S. Hrg. 114–681 

OPIOID CRISIS 

FIELD HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

BORDER SECURITY AND AMERICA’S HEROIN EPIDEMIC: THE 

IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND 

PRESCRIPTION OPIOIDS IN WISCONSIN, APRIL 15, 2016 

EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO, 

APRIL 22, 2016 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
OPIOID CRISIS—2016 
U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

22–773 PDF 2017

S. Hrg. 114–681 

OPIOID CRISIS 

FIELD HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

BORDER SECURITY AND AMERICA’S HEROIN EPIDEMIC: THE 

IMPACT OF THE TRAFFICKING AND ABUSE OF HEROIN AND 

PRESCRIPTION OPIOIDS IN WISCONSIN, APRIL 15, 2016 

EXAMINING THE IMPACT OF THE OPIOID EPIDEMIC IN OHIO, 

APRIL 22, 2016 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

RON JOHNSON, Wisconsin Chairman 

JOHN MCCAIN, Arizona 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JAMES LANKFORD, Oklahoma 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

JONI ERNST, Iowa 

BEN SASSE, Nebraska 

THOMAS R. CARPER, Delaware 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

CORY A. BOOKER, New Jersey 

GARY C. PETERS, Michigan 

CHRISTOPHER R. HIXON, Staff Director 

BROOKE N. ERICSON, Deputy Chief Counsel for Homeland Security 

MEGAN HARRINGTON, Legislative Assistant, Office of Senator Portman 

GABRIELLE A. BATKIN, Minority Staff Director 

JOHN P. KILVINGTON, Minority Deputy Staff Director 

HOLLY A. IDELSON, Minority Senior Counsel 

MARIANNA L. BOYD, Minority Staff Director, Subcommittee on Federal 

Spending Oversight and Emergency Management 

LAURA W. KILBRIDE, Chief Clerk 

BENJAMIN C. GRAZDA, Hearing Clerk 
(III) 

C O N T E N T S 

Page 

FRIDAY, APRIL 15, 2016 

Opening statements: Page 

Senator Johnson ............................................................................................... 1 

Senator Baldwin ............................................................................................... 3 

Prepared statements: 

Senator Johnson ............................................................................................... 47 

Senator Baldwin ............................................................................................... 49 

Senator Ayotte .................................................................................................. 51 

WITNESS 

James F. Bohn, Director, Wisconsin HIDTA, Office of National Drug Control 

Policy ..................................................................................................................... 5 

Tim Westlake, M.D., Vice Chairman, State of Wisconsin Medical Examining 

Board and Chairman, Controlled Substance Committee .................................. 7 

Tyler Lybert; Accompanied by Ashleigh Nowakowski, Your Choice-Live, Hartland, Wisconsin .................................................................................................... 9 

Ashley Nowakowski ................................................................................................. 11 

Lauri Badura, Mother of Archie Badura, Oconomowoc, Wisconsin ..................... 12 

Hon. R. Gil Kerlikowske, Commissioner, U.S. Customs and Border Protection, 

Department of Homeland Security ..................................................................... 24 

Hon. Brad Schimel, Attorney General, Department of Justice, State of 

Wisconson ............................................................................................................. 25 

Hon. Jon Erpenbach, State Senator, District 27, State of Wisconsin ................. 28 

Hon. John Nygren, State Represenatative, District 89, State of Wisconsin ....... 31 

ALPHABETICAL LIST OF WITNESSES

Badura, Lauri: 

Testimony .......................................................................................................... 12 

Prepared statement .......................................................................................... 74 

Bohn, James F.: 

Testimony .......................................................................................................... 5 

Prepared statement .......................................................................................... 53 

Erpenbach, Hon. Jon: 

Testimony .......................................................................................................... 28 

Prepared statement .......................................................................................... 86 

Lybert, Tyler: 

Testimony .......................................................................................................... 9 

Prepared statement .......................................................................................... 70 

Kerlikowske, Hon. R. Gil: 

Testimony .......................................................................................................... 24 

Prepared statement .......................................................................................... 76 

Nowakowski, Ashley: 

Testimony .......................................................................................................... 11 

Nygren, Hon. John: 

Testimony .......................................................................................................... 31 

Prepared statement .......................................................................................... 91 

Schimel, Hon. Brad: 

Testimony .......................................................................................................... 25 

Westlake, Tim: 

Testimony .......................................................................................................... 7 

Prepared statement .......................................................................................... 61 
Page

IV 

FRIDAY, APRIL 22, 2016 

Opening statements: Page 

Senator Portman .............................................................................................. 93 

Senator Brown .................................................................................................. 97 

Prepared statements: 

Senator Portman .............................................................................................. 139 

Senator Brown .................................................................................................. 142 

Senator Johnson ............................................................................................... 145 

Senator Ayotte .................................................................................................. 146 

WITNESS 

Dan Simon, President of University Hospitals Case Medical Center ................. 93 

Hon. R. Michael DeWine, Attorney General, State of Ohio ................................. 100 

Carole S. Rendon, Acting U.S. Attorney, Northern District of Ohio, United 

States Attorney’s Office, U.S. Department of Justice ....................................... 104 

Tracy J. Plouck, Director, Ohio Department of Mental Health and Addiction 

Services ................................................................................................................. 107 

Michele Walsh, M.D., Division Chief, Neonatology, UH Case Medical Center, 

UH Rainbow Babies and Children’s Hospital .................................................... 119 

Nancy K. Young, Ph.D., Director, Children and Family Futures, Inc. ............... 121 

Margaret Kotz, D.O., Director, Addiction Recovery Services, UH Case Medical 

Center, University Hospitals ............................................................................... 123 

Emily Metz, Program Coordinator, Project DAWN, ............................................. 125 

Rob Brandt, Founder, Robby’s Voice ...................................................................... 127 

ALPHABETICAL LIST OF WITNESSES

Brandt, Rob: 

Testimony .......................................................................................................... 127 

Prepared statement .......................................................................................... 214 

DeWine, Hon. R. Michael: 

Testimony .......................................................................................................... 100 

Prepared statement .......................................................................................... 148 

Kotz, Margaret D.O.: 

Testimony .......................................................................................................... 123 

Prepared statement with attachment ............................................................. 201 

Metz, Emily: 

Testimony .......................................................................................................... 125 

Prepared statement .......................................................................................... 211 

Plouck, Tracy J.: 

Testimony .......................................................................................................... 107 

Prepared statement with attachment ............................................................. 157 

Rendon, Carole S.: 

Testimony .......................................................................................................... 104 

Prepared statement .......................................................................................... 151 

Simon, Dan: 

Testimony .......................................................................................................... 93 

Walsh, Michele M.D.: 

Testimony .......................................................................................................... 119 

Prepared statement .......................................................................................... 170 

Young, Nancy K.: 

Testimony .......................................................................................................... 121 

Prepared statement with attachment ............................................................. 173 

APPENDIX 

Akron Beacon Journal article, submitted by Senator Brown ....................... 233 

Statement of Cleveland Clinic, Dr. Jason Jerry, M.D. .................................. 234 
(1) 

1The prepared statement of Senator Johnson appears in the Appendix on page 47. 

2The prepared statement of Senator Ayotte appears in the Appendix on page 51. 

BORDER SECURITY AND AMERICA’S HEROIN 

EPIDEMIC: THE IMPACT OF THE 

TRAFFICKING AND ABUSE OF HEROIN AND 

PRESCRIPTION OPIOIDS IN WISCONSIN 

FRIDAY, APRIL 15, 2016 

U.S. SENATE,

COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, 

Pewaukee, Wisconsin 

The Committee met, pursuant to notice, at 2:30 p.m., in the RTA 

Conference Room, Waukesha County Technical College, Hon. Ron 

Johnson, Chairman of the Committee, presiding. 

Present: Senators Ron Johnson and Tammy Baldwin. 

OPENING STATEMENT OF CHAIRMAN JOHNSON 

Chairman JOHNSON. This hearing of the Senate Homeland Security and Governmental Affairs Committee will come to order. 

I want to first thank Senator Baldwin for making this a very nice 

bipartisan effort and getting us a little bit closer here. 

[Applause.] 

Totally off topic. The Senate is actually a very collegial place. We 

actually get along quite well together. We serve on a couple of Senate Committees together. So, I think that is actually an area of 

hope for our country. We really do get along, so I really do appreciate you understanding what an important issue this is and participating in this today. 

I want to thank our witnesses. I will be thanking them in greater 

detail a little bit later as I start introducing them, but, particularly, those that have suffered. This takes real courage, and we certainly appreciate you coming here and sharing your story because 

if we are going to solve this problem, we need to understand it, we 

need to understand that the use and abuse of drugs, there is nothing glamorous about it. It ends in squalor and death and broken 

lives and broken families. So, we truly appreciate you coming here. 

Now, I have a written opening statement, which I never read, I 

just enter them into the record.1 So, with consent, I would ask that 

that occur. 

I also do want to add a—I have been requested by Senator 

Ayotte to enter her statement in the record as well.2 And, in that, 

by the way, she thanks Commissioner Kerlikowske, with the U.S. 
2 

Customs and Border Protection (CBP). The commissioner has been 

extremely helpful, and he has attended not only this hearing. We 

held a field hearing down in Arizona. We held a field hearing in 

New Hampshire on this issue. He is going to be going to a field 

hearing in Ohio. 

And, it really is these hearings, rather than in Washington, D.C., 

when we come into our communities, that can really impact and 

highlight these problems so that we can hopefully develop a consensus on how to start solving some very difficult issues. 

As part of this committee, as a matter of fact, our first field hearing was in Tomah, Wisconsin. In many ways, a very related hearing, the tragedies that occurred because of opioid overprescription 

at the Tomah Veterans Affairs (VA) health care facility. 

We also held a field hearing in Milwaukee on school choice, one 

up in Stevens Point on ‘‘Waters of the United States,’’ and now this 

one here today in Pewaukee. 

So, again, I want to thank the witnesses. I want to thank all of 

the members of the community for coming out here. I hope you will 

find this as informative as Senator Baldwin and I will. 

Let me just kind of speak from the heart in terms of how this 

journey to Pewaukee and this hearing really began. When I took 

over the Chairmanship of the Committee, we first established a 

mission statement. It is pretty simple: To enhance the economic 

and national security of America. 

And then, we established four priorities on the homeland security 

side: border security, cyber security, protecting our critical infrastructure, and combating Islamic terrorists. 

The first one we addressed—border security, we have held 15 

hearings on border security. We have issued an approximately 100- 

page report, and it is right here—I would recommend you going online or getting a copy of it—laying out the findings of our hearings. 

You might ask, well, how does border security relate to a hearing 

here in Wisconsin on the effect of heroin and the use and abuse 

and the overdoses here in Wisconsin. Well, certainly, my conclusion, as well as I think a number of our committee Members is, 

among many causes of our unsecure border, I place at the top of 

the list America’s insatiable demand for drugs. 

Now, that maybe is not readily apparent, but let me explain why 

I believe that. The fact that we have this demand for drugs, the 

flow is always going to meet the demand, the supply will meet the 

demand. General Kelly, formerly the Commissioner of U.S. Southern Command (SOUTHCOM) provided that information on a hearing we had in Washington, D.C., on Tuesday. 

