[Senate Hearing 115-788]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 115-788
 
                           THE OPIOID CRISIS:
                       LEADERSHIP AND INNOVATION
                             IN THE STATES

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

                                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 LEADERSHIP AND INNOVATION IN 
                               THE STATES

                               __________

                             MARCH 8, 2018

                               __________

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                  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, Democratic Staff Director
             John Righter, Democratic Deputy Staff Director
             
             
             
             
             
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        THURSDAY, MARCH 8, 2018

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State 
  of Washington, Opening statement...............................     3

                               Witnesses

Statement of Hogan, Hon. Lawrence J., Governor, Sate of Maryland.     5
    Prepared statement...........................................     6
    Summary statement............................................     9
Statement of Brown, Hon. Kate, Governor, State of Oregon.........     9
    Prepared statement...........................................    11
    Summary statement............................................    12


                           THE OPIOID CRISIS:

                       LEADERSHIP AND INNOVATION

                             IN THE STATES

                              ----------                              


                        Thursday, March 8, 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, presiding.
    Present: Senators Alexander [presiding], Isakson, Collins, 
Cassidy, Young, Murkowski, Scott, Murray, Casey, Bennet, 
Baldwin, Murphy, Warren, Kaine, Hassan, Smith, and Jones.

                 OPENING STATEMENT OF SENATOR ALEXANDER

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    Today, we are holding our sixth hearing in this Congress on 
the opioid crisis. Joining us, to talk about what is working in 
their states, is Governor Larry Hogan from Maryland and 
Governor Kate Brown, who has come all the way from Oregon. We 
thank you both for taking time from your very busy schedules to 
be here.
    This hearing is a follow-up to a roundtable that Senator 
Murray and I hosted last week with 13 governors, who were here 
for the National Governors Association Meeting. Thirty-two 
Senators of both parties attended at some time during that 
roundtable, which is a large gathering of Senators, to hear 
from the governors about the opioid crisis.
    Senator Murray and I will each have an opening statement, 
then I will introduce the witnesses, and then we will hear from 
the governors. Senators will each have 5 minutes of questions.
    In January, I dropped by a meeting at the Tennessee 
governor's residence in Nashville. Governor Bill Haslam had 
invited the heads of all of our state's institutions that are 
involved in educating doctors, and they were planning on how to 
discourage the over-prescription of opioids.
    Governor Haslam 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 amount of 
opioids prescribed--to that still very high number--the number 
of overdose deaths is still rising because of the abuse of 
fentanyl, a synthetic opioid.
    In fact, according to a recent report from the Centers for 
Disease Control and Prevention, opioid overdoses spiked 30 
percent between July 2016 and September 2017 across our 
country. So this is an evolving crisis that has affected nearly 
every state, but the specific challenges faced by Tennessee may 
be very different from what Oregon or Maryland faces.
    States really are the ones that come up with the best ideas 
on how to tackle big problems because states are on the front 
lines. It is usually the Federal Government's role to encourage 
them to cut the red tape and to create an environment so that 
states and communities can innovate. That is true with 
addressing the opioid crisis.
    Governors are coming up with innovative solutions. They are 
leading the fight against specific problems their states face 
in the midst of the crisis.
    For example, Governor Hogan in Maryland has allowed all 
pharmacies to dispense naloxone, the drug that stops a drug 
overdose, and opened an Opioid Operational Command Center to 
coordinate the state and local governments' response to the 
crisis.
    Governor Brown has prioritized improving Oregon's 
Prescription Drug Monitoring Program and is working with the 
state legislature in Oregon on a peer mentorship program for 
individuals struggling with addiction.
    Congress also has taken a number of steps to support states 
fighting the opioid crisis. In 2015, we passed the Protecting 
Our Infants Act to help ensure that Federal programs are more 
effective in helping expectant mothers struggling with opioid 
abuse, and that they receive more help so that they have 
healthy babies.
    In 2016, we passed the Comprehensive Addiction and Recovery 
Act to give new authorities to states, including grants to 
expand access to naloxone, and to provide a comprehensive 
response of education, prevention, treatment, and recovery.
    Also in 2016, we passed the 21st Century Cures Act and 
included $1 billion over 2 years in state grants to address the 
opioid crisis.
    Congress is considering, in the appropriations process, 
approving additional funding as well.
    In December, Senator Murray and I sent a letter to every 
governor and state insurance commissioner asking if these laws 
were working and how the Federal Government can be a better 
partner for states. We have heard back from 21 governors and 11 
state health officials, in addition to the feedback we heard at 
the roundtable this week.
    Governor Haslam suggested additional funding to encourage 
states to share data in their prescription drug monitoring 
systems, something we talked about at our hearing last week. I 
think this is one of the most promising areas where the Federal 
Government can be helpful to states.
    Former Governor Terry McAuliffe of Virginia suggested we 
support research on non-opioid pain management.
    I have encouraged Dr. Collins, Director of the National 
Institutes of Health, to use additional research money, which 
Congress has appropriated, to focus on finding a non-addictive 
painkiller. Senator Murray and I have introduced legislation 
last month to give him more flexibility and funding to do that.
    This Committee hopes to approve that piece of legislation, 
as well as others, later this spring so that we can recommend 
those bills to the full Senate to vote on. So it is helpful to 
have the input from governors here today, as well as the 
written responses from other governors and state commissioners.
    I am looking forward to hearing what Oregon and Maryland 
are doing to address this crisis and what lessons can be 
learned. Senator Murray.

                  OPENING STATEMENT OF SENATOR MURRAY

    Senator Murray. Well, thank you very much, Mr. Chairman.
    Thank you to both of our witnesses for making the trip out 
here to join us today, in particular, Governor Brown. You came 
a little bit longer way than Governor Hogan. But thank you to 
both of you.
    I am really glad that we are able to bring two leaders 
together to face an issue, who come not only from opposite 
sides of the aisle, but even from opposite sides of the 
country. So we look forward to hearing from both of you today 
on how you are working in your state to address this opioid 
crisis.
    Throughout our series of hearings on this crisis so far, we 
have heard from a wide range of voices with different and 
important perspectives on this epidemic.
    Whether we have been speaking with government officials or 
families, medical professionals or data experts, journalists or 
academics, individuals who have personally lost someone to an 
opioid addiction, or people who have personally overcome it, we 
have seen that this crisis does impact everyone. The 115 people 
who die each day from an opioid overdose are young and old, 
they are from all backgrounds, and they are from all over the 
country.
    We have seen that while this is a national problem, 
empowering local officials with the tools they need is one of 
the most important solutions. We have seen, after far too long, 
that we cannot simply treat this as a law enforcement issue. To 
fully address the crisis, we must also treat it as a healthcare 
issue, as a child welfare issue, and a drain on local 
economies.
    It is clear this disease is not only hard on the patients 
facing it. It impacts entire families and communities, 
including parents, like Becky Savage, the mother we listened to 
in a recent Committee hearing, who tragically lost two sons to 
opioid overdose; kids whose lives are thrown into uncertainty 
when a parent is battling addiction; and the grandparents and 
relatives who step up to raise them in this hardship; 
educators, like the principal I recently spoke with in Everett, 
Washington, who had seen firsthand the strain this crisis put 
on the students at school.
    We have heard time and time again how heartbreaking, how 
far-reaching, this crisis has become. And it is clear that in 
order to find the solutions, we are going to have to reach just 
as far.
    We have heard in our last hearing about how beneficial it 
can be when our states' prescription drug monitoring systems 
can talk to each other and work together. We discussed how, by 
making technology like the drug monitoring systems more 
interoperable, we could collaborate more effectively on the 
challenges we face. This is a lesson that also goes beyond 
data.
    It is not enough that we have technology in one state that 
is able to talk to technology in another state. We need to make 
sure this is happening on a human level too. We need to make 
sure that not only good data, but good ideas, are being shared. 
And that is what today's hearing is all about.
    A good example, of the potential of shared ideas, comes 
from my home state.
    Back in Washington, King County has been running a 
diversion program for a couple of years now that gives law 
enforcement a new resource in the fight against addiction. It 
lets them put struggling patients on the road to recovery, 
instead of into prison. The approach does not only help people 
themselves recover, but as one patient put it a few years ago 
it, ``Makes us feel human again.''
    After seeing that program succeed and learning more about 
it, Snohomish County recently opened a similar rehabilitation 
program. And these programs are a model for the similar grants 
authorized through the Comprehensive Addiction and Recovery Act 
that was passed last Congress. That is just one example of how 
Congress can take what is happening in the states and use it to 
benefit more people across the country.
    As this Committee undertakes another legislative effort 
around opioids, I believe we can again find room for similar 
progress between states and here in Washington, DC. As more 
states learn what is working in their communities, I believe 
conversations like this can help make sure good ideas are being 
put to good use for families everywhere.
    Which is why I am so eager to hear from both of our 
witnesses today, and so grateful they could join us to discuss 
the efforts you have underway in your states to address this 
crisis, and what lessons you have for other communities, and 
states, and those of us working on this nationally.
    I believe today's discussion will offer some interesting 
insights as we continue here to look for common ground and 
common sense solutions to help those struggling with the menace 
of opioid addiction.
    Mr. Chairman, before we begin, I do want to submit for the 
record, testimony from the Port Gamble S'Klallam Tribe. They 
have been doing some really important work to address the 
opioid crisis and call attention specifically to the challenges 
that our Tribes are facing in responding to this epidemic.
    Senator Murray. I look forward to this hearing.
    The Chairman. Thank you, Senator Murray.
    Governors, our practice is to ask you to summarize your 
remarks, if you can, in about 5 minutes and that will permit 
more time for conversation back and forth between you and the 
Senators.
    Governor Hogan is the 62d Governor of Maryland. He is a 
Republican. He has more than 25 years of private sector 
experience.
    In response to the opioid crisis, he signed an executive 
order creating a Heroin and Opioid Emergency Task Force, which 
developed 33 recommendations related to treatment, prevention, 
and enforcement. His administration has implemented many of 
these recommendations. We look forward to hearing these 
efforts.
    Our second witness is Governor Kate Brown. She is the 38th 
Governor of Oregon. She is a Democrat and previously served as 
Oregon's Secretary of State, and as a state Senator and state 
representative in the Oregon legislative assembly.
    Governor Brown has also convened an Opioid Epidemic Task 
Force. Two of her priorities is improving access to treatment 
and requiring that licensed prescribers use the State's 
Prescription Drug Monitoring Program.
    We look forward to hearing about her work as well.
    Welcome to each of you. Thank you, again, for being here.
    Let us begin with you, Governor Hogan, and then go to 
Governor Brown.

