[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]






                      COMBATING THE OPIOID CRISIS

=======================================================================

                                HEARING

                               BEFORE THE

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           NOVEMBER 28, 2017

                               __________

                           Serial No. 115-101

                               __________

Printed for the use of the Committee on Oversight and Government Reform












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              Committee on Oversight and Government Reform

                  Trey Gowdy, South Carolina, Chairman
John J. Duncan, Jr., Tennessee       Elijah E. Cummings, Maryland, 
Darrell E. Issa, California              Ranking Minority Member
Jim Jordan, Ohio                     Carolyn B. Maloney, New York
Mark Sanford, South Carolina         Eleanor Holmes Norton, District of 
Justin Amash, Michigan                   Columbia
Paul A. Gosar, Arizona               Wm. Lacy Clay, Missouri
Scott DesJarlais, Tennessee          Stephen F. Lynch, Massachusetts
Virginia Foxx, North Carolina        Jim Cooper, Tennessee
Thomas Massie, Kentucky              Gerald E. Connolly, Virginia
Mark Meadows, North Carolina         Robin L. Kelly, Illinois
Ron DeSantis, Florida                Brenda L. Lawrence, Michigan
Dennis A. Ross, Florida              Bonnie Watson Coleman, New Jersey
Mark Walker, North Carolina          Stacey E. Plaskett, Virgin Islands
Rod Blum, Iowa                       Val Butler Demings, Florida
Jody B. Hice, Georgia                Raja Krishnamoorthi, Illinois
Steve Russell, Oklahoma              Jamie Raskin, Maryland
Glenn Grothman, Wisconsin            Peter Welch, Vermont
Will Hurd, Texas                     Matt Cartwright, Pennsylvania
Gary J. Palmer, Alabama              Mark DeSaulnier, California
James Comer, Kentucky                Jimmy Gomez, Maryland
Paul Mitchell, Michigan
Greg Gianforte, Montana

                     Sheria Clarke, Staff Director
                    William McKenna, General Counsel
      Sarah Vance, Healthcare, Benefits, and Administrative Rules 
                      Subcommittee Staff Director
                Michael Koren, Professional Staff Member
                    Sharon Casey, Deputy Chief Clerk
                 David Rapallo, Minority Staff Director 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on November 28, 2017................................     1

                               WITNESSES
                                Panel I

The Honorable Chris Christie, Governor of New Jersey
    Oral Statement...............................................     5
    Written Statement............................................    10

                                Panel II

Mr. Richard Baum, Acting Director, Office of National Drug 
  Control Policy
    Oral Statement...............................................    43
    Written Statement............................................    46
Dr. Leana Wen, Health Commissioner, Baltimore City Health 
  Department
    Oral Statement...............................................    57
    Written Statement............................................    59
Dr. Caleb Alexander, Co-Director, Center for Drug Safety and 
  Effectiveness, Johns Hopkins Bloomberg School of Public Health
    Oral Statement...............................................    83
    Written Statement............................................    85

                                APPENDIX

``The Opioid Epidemic From Evidence to Impact'' October 2017 
  submitted by Dr. Alexander can be accessed here: https://
  www.jhsph.edu/events/2017/americas-opioid-epidemic/report/2017-
  JohnsHopkins-Opioid-digital.pdf................................   104
Representative Gerald E. Connolly Statement for the Record.......   105
Letter of November 21, 2017, from Association for Behavioral 
  Health and Wellness submitted by Mr. Cummings..................   107
National Healthcare for the Homeless Council Statement for the 
  Record submitted by Mr. Cummings...............................   110
Response from Mr. Baum, Office of National Drug Control Policy, 
  to Questions for the Record....................................   114
Response from Dr. Wen, Baltimore City Health Department, to 
  Questions for the Record.......................................   115
Response from Dr. Alexander, Johns Hopkins Bloomberg School of 
  Public Health, to Questions for the Record.....................   117

 
                      COMBATING THE OPIOID CRISIS

                              ----------                              


                       Tuesday, November 28, 2017

                  House of Representatives,
               Committee on Oversight and Government Reform
                                                   Washington, D.C.
    The Committee met, pursuant to call, at 12:42 p.m., in the 
Chevy Chase Auditorium, Johns Hopkins Hospital, 1800 Orleans 
Street, Baltimore, MD, 21287, Hon. Trey Gowdy [Chairman of the 
Committee] presiding.
    Members present: Representatives Gowdy, Grothman, Palmer, 
Comer, Cummings, Norton, Clay, Lawrence, Raskin, and Welch.
    Also present: Representatives Sarbanes and Ruppersberger.
    Chairman Gowdy. Thank you, Governor, thank you, Mayor Pew, 
thank you, Johns Hopkins for pardoning the inconvenience of 
having a Committee of Congress come, and appreciating the 
seriousness of the issue that brings us here. The Committee 
will come to order. Without objection, the Chair is authorized 
to declare recesses at any time. I am going to break from 
protocol a little bit because we are in Mr. Cummings's 
hometown, and because he cares so passionately about this 
issue, we are going to recognize you first for your opening 
statement.
    Mr. Cummings. Thank you very much, Mr. Chairman, and I want 
to first of all, take a--just to mention one thing that is so 
important to me, Mr. Chairman, and to the members of this 
panel.
    I cannot come into this hospital without saying thank you 
to Hopkins for saving my life, and spent 60 days here this 
summer, a lot of it in this building. And so I want to thank--I 
see a lot of white coats out there and others, but pass the 
word. I thank you for what you have done for me and my family.
    I want to begin by thanking Chairman Gowdy for calling 
today's very important hearing, and for bringing the Oversight 
Committee to Baltimore. I also thank my colleagues for coming 
to Baltimore, and certainly my colleagues who represent 
Baltimore along with me as Dutch Ruppersberger and John 
Sarbanes. I thank you for being here.
    I have been in Congress now for 20 years and I have been 
through and seen a lot of field hearings. I have never seen as 
many members attend any field hearing since I have been in 
Congress. I believe today's remarkable turnout reflects the 
fact that the opioid crisis is truly a national emergency that 
does not discriminate based on politics. It affects the red 
states and blue states, and every state in between. So I am 
extremely grateful that the Chairman agreed to my request to 
bring the Committee to--on the road to investigate the 
devastating effects of this very difficult problem.
    I also want to thank Dr. Miller and Johns Hopkins for your 
warm welcome and your hospitality. The work that you do makes a 
huge difference in our community and around the globe. I also 
thank our esteemed guests, Governor Hogan and Mayor Pew, for 
joining us. We are honored to have you in our presence. And of 
course, I thank our witnesses, Governor Chris Christie, 
Commissioner Wen, Dr. Alexander, and Mr. Baum. Thank you for 
testifying and for all that you are doing to help us combat 
opioids and save lives.
    A year and a half ago at our Committee's first hearing on 
this issue, I warned that so many people were dying in 
communities across America and that we could no longer ignore 
this emergency. Today, the Centers for Disease Control and 
Prevention estimates that more than 64,000 Americans died from 
drug overdoses in 2016, an increase of more than 20 percent 
over the year before.
    To put this in perspective, the death toll from drug 
overdoses last year alone was higher than all U.S. military 
casualties in Vietnam and Iraq wars combined. Every 20 minutes 
someone does from an opioid overdose. If today's hearing lasts 
for two hours, half a dozen families will have lost a parent, a 
sibling, or a child to opioids. We have the reports. We have 
had years of talk. Now it is time for action. The American 
people are looking for us to take action. They are looking to 
the President and the Congress, and they are asking what are 
you going to do?
    Governor Christie and the other members of the President's 
Commission on Drug Addiction have given us an excellent 
blueprint for action with dozens of recommendations. Now it is 
up to us, Republicans and Democrats, Federal, State, and local 
officials, researchers, policymakers, doctors, drug companies, 
health providers on the ground, and families of the faith 
communities. We need to work together to end this epidemic.
    There are some things that we can do right now to help 
prevent addiction and save those who already have this disease. 
For example, we can ensure that every single person who needs 
naloxone has it. The Commission's report highlights the 
importance of equipping first responders with naloxone, 
including police officers, fire departments, and public health 
officials. But here is a challenge. Drug companies have 
continued to hike the price of this 45-year-old drug and 
communities have been forced to ration it. In September, I led 
50 Members of the House of Representatives in sending a letter 
urging President Donald Trump to negotiate lower prices for 
naloxone, just as the Commission recommended. Unfortunately, we 
never received a response. The President should act now to 
ensure that naloxone is available at a reasonable price 
wherever and whenever it is needed.
    We also need to ensure that every affected person has 
access to effective treatment. According to the Commission, and 
I quote, ``Today, only 10.6 percent of youth and adults who 
need treatment for substance use disorder receive that 
treatment.'' Only 10 percent. There is simply no way to end 
this crisis if 90 percent of those affected are not being 
treated if we do not act now. To do this, we need funding.
    Last month, President Trump declared this epidemic a public 
health emergency, but he did not propose any additional funding 
to combat it. We cannot fight this epidemic without funds equal 
to the challenge we face. This is a sad but stark truth.
    So finally, we must recognize and acknowledge the many 
factors that put people at risk: woefully inadequate support 
for our children and our vulnerable residents, worsening 
economic inequality, lack of opportunity, and profound 
disparities in the criminal justice system. We cannot solve 
this crisis until these risk factors are addressed.
    With that, Mr. Chairman, again, I thank you for convening 
this critical hearing, and I look forward to the testimony and 
taking action on it, and I ask, Mr. Chairman, with unanimous 
consent, that Representatives Ruppersberger from the State of 
Maryland and Representative Sarbanes from the State of Maryland 
be permitted to sit in with the Committee and participate in 
this hearing today.
    And with that, I yield back.
    Chairman Gowdy. Without objection, welcome to our 
colleagues. I also want to thank the Johns Hopkins community 
for taking such great care of our friend and colleague over the 
summer. You sent him back stronger than ever, so thank you all 
for whoever had a role in that. You didn't send him back quite 
that strong, but you sent him back stronger than ever.
    Governor Christie, Governor Hogan, recent past and present 
governors have witnessed the most devastating drug epidemic in 
our Nation's history. Since 1999, more than half a million 
Americans have died from a drug overdose, and the epidemic is 
escalating. Over the span of nearly 20 years, the death toll 
has quadrupled with the emergence of even more potent drugs and 
an ever-expanding online marking for illicit distribution.
    Today, drug overdoses kill more Americans than gun 
homicides and car crashes combined. That is a staggering 
reality. Two out of three daily deaths from drug overdoses in 
the United States involve an opioid, a class of drugs commonly 
prescribed to relieve and manage pain. And actually, over 
33,000 Americans died from an opioid-related overdose in 2015, 
which is an 11 percent increase from the year before.
    In South Carolina where I come from, Greenville and 
Spartanburg Counties in particular, suffered more than 100 
opioid-related overdoses in 2015, and while the numbers in the 
upstate of South Carolina are fewer when compared with cities 
like Baltimore, behind every number and every statistic is a 
life with loved ones and friends and potential and aspirations. 
We have a tendency to use numbers in government and in our line 
of work, but the victims aren't numbers. The victims are fellow 
human beings ravaged by the consequences of drug addiction, 
including the abuse of prescription painkillers.
    We are a remarkable country of progress and innovation, 
community and charity. We can cure diseases that past 
generations lived in fear of. We can put people on the Moon and 
we can split atoms. Yet we are struggling with how to respond 
to this epidemic. I guess we need to start with how did we get 
here? There are more illicit users for these drugs, and there 
are illicit users for these drugs and there are licit users for 
these drugs. One is unlawful, of course, the other is legal, 
but with the potential for abuse and misuse remaining.
    Physicians have a role to play for certain. These drugs are 
not available legally without a prescription. What are the 
pharmaceutical alternatives? Is there overprescribing? Is there 
sufficient information shared with patients to avoid misuse and 
abuse?
    Frequent exposure and easy access to painkillers has led to 
dependency and tolerance, which drives those with a substance 
abuse disorder to intensify doses or methods with out without 
the help of a physician. Addiction to prescription painkillers 
is growing exponentially. On the illicit side of the equation, 
the level and actors are diverting high potent pills to the 
black market to be laced with heroin, resulting in drugs so 
lethal they have been called Gray Death, a term used to 
describe the high risk associated with every single injection. 
Opioid-related overdoses are now deadlier than the HIV-AIDS 
epidemic at its peak, more insidious that the cocaine base, 
cocaine powder epidemic that predated it.
    So there are a plethora of questions to be asked, such as 
whether we are being as effective as possible in the diversion 
of these highly toxic substances? I actually like doctors. I 
happen to be the son of one. But, I also prosecuted doctors. 
And I want to make sure the DEA and DOJ are effectively going 
to the source of prescriptions issued outside the course of a 
professional medical practice. Is HHS monitoring insurers, 
placing pricier but less addictive opioids out of reach for 
patients with acute pain? Are states regulating so-called sober 
homes, which can move vulnerable patients in and out of 
treatment, typically for profit? These are the questions our 
Committee and the American people want answers to. The health 
and safety of our communities all across the Nation are at 
risk. Although almost everything seems capable of being reduced 
to political exercise in our current environment, I genuinely 
hope that this epidemic is above that. I hope it is about 
protecting those susceptible to addiction and punishing those 
fueling the epidemic. Death, especially among the premature--
especially the premature death of a young life has no political 
or ideological bet. Victims are victims. Perpetrators are 
perpetrators. Addiction is addiction. Heartache is heartache.
    The issue, to me, comes down to those of good conscience 
earnestly seeking a solution and those of a malevolent 
conscience bent for profit off of other people's addiction and 
pain. It is not just the deaths that devastate our families and 
communities across the healthcare system; it is also the 
disease of addiction that is permeating and threatening in some 
places within our country the very fabric of those communities.
    At the same time, pain is real. It is real for a 
homebuilder in Mr. Cummings' district or mine with immense back 
pain who can't otherwise get out of bed in the morning without 
his physician-prescribed pain medication.
    So how do we solve this epidemic? There is a prevention 
aspect, there is a treatment aspect, there is an education 
aspect, there is an enforcement aspect, there is a punishment 
aspect, and there is an oversight aspect. In March, the 
President signed an Executive Order creating a Commission 
consisting of governors and attorney general mental health 
advocates, and a professor of psychobiology to recommend 
policies for the Federal response to this epidemic. Earlier 
this month, the Commission finalized recommendations for how 
the Federal Government can help states and stakeholders tackle 
the evolving crisis and stave off emerging threats. Today, we 
will have an opportunity to highlight the report, and in 
Baltimore, and appropriately so. We will also examine 
Baltimore's state and Federal partners and how they can assist 
with and learn from the efforts that are occurring here. The 
devastating statistics may leave us feeling like we have just 
left the start line, but our country is resilient and we have 
resources. We have compassion. I think we have the commitment 
to win this battle with opioid and opioid addiction.
    Chairman Gowdy. So I want to thank all of our witnesses. 
Governor Christie, you are the governor of the great State of 
New Jersey. As I mentioned to you in the ante room, you are 
also a former United States attorney, so you are uniquely well-
suited and we cannot thank you enough, not just for your 
presence today, but for your willingness to undertake this 
vitally important responsibility and role, and with that, you 
are recognized.

