[Senate Hearing 115-218]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 115-218

                   CURRENT ISSUES IN AMERICAN SPORTS:
         PROTECTING THE HEALTH AND SAFETY OF AMERICAN ATHLETES

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

                                HEARING

                               before the

                         COMMITTEE ON COMMERCE,
                      SCIENCE, AND TRANSPORTATION
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 17, 2017

                               __________

    Printed for the use of the Committee on Commerce, Science, and 
                             Transportation









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       SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                   JOHN THUNE, South Dakota, Chairman
ROGER F. WICKER, Mississippi         BILL NELSON, Florida, Ranking
ROY BLUNT, Missouri                  MARIA CANTWELL, Washington
TED CRUZ, Texas                      AMY KLOBUCHAR, Minnesota
DEB FISCHER, Nebraska                RICHARD BLUMENTHAL, Connecticut
JERRY MORAN, Kansas                  BRIAN SCHATZ, Hawaii
DAN SULLIVAN, Alaska                 EDWARD MARKEY, Massachusetts
DEAN HELLER, Nevada                  CORY BOOKER, New Jersey
JAMES INHOFE, Oklahoma               TOM UDALL, New Mexico
MIKE LEE, Utah                       GARY PETERS, Michigan
RON JOHNSON, Wisconsin               TAMMY BALDWIN, Wisconsin
SHELLEY MOORE CAPITO, West Virginia  TAMMY DUCKWORTH, Illinois
CORY GARDNER, Colorado               MAGGIE HASSAN, New Hampshire
TODD YOUNG, Indiana                  CATHERINE CORTEZ MASTO, Nevada
                       Nick Rossi, Staff Director
                 Adrian Arnakis, Deputy Staff Director
                    Jason Van Beek, General Counsel
                 Kim Lipsky, Democratic Staff Director
              Chris Day, Democratic Deputy Staff Director
                      Renae Black, Senior Counsel
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 17, 2017.....................................     1
Statement of Senator Thune.......................................     1
Statement of Senator Nelson......................................     3
    Prepared statement...........................................     4
Statement of Senator Sullivan....................................     4
    Prepared statement from Jake Wald, Business Development 
      Manager, Positive Coaching Alliance........................   102
Statement of Senator Markey......................................     5
Statement of Senator Moran.......................................    78
Statement of Senator Udall.......................................    82
    Letter dated May 16, 2017 to Hon. John Thune and Hon. Bill 
      Nelson from Katherine Snedaker, LCSW, Executive Director, 
      PINK Concussions...........................................    94
    Prepared statement from Katherine Starr, Founder, 
      Safe4Athletes..............................................    95
    Letter dated May 17, 2017 to Hon. John Thune and Hon. Bill 
      Nelson from David Goodfriend, Chairman, Sports Fans 
      Coalition..................................................    97
Statement of Senator Blumenthal..................................    84
Statement of Senator Cortez Masto................................    85
Statement of Senator Hassan......................................    87
Statement of Senator Young.......................................    89
Statement of Senator Moore Capito................................    90

                               Witnesses

Jay C. Butler, MD, Chief Medical Officer, Alaska Department of 
  Health and Social Services and Director of Public Health; and 
  President, Association of State Territorial Health Officials 
  (ASTHO)........................................................     6
    Prepared statement...........................................     8
Maureen Deutscher, Family Representative, Prescription Opioid 
  Abuse Advisory Committee, South Dakota Department of Health....    11
    Prepared statement...........................................    14
Shellie Pfohl, Chief Executive Officer, United States Center for 
  Safe Sport.....................................................    16
    Prepared statement...........................................    17
Scott R. Sailor, President, National Athletic Trainers' 
  Association....................................................    51
    Prepared statement...........................................    53
Robert A. Stern, Ph.D., Professor of Neurology, Neurosurgery, and 
  Anatomy, and Neurobiology; Director, Clinical Core, BU 
  Alzheimer's Disease and CTE Center, Boston University School of 
  Medicine.......................................................    57
    Prepared statement...........................................    58
Lauryn Williams, Olympian and Proud TrueSport Ambassador, United 
  States Anti-Doping Agency......................................    72
    Prepared statement...........................................    74 
 
                   CURRENT ISSUES IN AMERICAN SPORTS:
         PROTECTING THE HEALTH AND SAFETY OF AMERICAN ATHLETES

                              ----------                              


                        WEDNESDAY, MAY 17, 2017

                                       U.S. Senate,
        Committee on Commerce, Science, and Transportation,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m. in 
room 253, Russell Senate Office Building, Hon. John Thune, 
Chairman of the Committee, presiding.
    Present: Senators Thune [presiding], Fischer, Moran, 
Sullivan, Heller, Moore Capito, Gardner, Young, Nelson, 
Cantwell, Klobuchar, Blumenthal, Markey, Booker, Udall, 
Baldwin, Hassan, and Cortez Masto.

             OPENING STATEMENT OF HON. JOHN THUNE, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    The Chairman. Good morning and welcome to today's hearing.
    It is no exaggeration to say that Americans love sports. We 
love watching them, playing them, collecting sports 
memorabilia, and even arguing about our favorite teams and 
athletes.
    Whether it is watching the Super Bowl with friends, joining 
an office bracket pool for ``March Madness,'' or stretching out 
for the Turkey Trot 5K races on Thanksgiving morning, and the 
pickup football games later that afternoon, we love our sports.
    Personally, I am a Dodgers and a Packers fan, and some of 
my best moments have been spent competing in sports, or 
cheering on my two daughters at their meets and games.
    This Committee is committed to promoting American success 
in international competition, ensuring exciting play in our 
professional leagues, providing opportunity for our student 
athletes, and maintaining a vibrant sports culture for the 
benefit of all Americans. At the same time, protecting the 
health and safety of American athletes of all levels--
professional, amateur, student, and youth--is a longstanding 
priority of the Commerce Committee.
    The issue of sexual abuse within the United States Olympic 
movement has received considerable media attention in recent 
months. The troubling nature of these reports triggered the 
Committee's inquiry into the ability of the U.S. Olympic 
Committee, and the U.S. National Governing Bodies for 
individual sports, to conduct effective, timely, and impartial 
investigations into allegations of abuse. I am glad that 
Shellie Pfohl of the United States Center for SafeSport is here 
today to discuss the Center's work to protect these athletes.
    While I believe that nothing in the current law prevents 
USOC and NGBs from taking immediate steps to remove a suspected 
predator from being in contact with athletes, it is also clear 
that certain stakeholders have, at times, sown confusion about 
the legal requirements of the Ted Stevens Olympic and Amateur 
Sports Act, and manufactured ambiguities behind which to hide.
    I am pleased that Senator Feinstein and her colleagues on 
the Senate Judiciary Committee have advanced legislation to 
address this issue. I look forward to working with her to 
strengthen her bill as it advances to the full Senate.
    Specifically, any legislation to address this issue must 
include unambiguous language clarifying that it is the 
responsibility of our Olympic leaders to provide an environment 
that is free from abuse.
    In the same way Congress codified the United States Anti-
Doping Agency to combat the use of performance-enhancing drugs 
in 2001, I believe we should authorize the U.S. Center for 
SafeSport as an independent organization with the expertise to 
investigate and adjudicate abuse allegations as they arise.
    Speaking of anti-doping, I am pleased that we are joined 
here today by Olympic medalist, and True Sport Ambassador, 
Lauryn Williams, who will testify on behalf of USADA. The 
Committee last reauthorized USADA in 2014, and since that time 
has been active on a number of clean sport issues.
    For instance, in 2016, following the revelation of an 
elaborate doping program sponsored by the Russian Government, 
the Committee conducted oversight of the World Anti-Doping 
Agency's response, prompting the Agency to appoint a new 
independent investigator and to expand the scope of its 
investigation.
    Following a reanalysis of samples collected during the 2008 
Summer Olympic Games in Beijing, which revealed cheating in the 
men's pole vault event, I wrote to the International Olympic 
Committee to correct the final results of that competition and 
to award the bronze medal to an American, Derek Miles, just 
last month.
    The issue of prescription opioids to treat sports injuries 
is another growing concern, in particular because of the 
addiction and overdose risks they carry. Though substance abuse 
and misuse affects all demographics, athletes are a 
particularly vulnerable population.
    While the media has focused recent attention on the use of 
prescription opioids in professional sports leagues, this issue 
impacts all athletes, including at the high school and 
collegiate levels.
    While I wish she were here under different circumstances, I 
am glad that we are joined by Maureen Deutscher, and her 
husband Jeff, of Sioux Falls, South Dakota, who will testify 
about their family tragedy involving the loss of their son, 
Nick, to opioid painkillers. Maureen and Jeff, I am deeply 
sorry for your loss, and thank you for your bravery in sharing 
your story with us today.
    Finally, the issue of concussions in sports is a 
longstanding issue that this Committee has sought to address. 
Concussions are common injuries among athletes participating in 
contact sports, and are among the most complex injuries to 
manage in sports medicine. The Committee has conducted 
oversight of efforts to prevent and mitigate the occurrence of 
concussions in sports, including game rule changes, coaching 
and player education, guidelines, as well as the development of 
brain injury and equipment research.
    Dr. Jay Clarence Butler of the Alaska Department of Health 
and Social Services; Mr. Scott Sailor, President of the 
National Athletic Trainers' Association; and Dr. Robert Stern 
of Boston University School of Medicine will be able to speak 
to this issue, as well as many others, that affect our Nation's 
athletes.
    And so, I thank you all for being here today, and I look 
forward to hearing your testimony, and the opportunity for you 
to interact with members of this committee, and give us a 
chance to ask questions.
    With that, I will yield to the distinguished Senator from 
Florida, the Ranking Member, Senator Nelson, for his opening 
statement.

                STATEMENT OF HON. BILL NELSON, 
                   U.S. SENATOR FROM FLORIDA

    Senator Nelson. Thank you, Mr. Chairman.
    I think this is an opportunity, as the Chairman has said, 
to start a conversation about what more can be done to protect 
America's athletes. Obviously, we must protect the young 
athletes, some of whom are children. They are starting early. 
They are training for the Olympics.
    Obviously, we were all shocked by the revelations of 
widespread sexual abuse in USA Gymnastics, USA Taekwondo, and 
other Olympic sports. Even more appalling was evidence that 
responsible adults were indifferent and looked the other way. 
When so many young victims can be horribly abused by adults for 
so long without repercussions, it is a stain on America's proud 
Olympics heritage.
    So we in Congress need to respond to this travesty. I am, 
along with many others, a sponsor of the bill that has been 
introduced. This bill would require immediate reporting of 
sexual abuse allegations, require National Governing Bodies to 
adopt strict protocols and measures to protect children, and 
make it easier for victims to come forward and report to the 
authorities.
    We also need, as the Chairman has already outlined very 
well, to examine athletic doping at the international level. 
There was a time when we thought of the Olympics, we thought 
this is just above reproach. What now when we think of the 
Olympics? You think of scandals that have been revealed 
involving doping.
    Over 100 Russian athletes were banned from the Olympic 
Games in Rio de Janeiro. We should address attacks on clean, 
drug-free sports, and protect athletes who do things the right 
way.
    The issue of head injuries is something that is becoming 
alarming. Each one of us, more than likely, has had a fellow 
athlete friend along the way that has had concussions. And now, 
years later, we are seeing the manifestations of those 
concussions.
    Concussions and CTE are not limited to professional sports. 
They affect children and can have devastating effects on their 
still-developing young brains.
    I want to recognize and commend Senator Udall, who is here 
with us today, who has been such a champion and a leader on 
this issue. His dedication to preventing concussions and youth 
athletic safety is well known to everyone here. I want to thank 
him, on behalf of the Committee, for raising awareness about 
this very troubling issue.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Nelson follows:]

   Prepared Statement of Hon. Bill Nelson, U.S. Senator from Florida
    Thank you, Mr. Chairman, for holding this hearing. I'm pleased that 
we'll be able to start a conversation about what more can be done to 
protect America's athletes of all ages and at all levels.
    For instance, we must protect our young athletes, many of whom are 
children, training for Olympic sports. We were all shocked by the 
revelations of widespread sexual abuse in USA Gymnastics, USA 
Taekwondo, and other Olympic sports. Even more appalling was evidence 
that responsible adults were indifferent and looked the other way. When 
so many young victims can be horribly abused by adults for so long 
without repercussions, it's a stain on America's proud Olympics 
heritage.
    Congress needs to respond to this national travesty. It's why I'm 
proud to cosponsor the Protecting Young Victims from Sexual Abuse Act 
of 2017. This bill would require immediate reporting of sexual-abuse 
allegations, require national governing bodies to adopt strict 
protocols and measures to protect children, and make it easier for 
victims to come forward and report to the authorities.
    We also need to examine athletic doping at the international level. 
There are allegations that the Russian government runs a doping program 
for the sole purpose of providing its athletes an unfair advantage. 
Over 100 Russian athletes were banned from Olympic games in Rio. We 
should address attacks on clean, drug-free sports and protect athletes 
who do things the right way.
    Finally, the issue of head injuries in sports is something that 
only becomes more alarming as more research comes out. As we all know, 
concussions and CTE are not limited to pro-sports. It's also about kids 
and the devastating effects on their still-developing young brains. I 
want to recognize Senator Udall, who's been such a champion and leader 
on this issue. His dedication to preventing concussions and youth 
athletic safety is well known to everyone here, and I want to thank him 
for raising awareness about this very troubling issue.

    The Chairman. Thank you, Senator Nelson.
    I want to recognize, for an introduction of one of our 
panelists today, Senator Sullivan to introduce Dr. Butler, 
followed by Senator Markey for a short statement to introduce 
Dr. Stern.
    Senator Sullivan.

                STATEMENT OF HON. DAN SULLIVAN, 
                    U.S. SENATOR FROM ALASKA

    Senator Sullivan. Thank you, Mr. Chairman.
    Thank you and the Ranking Member for holding this important 
hearing.
    I do want to recognize Dr. Jay Butler, who came all the way 
from the great State of Alaska to testify today. Dr. Butler 
does great work in the State of Alaska and serves as the Chief 
Medical Officer and Director in the state.
    Although it is not an uplifting topic, Dr. Butler has 
committed his time and effort across the state, really across 
the country, to help stymie the opioid epidemic that is raging 
through Alaska like it is in so many of the other states in the 
United States.
    His efforts have included education and awareness on the 
dangers of opioid use especially for our young Alaskans; aiding 
in the distribution of Naloxone to nonmedical personnel and 
facilities; currently serving as the President of the 
Association of State and Territorial Health Officials; and 
representing the State of Alaska in his position of Director of 
Public Health and Chief Medical Officer for the state.
    I will not go through his extensive resume, but will just 
mention briefly, Mr. Chairman, my experience with Dr. Butler. 
We worked together last year when we put on a Wellness Summit 
in the State that was focused on conquering the opioid crisis. 
Dr. Butler was instrumental in the success of this Summit. Over 
500 Alaskans, with several hundred more online, showed up at 
this Summit.
    He participated in planning on the steering committee. He 
interviewed the United States Surgeon General for a fireside 
chat and moderated the ending panel of this discussion and 
Summit.
    I just want to thank him for, again, traveling from Alaska, 
all the work he is doing in our state, and participating on a 
national level on this important issue that crosses partisan 
lines. This is an issue that is impacting every single state in 
our great Nation and Dr. Butler is a leader in this, not only 
in Alaska, but in our country.
    Thank you.
    The Chairman. Thank you, Senator Sullivan. It is always 
nice to have you here.
    Senator Markey.

               STATEMENT OF HON. EDWARD MARKEY, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Markey. Yes, thank you, Mr. Chairman.
    Dr. Robert Stern, is a Professor at the Boston University 
School of Medicine and is the Director of Clinical Research for 
the BU Chronic Traumatic Encephalopathy Center. Also known as 
CTE, it is a neurodegenerative disease often found in athletes.
    While a lot of Dr. Stern's research focuses on repeated 
brain trauma in athletes, I know him best through his work on 
Alzheimer's disease as he is the Director of the Clinical Core 
at the BU Alzheimer's Disease Center.
    Throughout his career, he has won multiple national and 
federally funded grants for his work. He has published more 
than 250 journal articles, chapters, and abstracts in his 
field. He is a Fellow of both the American Neuropsychiatric 
Association and the American Academy of Neuropsychology.
    I just wanted to thank you, doctor, for all of the work 
which you have done on the brain. For helping to explain, not 
only Alzheimer's and the pathways that are possible for finding 
a cure, but also what you have done in becoming the center for 
the study of the impact on the brain that contact in sports 
has. You have become the national leader and I just wanted to 
thank you for that.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Markey, and welcome, Dr. 
Stern.
    I want to just introduce again for the panel in terms of 
the order of presentation. We will start on my left and your 
right with Dr. Butler, who is the Chief Medical Officer, as was 
pointed out by our colleague from Alaska, of the Alaska 
Department of Health and Social Services.
    Mrs. Maureen Deutscher, who is a Family Representative, 
Prescription Opioid Abuse Advisory Committee on behalf of the 
South Dakota Department of Health.
    Ms. Shellie Pfohl, who is the Chief Executive Officer of 
the United States Center for SafeSport.
    Mr. Scott Sailor, President of the National Athletic 
Trainers' Association.
    Dr. Robert Stern, Professor of Neurology, Boston University 
School of Medicine.
    Ms. Lauryn Williams, we will save our speedster for last, 
True Sport Ambassador, United States Anti-Doping Agency.
    So if you would proceed in that order. Dr. Butler, if you 
could, confine your oral remarks as closely to five minutes as 
possible, it will maximize the opportunity that members of the 
Committee will have to ask questions.
    Thank you all for being here.
    Dr. Butler.

         STATEMENT OF JAY C. BUTLER, MD, CHIEF MEDICAL

        OFFICER, ALASKA DEPARTMENT OF HEALTH AND SOCIAL

          SERVICES AND DIRECTOR OF PUBLIC HEALTH; AND

 PRESIDENT, ASSOCIATION OF STATE TERRITORIAL HEALTH OFFICIALS 
                            (ASTHO)

    Dr. Butler. Good morning, Chairman Thune, Ranking Member 
Nelson, and members of the Committee.
    It is an honor to be able to speak with you today.
    In my role as Chief Medical Officer in Alaska, I oversee 
State-related prevention, preparedness, and response 
activities. During the past 3 months, in addition to the roles 
that Senator Sullivan has described, I have also served as the 
Incident Commander of Governor Bill Walker's opioid response.
    In Alaska, we are responding to the opioid epidemic much as 
we would to any other disaster, whether an earthquake or a 
tsunami, using an incident command structure to coordinate 
communication across State Government. This response is 
addressing the three- to fourfold increase in opioid overdose 
deaths that have occurred in Alaska over the past two decades, 
which mirrors an increase that has occurred across our Nation.
    The epidemic started somewhat silently, with gradual 
increases in deaths caused by prescription painkillers as more 
and more of these drugs were prescribed. The problem has been 
compounded over the past decade by the increased availability 
of heroin and more recently of illicitly-produced Fentanyls. 
The majority of people who use heroin and Fentanyl report that 
they first became addicted through use of prescription opioid 
pain relievers.
    I want to be clear at the outset of the discussion that the 
health benefits of participation in sports and physical 
activity are extensive and well-documented: reduced risk of 
cardiovascular disease, obesity, diabetes, certain types of 
cancer, also better musculoskeletal strength, and an improved 
sense of well-being and connectedness to community.
    Youth who participate in sports historically have been 
shown to be less likely to use illicit drugs. Unfortunately, 
athletes have not been immune to the devastating effects of the 
opioid epidemic. Too often, sports-related injuries managed 
with opioid pain relievers have been the beginning of a path to 
addiction.
    One coach expressed her frustration to me by describing 
that she had seen too many times an injury leading to a 
prescription for pills, leading to additional prescriptions for 
pills, leading to use of a friend's pills, leading to use of 
any pills that could be obtained by any means, and 
unfortunately sometimes leading to use of heroin and overdose 
deaths.
    High profile stories of professional athletes who began 
using prescription opioids for injury and then struggled with 
addiction or died of overdose may grab the headlines, but we 
need to recognize that the problem is occurring at all levels 
of competition. One adult recreational softball league in 
Alaska with roughly 750 participants has had five players die 
of opioid overdose.
    An epidemiological study of high school students in 
Michigan found that boys who participated in organized sports 
were more likely to be prescribed opioid painkillers than those 
who did not. And as a result, participation in organized sports 
actually increased the risk of subsequent opioid misuse. With 
over 4 million youth sports and recreation-associated injuries 
occurring each year in the U.S., there is a reason for concern.
    What can be done? There are no easy answers and no magic 
bullets. We need to be clear about that. But I would like to 
highlight three areas of opportunity.
    First, we can promote evidence-based pain management 
strategies and more rational use of opioid pain relievers. 
Opioids can be useful for the management of acute pain and many 
people who receive these medications use them without problem.
    However, opioids should not be the first line of treatment 
following any sports injury. These medications are used best 
when they are prescribed in the lowest effective dose and for 
the shortest period possible, generally for less than 3 to 7 
days.
    Larger first time prescriptions have specifically been 
associated with higher risk of long-term use and thus greater 
risk of dependency and addiction.
    A school nurse recently told me about a student who came 
back to school after arthroscopic surgery for an athletic 
injury. In line with school policy, he checked in with her and 
turned his prescription medicines in. She was shocked to find 
that he had a bottle of 120 Oxycodone containing pills.
    Special care needs to be taken when prescribing these 
medications to teens. Adolescence is a particularly high risk 
period and use of opioids--even as prescribed by a healthcare 
provider--by high school students has been linked to increased 
likelihood of subsequent misuse.
    Second, we can provide more information on the risks of 
opioid pain relievers for both healthcare providers and the 
public, including coaches and trainers.
    In talking with teens, I frequently hear the sentiment that 
if opioid pain relievers are really dangerous, then why do 
doctors prescribe them? In talking to people in recovery, I 
frequently hear, ``No one told me.'' And, ``If I had had any 
idea how dangerous these drugs were, I never would have taken 
them.''
    We can do a better job not only describing the risk of 
opioids, but also providing information on what can be done in 
our communities to address the problem including promotion of 
leftover drug return and disposal, and talking openly about the 
recognition, and management of dependency, and addiction as a 
health issue rather than as solely a criminal justice issue or 
some type of moral failing.
    There is a role for professional athletes, as well as 
Olympians and other high profile athletes, to be able to serve 
as spokespersons in promoting conversations to reduce the 
stigma of addiction.
    There is also a need for better continuing medical 
education for all healthcare providers to improve their 
knowledge and confidence in optimal pain management and the 
basics of addiction medicine.
    Finally, maybe at the risk of sounding corny, the effective 
response to this epidemic will be a team sport. It will involve 
coaches, parents, trainers, and the athletes themselves, as 
well as organizations including professional, scholastic, and 
amateur sports leagues, public health agencies, healthcare 
providers, third party payers, the criminal justice system, 
educators, businesses, and lawmakers as well.
    Working together sports participation cannot only be made 
safer, but I believe can also be part of how we reduce the 
number of people who become newly dependent on opioids and 
increase the number of Americans living in recovery.
    Finally, I just want to conclude by pointing out that the 
issue of opioid abuse is not just an isolated event and not 
just an isolated topic as we talk about sports safety.
    It is no accident that we have the broad range of topics 
that we are discussing today. These topics are complementary 
and not in competition.
    Sexual assault is a trauma that ultimately can lead to 
unhealthy coping mechanisms and increase the risk of self-
medication.
    Traumatic brain injury is a brain process that can lead to 
altered cognition as well as altered risk assessment, and can 
also possibly create increased risk of abuse.
    So the question is not to ask one another, ``What are you 
doing to address these issues?'' But, what we can all do 
together to solve all of them?
    Thank you for your time.
    [The prepared statement of Dr. Butler follows:]