Because of our demand, we have created these drug cartels, some 

of the most evil people on the planet. The drug cartels control 

whatever part of the Mexican side of the border they wish to control. They are destroying public institutions in Mexico and Central 

America. 

As a result, we have porous borders. If you want a metric on 

that, by the way, we only interdict between 5 and 10 percent of illegal drugs coming through the southwest border. 

Evidence that we are not reducing the supply is in 1981, in inflation-adjusted dollars, the cost of heroin, a little more than 30 years 

ago, was $3,260 per gram. Today, you can buy a gram of heroin for 
3 

1The prepared statement of Senator Baldwin appears in the Appendix on page 49. 

about $100 a gram. There is ten doses in a gram. So basically, one 

dose, one hit of heroin, costs $10, which is roughly the equivalent 

of a nice craft beer in a fancy restaurant. Unfortunately, this is a 

very affordable addiction, and it is an affordable addiction that is 

destroying people’s lives. 

In early January, I also did a national security swing through 

Wisconsin. And, every public safety official I spoke to, local, State, 

and Federal, when I asked them what is the number one problem 

you are dealing with, they responded that is drug abuse, because 

the crime it is creating, it is the broken families, the broken lives, 

the overdoses. 

So, you combine the fact that every public safety official is saying 

drugs is the biggest problem, with what we found out with our border security hearings, that drug demand is the root cause of our 

unsecured border, which, by the way, threatens our national security, public health and safety, and really prevents us from fixing 

the illegal immigration problem, you start realizing our insatiable 

demand for drugs, the abuse of drugs, is fueling all these enormous 

problems that we face today in America. 

So, that is something we need to take to heart, and it is a problem we have to lay out the reality of, and that is, quite honestly, 

the purpose behind every one of these hearings of this committee: 

to lay out the reality so that the people attending the hearing, both 

senators at the dais here, or people in the audience, walk away 

from that hearing having taken the first step in solving any problem, which is admitting you have one and understanding the depth 

of it. 

So, again, I just want to thank everybody for coming here. I am 

looking forward to the testimony. Again, I thank the witnesses for 

having the courage to share your stories and also for, the dedication as public safety officials trying to solve a problem. 

With that, I will turn it over to Senator Baldwin. 

OPENING STATEMENT OF SENATOR BALDWIN 

Senator BALDWIN. Thank you, Chairman Johnson, for convening 

us here in our home State. I will also go through the formality of 

asking that my written opening statement be made a part of the 

record1 and follow your lead in speaking from the heart. 

We had a chance to talk between our formal meetings, just about 

how this impacts everybody, sometimes very immediately in one’s 

own family—sometimes coworkers, neighbors, and fellow 

congregants—just as it affects everyone across our State and affects everyone across our Nation and, regrettably, has not gotten 

the policy attention that it really has needed until recent years. 

I think part of that has to do with something we have struggled 

with as a nation over the years of stigmatizing issues and making 

it more difficult for individuals and family members to come forward and tell their stories, be vocal, be visible, but if we only realized we can solve problems when we do that. 

And so, I want to add my words to Senator Johnson’s in thanking the witnesses who sit before us right now, and we will have a 

second panel, and I want to greatly thank the second panel of wit-
4 

nesses in advance for being leaders and helping us sort of charge 

right through that stigma. 

I do not want anybody here to feel sorry for us in terms of the 

jurisdiction of our Committees. So, I am going to actually speak a 

little bit beyond the jurisdiction of the Homeland Security and Governmental Affairs Committee (HSGAC), because both Senator 

Johnson and I have the ability to serve on a couple of different 

Committees, and epidemics, crises, and tragedies do not fit neatly 

into necessarily one Committee’s jurisdiction. 

And so, I want to just add that in terms of addiction, the supplier 

is not always a drug cartel many miles away. Sometimes it is a 

medicine cabinet that has been left with unused pills. And, sometimes it is a prescriber who has been trained and takes an oath to 

care for our health and well-being, but yet well-meaning, has overprescribed or is overrelying on prescription drugs. 

And, the pathway to the tragedy and epidemic that we are seeing 

right now, I guess I will say there is several pathways, and we, as 

policymakers at the Federal level, and we will be joined by some 

amazing leaders at the State level in our next panel, can not be 

limited just by this this committee’s jurisdiction and not the other. 

We have to work together and put together comprehensive problems, because when, in 2014, 28,000 Americans lost their lives to 

either prescription opiates or illegal opiates, such as heroin and 

fentanyl, it demands that we work together and form those solutions. 

Recently, the Senate took a really significant step forward with 

the passage of an act called the Comprehensive Addiction and 

Receovery Act (CARA), and I think it is going to be a policy step 

forward. Resources need to come too. Because all of the treatment 

programs in the world unfunded will not provide the care and support that people need to lick an addiction and to stay sober and to 

partake in lifelong recovery. 

And so, the Federal Government is a partner, one partner of 

many, that need to come together to solve this issue, to strengthen 

our communities, but that is what needs to be done. 

And again, thank you, Chairman Johnson, for convening us here, 

and I so look forward to hearing from our witnesses, putting a face 

on those unspeakable statistics, in terms of overdose deaths and 

people in need. 

Chairman JOHNSON. Thank you, Senator Baldwin. It is the tradition of this Committee to swear in witnesses, so if you will all rise 

and raise your right hand. 

Do you swear the testimony you will give before this Committee 

will be the truth, the whole truth, and nothing but the truth, so 

help you, God. 

Please be seated. 

Our first witness is James Bohn. Mr. Bohn is the Director of the 

Wisconsin High Intensity Drug Trafficking Area (HIDTA), within 

the Office of National Drug Control Policy (ONDCP), a position he 

has held since February 2015. Prior to this, Mr. Bohn worked for 

the U.S. Drug Enforcement Administration (DEA), for almost 30 

years, 15 on which was spent serving as a special agent in charge 

of the DEA Milwaukee District Office. Mr. Bohn. 
5 

1The prepared statement of Mr. Bohn appears in the Appendix on page 53. 

TESTIMONY OF JAMES F. BOHN,1 DIRECTOR, WISCONSIN 

HIDTA, OFFICE OF NATIONAL DRUG CONTROL POLICY 

Mr. BOHN. Chairman Johnson, Senator Baldwin, and distinguished Members of the Committee, it is my privilege to address 

you on behalf of the Executive Board of the Wisconsin High Intensity Drug Trafficking Areas program concerning the statewide drug 

threat assessment of Wisconsin, and in particular, the HIDTA-designated region. 

My name is James F. Bohn, and I have been the Director of the 

Wisconsin HIDTA since February 2015. The HIDTA-designated 

counties in Wisconsin incorporate approximately 46 percent of the 

State’s population. The HIDTA program is designed to support and 

encourage Federal, State, local, and tribal law enforcement agencies to work together in task force situations to target identified 

drug threats in the local HIDTA-designated areas. 

Each year the Wisconsin HIDTA Investigative Support Center 

conducts a comprehensive assessment of the drug threats in our 

area to identify and prioritize any new and continuing trends or 

threats affecting Wisconsin. 

Wisconsin can best be described as a destination State for illegal 

drugs and drug activity. By ‘‘destination’’ state, I am referring to 

the fact that in most instances, once illegal drugs enter Wisconsin’s 

borders, they are almost always going to be used and/or resold 

within the State. 

Wisconsin’s proximity to the major source cities of Chicago and 

Minneapolis has a direct and significant impact on the presence of 

illegal drugs and drug activity in Wisconsin. Within Wisconsin, 

Milwaukee is considered a source area for illegal drugs for other 

parts of the State. 

Now, while Wisconsin is geographically located on the Northern 

border, our investigations and intelligence reports of any significant seizures being sourced by drug trafficking organizations on 

the Northern border from the Northern border, which are relatively 

few, confirm that their initial entry into this country occurred via 

some other Northern border location, such as Detroit or one of the 

more western States, or by shipped parcel, prior to making its way 

into Wisconsin. 

The Wisconsin HIDTA Drug Threat Assessment has consistently 

found that the vast majority of drugs entering Wisconsin are via 

passenger vehicle on one of the major highways intersecting the 

State. 

Preliminary indications of the 2016–17 Drug Threat Assessment 

are confirming some notable differences from last year’s threat assessment. However, what is the same is that opioid abuse, including both heroin and prescription drug abuse, remain the number 

one drug threat in Wisconsin. And, while Wisconsin has historically 

experienced relatively low levels of methamphetamine (meth)-related activity, methamphetamine is now beginning to show a much 

greater presence all around the State as well. 

For years, most of the methamphetamine activity in Wisconsin 

was concentrated along the western portions of the State due to its 

proximity to Minneapolis. However, within the past year, much 
6 

larger quantities of methamphetamine are showing up all around 

the State. Most of the seizures have been directly linked to groups 

out of Minneapolis and, at times, Chicago. Minneapolis continues 

to be a distribution center for large amounts of Mexican-produced 

methamphetamine coming directly from the southwest border by 

Mexican drug trafficking organizations bringing it into the Minneapolis area. 

Much of the heroin abuse in Wisconsin stems from users 

transitioning from prescription opioid drugs to heroin. Last year, 

100 percent of the Wisconsin survey respondents listed heroin as 

their number one drug threat. For 2015, Milwaukee County alone 

reported 109 heroin-related overdose deaths, with the vast majority 

of the heroin in Wisconsin being sourced from Chicago-based traffickers with connections to the southwest border and Mexican cartels. 

Over the course of the past 2 to 3 years, the majority of heroin 

present in Wisconsin is one of the several types of high purity 

Mexican heroin, as opposed to the high purity South American heroin that was routinely seen for the decade or more prior to that. 

In addition, the growing heroin problem has led to increased violence and challenges for law enforcement, especially in the Milwaukee area, not only by the ever-increasing number of overdoses 

and deaths, but also due to changes in the retail distribution market. 

In Milwaukee, for example, mobile drug houses have become 

commonplace and have presented law enforcement with new and 

more dangerous challenges. These opportunistic traffickers travel 

around the city in stolen vehicles, usually with multiple violators 

and weapons inside the vehicle, posing an increased level of danger 

not only for law enforcement, but also to the public. 

Of growing concern during 2015 and continuing into 2016 is the 

increased presence of fentanyl. This most recent increase in 

fentanyl abuse appears to stem from the importation of fentanyl 

that is most likely clandestinely produced in Mexico and mixed in 

with quantities of heroin being smuggled into Wisconsin. 

In response to Wisconsin’s identified drug threats, the Wisconsin 

HIDTA program uses a multi-faceted approach to address the identified threats and is committed to facilitating cooperation among 

Federal, State, local, and tribal law enforcement and prevention efforts through the sharing of intelligence, and by providing support 

to coordinated law enforcement efforts toward identified drug 

threats. 

Thank you for the opportunity, and I would be happy to answer 

any questions that you may have. 

Chairman JOHNSON. Thank you, Mr. Bohn. 

Our next witness is Dr. Timothy Westlake. Dr. Westlake is the 

Vice Chairman of the State of Wisconsin Medical Examining Board 

and Chairman of the Controlled Substance Committee. Dr. 

