[Senate Hearing 115-714]
[From the U.S. Government Publishing Office]


                                                    S. Hrg. 115-714

                           THE OPIOID CRISIS:
                   AN EXAMINATION OF HOW WE GOT HERE
                        AND HOW WE MOVE FORWARD

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                                   ON

      EXAMINING THE OPIOID CRISIS, FOCUSING ON HOW TO MOVE FORWARD

                               __________

                            JANUARY 9, 2018

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
          
                    LAMAR ALEXANDER, Tennessee, Chairman
                    
MICHAEL B. ENZI, Wyoming		PATTY MURRAY, Washington
RICHARD BURR, North Carolina		BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia			ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky			MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine			TAMMY BALDWIN, Wisconsin
BILL CASSIDY, M.D., Louisiana		CHRISTOPHER S. MURPHY, Connecticut
TODD YOUNG, Indiana			ELIZABETH WARREN, Massachusetts
ORRIN G. HATCH, Utah			TIM KAINE, Virginia
PAT ROBERTS, Kansas			MAGGIE HASSAN, New Hampshire
LISA MURKOWSKI, Alaska			TINA SMITH, Minnesota
TIM SCOTT, South Carolina		DOUG JONES, Alabama                                                                          
                                         
               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                  Evan Schatz, Democrat Staff Director
              John Righter, Democrat Deputy Staff Director

                                  (ii)       
          
                
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        TUESDAY, JANUARY 9, 2018

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening Statement.........................     1
Murray, Hon. Patty, Ranking Member, Committee on Health, 
  Education, Labor, and Pensions, Opening Statement..............     3

                                Witness

Quinones, Sam, Journalist and Author, Los Angeles, CA............     6
    Prepared statement...........................................     9
    Summary statement............................................    19

 
                           THE OPIOID CRISIS:
                   AN EXAMINATION OF HOW WE GOT HERE.
                        AND HOW WE MOVE FORWARD

                              ----------                              


                        Tuesday, January 9, 2018

                                        U.S Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:06 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Paul, Collins, 
Young, Murkowski, Scott, Murray, Casey, Bennet, Baldwin, 
Murphy, Warren, Kaine, and Hassan.

                 Opening Statement of Senator Alexander

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    Today, we turn our attention again to the opioid crisis, 
the Nation's No. 1 public health challenge. Our witness today 
is Sam Quinones, the author of Dreamland: The True Tale of 
America's Opiate Epidemic.
    Senator Murray and I will each have an opening statement, 
and then I'll introduce the witness. Then we'll hear from Mr. 
Quinones, and then Senators will each have 5 minutes of 
questions. Since he's our only witness, I've suggested to him 
that if he wants to take a little more than 5 minutes to say 
whatever he has to say, we would welcome that, but there'll be 
plenty of conversation back and forth from Members of the 
Committee.
    Mr. Quinones, it is unusual to have a single witness at our 
hearings, but this is an unusual topic, one you quote 
Washington State research professor, Gary Franklin, as calling 
the worst man-made epidemic in history. The challenge this 
crisis presents has captured the attention of every Member of 
this Committee. Your research and writing has been acclaimed 
for their depth and breadth.
    So this is what we call a bipartisan hearing--most of ours 
are--one in which Democrats and Republicans have agreed on the 
topic, on its importance, and on the witness. It is my hope 
that we Senators will restrain our habit of lecturing one 
another about health insurance and focus today on the topic, 
which is the opioid crisis. This epidemic kills more Americans 
every day than car accidents. In each of our states, we're 
reminded of that almost every day.
    Yesterday, I dropped by a meeting at the Tennessee 
Governor's residence in Nashville. The heads of all of our 
state institutions involved in training doctors were planning 
how to discourage the overprescribing of opioids. The Governor 
told me that in our state of 6.6 million people, there were 7.6 
million opioid prescriptions written in 2016, and that even 
though the state has reduced the amounts of opioids prescribed, 
the number of overdose deaths is up because of the abuse of 
fentanyl, a synthetic opioid.
    Rather than spend more time establishing the crisis, I want 
to focus today on what we can do about it. Here are two things 
I'm hoping to learn from you. First, when 100 million Americans 
live with pain, 25 million of them with chronic or severe pain, 
why is it not a good idea to continue to find the so-called 
Holy Grail of Medicine, a non-addictive pain medicine? Second, 
if stronger communities are the ultimate solution to this 
crisis, as you often suggest in your book, what can a central 
government in Washington do that actually helps?
    Now, my first question--you have a chapter in your book 
entitled Searching for the Holy Grail: Finding a Non-addictive 
Pain Medicine. I've actually read your book. I think there are 
a number of others here who have and who even brought it with 
them. This search for the Holy Grail began, you say, 75 years 
ago in 1928 with the Committee on Problems with Drug 
Dependence. That was the goal, as you describe it, quote, 
``Couldn't the best scientists find a way of extracting the 
pain-killing attributes from the morphine molecule while 
discarding its miserable addictiveness,'' unquote.
    This effort to find a better way to treat pain, you say, 
led to a revolution in attitudes toward pain treatment, first 
using opiates to relieve pain for dying patients; then for 
patients with chronic pain; and then, abetted by a multitude of 
helpers from Mexican gangs to pain clinics, overprescribing 
doctors, and enterprising drug companies, spiraling into the 
addiction and consequences we find today.
    At least twice before this Congress, Dr. Francis Collins, 
the head of the National Institutes of Health, has predicted 
that the Holy Grail that was first sought 75 years ago is now 
within reach. Last month, he said perhaps within 5 years. With 
our encouragement, Dr. Collins has organized NIH researchers in 
partnership with private companies to speed up the process, and 
the Food and Drug Administration Commissioner, Dr. Scott 
Gottlieb, in on board to fast-track the effort within the 
bounds of safety and efficacy.
    But I read at least some of your book to say that this Holy 
Grail may never be found. You even quote some scientists who 
say it should not be found. So I hope you'll tell us what you 
think about this. Should we not continue to try to find non-
addictive pain medicine to relieve suffering without addiction? 
Is that not the obvious antidote to the opioid epidemic?
    The second area I would hope to learn from you about is 
what we can do from Washington, DC. We have tried in important 
ways to address the ravages of this crisis which we've all 
experienced in our states. In 2016, Congress passed the 
Comprehensive Addiction and Recovery Act, CARA, and the 21st 
Century Cures Act to give states and communities, those on the 
front lines, the tools and resources they need to combat this 
crisis.
    For example, in CARA, a provision by Senators Warren and 
Capito was included that made it clear that pharmacies could 
only fill part of certain prescriptions, like oxycodone, an 
opioid. That way, a mom filling her son's pain medicine 
prescription after his wisdom teeth surgery could ask only for 
3 days worth of pills instead of the 30 days he was prescribed.
    In addition to encouraging the development of a non-
addictive pain medicine, Cures included more than $1 billion in 
state grants. We're considering additional funding for 
treatment and to discover alternative pain medicines. We've 
held hearings on wellness, lifestyle changes, which you mention 
in your book, such as exercising and eating healthier, that 
help people lead healthier lives and what incentives would help 
people make those lifestyle changes.
    But you and I apparently have at least one thing in common. 
I am a skeptic of Washington's capacity to solve problems that 
are essentially problems of communities, families, and 
lifestyle. You say that the opioid crisis is a problem of 
society, that when we lose our sense of community, we become 
easy prey for quick external solutions for complex problems 
like opioids. In your words, quote, ``I believe more strongly 
than ever that the antidote to heroin is community. Make sure 
people in your neighborhood do things together. Break down 
those barriers that keep people isolated,'' unquote.
    In my own experience in public life, including time as 
Governor, I've been increasingly convinced of the problem 
solving ability of communities with good jobs, good schools, 
strong families, where everyone seems to be interested in the 
well-being of everybody else. Whenever I've tried as Governor 
or Senator to solve a problem, in the end, it's boiled down to 
creating an environment in which communities could themselves 
fix problems, not sending in single-shot solutions from a 
distance.
    For example, after spending years on state reforms in 
education as Governor, I ended up traveling the state to create 
143 better schools community task forces, because I believed 
that communities who wanted good schools could have them, and 
those who did not would not. I held the same views as we fixed 
No Child Left Behind in 2015 when we restored more decisions to 
classroom teachers, school boards, and states.
    So exactly what does Congress do from Washington, DC, about 
this opioid crisis? This Committee has jurisdiction over a 
significant amount of what you have written about in Dreamland, 
but not the spending of money. That belongs in the 
Appropriations Committee. We're eager to hear your testimony 
and to hear your solutions.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Well, thank you very much, Mr. Chairman. 
I'm glad to be continuing our discussion on this really 
important issue. I know our witness today has been following 
the opioid crisis and its growth into the full blown epidemic 
families and communities across the country are facing today.
    Mr. Quinones, thank you for joining us. I also want to 
welcome your wife and daughter, whom I assume are sitting right 
behind you there. I'm glad they were able to be here with you 
today.
    I look forward to hearing your perspective on how we can 
better help our communities fight this crisis and support all 
of those who have been impacted, and I really appreciate the 
investigative work that you've done to help shed light on this 
challenge.
    Of course--and I'm sure you'd agree--the rise of this 
epidemic is broader in scope than any one book can tell. There 
are people from every background in every corner of the country 
who have stories about the harm that this has done, and they 
are parents who have lost children to an overdose, children who 
have lost parents to an overdose, veterans in chronic pain who 
are struggling with addiction, doctors who are treating babies 
born addicted to opioids, and a lot more.
    I've heard these heartbreaking stories firsthand traveling 
around my home State of Washington and meeting with doctors and 
families and communities fighting this disease. I was visiting 
a local hospital in Longview, a rural community in my state, 
and the staff there told me that almost one out of every two 
babies born there have mothers who struggle with substance 
abuse. That was astonishing and heartbreaking, but it's, 
unfortunately, not the only evidence of this epidemic.
    Since 2000, nearly 10,000 people in Washington State alone 
have died of opioid overdose, and this isn't just happening in 
Longview. It's happening in local hospitals across the Nation. 
We are losing 91 people every day to opioid overdose. When I 
say this epidemic affects everyone, I don't just mean the 
individuals facing opioid addiction. There are other victims as 
well. This epidemic hurts families. It leaves children 
struggling to cope with the impact of their parents' addiction. 
It leaves many of them in foster homes. It leaves parents who 
are shattered with the heartbreak of their child's illness and 
leaves many struggling with the financial cost of opioid misuse 
and treatment and recovery as well.
    This epidemic hurts our communities as a whole. It takes up 
resources of public health, hospitals, and law enforcement. It 
takes workers out of our local economy. It takes a toll on the 
morale of small towns and big cities alike with each new 
tragedy, and we are behind the curve on fighting this epidemic.
    One of the stories that stood out to me in your book was 
about a state employee from the Washington Department of Labor 
and Industries, a woman named Jaymie Mai. Jaymie was a 
pharmacist charged with overseeing the cases of workers who 
were receiving prescription drugs for injuries. After 6 months, 
she noticed that some of these workers were dying from the same 
painkillers that they'd been prescribed. The paper she 
published in 2005 about the uptick in high-strength opioid 
prescriptions and deaths was one of the first papers in the 
country to document the impact of the crisis we face today. But 
she published her paper over a decade ago, which just shows we 
have been fighting this battle for far too long, and we have to 
do more.
    Now, I'm glad that we have taken some necessary steps. In 
2016, Congress passed the 21st Century Cures Act, which 
included nearly $1 billion of funding for states to address the 
opioid crisis through prevention, treatment, and recovery 
efforts. The Comprehensive Addiction and Recovery Act, which 
supports specific outreach for veterans and pregnant and 
postpartum women, expands access to medication-assisted 
treatments and much more.
    But there is a lot more to do. Along with many of my 
colleagues, I hope that we can move more funding in the 
upcoming budget or appropriations agreements. First responders, 
state and local officials, treatment professionals and families 
have made it clear that continued Federal funding is key to 
addressing this crisis. Unfortunately, we have heard a lot of 
talk from the Administration on this, but we have yet to see 
the President take the kind of serious action this emergency 
demands and that he promised families on the campaign trail.
    The White House's own Council of Economic Advisors released 
a report estimating the economic cost of the opioid crisis to 
be over $500 billion dollars just for 2015. Addressing a 
problem this big will take an enormous investment of time, 
energy, focus, and robust funding. The President's third 
quarter paycheck is not going to cut it. Our communities are 
crying out for serious solutions, not stunts.
    So I am eager to see this Committee continue its bipartisan 
approach and take substantive action to address this epidemic 
over the next few months.
    Mr. Chairman, I look forward to working with you to have 
all of our Members bring their ideas forward so we can work on 
moving policies that help our families and communities.e have 
to do a lot more to fund prevention efforts and treatment 
programs and build on the gains we've made. This means 
immediately providing supplemental funding states need to 
implement evidence-based tools that can help turn this epidemic 
around.
    We need to ensure that local stakeholders and partners, the 
people on the ground who know what works best in their 
communities, have the resources and information they need to 
respond to this crisis. It also means going beyond prevention, 
treatment, and recovery. We have to work to support not only 
the individuals facing addiction, but the families and 
communities who are suffering as well.
    I'm interested to hear your perspective on this today and 
how we do that, and I'm really grateful for you coming here 
today to testify before us, because if we're going to beat the 
scourge of this opioid addiction, we have to fund and enact 
solutions that are as comprehensive as this challenge.
    So thank you again very much for having this hearing. I 
look forward to working with you and all our Members.
    The Chairman. Thank you, Senator Murray, and thank you for 
working in this way to have such an important hearing.
    I'm pleased to welcome Sam Quinones and his family today. 
Thank you for taking the time to be here. Mr. Quinones has 30 
years of experience as a journalist and author. He's written 
extensively on the opioid crisis and drug trafficking. He's the 
author of three acclaimed books. His most recent book, 
Dreamland: The True Tale of America's Opiate Epidemic, won the 
National Book Critics Circle Award for general nonfiction.
    Early in his career, Mr. Quinones was the recipient of the 
Maria Moors Cabot Prize, the oldest international award in 
journalism, for his work covering Latin America. He was also 
the recipient of an Alicia Patterson Fellowship awarded to 
outstanding print journalists who pursue stories in the public 
interest.
    Welcome again, Mr. Quinones. You'll have 10 minutes to give 
your testimony, and then Senators are looking forward to having 
a conversation with you.

