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


                                                        S. Hrg. 115-70

                 ECONOMIC ASPECTS OF THE OPIOID CRISIS

=======================================================================
 
                                HEARING

                               BEFORE THE

                        JOINT ECONOMIC COMMITTEE
                     CONGRESS OF THE UNITED STATES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              JUNE 8, 2017

                               __________

          Printed for the use of the Joint Economic Committee
          
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]  
      
                               
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
26-119 PDF                  WASHINGTON : 2017                     
          
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). 
E-mail, [email protected].          
          
          


                        JOINT ECONOMIC COMMITTEE

    [Created pursuant to Sec. 5(a) of Public Law 304, 79th Congress]

HOUSE OF REPRESENTATIVES             SENATE
Patrick J. Tiberi, Ohio, Chairman    Mike Lee, Utah, Vice Chairman
Erik Paulsen, Minnesota              Tom Cotton, Arkansas
David Schweikert, Arizona            Ben Sasse, Nebraska
Barbara Comstock, Virginia           Rob Portman, Ohio
Darin LaHood, Illinois               Ted Cruz, Texas
Francis Rooney, Florida              Bill Cassidy, M.D., Louisiana
Carolyn B. Maloney, New York         Martin Heinrich, New Mexico, 
John Delaney, Maryland                   Ranking
Alma S. Adams, Ph.D., North          Amy Klobuchar, Minnesota
    Carolina                         Gary C. Peters, Michigan
Donald S. Beyer, Jr., Virginia       Margaret Wood Hassan, New 
                                         Hampshire

                 Whitney K. Daffner, Executive Director
             Kimberly S. Corbin, Democratic Staff Director
                           
                           
                           C O N T E N T S

                              ----------                              

                     Opening Statements of Members

Hon. Patrick J. Tiberi, Chairman, a U.S. Representative from Ohio     1
Hon. Martin Heinrich, Ranking Member, a U.S. Senator from New 
  Mexico.........................................................     3
Hon. Margaret Wood Hassan, a U.S. Senator from New Hampshire.....     4

                               Witnesses

Statement of Richard G. Frank, Margaret T. Morris Professor of 
  Health Economics, Department of Health Care Policy, Harvard 
  Medical School, Boston, MA.....................................     5
Statement of Lisa N. Sacco, Crime Policy Analyst, Congressional 
  Research Service, Library of Congress, Washington, DC..........     7
Statement of Hon. Mike DeWine, Ohio Attorney General, Columbus, 
  OH.............................................................     9
Statement of Sir Angus Deaton, Laureate of the Nobel Prize in 
  Economic Sciences, Senior Scholar and the Dwight D. Eisenhower 
  Professor of Economics and International Affairs Emeritus, 
  Woodrow Wilson School of Public and International Affairs and 
  the Economics Department, Princeton University, Princeton, NJ..    12

                       Submissions for the Record

Prepared statement of Hon. Patrick J. Tiberi, Chairman, a U.S. 
  Representative from Ohio.......................................    34
Prepared statement of Hon. Martin Heinrich, Ranking Member, a 
  U.S. Senator from New Mexico...................................    36
Prepared statement of Hon. Margaret Wood Hassan, a U.S. Senator 
  from New Hampshire.............................................    37
Prepared statement of Richard G. Frank, Margaret T. Morris 
  Professor of Health Economics, Department of Health Care 
  Policy, Harvard Medical School, Boston, MA.....................    38
Prepared statement of Lisa N. Sacco, Crime Policy Analyst, 
  Congressional Research Service, Library of Congress, 
  Washington, DC.................................................    48
Prepared statement of Hon. Mike DeWine, Ohio Attorney General, 
  Columbus, OH...................................................    55
Prepared statement of Sir Angus Deaton, Laureate of the Nobel 
  Prize in Economic Sciences, Senior Scholar and the Dwight D. 
  Eisenhower Professor of Economics and International Affairs 
  Emeritus, Woodrow Wilson School of Public and International 
  Affairs and the Economics Department, Princeton University, 
  Princeton, NJ..................................................    87
Response from Richard G. Frank to Questions for the Record 
  Submitted by Senator Klobuchar.................................    91
Response from Richard G. Frank to Questions for the Record 
  Submitted by Senator Lee.......................................    91
Response from Richard G. Frank to Questions for the Record 
  Submitted by Senator Heinrich..................................    91
Response from Lisa Sacco to Questions for the Record Submitted by 
  Senator Lee....................................................    93
Response from Mike DeWine to Questions for the Record Submitted 
  by Senator Klobuchar...........................................    95
Response from Mike DeWine to Questions for the Record Submitted 
  by Senator Lee.................................................    95
Response from Sir Angus Deaton to Questions for the Record 
  Submitted by Senator Lee.......................................    97

 
                 ECONOMIC ASPECTS OF THE OPIOID CRISIS

                              ----------                              


                         THURSDAY, JUNE 8, 2017

                  House of Representatives,
                          Joint Economic Committee,
                                                    Washington, DC.
    The Committee met, pursuant to call, at 10:01 a.m., in Room 
1100, Longworth House Office Building, Hon. Pat Tiberi, 
Chairman, presiding.
    Representatives present: Tiberi, Paulsen, Schweikert, 
Comstock, LaHood, Delaney, and Beyer.
    Senators present: Sasse, Portman, Heinrich, Klobuchar, and 
Hassan.
    Staff present: Louis Agnello, Breann Almos, Theodore Boll, 
Doug Branch, Kim Corbin, Whitney Daffner, Barry Dexter, Connie 
Foster, Martha Gimbel, Colleen Healy, Adam Hersh, Karin Hope, 
Matt Kaido, Brooks Keefer, John Kohler, AJ McKeown, Victoria 
Park, Jana Parsans, Russell Rhine, and Alex Schibuola.

 OPENING STATEMENT OF HON. PATRICK J. TIBERI, CHAIRMAN, A U.S. 
                    REPRESENTATIVE FROM OHIO

    Representative Tiberi. Good morning, and welcome. I want to 
welcome especially our ranking member, Senator Heinrich, and 
our vice chairman, Senator Lee, as well as other members of the 
committee who join me in expressing the importance of holding a 
hearing on the threatening increase in opioid abuse. Drug abuse 
has become rampant in America and may be the worst the country 
has ever experienced.
    It is devastating families, degrading communities, and 
undermining several parts of our economy. For several states 
and districts represented by members of this committee, the 
problem is acute, as the map displayed shows. As figure 1 
indicates, the crisis has a regional character. My hometown of 
Columbus, Ohio, is part of the crisis' epicenter east of the 
Mississippi.
    Figure 2 shows the 2015 drug overdose death rates by State, 
which range from 40 per 100,000 in West Virginia to 6 per 
100,000 in Nebraska. The states represented by the members of 
this committee, among the 10 highest rates, are highlighted in 
red, including my home State of Ohio, which ranks third.
    Drug markets, both legal and illegal, can be analyzed from 
the demand and supply side. The exact reasons for the extent of 
drug abuse are not clear at this point. With respect to demand, 
a changing perception of pain as a health problem in the 1980s 
by the World Health Organization in particular laid the ground 
for more intensive treatment.
    The labor market and the economy can have a major impact on 
demand, although not necessarily in ways one might expect. Some 
research shows less substance abuse when unemployment 
increases, for instance, and while the prolonged downturns in 
labor market and economic conditions are associated with 
social, behavioral, and health problems, they do not 
necessarily affect all groups in the same way or to the same 
degree.
    All of society is vulnerable to this epidemic. It is 
compounding the economic distress that certain parts of the 
country and segments of the population already have been 
experiencing. Some areas of high employment tend to have higher 
rates of substance abuse. The Economic Innovation Group, a 
representative of which testified at our last hearing, ``The 
Decline of Economic Opportunity: Causes and Consequences,'' 
developed an economic distress index consisting of several 
economic indicators, a national map of which is shown alongside 
the map of overdose deaths in the TV screens in figure 3. The 
darker the red, the worse the distress. Striking correlations 
are visible. But it is also apparent from figure 3 that some 
economically distressed areas are not experiencing high 
overdose death rates.
    From a supply side, the particular locations where new, 
potent drugs initially happened to be become most readily 
available, and the path of geographic market expansion they 
took, track a visible trail of destruction in figures 1 and 3. 
Without question, new developments in the sourcing, cost of 
production, potency, and retail delivery have moved the supply 
of both legal and illegal addictive drugs substantially to the 
right. Newly effective pain medication, OxyContin, introduced 
in the 1990s, had initially unacknowledged addictive qualities 
and was overprescribed.
    So-called black tar heroin, which Senator Heinrich and I 
were just talking about, more powerful and less expensive than 
other kinds, expanded its market share just as OxyContin was 
reduced in potency around the country.
    The prescription drug explosion started in the Appalachian 
part of my State and spread to parts of Kentucky and West 
Virginia. Black tar heroin started in the Southwest and spread 
westward but eventually also eastward, crossing the Mississippi 
in 1998.
    Illegally distributed variations and counterfeit forms of 
prescription drugs like fentanyl can be poisonous and kill a 
person even in small doses, some by mere contact with the skin, 
as Attorney General DeWine informed me earlier this year. We 
now face pure poisons masked as narcotics that are shipped 
across our borders. Senator Portman and I introduced the STOP 
Act, which aims to stop dangerous synthetic drugs from being 
shipped through our own postal service, keeping them out of the 
hands of drug traffickers in the United States. Half the 
members of this committee have signed on as cosponsors in a 
bipartisan way, and we should continue to build support for 
this important legislation.
    It would be a mistake to blame these drugs entirely for the 
rise in mortality that some groups and regions are suffering. 
There are other causes apparently emanating from long-term 
challenges in the composition of the economy and skill 
requirements.
    Determining cause and effect is obviously critical to 
reaching the right conclusions. Feedback effects often 
complicate causality and make a clear understanding of major 
causes that we are experiencing difficult. For example, does a 
bad economy lead to drug abuse or does drug abuse to a bad 
economy by lowering productivity, labor force participation, 
and social cohesion? We will hear about the economic decline of 
certain groups leading to despair and self-destructive 
behavior; of damage drug abuse causes individuals, families, 
and communities in all segments of society; and of developments 
in the production and marketing of addictive drugs which have 
made them more dangerous, affordable, and available.
    I look forward to the statements of our witnesses.
    I will now yield to the ranking member, who has another 
hearing. Mr. Heinrich is recognized.
    [The prepared statement of Chairman Tiberi appears in the 
Submissions for the Record on page 34.]

 OPENING STATEMENT OF HON. MARTIN HEINRICH, RANKING MEMBER, A 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Heinrich. Thank you, Chairman Tiberi.
    And thank you so much for holding this incredibly important 
and timely hearing.
    Thanks to our panel for being here today.
    Addiction to both heroin and prescription opioid pain 
relievers is a public health epidemic that is devastating 
families and communities across our Nation.
    Every day, 91 Americans die from opioid overdose. Over-
prescription is partially responsible for this epidemic. Since 
1999, the amount of prescription opioids sold in the U.S. 
nearly quadrupled, and so too has the number of overdose deaths 
from opioids. The economic costs of that addiction are 
incredible, totaling more than $80 billion in 2013, from 
increased healthcare costs, higher rates of incarceration, and 
lost productivity.
    New Mexicans know all too well the devastation that heroin 
and prescription opioids can wreak. For years without adequate 
treatment resources, communities in New Mexico have suffered 
through some of the highest rates of opioid and heroin 
addiction and overdose deaths in the Nation. Rio Arriba County 
has a drug overdose death rate of 81 per 100,000, five times 
the national rate.
    I am reminded of a young man named Josh from Espanola, who 
I met at a roundtable I hosted last year in Rio Arriba County. 
At 14, Josh became addicted to prescription opioids. Over time, 
he moved to heroin. He stole from his family and his friends to 
maintain his growing addiction. Josh spent time in jail where 
he went through the pains of withdrawal. He even attempted 
suicide.
    Now in his 20s, Josh has turned his life around because he 
finally got access to treatment and services. For millions of 
Americans proven substance use treatment is available because 
of, one, behavioral health parity laws and, two, the Medicaid 
program. In New Mexico, Medicaid, called Centennial Care, is at 
the forefront of our fight against the opioid crisis, 
accounting for 30 percent of lifesaving medication-assisted 
treatment payments for opioid and heroin addictions.
    At exactly the time that Congress should be giving states 
more tools to fight this epidemic, House Republicans passed a 
bill that would repeal Medicaid expansion, artificially cap the 
program, and shift the burden about who and what to cut onto 
individual states.
    More than a million people who have been able to secure 
treatment for substance abuse would lose their coverage. 
Repealing Medicaid expansion would cut about $4.5 billion from 
treatment for mental health and substance abuse. We cannot 
fight a public health crisis with grant dollars alone. Grant 
dollars run out. Block grants lose their buying power over 
time, and private investment dollars, which are critical in 
this fight, won't come without certainty that the foundation is 
funded.
    Unfortunately, I will not be able to stay here to hear the 
important testimony of our witnesses today because of a hearing 
you may have heard about in the Intelligence Committee, but I 
will be leaving you in the very capable hands of my colleague 
Senator Hassan. New Hampshire loses at least one person every 
day to a drug overdose. As Governor, Senator Hassan used every 
tool at her disposal to fight the epidemic, including turning 
to the flexibility of the Medicaid program to gain ground in 
her State's fight. I will tell--I will let her tell you more, 
but I leave you with this: When a community faces a public 
health crisis, it is not long before a State turns to the 
Medicaid program to stem the tide.
    Thank you, Senator Hassan, I will turn over the rest of my 
time to you.
    And thank you, Mr. Chairman, for holding this critical 
hearing.
    [The prepared statement of Senator Heinrich appears in the 
Submissions for the Record on page 36.]

OPENING STATEMENT OF HON. MARGARET WOOD HASSAN, A U.S. SENATOR 
                       FROM NEW HAMPSHIRE

    Senator Hassan. Well, thank you, Mr. Chairman and Ranking 
Member Heinrich.
    And to our witnesses today, thank you for being here as 
well.
    As I travel across my home State of New Hampshire, I hear 
from countless families and those on the front lines about how 
the heroin, fentanyl, and opioid crisis has devastated 
communities across our State. And I know that many of our 
colleagues have heard of the impacts in their states as well.
    I am proud that, during my time as Governor, Republicans 
and Democrats in New Hampshire put our differences aside and 
came together to pass and reauthorize our State's bipartisan 
Medicaid expansion plan. Medicaid expansion is providing 
quality affordable health coverage to more than 50,000 Granite 
Staters, including coverage for behavioral health and substance 
use disorder treatment. Experts have said it is the number one 
tool we have to fight this crisis.
    We should be coming together here, just as we did in my 
home State, to support those on the front lines and help those 
who are struggling with addiction. And while members of both 
parties and the administration have discussed the severity of 
this crisis, we need these words to be matched by action. What 
we cannot do, however, is end Medicaid expansion and institute 
deep and irresponsible cuts to the traditional Medicaid 
program.
    This crisis is a public health and law enforcement issue, 
but it is also an economic one. I believe the investments in 
helping people recover are a far better use of our dollars than 
the long-term cost of addiction, both in terms of State budgets 
but also in ensuring that individuals are healthy enough to 
contribute to the economy.
    I am pleased that we are having this hearing today and very 
grateful to the chair for calling it, but we need to continue 
to hold hearings on how proposals made here in Washington would 
affect our ability to stem and ultimately reverse the tide of 
this epidemic. This is an issue that rises above partisanship, 
and this is the work that we need to be doing because the lives 
of our people in our states depend on it.
    I am going to continue to work with my colleagues on 
solutions, while standing firm against any policy that will 
pull us backwards. With that, I thank you, and I look forward 
to hearing from our witnesses.
    [The prepared statement of Senator Hassan appears in the 
Submissions for the Record on page 37.]
    Representative Tiberi. Thank you.
    Let me introduce our first witness. Richard G. Frank is the 
Margaret T. Morris Professor of Health Economics at the 
Department of Healthcare Policy at Harvard University Medical 
School. He has held several positions at the Department of 
Health and Human Services. Most recently, he served as the 
Assistant Secretary for Planning and Evaluation.
    Dr. Frank served as an editor for the Journal of Health 
Economics. He is the recipient of awards from the Southern 
Economic Association and the American Public Health Association 
and others, and he is the coauthor of the book ``Better But Not 
Well.''
    Dr. Frank, you are recognized for 5 minutes.