Westlake also serves on numerous boards designed to combat 

against the heroin and opiate epidemic, including as the Wisconsin 

State Coalition for Prescription Drug Abuse Reduction Chairman. 

For his day job, Dr. Westlake works as an emergency physician at 

the Oconomowoc Memorial Hospital. Dr. Westlake. 
7 

1The prepared statement of Dr. Westlake appears in the Appendix on page 61. 

TESTIMONY OF TIM WESTLAKE,1 M.D. VICE CHAIRMAN, STATE 

OF WISCONSIN MEDICAL EXAMINING BOARD AND CHAIRMAN, CONTROLLED SUBSTANCE COMMITTEE 

Dr. WESTLAKE. Thank you. I would like to take this time to 

thank Chairman Johnson and Senator Baldwin for holding this 

hearing. I am grateful for the opportunity to testify and share my 

experiences. 

My name is Tim Westlake. I am a full-time emergency physician 

at Oconomowoc Memorial Hospital, and I have been practicing 

there for 15 years. 

In my role as an emergency physician, I have witnessed firsthand the evolution of this crisis. This past week alone, I treated 

two heroin overdoses. One of them survived, and one did not. I 

later found out that the patient we could not save was the fourth 

person from his high school class to die of an overdose. 

The coroner that slipped him into the body bag said he has recently been seeing on average two opioid overdose deaths per day 

taken down to the Milwaukee County Medical Examiner. 

What can be said to comfort those who have lost a loved one in 

this way? Sometimes I feel like all I can do is sit there with the 

family and bear witness to the unimaginable pain and suffering 

that they experience. 

I wish I was making this next part up, but, while I was writing 

out the testimony, my wife received a text about the tragic news 

of another overdose death of a child in our area. He was at my 

daughter’s high school last year. He took a single pill. How dangerous could one single pill be? It was very dangerous. It was a 

highly potent, long-acting opioid and suppressed his respiration so 

much, his heart stopped and he’s brain-dead. And, I believe right 

now his organs are being harvested. 

And, tragedies like this play out every day once every 24 minutes 

in America, and it is truly the public health crisis of our time. But, 

there is hope. Awareness is increasing, and I applaud the efforts 

being made to address this issue. 

It is critical to remember that the lion’s share of healthcare regulation occurs at the State and local level, and as such, most of the 

responsibility for addressing the prescription drug epidemic will 

come from the State’s hospital systems and physicians themselves. 

The Federal Government has a limited, but useful, role, and there 

are small areas really only where that best solution involves Federal legislative change. 

The opioid crisis did not exist in epidemic proportions until the 

last 15 years. That was mainly due to a shift in the opioid prescriptive practices in the late 1990s. It was directly related to the 

premise that pain was being undertreated and that patients had a 

right to have their pain treated. And, people know this as the pain 

scale that we see every time you go into the doctor’s office, several 

times usually. 

This originated with the Federal Government as a probably wellintentioned program through the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs, and 

then it quickly was reinforced by the Joint Commission on Accredi-
8 

tation of Health Care Organizations (JCAHO) and embedded into 

the culture of the practice of medicine. It is now embedded, literally, in every single doctor-patient relationship, and it has been 

and continues to be a driving, causative factor in overprescription 

that is occurring. 

Earlier this week, I was working a night shift and woke up and 

got an e-mail and text saying that I could not believe how excited 

I was that Senator Johnson’s released a bill that will eliminate the 

pain scale, effectively. It is called the Pressure to Reduce Overprescribed Painkillers (PROP Act). It will make the Federal Government unable to tie medical reimbursement to pain outcome measures and will help take the government out of the doctor-patient 

relationship. 

It is already gained broad bipartisan support and backing from 

the medical community and recovery community. 

Senator Johnson, thank you. You really do not have an idea how 

much impact this will have in eliminating the pain scale. Perhaps 

as far as what you could do for regulation of prescribers, it is the 

single-most important piece of Federal legislative reform that you 

could do. It is very important. 

Another area of Federal legislative reform that was useful is the 

area of reform for prescriptive practices within the VA system, and 

legislation in this area was recently authored and released by Senator Baldwin, and I applaud her for the two bills. 

The Jason Simcakoski Memorial Opioid Safety Act models the reforms in the VA system after the best practices that the States are 

doing, and it applies them at the Federal level. 

Now, she also has another bill that passed some Senate hearings 

as well, the Heroin and Prescription Drug Abuse Prevention Act, 

and then there are good pieces that cover expanding access to 

Suboxone, increase the availability of Narcan, and access expansion 

for treatment, which is important. 

There are over 9 billion—with a B—Vicodin pills prescribed in 

the United States every year. It is estimated that between one-to 

two-thirds of these are not taken and are available lying around as 

leftovers. That is an excess supply every year of three to six billion 

pills. Fifty to 70 percent of the adolescents and young adults that 

abuse prescription drugs start by taking these leftovers. 

As the person becomes opioid dependent, tolerance develops, they 

need more pills, the cost of taking the increasing amounts of pills 

becomes too great, and the next step is, almost invariably, a switch 

to heroin use. As the chairman said, it is $10 a day or $10 a dose, 

so much cheaper than buying pills. In fact, 80 percent of heroin use 

starts with prescription opioids first. 

With the relatively cheap cost of heroin trafficked over the porous Southern border, along with drugs such as fentanyl and other 

synthetic opioids coming in over the border and through mail order, 

Wisconsin is awash in opioids. And, any bill that would encourage 

a change in this prescriptive practice, thus decreasing the amount 

of the excess opioid pills, would go a long way in addressing the 

current epidemic. 

We are actually currently working on a bill, fleshing an idea for 

a bill with Senator Johnson that would do exactly that, decrease 

that excess leftover supply. 
9 

1The joint prepared statement of the Lybert family appears in the Appendix on page 70. 

It is a small-volume, time-limited refill of a short-acting pain 

medication used for acute pain. Right now you cannot do refills on 

any medications. I want to go into a lot more detail to explain it, 

but I do not have the time. I had to cut some stuff. 

Chairman JOHNSON. We will give you some time. 

Dr. WESTLAKE. Excellent. So, at the State level here in Wisconsin, we have been blessed with the available leadership of Representative Nygren and Attorney General (AG) Schimel, who have 

thoroughly explored the best paths looking forward and what 

works and what does not in other States and truly listening to and 

involving all stakeholders in the process. 

In fact, we just came from a coalition meeting that had all the 

major health systems from the State in Madison, just like literally 

an hour ago, and that the purpose is to try to prepare the health 

systems unifying the best practices across the systems. 

They are really leading the country in establishing the ways that 

State government can best position the State and the community 

resources to address the epidemic. 

Thank you again, Chairman Johnson and Senator Baldwin, for 

the opportunity to testify, and thank you especially for your leadership on this issue in the battle against the scourge of prescription 

drug abuse. The bills you have both introduced will really help best 

position the State and our country to move forward, and it makes 

me proud to be from Wisconsin to see you guys both up there. 

Thank you. 

Chairman JOHNSON. Thank you, Dr. Westlake. And, we will give 

you some time in that question-and-answer period to expand on 

some of those points you made. 

Our next two witnesses are a brother and sister, but they are 

also joined by their parents, Rick and Sandi Scott. And, again, I 

just want to thank you as a family for your courage coming forward. This is not an easy thing to talk about. It is not, you are laying your life out there, you’re subjecting yourself to real scrutiny 

here, but you are doing it to save other lives. So, we really do appreciate that. So, we have Tyler Lybert and his sister, Ashleigh 

Nowakowski. 

Tyler is a recovering heroin addict and will share his personal 

experience with addiction and recovery. He is accompanied today 

by his sister, Ashleigh, who will provide her perspective as the sister of an addict for 11 years. Both Tyler and Ashleigh serve as public speakers for Your Choice to Live, Inc., a drug and alcohol 

awareness program created by their family to provide Wisconsin 

youth with the knowledge and skills to remain substance free. 

Again, Tyler and Ashleigh, thank you for sharing your story, and 

we are looking forward to hearing it. Tyler. 

TESTIMONY OF TYLER LYBERT1, ACCOMPANIED BY ASHLEIGH 

NOWAKOWSKI, YOUR CHOICE–LIVE, HARTLAND, WISCONSIN 

Mr. LYBERT. Thank you for having us. This is a real honor. We 

are honored that you guys asked us to come. I mean, we do this 

all of the time, and, honestly, I am nervous now. 
10 

But, like you said, I am a recovering heroin addict. I started really young. I started experimenting in sixth grade. It was introduced 

to me by older people. And, when I was younger, I was chubby and 

hyper, so it was a bad combination and I did not have many 

friends. Parents did not want me coming over because I was too 

hyper and stuff like that. 

So, alcohol was introduced to me by older people and I saw that 

as my golden ticket to popularity. I thought, ‘‘Yes, I can finally 

have friends now. All these old people want me to drink with 

them.’’ And so, I started drinking in sixth grade and I started 

smoking pot in seventh grade. I was doing pills by 15 and I was 

doing heroin by 16 or 17 years old. 

And, I never planned on this. I did not wake up and say, ‘‘My 

goodness, when I grow up, I cannot wait to be a heroin addict.’’ It 

started with that first small steppingstone. It started with drinking, it started with smoking pot, and it increased. 

And so, I chose drugs over everything else in my life. In going 

through high school, I got expelled from high schools, I got arrested 

all of the time, and I was in and out of jail. And, after high school, 

it just gave me more time to do whatever I wanted to. So, after 

high school, I worked every day, and I looked for drugs every 

night—and that was my entire life for 10 years. 

And, before drugs and alcohol, I was this hyper, fun-loving kid 

that was always in a good mood, always laughing, always smiling, 

always joking around. But, the farther I got into drugs and the 

more I got in trouble and the more that drugs mattered to me, the 

less I became who I was, and instead of being this hyper, fun-loving, little chubby kid, I was an angry, violent monster. I was never 

in a good mood. I did not laugh anymore. I did not know what smiling was. I did not know what life was anymore. And, the only thing 

that mattered to me was drugs. That was it. Just as long as I was 

getting high, that was the only thing that mattered. 

And, in the midst of it, I did not see what I was doing to everybody around me. While I was in it, the only thing that was important were, like I said, drugs. So, I did not care what was happening 

to my family, I did not care what was happening around me, and 

I did not really see what kind of damage I was doing until I got 

into treatment and I got sober. 

And, in my family, I have my sister and my mom and my dad. 

From each of them, I looked for something else. My mom—I am a 

mama’s boy, I can admit that. I looked for her support and her 

love. She was always there for me and she was always in my corner. From my dad, I just wanted his approval. And, from my sister—yes, she was my sister, so—— 

Chairman JOHNSON. Your older sister. 

Mr. LYBERT. Yes, my older sister. 

But, because of what I was doing, because I was getting arrested 

and going to jail and getting expelled, because I was making really 

bad choices all the time, I never got any of that from them. 

My sister wanted nothing to do with me, my mom cried every 

day because of what I was doing, and my dad and I fought like it 

was World War II every single day. And, I would wake up every 

morning terrified of what I did the night before, because I could 

usually never remember. And, I would wake up every morning ter-
11 

rified to go downstairs because I did not want to have to face my 

family. And, I hated it. I hated my life. I hated everything about 

it. 