STATEMENT OF SAM QUINONES, JOURNALIST AND AUTHOR, LOS ANGELES, 
                               CA

    Mr. Quinones. Chairman Alexander, Senator Murray, and 
Honorable Members of this Committee, I'd like to thank you for 
these hearings on our national epidemic of opioid addiction and 
for allowing me the honor of addressing you. I'm very happy to 
be here with my wife and daughter, who are part of producing 
Dreamland and without whom the book would never have been 
finished.
    This is the deadliest drug scourge we have known in this 
country, hitting areas of the country that have never seen this 
kind of drug problem. It is the first in modern America to be 
spread not by mafias, not by street dealers, but by doctors 
overprescribing pain pills, convinced they were doing right by 
their patients, urged on by the pharmaceutical industry, by the 
medical establishment, and, indeed, urged on by us, by American 
health consumers who too often wanted a quick and easy end to 
pain.
    ISIS could not have dreamed of inciting the kind of torment 
and death that we have visited upon ourselves through this 
overuse of opiates. These drugs are a symbol for our era. For 
almost four decades, we have exalted the private sector, the 
individual, while we ridiculed government as inefficient, 
incompetent, and wasteful. We admired wealthy business people, 
regardless of whether the way they made their money produced 
anything of value for our country and our communities. We 
wrought, I believe, a second gilded age.
    This epidemic of addiction to a class of drugs that thrives 
on isolation reflects all that. This epidemic's costs have been 
borne by the public sector. All its profits have been private.
    I believe this scourge is about issues far deeper than drug 
addiction. It's about the effects of this very cultural shift. 
It's also about isolation in areas rich and poor, about the 
hollowing out of small town America and the middle class, of 
the silo-ization of our society, and it's about a culture that 
acts as if buying stuff is the path to happiness.
    I believe we got into this because we believe problems 
could be attacked in isolation with one magical silver bullet, 
a pill for all our pain, a jail cell for every addict. We 
exalted the private and mocked the public and the communal, and 
in so doing, we rid ourselves of things so essential to us that 
they have no price. We have been invaded by cheap junk as a 
result. We dug up Dreamland Pool and replaced it with a strip 
mall--did things like that across America for years now.
    Heroin is what you get when you destroy Dreamland. I 
believe isolation is heroin's natural habitat. I believe, too, 
that this epidemic, therefore, is calling on us to revert these 
decades of isolation and come together as Americans. I believe 
more strongly than ever that the antidote to heroin is not 
naloxone. It is community, people coming together and working 
in small and local ways toward solutions, no one saving the 
world alone.
    The good news, in fact, in all of this, I believe, is that 
there is no solution. There are many solutions, each small. 
Each must be tinkered with, improved. Some may be discarded. 
Each must be funded fully and for a long time. But the good 
news, too, is that none of them is sexy. None will do the trick 
alone.
    I believe that across America today, communities are 
finding these solutions. The more they band together, the more 
they leverage all that talent and energy, bringing in PTAs, 
pastors, artists, and athletes, recovering addicts, and primary 
care docs, librarians, and the Chamber of Commerce. The more 
cops and public health nurses go out for a beer--bridge that 
cultural chasm between them. I do believe, as I said, that this 
is happening in counties across America.
    It's my opinion, as the evidence shows, that supply has 
ignited all this. We did not have this demand, this widespread 
addiction, until we unleashed a large supply of powerful, legal 
narcotics on the public for the last two decades. Thus, I 
believe it essential that doctors reassess how and to whom and 
in what quantity they prescribe these drugs.
    That does not mean just cutting people off who are on high 
doses of these drugs and leaving them to fend for themselves. 
It does mean lobbying insurance companies to reimburse for pain 
strategies that do not involve narcotics, allowing doctors a 
wider array of pain strategies than simply pain pills. Young 
docs, meanwhile, need more education in med school in both pain 
management and addiction treatment.
    I have to say that I think it's delusional to spend time 
and money on yet another wall along the U.S.-Mexico border, 
hoping that this will somehow staunch the supply of heroin and 
fentanyl. These drugs are coming in through areas with walls 
already. I believe a wall will, in fact, corrode the only thing 
that will truly help stop these drugs from flowing into our 
country, and that is a deep, respectful--but also forthright, 
sometimes blunt, certainly honest--relationship with Mexico 
that will lead to it finally becoming the kind of neighbor and 
partner we can work with effectively, and in so doing, become 
the kind of neighbor that country needs of us.
    Another wall, however, seems to me, is just like heroin. It 
feels good for the moment, but it will leave us in a worse 
place in the long run, another silver bullet for a complicated 
adult problem.
    Sometimes the solutions are about the mundane mechanics of 
governing. We should find, for example, new ways of funding 
coroners' offices around this country and expanding our 
national force of forensic pathologists, which is dangerously 
dwindling. This epidemic spread because so many of those 
offices are so poorly funded.
    I believe we must expand treatment options in this country. 
One place to do this, ironically, crucially, I believe, is 
jail. Consider how the country will be helped by transforming 
jail into a place of nurturing recovery instead of a place of 
predation and tedium. It becomes then an asset instead of a 
liability, and this is happening, particularly, I would note, 
in the State of Kentucky.
    I'd also like to add that all across America are families 
who are suffering due to the addiction of a loved one or the 
loss of that loved one. I believe they are a raw material to be 
marshaled, harnessed in this fight. Many now want to be 
involved, need to be involved to help salve the lacerating 
wounds that will last a lifetime. I believe you as Senators can 
help this by recruiting them, recognizing them, giving them 
platforms from which to tell their story. Maybe it's because 
I'm a reporter, but I believe that through their stories, the 
awful stigma of addiction will be reduced.
    I'm happy to elaborate on any of this. Before I do that, 
though, I want finally to urge you to view this as an 
opportunity, view this as an opportunity to revive those 
regions hammered by globalization and free trade. The roots of 
our national epidemic of narcotic addiction lie there, while 
the epidemic itself, in turn, stands in the way of their 
revival. Many of these regions cannot revive until enough of 
their people can pass a drug test to fill new jobs. Indeed, 
this is not only a story of drug addiction. It is a story of 
economic affliction.
    As politicians, I suspect your natural response to a crisis 
like this is to look about for things you can do quickly to 
show constituents you're taking action, and I believe that is 
entirely understandable. I would caution, however, against 
believing in short-term responses. CARA and the Cures Act make 
up a great start, and I thank you for them. But they are only a 
start.
    Everything I've learned about this issue has taught me the 
importance of long-term community responses and commitment. I 
believe American history offers us two templates for action 
from which you might take guidance and inspiration. First is 
the Marshall Plan to rebuild Europe after World War II. Second 
is our space program. Each involved government and the private 
sector acting in concert over many years, bringing money, 
brains, energy, and, of course, long-term focus to bear.
    Each achieved an unalloyed good for our country, though 
they were about doing things that seemed on first blush far 
beyond our own short-term self-interest. The Marshall Plan was 
about building up ravaged regions to allow them to function 
independently while containing the viral spread of Soviet 
Communism. It allowed reborn countries to prosper and 
contribute to the world again. A Marshall Plan for American 
recovery might focus on rebuilding those regions that have been 
caught in dependence on dope and ravaged by economic 
devastation to contain the viral spread of addiction.
    Through our space program, we were inspired as a people to 
spend years and dollars, all to achieve something no previous 
generation ever thought possible. We ended up far beyond the 
moon. The spillover in economic benefit, increase in knowledge, 
and in simple human inspiration is beyond calculation. It seems 
to me that we might profitably apply these examples, the 
Marshall Plan and the space program, to regions of forgotten 
Americans where this problem began.
    Let's do it perhaps not because it is easy, but, as JFK 
said, ``because it is hard'', because that's what Americans do 
and have always done at their greatest.
    Like our space program, I believe such an effort will have 
to last for years to be effective, focused far beyond the 
immediate goal of drug addiction and on the more profound 
problems of community destruction and the hollowing out of 
stretches of this country. Thus, I'm here today to urge you to 
see this not only as the catastrophe that it is, but also as 
the gift that it can be. It offers an opportunity to reinvest 
in areas that need it most, a chance to inspire us as Americans 
again to do something great. It's an opportunity to bridge that 
political polarization that so gnaws at our country. It is one 
of the few issues today that can do that. Do not miss this 
opportunity. It does not come around often.
    This calling, I suspect, is the very reason many of you got 
into public service in the first place, and you are lucky, I 
think, to be here when it has again. You will be remembered for 
acting when acting was not easy to do. If you do, I believe 
your hometowns will thank you. Your counties will thank you, 
and we, your country's men and women, will thank you long after 
you're gone.
    With that, I'm happy to talk about anything you guys want.
    [The prepared statement of Mr. Quinones follows:]
                                ------                                