STATEMENT OF RICHARD G. FRANK, MARGARET T. MORRIS PROFESSOR OF 
  HEALTH ECONOMICS, DEPARTMENT OF HEALTH CARE POLICY, HARVARD 
                   MEDICAL SCHOOL, BOSTON, MA

    Dr. Frank. Good morning, Chairman Tiberi and Senator 
Hassan. Thank you for inviting me to participate in this 
discussion of the opioid epidemic that is plaguing our Nation. 
Just over 33,000 people died in 2015 from opioid overdoses. In 
the time I have with you today, I want to focus on the gap 
between the need for treatment and the receipt of care.
    In 2015, there was an estimated 2.66 million people with an 
opioid use disorder in the country. The illness is concentrated 
in the low-income population. That is, 51 percent of people 
with an opioid use disorder, or OUD, have incomes below 200 
percent of the Federal poverty line. Only 26 percent of the 
people with an OUD receive treatment for that disorder. That 
means that 1.97 million people who needed care did not get it. 
This is tragic because they are treatments that work. 
Medication-assisted treatment has been shown to be the most 
effective treatment for OUDs. They are combinations of 
pharmaceuticals, psychotherapy or counseling, and drug testing 
to monitor treatment adherence.
    Now, national survey data show that over half the people 
that did not get treatment because they either couldn't afford 
it or there were no providers available. Other reasons for not 
getting care were not being ready to stop using substance, 
stigma, and the denial of the problem.
    Now, policy tools are most amenable for addressing the 
affordability and availability reasons. I will focus on three 
areas that are helping to make the treatment gap smaller: They 
are Medicaid, private insurance, and Federal grants.
    Medicaid covers about 34 percent of people with an OUD. 
Recent policy changes in Medicaid have bolstered Medicaid's 
impact. The combination of the Mental Health Parity and 
Addiction Equity Act that requires comparable coverage for 
mental health and substance abuse disorders with medical 
surgical care, the Medicaid expansions, and the essential 
health benefit that includes substance abuse treatment all have 
driven Medicaid to a growing role. Together, these provisions 
have resulted in large increases in the use of medication-
assisted treatment.
    A number of states have been using Medicaid as a central 
part of their attack on the opioid epidemic. The State of Ohio 
recently reported substantial increases in access to care for 
people with opioid use disorder. And in Ohio, Medicaid now pays 
for nearly half of all the buprenorphine prescriptions in that 
State, which is one of the key drugs in medication-assisted 
treatment.
    Let me now turn to private insurance. Private insurance 
covers about 42 percent of people with an opioid use disorder. 
Recent changes there have bolstered the ability of private 
insurance to shrink the treatment gap. They are the Parity Act 
applied to private insurance, the essential health benefit 
provisions in the small group and individual market, and the 
availability of subsidized insurance policies for low income.
    In 2011, a survey of individual market insurers revealed 
that 34 percent of policies sold did not cover substance use 
disorders. Today that is no longer the case.
    Finally, grants to states. The recently enacted 21st 
Century Cures Act appropriated $1 billion over 2 years that was 
intended to focus on closing the treatment gap by expanding 
capacity and expanding direct treatment. Just under $500 
million of that money has been recently allocated to the 
states.
    Let me take a moment to put the Cures money into context 
using the State of Kentucky's experience. Kentucky is receiving 
a grant of about $10.5 million under Cures. That buys about 
1,900 full-year treatments with medication-assisted treatment. 
Currently, Medicaid pays for 4,200 person years of treatment in 
Kentucky, and three-quarters of that is for the expansion 
population. That means if Medicaid cuts at the magnitude 
proposed occur, the Cures funds would likely not be used to 
expand capacity and treatment, but would instead backfill for 
Medicaid losses and wouldn't even be able to cover two-thirds 
of those.
    I now touch on availability. Since policy changes that I 
have described have begun, there has been a surge of new 
private money into this sector. There have been 170 private 
equity deals between 2012 and 2015, some as large as $100 
million. These private investments are aimed at scaling up 
evidence-based practices, and the investment community 
acknowledges it is directly linked to the flow of new funds, 
both on the private and the public sides.
    So the last 10 years have brought--have set a platform for 
closing the treatment gap. The evidence suggests we are 
starting to see important expansions in both capacity and 
treatment that will pay dividends in the future. Turning back 
now doesn't make economic sense and likely leads to tragic 
consequences. Thank you.
    [The prepared statement of Dr. Frank appears in the 
Submissions for the Record on page 38.]
    Representative Tiberi. Thank you, Dr. Frank, for your 
testimony.
    Our next witness, Dr. Lisa Sacco, has been an analyst in 
crime policy with the Congressional Research Service since 
2011. The past 5 years with CRS, she has specialized and 
published reports on domestic drug enforcement, synthetic 
drugs, prescription drug abuse, and various other drug and 
crime policy issues.
    Prior to working at CRS, she received her doctorate in 
criminology and criminal justice from the University at Albany, 
held several drug-related research positions, and taught 
college courses on drugs and crime.
    Dr. Sacco, welcome. You are recognized for 5 minutes.

STATEMENT OF LISA N. SACCO, CRIME POLICY ANALYST, CONGRESSIONAL 
     RESEARCH SERVICE, LIBRARY OF CONGRESS, WASHINGTON, DC

    Dr. Sacco. Thank you.
    Chairman Tiberi, Senator Hassan, and distinguished members 
of the committee, my name is Lisa Sacco, and I am a CRS crime 
policy analyst. Thank you very much for inviting me to speak 
with you. My testimony will focus on the scope of the supply of 
opioids in the United States. I will begin by stating three 
points from my written testimony that I will expand upon today.
    First, heroin, fentanyl, and controlled prescription drugs 
have been ranked as the most significant drug threats to the 
United States. While the reported availability of controlled 
prescription drugs has declined over the last several years, 
the reported availability of heroin and illicit fentanyl has 
increased. The availability of these drugs is a contributing 
factor to rising consumption. Second, the supply of opioids 
varies by region of the United States. Third, while the Federal 
Government has generally concentrated on reducing the supply of 
illicit drugs, Federal drug control funding for supply 
reduction has remained relatively flat over the last several 
years while funding for demand reduction has increased.
    While opioids have a long history in the U.S., this 
testimony focuses on the last several decades, as the market 
for these drugs has shifted a great deal. In the 1990s, 
availability of prescription opioids increased as the 
legitimate production of these drugs and ensuing diversion from 
lawful use increased sharply. This continued into the early 
2000s as users obtained their prescription drugs through means 
such as doctor shopping, pill mills, the internet, and through 
family and friends.
    The Federal Government and State and local governments 
undertook a range of approaches to reduce the unlawful 
prescription drug supply, including diversion control through 
prescription drug monitoring programs, the crackdown on pill 
mills, the increased regulation of internet pharmacies in 2008, 
the reformulation of OxyContin in 2010, and the rescheduling of 
hydrocodone in 2014.
    Some experts have highlighted a connection between the 
crackdown on the unlawful supply of prescription drugs and the 
subsequent rise in heroin supply and abuse. Heroin is a cheaper 
alternative to prescription drugs that is often more accessible 
to some who are seeking an opioid high. While most users of 
prescription drugs will not go on to use heroin, accessibility 
and price are central factors cited by drug treatment patients 
in their decision to turn to heroin.
    The trajectory for heroin supply over the last several 
decades is much different compared to prescription opioids, but 
the stories of their supply are connected. In the late 1990s 
and early 2000s, white powder heroin produced in South America 
dominated the market east of the Mississippi River, and cheaper 
black tar and brown powder heroin produced in Mexico dominated 
the market west of the Mississippi.
    Price and purity varied considerably by region. In 2000, 
most of the heroin seized was from South America while a 
smaller percentage was from Mexico. In recent years, this has 
dramatically changed. Over the last several years, heroin 
prices have declined while purity, in particular the purity of 
Mexican heroin, has increased. Over 90 percent of the heroin in 
the U.S. seized is from Mexico, and a much smaller portion is 
from South America. Mexican traffickers dominate the U.S. 
market because of their proximity to the U.S., their 
established transportation and distribution infrastructure, and 
their ability to satisfy U.S. heroin demand. Increases in 
Mexican heroin production have ensured a reliable supply of 
low-cost heroin, even as demand for these drugs has increased. 
Mexican traffickers have increased their production of white 
powder heroin and may be targeting those who abuse prescription 
opioids.
    Compounding the current opioid problem is a rise of non-
pharmaceutical fentanyl on the black market. Fentanyl is often 
mixed with or sold as heroin, and it is 50 to 100 times more 
potent than heroin. Non-pharmaceutical fentanyl largely comes 
from China and is reportedly cheaper than the cost of heroin. 
The increased potency of synthetic fentanyl compounds is 
extremely dangerous, and law enforcement expects that the 
fentanyl market will continue to expand in the future as new 
fentanyl products attract additional users.
    The threat posed by opioids has increased since 2007, and 
the threat varies by region. In 2016, approximately 45 percent 
of law enforcement agencies that responded to the National Drug 
Threat Survey reported heroin as the greatest threat in their 
area. In contrast, 8 percent of respondents reported heroin as 
the greatest threat in 2007. Reports of heroin as the greatest 
threat are concentrated in the Northeast, Midwest, and mid-
Atlantic regions.
    Opioids are the main cause of drug overdose deaths. Reports 
indicate that increases in overdose deaths are most likely 
driven by fentanyl and heroin. The increasing availability of 
heroin and other opioids throughout the U.S., largely, but not 
entirely, corresponds to the increases in drug overdose deaths 
around the country. For example, New Hampshire ranks second in 
the country in drug overdose deaths, and they have reported 
high availability of heroin in the area. New Mexico and Utah, 
on the other hand, rank eighth and ninth, respectively, but 
only 4.7 percent of survey respondents in the Southwest 
reported heroin as the greatest threat, and 22.6 percent 
reported high availability of the heroin. This discrepancy may 
be explained by a number of factors, including lethality of 
fentanyl.
    Historically, the Federal Government has concentrated on 
reducing the supply of illicit drugs, but in recent years, 
efforts to reduce the demand for these drugs have increased. 
Federal drug control dollars largely go toward addressing the 
supply side. However, Federal drug control funding for supply 
reduction has remained relatively flat over the last several 
years while funding for drug treatment and prevention has 
increased. Thank you.
    [The prepared statement of Dr. Sacco appears in the 
Submissions for the Record on page 48.]
    Representative Tiberi. Dr. Sacco, thank you for your 
testimony.
    It is an honor to introduce my attorney general, Senator 
Portman's attorney general, Mike DeWine, who has served as a 
State senator in Ohio, as a Member of the United States House 
of Representatives, as a U.S. Senator, and now as Ohio's 50th 
Attorney General. Your tough--Ohio's tough drunk driving law 
has been a leading proponent for highway safety and has 
advocated for victims of crime.
    He has assisted local law enforcement, advanced the use of 
DNA evidence for victims of crime, made efforts to assure 
prescriptions are safe, and worked tirelessly to fight the 
opioid epidemic in our State. I have known Mike for decades. I 
am pleased you were able to come today to testify and give us 
your thoughts.
    You are recognized for 5 minutes.

STATEMENT OF HON. MIKE DeWINE, OHIO ATTORNEY GENERAL, COLUMBUS, 
                               OH

    Attorney General DeWine. Chairman Tiberi, Senator Hassan, 
and members of the committee, thank you so much for inviting me 
today.
    The most visible sign of opioid epidemic in Ohio, of 
course, is the number of deaths that we have. Last year, the 
official total was eight per day. I think it was, frankly, more 
than that. Today, at least, it is clear that that number is 
going up.
    But the cost is so much more. Every day, in Ohio, we have 
babies who are born who are addicted. We don't know what the 
developmental cost for each of those children will be, what 
that will impact that particular child, but we know that many 
of them will in fact be impacted. We do know what the cost is. 
The cost in the hospital neonatal intensive care unit, the 
average child there I think spends about 14 days there at very 
tremendous cost.
    Our foster care system is bursting at the seams; our 
children services are. Fifty percent of all the foster care 
children--people--children who are in foster care are there 
because one or both parents are drug addicts. Seventy percent 
of the infants that are in foster care are there because one or 
both parents are drug addicts.
    Our jails in Ohio are overflowing. We have more women in 
our jails and our prison system than we ever had by far to 
date. Our jails in Ohio in our 88 counties are really detox 
centers, something that they were not really designed for at 
all.
    Narcan. All responders carry Narcan. As we move in that--it 
is a great thing, and we have advocated for that, but as we 
move from pain meds to heroin to fentanyl to carfentanil, it 
takes more and more dosages. I had an officer tell me the other 
day that it took 12 different dosages to bring someone back to 
life.
    But the number--the big cost that we really--I think it is 
much more difficult to determine, but it is huge, absolutely 
huge--is the number of people who are in Ohio who cannot pass a 
drug test and, therefore, cannot have a number of jobs. You 
could never hire someone who can't pass a drug test to be 
around machinery. Never hire someone to even be in charge of 
the local McDonald's or the Burger King. You cannot have 
someone to drive a truck.
    The missed opportunities, the fact that these people are 
not living up to their God-given potential with the tremendous 
impact it has on their own family but also the impact it has on 
the State of Ohio is just absolutely huge. I do kind of a 
little quiz when I talk to employers, and I say, ``Do you drug 
test?'' If they say, ``Yes, I drug test,'' I say, ``Well, what 
percent of the people who come in here--and you tell them they 
have to take a drug test--leave before they take the drug test 
and then add to that the percentage of people who come in here 
and are so arrogant or stupid or both that they take the test 
and fail it?'' The average that comes back when you put those 
two numbers together almost every single time is 40 percent. It 
is not scientific. It is anecdotal. But it tells us, I think, 
some of the great loss we have.
    What do we do about it? We start, I think, with the premise 
that most people who are addicted today of heroin, fentanyl, et 
cetera, started with pain meds. The first thing that we did is 
we took the licenses of over 100 doctors in the State of Ohio. 
These were bad people. These were drug dealers. They needed to 
go away.
    But what remains is a lot of good doctors who are still, 
frankly, influenced by a culture that we believe the evidence 
shows was caused by the drug companies purposely to indicate 
that someone who has long-time chronic pain that is not 
terminal, that they are an appropriate candidate for pain meds. 
These doctors still, I think, some believe that pain meds are 
appropriate for that circumstance. I think that is a problem. 
We are slowly changing that culture, Mr. Chairman, and I think 
making improvement.
    Local communities must own the problem. There must be an 
admission that there is in fact a problem. What follows that 
should be an inventory. What are the assets that we have? What 
are the challenges that we face? And then all the community has 
to go together. The business community, the law enforcement, 
the educators, and the churches. One of the things we have 
emphasized in our office is the faith-based community needs to 
be involved.
    Another thing that is happening in Ohio, Mr. Chairman, is 
law enforcement is doing something it never did before, and 
that is helping get people into treatment. Just amazing 
stories. Senator Tharp--excuse me, I gave him an increase in 
title. Sheriff Tharp in Lucas County does an amazing job. They 
go to the emergency room. They take people from the emergency 
room if they are ready for treatment, and they work with them 
and get them into treatment.
    Let me talk about two other things, if I could, Mr. 
Chairman, and then I will conclude. I believe that we need to 
move to a K through 12, every year, talking about--to kids in 
school about this problem. I think it should be repetitive, 
comprehensive, and school-based. And it must be age 
appropriate. You are not going to talk to kindergarten kids 
about heroin, but you will talk to them about maybe good 
choices and health. And if you see a pill, don't pick that up.
    I was on Reagan's National Commission on Drug Free Schools. 
Every expert who came in said you have to start in 
kindergarten; you have to do something every single year. We 
had a study commission that put this out, and I would make this 
available to anyone who is watching this or any members of the 
committee, it is on 23 or 24 page. We have mailed this to every 
superintendent in the State.
    Finally, Mr. Chairman, I think in this country we need to 
do something. And I think it really needs to be on a national 
scale. We have to change the culture. When I was a county 
prosecuting attorney in the 1970s, heroin was something that 
even people who were doing drugs, most people wouldn't touch 
heroin. There was a psychological barrier there. That barrier 
is simply gone today and no longer exists.
    I think what we need is a media blitz, a social media blitz 
on TV that is aimed at really two people--two groups of people. 
One are kids, and one are parents and adults. Get all the 
experts together. I am not an expert in this, but put them 
together, put the best media people we can put together, and 
let's try to change the culture. Because the irony is that as 
we have changed the culture in regard to tobacco--it took a 
long time; we have gone in the right direction--in regard to 
opiates, we have gone in absolutely the opposite direction. We 
can turn this around.
    Thank you, Mr. Chairman.
    [The prepared statement of Attorney General DeWine appears 
in the Submissions for the Record on page 55.]
    Representative Tiberi. Thank you.
    Our last witness is Professor Sir Angus Deaton, who is a 
senior scholar and Dwight D. Eisenhower Professor of Economics 
in International Affairs Emeritus at Princeton University's 
Woodrow Wilson School. He is also Presidential Professor of 
Economics at the University of Southern California. He is a 
member of the National Academy of Sciences, the American 
Philosophical Society, and an Honorary Fellow of the Royal 
Society of Edinburgh. He was president of the American Economic 
Association in 2009.
    In 2015, he received the Nobel Prize in Economic Sciences. 
In 2016, he was knighted by Prince William at a Buckingham 
Palace ceremony.
    Thank you for joining us today, Professor Sir Angus Deaton. 
You are recognized for 5 minutes.