And, we had tried multiple different treatments. We had tried inpatient and outpatient, Suboxone, methadone, everything under 

the sun, but nothing was working. So, I started to come to the conclusion that I was never going to be sober. 

And, coming to the conclusion that I was never going to be sober 

and hating the way my life was going, I drew one ultimate conclusion from that, that I did not think I should be here anymore. And, 

I figured that maybe if I die, maybe my family can finally get some 

peace and maybe if I die, maybe my family can finally lead the 

lives they were supposed to lead without me having to drag them 

down anymore. 

And, in the mornings, instead of wondering what I did the night 

before, I would start wondering, ‘‘Why am I still here? ’’ And, instead of being terrified to go downstairs, I would pray that I would 

not wake up the next day. There was nothing good in my life, there 

was nothing positive, and I could not stop what I was doing. 

And so, it eventually came to the point where my family came 

to the—well, they did not come to the same conclusion, but they 

came to the conclusion where they had tried everything they possibly could, but nothing was working. And so, they kicked me out, 

and I went down and I lived in Milwaukee, and I had given up on 

life completely. 

I was on the verge of taking my own life when I got a phone call 

from my mom. And, my mom goes, ‘‘You have two options, and 

these are the last two options we will ever give you. You can keep 

doing what you are doing, but we never want to see you again. You 

are not welcome to our house, you are not welcome to call us, you 

are not welcome to talk to us. If you choose this, you are no longer 

our son and we never want to see you again. Or you can get help, 

and we will support you 100 percent.’’ 

And so, I went into treatment again and learned more in treatment than I ever had in the past because this time I wanted to be 

sober. 

And so, I got out of treatment. I have been sober for a little over 

7 years now and, hands down, it has been the best—— 

[Applause.] 

Thank you. It means a lot. But, obviously, my family is still here 

supporting me. 

And so, that is my story. I will let Ashleigh talk. 

Chairman JOHNSON. Thank you, Tyler. 

Before Ashleigh begins, normally Rick, Sandi, and Ashleigh all 

chime in and tell us stories. For time, we are going to let Ashleigh 

speak for herself and for her parents. But, again, thank you for 

sharing this and we look forward to your testimony. 

TESTIMONY OF ASHLEIGH NOWAKOWSKI 

Ms. NOWAKOWSKI. OK. So, my name is Ashleigh. I am Tyler’s 

older sister. I am 3 years older than him. And, on behalf of my parents and myself, Tyler’s drug use deeply impacted all of us. We 

hurt 10 times more than he did because we were watching someone 

we love destroy his life. My mom cried all the time and blamed her-
12 

1The prepared statement of Ms. Badura appears in the Appendix on page 74. 

self for his problems, my dad was always angry, and I hated him 

for what he was doing to our family. 

When we should have been making childhood memories by going 

on vacations and spending time together, we were fighting, crying, 

and living in fear that we would get the phone call that Tyler was 

never coming home again. 

I could not even have him stand up in my wedding because I did 

not think he would be alive for it, and I did not want to have to 

explain to my wedding guests why there was a missing 

groomsman. 

My mom even had his funeral planned. There were times when 

I thought, ‘‘God, if you are going to take him,’’ just take him. He 

was suffering, we were suffering, and we did not know that there 

was a way out. 

When Tyler went into treatment, I did not think it was going to 

work. But, after many therapy sessions—and as a family we had 

family sessions—we were able to repair some of the broken pieces 

in our relationship. 

Today, I cannot put into words what the past 7 years of having 

Tyler clean and sober has brought to our family. Tyler is not only 

my little brother, but my best friend and someone I can look up to. 

We know that he can go back at any day and start using again, 

and that is a fear we will have to live with for the rest of our lives. 

And, we also have survivor’s guilt because we know so many families that are not as fortunate as us and do not get to experience 

what it is like to get their loved ones back. 

So, thank you. 

[Applause.] 

Chairman JOHNSON. Thank you for sharing that. I know that 

was not easy. 

Our final witness on this panel is Lauri Badura. Lauri lost her 

son Archie Andrew Badura to an overdose at age 19 in 2014. As 

a result, the foundation Saving Others for Archie (SOFA) was 

founded. 

Ms. Badura is a resource to Wisconsinites across the State of 

Wisconsin in sharing her story and offering hope to many. Today 

she is here to share this incredibly personal experience. Lauri. 

TESTIMONY OF LAURI BADURA,1 MOTHER OF ARCHIE 

BADURA, OCONOMOWOC, WISCONSIN 

Ms. BADURA. Good afternoon. My name is Lauri Badura, and I 

am a wife, a mother, and a dedicated businesswoman. I want to 

thank my family, my husband behind me, my two sisters, and my 

two very best friends, Bill and Kelly, who are on my board, and all 

of the countless other people—there are several people that have 

lost children that came here today—or have children in detox 

today. So, I just wanted to share that before I start. 

I want to thank you, first off, for listening. 

Second, I wish to thank you both for your past and future commitment to stemming the raging tide of this epidemic. 

In 2014, the year that my son Archie died, in our country, we 

lost over 47,000 people. My statistic was quoted from the Centers 
13 

for Disease Control (CDC). That is right, you heard it correctly. 

The figure was not a mistake. 47,000 people perished in this Nation due to drug addiction in one year alone! 

Those of us who have lost loved ones to an opiate epidemic, those 

of us who advocate for more attention to this issue, please understand what we certainly understand, why the latest news reports 

center upon the gravity of worldwide incidents across the globe, 

where a dozen of people might be killed by terrorists, or where 25 

or 68 people perish in a single suicide bomber attack, but we all 

defiantly cannot understand the importance of these news stories, 

with 47,000 compared to that. 

But, for moms and dads like us, we have lost our children to this 

opiate addiction and this epidemic. The lack of attention on this ridiculously large numbers of deaths, 47,000 in a single year, we do 

not always understand this lack of attention and outrage. 

That is why today is monumental. Because of your listening 

today and the scheduling of this hearing, you have changed the 

contours of this entire conversation. On behalf of the survivors here 

today, I applaud your leadership and express my deepest gratitude 

to each of you for the gift of your time and your talent. 

I was invited to speak to you because my son Archie died from 

a heroin overdose on May 15, 2014. And, I hope you have read my 

biography. I brought it along. You will read about the harrowing 

details of our family’s personal hell. You will learn about Archie’s 

cousin, who, while remaining alive, now lives with a debilitating 

traumatic brain injury at age 44. He will continue to require 24- 

hour, around-the-clock medical care for the rest of his life. 

Over the course of the past 2 years, I have told our story, a story 

of survival, to countless audiences of all ages, shapes, and sizes. 

But, today I want to talk to you about another aspect of my life. 

You see, every week I get calls from across southeastern Wisconsin, 

mostly from people who, like me, are coping with the pain of the 

death of a child. 

These people, many of them survivors of this opiate epidemic, are 

referred to me. Who refers them? You name it. I receive referrals 

from psychiatrists, psychologists, nurses, priests, and business professionals—even my boss. 

And, this is not an exaggeration—I receive referrals from funeral 

homes. I have the Kleenex to prove it. That is right, funeral homes. 

The directors give my name out now. 

My commitment to all of these people is unwavering. I talk to 

each and every person who calls me seeking help. Each person is 

suffering with and struggling with the horrors of substance abuse 

addiction, and I am one who can empathize, identify, and relate to 

their experience. 

What does my inner drive to serve others come from? I am not 

entirely sure. No doubt my faith of God sustains me. There is also 

no doubt that my son Archie motivates me. I refuse to allow his 

life to be taken in vain. 

I make sure that his memory will live on, even if, through the 

efforts of his mom to help others cope with their pain and suffering, it is my mission to ensure that Archie’s life story will continue to serve as an agent of change and transformation to saving 

others for Archie. 
14 

So, what you might ask, is my life like today? Well, I just want 

to share that, 10 days ago, when I received your invitation to the 

hearing—I want to recount a few details of what these days are 

like, similar to Dr. Westlake. I think we get the same texts, possibly. I hope you will gain a little bit of vision of what it is like 

in my life today. 

On April 5, a mother called me. Her teenage son had died, and 

she wanted to know if her hell would ever be put away or will ever 

go away. 

Two days later, on April 7, another mother called. She got my 

name from a funeral director who buried her child, and she told me 

she does not know how she will ever get out of bed and get a break 

from her personal grief. She is just devastated. 

On April 8, I learned of a young man who knew both of our sons 

from childhood who died of a heroin overdose this weekend. I 

cooked dinner, brought it to their family, and we all sobbed in each 

other’s arms as we looked at their Catholic school grade pictures. 

There were no words of comfort to offer. I sat in silence. This boy 

had carried my son’s casket. It made no sense. That young man’s 

funeral happened this past Saturday. I attended. The wounds reopened. I cried some more. 

Out of the blue a week ago, a psychologist called me. He asked 

permission to give my personal cell number to a patient, a woman 

that he feels he cannot reach. The psychologist has worked with 

this mother for a full year after she lost her 28-year-old daughter. 

This past weekend, a mother reached out to me with her 38-yearold son, who was turned away at the emergency room (ER) for a 

detoxer treatment. She had found him with a needle in his arm 

and did not know what to do. So, I made sure that she was armed 

with Narcan. She tried to call a hospital to get in, it would not be 

until next week, and she went to bed that night with the Narcan 

sleeping next to him. For two nights, that is how it was. The third 

morning, he was not there. He is still not home. The system let this 

mother and son down. 

I am not done, though. My son Augie called me from the University of Wisconsin (UW)-Eau Claire Sunday evening. Another freshman student in his dorm overdosed on opiates. Augie, who serves 

as a public speaker and knows more than anyone should at his age 

about drug addiction—it was Augie who was the first responder to 

this UW-Eau Claire student and called 911. The fellow student did 

survive and was grateful for Augie’s quick thinking. 

So, you see, it is all over. There are several more messages on 

my phone looking for help, several that I have not even returned 

as of yet today. But, why me? Why do they call me? Why do psychologists, business professionals, and funeral directors call me? 

Sometimes I feel like I am not quite sure, because I have terrible 

days. You know what I am talking about, these days when you can 

barely get out of bed. The heaviness of the grief is insurmountable. 

In other venues, it may look like I have it all together. I enjoy 

a good deal of success as a business marketing executive. I feel 

quite natural serving clients across the Nation from the East Coast 

to California. In this realm, I am comfortable and I am confident. 

But, here in this realm, there is no business school for parents 

whose children are addicted to opiates, like heroin. In this realm, 
15 

there is no textbook or guidebook to follow when you learn that 

your child has an addiction, no. 

But, people continue to reach out to me. I believe it is because 

I am raw, living-proof knowledge of this addiction storm. I lived it 

day after day with my son, Archie, and then I buried my own son. 

I am not embarrassed, nor do I apologize. I do not wallow in 

shame, nor do I blame others. Instead, I seek to find resources— 

resources which will build knowledge, create understanding, and 

help counsel others through this nightmare. 

Besides being a seeker, I am also waiting. I am waiting for leaders like you. It may be too late for my Archie and our family, but 

can we work together to save others? This hope is why I came 

today. 