                            PANEL I

                       WITNESS STATEMENTS

  STATEMENT OF THE HONORABLE CHRIS CHRISTIE, GOVERNOR OF NEW 
                             JERSEY

    Governor Christie. Thank you, Mr. Chairman. Ranking Member 
Cummings, thank you for your work in this area, and thanks to 
all members of the Committee for inviting us today.
    As the Chairman mentioned, in March the President asked me 
to chair his Commission on Opioid and Drug Addiction in our 
country. We worked together to name a bipartisan group of 
people to join that Commission. I think that is an important 
place to start. I can tell you, as the Chairman referenced in 
his remarks and Mr. Cummings in his, I am acutely aware as a 
Republican governor in the State of New Jersey that there is 
much that divides political dialogue in our country right now 
that makes it very difficult for us to get things done. This 
cannot be one of them.
    I read the obituaries that are happening regularly in our 
state, and in none of the obituaries do they designate whether 
the person that died was a Republican or a Democrat. They are a 
son or a daughter, a husband or a wife, a mother or a father. 
And so I hope that what we try to do in the Commission and this 
Committee is trying to do today will help to rise--give this 
problem the ability to rise above the partisanship that we have 
in our country today.
    It is true, this is the greatest and broadest public health 
epidemic of our lifetime. Everything else pales in comparison 
to the breadth of this problem. It is everywhere in America. 
One hundred seventy-five people are dying per day, which for 
someone who comes from where I come from, the most powerful 
analogy is that this means that we have a September 11 every 
two and a half weeks. Every two and a half weeks.
    Now I want to ask all of you and ask this Committee, if we 
had a terrorist organization that was invading our country and 
killing 175 of our citizens every day, what would you be 
willing to pay to make it stop? We don't ask that question in 
this country, and the reason we don't ask this question, in my 
view, is because we still believe that this addition is a moral 
failing. We are making moral judgments on the people who are 
suffering and dying, and we are making moral judgments on their 
families.
    Every time I go to a drug treatment center in my state and 
I ask someone who is in the midst of treatment, tell me your 
story. Within the first two minutes, they say to me but 
Governor, I am from a good family. And my response to that is 
why would you think I would think otherwise? The reason why 
they believe that is because the stigma that is attached to 
this disease each and every day makes people believe that they 
have to defend their very upbringing, their performance as 
parents, their role as a child. That somehow we believe that 
this is a choice.
    I would love to see a show of hands in this audience of who 
has not made a bad decision in their life. Usually works. The 
fact is, we all have. Many of us in this room are fortunate 
that bad decision was not to abuse opioids or heroin, because 
if it had been, we might be in a very different judgment 
position than some people are today. Addiction is a disease. It 
is a chronic disease, and it needs to be treated as such and 
viewed as such. That is why I am proud the President declared 
this a national public health emergency.
    Now, as Mr. Cummings mentioned, we need to fund the Public 
Health Emergency Fund, which by my last check was at $66,000. I 
don't think that is going to make it, everybody, in combating 
this problem. We need to fund the Public Health Emergency Fund 
to make sure that the Administration has at their disposal the 
resources that they need to implement the recommendations that 
the Commission has made.
    We had lots of discussion in the opening remarks about the 
role of physicians and healthcare providers in all of this. Let 
me be very clear. This is a drug epidemic that did not start on 
the corners of Baltimore or the corners of my hometown in 
Mendham. They started in doctor's offices and in hospitals 
across this Nation. And while some of it, as Chairman Gowdy 
implied in his remarks, are done by folks who have bad intent, 
most of these done by folks who have no intent. Why do 
physicians and healthcare providers have no intent on this 
issue? Because they are not educated on this issue. Broadly 
across our country in medical schools in every state in the 
union, we are not educating our future doctors and nurses, 
dentists, on the dangers of these drugs.
    We grant DEA licenses to write prescriptions for these 
drugs without requiring continuing medical education on opioid 
addiction and how it can lead to heroin addiction. I, as a 
lawyer--a recovering lawyer, but a lawyer nonetheless--I have 
to--even as governor today, I have to take continuing legal 
education every year to maintain my license. And I'm not 
practicing. How is it that physicians can have a DEA license 
and not be required to have continuing medical education on 
this very problem when 64,000 people died last year? The 
Commission recommends that we do that. And if you don't believe 
that limits on opioid prescription length as an initial 
prescription work, with exceptions, obviously, for people who 
are terminal from cancer and in hospice.
    Let me tell you what is happening in New Jersey just since 
we put a five-day limit on opioid prescriptions beginning on 
March 1 of this year. Opioid prescriptions in New Jersey are 
down 15 percent from March to October, and the number of pills 
are down 20 percent that have been prescribed in just that 
seven-month period of time. Those restrictions work, and they 
should be instituted in every state across this Nation, and 
that is also in the report.
    I want to commend the President for granting waivers to 
states now for the old-fashioned, antiquated, and ridiculous 
IMD restriction, Institutes of Mental Disease. It says that if 
there is any hospital healthcare provider that has more than 16 
beds, 16, that those folks cannot be reimbursed for the federal 
share of Medicaid because they are a state psychiatric 
hospital. What that means is there are literally thousands of 
beds that could provide the treatment that Chairman--that 
Ranking Member Cummings recommended in his remarks that could 
begin to take that 10.6 percent number up significantly, but 
are not opened because of this antiquated waiver. States have 
been asking for this ability to waive this for years. I commend 
the President for ordering that to be done, and tomorrow in New 
Jersey, the head of CMS will be coming to New Jersey with me to 
announce that New Jersey has received a waiver, and that 
hundreds of beds will open within the next six months for 
people who need drug treatment. And these are folks who are the 
neediest in our society, those folks who qualify for Medicaid.
    We need to increase physician education across the Nation, 
and we need to decrease the influence of the pharmaceutical 
industry on that education. See, right now most doctors only 
get their education from the very companies that are producing 
the pills that they want them to prescribe.
    Now as Chairman Gowdy said, I am a former prosecutor, and 
that makes me a little bit skeptical, and I am from New Jersey, 
which makes me completely cynical. And so what that tells me is 
if the only education physicians are getting are from those 
people who want them to prescribe these pills, and then in 2015 
259 million prescriptions for opioids were written in this 
country, enough to give every adult in this country their own 
bottle of 30 pills, 259 million. We are four percent of the 
world's population, and we consume 85 percent of the world's 
opioids. If you don't think that that is where this problem 
started, listen to the CDC who says that four of every five new 
heroin addicts began with prescription opioids.
    We need to have alternatives to opioids, because as the 
Chairman said, pain is real for many people in this country. 
But that is what pharmaceutical companies should be spending 
their money on, not on paying doctors to write more 
prescriptions for opioids. And so that is why we as a 
Commission brought together Dr. Francis Collins, the head of 
NIH, and all of the executives of the major pharma companies in 
this country in New Jersey and got them to agree to a 
partnership where they will now work with NIH to come up with 
two different solutions to this problem. First, more non-opioid 
painkillers to be put on the market and be affordable, and 
second, more alternatives to medication-assisted treatment for 
those who are already addicted. Right now we have three in this 
country. There should be more.
    Those pharma companies said they have 43 different 
compounds among them that could address either or both of these 
issues. If they are not moving forward, we need NIH to be the 
accelerant for moving them forward, and I would urge this 
Committee to look at additional funding for NIH specifically 
for that program to make sure that we work in partnership with 
the pharma companies to get these things to market, along with 
the FDA, as quickly as possible. If people have an alternative 
to opioids, both the physicians who prescribe these things for 
pain, and the consumer who wants to avoid addiction, to have 
non-opioid alternatives, that would be enormously helpful in 
stemming the tide here.
    The insurance companies play a large role in this as well. 
Now as a governor, I get folks all the time saying to me well, 
why don't you change the regulation of insurance companies to 
make sure that they are covering drug treatment, so that middle 
class folks in our country who have employer-provided health 
insurance can get treatment, when right now most of them do 
not. And I say well, remember this. Only 30 percent in my state 
of the health insurance policies, employer-based health 
insurance policies, are regulated by the State of New Jersey. 
Seventy percent are regulated by the Federal Government under 
ERISA. So we say why doesn't the Department of Labor step in? 
Well, they don't have the authority to do it. Under the statute 
that Congress passed in the Mental Health Parity Act, they do 
not allow the Department of Labor to fine an insurance company 
or an employer who is not treating mental health and addiction 
with parity, and they do not allow the Department of Labor to 
investigate individual insurance companies. They must go 
employer by employer. How ridiculous is that?
    We urge the Congress and the Commission to give the 
Secretary of Labor both the authority and the responsibility to 
fine insurance companies that are not treating addiction with 
parity to all other diseases, and to give the Secretary of 
Labor the authority and the responsibility to be able to 
investigate insurance companies directly, and not have to go 
employer by employer by employer, when we know that we have a 
number of very large insurance companies in this Nation that 
cover thousands of employers. As a former prosecutor, I can 
tell you, one robust investigation is a lot easier to staff 
than 2,000 little ones, and much more effective.
    Lastly, and then I will leave it for questions, because I 
can go on for a long time. Drug court is a very important part 
of this. We need alternatives to incarceration. We have put 
forward in New Jersey the largest criminal justice reform in 
the last two years of any state in America, and one of the 
things we have done is institute drug court in every county in 
our state.
    What does it mean exactly? When you come in, not as a 
dealer, not as a violent actor, but as a non-violent possessor, 
an addict, you are now in New Jersey required by law to go to 
drug court and you are diverted to treatment, not to jail. Now 
if you don't take your treatment seriously and the judge 
decides that you are not utilizing the opportunity that is 
being given to you, they will then send you to jail. But you 
are going to get a chance first to go to treatment. We should 
have drug court, and the Commission recommends this as well, in 
every federal district in this Nation. One judge in every 
federal district committed to dealing with the drug problem in 
this country, to diverting people into treatment and to giving 
those families and those addicts who are suffering from this 
disease hope and opportunity to get better. I am a former 
prosecutor. I am all for jailing people who profit from this 
poison, and I am in favor of putting them in jail whether they 
are standing on a street corner in any town or city in this 
country, or whether they are standing in a hospital or in a 
doctor's office. If you run a pill mill and you have a 
physician, you should go to jail just as soon as this drug 
dealer on the corner should go to jail, but we will not solve 
this problem by incarcerating addicts. And we must get them the 
treatment that they need to be able to have the tools to 
recover.
    In New Jersey, we have now been the first state in the 
country to convert a state prison into a drug treatment 
facility, and so now, state prisoners who are in their final 
year of incarceration who have a demonstrated drug problem 
transfer from a standard state prison to the state prison 
treatment facility that we have on the property of Fort Dix in 
New Jersey run by a certified addiction treatment company that 
works in conjunction with our Department of Corrections to give 
people the tools to deal with their addiction before they leave 
prison, so that when they get back on the street, we lower 
their chance for recidivism. All these things are in the report 
recommended for states and the rest of this country. We are 
proud of Governor Baker, Governor Cooper, Attorney General 
Bondi, Congressman Kennedy, and Professor Madras who joins me 
on the Commission and worked in a completely nonpartisan manner 
to make these recommendations to the President, and I hope that 
the members of Congress work with the President and hold the 
Administration and each other responsible for getting something 
done on this issue.
    Thank you, and I am happy to take questions.
    [The prepared statement of Governor Christie follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    
    Chairman Gowdy. Thank you, Governor Christie. I will now 
recognize the gentleman from Maryland for his questions.
    Mr. Cummings. Thank you very much, Mr. Chairman, and thank 
you, Governor Christie. I want to--and as I said to you before 
the hearing and now, an excellent report.
    I want to talk about naloxone a little bit. I had a 
situation, Governor, where not very long ago I was at an event 
for the Maryland Legislative, my caucus, and I walked outside 
coming out of the event and somebody just dropped a man right 
in front of the hotel. And I said well what's going on? They 
said well this happens all the time. We see people who may be 
at a party and they don't know--the person has an overdose and 
they don't know what to do. And I use that as an introduction 
with regards to naloxone, because of course, as you well know, 
it has been--it is a drug that has been used to save lives with 
regard to overdoses. And in your report, you are saying--this 
is what you said. Price increases of the various forms of 
naloxone continue to create affordability issues, preventing 
state and local governments, as well as community organizations 
from stocking naloxone at the levels necessary to rescue more 
people from the overdose. Is that correct, Governor?
    Governor Christie. That is true, sir, yes, and what we 
recommend in the report is that governments, starting with the 
Federal Government, should band together to use their 
purchasing power to make bulk purchases of naloxone at lower 
prices, and then there is no reason why--we do this in many 
other areas of bulk purchasing, whether it is through the GSA, 
as you know, or through other entities, to be able to do this. 
And there is no reason we shouldn't be able to do this with 
naloxone.
    And one of the things we are doing in New Jersey, which we 
are also recommending in the report, is co-prescribing. When 
you are a physician, you prescribe an opioid, to prescribe at 
the same time naloxone to go to the home, because some of these 
overdoses are not intentional. They are accidental. Someone is 
in severe pain, thinks well if two pills every four hours is 
good, four pills might be better. So it is not just for the 
person who is suffering from addiction, it is also for the 
person who unintentionally misuses this, to have naloxone 
available in the home so that--in an easy form so that the 
folks who live with them, if they have an overdose like the one 
you mentioned outside the hotel, it is--in its nasal form now 
it is very easy. It is two pushes of a button. One in one 
nostril, push the button, one in the other nostril, push the 
button, and you save a life.
    Mr. Cummings. You know, our health commissioner will be 
testifying in a few minutes. It is one who has been very 
strong, Dr. Wen here in Baltimore. You know, but the thing that 
I think bothers me so much about naloxone is that the price was 
jacked up, I mean, big time, when--at the very time when first 
responders and others were trying to get it because they saw 
the effectiveness of it.
    Did you have discussions with any of the manufacturers or 
drug companies with regard to naloxone?
    Governor Christie. We did not in terms of the pricing 
issues----
    Mr. Cummings. Okay.
    Governor Christie. --Congressman. What we did, though, talk 
about was the concept of bulk purchasing and their willingness 
to consider the idea of bulk purchasing lowering prices. And so 
we did talk about that with the manufacturer--with a few of the 
manufacturers, and that is why we urged it in the report. We 
believe it is something that can be done, and that these 
manufacturers recognize. And the Commission emphasized to them 
their social responsibility.
    Mr. Cummings. And that negotiation recommendation that you 
just talked about was in--I noticed it was in the interim 
report, but I didn't see it in the final report.
    Governor Christie. This is some confusion. The way the 
Executive Order was written, Mr. Chairman, was that the 
President wanted first an interim report and then a final 
report. They should not be read as mutually exclusive, they 
should be read together. And so if there is, I think, 56 
recommendations in the final report, there is nine in the 
interim report. We have made 65 recommendations. So the nine 
interim recommendations remain fully enforced and in effect and 
should be added to the final report. So----
    Mr. Cummings. Good. Well I am glad you clarified that. I 
thought you just kind of changed your mind.
    Governor Christie. No, sir. I think you know me well enough 
to know that changing my mind would be a difficult thing.
    Listen, I reminded the White House on a regular basis, and 
you need to know this.
    Mr. Cummings. My last question----
    Governor Christie. This was our report.
    Mr. Cummings. My last question is this. Have you discussed 
this report at length with the President? In particular, have 
you discussed this naloxone recommendation?
    Governor Christie. Yes, I have discussed it with----
    Mr. Cummings. And which response did you get?
    Governor Christie. I did not--let me fully answer this, 
sir. I didn't--we have discussed the report at length. I have 
not discussed the specific pricing issue of naloxone. My 
conversation with the President was more on how important it 
was for all law enforcement officers and first responders to 
have it, but we did not get into the pricing part of it in my 
conversation directly with the President. But I have had that 
conversation with other members of the Administration.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    Governor Christie. Thank you, sir.
    Chairman Gowdy. The gentleman from Maryland yields back. 
The gentleman from Wisconsin is recognized.
    Mr. Grothman. Sure, a couple questions.
    This is really a horrible thing, and I think it is a very 
publicized problem and it is still underpublicized. Did you 
look at other countries who perhaps did not have the opioid 
problems we have? I was in Taiwan like 10 years ago and they 
had almost no problem. Could--I think England has a big 
problem. Could you comment on the criminal justice systems and 
how they deal with possession or sale of opioids in other 
countries?
    Governor Christie. Yeah, we didn't look at it from a 
criminal justice perspective. What we looked at it from was an 
availability perspective, and the biggest difference we see 
between our country and the others is the extraordinary 
overprescribing of these drugs. We believe that part of it was 
caused by the Federal Government, quite frankly, with this, you 
know, pain as a vital sign requirement where everybody who 
leaves the hospital has to have the smiley face, you know, on 
their lack of pain. And the hospitals were evaluated on this 
basis, and so what was going on was hospitals were like heck, 
if we are going to be evaluated on this basis, you are going to 
leave with no pain, and the best way to leave with no pain is 
to give you a whole bottle of Percocet and get you taking it.
    And so the difference is the way at the very base of this 
problem we are dealing with the availability of this 
medication.
    Mr. Grothman. Okay. Do you know anywhere where I would even 
be able to get access to how they treat possession or sale of 
opiates in other countries that don't have this problem?
    Governor Christie. Sure. We--and the Commission can be very 
helpful in that regard, because we dealt with a lot of other 
countries on those issues but not on the particular one you are 
talking about. But we would be happy to help. Could you get 
your staff in touch with ours? We would be happy to help.
    Mr. Grothman. Yeah. Next question I have, what percentage 
of people who are arrested for opiates, heroin or whatever, are 
addicted and what percentage are just using it?
    Governor Christie. I don't know the exact numbers, 
Congressman. What I will tell you is that the rate of addiction 
in terms of the amount of time that it takes someone to get 
addicted to these, according to the CDC, is as little as three 
days. So if you have a predisposition to this, within three 
days of your use you could become addicted. Which is why the 
CDC says their recommendation is to limit prescriptions to no 
more than three days on initial prescription, because they 
think beyond three days you can become addicted.
    Mr. Grothman. Have you talked to anybody who--when you talk 
to people who are arrested for heroin, do they say they were 
addicted in one or two days?
    Governor Christie. I will tell you that this young woman--
yes. The answer is yes, and I have spoken to literally hundreds 
of people across my state in treatment centers about this who 
say that the time for addiction is very brief. I will tell you 
that young--one young woman who is part of our public 
advertising campaign on this issue in New Jersey, it is a young 
woman who suffered an injury, knee injury. She used her first 
bottle of pills. This young woman, who was a college graduate, 
cheerleader in college, went out, had her first job, and she 
was addicted within the first week that she was on these drugs. 
She went from being employed, having her own place to live, 
supporting herself, to within 60 days having lost her job, 
moved out of her apartment, and was living on the streets of 
Atlantic City in New Jersey and prostituting herself to get 
heroin.
    Mr. Grothman. Okay, I will give you one more question 
because I don't see--normally, as you know, on these Committee 
hearings have a clock, but I don't--in Vietnam, as I 
understand, heroin was somewhat widely used, and something has 
been said about how quickly it was not used by the troops once 
they got back in the United States, which would be a little bit 
inconsistent with the idea that heroin is always addicting. Can 
you comment on that?
    Governor Christie. Yeah, I don't think anything is always 
addictive to anybody. I don't think it is always addictive, 
sir. I think there are people, as we know, who use prescription 
opioids and some who use heroin who use it and can use it 
recreationally and not become addicted. So I think we have to 
be very careful about using the phrase always or never in this 
context, because you are dealing with human beings who have 
different genetic backgrounds and make-ups, different 
psychological make-ups, and different physiological make-ups, 
and I think any of the physicians who are here at Johns Hopkins 
would tell you this is what makes what they do an art, as well 
as a science.
    And so no, there is no always on this, sir, but what I 
would tell you is that when CDC says that four out of every 
five heroin addicts start with prescription opioids--and we are 
talking about the same compound--this is something that is 
lethal in terms of its ability to become addictive.
    Mr. Grothman. I will give you one more question.
    Governor Christie. Sure.
    Chairman Gowdy. The red light--if you are wondering where 
the lighting system is, it is right there in front of the 
Governor. Although I am in such a charitable mood, if you do 