 STATEMENT OF SIR ANGUS DEATON, LAUREATE OF THE NOBEL PRIZE IN 
ECONOMIC SCIENCES, SENIOR SCHOLAR AND THE DWIGHT D. EISENHOWER 
  PROFESSOR OF ECONOMICS AND INTERNATIONAL AFFAIRS EMERITUS, 
 WOODROW WILSON SCHOOL OF PUBLIC AND INTERNATIONAL AFFAIRS AND 
 THE ECONOMICS DEPARTMENT, PRINCETON UNIVERSITY, PRINCETON, NJ

    Professor Deaton. Thank you, Chairman Tiberi, Senator 
Hassan, and the other members of the committee for holding this 
hearing on economics and the opioid crisis.
    Deaths from legal and illegal drugs are contributing to an 
almost unprecedented increase in overall mortality among 
middle-aged white non-Hispanics. A century of mortality decline 
came to a halt at the end of the 20th century, and mortality 
rates for this mid-aged group were higher in 2015 than in 1998. 
Driven by these developments, life expectancy at birth, a key 
indicator of how well a society is doing, fell for white non-
Hispanics from 2013 to 2014, and for the whole population of 
the United States from 2014 to 2015.
    Opioids are a big part of the story. Supplies of opioids 
have stoked and maintained the epidemic. Selling heroin is 
profitable and illegal. Selling prescription drugs is 
profitable and legal. Pharmaceutical companies have made 
billions of dollars in profits on prescription opioids.
    Opioids have a legitimate, if limited, role in treating 
pain, but perhaps it would have been better had they never been 
approved. Physicians are far from infallible in detecting which 
patients are likely to become addicted, and once patients are 
addicted, treatment is difficult and often unsuccessful.
    My work with Anne Case has examined opioid deaths as part 
of an epidemic of mortality, what we call deaths of despair. 
These are suicides, deaths from alcoholic liver disease and 
accidental overdoses from legal and illegal drugs. The opioid 
deaths are the largest component. In 2015, for white non-
Hispanic men and women aged 50 to 54 without a college degree, 
who were much more seriously at risk than those with a college 
degree, deaths of despair are around 110 per 100,000, of which 
50 are accidental overdoses, 30 are suicides, and 30 are from 
alcoholic liver disease and cirrhosis.
    There has recently been turn-up in mortality heart disease 
after many years of decline. And if obesity is the cause, some 
of these deaths might be deaths of despair, which would put a 
total at levels approaching deaths from cancer or from heart 
disease, the two major killers in midlife.
    Figure 1 shows the all-cause mortality rate for white non-
Hispanics, the red line aged 45 to 54, together with mortality 
rates for selected comparison countries. The mortality rates in 
midlife in other countries continued to decline at the rates 
that prevailed in the United States before 1998.
    Americans are killing themselves by drinking, by 
accidentally overdosing, by overeating, or, more quickly and 
more straightforwardly, by committing suicide.
    Deaths of despair have risen in parallel for men and women, 
see figure 2. Such deaths, like all suicides, are lower for 
women than for men, but the increases have marched in lockstep. 
The key distinction here is not between men and women, but 
rather between those with and without a college degree.
    Deaths of despair cannot be explained by the economy. They 
were increasing before the Great Recession and continue to 
increase afterwards.
    We think of all of these deaths as suicides of a kind, and 
suicides respond more to prolonged economic conditions and to 
the associated social dysfunctions and loss of meaning in the 
interconnected worlds of work and family life.
    Workers who entered the labor market before the early 
1970s, even without a college degree, could find good jobs in 
manufacturing, jobs that came with benefits and on-the-job 
training, that could be expected to last, and that brought 
regular increases in earnings, and a road to middle class 
prosperity. Not so today.
    With fewer good jobs, there has been a decline in marriage 
rates, though couples often cohabit and have children out of 
wedlock. Those cohabiting relationships are less stable than 
marriages so that many fathers do not live with or even know 
their children, and many children have lived with several 
``fathers'' by their early teens, ``fathers'' in quotes.
    Heavy drinking, overeating, social isolation, drugs, and 
suicide are plausible outcomes of these processes that have 
cumulatively undermined the meaning of life for white working 
class people. Within this context, we tend to see the opioid 
epidemic as an accelerant, as something that has poured fuel on 
the fire of something that was already very bad already. Thank 
you very much.
    [The prepared statement of Professor Deaton appears in the 
Submissions for the Record on page 87.]
    Representative Tiberi. I would like to thank you all for 
your testimony today.
    Before I begin asking my questions, just two notes. In the 
spirit of bipartisanship, I allowed the Democratic witness to 
go first. I hope that is noted, as we move forward and continue 
bipartisanship on this panel. And I allowed the former Senator 
and former Member of this body, House, a little few extra 
minutes out of professional courtesy.
    With that, Mr. Attorney General, you hit on something in 
your testimony that I hear about all the time in the seven 
counties in my district, whether it be urban, suburban, rural, 
or small town, and that is the impact that this is having on 
the economy, employers who are saying: You know, I have three 
positions open and I can't find anybody to fill the position 
who can pass a drug test.
    From your perspective and all the work that you have done 
in this area, whether it is heroin or opioids or whatever type 
of drug abuse, where do you see in our State, the problem being 
the worst in terms of the economic conditions? Is it places 
that have historically been left behind? Does geography not 
make a difference? Can you give us your thoughts on it?
    Attorney General DeWine. Mr. Chairman, I think if we 
analyze this, what is different about this drug problem that we 
have is how pervasive it is. It is absolutely everywhere: It is 
in our smallest communities. It is in our cities. It is in our 
most affluent suburbs.
    I think if you go back historically, you could trace the 
beginnings of this to southern Ohio or Appalachian counties in 
regard to the pain med problem. We think that most of the 
addiction, although some people may start on heroin, most 
people become addicted to the pain meds, and they move to the 
heroin because, at some point, they can't get the pain med 
anymore and because heroin is so cheap. They move then possibly 
to fentanyl and carfentanil. So, if you go back 10 years, where 
you would see--where the biggest problem would be is in 
southern Ohio with the pain med problem.
    I am not a sociologist. I am not sure I can--I can guess, 
but I don't have a great deal of expertise in this area at all, 
but it starts with that. But it is absolutely everywhere.
    And part of the challenge, I think, always, as you look at 
this problem, and I know that some states are at a different 
stage than we are--we are well down the path--what I would 
suggest is the biggest challenge you have is getting people to 
understand that this is a problem in their community. Their 
community. And for the last 5 years, every interview I have 
done on this, I have looked into the camera, if it was a TV 
camera, and I have said: If you are watching this, you have an 
opioid problem, you have a drug problem in your community.
    Representative Tiberi. So just one followup, you mentioned 
a demand problem and talking to kids as early as kindergarten. 
How about the supply problem? Is there any way to deal with 
that? You said you see it everywhere in our State; law 
enforcement is seeing it everywhere. Any thoughts on the supply 
issue?
    Attorney General DeWine. Well, of course, you are talking 
to somebody who was a county prosecuting attorney. And what we 
do in the Attorney General's Office is assist local law 
enforcement. So we always look first to the law enforcement 
problem. And what we did 5 years ago is we created what we call 
the Law Enforcement Heroin Group--Unit out of BCI, and I can't 
really talk in public about exactly what we do, but we will go 
in and help the local sheriff or the local prosecutor or the 
local police. Once they have already started their drug 
investigation, we will help them take it to a higher level and 
to get the bigger fish and the bigger drug dealers. That 
remains an essential part of what we do.
    I have talked to the Attorney General of the United States 
about cooperation with information coming off the border, and 
that is a work in progress, so that we get real-time 
information coming off the border back into Ohio. So we do work 
with our Federal partners and the FBI, Drug Enforcement 
Administration, and we have a very close and good working 
relationship with them.
    So law enforcement is a key component part, but we are not 
going to arrest our way out of this problem. We have to deal 
with it holistically, which is do a better job in regard to 
treatment and getting people into treatment and keeping them in 
treatment. And we have to do a better job, a much better job, 
with prevention, which--where I think is the most opportunity. 
If you look at this from the long run, where are we going to be 
in 10 years, 15 years, 20 years? Start today in kindergarten, 
and very few schools are doing this.
    Representative Tiberi. Thank you.
    Professor Deaton, you talked about the deaths of despair, 
the economic conditions that cause it. Are those economic 
conditions, from your perspective, getting worse or trending 
better, or is it geographically different?
    Professor Deaton. I think they have gotten somewhat better 
in the short run, but I don't think of this as being a short-
run problem. I think this is a deep problem to do with, you 
know, what people who don't have a university degree are going 
to do with their lives. And the world that they used to inhabit 
is a world that is broken. And I think the meaning--the things 
that gave meaning to their lives, the steady jobs, are really 
not there anymore. And I am not particularly optimistic.
    I don't think it is a good idea for everyone to go to 
college. I mean, I just think maybe things like apprenticeships 
may be a new way of thinking about that world of work really 
would help. I should say, though, that I de-emphasized the 
opioids because that was my shtick here. But I think doing 
something about the opioids in some sense is the easy part of 
this, though, God knows it is hard enough and that we really 
have to do that. We really have to change this culture of 
doctors that believes that pain should be treated with heroin, 
essentially, which is something we never used to do.
    Representative Tiberi. Thank you, Professor. I appreciate 
that.
    My time has expired.
    Ms. Hassan is recognized for 5 minutes.
    Senator Hassan. Thank you very much, Mr. Chair.
    And, again, thank you all for your testimony.
    Dr. Frank, Medicaid has served as a lifeline for states 
that have been hit hardest by the opioid epidemic, and experts 
have said it is the number one tool we have in combating this 
crisis. As a former Governor, I certainly understand how 
critical it has been in ensuring that Granite Staters 
struggling with addiction have access to treatment and recovery 
services.
    So I am obviously concerned that the Republican bill that 
passed out of the House in May would fundamentally change the 
Medicaid program as we know it. Instead of being a guaranteed 
benefit for states and their residents, the per capita cap in 
the plan would result in massive cuts that would set limits on 
Federal contributions regardless of the need for care and 
services. That will mean less buying power over time and leave 
states with far fewer resources to provide services to their 
citizens.
    Could you address how a per capita cap approach to Medicaid 
would impact a State's ability to fight this epidemic and/or 
future public health emergencies?
    Dr. Frank. Sure. Thank you for that question. The per 
capita cap essentially is set up so that it locks in 2016 per 
capita spending patterns and then inflates them forward at what 
the Congressional Budget Office predicts is about 3.7 percent, 
which is the expected consumer price medical component. And so 
what that does is it allows you to keep up with general 
inflation based on the 2016 patterns of treatment.
    Now, as we know, mortality from opioids is growing at 15 
percent a year; hospital admissions at about 6 percent; drug 
treatments for opioid addiction is growing at 10 to 12 percent 
a year. And so what happens is, when you have a per capita cap 
that is based on that 2016 pattern and new things happen or old 
things grow faster, you start to fall behind very quickly.
    Senator Hassan. Thank you.
    Dr. Sacco, we know, to your point, that we need to attack 
the supply side of this epidemic, something that we have been 
working on in New Hampshire. And we know how law enforcement 
plays a critical role in cutting off supply side of illegal 
opioids and other drugs into our communities. But in New 
Hampshire, our law enforcement officials will be the first to 
say, just as Attorney General DeWine just did, that we can't 
arrest our way out of this problem. I still remember the 
colonel of my State Police calling me when I was a new Governor 
and saying, could I testify in favor of Medicaid expansion, 
because we need it?
    So we need to treat this as the public health crisis that 
it is, and focus on addressing the demand side, which means 
having an effective public health response that could be more 
cost efficient and effective. Oftentimes, Medicaid--medication-
assisted treatment is less costly than simply incarcerating 
someone with a substance use disorder, not to mention, being 
more effective at addressing the problem and reducing 
recidivism.
    Dr. Sacco, do you agree that the opioid epidemic requires 
both public health and law enforcement responses to address in 
the crisis? Do you agree with the law official--the law 
enforcement officials in my State and the attorney general here 
that we can't simply arrest our way out of the problem?
    Dr. Sacco. Senator Hassan, if you are seeking to address 
both the supply and the demand, then, yes, there should be a 
comprehensive approach. Generally, law enforcement addresses 
the supply issue. Right now, the response seems to be one that 
is comprehensive.
    Senator Hassan. And would you agree that working on 
expanding prevention, treatment, and recovery programs, 
including Medicaid, is important to helping address the entire 
crisis?
    Dr. Sacco. CRS does not take a position on the advisability 
of that. I am sorry.
    Senator Hassan. Okay.
    Dr. Frank, proposals coming out of the House would 
undermine the essential health benefits of the ACA that 
requires the coverage of substance use disorder services. CBO 
says that that could increase out-of-pocket costs by thousands 
of dollars.
    Do you believe eliminating substance use treatment places a 
barrier to access to care for people struggling with substance 
use disorders?
    Dr. Frank. Absolutely. We have seen in the states, for 
example, that expanded Medicaid and in states where there has 
been dramatic decreases in the uninsured rate from private 
insurance, we see those are the states that have responded most 
strongly with medication-assisted treatment in serving people 
with opioid use disorders.
    Senator Hassan. Thank you very much.
    And I see my time is up.
    Representative Tiberi. The gentleman from Minnesota is 
recognized for 5 minutes.
    Representative Paulsen. Thank you, Mr. Chairman, for 
holding this hearing on such an important issue that is having 
such a significant impact on communities across the country. 
This is certainly, as has been mentioned in the testimony, a 
problem that is everywhere. And, unfortunately, Minnesota has 
not been able to escape the devastating effects, economic and 
otherwise, of opioid addiction and the opioid crisis.
    Just last month, I spoke to a mother from Maple Grove, 
Minnesota, whose son bought acrylfentanyl, an analogue of 
fentanyl, online, consumed it, and died. And it goes without 
saying that she was devastated by the loss of her son. But she 
was also devastated by the ease with which he was able to 
purchase the opioid online. While it may not be within the 
scope of today's hearing or committee, there is certainly a 
role for Congress to play to ensure that opioids are not so 
easily accessible.
    Unfortunately, Minnesota was also the home to a much higher 
profile opioid overdose case on April 21st of last year. 
Prince, one of the most successful pop artists of all time, 
passed away in Chanhassen after taking fentanyl.
    My point is that this is a problem that affects many 
different types of people, old and young, rich and poor, your 
neighbor down the street, as well as an international 
celebrity. And while it is important that we understand and 
address the physical and emotional effects of the opioid crisis 
on Americans, there is also value in coming to grips with the 
economic toll it is taking on the country as well, which is why 
I appreciate having such a great panel of witnesses here with 
us today.
    Let me just start with a few questions. Mr. DeWine, the 
synthetic opioid fentanyl is 100 times more potent than 
morphine. And carfentanil is similar but is 10,000 times as 
strong as morphine, and it was developed for tranquilizing 
elephants and other large mammals. In just the past few years, 
fentanyl deaths have sky-rocketed. Ohio, as you have mentioned, 
averaged four fentanyl deaths per year from 2007 to 2011. And 
in 2015, there were 1,155 fentanyl overdose deaths.
    Do you have insight into the reasons for this development 
in Ohio in particular, and are there parallels or lessons that 
can be drawn for other states?
    Attorney General DeWine. Congressman Paulsen, thank you for 
the question. You know, carfentanil is so dangerous--and 
fentanyl as well, but carfentanil certainly much more--that 
about a year ago we sent a bulletin out to every chief of 
police and every sheriff in the State, telling him and her and 
their officers, men and women of these departments, don't field 
test drugs any more. Stop it. Don't touch it. We had an 
experience in Ohio within the last month or so where an officer 
overdosed literally because he was in the presence of this and 
somehow it got into his system. So it is highly dangerous.
    We believe a couple things are happening. We believe that 
the fentanyl is coming in primarily from China, although 
certainly some could be--actually be made in Ohio, but we think 
mostly it is coming in. I know Senator Portman has been 
directly involved in that concern, and Members of the House and 
the Senate have been.
    I think you see the drug dealers, they are great marketers. 
I mean, it is amazing. This whole system is all about customer 
service. And it is all about delivery. I mean, I tell people 
that, if you look at heroin, Mexican drug cartels have 
developed a perfect business model: They grow the poppies in 
Mexico. They ship it across our southern border into Ohio. They 
could control it down to the street level. At some point, they 
may sell it off to the local dealers. And then what kicks in is 
what I call a pizza delivery system. You pick up the phone, you 
call, and they will deliver it. You get it in half an hour, and 
you are going to get it cheap, but they get you started.
    I am told--I am not a medical expert--but I am told that 
the ratio between an early stage heroin addict and maybe a late 
stage heroin addict, the amount taken could be as high as 
hundred to one. So what starts as a $10-a-day habit may go to 
$1,000-a-day habit. They are always chasing a high.
    And the reason I think you get to fentanyl is two things. 
One, it is easier for the drug dealers to get, and it is 
cheaper for them, and they can make more money on it. And, 
number two, it is a way to broadcast that, you know, this is 
something different. This is a better high. The irony is that 
when we get a situation where five, six, seven people die in a 
weekend in some city in Ohio, obviously, because they were on 
fentanyl or they were on carfentanil and it is a different 
potency or something is there, the demand appears to go up.
    So we worry--you know, we put the bulletin out, and local 
law enforcement says, ``Look, be very, very careful.'' What we 
worry about is that we are just encouraging people to go seek a 
higher high. It is just--nothing makes sense about this. I 
think it is clear that people's brains are being altered, and 
the person who is buying it is not looking at it rationally or 