   STATEMENT OF HON. LARRY HOGAN, GOVERNOR, STATE OF MARYLAND

    Governor Hogan. Well, thank you, Chairman Alexander, 
Ranking Member Murray, distinguished Members of the Committee.
    Thank you for your focus on this issue, and thank you for 
giving us the opportunity to provide testimony here today 
regarding what I believe is the No. 1 health crisis facing our 
Nation.
    We have been sounding the alarm and shining a spotlight on 
this issue for about 4 years now. It was during my campaign for 
governor in 2014, as I traveled all across the State of 
Maryland, I would go and meet with local officials and 
community leaders, and I would ask them what was the No. 1 
issue facing their community.
    Everywhere I went, whether it was in the wealthy suburbs of 
Washington, or the inner city of Baltimore, or we were in small 
towns and rural communities, the answer was always the same, 
and it kind of took me by surprise. But we learned about the 
magnitude of this problem.
    In one of my first actions as governor, we established an 
emergency opioid and heroin taskforce which, as the Chairman 
said, came up with 33 recommendations, most of which we 
implemented.
    We focused on a four-pronged approach of education, 
prevention, treatment, and enforcement. I was the first 
governor in America to declare a real state of emergency on 
this issue because we decided that we needed to treat this 
crisis just like we would treat any other natural or manmade 
disaster.
    We have already committed, in our small state, more than a 
half a billion dollars toward fighting the heroin, opioid, and 
substance abuse epidemic from all directions.
    Yet, in spite of our efforts, we still had nearly 2,000 
people die last year. That is far more than those killed by 
firearms and motor vehicle accidents added together.
    The good news is that with our efforts, we have been able 
to bend the curve downward on prescription opioids and on 
heroin. But a new, and even more deadly drug, is now growing 
out of control across America, and that is fentanyl.
    Overdose deaths from fentanyl were up a staggering 70 
percent in our state last year. The majority of this fentanyl 
is being shipped in from China or it is crossing the border, 
being smuggled in from Mexico. We simply cannot stop it without 
the Federal Government stepping up.
    This crisis is going to take an all hands on deck approach 
from the Federal, state, and local governments along with 
community organizations and faith based organizations, and 
others in the communities. We all need to be working together 
on this issue.
    I urge you, and your colleagues, to make increased funding 
for the opioid crisis a top priority. Maryland, and many other 
states, are all working to provide naloxone to all of our local 
jurisdictions, but greater Federal support would help make this 
lifesaving medication available to even more of our first 
responders, our police officers, and emergency room personnel.
    I would like to recommend that the Federal Government 
encourage advertising, public service campaigns, to educate the 
public about how lethal fentanyl and these other drugs are.
    We also need more targeted and aggressive Federal 
enforcement interdiction efforts when it comes to fentanyl and 
these other opioids through initiatives like the Synthetic 
Trafficking and Overdose Prevention, or STOP, Act. As this 
crisis evolves, so must our response to it.
    I will agree with Senator Murray, this crisis is not just a 
health crisis. This is tearing apart families and communities 
from one end of the country to the other, from Maryland to 
Oregon and everyplace in between.
    Ultimately, this really is about saving lives. It will take 
a collaborative, holistic, and bipartisan approach to 
accomplish that.
    Again, thank you for having us and we look forward to the 
dialog and answering any of your questions.
    Thank you.
    [The prepared statement of Governor Hogan follows:]
  prepared statement of governor lawrence j. hogan, state of maryland
    Chairman Alexander, Ranking Member Murray, and Distinguished 
Members of the Committee:
    Thank you for the opportunity to be here today to discuss what I 
believe is the number one health crisis facing our Nation. In Maryland, 
we have been shining a spotlight on the heroin and opioid crisis for 
the past 4 years. Sitting next to my honorable colleague from Oregon, I 
want to underscore how non-partisan this issue is for the states. This 
is about doing everything we can to fight an epidemic that has already 
claimed too many lives and sparing families from the destruction and 
despair caused by opioid addiction and overdose.
    My message to the Federal Government is simple: With fentanyl--
which is fifty times more powerful than heroin--now the leading cause 
of overdose deaths in Maryland, we need our Federal partners to step 
up, stop the flow of illicit synthetic drugs into our country, and 
provide the resources necessary for battling this scourge. I am 
pleading with you, your colleagues in Congress, and the Administration 
to take action, as only the Federal Government can truly prevent 
illegal drugs from entering our country. Washington may be paralyzed by 
partisanship, but every second we waste in addressing this crisis, 
lives are being lost, families are being forever changed, and futures 
are being squandered.
    Since taking office in 2015, fighting the heroin and opioid 
epidemic in Maryland has been a top priority of our administration. The 
epidemic has hit Maryland hard, with statistically higher rates of drug 
overdose deaths than the national average. From 2015 to 2016, total 
intoxication deaths increased from 1,259 to 2,098, signaling an 
alarming upward trend. By contrast, in 2016, motor vehicle accidents 
accounted for only 569 deaths. Nearly every day, in the most prosperous 
suburbs, rural towns, and everywhere in between, people wake up to the 
reality of their community's heroin and opioid problem.
    Last March, I signed an executive order declaring a State of 
Emergency in response to the heroin, opioid, and fentanyl crisis, 
activating emergency management authority and enabling increased and 
more rapid coordination between our state and local emergency teams. 
Additionally, our administration has established the Opioid Operational 
Command Center to lead the state's response and coordinate directly 
with all 24 local jurisdictions.
    We remain steadfast in our commitment to using all the tools at our 
disposal to fight this epidemic and save lives. Our administration has 
committed half a billion dollars toward fighting the heroin and opioid 
epidemic and substance use disorders, with a four-pronged approach 
focused on education, prevention, treatment, and enforcement.
    But even as our state commits ever greater resources to this fight, 
the challenge we face continues to grow, and the evolving threat posed 
by fentanyl and other synthetic drugs has made our efforts that much 
more difficult. According to the latest Maryland Department of Health 
data released in January 2018, as heroin-related and prescription 
opioid-related deaths have started to show a slight drop, fentanyl and 
fentanyl analog-related deaths are steadily increasing. Illicit drugs 
blended or substituted with fentanyl are being purchased and trafficked 
into our country at a staggering rate and are more dangerous than ever. 
Due to the cheap price of fentanyl, wholesale suppliers sell heroin and 
other drugs mixed or substituted with fentanyl to make a larger profit. 
Law enforcement tells us that fentanyl is being unknowingly substituted 
in the drug supply prior to entering the Maryland area, and we're 
seeing that reflected in the latest overdose data.
    Fentanyl is now the deadliest controlled dangerous substance in the 
State of Maryland, with over two-thirds of all overdose deaths in 2017 
through September involving fentanyl. Of the 1,705 drug and alcohol-
related deaths across the state, the vast majority of those deaths 
(1,501) were opioid-related, and 1,173 deaths were related to fentanyl.
    The increase in fatal fentanyl overdoses is widespread across 
Maryland and is occurring within all demographic populations, affecting 
all ages and backgrounds. Fentanyl overdoses are increasingly impacting 
younger age demographics, possibly because of the increased chance of 
accidental overdose to unknowing users. However, the impact appears to 
be widening toward all age ranges. Additionally, the number of fatal 
cocaine overdoses is increasing and is primarily attributed to cocaine 
being mixed with fentanyl analogs. Fatal overdoses from cocaine laced 
with fentanyl are increasing across demographic lines and are driving 
an increase in overall fentanyl-related overdose deaths.
    We know that Maryland's current drug threat is primarily from 
fentanyl. Even more alarming, we know that fentanyl is now present in 
the majority of the drug market, not just opioids. As governor, I am 
committed to doing everything in our power at the state level to 
protect Marylanders from this scourge and prevent future victims. But 
there's no denying that the majority of this illicitly manufactured 
fentanyl killing our citizens is being shipped in from China or 
smuggled across the border from Mexico, so it naturally falls on the 
Federal Government to stop it. Without ramped up enforcement efforts at 
the Federal level, and more resources to supplement the state's efforts 
on prevention and treatment, we're tragically going to keep seeing more 
fentanyl-related deaths.
    Clearly, combating a crisis of this scale is going to require a 
much more aggressive approach from the Federal Government, backed up by 
sufficient Federal funding. I recognize this Committee's leadership on 
this issue and want to thank you for getting the 21st Century Cures Act 
passed back in 2016. As a result of this law, the Maryland Department 
of Health was awarded a $20 million grant from the Substance Abuse and 
Mental Health Services Administration (SAMHSA), to be used over 2 years 
to combat opioid abuse. This investment in Maryland's opioid response 
efforts has already made a positive impact, supporting our balanced 
approach of prevention, enforcement, and improving access to treatment. 
I also welcomed the Administration's declaration of the opioid crisis 
as a public health emergency in October 2017. However, while the 21st 
Century Cures funding and Federal emergency declaration are both 
significant steps in the right direction, they are clearly not enough 
to tackle a crisis that continues to ravage our Nation.
    Your outreach to states regarding specific recommendations is 
appreciated, as we are on the front lines of this epidemic. I'm 
grateful for the continued conversation this Committee has fostered and 
want to emphasize that action on these items can't come soon enough.
            Increased Federal Funding for the Opioid Crisis
    First, we need to treat the heroin, opioid, and fentanyl crisis as 
we would treat any other life-threatening emergency: with an all-hands-
on-deck approach and resources that measure up to the severity of this 
problem. I urge you and your fellow lawmakers to make increased funding 
for the opioid crisis a top priority as you negotiate the Fiscal Year 
2018 appropriations bill in the coming weeks.
    First Responder Training and Increased Availability of Naloxone
    In June 2017, our administration issued a statewide standing order 
that allows pharmacies to dispense naloxone, the non-addictive life-
saving drug that can reverse an opioid overdose, to all Maryland 
citizens. We are working tirelessly to bring naloxone to all 
jurisdictions through coordinated efforts and distribution to local 
health departments, and grant funding from the 21st Century Cures Act, 
along with state funds, is helping us accomplish this. However, the 
need continues to grow, especially with fentanyl and carfentanil 
requiring multiple doses of naloxone to be administered to help victims 
overdosing on these substances. More Federal support is needed to help 
us make naloxone available to first responders and law enforcement. We 
also must provide resources to first responders on safety around 
fentanyl and how to respond after exposure.
                         Education on Fentanyl
    We ask the Federal Government to support campaigns at the national 
and state level to educate the public about the lethality of fentanyl, 
which is increasingly mixed with heroin and other drugs, including 
those that appear to be prescription drugs.
    In May 2017, our administration launched ``Before It's Too Late,'' 
a web portal designed to provide resources for individuals, families, 
educators, and health care professionals and raise public awareness of 
the rapid escalation of the heroin, opioid, and fentanyl crisis in 
Maryland. We also signed into law the Start Talking Maryland Act (HB 
1082/SB 1060), which increases school and community-based education and 
awareness efforts to continue to bring attention to the crisis and to 
equip Maryland's youth with knowledge about the deadly consequences of 
opioids. Among other provisions, the legislation requires programming 
on heroin and opioid related addiction and prevention (including 
information on fentanyl) beginning in third grade, a county-level 
school policy on naloxone, the designation of a school health services 
coordinator, and community action officials to coordinate school-based 
community forums and public awareness efforts.
      Targeted Enforcement of Fentanyl and Other Synthetic Opioids
    One thing Congress can do right now is pass the Synthetic 
Trafficking & Overdose Prevention (STOP) Act, which would help address 
dangerous vulnerabilities in international mail by requiring the U.S. 
Postal Service to collect advanced electronic data on international 
packages. The tightening of international parcel shipping regulations 
has never been so critical for Maryland, with the majority of all 
opioid fatalities now coming from illicit synthetic fentanyl. Most 
deadly fentanyl is purchased online from labs in China and shipped into 
the U.S. through the mail, and funding and support for USPS drug 
detection and interdiction efforts is essential.
    The Federal Government can also be supportive of Maryland's law 
enforcement efforts by:

          Enhancing data collection, collation, and analysis 
        for strategic intelligence and situational awareness related to 
        the opioid threat.

          Increasing the availability of data to identify 
        criminal networks responsible for trafficking and distributing 
        fentanyl and other synthetic opioids in Maryland.

          Enhancing enforcement efforts focused around the 
        identification, dismantlement, and disruption of criminal 
        organizations importing drugs into the country.

          Expanding the capacity of law enforcement to quickly 
        and safely detect fentanyl seizures to better mirror overdose 
        data specificity and more quickly identify trafficking 
        organizations to increase interdiction.

    In January, as part of a package of proposed legislation targeting 
the opioid crisis, we introduced the Overdose Data Reporting Act to 
allow Emergency Medical Services (EMS) providers and law enforcement 
officers to input and share data about opioid overdoses. This enhanced 
data-sharing ability will enable first responders to track this 
information and allocate resources, including life-saving naloxone, in 
near real time to respond to an extremely potent batch of opioids in a 
specific area. We are eager to see a greater focus at the Federal level 
on information sharing initiatives to link law enforcement 
investigations across jurisdictions.
    Thank you for your time today and for your consideration of these 
recommendations. I was pleased to see many of these ideas embraced in 
the bipartisan opioid legislation introduced last week in the Senate, 
as well as in the House Energy and Commerce Committee legislative 
package on opioids. I urge you to keep this momentum going--Maryland 
needs action now, and we look forward to continuing to work with our 
Federal partners to address this epidemic. Federal support is 
desperately needed to stop the flow of fentanyl into our country and 
end this scourge. As this crisis evolves, so must our response to it, 
and in Maryland, we are using every possible tool at our disposal. 
Ultimately, this is about saving lives, and it will take a 
collaborative, holistic approach to achieve that.
                                 ______
                                 
                 [summary statement of governor hogan]
    Maryland's current drug threat is primarily from fentanyl, which is 
fifty times more powerful than heroin. Even more alarming, fentanyl is 
now present in the majority of the drug market, not just opioids. As 
governor, I am committed to doing everything in our power at the state 
level to protect Marylanders from this scourge and prevent future 
victims. But there's no denying that the majority of this illicitly 
manufactured fentanyl killing our citizens is being shipped in from 
China or smuggled across the border from Mexico, so it naturally falls 
on the Federal Government to stop it. Without ramped up enforcement 
efforts at the Federal level, and more resources to supplement the 
state's efforts on prevention and treatment, we're tragically going to 
keep seeing more fentanyl-related deaths.

    Recommendations: 

    Increased Federal Funding for the Opioid Crisis 

    I urge you and your fellow lawmakers to make increased funding for 
the opioid crisis a top priority as you negotiate the Fiscal Year 2018 
appropriations bill in the coming weeks.

    First Responder Training and Increased Availability of Naloxone 

    More Federal support is needed to help us make the life-saving drug 
naloxone available to first responders and law enforcement, especially 
with fentanyl and carfentanil requiring multiple doses of naloxone to 
be administered to victims overdosing on these substances. We also must 
provide resources to first responders on safety around fentanyl and how 
to respond after exposure.

    Education on Fentanyl 

    We ask the Federal Government to support campaigns at the national 
and state level to educate the public about the lethality of fentanyl, 
which is increasingly mixed with heroin and other drugs, including 
those that appear to be prescription drugs.