                   prepared statement of sam quinones
    As politicians, the natural response to a crisis like this is to 
look about for things you can do quickly, to show constituents you're 
taking action.
    I would caution, however, against acting too quickly, and 
especially in believing only in short-term responses to this problem.
    Everything I've learned about this issue has taught me the 
importance of long-term, community responses to this problem.
    CARA and the CURES Act make up a good start, but they are only a 
start.
    I think we, as your constituents, ought to be humble, remain aware 
that this has festered for more than two decades, though most of the 
country awoke to it in the last 2 years. We need, as your constituents, 
to be patient, and not demand perfection or quick fixes. That's what 
got us into all this in the first place--demanding quick fixes for the 
complicated problem of what to do about the mysteries of human pain.
    I believe, too, we run into trouble when we attack one drug problem 
in isolation--and then are surprised and unprepared when the next one 
emerges.
    Thus several of the ideas I've included here--that I've seen, or 
been told about as a reporter on this topic--are those that I suspect 
might have utility for years to come, regardless of the kind of drug we 
encounter today, tomorrow, or in a decade.
    * * *
    As I said in my oral testimony, I believe we have in American 
history two templates for addressing this problem: the Marshall Plan 
and the space program.
    Each involved government and the private sector, acting in concert 
over many years--bringing money, brains, energy, and focus to bear. 
Each achieved an unalloyed good for our country.
    A Marshall Plan for American Recovery would fund new drug treatment 
capacity, vastly increase research into addiction and pain treatment, 
expand law enforcement efforts, especially on the Internet, give 
incentives to counties transforming jails into recovery units, expand 
the use of medically assisted treatment, and provide money for coroners 
in small counties.
    It would also focus just as much on reviving those regions that 
have been caught in dependence on dope and ravaged by economic 
devastation. It might include a large and sustained Federal investment 
in infrastructure. These are Rust Belt areas, Appalachia. But also of 
parts of Maine and Vermont. Of the Central Valley of California, and 
the Rio Grande Valley of Texas. They are parts of Mississippi and 
Alabama, the inner cities of Baltimore and Chicago, but also rural 
areas of New Mexico, Kansas, and Oklahoma.
    I suspect, by the way, that increased investment in addiction and 
pain research has the chance to transform some of these areas and be a 
detonator of economic development over many years.
    One such area is the Ohio River Valley, including the states of 
Ohio, Kentucky and West Virginia.
    They possess a constellation of great university medical centers at 
Ohio State, Cincinnati, Kentucky, Louisville, and West Virginia. At 
Shawnee State (Portsmouth), Northern Kentucky (Covington), Marshall 
(Huntington) universities, enrollments are swelling with recovering 
addicts studying social work and addiction counseling. These students 
could provide eager workers in these studies. In some areas, abundant 
cheap real estate could house these studies over many years. They also 
have thousands upon thousands of addicts--active and recovering--who 
could be the subjects of these studies.
    This region could be a world center for the study of addiction--one 
of humankind's most persistent torments. Boston is the center of study 
of cancer and blood--to the great benefit of that area, and the world. 
Addiction, in all its forms, afflicts far more people than does cancer.
    Regional cooperation is key. One state alone, one sub-region alone, 
one school alone, probably couldn't achieve the synergies and the 
political pull needed. State and local government would have to work 
together toward this future. Folks at those medical centers would have 
to get know each other, cooperate on studies and leverage their 
research abilities.
    Again, a community approach to achieving this idea--leveraging 
brainpower of like-minded people and regions. Six Senators and a dozen 
or so Congressmen could form an Addiction Research & Solutions Caucus 
to expand Federal research grants. Add to that three Governors, several 
college presidents and many researchers. That's an impressive lobby, 
seems to me.
    This area as a center for addiction study would invite not just 
dollars but educated people to a region that has seen a lot of both 
depart over recent decades. Yet the benefit goes deeper. A recovering 
addict is more than a person who no longer does dope. A recovering 
addict discovers new energy for the possibilities of the future, with 
gratitude for a second chance. Harnessing that, I believe, is crucial 
to defeating not only this epidemic but also the fatalism and inertia 
on which dope feeds. The more research funding that's out there, the 
more those recovering addicts could be employed in those studies, 
channeling their new-found energy.
    So I'd urge you as Federal elected officials to be aware of the 
development potential in such multi-year research grants. I'd also 
suggest you contact Sue Ott Rowlands, who is the provost at Northern 
Kentucky University and has organized the Ohio River Valley Addiction 
Research Consortium, and events around this idea.
                                 Supply
    Prevention should be an important focus, but in this case, that 
means reducing supply.
    Supply has ignited all this. We did not have this demand, this 
widespread addiction, until we unleashed on the public a large supply 
of new, powerful, legal narcotic painkillers, indiscriminately 
prescribed in large quantities over more than two decades.
    Education is so important, but we should recognize that it doesn't 
have much effect on an addict once she's enslaved to the morphine 
molecule.
    If you want to reduce demand, you need to reduce supply.
    Less access means fewer new addicts starting down that path. 
There's a reason alcohol is the country's most abused drugs--it's also 
the cheapest and most prevalent. I think we hide our heads in the sand 
when we don't realize the effect in all this of massive supply--first 
pills, now also heroin and fentanyl.
    Very importantly, there's no way to really increase the chance of 
success of an addict coming out of treatment without reducing the 
supply on the street, that now batters him with massive and plentiful 
amounts of opiates in various forms as soon as he gets back to his 
hometown.
    We may not be able ``to arrest our way out of this,'' but it's not 
clear to me that we can treat our way out of this, especially if the 
supply of highly potent and now cheap opiates in various forms remains 
so prevalent.
    Much of what's been done up to now in certain parts of the country 
seem to me like good ideas: Reducing the amounts of drugs prescribed 
for acute post-surgical pain, or by emergency rooms.
    I'm a layman but no one has yet explained to me a satisfactory 
medical reason for prescribing 30-60 days worth of pain pills for the 
acute pain from routine surgery that should last only 2-4 days. Often, 
though, that's done because doctors don't want to see a patient again, 
and won't get reimbursed for another visit by that patient. So they 
prescribe large amounts of these pills right from the start. Many 
patients only use a few of them. But what happens to the pills that 
remain is the big question. But often, from my research, they end up in 
the black market, or misused in some way.
    Some states have used statutes to do curtail excessive prescribing 
for post-surgical acute pain.
    But I think this problem could be further--and perhaps better--
addressed by pushing insurance companies to reimburse for these 
(relatively few) second visits, and certainly to reimburse for a far 
broader array of pain strategies that do not involve opioids. Then 
doctors might feel more comfortable in prescribing far fewer of these 
pills after routine surgery.
    As a country, it seems to me, we still, even now, prescribe far too 
many of these pills far too often and in far too great a quantity at a 
time. By the end of 2016, prescribing was dropping nationwide. Even so, 
more than 214 million opioid prescriptions were written that year. 
That's only just below the number for 2006 and remains far above--
nearing triple--the prescribing levels for the mid-and late-1990's. 
Moreover, it remains very high in many specific regions and counties.
    It appears that these pills remain the pain strategy of choice for 
doctors in so many areas, largely I'd bet because these physicians 
don't have much training in anything else and/or can't get insurance 
reimbursement for much else. Dentists still seem to prescribe far too 
many of these pills after wisdom-teeth extractions.
    It doesn't surprise me, therefore, that those states that expanded 
Medicaid also see an increase in overdoses. Too often, my hunch is, new 
access to health care still means too much access to opioid 
painkillers--again too much supply.
    It's still just too easy for doctors to dispense a pill; too many 
patients demand it, too few reimbursed alternatives exist.
    That means that too many pain patients have not been given ample 
access to competing, non-opioid pain alternatives. One chronic-pain 
advocate told me that when it comes to these pills they face all-or-
nothing scenarios. ``There are multiple options out there besides 
opioids,'' he told me. ``[But] not prescribing is as bad as 
overprescribing. Sometimes we need those pills to even be able to get 
out of bed to go swimming or go to acupuncture. We don't want all or 
nothing. We want that balance.''
    Indeed, balance is the key, seems to me, a holistic approach--
again, think of it as a community approach--to one individual's pain. 
That is precisely what we've not seen from doctors, nor from what 
insurance companies reimburse for, for many years.
    As I travel, I encounter, however, good news on this front.
    Veterans Administration hospitals led the country into this 
epidemic and are now leading it out of it. The V.A. has installed new 
pain clinics around the country where patients can now get yoga, 
acupuncture, cognitive behavioral therapy, and much more.
    Another two places I'd point you to are Community Care of West 
Virginia in Bridgeport, WV, and Kaiser Permanente in Southern 
California. Both are returning to multi-disciplinary approaches to 
pain--involving many therapies and, importantly, patient accountability 
and participation in their own care--to treat chronic pain.
    Changes in medical-school curricula are crucial here. Young docs 
need more education in pain and addiction treatment. You, as Senators, 
might want to ask medical schools in your states how they're coming in 
adjusting curricula, and if they haven't done so, why not. I don't 
think you should underestimate your own public profile as a lobbying 
tool.
    I'd suggest reviewing whether patient evaluations of doctors (in 
Medicaid/Medicare) serve a purpose, or whether what they really serve 
to do is push doctors to prescribe more of these pills, which is my 
distinct understanding, in talking with physicians. These evaluations 
don't seem to add much knowledge or data.
    Let me add this: This does not mean just cutting off people on high 
doses of these drugs, and leaving them to fend for themselves. That is 
cruel and pushes them into the black market. I think we might do well 
to consider that there may be people out there for whom some dosage of 
these pills will have to be lifelong companions. That these pills are 
the only solution they've found in a lifetime of searching. That 
getting them off will do more damage than good.
    That's a doctor's call--not mine. We'd be better off, though, if 
that call were to come in an atmosphere of widely available, reimbursed 
non-opioid alternatives to pain, as well as increased education of 
doctors on how and when they might use these alternatives.
    In that regard, I'd mention that I wrote a blog post recently about 
a Federal bust of a heroin delivery service in the San Fernando Valley 
of Los Angeles. It was known as Manny's Delivery Service. One reader 
had this to say:
    ``I was a customer of Manny's and I am sad to see him go. After an 
accident, I was prescribed painkillers and was fine until I was cutoff. 
I lost my job and then switched to heroin. Everything was fine for 
almost 15 years, I had a better paying job and no problems. Then Manny 
was busted. I was too sick to work, and am now on the edge of being 
fired again.''
    One of the achievements of Community Care of West Virginia and 
Kaiser Southern California is that they don't cut people off. They work 
with them, as individuals, sometimes over years, to adjust their pain 
treatment. When they do, opioid painkillers are often part of the mix, 
albeit in reduced quantities.
    My point is this: If all we do is lower pain-pill prescribing 
without expanding the numbers of pain strategies available for people, 
and in which doctors are trained, then we'll have created another 
problem for ourselves.
                            Law Enforcement
    Given what I said above, I believe evidence shows that there is a 
strong and important role for law enforcement in all this.
    In part that's because I believe in a true community of solutions, 
and most certainly law enforcement is part of the mix--particularly 
when it comes to attacking mid-level and wholesale level street 
dealers. They're the ones who'll help in reducing that supply that is 
now so dangerous to recovering addicts leaving treatment and is such an 
instigator of addiction.
    I would say this, too: I find that it's in law enforcement where 
we're finding folks most willing to innovate, to change long-held 
practices and pivot based on new facts. Remarkably so. While it's 
common to believe that most cops want to arrest people as the solution 
to everything, I've found that many officers have a vastly different 
perspective today, one I suspect that has formed in response to what 
they're seeing in this epidemic.
                                 Courts
    One judge in a juvenile court I spoke with noted the wide-ranging 
problems emanating from this epidemic that jurists now face.
    She called for: More resources for targeted law enforcement. More 
services to support recovering addicts reintegration into the 
community. More services for families to avoid children being removed. 
A nationwide prevention campaign, similar to those undertaken to combat 
smoking, drunken driving, heart disease and lung cancer; the increased 
use of diversion and Drug Courts of all kinds, support for the 
frontline folks in law enforcement, emergency rooms, paramedics.
    This judge felt strongly about the reauthorization of the Children 
Health Insurance Program.
    As this epidemic has created a crisis in child protective services 
and foster care, she felt more dollars were needed to help those 
agencies in counties across the country--something I'll talk more about 
later.
    ``Unfunded mandates do not assist anyone,'' she wrote, in ending. 
``Communities across the country are doing their best without dollars. 
Research can be overwhelmingly helpful for now and in the future.''
                        Mexico and Another Wall
    I lived in Mexico for 10 years, where I wrote my first two books.
    More recently, I've spent a lot of time in Tijuana, interviewing 
old coyotes who ran immigrants across the border from the 1970's to 
1994, when the first wall went up between the two countries. That wall, 
they all agree, put an end to the illegal-immigrant traffic from 
Tijuana into Southern California, pushing it east to Arizona.
    So walls have been a factor--one of several--in slowing the arrival 
of illegal immigrants in recent years.
    As a reporter I remain open to new evidence. But so far, the 
evidence shows that they have done little to slow the arrival of 
illegal drugs.
    How to do that is a question of paramount importance, as virtually 
all our illegal drugs come from, or through, Mexico, and, as I've said 
above, supply is crucial, particularly when it comes to an enslaving 
class of drugs like opiates.
    Speaking here entirely about answers to our flow of illegal drugs, 
I just don't see how a 2000-mile wall will have much effect. We already 
have 700 miles of walls in the most vulnerable geographic areas. Two 
walls, for a span, stand between Tijuana and San Diego. These need 
maintenance and improvement perhaps.
    In the 1990's, American medicine began to claim that opiate 
painkillers could be prescribed virtually indiscriminately, with little 
risk of addiction, to all manner of patients. The result over the next 
two decades was a huge increase in our national supply of painkillers 
and thus in the number of opiate addicts.
    That happened without anyone realizing that our heroin market had 
also shifted during the 1980's. By the early 1990's, most of our heroin 
no longer came from the Far East (Turkey, Burma, Afghanistan) but from 
Latin America--from Colombia and, today especially, from Mexico. From 
so close by, this heroin got here cheaper and more potent than the Far 
East stuff. In other words, the Latin American heroin outcompeted the 
heroin from the Far East.
    Truth is, though, most Mexican traffickers for years didn't care 
much for trafficking heroin, which they viewed as decidedly scuzzy and 
back-alley and serving a relatively small market of tapped-out users in 
the United States. So they pushed cocaine and meth, and pot, of course.
    Then we began creating legions of new opiate addicts with this 
expansion of indiscriminate prescribing of narcotic painkillers.
    As years passed, that, in turn, unleashed the powerful and 
ingeniously creative forces of the Mexican drug-trafficking culture, 
then largely dormant when it came to heroin. By the way, that's not to 
say, necessarily, cartels. Just a widespread culture of drug 
trafficking, particularly in certain regions of Mexico.
    These drugs are coming in through areas with walls. I think it's 
delusional to spend time and money on yet another wall along the U.S.-
Mexico border hoping that this will staunch the flow of heroin and 
fentanyl.
    Heroin hasn't much medicinal benefit that other drugs don't provide 
with far less risk of addiction. Heroin really exists because it's a 
great drug to traffic: easy to make, very condensable, easy to cut. The 
important point to understand is that it is profitable to traffic even 
in small quantities. Plus, it creates customers who must buy your 
product every day, usually several times a day.
    All this means that small-scale heroin trafficking is a big part of 
the story of how it gets here from Mexico. To be sure, it comes in 50-
kilo, 100-kilo loads, too. But a lot of it comes in small loads--a la 
hormiga, in Spanish (anti-like)--of a few kilos. Again, most of it 
comes through areas with walls in place. It comes on people's persons, 
in cars, in trucks.
    It's easy to do that with heroin, and individuals can make good 
money on relatively small quantities.
    Fentanyl, which is far more potent and thus easier to traffic in 
tiny quantities, has only intensified the challenges to law 
enforcement, and the futility of another wall. It now comes from all 
over the world, I presume, and through the mail, given its frequent 
sale on the Dark Net.
    I believe a wall will corrode the only thing that will truly help 
stop these drugs from flowing into our country: a deep, respectful, but 
also forthright and honest, relationship with Mexico that will lead to 
it finally become the kind of neighbor and partner we can work with 
effectively.
    I understand your frustration, the frustration of the American 
people, in this. Mexico has long been unreliable.
    It's worth noting too, that we've hardly been the best neighbor 
ourselves. (A few days ago, I spoke with a former member of the 
Arellano Felix Cartel, which ran the Tijuana drug trade for many years, 
and was the most notoriously brutal in the days when cartels preferred 
to be discreet. He assured me that all the guns they used--from pistols 
to R15s and AK47s, as well as ``grenades, bulletproof vests, and more 
ammunition than you can imagine''--came down from the United States. So 
to the extent that there is a force as toxic as ISIS on our border, it 
has grown powerful and been enabled in good part to our own gun laws.)
    But from where I stand, it seems to me that we've done little of 
the work needed to cultivate that relationship, though we share 2000 
miles of border. Yet there is so much promise in doing so, if we'll 
take the time.
    Another wall, seems to me, is just like heroin: feels good for a 
moment, but will leave us in a worse place in the long run. Again, a 
Silver-Bullet answer to a complicated adult problem.
    As I said above, I do believe in a robust role for law enforcement 
in this issue. Law enforcement is one of the weapons we have in 
controlling supply.
    But U.S. law enforcement will only succeed to the degree that it 
partners with its international colleagues.
    I visited Dayton, Ohio over the summer. The city had been hammered 
by fentanyl-related deaths. Yet when I was there, suddenly the deaths 
stopped. I wondered why. Then I read that some 3 weeks before, an 
international coalition of law enforcement--the FBI, DEA, but also 
Europol, Thai police, and others--working together shut down two of the 
biggest marketplaces on the Dark Web, where fentanyl was offered, from 
screenshots I was provided, for $200 a gram up to $12,500 for a kilo--
all in Bitcoin.
    Was that why deaths stopped in Dayton? I have no idea. I do 
suspect, though, that there's more than a coincidence.
    But the point is that that kind of shutdown is possible only when 
we work deeply and consistently and over years with law enforcement in 
other countries. Heroin and now fentanyl show that we have no choice 
but to do that with Mexico.
    I fear that yet another wall will stifle that.
                               Treatment
    I suspect you have heard a lot about the need for dramatically 
expanding access to drug treatment across the country. This is 
something we should have done years, decades ago. Now would be a good 
time to do so.
    I'd add that expanding medically assisted treatment (MAT) seems 