have one more short question, emphasis on short.
    Mr. Grothman. Sure. One of the questions--or one of the 
things on treatment is, of course, some people feel that 
treatment is frequently ineffective. Could you give us your 
opinion on what constitutes ineffective treatment or how we can 
avoid ineffective treatment?
    Governor Christie. Well what constitutes ineffective 
treatment is anything that's not evidence-based. And so we 
should not be operating theoretically here, and there is no 
reason to because there is sufficient information across this 
country in the medical community about what works and what 
doesn't, and medication-assisted treatment works for most 
people who try it. The fact is, though, that the way to make 
sure the ineffective treatment isn't happening is through the 
state regulatory bodies who regulate the Departments of Health 
across this country need to be very vigilant about regulating 
what happens in treatment centers. And there are places in this 
country where you have a lot of fallacious treatment.
    I don't want to be the first to shock you and say that 
there is fraud in all different areas of our country when there 
is money to be made. That does not discount the value of 
treatment. What it does is it increases the need for regulatory 
bodies and prosecutors to go after those people who are ripping 
off people by giving them false hope and fake treatment.
    Chairman Gowdy. The gentlelady from the District of 
Columbia is recognized.
    Ms. Norton. I thank you very much, and I want to thank you, 
Mr. Chairman, and the Ranking Member for this very important 
hearing, and I want to thank you, Governor Christie, for coming 
and for your very forthright report which minces no words.
    The last Congress and the last Administration did come 
forward with a billion dollars, but we have seen no slowing in 
this epidemic. Indeed, my own district, which is not considered 
one of the most serious districts, the District of Columbia, 
tripled in this opioid crisis in just two years.
    This notion of a national emergency versus a public health 
emergency has emerged, and I note, Governor Christie, that the 
report indicated that this was a national emergency. Is that 
not the case?
    Governor Christie. Well no, what the report indicates is we 
believe it is a national emergency that can be addressed one of 
two ways, either through the calling of a public health 
emergency under the Public Health Safety Act, which was our 
preferred method, or on the declaring of an emergency under the 
Stafford Act.
    Ms. Norton. Now which--and why did you prefer one to the 
other?
    Governor Christie. Because of who would administer the 
funds. If it is under the Public Health Safety Act, the funds 
will be administered by the Department of Health and Human 
Services. If it was under the Stafford Act, it would be 
administered by FEMA. Having had a little experience with FEMA 
during a small storm in New Jersey, I would just tell you that 
I don't believe, based on my experience, that FEMA would be 
necessarily the best folks to administer these funds, and that 
the folks at Health and Human Services would be better. That is 
why we made that. We gave the President an alternative because 
our--we felt our job was to present alternatives, but I can 
tell you that my recommendation to the President was to do it 
under the Public Health Safety Act so the funds would be in the 
Public Health Emergency Fund; therefore, administered by folks 
who I think--no apparent disrespect to FEMA--that would have a 
greater sense of expertise on how to deal with this issue at 
HHS rather than at FEMA.
    Ms. Norton. You know, I can see that bureaucratic 
difference may make a difference otherwise.
    Governor Christie. Especially if you are a governor who 
dealt with FEMA, it makes a big difference.
    Ms. Norton. You--the region--this region where we are now, 
Maryland, Virginia, the District of Columbia, just had a summit 
on this issue. Governor Hogan has declared a national emergency 
or a state emergency here. I am trying to find whether the 
declaration of a national emergency would encourage Congress 
to, in fact, come forward with farther funding that you 
indicate that you thought was necessary. I mean, your remarks 
were replete with versions of funding one way or the other. You 
asked at the beginning of your testimony what would we pay a 
terrorist, for example, who invaded our country and making that 
analogy to what opioid has done. You have called in your 
testimony for funding the Public Health Emergency Fund for 
funding, NIH, but we sit here and Congress is, frankly, lost 
focus here. In fact, we are not sure whether the government is 
going to be kept open and therefore, nobody is thinking about 
this issue.
    Would declaration of some kind of emergency force this back 
to the front burner of the Congress of the United States, which 
has not funded anything since last Administration funded $1 
billion in additional funding for this emergency?
    Governor Christie. Well with all due respect, I think if 
Congress needs different wording to focus its attention, then 
we need----
    Ms. Norton. Then what would you suggest?
    Governor Christie. --a new Congress because if you can't 
tell from 64,000 Americans dying a day that this is an 
emergency because the President did it under the Public Health 
Safety Act as opposed to Stafford Act, then I would say to 
members of Congress on both sides of the aisle that you need to 
reassess from a Governor's perspective what you are doing. And 
I recognize the billion dollars that the last Administration, 
the last Congress put in. Let me put that into some context of 
what is needed.
    In New Jersey this year, in New Jersey, we are spending 
$500 million.
    Ms. Norton. Of their own money?
    Governor Christie. Yes, state money, $500 million. And so I 
am not, quite frankly, impressed with a billion dollars from 
the Federal Government for the Nation, when the State of New 
Jersey is dedicating from--in a $34 billion budget, we are 
dedicating half a billion dollars just to increasing 
availability for opioid treatment, training, naloxone. All of 
that is being supplied by the state to localities.
    Now we need help from the Federal Government, and I want to 
be clear about the public health emergency. It is a national 
emergency. It is just two different ways of doing it. Whether 
it is under the Public Health Safety Act or the Stafford Act, 
and my recommendation was the Public Health Safety Act to keep 
this away from people who don't know about this problem. There 
is confusion about all this, and you want to see real 
confusion? Let's put FEMA in charge of naloxone. As somebody 
who was, you know, waiting for blankets and food and water in 
Sandy, I don't want to be waiting for FEMA to give me naloxone.
    Ms. Norton. Thank you very much.
    Governor Christie. Thank you.
    Ms. Norton. I see the red light.
    Governor Christie. Thank you, ma'am.
    Chairman Gowdy. The gentleman from Alabama is recognized.
    Mr. Palmer. Thank you, Mr. Chairman.
    Is this on?
    Chairman Gowdy. There you go. Now we can hear you.
    Mr. Palmer. Is the clock started now, or did it----
    Mr. Cummings. It just started.
    Mr. Palmer. No, or did it start after my colleague turned 
on the microphone?
    Chairman Gowdy. I would ask me to--yes, I am restarting. 
Look into the Iron Bowl and how upset you are.
    Mr. Palmer. Don't go there.
    Governor Christie. It is worth at least 15 seconds.
    Mr. Palmer. All right. I just wanted to go back to 
something that was brought up by my colleague from Wisconsin 
about heroin, and as an initiator versus the over-prescription 
of painkillers. And what we found is that in opioid addiction 
as initiated by painkillers like oxycodone and hydrocodone has 
actually gone down from 42.4 percent for oxycodone to 27.8--I 
mean, to 24.1 and from 42.3 percent for hydrocodone to 27.8, 
but in terms of heroin as an initiator, it has gone from 8.7 
percent in 2005 to 33.3 percent in 2015. So I think we are on 
two tracks here, Governor, that I think that the medical 
community has to address, but also the law enforcement 
community has to address.
    Governor Christie. Oh, no question.
    Mr. Palmer. There needs to be a tandem effort.
    Governor Christie. Right, the report talks about that. 
There is no question that we need to make sure that enforcement 
against those--I think I said this in my opening statement, 
that as a former prosecutor, enforcement against those who are 
profiting from the poison that they are spreading throughout 
our communities has to continue, and has to continue 
aggressively. And so I don't think there is any--there is no 
reason you can't chew gum and walk at the same time. The fact 
is that we also need to acknowledge that treatment as a part of 
what our overall spend is across the national government and 
state governments is a fraction of what we spent on 
enforcement.
    And so I want the three-legged stool to operate. I want 
there to be education prevention, interdiction, and law 
enforcement and treatment. But right now, the prevention 
education part of the treatment part are shorter legs of that 
stool, and as long as that continues, we are going to continue 
to have this problem. But you will not find me being opposed to 
stricter enforcement. I am against those who are profiting from 
this, but we must draw a distinction, in my view, between those 
who are profiting from it and committing violent acts in 
support of it, and those who are addicted, and without those 
other elements. Those people I think, in the criminal justice 
system, need to be dealt with differently than those who are 
profiting from it.
    Mr. Palmer. I also think we need to look at this in a 
holistic manner. There is--I don't know anyone who doesn't know 
someone, either a friend who has a family member who hasn't 
lost someone to an opioid overdose. It crosses every boundary 
that you can think of: race, gender, income level, profession. 
But one of the interesting things is--that doesn't get talked 
about is family structure. When you take a look at that, 68 
percent of the population is either married or widowed. Yet 
that only represents 28 percent of the overdose deaths. Whereas 
the never married and divorced population is about 32 percent, 
but they represent 71 percent of the opioid overdoses.
    I would like to see us do a deeper dive into that to start 
looking at the ages in those categories, but I think that has 
got to be part of the discussion is the overall breakdown of 
the family and how that has contributed to this.
    Governor Christie. You know, I think as a father of four, 
married for 31 years, I believe we are doing something right, 
at least, we are trying to. But I also want to be very careful 
about this as well, because there are plenty of folks who are 
in the situation I am who wind up having children who wind up 
addicted. And so there is--part of what we said in the report 
is there is not one silver bullet to fix this problem. There 
just isn't, and whether it is treatment or interdiction, so I 
think all of those things have to be considered and looked at 
as part of what is leading our country to consume 85 percent of 
the world's opioids with four percent of the population. So 
something happened all across our country that is encouraging 
this. But there is no question that all those things have to be 
things that are considered, but I don't want to mislead anyone 
that there is one silver bullet to fix this, because there is 
not.
    Mr. Palmer. Well----
    Governor Christie. I am confident of that.
    Mr. Palmer. --for my own personal experience, one of my 
children's classmates, a tremendously talented young African 
American artist died of an overdose, and then one of my board 
members of the think tank that I ran, I literally sat in their 
living room with them while the local authorities removed the 
body of his son in his bedroom who had died.
    My last point, Mr. Chairman, if I may, is taking a look at 
the drugs prescribed through Tricare and through the VA. I have 
gotten information from different people about the tremendous 
numbers of drugs and--that are sent out that these people don't 
need. This is a huge issue in Alabama. It gets back to where we 
started--or where I started with the overprescribing of 
medicine. If you would like to address that?
    Governor Christie. That is a large part of the diversion 
problem, right, so that that is why we have advocated in the 
report and it is happening, and it is a good partnership with 
the private sector as well. Places like Rite-Aid and Walgreens 
and other major national pharmaceutical--pharmacy chains that 
are setting up kiosks in all their stores for people to safely 
dispose of these unwanted or unused medicines. A lot of times 
what happens is that a young man or young woman in their own 
home, their parents get a prescription for this. They don't use 
the entire prescription and it stays there, and they decide 
heck, I might as well try this. Or worse, they take it out and 
they go to sell it because there is great value on the streets 
for this.
    So the over-prescription of this in every way impacts this 
crisis in an enormous extent, and that is people who overuse it 
themselves, and it is also people who are--don't use it but 
don't know how to get rid of it safely, and as a result it 
winds up hanging around and is available for diversion to 
either other users directly in their home or to be sold outside 
of the home.
    Mr. Palmer. Thank you, Mr.----
    Governor Christie. I do want to mention one other thing, if 
I could, on the VA. We took a field visit as a Commission to 
the Louis Stokes Veterans Hospital in Cleveland, and they are 
doing some extraordinary things in lowering the opioid use by 
veterans with alternative therapies and other ways to deal with 
this issue with our vets, and we versed in the report that 
Secretary Shulkin expand that throughout all the veterans 
hospitals for the very reason you talked about. There are a lot 
of these vets who know they don't want to take this stuff, but 
are in real pain from the war wounds that they have suffered 
defending our country, and they are coming up with alternatives 
that are really helping the veterans community in Cleveland, 
and we think would help the entire country.
    Mr. Palmer. Thank you, Mr. Chairman. I yield back.
    Chairman Gowdy. The gentleman from Missouri is recognized.
    Mr. Clay. Thank you, Governor Christie, for your testimony 
today. You know, while we have made critical gains in coverage 
as a result of the ACA, we still have work to do. We need to 
make sure that they ACA's parity requirement, which requires 
that insurance benefits for our mental healthcare be comparable 
to those for physical healthcare. I guess that is why you 
recommend that the DOL must have authority to investigate 
insurance companies.
    Let me quote the report. It says ``The Commission found 
that there are commercial insurance barriers to Medicaid and 
assisted treatment, despite the fact that such treatment is 
evidence-based and largely successful.'' Would you agree that 
all insurers, both public and private, should work to remove 
barriers?
    Governor Christie. Sure, and that is the law in the 
country. I mean, this is the frustrating thing. Congress passed 
the Mental Health and Addiction Parity Act, but for reasons 
that are beyond me, gave the Executive Branch no ability to 
enforce it. And so we are--I don't want to be, again, New 
Jersey cynical, but we are counting on the goodwill of the 
insurance industry to cover this treatment that is required, 
but there is no penalty for not doing it.
    So my view is as a former prosecutor, the law should be 
followed, and if Congress's will and the President's will at 
that time is to make sure that mental health and addiction is 
treated with parity and physical ailments, then the law should 
be enforced.
    Mr. Clay. So we need to put more teeth in the----
    Governor Christie. You got it. And listen, we had Secretary 
Costa at a hearing of the Commission, and he asked for this 
authority. He said if you give me this authority, I will use 
it. And Chairman Gowdy I think knows that Secretary Costa is 
also a former U.S. attorney who served with me during the Bush 
43 Administration. I know Alex well and I am convinced that 
somebody with his background and experience as a prosecutor in 
Miami on this issue will be very, very aggressive if the tools 
were given to him, and I urge Congress to give him the tools.
    Mr. Clay. Thank you for that response. I represent the 
State of Missouri and I am proud of a lot of things, but one 
issue that I am not that proud of is that we have a patchwork 
for a PDMP in Missouri. It may go by county or by city, but it 
is not really statewide and it is not effective. Talking to law 
enforcement in Missouri, they tell me that it is really 
becoming pill mill, and that is an attraction for users as well 
as physicians who want to make profit off of that.
    Tell me how is Missouri--how do they compare to the rest of 
the Nation as far as being a PNA problem for law enforcement?
    Governor Christie. It pains me to say this to you, sir, but 
it is the worst state in the Nation.
    Mr. Clay. Yeah.
    Governor Christie. It is the only state in the Nation 
without----
    Mr. Clay. No, I appreciate----
    Governor Christie. --a comprehensive----
    Mr. Clay. We need to be critical of our state.
    Governor Christie. It is stunning to me that there is a 
state in this Nation any longer that doesn't have a 
comprehensive prescription drug monitoring program, and that 
they are not sharing that information with their neighbors. We 
know there are people who go from state to state to be able to 
fuel this addiction, and one of the--not only effective law 
enforcement tools, but it is also an effective healthcare tool 
predominantly for our physicians. They can use the PDMP, be 
able to see when someone comes in presenting with symptoms that 
might induce them to prescribe, but if they go the PDMP and see 
that this patient has had a dozen, two dozen, three dozen from 
other doctors prescriptions for this, they can stop adding to 
the problem then.
    So Missouri is a state that is the sole outlier on this 
issue, and one that is damaging the health and the safety and 
welfare, in my view, of the people of Missouri.
    Mr. Clay. And I appreciate hearing that, and I will make 
the effort with our legislature and governor to reinforce it 
and tell him how much we need to get our act together.
    Governor Christie. Yes, sir.
    Mr. Clay. Final question. HHS and CMS now get down to the 
tough work of implementing some of your Commission's report, 
and I understand that hey are calling for states to apply for 
waivers from the IMD exclusion. New Jersey and Utah just got a 
waiver approved, but as I understand it, CMS has insisted that 
waivers are budget neutral, so CMS is asking for states to 
fund--to find cuts elsewhere in underfunded behavioral health 
systems to pay for SUD treatment and residential settings. To 
me, that doesn't reflect the urgency of this epidemic.
    Can you talk to us about how New Jersey dealt with it?
    Governor Christie. Yeah, I think that we are finding 
areas--and this is part of, I think, each governor's 
responsibility, is to find places within the Medicaid program 
where spending is not being effective. And so I think it is a 
good start. I think once we become convinced at the state level 
that we have done what we need to do in terms of cost savings, 
that then the Administration is going to have to make the next 
decision, which is to lift budget neutrality requirements from 
it.
    You will notice in our report we do not ask for a waiver of 
IMD with budget neutrality, we just ask for a waiver of IMD 
exclusions. That is our ultimate recommendation, but I can tell 
you in New Jersey that governing is about choosing, and I do 
believe that given the level of this crisis, I can make the 
choices as governor that are necessary to make those beds 
available almost immediately. But there will come a moment when 
you are cutting into bone and not fat, and when that happens, 
then I think the broader IMD exclusion is something without 
budget neutrality that needs to be considered by the 
Administration.
    Mr. Clay. Thank you for your responses. My time is up.
    Chairman Gowdy. The gentleman from Kentucky is recognized.
    Mr. Comer. Thank you, Chairman Gowdy, and Governor 
Christie, thank you for being here today to discuss the growing 
crisis of substance abuse in our country.
    The opioid epidemic is a particular challenge for my State 
of Kentucky where overdose deaths rose by 12-1/2 percent last 
year alone. I appreciate your work as chairman of the 
President's Commission on Combating Drug Addiction, and look 
forward to working together to make progress on this issue for 
all the American people.
    My first question is I would like to discuss the issue of 
fentanyl, which accounted for nearly half of the overdose 
deaths in Kentucky last year. Can you briefly discuss the 
Commission's findings and recommendations related to this 
especially lethal drug?
    Governor Christie. Yes. Fentanyl and carfentanil is what 
will take this crisis to its next geometric explosion, because 
the strength of fentanyl and carfentanil is so beyond normal 
street heroin that the first usage of it can lead to death, and 
often does. It is so lethal that law enforcement officers who 
come to crime scenes where this is have to be careful in terms 
of the way they deal with the crime scene so they don't 
contaminate themselves and wind up overdosing. And in the 
report, we make it very clear that this is a Chinese problem, 
and we have urged the President and the Secretary of State to 
make this a priority with the Chinese and the negotiations that 
they are undergoing right now. China is where most of the 
fentanyl and carfentanil is coming from, sometimes--more times 
than not, we found--and this is why we recommend an increase in 
border security, not just at the Mexican border, but with the 
United States Postal Service. The United States Postal Service 
is delinquent in stopping these drugs. These drugs are being 
mailed in to the United States, and as are with the other 
carriers like FedEx and UPS and others, we are not having the 
level of enforcement that we need.
    And to your point before, Congressman, you know, this is 
one of those areas where I think we need to be able to step up 
our efforts at the Postal Service and at DOJ through the DEA to 
make sure that we are stopping this stuff from coming into the 
country, but we also need to make very clear to the Chinese 
that this is an act of war. You are sending this into our 
country to kill our people. There is no other purpose for this 
drug. This drug will kill people, and any foreign country, in 
my view, who is wilfully allowing this to be done is committing 
an act of extraordinary aggression on our country and it needs 
to be met with the right type of diplomatic response by the 
Administration and the Secretary of State, and we have urged 
that in the report.
    Mr. Comer. And I appreciate the work that you have done, 
along with the Administration, on seeing a recent crackdown in 
the Chinese manufacturers, and look forward to working with the 
Committee to see what more we can do through the Internet and 
postal systems to try to prevent that.
    My last question, through legislation like the 21st Century 
Cures Act, Congress has worked to provide more support and 
flexibility to states who are on the frontlines of this battle. 
From your experience as governor, as well as your work on the 
Commission, what advice do you have for Congress on how best to 
support state and local efforts to combat opioid epidemic both 
now and over the long term. And I know you mentioned the 
billion dollars didn't go very far when you divide it up among 
the 50 States, but as you know, we are in a financial crisis as 
well in this country so what advice do you have for Congress?
    Governor Christie. Well first off, I think if this battle 
is going to be won, it is going to be won with the Federal 
Government and the state governments acting as partners, but 
with the state governments taking the lead. We are the ones who 
are on the ground, and as you said, the problem in Kentucky is 
different than the problem in New Jersey, and the problem here 
in Maryland is different than the problem in Missouri. These 
are state circumstances depending upon all the different ways 
that you go about enforcement in your state, the ways you go 
about treatment in your state and its availability. So our view 
is that there is--there should be accountability block grants 
that block grants should be sent to the states for dealing with 
this crisis, and that Congress should be demanding 
accountability in return for the block grant. If I am given a 
block grant as a governor, and I say in New Jersey the best way 
for me to spend this money is X, and it will show a decrease in 
deaths, if I show that decrease in deaths, I should continue to 
get my funding. And if I don't, my funding should be reduced. 
To force me as a governor to be accountable for what I am 
doing.
    With all due respect to Congress, you know, it is a very 