    Targeted Enforcement of Fentanyl and Other Synthetic Opioids 

    We urge Congress to pass the Synthetic Trafficking & Overdose 
Prevention (STOP) Act, which would help address dangerous 
vulnerabilities in international mail by requiring the U.S. Postal 
Service to collect advanced electronic data on international packages. 
The tightening of international parcel shipping regulations has never 
been so critical for Maryland, with the majority of all opioid 
fatalities now coming from illicit synthetic fentanyl. Most deadly 
fentanyl is purchased online from labs in China and shipped into the 
U.S. through the mail, and funding and support for USPS drug detection 
and interdiction efforts is essential.
                                 ______
                                 
    The Chairman. Thank you, Governor Hogan.
    Governor Brown, welcome.

    STATEMENT OF HON. KATE BROWN, GOVERNOR, STATE OF OREGON

    Governor Brown. Chairman Alexander, Ranking Member Murray, 
Committee Members.
    Thank you so much for having me here today. I am also 
honored to be sharing the dais with my colleague, Governor 
Larry Hogan.
    By providing our states' perspectives, I hope we can 
underscore the urgency of tackling the opioid crisis that has 
touched every single corner of every state in our entire 
Nation.
    Part of what makes opioids so dangerous is the fact that 
there is so much of it and it is not hard to get. Abuse can 
begin as easily as reaching into the average family medicine 
cabinet.
    That is what happened to Max Pinsky of southern Oregon. He 
was a poet and a chef. When he was 17 years old, he got into a 
car accident and was prescribed opioid painkillers. What 
started as therapy became self-medication and spiraled into 
abuse.
    From prescription pills, he moved onto heroin. His mother, 
Julia, was devastated as she watched the grip of opioids 
consume his life. He died of an overdose at age 25.
    It is hard to look back on Max's story and wonder what 
could have been. What if we lived in a society where he was not 
shamed for having a problem or for reaching out for help? What 
if he had access to better treatment? What if the first 
responders had lifesaving overdose drugs?
    Addiction is blind to circumstance, but the high cost of 
addiction is borne by our children, whose parents are unable to 
care for them while struggling with substance abuse.
    Right now, the Federal Government recognizes the problem, 
but is focused on punishment. That leaves us, the states, to 
right the wrongs of a war on drugs that has done nothing to 
address the issues that drive this public health crisis, while 
our prisons and our foster care systems are filled to capacity 
with its victims. I have seen it firsthand.
    Prior to becoming governor, I worked as a lawyer 
representing parents and children in the foster care system. I 
watched children come in and out of foster care as their 
parents struggled with substance abuse disorders.
    As children struggled with the foster family they barely 
knew, their parents struggled with addictions that overwhelmed 
our treatment systems. In Oregon, 60 percent of foster children 
have at least one parent with a substance abuse issue, 
including opioids.
    If we can make meaningful change in prevention, treatment, 
and recovery from substance abuse, we can create better lives 
for our families. We can see more success for our students in 
schools. We would lift a burden off our hospitals, and our law 
enforcement, and our prisons.
    In my own family, access to comprehensive behavioral health 
treatments changed the trajectory of addiction. My stepchild 
started abusing drugs in high school. My husband, Dan and I, 
watched him change and felt powerless to do anything about it.
    Eventually, a teacher caught him using at school. Instead 
of kicking him out, she called us. We knew that just trying to 
stop using would not work. His daily routine had become 
centered around getting high. He needed an immersive treatment 
program, but our insurance policy stood in the way.
    He had to go through two separate outpatient and inpatient 
treatments, and relapses, before our insurance would cover the 
residential program he desperately needed.
    Fortunately for us, our family story turned out very 
differently than the Pinsky's, but it taught me how different 
recovery can look for every individual. We need to think about 
it as a process that needs to be tailored to a person's unique 
circumstances and environment, turning away from a failed first 
model. That is something we are working on in Oregon.
    We are also getting more lifesaving overdose drugs into the 
hands of first responders, and implementing creative programs 
to provide a warm hand-off from emergency room to treatment and 
recovery.
    In addition to increasing treatment resources, we need to 
make sure that we are focusing on decreasing stigma as well. We 
must break through the barriers of shame to provide the best 
treatments possible first and the most effective assistance 
now.
    We need to let people know that it is Okay to come out of 
the shadows. That it is Okay to ask for help and that there is 
help that is available for them.
    At the Federal level, there is so much that can and must be 
done: improving data sharing from the Federal to the state 
level, making affordable generic overdose drugs more available, 
and rejecting a punitive approach to addiction.
    Who knows? May be this could have saved Max Pinsky's life. 
We know it can save millions of others.
    Thank you.
    [The prepared statement of Governor Brown follows:]
    prepared statement of hon. kate brown, governor, state of oregon
    Chairman Alexander, Ranking Member Murray and Members of the 
Committee; thank you for the opportunity to speak before the Senate's 
Health, Education, Labor, and Pensions Committee as it continues to 
examine and respond to the opioid crisis.
    Like many states across the Nation, Oregon is in the throes of an 
ongoing opioid epidemic. In Oregon, I will soon declare addiction and 
substance abuse to be a public health crisis, in no small part because 
of the impacts of opioids. We have seen a 400 percent increase in 
opioid use disorder over a 10-year period ending in 2015. Roughly one 
in ten of our young adults aged 18 to 25 have abused opioids. Every 
other day, on average, we lose one more Oregonian due to an opioid 
overdose.
    These numbers are bad enough, but their ripple effects are 
horrific. In Oregon, 60 percent of foster children have parents that 
struggle with addiction in general, which includes opioid addiction. 
Our foster care system has one and a half times more children than the 
national average. If we can make meaningful change in prevention, 
treatment and recovery from opioid abuse, we will better the lives of 
not only these individuals, but of all Oregon families. Our students 
would be more successful, and we would lift the heavy burden from our 
overtaxed hospitals.
    It is important to recognize that large scale changes require first 
steps. Last year, I signed legislation that helps put life-saving 
overdose drugs into the hands of first responders. However, recognizing 
more needed to be done, I convened an Opioid Epidemic Task Force. This 
bipartisan, bicameral group is aimed at providing consensus-based 
recommendations to address the ongoing opioid epidemic. Each chamber of 
the Oregon Legislature is represented by a both a Republican and a 
Democrat. Additionally, the Task Force is comprised of treatment and 
recovery experts, doctors, public health officials and agency 
representatives, among many others. Their thoughtful advice and 
recommendations have become a key portion of my 2018 legislative agenda 
in Oregon, in the form of House Bill 4143 that recently passed the 
legislature.
    House Bill 4143 provides a three-pronged approach to tackling the 
opioid epidemic in the following ways: (1) Establishing a pilot program 
aimed at bridging the gap between an overdose episode and efficacious, 
evidence-based treatment; (2) Requiring that all licensed prescribers 
in the State of Oregon register for the Prescription Drug Monitoring 
Program (PDMP); and (3) Mandating that our Department of Consumer and 
Business Services, working in conjunction with the Oregon Health 
Authority, study barriers to accessing treatment for all Oregonians. 
These important steps will help us not only address the crisis in the 
present, but set Oregon on the right path for badly needed future 
policy changes. This bill is the first step in a long journey.
    In order to properly address this ongoing epidemic, we must employ 
data metrics to make certain we see the right results. Working with the 
Oregon Health Authority, our Task Force is committed to measuring the 
outcomes of this new pilot program. While we want to see deaths from 
overdose decline, we also want to see vast improvement in access to 
treatment, improved insurance coverage and better availability of life-
saving overdose drugs such as naloxone. Some Oregonians must travel 
great distances to access appropriate treatment, something that we must 
improve.
    Two weeks ago, I co-led a session at the National Governors 
Association winter meeting where I heard not only the struggles all 
states share in common, but also how other states have made progress 
through implementing creative approaches. As individual states we 
cannot tackle this crisis alone. That's why Oregon, California, 
Washington and the province of British Columbia are planning to tackle 
this issue as a region. As part of our existing Pacific Coast 
Collaborative, we will work together in sharing best practices and 
identifying opportunities to cooperate.
    Oregon already has a history of interstate cooperation in the fight 
against the opioid epidemic, particularly in the context of drug 
pricing. This is exemplified through the formation of the Oregon 
Prescription Drug Program and the Northwest Prescription Drug 
Consortium with Washington. Important lifesaving drugs such as naloxone 
have seen steep pricing increases from 2015 to the present, in some 
cases as much as 487 percent. These innovative programs have enabled 
Oregonians to benefit from more aggressive prescription drug pricing, a 
result of pooling our drug purchasing. Since 2007, groups that joined 
the Consortium have seen savings on their pharmacy benefit programs, 
more aggressive prescription drug prices, 100 percent pass-through 
pricing on drug costs and manufacturer rebates, lower administrative 
costs and complete program transparency. The Consortium today serves 
over 1,000,000 individuals and purchases in excess of $800 million in 
drugs each year. This program additionally offers aggressive discounts 
to participating programs for substance use disorder treatments.
    Oregon has also joined national Group Purchasing Organizations 
(GPO) to access special class-of-trade pricing for eligible 
institutions. Today, state facilities, public health and other state 
and local entities participate in our GPO arrangements and purchase in 
excess of $50 million annually. We continue to explore new and 
innovative ways that Oregon can leverage the value of pooling our 
resources in order to extract greater benefit from buying in bulk from 
suppliers. This, of course, extends to exploring options for purchasing 
and distributing naloxone and other substance use disorder treatments.
    We have also looked for ways to improve our healthcare system 
through increased efficiency. PDMPs represent an important tool for 
developing best prescribing practices and maximizing ease of use as the 
best way to ensure buy in from professionals. That's why Oregon has 
worked to integrate our electronic health records with our PDMP, thus 
providing prescribers with an important tool to make better informed 
decisions about their patients. This process has already begun with our 
emergency departments, and Oregon has an eye toward full integration 
across our healthcare system.
    Right now, the Federal Government has recognized the opioid 
epidemic but is overly focused on punishment. That leaves us, the 
states, to right the wrongs of a war on drugs that has done nothing to 
address the issues that drive this health crisis, while our prisons and 
our foster care systems are filled to capacity with its victims. I know 
that you have held several sessions on the opioid crisis to date, and I 
applaud this Committee for taking such a close, thoughtful look at the 
issue. There are a wealth of ideas that this Committee has the power to 
turn into reality. As part of this conversation, I ask that the Federal 
Government stop the punitive approach to addiction and begin treating 
substance abuse disorder as the disease it is.
    Oregon looks forward to continued collaboration and dialog with our 
Federal partners, who we are heartened to see take such a keen interest 
in this epidemic.
    Thank you again for the opportunity to provide testimony on this 
important issue.
                                 ______
                                 
                 [summary statement of governor brown]
    Snapshot of the opioid epidemic in Oregon

          Immediate effect

          400 percent increase in opioid use disorder from 
        2005-2015

          1 in 10 young Oregonians aged 18-25 have abused 
        opioids

          On average, one Oregonian a day is lost due to 
        overdose

          Ripple Effect

          60 percent of foster children have parents that 
        struggle with addiction

          Oregon's foster system has 1.5 times the national 
        average

    Proactive actions to address the epidemic

          Signed legislation that put overdose drugs in the 
        hands of first responders last year

          Created a bipartisan and expert-filled Opioid 
        Epidemic Task Force

          Championed a key 2018 legislative bill that recently 
        passed that the task force helped to shape

          Three-pronged approach: (1) new money for a pilot 
        program to provide immediate treatment after an overdose; (2) 
        requiring Prescription Drug Monitoring Program (PDMP) use; (3) 
        mandating a study of barriers to treatment access

    Needs of the state going forward

          Data/information--Oregon prides itself on data driven 
        policy decisions and thus there will be close measurement of 
        the pilot program and more data is needed to properly address a 
        complex and evolving epidemic

          Regional cooperation--Oregon is committed to working 
        with neighboring states and provinces to share information and 
        best practices.

          Reduce Prescription Drug Costs--Oregon has a history 
        of interstate cooperation dating back to the Northwest 
        Prescription Drug Consortium helping to reduce drug costs 
        including naloxone. Oregon also joined national group 
        purchasing agreements to purchase more than $50 million in 
        drugs for state and local entities annually.

