, Colerain Township, they have a similar program that
is going on. So, I think there is a lot of very good things
that are going on.
I do not think we can forget education. As a country, we
have to do more in the area of prevention and in the area of
education.
I was on President Reagan's National Commission on Drug-
Free Schools when I was in the U.S. House of Representatives in
the 1980s. A little different in some ways and in some ways the
same--a drug problem.
The one that every expert who came in on education and drug
prevention said to us is, you have to do something every single
year. You have to start in kindergarten. You have to have
something that is age appropriate. And, you have to go all the
way through the 12th grade.
And, if you think you are going to do something in the
fifth grade and the ninth grade, and that is all you are going
to do, I suppose that is better than nothing. But, it is not
going to really get the job done.
So, I think we have to kind of rethink how we are
approaching this. We cannot put all the burden on the schools.
But, we have to figure out some way, so that young people are
getting the information they need in something that has been
tested and we have data behind that it actually works as far as
prevention.
I was in Boardman a few weeks ago and talked to school
officials. They have a program there they are just starting.
They took a program basically off the shelf. They bought it, a
proprietary program. They have inserted it into kindergarten
all the way through 12th grade. And, they are just starting it.
They actually put it into their science program. So, they work
with their science teachers.
So, it is a way maybe to get around the problem that we are
always looking to schools to do everything. Well, let us figure
out how to put that in. They do it through their science
classes. It is basically nine periods a year, in kindergarten
all the way through 12th grade.
It will be a long time before we have the data. But, I
think it looked very promising. And, I think that is something
we need to look at in other communities.
Again, thank you both very much for holding this hearing.
It is very important.
We have looked at the members of the panel, and we have
looked at the people in the room. Mr. Chairman, as you said, we
have a lot of great talent here.
So, thank you for giving me the opportunity to talk about
what I see, how I see this problem, at least from the Attorney
General's view.
Thank you.
Senator Portman. Thank you, Attorney General DeWine.
Acting U.S. Attorney Rendon, we will hear from you.
TESTIMONY OF CAROLE S. RENDON,\1\ ACTING U.S. ATTORNEY,
NORTHERN DISTRICT OF OHIO, UNITED STATES ATTORNEY'S OFFICE,
U.S. DEPARTMENT OF JUSTICE
Ms. Rendon. Chairman Portman and Senator Brown, thank you
so much for the opportunity to discuss how we here in Northeast
Ohio are addressing the heroin, opioid and fentanyl overdose
epidemic that we are all experiencing.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Rendon appears in the Appendix on
page 151.
---------------------------------------------------------------------------
Here, in Northeast Ohio, we have a really innovative
program. It is the Northeast Ohio Heroin and Opioid Task Force.
And, if you look out into this room, you will see many members
of our task force from all different walks of life, all working
together to help to solve this problem.
The rise of heroin and fentanyl and the misuse of
prescription opioids threatens our communities, our families,
our safety. And, these things are all interrelated and they
have to be addressed together. And, that is why the Department
of Justice (DOJ) and the Administration are working closely
with our Federal, our State, our local law enforcement officers
to fight this growing epidemic through a combination of
enforcement, prevention, education and treatment. It is truly a
four legged stool, and without any one of those legs, the stool
will not stand.
And, this is truly a crisis in Northeast Ohio. We have
heard a little bit of some of the statistics. But, let me fill
you in on what we are seeing here in Cuyahoga County, and with
thank you to our Medical Examiner, who I have to tell you was
the first person to sound the alarm on this epidemic here in
our county. So, heroin overdose deaths increased in Cuyahoga
County by more than 400 percent between 2007 and 2012, when 161
people died of heroin overdoses. But, sadly, the number of
heroin overdoses has increased year by year. And, recently, it
has gotten dramatically worse with the introduction of
fentanyl, which, as you mentioned, Chairman Portman, is
incredibly potent and extremely deadly. So, according to the
Cuyahoga County Medical Examiner, while there were only five
overdose deaths in 2013 attributable to fentanyl, in 2014 that
number rose to 37, and last year it was 91--91 overdose deaths
attributable to fentanyl or a combination of heroin and
fentanyl.
And, last year 228 people, just in Cuyahoga County, died of
an overdose of either heroin or fentanyl--or a combination of
the two. And, this year we have already seen 125 fatal
overdoses in Cuyahoga County, and it is only April. So, the
devastation that this is wreaking throughout our community
cannot be overstated.
But, the crisis is not limited to Cuyahoga County. So, as
you know, there are 40 counties in the Northern District of
Ohio. And, we are seeing waves of overdose deaths everywhere in
our district; Lorain, Summit, Stark, Lucas, Marion. It is
everywhere throughout the Northern District of Ohio.
And so, faced with this crisis, what we did is we assembled
this task force. And, it brought together a wide diverse group
of stakeholders to identify and implement comprehensive
solutions to this growing crisis.
And, in 2013, we held a summit to focus on the heroin
epidemic. We had more than 700 people at that summit from all
walks of life, from all aspects of our community; treatment
providers, doctors, parents who had lost children, law
enforcement, across the board.
The result of that summit was the creation of a heroin and
opioid community action plan. And, let me emphasize the word
community action plan.