I wanted to briefly share some urgent needs that I think are important from all the telephone calls and what I have heard from 

across the State, for not only our State, but our Nation. 

First, the medical treatment model needs reworking. Think diabetes: Lifelong care; lifelong approach. Addiction: Lifelong care; 

lifelong approach. We need to change the way we use healthcare 

in our Nation when it comes to opiate addiction. We need a treatment model because true opiate addiction needs medication. And, 

also, treatment needs to be uninterrupted by insurance companies. 

Addicts need to be able to focus on the recovery and not whether 

or not their insurance company is going to deny or end their coverage. 

Second, the window to get treatment is so narrow, and these 

families are being turned away each day they come to an ER to get 

help. HFS–75 opiate detox, in general, is urgently needed to stabilize a person and is part of a treatment-oriented system of care. 

Traditional opiate detox is not generally covered by health insurance. The need for some type of detox facility remains in communities, and alternatives to traditional opiate detox are being explored by the private sector, such as ambulatory detox, rapid, 

home-based programs, and even visiting nurses. 

Third, step up the medically assisted treatment to aid the opiate 

epidemic. Use medical-assisted treatment for opiate users in a recovery program and in drug courts as part of the law. We must provide Vivitrol for those incarcerated and for those newly released. 

Fourth, restricting access to drugs not just from Mexico, but from 

all our borders and boundaries and professional responsibility. 

Tighten up education to drug companies and better educate physicians, oral surgeons about the how-to’s of writing an opiate script. 

Lastly, look into the data on those that have survived opiate 

overdose and the suffered brain trauma that are now wards of our 

State, like my nephew, that will need 24-hour care for the rest of 

his life and is unable to give back to society. 

Harnessing all of our stories together and looking at the hard 

facts for policymakers, this is the other side of the epidemic that 

nobody wants to speak about. 

So, I close with these five important unmet needs, and I hope my 

perspective provides you with insight so they may be reality for future policy changes. I thank you for your time, and hopefully together we can save lives. Thank you. 

[Applause.] 
16 

Chairman JOHNSON. Thank you, Lauri. Obviously, our sincere 

condolences to you and your family. Our sincere thanks for your 

commitment to help others turn your tragedy and the loss of Archie 

to something positive, trying to help others, and just for your courage for testifying here today. 

Tyler, I want to go to you, because you said you tried different 

types of treatments—different types of medications to get you off 

of heroin, and then finally one worked. 

Can you describe what did not work and why it did not work and 

what finally worked with you? 

Mr. LYBERT. I think the biggest part of why treatment did not 

work for me is because, at the first six treatments, I did not really 

want to be sober yet. I think that is the most crucial part to anyone 

getting sober is wanting to be sober. 

And, for everybody it is different. Methadone may not have 

worked for me, but it has worked for plenty of other people. 

Vivitrol may work for somebody else—it may not work—it is different for everybody. But, I think the key thing is, is that person 

has to be at a State where they are willing to change. 

Chairman JOHNSON. So, in your testimony, you described yourself pretty low stages for quite some time. 

Mr. LYBERT. Yes. 

Chairman JOHNSON. But, I mean, we always hear hitting rock 

bottom. I mean, it really was when your parents kicked you out of 

the house, you were living in some situation, and then it was when 

your mom called? I mean, what—describe rock—I hate to say this, 

but describe rock bottom, and what was different about it than 

what you were describing, which sounded pretty rock bottom while 

you were in the house as well every morning waking up. What is 

the difference? 

Then, Lauri, I am going to come to you, because I want to hear 

how that relates in terms of your situation. 

Mr. LYBERT. Well, I think the biggest thing is, is the last time 

that, every time that I hit rock bottom before that, I was like, well, 

this is just a fluke. This will not happen again. I will not get this 

low again. I will make sure of it. I will be better this time. I will 

be a better addict this time. 

The last time that I went in was the final realization that this 

just is not working anymore and that rock bottom was—I had a 

knife. I was ready to end everything. I was done. I could not take 

the burden anymore. 

Chairman JOHNSON. Ashleigh, real quick, did you and your parents, did you recognize rock bottom? Did you see something different about it this time? 

Ms. NOWAKOWSKI. Not at first we did not. When my parents 

kicked him out of the house, I had moved out of the house, but they 

had called me and said, we have kicked him out, and this is the 

ultimatum. If he calls you, do not answer his phone calls. 

And so, they were the ones that went to go pick him up and take 

him to treatment. But, it took a little bit for us to realize that he 

wanted to get help. So, at first, I did not know if we noticed a 

change in him or anything like that, but he felt it. 
17 

Chairman JOHNSON. Other than that attitude of now I really hit 

rock bottom, was there a difference in the treatment or was it 

strictly just the attitude? 

Ms. NOWAKOWSKI. I think a big thing that helped him was we 

changed as a family. So, we had to go to family sessions and—because throughout all the other treatments, my parents would take 

him, drop him off, pick him up, he was fixed. Like, you fix him, and 

he will come back into our house. And, that was not working. 

So, when we went to the final treatment, we actually had to go 

to family sessions and work on changing dynamics within the entire family. 

Chairman JOHNSON. So, you were with Tyler. So, now you went 

through treatment, to a certain extent, together. 

Ms. NOWAKOWSKI. Right, exactly. 

Chairman JOHNSON. And, that was the first time that happened. 

And, Tyler, was that—I mean, in addition to hitting rock bottom, 

was that family treatment, was that also key? 

Mr. LYBERT. Yes, I think that was a huge part, because family 

was—no matter how much I did that was wrong to them and how 

much I said I hated them, they were still the most important thing 

to me. So, knowing—like seeing their support and, seeing my dad 

tell the counselor that, well, I work every day, and I am not going 

to be there because you cannot set a meeting early enough, and the 

counselor saying, hey, tough luck, you are coming. And, for all of 

us to be in the same room and to be able to share, what we were 

feeling to each other, that was the first time that has ever happened. So, yes, I think that was a major part. 

Chairman JOHNSON. Lauri, I hate to even ask, because I hate to 

have you go through this process again, but were there attempts 

to put Archie in treatment? Did those work, did they not work, 

or—and/or can you talk about because you are helping so many 

other people, can you relate to this? Can you kind of—— 

Ms. BADURA. Yes, I can. And, I do not feel guilty, Tyler. We love 

you, and we are so glad you made it. But, Tyler is an anomaly. 

There is not a lot of them that make it out, there really is not. I 

wish there was a lot of Tylers. I wish I knew them; I do not. So, 

I am so glad. I mean, our families are close. We know each other 

well. They knew Archie. 

I guess, I have my sisters and husband, and it was 4 years of 

hell. It was marijuana. So, everybody says, oh, heroin. That was 

not even introduced before 2 months before he died. 

So, I guess rock bottom? There were so many rock bottoms. We 

kept thinking, this is it, this is it. But, if you look on the last page, 

when you walk into an ER and see that your kid ingested an opiate 

patch, and the physician said most kids ingest a spoonful, he ate 

the entire patch and was foaming at the mouth. This is his first 

overdose. He should have died that day, January 3; he did not. If 

anybody wants to see it back there. 

There were several times. And, just like any addict, they do not 

want to die. They are off trying to get to a high of feeling better, 

but this drug owns them. They are in a jail of something that none 

of us can understand. 

I cannot tell you how many people said to me, how in the world 

could that boy carry your casket and then he overdose this week-
18 

end? I said, because you do not get it, you really do not get it. People who say that, ‘‘Oh, they can just stop’’—they cannot. You cannot. And, it does, it starts with the pills. It starts with the pills, 

and then it goes, as you said, $10. 

Chairman JOHNSON. Tyler, when we were in the back and I 

asked Neal what he knows about the percentage of successful 

treatment. About 1 in 10 is what he said. That actually surprised 

me as being high. 

By the way, Rick and Sandi, if you would not mind, at the end 

of the panel, I will have you come forward if you wanted to just 

say a couple words or if there is something that you want to express here. That may be powerful. 

I do want to go to Mr. Bohn and Dr. Westlake. Anything you can 

kind of chime in on the treatment aspect of this? Things that you 

know, that we understand. Obviously, Dr. Westlake, you treat the 

emergency side of this equation. 

But Mr. Bohn? 

Mr. BOHN. One of the things we have learned from law enforcement over the years is the fact that it is going to take treatment 

to get people, otherwise we are going to see them again and again 

in the criminal justice system. We have now got an entire generation of addicted people out there. 

We focus on the people that bring it in. We focus on the people 

that deal in this stuff. But, I can tell you, the high level violators 

that bring this stuff in are smart enough to know not to use it, because they know how dangerous it is. 

So, it will take a lot of prevention, it will take a lot of rehabilitation, but law enforcement has a duty as well to keep it out as much 

as possible. 

Chairman JOHNSON. Could you just kind of speak to what we 

know about the success rate of treatment? Then I will turn it over 

to Senator Baldwin to ask questions. 

Dr. WESTLAKE. So, yes, I mean, my area of expertise really is 

more in emergency medicine, some of the policy areas, but it is 

abyssmal results. I mean, once someone gets addicted, it is, one out 

of 20, one out of ten tops. So, there is a lot of different drugs that 

are addictive. 

Alcohol, you are an alcohol addict, and you have maybe 50 years 

of drinking before you die. You get too drunk, you pass out, you 

throw up, maybe a car accident if it is that horrible. 

You take too much heroin one time, you take one pill, like this 

kid last week, and you are dead. And so, there is just no room for 

error. 

And, the biggest thing, we just had this coalition meeting, we 

asked the health systems, how can we partner together? We 

brought States together, the Department of Homeland Security 

(DHS) and all kinds of players at that level, and the shortfall is 

in the treatment. So, there is not enough treatment fighters. 

If we could get all the addicts, 168,000 opioid addicts, if we could 

get them into treatment now, we do not have, so that is an important piece. 

I believe in limited government, that the funds really need to be 

justified to be spent, but I think the return on investment for getting people clean is huge, and it is well worth the cost. 
19 

Chairman JOHNSON. What was shocking, before I turn it over to 

Senator Baldwin, in the testimony, I think you said the average beginning age was 11. Eleven years old. You were in sixth grade— 

11 or 12? 

Mr. LYBERT. Eleven, yes. 

Chairman JOHNSON. Nothing glamorous about that, is there? 

Mr. LYBERT. No. 

Chairman JOHNSON. Senator Baldwin. 

Senator BALDWIN. Thank you all again for your amazing and 

powerful testimony. I want to just pursue a number of the issues 

that each of you raised a little more deeply. 

Lauri Badura, if I can start with you. You just described your 

last few weeks. You are like the key resource for people who have 

your cell number and people who give out your cell number. We 

have an epidemic, and it strikes me that people have no idea where 

to turn, what to do. It does not sound like an emergency response 

to an epidemic at all. 

Tell me, what is out there for parents? When you talk to them, 

of course, you are doing some personal counseling. You are sharing 

your experience, hugging them. What sort of formal resources are 

out there, especially if you are hearing from parents who have not 

lost their children yet? 

Ms. BADURA. Absolutely. I am so glad you are asking. I am on 

the Alcohol and Other Drug Abuse (AODA) advisory committee for 

Waukesha County, and there are several wonderful things that are 

out there, but there are many—it is hard getting the word out 

there. They are doing great things, but no one really—I call it connecting the dots. That is if you look up my name—most people 

Google ‘‘heroin mom,’’ and my name comes up. 