          Increased efficiency/integration--Oregon continues to 
        work to integrate our electronic health records with our PDMP

          Value treatment over punishment--Federal Government 
        remains overly focused on punishment when the issues that drive 
        the epidemic require greater treatment focus
                                 ______
                                 
    The Chairman. Thank you, Governor Brown. And thank you, 
especially, for your personal story.
    We will now begin a 5 minute round of questions.
    Senator Isakson.
    Senator Isakson. Thank you both for being here today. We 
appreciate it very much.
    Governor Hogan, in my state, it is estimated by 
professionals that there are 541 million doses circulating in 
my state right now of opioids in Georgia.
    Last year in June, we had an epidemic run where, in 2 
weeks, there were eight deaths from overdoses, and 40 
hospitalizations through middle Georgia where a number of 
percocet pills laced with fentanyl had gotten loose in the 
public.
    You testified on fentanyl in your testimony and I 
understand your state has been dealing with similar problems, 
because fentanyl is a growing magnification of the opioid 
problem.
    What are you doing in Maryland that is working? What can 
you share with us that will help us to work to reduce the 
fentanyl effect?
    Governor Hogan. Thank you, Senator.
    First, the problem started with prescription opioids and we 
put in a region. In fact, we worked together with the District 
of Columbia and Virginia. We did a regional Prescription Drug 
Monitoring Program. We put in legislation to limit the number 
of pills you can prescribe. We were focused on that part of the 
issue and had done pretty well. We were squeezing that down.
    Then, unfortunately, more people were doing heroin because 
they could not get access to the prescription opioids. And 
then, we started to clamp down on the heroin distribution. We 
got this new fentanyl and carfentanil, which is 50 to 100 times 
more deadly than anything else.
    As we have been working on the crisis, it just evolves into 
something else. So we have to constantly be shifting.
    They are lacing not just heroin. They are stealing fentanyl 
directly. But they are also lacing now cocaine and marijuana, 
and people do not know that they are getting fentanyl.
    Some people are seeing out and some people are unaware, but 
it is killing people every day in our streets. We had seven 
people die in one of our wealthiest counties in 1 day.
    I know that you and I shared, I know your story about your 
back surgeries, and I am sure they prescribed opioids to you.
    I went through 18 months of battling cancer in my first 2 
years as governor and I had four or five surgeries. And I know 
one time three different doctors within a matter of weeks 
prescribed me 30-day supplies of three different opioids. That 
cannot happen anymore in our state.
    But the fentanyl, we are really trying to crackdown, but it 
is coming, a lot of it is coming through the U.S. Postal 
Service. It seems like nobody uses the postal service anymore, 
but the drug dealers from China are because they are not 
checking the packages the way the other delivery services are. 
We have to put some Federal funding in that.
    It is now being manufactured or transported and smuggled in 
across the border in Mexico.
    Senator Isakson. Right.
    Governor Hogan. This is actually, we have to do what we can 
from the local level on interdiction, but the Federal 
Government has to step up, keeping it from coming into the 
country.
    Senator Isakson. Would you agree with me that it is not 
totally an addiction problem? It is a one-time problem too 
because fentanyl is so powerful, a person could get one pill. 
They are not an addict. Never were one, but that one pill could 
kill them alone.
    Governor Hogan. Well, there is no question. People that are 
addicts and have fentanyl once are killing themselves. People 
that do not even know are doing it once and killing themselves. 
It is a deadly, deadly thing and it is 50 to 100 times worse 
than heroin.
    Senator Isakson. Governor Brown, I appreciate your 
testimony and I enjoyed our conversation earlier before your 
testimony, and as I told you or shared with you, I lost my 
oldest grandchild to an overdose the day before he was 
receiving his summa cum laude diploma from Georgia Southern 
University in mathematics. It was a one-time occurrence in 
terms of that.
    He had a problem, but it had been years ago. He had been 
clean. He had done everything he needed to do. He was 
rehabilitated and then one exposure took his life.
    The reason I am so big on this is prevention is as 
important as enforcing the law to arrest people to put them in 
jail. I mean, education is the key in this as Governor Hogan 
said.
    I got a first class education myself because of my back 
surgery and the pain management problems you get into there. 
Fortunately, I had heard everything that was going on up here, 
so I knew a lot of things to do and not to do, and Tylenol 
worked pretty doggone well, and hydrocodone can kill you.
    What all are you doing from the education process to get, 
not only those who are circulating the stuff, but to prevent 
people from thinking about even taking it in the first place?
    Senator Brown. Thank you, Senator Isakson, and I am 
terribly sorry for your loss.
    This is one issue that unites all of us regardless of where 
we live or what party we are with. We have had family, friends, 
relatives impacted by substance abuse. I think because it is an 
issue that unites us, we can all work together to tackle it.
    For us, education and prevention are key. We want to make 
sure that our students throughout our schools--Oregon is big, 
but we are small in terms of the number of population. We are 
only 4 million--we want to make sure that our students have 
access to mental health services, comprehensive mental health 
services, behavioral health services in every single school 
across the entire State of Oregon. We think that is key that 
students be able to access therapy and treatment if they need 
it from an early age.
    We also need to make sure we are working hard to educate 
students about the impacts of substance abuse in schools 
throughout the State of Oregon.
    I think the challenge is that these drugs are coming on so 
quickly and they are so dangerous. It is hard to get the word 
out. Certainly, partnering with us at the state level, 
providing resources around education and prevention would be 
extremely useful for us at the state level.
    Senator Isakson. Thank you very much.
    I know my time is up, Mr. Chairman.
    I would point out, though, that the methamphetamine program 
that has now been in place about 4 years to try and stop people 
from getting exposed has paid some dividends. So educating 
people against ever getting into it in the first place can be 
as big a help as stopping somebody from selling it to somebody 
who wants it.
    Thank you.
    The Chairman. Thank you, Senator Isakson.
    Senator Murray.
    Senator Murray. Thank you very much, Mr. Chairman.
    I want to follow-up on Senator Isakson's first question 
because we do know that there is a decrease in opioid 
prescribing, but overdoses are rising, as both of you talked 
about. And just this week, the CDC released new data that shows 
a 30 percent increase in emergency department visits associated 
with opioid overdose and we do know that illicit drugs, 
fentanyl is part of that.
    Mr. Chairman, I am working, and I hope to work with you on 
clarifying some of FDA's authorities at our international mail 
facilities where fentanyl is entering this country. I think we 
need to focus on some resources through our appropriations 
process to deal with it.
    But if either of you have any other ideas, and want to 
submit them to us, I think this is one we have to start getting 
a handle on. So I appreciate both of you commenting on that.
    Governor Brown, I understand Oregon does not allow law 
enforcement access to its State Prescription Drug Monitoring 
Program.
    Can you tell us what decision was made and what the 
implications are for sharing PDMP data with other states?
    Governor Brown. We are just beginning our work with our 
PDMP, and I just introduced legislation, and passed the 
legislature. I have not signed it yet.
    As a result of the work from the Opioid Taskforce, that 
would require our physicians to register with the PDMP. The 
Opioid Task Force is looking at the law enforcement issue.
    The goal for us is to make sure that we have a physician 
registry and that just got done this past couple of weeks.
    Senator Murray. It is not that you are not doing it with 
law enforcement. You want to look at it before you start.
    Governor Brown. Absolutely.
    Senator Murray. Okay.
    Governor, did you want to add anything to that?
    Governor Hogan. Well, I would just add that we are trying 
to look at it from both directions.
    People that are addicted need treatment, and they need 
help, and we are trying to get them the help they need rather 
than go after them on the law enforcement side.
    But the folks that are bringing in these large quantities 
of deadly drugs, knowing that they are going to kill our 
citizens, we are cracking down and getting tougher on those 
folks that are doing much of, not only the drug dealing that is 
killing people, but the shootings in Baltimore City where we 
had 343 people killed last year by gunshot. Nearly all of that 
was opioid-related as well with gangs.
    It has to take a comprehensive approach. It is the early 
education and the prevention, and then it is the treatment for 
the folks who need it, but also cracking down on the people 
that are profiting from death.
    Senator Murray. Over the past couple of years, through the 
actions of this Committee actually, we have increased the caps 
on the number of patients a healthcare provider can prescribe 
buprenorphine and expanded the types of providers who can do 
so.
    Can you both talk a little bit about some of the benefits 
from increasing the caps on MAT's and providers? Is there more 
you think we can do to increase those caps further?
    Governor Brown.
    Governor Brown. Thank you, Senator Murray.
    Yes, we think having access to evidence-based treatments is 
the most effective approach. And my understanding is that a 
Medically Assisted Treatment can be extremely effective.
    One of the challenges that we face in this arena is that 
the data--in terms of the physicians that are able to prescribe 
Medically Assisted Treatment--is not available to the states. 
It would be extremely useful if we could access that 
information.
    Senator Murray. It is not available because?
    Governor Brown. It is my understanding that we are not able 
to access which physicians are prescribing Medically Assisted 
Treatment.
    It is a challenge, as you might imagine, particularly in 
our rural communities where we have limited access to 
treatment. We cannot access that information for rural Oregon 
and make sure that folks get the treatment that they need.
    Senator Murray. Governor Hogan.
    Governor Hogan. Yes, I would agree with Governor Brown that 
we do need help from the Federal Government on expanding 
Medically Assisted Treatment. That is the only way that you can 
get people off these drugs. It is the most effective way to 
break these addictions.
    On the NARCAN-Naloxone front, we have opened them up. You 
no longer need a prescription. They are available in every 
pharmacy and drugstore across our state. We have tried to 
provide them to every single first responder, police officers, 
fire department officials, people in the emergency rooms, and 
it is saving lives temporarily.
    Senator Murray. Right.
    Governor Hogan. But the same folks are showing up over and 
over again in our emergency rooms.
    Senator Murray. Yes, it is the MAT side of it that we are 
not getting.
    Governor Hogan. Yes.
    Senator Murray. Okay. Go ahead.
    Governor Brown. Senator Murray, thank you.
    The only other thing I would add in terms of treatment, one 
of the new, innovative policies that we are moving forward on--
it was legislation that I just passed at the request of my 
Opioid Task Force--is making sure there is a warm handoff.
    Folks go into emergency rooms having overdosed. We have 
just saved their lives. What I have heard is that they go to 
the next room, the next bathroom and end up using right away.
    One of the innovative pilot programs that we just funded is 
a program to ensure a warm handoff, that we can have a peer 
mentor in the emergency room to help people get directly into 
treatment and recovery. We think that will be a creative 
approach to enable folks to access treatment immediately.
    Senator Murray. Thank you very much. My time is up.
    The Chairman. Thank you, Senator Murray.
    Senator Young. I am sorry. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    I know we look a lot alike.
    [Laughter.]
    Senator Collins. In all seriousness, thank you very much 
for holding this series of really important hearings from what 
is a public health crisis and also a crisis for families all 
across this country. As Governor Brown pointed out, there is no 
place that is immune.
    Governor Hogan, I wanted to start with you. This month, as 
we have been tallying up the numbers from 2017, we have been 
hit by a series of heartbreaking statistics.
    Just a few weeks ago, we learned that last year, drug 
overdoses killed a record 418 people in the State of Maine. 
That is an 11 percent increase. So we are going in the wrong 
direction.
    Then this week, the CDC announced that in Maine, emergency 
visits for opioid overdoses jumped by 34 percent last year.
    In the past 3 years, the number of people in Maine who died 
by drug overdoses has doubled. And at the same time we, at the 
Federal level, have increased funding and Federal efforts year 
after year to combat this crisis.
    My question to you is what are we not doing right? You 
talked about the multipronged approach, that I totally agree 
with: the education, prevention, treatment, and enforcement. 
We, due to the leadership of this Committee, have poured a lot 
of money into all four of those categories.
    What is it that we are not doing right?
    Governor Hogan. Well, Senator Collins, thank you.
    We ask ourselves that same question nearly every day. I 
mentioned in my testimony at the beginning that we were ahead 
of the curve focusing on this issue going back to 2014, and we 
immediately took every action that anyone could think of from 
every direction, and put half a billion dollars into it, in our 
little state, in state money.
    Then we created the first state of emergency where we stood 
up our emergency operations center to coordinate every single 
state, and Federal, and local agency to provide real time 
assistance in all these different directions.
    As I said, we made slight improvements in prescription 
opioids and in heroin. But because of these new synthetics, 
fentanyl and carfentanil, we still had more people die, and we 
had nearly 2,000 people die in our state and a 70 percent spike 
in this new drug that no one knew anything about.
    I mentioned a few things, but I think more coordination and 
more cooperation from the Federal Government with the state and 
local, so we all know what we can each do to collectively make 
this happen.
    I think we do need more Federal funding with some 
flexibility for each state, how they can utilize these funds 
depending on how the issue is shifting and where they are at 
that point.
    In talking with Governor Brown, fentanyl is not yet a big 
issue in Oregon, but I believe it will be. Other things are 
starting on the West Coast and coming out to us.
    I talked to other governors. We had all the Nation's 
governors together last week at NGA, and there were people 