Prepared Statement of Jay C. Butler, MD, Chief Medical Officer, Alaska 
   Department of Health and Social Services, and Director of Public 
    Health; and President, Association of State Territorial Health 
                           Officials (ASTHO)
    Good morning Chairman Thune, Ranking Member Nelson, and Committee 
members. Thank you for the invitation to speak to you this morning. My 
name is Jay Butler, Chief Medical Officer for the Alaska Department of 
Health and Social Services and Director of Public Health, and President 
of the Association of State Territorial Health Officials (ASTHO). In my 
role of Chief Medical Officer in Alaska, I oversee state health-related 
prevention, preparedness, and response activities. I maintain board 
certifications in internal medical, pediatrics, and infectious 
diseases, and much of both my clinical and public health activities 
have been focused on infectious diseases. While I am not a specialist 
in addiction medicine, I have had firsthand experience with the 
infectious complications of drug use, including endocarditis, skin and 
soft tissue infections, and HIV and hepatitis C infections.
    During the past 3 months, I have also served as incident commander 
of Alaska Governor Bill Walker's opioid response activity. In Alaska, 
we are managing the response to the opioid epidemic much as we would 
the response to any disaster whether that is a pandemic of infectious 
disease, a terror attack, an outbreak of wildfires, a major earthquake, 
or a tsunami. In fact, the intensified, multiagency response started 
with a disaster declaration by Governor Walker in February. Some have 
criticized describing the increase in opioid misuse, addiction, and 
overdose deaths as an ``epidemic'', and I admit that I generally avoid 
using the term ``epidemic'' myself. However, when a single cause of 
death increases three to four fold over a period of roughly 20 years, 
as has occurred with opioid overdose deaths in our nation, even the 
most rigorous definition of ``epidemic'' has been met.
    The first 15 years of this epidemic appears to have been driven by 
changes in clinical practices relating to pain management and a three-
fold increase in prescriptions for opioid pain relievers. The opioid 
epidemic is like a tsunami in that most of us did not feel the seismic 
shift in medical practice until the first wave of overdose deaths was 
upon us. And like a tsunami, additional waves have come ashore--with 
dramatic increases in heroin deaths over the past decade, driven by the 
increased prevalence of opioid pain reliever dependence and addiction 
and by the increased supply, and decreased price, of heroin. The 
majority of persons who use heroin today report that their addiction 
started with use of prescription opioid pain relievers. More recently, 
a third wave of overdose deaths has been driven by an influx of 
illicitly produced fentanyl and related synthetic opioids. These drugs 
have spread throughout our nation--overdose deaths due to synthetic 
opioids have even occurred in the most remote Alaska villages.
    Why are we discussing drug misuse and addiction at a hearing on 
sports safety? The health benefits of participation in sports and 
physical activity are extensive and well-documented: reduced risk of 
cardiovascular disease, obesity and diabetes, and certain types of 
cancer, better musculoskeletal strength, and improved sense of well-
being and social connectedness, to name a few. Active people live 
longer and have better quality of life. Youth who participate in sports 
generally achieve greater academic success, have been less likely to 
use drugs or suffer from depression, and are more likely to be 
physically active adults.
    Despite these benefits, athletes have not been immune to 
devastating effects of the opioid epidemic. Too often, sports-related 
injuries managed with opioid pain relievers have been the beginning of 
a path to physical dependency and addiction. While these drugs can be 
useful in management of pain in severe acute injuries, too often, they 
are prescribed in large amounts that can lead to prolonged use, leading 
to physical dependency and addiction, or to diversion and misuse of 
unused pills. One coach described to me the too-familiar sequence of a 
sports injury leading to prescribed pills, leading to more prescribed 
pills, leading to a friend's pills, leading to any pills that can be 
obtained, leading to heroin, and ultimately leading to addiction or 
overdose death. High profile stories of professional athletes who begin 
using prescription opioids for injury and then struggled with 
addiction, or died of overdose, may grab headlines, but we need to 
recognize that the problem of opioid misuse occurs at all levels of 
competition.\1\ One adult recreational softball league in Alaska with 
roughly 750 participants has had 5 players die of opioid overdose. An 
epidemiological study of high school students in Michigan found that 
boys who participated in organized sports were more likely to be 
prescribed opioid painkillers.\2\ What was more disturbing was the 
finding that participation in organized high school sports actually 
increased the risk of subsequent opioid misuse. With over 4 million 
youth sports- and recreation-related injuries occurring each year in 
the U.S., there is reason for concern.\3\
    So what can be done? There are no easy answers and there are no 
magic bullets. Responding to the health challenges of all substance 
misuse and addictions, including those that are part of the opioid 
epidemic, requires a multifaceted and multisector approach as outlined 
in the 2017 ASTHO President's Challenge on public health approaches to 
preventing substance misuse and addictions.\4\ People are dying today; 
therefore, let's start with what is immediately lifesaving for those 
who are already living in addiction. We need to prevent drug overdose 
deaths by increasing access to naloxone, an easy-to-administer 
medication that can reverse the fatal respiratory depression that kills 
in an overdose. We can reduce the risk of life-threatening infections 
related to drug use by removing barriers to clean syringes and needles 
and by promoting testing for HIV and hepatitis C infections. While 
these measures can save lives, they do not solve the problem or treat 
addictions. To increase the number of people living in recovery, we 
need to fill the immense gap between the number of people in need of 
treatment and the availability of services to manage drug withdrawal 
and maintenance of recovery. We also need to reduce the stigma 
associated with addictions and increase recognition of opioid addiction 
as a chronic health condition involving the brain. Ultimately, we must 
prevent substance misuse and addictions by reducing the flood of 
prescription and illicit opioids into our communities and by improving 
personal resiliency and community connectedness to reduce the need to 
self-medicate.
    I would like to highlight three specific areas of opportunity to 
reduce the risk of opioid misuse and addiction among athletes at all 
levels of competition:

    First, we can promote evidence-based pain management strategies and 
more rational use of opioid pain relievers. Opioids can be useful for 
management of acute pain, and many people who receive these medications 
use them without problem. However, it has become clear that opioids 
should not be the first line of treatment following sports injury, and 
that these medications are used best when prescribed at the lowest 
effective dose for the short periods, generally less than 3-7 days, as 
recommended in the Centers for Disease Control and Prevention's 2016 
guideline on use of opioids for pain.\5\ While there are encouraging 
data indicating that there has been some recent decline in total amount 
of opioids that are prescribed, the number of pills dispensed is still 
often too many.\6\ Larger first-time prescriptions of opioids have been 
associated with higher risk of long-term use, and thus, greater risk of 
dependency and even addiction.\7\ A school nurse recently told me of a 
high school athlete who returned to school after arthroscopic surgery--
in keeping with school policy, he checked his prescription medications 
in with the nurse, and she was surprised to see a bottle of 120 pills 
containing hydrocodone. Special care needs to be taken when prescribing 
these medications to teens: adolescence is a particularly high risk 
period and use of opioids as prescribed by a health care provider by 
high school students has been linked to increased likelihood of 
subsequent misuse.8,9
    Second, we can provide more information on the risks of opioid pain 
relievers for both health care providers and the public, including 
coaches, trainers, and athletes. In talking with teens, I frequently 
hear the sentiment that if opioid pain relievers are prescribed by 
doctors, they must be safe. We can do a better job in not only 
describing the risks of opioids but also providing information on what 
can be done in our communities, including promoting leftover drug 
return and disposal and talking about the risks of dependency and 
addiction. Professional athletes and major league sports can play an 
important role as spokespersons and in promoting conversation to reduce 
the stigma of addiction and to encourage positive community action. We 
need to recognize that the goal of complete absence of pain may not be 
realistic and pursuing that goal will come at the high price of higher 
rates of addiction and death. There is also a need for better 
continuing medical education for all health care providers to improve 
their knowledge and confidence in optimal pain management and the 
basics of addiction medicine.\10\
    Finally, we need to recognize that we all have a part to play in 
addressing the opioid epidemic. The problem cannot be solved by simply 
placing blame or by pinning the responsibility to address this health 
crisis on one sector. The response to the opioid crisis and prevention 
of future drug addiction will require teamwork involving the combined 
efforts of all Americans, including parents, coaches, trainers, and the 
athletes themselves, as well as organizations such as professional, 
scholastic, and amateur sports leagues, public health agencies, health 
care providers, third party payers, the criminal justice system, social 
service agencies, educators, businesses, and law makers. Working 
together, sports participation cannot only be made safer, but can also 
be part of how we reduce the number of people who become newly 
dependent on opioids and increase the number of Americans successfully 
living in recovery.
Endnotes
    1. Wertheim LJ, Rodriguez K. Smack epidemic: how painkillers are 
turning young athletes into heroin addicts. Sport Illustrated. June 22, 
2015.
    2. Veliz P, Epstein-Ngo QM, Meier E, Ross-Durow PL, McCabe SE, Boyd 
CJ. Painfully obvious: a longitudinal examination of medical use and 
misuse of opioid medication among adolescent sports participants. J 
Adolesc Health 2014; 54:333-340.
    3. Gotsch K, Annest JL, Holmgreen P, et al., Non-fatal sports and 
recreation-related injuries treated in emergency departments--United 
States, July 2000-June 2001. MMWR Morb Mortal Wkly Rep 2002; 
51(33):736-740.
    4. Association of State and Territorial Health Officials. 2017 
President's Challenge: Public Health Approaches to Preventing Substance 
Misuse and Addictions. http://www.astho.org/addictions/
    5. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing 
opioids for chronic pain--United States, 2016. MMWR Recomm Rep 2016; 
65(RR-1):1-49.
    6. Hill MV, McMahon ML, Stucke RS, Barth RJ. Wide variation and 
excessive dosage of opioid prescriptions for common general surgical 
procedures. Ann Surg 2017; 265(4):709-714.
    7. Shah A, Hayes CJ, Martin BC. Characteristics of initial 
prescription episodes and likelihood of long-term opioid use--United 
States, 2006-2015. MMWR Morb Mortal Wkly Rep 2017; 66(10);265-269.
    8. Miech R, Johnston L, O'Malley PM, Keyes KM, Heard K. 
Prescription opioids in adolescence and future opioid misuse. 
Pediatrics 2015; 136(5):e1-e9.
    9. McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, Boyd CJ. 
Trends in medical and nonmedical use of prescription opioids among U.S. 
adolescents: 1976-2015. Pediatrics 2017; 139(4):e20162387.
10. Volkow ND, McLellan AT. Opioid abuse in chronic pain--
misconceptions and mitigation strategies. N Engl J Med 2016; 
374(13):1253-1263.

    The Chairman. Thank you, Dr. Butler.
    Ms. Deutscher.

             STATEMENT OF MAUREEN DEUTSCHER, FAMILY

 REPRESENTATIVE, PRESCRIPTION OPIOID ABUSE ADVISORY COMMITTEE, 
               SOUTH DAKOTA DEPARTMENT OF HEALTH

    Ms. Deutscher. Chairman Thune, Ranking Member Nelson, and 
members of the Committee.
    Thank you for the opportunity to provide testimony and our 
insight regarding opioid use as it relates to the effect on our 
young athletes in our home state of South Dakota and around the 
country.
    In our 30 years of marriage, my husband Jeff and I have 
been blessed with three wonderful children: Jeremy, Nick, and 
Annie. Today, we are here to tell you about our son Nick.
    Kind, funny, happy, uplifting--these were some of the words 
used in memory of Nick by friends and family following his 
death on July 18, 2015. We would add smart, intuitive, 
adventurous, frustrating, and amazing. Another recurring theme, 
``Nick always had your back.'' He was a true and loyal friend.
    We are just a regular Midwest family gathering for meals, 
enjoying family vacations, and celebrating special occasions 
together. Jeff and I have supported our children in their 
education and activities as religious ed. leaders, room 
parents, coaches, and club leaders.
    Nick had positive role models in extended family, teachers, 
and coaches. Our parenting style, as I would describe it, is 
consequence when called for, praise, and always love, and we 
all take care to be there for one another.
    So what happened? What did we miss in protecting our son? 
This has been our daily reflection for the past 21 months and 
29 days. We would like to share with you some of Nick's journey 
through the last 4 years of his life.
    Nick excelled in academics and athletics. Nick had many and 
varied friends. Nick was a bit of a risk taker, always up for 
the challenge.
    Nick's experience with opioids began shortly after his 18th 
birthday in the fall of 2011 with his MCL/ACL injury; second 
play of the second game senior year with his High School State 
Champion football team. Then they prescribed Hydrocodone, and 
Percocet or Oxycodone, through the partial tear, rehab, back in 
play for the last game of the season, and subsequent surgery 
for the full ACL tear.
    As though it were yesterday, we recall driving to Walgreens 
pharmacy directly from the game field for the first of a series 
of prescriptions. I personally maintained possession and 
control of Nick's opioid prescriptions for his welfare, but my 
understanding of the risks associated with the medication did 
not even scratch the surface.
    An alarm went off in November when Nick indicated the 
Hydrocodone was no longer sufficiently addressing his pain. We 
shared this information with his orthopedic staff. We were told 
they were not concerned with the progression, and Percocet was 
prescribed over the phone and without further evaluation.
    Following recovery and rehab from surgery through December 
of that year, the prescriptions abruptly ceased. Beginning in 
January, it became very clear that Nick was struggling. He 
underwent counseling and through our physicians, alternative 
medications were prescribed to help with the withdrawal 
culminating in 30 days of residential treatment.
    Still, Nick graduated with his class as a Regents Scholar. 
No stranger to hard work, Nick made it through that very 
frightening and challenging time, all while under the care of 
excellent physicians, and all with the continued love and 
support of his family, and the support of his high school 
principal, coaches, and staff.
    For the next 3 years, Nick attended college classes and 
worked, but the disease had taken hold and did not retreat. As 
he continued to struggle, protecting us, his family, as best he 
could from the fear of what could happen to him and the 
frustration at not being able to diminish the symptoms of 
addiction. Still good, kind, and fun, Nick continued to share 
with us his hope in recovery.
    The symptoms of addiction can move a person in directions 
they do not want to go and often do not comprehend. That 
happened to Nick as he found himself faced with charges 
stemming from substance use in 2014. Nick knew what to do, ask 
for help.
    We were blessed to have been able to support him through 
his work with Tallgrass Recovery in Sioux Falls in two 30-day 
stays between October 2014 and March 2015. Coming home in March 
was a young man renewed in his recovery, attending meetings, 
getting together with his sponsor, going to church, working, 
and spending time at Tallgrass.
    On May 20, 2015 we attended Nick's sentencing hearing for 
the 2014 offences, and on June 3, Nick checked into the work 
release program with Minnehaha County for just under four 
months.
    July 18 brought a visit by the sheriff's department at our 
home at approximately 8:30 p.m. Nick had died in his sleep, 
having returned to the work release facility after work at 
approximately 3:30 that afternoon, spending time with others in 
the program, and laying down for a nap.
    Nick died an accidental death. Reports indicated 
prescription medications in Nick's system, all but two 
prescribed; one of which was Oxycodone at an elevated level. 
Nick was 21.
    From what we can discern through conversations with Nick's 
friends and investigative findings, Nick likely relapsed due to 
the stress of his situation. We believe the medications were 
intended by Nick for use as a coping tool and to aid in sleep 
at the corrections facility. But as all too many parents, 
family members, and friends across the Nation are learning 
every day, for some people, opioids have their own intentions.
    We can no longer experience the joy of Nick's laughter, 
awesome hugs, and genuine goodness. What we hope to accomplish 
here is to reinforce the need for careful consideration of the 
effects of opioid therapy in the management of injury as our 
young athletes press forward to perform, to highlight the 
responsibility of medical professionals in prescribing 
practices relating to opioid pain medication, and to reinforce 
the need for education of the public on the addiction risks 
associated with the use of opioid therapy in sports injury 
management.
    In our experience with Nick, the addiction hit swiftly and 
without retreat, reinforcing that addiction is a chronic 
disease.
    Over the past 21 months, we have had meetings and 
conversations with county and State appointed, and elected 
officials, members of the medical and legal communities, and 
judicial systems, and agency directors in the very 
misunderstood field of addiction and recovery.
    Jeff and I have provided testimony at our State's 
Legislative Study on Substance Abuse Prevention, and are 
currently serving on the South Dakota Governor's Opioid Abuse 
Advisory Committee.
    Through all of the conversations and meetings, there are 
key issues that rise to the top for Jeff and me. Number one, 
the risks of addiction to opioid medications and the risk of 
that leading to further addiction are seriously misunderstood 
and understated.
    And second, the prescription opioid issue begins with just 
that, a prescription, calling for responsible prescribing 
practices and distribution monitoring.
    As parents, Jeff and I feel our most important role in life 
is to protect our children; if only we had known then what we 
know now.
    In closing, we are grateful for the current work being done 
to address the issues at hand. Now, we ask for your thoughtful 
consideration of the information we have provided and 
experience gained through our journey with our son, Nick.
    Thank you.
    [The prepared statement of Mrs. Deutscher follows:]

           Prepared Statement of Maureen and Jeff Deutscher, 
                       Sioux Falls, South Dakota
    Ladies and Gentlemen,

    Thank you for the opportunity to provide testimony and our insight 
regarding Opioid use as it relates to the effect on our young athletes 
in our home state of South Dakota and around the country.
    In our 30 years of marriage, my husband Jeff and I have been 
blessed with 3 wonderful children, Jeremy, Nick and Annie.
    Today we are here to tell you about our son, Nick.
    
    
    
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Kind, funny, happy, uplifting--these were some of the words used in 
memory of Nick by friends and family following his death on July 18th 
of 2015.
    We would add smart, intuitive, adventurous, frustrating and 
amazing! Another recurring theme, ``Nick always had your back'', a true 
and loyal friend.
    We're just a regular Midwest family gathering for meals, enjoying 
family vacations and celebrating special occasions together. Jeff and I 
have supported our children in their education and activities as 
religious ed leaders, room parents, coaches and club leaders. Nick had 
positive role models in extended family, teachers and coaches. Our 
parenting style, as we would describe it, is consequence when called 
for, praise and always love and we all take care to be there for one 
another.
    So what happened? What did we miss in protecting our son? This has 
been our daily reflection for the past 21 months and 29 days.
    We would like to share with you some of Nick's journey through the 
last four years of his life.
    Nick excelled in academics and athletics. Nick had many and varied 
friends. Nick was a bit of a risk taker, always up for the challenge.
    Nick's experience with Opioids began shortly after his 18th 
Birthday in the fall of 2011 with his MCL/ACL injury--second play of 
the second game Senior Year as a starter with his High School State 
Champion football team. Then the prescribed Hydrocodone and Percocet 
(Oxycodone)--through the partial tear, rehab, back in play for the last 
game of the season and subsequent surgery for the full ACL tear.
    As though it were yesterday, we recall driving to Walgreen's 
pharmacy directly from the game field for the first of a series of 
prescriptions. I personally maintained possession and control of Nick's 
Opioid prescriptions for Nick's welfare, but my understanding of the 
risks associated with the medication did not even scratch the surface.
    An alarm went off in November when Nick indicated the Hydrocodone 
was no longer sufficiently addressing his pain. We shared this 
information with his orthopedic staff, were told they were not 
concerned with the progression and Percocet was prescribed over the 
phone without further evaluation.
    Following recovery and rehab from surgery through December of that 
year, the prescriptions abruptly ceased.
    Beginning in January, it became very clear that Nick was 
struggling. He underwent counseling and through our physicians, 
alternative medications were prescribed to help with the withdrawal 
culminating with 30 days of residential treatment. Still, Nick 
graduated with his class as a Regents Scholar. No stranger to hard 
work, Nick made it through that very frightening and challenging time, 
all while under the care of excellent physicians and all with the 
continued love and support of his family and the support of his high 
school's principal, coaches and staff.
    For the next 3 years Nick attended college classes and worked, but 
the disease had taken hold and did not retreat as he continued to 
struggle, protecting us, his family, as best he could from the fear of 
what could happen to him and the frustration at not being able to 
diminish the symptoms of Addiction.
    Still good, kind and fun Nick continued to share with us his hope 
in recovery.
    The symptoms of Addiction can move a person in directions they do 
not want to go and often do not comprehend. That happened to Nick as he 
found himself faced with charges stemming from substance use in 2014. 
Nick knew what to do, ask for help. We were blessed to have been able 
to support him through his work with Tallgrass Recovery in Sioux Falls 
in two 30 day stays between October 2014 and March 2015. Coming home in 
March was a young man renewed in his recovery, attending meetings, 
getting together with his sponsor, going to church, working and 
spending time at Tallgrass.
    On May 20th of 2015 we attended Nick's sentencing hearing for the 
2014 offences and on June 3rd Nick checked into the work release 
program with Minnehaha County for just under four months.
    July 18th brought a visit by the Sheriff's Department at our home 
at approximately 8:30 p.m. Nick had died in his sleep, having returned 
to the work release facility after work at approximately 3:30 that 
afternoon, spending time with others in the program and laying down for 
a nap. Nick died an accidental death. Reports indicated prescription 
medications in Nick's system, all but two prescribed--one of which was 
Oxycodone, at an elevated level.
    Nick was 21.
    From what we can discern through conversations with Nick's friends 
and investigative findings, Nick likely relapsed due to the stress of 
his situation. We believe the medications were intended by Nick for use 
as a coping tool and to aid in sleep at the corrections facility. But 
as all too many parents, family members and friends across the Nation 
are learning every day, for some people, Opioids have their own 
intentions.
    We can no longer experience the joy of Nick's laughter, awesome 
hugs and genuine goodness. What we hope to accomplish here is to 
reinforce the need for careful consideration of the effects of Opioid 
therapy in the management of injury as our young athletes press forward 
to perform, to highlight the responsibility of Medical Professionals in 
prescribing practices relating to Opioid pain medication and to 
reinforce the need for education of the public on the Addiction risks 
associated with the use of Opioid therapy in sports injury management.
    In our experience with Nick, the Addiction hit swiftly and without 
retreat, reinforcing that Addiction is a Chronic Disease.
    Over the past 21 months we have had meetings and conversations with 
county and state appointed and elected officials, members of the 
medical and legal communities and judicial systems and agency directors 
in the very misunderstood field of Addiction and Recovery.
    Jeff and I have provided testimony at our state's Legislative Study 
on Substance Abuse Prevention and are currently serving on the SD 
Governor's Opioid Abuse Advisory Committee.
    Through all of the conversations and meetings there are key issues 
that rise to the top for Jeff and me:

  1.  The risks of Addiction to Opioid medications and the risk of that 
        leading to further addiction(s) are seriously misunderstood and 
        understated.

  2.  The prescription Opioid issue begins with just that--a 
        prescription--calling for responsible prescribing practices and 
        distribution monitoring.

    As parents, Jeff and I feel our most important role in life is to 
protect our children . . . if only we had known then what we know now. 
. . .
    In closing, we are grateful for the current work being done to 
address the issues at hand. Now, we ask for your thoughtful 
consideration of the information we have provided, experience gained 
through our journey with our son, Nick.

    The Chairman. Thank you, Ms. Deutscher.
    Ms. Pfohl.

  STATEMENT OF SHELLIE PFOHL, CHIEF EXECUTIVE OFFICER, UNITED 
                  STATES CENTER FOR SAFESPORT

    Ms. Pfohl. Thank you, Chairman Thune, Ranking Member 
Nelson, and members of the Committee.
    Mr. Chairman, I am Shellie Pfohl, CEO of the United States 
Center for SafeSport, a national, nonprofit headquartered in 
Denver, Colorado. Our organization exists to protect athletes 
from all forms of abuse. We serve sports' participants from the 
local recreation leagues to the professional ranks.
    The ongoing national discourse around sports has focused 
largely on two issues, concussions and doping, which remain 
important topics today.
    I thank you, Mr. Chairman, Ranking Member Nelson, and your 
staffs for adding our voice to the conversation. By bringing 
attention to emotional, physical, and sexual abuse prevention 
in sports, you are advancing SafeSport's call to action, which 
is to champion respect and end abuse.
    Forty-five million youth in the U.S. play sports, as well 
as scores of adults at the collegiate, professional, and 
recreational level. Athletics offer unparalleled opportunities 
for personal growth and developing character, all while 
advancing health and fitness.
    A study of 400 female executives found that more than 90 
percent participated in sports at sometime in their life. I can 
honestly say I would not be who I am today without sports.
    We never want to see those benefits that I just mentioned 
undermined by abuse. Sadly, it exists in society as it does in 
sports, whether it is an athlete bullying another athlete, or a 
coach exploiting his or her power to sexually assault a player.
    While we do not have statistics specific to sports, we know 
that in the U.S., one in five youth are bullied, and one in ten 
will be sexually abused before the age of 18.
    Fancy slogans are not enough to prevent abuse. We know that 
best practices and prevention include policies, tools, and 
training that are embedded in an organization's culture. While 
we are working to get data on how well sports organizations are 
doing at preventing abuse, we know anecdotally that much more 
needs to be done.
    Ask any parent of a child playing sports these three simple 
questions. Did you or your child receive training on how to 
prevent abuse? Do you know what the sport organization's policy 
on adult to youth interaction is? Would you know who to turn to 
if you were concerned about an abuse situation involving your 
child? My guess is they would answer no to at least one of 
those questions, which is simply unacceptable.
    Our goal is to establish a national SafeSport standard that 
organizations can use as a measuring stick of their own 
policies. SafeSport best practices, resources, and training 
tools will then help these organizations to get to where they 
need to be.
    SafeSport sought the counsel of many organizations in 
establishing the SafeSport Code that I refer to in my written 
testimony. From that interaction with other professionals, 
including those from youth-serving organizations, we understand 
that simply conducting criminal background checks is not 
enough.
    Awareness and training are at the heart of a good 
prevention effort and are essential to our work. To date, more 
than 300,000 coaches affiliated with the U.S. Olympic and 
Paralympic movements receive SafeSport training.
    We must now work to expand that education beyond coaches to 
include parents and athletes, and at all levels of competition 
beyond the Olympics.
    In addition to our education and outreach efforts, 
SafeSport is the independent response and resolution office for 
the U.S. Olympic and Paralympic movements including the 47 
National Governing Bodies that represent each of the sports.
    Reports can be made multiple ways including anonymously and 
are handled by our team of highly qualified investigators. 
Reports of sexual misconduct fall within the exclusive 
authority of SafeSport. If a report is substantiated, SafeSport 
will determine appropriate resolution, which could include a 
lifetime ban that would apply across any U.S. Olympic 
organization.
    Sports are in my DNA. Every person here has a sports 
experience, either your own or through a family member 
underscoring the magnitude of this challenge. We have a lot of 
work to do. Your efforts to prioritize the health and safety of 
U.S. athletes goes a long way toward making our SafeSport Call 
to Action to champion respect and end abuse a reality.
    Thank you and I look forward to your questions.
    [The prepared statement of Ms. Pfohl follows:]