This is the plan that guides the work of our task force.
And, it addresses the heroin and opioid crisis from four
different perspectives; law enforcement, health care policy,
education and prevention and treatment.
I want to take a minute just to highlight a few of the
successes we have had, because the news is all so grim. But,
there have been some successes, and they are worth noting.
So, law enforcement. We created a heroin involved death
investigation team. And, what this is, is a group of dedicated
law enforcement officers who roll out to every overdose scene.
And, they treat it like what it is, a crime scene, and they are
there to gather evidence that we can then use in our criminal
prosecutions.
To date, the United States Attorney's office has brought
nine death specification indictments, which carry a 20 year
minimum mandatory term of incarceration for the dealers who are
killing people in our community. And, there have been a dozen
more manslaughter cases brought in the State court system,
because we partner, of course, with the attorney general and
all of our local county prosecutors.
Health care policy. So, members of the task force, many of
whom are sitting in this room, have worked to increase the
physicians' use of the Ohio Automated Rx Reporting System
(OARRS), which is the statewide prescription drug monitoring
program. And, they have helped to develop really important
increased training and education for doctors about the dangers
and the unintended consequences of over prescribing opioids.
And, I will note that a recent Centers for Disease Control
(CDC) report showed that the total doses of opioids prescribed
in Ohio decreased by 11.6 percent from 2012 to 2015, in no
small measure as a result of the work of the members of our
task force.
Education and prevention. Members of the task force have
organized town hall meetings and presentations at schools and
with labor unions and community organizations throughout
Cuyahoga County. And, through this, task force members have
reached literally thousands of people. And, they have also
spearheaded two significant media campaigns to raise very
importantly awareness of this crisis.
And then, finally, last but not least, I am looking at Dr.
Jerry, treatment. So, the task force members have led the
effort to expand the availability of the opioid overdose
reversal drug naloxone to first responders and relatives of
those who have substance use disorders. And, that work has
literally saved hundreds of lives.
And, they are continuing that work, while also addressing
what you mentioned, which is the critical shortage of treatment
facilities in our District and throughout the United States.
These efforts, in my opinion, they are an incredible
example of what we always talk about in the Department, a
multi-faceted approach, that really is what we mean when we
talk about being smart on crime. And, our task force, because
of its success, is now a model that is being replicated at U.S.
Attorney's offices all across the country.
But, while we have had some successes, we are keenly aware
that this problem just continues to grow and get worse by the
day. And, it is morphed, as we have discussed, from painkillers
to heroin to now an incredibly deadly new drug, fentanyl.
And, as you have noted, Chairman Portman, we cannot arrest
our way out of this problem. But, we have to aggressively
prosecute the drug dealers who are bringing this poison into
our community. And, we have to find a way to choke off the
supplies of the drugs into our community.
And, of course, simply getting treatment for everyone who
has suffered through addiction, that is not going to solve the
problem by itself either.
But, given the number of people who we know are already
addicted to opioids in our communities, we have to find a way
to make treatment readily available to those who need it.
And, of course, changing prescribing practices alone, that
is not going to curb the problem either. But, we have to start
impacting the way that doctors are prescribing opioids.
And, we have to address the underlying incentives that
cause that to happen in the first place.
And, education is critical. And, that is why the
Administration is now championing a practice that requires
people who are seeking a DEA registration to get specifically
trained on prescription opioids and the dangers and the need to
carefully prescribe.
And then, finally, every one of us has to continue to talk
to our children, to our friends, to our colleagues about the
dangers of opioids. Because no one is immune from this threat.
As you mentioned, Chairman, Senator Brown, opioid addiction
knows no boundaries. It is an equal opportunity killer of men
and women, young and old, city, suburban, rural, wealthy and
poor, white, black and Hispanic. It is everywhere. And, it is
killing people in our community every day. We are all at risk.
And, you mentioned, Senator Brown, Ebola and the Zika
virus--sometimes I wonder if people were dropping dead at this
rate of Ebola or Zika, how would we all be responding? And,
would it look like the response that we are seeing to this
crisis? And, if not, why not? How do we get to the stigma that
underlies our failure to address this crisis with every single
tool in our tool kit?
And so, from my perspective, this is going to take what we
have all come to talk about as the ``all of the above''
approach. Everyone has to work together in concert. We have to
roll up our sleeves to address what from my perspective, in my
little corner of the world, is one of the worst public health
crises I have ever seen and one that I hope never to see again.
So, thank you.
Senator Portman. Thank you, Ms. Rendon. Director Plouck.
TESTIMONY OF TRACY PLOUCK,\1\ DIRECTOR, OHIO DEPARTMENT OF
MENTAL HEALTH AND ADDICTION SERVICES
Ms. Plouck. I really appreciate the opportunity to present
at this hearing today.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Plouck appears in the Appendix on
page 157.
---------------------------------------------------------------------------
And, as you are aware, the opioid epidemic has hit all
States. And, Governor John Kasich and his administration has
worked tirelessly in the last 5 years with both State, local
and Federal partners to curb the tide, and yet the storm just
continues to rage.