difficult job to be able to determine individual programs that 
are necessary and effective in all 50 states, and so I really 
believe we have to trust the governors. And because I don't 
believe this is a partisan issue, I don't think there is a 
Republican or a Democratic way to combat this. So I think part 
of this is going to have to be a leap of faith between Congress 
and the governors to be able to sit down, and I really do 
believe that if Congress is serious about doing this--and the 
President--they need to sit down with the governors. They all 
come to Washington in February. I won't be there, but the rest 
of them will be. And the fact is that we need to sit down and 
say listen to the governors as to what they need and Congress 
then needs to make demands on the governors and say okay, if we 
are going to be partners in this and we are going to help you 
fund this, then what accountability measures are you willing to 
give us so that we can be accountable in the financial 
situation we are in, that this money is being spent in a way 
that is effective to save lives? And that should--in my view 
should be the determining factor. If that number, that 64,000 
continues to go up, we are failing. When it starts to go down, 
we are succeeding.
    Mr. Comer. Well thank you, Governor, and I yield back.
    Chairman Gowdy. I have not gone yet either, so let me share 
this with my colleagues. We want to be a good steward of the 
Governor's time. We also want to be a good steward of the next 
panel's time, so to the extent we can get it done before the 
red light comes on, that would be great for everyone.
    And with that, I would recognize my friend from Michigan, 
Ms. Lawrence.
    Ms. Lawrence. Thank you, Mr. Chairman and Ranking Member 
Cummings, and thank you, Governor, for being here.
    You know, there is a saying that in government, if you want 
to know my priorities, follow my budget. Many of the 
organizations receiving funding through the Community Mental 
Health Block Grant through the Substance Abuse and Mental 
Health Services, and these fundings provide the wraparound 
services. We are talking about the access to the drug, but 
those of in this room and those who have been on the ground 
with this know putting those services to transition and nurture 
a person out of addiction back to a healthy life, training, 
rehabilitation, case management, comes through the Substance 
Abuse and Mental Health Services.
    Unfortunately, the House Appropriation bills which we will 
vote on this month proposes cutting funding for the Community 
Health Mental Health Services Block Grant by $141 million, and 
our President's budget proposed cutting it by 116. Now the 
Commission--and I read your report. Thank you for it, but you 
strongly recommend and urge Congress to do their 
constitutionally delegated duty and appropriate sufficient 
funds. It is--being in Congress and being a former mayor and 
being in local government, sir, being held accountable for my 
budgetary decisions, I find I am perplexed how we can have this 
Commission have--you being appointed, doing all this work, yet 
still what we do in our budget would just cut the legs from 
under this program.
    I need you to know in your leadership and in your 
recommendations to this bipartisan body, this agenda of this 
budget that cuts the thing that we are saying that we are so 
passionate about--we have statistics. I wanted to say in 
Michigan we have enough drugs, like you said, in the United 
States to give every person in the State of Michigan 1.8 
prescriptions, 1.1 prescriptions, which is 84 opioid pills for 
every resident in my state. That is how many prescriptions we 
write.
    So--but if we really want to make a difference, if they 
live, we want to get them off of it. So I need you to comment 
on that.
    Governor Christie. Well yes, and I think we are very clear 
in the report. We believe there needs to be a greater financial 
commitment at all levels of government to this problem.
    Now, you know, the fact is there are lots of other things 
that we can do as well and should be doing that won't cost us 
anything, so increased medical education, increased 
requirements of continuing medical education for DEA licensees. 
There are a lot of good things we can do that don't, but 
please, what we said in the report, we mean, which is that we 
do not sufficiently fund these programs now and we also 
recommend in the report that there needs to be an evaluation of 
all the different programs, and you just mentioned one of them, 
and there are literally dozens and dozens of programs we looked 
at that are being funded. How effective are they? I can tell 
you that GAO did two reports during the Obama Administration 
that said that these programs were not being effective in 
stemming the tide. We know that from the sign that is behind 
all of you, the number of deaths.
    So I think there are a couple of things that need to be 
done. One is to--for us to hold ourselves accountable for all 
the good ideas we have had in the past. Some of them were good 
and some of them weren't. Let's reevaluate it and reassign that 
money to places that we think can be effective, and then there 
is going to have to be additional funds given. And I--we made 
that very clear. I made it clear to the President in my direct 
conversations with him, and every member of Congress who has 
asked me about this, I have said there is no avoiding having to 
increase funding to deal with this problem. The question is how 
and you guys get to make that call.
    Ms. Lawrence. Mr. Governor and to the panel, we often hear 
the thing of repeal and replace the Affordable Care Act, and I 
equate that to you having a Cadillac and you don't change the 
oil or you don't rotate the tires, and then when the car 
doesn't operate, you say that the car is inefficient and you 
just throw it away.
    The Affordable Healthcare Act is--provides essential health 
benefit services that actually directly go to the mental health 
parity part, but all we talk about is repeal and replace, and I 
don't know if you are comfortable talking about this, but I am 
very comfortable. It is a time for us to have real discussion 
on this. We talk about the lives that we are losing, and we are 
so compassionate and our hearts break when we read the 
obituaries, but we must do the work. And I want to be that 
voice in the room while we are talking about this, the action 
that needs to be taken needs to happen. It is not good enough 
to get a Commission together, write an excellent report, if you 
don't fund it. If you don't look at the Affordable Healthcare 
Act that had those essential services that we are saying 
eliminate, how are we going to get to where we need to go?
    Thank you so much. My red light is on.
    Governor Christie. One thing I would just quickly in 
response to that say to you is we need to remember that no 
matter--my position on the Affordable Healthcare Act is pretty 
clear over time, but I won't get into all of that. I will just 
tell you this. The Affordable Healthcare Act insures a fraction 
of the number of people that private health insurance in this 
country insures, and yet, Congress is not permitting mental 
health and addiction parity to be enforced for them. And so, 
you know, the fact is that we have tens of millions of 
Americans who work hard every day and are able to obtain health 
insurance through their employer and pay for a good part of 
that as well, and they are not getting the benefit of the law 
and parity either.
    And so I don't think it is just in talking about the 
Affordable Healthcare Act, we are not enforcing that as the 
Affordable Healthcare Act. We are not enforcing that as to 
private insurers. You want to talk about a feel good piece of 
legislation, okay, the Mental Health and Addiction Parity Act 
is a feel good piece of legislation, because when all you do is 
ask would you please do this, and if you don't, there is no 
penalty, we know what happens in those circumstances.
    And so I think we have to have even a broader discussion 
about it, because it is not just for those people who are 
covered now under ACA, it is also those people who have been 
covered under private insurance for a very long time who are 
not getting the benefit of that law that is now a decade old. 
We have not been enforcing that law since the day we passed it. 
So it seems to be we got to have an even broader discussion 
that I think includes all of that.
    Ms. Lawrence. We have to do the work.
    Governor Christie. Right.
    Chairman Gowdy. Professor Raskin?
    Mr. Raskin. Mr. Chairman, thank you. Governor Christie, 
again welcome to Maryland. I want to, first of all, salute you 
for the passionate intensity of your leadership of this 
Commission and the way that you have clearly absorbed all of 
the lessons of it in a powerful way. And I also want to thank 
you for the comprehensive nature of the recommendations that 
are in the report, which have--which include messages for us in 
Congress, and I very much take your point about empowering the 
Secretary of Labor to act, and I hope that is one of the things 
that will come out very concretely from today's session. But 
also, there are a whole series of recommendations across the 
Federal Government, the Department of Education, the Department 
of Justice, the National Highway Traffic Safety Administration, 
HHS, and so on.
    So I know you are a big Bruce Springsteen fan. Who is the 
boss now? In other words, who is in charge of implementing all 
these recommendations across the Federal Government and being 
the leader and making sure that these things comes to fruition?
    Governor Christie. Well first and foremost, the President 
has to be the leader. He is the person who empowered this 
Commission, and he is the leader of the Executive Branch of 
government and it is his responsibility under the Constitution 
to make sure that the laws are duly executed. So the buck stops 
with the President of the United States, and I am confident 
that the President is serious about this effort and will put 
the resources that are necessary to do it.
    Mr. Raskin. Can I just follow up on that point? So I was 
following your work very closely. You came out with the 
Commission report on November the 1st, I think it was. It was 
just----
    Governor Christie. Yes, it was.
    Mr. Raskin. --earlier this month. Did you come down and 
have a session with the President and his advisors about 
everything that is in this report and talk about what the next 
steps are?
    Governor Christie. Yes, sir.
    Mr. Raskin. Okay, and what came of that meeting? I mean, 
has he appointed--is there an opioid crisis czar in the White 
House now?
    Governor Christie. Not to the best of my knowledge.
    Mr. Raskin. Should there be one?
    Governor Christie. Listen, I think as a governor, you know, 
the czar I think sometimes gets a little overplayed. I think 
the fact is the President needs to give direction to his new 
HHS Secretary. Because if you look at the recommendations, you 
are right that they are all across government. That is why at 
every one of the Commission hearings, we had the Deputy 
Attorney General, we had the Secretary of HHS until there was a 
change there, and then the Acting Secretary. We had Secretary 
of Labor. We had the Secretary of Veterans Affairs. All of 
those individual cabinet officers I think need to be empowered 
to take the section of the report that is theirs and report 
back to the President on what they are doing on a regular basis 
to implement it.
    Mr. Raskin. But you--but as a governor, you also know if 
everyone is responsible, no one is responsible.
    Governor Christie. The President is responsible.
    Mr. Raskin. Okay, well----
    Governor Christie. It is----
    Mr. Raskin. --with no respect to the President then, I 
mean, we have tweets about people kneeling during the playing 
of the National Anthem. We have tweets about who got the 
Americans out of China from shoplifting charges. I haven't seen 
any tweets about the opioid crisis, and I don't see the kind of 
passionate intensity of leadership that we need to deal with 
what you described as the equivalent of a 9-11 every two weeks 
in the United States of America.
    Governor Christie. Well let me respectfully say this. 
Before this President, you didn't see a national Commission on 
this problem. This problem didn't just start on January 20 of 
2017. This problem was building for years before this, and 
neither President Obama nor President Bush empowered a national 
Commission to come up with recommendations, put absolutely no 
restrictions on that national Commission on what restrictions--
what recommendations I could make. This President is the 
President who has declared a national emergency. This President 
is the one who has begun to grant IMD waivers. This President 
is the one who is taking the leadership on this.
    So listen----
    Mr. Raskin. I am just asking about constructively moving 
forward----
    Governor Christie. But that is----
    Mr. Raskin. --how do we make sure that--you know, there are 
dozens of recommendations in here. How do we make sure that 
they actually get into practice at every level of government?
    Governor Christie. Well there are a few ways. First of all, 
the President of the United States is the Chief Executive and 
he should require of those men and woman who serve in the 
Cabinet offices that he has appointed them to that are covered 
in this report to report to him on the progress they are making 
in implementing the report. I don't think that requires another 
person sitting in the office in the executive office building, 
you know, sending out emails, with all due respect. I, as a 
governor, I hire cabinet people. Those cabinet people are 
supposed to run those departments and I think that is what the 
President is going to require of them, but more importantly, 
what they have seen is that this President is the first 
President who has elevated this to this level, and he deserves 
great credit for that. And I know it is very fashionable right 
now in lots of different corners to be critical of all those 
different things, and I have been critical of some of it 
myself, but I don't believe it is right at this moment in time 
to be critical of the President's efforts in this regard, and 
he will be held to account for what he produces.
    But I would also say that Congress has to step up as well, 
and this is not just the President's responsibility, but every 
person sitting up here and every other member of the 535 of you 
know about this problem. You didn't need my report. Our report 
gives you some good recommendations, but what you know is that 
people are dying in your district every day. And so I would say 
what are members of Congress doing as well to demand that this 
be done? If that happens, then there will be a cacophony in 
that city which will force action from both the Executive and 
the Legislative branch.
    Mr. Raskin. Thank you, Mr. Chairman.
    Chairman Gowdy. Gentleman from Vermont, Mr. Welch.
    Mr. Welch. I will try to be quick in light of your 
admonition.
    Number one, Governor Christie, greetings from Governor 
Shumlin. He gave the State of the State in 2014 where it was 
totally dedicated to opiate crisis, and I remember many of my 
colleagues wondered why in the world would you do that, and 
then started acknowledging that this is a huge problem in their 
states.
    Second, we need concrete actions. There is bipartisan 
concern about this issue. There is bipartisan conflict about 
spending on just about anything. But you outlined some concrete 
things we could do. For instance, if we can't appropriate 
money, which I would be in favor of, many people here would be, 
we can at least deal with the drug company rip-offs, and you 
acknowledged that cost increase that is really becoming an 
enormous burden on our local communities that are on the 
frontlines of trying to address this.
    So my--I want to ask you this question and then I will 
stop. The ideal outcome here is that Congress would step up and 
find the areas where we can act that it would make a 
difference, like addressing the cost issue, like the 
prescription issue. And my question to you is what would be 
your advice to this Committee, knowing that we are divided on 
many issues, but we have a common concern about this horrible 
scourge in our communities. What are the three things you would 
recommend for us to do?
    Governor Christie. You know, you are asking me to take 65 
recommendations and boil it down to three. I am pretty good, 
but I am not that good.
    I would just tell you this, that the first thing we need to 
make sure we do on the supply side is to nip this fentanyl and 
carfentanil problem in the bud. If we don't, 64,000 is going to 
look like the good old days. And so our interaction with the 
Chinese on this needs to be unequivocal, and our ability to 
invest in making sure that we are stopping this as best we can 
from coming into our country is going to be enormously 
important, because fentanyl and carfentanil is going to make 
heroin and prescription opioids look like child's play.
    Secondly, I would say that the issue of education of our 
medical community, and I include the pharmaceutical companies 
in this, about the danger of these drugs and having a real 
national conversation on the cost benefit of using these drugs 
has to happen. With this many deaths--and I understand pain is 
real and the Chairman is right in his recommendation on that, 
that we need to deal with those folks who need to get to work 
every day and suffer from chronic pain, but I can tell you we 
are losing that fight. We are losing that fight because that 
homebuilder can't go to work if he is dead. And so, you know, 
we need to try to have a conversation about that with our 
medical community and get them more tuned to the fact that this 
is killing people.
    Third, I would say we have to fund greater treatment in 
this country. We just have to. And so if you made me come down 
to three, I would say fentanyl and carfentanil and the 
interaction with the Chinese and our own law enforcement has to 
be strengthened, and our communications with the Chinese on 
this has to be unequivocal and see it as an attack on our 
country and its people. Secondly, we need to work on medical 
education because our medical community is not educated enough 
at this time on this issue across the country, and that is why 
we also recommend things like, you know, distance, you know, 
treatment of folks who are in rural areas, can't get to a 
physician, being able to do that stuff in different ways is 
very important to do. And then lastly, we have underfunded 
treatment in this country and we need to make treatment more 
available to folks. I think it was as Member Cummings said in 
his remarks quoting the report, ``When 10.6 percent of the 
people who need treatment are getting treatment, we need to do 
better.'' And I think if you maybe boiled down 65 to three, I 
would go with those three. And I am sure when I leave, I will 
kick myself for not having picked a different one.
    Mr. Welch. Thank you very much.
    Mr. Cummings. Yield?
    Mr. Welch. I yield back. I yield to----
    Mr. Cummings. Just one question. I told the Chairman just a 
moment ago that this is one of your finest moments, and I 
really mean that. And I got to ask this question, because I 
think it is critical.
    How can you, Governor, with your passion and your full 
understanding and embracing of this issue, how can you help us 
bridge the gap between Republicans and Democrats so that we can 
get something done on this? And I mean--I don't mean to put you 
on the spot, but I mean, it is a critical moment. And when you 
just said what you said about fentanyl, we got to do something, 
and you seem to have pulled it all together and come out with a 
very balanced report so that we can be effective and efficient, 
and that is all.
    Governor Christie. Well I appreciate the opportunity. I 
don't feel burdened by it at all, by your question.
    The fact is that I will play any role that leaders of both 
the Congress and Administration want me to play as a private 
citizen in 49 days to be able to continue this fight. Mr. 
Cummings, this is something that began to be passionate for me 
in 1995 when as a local county official, I was brought to a 
drug treatment center in my county for adolescents, and I saw 
what was going on there. And the priest who started this 
treatment facility said to me at the end of my visit, Chris, 
this is something you are going to want to be involved in for 
the rest of your life. Now in 1995 I was 32 years old. The rest 
of my life seemed a lot longer than it does right now, but I 
said to him Father, with all due respect, I mean, why am I the 
one being involved in this the rest of my life? And he said 
because you just walked out of a place where God makes miracles 
happen on Earth.
    And from that moment on, Mr. Cummings, I have been hooked 
on this problem and on saving lives. And so you can see what 
happened in New Jersey. I have worked as a Republican governor 
every one of my 2,920 days with a Democratic legislature, and 
with broad majorities, yet the package that we have done on 
this twice has passed overwhelmingly bipartisan majorities. And 
I gave my State of the State in 2016 on this with a package of 
reforms to insurance, to pharmaceutical companies. All things 
that are difficult things to do, they passed within 30 days and 
were signed.
    I am happy at any time, sir, at the encouragement of the 
chairman or of you to come and speak and meet with anyone and 
to use my relationship with the President, which goes back 15 
years, to encourage people to say this is the new water's edge 
in our Nation's conversation. We have to end the politics here. 
We have to compromise with each other. There are going to be 
some things that people on my side of the aisle are going to 
have to vote to fund that they may have some concerns about, 
and there is some flexibility and trust that folks on your side 
of the aisle may have to give to governors that you are not 
normally accustomed to doing. But I think I can speak to that 
directly, and you have my word that I will not only speak out 
and continue to speak out publicly, but I am cool with every 
role you two gentlemen want me to play in helping you to do 
this, and the President knows I that I feel exactly the same 
way. And I am one of the folks who has known him for 15 years, 
so when he needs to hear some truth, he comes to New Jersey not 
just to play golf. Let's put it that way.
    Chairman Gowdy. Gentleman from Maryland is recognized.
    Mr. Sarbanes. Thank you, Mr. Chairman, and thanks for the 
opportunity to sit in on the hearing today. Governor, thank you 
for your testimony and thank you for the report of the 
Commission, which I think is outstanding and has a myriad of 
very positive recommendations that we need to--probably need to 
prioritize so that we can make forward progress. But I think a 
lot of the building blocks are there.
    We are very proud of the efforts here in Baltimore that our 
health commissioner, Leana Wen, who we will hear from shortly, 
has undertaken that healthcare providers, institutions like 
Johns Hopkins and others, are undertaking to change the 
trajectory on this. It is obviously a heavy lift. But these 
recommendations will help.
    I want to echo Congressman Cummings' concern about making 
sure that naloxone is available in a way that it should be and 
there is not price gouging going on around that. I think that 
does need a closer look. I was able--and I want to thank you 
for the recommendation around co-prescribing of naloxone. We 
were able to get included in one of the bills that was passed 
last year, the Comprehensive Addiction Recovery Act, a proposal 
for demonstration project on co-prescribing of naloxone, to 
examine best practices around that, your recommendations, in a 
sense, are running along side that in a very positive way, so 
we thank you for that.
    My question is this. I would imagine that you don't think 
yet that the sense of urgency that needs to be in the country 
around this issue is there, but it is changing. And as I move 
around in my district--and I am sure this is the experience of 
others--not only are you hearing about these tragedies that 
raise your awareness, but you are also hearing people say 
things like, you know, I went to my doctor the other day. I 
went to the dentist, and they gave me a prescription for this 
Oxycontin or something like that, and all I really needed was 
Tylenol. So patients are starting to step back from this, so 
something is getting to them. There is beginning to be a level 
of public awareness around this.
    When will you look at the situation, based on your 
experience and being involved with this Commission, and what 
will you see? What will be the indications to you that the 
level of urgency is where it needs to be among policymakers 
that the level of education and awareness out in the public is 
where it needs to be? Is it PSAs coming across the airwaves in 
a way that matches, you know, election time in a swing election 
somewhere? Is it the President getting a briefing every Monday 
morning on what the status is with all the steps that are being 