talking about how crystal methamphetamine is now reviving in 
their states, and they are lacing that with fentanyl. They do 
not even have opioids and heroin. But I think it is going to 
take all of us working together.
    You are right. The Federal Government, and your Committee, 
has been on top of this issue. It has been a focus and I know 
that there was a taskforce put together with a lot of smart 
people with lots of recommendations. But it is going to need 
Federal funding.
    I think the STOP Act on fentanyl, so we can interdict, is 
important. The Opioid Response Enhancement Act, the 
Comprehensive Addiction and Recovery Act, the CARA, Synthetic 
Trafficking and Overdose Prevention Act; there are many good 
pieces of legislation in the House and the Senate that should 
be passed, and they are coming from both sides of the aisle in 
both houses, and they all ought to be considered because we 
have to look at this thing from every direction.
    Senator Collins. Thank you. My time is nearly expired, so 
Governor Brown, I will submit a question to you for the record.
    But just so you know what it is going to be about, you 
mentioned that lifesaving drugs such as naloxone have seen 
exorbitant price increases in the past 3 years, in some cases, 
as much as 487 percent.
    For the record, I am going to ask you to explain what your 
state is doing to try to combat those huge price increases 
which limit the availability to first responders.
    Senator Collins. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Collins.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    Thank you both for being here today.
    Far too many families in Massachusetts, and all across the 
country, have had to bury someone they love because of this 
opioid crisis; more deaths, more funerals. But this crisis did 
not happen overnight and it did not happen on its own.
    A big reason it happened is because the biggest drug 
companies in the country pushed powerful and addictive pills, 
lied about how addictive those pills were, and made billions of 
dollars doing it.
    I think it is time to start talking about holding these 
companies accountable and holding their executives accountable 
for the crisis they helped create.
    In Massachusetts, Attorney General Maura Healy is helping 
lead a bipartisan coalition of 41 states investigating drug 
manufacturers and distributors for their role in the opioid 
epidemic. More than 30 cities and towns in Massachusetts have 
already filed lawsuits, and a number of Native Tribes, 
including the Cherokee Nation, have also sued in both Tribal 
and Federal Courts.
    Let me ask this. Governor Hogan, Maryland is also part of 
this investigation. Baltimore and several county governments in 
Maryland have filed lawsuits against manufacturers and 
distributors.
    Do you agree that part of tackling this crisis is holding 
these companies accountable?
    Governor Hogan. There is no question about that.
    We have directed our Attorney General, Brian Frosh, to also 
take action and to sue some of these pharmaceutical 
manufacturing companies. There is liability. Some of them 
knowingly pushed the sale of some of these drugs knowing that 
they had these addictive capabilities and did not disclose it.
    You cannot paint all of the people that were trying to help 
people with pain with a broad brush, but the ones who were 
doing these things definitely should be held accountable. I 
agree with you. Absolutely.
    Unfortunately, we can take those actions, and we should, 
but it is not going to stop the people that are dying on the 
streets.
    Senator Warren. Yes, I understand. But the investigation is 
ongoing and we should let the attorneys general do their work 
on this.
    But if it turns out that the drug companies broke the law, 
lied about it, and hurt people in order to rake in profits, it 
will not be the first time on this.
    A few years ago, a corporation called INSYS Therapeutics 
made a spray out of fentanyl, a power opioid. The FDA told the 
company that its spray was approved only for use in cancer 
patients who were in such pain that other drugs like morphine 
just were not enough to control that pain.
    But it turns out, there just were not enough of these 
cancer patients for the company to make buckets of money. And 
so, it started illegally marketing the drug to people with 
milder forms of pain and bribing doctors to overprescribe it.
    A lot of states sued INSYS, including Massachusetts. Oregon 
was the first state in the country to reach a settlement and it 
forced the company to pay up. So Governor Brown, that 
settlement occurred a few months after you took office in 2015.
    Has the money that Oregon recovered from INSYS helped the 
state fight the opioid epidemic?
    Governor Brown. Absolutely. Thank you for the question, 
Senator Warren.
    We received a little over $1 million. Over half of it went 
directly to opioid substance abuse treatment and recovery. A 
portion of it went to Oregon Health Sciences University. They 
are a world renowned research medical university and they are 
doing incredible work. And I was very pleased with how the 
dollars were targeted.
    Senator Warren. Good. I am glad to hear it, because here is 
the thing. When a company breaks the law, it is because the 
people running the company broke the law.
    A few months ago, the Department of Justice announced that 
the founder and owner of INSYS, along with six top executives, 
had been indicted for fraud and racketeering because of their 
actions. So let me ask you this, Governor Brown.
    Do you agree that CEO's deserve to be held personally 
accountable when the companies they run break the law and hurt 
people?
    Governor Brown. Senator Warren, in egregious cases like 
INSYS, absolutely. But obviously, these cases need to be taken 
on a case by case approach. This was a particularly egregious 
case and people should be held personally accountable.
    Senator Warren. I agree on this one. This crisis is not a 
Democratic or a Republican issue, and neither is holding drug 
companies accountable.
    The Department of Justice announced last week, they are 
forming a taskforce to target opioid manufacturers and 
distributors that have contributed to the epidemic, and I am 
very glad to see it. I think it is important.
    Families and communities have already paid an enormous 
price for this crisis, and it is time to start holding 
companies and their CEO's accountable.
    Thank you both.
    The Chairman. Thank you, Senator Warren.
    Senator Cassidy.
    Senator Cassidy. Thank you, Chairman, and the Ranking 
Member for holding these series of meetings highlighting both 
the statistics, but also the individual families, and that is 
what we are here for.
    Governors, thank you all for being here. Thanks for being 
frontline and finding solutions.
    I want to agree with using the PDMP data. We have a bill 
included that would encourage states to proactively share this 
with law enforcement.
    Governor Brown, you have mentioned that; I think you said 
that is your goal. But Governor Hogan, I do not know that 
Maryland does not proactively share with law enforcement. I say 
that not to accuse, but rather to ask.
    Why not and what can we learn from the difficulties of 
implementing this program?
    Governor Hogan. Well, I think we have to be careful about 
the sharing of information. We want to protect the folks that 
actually have drug addictions and not treat them just as law 
enforcement cases. That is what we were talking about all the 
treatment, and all the other education, and prevention.
    Senator Cassidy. Now, if I may.
    Governor Hogan. Yes.
    Senator Cassidy. The way I see this is not so much that you 
would track folks down who are addicts. Rather, you would track 
down pill mill doctors and pharmacies which are knowingly 
overprescribing and for pharmacies which are not aware that a 
patient is going from pharmacy to pharmacy to pharmacy, and 
doctor-doctor-doctor in order to aggregate.
    Governor Hogan. Yes, we are doing exactly that, actually.
    I was just talking with our czar who is heading up this 
entire emergency operation that we have declared and we are 
shutting down pill mills all across the state, and certainly 
would be happy to share that information across state lines.
    Senator Cassidy. Now, let me ask. Again, not to interrupt, 
but I just have such limited time.
    What are the lag times, in each of your states, between 
someone getting a prescription filled and it showing up on your 
PDMP? I say that because I spoke yesterday to Walgreens and 
they said in most states, it is at least 5 days, at which 
point, some doctor-shopping patient can go to five different 
pharmacies.
    Governor Hogan. I do not know the exact time, but we will 
get back to you with that information, but we did boost the 
enforcement capabilities, and we are trying to go after it as 
fast as possible.
    Senator Cassidy. I have to ask you a question. If your czar 
were a woman, would she be a czarina? Just to ask that.
    Now, let me also ask because Senator Murray and I have both 
discussed, in different settings, the limitation because, 
apparently, there is a huge lag time as Walgreens reports.
    Would you agree that the ideal system would have real time 
upload of prescriptions being written, capturing people from 
all states and capturing people who are paying cash?
    Governor Hogan. I think that is exactly what we are doing 
in the Washington Metropolitan region with Virginia, DC, and 
Maryland.
    Senator Cassidy. My only concern is your PDMP probably has 
a lag time. According to the pharmacists, that can be up to 
five maybe even 2 weeks; 5 days, 2 weeks.
    Governor Brown. Senator Cassidy, in terms of Oregon, the 
legislation just passed 2 weeks ago. I have not signed it into 
law yet in terms of requiring physician registration with the 
PDMP. So our time frames, we will get that to you as soon as we 
have any available evidence.
    In terms of connecting with law enforcement, that is 
something we want to take a look at. I think it is going to be 
critically important.
    One of the tools that we think is going to be extremely 
effective, in terms of the PDMP, is that we now have a good 
electronic records health system. We are able to connect the 
PDMP with electronic health records----
    Senator Cassidy. Can I interrupt?
    Governor Brown.----In our emergency rooms.
    Senator Cassidy. Are vendors cooperating with that?
    Governor Brown. Yes, so far, yes. But like I said, the law 
was just passed 2 weeks ago, so I have not even signed it into 
law yet.
    Senator Cassidy. The Chairman and the Ranking Member have 
intense interest in EHR's, as do I, so if you can give us 
feedback on whether or not that is collaborating, we would like 
that.
    Can I move on? Not to be rude, but just because there is so 
much to ask you.
    You all are implementing treatment programs. Not all 
treatment programs are equal. Some are very effective; some 
have high rates of recidivism.
    How do you decide which programs to use? And how do you 
monitor whether or not they are a good program or there is a 
high rate, not of recidivism, but rather of relapse?
    Governor Brown. Senator Cassidy, I will be signing an 
executive order in the next few days, asking for a 
comprehensive, strategic plan regarding our treatment program 
statewide.
    Seventy-four percent of the people in treatment for 
substance abuse are on the Oregon Health Plan. So one of the 
challenges is making sure every one has access to healthcare 
and that we have comprehensive----
    Senator Cassidy. Let me ask, because when I speak to 
providers, and I say this statement, their heads nod. There are 
some that are merely combing jails, finding people on Medicaid 
to bring them out and to put them into a treatment without 
follow-up and with high rates of relapse. And there are others 
who do it right. You say that to providers, they nod their head 
yes.
    How do you sort those from those?
    Governor Brown. Senator Cassidy, we are going to use 
evidence based in terms of our treatment and that is why we 
think Medically Assisted Treatment is so effective because 
there is evidence that it works.
    Senator Cassidy. I am out of time; much to ask, but no more 
time.
    I yield back. Thank you.
    The Chairman. Thanks, Senator Cassidy. If you want to stick 
around, we will have a second round, if you would like to do 
that.
    Senator Hassan.
    Senator Hassan. Well, thank you, Mr. Chairman and Ranking 
Member Murray.
    Thank you, Governors Hogan and Brown, for being here.
    Thank you, Governor Brown and Senator Isakson, too, for 
being brave to speak about your personal stories as they 
connect to this epidemic.
    Other Americans have been speaking up, being brave, and 
sharing their stories, too. So I just would like unanimous 
consent to enter some narrative and some photos from this 
week's ``Time'' magazine called, ``The Opioid Diaries.'' It is 
compelling and I think the pictures, in particular, capture 
what is happening in our country because of this epidemic.
    With unanimous consent, I would like to enter some of those 
photos into the record.
    The Chairman. It is so ordered.
    Senator Hassan. I want to return to the issue of Medication 
Assisted Treatment in a minute, but I want to touch on 
something that we have not talked about that much yet.
    I believe that strategies to address the opioid epidemic 
need to be thoughtful. They need to be long-sighted and 
multifaceted because while we talk about this as a crisis, we 
now have a generation's worth of work to do before we begin to 
truly turn ourselves around from the impact of this health 
epidemic.
    It is not something we can fix overnight. So while the $6 
billion we secured in the bipartisan budget agreement is a 
start, we know that we ultimately need far more funding beyond 
this to truly address this crisis.
    I am going to keep fighting to make that happen. I know a 
lot of people here are doing that as well.
    The National Governors Association recommendations for 
Federal action to end the Nation's opioid crisis, recognizes 
the need to increase Federal investments. During my time as 
Governor of New Hampshire, I worked with Governor Baker to 
develop the first NGA recommendations on the epidemic, which 
similarly noted the need for additional resources.
    The bipartisan consensus among governors on the need for 
increased resources highlights just how serious this epidemic 
is. I have made this point in our other opioid hearings and I 
will make it again.
    We have to make sure we are making robust, sustained 
investments to stop this epidemic; investments to support those 
on the frontlines of this crisis and investments in prevention, 
treatment, and recovery.
    To that end, governors, what would additional funding mean 
for your efforts on the ground?
    Governor Brown, why do I not start with you?
    Governor Brown. Thank you, Senator Hassan.
    In terms of additional resources, I think they would be key 
for making sure that we have affordable, generic overdose drugs 
available to all of our first responders. That is huge. It is 
an issue for us. And having additional resources would be key.
    Making sure that we have access to comprehensive behavioral 
health treatment, and effective substance and alcohol abuse 
treatments; that is how our dollars would be focused.
    Senator Hassan. Thank you. Governor Hogan.
    Governor Hogan. Senator Hassan, I agree with you that we 
need more Federal funding. And not to say that $6 billion is 
not a lot of money; it is to the taxpayers. But it is a drop in 
the bucket compared to what we actually need.
    I mentioned earlier, our small, little State of Maryland, 
we have already spent half a billion dollars in state funds.
    Senator Hassan. Yes.
    Governor Hogan. $6 billion stretched across the country is 