I know you both share the same concerns that the Governor
does. And, I would like to talk to you a little bit today about
Ohio's overall efforts and where we still have work ahead of
us.
Unintentional drug overdose deaths in Ohio reached an all
time high of 2,482 in 2014, which is the most recent year
available. That is 2,482 families that have been affected by a
death related to overdose in our State just in one year. Opiate
related deaths, which include both heroin and prescription
painkillers, peaked at 1,988 deaths in 2014, up from only 296
in 2003. With 502 fentanyl-related drug overdose deaths in this
State in 2014, fentanyl was a significant contributor to the
rise in drug overdose deaths according to the preliminary data
that has been released by the Ohio Department of Health (ODH).
By comparison in 2013, just 84 deaths involved fentanyl. As a
result, Ohio proactively requested assistance from the Center
for Disease Control's EpiAid to better analyze our opiate
related deaths. We are currently reviewing the recommendations
and determining what should be implemented in Ohio to build on
our effort. This continues to be a pressing issue for the
State.
Governor Kasich has made the fight against opiates a
priority and is one of the nation's most outspoken advocates on
the issue. Early in his administration, the Governor announced
the establishment of the Governor's Cabinet Opiate Action Team
(GCOAT) to fight opiate abuse in Ohio. GCOAT is comprised of
directors from multiple cabinet agencies that touch the opiate
issue. And, it is designed to foster collaboration across
public health, treatment, law enforcement, education and other
agencies that touch some facet of this complex challenge.
I know you understand the importance of taking this issue
in a multi-pronged way because of your work on CARA. Senator
Portman, I would like to thank you for your sponsorship of the
bill, and I would like to thank you, Senator Brown, for your
support as well. CARA takes a similarly comprehensive approach
and addresses on a national level several things that Ohio has
demonstrated we know are working and making some progress.
I would like to talk a little bit about some specific
areas. And, I am going to start with prescribing practices and
prescribing guidelines specifically.
In its ongoing efforts to combat drug abuse and save lives,
the Governor's Cabinet Opiate Action Team developed
comprehensive prescribing guidelines for outpatient management
of acute pain this past January. The acute guidelines follow
previous prescribing guidelines for emergency departments,
which were released in 2012, and the management of chronic pain
in 2013. All three of these guidelines were developed in
conjunction with clinical professional associations, health
care providers, State licensing boards and State agencies. I
know that CARA also addresses this issue from a national
perspective. And, I applaud efforts to limit the number of
opioids prescribed nationally to ensure that these powerful
drugs are only used in the course of appropriate medical care.
As a result of the prescribing guidelines and the increased
utility of OARRS, our prescription drug monitoring system in
Ohio, the number of prescriber and pharmacist queries using
OARRS increased from 778,000 in 2010 to 9.3 million in 2014.
And, Ohio is making further progress.
The number of prescription opiates dispensed to Ohio
patients in 2014 decreased by more than 40 million doses
relative to the previous year.
The number of individuals doctor shopping for controlled
substances, including opiates, decreased from more than 3,100
in 2009 to approximately 960 in 2014.
From 2013 to 2014, there was a nearly 11 percent decline in
the number of patients prescribed opiates at a dose higher than
the current guidelines that are recommended. Ohio patients
receiving prescriptions for opiates and benzodiazepine
sedatives at the same time dropped by 8 percent. So, we are
seeing some progress related to these interventions.
I want to say a little bit about prevention, which has been
mentioned by both of the other panelists. In 2014, the Governor
and the first lady launched ``Start Talking,'' which is a
statewide youth drug prevention initiative based on the premise
that youth are up to 50 percent less likely to initiate drug
use if an adult who cares about them talks directly with them
about this issue and the risks involved. Understanding that
this is not an easy discussion to begin, the program aims to
help parents and other adults communicate better with kids on
these topics. ``Start Talking'' offers three free tools for
parents and other youth leaders to approach children and young
adults.
Nearly 57,000 adults are receiving these biweekly messages
via e-mail to help start important conversations.
``Parents360Rx'' is the second component of the program. It
is a national program that Partnership for Drug-Free Kids
established that is designed to help educate adults about the
dangers found in their own medicine cabinets. This is a good
topical source for community meetings to help draw attention to
some precautions that every household can take in the fight
against the opiate epidemic.
And then, finally, ``5 Minutes for Life'' is a program that
is led by the Ohio State Highway Patrol, the National Guard and
local law enforcement in partnership with high schools.
Troopers, law enforcement officers and National Guard members
talk directly with students, usually student athletes, to
encourage them to become ambassadors and lead peer-to-peer
conversations about the importance of healthy choices. During
this school year alone, over 260 events have been hosted with
more than 35,000 students participating.
I want to say just a moment about criminal justice
initiatives and our support for court involved individuals.