taken with respect to addressing this crisis? What are the 
indicators that you are looking for to say to yourself we are 
starting to get it here?
    Governor Christie. That is a really good question, 
Congressman. Thank you.
    So I have been asked this before. Someone in their remarks, 
I forget which member said it, talked about this epidemic being 
in greater numbers of deaths now than the AIDS crisis at the 
peak of the AIDS crisis in the mid-1980s. I was alive then, and 
a young adult, and here is what I think. Were are the marches?
    See, I remember the AIDS epidemic and I remember marches in 
every major city in this country, and in Washington, D.C., with 
people marching to say the government must do something to find 
a way to stem the deaths. In this crisis, there are many, many, 
many more people impacted than were impacted in the AIDS 
crisis, yet we have no marching. And I will tell you that I 
think we will have seen that we have begun to remove the stigma 
of this disease when the people who are impacted are willing to 
show their face and march and demand from their government a 
response. And I believe they don't march today because they are 
ashamed to march, because they don't want to be identified--I 
am not talking about everybody, but I am talking about mass 
numbers. They don't want to march. They don't want to be 
identified as this having happened in their family to their 
loved one. And I think that that is why we recommended a 
national advertising campaign beyond PSAs.
    I will tell you, in New Jersey in this year, we will spend 
$50 million on an advertising campaign in my state to remove 
stigma and to let people know how to get treatment, $50 million 
of state money. And the reason we are doing it is because I 
don't want people to be stigmatized anymore for this and to 
avoid treatment and avoid asking for help and avoid demanding 
that there be something done about this.
    I will tell you one quick story. My mother was an addict. 
She was addicted to nicotine. She began smoking when she was 16 
years old, and she smoked for 55 years and she tried everything 
that she could to quit, and she couldn't. And when she 
inevitably, it seemed, was diagnosed with lung cancer at the 
age of 71, nobody said to me well, your mother was smoking for 
55 years. She has known since 1964 that it could cause cancer. 
She is getting what she deserved. No one said that. People said 
oh, we are so sorry for your mom. What can we do to help? Let's 
recommend doctors or treatments, that she go to this hospital 
or that hospital. We are praying for you. They came and visited 
her. They consoled her. They encouraged her. And I felt no 
shame in telling people that my mother had lung cancer and that 
her lung cancer was caused by smoking. I want to ask you, sir, 
if my mother was a heroin addict, would I have done the same 
thing? And would all those people have come to her aid and 
recommended treatments and help? Would my dad have been willing 
to ask for that?
    I will know that we are at the brink of the urgency to this 
when those barriers go away, when people march to demand that 
Congress and the President and their government along with our 
private sector find treatments to treat people who are addicted 
and to find ways for them not to get addicted in the first 
place by alternative medicines. I will believe it when people 
are marching and showing their faces. And when that happens, we 
will know that we are on our way to a solution, and that is why 
I firmly believe in my heart and I believe the stigma is 
causing death every day, almost as much as the drug is itself.
    Mr. Sarbanes. Thank you. I yield back.
    Chairman Gowdy. The gentleman from Maryland is recognized.
    Mr. Ruppersberger. Yes. Thank you, Chairman Gowdy and 
Ranking Member Cummings, thank you for having this hearing in 
Baltimore. It is such an important area, and to all our members 
on both sides of the aisle, welcome to Baltimore.
    Governor--and I want to acknowledge Dr. Wen, who has done a 
lot in the Baltimore area.
    Governor, I think you are at the right place at the right 
time. You were in local government. You were a prosecutor. You 
managed a major jurisdiction. That is kind of my life, local 
government and managing a jurisdiction, except I am in Congress 
and you are a governor. And I really appreciate the fact that 
you have made this one of your highest priorities. When you 
leave office, probably it will dominate your life for a while.
    Now there are a couple suggestions that I do have, though, 
and to make sure that we pull all this together. The first 
thing when you have a major crisis, you have got to identify 
the problem, and I think these hearings--we understand it with 
the deaths throughout the country, it is a national issue. It 
is not just in urban areas, rural areas, everywhere. But the 
part that I am interested in--I am an appropriator, and you 
know, one of the issues that we have to deal with is clearly 
money, and you know, we have to have that. There has been a lot 
of money put into this. There are other areas as far as 
treatment and drug--doctors, nurses, treatment centers, all 
those types of things. But I know in your report, which is a 
good report--I haven't read it, but I have heard and I have 
been briefed on it. There are a lot of recommendations, and 
when you have that many recommendations, you have to pick 
priorities. But I think for us to get to the level--those of us 
who are appropriators, we are going to have to find out what 
your recommendations are for money, especially from the Federal 
Government. We have to have a number, and I would hope that 
your Committee or your staff on your Committee to start putting 
together a report.
    The second thing is there is no question you said that 
Congress maintains the power of the purse. But in this 
situation, the President who has within his power as President 
to free up funding as well. And I am glad the President has 
made this a priority, but everything in life you have to have 
follow through. And what your relationship--I didn't know you 
knew the President for 15 years, that is even better--and with 
your tenacity, with your experience in all the areas that I 
talked about, I would like to know what your plan would be to 
work with his advisors, his Administration, to make sure we 
find out where we are as far as the money.
    Our governor, and I praise him, has--Governor Hogan has 
dedicated $10 million per year for the next five years to fight 
this epidemic. I think other governors throughout the country 
need to do that too, whether Republican or Democrat. And this 
is not a partisan issue. If there is anything that is partisan, 
this can't be the case.
    So my question to you is, first thing, can you decide what 
the recommendations would be as far as funding is concerned? 
When we find that number, we will work with you. I will pledge 
to work with you as other appropriators, Democrats and 
Republicans, to find a way to get Congress to fund this issue 
and also to get the President.
    You know, Congresswoman Brenda Lawrence made a comment 
about certain cuts that are already there, so if the President 
has made this such a high priority, we are going to have to 
influence it. We are going to have to find a way to get him to 
make this a high priority to go forward in what we need to do.
    Governor Christie. Sure, a few things. I think when you say 
the Commission or my staff, I want to be clear. My staff is 
sitting right over there. My chief of staff in the governor's 
office was the main staffer. We were not given staff on this. 
We had some support from ONDCP, but I will tell you that the 
work that you see in that report is the product of the 
Commissioners, and so we did not get into an amount of money, 
and quite frankly, I didn't think it was our province to do 
that. We laid out the priorities that we believe are very 
important, and we believe that every one of those are important 
priorities.
    Now I know from personal experience that governing is 
choosing, but the choosing now needs to be done by the 
President and the Congress, not by an unelected Commission. We 
have laid out all the things that we think need to be done in 
both near term and long term. Now I really believe it is up to 
the leadership of the Congress and the President, along with 
the appropriate Cabinet members, to sit down and to say how do 
we implement this plan? How do we want to do that? And I don't 
think--listen. I have done this stuff as a governor, but no one 
elected me to do this. And I really believe that all of you are 
the ones who have both the authority and the responsibility to 
do it. I am happy to identify the problem and identify 
solutions and bring a practical opinion to it, but I don't 
believe it is my realm to talk about how much.
    Mr. Ruppersberger. I respect you, what you have done, but 
you are the man and if you can't do it, nobody can.
    Governor Christie. I am going to have you call my wife and 
tell her that.
    Mr. Ruppersberger. You have the expertise, you are an 
advocate, you have committed. But if you don't have the money, 
it is not going to work.
    Governor Christie. I agree with you.
    Mr. Ruppersberger. So we need you to be not only the 
advocate, we need you to be the lobbyist. We will work with 
you. We will--I will--Democratic and Republican staff, I 
guarantee you on the Appropriations Committee on the House will 
come together. But we need your expertise and your advocacy, 
especially when it comes to this President.
    Governor Christie. Sure. Listen, I--as I said to both Mr. 
Cummings and Chairman Gowdy, I am and will continue to be 
available to all the folks on this Committee and other members 
of Congress who care passionately about this issue to give you 
my advice, my counsel, my opinions, and to be an advocate. I am 
going to continue to be an advocate no matter who is in the 
Congress, no matter who is in the White House. I have been an 
advocate on this issue for 22 years. I am going to continue to 
be an advocate on this issue because in my heart, I believe 
that the most important role of government is to protect the 
health, safety, and welfare of its citizens. And this is right 
at the core of that, so--I don't know if I like the phrase 
lobbyist that you threw in there at the end, but I will 
certainly be----
    Mr. Ruppersberger. Persuader.
    Governor Christie. Yeah, I will be an advocate for this and 
I have been an advocate with the President all along, and I 
will continue to be.
    Mr. Ruppersberger. My time is up, but my staff--I want to 
reach out to your staff to find a way how we can start working 
on the numbers.
    Governor Christie. Excellent.
    Mr. Ruppersberger. That is end game.
    Governor Christie. I look forward to it, sir.
    Chairman Gowdy. Gentleman from Maryland yields back. 
Governor, I want to thank you on behalf of everybody for--not 
just for being here and sharing your perspective today, but for 
the hard work the Commission did.
    I go last when it comes to questioning, and I want you to--
while we appreciate the audience that is here, they would be 
the upper echelon in terms of engagement and education. I want 
you to think of broader audience, broader jury, our fellow 
citizens that have heard about the epidemic, perhaps someone 
close to their family has been touched by it, but they don't 
live and breathe it every day.
    As I listened to your opening, you can put physicians, I 
guess, in one of three categories. The vast majority of 
physicians are incredibly well-intentioned and they are well 
trained and they are well educated and they do it the right way 
for the right reasons. And then you have a group that is 
equally well-intentioned, but they lack the education on it, 
and you made reference to continuing legal education, 
continuing medical education. There is that group, and I don't 
know how big it is. Our perspective is swayed by being 
prosecutors. There is that group that is profiting from 
people's addiction, and I don't see the diversion cases being 
prosecuted like I did in olden days. Am I missing it? Did you 
all find it?
    Governor Christie. No, I don't think you are missing it. I 
do think that there has been over the course of the last decade 
or so a de-emphasis on that priority, and I think it is a 
mistake. It is--I often think, Mr. Chairman, that folks believe 
that to emphasize one issue is to deemphasize another.
    So in New Jersey, for instance, we have done broad criminal 
justice reform that has lowered our prison population more than 
any state in the country. During my time as governor, we have 
closed two state prisons. Yet our crime rate is down 
significantly in our state. That doesn't mean that I don't want 
to see my attorney general continuing--and he has--to 
continually aggressively pursue the drug dealers in our state 
who are killing our people.
    I think that sometimes justice departments, which we have 
both been members of, think that if you are in favor of 
criminal justice reform, you can't be in favor of aggressive 
prosecution of criminals. Or if you are in favor of aggressive 
prosecution of criminals, you can't be for criminal justice 
reform. I don't believe that, and I think as governor it has 
taught me even more than as a prosecutor, the Federal 
Government, in my view, over the last decade has dropped the 
ball on these cases. And I think that it is contributing--not 
causing, but contributing to the problem that we have today. 
And that is why I am not in favor of shortening the leg on the 
stool of enforcement interdiction. We need to continue to do 
that and do it aggressively. I have shared that opinion with 
General Sessions, and I believe he understands that piece of 
it. But that message has to get out to the U.S. attorneys, and 
that can only come from the attorney general and the deputy 
attorney general. You and I both know, and when you were a U.S. 
attorney, it is kind of like being the captain of a ship out at 
sea, you know. Sometime the radio works from the shore, and 
sometimes maybe you can't hear it quite as loudly. We need to 
make sure the radio is working on this one, and that U.S. 
attorneys are not given an option, but are given a directive 
from their boss, the Attorney General of the United States, 
that these are important cases to do. That doesn't lessen our 
commitment to providing more treatment. It doesn't lessen our 
commitment to confronting the Chinese on what they are doing 
and using our foreign policy tools in addition to law 
enforcement in doing that, and it doesn't mean that we don't 
believe that education and prevention are really important. We 
didn't talk about that today, but let me say in conclusion 
here, from my perspective that if we don't start talking to our 
children in the middle school about this issue, we will lose 
them. And it is frightening to me as a father to think that my 
11 and 12-year-old daughter or son needs to be spoken to about 
this issue in stark terms, but they do.
    And we can't do it anymore. I saw from the Department of 
Education they were very proud. They showed me when I first 
came to--oh, we have this new pamphlet that we are going to be 
giving out in schools on this issue. And I looked at it and I 
said so listen, it is a great pamphlet. I read it. There is a 
lot of good information. I said if my kids got this pamphlet, 
it would go in their backpack. By the end of the school year, 
it would be all the way at the bottom of their backpack, and 
they would never read it. Because if it is not on here, they 
don't read it. We need to modernize the way we are educating 
our children. We should be demanding of companies like Google 
and Facebook who are such predominant players in communication 
today to our young people, that they step up to the plate and 
start educating our kids on the things that we need to do.
    So what I am saying to you is we have dropped the ball in 
my view in the last decade since I have left the Justice 
Department in 2008 in doing these cases. We need to do them to 
slow the supply, but we also need to make sure that we are 
doing those other things as well. And this is the bipartisan 
nature of it, and I believe that Mr. Cummings agrees with this 
as well. We have got to get rid of our old barriers on this 
issue, to think that if you are for one thing, you must be 
reflexively against the other, and vice versa. We can do both 
and we must do both. And there are people of goodwill and great 
experience who are ready to help to do this, and I hope that 
they are called upon to do it, and I count myself as one of 
them, and I will allow myself to be called upon to do it.
    And so I think you make a very good point, Mr. Chairman, 
and I think we need to make sure that we don't get caught in 
the trap of mutual exclusivity. It is a trap that will lead to 
failure, and failure we can't afford.
    Chairman Gowdy. Well I want to finish up with drug courts, 
because we agree on that. If you want to not only have your own 
life change, but see other people's lives change, attend a 
graduation for a drug court. That graduation ceremony will be 
with you for the rest of your life. And I want to mention one 
kind of a niche issue there at the end. I also want you to 
address what barriers did you find, if any, for the 
pharmaceutical alternatives, non-habitual aiding, non-addictive 
pharmaceutical alternative. What are the barriers to either 
having them researched, developed, or to market?
    Governor Christie. They don't believe they are going to be 
profitable. I think that is the single biggest barrier to it, 
and that is why I believe bring NIH in as a partner to be a 
fair broker of the compounds and say which ones are most 
effective, and let's move those most effective ones to the 
front of the line and allow them to go to market, and let's see 
how it goes.
    What I say--and listen, you know that New Jersey has more 
pharmaceutical companies than any state in the country, and so 
I am very sensitive to the importance of the pharmaceutical 
industry, the role that they play in our country as an economic 
driver, in addition to being a healer. And I am an advocate for 
the pharmaceutical industry. But what I reminded my friends in 
the pharmaceutical industry is they have a social 
responsibility that goes along with that, and that to stand by 
and not develop these compounds purely on the basis of concern 
about profitability is to, in my view, walk away from part of 
your social responsibility as a corporate citizen in this 
country.
    Now NIH needs, I think, to be a fair broker in all this so 
that the right compounds get the right money spent on them to 
develop them, but what I heard from them was the biggest 
concern was an issue of--with the R&D money that they have 
available, is this the best way to spend that money for our 
shareholders? And that is an absolutely legitimate fiduciary 
concern that they need to have under our laws and our system 
of--our economic system, but they also have a social 
responsibility as well.
    And so what I would say and what we did say to 
pharmaceutical companies is would you trust NIH to be a fair 
broker on, say, okay, all 43 of these compounds don't need to 
be developed, but these five have real potential to be non-
addictive pain relief and/or great medication assisted 
treatment to help those who are already addicted. And the 
pharmaceutical companies at that meeting in New Jersey agreed 
to submit their compounds to NIH. What we need to make sure of 
now is that NIH has the funding to make sure that they complete 
that job. If they do--I know Dr. Collins is really committed to 
this. If they do, we are going to get some of those compounds 
onto the market, and that is going to help significantly. 
Because I know physicians would much rather prescribe a pain 
reliever that is non-addictive but effective, rather than one 
that is addictive.
    Chairman Gowdy. You mentioned though the phrase social 
responsibility--this will be my last point.
    In addition to being a colleague, one of my favorite 
colleagues in the entire body, Peter Welch, is also a former 
public defender, and his clients would have been incredibly 
fortunate to have him. In South Carolina, I saw sometimes in 
the state system, public defenders would opt for straight 
probation as opposed to drug court because it was easier. Now 
that is not in their client's best interest. Their client will 
remain an addict. But they are right. Straight probation is 
easier than drug court. How do we develop around the grant 
strategy in sending the defense attorney, the public defender 
to encourage their client to go get help as opposed to just 
being on probation for the next 12 months and remaining an 
addict?
    Governor Christie. Well let me tell you, in New Jersey what 
we did was we took away the option. You don't have the option 
of probation anymore. Your option is this: go to treatment or 
go to jail. Now when given that option, it is kind of the 
gentle encouragement I am known for, Mr. Chairman. You know, it 
is--and where a lot of people absolutely opposed that, said how 
dare you do that. If they are not ready, they shouldn't go. I 
said I have never met an addict who is ready. I have never met 
an addict who is ready. I have done interventions. I have never 
seen a--I had a great friend of mine who sat there and argued 
with me that I was wrong that he was addicted, he didn't need 
treatment. He was fine. Well he is dead now, and the fact is I 
have never met an addict who was ready.
    So I think one of the things that you could work on from a 
grant structure perspective is to say that we want to encourage 
those programs that don't give an option, that your option--you 
don't have a probation option, because I know. I know exactly 
what you are talking about. That was happening in my state 
before we passed this law. Now defense attorneys have a really 
easy equation to give their clients. You can go to drug court 
and go into treatment, or you can go to state prison. And what 
we are finding is most people are choosing treatment. And even 
when they don't think they are ready and what has happened--you 
talked about drug court graduations. The miracle of those drug 
court graduations is, in my mind, not the young men and women 
and older men and women that I am sitting with on stage, it is 
looking out in the audience at their families. Their lives are 
hopeful again. Their eyes are lit with joy for the restoration 
of a life that they initially brought onto the earth, and which 
they had almost given up on.
    So from my perspective, the drug court and why I advocate 
it for every federal district in this country is because I have 
watched it change lives, and so have you. And there is no 
reason--even though there are fewer cases on the Federal 
Government than would be appropriate than on the state level, 
there is no reason that we should have our federal prisons 
filled with people who would be better off being treated, for 
themselves and for us as a society. Because the recidivism 
rate, as you know, for drug court graduates goes down 
significantly, and that is what we all want anyway. We would 
much rather spend less money on corrections, on BOP, than we 
would on other issues that are confronting our country in a 
time of limited resources. If we can lower the prison 
population like we have done in New Jersey and close two state 
prisons in eight years--I defy you to find any other state in 
America that is closing state prisons with a decline reduction, 
and it is because we are treating folks who have this problem 
like they have a disease, not like they have a moral failing.
    Chairman Gowdy. Well thank you for your passion and your 
expertise, and I know Mr. Cummings would want to thank you also 
as we transition from your panel to the next panel. Thank you 
on behalf of all of us.
    Governor Christie. Mr. Chairman, thank you very much. Mr. 
Cummings, thank you for inviting me.
    Mr. Cummings. Mr. Governor, thank you very much. Just one 
thing being our good colleague from Maryland, Mr. Delaney, has 
a phrase that I wish I had invented. He said ``The cost of 
doing nothing is never nothing.'' And you have given us a broad 
blueprint, and now we have got to act. Thank you very much.
    Governor Christie. Thank you, sir. I appreciate that very 
much.
    [Recess.]
    Chairman Gowdy. The Committee would like to welcome our 
second panel of witnesses. We have Dr. Richard Baum, Acting 
Director of the Office of National Drug Control Policy; Dr. 
Leana Wen, the Health Commissioner for the Baltimore City 
Health Department; and Dr. Caleb Alexander, Co-Director of the 
Center for Drug Safety and Effectiveness at Johns Hopkins 
Bloomberg School of Public Health.
    Welcome to you all. I am not going to swear you because I 
didn't swear the first witness, so I will violate Committee 
rules there and hope that nobody knows that I have done it. We 
are going to call on you sequentially for your opening 
statements. To the extent possible, I will limit those to five 
minutes, just understanding that we have the full body of your 
opening statement in the record, and then we will--once Dr. 
Alexander gives his opening statement, we will then recognize 
the members for their questions.
    With that, Dr. Baum, you are recognized.