not going to go very far. But we need it from different places 
and for different reasons. Medically Assisted Treatment, we 
talked about. Long term, you mentioned.
    It is not just the immediate crisis, but it is the long 
term recovery support services that we are going to need a way 
to pay for.
    Senator Hassan. Such as housing, for example.
    Governor Hogan. Exactly. So it might be additional funding 
in multiple different departments' budgets. This is not just a 
health issue.
    Senator Hassan. Yes.
    Governor Hogan. Or just an education issue or just a crime 
prevention issue; it is across almost everything you are 
funding.
    Senator Hassan. Well, I appreciate that. The cost to New 
Hampshire in 2014 economically was $2 billion. The cost to our 
country in 2015 was $504 billion from this. That is the 
economic impact of this crisis. So I agree, $6 billion, while 
it is a lot of money, is not going to do the trick.
    Just quickly on the Medication Assisted Treatment, and if I 
am around for a second round of questions, I will go into it 
more, but SAMHSA does have a buprenorphine practitioner locator 
on its website by state and by ZIP Code even. So that may be of 
assistance.
    I have a bill, and I will provide it to you, that would 
provide grants to medical schools to develop curricula around 
Medication Assisted Treatment. Standardize those curricula so 
that, as people are learning about prescribing opioids, they 
can also learn about addiction and treating addiction.
    If we can standardize those curricula, and agree on some 
basic credentials for it, that would allow them to 
automatically get the kind of waiver that they need to become 
practitioners in this field wherever they decide to go 
practice.
    I am hopeful that will help us with the volume of 
practitioners because in New Hampshire, it is a great need and 
I am hearing from you it is too.
    Governor Hogan. Yes, I would agree with that completely, 
Senator.
    Governor Brown. Absolutely, thank you.
    Senator Hassan. Thank you, both.
    The Chairman. Thank you, Senator Hassan.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Thank you for this very important hearing.
    Thank you, Governors, for your appearance here today, but 
also for participating with the broader group of governors 
around the country to focus on this issue.
    Senator Cassidy has raised the fact that not all treatment 
is equally effective. And in far too many places and cases, we 
simply do not have the treatment facilities available. Alaska 
is a pretty sad case in point, unfortunately.
    While we are getting more treatment beds, our reality is we 
have eight detox beds in the state for opioids. We have more 
detox beds for alcohol, but our reality is it is pretty dire 
and pretty desperate for somebody who is addicted and decides 
that they are ready for treatment. Where do you go? How do get 
the services?
    A question for you, in either Oregon or Maryland, within 
your jails, are there any treatment programs for addiction 
within your facilities?
    Governor Hogan. Yes, it is an important part of the program 
because people enter jail addicted. They leave jail addicted. 
We are hitting that from a number of different directions.
    First of all, we had some corruption in our prison system 
where jail guards were smuggling drugs into the prison 
population, and we have indicted 100 people in that scandal by 
rooting out that corruption.
    But we have also increased the dollars, the funding, and 
the number of treatment beds and options for prisoners because 
getting them the help they need while they are in prison makes 
a big difference.
    We have a problem, though. We have these 8-507 beds, as we 
call them, that judges can send people to a treatment bed 
rather than jail. These are supposed to be for the nonviolent 
offenders who really need help.
    We have our judges now, there was a huge, front page expose 
in the ``Baltimore Sun'' yesterday about judges sending 
hardened, repeat violent criminals to the 507 beds. And so, the 
people that really need the treatment are not getting them.
    The people that really should be in jail for a long time 
are getting out, and they are sentenced to a 10 or 20 year 
sentence, and they are getting out in a year or two after they 
have received the treatment.
    We have to look at it from all directions.
    Senator Murkowski. But it is a program that, from the 
state's perspective, having those individuals, again, who need 
that treatment. They are there. You do not need to build a 
standalone facility on the treatment side. They are getting the 
treatment program within the jail itself.
    Governor Hogan. It is very effective.
    Senator Murkowski. Yes. Governor Brown.
    Governor Brown. Senator Murkowski, yes, we are.
    But I cannot say that every one of our adults in custody 
has access to the substance and alcohol abuse treatment that 
they need. We simply do not have the resources to provide it.
    We now have 14,733 adults in custody right now. The vast 
bulk of them, as you probably are aware, are suffering from 
some type of substance and alcohol disorder, as well as some 
type of mental health issue.
    We have really focused on tackling it at the front end, in 
terms of our law enforcement system. A number of our state 
courts have drug courts that have been extremely effective. We 
also recently reduced possession of a controlled substance, 
small amounts, from a felony to a misdemeanor because of the 
significant impacts, particularly on African-American and 
Latino men in our state.
    But certainly, we would like to have substance abuse 
treatment available to everyone that is in custody.
    Senator Murkowski. Let me ask you, Governor Hogan. You just 
mentioned that you spent about half a billion dollars that the 
State of Maryland has put for treatment, education, prevention, 
and enforcement.
    Can you break that down? I always think that the more that 
we can put in prevention, the less we have to put in treatment. 
But for purposes of your spending, how does that break out?
    Governor Hogan. Most of the funding goes into treatment, 
probably less on education. But we have also put into 
interdiction and crime fighting, because you have to do both.
    We have a situation in our largest city where, as I 
mentioned, 343 people were shot. A thousand people are killed 
by overdoses. We got tougher. I passed the biggest criminal 
justice reform bill in Maryland in a generation, which lowered 
sentences for certain crimes, but also toughened sentences for 
people who commit a crime with a gun; people who are repeat 
violent offenders because we have to get them off the streets.
    We just had a very successful kind of surge in Baltimore 
where we sent in 500 state and Federal officers and arrested 
500 people, including 289 of the most violent repeat offenders. 
Those are the folks that we want to get off to jail.
    All of these things require funding, but most of our money 
goes into treatment. But we are spreading it out to wherever 
the need is and no matter how much we spend, it does not seem 
to be enough.
    Senator Murkowski. Thank you, Mr. Chairman.
    I am out of time, but I appreciate the responses and your 
leadership.
    The Chairman. Thank you, Senator Murkowski.
    Senator Smith.
    Senator Smith. Thank you, Mr. Chairman and Ranking Member 
Murray.
    Governor Hogan and Governor Brown, it is wonderful to have 
you here. Governor Brown is from Minnesota originally, and so I 
am very happy to see you here today.
    Governor Brown, you mentioned in your testimony about how 
this opioid epidemic touches every one of us in one way or 
another. It does not matter whether you are rich or poor, or 
you live in rural communities or urban communities. I certainly 
know that is true in Minnesota.
    Also, we see in our Tribal communities in Minnesota a 
particular challenge. I know that this is true in many of our 
states, including Alaska as well.
    When I was Lieutenant Governor, I helped to convene a 
Tribal Opioid Summit so that we could benefit from the 
learning, and the understanding, and the strength, and the 
cultural resources of tribal communities.
    Mr. Chairman, this November, the Indian Affairs Committee 
held a roundtable with witnesses, including representatives 
from the White Earth MOMS program in Minnesota, talking about 
the challenges of coordinating with tribal communities.
    I would like to ask unanimous consent to submit this 
transcript for the record.
    The Chairman. It is so ordered.
    Senator Smith. Thank you.
    Senator Smith. Governor Brown, could you talk a little bit 
about what you are seeing in Oregon and what you are hearing 
from tribes in Oregon about this issue?
    Governor Brown. Thank you, Senator Smith.
    We have nine federally recognized tribes in Oregon. Our 
tribes feel the impacts of historical trauma on a regular 
basis, and the consequences and the high rates of substance and 
alcohol abuse on our tribal communities, on our Reservations.
    We have on some of our Reservations very high unemployment 
rates. Warm Springs, for example, over 50 percent, and the 
substance and alcohol abuse is very, very high.
    I think what is really important is to make sure that we 
are not doing a one size fits all approach. And so, we worked 
closely with the tribes at a number of levels. I have good 
working relationships with our tribal chairs and with their 
health policy advisors.
    We meet annually in a government to government summit, but 
we also have cluster meetings on a quarterly basis to make sure 
that we are working hard to collaborate around this issue.
    One of the most successful programs has been the Native 
American Rehabilitation Association, a long time, culturally 
competent program designed to meet the needs of our tribal 
communities, and they have had very good and effective results.
    But I think it is really important that we look at it in a 
comprehensive way, that we provide wraparound services for the 
families that are struggling. We cannot just treat the 
underlying substance abuse issue. We need to treat the other 
issues that follow that: the homelessness, the lack of 
employment, those other issues as well.
    We are finding, in our tribal communities, that a 
wraparound approach can be extremely effective.
    Senator Smith. Thank you. Thank you very much.
    I think that sounds like a great model and a very important 
way of thinking about this.
    In just the little bit of time that I have left, I would 
like to touch a little bit also on this connection between 
substance abuse and behavioral health, and how we need to make 
that connection more firmly.
    I think it also relates to this tendency that we have where 
we focus on one crisis, while another crisis is developing. You 
spoke about this, Governor Hogan, in your comments.
    I am wondering if each of you, in just the little bit of 
time that I have, could just talk a little bit about what we 
can do at the Federal level to avoid that and try to have more 
of a long term sustainable strategy that addresses all of these 
``diseases of despair,'' as some of our friends in the public 
health community call them.
    Governor Hogan. Well, Senator Smith, I agree with that.
    I think at the Federal level, we have to focus on mental 
health and substance abuse issues together because, in many 
cases, they are overlapping. And those are the two issues that 
almost everyone in our prison system has: mental health or 
substance abuse issues are responsible for a lot of the crime 
that we are dealing with. It is tearing apart families.
    We should not look at them separately. They are different 
problems, but we need more coordination and funding for both.
    Senator Smith. Thank you.
    Governor Brown.
    Governor Brown. Thank you. I absolutely agree.
    I think we need to reduce the stigma related to substance 
and alcohol treatment, and I appreciate Senator Isakson coming 
forward and sharing his family's story.
    I think it is also critically important that we expand 
access to comprehensive behavioral health treatment. And the 
only way you can do that is to make sure that everyone has 
access to healthcare.
    I just want to share again, 74 percent of those diagnosed 
with opioid disorder rely on the Oregon Health Plan for 
treatment. We could not be providing treatment without the 
Oregon Health Plan and it is a comprehensive behavioral 
approach.
    Senator Smith. Yes. I know I am out of time, but I also 
just have to add that we have laws about mental health parity, 
yet we know that we are not living up to the promise of that 
legislation.
    Governor Brown. Thank you.
    The Chairman. Thank you, Senator Smith.
    Let me ask as couple of questions. We often have good ideas 
presented to us, and then we have a spirited discussion here, 
and sometimes differences of opinion about whether the Federal 
Government ought to do the good idea or whether the state 
government ought to do the good idea. And as a former governor, 
I have a bias in that respect.
    But I wanted to get your advice for us about some good 
ideas we have heard and to what extent the Federal Government 
should do it, or to what extent the states should do it, or how 
should we do it together?
    For example, and you have mentioned this, curriculum. I 
mentioned I dropped by Governor Haslam's meeting with heads of 
institutions that train doctors. They were talking about a 
different curriculum for each of those medical institutions so 
that doctors would have a better understanding about how to 
prescribe opioids.
    Should that be done from Washington or should that be done 
in the states?
    Another example would be Prescription Drug Monitoring. 
Senator Cassidy asked some questions about that. Forty-nine 
states have a Prescription Drug Monitoring system, and we have 
had a variety of suggestions about how to make those more 
effective.
    One proposal is that we have a Federal Prescription Drug 
Monitoring outfit--in addition to the state organizations--
housed at the Department of Justice.
    Another is that we help states do a better job of 
connecting interoperability.
    Another is that we establish Federal standards about how 
states should set up their systems.
    What should we do about Prescription Drug Monitoring from 
here?
    Another example is e-prescribing. Many witnesses have 
suggested that is a very good thing to do, and seven or eight 
states have already taken steps to do that, some in different 
ways.
    Is that something we should do from here or something that 
states should continue to explore and do?
    Then finally, limits on prescriptions. In an effort to try 
to avoid overprescribing, about half the states, in different 
ways, have limited the doses of opioids that a doctor may 
prescribe. Some say three, some say seven, some say ten pills. 
It has been suggested that we ought to have Federal rules about 
that.
    In terms of curriculum, Prescription Drug Monitoring, e-
prescribing, limits on opioids, what is your advice about the 
division between the Federal responsibility and what states 
ought to do?
    Governor Hogan.
    Governor Hogan. Well, Mr. Chairman, those are all really 
difficult and important questions.
    Typically, I agree with you. I am a states' rights guy, and 
I believe that much of the innovation is happening out in the 
states. I like the flexibility of states being able to do what 
they feel is right for their own individual state.
    But some of these things, I think the Federal Government 
needs to play a role. We are a small, border state. Some of 
these issues that we may be trying to address in Maryland do 
not really help if somebody goes into Washington, DC. to buy 
heroin or they cross over the border into Virginia.
    The Chairman. But any specifics, for example, on 
prescription drug monitoring? Do you think we need Federal?
    Governor Hogan. It has been working in our state and it has 