like something we urgently need to do.
    I understand the skepticism of some folks who believe this seems to 
be substituting one drug for another. I felt that too when I began this 
book. But a couple things changed my mind.
    One is that our supply of dope on the streets is so vast that it is 
tantamount to a death sentence to send a recovering addict from rehab--
clean--back to the neighborhood where she first got addicted without 
some sort of shield. Part of addiction recovery is relapse. I relapsed 
on cigarettes nine times before I quit smoking for good on January 19, 
1996 in Mexico City. Never did I die. But relapse on this class of 
drugs often means death. Hence the need for medically assisted 
treatment, a shield in a sense for addicts leaving treatment.
    These drugs allow addicts a chance to repair their lives, restore 
broken relationships, find work and stay with jobs they find. Above 
all, though, it keeps them alive. This option, though, is often sparse 
in rural areas.
    Debbie Allen, chief planner for the Adams County Criminal Justice 
Coordinating Council (a group that works with two other counties to 
muster responses to this epidemic), writes:
    ``Rural areas tend to have higher risk occupations that are 
physically demanding and prone to injury, for which opioids may be 
prescribed for treatment. Rural primary care providers are less likely 
to have received waivers to prescribe buprenorphine in rural 
communities. MAT reduces overdoses, keeps people in treatment and cuts 
the number of relapses. [But] Medicare doesn't cover medication-
assisted treatment and there is shortage of trained providers in 
locations such as Veterans Affairs and Indian Health Service 
facilities. . . . Many counties, particularly, rural counties, have 
fewer providers, more people who are uninsured, and inadequate capacity 
to connect individuals and families to the resources they need.''
    The key thing, seems to me, is that MAT be done with a community 
focus. It is medically assisted treatment, after all. That means these 
drugs are tools to be used with other strategies: mentors, group 
therapy, assisting recovering addicts in finding work, housing, etc.
    Part of any Marshall Plan for Recovery might well be investment in 
vastly expanding our now saturated treatment capacity.
    A lot has been said about this. I agree with it.
    So let me talk about a place where we can do that, an idea I think 
is promising and important, but that doesn't get much attention.
                                  Jail
    We know that as the country has awakened to that epidemic, a new 
mantra has emerged: ``We can't arrest our way out of this.'' It is 
usually accompanied by calls for more drug-addiction treatment.
    Yet this plague of addiction has swamped our treatment-center 
infrastructure. Only one in ten addicts gets the treatment he needs, 
according to a national government survey. New centers are costly to 
build, politically difficult to site, and beyond the means of most 
uninsured street addicts, anyway.
    So where can we quickly find cheap new capacity for drug treatment 
accessible to the street addict? One place, I believe, is jail.
    Jail, which houses inmates awaiting trial or those serving up to a 
year for a misdemeanor crime, has always been accepted as an 
unavoidable fixed cost. It's a place to park inmates, most of whom are 
drug addicts. They vegetate for months, trading crime stories amid an 
atmosphere of boredom and brutality. ``Treatment'' is usually limited 
to a weekly visit by a pastor or AA volunteer. When inmates release, 
it's often with no help, wearing the clothes they came in with, 
regardless of the weather at the time.
    Our opiate-addiction epidemic, however, is one of the great forces 
for change in America. One new idea is rethinking jail. It is jail not 
as a cost, but as an investment in recovery. Jail as full-time rehab 
centers--from lights on to lights out--and with help for inmates when 
they release. The good part is, the buildings are already up and ready 
to be used in this way.
    This is happening and you can encourage it further.
    One state moving ahead on this is Kentucky, where some two-dozen 
jails have now formed rehab pods. The one I've visited is in Kenton 
County.
    There are others. I'd suggest contacting the jail in Chesterfield 
County, Virginia, run by Sheriff Karl Leonard. Or the jail in Lucas 
County, Ohio, run by Sheriff John Tharp.
    Jailing addicts is anathema to treatment advocates. But, as any 
parent of an addict can tell you, opiates are mind-controlling beasts. 
A kid who complained about the least little household chore while sober 
will, as an addict, walk through five miles of snow, endure any 
hardship or humiliation, to get his dope. Waiting for an addict to 
reach rock bottom and make a rational choice to seek treatment sounds 
nice in theory. But it ignores the nature of the drugs in question, 
while also assuming that a private treatment bed is miraculously 
available at the moment the street addict is willing to occupy it.
    The reality is that, unlike other substances, with opiates rock 
bottom is often death.
    Jail can be a necessary, maybe the only, lever with which to 
encourage or force an addict to seek treatment before it's too late. 
``People don't go to treatment because they see the light. They go to 
treatment because they feel the heat,'' said Kevin Pangburn, director 
of Substance Abuse Services for the Kentucky Department of Corrections 
(DOC).
    In fact, jail may actually be one of the best places to initiate 
addict recovery. It's in jail where addicts first interface with the 
criminal-justice system, long before they commit crimes that warrant a 
prison sentence. Once detoxed of the dope that has controlled their 
decisions, it's in jail where addicts more clearly behold the wreckage 
of their lives.
    The problem is that at that moment of clarity and contrition we 
plunge them into a jail world of extortion, violence, and tedium.
    ``Imagine your most stressful day at work, multiply that by two or 
three, then imagine that every day,'' said one inmate told me. ``Having 
to be on your guard. Always tense. Then you're released from that; the 
first thing you're going to take up is heroin'' again.
    Interestingly, rethinking jail is cheaper. These rehab pods have 
fewer fights, fewer health costs, fewer lawsuits. Usually pods run in 
this way are cleaner and free of contraband.
    Pods like this do require political will, changing our long-held 
ideas regarding addiction, and, above all, rethinking what jail can be. 
They require elected officials like you to get out front, champion 
these ideas, urge others to adopt them.
    With state DOC funds, Kenton County, has expanded its counseling 
staff to seven, of whom five are recovering addicts--folks whose 
backgrounds, it's safe to say, would have kept them from finding work 
in any other jail.
    I don't believe that these pods are some magical cure-all to our 
national affliction. There is no one solution to what our country 
faces. But they seem to be a smarter bet of public money than the 
counterproductive way so many jails across the country function today, 
while offering some hope to a population that has lost it.
    What's more, a pod run that way today is more likely to be an 
asset, not a liability, in the next drug problem we face.
    As Federal officials, you might give some thought to grants the 
give incentives to counties to rethink jail in this way.
    Again, I'd suggest that you make a big deal of those jails that are 
doing it. Why not visit these jails and see how they work? Talk them 
up. Mention them when you travel, in private meetings with local 
officials, or when you speak to large groups. Get a buzz going.
    Your public profile could go a long way to spreading news about 
some of these ideas and this is one of them.
                                Counties
    No level of government is more affected by this problem than the 
county, which funds local public health departments, coroners offices, 
jail and courts, law enforcement, county hospitals and drug counseling, 
libraries, etc.
    Thus it's not surprising that counties are forming coalitions and 
task forces to attack this problem. This is where Americans are 
battling heroically, to find community solutions in county after 
county. Sometimes they're feeling their way, half-blind. Is it messy? 
Of course! Why would we expect it not be? This is new to most of them. 
Sometimes they fail. We should applaud them, urge them on, and go to 
them for their ideas on how to do it better.
    They are performing what I believe to be the essential endeavor: 
that is, leveraging talents and expertise and budgets, bringing 
together folks who didn't know each other before this, building a 
community effort to combat the effects of a drug problem that grew from 
our isolation.
    It's here, too, that I think some of the essential work of 
combating the stigma of addiction is taking place, as well you might 
imagine it would. It's at the local level, in these kinds of groups and 
in public forums and churches, where people know each other and the 
stories they have to tell ring true to their neighbors, that the 
horrifying stigma that has done so much to push this epidemic 
nationwide is, I believe, slowly fading. Can't happen soon enough. You 
might consider grants that move it along.
    From my reporting, this epidemic is calling us to this kind of 
community effort.
    In Lycoming County, PA, home to the town of Williamsport, Project 
Bald Eagle has been operating for several years, focused on bringing 
together folks from across the area to address this problem.
    They just voted to become a regional project, combining several 
counties. Seems like the right approach too me. In doing so, they hope 
to be more attractive to funders.
    ``Our coalition is expanding and we have had no problem getting 
program funding. But no one funds infrastructure or basic operations,'' 
said Davie Gilmour, president of Pennsylvania College of Technology and 
chair of this project.
    When the group moved to seek grants for their work, she told me, it 
found grants that ``could only fund programs--naloxone training, school 
education.'' That looks and feels good. But it takes staff to write, 
manage and spread the word. It takes office space. That's not sexy but 
it is essential.
    ``Finally,'' she told me, ``we are beginning to work with our local 
chamber of commerce and workforce development boards on `reemployment' 
of folks in recovery or recently out of prison. They are successful in 
programs but they now need to return to society. Funds for employer 
incentives to reemploy these folks would go a long way to assist.''
    I've seen examples of things that are working and might be 
continued and expanded.
    The Office of National Drug Control Policy provided grants that 
have allowed three rural counties in another part of Pennsylvania--
Armstrong, Clarion and Indiana counties--to form community coalitions 
aimed at educating youths about substance abuse.
    Once organized, these coalitions applied for grants from the Health 
Resource Service Administration.
    One HRSA grant allowed the counties to form an Addiction Recovery 
Mobile Outreach Team (ARMOT), training hospital staff to screen 
patients for drug problems, and then find treatment programs for those 
they treated.
    ``Educational programs on drug and alcohol abuse and treatment such 
as the Science of Addiction were standing room only for many of the 
sessions for nurses and medical doctors,'' said Kami Anderson, director 
of the tri-county coalition. ``The ARMOT members were given offices in 
the hospital, participated in the hospital's orientation programs, and 
were given hospital identification badges, and were treated similarly 
to their employees. Stigma toward our patients started to subside. At 
the end of Year 2, the ARMOT team had 427 referrals. Of those 427 
referrals, 207 agreed to participate in a level of care assessment. Of 
the 207 patients assessed, 143 were admitted to drug and alcohol 
treatment, a 69 percent success rate if the patient agreed to the level 
of care assessment. Our overall access rate to treatment is 33.25 
percent, compared to 11 percent nationally.''
    I bring these up not because I'm intimately familiar with their 
details. Rather, as I travel and talk to folks, they seem to me to be 
geared toward bringing together people who hadn't worked together 
before, who are finding their energy and power in working and learning 
together.
    It's at these newly formed county task forces where I believe your 
support, moral and especially financial, would have great impact, for 
these groups are already hard at work on this. They just need that nod 
of encouragement, that extra budget to try some new things, or expand 
what they're trying.
    So don't be shy about getting to know them, learning their work. In 
my travels, the formations of these groups over really only the last 2 
years for the most part is one of the great and invigorating aspects to 
an otherwise pretty bleak panorama.
    Seems to me that what they're doing is essential in combating 
addiction to a class of drugs that thrives on our isolation and creates 
more of it.
                       Coroners/Medical Examiners
    I believe one reason this epidemic spread is that it started in 
states with too many counties:
    Ohio: 88 counties (pop. 11 million) Kentucky: 120 counties, (pop. 4 
million) West Virginia: 55 counties (pop. 1.8 million) Indiana: 92 
counties, (pop: 6.6 million) Tennessee: 95 counties, (pop. 6.5 million) 
Virginia: 95 counties, (pop. 8 million)
    Years ago, the worst of the crack epidemic was seen publicly: 
drive-by shootings, car jackings, gang graffiti and lines of street 
dealers. Public mayhem sparked public outrage, and media reports about 
crack remained constant for more than a decade.
    Addiction to opiate painkillers, however, has spawned little of 
that. Crime plunged as overdose deaths rose, in fact. Most of the 
victims were white and that further concealed the scourge. It spread 
through Appalachia, and if there's one part of the country that we're 
used to ignoring, it's Appalachia. Then it spread to the rest of white 
America--middle-and upper-middle class suburbs, rural towns. These 
families were aghast and ashamed. Their loved ones were now stealing, 
shooting up in library bathrooms, and dying with needles in their arms. 
So these families kept silent, hid it from public view.
    Thus, in the end, deaths--bodies--were this plague's only clear 
warning signs.
    Coroners' offices should have been where this problem was most 
clearly viewed. But these offices are funded by counties. In small 
counties, with depleted populations and withered tax bases, these 
offices were barely hanging on. These counties also had relatively few 
doctors who could do the job. Even in larger, wealthier counties, 
properly funding the Coroner is hardly a top priority.
    In some states, moreover, each county coroner is autonomous, 
answering to no state medical-examiner authority. In these states, 
especially, the quality of those investigations depends on a coroner's 
budget, time, fatigue, interest, and level of experience--all of which 
have been tested by the rising body count.
    The CDC estimates an undercounting of something like 20 to 25 
percent, due to problems with our death-investigation system, and 
largely because coroners offices are funded, or not, in such a 
disparate way, depending often on county tax base.
    This epidemic, seems to me, is calling us to find new, dependable 
funding for coroners offices. Americans need to clamor for it, to make 
it politically palatable.
    One idea that professionals have suggested is a HIDTA-like (High 
Intensity Drug Trafficking Area) model of Federal support for coroners 
and medical examiners, similar to what is available to law enforcement 
agencies in highly impacted drug areas. Medical examiners and coroners 
would get access to Federal funds in a block-grant style, the way law 
enforcement gets grants through the regional HIDTAs. This model would 
let the medical examiners in the most impacted areas determine, through 
an executive board, which initiatives would be most beneficial (funding 
for complete toxicology studies, funding for up-to-date data 
collection/sharing programs, etc.) in combating the opioid problem.
    Experts also tell me that Federal Government funding for the 
centralization of data management and analysis within the Coroner/ME 
system would be helpful. This would allow for sharing of data across 
county, even state lines, and thus identify early trends, emerging 
threats.
    Federal funding, they say, might allow smaller offices to afford 
the expensive machines that are now necessary in some autopsies, 
including new chemistry instrumentation for forensic toxicology.
    We face a serious lack of trained forensic pathologists. We have 
only some 500 nationwide, roughly half of what was believed necessary 
before this epidemic hammered the profession. New estimates are that 
we'll need 5700 nationwide by 2030.
    This year, the National Association of Medical Examiners believes, 
some 250 full-time Medical Examiners will be required to do handle 
nothing but the country's opioid-related deaths--estimated at about 
63,000 for 2017.
    Incentives to increase the forensic pathologist workforce could 
include student-loan forgiveness, J1 waivers for forensic pathologists, 
increased National Institute of Justice funding of forensic pathology 
fellowships, and the funding of fellowships by Health and Human 
Services. Federal funding might also help train paraprofessionals, 
physicians assistants and the like, who can easily do more routine 
autopsies, thus expanding capacity.
    ``Short of that,'' one told me, ``the feds need to fund the 
professionals, forensic pathologists, such that our salaries are 
competitive with private practice and help with capital investments 
such that the work environments are modern and not in the basement of 
some old building.''
    Speaking with forensic pathologists, they urge that the CDC be 
reorganized to create a new Office of Forensic Medicine. ``The DOJ 
should be reorganized to carve out the current Office of Investigative 
and Forensic Science from the National Institute of Justice (NIJ) and 
elevate a new Office of Forensic Science,'' said one pathologist. 
``These two new offices (the CDC OFM and the DOJ OFS) should work 
together. Formula grant support of medico-legal death investigation 
operations should be funded. CDC needs to expand efforts to mine the 
data in near real time of forensic toxicology testing.''
    The National Institute of Drug Abuse (NIDA), they suggest, might 
establish a multicenter network for studying novel drugs and their 
effects in humans needed to support permanent scheduling of these 
drugs, as well as to support interpretation of the drug levels and 
support prosecutions. These centers could also help train forensic 
toxicology doctoral students.
                               OBAMACARE
    I think we need to stop the attempts to dismantle Obamacare, and 
focus instead on improving it.
    I'm no expert in the functioning of Obamacare.
    But I can say that we need some non-employer, nationwide form of 
healthcare, as that part of our economy that involves freelancers--the 
so-called ``gig economy''--expands dramatically with the tech 
innovations that allow it. As a freelancer, I can say I feel this need 
acutely in my own life. Not to do so would risk blunting the huge 
increase in productivity that can be unleashed when these folks go 
independent, which they can do when working on their own, but only with 
some kind of independent health care.
    These attempts to dismantle Obamacare have only served to show how 
out of touch a lot of Congress is with this problem of opiate 
addiction. Obamacare allowed states to expand Medicaid, which allowed 
people to get coverage for drug treatment. Why would you dismantle the 
only thing standing between your most vulnerable constituents and the 
drug treatment they need and couldn't otherwise afford?
    From what I saw, nothing you proposed would have replaced what you 
were planning to dismantle.
    So I've been perplexed to watch these attempts over the last year.
    * * *
    These are a few ideas that I believe evidence from this epidemic 
shows are necessary.
    I would say again that they all require qualities in short supply: 
Patience and commitment for the long term.
    It's hard to suggest patience when so many people are dying.
    But this scourge is about issues far deeper than drug addiction.
    It's about isolation, hollowing out of small-town America and the 
middle class, of the silo-ization of our society, and it's about a 
culture that acts as if buying stuff is the path to happiness.
    This epidemic shows us no matter how high the stock market rises, 
how rich some Americans have grown, that neither we, nor they, can 
isolate ourselves from the world. Problems will find them, and us. 
Again, a holistic, community view is the only way--and the approach 
that will be prepare us for the next drug crisis.
    I believe therefore that the antidote to heroin is not naloxone. It 
is community.
    Community is the response to a scourge rooted in our own isolation.
    So I'm urging you to see this not only as the catastrophe that it 
is, but also as the gift that it can be.
    Just as chronic pain is best addressed with a holistic approach. 
Just as addiction recovery requires a community and not just a tab of 
Suboxone, and just as chronic pain is best treated with an array of 
techniques and strategies--so this problem overall, I believe, requires 
a community response.
    I hope you will think of what you can do to foment community in an 
era that discourages it. I suspect that it will require a lot more 
money and a focus that lasts a long time. It will also require 
sacrifice--from the American people above all.
    But it offers something even greater.
    It offers an opportunity to reinvest in areas that need it most. To 
include those Americans who have been left out, or left behind.
    To you, as public officials, above all, it offers a chance to 
inspire us, as Americans, to something great again. Thank you very 
much.
                               ADDENDUM:
    I'm taking the liberty to provide you links to stories/op-ed 
pieces/blogposts that I've written that are related to what I've 
mentioned above:

    Manny's Delivery Service: http://samquinones.com/reporters-blog/
2017/12/27/mannys-delivery-service-2/ (A well-put comment to this post 
is also worth reading.)
    Another Border Wall and Heroin:https://www.nytimes.com/2017/02/16/
opinion/sunday/why-trumps-wall-wont-keep-out-heroin.html
    Rethinking Jail: https://www.nytimes.com/2017/06/16/opinion/sunday/
opioid-epidemic-kentucky-jails.html
    Kaiser Permanente Reduces Opioid Prescribing: https://
www.theatlantic.com/health/archive/2017/03/california-doctors-opioids/
518931/
    Addiction Research and Economic Opportunity in the Ohio River 
region: http://www.kentucky.com/opinion/op-ed/article70835552.html
    Immigration: http://beta.latimes.com/opinion/op-ed/la-oe-quinones-
immigration-and-consumer-culutre-20170129-story.html
    Marijuana Legalization and Hyper-Potent Pot: http://www.sacbee.com/
opinion/california-forum/article96718922.html
    Donald Trump and Opiates in America: http://samquinones.com/
reporters-blog/2016/11/21/donald-trump-opiates-america/
                                 ______
                                 
                  [summary statement of sam quinones]
    Chairman Alexander, Sen. Murray, and Honorable Members of this 
Committee:
    I'd like to thank you for these hearings on our national epidemic 
of opiate addiction and for allowing me the honor of addressing you.
    I'm very happy to be here with my wife and daughter, who were part 
of producing Dreamland, and without whom the book could never have been 
finished.
    This is the deadliest drug scourge we've known. Hitting areas of 
the country that had never seen this kind of drug problem.
    It is the first in modern America to be spread not by mafias and 
street dealers, but by doctors overprescribing pain pills, convinced 
they were doing right by their patients. Urged on by the pharmaceutical 
industry, by the medical establishment, and, indeed, urged on by us, by 
American health consumers, who too often wanted a quick and easy end to 
pain.
    ISIS could not have dreamed of inciting the kind of torment and 
death that we have visited upon ourselves through this overuse of 
opiates.
    These drugs are the symbol for our era.
    For almost four decades we have exalted the private sector, the 
individual, while we ridiculed government as inefficient, incompetent 
and wasteful. We admired wealthy businesspeople, regardless of whether 
the way they made their money produced anything of value for our 
country and our communities. We wrought a second Gilded Age.
    This epidemic of addiction--to a class of drugs that thrives on 
isolation--reflects all that. This epidemic's costs have been borne by 
the public sector. All its profits are private.
    I believe this scourge is about issues far deeper than drug 
addiction. It's about the effects of this cultural shift. It's also 
about isolation in areas rich and poor, about the hollowing out of 
small-town America and the middle class, and of the silo-ization of our 
society. It's about a culture that acts as if buying stuff is the path 
to happiness.
    I believe we got into this because we believed problems could be 
attacked in isolation, with one magical Silver Bullet. A pill for all 
our pain. A jail cell for every addict.
    As we exalted the private and mocked the public and the communal, 
we rid ourselves of things so essential to us that they have no price. 
We have been invaded by cheap junk.
    We dug up Dreamland pool and replaced it with a strip mall. Did 
things like that across America for years now.
    Heroin is what you get when you destroy Dreamland.
    Isolation is heroin's natural habitat. This epidemic is calling on 
us to revert these decades of isolation and come together.
    I believe more strongly than ever that the antidote to heroin is 
not naloxone. It is community. People coming together and working, in 
small and local ways, toward solutions. No one saving the world alone.
    The good news, in fact, is that there is no solution. There are 
many solutions, each small, each must be tinkered with, some discarded. 
Each must be funded, fully and for a long time.
    But none of them is sexy; not one will do the trick alone.
    I believe that communities are finding those solutions the more 
they band together, leverage all that talent and energy, bring in PTAs, 
pastors, artists, athletes, recovering addicts and primary care docs, 
librarians and Chambers of Commerce. The more cops and public health 
nurses go out for a beer, and bridge the cultural chasm between them.
    This is happening--in counties across America.
    * * *
    Supply has ignited all this. We did not have this demand, this 
widespread addiction, until we unleashed a large supply of powerful 
legal narcotic painkillers on the public for the last two decades.
    Thus doctors must reassess how, and to whom, and in what quantity, 
they prescribe these drugs.
    That does not mean just cutting off people on high doses of these 
drugs, and leaving them to fend for themselves.
    It does mean lobbying insurance companies to reimburse for pain 
strategies that do not involve narcotics. Allowing doctors a wider 
array of pain strategies than simply pain pills.
    Young docs need more education in pain and addiction treatment.
    * * *
    I have to say I think it's delusional to spend time and money on 
yet another wall along the U.S.-Mexico border hoping that this will 
staunch the supply of heroin and fentanyl. These drugs are coming in 
through areas with walls.
    I believe a wall will corrode the only thing that will truly help 
stop these drugs from flowing into our country: a deep, respectful, but 
also forthright and honest, relationship with Mexico that will lead to 
it finally become the kind of neighbor and partner we can work with 
effectively.
    Another wall, seems to me, is just like heroin: feels good for a 
moment, but will leave us in a worse place in the long run. Another 
Silver Bullet for a complicated adult problem.
    Sometimes the solutions are about the mundane mechanics of 
governing. We should find, for example, new ways of funding coroners 
offices, and expanding our national force of forensic pathologists, 
which is dwindling. This epidemic spread because so many of them are 
poorly funded.
    We must expand treatment options. One place to do this is, 
crucially, jail. Consider how the country will be helped by 
transforming jail into a place of nurturing recovery, an asset instead 
of a liability. This is happening.
    I'd like to add that all across America are families who are 
suffering due to the addiction of a loved one, or the loss of that 
loved one. I believe they are a raw material to be marshaled, harnessed 
in this fight. Many now want to be involved, need to be involved to 
help salve the lacerating wounds that will last a lifetime. I believe 
you as Senators can help this, by recruiting them, recognizing them, 
giving them platforms from which to tell their stories. Maybe it's 
because I'm a reporter, but I believe that through their stories the 
awful stigma of addiction will be reduced.
    I'm happy to elaborate on any of this.
    Before I do that, though, I want to urge you to view this as an 
opportunity.
    An opportunity to revive those regions hammered by globalization 
and free trade.
    The roots of our national epidemic of narcotic addiction lie there, 
while the epidemic itself, in turn, stands in the way of their revival. 
Many cannot revive until enough of their people can pass a drug test to 
fill new jobs.
    As politicians, your natural response to a crisis like this is to 
look about for things you can do quickly, to show constituents you're 
taking action.
    I would caution, however, against believing in short-term 
responses.
    CARA and the CURES Act make up a good start--thank you for them--
but they are only a start.
    Everything I've learned about this issue has taught me the 
importance of long-term, community responses.
    American history offers two templates for action from which you 
might take guidance and inspiration.
    The Marshall Plan to rebuild Europe after World War II, and our 
space program.
    Each involved government and the private sector, acting in concert 
over many years--bringing money, brains, energy, and long-term focus to 
bear.
    Each achieved an unalloyed good for our country--though they were 
about doing things that seemed, on first blush, far beyond our own 
short-term interest.
    The Marshall Plan was about building up ravaged regions to allow 
them to function independently, while containing the viral spread of 
Soviet communism. It allowed reborn countries to prosper and contribute 
to the world again.
    A Marshall Plan for American Recovery might focus on rebuilding 
those regions that have been caught in dependence on dope and ravaged 
by economic devastation to contain the viral spread of addiction.
    Through our space program, we were inspired to spend years and 
dollars, bringing together smart people--all to achieve something no 
previous generation thought possible. We ended up far beyond the moon.
    The spillover in economic benefit, increase in knowledge, and in 
simple human inspiration is beyond calculation.
    Seems like we might profitably apply these examples--the Marshall 
Plan and the space program--to the regions of forgotten Americans where 
this problem began. Let's do it not because it is easy, but as JFK 
said, ``because it is hard.'' Because that's what Americans have always 
done at their greatest.
    Like our space program, I believe such an effort will have to last 
for years to be effective, focus far beyond the immediate goal of drug 
addiction, and on the more profound problems of community destruction 
and the hollowing out of stretches of this country.
    Thus I'm urging you to see this not only as the catastrophe that it 
is, but also as the gift that it can be.
    It offers an opportunity to reinvest in areas that need it most. A 
chance to inspire us as Americans to something great again.
    It's an opportunity to bridge the political polarization that so 
gnaws at our country--one of the few issues that can do that.
    Do not miss this opportunity. It does not come around often.
    I suspect this is the reason you got into public service. You are 
lucky to be here when it has.
    You will be remembered for acting when acting was not easy to do.
    Your hometowns will thank you.
    Your counties will thank you.
    We, your countrymen and women, will thank you long after you're 
gone.
                                 ______
                                 