                            PANEL II

                   STATEMENT OF RICHARD BAUM

    Mr. Baum. Well I thank you, Mr. Chairman, Mr. Cummings. 
Thanks so much for inviting me and for the Committee, I am 
really honored and pleased to be here in Baltimore for this 
important hearing.
    You are all familiar with the problem we face because you 
see it in your districts. This epidemic knows no geographic, 
political, socioeconomic, or racial bounds. We are very mindful 
of the fact that your constituents share heartbreaking stories 
with you about the loss of too many of our country's sons and 
daughters. ONDCP is committed to working with you to turn this 
awful crisis around. This truly is the worst epidemic in 
American history.
    As has been referenced in earlier testimony, we have seen 
over 60,000 drug overdoses in 2016, mostly caused by opioids 
such as heroin, illicit fentanyl, and prescription pain 
medications. Now listen, fentanyl is being added to heroin, 
cocaine, and other drugs, increasing their lethality. It is 
often being pressed into counterfeit prescription pills, 
complete with fraudulent manufacturer logos. We are not getting 
enough people with addiction into evidence-based treatment. Our 
whole system through response to overdoses and other outreach 
efforts has to be faster to go out and find the people that 
need help. Once people go through detox or treatment, they need 
ongoing recovery support, as well as help with sober housing 
and employment so they can fully rebuild their lives and 
reintegrate into society. We also need to ensure that law 
enforcement agencies have the tools they need to reduce the 
drug supply and disrupt and dismantle the drug trafficking 
organizations that threaten the safety and health of our 
people.
    The Administration is working hard on multiple fronts to 
address this crisis. As you know, President Trump has been 
vocal about the drug crisis, both during the campaign and since 
taking office. When the President established the Commission, 
he directed it to look at additional actions the government can 
take to address this epidemic. ONDCP was tasked with providing 
policy and administrative support to the Commission. I had the 
honor to serve as the executive director of the Commission, and 
ONDCP staff contributed their expertise and time to assist the 
Commission with its work, totaling more than 5,500 total staff 
hours. On November 1, the Commission released its final report, 
which included 56 recommendations, as Governor Christie just 
described. The recommendations have now been circulated to all 
the agencies in the Administration for careful consideration. I 
am glad to say that the Administration is already working on a 
number of them.
    President Trump declared the opiate crisis a national 
public health emergency as the Commission recommended in its 
interim report, and he has mobilized the entire Administration 
to address the crisis. HHS has announced a proactive policy to 
allow states to waive the decades-old ban on Medicaid 
reimbursement for patients receiving inpatient treatment at 
facilities with 16 or more beds, known as the IMD exclusion. 
Utah and New Jersey have already received approvals under the 
new policy, and we hope to have many more requests for waivers 
in the coming months.
    In terms of reducing the availability of these illicit 
drugs, the Administration has also taken a number of steps. We 
are working with the Chinese government to reduce the flow of 
fentanyl and its add-alongs to the United States. This includes 
getting additional advanced electronic data from China on 
packages mailed into the U.S. This summer, DOJ took down the 
dark web marketplace, AlphaBay, and other sustained actions 
like this over time will reduce trade over the Internet that 
has been threatening the health of our citizens.
    The Heroin Response Strategy, which is an initiative of our 
ONDCP-run HIDTA program, is bringing law enforcement and public 
health together to quickly respond to overdose at the local 
level, and to increase law enforcement and--efforts. And the 
FDA is working to make prescription opioids safer and lend the 
effort to remove the opioid medication Opana extended release 
from the market, since it was frequently being diverted and 
abused.
    The Administration has provided significant resources to 
address this crisis. For fiscal year 2018, the President 
proposed a $28.7 billion drug budget overall, including $10.8 
billion for drug treatment. This year, we have already sent 
$800 million out to states for intervention, treatment, first 
responders, prescription drug monitoring programs, and recovery 
services. The President has requested $500 million additionally 
to help states expand access to opioid treatment in the fiscal 
year 2018 budget. And at ONDCP, as you know, we are developing 
the Trump Administration National Drug Control Strategy, which 
will be out early next year. So we are using all the tools in 
the toolbox to make headway against this enormous problem which 
is affecting every state and many of your constituents in some 
way, shape, or form.
    I have not yet had the privilege to visit South Carolina as 
acting director, but I have visited Anne Arundel and Cecil 
Counties in Maryland and I have seen how people in these 
communities are coming together to address this crisis at a 
local level. This is a critical part of our country's response 
to the epidemic.
    As I said, this crisis is unlike anything we have seen 
before and have been working hard to address it, but we have a 
lot more to do. I thank Governor Christie and the Commission 
for their recommendations which will help to this end. I also 
want to thank the dedicated ONDCP career staff for so 
skillfully supporting the Commission's work. And I thank the 
Committee for holding today's hearing on this important matter, 
and I look forward to more discussion and dialogue. Thank you 
very much.
    [The prepared statement of Mr. Baum follows:]
    
    
    
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    Chairman Gowdy. Thank you. Dr. Wen?

                     STATEMENT OF LEANA WEN

    Dr. Wen. Chairman Gowdy, Ranking Member Cummings, thank you 
for calling this hearing in our city of Baltimore where today, 
two residents will die from overdose.
    Our aggressive approach to this epidemic has three pillars. 
First, we save lives by making the opioid antidote, naloxone, 
available to everyone. Not only have we equipped paramedics and 
the police, I issued a blanket prescription to all 620,000 
residents. Since 2015, everyday individuals have saved the 
lives of 1,500 people. But our city is out of funds to purchase 
naloxone, as Congressman Cummings mentioned, forcing us to 
ration and make decisions about who can receive this antidote. 
And at the time of a public health crisis, it is unconscionable 
that we are being limited in our ability to save lives.
    Second, we aim for on demand addiction treatment, because 
the science is clear that addiction is a disease and treatment 
works. But nationwide, only 1 in 10 people with addiction get 
treatment. Imagine if only 1 in 10 patients with cancer get 
chemotherapy?
    As an emergency physician, I see patients coming to the ER 
all the time asking for help, but I tell them they have to wait 
weeks or months. My patients have overdosed and died while they 
are waiting, because our system failed them. Here we are 
starting a stabilization center, which is the beginning of a 
24/7 ER for addiction and mental health. We are expanding 
medication assisted treatment, which is the gold standard for 
helping people to recover from opioid addiction.
    Third, we reduce stigma and prevent addiction. Treating 
addiction as a crime is unscientific, inhumane, and 
ineffective. That is why our public health and public safety 
agencies collaborate closely, including to pilot law 
enforcement assisted diversion where individuals caught with 
small amounts of drugs are offered treatment instead of 
prosecution. Recognizing that it has hurt people who hurt 
people. We are working to prevent the next generation of 
addiction by addressing trauma and providing mental health 
services in our schools.
    My written testimony has point-by-point analyses of the 
President's Commission's recommendations, and I agree with many 
of them, but they do not go nearly far enough in four areas.
    First, the Commission did not identify substantial 
additional federal funding. We on the frontlines know what 
works, and we desperately need new resources, not repurposed 
funding that will divert from other critical priorities. These 
funds should also be given directly to communities of greatest 
need. Cities have been fighting the epidemic for years, and we 
shouldn't have to jump through additional hoops. Competing for 
grants and having funding passed from the states to cities will 
cost time and many more lives.
    Second, the Commission failed to advocate for taking on 
necessary steps to expand health insurance. One in three 
patients with addiction depend on Medicaid. If Medicaid were 
gutted and they were to lose coverage, many more would overdose 
and die. Other patients on private insurance could find 
themselves without treatment if addiction is no longer required 
to be part of their health plan. It is estimated that ACA 
repeal could result in three million people losing access to 
addiction treatment. Block grants should not replace insurance 
coverage, because no disease can be treated through grants 
alone.
    Third, the Commissions' recommendations did not guarantee 
access to treatment for addiction. Medication-assisted 
treatment reduces the likelihood of death, incidents of other 
illness, and criminal behavior. At the very least, medication-
assisted treatment should be the standard of care for all 
treatment centers, and we can go further. If doctors can 
prescribe opioids that lead to addiction, why shouldn't 
hospitals all be required to treat this disease?
    Fourth, the Commission ignored evidence-based harm 
reduction practices. In Baltimore, needle exchange has resulted 
in the percentage of individuals with HIV from injection drug 
used decrease from 63 percent in 1994 to seven percent in 2014. 
Our programs are staffed by people in recovery themselves who 
help patients connect to treatment.
    Here in Baltimore, we know what works. We need support from 
the Federal Government in three ways: number one, urgently 
allocate additional funding to areas hardest hit by the opiate 
epidemic; number two, directly negotiate with the manufacturers 
of naloxone so that communities no longer have to ration; 
number three, protect and expand insurance coverage to get to 
on demand treatment for the disease of addiction.
    Here in Baltimore, we have done a lot with very little. We 
can do so much more if we had more resources, and I urge 
Congress to commit these resources so that we can save lives 
and reclaim our futures.
    I thank you for coming to our city and for calling this 
hearing.
    [The prepared statement of Dr. Wen follows:] 
    
    
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    Chairman Gowdy. Thank you, Dr. Wen. Dr. Alexander?

                  STATEMENT OF CALEB ALEXANDER

    Dr. Alexander. Good afternoon, Chairman Gowdy, Ranking 
Member Cummings, and members of the Committee. I appreciate the 
opportunity to speak today.
    I am a practicing primary care physician and co-director of 
the Johns Hopkins Center for Drug Safety and Effectiveness at 
the Johns Hopkins Bloomberg School of Health. My research 
focused on identifying political and policy solutions to the 
opioid epidemic, but as a practicing physician, I also know the 
power of stories to compel action, and I would like to share 
with you a brief one now.
    In 2011, Judy Rummler lost her son Steve from an overdose. 
I work with Judy on policy reform and I asked her if I could 
share his story. She said, I am always happy to share Steve's 
story if it helps the cause. Steve's journey began like so many 
with a lower back injury that led to chronic opioid use and 
subsequent addiction. Years before his death, he wrote 
presciently of opioids, ``At first they were a lifeline, and 
they became a noose around my neck.'' Steve tried as best he 
could to get well and he didn't want to die, but he ultimately 
succumbed from an overdose after discharge from a rehab 
facility. Now, Judy keeps a picture of Steve along with a note, 
``If love could have saved you, you would have lived forever.''
    Steve's story, and his family's resolve to ensure that 
other families don't have to experience what they have, is a 
reminder to me of what is at stake here, and of the loss that 
so many have endured.
    During the past year, my colleagues at Johns Hopkins and I 
have reviewed hundreds of scientific studies and other data 
points on the epidemic. Last month, we released this report, 
``From Evidence to Impact'', that has been provided with my 
written testimony, and that synthesizes the field and provides 
recommendations to address the epidemic. Ranking Member 
Cummings, we were so honored that you participated in the 
release of this report.
    In the remainder of my time, I would like to highlight two 
points regarding how the Commission's report can best drive 
change. First the Commission's findings provide a comprehensive 
framework for action. Simply put, the science is the science, 
and the Commission's report gets it right. It is based on 
evidence and lines up closely with our own appraisal in most 
areas. For example, both assessments agree that providers 
should be required to use prescription drug monitoring 
programs, that the CDC's guidelines should be standard practice 
nationwide, and that high quality evidenced-based addiction 
treatment should be available on demand.
    In my written testimony, I make specific recommendations 
regarding steps Congress can take, such as passage of the 
Prescription Drug Monitoring Act of 2017, and I also highlight 
areas where the Commission might have increased the 
comprehensiveness or impact of their review.
    Second, as we have already heard urged by some of you this 
afternoon, it is now critical for the Administration to develop 
a strategy to support the implementation of its 
recommendations. It is one thing to say we are going to send a 
man to the moon, and it is totally a different thing to have a 
plan in place to do so. In my humble opinion, the Commission's 
two most important recommendations are that we need to reduce 
over-prescribing and provide high quality evidence-based 
treatment for addiction upon demand, although I think reducing 
the supply of fentanyl in the country is a very close third.
    But I am left asking the questions that some of you may be, 
which is what specific steps is the Federal Government going to 
take to reduce, for example, opioid over-prescribing? What 
resources are required? Which agencies are responsible? What 
timeline will be followed? And how will we know when we have 
been successful? In short, we urgently need an implementation 
plan, and this Committee could support this effort by asking 
for and reviewing such a plan for the Commission's most 
important recommendations. This Committee can also exercise 
oversight capacity to ensure that other federal agencies act on 
the Committee's recommendations.
    Esteemed representatives, we are missing more than half a 
million Americans from overdose that should be with us today, 
people like Steve Rummler and so many others. Incredibly, more 
deaths from opioids are expected in 2017 than ever before; yet 
as we look to 2018, there are reasons for hope. Providers are 
increasingly using safer and more effective treatments for 
pain. There is growing awareness that addiction is a disease 
and treatable, and more Americans are living fulfilling lives 
in recovery. Communities are increasingly mobilized, demanding 
affordable naloxone, reliable access to addiction treatment, 
stronger FDA regulation, and coordinated federal action. This 
is a fixable crisis, but not without an implementation plan to 
accompany the Commission's recent recommendations.
    Thank you again for the opportunity to testify. I look 
forward to your questions.
    [The prepared statement of Dr. Alexander follows:]