     Prepared Statement of Shellie Pfohl, Chief Executive Officer, 
                       U.S. Center for SafeSport
I. Introduction
    The U.S. Center for SafeSport congratulates and thanks the Senate 
Commerce, Science and Transportation Committee for holding this hearing 
to address the issue of ``Current Issues in American Sports: Protecting 
the Health and Safety of American Athletes.'' A special thank you to 
Chairman John Thune for inviting SafeSport to testify.
    The written testimony herein highlights the efforts of SafeSport to 
foster a national sports culture built on respect and free from abuse. 
SafeSport is the first of its kind: a national nonprofit dedicated to 
preserving the safety and well-being of athletes by preventing 
emotional, physical and sexual abuse in sports. This includes bullying, 
harassment, hazing and all other forms of misconduct and abuse.
II. State of Play of Abuse with Athletes
    The national discourse in the sports world to date has focused on 
two serious issues: concussions and doping. But there is another that 
demands our attention. Today, we need to discuss how to recognize, 
reduce and respond to emotional, physical and sexual abuse of athletes, 
regardless of age or competitive level.
    Three out of four American families with school-aged children have 
at least one playing an organized sport--that is over 45 million youth. 
All deserve to reap the benefits of participating in sports, including 
fitness, fun, social connections, character development and more.
    But sports do not happen in a vacuum, they occur in communities 
across the country where statistics suggest one in five youth are 
bullied,\1\ and one in ten will be sexually abused \2\ before the age 
of 18. These are startling numbers and while we do not know what the 
data looks like among athletes specifically, we know that abuse is 
happening and that more must be done.
---------------------------------------------------------------------------
    \1\ Stopbullying.gov
    \2\ Townsend/Rheingold Study (2013)
---------------------------------------------------------------------------
    Sports afford participants a unique ability to learn respect, 
perseverance and teamwork while building self-esteem, confidence and 
social skills. Sports are more than a game or competition, sports build 
character. The sports community must at its core champion respect and 
protect all athletes from any form of abuse.
    That is why ask for your support in authorizing the U.S. Center for 
SafeSport in S. 534 ``Protecting Young Victims from Sexual Abuse Act of 
2017.''
III. Who We Are
    Originally created by the United States Olympic Committee, 
SafeSport is now an independent 501(c)(3) nonprofit headquartered in 
Denver, Colorado. The organization is governed by a nine-member board 
of independent directors, including subject-matter experts in the areas 
of abuse prevention and response, ethics compliance and sports 
administration. It's supported financially through the USOC, NGBs and 
charitable donations.
IV. What We Do
    SafeSport is committed to creating and maintaining a culture where 
all persons who participate in sports programs and activities can work 
and learn together in an atmosphere free of all forms of emotional, 
physical and sexual misconduct. SafeSport believes when athletes are 
safe, they can achieve their full potential.
    Prevention is at the heart of SafeSport's mission. SafeSport serves 
sports organizations across the Nation by providing educational 
resources that instill positive behavior, build character and develop 
strong communities. Its programs help to reinforce respect, safety and 
health in sports. SafeSport is working to help equip these sports 
organizations and, in turn, millions of athletes, parents and coaches, 
with tools to address issues of abuse before they occur.
    For athletes at every level--from amateur to elite, community-based 
to professional--SafeSport's approach to prevent emotional, physical 
and sexual abuse is designed to create a greater positive impact than 
any single sports organization can achieve alone.
    Additionally, the USOC retained SafeSport to investigate all cases 
of sexual misconduct or abuse for its 47 National Governing Bodies 
(NGBs).
    SafeSport's prevention efforts take shape in the form of two 
offices within the organization.
Education and Outreach Office
    The Education and Outreach Office administers programming to 
promote respect and prevent abuse; raise awareness of issues; and 
develops and distributes educational materials and resources. It serves 
all sports organizations, athletes, parents and coaches.
    SafeSport's current training has been taught to more than 300,000 
coaches in the United States.
    SafeSport is working on a resource guide that organizations can use 
to evaluate their own policies, procedures, tools and training. 
SafeSport's goal is to ensure that every sports organization in the 
United States has access to the right kinds of policies and procedures, 
tools and training materials to keep their athletes safe, regardless of 
geography, socioeconomic status or competition level.
    While SafeSport addresses the well-being of all athletes, its top 
priority is on its most vulnerable participants, children. And while 
best practices and training are essential, awareness of these issues is 
an important first step, an additional accent on the importance of this 
hearing. Our awareness campaigns will be supported by ``SafeSport 
Champions'', a program that will draw on the popularity of certain 
athletes and coaches to bring attention to these important issues.
The Response and Resolution Office
    The Response and Resolution Office investigates and resolves 
reports of sexual misconduct for the U.S. Olympic and Paralympic 
Movements. Its neutral and independent investigators and arbitrators 
review reports, and gather and analyze data, to improve awareness and 
prevention programs. Currently, SafeSport has 35 active cases in 14 
different sports.
    SafeSport's reporting process is available to anyone wanting to 
report abuse within the Olympic and Paralympic NGBs. SafeSport 
immediately reports allegations of child abuse to the appropriate law 
enforcement agency. If a covered individual violates the SafeSport 
Code,\3\ that person can be sanctioned, up to and including a lifetime 
ban enforced across the Olympic and Paralympic Movements.
---------------------------------------------------------------------------
    \3\ SafeSport Code full copy in Appendix
---------------------------------------------------------------------------
    Three policies govern the resolution process for the U.S. Olympic 
and Paralympic Movement's 47 sport's National Governing Bodies:

   SafeSport Code for the U.S. Olympic and Paralympic 
        Movement--The Code applies to all Covered Individuals and 
        identifies and defines prohibited conduct.

   SafeSport Practices and Procedures for the U.S. Olympic and 
        Paralympic Movement--These Procedures set forth the informal 
        and formal resolution process the Office uses to resolve 
        possible violations of the Code within the Office's authority.

   Supplementary Rules for U.S. Olympic and Paralympic Movement 
        SafeSport Arbitrations--The Rules govern the arbitration 
        process (when applicable).

    Below is a graphic that illustrates how the Response & Resolution 
Office works to investigate and resolve possible violations of the 
SafeSport Code. This chart is not meant to represent every aspect of 
the process.



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    Appendix can be found at https://safesport.org/files/index/tag/
                          policies-procedures
                          
                          
                          
                          
                          
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     The Chairman. Thank you, Ms. Pfohl.
    Mr. Sailor.

           STATEMENT OF SCOTT R. SAILOR, PRESIDENT, 
            NATIONAL ATHLETIC TRAINERS' ASSOCIATION

    Mr. Sailor. Chairman Thune, Ranking Member Nelson, and 
members of the Senate Committee on Commerce, Science, and 
Transportation.
    Thank you for the opportunity to participate in today's 
hearing.
    My name is Scott Sailor, and I am Chair of the Department 
of Kinesiology, and Professor of the Athletic Training Program 
at California State University Fresno. I am also proud to be 
the President of the National Athletic Trainers' Association. 
NATA is a professional organization serving more than 46,000 
Certified Athletic Trainers, students of athletic training, and 
other healthcare professionals.
    Protecting the health and safety of athletes is exactly 
what members of NATA have been doing since the organization was 
founded in 1950. The mission of NATA is to represent, engage, 
and foster the continued growth and development of the athletic 
training profession and athletic trainers as unique healthcare 
providers.
    Athletic trainers are healthcare professionals who 
collaborate with physicians to provide preventative services, 
emergency care, clinical diagnosis, therapeutic intervention, 
and rehabilitation of injuries. They are required to graduate 
from an accredited baccalaureate or master's degree program. An 
academic curriculum and clinical training follow the medical 
model. Athletic trainers are licensed and otherwise regulated 
in 49 States and the District of Columbia.
    NATA has long been a leader in bringing a voice to the many 
health and safety issues facing athletes. We actively provide 
our expertise and specific recommendations to policymakers at 
the local, State, and Federal levels.
    NATA believes Congress should fully invest in efforts to 
track youth sports injuries and fatalities. It is only with a 
comprehensive system for collecting and analyzing this data 
that we will be able to understand the scope of the problem and 
the best methods for addressing it.
    Based upon current published studies and available data, we 
know America faces challenges balancing an active and healthy 
sports culture while protecting the safety of the youth 
athlete.
    I would like to give you a few of the current statistics on 
athletic involvement and injuries in the United States.
    There are 420,000 college-level athletes who experience 
209,000 injuries per year. At the secondary school level, there 
are 7.6 million athletes who have 1.4 million injuries per 
year. The 46.5 million children playing team sports in our 
country have 1.35 million injuries per year. In 2013, there 
were 124 million emergency room visits by children 19 years of 
age and younger for injuries related to sport.
    These injury statistics are compelling, but to athletic 
trainers, the most compelling fact is that the secondary school 
athletic population leads the Nation in athletic-related 
deaths.
    Between 2008 and 2015, there were more than 300 sports-
related fatalities among young athletes. Let me underscore that 
fact. In a 7-year period, we lost over 300 children who were 
merely playing sports. As a Nation, we must do a better job of 
protecting our youth athletes.
    However, only an estimated 42 percent of high schools 
employee a full-time athletic trainer. We need to improve 
access to athletic trainers in secondary schools and youth 
sports organizations.
    We have a responsibility here to our athletes to provide 
appropriate medical care. The investment in proper safety 
measures and adequate medical supervision such as a full time 
athletic trainer is not costly when compared to the death or a 
catastrophic injury of a young athlete.
    In 2010, NATA founded the Youth Sports Safety Alliance, 
YSSA, which is now comprised of nearly 290 organizations. The 
members of YSSA range from parent advocate groups, research 
institutions, professional associations, healthcare 
organizations, and youth sports leagues. NATA and YSSA are 
working to promote and preserve sports, but we must also ensure 
that sports are played safely. When injuries occur, we must be 
adequately prepared to respond.
    In 2013, NATA also sponsored the Safe Sports School Award, 
a program designed to establish a standard for secondary school 
athlete safety and recognize those athletic programs that excel 
in taking all the necessary steps to ensure athlete safety. To 
date, there have been more than 1,100 schools that have 
received the Award.
    NATA partners with the American Medical Society for Sports 
Medicine, and the Korey Stringer Institute in organizing 
Collaborative Solutions for Safety in Sports. This is an annual 
event among youth sports safety leaders from every state who 
come together to discuss appropriate sports medicine policy.
    Finally, over the past several years, NATA has partnered 
with the NFL Foundation, Gatorade, and the Professional 
Football Athletic Trainers Society to fund multimillion dollar 
efforts to place athletic trainers in underserved high schools.
    With the knowledge and understanding of the physical and 
mental benefits of being physically active, NATA has taken a 
leadership role within a number of national coalitions involved 
in promoting physical activity issues.
    This week, NATA members were here on Capitol Hill urging 
members of Congress to support the Personal Health Investment 
Today Act or the PHIT Act. This legislation provides an 
incentive for adults and their children to get fit, which will 
help prevent healthcare costs related to preventable chronic 
diseases.
    I would like to thank Chairman Thune for being the lead 
sponsor of the bill in the Senate and to thank Senators Wicker, 
Moore Capito, and Baldwin for being cosponsors.
    Athletic trainers are uniquely positioned to help with the 
prevention of opioid abuse and successful rehabilitation from 
injury among student athletes.
    NATA supports proposals to increase access to and training 
in administrating Naloxone.
    NATA also supports the Student and Student Athlete Opioid 
Misuse Prevention Act introduced by New Hampshire Senator 
Shaheen. This bill authorizes new Federal grant funding to 
support programs for students and student athletes as well as 
training for teachers, administrators, and athletic trainers.
    As a leading organization representing athletic trainers, 
NATA fully supports Chairman Thune's and Senator Klobuchar's 
Sports Medicine Licensure Clarity Act. I would like to thank 
Senators Wicker and Moore Capito for being cosponsors of the 
bill.
    The Sports Medicine Licensure Clarity Act clarifies medical 
liability rules for athletic trainers, and other medical 
professionals, to ensure they are properly covered by their 
liability insurance when traveling with athletic teams in 
another state. This legislation also has the support of sports 
leagues and professional medical associations. This week, most 
senate offices were visited by athletic trainers requesting 
support for this legislation.
    I want to join my fellow athletic trainers, and the more 
than 46,000 members of the NATA, in urging Members of the 
Senate, including the members of this committee, to cosponsor 
the Sports Medicine Licensure Clarity Act.
    Thank you for this opportunity to present the views of the 
National Athletic Trainers' Association and I welcome your 
questions.
    [The prepared statement of Mr. Sailor follows:]

           Prepared Statement of Scott R. Sailor, President, 
                National Athletic Trainers' Association
    On behalf of the National Athletic Trainers' Association (NATA), I 
am pleased to have the opportunity to provide testimony to the United 
States Senate Commerce, Science, and Transportation Committee on the 
important topic of protecting the health and safety of American 
athletes. My name is Scott R. Sailor and I am the President of NATA and 
Chair of the Department of Kinesiology and Program Director for the 
Athletic Training Program at Fresno State University.
    NATA is a professional organization serving more than 46,000 
certified athletic trainers, students of athletic training, and other 
health care professionals. Protecting the health and safety of athletes 
is exactly what NATA members have been doing since the organization was 
founded in 1950.
Background on the Athletic Training Profession
    The mission of NATA is to represent, engage, and foster the 
continued growth and development of the athletic training profession 
and athletic trainers as unique health care providers. Athletic 
trainers are health care professionals who collaborate with physicians 
to provide preventative services, emergency care, clinical diagnosis, 
therapeutic intervention, and rehabilitation of injuries. As part of 
the health care team, services provided by athletic trainers include 
injury and illness prevention, wellness promotion and education, 
emergent care, examination and clinical diagnosis, and therapeutic 
intervention.
    Athletic trainers provide urgent and acute care of injuries; they 
specialize in preventing, diagnosing, and treating muscle and bone 
injuries. Athletic trainers are included under the allied health 
professions category as defined by the U.S. Department of Health and 
Human Services and are assigned National Provider Identifier numbers. 
In addition to employment by sports and athletic organizations, 
athletic trainers are employed by hospitals, clinics, occupational 
health departments, wellness facilities, the United States military, 
and numerous other health care settings.
    Athletic trainers are highly qualified, multi-skilled health care 
professionals. To provide appropriate care for patients, athletic 
trainers receive training in prevention, recognition, and treatment of 
critical situations. They must graduate from an accredited 
baccalaureate or master's program and it is required that athletic 
trainers' academic curriculum and clinical training follow the medical 
model. Leaders of key athletic training organizations, including NATA, 
have jointly decided to change the athletic training degree level to be 
a master's; this change is in process and will become effective by 
2022. Currently, 70 percent of athletic trainers already have advanced 
degrees beyond a bachelor's degree. Athletic trainers are licensed or 
otherwise regulated in 49 states and the District of Columbia.
    Using a medical-based education model, athletic trainers serve as 
allied health professionals with an emphasis on clinical reasoning 
skills. The curriculum of an accredited athletic training program must 
include a comprehensive basic and applied science background and uses a 
competency based approach in both the classroom and clinical settings.
    Athletic training education programs are accredited by the 
Commission on Accreditation of Athletic Training Education (CAATE), 
which is recognized by the Council for Higher Education Accreditation. 
The CAATE sets forth rigorous standards for the preparation of athletic 
training graduates that are science-based and didactic. CAATE also 
administers post-professional athletic training residency programs.
    Upon completion of an accredited athletic training program, 
athletic trainers are required to pass a comprehensive examination 
administered by the Board of Certification, Inc. (BOC). The BOC 
certification program ensures that individuals have the knowledge and 
skills necessary to perform the tasks critical to safe and competent 
practice as an athletic trainer. Athletic trainers who pass the BOC's 
examination are awarded the ATC credential.
Athlete Health and Safety Issues
    NATA has long been a leader in bringing a voice to the many health 
and safety issues facing athletes. We are actively engaged in providing 
our expertise and specific recommendations to policymakers at the 
local, state, and Federal levels.
    As a health professional organization, we pride ourselves on 
staying informed of the latest research findings and reports related to 
athlete safety. The athletic trainers involved in conducting research 
and analyzing sports injuries are doing outstanding work. However, NATA 
urges Congress to fully invest in efforts to track youth sports 
injuries and fatalities. It is only with a comprehensive system for 
collecting and analyzing this data that we will be able to understand 
the scope of the problem and the best methods for addressing it.
    Based upon current studies and reports, the following statistics 
provide the best snapshot of the relationship between athletic 
participation and sports-related injuries in the Unites States:

   420,000 college-level athletes experience 209 million 
        injuries per year;

   7.6 million secondary school athletes experience 1.4 million 
        injuries per year;

   46.5 million children playing team sports experience 1.35 
        million injuries per year;

   62 percent of injuries occur during practice; and

   1.6 to 3.8 million sports-related concussions occur every 
        year.

    In 2013, there were 1.24 million emergency room visits by children 
19 years of age and under for injuries related to sports; that is 3,397 
visits per day, 141 per hour, and 1 every 25 seconds.
    These injury statistics are compelling, but to athletic trainers, 
the most concerning fact is that the secondary school athletic 
population leads the Nation in athletic-related deaths. Between 2008 
and 2015, there have been more than 300 sports-related fatalities among 
young athletes. Let me underscore this fact; in a seven-year period, we 
lost over 300 children who were merely playing sports. As a nation, we 
must do a better job in protecting youth athletes.
    Athletic trainers are experts in creating and applying strategies 
to prevent and reduce the many different causes of sudden death in 
athletic participation. The underlying causes of sudden death in 
athletics might include asthma, catastrophic brain injuries, cervical 
spine injuries, diabetes, exertional heat stroke, and sudden cardiac 
arrest, which is the leading cause of death in young athletes.
    NATA supports proposals to ensure that every high school with an 
athletics department has a full-time athletic trainer on staff to 
monitor the health of student athletes. However, only an estimated 42 
percent of high schools employ a full-time athletic trainer. We must 
improve access to athletic trainers in secondary schools and youth-
sports organizations.
    The investment in proper safety measures and providing adequate 
medical supervision, such as a full-time athletic trainer, for sports 
practices and games is not costly when compared to the loss of a young 
life to injury that may have been prevented or properly treated.
    NATA further advocates for the implementation of emergency action 
plans for all sporting events and venues. These plans, developed in 
conjunction with a health care team, ensure a plan of action is in 
place in case of injury, whether minor or catastrophic.
NATA's Leadership on Youth Athlete Safety Issues
    In 2010, NATA founded the Youth Sports Safety Alliance (YSSA), 
which is now comprised of nearly 290 organizations. The members of YSSA 
range from parent advocate groups, research institutions, professional 
associations, health care organizations, and youth sports leagues.
    Organized sports bring enormous health benefits to children, but 
certain factors may cause them to ignore pain and injuries, which could 
result in lifelong injuries or even death. NATA is working to preserve 
amateur and professional sports, but we must also ensure that sports 
are played safely and that when injuries occur, we are adequately 
prepared to respond.
    NATA has worked on a number of other partnerships and initiatives 
to bring attention to youth athlete safety issues at a local, state, 
and national level including the following:

   NATA Safe Sports School Award: Since 2013, NATA has 
        sponsored the Safe Sports School Award, a program designed to 
        establish a standard for secondary school athlete safety and 
        recognize those athletic programs that excel in taking all the 
        necessary steps to ensure athlete safety. To date, there have 
        been more than 1,100 schools that have received the award.

   At Your Own Risk Campaign: NATA has developed a public 
        awareness campaign, At Your Own Risk, aimed specifically at 
        educating parents, student athletes, school administrators, 
        legislators, and employers on the role of athletic trainers as 
        experts in prevention and safety in work, life, and sport.

   Annual Youth Sports Safety Leaders Event: NATA partners with 
        the American Medical Society for Sports Medicine, the Korey 
        Stringer Institute, and the National Football League (NFL) in 
        organizing ``Collaborative Solutions for Safety in Sports,'' an 
        annual event among youth sports safety leaders from every state 
        to discuss emergency action planning and coaching education in 
        secondary schools.

   Athletic Trainers in Underserved High Schools: Over the past 
        several years, NATA has partnered with the NFL Foundation, 
        Gatorade, and the Professional Football Athletic Trainers 
        Society to fund multimillion dollar efforts to place athletic 
        trainers in underserved high schools.

   Publications on Best Practices: NATA continues to publish 
        resources on best practices related to preventing sudden death 
        in secondary school athletics, concussion, heat 
        acclimatization, emergency action plans, lightning safety, and 
        other emerging athlete safety issues.
Promoting Physical Activity
    Athletic trainers more than any other health profession understand 
the physical and mental health benefits of an active lifestyle. While 
NATA has been engaged in raising awareness of youth athlete safety 
issues, we have remained just as steadfast in our efforts to promote 
the benefits of physical activity and sports. NATA has had both of 
these issues at the top of its Federal legislative agenda for many 
years.
    The Centers for Disease Control and Prevention's National 
Prevention Strategy ``outlines the importance of preventive care and 
recognizes that active living is important to reducing the burden of 
disease and death.'' According to the U.S. Department of Health and 
Humans Services' 2008 Physical Activity Guidelines, ``adults who are 
physically active are healthier and less likely to develop many chronic 
diseases than adults who are not active--regardless of their gender or 
ethnicity.''
    Further statistics show that participation in sport helps children 
develop and improve cognitive skills. Physical activity in general is 
associated with improved academic achievement, including grades and 
standardized tests scores. Such activity can affect attitudes and 
academic behavior, including enhanced concentration and attention and 
improved classroom behavior. Physical activity and sports in particular 
can positively affect aspects of personal development among young 
people, such as self-esteem, goal setting, and leadership. Moreover, 
high school athletes are more likely than non-athletes to graduate from 
high school, attend college, and receive a degree.
    On Tuesday, May 16, 2017, NATA members were on Capitol Hill, urging 
Members of Congress to support the Personal Health Investment Today Act 
or the PHIT Act. This legislation provides an incentive for adults and 
their children to get fit, which will help prevent health care costs 
related to preventable chronic diseases. I would like to thank Chairman 
Thune for being the lead sponsor of the bill in the Senate and to thank 
Senators Wicker, Capito, and Baldwin for being cosponsors. I would 
encourage the other members of the Senate Commerce Committee to 
cosponsor the PHIT Act.
    Also, NATA has taken a leadership role within a number of national 
coalitions involved in promoting physical activity issues. NATA's 
Director of Government Affairs, Amy Callender, represents us on the 
Board of Directors of the National Physical Activity Plan Alliance and 
she is the President of the Board of Directors of the National 
Coalition to Promote Physical Activity.
The Opioid and Prescription Drug Epidemic
    The widespread availability and abuse of prescription opioids and 
heroin has been recognized as a public health crisis by both lawmakers 
and the public.
    In 2016, an estimated one in five patients with non-cancer pain or 
pain-related diagnoses was prescribed an opioid. In many cases, 
addiction to prescription opioids can lead to abuse of less expensive 
heroin. In 2014, there were 18,893 overdose deaths related to 
prescription pain relievers and 10,574 overdose deaths related to 
heroin.
    Athletic trainers can play an important role in promoting safe 
opioid use and preventing opioid abuse. Sports injuries may result in a 
student being prescribed an opioid pain medication, putting student 
athletes at a higher risk for abusing those medications. Athletic 
trainers are uniquely positioned to help with the prevention of opioid 
abuse and successful rehabilitation from injury amongst student 
athletes.
    If a student athlete is prescribed an opioid, the athletic trainer 
at his or her school should be informed so they can assist with 
monitoring the student's usage and recovery progress. Opioid overdoses 
can be reversed when the lifesaving drug naloxone is promptly 
administered. NATA supports proposals to increase access to and 
training in administering naloxone, including amongst athletic 
trainers.
    In October 2015, the Obama Administration encouraged federal, 
state, local, and private sector entities to address the prescription 
drug abuse and heroin epidemic. NATA was invited to participate in this 
effort and we shared educational materials on opioid misuse prevention 
with our entire membership.
    We were strong advocates for the passage of the Comprehensive 
Addiction and Recovery Act or CARA. Also, NATA has provided comments 
and recommendations on National Pain Strategy and we were represented 
at the recently held ``Implementation of the National Pain Strategy 
Listening Session'' hosted by the Office of the Assistant Secretary for 
Health.
    NATA also supports S. 786, the Student and Student Athlete Opioid 
Misuse Prevention Act, introduced by New Hampshire Senator Jeanne 
Shaheen. The bill is focused on preventing opioid abuse amongst 
students, and particularly amongst student athletes. The bill 
authorizes new Federal grant funding to support programs for students 
and student athletes, as well as training for teachers, administrators, 
and athletic trainers.
Other Federal Legislative and Regulatory Policy Issues
    As the leading organization representing athletic trainers, NATA 
fully supports Chairman Thune's Sports Medicine Licensure Clarity Act. 
I would also like to thank Senators Klobuchar, Wicker, and Capito for 
being original cosponsors of the bill.
    The Sports Medicine Licensure Clarity Act clarifies medical 
liability rules for athletic trainers and other medical professionals 
to ensure they are properly covered by their liability insurance while 
traveling with athletic teams in another state.
    The legislation has the support of the Academy of Orthopedic 
Surgeons, the American Medical Society for Sports Medicine, the 
American Academy of Neurology, and numerous other physician and sports 
medicine organizations. Additionally, the United States Olympic and 
Paralympic Committee, the National Collegiate Athletic Association, and 
every major American professional sports league have endorsed the bill.
    The House version of the bill, H.R. 302, passed on January 9, 2017 
and awaits action by the Unites States Senate. This week, most Senate 
offices were visited by athletic trainers requesting support for this 
legislation. I want to join my fellow athletic trainers and the more 
than 46,000 members of NATA in urging members of the United States 
Senate, including the members of this Committee, to cosponsor the 
Sports Medicine Licensure Clarity Act.
    Thank you for this opportunity to present the views of the National 
Athletic Trainers' Association and I welcome your questions.

    The Chairman. Thank you, Mr. Sailor.
    Dr. Stern.