    The Chairman. Thank you, Mr. Quinones.
    We'll begin now to have 5-minute rounds of questions. I'll 
say to Senators I'm going to try to stick to the 5-minutes 
because we have lots of Senators who want to ask questions, and 
I'll be glad to stay for a second round of questions if any 
Senators would like to.
    Senator Paul.
    Senator Paul. Mr. Quinones, thanks for coming. The book was 
great, and I think----
    Mr. Quinones. My pleasure.
    Senator Paul ----when you write a book, you're not sure how 
many will read it, but you're also not sure how much public 
policy effect it will have. But I can see copies around the 
desk, and I would say half or more of our Committee have read 
your book probably, at least. It's having some effect on the 
public policy, and that's why you're here.
    As I read the book, I was reminded when I was a kid, I used 
to visit my grandparents in Pittsburgh, and there's a big pool 
like Dreamland. It's 100 yards long, built around the same 
time, probably in the 1930's, and an amazing pool--100 yards 
long with the slides in the center, and so you can see how the 
community was surrounding that pool and the activities.
    As I read through the book, and we try to think what we can 
do better or change, the idea that Big Pharma lied and 
committed fraud is a part of the book and a part of the 
problem. They were punished, but we need to make sure that 
people cannot lie and that it is fraud and that it's punished 
and it is preempted in some way. Some of that can be Federal. 
Some of that could be state law.
    As a physician, I continue to become more and more alarmed 
that our profession was part of the problem, and we've tried to 
fix it. In Kentucky, we've done a lot of things. We monitor, 
and you can type into the computer a patient's name and find 
out if they're seeking different doctors, or have they gotten 
opioids somewhere else 2 days before. We have gotten rid of the 
bad doctors, the doctors you mentioned up south of Portsmouth, 
you know. They're mostly gone. The pill mills are no longer in 
Kentucky, and yet we have a county up in the mountains that has 
21,000 people last year that had 2.8 million doses of 
hydrocodone and oxycodone. This is after all of the stuff.
    So all of the stuff--everybody knows it's a problem. 
Everybody knows more people are dying than are dying from car 
accidents, that it is a horrible problem, and it was worse last 
year in this county. They prescribed more. And, in fact, since 
Medicaid expansion, it's an 11 percent increase.
    So when we look at what we do, we say, ``Well, let's have a 
Marshall Plan or let's spend more money.'' We have to think 
about how we spend it and what we do, because we want more 
people to have healthcare, so we expanded Medicaid. If you look 
at the expansion of Medicaid and you put that map overlaying 
the United States, you have an overlay of the heroin problem 
and the opioid problem, and it's related to poverty and the 
expansion of healthcare.
    So in your book, you talk about, well, you can get--for $3, 
you can go--you don't have to pay $200 to go--now you pay $3 a 
month, and you can get it and trade it and all of that that 
came. So we do have to figure out more rules on this. We have 
some new rules in Kentucky on acute management, but I think the 
hard part is the chronic. So if I'm your physician, and you've 
been on it forever for low back pain, how do I get you off of 
it, and how do I get you to keep coming to me? Or would you 
just choose another doctor if I take you off of it?
    So I guess that's the problem, and the question is: We all 
know the knowledge. People have read your book. We know there's 
a problem out there and we've done some changes, and yet we 
still have this enormous prescription opioid problem. So what 
do you think we do beyond that? I agree with you that 
community--more local than Federal is probably better and it's 
a local response. But we still--how do we fix the medical 
aspect of this? How do we go a step beyond where we are?
    Mr. Quinones. Well, I mean, there's a lot--that's a massive 
question, and I think there are smarter people than I who might 
also contribute to it. I think one of the reasons that you find 
that kind of correlation between heroin overdose and Medicaid 
expansion is because more access to medical care means more 
access to pills. We still have not changed, really, the basic 
culture, and one of the reasons of doctors to prescribe pills 
as a solution.
    So it seems to me that crucial in all this is that we get 
back to what we were doing in the 1970's, and that is where 
insurance companies were reimbursing a wide array of strategies 
for pain. They have cut back significantly in many areas, I 
think, that for one time I think it was all across the country. 
Some insurance companies are stepping up a little bit more.
    But, to me, it gets back to what the doctor has available 
to him or her in the appointment, at the point of contact with 
the patient. To me, that feels like a crucial step. Every place 
I go to speak on this topic, I run into doctors who tell me 
that they just don't have much in the way of other options to 
provide.
    Senator Paul. I guess the hard part of this is, like, I 
live in a county where we have 4 percent unemployment, and the 
employers come to me and say, ``We can't find enough workers 
who are drug free and have a work ethic.'' There's not enough 
workers. Then I have counties where 30 percent of the people 
don't work, and 30 percent of the people are disabled, whereas 
in my county, 4 percent of the people are disabled.
    So the problem is we all have big hearts, and people say, 
``Well, let's help the disabled. Let's help the unemployed,'' 
and we give them stuff. But perhaps once you become a non-
worker, a permanent non-worker, we get you into this cycle 
where it's much more difficult to avoid addiction.
    Mr. Quinones. Oh, I agree.
    Senator Paul. So we have to figure out how to do it with 
both a heart and a brain, where we have work requirements and 
where you're only temporarily disabled until you're back in the 
workforce. So it might involve money, but we do have to be 
careful about how we do it, such that they don't have perverse 
incentives.
    Thank you.
    The Chairman. Thank you, Senator Paul.
    Mr. Quinones, you can see the little time clock we have on 
these Senators, because everybody will be very interested in 
having long conversations with you. So we're going to try to 
wrap each segment up in 5 minutes, and then we'll keep going as 
long as we can.
    Mr. Quinones. All right, then.
    The Chairman. Senator Murray.
    Senator Murray. Thank you, Mr. Chairman.
    Thank you very much for your compelling testimony and 
thoughts. Specifically here, I wanted to talk about the Federal 
Government. We play a very critical role in preventing and 
tracking and solving this epidemic and in some areas have truly 
unmatched capacity and reach to be able to affect broad change.
    One example is the Centers for Disease Control and 
Prevention. They provide funding today to 45 states and 
Washington, DC. They support prescription drug monitoring 
programs, are invested in running a much needed public 
awareness campaign, and manage a critical national surveillance 
program, which is the only surveillance program to capture non-
fatal overdoses as well as fatal overdoses, and it uses some 
innovative ways to get timelier data.
    That public awareness program actually started under the 
Obama administration back in 2016 to raise awareness of the 
opioid crisis and is funding states to actually personalize and 
disseminate this messaging. This administration has repeatedly 
requested cuts to CDC's budget.
    So I wanted to ask you--you have mentioned in your writing 
that we need quality data collection in raising awareness in 
communities. Can you share your thoughts on the necessity for 
continued robust funding for programs like that in CDC?
    Mr. Quinones. Yes. I would suggest that the evidence shows 
it is probably a good idea. I would also say that I think we 
need to greatly expand the amount of money we provide for 
research about addiction as well as pain management or pain 
treatment.
    All of this is part of all these many solutions, and when I 
talk about the Federal Government's role in all this, it is in 
no way to suggest that it has a dominant role or that--I 
believe the important stuff is going on very often at the local 
level, and the role of the Federal Government might well be to 
just simply facilitate, make easier their lives. I think CDC 
has a number of proposals and programs that I think are 
extraordinarily effective.
    I would say that when I was doing this book, I found almost 
nobody who wanted to talk about this except for government 
workers. This was the first line of defense in this. When 
nobody really knew about this topic, when nobody really cared, 
when I thought I'd bitten off an enormous contract to write a 
book and put my family at jeopardy for a story that no one 
cared about, the people who really did care, who were working 
on this from the beginning--cops, coroners, CDC, DEA, 
prosecutors, public health nurses, all of whom were gaining--
earning a government salary, many of whom were at the local 
level. Of course, CDC is not that.
    But I believe that the folks at CDC do remarkable stuff. In 
fact, I was a crime reporter. I am a crime reporter and did not 
write a word about healthcare until I wrote this book, and my 
overall feeling is one of awe for our public health folks. 
Honestly, they have done amazing work in the face of almost 
rare thanks. I would put it that way.
    Senator Murray. I also want to ask you--you've written 
about the importance of Medicaid expansion to make sure 
patients get medication-assisted treatment, key to responding 
to part of this very complex crisis. In fact, Medicaid 
expansion allowed about 1.6 million previously uninsured people 
with substance use disorder to get the healthcare and the 
treatment for mental and health that they need to fix this.
    Can you talk a little bit about the importance of Medicaid 
in making sure individuals with opioid----
    Mr. Quinones. Well, Medicaid expansion provided drug 
treatment for people who did not have it, hundreds of thousands 
of people in different states. It's extraordinarily important, 
I think. I know people in different communities who have been 
enormously helped by this. I don't want to downplay, though, 
what Senator Paul was talking about, which is that you do have 
increases in overdose when that happens, and I think one reason 
for that--my hunch is that in too many communities, pills are 
still the only medical treatment that's----
    Senator Murray. An important part of that is also the 
mental health support and everything else that Medicaid brings.
    Mr. Quinones. Of course. When you get more access to 
healthcare, there are other things that come along with it, and 
I think one thing that does come along with it is a reliance 
still to this day on these pills. We have dropped our 
prescribing, but it's still at about 2006 levels and almost 
triple what it was in the late 1990's. To me, that means that 
we probably still rely far too much on these.
    That said, of course, I do not understand the impulse to 
strip away Medicaid expansion, particularly in areas where this 
problem is so intensively felt. To me, it feels like these are 
regions that desperately need the services that they've been 
provided through Medicaid expansion, drug treatment being 
primary among them.
    Senator Murray. Thank you.
    The Chairman. Thank you, Senator Murray.
    Senator Collins.
    Senator Collins. Thank you.
    First of all, let me thank you for writing such an 
important book that offers us possibilities. What has been 
discouraging to me is despite much greater public awareness and 
much more money and much greater intentions that the problem 
does not seem to be getting much better. One possible 
community-based approach was described in the Morning Sentinel, 
a paper in Waterville, Maine, and it struck a chord with me 
because law enforcement officials in my state tell me that 
their jail intake rooms resemble hospital emergency rooms.
    So what some police departments in Maine--including in 
Waterville and Scarborough and other areas--are doing is they 
are telling addicts that if they come in with their drugs and 
turn them in that they will place them in treatment facilities. 
This is a whole different approach for law enforcement to 
take--rather than locking people up, helping them to get the 
help that they need. It's also very community-based, as you 
have suggested in your book.
    In your experience, have you seen that type of program work 
better than the traditional approach?
    Mr. Quinones. A couple of things I'd say. First of all, in 
reference to your first point, Senator Collins, I think we need 
to keep in mind that we've been--this problem has been 
festering for 20-plus years. People come to me all the time--
why isn't the--I'm like, ``It's been going on for 20 years. 
We've been at this for a year and a half or 2 years.'' It seems 
to me that as a culture we need to learn patience and to not 
believe in silver bullet answers to mysterious problems like 
the mysteries of human pain. Those are complicated things.
    So if we have not solved this problem in the last year and 
a half to 2 years, I would say, well, yes, of course not. We 
just need to keep working at it. It's not--these things exist 
because it took a long time for these things to exist.
    Now, with regard to law enforcement, I'd say, in general, 
some of the most innovative folks and innovative things I've 
seen come from law enforcement. You'd think not. You'd think 
that law enforcement would be holding onto the old ways of 
locking people--no. I've been amazed to see the remarkably 
innovative ideas that are coming out of law enforcement. The 
one you mentioned is one of them.
    The one that I mentioned in my written testimony is about 
the transformation of jail. I believe if we come out of this 
with a new kind of jail, a new way that jail is run, as you 
see, actually, in the State of Kentucky--two dozen jails doing 
this--that would be an enormous advance. And, what's more, jail 
would then be an asset, again, and not a liability. Today, jail 
is a liability. It's a place where you take people who, once 
they've detoxed, want to see clearly the records of their own 
lives and want to change, and then we put them in a place that 
is tedious, predatory, ganged up, sexual stuff going on, all 
that kind of baloney.
    The pods that I've seen in certain jails--and one, in 
particular, in Kentucky--are a remarkable change, one of 
nurturing, one of coming together. It's where you're working on 
your recovery from the moment you get up at 8 o'clock in the 
morning and make your bed military style until 11 o'clock or 
whenever lights go out. That kind of change in jail would be 
enormous. As I said in my testimony, I tried to highlight 
things that I thought would not just be beneficial to this 
problem, but for the next drug problem as well, so we're not 
playing whack-a-mole with this stuff.
    So I believe jail, in fact, is one of the great places of 
effervescence, you might say, when it comes to this epidemic, 
and the way new ideas are being tried is in jail. I've never 
been to Maine, but it sounds like what you're highlighting is 
one of those. I do believe it's an essential part of this, that 
if we come out with jail the way we always have used to run 
jail, then we will not really have advanced. The next problem 
will hit us, and we'll wonder why we're not making greater 
advances. My feeling is changing jail is the way it's 
happening. It's not just a revolutionary idea. This is an--you 
can find various examples of this around the country, and it's 
very invigorating to see it.
    Senator Collins. Thank you.
    The Chairman. Thank you, Senator Collins.
    Senator Casey.
    Senator Casey. Thank you, Mr. Chairman.
    Mr. Quinones, thank you for your testimony and for your 
work on these issues.
    Mr. Quinones. My pleasure.
    Senator Casey. I wanted to start with some of the realities 
that, at least, I see in a state like Pennsylvania. We've had, 
last year, the last count in 2016, 4,624 overdose deaths. 
That's up 37 percent from the prior year, 2015, and in rural 
areas, higher, almost 10 percentage points higher by way of 
percentage of an increase. That's overdose deaths overall, 
obviously a lot of that being driven by the opioid crisis--
epidemic, really.
    What I see--and I missed some of your testimony going back 
and forth between hearings. But what I see in Pennsylvania is a 
tremendous resource gap. When we went across--when I went 
across Pennsylvania the last year, especially this past summer, 
we would have meetings with county officials, often in small 
rural counties, small town counties, where you have kind of a 
group of people coming together. You have the mayor of a small 
town and the police chief and the coroner and the medical 
professionals, the treatment professionals, all around the 
table, meeting all the time, every week, because the dead 
bodies keep coming in.
    One county, a very small county, said to us--maybe the most 
graphic metric was they didn't have enough places to put 
bodies. That's how bad it was.
    So it's everywhere, but what I keep hearing from folks at 
the local level is, ``We need more resources. We're getting our 
arms around this. We're dealing with it as a local community, 
but we need more resources.'' They certainly need it for 
community health workers, social workers--law enforcement, 
obviously, is bearing a lot of the burden--pathologists and 
otherwise.
    So I guess the first question I'd ask you is what 
recommendations do you have for closing that resource gap, 
which I think is a--even though the Federal Government has made 
some strides, as you note, with Cures and with CARA, what's 
your sense of the ways the Federal Government can provide more 
resources?
    Mr. Quinones. Well, in speaking with people in the county--
this is one of the great places in America where this is taking 
place. Counties are the level of government most affected, 
right? It's coroners, jails, libraries, public health, sheriff, 
et cetera, courts. So I've been struck, particularly in the 
last year, year and a half, to watch these very organic task 
forces or committees or what have you--whatever you call them--
sprout up in county after county.
    In fact, in Pennsylvania, I know I was in Lycoming County, 
which is--it's the home of Williamsport where they hold the 
Little League World Series. I spoke with those folks at some 
length. Yes, these folks are coming together in very healthy 
ways, it seems to me. They are leveraging a lot--there's a 
whole bunch of people on that committee in Lycoming. There's 
recovering addicts, primary care docs, I mean, a lot of 
different folks.
    Speaking with the president there recently, she said, ``You 
know, one of the problems is we cannot find--we can find money 
for programming, for naloxone, for whatever. We can't find 
money for the nuts and bolts that make it work, like office 
space and telephones,'' that kind of stuff that is as essential 
if not as sexy as the other stuff.
    To me, I think that's where the Federal Government needs to 
step up, and I would say again, as I said in my testimony, that 
CARA and the Cures Act--that's wonderful. Thank you. But do not 
think that that--we've been doing this for 20 years, 
overprescribing, creating addiction unintentionally for 20 
years. One year, $1 billion--it's a lot of money in some sense, 
but in comparison to what the country needs--it's in every 
state in America. There's an unprecedented problem, because 
it's in every state in America, coast to coast.
    So this is--what I'm suggesting is that the evidence shows 
that there's a need for sustained--I'm talking years worth--
sustained investment in, I think--thinking in terms of, for 
example, this more mundane idea of how to let their job be 
easier. Well, fund the office space, fund the telephones, that 
kind of thing. And, again, we could talk later if you like 
about the issue of coroners. But, to me, that's a crucial part 
of this as well.
    So I think--I know it feels like a lot of money--a billion 
dollars. It is a lot of money, but not compared to the breadth 
and depth and length of time of this problem. It seems to me 
that this needs to go for some time now.
    Senator Casey. Well, thank you for that, and I know we're 
out of time. I actually introduced a bill to commit $45 billion 
over 10 years, so roughly $4.5 billion a year. I borrowed the 
idea from, of all places, the Republican version of the repeal 
of ACA, where they were setting up a separate fund. So I just 
took what I thought was a good idea and made it into a 
different bill. We're hoping that we can get support that will 
be bipartisan. But we appreciate your testimony and your 
commitment to these issues.
    Mr. Quinones. My pleasure. Thank you for having me.
    The Chairman. Thank you, Senator Casey.
    Senator Young.
    Senator Young. Mr. Quinones, thanks for being here today. 
Thank you so much for writing this important book, and I 
appreciate your visit to Zionsville, Indiana, to visit with us 
last week.
    I'd like to discuss our children. Thousands of children 
across my state and really around the country are having their 
lives turned upside down on account of this epidemic, not 
because they are addicts, per se, but because they're being 
removed from the home. Their parents have become addicted. 
They're entering an already overwhelmed foster care system.
    You've identified in your book a need for more services for 
families. Can you elaborate on what, specifically--what sort of 
either programmatic needs there are for families or resources 
in your experience that might help mitigate this crisis?
    Mr. Quinones. Well, I think--honestly, as a reporter, I 
would like to say that probably you'd be best off talking to 
people who work in that field. I do think one of the areas 
that's just been devastating is foster care, though. I mean, my 
goodness, there's so much need now. If it weren't for 
grandparents in America today, it would be just mind boggling 
to think of what the need would be. I mean, seriously, so many 
kids are living with their grandparents now because their mom 
and dad are gone or they're in prison or what have you.
    So my feeling, just on a very blunt basic kind of macro 
level, is that we need to look at how to fund more foster care. 
How to do foster care better is most likely another great 
question, but it's not one I feel I can answer.
    Senator Young. Well, I think your larger point about the 
solution, if you will, to this broader epidemic is hundreds, 
thousands of individual solutions, and, collectively, many of 
them fall under the banner of community.
    Mr. Quinones. Absolutely.
    Senator Young. If we can persuade individuals that a fellow 
human being's plight, a fellow child's hard luck, is actually 
their own plight, then we can entice more people to be foster 
parents, to care for these children, to lobby on their behalf 
and so forth. So I think that's a good overall message that 
I've taken away from your book.
    We've already discussed jails, and in your book you 
highlight some jails that offer rehabilitation services, and, 
peculiarly, in those areas, you have people putting themselves 
into the criminal justice system just so they can get 
assistance, or you have the relatives or friends doing so. I'd 
like to sort of discuss a different sort of setting.
    I've visited with jails. I used to represent in the House 
of Representatives, Austin, Indiana.
    Mr. Quinones. I've been there.
    Senator Young. You know that name, because we have a huge 
HIV outbreak there on account of the intravenous use of an 
opioid by the name of Opana. Many local sheriffs in communities 
like that around Indiana have a strong suspicion, because I've 
spoken with them, that their inmates have either HIV or Hep-C 
or something else that they might typically test for.
    But they have a moral dilemma. They're on the horns of a 
dilemma because if they test these individuals, they are 
legally on the hook to provide medical services to them, and in 
a place like, say, Scott County, Indiana, that would deplete 
their entire law enforcement budget for a year if many of them 
tested positive.
    Now, look, I'm not asking you be a magician here. But, No. 
1, have you encountered this dilemma, and if yes, do you have 
any thoughts about how we----
    Mr. Quinones. I honestly, Senator, have not. I don't doubt 
it exists. I mean, nothing surprises me anymore about this 
topic, I have to say, but I don't doubt it exists. You know, 
all I can say is that this seems to be the nature of this 
problem, that we are asking, well, in one case, foster care, 
but in another case that you just mentioned, jailors to be, 
again, the magicians, to figure out this deep social problem 
that I don't think they have an answer for--they do not have an 
answer for, nor do they have the funding for.
    What they go about doing--sometimes I'm a reporter. 
Sometimes I just have to say, I mean, I don't know. Honestly, 
sometimes it gets to that point where I'm just kind of 
overwhelmed by all the ways that this problem manifests itself. 
I do believe locally is the place where we find the solutions, 
but that you all have an absolute role in facilitating, making 
sure that they have the resources they need, because on the 
ground, I have to say the counties, the people in those 
counties that I've been to, are working hard and working very 
imaginatively.
    So you going to them and finding out what they need, to me, 
seems to be the way we proceed on this. I don't believe that--I 
do not believe most of these solutions are many from 
Washington, DC. I do believe, absolutely, Federal Government 
has a profound role in helping those solutions and facilitating 
those solutions.
    Senator Young. I agree. Thank you.
    The Chairman. Thank you, Senator Young.
    Senator Bennet.
    Senator Bennet. Thank you, Mr. Chairman. I very much 
appreciate you having this hearing.
    Sam, it's nice to see you again. Thank you.
    Mr. Quinones. You too, Senator.
    Senator Bennet. Your book is one of the most compelling 
pieces of nonfiction I've read in a long, long time, and it's 
very, very depressing. The story you tell about something we 
haven't really talked about, which is the heroin epidemic that 
rode on the back of the prescription drug--I mean, you just 
tell it brilliantly, and my reaction when reading it was this 
was all happening in plain sight, but somehow we missed it.
    Today, 42,000 people a year are dying from this. The White 
House estimated that this is costing the United States economy 
$504 billion a year. So a billion dollars is a lot of money, 
but it's .2 percent, what it's costing our economy. And the 
rural counties in my state--now, this isn't just about rural 
counties anymore, but the rural counties in my state, where you 
go and the sheriff tells you that 92 percent of the people he's 
admitting into his jail are testing positive for heroin, or the 
jailor who opens up his jail and takes you to the back and 
opens the window and says, ``Look, look,'' and you say, ``Well, 
what are you showing me?'' ``There are women in my jail. I've 
never had women in my jail,'' and they have two jail cells 
full, and we're spending .2 percent on treatment, targeted 
treatment.
    So I'm all--as a former local person--all about people in 
the local community. But they can't do it without resources, 
and in the rural counties that I go to, if anything, they have 
less access today to addiction treatment than they did 10 years 
ago. So it strikes me that we're moving in the wrong direction. 
I wonder whether you'd want to comment on that.
    Mr. Quinones. Well, there's a lot to comment on. One of the 
problems is that with our opiate--with our overprescribing of 
these pills, we, in time, created legions of addicts, and that, 
in turn, awakened the vast logistics potential of the Mexican 
drug trafficking culture, which I lived in Mexico 10 years and 
know fairly well.
    Most traffickers never really cared to traffic heroin. It's 