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    Chairman Gowdy. Thank you, Dr. Alexander. The gentleman 
from Maryland is recognized.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    Dr. Wen, on June 18, 2017, the Baltimore Sun published an 
article on naloxone entitled ``Baltimore City Running Low on 
Opioid Overdose Remedy.'' The article stated that ``The city 
has about 4,000 doses left to last until next May.'' You were 
quoted in that same article as stating that, and I quote, ``We 
are rationing. We are deciding who is the highest risk and 
giving it to them.'' How many doses of naloxone does the city 
have left now, and is that number adequate to meet the city's 
needs?
    Dr. Wen. Thank you, Congressman. We--I have people----
    Mr. Cummings. And who are the highest priority people?
    Dr. Wen. The highest priority individuals that we allocate 
this lifesaving medication to are the individuals who are 
clients of our needle exchange plan. These are individuals who 
we know are actively using drugs.
    Now, I will say that we do not in any way condone drug use, 
but we do believe in saving someone's life. If it is a question 
of preventing the spread of hepatitis and HIV we need to do 
that, and if someone had died today, there is no chance for 
them to get into treatment tomorrow. So for 11 unit of naloxone 
given out on the needle exchange plan, one unit is used to save 
someone's life.
    Now I don't know how many medical advances there are out 
there that have a number needed to save someone's life as 1 in 
11. I have to answer your question. I have about 8,000 units 
left between now and July of 2018. Now we are grateful for the 
work of our state. Clay Stamp is here from the state. They have 
been gracious in providing additional funding for naloxone once 
they saw the need in Baltimore City. But if I got 8,000 more 
units today, I could distribute them all by this weekend, and 
then we can calculate how many more lives are going to be able 
to be saved. That is the very definition of rationing. In the 
middle of an epidemic, I shouldn't have to be forced to decide 
who gets to carry a medication that could save their lives or 
their family's lives.
    Mr. Cummings. So how many doses do you need? I mean, let 
me--to adequately distribute enough to be effective? In other 
words, what is your goal?
    Dr. Wen. I want----
    Mr. Cummings. What would be your goal amount?
    Dr. Wen. I would like for everyone in our city to carry 
naloxone in their medicine cabinet or their first aid kit. 
Imagine if we had the remedy--if Ebola had hit our city or some 
other horrible contagious illness were to hit our city, we 
would want to make sure that every single person carried the 
antidote. I have community members, neighborhood faith leaders 
calling me every day asking for naloxone. Why shouldn't it be 
available everywhere in every public place in a way that we 
have defibrillators available in public places?
    Mr. Cummings. Now that Baltimore Sun article in February of 
this year said, and I quote, ``The price of a popular 
injectable version jumped 500 percent in the past two years, 
and the cost of a nasal spray used in Baltimore has increased 
nearly 63 percent.'' One auto-injector can now cost about 
$4,500 for just two doses, is that correct?
    Dr. Wen. That is correct.
    Mr. Cummings. So Dr. Wen, what formulation of naloxone is 
your office using? I mean, what do you----
    Dr. Wen. We use nasal Narcan, which is manufactured by a 
company called Adapt Pharma. It is one of the FDA-approved 
versions of the medication, and we would hope that in this 
epidemic the Federal Government can directly negotiate the 
price so that we can get this at a much discounted one.
    Mr. Cummings. Some kind of way--we have spent a lot of time 
dealing with this issue of drug pricing and over-drug pricing, 
and it seems sad--and this is my conclusion--that a lot of 
these price hikes are about greed, not about cost of research, 
R&D, but greed. And at the same time, we know that we have 
something here that works.
    Are there other things coming down the pike that you know 
of that might be just as effective as naloxone? Have you heard 
of any of those things?
    Dr. Wen. I have not. There are very few antidotes available 
in modern medicine. This is one of them. Naloxone is on the 
World Health Organization's list of essential medications. It 
is available by the pennies in other countries.
    Mr. Cummings. By the pennies?
    Dr. Wen. In other countries.
    Mr. Cummings. Wow. Thank you very much.
    Chairman Gowdy. The gentleman from Wisconsin.
    Mr. Grothman. First question for all of you, on the break I 
ran into a woman down here--it was very interesting--who had a 
relative who had been through treatment dozens of times, which 
kind of obviously means that treatment doesn't always work. I 
would like you folks to comment on percentage-wise how often in 
your experience in programs you deal with treatment works, and 
what distinguishes the programs that treat--that are successful 
and those programs that are not successful? And also, what 
percentage of admissions do you expect to be successful with 
regard to treatment?
    Dr. Alexander. Well I could begin and say that there is no 
question that opioid use disorders are really, really serious, 
and the individuals that have opioid addiction remain with a 
lifelong vulnerability to the products, and this is one the 
reasons that it is so important that we reduce the 
overprescribing of prescription opioids in the first place.
    Mr. Grothman. They only give me so much time. Can you tell 
me percentage-wise in the treatment programs you are familiar 
with, percentage-wise how many times people go into treatment, 
percentage-wise how often are they successful?
    Dr. Alexander. I don't----
    Dr. Wen. The data that I have seen are about 40 to 60 
percent rate of recovery, recognizing that addiction is a 
complex disease and that we need to be ready for people 
whenever they want to go into treatment.
    Governor Christie had mentioned that he had not met people 
who were ready for treatment. I meet them all the time, and the 
problem is that we need to be ready for people at that moment, 
not have them wait weeks or months, and then recognize that 
relapses are part of recovery because that is the nature of the 
disease.
    Mr. Grothman. So you expect a treatment program to be 
successful half the time? Whether it is half the time of a 
heroin addict or an opiate addict goes in, they will never do 
it again? Is that what your expectation is?
    Dr. Wen. They may not be successful that first time, but 
they may be successful that second time, and recognizing that 
there are forms of treatment that are evidence-based and some 
that are not, and so we need to be promoting these evidence-
based treatments which include medication-assisted treatment.
    Mr. Grothman. Well just when you get on the Internet, it 
implies that, you know, these are wildly unsuccessful, that is 
why I am asking.
    Mr. Baum. Yeah, I just want to add to that. It is true that 
relapse rates are a challenge, but I think that if we move away 
from this sort of isolated episodic treatment model to an 
ongoing, continuing care, we can drive down relapse rates. 
Sometimes we have a detox program that is separate from an 
inpatient that is separate from ongoing recovery supports, and 
we have to stop doing it that way. The system has to evolve to 
have ongoing recovery support so that relapse rates are driven 
down.
    And just in summary, I would say we shouldn't accept the 
level of relapse rates. I think we can drive them lower if we 
work harder and work smarter.
    Mr. Grothman. Okay. I asked Governor Christie and I will 
ask you as well. Some of you made about the fact that heroin 
was fairly apparently common in Vietnam. I don't know. And when 
people came home, almost all the troops stopped using heroin. 
Could you comment on that?
    Mr. Baum. Yeah, it is a very interesting point in history. 
In Vietnam was when they had the first drug testing program, 
and people weren't cleared to go home from Vietnam until they 
tested negative for drugs. And so there was--people in Vietnam 
were highly motivated to get home. They had to step using 
drugs, they had to test negative, and then they went home.
    I mean, I do--I don't dispute the point that you changed 
the environment and you changed the behavior, but it was also 
part of a program to test people and to encourage them to get 
off heroin before they came back.
    Dr. Wen. Part of it, too, is why it is that people are 
using drugs? Part of it may be overprescribing because of 
treating physical pain, but people are also treating other 
types of pain too. We know that the same communities facing 
high rates of overdose are also facing poverty and homelessness 
and unemployment, and in order for us to break that cycle of 
addiction, we also have to be addressing those underlying 
factors and helping those communities thrive too.
    Mr. Grothman. Okay, you are touching on something that I 
think Governor Christie wanted to stay away from, but do you 
find that sometimes family background is a correlation with 
abuse?
    Mr. Baum. I mean, I think that there is evidence that 
people on all walks of life and all type of background, of 
every level of wealth and every racial group are affected by 
the drug problem.
    Mr. Grothman. That goes without saying, but I mean 
percentage-wise.
    Mr. Baum. No, I think if you look at the percentage 
breakdown by socioeconomic group there is a little bit of 
variation, but really, everyone is being affected by this 
problem. Everyone with the disease of addiction needs and 
deserves treatment and ongoing recovery support.
    Mr. Grothman. Okay, that is it. On to the next.
    Chairman Gowdy. The gentleman yields back. The gentlelady 
from the District of Columbia is recognized.
    Ms. Norton. I think you can hear me now.
    I think it is fair to say that both Democrats and 
Republicans underestimated the standing of the Affordable 
Healthcare Act until the most recent election where we saw 
governor-to-be--governor elect Northam win an election and the 
polls say that a lead indicator was the Affordable Healthcare 
Act, and they don't even have that in Virginia. People 
apparently are very, very afraid for their healthcare, and they 
chose that election, which is considered a kind of herald 
election for the coming elections to express themselves, even 
though they knew that Northam would have a hard time getting 
them the Affordable Healthcare Act.
    So I--my question is about what role the Affordable 
Healthcare Act can play or is playing in this crisis? I know 
that Governor Christie indicated that the Affordable Healthcare 
Act, unlike, by the way, the plans that many Americans have, 
does require that substance abuse be afforded in the same way 
as other healthcare. That is an important gain for healthcare 
in the United States, at least for those who have the 
Affordable Healthcare Act. One of the figures that interested 
me was the one on Medicaid expansion and who, in fact, has 
benefitted from it? It appears that 3 in 10 non-elderly adults 
with substance abuse disorders nationwide get Medicaid 
expansion. It says to me it is being used by the very people 
that we are discussing here today.
    So I need to know from you, perhaps Dr. Wen, Dr. Alexander, 
what you think would--what you believe would occur if, in fact, 
those states that have Medicaid expansion--this is one of them, 
New Jersey, Governor Christie's state, is another--suppose that 
was no longer available? What would that do to the crisis under 
discussion here this afternoon?
    Dr. Wen. More people would die. Because of Medicaid 
expansion, 1.6 million people who have substance abuse 
disorders are now able to have access to treatment. Prior to 
the ACA, one-third of the individual market plans did not cover 
substance abuse disorders, and for people who have the disease 
of addiction, there is no margin of error. If you are to take 
away their treatment today, their only option may be to 
overdose and die. And so studies have shown that it will take 
$180 billion over a decade to provide healthcare to those who 
lose coverage.
    So back to the point that Ranking Member Cummings made that 
the cost of doing nothing isn't nothing, we are spending that 
money anyway. We are spending the money now on medical costs 
and cost of incarceration. We can choose to invest it in 
treatment instead.
    Ms. Norton. Is the Affordable Healthcare Act being used to 
prevent opioid addiction and not simply to intervene once it 
occurs?
    Dr. Wen. We need to do a lot more when it comes to 
prevention, including stopping the overprescribing of drugs, 
stopping the trafficking of drugs, but also, things like 
investing in nutrition, in family literacy, in home visiting. 
All those things also help to boost family structure and reduce 
poverty, which ultimately also reduces addiction.
    Dr. Alexander. I would just add that there are several 
provisions--although the ACA wasn't designed for the treatment 
of patients with opioid use disorders alone, there are several 
provisions within it that have been very important for those 
seeking treatment for opioid addiction. And that is not just 
the parity provision, but also the requirement that treatments 
for addiction be considered an essential health benefit. So 
this is something that--the Commission speaks--the Commission's 
report speaks to ways that there may be insurance barriers to 
accessing, for example, medication-assisted treatment, but is--
does not directly address the role of insurance in the first 
place. And as a colleague of mine has, I think, eloquently put 
it, until you make it easier for patients to access high 
quality addiction treatment than it is to find their next bag 
of heroin or their next bottle of Oxycontin, they aren't going 
to flock towards treatment. So it is vital that treatment is 
expanded.
    Ms. Norton. Could you give us some insights on why some 
jurisdictions are so much worse off in this crisis than others? 
For example, the District of Columbia is a big city. They have 
taken--they have used the Affordable Healthcare Act and done a 
lot of prevention. The crisis, I think, over the last three 
years tripled. Are there characteristics of a jurisdiction that 
will predict the opioid crisis that you could speak about, Dr. 
Alexander?
    Dr. Alexander. Well it is an outstanding question, and 
indeed, if you look at maps of the country, county maps, it is 
stunning the variation county to county, both in terms of 
opioid prescribing as well as injuries and deaths from opioids.
    The first point I would make is that these are highly 
correlated. That is, if I showed you plots, you don't have to 
have a degree in biostatistics to see that there is a very high 
correlation between the volume of opioids that is being 
prescribed in a given area and injuries and deaths from these 
products. We do know that there are a variety of different 
state policies and county policies that can make a difference 
in the volume of opioids that are prescribed, and in rates of 
heroin and illicit fentanyl use.
    But I think that there is a lot more that we have to learn, 
not only in why it is so bad in some countries, but also why we 
have seen counties that have had remarkable gains in terms of 
reducing both volume of overprescribing, but also injuries and 
deaths from these products. And state policies like 
prescription drug monitoring programs ensure policies and state 
policies like caps on the volume of prescription opioids that 
are prescribed, investments that cities and states are making 
and addiction treatment services, all of these can play an 
important role.
    Ms. Norton. Thank you.
    Chairman Gowdy. Gentleman from Alabama, Mr. Palmer, is 
recognized.
    Mr. Palmer. Thank you, Mr. Chairman.
    Mr. Baum, there was a report in the November 2017 Journal 
Addictive Behavior that noted that there has been a shift in 
drug--opioid abusers first use. According to the report, in 
2005 8.7 percent of individuals who began abusing opioids in 
2005 began with heroin. By 2015, that had changed to 33 
percent. Has your office been able to determine what caused 
this shift?
    Mr. Baum. You know, thank you for the question. I don't 
have a definitive answer, but I would say that the epidemic 
continues to evolve rapidly. We know--and I won't repeat what 
was discussed what has caused this epidemic, which was the 
overprescribing of narcotic painkillers. As more people have 
been using heroin, there has been a spread of heroin shared 
between family members, boyfriends, girlfriends, and others, 
and so I have seen those reports and it is concerning.
    And let me just emphasize, we need to get out the message 
about the incredible lethality of the drug supply. When someone 
consumes heroin, it could contain fentanyl. It might contain 
other substances as well. Same with these prescription pills 
that people buy. The drug supply is more lethal than ever 
before, and really people are taking their lives in their own 
hands when they are using these drugs.
    Mr. Palmer. Dr. Alexander, it has been reported that there 
were 64,000 deaths in 2016. Is that an accurate number?
    Dr. Alexander. Yes, correct, from all overdoses.
    Mr. Palmer. The information that I have indicates that it 
might be reported--underreported by as much as 20 percent, and 
each of you have touched on this a little bit because the 
reluctance of family members to have that cited as the cause of 
death would--is that 20 percent underreporting--does that--is 
that real?
    Dr. Alexander. Well I don't have a--I am not sure of the 
precise degree to which there is underreporting, but there is 
no doubt you raise a very good point. And any underreporting 
would mean that the epidemic is even more worse than the 64,000 
number would suggest.
    Mr. Palmer. Well that is my point. The epidemic is at a 
point now where it has literally reduced the life expectancy of 
Americans. We--for the first time in I forget how many years, 
but it has been at least a couple of decades, our life 
expectancy in the United States has declined, and there are 
some studies indicating it is related to the number of people 
dying from drug overdoses, drug poisoning.
    Dr. Alexander. Yeah, that is correct, and we see 
manifestations in many different sectors of the economy. The 
labor force--I think the Commission's report did a good job of 
outlining many of the ripple effects. We have heard about 
strains on the foster care system, and so there are effects 
manifested throughout.
    And the other point to make is that the deaths are tragic, 
and I know many of you have met with constituents and, you 
know, you'll never forget those stories and those days, and yet 
the deaths are the tip of the iceberg. For every patient that 
has died, there are dozens or more that have opioid addiction. 
There are hundreds that are experiencing the effects of going 
to emergency departments or having a chaotic household where 
someone has an opioid use disorder.
    Mr. Palmer. I want to touch on something my colleague from 
Wisconsin brought up, and that is about the efficacy of the 
treatment using medication assisted treatment. I think the 
number--it is not effective for about 40 percent of the 
population. We talked a good bit about--but there is another 
drug out there, Vivitrol, that does not give the same impact as 
opioids. It is not--it is a once a month type pill, but it 
literally requires that people go into withdrawal for--I mean, 
it takes three to ten days for someone to become clean and use 
that. Have you used that, Dr. Wen? I guess that would be more 
appropriate to address that to you.
    Dr. Wen. Yes, we believe that all three forms of FDA-
approved medications, which are methadone, buprenorphine, and 
naltrexone, also called Vivitrol, that all three should be 
available in all settings without there being prior 
authorization for insurance, without only one form being 
available at some places. Because just like for other 
illnesses, some patients may do well with one medication, some 
may not do well with that medication but may do well with 
another one. And so we believe that all three should be 
available. And methadone and buprenorphine have had a bag 
reputation because they can be abused and misused, but so can 
many medications. And we have to follow the signs and evidence 
which show that medications as a treatment is the gold standard 
and that it reduces illness and death and even criminal 
behavior.
    Mr. Palmer. I see my time is expired. I appreciate your 
responses to this.
    I just want to point out, though, this is not a political 
issue. This is--it is, in my opinion, a public emergency and to 
bring the politics into it, I think, is inappropriate. We have 