the way you and I would be looking at it today, not being 
addicts.
    Representative Paulsen. Thank you, Mr. Chairman.
    Representative Tiberi. Mr. Delaney is recognized for 5 
minutes.
    Representative Delaney. Thank you, Mr. Chairman. I want to 
thank you for holding this hearing on obviously a very 
important issue that affects all of our districts.
    As Mr. DeWine said, this is in every community in the 
country. And the fact that you have assembled such a terrific 
group of witnesses, I am grateful for that.
    And, in particular, I want to thank Mr. DeWine for what he 
is doing in holding the pharmaceutical industry accountable. 
You will make them pay like other people will, and that won't 
solve the problem, but it is the right thing to do, and it will 
send a message that we are going to start thinking about these 
things differently.
    And we believe in a capitalistic system in this country, I 
certainly do, but we want it to be just at some level, and 
efforts like what you are doing will help make that happen.
    And it is fairly obvious what we need to do, and the 
witnesses have very eloquently covered it here today. Whether 
we have the commitment and conviction to do it is a question. 
But the steps that Mr. DeWine is taking are obviously 
incredibly important, making sure we manage ourselves through 
the situation by having the healthcare system in place that can 
support the people afflicted by this. And I associate myself 
with the Senator from New Hampshire and her eloquent comments 
about the importance of Medicaid.
    Dr. Frank, your comments were very encouraging when you 
talked about how private investment sees this, as effectively, 
a very large business opportunity, and they are putting a lot 
of money and resources against it, and there will be a lot of 
innovation. So the same forces of capitalism that caused the 
problem here hopefully will be directed toward solving the 
problem. And so, if we are optimistic, perhaps we see a path 
out of the opioid crisis.
    Professor Deaton, your comments were the most sobering in 
many ways. These deaths of despair are a manifestation of 
something that is going on in our society, something very broad 
and very significant and vexing in terms of how we deal with 
it.
    You know, we have allowed globalization and technological 
innovation to occur, which have been extraordinarily positive 
for the state of humankind, but they have been very negative--
very, very negative for certain communities in particular who 
weren't prepared for it; it happened too fast. And it has been 
negative for pockets really in every community and how we 
confront that and the isolation, lack of security the human 
beings have. You touched on it. They are not getting married. 
This opioid situation was really kind of a perfect storm or the 
confluence of events, almost like a match to fire based on 
that. They are not moving. There is no mobility. These people 
are frozen. They lack security. They are not engaging in 
society the way Americans have historically engaged.
    And the cost of doing nothing against this is obviously not 
nothing. So, as an economist, how do you think about how we 
should approach this, because it seems to me a transformative 
investment is required in these communities if we are actually 
going to jump start them and the citizens of these communities 
out of the condition that they are in right now, which will 
obviously be very expensive? But how do you think about that in 
terms of not doing something?
    Professor Deaton. Thank you, Representative Delaney. I wish 
I knew the answer to that question. I don't--I think 
globalization has been the issue. I think automation in some 
ways is more of a threat to many of those jobs. There has not 
been much of a decline. In fact, in most industries, there has 
been substantial increase in American manufacturing output, but 
the jobs are not there anymore because we don't need the labor 
to do that.
    I don't know. I mean, I think, you know, you saw the slides 
I showed. This is not happening in Europe. And Europe is facing 
the same challenges. Globalization is happening to Europe. The 
pressure in jobs is the same in Europe. And one of our research 
topics--I don't know the answer. I mean, my friends on the left 
tend to say Europe has a much better social safety net than we 
do. One of the policies that people talk about is mothers--
children get State allowances on a regular basis, which stops 
mothers having to shop around for men all the time, and this 
sort of merry-go-round of marriage has slowed down. But there 
is a lot of dysfunction going on.
    Representative Delaney. What is the cost to us if we don't 
solve this problem?
    Professor Deaton. Well, I think the opioid problem will get 
solved.
    Representative Delaney. Yeah, putting aside the opioid 
problem. The more structural problem that you identified.
    Professor Deaton. Well, the cost to us depends on what the 
counterfactual is. I mean, do you actually think we can do 
something about this? And what is that something that we can 
do? And I certainly think we need to think through all 
possibilities and look at some of the things that are happening 
in Europe.
    The German apprenticeship system seems to really hold 
people together in a way that doesn't happen in this country, 
for instance. I know a lot of employers are upset about the 
labor force coming out of college or below is not trained for 
what they want, and some sort of apprenticeship system may help 
that. But I really--I don't have any surefire solution to solve 
this.
    Representative Delaney. That you, sir.
    Representative Tiberi. The gentleman from Arizona is 
recognized for 5 minutes.
    Representative Schweikert. Thank you, Mr. Chairman.
    Have you ever had one of those evenings where you can't 
sleep, so you are up reading about what is--and I read over all 
of here. I want to find an eloquent way to say because, being 
from Arizona, a border State, we at least document a couple 
lost lives every single day in Arizona. But in not talking--the 
book from my friends on the left. I would love to actually take 
a step backwards because there are things in the data--I 
actually built some charts off of Dr. Frank's information. And 
in some ways, I couldn't make parts of your argument work with 
the chart. You know, on saying during time of Medicaid 
expansion, my numbers are going up still double digits.
    Are there any data sets--if we were to just wipe our minds 
clean of our partisan angst and say, give me something to look 
at that would help us do policy of--is it an economic driver? 
Is it the synthetics that are so small they are easy to 
transport and ship? Is it border? Is it demographics of the 
aging of my society? If I were to try to build a number of 
charts and say, here is my inflection, here is where we are 
going to build our policy goal, please, someone help me build 
what that policy is.
    And I was going to go to Dr. Sacco. You live in this. You 
have been doing this for years. You had some real interesting 
stuff in your write-up. Where would you take us if you were 
building the policy?
    Dr. Sacco. I think some things have already started. As you 
are aware, most of the fentanyl is coming from China. China 
recently announced its intent to schedule four fentanyl 
products. It remains to be seen whether this has an effect on 
what is coming over from China.
    There is, as I think I mentioned, an increased production 
of heroin in Mexico and declining production in South America. 
It may be worthwhile to take a look at reducing the poppy 
supply in Mexico.
    Representative Schweikert. But my fear is that is not my 
global solution. I am just now chasing a substitution of 
product.
    Dr. Sacco. I am speaking to the supply side today. 
Absolutely, you should speak to my colleagues about this issue.
    Representative Schweikert. Dr. Frank, you have something to 
say about this?
    Dr. Frank. Yeah. In a sense you are asking: There is the 
sort of growth problem, and there is the levels problem. On the 
levels problem, if we cut the number of opioid prescriptions in 
this country by 90 percent, we would still be the largest 
consumer of opioids in the world.
    Representative Schweikert. So, in that model, one of the 
first things you would do is--let's say we could wave a wand 
and elimination of prescription opioids.
    Dr. Frank. No. I think it is more making sure that all our 
providers are trained in the best possible practices, because I 
don't think we can ignore the pain problem. We have a real pain 
problem in this country.
    Representative Schweikert. Okay.
    Dr. Frank. So I think that we need to sort of balance the 
two. And, so far, we have tipped the scale too far the other 
way.
    Representative Schweikert. And just from a, you know, a 
junior standpoint, just looking at what the chemical compounds 
were in the synthetics, it is not that hard to make. I mean, 
the precursors--I am still not hearing a global--professor, 
from an economist's standpoint, what is my global solution?
    Professor Deaton. I wish I knew. I am more skeptical than 
Dr. Frank is about treatment. I think, you know, somehow we 
have to choke back the supply. I mean, it is interesting to 
look back 30 years ago what happened with the crack epidemic, 
which devastated a different set of communities. And I think 
that that's----
    Representative Schweikert. Is there a parallel we can learn 
from that?
    Professor Deaton. Well, I think the communities dealt with 
it in the end, and it became sufficiently pervasive that the 
communities--you know, it is what Attorney General DeWine was 
talking about. We can educate the communities to the point 
where this becomes completely intolerable. And I think we need 
to be able to do that. And the schools would be a place. But 
the police are working on this. And it is still true that not 
all that many people know about it.
    And I think the doctors really have to be choked back. I do 
believe there is a genuine pain epidemic in this country. I 
don't know how much of it was stoked by opioids, how much of it 
was stoked by the pharma companies, but I think there is 
something else there. And we have no idea how to treat that.
    Representative Schweikert. Thank you, Professor.
    Mr. Chairman, I am generally prone to believe this is one 
of those, we do everything, from economic, to information, to 
restrictions to access, to it may be there is not a magic 
bullet; it needs to be an armory.
    Thank you, Mr. Chairman.
    Representative Tiberi. Thank you.
    The gentlelady from Minnesota is recognized for 5 minutes.
    Senator Klobuchar. Thank you very much. Thank you to all of 
you.
    I see Senator Portman is here, and along with Senator 
Hassan, we have been working hard on these issues for many 
years. We passed our bill last year, which, of course, set the 
framework out.
    And I really look at this as three different things. One is 
trying to stop people from being addicted in the first place. 
And that is things like getting the drugs out of the medicine 
cabinet, changing doctor prescribing practices, and doing 
something on stopping the huge amount of drugs out there that 
are legal but aren't being used in the right way.
    The second is treatment, of course.
    And the third is then going after the illegal drugs. And we 
are going to see more use of that as we hopefully can reduce 
the number of legal drugs that are going out and getting people 
hooked.
    So, along those lines, Attorney General, I was really 
interested and happy to see that you brought that lawsuit 
against five opioid manufacturers alleging that the drug 
companies engage in fraudulent, deceptive marketing campaigns 
about the risks and benefits of these opioids. I know there was 
a settlement in West Virginia on a similar case. The idea is 
the money, of course, goes into treatment. And it seems to me 
that the people responsible for marketing these drugs should 
pay for the human costs of what has happened here. So can you 
talk about what you can about that lawsuit and how you think it 
could be replicated across the country? Because all the 
education we are doing isn't getting us the money we need for 
treatment, and it is not stopping the bad guys from getting 
people hooked. And by that, I don't mean illegal drugs.
    Attorney General DeWine. Senator, thank you for the 
question.
    You know, I made it plain last week when I held a press 
conference that--when I explained what we were doing and why we 
were doing it. One thing I said to my Ohio citizens is this is 
not a substitute for the hard work at the local level. I am 
convinced that the work has to be done at the local level.
    I started seeing 5 or 6 years ago, when we were dealing 
primarily with the pain med problem, that the communities that 
were making the most progress were communities where it had 
gotten so bad, they just got sick of it. And it was usually a 
grassroots effort led by a mom. Sometimes a dad, but it is 
usually a mom. And they just go and they try to transform the 
culture in that community.
    Senator Klobuchar. But do you think a lawsuit, which I 
believe, like in the tobacco industry, the lawsuits actually 
got the information out there and----
    Attorney General DeWine. Sure. Yeah.
    Senator Klobuchar [continuing]. It stopped people from 
doing bad things?
    Attorney General DeWine. Yeah. Let me get to the second 
part, Senator. Thank you, very much.
    We believe this lawsuit is a fair lawsuit. We believe that 
what the evidence will simply show is that the pharmaceutical 
companies, beginning in the late 1990s, tried to change the 
culture. The culture, historically, had been, for pain meds, 
that they are used for acute pain. You have your tooth taken 
out, you take it for a day, 2 days, 3 days, or it is used at 
the end of life when you have someone who is terminally ill.
    What the pharmaceutical companies did is they tried to 
convince doctors, and did convince doctors, that, hey, it was 
just okay to use it for a third purpose. And that third purpose 
was for pain----
    Senator Klobuchar. Pain management.
    Attorney General DeWine [continuing]. That goes on day 
after day after day but is not terminal. And they did it, and 
they were very successful in doing it.
    In response to your question, one of the things I would 
like to see these companies do--and they can do it tomorrow and 
start, lawsuit or no lawsuit--is to spend some money to change 
the culture back to where the culture should be, which, as 
several of you have said, is somewhere in the middle.
    Senator Klobuchar. Thank you.
    And we also have a bill with Senator Manchin that would put 
a fee on some of these drugs, and have, again, that go, per 
milligram, have that go to treatment.
    And so I guess, Professor Deaton, congratulations on your 
good work. Can you comment on what the attorney general has 
done here, which I think is commendable, and how sometimes 
lawsuits can change the economic situation if companies are 
afraid of getting sued, that it is not just public shaming but 
actually out of their bottom line, that that can make a 
difference in how they behave?
    Professor Deaton. Thank you, Senator.
    Yes, I think it can make a difference. I mean, I don't have 
the figures, but the LA Times reported that family that owned 
OxyContin had made $31 billion from it by the middle of last 
year. This is at a time where that drug is killing large 
numbers of people, and I think, you know, we ought to make it 
clear that this cannot be tolerated.
    I also agree with the attorney general that the local 
effort is where the culture will be changed. But we don't need 
pharma companies trying to push doctors to prescribe addictive 
opioids for lower back pain.
    Senator Klobuchar. Right. It just makes me cry when you see 
all these rehab people and small town mayors and cops are all 
trying to do the right thing, and then these people are getting 
a different message either on TV or when they go into the 
doctor's office. And it just has to change.
    Thank you.
    Representative Tiberi. Thank you.
    It is an honor to introduce my Senator, who has been a 
national leader, as you know, Attorney General, on this issue, 
and talked to me last session of Congress about introducing a 
bill, which I did, that you have been a leader on, the STOP 
Act, deals with this issue of fentanyl coming in from China.
    Mr. Portman, you are recognized for 5 minutes.
    Senator Portman. Thank you, Chairman Tiberi, and thanks for 
your leadership all along and more recently taking the lead on 
the STOP Act. I think you have 165 cosponsors, I am told. And 
thanks to CRS for helping us with that situation, and to Mike 
DeWine for his help, both as the top law enforcement official 
in the State of Ohio who cares a lot about the supply side and 
keeping this poison out of our communities, but also someone 
who gets it, that this is ultimately going to be solved through 
a comprehensive approach focusing on the local community. I was 
in this room 20 years ago as a House Member trying to get 
legislation through called the Drug-Free Communities Act, which 
is now a law that has helped spawn over 2,000 community 
coalitions. Our whole focus was local, including one that I 
founded and chaired in Cincinnati.
    And yet here we are: The worst drug crisis in our history, 
by any measure, worse than it has been in the past. And I think 
what we have learned today from this terrific panel of experts 
and also from some of our colleagues, including Congressman 
Schweikert, is that, Mr. Chairman, the comprehensive approach 
that you have been advocating is the only way, and it has to be 
at every angle. And it has to include much more aggressive 
prevention and education efforts. Senator Klobuchar and I are 
cosponsors and authors of this STOP Act. Senator Hassan, one of 
our original four cosponsors, by the way, is here too. Senator 
Klobuchar, along with me, Whitehouse, and others, pushed this 
comprehensive approach in the Comprehensive Addiction and 
Recovery Act, called CARA. It includes a big component of 
education and prevention that has yet to be implemented, 
including a national awareness campaign on making this 
connection, as Attorney General DeWine has made clear today, 
between prescription drugs, and heroin, fentanyl, and other 
opioids. And I think Professor Deaton is right: A lot of people 
don't make that connection because they are not aware of the 
information. So, when you go to a doctor and someone who you 
trust prescribes opioid pain medication and says, ``Here is 60 
Percocets, take this for this oral surgery you have had,'' you 
trust that doctor, and you do that. And for some people, there 
is, obviously, a change in their brain, which is the disease of 
addiction.
    And there are other aspects of the CARA legislation that 
need to be implemented, and I have urged the Obama 
administration, as I am now urging the Trump administration to 
move quickly in implementing these things in the face of this 
crisis.
    Couple quick questions, one to Attorney General DeWine--
and, again, as the chief law enforcement officer in our State, 
you know much better than I what is going on. But I just got an 
email yesterday from the coroner in Cuyahoga County, Chief 
Medical Officer Dr. Gilson, who was here testifying about the 
week before last over in the Senate, and he reported to me that 
43 people have died in Cleveland in the couple of weeks since 
Memorial Day. He believes it is fentanyl-driven. By the way, 
this is in contrast even to the horrible rate of overdoses and 
deaths last year of being, you know, more in the 20 to 30 
range. We are now even this year--in April, it was under 40. 
Now, in 2 weeks, over 40.
    So can you talk a little bit about what has happened in 
Ohio and maybe specifically what I am hearing back home, which 
is this notion, to Professor Deaton's point about who is being 
affected, that this is now being spread into the African 
American community more now with regard to these evil 
traffickers sprinkling fentanyl in cocaine and starting a whole 
other series of addictions? If you could just speak to that a 
little bit, I would appreciate it.
    Attorney General DeWine. Well, Senator, thank you very much 
for the question. Thank you for the great work that you have 
done. You have been a real leader in this field.
    You know, I think there is a natural progression which 
starts generally with the pain med, 35-year-old, 40-year-old, 
blue-collar male hurts his back, is prescribed pain meds, 
becomes addicted to it, and everything goes downhill from that. 
He moves over to the heroin because it is cheaper and it is 
maybe more available.
    And then the other thing that you have, as you point out, 
going on, is fentanyl now. And the fentanyl, we are finding 