So, I call it connecting the dots in the State because each county 

is doing fabulous. I mean, I have worked with Milwaukee. No one 

is talking to each other. Why redo each other’s work? But, what I 

would tell somebody that would call is there is something called 

211, which is—you know what that is, right? 

Senator BALDWIN. Of course. 

Ms. BADURA. OK, the 211. And then, a lot of people do not know 

it. So, they are just comforted with that fact. 

If they cannot, most of the problem is a lot of these people, the 

resources are tapped, there is no more insurance, they have done 

treatments, most of them, I would say, have done three, under 

their family’s insurance, and they are tapped out. 

So, then they go to a county, and the county it takes 4 or 5 days 

on a good day. That is what my friend was waiting for this past 

weekend when the boy—they were trying to wait to get him in, and 

that is just because they are so backed up. 

But, I know so besides that, it is arming—if you are living with 

somebody with an addiction and they are using opiates, you have 

to have the Narcan, and the public does not know about that. 

There is great resources here that are training, they are handing 

out needles, they are doing things here, but they just need help 

getting the word out. 

There is also the Addiction Resource Council (ARC), they are 

doing fabulous things, but we do not even have counselors. The 

counselors are going to age out soon, and there is not enough coun-
20 

selors to counsel people. Because, really, Archie was 77 days clean. 

He wanted to be clean. That is the most dangerous time. You can 

get them through treatment, but they still need—that is why I am 

saying, ‘‘We need the care like diabetes, where for life, you are getting looked at, you are getting to see a doctor and saying, ‘OK, how 

is it going? Well, maybe you need to go do this again.’ ’’ 

So, those are the steps. And, there is also—I give several different numbers of private homes, that care that will take the people, and then public places, but there is not many beds. 

Senator BALDWIN. About those beds. Just in terms of your own 

knowledge and your own experience, is it because of lack of professionals to staff them or lack of local resources, State resources, national resources to fund them, lack of insurance coverage, all of the 

above? 

Ms. BADURA. It is really all the above. 

Senator BALDWIN. I think I know the answer to the question, but 

I want to hear you—— 

Ms. BADURA. No, but it is a great question. Like Lutheran Social 

Services (LSS) is one I can tell you in Waukesha County who has 

been pushed around because they cannot get a building. Nobody 

wants them. And, they have the funds, they are ready to have a 

building, and I know they are working on that, so—but people do 

not want a hospital full of addicts maybe in their neighborhood, I 

do not know. I know that is one problem. 

I think that they are definitely limited on doctors. I think we do 

not have the physicians as many as possible. I know we do not 

have the counselors. I absolutely know that. 

But, I think our resources for what the epidemic has done. Because I joined this advisory group when Archie was alive, I came 

to this meeting saying, please help, my son is so sick, please help, 

I do not know what to do. And, I wanted to educate myself. 

I can tell you, in those 2 years, these people that are working in 

their daily job—it is not my daily job—they are tapped. There is 

nothing. They are not getting any more help. I mean, we really 

need more people, more resources, more help. And, I am thinking 

almost like hospice care, where it is, it is in your home, and people 

come. I am not sure, because I know it is expensive. But, we have 

to save lives. 

Senator BALDWIN. That is right. 

Tyler and Ashleigh, before I ask the question, I also want to give 

you permission to plug the prevention work that you have done 

through Your Choice to Live. We will get a series of public service 

announcements as I go across and ask questions, so if you want to 

say anything about that as a precursor. 

But, Tyler, I want to ask you about the impact of your interactions with the criminal justice system. You talked about several 

arrests, I think several incarcerations at the local level. And, I understand that everybody’s path is different. Were those experiences 

helpful or motivational for you to actually make the decision to ultimately seek treatment? How did that play out in the path that 

your addiction took? 

Mr. LYBERT. Well, I think one of the things, and we talk about 

this quite a bit, but, back 10 years ago, when I was using or—yes, 

it is—wow, it was 10 years ago, when I was 18, when I was 19, 
21 

when I was 20, things like that, there was not the problem there 

is now. So, the—the—oh, my gosh. 

Ms. NOWAKOWSKI. Criminal system? 

Mr. LYBERT. That is it. The criminal system did not have the resources they did either. So, when I was arrested for driving under 

the influence (DUI)—or whatever I was arrested for—I was never 

offered classes, I was never offered anything like that. So, for me 

to say it helped me, not necessarily, because I would blame the system every time. 

Now, a lot of different things are put into place for people that 

do get arrested and things like that, like the 180 Diversion Program. I went through the alcohol treatment court in Waukesha 

County after my third DUI. And so, in that respect, it did help, because that gave me a year after I was already sober to be held accountable. 

So, I think that the criminal system is getting better and doing 

better at trying to help addicts rather than lock them up. Especially in our community in Waukesha County, Oconomowoc specifically, when kids get in trouble for underage drinking or paraphernalia or possession or anything like that, their first offenses, 

Judge Kay in Oconomowoc, he refers them to our program, to our 

detour class, so they can take a 12-hour class on—all about risk 

taking and choices and making better decisions and stuff like that. 

So, I think that the justice system and criminal system together is 

starting to see a need for help rather than sentencing. 

Senator BALDWIN. Dr. Westlake, I have a question for you, but 

before, you just heard Ms. Badura say that too few people even 

know about Narcan or naloxone. So, for people in this room who 

might not know, for people who might be hearing about this hearing by watching the nightly news, can you give us one minute on 

what the heck those two drugs—or what that one drug with two 

different names is, what it does, and why people need to know 

about it? 

Dr. Westlake. Sure, yes. Narcan, or naloxone is the drug name 

for it, is an opioid reversal agent. So, what happens when you take 

opiates is they sedate your respirations, they fill these chemical receptors in your brain, and eventually it suppresses your respirations so much, you stop breathing, it lowers your oxygen level, and 

your heart stops after that. 

What the Narcan does, if you can get it in before that whole cycle 

is completed, is it kicks off all the opioid chemical analogs, and so 

it clears it, just immediately, literally takes them off. I have given 

it to patients where they come in and they are breathing at two 

breaths a minute and they are blue, I give it to them, and if you 

give a little too much, sometimes they are wide awake and they are 

angry as heck right away. I mean, it is just like turning a switch, 

if you can get it in the patient in time. 

Chairman JOHNSON. Just real quick, is there any danger to having that in the general population? Is there any abuse of that drug? 

Dr. WESTLAKE. No. The theoretical risk would be, well, are you 

motivating people to feel safer using? And, initially, I kind of 

thought that maybe 10 years ago, until I had some insight into it. 

And absolutely, those people are going to be using. When you are 

an addict, that is what you do, is you use. 
22 

And then, I think Attorney General Schimel is going to talk 

about it, he is pushing to possibly go the Food and Drug Administration (FDA) with no prescription necessary. 

And, I think—I mean, the only issue I would have would be that 

we have to make sure the supply is enough that we can get it in 

the ambulance services. I would not want it to just disappear, and 

all of a sudden there is shortages, because there are drug shortages 

on a lot of different things. So, but apart from that, there is 

no—other than, you feel a lot of pain if you give it to someone. 

Chairman JOHNSON. Is it injected, or how is it—— 

Dr. WESTLAKE. You can shoot it in someone’s nose. So, there is 

a nasal atomizer that you can use. You can inject it. 

Chairman JOHNSON. Sorry to take your time. 

Senator BALDWIN. No, I absolutely wanted this to be a public 

service announcement on this topic. I have a question too, but—— 

Dr. WESTLAKE. Yes, it is a great message. 

Senator BALDWIN [continuing.] No, I think it is a really important question. And, not unlike the distribution of clean needles to 

prevent other deaths related to people who shoot drugs, this does 

have that side debate, but it reverses an overdose. 

So, my question for you actually relates to the recently released 

Centers for Disease Control safe prescribing guidelines. I think 

they went through a fairly long process trying to look at the latest 

evidence on appropriate and safe use of opioid pain medications. 

I would like to ask you, in terms of educating your peers in the 

medical community about safe and appropriate prescribing, sort of 

what is the most important piece of information that this guidance 

should include to support prescribers in preventing adverse outcomes of addiction and recognizing addiction in their practices? 

Dr. WESTLAKE. Yes, the guideline piece is—we actually just 

pushed and Representative Nygren had a bill that went through 

that we just signed that gave the Medical Exam Board the ability 

to promulgate guidelines. We actually—Mike McNett is a doc that 

I work with who would come—modified the CDC guidelines and 

put them into our language. 

The thing that is important is to get the changes to come from 

underneath within. So, you have to get the providers, which I think 

there is an awareness now, to understand that there is inappropriate prescription. So, it cannot just be another Federal mandate 

like, you got to do this and it needs to come from underneath within the health systems and from within the doctors. And so, what 

we are trying to do at the State level, through the controlled substances committee, which is what promulgates the guidelines, is to 

have input from the stakeholders. 

So, then when we come out with these guidelines, the systems 

can then say, OK, these are reasonable guidelines, they are good 

guidelines. And, when you get buy-in from the providers in the systems, then it can be incorporated into the culture of the practice, 

and education is important with that as well. 

It has to be limited, though. Because, again, we have a crisis 

now, so there is a huge opioid epidemic. The problem I have with 

legislation, State and especially Federal, is once it is in place, it is 

never going to get repealed. There is never going to be enough will 

to repeal it. 
23 

So, if you put something in place—there is a great piece of legislation that had, continuing medical education (CME)—4 years of 

opioid CME per year for the DEA. The problem with that is in 20 

years, hopefully, the culture will have changed that it will not be 

a problem, but I will still be stuck doing 4 hours of opiate CME. 

And so, that is the thing is, that Representative Nygren used 

sunsetting. So, after three years, the restrictions on checking the 

prescription database will go away. And then, hopefully by then, 

the culture of prescriptive practice will have changed. So, that is 

the wisdom of the legislation. 

Senator BALDWIN. Yes. But, and you raise a great point. I remember reading an article about how sometimes change in the 

medical community is slow, and it was Dr. Gawande talking about 

how a recipe change in New York City was adopted universally in 

all the certain type of restaurant in 7 days, but it took 7 years to 

change a protocol at the medical profession. So, we obviously need 

to put a huge exclamation point behind these new guidelines. 

Dr. WESTLAKE. And, have the systems within own their part of 

the guidelines. 

Senator BALDWIN. Yes, exactly. 

One last question of this panel from me for you, Mr. Bohn. So, 

you have the rather unique role of overseeing the coordination 

among so many different levels of the Federal, State, and local law 

enforcement efforts to combat drug trafficking. 

And, I guess I just want to—from that unique perspective, I want 

to know how you believe it Is working and what more we can be 

doing at the Federal level in Congress to support coordination to 

more effectively combat the flow of heroin and other illegal opioids 

into this community. 

Mr. BOHN. It is just that the support is both funding for training, 

for enforcement, and for prevention methods. In HIDTA, we have 

a heroin-specific task force that we have just beefed up by about 

50 percent with more manpower, but at the same time, we are always doing costly training out there. 