Established in 2014, we launched the addiction treatment
program. This supports drug courts in establishing a program to
provide addiction treatment, including medication assisted
treatment, to non-violent adult offenders with dependence on
opiates, alcohol or both. The first phase of the program
reached 410 men and women, two-thirds of whom also had a co-
occurring mental health disorder. According to a Case Western
Reserve University evaluation of the program, past months drug
use among program participants decreased by almost 70 percent,
while crimes committed dipped 86 percent. At the same time,
employment increased by 114 percent, while stable housing
increased by nearly 29 percent. Among participants, 60 percent
had a job, and 91 percent had stable housing upon completion of
the program. This program is funded with $11 million over the
current biennium in 14 Ohio counties. CARA emphasizes the
importance of treatment as an alternative to incarceration, and
we are seeing that work here in Ohio is effective in that
regard with the drug court model.
I want to say just a little bit about expanding the
availability and the use of naloxone or Narcan, as has been
noted earlier.
Our department administers grants for first responders
across the State. We know that through State emergency medical
services (EMS) data, naloxone was administered to 18,438
patients in 2015. That is more than 18,000 deaths avoided as a
result of this lifesaving measure. Without this important
overdose antidote, Ohio's already two large number of overdose
deaths would be much higher. The most recent State budget
included $1 million to purchase naloxone for first responders,
including police and fire. A concerted effort has been made to
convince local agencies of the importance of carrying naloxone,
oftentimes as an overdose victim cannot wait for EMS to arrive.
And, we have seen many communities sign on to this. CARA also
addresses this issue, and we support your efforts. Naloxone use
is critical to saving lives and getting people into treatment.
I would like to say a little bit about Neonatal Abstinence
Syndrome. In 2013, the Kasich administration launched an effort
to address the epidemic among the smallest of Ohioans, babies
born to mothers who are addicted to prescription painkillers,
opiates and heroin. By engaging expecting mothers in a
combination of counseling, medication assisted treatment and
case management, the 3-year project is estimated to reduce
infant hospital stays by 30 percent among those enrolled moms
and babies. One of the goals of CARA is to improve addiction
and treatment services for pregnant and postpartum women. And,
we believe Ohio is developing a model that can be replicated
nationally.
Across the State, I continue to hear stories of waiting
lists and difficulty accessing treatment, in part due to the
Federal Institutions for Mental Disease (IMD) exclusion.
Treatment works, but it is not easy. I recently read of a
couple who, after multiple relapses, found themselves homeless,
involved in criminal justice and lost custody of their young
daughter. Through treatment received through extended Medicaid
benefits, they have over a year of sobriety. They have regained
custody of their daughter, and they are now employed. We know
that approximately 400,000 additional Ohioans were able to
connect with mental health and/or drug addiction treatment as a
result of the Medicaid expansion when it was extended to adults
up to 138 percent of poverty. Capacity and workforce continue
to be a challenge. And, the IMD exclusion poses a barrier to
treatment access. I appreciate that CARA sets up a way to take
a serious look at the IMD exclusion and its impact on
treatment.
Thank you again for inviting me to testify on this very
important topic today. I want to commend both of you on your
work on this issue. And, I especially commend you, Senator
Portman, on your leadership on this issue through your career.
Again, as I described in my testimony and at length in my
written statement for the record, a number of the provisions in
the CARA bill are activities that Ohio is undertaking. And, we
fully support the expansion on a more national scale of these
efforts.
I stand ready to work with you as we move forward. And, we
look forward to any questions that you might have.
Senator Portman. Great. Thank you, Director Plouck. I
appreciate it. And, we will have some questions. I am going to
ask Senator Brown to go first.
I want to just make one comment that is pretty obvious to
everybody in the room. If we can get CARA passed, because of
the programs that all three of these panelists talked about, we
will be in a good position to access some of these grants,
whether it is with regard to prevention, education or
treatment, medication assisted treatment or, as you mentioned,
the Neonatal Abstinence Syndrome, working with pregnant women.
Our veterans, of course, in Ohio are great. And, they are
funded in here.
So, there is the diversion programs, drug courts. So, there
is a lot of opportunity here for Ohio. We play a leading role
thanks for the additional help that will come from CARA going
forward.
I will ask Senator Brown to go first with questions--and I
want to ask you some myself.
Senator Brown.. Mr. Chairman, thank you.
And, Director Plouck, let me start with you. First of all,
you were some years ago, in addition to what you are doing now,
some years ago you were a Medicaid director in the State,
right, so you know this issue pretty well.
On March 30, an Akron Beacon Journal editorial discusses
the role that Medicaid expansion, when the Governor made his
decision as part of the Affordable Care Act (ACA) to expand
Medicaid, and discussed in part Ohio's battle of its addiction.
I would like, Mr. Chairman, to enter into the record this
editorial,\1\ if I could.
---------------------------------------------------------------------------
\1\ The editorial submitted by Senator Brown appears in the
Appendix on page 233.
---------------------------------------------------------------------------
Senator Portman. Yes. No objection.
Senator Brown. Folks who have health insurance are better
able to access critical mental health, of course, mental health
and substance abuse services, including medication assisted
therapy, as we talked about.
I would like to focus on a different benefit of Medicaid
expansion, if I could, because the expansion localities around
the State are now able to use money they would have spent on
health care for other critical services.
For example, Summit County's Alcohol, Drug Addiction &
Mental Health (ADM) services board used to rely on a local tax
levy to help pay for basic health costs for the disadvantaged.
Now, after the expansion of Medicaid, the board can utilize
these levy dollars to meet other urgent needs in Summit County.