         STATEMENT OF ROBERT A. STERN, Ph.D., PROFESSOR

            OF NEUROLOGY, NEUROSURGERY, AND ANATOMY,

           AND NEUROBIOLOGY; DIRECTOR, CLINICAL CORE,

             BU ALZHEIMER'S DISEASE AND CTE CENTER,

              BOSTON UNIVERSITY SCHOOL OF MEDICINE

    Dr. Stern. Good morning, Mr. Chairman, Ranking Member 
Nelson, and distinguished members of the Committee.
    It is a great honor to appear before you today.
    My name is Dr. Robert Stern. I am a Professor of Neurology, 
and Neurosurgery, and Anatomy, and Neurobiology at Boston 
University School of Medicine. I am also the Director of the 
Clinical Core of the BU Alzheimer's Disease and CTE Center.
    For the past 30 years, I have been conducting clinical 
neuroscience research, primarily focused on issues pertaining 
to neurodegenerative diseases such as Alzheimer's. Since 2008, 
my research has focused on the long-term consequences of 
repetitive brain trauma in athletes including Chronic Traumatic 
Encephalopathy or CTE.
    CTE is a neurodegenerative disease that can lead to 
dramatic changes in mood, behavior, movement, and cognition 
eventually leading to dementia. It is similar to Alzheimer's 
disease, but it is a unique disease easily distinguished from 
Alzheimer's and other diseases through postmortem 
neuropathological examination.
    We have actually known about CTE for almost 100 years. It 
was originally called ``punch drunk'' or dementia pugilistica 
in the early 1900s when it was believed to occur only in 
boxers.
    However, CTE has now been found in people who never boxed 
from ages 16 to 98, including former youth, college, and 
professional contact sport athletes such as football, hockey, 
soccer, and rugby players. At this time, CTE can only be 
diagnosed after death through postmortem neuropathological 
examination.
    It is very important to understand that concussion and CTE 
are very distinct. A concussion is an acute brain injury which, 
if managed appropriately, results in transient symptoms without 
long-term consequences.
    CTE, on the other hand, is a neurodegenerative disease that 
appears to begin earlier in life when repetitive brain trauma 
starts to trigger a cascade of events leading to progressive 
destruction of the brain tissue. The symptoms often begin years 
or decades after the brain trauma, after the cessation of the 
athletic activity and continue to worsen as the individual 
ages.
    There have been numerous cases of advanced stage CTE 
diagnosed postmortem in former athletes who had no symptoms of 
concussion, no history of concussion, but who had extensive 
exposure to what is referred to as sub-concussive trauma.
    Several important questions about CTE remain unanswered 
such as, how common is CTE? Why does one person get it and 
another person does not? How can CTE be differentiated during 
life from other diseases and conditions with similar symptoms? 
To answer these and other questions the ability to diagnose CTE 
while someone is living is the critical next step.
    Our group at Boston University, and other scientists from 
around the country and abroad, are actively conducting research 
to develop methods to accurately diagnose CTE during life. I am 
honored to be the lead investigator of a seven-year 
longitudinal multicenter investigation funded by the National 
Institute of Neurological Disorders and Stroke that brings 
together a network of approximately 50 scientists from ten 
major research institutions across the country.
    The study referred to as the Diagnose CTE Research Project 
is aimed at developing methods of diagnosing CTE during life. 
In total, hundreds of former professional football players, 
former college football players, and healthy controls will 
undergo extensive testing over a three-day period at one of 
four sites around the country, and then return 3 years later 
for a follow-up evaluation. We are well underway, and yet, this 
is just one study. So much more research is needed.
    In closing, it is imperative that we do everything we can 
as a Nation to continue to reap the profound benefits of 
American sports and athletic participation, while also assuring 
that we protect the health and safety of former, current, and 
future American athletes. That is a difficult balance and 
requires a combination of unbiased scientific information and 
common sense.
    I want to thank the Committee for your interest in 
addressing this important issue, and for your continued 
commitment toward protecting the health and safety of all 
athletes.
    I also want to express my gratitude toward the Senate for 
approving the Fiscal Year 2017 Appropriations bill that was 
recently signed into law with a $2 billion increase for the 
National Institutes of Health including an additional $400 
million in funding of Alzheimer's disease research. I urge you 
to continue and to expand upon that type of support.
    Thank you.
    [The prepared statement of Dr. Stern follows:]

 Prepared Statement of Robert A. Stern, Ph.D., Professor of Neurology, 
 Neurosurgery, and Anatomy & Neurobiology; Director, Clinical Core, BU 
    Alzheimer's Disease and CTE Center, Boston University School of 
                                Medicine
Introduction
    Mr. Chairman, Ranking Member Nelson, and distinguished Members of 
the Committee, it is a great honor to appear before you today for this 
hearing on ``Current Issues in American Sports: Protecting the Health 
and Safety of American Athletes.'' I am a Professor of Neurology, 
Neurosurgery, and Anatomy & Neurobiology at Boston University School of 
Medicine. I am also the Director of the Clinical Core of the Boston 
University (BU) Alzheimer's Disease and CTE Center, one of 29 
Alzheimer's research centers funded by the National Institute on Aging. 
For the past 30 years, I have been conducting clinical neuroscience 
research, primarily focused on the cognitive, mood, and behavioral 
changes of aging, in general, and in neurodegenerative diseases, in 
particular. I have been on the faculties of the University of North 
Carolina School of Medicine, Brown Medical School, and, for the past 13 
years, BU School of Medicine. In my role in the BU Alzheimer's Disease 
and CTE Center, I oversee all clinical research pertaining to 
Alzheimer's disease (AD), including studies aimed at the diagnosis, 
genetics, prevention, and treatment of this devastating cause of 
dementia.
Chronic Traumatic Encephalopathy (CTE)
    You may be asking, ``Why is an Alzheimer's disease specialist 
testifying at a hearing on Protecting the Health and Safety of American 
Athletes?'' The answer is, in short, that repetitive hits to the head, 
such as those incurred through American tackle football and other 
contact sports, can have long-term negative consequences to brain 
health, including the development of another neurodegenerative disease, 
chronic traumatic encephalopathy or CTE. In 2008, I co-founded the BU 
Center for the Study of Traumatic Encephalopathy (now referred to as 
the BU CTE Center) with Dr. Ann McKee, Dr. Robert Cantu, and Mr. 
Christopher Nowinski.\1\ Since that time, my research has focused on 
the long-term consequences of repetitive brain trauma in athletes, 
including CTE, a progressive neurodegenerative disease that can lead to 
dramatic changes in mood, behavior, and cognition, eventually leading 
to dementia. It is similar to Alzheimer's disease, but it is a unique 
disease, easily distinguished from AD and other diseases through post-
mortem neuropathological examination (McKee et al., 2013; 2016). CTE 
has been found in individuals from ages 16-98, including youth, 
college, and professional contact sport athletes (e.g., football, 
hockey, soccer, and rugby players, as well as boxers), military service 
members exposed to blast trauma and other brain injuries, and others 
with a history of repetitive brain trauma, such as a physically abused 
woman, developmentally disabled head bangers, and seizure disorder 
patients. (See Table 1)
---------------------------------------------------------------------------
    \1\ Christopher Nowinski will formally receive his Ph.D. in 
Behavioral Neurosciences from Boston University School of Medicine on 
the day following this Hearing (May 18, 2017).




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    CTE has been known to affect boxers since the 1920s (previously 
referred to as ``punch drunk'' or dementia pugilistica). The post-
mortem neuropathological characteristics were first clearly described 
in the 1970s by Corsellis et al., (1973). In 2002, CTE was diagnosed 
neuropathologically in a former professional football player for the 
first time (i.e., Mike Webster of the Pittsburgh Steelers). That case 
and subsequent discoveries of CTE in other deceased former NFL players 
led to growing media attention on CTE. Until recently, I have stated 
publicly that the scientific knowledge of CTE is in its infancy. 
However, due to important new scientific discoveries about CTE, along 
with an exponential increase in the number of publications in medical/
scientific journals focusing on CTE (See Figure 1), I am led to think 
that we are now in the ``toddlerhood'' of our scientific knowledge 
about this disease.





[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

CTE Neuropathology
    What is currently known about CTE is based primarily on post-mortem 
examinations of brain tissue, and interviews from the family members of 
the deceased athletes. My colleague, Dr. Ann McKee, and her team have 
examined more brains of individuals with a history of repetitive brain 
trauma than any group in the world. What these studies have shown is 
that, in some individuals, repetitive brain trauma triggers a cascade 
of events in the brain leading to progressive destruction of the brain 
tissue. The hallmark feature of CTE is the build-up of an abnormal form 
of a protein called tau (See Figure 2; based on the work of Dr. McKee). 
The tau protein becomes hyperphosphorylated (referred to as p-tau) and, 
rather than serve its vital role in the structure and function of brain 
cells, it becomes toxic, eventually destroying the cells. In 2015, the 
National Institute of Neurological Disorders and Stroke (NINDS) and the 
National Institute of Biomedical Imaging and Bioengineering (NIBIB) 
convened a consensus conference panel of seven independent 
neuropathologists with specific expertise in neurodegenerative 
tauopathies (McKee et al., 2016). The group of experts agreed that CTE 
is a unique disease, only seen in individuals with a history of 
repetitive brain trauma. Further, they agreed that the pathognomonic 
lesion of CTE (i.e., the changes in the brain that are uniquely found 
in CTE and can be used to diagnose it) is an irregular deposition of p-
tau around small blood vessels at the depths of the cortical sulci 
(i.e., the valleys of the cerebral cortex). This pattern of p-tau was 
agreed to be distinct from any other neurodegenerative tauopathy, 
including Alzheimer's disease and frontotemporal lobar degeneration. As 
the disease advances, the disease spreads to other areas of the brain, 
leading to progressive destruction of brain tissue (i.e., atrophy). The 
changes in the brain from CTE can begin years, or even decades, after 
the last brain trauma or end of athletic involvement.
    CTE is not prolonged post-concussion syndrome, nor is it the 
cumulative effect of concussions or mild traumatic brain injuries. 
Rather, CTE is not a ``brain injury,'' per se; CTE is a 
neurodegenerative disease that appears to begin earlier in life, at the 
time of exposure to repetitive head impacts, but the symptoms often 
begin years or decades after the brain trauma and continue to worsen as 
the individual ages. Importantly, there have been numerous cases of 
neuropathologically-confirmed later stage CTE without any history of 
symptomatic concussions, but with extensive exposure to 
``subconcussive'' trauma (see below).
The Clinical Features of CTE
    Depending upon the areas of the brain destroyed by the disease, CTE 
can lead to a variety of changes in cognitive, behavioral, mood, and 
often motor functioning (See Table 1). As cognitive impairment worsens, 
the individual typically demonstrates progressive dementia, i.e., 
memory and other cognitive dysfunction severe enough to impair 
independence in activities of living. Although the cognitive changes in 
CTE are very similar to those in Alzheimer's disease, many individuals 
with CTE develop the significant changes in mood and behavior 
relatively early in life (Stern, et al., 2013). This can lead to 
significant distress for the individual with CTE as well as their 
family, friends, and other loved ones. These mood and behavioral 
impairments associated with CTE are often misdiagnosed and attributed 
to routine psychiatric disorders, stress, substance abuse, or pre-
existing personality traits. Although there can be many potential 
underlying causes for changes in mood and behavior in individuals in 
their 20s-50s, it is also known that the areas of the brain damaged in 
CTE could lead to these problems, including depression, impulsivity, 
emotional liability, irritability, and behavioral dyscontrol. Based on 
reviews of the published case reports and other literature, along with 
our own research of the reported clinical features of CTE in 
neuropathologically-confirmed cases (Stern et al., 2013), our group 
published provisional Research Diagnostic Criteria for the clinical 
presentation of CTE, referred to as Traumatic Encephalopathy Syndrome 
or TES (Montenigro et al., 2014). An important aspect of these proposed 
diagnostic criteria is the use of objective biological tests (i.e., 
biomarkers), when they are available and validated, to indicate that 
CTE is the underlying disease for the clinical presentation. This 
diagnostic approach is similar to that currently accepted in the 
research community for the clinical diagnosis of Alzheimer's disease, 
including Mild Cognitive Impairment (MCI) due to Alzheimer's disease 
and dementia due to Alzheimer's disease.



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    Although there are have been tremendous gains in our understanding 
of CTE during the last decade, there remain many important questions 
(see Table 2). Most of these questions cannot easily be answered until 
CTE can be diagnosed during life. However, we cannot wait until CTE can 
be diagnosed during life to begin to examine the short-term and long-
term neurological consequences of repetitive head impacts in athletes.





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Concussions are the Tip of the Iceberg: Importance of Subconcussive 
        Trauma
    The Centers for Disease Control and Prevention (CDC) estimates as 
many as 3.8 million concussions occur in the U.S. each year through 
sports and recreational activities. It is clear that a single sports-
related concussion can result in significant physical, emotional, and 
cognitive symptoms and signs. Although the majority of concussions 
resolve within a few weeks, 10-30 percent result in prolonged recovery 
(i.e., post-concussion syndrome). However, at some point, a single 
concussion is likely to completely resolve and result in no long-term 
consequences. It is likely that concussions are only the ``tip of the 
iceberg,'' when it comes to long-term neurological problems, in 
general, and CTE, in particular. What is significantly more common than 
symptomatic concussions are ``subconcussive'' hits. This subconcussive 
trauma is believed to occur when there is impact to the brain with 
adequate force to have an effect on neuronal functioning, but without 
immediate symptoms and signs of concussion. Some sports (e.g., American 
tackle football) and positions (e.g., lineman) are very prone to these 
impacts. The most common method used to quantify the number of these 
subconcussive impacts involves helmets outfitted with accelerometers, 
devices that measure the linear, lateral, and rotational forces of 
impacts. Numerous studies have been published over the past 10 years, 
primarily in tackle football at the high school and college level. For 
example, a study by Broglio and colleagues (2011) found that high 
school football players received, on average, 652 hits to the head in 
excess of 15g of force in a single season. One player received 2,235 
hits. The average number of hits in college players is even greater. 
There is now growing evidence that even after one season, repetitive 
subconcussive trauma can lead to cognitive, physiological, and 
structural changes to the brain (e.g., Abbas et al., 2015; Davenport et 
al., 2014, 2016; Helmer et al., 2014; McAllister et al., 2012; 
Breedlove et al., 2012; Poole et al., 2015; Kawata et al., 2017). One 
recent study of youth (8-12 year olds) tackle football by researchers 
at Wake Forest University (Bahrami et al., 2016) had rather striking 
results. In this study, the players underwent a special type of MRI 
scan, referred to as diffusion tensor imaging (DTI), prior to the 
season, and then again following the football season. The players wore 
helmets with accelerometers during the course of the season. Without 
including any players with symptomatic, diagnosed concussions, the 
researchers found that players who experienced greater cumulative head 
impact exposure (i.e., more hits above a g-force threshold across the 
season) had more changes in the integrity of the white matter of the 
brain. Research studies such as these provide strong support that there 
are short-term neurological consequences of repetitive subconcussive 
trauma.
Cumulative Head Impact Exposure
    One thing we do know about CTE is that every case of post-mortem 
diagnosed CTE has had one thing in common: a history of repetitive 
brain trauma (Bieniek et al., 2015). This means that the repetitive 
brain trauma is a necessary factor in developing this disease. However, 
it is not a sufficient factor. That is, not everyone who hits their 
head repeatedly will develop this progressive brain disease. There are 
additional, as yet unknown, variables that lead to CTE, such as genetic 
susceptibility or specific aspects of the exposure to the brain trauma 
(e.g., severity and type of trauma, amount of rest between hits, total 
duration of exposure to trauma, cumulative number of head impacts, age 
of first exposure). An important next step in CTE research is to 
examine the specific aspects of head impact exposure, vis-a-vis risk 
for later life neurological changes.
    Similar to measuring and modeling ``exposure'' to toxins in the 
environment or in the workplace, our group has been employing the 
approaches and techniques used in Exposure Science to guide our 
examination of exposure to head impacts through tackle football. We 
recently published a study evaluating the relationship between the 
estimated cumulative number of head impacts received playing amateur 
football and later life mood, behavioral, and cognitive functioning 
(Montenigro et al., 2016). In this study, we developed the cumulative 
head impact index (CHII), using a sample of 93 former high school and 
college American football players, with an average age of 47. The CHII 
was calculated from an algorithm based on the number of seasons played, 
position(s) played, levels played (youth, high school, college), and 
estimated head impact frequencies from published helmet accelerometer 
studies. The total number of hits was not meant to reflect merely the 
number of ``concussions,'' but, rather, all impacts above a minimum 
force, including those referred to as subconcussive hits. The average 
number of total impacts estimated to have been received by participants 
in our study was 7,742, a number that is consistent with the range of 
cumulative impacts expected for former high school and college football 
players based on previous published helmet accelerometer studies. We 
found a strong, dose-response relationship between the estimated total 
number of head impacts experienced through youth, high school, and 
college football and the risk of developing clinically-meaningful 
cognitive, mood, and behavioral impairments later in life. Figures 3 
and 4 depict the dose-response relationships between the CHII and 
later-life depression and cognitive impairment, respectively. In 
layman's terms, the more hits to the head a football player received in 
his career, the more likely he was to have impaired cognitive 
functioning, as well as depression, apathy, and behavioral regulation 
difficulties.

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    We have also found significant relationships between greater 
lifetime exposure to head impacts in football (using the CHII metric) 
and objective biomarkers of possible overall neurodegeneration in 
former NFL players between the ages of 40-69 years. For example, in one 
study (Alosco et al., 2016), the greater the exposure level (i.e., the 
amount of estimated head impacts), the higher the amount of total tau 
protein in blood, as determined by a state-of-the-art blood test using 
ultrasensitive single-molecule array (Simoa) assays (p = 0.014; see 
Figure 5). Other studies from our group have found significant 
relationships between the estimated overall exposure to head impacts 
and the amount of atrophy of specific areas of the brain (using 
magnetic resonance imaging [MRI]), as well as alterations in brain 
chemistry (using magnetic resonance spectroscopy [MRS]). The 
relationship between the total years playing football and the severity 
of postmortem tau pathology in CTE has also been reported (Cherry et 
al., 2016).

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Age of First Exposure to Tackle Football
    The brain undergoes significant maturation and development during 
childhood, with several brain structures and functions reaching their 
peaks or plateaus of development during the period leading up to age 12 
(see Table 3). Our group conducted a study to investigate whether or 
not there is a relationship between experiencing repeated hits to the 
head during this critical period of brain development and cognitive 
difficulties later in life (Stamm et al., 2015). Participants in this 
study were former NFL players ages 41-65 who were part of my NIH-funded 
DETECT study at Boston University. The former players were divided into 
two groups: those who began playing tackle football before age 12 and 
those who began at age 12 or older. We examined their performance on 
tests of memory and mental flexibility. We found that even after 
accounting for the total number of years they played football, those 
who began playing before age 12 performed significantly worse on all 
tests we measured. This suggests that being hit in the head repeatedly 
through tackle football during a critical time of brain development is 
associated with later-life cognitive difficulties. In a subsequent 
similar study (Stamm et al., 2015) of the same sample of former NFL 
players, conducted in collaboration with my colleagues, Drs. Martha 
Shenton and Inga Koerte at Brigham and Women's Hospital in Boston, we 
examined the relationship between the age of first exposure to tackle 
football and the structural integrity of the corpus callosum, the large 
white matter fiber tracts connecting the two hemispheres of the brain. 
The former players underwent MRI scans with diffusion tensor imaging 
(DTI) which showed that subjects who began playing football before age 
12 were found to have significantly altered integrity of the anterior 
portions of the corpus callosum at middle-age, compared to those who 
began playing football at age 12 or older.
    The participants in these studies were all former NFL players, 
which limits the ability to apply these findings to other groups of 
athletes. However, in another investigation from our group, we studied 
former football players who only played up through high school or 
college, and we found that those who began playing tackle football 
before age 12 had significantly greater impairments in mood and 
behavior as adults, compared with those who began playing at age 12 or 
older. More research is needed to study this question in athletes who 
played other sports, and female athletes, as females generally reach 
milestones of brain development earlier than males.




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Diagnosing CTE During Life
    Our group at BU and other scientists from around the country and 
abroad are conducting research to develop methods of accurately 
diagnosing CTE during life. Fortunately, because CTE is similar to 
Alzheimer's disease and other neurodegenerative disorders, we can 
exploit the incredible discoveries and advances in diagnostic tests 
developed for these other disorders in recent years to accelerate our 
ability to diagnose CTE during life. Once we can accurately diagnose 
CTE, we will be able to more clearly address the important questions 
listed above in Table 2. We will be able to differentiate between CTE 
and other causes of cognitive and behavioral change, including 
Alzheimer's disease, Frontotemporal Dementia, PTSD, persistent symptoms 
from previous repetitive or single concussions, ``routine'' depression 
and aggressive behavior, and others. We will be able to measure more 
clearly the true incidence and prevalence of the disease. We will be 
able to determine more accurately the risk factors (including genetic 
and exposure variables) for developing CTE. Perhaps most importantly, 
we will be able to begin clinical trials for the treatment and 
prevention of CTE, as new anti-tau compounds (as well as other disease 
modifying treatments) move through the pharmaceutical development 
pipeline. And, similar to Alzheimer's disease and other 
neurodegenerative diseases, the earlier a disease modifying treatment 
can be initiated, the more likely it will be successful in slowing the 
progression of symptoms. That is, once a disease has resulted in too 
much destruction of brain tissue, it may be too late to intervene 
successfully (i.e., the destroyed tissue cannot be regenerated). 
Therefore, early detection of the disease, before symptoms manifest, 
can potentially prevent the symptoms from ever appearing. However, it 
is likely that not all CTE will be able to be prevented and, therefore, 
there will always be need for successful methods of treating and 
slowing the progression of symptoms.
Development of Biomarkers for CTE Diagnosis
    In 2011, I was fortunate to receive a grant co-funded by the 
National Institute of Neurologic Diseases and Stroke, the National 
Institute of Aging, and the National Institute of Childhood Health and 
Development (Grants #s R01NS078337 and R56NS078337) for a study 
referred to as, ``Diagnosing and Evaluating Traumatic Encephalopathy 
using Clinical Tests'' (DETECT). The goals of the DETECT study (which 
was the first grant ever funded by NIH to study CTE) were to examine 
the later-life clinical presentation of former NFL players at high risk 
for CTE, and to begin to develop in vivo biomarkers for CTE. The DETECT 
study concluded in 2015 and involved a total of 96 symptomatic former 
NFL players and 28 same-age asymptomatic controls without head trauma 
history. All research participants underwent extensive brain scans, 
lumbar punctures (to measure proteins in cerebrospinal fluid), 
electrophysiological studies, blood tests (e.g., for genetic studies 
and novel potential biomarkers), and in-depth neurological, 
neuropsychological, and psychiatric evaluations. In addition, Dr. 
Martha Shenton of the Brigham and Women's Hospital and I received 
Department of Defense funding for a related study to examine a 
promising new Positron Emission Tomography (PET) ligand (developed and 
owned by Avid Radiopharmaceuticals) that is designed to attach to 
abnormal forms of tau protein, such as those found in CTE. I also 
received a separate grant from Avid Radiopharmaceuticals to examine 
that same PET scan, in conjunction with colleagues from Banner 
Alzheimer's Institute and Mayo Clinic Arizona. Results from the DETECT 
study have been very promising, resulting in preliminary support for 
potential blood biomarkers of CTE (e.g., Alosco et al., 2017; Stern et 
al., 2016; See Figure 6), as well as a variety of potential MRI and MRS 
biomarkers (e.g., Koerte et al., 2016). In addition, preliminary 
analyses of the tau PET data are encouraging.



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    The DETECT study was just the first step. Much more research is 
needed, including studies with longitudinal designs and much larger and 
more diverse samples, the inclusion of newer techniques and 
technologies, as well as post-mortem validation of the findings during 
life.
DIAGNOSE CTE Research Project
    In December 2015, I, along with three co-principal investigators 
(Jeffrey Cummings, M.D., from the Cleveland Clinic; Eric Reiman, M.D., 
from Banner Alzheimer's Institute; Martha Shenton, Ph.D., from Brigham 
& Women's Hospital), were honored to receive a $16 million 
collaborative research grant funded by the National Institute of 
Neurological Disorders & Stroke (U01NS093334), entitled, ``Chronic 
Traumatic Encephalopathy: Detection, Diagnosis, Course, and Risk 
Factors.'' The goals of the project are summarized in Table 4.




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    To study the clinical presentation, diagnostic criteria, 
biomarkers, and risk factors of CTE requires expertise across many 
disciplines, including neurology, neuropsychology, psychiatry, 
neuroimaging, molecular medicine, neuropathology, exposure science, 
genetics, biostatistics, bioinformatics, engineering, and others. This 
project brings together a network of approximately 50 scientists from 
10 major research institutions from across the country, including 
Banner Alzheimer's Institute in Arizona, BU Schools of Medicine and 
Public Health, Brigham and Women's Hospital (Harvard Medical School), 
Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Mayo 
Clinic Arizona, New York University (NYU) Langone Medical Center and 
NYU School of Medicine, VA Puget Sound, University of Washington, 
Molecular NeuroImaging (New Haven, CT), and the Neuroinformatics 
Research Group and Central Neuroimaging Data Archive (CNDA) at 
Washington University School of Medicine (in St. Louis).
    This 7-year, longitudinal, multicenter investigation, referred to 
as the Diagnostics, Imaging, And Genetics Network for the Objective 
Study & Evaluation of Chronic Traumatic Encephalopathy (DIAGNOSE CTE) 
Research Project, is well underway. In total, we will examine 240 
former professional football players, former college football players, 
and healthy controls (without history of contact sports of brain 
trauma), between the ages of 45-74. Participants will undergo extensive 
testing over a three-day period at one of four sites (see Table 5), and 
then return three years later for a follow-up evaluation. Examinations 
include: Advanced MRI and MRS imaging; two brain PET scans to measure 
abnormal tau and amyloid protein deposits, respectively; lumbar 
punctures, to measure proteins and other substances in cerebrospinal 
fluid; blood and saliva collection, to measure proteins and other 
compounds using state-of-the-art analyses; extensive 
neuropsychological, neuropsychiatric, neurological, and motor 
examinations; and genetic testing, as part of risk factor analyses. We 
are fortunate to have an External Advisory Board made up of Key Opinion 
Leaders, including David Knopman, M.D., External Advisory Board Chair 
(Professor of Neurology, Mayo Clinic), Col. Dallas Hack, M.D. (Ret.) 
(Medical Leader, One Mind), Brian Hainline, M.D. (Chief Medical 
Officer, National Collegiate Athletic Association), Mike Haynes (Member 
of Pro Football Hall of Fame, President and founder, Mike Haynes & 
Assoc.), Thomas McAllister, M.D. (Chair, Department of Psychiatry, 
Albert Eugene Stern Professor of Clinical Psychiatry; Indiana 
University School of Medicine), Arthur Toga, M.D. (Provost Professor; 
Director of the Institute for Neuroimaging and Informatics, University 
of Southern California), and Michael Weiner, M.D. (Professor of 
Medicine, Radiology, Psychiatry, and Neurology, University of 
California San Francisco). We are confident that based on the results 
of this study, along with scientific advances in the diagnosis of other 
neurodegenerative diseases, CTE will be able to be accurately diagnosed 
during life within the next 5-10 years.