been working in the region. I do not know why it would not work 
if there was, at least, some standards from the Federal level.
    The Chairman. What about e-prescribing?
    Governor Hogan. On e-prescribing, it is worth taking a look 
at, too, because the state cannot really control what is 
happening across the Internet.
    What is the other one? You mentioned a couple of others. I 
am sorry.
    The Chairman. Well, curriculum, limiting the doses.
    Governor Hogan. On the limiting the doses, I know 
Massachusetts just recently passed a 3-day limit. We pushed for 
a 7-day limit in Maryland.
    The Chairman. Right.
    Governor Hogan. I think limiting the doses is important, 
but many of the states are already taking those actions.
    The Chairman. Governor Brown.
    Governor Brown. Senator Alexander, I do not know that I 
disagree with anything that Governor Hogan said.
    There are two areas that I think the Federal Government can 
be most effective and that is we are doing some pooling with 
the State of Washington around reducing drug costs. To the 
extent that the Federal Government can assist us with making 
sure that we have generic overdose drugs available and 
affordable that would be absolutely key.
    The other area where I think that the Federal Government 
can assist is around a more comprehensive approach to pain 
management. From my perspective, obviously, the opioid crisis, 
part of it results in our challenge in this country in dealing 
with effective pain management.
    Certainly, we have work happening at our research 
institutions around this arena. But for us, to be able to see 
what is happening across the country would be absolutely key.
    I recently appointed Esther Choo, a well-renowned 
researcher from Oregon Health Science University, to head our 
Cannabis Commission. We are just beginning to take a look at 
the data there. It is just beginning the research.
    But I think we could sure use the support of the Federal 
Government around comprehensive pain management strategies for 
our people.
    The Chairman. Thank you, Governor Brown.
    We will go to Senator Kaine.
    But we have encouraged--this Committee--Dr. Collins at the 
National Institutes of Health to accelerate research on non-
addictive pain medicine and management strategies. Senator 
Murray and I have introduced legislation to allow him to move 
money around in a way to accelerate that. So that is very 
helpful.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chairman.
    Thank you to the witnesses.
    In 2016 in Virginia, 1,460 people overdosed; 80 percent 
were an opioid-based overdose. The thing that is really tragic 
about that is that was a 38 percent increase in the O.D. deaths 
from 1 year before, 2015, even though we had been paying 
attention to it. So it was not increasing because we were not 
paying attention. To the contrary, our governor, Governor 
McAuliffe had an opioid taskforce.
    We were debating and passing CARA. We were having endless 
hearings. Books are being written, ``Dreamland: The True Tale 
of America's Opiate Epidemic,'' and others. And with all eyes 
on it, the O.D. deaths still went up by 38 percent, largely 
because of the potency of fentanyl. So this details the 
magnitude of our challenge.
    We have a wonderful journalist in Virginia, Beth Macy. We 
heard from Sam Quinones recently who wrote the book 
``Dreamland.'' Beth is a great journalist who is writing a book 
about opioids in Appalachia. The working title of the book is, 
``Dopesick: Dealers, Doctors, and the Drug Company that 
Addicted America.''
    She points out something that just widened my thoughts 
about the magnitude of the challenge. She was interviewing a 
teacher who works as a summer counselor at a camp and has for 
decades. And says when he started working as a counselor at a 
camp, the campers would come in, and some would have 
medications they were supposed to take during the week. It 
might be asthma, but it was just a handful.
    But now he talks about the kids who come. They are 11 or 12 
years old and so many of them are bringing medications, not 
just asthma, but ADHD, and all kinds of other medications.
    This was an observation, not a scientific study, but the 
individual was asking whether we are just so normalizing pills. 
Not just as a pain management strategy, but normalizing at a 
younger and younger life that pills are what you take whether 
it is to your summer camp, or pills dumped into a hat and 
passed around at a party, or pills prescribed for pain 
management.
    This demonstrates the magnitude and the complexity of what 
we are dealing with. I want to thank both of you for the work 
that you have done and especially Governor Brown.
    My brother and sister-in-law live in Oregon and they are 
both involved in substance abuse prevention, suicide prevention 
activities in the state, and they are big fans of yours.
    Governor Brown, you talked about foster care and I want to 
ask each of you about that. In Virginia, we are seeing a 
tremendous increase in the number of children who come into the 
foster care system because their parents are either disabled, 
or in jail, or died because of opioid overdoses.
    Talk a little bit about what you are seeing in foster care 
in your own state and are there things that we could do to be 
helpful in foster care policies as you are dealing with this 
challenge?
    Governor Brown. Thank you, Senator Kaine.
    As a lawyer, I represented children and parents in the 
foster care system. I saw the havoc that substance and alcohol 
abuse wreaked on our families. Sixty percent of our children in 
foster care have one parent struggling with a substance abuse 
issue.
    I have to say a shout out. I mentioned the foster families 
that are caring for these children. A lot of the foster 
families are grandparents, and I want to say thank you to the 
grandparents that are just doing an extraordinary job taking 
care of their grandchildren across the country.
    The other thing that we are doing, and I just met on Monday 
at our governor's residence with what we call the three 
branches of government. We had our judicial branch, our 
executive branch, and our legislative branch there to tackle 
the issues that we are facing in our foster care system because 
of the growing numbers of children being placed in foster care 
due to the substance abuse issues.
    I think it is so critical that we work together, that we 
work collaboratively. Some of our courts have created a one 
family court, so if there is a drug issue, a domestic violence 
issue, a juvenile court issue that one judge is dealing with 
the whole family one judge at a time, one family at a time. 
That has been a very successful model, and we hope to share it 
with the rest of the country.
    Senator Kaine. Governor Hogan, how about foster care issues 
in your state?
    Governor Hogan. Well, thank you, Senator Kaine and your 
opening comments about Virginia. We were working very well with 
Governor McAuliffe, and we both had great ideas, and we both 
focused on it, and we both had increases.
    Senator Kaine. Yes.
    Governor Hogan. The frustrating part is just imagine if we 
had not taken all the steps we have taken, how many deaths we 
would have had.
    But the child welfare and foster homes are a really 
important part of the issue. I think most of the children that 
we are dealing with, that are going into foster care now, have 
some relation to the parents being involved in substance abuse 
of some kind; much of that are opioids.
    In many cases, the grandparents are actually taking care 
because the parents of the children are addicted and have 
issues. But in many cases, they do not have someone directly 
family related to take care of them, and they are going into 
foster homes. It is a growing, growing problem.
    In addition to that, we are getting a big issue on the 
neonatal. Many of our babies being born into our hospitals are 
addicted. So it starts even before they get to the foster care 
level.
    Senator Kaine. Great, thank you.
    Mr. Chairman, thank you very much.
    The Chairman. Thank you, Senator Kaine.
    We have a couple of Senators who would like to ask 
additional questions, if the governors have a few more minutes.
    Senator Murray, do you have any other questions?
    Senator Murray. I do not. I would believe on our side, 
Senator Hassan wanted to ask another question. Anybody else? 
Senator Kaine? I believe Senator Baldwin is hoping to return.
    The Chairman. Well, why do we not go to Senator Cassidy?
    Senator Cassidy. Governors, I actually have questions from 
a father whose son died. As I read his testimony, it is very 
moving. So excuse me as I feel his pain. He says, ``If your son 
is 17-years-old, treatment options are limited.''
    In your state, what is available for someone who is a less 
than an 18-year-old person, as his was?
    Governor Brown. Thank you, Senator Cassidy. And I am 
terribly sorry for this man's loss.
    In Oregon, we are working hard to make sure that our young 
people have access to treatment. I mentioned earlier, focused 
on comprehensive behavioral health.
    We, unfortunately, are struggling with some of the barriers 
through insurance policy and requiring failure first before 
getting the best possible treatment. We want to change that 
dynamic.
    The legislation that just passed 2 weeks ago is going to be 
taking a look at the insurance barriers that are out there.
    Senator Cassidy. Let me come back to that.
    Governor Brown. Okay.
    Senator Cassidy. But if somebody is less than 18 years old, 
do they have the same access to treatment as does someone who 
is over 18?
    Governor Brown. Yes, I believe so.
    Senator Cassidy. Governor?
    Governor Hogan. Yes, I do not think we discriminate based 
on age.
    Senator Cassidy. Let me ask. He also suggested--these 
questions are based upon his suggestions--he suggested, and one 
of you thought, I thought I might have gleaned this, that you 
decriminalize possession, if you will. You decriminalize 
addiction because a 17-year-old could end up being forever 
ostracized from normal society if that is on his record.
    Have your states decriminalized addiction, if you will?
    Governor Hogan. Well, we have not decriminalized drug use, 
but we have lowered penalties and changed things from felonies 
to misdemeanors.
    Senator Cassidy. But if the 17-year-old was found with 
fentanyl, and it was clearly he was not a distributor, but 
rather he was a user, would he end up with a criminal record?
    Governor Hogan. He would. It would depend on the 
circumstances of the individual case, but our preference would 
be to try to get him into treatment. But obviously, each case 
is separate and it would be dealt with in drug courts.
    Senator Cassidy. Are there increased penalties for dealers 
associated with an addict's death? Not just a dealer, but 
someone associated with someone dying?
    Governor Brown. Senator Cassidy, I will have to get back to 
you on that specific question, but I will get the information 
to you.
    Governor Brown. In terms of our decriminalization, it was a 
lowering, just like Governor Hogan, it was lowering of the 
penalty from a felony to a misdemeanor.
    I am not sure what the sentencing is for juveniles. Again, 
particularly with regard to juveniles, we obviously want to 
take a treatment first approach.
    Governor Hogan. We increased the penalties for people who 
knowingly deal fentanyl, knowing that it could cause the death 
of another individual.
    Senator Cassidy. But would they get also a secondary 
manslaughter charge?
    Governor Hogan. Yes, they would get a primary manslaughter 
charge on top of anything else. In fact, we just passed a law 
that I introduced and the State of Maryland passed our 
legislature.
    My daughter is a prosecutor in St. Mary's County, southern 
Maryland, who actually is prosecuting eight of these cases. We 
are charging them with second degree depraved hard murder, 
which is a step higher than manslaughter.
    Senator Cassidy. Wonderful. Can I ask? Again, limited time; 
I do not mean to interrupt.
    Now, you mentioned the obstacles in mental health parity. 
Do your state group plans offer mental health parity for both 
addiction and mental health services? If so, does it cost 
money? Or if not, what are the obstacles?
    Governor Brown. Senator Cassidy, we passed mental health 
parity legislation in the mid 2000's in Oregon. I spent 10 
years working to pass that legislation.
    In terms of coverage, I do not know from specific plan to 
specific plan. I will tell you through the Oregon Health Plan, 
we now have 100 percent of our children covered. We treat our 
substance abuse as part of our comprehensive.
    Senator Cassidy. Now, publicly funded seems to work in some 
cases, but it seems to be the private insurance. I am told that 
there can be, as you said, you have to fail or there has to be 
preauthorization and other obstacles that seem to inhibit in 
fact if not in the law. Is that also your impression in your 
state?
    Governor Hogan. Yes, I think if you are using the Federal 
programs, I think you are covered. But different individual 
health plans, I think, vary.
    Senator Cassidy. Do you have suggestions as to how the law 
could be changed so that it is actually in fact as opposed to 
just on paper?
    Governor Brown. Sorry, Governor Hogan.
    We need to provide the best possible treatments first and 
the most effective assistance immediately. The legislation that 
just passed, that I have not signed yet into law, will take a 
look at the insurance barriers that are present that my own 
family had to deal with.
    Senator Cassidy. Governor Hogan.
    Governor Hogan. I think it is something maybe that the 
Federal Government and all of you ought to take a look at for 
Federal standards.
    Senator Cassidy. If you have suggestions of how to do so, I 
think we would be interested in understanding that.
    Governor Hogan. Absolutely, we will.
    Senator Cassidy. Thank you.
    Governor Brown. Thank you.
    The Chairman. Thanks, Senator Cassidy. Thank you for 
staying.
    Senator Hassan.
    Senator Hassan. Well, thank you, and thank you for having 
the second round of question, Mr. Chairman and Ranking Member 
Murray.
    Thank you both for your persistence and stamina.
    Look, I think one of the things that is really important, 
as we talk about all the challenges that this epidemic brings, 
is for us also to focus on the fact that recovery is possible.
    In my state, I have been just honored to know people who 
have suffered from this disorder, and gotten better, and turned 
their lives around, and then are in the field working for 
people every day.
    I am reminded of a grandmother. I did not know it at the 
time. It was the annual egg roll hunt at the state house the 
day before Easter a few years ago when a woman came up to me 
with a baby in her arms, and I admired the baby. We took our 
picture. You both know how this works.
    She then pulled me aside, the woman, and she said, ``I am 
not this child's mother. I am his grandmother. His mother died 
of an overdose a month ago.''
    That grandmother was there with her grandbaby to ask me for 
help on the weekend that we celebrate renewal and resilience as 
Christians. And I keep her in mind all the time because, in 
fact, this is an illness that can be treated and people can 
have productive lives afterwards.
    We had talked a little bit about the importance of 
Medication Assisted Treatment here. We have talked about the 
barriers of insurance. One of the things I would like you both 
to address is whether there is action we can take from here. 
Generally, we regulate insurance, both state and the Federal 
levels.
    Should we be looking at Federal regulations to make sure 
that insurance coverage gets the best treatment to the person 
first? How can we increase our capacity for treatment and 
recovery services?