fentanyl a lot more now, more, and more, and more, and less and 
less heroin. It used to be it was sprinkled in with it. One of 
the things that we are seeing in our crime lab is that these 
cases are much more complex and take longer to do because, 
instead of it being all heroin or all fentanyl, it is all mixed 
up. And so it slows that down.
    But I go back to something I said a moment ago. I think it 
is a marketing technique. And these people who are selling this 
stuff, who are killing people, they are good marketers. And it 
is all about service. And it is all about getting the best 
high. And part of the marketing is, ``Hey, we got something 
new,'' and that something new may, in fact, be fentanyl.
    As far as it moving more into the African American 
community, I don't have any data on that, but, sure, it would 
appear that. That anecdotally would appear that it is getting 
pushed out.
    And, you know, as I look at this problem from maybe a big-
picture point of view, sometimes people will ask me, ``You 
know, Mike, what keeps you awake at night as the attorney 
general?'' My quick answer is ``the opiate problem.'' I think 
it is a bigger problem. It has been alluded to by several 
people here today. The opiate problem is a subset of a bigger 
problem. The bigger problem is that we have a large number of 
people in Ohio and other states who are not living up, for many 
reasons, to their God-given potential. And we have got a 
problem with people not having the right skills, and that does 
impact this some--not in every case. We are seeing a lot of 
middle class people who everything would appear to be going 
fine in their life, but there is something going on there that 
causes that person to become addicted.
    But a related problem is the fact that we have got Ohioans, 
and people, I am sure, in other states, who are not living up 
to their God-given potential because they are addicted or--and/
or, usually, many times--they don't have the education. As the 
professor said, they do not have the education. They do not 
have the set of tools to make it. And part of it is we do have 
to, I think, start saying to people, and we have to start--
parents need to be saying to their kids: We want you to live up 
to your full potential. Maybe you are working with your hands, 
and you don't go to college, but maybe you go to, instead, an 
apprentice program or something else where you can become a 
welder or you can become a machinist and make a very good 
salary.
    So I think all of these things are tied into each other. 
And part of our challenge in Ohio and other states, I think, is 
to focus on kids who are growing up--because it is easier to 
impact them than it is to--it is not that we are not going to 
try to impact someone older--but the kids that are growing up, 
and make sure that they have all the opportunities that are 
there no matter where they are born and no matter what their 
income or who their dad is or who their mom is. And I think, to 
me, that is part of our solution as we look at the pain med 
problem.
    Senator Portman. Thank you. My time has expired.
    Thank you, Mr. Chairman, for your indulgence.
    I am going to have some questions for you, Professor 
Deaton, for the record, about the economic impact of what you 
described. And I think the notion of opioids being an 
accelerant to what you and Attorney General DeWine just talked 
about is actually an apt description.
    Thank you, Mr. Chairman.
    Representative Tiberi. Thank you.
    The gentleman from Virginia is recognized for 5 minutes.
    Representative Beyer. Thank you, Mr. Chairman.
    And thank all of you, very much, for being here.
    It is fascinating. It at least looks like a triangle in 
terms of there is the supply problem, as argued by Attorney 
General DeWine and Dr. Sacco. There is the economic 
dislocation, the hopelessness, from Professor Deaton, and then 
the treatment side from Dr. Frank.
    Dr. Frank, can you cite the reasons why those with an 
opioid abuse disorder would not seek treatment?
    Dr. Frank. Yeah. About a little over half don't seek 
treatment because either they can't afford it, which is the 
biggest chunk, or there are no providers available to them. And 
so that is a little bit more than half.
    And then the other main reasons have to do with stigma in 
the workplace, in the community, and also there are a lot of 
people who deny that they have a problem.
    If I could take one other second, I just want to kind of 
clarify the issue around treatment, which is medication-
assisted treatment is really the most effective treatment we 
have. But only about a quarter of the people who get treatment 
get that. And so we are undershooting our potential by a great 
deal. And that is what, in a sense, causes us to underachieve.
    Representative Beyer. Thanks.
    You know, we have the ObamaCare reform, replacement, repeal 
bill, is in the Senate right now. I think Cassidy said he wants 
to make sure it passes the Jimmy Kimmel test, which the House 
bill clearly didn't pass. But I am hoping that, based on all 
that we are learning now, and Senator Portman talked about this 
is the worst addiction crisis in the Nation's history, that 
whatever bill comes out of the Senate would pass the opioid 
epidemic test.
    Professor Deaton, you said this really hasn't hit Europe 
yet. That might just be a temporary reprieve. Can you explain 
why the fentanyl from China and others hasn't affected that 
population at least yet?
    Professor Deaton. At least yet.
    I mean, that is for us--I guess it used to be the $64,000 
question, now the $64 billion question. You can see some of 
this in the English-speaking countries of the world. You see 
some of it in Canada. There is a little bit in Britain and in 
Ireland and Australia, perhaps a little bit in Denmark. And if 
you looked at those countries just by themselves, you would be 
worried about it. But when you put it in the context of the 
U.S., there is nothing happening there.
    Partly, I think, it is because the prescription drugs are 
controlled much more carefully in Europe, and they are used in 
clinical, acute settings, and they are not prescribed in the 
community--yet. But, I mean, there is a concern that they will 
spread out into the community.
    And I think the fentanyl thing, I don't know. But the black 
tar heroin, for instance, is coming from Mexico, and they have 
very easy targets here, and maybe fentanyl will come to Europe 
in the same way too.
    So I think the Europeans ought to be worried, and they 
ought to--you know, they ought to make sure that they don't get 
to where we have gotten to. And they want to be very careful 
about it. But we don't see the signs of this epidemic, and I 
think part of it is the control of----
    Representative Beyer. Thank you.
    Dr. Sacco, you have been, it looks like, studying this drug 
thing for many, many years, academically and in CRS. What did 
we learn from the crack epidemic that is relevant to fighting 
the opioid epidemic?
    Dr. Sacco. I am sorry. You said what did we learn from the 
crack epidemic?
    Representative Beyer. Yeah. Are there lessons from the 
crack epidemic that are relevant here?
    Dr. Sacco. I am not sure I can offer an opinion on that 
today.
    Representative Beyer. Okay.
    Dr. Sacco. It is a little bit outside of the scope of what 
I am prepared for. But I am happy to follow up with you. Is 
there anything specific to the crack epidemic?
    Representative Beyer. Well, for example, we seemed to have 
responded to the crack epidemic, for example, with lots of 
incarceration. We were pretty harsh about that.
    You know, there has been a movement, bipartisan, in the 
criminal justice, away from, you know, criminalizing 
essentially nonviolent drug offenders or the harshness of it; 
perhaps not with the Attorney General recently. But is that a 
solution here, too, or do we tilt toward the treatment side?
    Dr. Sacco. I can't advise one way or the other. I can tell 
you that drug offenses account for the majority of Federal 
offenses carrying a mandatory minimum, if that is what you are 
speaking to. Mandatory minimums did come out of that era of the 
crack epidemic. And there are different ways of looking at the 
efficacy of mandatory minimums. From an economic standpoint, 
research says that lengthy mandatory minimums are not cost-
effective and that other factors, such as certainty of arrest 
and prosecution, have a greater deterrent effect than the 
severity of the punishment. So, in other words, a 1-year 
sentence has the same deterrent effect as a 10-year sentence. 
On the other hand, incapacitation prevents an individual from 
committing harm to society for that set period of years.
    At the same time, it is not clear if that punishment 
reduces crime. Often, low-level drug offenders are easily and 
quickly replaceable.
    Representative Beyer. Thank you very much.
    Mr. Chairman, yield back.
    Representative Tiberi. Thank you.
    The gentlelady from Virginia is recognized.
    Representative Comstock. Thank you, Mr. Chairman.
    And thank the witnesses for being here today.
    We have seen in my district--and I am in northern Virginia, 
here just over the bridge here. And we have had a rise in MS-13 
gangs getting more involved now in trafficking of heroin and 
opioids. And so we are seeing this convergence of, you know, 
very violent gang, and them preying upon some very young 
people, both trying to recruit younger people into the gangs 
but then also getting them involved in these various things.
    You know, what kind of effect--are you seeing anything like 
that? Are you seeing that elsewhere? Or how that is going to 
impact the economy? And what we see, you know, particularly 
when you get these young people, that they are getting into 
these gangs, and it is a whole lifestyle, and that is how they 
are making a living. They are not getting educated, and it will 
be even a worse situation.
    Attorney General DeWine. I am sorry. Is that addressed to 
me?
    Representative Comstock. Sure. That would be great, 
Attorney General.
    Attorney General DeWine. I am not sure I can really answer 
that question. What I can say is that, when we look in Ohio, 
you know, our violent crime in our cities, a great extent of 
that is driven by gangs. And there is, many times, a connection 
between drug trafficking and the gangs.
    Representative Comstock. And I know we have been focusing 
on the lower income, and how we have seen the rise there, but I 
know we have seen--in my district, we have, you know, very 
high--a lot of high-income areas in this region, and we are 
seeing it hitting everywhere. So I did want to make sure here 
today, even though it was focusing on that lack of opportunity, 
we are seeing this in every community and with every aspect. 
And so what is the difference when you are seeing, say, you 
know, a college-educated kid who maybe just got addicted to 
these from a sports injury and then just, you know, took it too 
far, and then they are in this lifestyle? What are you seeing, 
the difference between, you know, somebody like that versus, 
you know, this expansion in a lower income area?
    Professor Deaton. Thank you very much.
    Representative Comstock. Professor, thank you.
    Professor Deaton. I think income is not the best marker of 
this, partly because African Americans tend to be--there are a 
lot of low-income African Americans, and until recently, 
African Americans have been largely exempt from this epidemic. 
That does seem to be changing, and there is a tick up in the 
last 2 or 3 years in mortality of African Americans from 
opioids. And that may be fentanyl, and that may be spilling 
over into those communities. But low education has certainly 
been an issue. And what you say is true, that higher education 
are suffering from this too but nothing like to the same 
degree. I mean, this huge explosion has been among people with 
only a high school or even some college, but with a B.A., it is 
much, much less. You certainly find people, for sure. It is 
everywhere. But it is throughout the community.
    I think, also, some of the standard protective forces from 
people have sort of broken down. I mean, one example I like to 
give is Utah has always been a very healthy place compared with 
Nevada and for sort of obvious reasons. But Utah has not at all 
been exempt to this epidemic. And that is because, you know, 
Mormons tend not--they don't drink. They don't smoke. They 
don't do things that are bad for your health. But when your 
doctor gives you pills, that is not something you are 
programmed to resist, and the church has not been very good at 
dealing with that.
    Representative Comstock. So the education efforts and the 
comprehensive approach that Senator Portman and others were 
talking about and the attorney general was talking about, 
really, at that young age, kindergarten, and making sure--
education efforts really needs to go everywhere then.
    Professor Deaton. But stop the docs pushing this----
    Representative Comstock. Yeah.
    Professor Deaton [continuing]. So that people know it is 
dangerous.
    Representative Comstock. Thank you.
    I yield back, Mr. Chairman.
    Representative Tiberi. Thank you.
    The gentleman from Illinois is recognized for 5 minutes.
    Representative LaHood. Thank you, Mr. Chairman, for this 
hearing today and for this subject matter.
    And I want to thank the witnesses for your valuable 
testimony here today. I have seen the devastating effects of 
opioid abuse and heroin deaths in my own district. I represent 
a district of 19 counties in central and west central Illinois, 
a very rural district, and did a series of townhall events 
related to this issue with all the stakeholders, and it 
continues to be a problem.
    We have talked a little bit here today about some of the 
analogies to this epidemic, and we talked a little bit about 
crack cocaine. I spent 10 years as a State and Federal 
prosecutor. And I think back to, in Illinois, 20, 25 years ago, 
we had a real problem with drunk driving. It was the number one 
killer in Illinois of young people.
    And so what happened? We had an aggressive law enforcement 
effort. We raised awareness, a lot of tragic deaths. But we 
also had Mothers Against Drunk Driving, which played a 
significant role from an organic level, kind of like what you 
talked about, Attorney General DeWine. We also used technology, 
ignition interlock.
    So, today, we have some of the lowest levels of drunk 
driving deaths anywhere in the country. And that is because of 
an effort. And it was a movement at the time to do that. And I 
think about that analogy here today.
    The addiction is much different here. But we are able to 
reduce that problem and solve that in a variety of ways. And I 
think you have to--we have talked about this--holding everybody 
in the chain accountable all the way through. And I am not sure 
we are doing enough of that right now. And we have touched on 
some of those things.
    Attorney General DeWine and then Dr. Frank, you want to 
comment on that?
    Attorney General DeWine. Well, Congressman, I totally agree 
with you. This comes at the local level, comes at the State 
level. Certainly the Federal Government can play a role. But, 
ultimately, I think it comes back to the individual community. 
And, you know, what we have seen in Ohio in this area is the 
communities that have started to make some real progress, 
number one, admit they have a problem. Number two, there is a 
citizens group that is put together by a mom who has lost a son 
and lost a daughter. And they go out, and they just--they 
change the culture. Now, you still have a problem. But they 
make some progress.
    I saw it in my own career. I introduced a bill in the Ohio 
legislature, a drunk driving bill, and people were laughing at 
it. It was back in the early, early 1980s. And it was the 
Mothers Against Drunk Driving, frankly, who got it passed,
    Representative LaHood. Yep.
    Attorney General DeWine. And it just shows that--you know, 
it is the example I think we can all use with people: look, you 
can make a difference. You can change the culture. You can 
change what people are talking about by a very active citizens 
group, either at the local level or the State level or the 
national level.
    Representative LaHood. Dr. Frank, you know, people also 
remember when we talk about drunk driving about, you know, the 
TV commercials that talked about these tragic deaths and 
highlight of just how horrific some of these were. And I am not 
sure that we have that level. And if we have, maybe there are 
some states or local areas that we can use as a success model 
on that.
    Dr. Frank. Yeah. I do want to offer a ray of hope, because 
we haven't had much here today. And that is one area that we 
have been really successful on is in reducing the number of 
prescriptions on methadone for pain. It used to be that they 
were 6 percent of the prescriptions in opioids and 30 percent 
of the deaths. And we have turned that around. And the way we 
have turned it around is, I think, by being very aggressive in 
training and educating of the physician community, making sure 
that our prescription drug monitoring programs really focused 
on that, and then CMS, through the Medicaid program and through 
Medicare, took measures to issue guidance to states and to do 
edits in the prescription drug plans under part D. And together 
they really brought down those prescriptions. And I think that, 
you know, in a sense, that is a reflection of the sort of 
multipronged approach. And I do think that that offers us a bit 
of hope here.
    Representative LaHood. Professor Deaton, you touched a 
little bit on how we maybe hold doctors accountable and what we 
need to do. And much of that oversight on doctors and 
physicians is done at the State level. Is there an example of a 
State that has done a pretty good job in terms of holding 
doctors accountable?
    Professor Deaton. I am afraid I don't have an answer to 
that. We have done very little work on the geographic aspects 
of this epidemic. So I can't answer that. Thank you.
    Representative LaHood. Thank you.
    Thank you, Mr. Chairman.
    Representative Tiberi. Thank you.
    I really appreciate all four of you being here. What great 
testimony we were able to hear today.
    I am going to allow the acting ranking member, the 
gentlelady from New Hampshire, have some final comments as 
well.
    Senator Hassan. Thank you, Mr. Chair.
    And thank you all on behalf of Ranking Member Heinrich and 
myself for being here and for your testimony.
    And I just wanted to close with the thought of a particular 
constituent of mine who is now in recovery from heroin 
addiction, because I think it is important, as we have had this 
discussion, to remember that ultimately this addiction is a 
disease. It is caused by a chemical reaction in the brain. And 
it is because people like my constituent, Ashley, who woke up 
one morning to find her husband having overdosed and died next 
to her, went and got treatment under Medicaid expansion, that 
she has gotten well. And she now is working. And she is getting 
her health insurance through her private employer. She is off 
of Medicaid expansion.
    And I think it is really important that we--also to 
acknowledge the comments we have had about the importance of 
community response--thank the people who have this disease who 
have stood up, who have identified themselves as people 
suffering from addiction, have done the hard work of getting 
better, and then have turned their efforts to make sure that 
they help with the prevention and recovery efforts that we need 
to undertake.
    So I am going to keep Ashley in my thoughts today. She is 
about 17 or 18 months in sobriety now. She continues to get 
treatment for recovery. She is going to be reunited with her 3-
year-old son soon. There is hope if we go at this with the all-
of-the-above approach.
    Thank you so much.
    Representative Tiberi. Thank you, Senator.
    Thank you again. There are stories like that that we all 
can share. Attorney General DeWine has shared many with me, as 
he is on the front lines. And I appreciate, and I think this 
entire panel, if you couldn't tell, appreciates the time you 
put into this testimony. You all complemented each other quite 
well. This is a battle that we are going to continue to fight 
in a comprehensive way, and I appreciate the knowledge that you 
were able to share with us today. And we look forward to 
working with you in the future.
    The record will be open for 5 business days for any Member 
that would like to submit questions to the four panelists for 
the record, and our hope is that you would respond as well.
    This hearing is adjourned
    [Whereupon, at 11:37 a.m., the committee was adjourned.]