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Concussions, Repetitive Subconcussive Head Impacts, and CTE
    Over the past 10 years, there have been tremendous strides made in 
sports concussion awareness, prevention, detection, and management. 
These gains have resulted in improved public health and have likely 
saved the lives of many American athletes. Continued efforts must be 
made to better detect concussion using objective tests, to reduce risk 
for concussion, and to educate players, parents, coaches, medical 
staff, and the public as a whole, about the concussions. However, I am 
concerned that there is confusion regarding the difference between 
concussion and CTE. A concussion is an acute brain injury, which, if 
managed appropriately, results in transient symptoms, without long-term 
consequences. CTE, on the other hand, is a neurodegenerative disease 
that has only been diagnosed in individuals with a history of 
repetitive head impacts. As stated above, the disease appears to begin 
at the time of exposure to those repetitive impacts but often does not 
result in any symptoms until years or decades following the cessation 
of the exposure (i.e., ending involvement in the sport). It also 
appears that it is the overall exposure to repetitive head impacts 
(including the much more common subconcussive trauma) that results in 
later life neurological disorders, including CTE. In short, concussion 
and CTE are very distinct, and yet, there seems to be widespread 
confusion about this. My hope is that the national discussion about 
brain trauma in football and other contact sports can shift from a 
focus primarily on ``concussion'' to the much more common and, 
potentially more problematic, subconcussive trauma. In other words, the 
big hits and symptomatic concussions can be easily observed, counted, 
and, with appropriate societal effort, reduced. However, the 
repetitive, subconcussive hits are currently viewed as fundamental to 
certain sports (e.g., routine plays in American tackle football, 
heading in soccer), but may have a greater negative overall impact on 
public health.
Tackle Football History
    American tackle football began in the late 19th century. It was 
originally played without any protective headgear and then thin leather 
helmets were worn. However, it was not until the 1950s and 1960s that 
hard plastic helmets with facemasks were used. The helmets were 
developed to prevent skull fractures (which they did and continue to do 
extremely well), but they also allowed individuals to hit their head 
repeatedly against their opponent without feeling pain, thus possibly 
creating a sense of invincibility and also portraying minimal safety 
concerns. In the 1960s and early 1970s, children started to play 
organized American tackle football when Pop Warner youth football 
became popular nationally. From a public health perspective, the first 
individuals who played youth football are currently in their late 50s 
and 60s, and the first individuals who played college football with 
hard plastic helmets and facemasks are currently in their mid-70s. 
Aside from boxing, there does not seem to be any other activity that 
human beings have been involved with that includes exposure to 
hundreds, thousands, or even tens of thousands of head impacts. 
Although boxing has been around for hundreds of years, it was not until 
the mid-20th century that it involved extensive exposure to repetitive 
head impacts. It was at that time that the padded glove was used 
routinely (initially meant as a means of protecting the hands from 
injury, but also resulted in increased numbers of blows to the head). 
Therefore, it is only in the past 55-65 years that large numbers of 
human beings have been exposed to repetitive head impacts. While the 
epidemiology of CTE is unknown, it is possible that millions of living 
older adults are currently at high risk for CTE or other long-term 
neurological conditions due to their history of exposure to repetitive 
head impacts.
Decision-Making Regarding Participation in Tackle Football
    With increased knowledge of the potential short-term and long-term 
risks of repetitive head impacts and other injuries incurred through 
tackle football, adult athletes should be able to make informed 
decisions about participating. However, the issue of youth 
participation is quite different because children's brains are not yet 
fully developed, especially the frontal lobes, the parts of the brain 
responsible for complex thought, planning, judgement, abstract 
thinking, and decision-making. As such, children and adolescents are 
not able to weigh the long-term risks and benefits of playing tackle 
football (Bachynsky, 2016). Parents and other adults involved in the 
decision-making process and in setting policies often search for 
guidance from professional organizations, such as groups of medical and 
scientific experts. One such organization is the American Academy of 
Pediatrics (AAP) and its Council on Sports Medicine and Fitness which, 
after reviewing the literature regarding tackling and football-related 
injuries (including concussions, subconcussive trauma, and CTE), 
published a Policy Statement, as part of the AAP ``Organizational 
Principles to Guide and Define the Child Health Care System and/or 
Improve the Health of all Children.'' (Council on Sports Medicine and 
Fitness, 2015). At the end of their review, they provided the following 
summary (with italics added for emphasis):

        Removing tackling from football altogether would likely lead to 
        a decrease in the incidence of overall injuries, severe 
        injuries, catastrophic injuries, and concussions. The American 
        Academy of Pediatrics recognizes, however, that the removal of 
        tackling from football would lead to a fundamental change in 
        the way the game is played. Participants in football must 
        decide whether the potential health risks of sustaining these 
        injuries are outweighed by the recreational benefits associated 
        with proper tackling. (Council on Sports Medicine and Fitness, 
        2015; p. e1426)

    It is my opinion that if making a fundamental change to the way a 
game is played would likely decrease injuries, severe injuries, 
catastrophic injuries, and brain injuries (i.e., concussions), then 
perhaps there should be a recommendation that such a fundamental change 
should be made. And, similar to Bachynsky (2016), in his editorial in 
the New England Journal of Medicine critiquing the AAP Policy 
Statement, I strongly believe that youth are not capable of making 
their own decisions about participation in a game with these known 
short-term and long-term risks. Therefore, parents, guardians, school 
officials, leagues, coaches, state Departments of Health, and other key 
decision-makers, require ongoing, up-to-date scientific/medical 
information and guidance, not merely from the media or from groups with 
potential financial conflicts of interest or other biases.
    Consensus Statements developed at conferences sponsored and 
organized by institutions with financial conflicts of interest (e.g., 
Federation Internationale de Football Association [FIFA], Federation 
for Equestrian Sports [FEI], International Olympic Committee [IOC], 
International Ice Hockey Federation [IIHF]), and written by experts in 
concussion and brain injury, rather than in neurodegenerative diseases, 
may not necessarily result in accurate summaries and recommendations 
regarding the relationship between repetitive head impacts and CTE. One 
example of a Consensus Statement published by a less biased group of 
clinicians and scientists (including several with expertise in 
neurodegenerative diseases and neuroscience) is the ``Expert Consensus 
Document'' resulting from a one-day meeting convened by Safe Kids 
Worldwide, the Alzheimer's Drug Discovery Foundation, and the Andrews 
Institute for Orthopedics and Sports Medicine (Carmen et al., 2015). 
Based on their review of the literature pertaining to CTE, they 
concluded that CTE is a ``disease associated exclusively with 
repetitive head trauma,'' that ``. . . long sporting careers are not 
required for CTE development, and that youth athletes represent an at-
risk population.'' (p. 233)
    Continued discussion and collaboration amongst expert scientists 
and clinicians about the current state of scientific knowledge 
regarding short-term and long-term consequences of repetitive head 
impacts in contact sports is critically needed. Governmental 
organizations (e.g., NIH, Department of Defense, Centers of Disease 
Control and Prevention, Department of Veteran's Affairs) which serve as 
the primary funders of biomedical research can and should take the 
lead, by convening expert panels to help guide future scientific 
discovery in this area, as well as to provide the public with accurate, 
unbiased, state-of-the science summaries and recommendations aimed at 
issues pertinent to improving public health.
Increased Funding for CTE Research
    In order to tackle the complex issue of CTE, we must continue to 
expand upon current approaches to conducting research in 
neurodegenerative disease. We must continue to break down the 
traditional silos of individual research labs, research institutions, 
and disciplines, and begin to conduct multidisciplinary, collaborative, 
and translational research, bringing together the very best scientists, 
novel methodologies, and state-of-the-art technology. Most importantly, 
we cannot forget that our research must focus on reducing individual 
human suffering and improving public health. Alas, this requires 
tremendous financial support. There is the possibility that millions of 
Americans are at risk for developing CTE and other long-term 
neurological complications from exposure to repetitive head impacts in 
the sports they participated in during youth, high school, and college, 
over the past six decades. However, there remain critical questions in 
need of answers and gaps in our scientific knowledge are in need of 
filling. We must do everything we can to continue to reap the profound 
benefits of American sports while also assuring that we protect the 
health and safety of former, current, and future American athletes.
Summary
    In summary, many of our most cherished American sports, such as 
tackle football, soccer, and hockey, involve repetitive blows to the 
head, often resulting in changes to brain structure and function, even 
after just one season of play. This exposure to repetitive head impacts 
(often without any experience of symptomatic concussions) potentially 
leads to a degenerative brain disease with later life impairments in 
behavior, mood, and cognition, as well as the development of dementia 
and lack of independent functioning. Therefore, it is imperative that 
we: (1) determine who may be at increased risk for CTE and other long-
term consequences of the repetitive head impacts experienced by 
athletes at all ages; (2) develop methods of accurately diagnosing CTE 
during life (perhaps even before symptoms); and (3) create and test 
methods of slowing the progression of the disease, treating its 
symptoms, and even preventing the onset of symptoms altogether. I want 
to close by thanking the Committee for your interest in addressing this 
important issue and for your continued commitment toward protecting the 
health and safety of all athletes.
References Cited
    Abbas K, Shenk TE, Poole VN, Robinson ME, Leverenz LJ, Nauman EA, 
Talavage TM. Effects of repetitive sub-concussive brain injury on the 
functional connectivity of Default Mode Network in high school football 
athletes. Dev Neuropsychol. 2015; 40:51-6
    Alosco ML, Tripodis Y, Jarnagin J, Baugh CM, Martin B, Chaisson CE, 
Estochen N, Song L, Cantu RC, Jeromin A, Stern RA. Repetitive head 
impact exposure and later-life plasma total tau in former National 
Football League players. Alzheimers Dement (Amst). 2016 Dec 10;7:33-40.
    Bachynski, K.E. Tolerable Risks? Physicians and Youth Tackle 
Football. NEJM 2016:374:405-407.
    Bahrami, N., Sharma, D., Rosenthal, S., Davenport, E. M., Urban, J. 
E., Wagner, B., . . . Maldjian, J. A. (2016). Subconcussive Head Impact 
Exposure and White Matter Tract Changes over a Single Season of Youth 
Football. Radiology, 160564. doi: 10.1148/radiol.2016160564
    Bieniek, K. F., Ross, O. A., Cormier, K. A., Walton, R. L., Soto-
Ortolaza, A., Johnston, A. E., . . . Dickson, D. W. (2015). Chronic 
traumatic encephalopathy pathology in a neurodegenerative disorders 
brain bank. Acta Neuropathol, 130(6), 877-889. doi: 10.1007/s00401-015-
1502-4
    Breedlove EL, Robinson M, Talavage TM, Morigaki KE, Yoruk U, 
O'Keefe K, King J, Leverenz LJ, Gilger JW, Nauman EA. Biomechanical 
correlates of symptomatic and asymptomatic neurophysiological 
impairment in high school football. J Biomech. 2012 Apr 30;45(7):1265-
72.
    Broglio, S. P., Eckner, J. T., Martini, D., Sosnoff, J. J., 
Kutcher, J. S., & Randolph, C. (2011). Cumulative head impact burden in 
high school football. J Neurotrauma, 28(10), 2069-2078. doi: 10.1089/
neu.2011.1825
    Carman, A.J., Ferguson, R., Cantu, R., Comstock, R.D., Dacks, P.A., 
DeKosky, S.T., Gandy, S., Gilbert, J., Gilliland, G., Gioia, G., Giza, 
G., Greicius, G., Hainline, B., Hayes, R.L., Hendrix,H., Jordan, B., 
Kovach, J., Lane, R.F., Mannix, R., Murray, T., Seifert, T., Shineman, 
D.W., Warren, E., Wilde, E., Willard H., & Fillit, H.M. Expert 
Consensus Document: Mind the gaps--advancing research into short-term 
and long-term neuropsychological outcomes of youth sports-related 
concussions. Nat. Rev. Neurol. 2015; 11:230-244
    Cherry, J. D., Tripodis, Y., Alvarez, V. E., Huber, B., Kiernan, P. 
T., Daneshvar, D. H.,. . .Stein, T. D. (2016). Microglial 
neuroinflammation contributes to tau accumulation in chronic traumatic 
encephalopathy. Acta Neuropathol Commun, 4(1), 112. doi: 10.1186/
s40478-016-0382-8
    Chugani, H.T., Phelps, M.E. and Mazziotta, J.C. (1987). Positron 
emission tomography study of human brain functional development. Ann 
Neurol 22, 487-497.
    Corsellis, J. A., Bruton, C. J., & Freeman-Browne, D. (1973). The 
aftermath of boxing. Psychol Med, 3(3), 270-303.
    Council on Sports Medicine and Fitness. Tackling in youth football. 
Pediatrics 2015;136: e1419-30.
    Davenport EM, Apkarian K, Whitlow CT, Urban JE, Jensen JH, Szuch E, 
Espeland MA, Jung Y, Rosenbaum DA, Gioia GA, Powers AK, Stitzel JD, 
Maldjian JA. Abnormalities in Diffusional Kurtosis Metrics Related to 
Head Impact Exposure in a Season of High School Varsity Football. J 
Neurotrauma. 2016 Dec 1;33(23):2133-2146. Epub 2016 May 18.
    Davenport EM, Whitlow CT, Urban JE, Espeland MA, Jung Y, Rosenbaum 
DA, Gioia GA, Powers AK, Stitzel JD, Maldjian JA. Abnormal white matter 
integrity related to head impact exposure in a season of high school 
varsity football. J Neurotrauma. 2014 Oct 1;31(19):1617-24.
    Giedd, J.N., Blumenthal, J., Jeffries, N.O., Castellanos, F.X., 
Liu, H., Zijdenbos, A., Paus, T., Evans, A.C. and Rapoport, J.L. 
(1999). Brain development during childhood and adolescence: a 
longitudinal MRI study. Nat Neurosci 2, 861-863.
    Helmer KG, Pasternak O, Fredman E, Preciado RI, Koerte IK, Sasaki 
T, Mayinger M, Johnson AM, Holmes JD, Forwell LA, Skopelja EN, Shenton 
ME, Echlin PS. Hockey Concussion Education Project, Part 1. 
Susceptibility-weighted imaging study in male and female ice hockey 
players over a single season. J Neurosurg. 2014 Apr;120(4):864-72.
    Kawata K, Rubin LH, Takahagi M, Lee JH, Sim T, Szwanki V, Bellamy 
A, Tierney R, Langford D. Subconcussive Impact-Dependent Increase in 
Plasma S100β Levels in Collegiate Football Players. J Neurotrauma. 
2017 Apr 27. [Epub ahead of print]
    Koerte, I. K., Hufschmidt, J., Muehlmann, M., Tripodis, Y., Stamm, 
J. M., Pasternak, O., . . . Shenton, M. E. (2016). Cavum Septi 
Pellucidi in Symptomatic Former Professional Football Players. J 
Neurotrauma, 33(4), 346-353. doi: 10.1089/neu.2015.3880
    Lebel, C., Walker, L., Leemans, A., Phillips, L. and Beaulieu, C. 
(2008). Microstructural maturation of the human brain from childhood to 
adulthood. Neuroimage 40, 1044-1055.
    McAllister, T. W., Flashman, L. A., Maerlender, A., Greenwald, R. 
M., Beckwith, J. G., Tosteson, T. D., Turco, J. H. (2012). Cognitive 
effects of one season of head impacts in a cohort of collegiate contact 
sport athletes. Neurology, 78(22), 1777-1784. doi: 10.1212/
WNL.0b013e3182582fe7
    McKee, A. C., Cairns, N. J., Dickson, D. W., Folkerth, R. D., 
Keene, C. D., Litvan, I.,. . .group, T. C. (2016). The first NINDS/
NIBIB consensus meeting to define neuropathological criteria for the 
diagnosis of chronic traumatic encephalopathy. Acta Neuropathol, 
131(1), 75-86. doi: 10.1007/s00401-015-1515-z
    McKee, A. C., Stern, R. A., Nowinski, C. J., Stein, T. D., Alvarez, 
V. E., Daneshvar, D. H., . . . Cantu, R. C. (2013). The spectrum of 
disease in chronic traumatic encephalopathy. Brain, 136(Pt 1), 43-64. 
doi: 10.1093/brain/aws307
    Montenigro, P. H., Alosco, M. L., Martin, B. M., Daneshvar, D. H., 
Mez, J., Chaisson, C. E., . . . Tripodis, Y. (2016). Cumulative Head 
Impact Exposure Predicts Later-Life Depression, Apathy, Executive 
Dysfunction, and Cognitive Impairment in Former High School and College 
Football Players. J Neurotrauma. doi: 10.1089/neu.2016.4413
    Montenigro, P. H., Baugh, C. M., Daneshvar, D. H., Mez, J., Budson, 
A. E., Au, R., . . . Stern, R. A. (2014). Clinical subtypes of chronic 
traumatic encephalopathy: literature review and proposed research 
diagnostic criteria for traumatic encephalopathy syndrome. Alzheimers 
Res Ther, 6(5), 68. doi: 10.1186/s13195-014-0068-z
    Poole VN, Breedlove EL, Shenk TE, Abbas K, Robinson ME, Leverenz 
LJ, Nauman EA, Dydak U, Talavage TM. Sub-concussive hit characteristics 
predict deviant brain metabolism in football athletes. Dev 
Neuropsychol. 2015 Jan;40(1):12-7
    Shaw, P., Kabani, N.J., Lerch, J.P., Eckstrand, K., Lenroot, R., 
Gogtay, N., Greenstein, D., Clasen, L., Evans, A., Rapoport, J.L., 
Giedd, J.N. and Wise, S.P. (2008). Neurodevelopmental trajectories of 
the human cerebral cortex. J Neurosci 28, 3586-3594.
    Stamm, J. M., Bourlas, A. P., Baugh, C. M., Fritts, N. G., 
Daneshvar, D. H., Martin, B. M., . . . Stern, R. A. (2015). Age of 
first exposure to football and later-life cognitive impairment in 
former NFL players. Neurology, 84(11), 1114-1120. doi: 10.1212/
WNL.0000000000001358
    Stamm, J. M., Koerte, I. K., Muehlmann, M., Pasternak, O., Bourlas, 
A. P., Baugh, C. M., . . . Shenton, M. E. (2015). Age at First Exposure 
to Football Is Associated with Altered Corpus Callosum White Matter 
Microstructure in Former Professional Football Players. J Neurotrauma, 
32(22), 1768-1776. doi: 10.1089/neu.2014.3822
    Stern, R. A., Daneshvar, D. H., Baugh, C. M., Seichepine, D. R., 
Montenigro, P. H., Riley, D. O., McKee, A. C. (2013). Clinical 
presentation of chronic traumatic encephalopathy. Neurology, 81(13), 
1122-1129. doi: 10.1212/WNL.0b013e3182a55f7f
    Stern, R. A., Tripodis, Y., Baugh, C. M., Fritts, N. G., Martin, B. 
M., Chaisson, C., . . . Taylor, D. D. (2016). Preliminary Study of 
Plasma Exosomal Tau as a Potential Biomarker for Chronic Traumatic 
Encephalopathy. J Alzheimers Dis, 51(4), 1099-1109. doi: 10.3233/jad-
151028
    Thatcher RW. Maturation of the human frontal lobes. Physiological 
evidence for staging. Developmental Neuropsychology 1991; 7: 397-419
    Uematsu, A., Matsui, M., Tanaka, C., Takahashi, T., Noguchi, K., 
Suzuki, M. and Nishijo, H. (2012). Developmental trajectories of 
amygdala and hippocampus from infancy to early adulthood in healthy 
individuals. PloS One 7, e46970.

    The Chairman. Thank you, Dr. Stern.
    Ms. Williams.

             STATEMENT OF LAURYN WILLIAMS, OLYMPIAN

                AND PROUD TRUESPORT AMBASSADOR,

                UNITED STATES ANTI-DOPING AGENCY

    Ms. Williams. Mr. Chairman, Ranking Member Nelson, members 
of the Committee.
    Good morning. My name is Lauryn Williams. I am a four-time 
Olympian, a three-time Olympic medalist, and a proud United 
States Anti-Doping Agency TrueSport Ambassador.
    I want to thank this Committee for its interest in clean 
sport and for the opportunity to appear before you today to 
discuss how we can better protect the rights of athletes around 
the world.
    When I started running at 9 years old, I never imagined I 
would one day be competing in the Olympic Games, much less to 
compete four times. Yet, I obtained the unobtainable. I became 
the first American woman to win medals in both the Summer and 
Winter Olympics. I was naturally fast from the start, but 
innate talent was not always enough.
    The cost of Olympic achievement is high. Opportunities 
cost. The pursuit of an Olympic dream costs money, time, 
experiences, and your social life among other things. But these 
expenditures are not always a sacrifice, but a choice.
    The thing is while we choose to chase the extraordinary 
moments, we do so believing the basic idea that every athlete 
deserves to compete on a level playing field. Sadly, that 
notion is under attack and with it, the very credibility of the 
Olympic Games.
    Why? Because of the use of performance enhancing drugs. 
Shortcuts are being taken for personal gain. Podium moments are 
being stolen. And perhaps most disheartening, this kind of 
abuse continues ad nauseam because sports leaders around the 
world cannot find the will, or courage, to properly protect 
athletes.
    Chairman Thune, members of the Committee, I encourage you 
to imagine dedicating your entire life to the mission of 
representing your country and achieving your best performance. 
To give your blood--literally give your blood--sweat, and 
tears, only to have your dreams stolen by someone willing to 
cheat. Someone willing to corrupt themselves and the sport you 
love for a hollow victory. It is devastating. And when this 
happens, clean athletes look to sport leaders who are supposed 
to be our advocates, but we seldom get worthwhile responses.
    When doping goes unpunished, clean athletes are left 
wondering, what would my life look like if I had actually 
competed on a level playing field? Am I owed a moment on the 
podium? Should I have trained for another Olympics? Did I miss 
sponsorships and endorsements that only come with an Olympic 
medal? The unanswered questions degrade the experience 
significantly.
    Of course, there is individual suffering when clean 
athletes lose their moments to cheaters, but it corrupts the 
experience for others. Fans, spectators, sponsors, and society 
as a whole are left asking, ``Why play if the game is rigged 
and if the destination has become more important than the 
journey?''
    I am not the first athlete to say this on Capitol Hill. In 
February, the House Energy and Commerce Subcommittee on 
Oversight and Investigations heard Adam Nelson, the American 
shot putter who, 9 years after the 2004 Summer Olympics, 
received his gold medal in an airport food court; really, a 
food court. And they heard from Michael Phelps, the most 
decorated Olympian in history, who despite his own 
unprecedented success, still questions whether he truly ever 
competed on a level playing field while on the international 
stage.
    The reason that athletes like Adam, Michael, and myself 
speak on issues like this is because we know that here in the 
United States, we are being held to the highest standard there 
is.
    However, while American athletes are asked to report their 
whereabouts 24 hours a day, 7 days a week so that drug testers 
can knock on our door unannounced to request we pee in a cup, 
or give blood, many athletes from other parts of the world are 
not.
    The simple truth is, not all elite athletes worldwide are 
being held to the same standard we are and it is a frustrating 
reality.
    I was tested 66 times during my athletic career. That is 66 
different times that a doping control officer tapped me on the 
shoulder after a competition, or showed up at my home at 6 
a.m., waking me and my family to take my blood, watch me pee in 
a cup no matter what time of the month it was. That is 66 times 
I bore the burden of having to prove I was competing clean, 
that I was doing it the right way.
    Yet somehow, and this is important, of the 11,470 athletes 
who competed in Rio de Janeiro last summer, a staggering 4,125 
of those athletes have no record of testing in the 12 months 
prior to the Olympic Games. That is unacceptable!
    So, I am here today to ask you this, how many more? How 
many more Olympic Games are we going to allow to be corrupted 
by performance enhancing drugs? How many more podium moments 
need to be stolen? How many more dreams crushed? What kind of 
message are we sending to the next generation of competitors?
    As athletes, we have a responsibility to require that our 
voices are heard and that we have an opportunity to be engaged 
in the conversation that directly affects us.
    Mr. Chairman, I encourage our Government, and governments 
from around the world, to exercise your influence for this 
important cause.
    We are just 266 days away from the Winter Games in 
PyeongChang. The clock is ticking. The time is now.
    Thank you for your time.
    [The prepared statement of Ms. Williams follows:]

  Prepared Statement of Lauryn Williams, Olympian and Proud TrueSport 
              Ambassador, United States Anti-Doping Agency
    Mr. Chairman, members of the Committee, good morning. My name is 
Lauryn Williams; I am a four-time Olympian, three-time Olympic medalist 
and a proud United States Anti-Doping Agency TrueSport Ambassador. I 
want to thank this Committee for its interest in clean sport and for 
the opportunity to appear before you today to discuss how we can better 
protect the rights of athletes around the world.
    When I started running at 9 years old I never imagined I would one 
day be competing in the Olympic Games, much less four times. Yet, I 
obtained the unobtainable, and I became the first American woman to win 
medals in both the summer and winter Olympics. I was naturally fast 
from the start, but innate talent isn't always enough.
    The cost of these achievements is high. Opportunities cost. The 
pursuit of an Olympic dream cost time, money, experiences, social life, 
but the cost of these things are not a sacrifice but a choice.
    But the thing is: while we choose to chase the extraordinary 
moments, we do so believing the basic idea that every athlete deserves 
to compete on a level playing field. But sadly, that notion is under 
attack . . . and with it, the very credibility of the Olympic Games.
    Why?
    Because of performance-enhancing drug use.
    Shortcuts are being taken for personal gain. Podium moments are 
being stolen. And perhaps most disheartening, this kind of abuse 
continues ad nauseam because sport leaders around the world cannot find 
the will, or courage, to properly protect athletes.
    Mr. Chairman I encourage you to imagine an entire life dedicated to 
the mission of representing your country and achieving your best 
performance. To give your blood, literally give your blood, sweat and 
tears, only to have your dreams stolen by someone willing to cheat. 
Someone willing to corrupt themselves and the sport you love for a 
hollow victory. It's devastating. And when this happens, clean athletes 
look to the sport leaders who are supposed to be our advocates . . . 
but we seldom get a worthwhile response.
    When doping goes unpunished, clean athletes are left wondering: 
What would my life look like if I had actually competed on a level 
playing field? Am I owed a moment on the podium? Should I have trained 
for another Olympics? Did I miss sponsorships or endorsements that only 
come with an Olympic medal? The unanswered questions degrade the 
experience significantly.
    There is individual suffering when clean athletes lose their moment 
to cheaters, but it corrupts the experience for everyone. Fans, 
spectators, sponsors, and society as a whole are left asking ``Why play 
if the game is rigged? . . . If the destination has become more 
important than the journey?''
    I'm not the first athlete to say this on Capitol Hill. In February, 
the House Energy and Commerce Subcommittee on Oversight and 
Investigations heard from Adam Nelson, the American shot putter who, 
nine years after the 2004 Summer Olympics, received his gold medal in 
an airport food court. And they heard from Michael Phelps, the most 
decorated Olympian in history, who despite his own unprecedented 
success, still questions whether he ever truly competed on a level 
playing field while on the international stage.
    The reason that athletes like Adam, Michael, and myself speak on 
these issues is because we know that here in the United States, we are 
being held to the highest standard there is.
    However, while American athletes are asked to report their 
whereabouts 24 hours a day, seven days a week so that drug testers can 
knock on our door unannounced to request we pee in a cup, or give 
blood, many athletes from other parts of the world are not. The simple 
truth is, not all elite-level athletes worldwide are being held to the 
same standard as we are and it is frustrating reality.
    I was tested 66 times during my athletic career. That's 66 
different times a doping control officer tapped me on a shoulder after 
a competition, or showed up at six a.m. to take blood or watch me pee 
in to cup. That's 66 times that I bore the burden of having to prove I 
was competing clean--that I was doing it the right way. Yet, somehow--
and this is important . . . Of the 11,470 athletes who competed in Rio 
de Janeiro last summer, a staggering 4,125 of those athletes had no 
record of testing in the 12-months prior to the Games. That's 
unacceptable!
    So, I'm here today to ask you this:

        How many more?