That is funding recovery coaches, Project Deaths Avoided with
Naloxone (DAWN), funding detox, both to the local community.
Medicaid expansion enabled Summit County to save more than
$4 million last year, and is projected to save the county more
this year, money that is being used to address other urgent
needs.
My question is this: The new ``Healthy Ohio'' plan out for
comment through the Ohio Department of Medicaid, out for
comment from the Senators from Medicare and Medicaid Services,
would require nondisabled adults, including some pregnant
women, to pay premiums for coverage that is free today, would
impose new limits on how many times Ohioans can go to the
doctor or get care they need each year, or require patients to
pay out of pocket, as I think you know, when they go to the
doctor, pick up prescriptions, on top of monthly premiums that
they may face. And, additionally, if individuals cannot afford
to pay the premium or they get locked out of coverage, they
have to again rely on help from local counties.
Walk through, if you would, what ``Healthy Ohio,'' if the
Medicaid waiver is granted to the State from Center for
Medicare, Medicaid services, how ``Healthy Ohio'' would affect
folks who rely on Medicaid for addiction treatment?
Ms. Plouck. Chairman Portman and Senator Brown, I am not
the lead cabinet director on this issue. And, I would want to
defer to any clarification that Director McCarthy from Ohio
Medicaid would want to bring to this.
I think the general philosophy behind ``Healthy Ohio,''
when it was added into the last biannual budget, was a
philosophy of personal responsibility for individuals. And,
Medicaid is following the law to request the waiver that was
stipulated in the budget bill.
As far as access to addiction and mental health services,
those are named services in the Ohio Medicaid benefit. And if,
those would be subject to the same requirements related to call
sharing or anything that would be required as a part of
``Healthy Ohio'' waiver.
So, I do not believe that addiction treatment is approached
any differently than other Medicaid services in that regard.
Senator Brown. Understanding you are part of an
administration with the legislature that is asking for the
waiver. But, does that make sense to you, when dollars that
would have been available now may be used for other things,
when we know how every community is starved for dollars on
treatment programs?
Ms. Plouck. The Ohio Department of Medicaid is following
the law that was enacted in the budget bill to request the
waiver from the Federal Government.
Senator Brown. And, I understand they are following the
law. I want your opinion of that law. Granted I understand you
are part of the administration. Does that make sense to you? If
you can step in that other role, and it is probably unfair to
ask you to step in the other role. But, can you kind of talk
that through?
Ms. Plouck. As an advocate for individuals and families
that are struggling with mental health and addiction challenges
in their lives, I think that we should work to try to overcome
any barrier to access to treatment that exists.
Senator Brown. OK.
Ms. Plouck. I recognize that to an individual, the waiver,
if enacted as it has been proposed pursuant to the budget bill,
does create some obstacles that would need to be overcome on an
individual basis depending on the resources of the individual.
Senator Brown. Thank you. And, I ask that in part--I mean,
I opposed the waiver pretty obviously.
But, I also ask in part, because the Centers for Medicare
and Medicaid Services (CMS) in Washington can make a
determination to choose parts of that waiver to grant and parts
to deny. I think they should deny the entire waiver. I
understand they may not.
And, I know that hospitals around the State are concerned
about the waiver period, because they so applaud it when the
Governor expanded under the ACA Medicaid, I will not speak for
others. But, the ones that have talked to me think that this is
backsliding and particularly with the acute needs we have now.
But, thank you for your candor there. I appreciate that.
For General DeWine and again U.S. Attorney Rendon, an
easier question than I would asked Director Plouck. [Laughter.]
Senator Brown. I just really wanted to kind of flush out
some of the things you already said.
We know that the opioid crisis is not just law enforcement.
Senator DeWine, you said you cannot arrest your way out of it.
We have all said that. We all understand that. And, we kind of
made those mistakes in the war on drugs in the past.
You cannot arrest your way entirely out of this, we know.
So, we know it is not just the law enforcement. As you said, it
is law enforcement, not just law enforcement.
It is not just treatment. It is a problem that requires
something more comprehensive, as Senator Portman has mentioned
many times with CARA overall.
But, what can regular people do to help address this
crisis? And, we have some of the State's best experts here. We
have people that devote much of their workday and beyond that
to doing this. Talk more about the general public, what people
can do?
Mr. DeWine. Chairman and Senator Brown, I think that is an
excellent question.
Because I truly believe that the success that we have
achieved so far and that we can achieve in the future is going
to be very much depending on what occurs at the local level.
We all have a role. We do what we do. U.S. Attorney does
what they do in regard to law enforcement. We try to help with
the six individuals who I told you about who will go out and
help in the local community.
The communities that have started to change the culture, to
change how we look at it, communities that have begun to really
assist people with not only getting in treatment, but what
happens when we get out of treatment, those communities--where
we have seen that happen is because the local community got
together.
I know you had a lot of town hall meetings. Senator Portman
has had town hall meetings. I suspect you found what I found
when I did this.
We did a number of town hall meetings over a year ago. And,
to me the interesting thing, but also kind of scary thing was,
that we would have a lot of people, a lot of just citizens who
came. And, we would have a panel of experts. But, we would have
a roomful of citizens. And, we encouraged just a conversation.