We are training law enforcement, because in a lot of the communities, this is something relatively new to, on how to handle overdose investigations and—because it is in every community. 

At the same time, we do a lot of public awareness training to go 

out and just let people know that this is out there. And, we have 

participated in countless heroin summits around the—and opioid 

summits around the State to raise awareness both within law enforcement and within the public in general. 

We are working hard to get the intelligence sharing that needs 

to be done at the law enforcement level so that all the agencies 

that are participating in these share intelligence so that we can 

make connections and close those intelligence gaps as well. 

So, there is several levels to the problem, several levels to the solution, and it is not going to be one thing; it is going to be a multifaceted solution. 

Senator BALDWIN. Thank you. 

Chairman JOHNSON. Thank you, Senator Baldwin. I do not want 

to put too much pressure on Rick or Sandi. Would you like to make 

any comments before we seat the next panel? Do you think 

Ashleigh did a pretty good job for you? 
24 

1The prepared statement of Mr. Kerlikowske appears in the Appendix on page 76. 

Ms. SCOTT. I do. 

Chairman JOHNSON. OK. I think she did as well. 

Mr. LYBERT. Are you sure, mom? [Laughter.] 

Ms. SCOTT. Yes. 

Chairman JOHNSON. Thank you all for your powerful testimony. 

This is not the last hearing on this, trust me. So, thank you, and 

we will seat the next panel with that. 

[A recess was taken from 3:42 p.m. to 3:46 p.m.] 

Chairman JOHNSON. As I mentioned to the earlier panel, it is our 

tradition to swear in witnesses, so if you all rise and raise your 

right hand. 

Do you swear the testimony you will give before this Committee 

will be the truth, the whole truth, and nothing but the truth, so 

help you, God. 

Please be seated. 

Our first witness is Commissioner Gil Kerlikowske, and we know 

you have a hard stop at 4:30, so when we get done with the testimony, we will come to you and ask you the questions, and then, 

feel free to, I guess, probably catch your plane, right? 

Commissioner KERLIKOWSKE. Thank you, Senator. I appreciate 

it. 

Chairman JOHNSON. So, Commissioner Gil Kerlikowske is our 

first witness. He is the Commissioner of the U.S. Customs and Border Protection at the U.S. Department of Homeland Security. Commissioner Kerlikowske is also the former director of the Office of 

National Drug Control Policy. Mr. Kerlikowske has four decades of 

law enforcement and drug policy experience. 

And, again, I just want to express our—this committee’s thanks 

for all the traveling you have done to participate in these similar 

types of hearings in the States which are being affected by this 

tragedy. Commissioner. 

TESTIMONY OF THE HONORABLE R. GIL KERLIKOWSKE,1 COMMISSIONER, U.S. CUSTOMS AND BORDER PROTECTION, DEPARTMENT OF HOMELAND SECURITY 

Commissioner KERLIKOWSKE. Thank you. 

Chairman Johnson and Senator Baldwin, thank you so much for 

the opportunity to appear today and to be here to discuss this significant abuse and addiction issue of heroin. It is an important discussion about a complex, difficult challenge that our Nation faces. 

Customs and Border Protection has a critical role in the effort to 

keep heroin and other dangerous drugs out of communities. We 

seize nearly 4 tons of illegal drugs every single day, and it is a variety of drugs. Our seizures of heroin increased 22 percent in the 

last fiscal year (FY). 

While the vast majority of the seizures still occur along the 

southwest border, we interdict heroin in all modes, air, land and 

sea, in both the travel and the cargo environments. Add in between 

the ports of entry (POE), our frontline officers and agents use a variety of technology and assets, everything from canine to large xradiation (x-ray) equipment, etc., along with intelligence and information sharing with our State, local, and Federal partners. 
25 

Continued efforts to intercept drugs at the border are a key aspect of addressing the crisis, but I think we all know and recognize 

that interdiction and arrests alone will not solve this problem. 

President Obama conveyed just a couple weeks ago at the National Prescription Drug Abuse and Heroin Summit in Atlanta that 

we need to focus efforts on prevention and treatment in conjunction 

with the deterrence of drug trafficking via criminal organizations. 

And, we need to better integrate our efforts and share information. 

I am pleased to support the Department of Justice (DOJ) and the 

Office of National Drug Control Policy on the National Heroin Task 

Force, which fosters a collaborative relationship between public 

health and law enforcement across all levels of government. 

Law enforcement at all levels is committed to security, but also 

in protecting the health and safety of the public. And, for Customs 

and Border Protection, this is especially important because nationwide we encounter nearly 1 million people every day that come into 

our country through our ports of entry. And, we were the first Federal law enforcement agency to initiate naloxone training for our 

officers who may encounter someone experiencing an overdose. 

I want to acknowledge the significant strides that we have made 

with Mexico and that they have taken in recent years to address 

transnational organized crime, and narcotic smuggling specifically. 

The relationship with our Mexican counterparts is stronger today 

than it ever has been, and while more can be done, we know that 

we receive information from Mexican authorities on a daily basis. 

They sit with us in some of our targeting centers, we work closely 

with them, and I think the recognition that we are all very much 

in this together is clear. 

So, thank you for holding this important hearing, and I am 

happy to answer your questions at the appropriate time. Thank 

you. 

Chairman JOHNSON. Thank you, Commissioner. 

Our next witness is Attorney General Brad Schimel. Attorney 

General Schimel was elected as the Wisconsin Attorney General on 

November 4, 2014. A front-line prosecutor, first elected Waukesha 

County District Attorney in 2006, Schimel has pledged as attorney 

general to put public safety over politics and continue to fight 

against heroin and human traffickers. General Schimel. 

TESTIMONY OF THE HONORABLE BRAD SCHIMEL, ATTORNEY 

GENERAL, DEPARTMENT OF JUSTICE, STATE OF WISCONSIN 

Mr. SCHIMEL. Good afternoon. And, thank you, Chairman Johnson and Senator Baldwin, for the opportunity to testify, and thank 

you for both of your commitment too. 

Thank you for your commitment to finding bipartisan ways to 

address this opiate epidemic that we are facing. Some of the legislation that you have both proposed will make a difference in this 

battle for us. 

And, Senator Baldwin, you asked whether—in the question-andanswer (Q&A) period earlier, whether this was an—this sounded 

like an emergency response to a crisis, and it does not. And, many 

of the people in this room have been on kind of the speaking circuit 

together for a long time, and we have been asking for a long time, 
26 

after we talk about the nature of the problem, we are asking people 

what are we prepared to do about this? 

We have seen in the course of a little over a decade, opiate overdose deaths more than quadruple. And, if we saw that kind of a 

change in traffic crash deaths, we would put a roundabout every 

200 feet. We would lower speed limits to 15. We would not let people get their driver’s license till they are 30. We would do things 

that sound crazy. And yet, as to this, we are still kind of struggling 

for awareness. So, I appreciate your committee’s willingness to help 

raise this awareness. 

I do not want to repeat things that others said, but I will reiterate what Mr. Bohn said. This is also driving virtually every other 

kind of crime in our nation. 

Dr. Westlake, he has had enough in the emergency department. 

Me, I have had enough. There have been years in Waukesha County where we have had close to 50 overdose deaths, right in this one 

county while I was the district attorney (DA). I have met now all 

along the way, hundreds of parents who have buried their children. 

I have had enough. I am tired of this. 

The law enforcement officers and emergency medical services 

(EMS) that are in this room today, they have had enough, of often 

going back over and over to the same house, to the same person, 

who was saved recently and just went right back to using, because 

we do not have enough help for them. And, they are often, as Tyler 

Lybert said, they are often not ready to get help. 

And, the Lyberts and Mrs. Badura, we have spoken together dozens of times, and still, every time any of them talk, I still get 

choked up and get teary-eyed, because their story does not get any 

better no matter how many times you hear it. 

So, ask any law enforcement officer here in this room or anywhere, what is the worst problem we have seen in the last quarter 

century, this is it, this is the one. 

And, now, you have heard a lot about how this devastates people 

in many ways. There is one way that has not been mentioned yet, 

and that is employers. It is affecting our economy. Four out of five 

employers in a survey conducted in Indiana, which is not so different from Wisconsin, four out of five employers in that survey 

had to address opiate abuse and addiction in their workplace. Conservative estimates suggest that opiate abuse is costing employers 

nationwide over $26 billion annually. This is affecting our economy. 

And, I do not want to repeat all the things that have been said 

about the issue on the border, but any discussion about this problem has to include a discussion about our Nation’s international 

borders. In years past, heroin came to America from southeast and 

southwest Asia. Because it was so hard to get it here, it had to be 

cut drastically in order to be profitable. 

In the 1980s, the average heroin purity on the street was about 

5 percent. We do not see 5 percent anymore, because it is so easy 

to get it into our country, they do not have to cut it to make it profitable. Instead, they are competing with each other for who has the 

most potent heroin. And so, now we find heroin between 20 percent 

and all the way up to close to 80 percent pure. And, when you look 

at it in your hand, you do not know what you have. That is part 

of why we are seeing so many overdoses, because a young person, 
27 

or even a middle-aged person, using that has no idea. So, it is 

going to be necessary in this to address the border security as part 

of this problem. 

And, I want to mention methamphetamine. Mr. Bohn mentioned 

it briefly. Wisconsin and many other States took drastic steps to 

make it harder to produce methamphetamine here in America. So, 

we made it harder to buy the necessary ingredients to make it, and 

we have cut down domestic production. 

Unfortunately, the production shifted to Mexico. Our problem 

with methamphetamine is worse than it was before, and it is growing, and it is spread to parts of our State that did not use to have 

the problem. So, we do have to address the border in this issue. 

And, in terms of how we are going to solve this problem, it has 

been said as well today that this is an all-hands-on-deck answer 

that we need to have. Law enforcement will not do this alone, 

treatment will not do it alone, and prevention will not do it alone, 

but they all three have to be as a part of this. 

One of the challenges is that unlike investigating an armed robbery that happens at one place and one point in time, the drug 

trafficking does not respect any municipal or State boundaries. It 

is moving everywhere. And, it is necessary for law enforcement to 

be able to work across jurisdictions together. 

One of the ways they have been able to do that over the years 

is through the assistance of the Byrne Justice Assistance Grants. 

Those grants have been shrinking over the years, and it is making 

it harder for the local, municipal police departments and the metropolitan drug enforcement groups to do their work. 

And, it has been years ago already now in Waukesha County, 

and I am a little bit reluctant to even say this out loud, but years 

ago we stopped focusing on marijuana at all with our metropolitan 

drug enforcement group because the opiate problem is consuming 

so much of our efforts. 

Narcan has also been mentioned today, and I just want to echo 

the comments. There is no reason to take it unless you need to reverse an opiate overdose. You do not get high off of it, it does not 

do anything to you, it has no harmful effects. Still, it requires a 

prescription. I am hoping we can see that change. 

Also, medication assisted treatment has been mentioned. And, 

you heard from Mrs. Badura about the concerns that oftentimes, a 

person who has been confined, be it a jail, a prison, or inpatient 

treatment, oftentimes the most dangerous time for them is right 

after their release. Relapse is a very common phenomenon, and 

their tolerance is now lower, and frequently they try to use at the 

same level they did before they were confined, and we are seeing 

so many of the overdose deaths happen at that time frame. 