        How many more Olympic Games are we going to allow to be 
        corrupted by performance-enhancing drug use?

        How many more podium moments need to be stolen?

        How many more dreams crushed?

        What kind of message are we sending to the next generation of 
        competitors?

    As athletes, we have a responsibility to require that our voices 
heard and that we have an opportunity to be engaged in a conversation 
that directly affects us. Mr. Chairman I encourage our government, and 
governments from around the world, to exercise your influence for this 
important cause.
    We are just 266 days away from the Winter Games in PyeongChang . . 
. The clock is ticking . . . The time is now.

    The Chairman. Thank you, Ms. Williams.
    I will start with asking questions and we will do five 
minute rounds with members of the Committee.
    Ms. Deutscher, I want to begin again by thanking you and 
your husband for being here and express our sympathy to you for 
your family's loss.
    Just looking back on that tragic experience, do you have 
recommendations for other parents whose children face sports 
injuries? And then maybe as a follow-up, are there warning 
signs that you can share with other parents who are in similar 
situations?
    Ms. Deutscher. Education to me is key for the parent.
    When it happened with Nick when he said, ``This Hydrocodone 
is not cutting it,'' we should have just said stop. That would 
be the advice that I would give to other parents. If it does 
not seem right, it is probably not right.
    The thing is we had excellent physicians. We had a great 
athletic trainer who was working with Nick at OI. It just seems 
like education and awareness of this issue is just so key.
    The warning sign for Nick was when he said he needed 
additional. I told Jeff, ``He has his hand out for this 
Hydrocodone.'' So that is a big red flag. But he was still 
going to school. He was training. He was rehabbing to get back 
for the last game of the season.
    I just think education and awareness and follow your 
instincts, but it was 2011 and there was not the highlight on 
it that there is now.
    I do have to say, though, that addiction hits so swiftly. I 
mean, it just kind of happened before our eyes. We all wanted 
Nick to play football, everybody from the coaches, to the other 
parents, to us. So education, awareness, and do not be afraid 
to raise your hand and say stop. Then once the addiction does 
kick in, it is just a sad, long journey.
    Thank you.
    The Chairman. Thank you.
    Ms. Williams, Derek Miles who, as you know, is the 
Associate Coach at the University of South Dakota recently 
received a bronze medal for his performance at the 2008 Olympic 
Games in Beijing. He received this medal more than eight years 
after the actual games because the athlete that actually stood 
on the podium in Beijing tested positive for a banned 
substance. You mentioned this in your testimony and referred to 
it.
    How many other American athletes like Derek, do you think, 
are still waiting to receive the Olympic medal they rightfully 
earned? What can be done to ensure that that long awaited and 
deserved medal gets there sooner rather than later?
    Ms. Williams. I believe there are many other athletes that 
are entitled to a medal that they did not receive, a moment 
that has been stolen from them.
    The thing that we need to do, one of the most important 
right now, is to store samples a lot longer. So right now, they 
are storing samples for 10 years, which is how Adam Nelson, 9 
years after his medal, was able to find out that the person had 
used performance enhancing drugs.
    The longer we can store these samples, the better our 
technology is getting, and we can look back and say, ``Now we 
have new technology and we can know what you were using at this 
time.'' And we can restore those opportunities.
    But what we need to be doing too is to stop that from 
happening and get the technology now, so that if we are getting 
positive tests, we do not give medals to people who did not 
rightfully earn them.
    The Chairman. Yes, getting your Olympic medal at a food 
court seems a little anticlimactic.
    Ms. Williams. Very anticlimactic.
    The Chairman. Mr. Sailor, in your written testimony, you 
state that, and I quote, ``Underlying causes of sudden death in 
athletics might include asthma, catastrophic brain injury, 
cervical spine injuries, diabetes, exertional heat stroke, and 
sudden cardiac arrest,'' to quote from your statement.
    Given the diverse range of underlying causes that young 
athletes may experience, is it reasonable to single out contact 
football as the most problematic sport in need of fundamental 
change?
    Mr. Sailor. Well, as athletic trainers, we recognize that 
the number one cause of death in athletes is cardiac. The other 
issues that are killing our athletes today are related heat 
stress, heat illness, as well as issues that deal with 
concussion, of course.
    The important thing that we need to recognize is that the 
response to those crisis situations within the first few 
minutes dictates in a large part to their outcome. It is 
important that we have individuals there and a plan in place to 
care for those athletes when those situations exist.
    These are not strictly limited to the sport of football, of 
course. We see concussion, we see heat, and we see cardiac in 
many of our sports and it is important for us to be prepared 
for those.
    The Chairman. Do you think accessibility and influence of 
athletic trainers in youth sports is a more appropriate 
solution than fundamentally altering sports like football, for 
example?
    Mr. Sailor. I certainly believe in a comprehensive aspect 
of addressing these issues.
    I advocate for athletic trainers because I believe that it 
is important for an individual, an adult, to be present that is 
taking into consideration the safety as well as the preparation 
for catastrophic injury at that site.
    Often, we have other adults, but their primary charge is 
things like coaching, and strategy, and things like that. We 
need someone that is there, a trained professional, that looks 
at things like creation of an emergency action plan and access 
to the appropriate medical care. How do we access facilities in 
the case of a catastrophic injury? That is what an athletic 
trainer does by nature.
    The Chairman. Thank you.
    I will yield to Senator Nelson.
    Senator Nelson. I will be quick so that we can get onto our 
members' questions.
    First of all, I want to say to Ms. Williams. Amen. Thank 
you. You did it the right way and others cheated, and you still 
got the medals, so, amen.
    I want to say to Mrs. Deutscher, I do not understand how 
you survived. What I do not understand is when your son was 
asking for some more Oxycontin, what was it that you said you 
ought to stop right there?
    Ms. Deutscher. As I said, everybody wanted Nick to play 
football and Nick wanted to play football. I mean, he loved 
being part of the team. He loved everything about that sport.
    We should have said stop, reevaluate. Is this worth it? He 
was getting football letters and he was looking forward to 
maybe playing college ball. So had we known then what we know 
now, I would have said stop. We need to decide if this is 
worthwhile or right. And unfortunately, we did not.
    Senator Nelson. To all the panel, the Chairman and I were 
discussing that we could have a separate hearing on each one of 
the topics that each of you have brought up.
    Dr. Stern, I got the impression that you said a person 
could not have any concussions and still get to CTE. What is it 
about that? If you have many concussions, is that a cause of 
ultimately becoming CTE?
    Dr. Stern. Yes, to both of those.
    Concussion is a form of a mild traumatic brain injury. 
There is no real hard and fast line between what is a 
concussion and what is not a concussion. Right now, I think 
there are 140 or more published definitions of concussion. 
Actually, the one published by the NATA is one of my favorites. 
But it is all based on having symptoms, having an individual 
report symptoms, or signs of the injury.
    That does not mean that there are no problems to the brain, 
and those brain cells, and the brain tissue. If the injury did 
not either result in the type of problem that leads to the 
symptoms, or very commonly, the person does not report the 
symptoms for a whole range of reasons.
    But what our research, and that of many others, is now 
showing is that these sub-concussive hits--the ones that happen 
in every play, in every game, in every practice of many sports, 
but especially tackle football--do have consequences, short 
term and long term.
    There is now growing evidence that even after just one 
season of football, tackle football in high school, let us say, 
there are structural changes to the brain, physiological 
changes to the brain, changes to blood-based biomarkers, and 
changes to thinking and memory without any symptomatic 
concussions. And those changes are directly associated with the 
number of hits the person gets to the head as measured by 
accelerometers in the helmets.
    Senator Nelson. So would that apply to soccer and headers 
as well?
    Dr. Stern. It would. And that is, to me, a very scary next 
part of the journey that now there is growing evidence that 
heading in soccer, not the concussions in soccer, but heading 
does seem to lead to changes over just one season, but also 
after a lifetime of heading.
    In fact, there is now, just recently, several cases of 
postmortem confirmed CTE in individuals who were demented at 
the end of their lifetime who never had histories of 
concussion, or maybe just one concussion, through professional 
and semi-professional football. But they had a huge amount of 
heading through their career suggesting, again, that the 
exposure to these repetitive hits, whether or not they lead to 
the symptoms of concussion, seem to be raising the risk for 
these later life complications.
    Senator Nelson. Are you following our former military 
members and the traumatic brain injury there, and seeing if 
that produces CTE?
    Dr. Stern. Our group has sadly found CTE postmortem in 
former military service members who were exposed to blast 
trauma and other brain trauma. It is a very complex issue, and 
it is a very, very important one, and one that the Department 
of Veterans Affairs and the Department of Defense is taking 
very seriously.
    The symptoms of PTSD, the long-term problems of traumatic 
brain injury, the difficulties that we now see in the 
tremendous increase in suicide in our veterans, all of those 
seem to overlap with the symptoms of CTE. We are seeing that, 
indeed, CTE may be playing a very important role in the 
development of these cognitive, and behavioral, and mood 
changes later in life in our military service members.
    Senator Nelson. Thank you.
    We could spend a whole day just on that subject.
    The Chairman. We could. No question about it. Thank you, 
Senator Nelson.
    Senator Moran.

                STATEMENT OF HON. JERRY MORAN, 
                    U.S. SENATOR FROM KANSAS

    Senator Moran. Mr. Chairman, thank you.
    Thank you and the Ranking Member for hosting this hearing.
    Dr. Stern, thank you for those comments. I chair the 
Appropriations Subcommittee. I am on the Veterans Committee 
related to veterans, and you have given me some ideas of things 
that I need to personally pursue with the Department of 
Veterans Affairs. Thank you.
    Mrs. Deutscher, at least in Kansas that is how we pronounce 
your name, thank you very much for you being here. What you 
described was very compelling to me because what you described 
in your family's situation, who you are, and the way you 
conduct your lives, and the way your family operates is the way 
that I recognize the way so many Kansans live their lives. We 
do not expect bad things to happen. I am very sorry.
    I chair the Subcommittee that has responsibility here in 
the Commerce Committee over amateur and professional sports, 
and I will address most of my questions to Ms. Pfohl.
    Senator Thune and I wrote the CEO of the United States 
Olympics Committee about 2 months ago raising questions about 
sexual activity, abuse, and harassment within the Olympic 
Games.
    I think kind of a take away from the response that we 
received is that your organization was coming into play. That 
the solution to this challenge is going to lie with you. I 
would ask you if that is the way you see it, the relationship 
between the United States Olympic Committee and SafeSport.
    What is that relationship and who has responsibility for 
these issues?
    Ms. Pfohl. Thank you, Senator Moran.
    To quote Dr. Butler, I think, it is going to take all of 
us, first and foremost.
    We, like USADA, the U.S. Anti-Doping Association, we were 
formed first, if you will, within the U.S. Olympic Committee. 
We would not exist without the support of the U.S. Olympic 
Committee, financial and otherwise. But we are an independent 
501(c)(3) nonprofit organization charged with this issue.
    That said, all of the 47 NGBs, the National Governing 
Bodies of the Olympic sports, all have SafeSport 
responsibilities. They all have their SafeSport programs by 
which they are tasked with implementing training, with making 
sure all of their coaches and covered individuals, as we call 
them, are certified related to SafeSport. So implementing and 
creating a culture that prevents abuse is really important.
    We are absolutely working in partnership with the USOC and 
the National Governing Bodies. We are independent in terms of 
our investigations. USOC has retained us, if you will, to 
investigate all areas of sexual abuse. So any report of sexual 
misconduct or abuse, we investigate those reports.
    Senator Moran. Let me ask, then. If you are the 
investigative arm, who is the enforcing arm?
    Ms. Pfohl. The sanctions, if we have a finding from a 
report--a case, if you will--that finding goes to the National 
Governing Body. Not only must they enforce--and which could be 
anything up to and including a lifetime ban--not only must that 
NGB enforce that sanction, but it must be enforced across the 
Olympic and Paralympic movements.
    Senator Moran. So when you say they must enforce, what is 
it that requires them to do so? Maybe your report is ignored or 
just taken as a recommendation. Who determines what the 
consequence is?
    Ms. Pfohl. The USOC has mandated, if you will, that the 
NGBs adhere to not only the SafeSport code and part of the 
SafeSport code is that the sanctions must be enforced. So in 
that case, we hand down the sanction and the USOC and the NGBs 
themselves make sure that it is enforced.
    Senator Moran. Ms. Williams, is that any different than the 
way that the Anti-Doping Agency works?
    Ms. Williams. It is similar. Well, USADA has the ability to 
hand the sanction down. Then the actual enforcement goes up to 
the World Anti-Doping Agency and then the enforcement happens 
there.
    Senator Moran. Thank you.
    And Ms. Pfohl, it seems to me, and this may be a false 
impression, but your organization was slow to come into 
existence. My impression is, it is related to fundraising, the 
ability to have the necessary resources to do the work that you 
are setting out to do.
    Can you assure us that the dollars, the resources are now 
available?
    Ms. Pfohl. Senator, thank you.
    I think that is a reason that it has taken a while for the 
Center to be up and running. We opened our doors in early 
March. I will tell you that we have funding from the USOC, from 
NGBs, and from other charitable organizations.
    I would ask the Committee's support and the Senate support 
in authorizing, as Chairman Thune stated at the beginning of 
his remarks. Authorizing the Center in legislation would go a 
long way to establishing our credibility, our place, if you 
will, in terms of addressing all of these SafeSport issues.
    So make no mistake. We have a ways to go. We need more 
funding, and part of my job is to go out and raise private 
sector dollars, foundations, corporations, and individuals in 
addition.
    Senator Moran. No one that you know of would object to 
legislation that the Chairman was describing?
    Ms. Pfohl. Not that I know of.
    Senator Moran. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Moran.
    That was a good exchange and discussion there because we 
need to figure out how to formalize that role and ensure there 
is enforceability there associated with it. Thank you.
    Senator Markey.
    Senator Markey. Thank you, Mr. Chairman, very much.
    The cover story this week in Sports Illustrated is Nick 
Buoniconti. He is a great football player, a hall of fame 
football player. Essentially what it says is that his brain has 
atrophied to a point where he cannot tie his tie or his shoes. 
Unfortunately, that is the story that is all too common to 
former athletes.
    Dr. Stern, if you could, would you talk a little bit about 
the warnings that you are giving to the country, especially to 
those who have young athletes in their families about injuries 
that can occur? Not just in football, but in hockey, and 
soccer, and in any sport where concussions are possible.
    What is the core message you are sending to athletes, 
especially to their parents?
    Dr. Stern. Thank you, Senator Markey.
    It is a complex message. It is one that is hard to always 
get across because there are many different forces out there 
that move the message in different ways.
    One important part of the message is that concussion is 
just the tip of the iceberg. We have heard so much about 
concussion. There has been concussion-this, concussion-that and 
thank goodness because there have been so many important 
changes in the way concussion is being dealt with, and is being 
detected and managed thanks to NATA and others. The problems 
associated with concussion are indeed, I think, moving in the 
right direction.
    But for me what people need to understand is when they read 
stories about Nick Buoniconti and others, those were not 
necessarily caused by concussions. They were caused by the 
cumulative amount of the hits they received to the head from 
youth, to high school, to college, to the pros.
    One part of the message is just because your child plays 
football does not mean they are going to develop this bad 
disease and they are going to have suicidal ideation. We cannot 
have a kneejerk response.
    We have to have appropriate scientific understanding. We 
have to have advances in our scientific knowledge that can be 
given to informed parents, and informed leaders, and informed 
policymakers.
    But as we are gathering that scientific information, people 
also have to make decisions based on common sense. In other 
words, our brains are pretty darn important. They control who 
we are, what we are, how we move. They control our athleticism. 
They control our passion to participate. They do everything and 
they are precious.
    One of the things that we are focusing on is what happens 
during that time in childhood when the brain is going through 
unbelievable growth and maturation. It is the period before age 
12 with all kinds of changes and developmental milestones are 
occurring.
    If we then say it is OK to put our kids in fields and say, 
``Go at it. Hit your head. Move that brain around over and over 
and over again,'' during those times of potential 
neurodevelopmental vulnerability, then we may need to question 
that decision.
    Senator Markey. So what percentage of your research is 
funded by the Federal Government, doctor?
    Dr. Stern. I would say around 90 percent of my current 
research is funded by the Federal Government.
    Senator Markey. So if the NIH budget was cut by 18 percent, 
which is the proposal for the next fiscal year, how would that 
impact?
    Dr. Stern. It would be devastating, not just to me 
personally, and to the research that we are doing, and to our 
future research. It would be devastating to science as we know 
it. It would get rid of an entire generation of future 
scientists across all areas.
    I can speak to the neurodegenerative diseases and brain 
research in particular. We cannot move forward even with the 
current budgets at the rate that is required to make important 
discoveries to alleviate the pain and suffering from all of 
these brain diseases.
    Senator Markey. Senator Udall is doing great work on this 
issue.
    My question, is there a relationship between the research 
you are now doing on brain injury and your Alzheimer's 
research? Can one inform the other in terms of perhaps trying 
to find the clues that can give hope to families?
    Dr. Stern. Tremendously. That is, in fact, why I got 
involved and interested in CTE work in the first place because 
as an Alzheimer's researcher, I realized that this is a very 
similar disease. As we learn more about it, the more we 
understand. Yes, indeed.
    What we are gaining in our understanding of CTE is directly 
informing what we know about Alzheimer's disease and other 
related disorders. What we learn about Alzheimer's disease is 
now helping us move forward rather quickly in our understanding 
of CTE. They are very intertwined.
    Senator Markey. How much more transparency would you like 
to see in terms of all the information about brain injury being 
put out into the public just so that there can be a full 
understanding of this problem?
    Dr. Stern. Unfortunately, there are so many organizations 
out there and statements that are made that are filled with 
conflicts of interest; organizations that are funded, directly 
or indirectly, from professional sports leagues around the 
world. Those conflicts lead to, I think, either a 
misunderstanding or a misrepresentation of what the science 
tells us.
    Most importantly, scientists need to be transparent 
themselves. We need to share data. We need to break down silos. 
We need to explain our findings in ways that are meaningful, 
appropriate, and not beyond what the science says.
    Senator Markey. I think the brain health of this generation 
of young athletes is going to depend upon the transparency of 
this generation of leaders who control the information that can 
help to inform parents in making the correct decision.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Markey.
    Senator Udall.

                 STATEMENT OF HON. TOM UDALL, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Udall. Chairman Thune, thank you so much.
    You and I have been talking for a long time about doing a 
hearing like this. So we really appreciate you doing it.
    I also just want to thank Senator Nelson for all of his 
kind comments and also Senator Markey.
    The issue here, and I want to emphasize, I do not think, 
Dr. Stern, you got a chance to say this specifically. I am just 
going to read it from your testimony and ask you to talk about 
it a little bit more.
    You said, ``It is only in the past 55 or 60 years that 
large numbers of human beings have been exposed to repetitive 
head impacts.'' So we are talking about constant impacts to the 
head.
    ``While the epidemiology of CTE is unknown, it is possible 
that millions,'' millions we are talking about, ``living older 
adults are currently at high risk for CTE or other long term 
neurological conditions due to their history of exposure to 
repetitive head impacts.''
    This is something we need to realize in terms of human 
history. Talk a little bit about human history and repetitive 
head impacts and where we are, because I think that is where we 
get to millions of people.
    People, I think, would be surprised and kind of shocked to 
know we are talking here about millions of people with CTE, 
especially if they have seen the sports figures, and seen the 
deterioration, and the kinds of things that happened to them. 
Please, go ahead and put that in a little bit of context there.
    Dr. Stern. To preface it, I am not an anthropologist. I am 
not an epidemiologist. But I am someone who speaks a lot with 
those experts and look at what the history tells us.
    Boxing has been around for a thousand-plus years and boxers 
only started putting these heavy padded gloves on in the mid 
part of the last century in order to protect their hands from 
being broken. But that also led to increased hits to the face, 
to the head, and changed perhaps the numbers of those types of 
hits that boxers get, but more importantly for this country, 
our national pastime of American football.
    It was not until the mid-1950s that hard plastic 
encasements, these big helmets, started to be used in American 
football, plus the big facemasks. Even though, yes, we have 
been playing football since the 1800s, it was not until then 
that leather helmets were used to start maybe preventing skull 
fractures. And then the big helmets were there to do a great 
job to prevent skull fractures and death. They have done an 
amazing job at doing that.
    But in the mid-1950s, to late 1950s, to early 1960s, there 
was this beginning of a sense of invincibility because it did 
not hurt to hit your head, and the way the game was changed 
included lots of these hits, the line of scrimmage and 
elsewhere. Not the big hits, not the spearing, not the use of 
the helmet as a weapon. Those are important, but I am talking 
about just routine hits.
    Then it was not until the 1960s and early 1970s that Pop 
Warner football began to be a national pastime. Our youth, our 
children 6 years old and older, were going into fields wearing 
these helmets and facemasks, and again hitting their heads 
repeatedly.
    That is where the concept of we do not know where we are 
yet with a little bit of fear, or perhaps a lot of fear. That 
is the only type of experience that humans have been involved 
with that really include repetitive hits to the head with the 
brain moving back and forth in millions of people just in our 
country alone.
    Those people who started playing high school and college 
football in the 1950s and 1960s, the people who started playing 
youth football in the late 1960s and 1970s. Well, they are in 
their late fifties to seventies right now. That is the age that 
we see the clinical manifestation of many neurodegenerative 
diseases and other diseases of aging. And so, that is when we 
also see a lot of the incidents of CTE.
    With all of those millions of people who have had that type 
of exposure to those hits for the first time in history, I do 
fear that--based on the knowledge of what we understand of the 
risk for CTE and other neurological problems later in life--we 
are going to see a very shocking number of people over the next 
few decades.
    Senator Udall. Yes. I really appreciate that testimony and 
I want to be clear that I think sports are good for young 
people. I think exercise is good.
    I think what you are emphasizing, though, is you are 
talking about repetitive hits to the head when you have 
protective equipment that can make it feel like it does not 
hurt and it is okay. What you are telling us is that we need to 
recognize that this could have a big impact. We may be on the 
tip of the iceberg as to what we start seeing in the future.
    I thank you for all your work, and thank you for being 
here, and being so frank about this. Appreciate it.
    The Chairman. Thank you, Senator Udall.
    Senator Blumenthal.