And, what I found was that you would get someone who would
stand up on one end of the room and say, well, in this
community we need such and such. We do not have that. Somebody
else on the other side of the room stands up and says, yes, we
do.
So, a lot of it is I think pulling people together and
getting people out of their normal area where they work and
communities coming together.
And, when you have a grass roots effort in the local
community, what happens is, people in that community start
talking to each other more. That is how we are going to do
this.
I think the other thing average citizens can do is to say,
hey, look, in this community, somehow we have to have education
at every grade level. And, we have to work with our schools,
who we ask to do all kinds of a million things. And, they are
overburdened. But, we have to work with our schools. And, the
community has to say to the school, this is very important.
If we are going to deal with this problem in the future, if
we are going to have some success 5 years, 10 years, or 20
years from now, we have to start in kindergarten. And, we have
to work all the way through.
So, I am a great believer in the local community and where
the local community comes together, where the business
community is involved, where the church faith based community
is involved. I think we can see some progress. That is what the
individual can do.
Ms. Rendon. Senator Brown, I think that is an excellent
question. Because I think there are things that every single
person in our community can do to help with this crisis.
And so, what you are doing here today is a huge step,
because we all need to be educated about what is happening. And
so, the more we get the word out, the more people know that
this is out there, the more they can figure out where their
piece is, where they can help.
But, for the average citizen, what I tell people when I am
at these town hall meetings, there is a ton that everyone can
do.
So, you can start by going home and opening your medicine
cabinet and figuring out what is in there that should not be
there that you were prescribed a year and-a-half ago.
And then, on April 30, you can see my good friends at the
DEA on their drug take-back day, and take that medication
safely to a drug drop box and get rid of it before somebody
accidentally tries it, some young kid who thinks it is safe
because it is in a medicine bottle, somebody who happens to be
in your home.
You can do that on a daily basis in many of our police
stations. And, I know some of our pharmacies are now starting
to agree to have drug drop boxes in the pharmacy, which I think
is phenomenal. So, that is something you can do.
You can talk to your kids, to your family, to your friends.
My oldest son is here. And, he can tell you, I think maybe
because of my career, I have been talking to my children about
the dangers of drugs since they were toddlers.
So, just as we have taught all of our children to buckle
their seat belt and not smoke cigarettes and not drink and
drive, we have to have on that list, do not use drugs. You do
not know, that first time that you take it, you have no idea
how it is going to impact you. And, then we all have to look at
ourselves in the mirror and figure out when we became a culture
that has to be pain free at all times. Right?
So, when I had my wisdom teeth out, I got Tylenol, and I
think I got to stay home from school for a day. Now, you take
your children to get their wisdom teeth out, and they want to
give you Percocet. Percocet. We as parents, we as citizens,
need to stand up and say, no. I am not taking that
prescription. I do not need that prescription.
My husband had his elbow operated on--not removed. We do
not need a 60 day supply of Vicodin. I want three. Right?
But, I found out you can do the same thing at the pharmacy.
So, if they do give you the prescription for 30 Vicodin, you do
not have to take 30 Vicodin. You can talk to your pharmacist
and say, how many of these do I actually reasonably need to
address this problem? And, they will tell you, two, three. And,
you can walk home from the pharmacy with just what you need.
So, it has to start with each one of us in our homes with
the things that we care about, with our commitment to this next
generation and the future of our community. And so, there is a
role for every single person in our community to help with
this. And, getting the word out is the first step.
So, thank you.
Senator Portman. Thank you. Thank you, Senator Brown.
I could not agree you with more. And, tragically, we are
going to hear from a witness in a little while about wisdom
teeth extraction and the specific issue that you raised and how
that led to an addiction and eventual overdose and death.
But, and you are right, everybody has a role. One of the
things we tried to do in this legislation, drop boxes, for
instance, we do provide for them to be at pharmacies and at
long term care facilities and in hospitals that have
pharmacies.
I must tell you, I have a frustration on the prevention and
education side, because, 22 years ago, I started this group in
Cincinnati. Officially, we were having our 20th year
anniversary I think in a couple weeks. I founded it. I chaired
it for the first 9 years. I was on the board until I joined the
Senate.
It is called Coalition for a Drug-Free Greater Cincinnati.
Now, it is called Prevention First. And, we are considered a
model coalition. I was the author of the Drug Fee Communities
Act of 1997. We have spawned 2,000 coalitions throughout the
country.
As all three of you have acknowledged, we are still not
able to persuade so many of our fellow citizens, not just kids,
this is not just about young people, of the dangers. And, the
best research shows that it is this recognition of the danger
that kept those people from trying heroin. In the 1990s when we
started our coalition, it was not an issue. Now, we have 13
year old kids in Ohio trying heroin, first time, shooting up.
Parents, all the evidence shows parents or other
caregivers, when there is not two parents at home--which
unfortunately is the case in many of our communities. And, in
many situations you do not have a parent who is available, even
if the parent is in the family. But, parents make a huge
difference.