                       SUBMISSIONS FOR THE RECORD

Prepared Statement of Hon. Patrick J. Tiberi, Chairman, Joint Economic 
                               Committee
    Good morning and welcome. I want to welcome especially our Ranking 
Member Senator Heinrich and our Vice Chairman Senator Lee, as well as 
the other Members of this Committee, who have joined me in expressing 
the importance of holding a hearing on the threatening increase in 
opioid abuse.
    Drug abuse has become rampant in America and may be the worst the 
country has experienced. It is devastating families and degrading 
communities, and undermining parts of the economy.
    For several states and districts represented by members of this 
committee, the problem is acute. As Figure 1 indicates, the crisis has 
a regional character. My hometown of Columbus, Ohio is part of the 
crisis' epicenter east of the Mississippi.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Figure 2 shows the 2015 drug overdose death rates by State, which 
ranged from 40 per 100,000 in West Virginia to six per 100,000 in 
Nebraska. The states represented by members of this committee among the 
ten highest rates, are highlighted in red, including my home State of 
Ohio, which ranks third.
    Drugs markets, both legal and illegal, can be analyzed from the 
demand and the supply side. The exact reasons for the extent of drug 
abuse are not clear at this point. With respect to demand, a changing 
perception of pain as a health problem in the 1980s by the World Health 
Organization in particular laid the ground for more intensive 
treatment.
    The labor market and the economy can have a major impact on demand, 
although not necessarily in ways one might expect. Some research shows 
less substance abuse when unemployment increases, for instance. And, 
while prolonged downturns in labor market and economic conditions are 
associated with social, behavioral, and health problems, they do not 
necessarily affect all groups in the same way or to the same degree.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    All of society is vulnerable to the opioid epidemic, but it is 
compounding the economic distress that certain parts of the country and 
segments of the population already have been experiencing. Some areas 
of high unemployment tend to have higher rates of substance abuse. The 
Economic Innovation Group, a representative of which testified at our 
last hearing, The Decline of Economic Opportunity: Causes and 
Consequences, developed an economic distress index consisting of 
several economic indicators, a national map of which is shown alongside 
the map of overdose deaths in Figure 3. The darker the red, the worse 
the distress. Striking correlations are visible.
    But it is also apparent from Figure 3 that some economically 
distressed areas are not experiencing high overdose death rates.
    From the supply side, the particular locations where new, potent 
drugs initially happened to become most readily available, and the path 
of geographic market expansion they took, track a visible trail of 
destruction in Figures 1 and 3. Without question, new developments in 
the sourcing, cost of production, potency, and retail delivery have 
moved the supply of both legal and illegal addictive drugs 
substantially to the right. Newly effective pain medication, OxyContin, 
introduced in the mid-1990s had initially unacknowledged addictive 
qualities and was overprescribed. So-called black tar heroin, more 
powerful and less expensive than other kinds, expanded its market share 
just as OxyContin was reduced in potency.
    The prescription drug explosion started in the Appalachian part of 
Ohio and spread to parts of Kentucky and West Virginia. Black tar 
heroin entered the Southwest and spread westward but eventually also 
eastward, crossing the Mississippi in 1998.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Illegally distributed variations and counterfeit forms of 
prescription drugs like fentanyl can be poisonous and kill a person 
even in small doses, some by mere contact with the skin. We now face 
pure poisons masked as narcotics that are shipped across our borders. 
Senator Portman and I have introduced the STOP Act, which aims to stop 
dangerous synthetic drugs from being shipped through our own postal 
service, keeping them out of the hands of drug traffickers in the 
United States.
    But it would be a mistake to blame these drugs entirely for the 
rise in mortality that some groups and regions are suffering. There are 
other causes apparently emanating from long-term changes in the 
composition of the economy and of skill requirements.
    Determining cause and effect is obviously critical to reaching the 
right conclusions. Feedback effects often complicate causality and make 
a clear understanding of major causes difficult. For example, does a 
bad economy lead to drug abuse or does drug abuse to a bad economy by 
lowering productivity, labor force participation, and social cohesion? 
We will hear perspectives that run in both directions today.
    We will hear about the economic decline of certain groups leading 
to despair and self-destructive behavior; of damage drug abuse causes 
individual lives, families, and communities in all segments of society; 
and of developments in the production and marketing of addictive drugs, 
which have made them more dangerous, affordable, and available.
    I look forward to most insightful testimony from our panel of 
experts.
                               __________

  Opening Statement of Hon. Martin Heinrich, Ranking Democrat, Joint 
                           Economic Committee
    Thank you, Chairman Tiberi, and thank you to our panel for being 
here today.
    Addiction to heroin and prescription opioid pain relievers is a 
public health epidemic that is devastating families and communities 
across the country.
    Every day, 91 Americans die from an opioid overdose.
    Over-prescription is partially responsible for the epidemic.
    Since 1999, the amount of prescription opioids sold in the U.S. 
nearly quadrupled and so too has the number of overdose deaths from 
opioids.
    The economic costs of addiction are enormous--totaling more than 
$80 billion in 2013 from increased health care costs, higher rates of 
incarceration, and lost productivity.
    New Mexicans know too well the devastation heroin and prescription 
opioids can wreak.
    For years, without adequate treatment resources, communities in New 
Mexico have suffered through some of the highest rates of opioid and 
heroin addiction and overdose deaths in the Nation.
    Rio Arriba County has a drug overdose death rate of 81 per 
100,000--five times the national rate.
    I'm reminded of Josh from Espanola, who I met at a round table I 
hosted in Rio Arriba County last spring.
    At 14 years old, Josh became addicted to prescription opioids.
    Over time he moved to heroin. He stole from family and friends to 
maintain his growing addiction.
    Josh spent time in jail where he went through the pains of 
withdrawal. He even attempted suicide but his gun didn't go off.
    Now in his 20s, Josh has turned his life around because he finally 
got access to treatment and services.
    For millions of Americans, proven substance use treatment is 
available because of 1) behavioral health parity laws, and 2) the 
Medicaid program.
    In New Mexico, Medicaid--called Centennial Care--is at the 
forefront of our fight against the opioid crisis, accounting for 30 
percent of life-saving medication-assisted treatment payments for 
opioid and heroin addictions.
    At exactly the time Congress should be giving states more tools to 
fight this epidemic, House Republicans passed a bill that would repeal 
Medicaid expansion, artificially cap the program, and shift the burden 
about who and what to cut onto states.
    More than a million people who have been able to secure treatment 
for substance abuse would lose their coverage.
    Repealing Medicaid expansion would cut about $4.5 billion from 
treatment for mental health and substance abuse.
    We can't fight a public health crisis with grant dollars alone. 
Grant dollars run out. Block grants lose their buying power over time.
    And private investment dollars--which are critical in this fight--
won't come without certainty that the foundation is funded.
    Unfortunately, I won't be able to stay to hear your important 
testimony because of a hearing in the Intelligence Committee.
    But I will be leaving you in the very capable hands of my 
colleague, Senator Hassan.
    New Hampshire loses at least one person every day to a drug 
overdose. As Governor, Senator Hassan used every tool at her disposal 
to fight the epidemic, including turning to the flexibility of the 
Medicaid program to gain ground in her State's fight.
    I will let her to tell you more, but I leave you with this: when a 
community faces a public health crisis, it's not long before a State 
turns to the Medicaid program to stem the tide.
    What will our states and communities do for this public health 
crisis--and the next one--without the guarantee of Federal Medicaid 
dollars to support them?
    Thank you, Senator Hassan.
    Mr. Chairman, I'd like to yield my remaining time to Senator Hassan 
for brief remarks.
                               __________

           opening statement of senator margaret wood hassan
    Thank you Chairman Tiberi, Ranking Member Heinrich, and to our 
witnesses for being here today.
    As I travel across my home State of New Hampshire, I've heard from 
countless families and those on the front lines about how the heroin, 
fentanyl, and opioid crisis has devastated communities across our 
State.
    And I know that many of our colleagues have heard of the impacts in 
their states as well.
    I'm proud that during my time as the Governor of New Hampshire, 
Republicans and Democrats put our differences aside and came together 
to pass--and reauthorize--our State's bipartisan Medicaid expansion 
plan.
    Medicaid expansion is providing quality, affordable health coverage 
to more than 50,000 Granite Staters, including coverage for behavioral 
health and substance use disorder treatment. And experts have said it 
is the number one tool we have to fight this crisis.
    We should be coming together--just as we did in my home State--to 
support those on the front lines and help those who are struggling with 
addiction. And while members of both parties and the Administration 
have discussed the severity of this crisis, we need the words to be 
matched by strong action.
    What we cannot do, however, is end Medicaid expansion and institute 
deep and irresponsible cuts to the traditional Medicaid program.
    This crisis is a public health and law enforcement issue, but it is 
also an economic issue. I believe the investments in helping people 
recover are a far better use of our dollars than the long-term costs of 
addiction, both in terms of State budgets but also in ensuring that 
individuals are healthy enough to contribute to our economy.
    I am pleased that we are having this hearing today, but we need to 
continue to hold hearings on how proposals made here in Washington 
would affect our ability to stem and reverse the tide of this epidemic.
    This is an issue that rises above partisanship, and this is the 
work that we need to be doing--because the lives of people in our 
states depend on it.
    I am going to continue to work with our colleagues on solutions, 
while standing firm against any policy that would pull us back.
    Thank you, and I look forward to hearing from our witnesses.
                               __________
                               