             STATEMENT OF HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Mr. Chairman.
    Thank you for having this hearing which could extend for 
several days, the topics are so varied and important.
    As a father of four children, who all play sports, I know 
that we cannot protect our children from all sports injuries, 
but at least we can protect them from some if we are attentive 
and respectful of science. I want to talk about two areas where 
I think we have been somewhat less than respectful.
    One is the NHL in denying concussion science, and I intend 
to reintroduce legislation that would, in effect, create very 
strong incentives for improvements in this area. And the other 
relates to sexual assault, particularly in gymnastics that we 
were hearing recently in the Judiciary Committee, and I am 
going to ask some questions, if I have time, about that as 
well.
    Let me begin with you, Dr. Stern, if I may.
    Last year, an NHL executive made headlines while testifying 
at a hearing exactly like this one, it should not have been 
earth shattering news, but it was. For the first time, the NHL 
admitted that there is, in fact, a link between head trauma and 
CTE, and you know how debilitating and disruptive that disease 
is.
    But reports surfaced last year, revealing e-mails from 
league officials recognizing the danger of concussions, but 
also demonstrating a very dismissive attitude in addressing 
them.
    And so I wrote to the NHL Commissioner and in response, he 
flat out dismissed any connection between head trauma and 
concussions and CTE. In my letter to him, I cited research done 
at Boston University.
    Beyond the resistance, there are now troubling reports that 
the NHL is trying even to intimidate scientists using tactics 
employed in other industries. Without making unfair 
comparisons, the tobacco industry is one of them.
    Let me ask you, does it trouble you that leading officials 
with such power and sway in this sport and in important 
positions of responsibility actually deny the science of CTE 
and have no apparent willingness to learn more? And have you 
experienced this kind of intimidation yourself, Dr. Stern?
    Dr. Stern. It does not surprise me because we are talking 
about businesses that have billions of dollars on the line. And 
that if some aspect of the way that their sport is played is 
going to have to change, and therefore they may lose viewers or 
support from advertising, that is a big deal. I understand 
that. But I think that everyone needs to put athletes first.
    What the NHL did and the Commissioner's statements have 
done is indeed sad. I do not agree with them. I find them kind 
of antiquated and perhaps they should take the lead of what the 
NFL has recently done and accepted the link.
    Senator Blumenthal. In my opening, I may have confused the 
NFL with the NHL. It was the NFL that acknowledged the 
connection.
    Dr. Stern. That is right. It was the NFL that finally 
acknowledged the association between getting your head hit and 
CTE later in life after years and years and years of dismissing 
it. The NHL continues to say, ``Oh, no. There is no 
association,'' contradicting the science.
    I cannot go on too much about it because, in fact, you 
raised the issue of their attempt to get in the way of science. 
In fact, my colleague and I at the University were subpoenaed 
by the NHL for a great deal of information that went way beyond 
any reasonable request within how science is conducted. And, in 
fact, the court denied their request.
    So I cannot really get into it because there is this 
ongoing case.
    Senator Blumenthal. Thank you.
    Let me ask you, Ms. Pfohl. Recently, the Judiciary 
Committee had hearings on sexual abuse in gymnastics 
particularly the youngest of participants in this sport. 
Statistics from SafeSport indicate that one in ten youth who 
participate in organized sports will be victims of sexual 
abuse. And I think you would agree with me that number is 
clearly unacceptable.
    The United State Olympic Committee bylaws require National 
Governing Bodies to comply with SafeSport policies in order to 
remain in good standing.
    How can those policies be better enforced?
    Ms. Pfohl. Thank you, Senator Blumenthal.
    Just a quick note on the one in ten that will be sexually 
abused, that is actually in the general population.
    One of the problems is we do not know the true prevalence 
within the sports community. That is one of the reasons we 
exist is to gather that data, to have that data, to follow the 
trends, and to help our prevention efforts. That is what needs 
to happen.
    So your support, certainly, of the U.S. Center for 
SafeSport and hopefully being authorized perhaps in S. 534, the 
Protecting Young Victims from Sexual Abuse Act of 2017, would 
go a long way in helping us to develop policies. We already 
have the SafeSport code that has been taken up by the USOC and 
all the NGB's. But our work goes far beyond the Olympics 
movement.
    Senator Blumenthal. Would you support young athletes having 
the right to win cases in court as opposed to arbitration?
    Ms. Pfohl. In terms of what is currently in the S. 534, we 
are certainly favorable to the bill overall and have been 
providing that technical assistance. So we support the rights 
of athletes. Period.
    Senator Blumenthal. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Blumenthal.
    Senator Cortez Masto.

           STATEMENT OF HON. CATHERINE CORTEZ MASTO, 
                    U.S. SENATOR FROM NEVADA

    Senator Cortez Masto. Thank you.
    And like my colleagues, thank you, Chairman Thune for 
bringing this topic forward, these many topics. And I agree, 
they could all be a separate hearing. And every single one of 
the areas, I have worked in and will continue to work in and to 
address.
    And so, let me just say, first of all, Mrs. Deutscher, 
thank you so much. I was the Attorney General of Nevada for 8 
years and this was an issue. I chaired a working group on 
substance abuse and opioid abuse, and then followed by heroin 
abuse is a problem; not just in Nevada, but across the country. 
And you coming forward, telling your story, you will make a 
difference and save a life. I want you to know that. So thank 
you to both of you for being here.
    Dr. Stern, I have a quick question for you. From your 
knowledge, are the medical resources and research into CTE and 
other long term brain concerns equally distributed between 
males and females? And what would you say their allocation 
percentage is by gender?
    Dr. Stern. That is one of the most important issues that 
needs to be dealt with.
    CTE as a neurodegenerative disease diagnosed only after 
death at this point has been found almost exclusively in males 
to date. There have been a small number of women, not athletes. 
Sadly, it includes a woman who was domestically abused and had 
her head hit repeatedly.
    This goes along with my testimony earlier about what is 
going to happen in the future. I think women have been involved 
now with sports at the level where their heads are being hit to 
such a degree and for over a greater period of time, again, 
over the last 50 years or so.
    So, for example, soccer or the original football, women 
now, at least in this country, are at the age now where they 
started back in the 1970s playing at an early age, and playing 
in club sports, and playing around the year, and doing a lot of 
heading, and having a lot of concussions. So I think now as 
that generation gets older, sadly, we will probably be seeing 
more of this disease.
    However, just because we have not seen the disease in women 
that does not mean that the rest of the resources being focused 
on brain diseases, brain conditions associated with athletic 
involvement should be focused on men. We need to put a lot of 
effort.
    In fact, I am hoping to be starting a few different studies 
coming up where we are actively going to be following women to 
be able to look at the effects of various sports, various 
aspects of the sport, and the head trauma in terms of later 
life problems.
    It is a very big deal.
    Senator Cortez Masto. It is. And I thank you for saying 
that because in my own family, I have a niece who played soccer 
through high school and college. There are concerns because 
they have had injuries in soccer just as they do in football 
and other sports.
    And then, as you well know, in Nevada, and you have said it 
in your testimony, the Cleveland Clinic, the Lou Ruvo Center 
for Brain Health in Las Vegas is a leader in this research, 
particularly when it comes to the brain health of boxers and 
MMA fighters, and we know a lot of women now are partaking in 
those sports. And so I am glad to see that we are actually 
going to be looking at women's brain health as well.
    With respect to boxers and MMA fighters, do you feel that 
there is enough being done at the State level to ensure that 
standardized safety precautions are adapted to protect boxers 
in every state?
    Nevada has just recently adopted a requirement to our 
athletic commission ensuring that the brain health of our 
fighters is tested and we are making sure that is being 
checked.
    Do you think enough is being done across the country and in 
other states?
    Dr. Stern. I am not aware enough to be able to answer it 
about all states. I do know that Nevada is a real leader. 
Thanks to the partnership between the State, and the City of 
Las Vegas, and the commission with the Cleveland Clinic Lou 
Ruvo Center, there has been a tremendous gain, including great 
research being done, to look at what is really important.
    When it comes to boxing and MMA, to me I always just have 
to stop and say, what could be done at the State level? What 
kind of rules and changes could be done when you have sports 
that are geared toward inducing brain damage?
    If in boxing, a knockout is a way to win, a knockout is 
brain damage. And I may be saying things a little bit too 
indelicately, but one has to question how can we really make 
those activities safe in terms of brain health?
    Senator Cortez Masto. Thank you. Thank you very much for 
all of you being here today. Appreciate the testimonies.
    The Chairman. Thank you, Senator Cortez Masto.
    Next up is Senator Hassan.

               STATEMENT OF HON. MAGGIE HASSAN, 
                U.S. SENATOR FROM NEW HAMPSHIRE

    Senator Hassan. Thank you very much, Mr. Chair.
    And thank you to all the witnesses for being here today, 
especially I would like to extend my thanks to Mrs. Deutscher 
and Mr. Deutscher for meeting with me earlier today, and for 
being here, and for sharing and honoring your son's life and 
story by being here.
    I want to focus a little bit on the issue of athletes and 
addiction to help address the increased level of risk of opioid 
addiction that student athletes experience.
    Earlier this year, I co-sponsored the Student and Student 
Athlete Opioid Misuse Prevention Act. This bill is being led by 
my friend and colleague, Senator Shaheen, and it would 
authorize the Substance Abuse and Mental Health Services 
Administration, or SAMHSA, and the U.S. Department of Education 
to grant money to help efforts to educate students and 
communities about opioid use, abuse, and addiction.
    In New Hampshire, SAMHSA grants have been an integral part 
of funding in our State's substance misuse and prevention 
efforts. So this is really a question to the whole panel.
    Do you agree that further resources and dedicated funding 
would help in the work you and others are doing to meet the 
tough challenges associated with opioid addiction?
    Dr. Butler. Thank you, Senator, for that question and do 
not mind if I go first.
    Senator Hassan. Yes.
    Dr. Butler. I just want to agree with Dr. Stern's comments 
earlier about the importance of support to the NIH to address 
new knowledge. And that applies also in terms of our 
understanding of pain and also the understanding of addiction.
    NIH Director, Francis Collins, has observed that it is 
amazing when we have millennia of writing about pain as a 
cardinal sign of inflammation that we know so little about it.
    But I also want to point out the critical importance of 
education and using the knowledge that we already have much of 
which is implemented through agencies such as the Centers for 
Disease Control and Prevention, and also SAMHSA.
    So it is, I think, not an either-or when we look at new 
knowledge versus reacting and acting on the information that we 
already have, but it really is going to require both to address 
these issues.
    Senator Hassan. Thank you.
    Another component of the bill is to provide funding to 
train State and local officials, and coaches, and trainers 
among others to recognize and address substance misuse among 
students.
    Would this be helpful in your view and especially maybe Mr. 
Sailor, you would like to comment on that?
    Mr. Sailor. Yes. The National Athletic Trainers' 
Association is in full support of this bill and we appreciate 
that.
    Senator Hassan. Thank you. And also to Ms. Williams and Mr. 
Sailor, although we are starting to have a greater 
understanding of substance abuse disorders, there is, as we all 
know, still a lot of stigma attached.
    One of the reasons I am so grateful to Mrs. Deutscher and 
her family is because when people stand up and talk about their 
experiences, and help us to understand the disease, that really 
makes a difference. In my experience in New Hampshire that has 
been the thing that has really helped us begin to change the 
conversation.
    But I suspect that it may be especially true for athletes 
who may suffer consequences of being sidelined if they admit to 
an addiction to opioids, or even to acknowledge the injury that 
underlies their use of prescription pain medications.
    In your experience, does this stigma and maybe the fear of 
being sidelined prevent student athletes or professional 
athletes from acknowledging a dependency on opioids?
    Ms. Williams. I definitely think that the stigma is a 
problem and something that we need to address.
    I think the way that we address it is by outreach, 
educating from the grassroots level all the way up into the 
professional level. Starting the conversation before it becomes 
a problem for people that are not using opioids, getting that 
conversation going, having it frequently instead of just, 
``There is this thing we probably should not talk about.'' Or, 
``I think my friend or struggling, but I am not sure exactly 
what I should do about it.''
    Before it becomes a problem, we need to implement that as a 
standard thing that we are doing on a regular basis and that 
the conversation is being had.
    Senator Hassan. Thank you.
    Mr. Sailor. As an athletic trainer, we believe in a 
comprehensive healthcare system for our athletes. And that 
includes having access to resources that we can help obtain for 
them when they are in need of things like addiction treatment 
and things like that.
    Senator Hassan. Thank you. Thank you all very much for 
being here.
    I will echo what the other Senators have said. We could 
have a hearing on each of the issues that you all have spoken 
about and I know we will look forward to continuing to work 
with you help make athletics safer.
    The Chairman. Thank you, Senator Hassan.
    Senator Young.

                 STATEMENT OF HON. TODD YOUNG, 
                   U.S. SENATOR FROM INDIANA

    Senator Young. Thank you, Chairman Thune.
    I want to thank you for holding this hearing on protecting 
the health and safety of American athletes. I want to thank all 
our panelists for being here today.
    It is a timely hearing given the scrutiny the USOC has 
received thanks, in large part, to the ``Indianapolis Star.'' 
So I want to commend them on their investigative reporting.
    I am proud to have worked with many of my colleagues in the 
Senate to address this issue and I look forward to working with 
you, Mr. Chairman, as we continue to find ways to address this 
very real problem.
    Ms. Pfohl, I would like to ask you a question about the 
independence of SafeSport from USOC. The USOC initially created 
SafeSport and provided its initial seed funding.
    I think this was certainly a recognition by USOC that they 
finally needed to act in an aggressive manner to address the 
serious problem that has been lurking within its ranks for 
years. They ought to be applauded for implementing this 
initiative. I have concerns about, as I stated, with 
independence, specifically personnel and staffing issues.
    What is your policy on hiring individuals directly from 
USOC and National Governing Bodies into SafeSport? Do you have 
any reservations about SafeSport's independence, if your 
organization simply hires individuals from USOC and NGBs?
    Ms. Pfohl. Thank you, Senator. Yes.
    I have no issues or concerns related to our independence. 
Our board, we have a nine person board of independent 
directors. We have independent investigators, and outside 
counsel, and arbitrators that meet a high bar of independence. 
So we really look for those conflicts.
    I will tell you that we have brought two people from the 
USOC as employees. These are, at least one of them is a subject 
matter expert in this space, not only in terms of SafeSport, in 
terms of the abuse issues, but in terms of how the Olympic and 
Paralympic movements are structured, which is hugely helpful to 
us.
    And again, following in the footsteps of USADA, they too 
were born within the USOC. They had staff members that came 
over to USADA. I do not think anyone can question their 
independence. And so, we have followed that framework.
    Senator Young. So these independent investigators who 
presumably produce reports and various findings to inform your 
future work, are these reports made available to members of the 
public or would they be made available to Congress, because I 
presume they touch on staffing issues, correct?
    Ms. Pfohl. If we have the actual reports from victims, if 
you will, cases that come in, is that what you are speaking to, 
sir?
    Senator Young. Yes, and also the performance of former 
employees of the National Governing Bodies, and USOC, if they 
are consistently subpar, suboptimal, or conflicted, which you 
have emphasized they are not. That would be a finding that 
would be of interest to this committee, I know.
    Ms. Pfohl. Our jurisdiction lies in addressing sexual 
misconduct and abuse within the Olympic and Paralympic 
movements.
    So we would take in reports. If we have a finding against 
an employee of an NGB, or the USOC, or a coach, or anything, or 
anyone that is a covered individual that sanction is then 
handed down, if you will. And it must be enforced across the 
Olympic and Paralympic movements.
    Senator Young. With your permission, I may have a follow-up 
question or two.
    Ms. Pfohl. Absolutely.
    Senator Young. I will submit it by writing. If you would 
offer me the courtesy of a response, I would be grateful for 
that.
    Ms. Pfohl. Absolutely, sir.
    Senator Young. Because I want to turn to another matter. I 
know that reporting incidents of abuse is critical to starting 
the investigation process. Unfortunately, our staff discovered 
a problem here.
    On SafeSport.org, the website, there is a link entitled 
``Report.'' Unfortunately, that link is broken and takes 
visitors to a ``Page Not Found'' website.
    Moreover, if someone were to try and find more information 
on reporting confidentiality--those concerns as referenced in 
your materials to the USOC Athlete Ombudsman at www.AthleteOm
budsman.org--that website does not work either.
    I know this is likely a surprise for you. What I am seeking 
from you is some assurance that you will resolve this matter 
expeditiously, and maybe the courtesy of informing our staff 
this week about its status. Because one could see why you could 
infer from this a lack of seriousness taken toward this issue, 
which I have not heard from your testimony so far, by the way. 
I have heard seriousness.
    Can I get your commitment to report back about this or am I 
missing something perhaps?
    Ms. Pfohl. Absolutely, Senator.
    Senator Young. All right.
    Ms. Pfohl. I will check into it and get back to you.
    Senator Young. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Young.
    Senator Moore Capito.

            STATEMENT OF HON. SHELLEY MOORE CAPITO, 
                U.S. SENATOR FROM WEST VIRGINIA

    Senator Moore Capito. Thank you, Chairman Thune.
    And thank all of you for being here today.
    I come from the State of West Virginia. We have, 
unfortunately, some of the largest and greatest statistics of 
overdose from and deaths caused by drug addiction and drug 
overdose. We have a lot of good things going on in terms of the 
sports area. Our WVU Sports Medicine Center is, I think, on the 
cutting edge of some of the research that is being done.
    I would like to speak just personally to Mrs. Deutscher, 
and thank you for coming, and telling your story. I think it is 
so important that we hear from you because it is a hesitating 
thing for, I think, parents and grandparents to talk about. So 
I read your testimony. I am sorry I was not here to hear you 
give it.
    We are trying to work with families on certain things sort 
of outside the athletic. Well, actually, one of them was an 
athlete and she had described herself in the hospital as an 
addict, and said she had been in and out of recovery. 
Unbeknownst to the discharging physician, who did not read all 
through the chart, they discharged her with 56 Oxycodone, which 
she melted 8 and put into her PICC line, and did not wake up 
the next day. So we are trying to fix those kinds of things so 
that that situation cannot happen again.
    But one of the things I am curious to know, tracing back 
and looking at what happened with your son, we are trying to 
get to this partial fill or acute pain issue. If you have a 
wisdom tooth, if you have an acute athletic injury that you do 
not need 2 weeks of pain medicine; maybe 48 hours or 72 hours.
    Was that ever offered to your son, a short term sort of 
treatment or short term prescription option for him?
    Ms. Deutscher. The initial prescription, I believe, was 
shorter term. I do not have that record. I did get his pharmacy 
records for the balance of the prescriptions. But that would 
have been offered when he first had his injury. It was a Friday 
night and so he got in to get evaluated.
    Then the other in a series of prescriptions started a 
little bit later in the season when he was rehabbing to get 
back into the game and those prescriptions, if memory serves me 
correctly, were 40, 50 tablets.
    Senator Moore Capito. Were there ever any diversionary 
other pain methods to deal with the pain offered to him?
    Ms. Deutscher. Well, by Jeff and I, the Tylenol.
    Senator Moore Capito. Right.
    Ms. Deutscher. But no, there was not that discussion. It 
went to Hydrocodone and to Percocet.
    Senator Moore Capito. Right away.
    Well, that is something else I have been working on with 
Senator Warren from Massachusetts to look at the partial fill. 
And also an acute pain issue that I am working with Senator 
Gillibrand on to try to eliminate that lengthy prescription 
that it becomes quite a temptation in a lot of cases.
    I wanted to ask Ms. Williams. Actually, I am the 
appropriator for the General Government, which also covers the 
U.S. Anti-Doping Agency and because of that, I got to meet 
Michael Phelps and I get to meet you. So that is good.
    It was interesting to me. We do appropriate that as a 
member of the Anti-Doping Association of the United States and 
then also try to help the worldwide organization for the elite 
athletes that are competing on the stage, such as you.
    But it was interesting what he said to me. I mean, think of 
how many races he has been in and how many international races. 
He said, ``I do not think I have ever had a clean race.'' He 
was not talking about him. He was talking about everybody else 
in the pool and he still won all the gold medals and you did 
too, the medals.
    So I am thinking to myself, ``What kind of pressure is that 
at the elite level?'' Because of what the other countries are 
doing.
    Ms. Williams. I think there is a good amount of pressure 
for athletes and I think that is why outreach is so important, 
like I said, educating athletes from the grassroots level.
    Also, the World Anti-Doping Agency does a good bit of 
outreach trying to cross cultures because there are different 
things that different cultures are dealing with as it pertains 
to win-at-all-costs and all these sorts of things.
    Being able to create examples, so for example, I did not 
use any supplements for my whole career; not only did I not use 
performance enhancing drugs, but I did not use vitamins or 
protein powder. I go out and tell people as much as possible 
that I made it to four Olympic Games without any of those 
things, no multivitamin or whatever the case may be.
    I think really being able to explain to athletes from the 
grassroots level all the way up to the professional level that 
it is not worth it, that the medal, that one moment on the 
podium is not going to be rewarding enough. You are not going 
to feel satisfied because you did this thing that was wrong in 
order to get to that point.
    And really being able to convey that and articulate that in 
a way that is going to hit home so that they are not encouraged 
to want to try and reach this next level or win at all costs is 
really going to be the important thing.
    Senator Moore Capito. That is an excellent point and thank 
you for being that advocate.
    I actually had the opportunity to meet Simone Biles just a 
few weeks ago. She is working and outreaching to young people 
to inspire them on different levels, clean living, and staying 
away from substances.
    So it is so important the work that you are doing and I 
appreciate you all working with the next group of stellar 
athletes. Thank you.
    Ms. Williams. Thank you.
    Senator Moore Capito. Thank you very much.
    Senator Young. Mr. Chairman, could I just note that my 
colleague is dropping a lot of impressive names here 
gratuitously.
    Senator Moore Capito. You wonder why they all come to see 
me.
    The Chairman. And they are out there dropping her name.
    [Laughter.]
    The Chairman. Well, thank you, Senator Capito.
    I think Senator Sullivan is on his way back and would like 
to ask a question or two, so let me keep it going here for just 
a minute.
    Ms. Pfohl, as the former Executive Director of the 
President's Council on Fitness, Sports, and Nutrition and we 
have talked a lot about the challenges that we face, the 
problems, and things that we need to address in the world of 
competitive sports.
    Just as a question, do you believe we ought to be 
discouraging participation in certain sports? I mean, are there 
positive benefits to playing sports including contact sports 
that we ought to be talking about as well?
    Ms. Pfohl. Thank you, Chairman Thune.
    But obviously, I believe in sports and all that comes from 
it. Not only the health and fitness benefits, but certainly the 
emotional benefits that come from it, the teamwork that you 
learn, the perseverance, the dedication; all of those kinds of 
character building things that are learned with and through 
sports. I am not just talking competitive sports, but just 
recreational, getting out there and having fun, I believe, are 
so important.
    I think all the issues, the safety issues that have been 
talked about on this panel, are also critical so that we can 
save sport not only for our generation, but for every 
generation to come. So it is absolutely critical.
    And Go Packers, by the way.
    The Chairman. Very good. I like you more already.
    Is your focus just Olympic athletes, or does your work go 
beyond elite level sports participants? Is your focus solely on 
children or does your work go beyond youth in terms of the 
things that you are undertaking there?
    Ms. Pfohl. Thank you for that question, Chairman Thune.
    It absolutely goes beyond children. We address athletes at 
every age and at every level. So again, really from the 
recreation leagues, if you will, for folks that are just going 
out and having fun whether that is children or adults, all the 
way up to the Olympic and professional ranks. So all of the 
above in terms of our education and outreach, and the training, 
and awareness that we want to get out for sports organizations, 
parents, and athletes all across the Nation.
    The Chairman. Well, and we appreciate everything that 
SafeSport is doing to stand up best practices to prevent abuse 
within the Olympic movement.
    As we examine legislative proposals in this area, and you 
heard some of my colleagues speak to that earlier today, we 
have to consider how best to craft policies governing one-on-
one contact between athletes and coaches. We definitely want to 
avoid situations that put young athletes at risk of abuse. At 
the same time, we want to avoid overbroad policies that 
unnecessarily strain the athlete-coach relationship.
    So the question is, do you support a blanket rule against 
one-on-one contact or does a risk-based standard like the 
standard the Centers for Disease Control and Prevention 
advocates make more sense?
    Ms. Pfohl. Thank you again, Chairman Thune.
    We really follow the CDC, the Centers for Disease Control's 
standards and guidelines in this space. We recognize and agree 
with the Centers for Disease Control that limiting those one-
on-one interactions between adults and children, and making 
sure that there are two adults present as often as possible is 
the absolute right thing to do.
    We also agree with their risk-based guidelines, as you 
indicated. It basically says that maybe one size does not fit 
all. So many sports organizations are so diverse that there may 
be multiple options for achieving safety.
    Their standards or their guidelines certainly are those 
that we have made part of our best practices.
    The Chairman. Just out of curiosity and other members of 
the panel, do you share that view? Does anybody else want to 
comment on that? Do you agree with that as articulated by Ms. 
Pfohl? OK.
    Senator Sullivan is coming in the door.
    Senator Udall had asked that we include in the record three 
items that he wanted included. So we will do that without 
objection.
    [The information referred to follows:]

                                           PINK Concussions
                                                       May 16, 2017

Hon. John Thune,
Chairman,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.

Hon. Bill Nelson,
Ranking Member,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.