The single largest difference as a parent, when I had three
teenagers, well, all three are passed teenagers now barely, you
kind of wonder sometimes. But, it is incredibly important, as
you say.
But, on the issue of community coalitions and this whole
issue of prevention and education, we are going to hear from
Rob Brandt later, who has become an expert on this by
necessity.
But, what should we be doing differently? The CARA program
starts a national awareness campaign, specifically on this
issue of the connection between prescription drugs and opioid
addiction, and the fentanyl and the heroin connection.
Because four out of five people who are addicted to heroin
start on prescription drugs. That is what they say. And, we
need to--people do not know that. So, they do not know when
they go to have a relatively small procedure that they should
not be asking for the Percocet. Instead they should be asking
for the Toradol or the Tylenol. So, that specifically is in
here.
But, what would you say? And, Attorney General DeWine,
again you have been active on this, Ms. Rendon and Director
Plouck, if you would like to jump in. But, what would you do
differently in terms of the prevention and the education side
of this, something different and new?
Mr. DeWine. No. You go ahead.
Ms. Rendon. Well, so one of the things that I think is an
example that is really incredible to me from our task force
here in Northeast Ohio is the partnership between law
enforcement, treatment, education and regular community
members, which has allowed us in some respects to get a little
bit ahead of the curve.
So, I talked earlier about our Medical Examiner (ME)
sounding the alarm on this problem as it came on the horizon.
So, they were the first to see fentanyl in pill form in our
district. They sent out an alert, and it came to us, because we
are on this task force.
And so, it went immediately to the DEA. And, within weeks,
the DEA had made a massive seizure of fentanyl in pill form,
just shy of 1,000 pills. And, we were able to charge that
individual in Federal court within days and address this
problem and get the word out very publicly.
And, what was so important about that is the fentanyl pills
were shaped and dyed to look like oxycodone. And so, if you are
an oxycodone user, and that is what you think you are taking,
and it is fentanyl, it is an overdose waiting to happen. I
mean, every one of those pills was an overdose waiting to
happen.
But, we were able, because of this group that we have
together and the constant communication that we have, both when
we are sitting together in our office and then also on a
regular basis by e-mail and phone, we were able to sound a
really loud alarm bell and get the word out to the drug using
population.
Joan Synenberg was here earlier. She is a common pleas
court judge. She has one of the drug courts. There she is, back
there. She is a member of our task force. And, told us a really
heart-breaking story of one of her graduates--I was at the
graduation--who 2 days after graduation overdosed and died.
And so, that caused us to realize that we have to get to
her graduates as they are walking out the door to make sure
that they understand how dangerous the world has become while
they have been sober.
Because the heroin users do not know how deadly and
dangerous the fentanyl is. And, when you are taking an illegal
drug, unlike a drug that you get at the pharmacy, you have no
idea what it is you are about to put in your mouth.
And so, unless you can get the word out, really actively,
really publicly through the media, through one on one meetings,
through this combination of people working at all levels, you
cannot impact the problem.
But, all of us together, that is why the stool has to have
the four legs, all of us together, we can make a difference.
And, we are. It is disheartening when it is not going in the
direction that you want it to. But, I am telling you every day
we are saving lives and will continue to do so.
Mr. DeWine. I have a couple of comments. Mr. Chairman, you
are absolutely right. There is a natural progression from
opiates to heroin.
One of the things that we partnered with Governor John
Kasich's office, right after he took office and I took office,
was to really crack down on doctors who are really nothing more
than drug dealers.
We have taken, and I say we, because we are the lawyers for
the State Medical Board, and we pushed this. But, the State
Medical Board has really stepped up. For many years they were
not frankly doing what they needed to do.
They have taken I believe 70 doctors' licenses in the State
of Ohio. I was involved in some of the raids. And, I will not
take your time to tell you the horror stories. But, we had one
doctor who was on the circuit, basically. He would spend one
day--and he had 10 offices around the State.
And so, that--if we can stop people from--change the
culture regarding an opiate, we are going to see some progress
in the heroin as well. Because one flows, one flows from the
other.
We had a real pendulum swing, in regard to the culture of
prescribing pain meds. And, if you recall, 15 years ago or so,
the concern was that doctors were not treating pain. And, that
was probably a correct comment, that we needed to do a better
job, particularly people who have long term retractable pain.
But, we went too far the other way. We are now starting to move
back.
But, I will tell you, I had the same experience as I have
experienced with a granddaughter who had her wisdom teeth taken
out and was given dozens and dozens of pills. That was what the
prescription was. Our daughter, we told her not to take any of
them. She did not take any of them.
So, we are not there with changing the culture with the
medical community. We have come a long way.
As to the second thing, I will go back to what I said, Mr.
Chairman and Senator Brown, we have not done a very good job in
this country in regard to education. I think you have to be--we
have to be careful, is what some of the experts will--I do not
intend to be an expert. But, will tell me is, there is some
things we do--we could be doing that we might think is the
right way in education, and it may be exacerbating the problem.
So, I think whatever we do, it would have to be evidence based.
And, we have to have that tested.
But, you all will remember when I was about leaving, and
when Senator Brown was about coming, I think, in the Senate,
you were in the House, but, killed the national funding. It was
not very much in education. But, every school got some of it.