    Why do I not start with those two general themes, whichever 
one of you wants to start?
    Governor Brown. Well, thank you, Senator Hassan.
    I think one of the key pieces is making sure that our 
substance and alcohol abuse treatment programs are effective, 
and that folks have access to the best treatment first, and the 
most effective assistance immediately.
    I would welcome--normally, as a governor, I do not always 
welcome Federal engagement in this issue--but to the extent of 
Federal conversation about what comprehensive behavioral health 
looks like, and making sure that we understand that every one 
needs to have access to it, I think, are absolutely key.
    We know that we are seeing challenges in our kindergartens 
and early pre-K with children that are really struggling. We 
need to be able to make sure that they have access to therapy, 
the support, and the wraparound services they need so they can 
be successful.
    We do not want to end up 20 years from now having to 
address substance and alcohol abuse treatment issues.
    Senator Hassan. Thank you.
    Governor Hogan.
    Governor Hogan. Senator, thank you for sharing that story. 
I think every one of us has been either touched by it 
personally or we had those same kinds of conversations with 
people that moved us.
    I mean, I did not mention it early and do not talk about it 
much, but I had a first cousin who went through 3 years of 
treatment, and became clean, and got married, and had a kid. 
And was happy, and turned his life around, and had a good job, 
and then one time, went out and died of a heroin overdose.
    It is great to see the people who have gone through 
treatment and been successful, and many of them are the best 
folks to talk to other people and to work in some of these 
treatment and counseling centers. But there are the sad cases. 
Unfortunately, the majority of people, the treatment does not 
work.
    Senator Hassan. Let me interrupt there and then move on to 
one other quick issue.
    I think the treatment over time can work, but this is a 
chronic illness.
    Governor Hogan. Yes.
    Senator Hassan. When a diabetic happens to have an insulin 
level go wrong, we do not say, ``No treatment will ever work 
for that person again.'' We understand it is the chronic 
disease that it is.
    I think we are just learning about how to treat this 
disease, especially with the onslaught of these incredibly 
powerful opioids like fentanyl, which just has raised this to a 
different level.
    I will ask, for the record, because my time is almost up. 
One of the things we are doing in New Hampshire with Federal 
funds is bringing mental health and substance use professionals 
into our school systems to deal with the trauma that children 
are facing who are coming from situations where addiction has 
really turned their lives upside down, and created trauma.
    I would love to know whether you have similar programs in 
your state, and if and how Federal funds could help you do more 
of that.
    Governor Brown. Thank you.
    Governor Hogan. Yes, thank you, Senator. We just recently 
beefed up our program after the school shootings in Florida. I 
put $125 million more into our schools for school safety issues 
and $50 million or more per year. Part of that was specifically 
geared toward mental health counselors in the school to make 
sure that every single school had the capacity, so that they 
could catch some of these troubled youth at an earlier stage 
before we have a tragedy happen.
    Senator Hassan. Thank you.
    The Chairman. Thank you, Senator Hassan.
    Senator Scott and Senator Baldwin are here. We will go 
first to Senator Scott, then to Senator Baldwin, then we will 
conclude the hearing.
    Senator Scott.
    Senator Scott. Thank you, Mr. Chairman.
    It is good to see both of you here this morning. Thank you 
for being willing to share your stories. Governor Hogan, it is 
certainly good to see you healthy.
    Governor Hogan. Thank you very much.
    Senator Scott. We know that, at least in South Carolina, we 
have seen about a 9 percent increase in opioid related deaths; 
about 616 in 2016. I think nationwide, that number seems to be 
heading toward 70,000.
    The crisis is absolutely an epidemic, but when you think 
about the crisis--perhaps larger--we would need more time 
together to discuss the crisis around mental health.
    My understanding is we are focusing some attention on gun 
violence in this Nation and I think we should. We had 33,000 
gun-related deaths last year. About 20,000 plus of those deaths 
were suicides.
    Governor Hogan. Yes.
    Senator Scott. My question is how are you and your states 
using telemedicine as a means of addressing some of the 
shortages that we are all experiencing?
    South Carolina is a fairly rural state. Our Medical 
University of South Carolina is spending some resources toward 
the challenges that we see in some of our areas where it is 
harder to get healthcare workers, much less mental healthcare 
workers.
    As opposed to specific programs that you have within your 
states, can you talk about a willingness to use telemedicine 
and/or its application in parts of your state that may have a 
mental health desert from folks who could help treat folks who 
are suffering because it does appear to be a major challenge 
that is growing?
    Governor Hogan. Well, thank you, Senator Scott.
    I just mentioned a moment ago, we are trying to put more 
money into mental health counseling. I am not sure that we are 
taking advantage of that, using telehealth for mental health 
issues, but I would love to hear how it is working in South 
Carolina, and maybe reach out, and talk with folks there.
    Senator Scott. Absolutely.
    Governor Hogan. To get some input because it sounds like 
you are right. You cannot hire enough people to be everywhere 
if it is to be effective.
    Senator Scott. Absolutely.
    Governor Hogan. We would love to take a look at it.
    Governor Brown. Thank you, Senator Scott.
    I know we are using telemedicine very effectively, 
particularly under unique or emergency situations in rural 
Oregon. But I am not aware of its use in mental health.
    I will certainly ask my experts and get back to you with 
some information on that.
    Governor Brown. I will tell you that suicide is a huge 
challenge for my state. Obviously, drugs certainly contribute 
to that and guns also contribute to that as well.
    We were able to pass red flag legislation last year that 
enables courts to take away guns from folks who are a danger to 
themselves or others. I was very pleased to sign that into law.
    Senator Scott. Thank you.
    Mr. Chairman, I will just note the fact that my answer, 
really, started in a conversation with my brother, who is now a 
retired Command Sergeant Major in the military. They were 
experiencing a suicide a day.
    The importance of focusing our resources for those folks, 
who need the help desperately, seems to be an urgent 
opportunity for us.
    I hope that as we look for ways to deal with the challenges 
that we face as a Nation, whether it is our military folks or 
our civilians, the reality of it is we just simply do not have 
enough people who are experts to help other people who are 
suffering.
    If there is a new way to help them through telemedicine, I 
hope that we have more time and more information on the success 
of telemedicine, not simply from a mental health perspective, 
but just overall. That uniquely, with 20,000 plus suicides from 
the gun-related perspective, it would be helpful.
    Governor Brown. Senator Scott, if I may?
    One of the challenges we face in rural Oregon is a lack of 
pediatric specialists in children's mental health care. I am 
hoping that your suggestion around telehealth, telemedicine can 
be a useful tool. But we literally lack specialists in 
children's mental health care outside of our metropolitan 
areas, and it is a dire need. Our children are desperate.
    Senator Scott. Thank you so much, ma'am. Thank you, 
governors.
    Governor Hogan. Thank you, Senator.
    Governor Brown. Thank you.
    Senator Scott. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Scott.
    Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman and Ranking 
Member.
    Thank you to our witnesses for being here. You are on the 
frontlines and your perspective is very, very helpful to us.
    I have had an opportunity now for several years to meet 
with some of the workers on the frontline in Wisconsin, as well 
as families, impacted by the opioid epidemic. And the lion's 
share of work is done on the ground.
    But I recently introduced a bill--Governor Hogan, I 
understand you referenced it earlier before I arrived--that 
would increase and extend funding for the state targeted 
response opioid grant that we included in the 21st Century 
Cures Act. This funding expires at the end of this year. So we 
have to act to maintain it.
    My bill would also give states flexibility to use some of 
the funding for other substance abuse issues such as 
methamphetamine.
    In Wisconsin, meth abuse has drastically increased by more 
than 300 percent in parts of our state, while we continue to 
see a record number of fentanyl deaths and heroin deaths in 
other parts of the state, particularly. It is almost an eastern 
part of the state, western part of the state division, if you 
travel around and listen to what people are struggling with.
    This is further straining our local resources and forcing 
our leaders to look for other ways to adapt to this crisis.
    Governor Hogan, how would additional funding, and that sort 
of flexibility through the Cures opioid grant, help you in your 
fight against this ever evolving epidemic?
    Governor Hogan. Well, thank you, Senator Baldwin.
    It would help tremendously and I did mention your 
legislation earlier. I think it needs to get passed and we need 
to reauthorize the bill. We cannot have it run out. It would be 
a critical situation if that happened.
    I agree with you on creating more flexibility for the 
states to be able to utilize and focus on the problems that 
they are having.
    You just mentioned in your state, and Governor Walker 
brought this up at the National Governors Association, it 
surprised me because we do not really have a methamphetamine 
problem, and we have a fentanyl problem. Most of the other 
governors were dealing with heroin, but a couple of states did 
mention that this was coming back again, making a comeback.
    I think providing the funding and giving us the flexibility 
at the state level to use it as we see fit in this critical 
fight. We need the help. Thank you.
    Senator Baldwin. Thank you.
    I understand that Senator Kaine had some questions about 
foster care earlier. I want to follow on that.
    The rise, the dramatic rise in opioid addiction has 
proliferated a cycle of trauma that has significantly impacted 
Wisconsin children. The number of children in foster care in 
Wisconsin has grown 20 percent in the last 5 years due, in 
large part, to parental substance use addiction.
    The last time we convened for a hearing on the opioid 
epidemic, I shared with the Committee a little bit. They had 
heard me for years talk about the fact that I was raised by my 
grandparents. But revealing that part of the reason I was 
raised by my grandparents was my own mother's struggle with 
addiction due to prescribed narcotics for chronic pain that she 
suffered throughout her life.
    I have bipartisan legislation called the Family Based Care 
Service Act. This focuses on therapeutic foster care by 
providing foster care for a child with significant medical or 
mental health needs.
    What it would do is help enhance access to services through 
Medicaid. It provides special training to foster parents and 
kinship families for youth with major mental health challenges 
where children receive in-home clinical trauma informed 
services to help keep them in the community.
    Governor Brown, you note that Oregon's foster care system 
is similarly struggling with the impacts of childhood trauma 
from addiction.
    Can you discuss what your state is doing to address this 
and why it is important to strengthen Federal programs like 
Medicaid and foster care services to prevent our struggling 
kids from growing up to be struggling parents?
    Governor Brown. Thank you, Senator Baldwin, and thank you 
for your leadership in this arena.
    We are struggling, our foster care system. We have one-and-
a-half times the children of the national average. Sixty 
percent of the children that are in our foster care system, one 
of their parents is struggling with substance abuse. A good 
portion of them, obviously, being opioid abuse.
    I think more resources are key for us. As you know, 
intensive, comprehensive foster care programs, like the one you 
just mentioned, are extremely expensive. But I will tell you 
that by investing those dollars at the early age, we will 
prevent significant expenses to state government in the future. 
So I applaud your efforts. More resources would be key for us.
    We are struggling trying to get the appropriate number of 
caseworkers and the appropriate number of trained foster 
families to deal with these children's special needs; these 
trauma impacts that they are seeing from their families.
    Resources would be absolutely crucial to a state like 
Oregon.
    Senator Baldwin. Thank you.
    The Chairman. Thank you, Senator Baldwin.
    Senator Murray, do you have concluding remarks?
    Senator Murray. I just want to thank both the governors for 
being here today. It is an incredibly helpful part of our 
conversation as we move forward on bipartisan legislation.
    Thank you.
    The Chairman. Thank you.
    This is our sixth hearing. Very, very helpful and we are 
working on drafts of legislation we hope to recommend to the 
full Senate shortly.
    As the staff works on that, we heard Senator Murray's 
comment and my interest also when the witnesses in suggesting 
that Scott Gottlieb, the FDA Commissioner, interdict fentanyl 
from China through the U.S. Postal Service, and more authority 
to seize fentanyl in different ways sent through the U.S. 
Postal Service. There is the STOP Act that Senator Portman and 
others have introduced.
    Also, your comment about public service television; I wish 
there was a way we could have the testimony of Becky Savage, 
whom Senator Murray mentioned, who said that when she showed 
the picture of her two sons who took an overdose--that the 
children she was talking to listened--died from that mixing at 
a graduation party at her own home. When she put their picture 
up and told their story that the high school students listened.
    It made me think if we could find some way to find 
something that would go viral on the Internet or be on 
television that many young people simply do not know that if 
they mix a pill with a drink, they might be dead in their 
basement the next morning.
    I heard your comment on additional funding that making 
overdose drugs available to everybody and then treatment.
    Then the comment on the unevenness of treatment programs; I 
think that is an area that we need to be careful about because 
we are obviously going to have a large number of new treatment 
programs. They are very expensive and they are very uneven, and 
it is hard for us to regulate that from here. But obviously, 
that may be something where the Federal Government and the 
states could work together, but states could take a lead on.
    Thank you, again, for coming.
    The hearing record will remain open for 10 days. Members 
may submit additional information for the record within the 
time, if they would like.
    The Chairman. Our Committee will meet again Thursday, March 
15 at 9:45 a.m. for a hearing on the 340-B program.
    Thank you for being here.
    The Committee will stand adjourned.
    [Whereupon, at 11:49 a.m., the hearing was adjourned.]

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