Dear Chairman Thune and Ranking Member Nelson:

    Please allow this letter to be included in the official record for 
the hearing ``Current Issues in American Sports: Protecting the Health 
and Safety of American Athletes'' taking place on May 17, 2017, on the 
topic concussions in female athletes.
    My name is Katherine Price Snedaker, and I am LCSW and the 
Executive Director of PINK Concussions, a non-profit which focuses on 
female brain injury from sports, domestic violence, accidents and 
military service.
    I would like to share with you some very important information 
about female brain injury which is not reaching our women athletes and 
their coaches. Research in the early 2000s showed that female brain 
injuries including concussions, were not the same as brain injuries in 
males. Yet today, almost 20 years later, most woman and doctors are 
still unaware of the biological differences in brain injury.
    THE FACT is that, in multiple research studies dating back to the 
early 2000s, women have been shown to:

   Sustain more concussions at a higher rate than males in 
        sports with similar rules

   Report a higher number, and more severe, symptoms than males

   Have longer recovery periods than males

    THE CHALLENGE is since women and girls are rarely educated about 
female brain injury, many of these women are not prepared to cope with 
more severe symptoms and often have unrealistic expectations of 
recovery time of a few days or weeks when faced with months or years of 
Post Concussion Syndrome.
    And despite the established facts of female brain injury, the 
sport, academic, military, and medical communities do not have any 
female-specific medical guidelines, return to school/play/work/duty 
protocols or education resources designed for women.
    1. What are the differences between males and females in terms of 
concussion frequency, severity, symptoms, outcomes, etc.?

        Scientific research has shown that female and male brains 
        differ in more than 100 ways in structure, activity, chemistry, 
        and blood flow, and so it is logical that damage to the brain 
        would also manifest differently in women and men.

        However, brain injury research including sport concussion 
        research has long been viewed through a masculine perspective 
        partly due to the findings that TBI in general occurs about 
        twice as often in males as it does in females (Rao & Lyketsos, 
        2000). The riskiest sports for concussion often have being 
        male-dominated (i.e., collision/contact sports such as ice 
        hockey, boxing/combat sports, football, rugby).

        It is critical to recognize multiple research studies have 
        found in sports with similar rules between females and males, 
        in particular soccer, basketball and baseball/softball, the 
        rates of concussion are actually higher in women (Gessel, 
        Fields, Collins, Dick, & Comstock, 2007; Hootman, Dick, & Agel, 
        2007; A E Lincoln et al., 2012).

        In the 2012 American Medical Society for Sports Medicine 
        Position Statement: Concussion in Sport research showed that in 
        sports with similar rules female athletes sustain more 
        concussions than their male counterparts. In addition, female 
        athletes experience or report a higher number and severity of 
        symptoms as well as a longer duration of recovery than male 
        athletes in several studies.

    2. What are the proposed reasons for these differences?

        Female athletes may be at a greater risk for concussion due to 
        which phase of their monthly hormones at the time of injury, an 
        increase in angular acceleration at the neck, AND/or neck 
        strength-to-head size ratios.

    3. What can be the clinical implications of #pinkTBI?

        While research shows females may have different injury rates, 
        symptoms, and rates of recovery, the medical community does not 
        yet have any female-specific guidelines, protocols, care plans 
        or education resources for women with brain injury including 
        concussions.

        Since more men than women have brain injury, a woman, her 
        support system and the people around her will most likely know 
        more men than women who have had concussions therefore 
        typically judge her symptom pattern and length of recovery by 
        the male experience. The patient may doubt herself when the 
        speed of her recovery or the severity of her symptoms do not 
        match the more familiar and more publicized male experience. 
        Family members, school staff or employers judge her experience 
        to be abnormal, malingering or perceive that there maybe other 
        non-brain injury issues at play.

    Without proper education of patient, family and community supports, 
women and girls with brain injury including concussion, can experience 
an additional lack of support, doubt, isolation and anxiety beyond that 
which comes with brain injury.
    Thank you for your interest in PINK Concussions. Please let me know 
if you have any additional questions.
            Sincerely,
                                        Katherine Snedaker,
                                           LCSW Executive Director,
                                                      PINK Concussions.
                                 ______
                                 
     Prepared Statement of Katherine Starr, Founder, Safe4Athletes
    Over 44 million young Americans participate in sport on a daily 
basis; the United States Olympic Committee (USOC) members account for 
approximately 3 million athlete members across the Olympic sports 
family. The other 41+ million child athletes are members of various 
non-governmental organizations; the AAU, YMCA, Little League, Pop 
Warner, and several independent sports leagues, that don't fall 
directly under the jurisdiction of the USOC or any other oversight 
body. Each of these organizations set their own policies for their 
respective communities with very few having any policies that address, 
or even mention, the issue of coach-athlete abuse.
    One of the most comprehensive studies of sexual abuse in sport was 
done in Canada, with a survey of that country's Olympic athletes, 
concerning their experiences in sport. In the study, 22 percent of the 
athletes responding reported that they had engaged in sexual 
intercourse with an authority figure in sport. Nearly 9 percent of 
respondents reported experiencing a forcible sexual encounter. This 
study is consistent with Safe4Athletes most recent survey that found 
over 25 percent of the athletes that responded stated they experienced 
some sort of sexual harassment over multiple seasons.
    Coaches spend more time every day with their athletes than teachers 
do. Coaches, unlike child health care workers, travel with their 
athletes. Teachers and child health care workers are held to stringent 
standards--as they should be--in regard to their behavior around 
children. Many schools require that doors be kept open when teachers 
counsel students, and mandate that parents be present for medical 
examinations. Any suspicion of abuse is required by law to be reported. 
Yet there are no guidelines or laws that dictate appropriate behavior 
when it comes to coaches and athletes in non-school sports.
    Requiring background checks for coaches will deter the convicted 
pedophiles that we know about but will do nothing for the ``predator 
amongst us'' who has not yet been caught. A background check is the 
first line of defense, once the sports programs are active and if the 
organization does not have a meaningful reporting and investigative 
practice process identified and utilizes experts who understands the 
complexities of any form of athlete-abuse that occurring on the field, 
in the gym or at the pool.
    This limitation is further exploited in our courts by the national 
governing sports bodies that consistently defer blame back to the local 
clubs. While giving the local sports club limited power and full 
responsibility, for a multitude of reasons including claiming no 
responsibility for the hiring choice, not being present to see the 
wrong doing, or simply passing on any responsibility by not receiving 
any complaint that requires investigation.
    Many of these national organizations, have comprehensive rules that 
dictate the uniform policy, presence or absence of make-up/jewelry, 
grade point averages, practice times but fail completely to mandate 
local policies that for hiring standards, reporting requirements, 
investigation process into inappropriate coach-athlete behavior, and a 
clear structure (that is athlete focused) to deter such behavior from 
thriving in the sports environment.
    The newly implemented `Center for Safe Sport' addresses some of 
these issues for their approximately 3 million membered community by 
creating a uniform and centralized system to investigate and 
adjudicated coach-athlete sexual abuse across their sport families. 
Other concerns remain in the sport organizations themselves as member 
clubs are not required to have clear policies at the local level but 
refer to the national governing bodies for their direction. While the 
Center for Safe Sport has a set a standard, and created some uniformity 
in USA sport, it has failed to reach the other 41+ million athletes 
that are presently outside of their jurisdiction.
    This leaves local clubs at the direction of their national 
governing body and often they are not permitted to set their policies 
regarding abuse in sport issues, often they are pressured into only 
following the limited policies set at their respective national 
governing sport bodies. Often when incidents occur the National 
organizations pass the blame back to the local level to absolve 
themselves of any responsibility whatsoever.
    In general, these national organizations lack knowledge in coach-
athlete sexual abuse investigation. As a result, the predator coach can 
easily take advantage and manipulate the sports clubs and their 
leadership and of special concern, such coaches are allowed to leave 
their current position prior to their behavior being questioned. This 
is a direct result of the flaws in governance and leadership of the 
youth serving organization. There is a lack of will to implement and 
mandate stronger policy and in many cases NO policies exist at all.
    Without empowering the local clubs and mandating policies to 
prevent sexual abuse and all forms of abuse in sport, the issue will 
continue to harm our youth. The abuse that occurs at a young age has 
the ability to negatively impact a young person for life, denying the 
child-athlete the opportunity to know the positive benefits of sport 
that we all believe are going to make the individual a better person 
all around.
    In closing, the need for oversight to protect all athletes, across 
all sports and all sport organizations must be put in place. This 
system needs to start at the local level with sports clubs adopting 
policies, committing to the creation of a safe environment that puts 
the athlete first. The policies need to be designed to provide clubs 
with a system that explicitly creates a positive environment free of 
sexual abuse, bullying and harassment.
    If we believe in and support the child-athlete anything less is 
unthinkable.
                                 ______
                                 
                                      Sports Fans Coalition
                                                       May 17, 2017

Hon. John Thune,
Chairman,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.

Hon. Bill Nelson,
Ranking Member,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.

Dear Chairman Thune and Ranking Member Nelson,

    Sports Fans Coalition (``SFC'') is the largest fan advocacy group 
in the U.S. devoted to representing the interest of sports fans 
wherever public policy impacts the games. We were founded in 2009 and 
today have members in all 50 states. SFC is best known for successfully 
petitioning the Federal Communications Commission to end the decades-
old Sports Blackout Rule, which the Commission unanimously voted to 
eliminate in 2014. The NFL subsequently suspended its local blackout 
policy. We continue to advocate for public policy that maximizes fans' 
access to games, grants fans and other members of the public a fair 
return on any public resources devoted to sports facilities, and 
upholds fair play both on and off the field.
    SFC thanks you for holding today's hearing titled, ``Current Issues 
in American Sports: Protecting the Health and Safety of American 
Athletes.'' Fans believe that we can preserve the essence of our great 
sports without unfairly compromising the health and safety of athletes. 
SFC has called on the NFL, NHL, and other leagues to fully disclose 
what they know about the risk of concussions posed by their sports so 
that players and coaches can make informed decisions. Moreover, we 
believe that Members of Congress currently investigating league 
practices regarding concussions should not accept campaign 
contributions from league Political Action Committees or team owners 
while such investigations are pending. Tens of thousands of fans sent 
that very message to Members of the House Energy and Commerce Committee 
through a campaign organized by SFC and we urge Members of your 
committee to heed that call. Fans want fair play, and that begins with 
leagues telling the public the truth.
    Our members do not want to see the rules of play altered to such a 
degree that the sports themselves become unrecognizable from their 
traditional origins. No one wants to see the NFL turn into a flag 
football league. SFC believes, however, that just as football leagues 
at all levels altered helmets to include facemasks, then created a new 
rule that no player shall ``twist, turn or pull the facemask of an 
opponent in any direction'' (NFL Rulebook at Rule 12, Sec. 2, Art. 5), 
leagues can and should develop practices that reasonably protect 
players. At the very least, we should have full disclosure of leagues' 
knowledge on issues of player safety.
    Thank you again for your attention to these issues.
            Sincerely,
                                          David Goodfriend,
                                                          Chairman.

    The Chairman. I would say to all of you thank you for being 
here. Thanks so much for your thoughtful input and suggestions 
in response to our questions. These are all important issues; 
in many cases life and death issues. Certainly when it comes to 
safety, it is really critical that we get this right. So we 
welcome your continued input.
    I just want to indicate to you that there are members of 
this committee who will have questions that they would like to 
submit for the record, and if you could get those back to us as 
soon as possible. We normally keep the record open for a couple 
of weeks to allow your responses. So if you could get those 
back to us as quickly as possible, we would appreciate it.
    With that, I will yield to my colleague from Alaska, 
Senator Sullivan. I think he is going to take us out.
    But let me again just thank you for being here today. I 
cannot tell you how much we appreciate your participation.
    Senator Sullivan.
    Senator Sullivan [presiding]. Thank you, Mr. Chairman.
    I want to thank you again for calling this hearing. It is a 
really important issue that is impacting the entire country. So 
thank you for your leadership on that.
    I want to thank the panel. Again, I am sorry. I had to step 
out. I have my freshman duties where I have to preside over the 
Senate. If you are a senior esteemed Senator like Chairman 
Thune, you do not have those duties, but I had those for the 
last hour. So it was not my lack of interest. I was over with 
another gavel on the Senate floor.
    I do want to thank the panel again. I have been keeping 
tabs from my staff on the questions and I read the testimony.
    Let me just start. Dr. Butler, I want to start with you. 
Thanks again for coming and thanks again for all that you are 
doing. You may have seen, you were quoted in the Alaska 
Dispatch News this morning, front page, above the fold 
headline, ``Anchorage is seeing a dramatic surge in heroin 
overdoses.''
    Let me ask a little parochial question, but still important 
because I think it can shed light on what is going on in the 
country. What do you think is behind that surge in our biggest 
city back home?
    As I mentioned, we held this Wellness Summit last August in 
the Matsu Valley. One of the reasons I hosted that was a kind 
of a warning signal in some ways to our state that this is 
happening in a lot of places. We are not in the dire straits of 
some lower 48 communities yet, and hopefully never, but this 
could be coming.
    Unfortunately, I fear that since we held that Summit, we 
have been focused on this issue a lot in the Congress, but I 
think in Alaska, it is getting worse. I think throughout the 
country it is getting worse.
    Do you mind addressing the headline today in the paper, the 
dramatic surge of heroin overdoses in Anchorage? And then if 
you want to address whether you think it is getting worse in 
Alaska or not. And then if any of the panelists want to just 
talk about it relating to the Nation, because it does look like 
we are not winning this battle right now, at least in my view.
    Dr. Butler. Senator Sullivan, I think Alaska really 
reflects what is happening nationally.
    What we have seen in Alaska is that while we have had some 
leveling of the number of overdoses due to prescription 
opioids, there has been an additive effect of an increasing 
number of overdoses due to heroin and also the synthetic 
Fentanyl-related compounds.
    There has even been some decline in opioid prescribing. So 
I think it is important to point out that we may be beginning 
to bend that trend, but we are nowhere near where we need to 
be.
    We have heard a number of stories this morning of where 
large amounts of opioids have been prescribed and have led to 
problems or that problems with misuse have gone under-
recognized. And I think a lot of that is driven by a lack of 
awareness among the healthcare provider community and even 
among the public in terms of the risks associated with these 
drugs.
    Specifically, what is happening in Anchorage, I think, 
highlights a number of issues. At this point, we do not know if 
the increase in overdoses is being accompanied by an increase 
in overdose deaths. It is possible that we are actually seeing 
more people survive to interact with the EMS system because we 
have been very aggressive in getting Naloxone kits out into the 
community, distributing over 5,000 of those kits over the past 
3 months.
    It also highlights the importance of the interagency 
communication between public health and law enforcement so that 
we are sharing data and able to discuss exactly what we are 
each seeing from our own perspectives.
    For example, it is not clear whether or not this may be a 
batch of some substance that is much more powerful than the 
heroin that has been on the street in the past, or is it an 
influx of primarily people who have reduced tolerance? We do 
not know that degree of detail yet. But that is where working 
together and having our incident command response really has 
helped to be able to facilitate those communications.
    We learned a bit of this during an outbreak of ``Spice'' 
overdoses of the synthetic cannabinoid a couple of years ago 
where it actually took several weeks to be able to recognize 
the problem and connect those dots.
    In this case, we actually were aware of the increase late 
last week and we were able to start having those conversations 
as soon as we recognized it.
    The final comment I was going to make is that while it is 
important to address the challenge of illicit opioids, we have 
to recognize that part of the reason heroin found such a ready 
market when it came in, in larger quantities and at much lower 
prices.
    Starting about a decade ago, we had a much larger 
proportion of our population that had physical dependency or 
addiction to opioids. And that the way we oftentimes use 
opioids with good intent and good intention therapeutically 
oftentimes can be a set up for physical dependency.
    Withdrawal can be awful even if it is not the more chronic 
condition of addiction, people will oftentimes turn to whatever 
they can turn to, to be able to avoid the rigors of dope 
sickness.
    Senator Sullivan. Anyone else on the panel want to comment 
on what they see nationally as a trend and the reasons for it?
    I do want to comment. Mrs. Deutscher, I was here for your 
testimony and I really just appreciate it. I know that that 
could not have been easy for you to testify before this 
committee and recall some things that are obviously incredibly 
heart wrenching for you personally and your family.
    But unfortunately as I have dug into this issue, the story 
that you told about your son, it is not an uncommon story in 
terms of an athlete who has a bright future, a high school 
star, and then there is an injury, and then this happens. Have 
we learned enough from that? It is a very common story that we 
are hearing.
    How you talked about how you did not understand fully the 
risk. Do you think there is more that needs to be done? Do you 
think that people are recognizing that?
    And again, I just want to commend you for being here today. 
I am sure it is not easy.
    Ms. Deutscher. Thank you.
    I do not think there is enough being done. I think funding 
is a huge issue to get the awareness out, to get into the high 
schools, to get it to the coaches, to get it out to the general 
public of opioids just in general, but also as it relates to 
our athletes.
    We had great coaches. Jeff and I are very involved. We had 
a great athletic trainer. We had great physicians. But as I 
have told in a couple of deliveries that we made to within our 
state, it was ignorance that was part of Nick's death. We just 
did not know.
    And so, I think that is so crucial.
    Senator Sullivan. Thank you.
    Are there any other thoughts on the broader trends on the 
opioid issue throughout the country and what direction you see 
it going in?
    Ms. Williams. This is not my area of expertise, but I would 
like to add something, Senator.
    I have lost three of my classmates. I am of the graduating 
class of 1988 in my small town in Pennsylvania to heroin 
overdose. I think the thing that is really important here, I 
have said it multiple times, is outreach and communication. 
What are we not communicating to people? This is getting to a 
point where there is someone that is more charismatic or there 
is something that is happening.
    These were not the bad kids. These were not the ones that 
were headed to nowhere. These were bright students. These were 
people who had transitioned well from high school into college, 
and gone on to professional careers that we have now lost to 
heroin.
    What is being said? What environment is being created 
outside of the opioid use? What is the gateway that people are 
entering into the heroin use? What can we do, like you said, to 
be having constant communication, constant outreach?
    I remember as I was growing up as a child there was 
D.A.R.E. There was PAL. There were all kinds of songs, and 
raps, and things about not using drugs. It seems like we saw 
something that was working and we got away from it.
    So now it appears there occasionally, but we are not 
starting at the grassroots level saying this is really 
important. These are the reasons that you should stay away from 
drugs. At some point, the bad guys entered and they are doing 
something that is convincing really good people to go down a 
really bad path.
    Senator Sullivan. Well, I think that is a really important 
point. We are certainly trying to do that in Alaska.
    Dr. Butler, you may have seen the head of the FBI in the 
state and I have sent that FBI video. Some of you may have seen 
it, ``Chasing the Dragon,'' which is very graphic, scaring the 
young children into, ``This could happen to you,'' trying to 
get it into all the high schools just to wake all these young 
men and women up. But you are certainly correct about the point 
of how some of the best and brightest in the country are 
getting addicted.
    Let me finish with one final question. And again, I want to 
thank everybody for your patience and testimony today. On 
another issue, and Dr. Butler, you mentioned how some of these 
things are related, and I certainly have seen that as well.
    On the issue of the sexual assaults and abuse of our 
athletes, do we have enough safeguards, do you think, in place? 
With regard to our young men and women who are, again, 
America's finest and some of the most disciplined with regard 
to some of the reports that has obviously alarmed a lot of us. 
I am just wondering for the expertise here at the panel, if you 
believe that we do have enough safeguards?
    Congress always tries to act. Maybe it is an appropriate 
role. But what do you think the role that we should be doing 
and the role that you should be doing?
    Ms. Pfohl. I would be happy to start. Thank you, Senator 
Sullivan.
    I think the answer is no. We do not have enough safeguards. 
That is the reason the U.S. Center for SafeSport has been 
created and the reason we exist, and the reason we need to 
exist.
    I think you asked what the Senate can do. I will say again, 
I think having an authorization, again, following in the 
footsteps of USADA, but being authorized in legislation. 
Certainly, we would not turn down an appropriation, but being 
authorized in legislation goes a long way into establishing the 
credibility, the need for these safeguards as you have said.
    It is our absolute goal, our mission to not only address 
the abuse and weed out the bad actors, but to really get 
upstream on prevention. To make sure that we are educating all 
parents and youth sport organizers, if you will, the athletes 
themselves on how to identify grooming behaviors, for example, 
when we are talking about youth. What does that look like?
    And so, all of the education, the outreach, the training 
that needs to take place that is not currently taking place, 
that is why we are here. We are absolutely committed to 
creating change. Again, our motto is champion respect and end 
abuse. That is our call to action.
    Senator Sullivan. Thank you. Anyone else on that question?
    Ms. Williams. I would also say no, that the safeguards that 
we have in place are not enough. What we need in place is 
uniform, baseline education across all the different levels of 
sports from, like I said, the grassroots level, youth, moving 
up into the elite ranks.
    There needs to be something for when a coach, when a person 
that is going to be of authority that is going to be dealing 
with an athlete on a regular basis. Once they enter into this 
field, what are the baseline requirements to make sure that you 
are going to do what is in the athlete's best interest?
    Right now, there is no uniformity across all these 
different levels, different organizations that exist. You can 
just wake up one morning and say, ``I am going to go coach 
people and I am going to go coach kids.'' You are there and you 
are coaching. Everyone is like, ``Oh, he is nice.'' And then 
you are bringing kids home and it just degrades from there.
    Senator Sullivan. Yes.
    Ms. Williams. So baseline education and baseline points of 
entry. There are requirements that make sure that we do have 
proper safeguards. Those are the things that need to be put in 
order.
    Senator Sullivan. Thank you.
    Before we conclude, I would ask unanimous consent to 
include in the record letters from stakeholders providing 
additional perspectives on today's hearing including the Sports 
Fans Coalition* and the Positive Coaching Alliance.
---------------------------------------------------------------------------
    \*\ This letter can be found on page 97 of this hearing.
---------------------------------------------------------------------------
    Without objection, so ordered.
    [The information referred to follows:]

    Prepared Statement of Jake Wald, Business Development Manager, 
                       Positive Coaching Alliance
    Mr. Chairman, Mr. Ranking Member, and Members of the Committee. My 
name is Jake Wald, and I appreciate this opportunity to submit 
testimony on behalf of the Positive Coaching Alliance (PCA) for the 
Committee's hearing entitled ``Current Issues in American Sports: 
Protecting the Health and Safety of American Athletes.'' We appreciate 
the Committee focusing attention on the issues facing athletes, both on 
and off the field.
    PCA is a non-profit, educational organization that provides 
resources for students, parents, coaches, and leaders with the aim of 
improving the culture around youth sports. Operating under the motto 
``Better Athletes, Better People,'' PCA works to ensure that all youth 
and high school athletes have positive and character-building sports 
experiences.
    We pursue this goal by working directly with youth and high school 
sports leaders, coaches, athletes, parents, and officials through 
partnerships with schools and youth sports organizations nationwide. 
These partnerships consist of live workshops, online courses, books, 
and more--all geared toward changing the culture of youth sports. Since 
its inception, PCA has reached more than 8.6 million young people; 
partnered with roughly 3,500 schools and youth sports organizations; 
and delivered hundreds of thousands of online courses.
    I joined PCA in 2012, and I am responsible for the development and 
establishment of new PCA chapters, to add to the 17 we already have in 
major cities including Chicago, New York, Houston, Los Angeles, and 
Tampa Bay. I came to PCA after being fortunate enough to have a career 
first as a student-athlete at George Washington University (GWU) and 
then as a professional athlete in the San Francisco Giants and Arizona 
Diamondbacks organizations. Upon my retirement, I returned to college 
baseball as a coach, first at my alma mater, GWU, and then at 
Georgetown University. These experiences informed my decision to get 
involved with PCA, and provided me with the insight to speak firsthand 
about the issues facing youth athletes today.
    As the Committee begins exploring factors impacting athlete safety, 
we urge the Committee to assess the culture of youth sports as an 
integral factor affecting young athletes. Last Congress, the House 
Energy and Commerce Subcommittee on Oversight and Investigations 
convened a hearing to evaluate concussions in youth sports. At that 
hearing, members noted that improving the safety of sports is not 
merely about science; it is also about culture.
    We strongly agree with the notion that that culture plays a 
critical role in improving awareness, attention, and care for youth 
athletes, and we are concerned that today's win-at-all-costs culture 
incentivizes and normalizes damaging behaviors--including use of 
performance enhancing drugs, opioid abuse, and overuse injuries spurred 
by premature sport specialization. In fact, each year, the current win-
at-all-costs culture drives millions of kids out of sports for good. 
Not only does this deprive them of the well-researched benefits of 
participating in organized athletics, but their negative experiences 
may have further effects throughout their lives.
    PCA leads the charge for youth sports organizations to overcome 
these cultural challenges and help millions of kids reach their 
potential. Young people can only reap the full benefits of competing in 
organized sports if the adult leaders, coaches, and parents behave as 
character educators, intent on teaching life lessons--including healthy 
competitiveness--through sports. With a winning combination of 
truthful, specific praise; constructive criticism; and positive 
motivation, athletic performance improves, and so do the chances that 
kids stay involved and learn all the valuable life lessons that 
organized competition can teach. As such, we appreciate and are pleased 
to see that the Committee has an established interest in evaluating all 
factors that impact athlete safety, beyond just the physical.
    PCA is concerned with the decline in participation in youth sports, 
which reduces the number of American youths who can benefit from the 
experiences and life lessons a positive experience in sports can 
provide. While there are a number of factors contributing to this 
trend; it can be in part attributed to the tremendous negativity that 
pervades youth sports today and the pressure placed on young athletes 
to succeed at any cost. We appreciate and are pleased to see that the 
Committee has an interest in evaluating factors that impact athlete 
safety, and we urge you to continue to bring attention to the issue of 
sports culture--particularly in the context of its role in the 
development of our Nation's youth.
    Thank you again for this opportunity. We would be happy to discuss 
this and other issues related to youth sports with you at your 
convenience.

    The hearing record will remain open for two weeks. During 
this time, senators are asked to submit any questions for the 
record for our witnesses. Upon receipt, the witnesses are 
requested to submit their written answers to the Committee as 
soon as possible.
    I want to, again, thank the witnesses for appearing today. 
These are very important issues. You can see there is a lot of 
bipartisan interest and, I think, motivation to address these 
in a bipartisan way. We are going to continue to engage with 
you and others to make sure we address some of these in the 
best way possible.
    This hearing is now adjourned.
    [Whereupon, at 12:20 p.m., the hearing was adjourned.]

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