                               [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                               
        Prepared Statement of Ohio Attorney General Mike DeWine
    Thank you, Chairman Tiberi, Vice Chairman Lee, and Ranking Member 
Heinrich for inviting me to testify at this very important hearing 
today on the opioid epidemic in Ohio.
    Ohio is facing the worst public health crisis in our lifetime, 
leading the Nation in opioid overdose deaths. In 2015, 85 percent of 
all accidental drug overdose deaths in Ohio were caused by an opioid. 
According to new data recently released by the Columbus Dispatch, 4,169 
Ohioans died from accidental drug overdoses last year--that's a 36% 
increase over 2015.
    Cuyahoga County Medical Examiner Dr. Thomas Gilson recently 
testified in front of a U.S. Senate Committee that those who are 
addicted to drugs in Cuyahoga County, which includes the City of 
Cleveland and suburbs, would fill the First Energy Stadium where the 
Cleveland Browns play (73,000-plus), and those who switch to fentanyl 
each year would fill the Quicken Loans Arena, home of the 2016 world 
champion Cleveland Cavaliers (20,000-plus).
    We are seeing this scourge in the Ohio crime lab. In 2010, the Ohio 
Bureau of Criminal Investigation (BCI) had only 34 cases of fentanyl, 
but in 2016, we had 2,396 cases. In fact, more fentanyl came through 
BCI in 2016 than had come through in the previous five years combined. 
And BCI went from zero cases of carfentinil--an elephant tranquilizer--
in 2015 to 214 cases in 2016. Our organized crime drug task forces have 
already seized more fentanyl in 5 months of 2017 (30.8 pounds seized) 
than in all of 2016 (27 pounds).
    Four out of five individuals now suffering from heroin or fentanyl 
addiction first started down this road by using prescription opioids. 
In 2010, when I first ran for Attorney General, my wife Fran and I both 
learned of the families who were ravaged by addiction to prescription 
pain meds and the pill mills that were fueling it, especially in 
southern Ohio. When I took office, we started going after the doctors 
who overprescribe these painkillers. Since that time, we have revoked 
the licenses of 90 doctors and 22 pharmacists.
    Last week, my office filed a lawsuit against five of the leading 
prescription opioid manufacturers and their related companies in the 
Ross County Court of Common Pleas. The lawsuit alleges that these drug 
companies engaged in fraudulent, deceptive marketing campaigns about 
the risks and benefits of prescription opioids, leading doctors to 
believe that opioids were not addictive, that addiction was an easy 
thing to overcome, and that addiction could actually be treated by 
taking even more opioids. As a result, we believe the evidence will 
show that these companies got thousands and thousands of Ohioans 
addicted to opioid pain medications, which has all too often led to use 
of the cheaper alternatives of heroin and synthetic opioids.
    This lawsuit is about accountability. It should not be looked at as 
a substitute for the many things we now must do to battle addiction--
nor should it be looked at as a quick fix.
    That's why my office is taking a holistic approach to combat the 
problem.
    We must continue our efforts to go after drug dealers. We must 
continue our outreach work with local communities. And, we must 
implement our recommendations for early drug abuse prevention education 
in schools.
    In 2013, we established a heroin unit in my office that includes 
lawyers, investigators, and community outreach liaisons. They fight the 
opioid battle on both the law enforcement side and on the community 
outreach side. Our community outreach team works on grassroots efforts 
that include bringing together law enforcement, schools, clergy, 
business leaders, and other citizens to help form a plan specific to 
that community to address the drug problem. This team helps communities 
identify needs and recommends resources to address those needs. And, 
earlier this year, we held an opiate conference in Columbus, with over 
1,300 people in attendance, about the opioid crisis and talk about 
efforts that are working across Ohio to help families and communities.
    To make a real difference in this fight we also need to teach our 
kids early about the dangers of drug use and how to make good 
decisions. In the 1980s, I served on President Reagan's National 
Commission on Drug Free Schools. The experts we talked to told us that 
repetitive, comprehensive, school-based education was necessary to 
successfully combat drug addiction.
    I have often said that there has been a cultural shift in the wrong 
direction in how our society views drug abuse. The psychological 
barrier that once stood in the way of someone taking deadly drugs is 
simply gone. To address this, the Speaker of the Ohio House Cliff 
Rosenberger and the former Ohio Senate President Keith Faber and I 
convened a group of experts on education and drug prevention. They 
recently issued 15 recommendations, including the need for consistent, 
age-appropriate, evidence-based drug abuse prevention education in 
kindergarten through 12th grade. The recommendations are not mandates. 
However, if progress is not made, we must ensure communities are 
instituting prevention efforts to reach youth before it's too late.
    Further, if we are serious about changing the culture around 
substance abuse, we must engage the best and brightest in the private 
and public sectors to create a statewide anti-drug campaign. We can 
change the public mind-set through messaging on social media, 
television, and other mediums.
    Local law enforcement is doing some great things, and we need to 
replicate efforts that work--programs like Lucas County's Drug Abuse 
Response Team, created to help addicts navigate the treatment system. 
What's unique about this program is that law enforcement officers 
develop personal relationships with addicts, investing both time and 
compassion.
    Ultimately, breaking free from addiction in the long-term requires 
access to services across a continuum of care--a holistic, wrap-around 
approach from overdose to sobriety. Most Ohio counties have gaps in 
that continuum, and we must address the different needs of each local 
community.
    Tragically, children and babies are the silent victims of this 
epidemic. Babies born with neonatal abstinence syndrome because their 
moms were addicts spent approximately 26,000 days in Ohio hospitals in 
2014, with health care costs totaling $105 million. And our foster care 
system is overflowing with kids. At least 50% of kids and 70% of 
infants placed in Ohio's foster care system have parents with opiate 
addictions, costing the State an estimated $45 million per year.
    My office is funding an innovative new pilot program in 19 southern 
Ohio counties called START that increases resources to children's 
services agencies for intensive attention for both children and parents 
to promote recovery and family reunification. We hope to be able to 
expand this program to every county in Ohio.
    The opioid epidemic is a human tragedy of epic proportion. No doubt 
the human toll would be much greater, though, but for the life-saving 
effect of the drug naloxone, which reverses overdoses. I've been very 
supportive of expanding access to naloxone for first responders. 
Naloxone was administered at least 74,000 times in Ohio between 2003 
and 2012. In 2014, alone, EMS treated 12,847 overdose patients with 
naloxone.
    I'm pleased to report that we've renewed our agreement with 
Amphastar Pharmaceuticals, Inc.--a manufacturer of naloxone--to provide 
rebates to consumers, such as police departments and other non-Federal 
Government agencies that distribute the drug in Ohio. So far, 117 Ohio 
agencies have applied for a total of $539,986.00 in rebates over the 
past two years. Also, Adapt Pharma worked with my staff and agreed to 
freeze the Public Interest Price over the next year for its naloxone 
nasal spray for Ohio.
    In 2015, the law changed in Ohio to allow pharmacies to sell 
naloxone over the counter without a prescription. Since then, we worked 
with several Ohio retail stores, including CVS, Kroger, and Walgreens, 
who have agreed to sell naloxone. This also will help families and 
friends who know someone who is addicted by letting them keep this 
life-saving medication on-hand.
    My office will continue to support families, schools, law 
enforcement, the faith-based community, and others to bring hope and 
healing to those who struggle with substance abuse and addiction. Thank 
you again for the opportunity to testify today. I'm honored to be here 
with the other witnesses and have the opportunity to hear about their 
good work.
    I'm happy to answer any questions at this time.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
 Response to Question for the Record for Richard G. Frank From Senator 
                               Klobuchar
                        importance of treatment
    What would be the economic costs for communities if funding for 
treatment from any of these programs was weakened?
    The CDC estimates that the treatment cost of Opioid Use Disorder is 
$28.9 billion and the overall cost to society is $78.5 billion in 2013. 
Weakening funding would put new burden on communities for treatment 
costs. But perhaps more importantly weakening funding would likely 
reduce access to treatment. That would in turn increase other costs 
associated with opioid use disorders like disability costs, child 
welfare costs, and criminal justice costs among others.
                               __________
                               
Responses to Questions for the Record for Richard G. Frank from Senator 
                                  Lee
    How prevalent is Medicaid program abuse by addicts and dealers? Is 
it more prevalent in certain parts of the country than others? Have any 
states or communities found ways of fighting back or preventing this 
potential risk?
    In order to properly answer these questions it is important to put 
the sources of prescription opioid misuse into context. The National 
Household Survey on Drug Use and Health offers data on this issue. That 
survey allows for the tracking of the sources of drugs that were 
misused. Nearly 65% of misused prescription opioids were obtained from 
family and friends (55% free and 9.9% via purchase), 5% were stolen 
from family and friends. Roughly 17.6% were obtained through a 
prescription and just under 5% were obtained from a drug dealer. So 70% 
came from family and friends. All health care payment programs face the 
challenge of diversion. This includes private health insurance, 
Medicare, Medicaid, the VA, and the military health insurance programs.
    As you know, the Affordable Care Act gave states new authority to 
fight fraud and abuse related to drug diversion. This enables states to 
take measures that focus on Medicaid but also on the range of insurers 
and other payers.
    Specifically the new authorities include:

      Establish enhanced oversight for new providers.
      Establish periods of enrollment moratoria or other limits 
on providers identified as at high risk for fraud and abuse.
      Establish enhanced provider screening.
      Require states to suspend payment when there is a 
credible allegation of fraud, which may include evidence of 
overprescribing by doctors, over-utilization by recipients, or 
questionable medical necessity.

    The result has been that states have adopted a variety of 
approaches aimed at stemming diversion of prescription opioids. 
Kentucky has put into place a State-wide data base of all controlled 
substances prescribed in the State. The Medicaid program has 
effectively used that tool to identify aberrant prescribing and has 
made investigations better targeted and more efficient. The State of 
Pennsylvania has implemented a pro-active drug utilization review 
process that targets drugs of abuse. Efforts in Florida and Oklahoma 
have focused more specifically on pain management clinics for all 
payers and have realized success in limiting diversions stemming from 
``pill mills.'' States are also using so-called lock-in programs and in 
some cases linking prescription drug monitoring programs to electronic 
health records. Again these are not specifically aimed at Medicaid but 
at all payers.
    These efforts are meeting with some success as data reveal a 
decline in the level of opioid prescribing. In sum, states are fighting 
back and most of the efforts are aimed at prescribing broadly. Some of 
these efforts are the result of new tools created for states, under the 
Affordable Care Act.
                               __________
                               
Responses to Questions for the Record for Richard G. Frank from Senator 
                                Heinrich
                             medicaid cuts
    1. What would happen to patients if their treatment for an opioid 
addiction was interrupted because the patient no longer had coverage 
for SUDs?
    There are several results that emerge clearly from the literature 
on treatment effectiveness that inform this question. First is that 
Opioid Use Disorders are most effectively treated with Medication 
Assisted Treatment or MAT. Second, is that receiving and remaining in 
treatment with MAT reduces all cause overdose mortality. Third is that 
the likelihood of a relapse increases significantly when MAT is 
interrupted. In addition, relapse is associated with reduced functional 
status, increased likelihood of family disruption, spread of infectious 
disease, and contact with the criminal justice system.
    2. Given that addiction is a lifelong disease, how would converting 
Medicaid to a per capita cap hinder State efforts to address the long-
term health needs of people struggling with an SUD?
    The consensus in the scientific community as recently summarized by 
the Surgeon General of the United States is that addictions generally 
and opioid use disorder specifically are chronic relapsing diseases of 
the brain. These illnesses also co-occur with a variety of other 
medical problems and chronic illnesses (depression, HIV, hepatitis C). 
The result is that the average cost of treating someone with an opioid 
use disorder in Medicaid is on the order of $11,000 to $12,000 per year 
compared to $3,000 to $4,000 for the average Medicaid recipient. A per 
capita cap changes the incentives to the states. Currently states 
receive matching payments from the Federal Government so that Federal 
payments increase with State spending increases. The per capita cap 
would change the incentives in that increased State spending would not 
longer be met with higher Federal payments, thereby rewarding 
aggressive cost cutting. One of the easiest ways to cut costs is to 
avoid the sickest people and enroll the healthiest. This is easy to do, 
especially with people suffering from a substance use disorder. That 
is, because these illnesses require outreach and on-going support to 
engage and retain them in treatment. Curtailing such activities will 
reduce participation in Medicaid for people with SUDs. Thus because 
people with an opioid use disorder are much more costly than the 
average Medicaid enrollee, the incentives suggest that we would likely 
encounter less outreach and engagement activities in Medicaid and less 
aggressive follow-up efforts to retain people in treatment.
    3. How would converting Medicaid to a per capita cap impact a 
State's ability to cover treatments for these co-occurring conditions?
    In my answer to #2 above I touch on the basic economics that are at 
work in serving people with costly co-occurring conditions. In addition 
to the issues raised in that response, there is the matter of what 
happens when the population with addictions and co-occurring diseases 
is growing in size. There is a great deal of evidence indicating that 
the opioid use epidemic is growing. Recent evidence on emergency room 
growth and hospital use for opioid use disorders shows they have been 
growing at annual rates of 5.7% and 8%, respectively. Mortality from 
OUD has been increasing at roughly 9% per year since 1979 and at about 
15% in recent years and prescribing of MAT drugs has grown rapidly as 
well. For this reason people with opioid use disorder can be expected 
to make increasing claims on the health care system and Medicaid. A per 
capita cap would lock in spending patterns using 2016 as the baseline 
and then increase Federal payments by either CPI or CPI-M. Thus the 
proposed growth in Federal payments is forecasted by CBO to be at 3.7% 
(CPI-M) or less. This heightens the incentives to avoid people with 
these illnesses that I described earlier.
    4. How important is treating these conditions to supporting a 
person's long-term recovery?
    Addictions and opioid use disorders specifically frequently are 
intertwined with mental health problems and other medical issues. For 
example, an estimated 30% of people with an opioid use disorder are 
also depressed. Misuse of drugs has been linked to self-medication for 
mental illnesses and pain. Thus, having coverage for the range of 
health needs is critical for populations that suffer from complex 
arrays of mental, addictive and other medical conditions.
    5. Would this one-time investment sufficiently offset the harm the 
underlying bill would do to millions of Americans with SUDs?
    The $15 billion proposed in the AHCA to address mental health SUD 
and maternity care needs would not come close to compensating for the 
funding cuts that would result from package of coverage reductions in 
the AHCA. Let me illustrate with some relevant data. There are about 
220,000 people with an opioid use disorder and an additional 1.2 
million people with a serious mental illness that are currently covered 
through the Medicaid expansion and the Health Insurance Marketplaces. 
In addition, there are 713,000 people with an opioid use disorder with 
incomes below the poverty line, many of who are uninsured. Data 
collected from State Medicaid programs noted earlier indicate that 
today it costs about $11,000 per person to treat someone with a serious 
mental illness or an opioid use disorder. If states apply all those 
funds only to people with these serious illnesses in the Medicaid 
expansion and Health Insurance Marketplaces, that would make up 1.42 
million people. If we make the conservative assumption that these 
individuals only use services in two out of the next five years, the 
total cost would exceed $31 billion. This cost would exhaust these 
funds even assuming every dollar were spent only on such services for 
such individuals rather than all those who qualify. Thus, the new money 
added to the AHCA would fall short making up for the bill's reduced 
coverage of people with the most serious mental and addictive 
conditions let alone other conditions.
                               __________
                               
Responses to Questions for the Record for Lisa Sacco from Senator Mike 
                                  Lee
    This memorandum responds to two questions submitted by Vice 
Chairman Mike Lee for the Joint Economic Committee Hearing, ``The 
Economic Aspects of the Opioid Crisis'':

      How have different states adapted their justice systems 
to deal with the opioid crisis?
      What impact have drug courts had?