viewed as a pretty disgusting drug, and people are far more 
enamored with meth and coke and stuff. So they didn't really 
traffic heroin, or they didn't really want to get involved in 
it too much until we began to--and now, of course, their profit 
motivation is that that radar is at a very high level, and they 
want to get involved in that, and it's exploded the numbers of 
people who are trafficking it, I think, from Mexico and 
elsewhere. So that's one thing.
    As I said before, I believe that the community solutions--
community is where it seems to me that I have seen people 
working hard and coming up with solutions appropriate to their 
counties and their regions. I do not believe that they can 
continue long-term without a whole lot more help and sustained, 
as I said, long-term focus from the Federal Government. I 
believe that a lot of folks are looking to the Federal 
Government, Republican and Democrat, right wing and left wing, 
in this fight for sustained help, not one off kind of idea.
    Senator Bennet. Could you also say a word about--you 
mentioned it very briefly earlier--about the ways in which 
health insurance reimbursement create challenges for the work 
at the local level that people are trying to do? What are you 
writing about the inability of people to get low-cost social 
work, for example, reimbursed as opposed to pills, which----
    Mr. Quinones. Right. Initially, in pain management--for 
many years, pain management was to take one individual and 
design over a period of time in close connection, the patient 
and the doctor together--design a menu of strategies that would 
help this one individual. So one individual, many, many, many 
strategies--marital counseling, diet, acupuncture, on and on 
like that--physical therapy, et cetera, social--job therapy.
    As we began to believe that one pill--one kind of pill or 
drug would be the solution to all pain, insurance companies 
dropped a lot of that, and you couldn't really design the full 
panoply of strategies--a doctor could not--because you were no 
longer getting reimbursed for a lot of that. To me, I think 
that's fundamental in this whole problem.
    Doctors need to be more educated, but when they get 
educated, they also need to have the tools. And doctors were 
told, ``There's a pain epidemic in this country,'' and, 
increasingly, through the 1990's and the 2000's, they were left 
with one tool, and that's a big reason why we got into this.
    So my belief, strongly--and this comes from talking with 
lots of doctors about their dilemmas--is that they need more 
solutions in that moment when they're meeting with the--and 
some places are doing it. By the way, the VA--hats off to them, 
I think. They started us--they were a leader into all this, and 
now they've done a U-turn, and I think you can get yoga, 
acupuncture, et cetera, as well as some dose of opioid pain 
killers, not to say that these drugs have no use. They are 
absolutely useful in certain windows. So I think we are seeing 
these kinds of changes.
    It seems to me that the reimbursement for different kinds 
of pain strategies is just like a fundamental part of this.
    Senator Bennet. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Bennet.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Mr. Quinones, welcome, and thank you for your leadership on 
this issue and really raising that level of awareness. As you 
point out, this has been out there for a while. But I think my 
colleague just mentioned it's been growing in plain sight here, 
and thank you for acknowledging that there is no one silver 
bullet. I think you said it's a complicated--no silver bullet 
for a complicated adult problem.
    Yet we all know, as has been mentioned, it's not just an 
adult problem. Our children are dying of overdoses. Our 
children are suffering because the parents are checked out.
    I went to a senior center. I was sitting with a group of 
primarily senior ladies, and I said, ``Well, if I weren't here 
having lunch with you today, what would you be talking about?'' 
And they looked around, and they said, ``Where we would find 
services for our grandkids, because all of us, all of us, are 
taking care of our grandkids because our kids are either in 
jail, have given up the kids, or whatever.'' So this is truly a 
problem that consumes all ages, all spectrums, all classes.
    I'm interested in your suggestion that we need to look at 
this from a very, very broad perspective and really strive 
high--a Marshall Plan, follow the same lines of the space 
program.
    Mr. Quinones. Yes.
    Senator Murkowski. The problem that I see with that is we 
are still suffocated, strangled, by the stigma that is 
attached. It seems like it's just been recently that you will 
see in the obituaries that there is an acknowledgment that this 
young person or this individual died from an overdose.
    But we have buried it because there's a sense of, ``Well, I 
failed as a parent if my kid died from a drug overdose.'' So 
until you can get beyond that stigma--I think are still so many 
that it's like, ``Well, those are the ones who just couldn't 
make it. Those are failures, losers,'' which is a horrible 
thing to say, and I even hate to say it in front of a 
microphone. But there is that stigma that is out there.
    So how do we get people galvanized to help and to be 
inspired to do something as big as--I agree with you. This 
needs to be in order to make that difference. Are we making 
headway in reducing the stigma?
    Mr. Quinones. Yes. A great question, Senator. Thanks for 
asking. I think, definitely, we are. I can tell you in 2013, I 
was writing this book, and I had a conversation with my wife. I 
said, ``You know, we're going to write this book. We're going 
to put it out and fulfill the contract. But the truth is it's 
going to die when it comes out, because nobody in this country 
cares about this problem.'' I could not find anybody to want to 
talk about it, except for a public health nurse, an occasional 
narcotics officer, or a judge.
    But everybody else--and the reason was--one of the main 
reasons was that parents or families were mortified, 
embarrassed. This is a different kind of problem than has 
existed in the past. People were mortified at what had happened 
to their children, and you never, ever saw an obituary that 
told the truth. It's like the AIDS thing early on, the AIDS 
issue. People were like, ``Well, he died of cancer.'' Well, in 
this case, it was, ``Well, he died at home of a heart attack at 
age 25.''
    Now, I believe that what is helping to change that--I think 
similar to say the gay marriage issue, which is a radical 
transformation in public attitudes in the last 10 years--is 
getting to know people who are actually affected by it. That's 
where I believe--I know you've heard a lot about how you need 
to provide more funding, but I do believe you have a public 
profile role as Senators. If you go to communities, find those 
parents, talk to them, point out the programs, meet with those 
county groups that are sprouting up all over the country--it's 
amazing to see this--and lend your own high public profile to 
them.
    Meet with parents and say, ``Thank you, tell us your 
story.'' Recruit them. I think, frequently, there's a lot of 
folks who would go along--would do that if they were asked, if 
they were pled with--please do this. And as I said in my 
testimony--maybe it's because I'm a reporter--but I believe in 
the enduring power of story to change people's minds. We have, 
as human beings, from the prehistoric times until today, always 
needed stories to help us understand. The only people--and the 
reason this was not very well publicized years ago and hidden 
was because the people who could best tell the story didn't 
want to talk.
    Now, increasingly, they want to talk, and it's so important 
to embrace them, to bring them out of the shadows. They want 
to, many of them--some of them not yet, but maybe someday soon. 
And with that, my feeling is there's a horrible stigma, exactly 
as you say, and that one of the main ways we defeat that is 
through stories. I believe, as public officials, you all could 
have a magnificent role.
    Whenever you go home, whenever you go to some public event 
that may deal with this, find those parents, bring them out, 
have them talk a little bit about their lives, recruit them, 
give them a phone call saying, ``Hey, I heard this happened. We 
would love for you to tell your story. If you can't right now, 
fine.'' But just let them know we're here together. So many of 
them felt alone. They made horrible, bad mistakes because they 
thought there was nobody else nearby to--that they were all 
alone in this. I think defeating that isolation, again, is part 
of the many, many solutions, the things that have to be tried.
    Senator Murkowski. That's a great reminder to us that it's 
not just all resources, but that we can have that role, too.
    Mr. Quinones. Yes.
    Senator Murkowski. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski.
    We have several Senators remaining who want to ask 
questions. So I'm going to try to stick to that 5-minute----
    Mr. Quinones. Okay, my bad; I'm sorry.
    The Chairman ----if I may, just so we have time for 
everybody to be involved.
    Senator Murphy is next.
    Senator Murphy. Thank you very much, Mr. Chairman.
    You know, if one of us were to go down to the Senate floor 
and give a speech on loneliness, we would worry that we would 
come off sort of feeling or looking silly. And yet if you look 
at the map of the suicide epidemic in this country, the crisis 
is the worst where social isolation is the greatest. If you 
read Pete Earley's great book about the mental health crisis in 
this country, he comes to the conclusion that in the end, the 
only really effective treatment programs are the ones that 
build connectivity between people.
    You didn't title your book The Great American Heroin 
Epidemic. You titled it Dreamland, and you made your case in 
your opening comments, that this is really about 
connectiveness. But the story of Dreamland, that pool, is a 
complicated one. It was a private, low-cost, community pool 
that closed in part because of factors that were outside of 
government's control. People just had a lot more going on in 
their house. They had their own pools. They had more TV 
channels, and kids had lots of reasons to stay inside.
    Yet you are sort of--you hint at being critical about the 
decision by the government to let that pool close, because, 
theoretically, there were other options. They could have spent 
some taxpayer money in order to keep it open. They probably 
would have been criticized for throwing away money in a money-
losing effort. But the result might have been that a community 
asset stayed open.
    I guess--let me sort of take you from where you left off in 
your testimony. You focus your book on this question of 
building community, and we're really awkward when we try to 
address the ways in which government can build community and 
attack loneliness, because it sounds like something we're not 
supposed to do. Yet, at the heart, this is a critique that we 
should be thinking about those things.
    Just share with us your thoughts on how we can change maybe 
the way that we spend money, the way that we do public policy, 
to try to build communities rather than tear them down.
    Mr. Quinones. I think it's to--the best idea that I can 
come up with is to consult those people who are already working 
on that, and I think all across the country, that's happening. 
That's another thing that's changed, in an answer to Senator 
Murkowski, that we have now on the ground lots and lots of 
people working on this in a variety of ways.
    My feeling as a reporter is always to go there and ask 
them, but also understand that government has, it seems to me, 
an essential convening role by providing the infrastructure 
that does bring people together. That includes stop signs and 
good roads, by the way. I mean, that kind of thing, but also 
funding to provide the community centers and this kind of 
thing.
    I think you guys might talk more about that on the Senate 
floor, honestly. I think it's not a conversation that we have 
enough in this country, and you all might be the ones to 
perhaps lead it, honestly. I think we'd all be inspired if you 
did, seriously--my feeling, anyway, would be.
    How do you do that? I mean, I'm a reporter. I'm not sure I 
know all the ways. My impulse as a journalist is to go to those 
areas, talk to as many people as you can, and also highlight 
them. As, again, I was saying to Senator Murkowski, just find 
the people who are working hard. Find those community 
coalitions, those task forces, and your presence at one of 
their meetings would be huge, huge. Try that. Try doing that. 
It's a great idea. I mean, try to be there with these folks and 
understand and see.
    Will it be a PR event? Probably. Who cares? You want to 
highlight--these are the folks working--and from that kind of--
that's how innovation works, right? You've got--on the factory 
floor, you've got the factory worker, the supervisor, the 
computer software guy, the accountant. They're all putting 
their brains together and they're finding little incremental 
ways to make that product better, and that's--I think cities 
and towns work the same way. No magic bullet, no silver magic 
wand. Just slow incremental work.
    Senator Murphy. I just raised the question because if we're 
going to spend an awful lot of money on this epidemic, I think 
it's worth challenging us to think about the ways in which we 
can----
    Mr. Quinones. Oh, most definitely, and I'm not saying I 
have all the answers, either.
    Senator Murphy ----be in the community as well as paying 
for treatment, right?
    Mr. Quinones. Absolutely. No, I do believe in the overall--
if somebody asks me, ``Well, what are some of the details?'' I 
don't have a clue. I'm not--I'm just a guy, a reporter out 
there trying to understand this enormous country we have, and 
sometimes it's hard.
    Senator Murphy. Thanks, Mr. Chairman.
    The Chairman. Thank you, Senator Murphy.
    That's a pretty good description of the way we feel.
    Mr. Quinones. Yes, I bet you do. I don't blame you.
    The Chairman. I want to ask you about the Holy Grail, your 
chapter, ``Searching for the Holy Grail.'' What do you think 
about that? You don't pretend to be a medical expert, but why 
is it not a good idea to try to find non-addictive pain 
medicine?
    Mr. Quinones. You know, it's a strange thing. My friends 
from college would look askance when they hear me say this, but 
as I got into this story, I, for the first time in my life, 
began reading philosophy about how we create happiness as human 
beings, how we achieve--what is happiness? How do we--because 
it seems like all these people all across the country are 
looking to this substance in one form or another of opiates to 
be happy, at least for a few hours.
    It seems to me that--a few ways that I think the 
philosophers that I read talked about--working hard toward 
something that you are fulfilled by, that you are excited by, 
that you love to do, and along the way comes a fulfillment that 
we call----
    The Chairman. But if I may interrupt, in your book, you go 
through how, first, opiates were used to help people dying who 
were in horrible pain. Then it appeared that, erroneously, they 
might not be addictive, and so this whole revolutionary, as you 
describe it, way of making pain a vital sign came about. Then 
they turned out to be addictive. But just because opiates 
turned out to be addictive, is that a reason not to try to find 
other medicines that are non-addictive----
    Mr. Quinones. I would never stand in the way of----
    The Chairman ----for people who are in severe pain today, 
and the hundred million who have some pain?
    Mr. Quinones. Exactly, and I would never stand in the way 
of science. But I feel that in the long run, we are humans, and 
humans have never done well when they have it all, when they 
have all the pain treatment and none of the consequence. To 
me--this is a hunch. I'm not saying I know, and if 10 years 
from now, science has come up with a pill that reduces all pain 
to negligible amounts and does not addict anybody, I'd be 
thrilled and happy for those people who benefit, and I'd 
probably be one of the----
    The Chairman. Well, it sounds like with your general 
approach, you--and I don't want to put words in your mouth, but 
it sounds like you would suggest if that could be possible, 
that would be good if it were, but it might only be one 
strategy for dealing with a complicated----
    Mr. Quinones. I believe other strategies--given the fact 
that we are humans and need friction and tension in our lives 
to actually be productive and be happy, in fact, I believe that 
there are other things that need to happen in American culture. 
I believe as individuals--when I was writing this book, I 
stopped drinking sodas. I believe--I wanted to be the change 
that I wanted to see in the country, so I stopped eating food 
that I saw advertised on TV. I felt that it was important to do 
things that would reduce the chance that I would have of pain.
    I have no problem with research trying to find a pill that 
would be completely pain killing without any addiction. I just 
have a skepticism that in the long run it would be--that we 
would, as humans, be able to handle it, that some problem 
would--we behave very poorly. Kings, dictators, Hollywood 
producers apparently these days behave very poorly when they 
have no other friction in their lives, nobody to--no 
accountability.
    The Chairman. I mentioned earlier that yesterday, I dropped 
by the Governor's residence, and he had a meeting of all the 
people in the state and the universities who were in charge of 
training physicians with the goal of changing their attitudes 
toward prescribing of opiates. One of the health officials 
there said to me when I told them that I would be hearing from 
you today--said, ``Ask him about fentanyl and where it fits. So 
in 50 seconds, can you tell us about that?
    Mr. Quinones. Fentanyl has transformed the heroin market 
completely. It has democratized it. Used to be when heroin was 
in our country, we knew it came from four or five Mexican 
states. Now, it could come from Hungary, it could come from 
Nebraska, from Canada. It has made heroin dealers far more 
willing to kill people.
    Used to be for many years, you got--one way you got 
customers was by overdosing your clients. When someone 
overdosed, that was not a warning. That was an advertisement on 
the street. A lot of addicts ran to find that dope that just 
ODed that person or killed them.
    But that was very expensive to do. In heroin trafficking, 
what you want to do is cut. You want to reduce--because it gets 
you more volume. So you get a kilo, you cut it into two or 
three, and you sell that. But it's weaker--less chance of ODing 
people.
    So what fentanyl has done--has made it far, far cheaper to 
OD people and therefore create buzz around your product. It's a 
diabolical thing to describe. But that is the nature, it seems 
to me, of this world. Also, it has allowed many, many, many 
more people to get involved in this, and by the Dark Web--it's 
coming from Mexico, but it's also being sold on the Dark Web 
very prevalently, and that has allowed a lot of people now to 
get involved in selling it that probably never would have 
before.
    The Chairman. Thank you.
    Senator Hassan.
    Senator Hassan. Thank you, Mr. Chair and Ranking Member 
Murray, for holding this hearing.
    Thank you, Mr. Quinones, for being here and for your work. 
Just at the outset, I would say that some of the themes you've 
touched on today about community are also themes that the 
author and sociologist, Robert Putnam, has touched on in his 
book, Our Kids----
    Mr. Quinones. Absolutely, yes.
    Senator Hassan ----and I think your book and his together 
are really important.
    I want to just start by laying a little bit of groundwork. 
I was Governor of New Hampshire starting in January 2013. I'm 
also a Governor who worked with my Republican legislature to 
implement Medicaid expansion which was implemented in the 
middle of 2014 in August, I think. In 2013, we had 192 overdose 
deaths in New Hampshire, and in 2014, 326. We were on an upward 
trajectory, even before Medicaid expansion.
    In fact, one of the reasons we all came together to 
implement Medicaid expansion is because we had a crisis in our 
behavioral health and drug overdose deaths in our state, and we 
knew that Medicaid expansion would get more treatment to 
people. And my own anecdotal sense that Medicaid expansion did 
not, in fact, cause an increase in opioid deaths is reinforced 
by a recent article in Health Affairs. So I just want folks to 
have a sense of that. I think there may be a correlation here. 
But to suggest that there is a causation is very troubling to 
me and I also think speaks to some of the stigma issues that 
you've talked about.
    I do also want to thank you for your insistence that this 
is a problem that was decades in the making. It is going to be 
decades in the fixing, and it requires subtle approaches and 
approaches that can evolve with the way this epidemic is 
evolving. To the Chairman's point, fentanyl in our state has 
changed a lot in the way law enforcement and the treatment 
community addresses this. So I thank you for your advocacy for 
that.
    I want to spend a little bit of time on one of the issues 
that I don't think we've touched on as much right now as it 
deserves. In your book, you chronicle the so-called Porter and 
Jick letter----
    Mr. Quinones. Yes.
    Senator Hassan ----which was a 1980 letter to the editor of 
the New England Journal of Medicine that was completely 
misinterpreted and used by prescription opioid makers to claim 
that their products are, quote, ``virtually non-addictive.'' 
Doctors also wrongly relied on the letter as scientific 
evidence that addiction is rare when using opioids. It's 
astounding that one paragraph jotted down in 1980 helped fuel 
the horrible epidemic that we are seeing today.
    Your book outlines how drug companies have played a big 
role here and how some of them have misled patients, providers, 
and public officials about the addictive nature of their 
products.
    Can you give us a brief overview of the role of the 
pharmaceutical industry in creating the misconceptions about 
the Porter and Jick letter?
    Mr. Quinones. Brief?
    Senator Hassan. You've got a minute and 45 seconds.
    Mr. Quinones. I've got a minute and 45 seconds. Well, I 
think the evidence shows it was pivotal in all this. This 
starts really with pain specialists believing that we were 
poorly treating pain, and we were. This was not--this is a 
story of a lot of people doing what they thought was the right 
thing, but doing too much of it, maybe, or--it turned out 
badly.
    I don't believe that they would have had the megaphone that 
they came to have were it not for a lot of the money and the 
funding and use of their--the selective use of their 
information by pharmaceutical companies. I think their money 
and influence was what really changed the tide, and then, of 
course, they were joined by certain institutions, like the VA 
and JCAHO, the hospital accreditation organization, the fifth 
vital sign, and all that kind of stuff.
    But I think they saw early on--and Perdue was one of these 
that saw--that they had tried a time-released opioid, right, MS 
Contin, only for cancer patients, and it was a magnificent 
drug. Had they just kind of stuck right there, we'd have been 
applauding them.
    Senator Hassan. Right.
    Mr. Quinones. Instead, what they saw was that the dying 
cancer patient market was pretty small, and there was a much, 
much larger one called chronic pain or just normal pain of 
Americans, basically, and they got on board. This was also, by 
the way--an important part of all this is that these years 
were--involved a--the industry went through a sales force arms 
race, where every company was hiring more and more and more 
sales reps, and these were not the older sales reps who were 
really more grounded.
    In fact, it's my impression in talking with doctors who 
knew these older fellows--mostly guys--that these guys knew 
what they were doing, and they were not such a hard sell. They 
were more informational. And then you hire a bunch of young 
folks, a lot of very good-looking young folks, to inundate, and 
so our pharmaceutical reps went from something like 35,000 to 
over 100,000 in about a 5-year period. All of that also is part 
of this story.
    I have to say this, though. This is a complicated tale, and 
I wanted to not blink at the complications. I believe also that 
we as Americans play a huge role in all this--our desire to 
have quick end to pain, to not be accountable for our own 
wellness.
    Senator Hassan. I think that is fair. I am over time, and I 
see that. I thank you for this. I also just won't have time for 
a second round of questions. But I will say that in my state, 
the need for funding to support the grassroots efforts like our 
safe station programs and some of the things our law 
enforcement is doing in treatment is critical, and I would look 
forward to talking with you more about that.
    Thank you, Mr. Chair.
    The Chairman. Thank you, Senator Hassan.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chair.
    Thank you, Mr. Quinones. I think Dreamland and The Factory 
Man are the two best works of reporting that I've read in the 
last 25 years.
    Mr. Quinones. Well, thank you so much.
    Senator Kaine. I think it's tremendous work. I want to ask 
two questions, if I can get to two. The first one is we've had 
witnesses here, Mr. Quinones, and I've asked them the 
question--Francis Collins, Scott Gottlieb--could we set a goal 
of addiction free by 2030. I'm mindful of your point that 
there's no silver bullet. But I'm also mindful if you don't 
have a target to organize around--we will be on the moon by the 
end of the decade.
    Mr. Quinones. Well, that's probably true.
    Senator Kaine. We will rebuild these economies and enable 
them to protect themselves from the spread of Soviet Communism. 
If you don't set the target, then you don't marshal your 
resources around meeting the target. So if you were to advise 
us about what the target would be--again, I posed the question 
to these folks, could we set the target of addiction free by 
2030, and Francis Collins and Scott Gottlieb said yes, that's 
doable, if you define it the right way, and it's doable within 
the current scientific knowledge and technological--likely, 
near-term future.
    But if you were to give us a target, what would you tell 
us?
    Mr. Quinones. If I were to give you a target, we'd all be 
in trouble. I would say that a target is good, and it's my 
hunch as an American that that is something to strive toward. 
It's always good to have a deadline, always good to have a 
goal. What that year should be and whether or not humans can 
ever be addiction free is a debatable point in my opinion. I'm 
not sure that's possible.
    However--and as I said in some of my testimony, written and 
oral--to me, this is a supply story. I lived in Mexico 10 
years, and when I was in Mexico, I grew--not having thought 
about it very deeply, I just adopted the idea that all our 
American drug problem was demand driven.
    Senator Kaine. There's a lot of evidence for that. When you 
arrest a street corner dealer, another one pops up right there.
    Mr. Quinones. Of course.
    Senator Kaine. You go after it on the supply side, but the 
demand is going to keep producing street corner dealers.
    Mr. Quinones. Yes, but what really--I agree. But what 
really--the primer and all that, the thing that starts it, I 
believe, is supply. I came to believe that after living in 
Mexico, where I believed the demand--because Mexicans like to 
believe that because it absolves them of the responsibility in 
our drug problem, which is really not our drug problem. It's a 
binational drug problem and needs to be addressed as such--us 
and them.
    But when I started doing this book, I began to realize--no, 
that's exactly not what happened, that we had no real problem 
with this before this overprescribing of opiates. The 