Every school got something. And, that just went away. I lost
that fight. And, those who were fighting on our side also lost.
We lost that.
So, I think we have to look at that more and see what the
Federal Government can do. I think candidly we have to do
something in this State, so that we are doing something with
education K through 12 every year. Nothing less than that is
acceptable. Nothing less than that is going to begin at least
to deal with this problem.
We are not doing that. And, I am not blaming anyone. But,
we have to start doing that again.
Senator Portman. Thank you.
I have so many other questions. And, I am going to continue
the discussion with all three of you and then with Senator
Brown on these issues.
But, we do have another panel that is patiently waiting.
And, I want to get them up here, too.
Thank you to all three of you for not just coming today and
sharing your views with this distinguished group of people who
are in the trenches, but for what you do every single day to
help to save lives and to pull lives back together. So, we look
forward to continue to work with you. And, thank you for your
testimony.
Ms. Rendon. Thank you.
Senator Portman. I would now like to call the next panel
up, if we could, please. Dr. Michele Walsh, Dr. Kotz, Emily
Metz and Rob Brandt.
OK. We are on to the next panelists here. I would like to
get started. Why do we not start by swearing in the panel,
since this is the custom of this Committee to do this. So,
please stand and raise your right hand.
Do you swear the testimony you will give before this
Committee will be the truth, the whole truth and nothing but
the truth, so help you, God?
Thank you. Let the record show that all the answers were in
the affirmative.
We appreciate each of you coming today and look forward to
the opportunity to hear from you and also to get some questions
in.
I was probably negligent in not mentioning for the last
panel that we are asking for five minute opening statements.
And, I know you all know that. But, try to stick to 5 minutes,
if you can, because that will give us more time to have
interaction between yourselves and we will be able to ask you
direct questions.
Again, we have an amazing group here. First, is Dr.
Michelle Walsh, who is right here. I mentioned earlier the
Rainbow Babies and Children's Hospital work. It is incredible.
She has given the opportunity to tour it a couple times, I
think, maybe a few times, but more recently with regard to this
issue of babies who are born with Neonatal Abstinence Syndrome.
So, thank you for being here.
Dr. Michele Walsh is division chief of neonatology right
here at UH. She will talk about that issue. After Dr. Walsh, we
will hear from Dr. Nancy Young. Dr. Young is an expert in the
issue of substance abuse and its impact on children. She is
going to expand on the broader impact of the Neonatal
Abstinence Syndrome we mentioned earlier.
In particular, Dr. Young is going to discuss the
correlation of substance abuse and children entering the child
welfare system. Again these are areas that she has testified
about before. In fact, she came to our Finance Committee, where
Senator Brown both and I serve, and testified before the U.S.
Senate. I appreciate her willingness to come here to Cleveland.
Dr. Margaret Kotz is here. Dr. Kotz is an addiction expert.
She is a specialist right here at University Hospital. And, she
told me this in our round table discussion last year. We got to
talk to her about some of her work.
And, she is going to discuss the merits of medication
assisted treatment. That is one we did not get a chance to get
into as deeply as I wanted to in the first panel. We look
forward to that.
Emily Metz is here from project DAWN. She is going to speak
about the work in the community to get naloxone out to prevent
these overdoses. We talked a lot about that today.
I think I am going to be with you later this afternoon and
be able to see some of your good work directly at the free
clinic. And, also I know you work with MetroHealth, their
facility here in Cleveland. So, we look forward to hearing from
you.
And then, last but not least, Rob Brandt is here with us.
And, I was looking at Rob when there was discussion about this
issue of prescribing to our kids prescription drugs that are
addictive, in the case of a wisdom tooth extraction.
And, unfortunately, Rob is an expert. He is a business
leader. He got involved with prevention because of his family--
his son, Robby. He has a group called Robby's Voice. They are
awesome, because they are out there in the schools. We talked
about doing it at young ages. He is there in the elementary
schools. And, he works to bring the message of drug education
and drug prevention to students and families.
So, again, thank you all for being here.
And, Dr. Walsh, we look forward to your testimony.
TESTIMONY OF MICHELE WALSH, M.D.,\1\ DIVISION CHIEF,
NEONATOLOGY, UH CASE MEDICAL CENTER, UH RAINBOW BABIES AND
CHILDREN'S HOSPITAL
Dr. Walsh. Thank you, Chairman Portman, Senator Brown and
distinguished guests. I am Michelle Walsh. I am the Chief of
Neonatology here at Rainbow. I thank the Committee for holding
this field hearing in Cleveland. And, we are proud to host you
at the UH Case Medical Center. I thank the Committee for
holding this field hearing in Cleveland. And, we are proud to
host you at the UH Case Medical Center. I have been privileged
to care for the tiny babies of Northeastern Ohio for over 25
years. And, I appreciate the opportunity to speak on their
behalf.
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\1\ The prepared statement of Dr. Walsh appears in the Appendix on
page 170.
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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.
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\1\ The prepared statement of Dr. Young appears in the Appendix on
page 173.
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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.
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\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.
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\1\ The prepared statement of Ms. Metz appears in the Appendix on
page 211.
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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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