seen a major increase in deaths from drug overdoses since 2010, 
so I just want to encourage folks to not look at this as a 
political issue. This is a national crisis.
    I yield back.
    Chairman Gowdy. Gentleman yields back. Gentleman from 
Missouri is recognized.
    Mr. Clay. Thank you, Mr. Chairman.
    If we are to be successful, I am a firm believer that we 
must first remove the stigma traditionally associated with drug 
use. For far too long, society has deemed drug users criminals 
in need of incarceration rather than patients in need of 
treatment, as we saw so clearly during the 1980s and '90s.
    Dr. Wen, you summarize that change back in January stating, 
and I quote, ``Traditionally, it has been seen that if you have 
an addiction, it is a moral failing. It is a personal choice. 
Now we are calling it a disease.''
    Drs. Wen and Alexander, how important is it that we as a 
society are finally recognizing addiction for what it is, a 
disease?
    Dr. Alexander. Well I think it is vital, and I think we 
heard this question posed which is can you imagine if we told 
people with diabetes that 10 out of 100 will get treatment or 
that we told people with kidney cancer we will take 100 of you 
and we are going to offer 10 of you the best treatment that we 
have. And it is when you look at settings like that where one 
realizes the role that stigma has. Another very pervasive and 
under-appreciated point is that all too often, we discuss 
abuse. And I was heartened by the Commissions' report, the word 
addiction is throughout. It is in the first sentence, I 
believe. It is in the title and the charge to the Commission. 
This is an epidemic of addiction. It is not an epidemic of 
abuse. There is non-medical use that takes place, but for far 
too long, we have suggested that there are sort of two 
populations of individuals. We have the drug abusers that we 
need to do everything we can to prevent them from accessing the 
medicine, and then, you know, when I was a resident, I was 
taught that we need not worry about the addictive potential of 
opioids if a patient had ``true or legitimate pain.'' And 
nothing could be further from the truth.
    So I think that the issue of stigmas is really front and 
center, and I think that this will take resources of massive 
scale, really, to continue to educate individuals. Who would 
choose a life of addiction? It is on anybody who has really 
understood and met somebody that has addiction knows that this 
isn't a choice that people are making any more than it is a 
choice of a 10-year-old to have Type I diabetes.
    Dr. Wen. We would never say to somebody with diabetes that 
they should go to jail, and if--they should not get treatment 
in jail, but once they return, they should be cured. Which is 
the type of stigma that we continue to put on people and--who 
have the disease of addiction.
    I think one of the questions I would ask was about the 
communities that are the most heavily affected. Our community 
here in Baltimore has been affected for decades. This is not a 
new issue, and Congressman Cummings has spoken very eloquently 
about this in many talks past that we owe an apology to 
generations we have incarcerated. And we owe an apology because 
we knew the signs but didn't speak up then.
    Mr. Clay. Mr. Baum?
    Mr. Baum. Thank you, Congressman, for the question.
    Police chiefs and sheriffs, they are doing an incredible 
job around this country. They know the difference between 
someone who is a drug user who needs treatment and someone who 
is a drug trafficker, a major drug dealer who deserves 
punishment. It is no question that someone whose criminal 
activity is limited to buying and using drugs should be 
diverted to treatment. I have been really encouraged with the 
police diversion that is happening now around the country pre-
arrest, working very closely with the police assisted addiction 
recovery initiative parry. Over 300 precincts and sheriff 
offices allow you to walk into a police department or sheriff's 
office 24 hours a day and get diverted right to treatment. They 
do a quick intake, they put you in the front seat of the police 
car, and they drive you to treatment. This program is expanding 
rapidly. So we are doing more police pre-arrest diversion than 
ever before.
    On the other hand, if somebody is selling heroin laced with 
fentanyl to our citizens and causing overdoses that are killing 
people, that is a serious crime and they deserve prosecution 
for that.
    So I think we are able to tell the difference between those 
who need to be diverted to treatment and those who deserve 
prosecution.
    Mr. Clay. As well as those physicians who turn their 
offices into pill mills.
    Mr. Baum. No question there have been some abusive doctors 
who have been incredibly reckless and they deserve prosecution 
for those crimes as well.
    Mr. Clay. Now not to put you on the spot, but is it--is 
that the official position of the U.S. Department of Justice, 
or can you share with us that----
    Mr. Baum. The Department of Justice wants to prosecute 
traffickers and criminals and those that are killing our 
citizens with these deadly drugs. There is no conflict at all 
for diversion for minor, non-violent offenders for treatment.
    Mr. Clay. Thank you for your responses, and I yield back, 
Mr. Chairman.
    Chairman Gowdy. Gentleman from Missouri yields back. The 
Chair will now recognize himself.
    Dr. Alexander, you mentioned overprescribing as being one 
of the--kind of the dual things that you would address first. 
What are the causes of over-prescription? Is it a misdiagnosis? 
Is it a failure to consider alternatives? What are the root 
causes of the over-prescription?
    Dr. Alexander. Well thank you for the question, Mr. 
Chairman, and the Commission's report discusses these in some 
detail. And here again, I think that they hit most of the high 
points. Misinformation, as I noted from my own training, when 
we were taught in the late 1990s that we had overestimated the 
addictive potential of prescription opioids. Labeling that is 
inconsistent with the totality of evidence regarding the safety 
and effectiveness of these products, and of course, the 
labeling, as you know, in turn affects the ways that 
pharmaceutical companies can market and promote the products. 
The widespread prevalence of pain and a notion that pain needs 
to be fully abated and that people should, you know, get to a 
zero on a scale of 1 to 10, rather than in many countries, 
cultures where pain is something to be managed. I think many 
pain experts would say pain is something to be managed and 
lived with, not just grin and bear it, but not expect that you 
are going to be taking enough opioids that you get down to a 
zero.
    There are many, many, many causes that have contributed to 
the overprescribing.
    Chairman Gowdy. Are there certain specialties or 
subspecialties where you have identified where the 
overprescribing is more prevalent?
    Dr. Alexander. Well it is a terrific question. It would be 
a privilege to share with the Committee some of our own data 
and own analyses in this regard. The point that I would make is 
that the prescribing volume of opioids is highly skewed so that 
if you look, for example, within primary care physicians, it is 
a small subset of primary care physicians that account for the 
lion's share of opioids that are prescribed.
    With that being said, these are not primarily rogue 
prescribers that are down on Main Street seeing 300 patients in 
a day and only accepting cash. I think that there is a very 
important point here, and in fact, Governor Christie spoke to 
it when he said that most prescribers that are contributing to 
this epidemic aren't doing so out of ill intent. They are doing 
so out of non-intent. So it is important to recognize that 
while opioid prescribing is highly skewed, that the prescribers 
that are prescribing in such enormous volumes are not 
necessarily, you know, just flouting any standard of best 
medical practice.
    Chairman Gowdy. Now when you say primary care physicians, I 
am thinking pediatricians, internists, and GPs. What am I 
missing?
    Dr. Alexander. Family docs, internists are the big two. 
Pediatricians are lower volume only because fortunately, not 
many kids are prescribed opioids.
    Chairman Gowdy. So we can take pediatricians out of it. 
Internists----
    Dr. Alexander. Sure.
    Chairman Gowdy. --or would you--internists and GP----
    Dr. Alexander. Yeah.
    Chairman Gowdy. --or what used to be GPs, family doctors.
    Dr. Alexander. Um-hum.
    Chairman Gowdy. Two questions in this realm. Has there been 
any analysis of physicians who write prescriptions for opioids 
after a patient has been declined a prescription from another 
physician? In other words, doctor shopping?
    Dr. Alexander. Yeah, that is a terrific question, and here 
again, as with the rogue prescribers, when we look at the data 
we reach a very interesting conclusion, which is that opioid 
shoppers are exceedingly rare, and almost around the era in 
importance relative to other populations of high risk patients. 
That is not to suggest that it is not vital that we identify 
and intervene upon opioid shoppers, but there are other 
populations of chronic opioid users that are much higher risk 
when you look at a population level, a public health level than 
opioid shoppers. And so I am speaking about individuals that 
are on chronic high-dose opioids and also individuals that are 
on the combination of prescription opioids and benzodiazepines.
    Chairman Gowdy. I have a couple more questions. I am going 
to try to fit them in so I don't violate my own rules.
    In terms of alternatives--well let me ask you this. We can 
test blood pressure, we can test cholesterol, we can check 
somebody's temperature. How close are we to having a diagnostic 
test for pain?
    Dr. Alexander. It is, you know, nowhere in our lifetimes 
would be my best guess, and I think it is one of the other 
factors that has contributed to the epidemic because it is 
really--because pain is so inter-subjective. It varies a lot 
person to person, and it is very difficult--there is no 
objective test for it.
    This is one of the reasons that I think it is so important 
that we teach the next generation of professionals and those 
currently in practice, there are lots of tools in the toolbox. 
We don't need to just wait for the FDA to bring new drugs down 
the pipeline 10 or 20 years from now. We already have dozens of 
different treatments, both pharmacologic and non-pharmacologic 
for pain. And I think one of the things that is happening with 
the opioid epidemic is that we are shining such a bright light 
on opioids that we are neglecting to consider all of the 
alternatives that, in many cases, are safer and more effective.
    Chairman Gowdy. The gentlelady from Michigan, Ms. Lawrence.
    Ms. Lawrence. Thank you.
    I am going to ask this question to Ms. Wen and anyone else 
who can answer. You spoke about the Baltimore schools having 
addiction screening. We have approximately, as reported, about 
430,000 foster children in America. I sit on the Foster Care 
Caucus, and it is a high priority for me. Mental health for our 
foster children in that alarming rate they suffer five times 
more likely from PTSD and from trauma.
    With that being said--and we talked about the priority 
groups based on the socioeconomics. Is there any focus on 
foster children as far as education, screening, and support?
    Dr. Wen. That is an excellent question. We know from 
studies that children who experience trauma, which losing their 
family certainly would be that trauma, or growing up in 
families with high rates of addiction would also be traumatic 
too, that these children have higher rates of addiction 
themselves. And that is this vicious cycle then of poverty, 
trauma, and addiction, and addiction begins to beget addiction 
too.
    So from our standpoint, we absolutely need to provide 
services for those children experiencing trauma, but 
critically, we also have to provide treatment for their parents 
and caregivers, because unless we do that, we are going to have 
issues like we have a tripling of the number of children born 
with neonatal abstinence syndrome. Some studies show that 40 
percent of neonatal ICU days are because of their--the child 
being born with and with the opiate addiction themselves. That 
is a dangerous cycle, and we can stop it by providing treatment 
for the mother, for the parent, for the caregiver.
    Ms. Lawrence. I am told by the Department of Human Services 
that the fastest growing contributor to foster children growth 
in America is from opioid addiction, because children are being 
taken away.
    The last thing I want to say is that I did enter a bill 
that would--the Timely Mental Health for Foster Youth, which 
would require all children to be mandated, like they get a 
physical health assessment. They need to get a mental health 
assessment because we know these children have experienced the 
first level of trauma, that is being separated from their 
family, and I really hope that as we continue of targeting and 
addressing addiction screening, that we keep a focus on our 
foster children in America.
    Thank you.
    Chairman Gowdy. Gentlelady yields back. The Chair would now 
recognize the gentleman from Vermont, Mr. Welch.
    Mr. Welch. Thank you, Mr. Chairman, and Mr. Gowdy and Mr. 
Cummings, I thank you for organizing this hearing. I think all 
of us should leave this hearing with some significant amount of 
humility. You know, as I see it, the Federal Government 
primarily has to be a partner to the local communities that are 
doing all the frontline work, and when I look at what you have 
done here in Baltimore, just the training of the number of 
people who are capable of administering lifesaving medication, 
a kind of all-in approach that the city has taken, and also 
Johns Hopkins has taken as well. Our role, as I see it, is to 
try to get resources back to the communities so that you can 
your job, because this appears to me to be fundamentally an 
issue that can only be dressed--be addressed at the very local 
institutional individual level. I mean, that story, Dr. Wen, 
about your 24-year-old patient was--it really says it all. So I 
want to thank you--all of you, really, Dr. Alexander and Mr. 
Baum. Thank you for your work.
    We are going to have a tough time in Congress on money. You 
need more and when we don't provide it, our local first 
responders are put in a jam, our police officers, the 
hospitals. But we can do something about the cost of these 
drugs that have gone way up, and it is my hope that this 
Committee--there has been a lot of interest by many of our 
members in trying to take practical steps to contain the cost. 
Both Mr. Gowdy and Mr. Cummings have been leaders in this.
    What has the cost of these lifesaving drugs, Dr. Wen, done 
to your budget in your health department or in Baltimore?
    Dr. Wen. We have redirected--given the scope of the opioid 
epidemic, we have redirected funds from other critical programs 
in order to fund this. So we--I have to choose all the time, do 
we fund asthma programs for children, lead poisoning reduction, 
or do we fund the opioid epidemic? And we had to----
    Mr. Welch. I will ask all of you. On these drugs like 
naloxone and these others, have the changes that have been made 
largely, in my view, to extend intellectual property protection 
and allow additional price increases, have they made a 
significant different in the benefit to the lifesaving 
qualities given to the patient, or is it just the higher price? 
And you can all address that.
    Dr. Wen. Hard to say except that, again, this is available 
in other countries for very little, and I would love to see us 
get the broad access that this epidemic requires.
    Mr. Welch. Mr. Baum, is that an issue?
    Mr. Baum. Yeah, I don't know if that is an issue. I have 
met with all the manufacturers of these medications and talked 
to them about pricing, and they have talked about how if you 
have insurance, either public or private, they have a very low 
copayment, sometimes----
    Mr. Welch. Can I interrupt?
    Mr. Baum. Please.
    Mr. Welch. I hear that all the time.
    Mr. Baum. Yes.
    Mr. Welch. It is so corrupt. I mean, what is the problem--
and I am not directing this at you, I am directing it at them. 
What is the problem with being able to go on the internet and 
finding out what it costs without all the convoluted 
obfuscation that occurs in drug pricing? I mean, is that as 
frustrating to you as it must be to practitioners?
    Mr. Baum. I guess where I am is naloxone saves lives. We 
want everyone who needs access to it to get access to it. I was 
trained on how to use it. I want it out available----
    Mr. Welch. What happens when the drug companies hold 
hostage your desire to save lives with a stick up price that 
bankrupts your operation?
    Mr. Baum. You know, I think that the story is more 
complicated than that, and they are getting a lot of this 
product out at discounted prices. I think we need to continue 
to work with them and need to continue to find resources to 
fund naloxone, because I----
    Mr. Welch. Explain to me why the price has gone up so much 
when it is basically the same product?
    Mr. Baum. Well I really--I don't want to speak for the 
manufacturers, but my understanding is they had a list price 
but the actual price at the retail level that is paid by 
consumers is much less.
    Mr. Welch. See, that again is gobblygook, because it is a 
price--you know, if you went and bought a car and paid $15,000, 
and the same car a year later was $25,000, you would be able to 
figure out that is a $10,000 difference. You can't figure that 
out now.
    Mr. Baum. All I can say is, you know, we are committed to 
keep working to getting naloxone at a fair price.
    Mr. Welch. Well we would love to work with you. You know, 
President Trump has said that he wants--he said that the pharma 
companies on pricing are getting away with murder.
    And by the way, all of us acknowledge that pharma does 
fantastic things, life extending and pain relieving drugs. But 
if the price kills us, we are not really getting ahead. So we 
really need the President and all of us to get involved in 
trying to do legitimate things to contain this, in my view, 
price gouging.
    I yield back.
    Chairman Gowdy. Gentleman from Vermont yields back.
    I want to thank our panel. We have votes back in Washington 
that they expect us to be there for, whether we want to be 
there or not. They expect us to be there. So I want to thank 
all three of you not just for your time and your expertise 
today, but for the dedication of your lives in helping other 
people. It has been very instructive. I think we are--all the 
members--I want to thank again the good folks at Johns Hopkins 
and the mayor and the governor and Governor Christie, and I 
want to thank you, Mr. Cummings, for being such a phenomenal 
host to all of your colleagues.
    Mr. Cummings. Again, I want to thank you, Mr. Chairman. You 
didn't have to do this, but you did, and you made a commitment 
to me right after you became Chairman that you were going to do 
this hearing, and you kept your word. And I really do 
appreciate that.
    And to all of our witnesses and to Johns Hopkins, we thank 
you, and to the members, I want to thank every member. People 
in the audience, this is a little bit of a sacrifice for 
members to come here. I know it is close to D.C., but they 
literally have to come in earlier than they normally would 
have, probably catch some earlier flights than they would have 
to be with us. And so I want to thank all of our members for 
being here.
    I just have one quick unanimous consent request, Mr. 
Chairman, and that is that the letter dated November 21, 2017, 
from the Association for Behavioral Health and Wellness be 
entered into the record, and that the testimony of the National 
Healthcare for the Homeless Council be admitted into the 
record, and it is dated November 28, 2017.
    Chairman Gowdy. Without objection.
    Chairman Gowdy. The gentleman from Alabama looks like he 
seeks recognition.
    Mr. Palmer. We will have the opportunity to submit 
questions in writing?
    Chairman Gowdy. You may. Let me get to that part of it.
    The hearing record will remain open for two weeks for any 
member to submit a written opening statement or questions for 
the record. If there are no further questions, no further 
business, we want to thank our second panel again, particularly 
for your patience in that the first panel was super important, 
but it also maybe went a little bit longer. So we appreciate 
your patience and your expertise and your comity, with a t, 
with the Committee.
    With that, we are adjourned.
    [Whereupon, at 3:53 p.m., the Committee was adjourned.]


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