difference in this story is that the supply did not come from 
Colombian dealers and Mexican cartel guys from Sinaloa. It came 
from doctors buying into--sincere, well-meaning, good, well-
trained doctors buying into an idea that they could help their 
patients by just massively prescribing these pills.
    So the goal is a laudable one--the goal, the target, and 
all that. But to my way of thinking, supply is the issue--and, 
of course, that means pills, also with heroin and fentanyl--
and, therefore, to get there, I believe, requires that--there's 
a reason why all those guys from Vietnam came back addicted--so 
many of them kicked, because, first of all, they were no longer 
in war-torn Vietnam.
    But second of all, they were in rural Tennessee, they were 
in Alaska--there was no supply. So they found it--the more you 
separate the addict from the supply, the better chance that 
addict has of success, and that's what they're finding in some 
parts of Portsmouth, Ohio.
    Senator Kaine. Let me ask you a second question. I have a 
brother-in-law, Dwight Holton, who's the----
    Mr. Quinones. Well, I know him well, and I was going to say 
thanks to Dwight. He's a wonderful guy.
    Senator Kaine ----U.S. Attorney in Portland, who then 
decided for his next gig he would be the CEO of a substance 
abuse and suicide prevention organization, Lines for Life. 
Dwight says this. He's told me this many times. If there was a 
social movement for the recovering, it would become the most 
powerful political movement in the United States, because he's 
grappling with this issue of how do you get over the stigma, 
and then Democrats, Republicans, red state, blue state--this 
recovering social movement would be massive and would help us 
meet whatever target we set. I'm curious what you think about 
that.
    Mr. Quinones. Again, I believe, the more stories you tell, 
the more people who end up--this is what happens to me on 
airplanes all the time. I'll start talking about the book I 
just wrote--or what do you do for a living? I'll tell them, and 
they'll start looking around like this, and they'll touch my--
and under their breath, they go, ``Well, my cousin is--he's 
doing 5 years in prison,'' whatever.
    I think the more those stories come out, the more we all 
know how many people around us have this issue in their lives, 
the more it becomes a way of--you don't have to lower your 
voice anymore. It becomes natural. ``Well--you know, recovering 
from X.'' That's why I think it's very important for recovering 
addicts to mention that a lot, just because it normalizes and 
it makes us all understand that this is actually something 
that's going on all around us. It is an amazing thing to have 
written a book like this and then go on the road and have these 
encounters in airports and places like that. So I believe in 
the power of story, as I said.
    Senator Kaine. I'm over my time. But I really, really 
appreciate you being here today. Thank you.
    Mr. Quinones. Oh, it's my pleasure.
    The Chairman. Thank you, Senator Kaine.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    Thank you, Mr. Quinones, for being here, and thank you for 
your research on the rise in prescription opioid use. I want to 
follow-up on your point about supply. In your book, you write 
about a hospital in Columbus where a doctor in the Adolescent 
Medicine Department helping heroin addicts get detoxed talks 
about the kids he was seeing who had started with prescription 
painkillers. He says it was all of them. That's how all of them 
had gotten started, was with prescription painkillers.
    Mr. Quinones. Right.
    Senator Warren. A story that is true, I take it, for far 
too many Americans. According to the CDC, people who are 
addicted to prescription painkillers are 40 times more likely 
to be addicted than to heroin, and many people who misuse 
prescription opioids take the pills that were legally--start 
out with pills that were legally prescribed, whether it was to 
them or to a friend or to a relative.
    I know you've written about your own personal experience 
with opioid prescriptions when your appendix was removed.
    Mr. Quinones. Right.
    Senator Warren. Do you mind saying a bit more about that 
experience, about how many painkillers--you can keep this one 
short--how many painkillers you were prescribed and how many 
you think you actually needed?
    Mr. Quinones. Sure, and I don't think my story is very--I 
think my story is multiplied by millions every year for 20 
years. I mean, I had an appendix rupture at work when I was at 
the L.A. Times. On the night shift one night, I had a--I didn't 
realize it and went home and went to the hospital later. They 
said my appendix had ruptured, and I spent 2 days in the 
hospital. Each of those--it was a perfect example of what to do 
and what not to do in my case, I think.
    Each of the two days I was in the hospital, they gave me 
two Vicodin--perfectly--very good idea. I had just been cut 
open--very good idea. And then when I left, they gave me a 
bottle of 60 Vicodin and said to take as needed. This was--
again, I'm a crime reporter. I've done work on gangs and stuff 
like that. I did not--had never written about healthcare. I did 
not know--once I'd spent most of my last 10 years in Mexico, 
not really paying attention to this issue at all, I did not 
know what Vicodin was. I thought it was a glorified aspirin, 
because they told me as I left, ``Take as needed,'' and I was 
like, ``Okay. That sounds like aspirin to me.'' I don't like 
taking pills, so I took two of them.
    Senator Warren. So two----
    Mr. Quinones. Right, of the 60.
    Senator Warren ----is what you think you actually needed, 
and you got 60. So you had 58 unused pills.
    Mr. Quinones. Fifty-eight remained in my medicine cabinet 
for 4 years until I got in the middle of this project and said, 
``I think I've still got that Vicodin.'' I knew now what 
Vicodin was and, sure enough, dug through and found it and 
disposed of it. But, again, a couple of things. That is a 
perfect example of the supply that we have unleashed on this 
country. You multiply my case by millions and millions of 
people every year for 20 years and you get to where we are.
    Senator Warren. So there's actually some data on this. 
There's a study in the Journal of the American Medical 
Association that found that between two-thirds and 92 percent 
of patients who underwent various surgical procedures like you 
did report that they end up with unused opioids afterwards.
    Mr. Quinones. Sure.
    Senator Warren. Just like you, a lot of these sit around in 
the medicine cabinet and can then fall into the wrong hands 
because of the wrong reasons.
    Mr. Quinones. Very easily.
    Senator Warren. As Senator Alexander very generously noted 
earlier, last Congress, Senator Capito and I had passed a bill 
to try to tackle this problem by letting patients request only 
a fraction, only a day or two's worth of their opioid 
prescription to be filled at the pharmacy, and if they're still 
in pain a few days later, they can get a few more pills if 
that's what they want to do. I know it's not--you've talked 
about how complex this problem is. But I just want to talk 
about that one little part.
    Mr. Quinones. I think that's exactly the kind of thing I'm 
talking about, these small solutions, many, many small 
solutions. One of them is to take that kind of supply out of 
the medicine cabinets of America, basically, and I think also 
to get doctors in the habit of questioning--I think it was 
routine for years in this country to prescribe 60 or 90 of 
these pills--get doctors out of that.
    Think of the windfall, by the way, to a pharmaceutical 
company when a doctor in a white coat prescribes you 10 times 
more of the pills than you need, and you dutifully, like I did, 
say, ``Oh, okay''----
    Senator Warren. Or in this case, 30 times more.
    Mr. Quinones. Sometimes, plus there's refills and so on. 
Again, I get back to the basic dichotomy here. This is a story 
built on belief in a magic bullet solution. No. I think there's 
lots and lots of little things, and what you're outlining 
sounds like to me one of those little things.
    Senator Warren. Good, and I just want to say on this we got 
the law passed here, but that doesn't make it a reality. So 
we've sent letters--Senator Capito and I have--to every 
Governor in the country, to a lot of the different medical 
organizations, asking them to back us on the implementation of 
partial fill, and, also, here we are, more than a year after 
the law has changed, and the Drug Enforcement Administration 
still has a definition of partial fill that is out of date, not 
in compliance.
    So just a couple of weeks ago, Senator Capito and I along 
with Senator Grassley and Senator Feinstein sent a letter to 
the DEA to ask them to update these regulations. So, as you 
say, big and complex problem. We've done our part. Now, we've 
got to get the bureaucracy to get in line with this. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    Senator Baldwin.
    Senator Baldwin. Thank you.
    I really appreciate your being here today.
    Mr. Quinones. It's my pleasure, Senator.
    Senator Baldwin. What an opportunity to really have a 
conversation. You chronicle this epidemic as having its roots 
two decades ago, at least.
    Mr. Quinones. Yes.
    Senator Baldwin. Yet we find ourselves still scrambling and 
in some cases not gaining ground but losing ground. I want to 
share--I represent Wisconsin, and the new front of this battle 
appears to be fentanyl.
    Mr. Quinones. It does, indeed.
    Senator Baldwin. In a community like Milwaukee County, the 
largest county in the State of Wisconsin, fentanyl, 
specifically, was the cause of 170 deaths in 2017. Combined 
with other opioid overdoses, there were about 420 in that 
county last year.
    Mr. Quinones. I'm sorry.
    Senator Baldwin. Yes. It's just one example in the State of 
Wisconsin, and at this point, there's no sense that 2018 is 
going to be a turnaround here, despite the fact that Milwaukee 
County has a very committed heroin task force, and leaders from 
our local law enforcement and health providers have been 
collaborating to address this.
    I wanted to sort of dovetail on your conversation with the 
Chairman about synthetics like fentanyl sort of changing this 
epidemic in some ways. Do we need to be prepared for even a 
next generation of synthetic opioids, and what is the Federal 
role, again, in assisting communities?
    Mr. Quinones. Well, gosh, that's a huge question, I think, 
and I'm not sure I have all the answers to it.
    Senator Baldwin. I have a couple of more huge questions for 
you, too.
    Mr. Quinones. There's just nothing but huge questions on 
this topic, it seems to me. Yes, fentanyl has been remarkable 
in its transformative--it's like the third stage--starts with 
pills, then the heroin, and now we're on to fentanyl and 
carfentanyl, which is a rhinoceros painkiller. I do believe--
it's my belief, strongly, having lived in Mexico, that it is 
calling on us to understand that the only way we are going to 
stop any--have any kind of effect on fentanyl is by working 
with Mexico, not at odds with Mexico.
    There's no way you can stop the smuggling of fentanyl--we, 
alone, can stop the smuggling of fentanyl into the United 
States because it is so small. A sugar packet worth of fentanyl 
can kill everybody in this room, and probably on this whole 
floor.
    So my feeling is that one thing we need to--that seems to 
be extraordinarily counterproductive, in my opinion, having 
lived in the country for a lone time, is rhetoric that 
demonizes Mexico. I'm not saying that as a way of putting on 
rosy--kind of rose colored glasses with regard to Mexico. I 
lived there. I know the issues. I know the corruption. I know 
the depth of problems that they have there.
    But, nevertheless, I think, in a person-to-person 
connection, which we never really have achieved as government-
to-government, I don't think, from what I can see--that is how 
you advance. You know, they just shut down--it was a very 
interesting case in July. They shut down two major Dark Web 
marketplaces in July of last year, and they did it with 
Europol, Thai police, Dutch police, FBI, DEA, and some others, 
I think. It was a classic example of how you make a huge dent 
in supply by working with these governments.
    A global economy--the only groups, apparently, that don't 
work together are governments, and that was one example I 
thought was fascinating of how you move forward. To me, those 
are the ways that you help local law enforcement. Being in 
local law enforcement today feels to me like you're standing in 
the ocean trying to keep back the tide, when you're talking 
about this topic.
    Senator Baldwin. I want to ask a question. I don't think 
there's going to be time for an answer, but maybe we can 
follow-up.
    Mr. Quinones. Sure.
    Senator Baldwin. I've held a lot of roundtables with 
stakeholders, from recovering addicts, family members who have 
lost loved ones, law enforcement, health, et cetera, around the 
state. You talk so much about solving this through ending 
isolation and having stronger communities. I do find some 
significant variation between what I hear in urban centers in 
Wisconsin and what I hear in rural areas, everything from the 
availability of resources to help people who want to get 
treatment for their abuse, even to what drugs are being taken 
and abused.
    I would love to hear your thoughts--I'm not going to be 
able to stay for the second round, but perhaps in follow-up--
about how we strengthen communities in all of those different 
settings as they respond to sometimes unique and sometimes 
common challenges.
    Mr. Quinones. Okay.
    The Chairman. Thank you, Senator Baldwin.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    I want to explore further with you the link between 
economic affliction and drug addiction that you referred to. 
Many of the communities featured in your book, like Portsmouth, 
Ohio, have been devastated by mill closures, for example. Also, 
you've said that heroin is what you get when you destroy 
Dreamland. You've said that isolation is heroin's natural 
habitat.
    In the State of Maine, the opioid crisis appears to have 
started decades ago in Washington County, which borders Canada, 
and is an economically disadvantaged county with very high 
rates of unemployment and a lot of isolated communities. It 
then spread everywhere in Maine, including our most prosperous 
towns and cities.
    The Portland Press Herald last summer ran a 10-part series 
on the opioid epidemic, and it focused one story on the lobster 
industry, highlighting the high entry rate in that industry and 
also the logistical challenges of securing treatment in rural 
communities.
    Mr. Quinones. Great story. I read it.
    Senator Collins. So you read it. They'll be glad and 
impressed to know that.
    Mr. Quinones. Oh, yes. Tell them I tip my hat.
    Senator Collins. In your investigation, did you find that 
drug dealers tend to target communities that are economically 
devastated? Are they more fertile grounds for addiction?
    Mr. Quinones. I didn't notice that. I don't think drug 
dealers are deep sociologists. I think they're following the 
money, and the first place where this began--again, this began 
in areas that are economically devastated because pain 
treatment and resorting to doctors was part of how you navigate 
economic disaster. You get disability, as we were talking about 
earlier. I can't remember which Senator asked about this. You 
know, people who are trying to navigate their--and they go get 
workers' comp, they get SSI or SSDI, whatever it happens to be. 
To get that, you need a doctor. Again, this seemed to be also--
as time went on, the pills became something to resort to for 
economic sustenance.
    You could get pills, you could get high on them, but you 
could also sell them, and people figured that out. Some of the 
first dealers in Appalachia were seniors. They were not young 
people at all. They were seniors who figured out--``Gee, all 
these kids will buy this stuff, and I'll sell half of--keep 
what I need and sell the rest,'' that kind of thing.
    I do believe, as you say, that this starts in areas of deep 
economic affliction and, again, the areas that are viewed as 
kind of like the losers in the great free trade globalization 
gambit we've had over the last about 30 or 40 years perhaps. 
Now, of course, those are some of the things that I began to 
realize--what made me change my view of the story that I was 
writing was that it had now switched to, Charlotte, North 
Carolina--banking center, very, very wealthy, country clubs and 
mansions. They had the problem as well, and I think it gets 
into some larger questions, and also of we, as Americans, how 
we view pain and whether we--what we want to--how quickly we 
want to--easily we want to deal with it.
    Senator Collins. I also want to follow-up on your comment 
about the heroic role that's played by grandparents. I held a 
hearing in the Aging Committee to look at this issue of 
grandparents raising their grandkids due to the opioid crisis. 
Just as an important statistic, I will tell you that in my 
state, between 2010 and 2015, the number of grandparents taking 
care of their grandchildren and being solely responsible for 
their care soared by 24 percent, and it's because of the opioid 
epidemic.
    Mr. Quinones. Yes, and I think that's what's happening--I 
think that story is repeated in almost every--well, in many 
states in this country.
    Senator Collins. Thank you for your good work.
    Mr. Quinones. Thank you, Senator.
    Senator Collins.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Collins.
    Senator Murray, do you have additional questions or 
comments?
    Senator Murray. Well, I just want to thank our witness for 
being here today.
    Your name has been pronounced a lot of different ways. Can 
you pronounce it for me?
    Mr. Quinones. Quinones.
    Senator Murray. Quinones. Thank you.
    Mr. Quinones. It's been pronounced to me numerous different 
ways through our lives.
    Senator Murray. Thank you for tolerating us. Thank you for 
your excellent work and your thoughts.
    Mr. Chairman, I look forward to working with you and all of 
our Committee Members on this.
    The Chairman. Thank you, Senator Murray.
    I think Senator Murkowski has a question, and then we'll 
wrap up the hearing.
    Senator Murkowski. Thank you, Mr. Chairman.
    Mr. Quinones, thank you, truly, thank you. There are so 
many statistics that you have cited in your book, but one that 
just really floored me was the reference to the volume, really, 
that those in the United States consume when it comes to 
narcotics. You state that the United States consumes--and at 
the time of the writing--83 percent of the world's oxycodone 
and fully 99 percent of the world's hydrocodone. Gram for gram, 
a group of specialists wrote in the journal, Pain Physician, in 
2012, people in the United States consume more narcotic 
medication than any other nation worldwide.
    Okay, so people can become addicted, whether you're a U.S. 
citizen or whether you're some place in South America, Europe. 
What is it about this country that has us at fully 99 percent 
of the world's hydrocodone, the opiate, and Vicodin and Lortab? 
What is it that has happened here?
    Mr. Quinones. You know, that's a terrific question and one 
that began to hit me as I got into this book and realized that 
this was not really just a story about drug addiction. It was a 
story about who we've become as Americans.
    Senator Murkowski. The United States as drug addicts.
    Mr. Quinones. Exactly. Two generations ago or so, 11 
million people joined the Army, and the whole country 
participated in defeating the Nazis, and now we can't get our 
wisdom teeth out without getting massive doses of opiates. I 
sought the answer to that. Why--what is the common denominator 
between Portsmouth, Ohio, a Rust Belt town battered by almost 
every economic force for the last 30 years, and Charlotte, 
North Carolina, a very wealthy town, Salt Lake City. These 
towns have done very, very well. What is the overriding common 
denominator? It's not economics, obviously. You've got two very 
different economic situations.
    In my way of feeling, it's a combination of isolation, and 
also, frankly, maybe this is an essay on the dangers of 
prosperity, that too much stuff given too freely, people not 
expecting to--kids being raised bubble wrapped against any kind 
of pain, everybody fearing what skinning their knees may do to 
kids when they're outside, so keeping them indoors, and all 
across the country, you can see that.
    Senator Murkowski. Was it interesting to you that the 
Nayarit boys, those that were doing the deliveries, did not--
they didn't use the stuff?
    Mr. Quinones. No, they were addicted to something else.
    Senator Murkowski. They were addicted to----
    Mr. Quinones. Going home a king.
    Senator Murkowski ----to the resources that came back.
    Mr. Quinones. Giving away pants and what-not.
    Senator Murkowski. But, still, you look at that, and you 
say, ``What is it about Americans that has pushed us in this 
direction, in such an extreme direction? You have other 
countries that have the same issues that we have. They have 
economic decline. They have isolationism. They have the same 
things that we have, and yet we have turned to opioids to numb 
it all.
    Mr. Quinones. I think, in part, it's also what I was 
talking about at the beginning, which was there's this focus--
we have focused on the individual, exalted the individual, and 
so great ideals of American kind of experiment, become twisted 
in our pursuit of convenience and our pursuit of an end to 
pain. So self-reliance, this wonderful American ideal, becomes 
isolation. Accountability becomes tantrums whenever any 
political official or any cop or any doctor doesn't do exactly 
what we say. It seems to me that these are things that are 
behind a lot of this, that we maybe have had too much. We've 
become pampered in some sense.
    I don't pretend to know it all. These are questions that 
I'm fascinated by and I love to talk about them, but I make no 
claim to know all the answers to these very important questions 
you're posing here.
    Senator Murkowski. So this statement was made back in 2012 
in the journal, Pain Physician. Would you assume that those 
numbers have continued to increase even, or----
    Mr. Quinones. Well, they have not dropped significantly.
    Senator Murkowski ----relative to other countries?
    Mr. Quinones. Yes, yes, and part of it--I have to say this, 
also. It bears noting. Part of that is because a lot of 
countries don't use enough of these drugs. People die in 
horrible agony from cancer when they shouldn't. There is a 
proper role for these drugs in human medicine. It's just 
debatable what that role is. It's a very, very important one, 
and up to now, in the last 20 to 25 years in this country, the 
proper role appeared to be, a bottle in every medicine cabinet, 
and that's where we got into trouble, essentially.
    Senator Murkowski. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Quinones, if I may just make a couple of 
quick observations about your testimony and then one about your 
Space Shot, Marshall Plan idea, listening to this, one thought 
I had was, with your family here especially, as I mentioned to 
you before, you should be glad you weren't nominated for 
something, or some Senator would have chased you under a table 
and accused you of killing your grandmother in the process.
    [Laughter.]
    Mr. Quinones. I'm aware of that.
    The Chairman. But we have thoroughly benefited from your 
testimony, and it strikes me that with your book and with your 
testimony, you may be helping to lead a revolution in a 
different direction than the one you describe in your book----
    Mr. Quinones. Thank you.
    The Chairman --when people, as you say, mostly well-
meaning, but a whole variety of participants from--some not so 
well-meaning--but Mexican drug dealers and enterprising 
pharmacists and doctors who thought they were doing the right 
thing all caused an over-prescription and use of opiates, that 
now there is some relatively simple steps that we can take to 
move back in the other direction. But it takes being aware of 
that, and your book is helping us do that.
    I think of the meeting I dropped by and that I mentioned, 
yesterday. If you have all of the heads of the universities and 
institutes training physicians in Tennessee, one of the leading 
states for this problem, working together with the Governor to 
change the way they teach doctors about what to do about 
opiates, then you'll have many more prescriptions of 3 days 
worth instead of 60, as needed. So there's some steps that we 
can take, and I congratulate you for that.
    On your testimony, two aspects. One is you've demonstrated 
some humility. You don't claim to know everything. We find 
around here that's a very useful attribute, because we don't 
know everything, either. It helps to hear from you. And, 
second, you're a wonderful storyteller. It reminds me of my 
late friend, Alex Haley, who wrote Roots, who was a great 
storyteller, and he once told me after hearing me make a 
speech--he said, ``May I make a suggestion? If you would--when 
you begin, you would say `May I tell you a story?' instead of 
making a speech, someone might actually listen to what you have 
to say.'' So because of your storytelling, people--we're 
listening to what you have to say.
    Finally, on the Marshall Plan and the Space Shot, Senator 
Murray and I and Senator Murkowski all worked together to fix 
No Child Left Behind a couple of years ago. One of the things 
No Child Left Behind did in education was have as a goal that 
100 percent of children would be proficient in reading and math 
by the year 2014. I remember when that was said--I wasn't in 
the Senate--and I thought, ``Well, I guess that's all right.''
    We say all people are created equal, and Samuel Huntington, 
a professor at Harvard, once wrote that most of our politics is 
about setting high goals for ourselves that we never reach, and 
then dealing with the consequences of not having reached them. 
But that's sort of what we do as a country.
    Then I was thinking about--but it created a lot of problems 
for us that we had to--the consequences that were attached to 
that high goal did.
    On the Marshall Plan and the Space Shot, I think this may 
be more like the Marshall Plan. The Space Shot was a high goal, 
inspired everybody, but it was done really from Washington. It 
was a centrally organized single shot effort, and when it 
succeeded, we'd reached the moon. The Marshall Plan actually 
was a request of European countries to come up with their own 
plan.
    Mr. Quinones. Yes. Correct.
    The Chairman. It wasn't General Marshall's plan or 
President Truman's plan. It was--those countries came up with a 
plan, and we funded it. But then they implemented it, and some 
succeeded more than others, which is probably what will happen 
here. So some sort of high goal, but I think the more important 
and better example may be the Marshall Plan.
    Mr. Quinones. You may be right.
    The Chairman. Because each of the states are different, and 
I like the fact that you talk about the parts of the country 
that are ravaged by globalization and online purchasing and all 
this business that leaves main streets empty and people without 
things to do. But then we have the problem that spreads to 
Charlotte and Nashville, too, and those aren't poor cities.
    So it's a complex problem, and you've helped us understand 
it. Thank you for your leadership, and we appreciate your 
family coming as well all the way from Los Angeles.
    Senator Murray, do you have anything else?
    [No verbal response.]
    The Chairman. The hearing record will remain open for 10 
days. Members may submit additional information for the record 
within that time if they would like. Our Committee will meet 
again on Thursday, January 11th, for an executive session on 
nominations.
    Thank you for being here. The Committee will stand 
adjourned.
    [Whereupon, at 12:06 p.m., the hearing was adjourned.]

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