    While the information below is tailored to your specific questions, 
portions of it may be included in other Congressional Research Service 
products available to other Members of Congress. If you have any 
additional questions, please do not hesitate to contact me.
    How have different states adapted their justice systems to deal 
with the opioid crisis?
    Across the country, states have dealt with rising death rates 
linked to opioid overdoses. In response, they have adapted certain 
elements of their criminal justice responses--including police, court, 
and correctional responses \1\--in a variety of ways. While this 
response does not provide a State-by-State analysis, it highlights 
several examples of how States' justice systems have responded to the 
opioid crisis.
---------------------------------------------------------------------------
    \1\ Not all states respond by adapting every component of the 
criminal justice system.
---------------------------------------------------------------------------
    One of the more widespread responses is increasing law enforcement 
officer access to naloxone, an opioid overdose reversal drug.\2\ 
Officers receive training on how to identify an overdose and administer 
naloxone, and they carry the drug to be able to immediately respond to 
an overdose. As of December 2016, over 1,200 police departments in 38 
states had officers that carry naloxone.\3\ In addition, most states 
that have expanded access to naloxone have also provided immunity to 
those who possess, dispense, or administer the drug. Generally, 
immunity entails legal protections from arrest or prosecution and/or 
civil suits for those who prescribe or dispense naloxone in good 
faith.\4\
---------------------------------------------------------------------------
    \2\ National Conference of State Legislatures, Drug Overdose 
Immunity and Good Samaritan Laws, June 5, 2017, http://www.ncsl.org/
research/civil-and-criminal-justice/drug-overdose-immunity-good-
samaritan-laws.aspx.
    \3\ See North Carolina Harm Reduction Coalition (NCHRC), Law 
Enforcement Departments Carrying Naloxone, http://www.nchrc.org/law-
enforcement/us-law-enforcement-who-carry-naloxone/.
    \4\ Some laws also provide disciplinary immunity for medical 
professionals.
---------------------------------------------------------------------------
    Another criminal justice adaptation is the enactment of what are 
known as ``Good Samaritan'' laws to encourage individuals to seek 
medical attention (for themselves or others) related to an overdose 
without fear of arrest or prosecution. For example, this immunity would 
prevent criminal prosecution for illegal possession of a controlled 
substance in certain states and under specified circumstances. While 
these laws vary by State as to what offenses and violations are 
covered, as of June 2017, forty states and the District of Columbia 
have some form of Good Samaritan overdose immunity laws.\5\
---------------------------------------------------------------------------
    \5\ National Conference of State Legislatures, Drug Overdose 
Immunity and Good Samaritan Laws, June 5, 2017, http://www.ncsl.org/
research/civil-and-criminal-justice/drug-overdose-immunity-good-
samaritan-laws.aspx.
---------------------------------------------------------------------------
    Most states have drug diversion or drug court programs \6\ for 
criminal defendants with substance abuse issues including opioid 
abuse.\7\ Some states view drug courts as a tool to address rising 
opioid abuse and have moved to further expand drug court options in the 
wake of the opioid epidemic. In August 2016, representatives from 
several states that have been confronted with high opioid overdose 
death rates \8\ convened for the Regional Judicial Opioid Summit. Part 
of these states' action plans to address opioid abuse was to expand 
drug courts and other court diversion and sentencing options that 
provide substance-abuse treatment and alternatives to incarceration.\9\ 
Further, in April 2017, the National Governors Association announced 
that eight states would participate in a ``learning lab'' to develop 
best practices for dealing with opioid abuse treatment for justice-
involved populations--including the expansion of opioid addiction 
treatment in drug courts.\10\
---------------------------------------------------------------------------
    \6\ Some specialized court programs are designed to divert certain 
defendants and offenders away from traditional criminal justice 
sanctions such as incarceration while reducing overall costs and 
helping these defendants and offenders with substance abuse issues. 
Drug court programs may exist at various points in the justice system, 
but they are often employed post-arrest as an alternative to 
traditional criminal justice processing. For more information, see CRS 
Report R44467, Federal Support for Drug Courts: In Brief, by Lisa N. 
Sacco.
    \7\ National Governors Association, States Expand Opioid Addiction 
Treatment in Drug Courts, Corrections, April 11, 2017, https://
www.nga.org/cms/news/2017/states-expand-opioid-addiction-treatment. For 
more information, see CRS Report R44467, Federal Support for Drug 
Courts: In Brief, by Lisa N. Sacco.
    \8\ These states include Kentucky, Illinois, Indiana, Michigan, 
Ohio, Pennsylvania, Tennessee, Virginia, and West Virginia.
    \9\ Michelle White and Tara Kunkel, National Center for State 
Courts, ``Opioid Epidemic and the Courts,'' Trends in State Courts, 
2017, http://www.ncsc.org.
    \10\ National Governors Association, States Expand Opioid Addiction 
Treatment in Drug Courts, Corrections, April 11, 2017, https://
www.nga.org/cms/news/2017/states-expand-opioid-addiction-treatment.
---------------------------------------------------------------------------
    Further, in recent years, several states have enacted legislation 
increasing access to medication-assisted treatment for drug-addicted 
offenders who are incarcerated or have recently been released.\11\
---------------------------------------------------------------------------
    \11\ National Conference of State Legislatures, American Epidemic: 
Overdose on Opioids, State Legislatures Magazine, April 2016, http://
www.ncsl.org/bookstore/state-legislatures-magazine/overdosed-on-
opioids.aspx.
---------------------------------------------------------------------------
    What impact have drug courts had?
    Drug courts are specialized court programs that present an 
alternative to the traditional court process for certain criminal 
defendants and offenders. Traditionally, these individuals are first-
time, nonviolent offenders who are known to abuse drugs and/or alcohol. 
While there are additional specialized goals for different types of 
drug courts, the overall goals of adult and juvenile drug courts are to 
reduce recidivism and substance abuse.\12\
---------------------------------------------------------------------------
    \12\ For more information, see CRS Report R44467, Federal Support 
for Drug Courts: In Brief, by Lisa N. Sacco.
---------------------------------------------------------------------------
    Drug court programs may exist at various points in the justice 
system, but they are often employed post-arrest as an alternative to 
traditional criminal justice processing. Any drug courts, including 
some Federal drug court programs, are actually reentry programs that 
assist a drug-addicted convict in reentering the community while 
receiving treatment for substance abuse.
    While drug courts vary in composition and target population, they 
generally have a comprehensive model involving

      offender screening and assessment of risks and needs,
      judicial interaction,
      monitoring (e.g., drug and alcohol testing) and 
supervision,
      graduated sanctions and incentives, and
      treatment and rehabilitation services.\13\
---------------------------------------------------------------------------
    \13\ U.S. Department of Justice, National Institute of Justice, 
Drug Courts, March 2015, http://www.nij.gov/topics/courts/drug-courts/.

    Drug courts are typically managed by a team of individuals from (1) 
criminal justice,\14\ (2) social work, and (3) treatment service.\15\
---------------------------------------------------------------------------
    \14\ Including judges, prosecutors, defense attorneys, and 
community corrections officers.
    \15\ U.S. Department of Justice, Office of Justice Programs, Drug 
Courts, June 2015, https://www.ncjrs.gov/pdffiles1/nij/238527.pdf.
---------------------------------------------------------------------------
    Jurisdictions have sought to utilize drug courts in efforts to 
treat individuals' drug addictions, lower recidivism rates for drug-
involved offenders, and lower costs associated with incarcerating these 
offenders. Since the inception of drug courts, a great deal of research 
has been done to evaluate their effectiveness and their impact on 
offenders, the criminal justice system, and the community. Much of the 
research yields positive outcomes.\16\
---------------------------------------------------------------------------
    \16\ U.S. Department of Justice, National Institute of Justice 
(NIJ), Do Drug Courts Work? Findings from Drug Court Research, http://
www.nij.gov/topics/courts/drug-courts/Pages/work.aspx; Douglas B. 
Marlowe, Painting the Current Picture: A National Report on Drug Courts 
and Other Problem-Solving Court Programs in the United States, June 
2011, http://www.ndci.org/sites/default/files/nadcp/
PCP%20Report%20FINAL.PDF.
---------------------------------------------------------------------------
    Several studies have demonstrated that drug courts may lower 
recidivism rates and lower costs for processing offenders compared to 
traditional criminal justice processing.\17\ One group of researchers 
examined the impact of a drug court over 10 years and concluded that 
treatment and other costs associated with the drug court (investment 
costs) \18\ per offender were $1,392 less than investment costs of 
traditional criminal justice processing. In addition, savings due to 
reduced recidivism for drug court participants were more than $79 
million over the 10-year period.\19\ A collaboration of researchers 
conducted a five-year longitudinal study of 23 drug courts from several 
regions of the United States and reported that drug court participants 
were significantly less likely than nonparticipants to relapse into 
drug use and participants committed fewer criminal acts than non-
participants after completing the drug court program.\20\
---------------------------------------------------------------------------
    \17\ Steven Belenko, ``Research on Drug Courts: A Critical 
Review,'' National Drug Court Institute Review, vol. 1, no. 1 (June 
1998), pp. 15-16.
    \18\ These include costs associated with arrest, booking, court, 
jail, and probation.
    \19\ Michael W. Finigan, Shannon M. Carey, and Anton Cox, The 
Impact of a Mature Drug Court over 10 Years of Operation: Recidivism 
and Costs, NPC Research, Final Report, April 2007.
    \20\ For a summary of and various publications discussing the 
Multisite Adult Drug Court Evaluation funded by NIJ and conducted by 
the Urban Policy Institute, Justice Policy Center, RTI International, 
and the Center for Court Innovation, see http://www.nij.gov/topics/
courts/drug-courts/Pages/madce.aspx.
---------------------------------------------------------------------------
    Still, some are skeptical of the impact of drug courts. The Drug 
Policy Alliance \21\ has claimed that drug courts help only offenders 
who are already expected to do well and do not truly reduce costs. This 
organization also has criticized drug courts for punishing addiction 
because drug courts dismiss those who are not able to abstain from 
substance use.\22\
---------------------------------------------------------------------------
    \21\ The Drug Policy Alliance is a national advocacy group that 
advocates for drug law reform.
    \22\ Drug Policy Alliance, Drug Courts are Not the Answer: Toward a 
Health-Centered Approach to Drug Use, March 2011, https://
www.drugpolicy.org/docUploads/Drug--Courts--Are--Not--the--Answer--
Final2.pdf.
---------------------------------------------------------------------------
                               __________
                               
Questions for the Record for Hon. Mike DeWine Submitted by Senator Amy 
                               Klobuchar
                        state treatment programs
    Attorney General DeWine--Two weeks ago, I participated in a hearing 
at the Senate Permanent Subcommittee on Investigations on ``Stopping 
the Shipment of Synthetic Opioids: Oversight of U.S. Strategy to Combat 
Illicit Drugs.'' At that hearing the Policy Chief from Newtown, Ohio, 
testified on the importance of Medicaid when it comes to fighting this 
epidemic.

      How much funding does the State of Ohio annually spend to 
reduce drug abuse and overdose deaths?

    I would refer you to the Ohio Office of Budget and Management for 
specific figures. The figures from OBM may not necessarily include 
dollars spent locally on the epidemic for items such as recovery 
services, support of law enforcement programs, coroner and funeral 
services, hospice care, the cost to business, costs related to 
increased crime, and medical care. In my office, we fund numerous 
efforts to support law enforcement such as lab services, technical 
equipment, and investigation support. We also provide funding for 
specialized programs to address the needs of children in the child 
welfare system and to address drug abuse education in schools.

      How much of this funding comes from Medicaid--both as a 
percentage and in total?

    I would refer you to the Ohio Office of Budget and Management for 
specific figures.

      How would you expect the elimination of the Medicaid 
expansion program to affect the ability of Ohio to continue fighting 
the opioid epidemic and the increasing treatment gaps that you 
mentioned during your testimony?

    Medicaid expansion has allowed many Ohioans to establish and 
maintain access to mental health and addiction services. Reductions in 
Medicaid would reduce Ohioans' access to treatment services needed to 
recover from addiction.
                               __________
                               
   Questions for the Record for Attorney General DeWine Submitted by 
                            Senator Mike Lee
    Attorney General DeWine--Federal and State policymakers have not 
always responded in the most prudent or humane way in response to past 
drug epidemics. We have made some grave errors, some of which are 
reflected in today's criminal code, for example. Given the wide-ranging 
expertise you bring to bear on these issues, what, in your view, is the 
most important mistake for us to avoid as we craft policy addressing 
this epidemic?
    It is very important to always include different perspectives by 
those who are affected by the opioid crisis. For example, hearing from 
medical professionals, first responders, and individuals in recovery is 
very important. Considering the diversity among counties is also 
critical. A solution in a rural community may be vastly different from 
a solution in an urban community. We have been very fortunate to work 
on a grass roots level so that when programming is crafted it is done 
so that it fits who and where it was designed for.
    The Federal Government and State governments obviously play 
important roles in combating the opioid crisis. But I'm particularly 
interested in what local communities and voluntary organizations are 
doing on this front. Can you point to any examples of local 
organizations or initiatives in Ohio that have been successful in 
helping people overcome opioid addiction?
    Throughout the State of Ohio, numerous communities have implemented 
programs and services that have made a positive difference. One of the 
examples can be found in Pickaway County, just south of Columbus. 
Pickaway County has an Addiction Council that is comprised of 
approximately 60 individuals from a cross section of the community. 
Since their inception, they have developed an excellent website 
(https://www.drugfreepickaway.com/) and social media page, held 
numerous awareness and assistance events, produced a Parent Guide that 
has been distributed to approximately 3,000 parents, implemented drug 
prevention programming in the schools in addition to DARE, trained law 
enforcement on how to administer naloxone and how to better investigate 
an overdose scene, changed the approach in the judicial system, and 
designed a program in the jail that has reduced recidivism.
    The jail program is an excellent example of how lives can be 
changed by community collaboration. The Pickaway County jail was 
crowded to overcapacity and the same people continued to cycle through. 
The jail administrator set up a program that has reduced the recidivism 
rate and led to a decline in the jail population.
    Upon release an inmate has the opportunity to receive Vivitrol. To 
have this opportunity, the inmate must complete a questionnaire asking 
them how they plan to remain drug free. If the inmate is approved, a 
judge is asked to grant that the inmate will be released to a nearby 
treatment facility. Job and Family Services signs the inmate up for 
Medicaid the day of release. If the inmate and the team agree that 
additional help may be needed, the Sheriff's Office reaches out to a 
church who will have a member walk alongside the inmate upon release. 
The inmate is also provided a packet of information about a variety of 
support services. No additional dollars were needed for this program.
    My office held our first faith conference in March of 2015. We have 
held seven faith conferences across the State with two in conjunction 
with the West Virginia Attorney General's Office. We have worked very 
closely with the faith community to develop ``champions'' across the 
State. Champions are individuals within a faith community who have been 
trained on how to provide support to those with the disease of 
addiction and to their families. We now have almost 200 champions 
across the State. These champions and others from the faith community 
have held events, provided resources, visited families after the 
overdose of a loved one, worked with law enforcement on their outreach 
efforts, provided a place of safety and comfort, and opened recovery 
homes.
    I and others are concerned about the state of social capital in 
America--the strength of our associational life and our connectedness 
to each other. A recent study published in the journal Drug and Alcohol 
Dependence found that counties across America with lower social capital 
also generally have higher drug overdose rates. The findings suggest 
that tight-knit communities possess a greater resiliency to drug 
epidemics. I would be interested to hear your thoughts as to the 
importance of healthy social relationships and a thriving civil society 
in mitigating the threat of the opioid crisis.
    I agree with Sam Quinones, author of Dreamland, who refers to the 
disease of addiction as a disease of isolation. He stated that as the 
addition progresses, the person affected and often their family become 
isolated in their home (due to stigma and lack of services).The 
addicted individual remains isolated through their addiction and, 
unfortunately, the end result may be death.
    We know that this epidemic has caused stress in our communities, 
leading to the destruction of families, the economic impact, and the 
compassion fatigue of those overwhelmed by what they have experienced.
    But there is hope. When communities come together, stigma declines 
and people feel supported in their journeys to recovery. We hear from 
those in recovery that they need places to go where they can be with 
others in recovery, not a treatment center or a recovery home. They 
need, as do many others, a place where they can build healthy social 
relationships and once again contribute to society.
                               __________
                               
Question for the Record for Professor Deaton Submitted by Senator Mike 
                                  Lee
    Professor Deaton--In your research you've noted a connection 
between, on the one hand, low rates of marriage and high family 
instability among working-class whites and, on the other hand, ``deaths 
of despair.'' Can you describe some of these trends in family 
instability and discuss how they may have played a role in the opioid 
epidemic?
    Thank you, Senator Lee. It is a good question, and one to which, at 
this stage, we have only partial answers and a good deal of 
speculation. In my work with Anne Case, we have followed the findings 
of a number of sociologists and political scientists who have 
identified a long-term increase in dysfunctional family behaviors, 
particularly among those who do not have a university degree. Marriage 
rates are falling, and cohabitations are rising. Cohabitations often 
come with out-of-wedlock births. Cohabitations in the U.S. are 
unstable, at least compared with Europe, so many dads do not live with, 
or even know their kids, and many kids have many ``father'' figures, 
who are not their fathers. There is good evidence that one cause, 
though not the only one, is progressive failure in the labor market, 
where, for those without a BA, good, committed, long-term jobs with 
prospects have become ever scarcer, and where real earnings have not 
risen for 40 years. Other dysfunctions that have increased in parallel 
include withdrawal from the labor force, increased social isolation, 
and a range of morbidities, including physical pain. Many men and women 
without a BA, when they reach middle age, feel that their lives have 
failed; they have done worse than their parents, and they are missing 
the meaning and satisfaction that a good career and a good family life 
brings to people in late middle-age. This raises the risk of suicide, 
of alcoholism, and the susceptibility to other addictions. Addictions, 
in turn, undermine family life and the ability to work. We think of 
opioids--both legal and illegal--as having thrown fuel on the flames, 
and they greatly aggravated a crisis that was already there. Of course, 
we do not claim that opioids are not incredibly dangerous on their own, 
nor that legal and illegal drug dealing is not reprehensible. As the 
example of Utah shows, a good family life and a supportive church may 
not protect people against over-enthusiastic physicians. But we believe 
that the slow erosion of white working class life has predisposed 
people to the epidemic.
  

                                  [all]