Medication-assisted treatment (MAT) can help with this. We 

should fund having this available to people who are about to get 

out of jail or prison, people who are going to get out of a treatment 

setting, so that they can have assistance in resisting those urges 

that result in relapse. 

And, then one of the wisest things we have done in the criminal 

justice system—and that was also mentioned by Tyler Lybert— 

have been treatment courts. And, we have now treatments courts 

in about half of the counties in Wisconsin. 
28 

1The prepared statement of Senator Erpenbach appears in the Appendix on page 86. 

Most of the counties that did that, like Waukesha County, when 

we started up our drug treatment court, we did so with Federal 

grant assistance, a startup grant. That is invaluable. You cannot 

get your county board to pony up the money to start it until you 

can demonstrate that it is doing something, that those startup 

grants are critical. You can start them up and you can show your 

county board the graduates and how your county is becoming 

healthier as a result, and then they will continue to fund it. So, 

please continue to support those grants to startup treatment 

courts. It is the wisest thing we have done, because we have started as a criminal justice system to treat addiction not as a felony, 

but as the disease it is, and it is a real opportunity for us. 

And, I also encourage making available more competitive grants. 

There are innovative ideas out there, in law enforcement, in social 

services, in nongovernmental groups. The only problem is, they are 

expensive, and, again, they have to demonstrate success before 

they can get that outside funding. Start-up grants, a competitive 

process, administered by the Office of Justice Assistance or the National Association of Attorneys General (NAAG), you name it, they 

can make a difference in finding new ways to approach this problem. 

So, I appreciate very much the committee’s interest in tackling 

this Nation’s opiate epidemic, and thank you, Chairman Johnson 

and Senator Baldwin, for the opportunity to testify today and for 

your work. 

Chairman JOHNSON. Thank you, General Schimel. 

Our next witness is Senator Jon Erpenbach. Senator Erpenbach 

was elected to represent the 27th Senate District in November 

1998. His Senate colleagues elected him Senate Democrat leader in 

December 2002 through 2004. Currently, Senator Erpenbach is a 

member of the Joint Committee on Finance of the Wisconsin Legislator’s Budget Writing Committee. Senator Erpenbach. 

TESTIMONY OF THE HONORABLE JON ERPENBACH,1 STATE 

SENATOR, DISTRICT 27, STATE OF WISCONSIN 

Senator Erpenbach. Thank you, Mr. Chairman. 

First, I would like to commend Brad and John for their work on 

this issue. They say Democrats and Republicans in Madison cannot 

get along. We have on this issue. And, especially John with his 

work on this has been great, and you too as well, Mr. Chairman 

and Senator Baldwin. I really truly appreciate what you have done. 

The problem we are talking about today is well documented. I do 

not need to spend a whole lot of time on statistics other than to 

say, we would not be here if it was not the urgent problem that 

it is. 

The State of Wisconsin and the Federal Government need to 

partner together if we are going to be successful in the fight 

against this epidemic. In my testimony today, I will talk about a 

couple of different ways that we can partner together, the local, 

State, and Federal Governments, to combat the epidemic that 

brings us all here today. 
29 

I am proud to represent Sauk County in my Senate District. 

Sauk County is home to the Community Activated Recovery Enhancement (CARE) program. This is a program that could, potentially, be a statewide or even a nationwide model. There are several 

things we can do to help it be even better. 

In Sauk County in 2010, law enforcement and the medical community started noticing a growing problem. There were 20 heroin 

and opiate deaths in a 2-year period. Ambulance companies and 

first responders reported over 80 uses of Narcan, an opiate 

that—we have talked about that already. 

Law enforcement and the medical and legal community and local 

businesses—this is important, local businesses—joined together to 

address what they saw as a community crisis. They had the foresight to recognize that this problem could not be solved by law enforcement alone, and they knew they needed a more comprehensive 

approach, so they developed the CARE program. 

CARE is an integrated system, putting the individual at the center of their treatment, which empowers the individual to make better life choices. CARE recognizes that addiction can be treated and 

overcome using an integrated, multidisciplinary approach that requires medical treatment, mental health services, social services, 

and healthy support systems. It is a program that recognizes addiction is a disease, as the attorney general said. A lot of us used to 

see it the other way around, as somebody just choosing to do this. 

It is a disease, and as a speaker said earlier, it needs to be treated 

throughout the lifetime. 

It is an important piece of the CARE program is Vivitrol, a drug 

that we have heard about already, injected monthly and blocks the 

receptors in the brain responsible for an opiate high. Vivitrol is expensive. The average cost of a monthly shot is about 1,200 bucks. 

St. Vincent de Paul was the first to step in in Sauk Prairie to 

cover the cost for the drug for inmates who agreed to the program, 

but they could not afford it much longer. 

While enrolling inmates in the CARE program, Sauk County realized that Medicaid-eligible inmates leaving jail were experiencing 

a gap in coverage, jeopardizing their ability to continue to receive 

the shots. Wisconsin is a State that chooses to terminate rather 

than suspend Medicaid coverage for those who are incarcerated, 

and that needs to change. 

With us here, by the way, in the audience tonight from the UWExtension is a member of the CARE team in Sauk County, Dr. 

Morgan McArthur, and he is a great resource for anybody on your 

committee who has any questions about the CARE program and 

how it is worked to this point. 

According to the National Conference of State Legislatures, at 

least 18 States currently suspend rather than terminate Medicaid 

coverage for people who are incarcerated. The suspension approach 

yields administrative savings related to reapplication eligibility determination process, which can take as long as 45 to 90 days. 

I would be remiss if I did not take this opportunity, Mr. Chairman, to advocate for Wisconsin to take the Federal Medicaid Expansion dollars that have available to it through the Affordable 

Care Act (ACA). Our Legislative Fiscal Bureau estimates that Wisconsin is losing about $320 million over the biennium. 13.4 percent 
30 

of the people in Wisconsin that would qualify for this Medicaid expansion have substance abuse disorders, 13.4 percent. So, needless 

to say, they could be helped by this. 

Mr. Chairman, in order to confront this horrible epidemic headon, in order to begin to win this fight, we must break down the barriers, we must change the way we look at addiction, and, again, 

treat it as a disease. 

And, on a personal note, we heard from Tyler and Ashleigh. 

Growing up in my family, my sisters, Mary and Kim, and I were 

Ashleigh. My brother, Will, was Tyler. We lost Will in January. He 

was 53 years old—lifelong battle with addiction. He used up until 

the day he died. He did not die of a single overdose. He just died 

of a lifetime of abuse. He was a brother, he was a son, and most 

importantly, he was a father. And, even being a father could not 

help him overcome this. 

And, I remember, Ashleigh talked about counseling. I remember 

the Erpenbachs going to family counseling in middle school and 

high school, and back then I had no idea why I was there. I was 

angry. I was really upset with my brother. I just wanted him to 

knock it off. And, there were days, in fact even months, when he 

would not use. But, when we would not see him for 2 or 3 days, 

or 2 or 3 weeks, or 2 or 3 months, we knew what was going on. 

I saw what it has done to my mom and dad. And, the one picture 

I will remember on the day he died, which was this past January, 

were two people approaching 80 years old, being married together 

probably close to 60 years now, hugging in a hallway of the hospital, turning and walking out. I am a dad. I cannot imagine that. 

I cannot imagine that whatsoever. 

We have a real serious problem, and it is threefold. It is the border issue, which is way above my pay grade, but it is also an issue 

how society sees drugs and addiction. And, it is not just drugs. It 

is addiction, period. It is gambling. Addiction takes on many forms, 

but the results are the same. It tears the individual apart, tears 

the family apart, tears the community apart, tears society apart. 

If you want to look at it as a dollars and cents figure—and this 

is the last thing I will say, and then I will be happy to answer 

questions—the amount of money taxpayers could save if we do this 

right would be tremendous, not only in Wisconsin, but certainly nationally. 

Thank you. 

Chairman JOHNSON. Thank you, Senator Erpenbach. 

Sorry for your loss and thank you for sharing that. Our final witness is Representative John Nygren. Representative Nygren was 

elected as a Wisconsin State Representative from the 89th Assembly District in November 2006. Representative Nygren has made 

addressing the heroin-opiate epidemic in Wisconsin a major priority, leading the way in the passage of 17 bills by the Wisconsin 

legislature, 16 of which have been signed into law. And, again, a 

person of real courage to kind of lay bare your story for public scrutiny. So, we certainly appreciate your willingness to do so. Representative Nygren. 
31 

1The prepared statement of Representative Nygren appears in the Appendix on page 91. 

TESTIMONY OF THE HONORABLE JOHN NYGREN,1 STATE 

REPRESENTATIVE, DISTRICT 89, STATE OF WISCONSIN 

Representative NYGREN. Thank you, Senator Johnson and Senator Baldwin, for having a hearing today on the impact of trafficking and abuse of heroin and prescription opiates in Wisconsin. 

It is already been said, our country is currently facing a prescription opiate and heroin epidemic. This problem knows no boundaries. All demographics of people are affected in one way or another, no matter their income, no matter their race, no matter 

whether they are from an urban community or a rural community. 

And, Senators, no matter if you are Republican, no matter if you 

are a Democrat. 

Many of us know too well that Wisconsin is not exempt from this 

epidemic. As mentioned, I have a daughter, Cassie, who is now 27 

years old, who, unfortunately, to this day, is still struggling with 

addiction. Hers began with an illegally obtained prescription. We 

had a doctor selling prescriptions of OxyContin that, unfortunately, 

she got access to. When that supply dried up, she moved onto heroin, like many others. 

So, my family is no different—my community is no different. The 

county of Marinette led the State in overdose deaths per capita a 

couple years in a row. Initially, as an elected official—initially as 

a parent—we dealt with this problem, privately, like most would. 

But, when I began to read the obituaries of my friends’ and neighbors’ children, it was a call to action, and it was for that reason 

that I am very proud of the steps that the legislature in Wisconsin 

has taken over the past 3 years to combat this devastating problem 

in our State. 

In 2013, we laid the foundation of what was to become the Heroin Opiate Prevention and Education Agenda (HOPE). This foundation was laid with seven bills that aimed to fight heroin’s use and 

addiction in our State. 

We expanded access to drug treatment opportunities; made opiate antagonists, like Narcan, more readily available to first responders; and enacted a Good Samaritan law. However, after the 

session ended, it was very clear that there was much more work 

to be done to combat our problem in Wisconsin. 

As this session began, we continued our work to build on the 

HOPE Agenda. Instead of specifically targeting heroin—heroin gets 

a lot of headlines, it is very dramatic and oftentimes has been 

talked about in the news, but it starts much more innocently in 

most cases. The root problem of our situation in Wisconsin has 

been readily agreed by many experts lies with prescription opiate 

misuse, abuse, and addiction. 

Studies show that in most cases, heroin addicts begin with an 

addiction to prescription painkillers. Whether these medications 

are obtained legally or not, we need to do our best to curtail the 

illegal use of these dangerous medications. 

As a continuation of the HOPE agenda, this session we passed 

10 additional bills—9 of which have already been signed into law 

by Governor Walker. These bills continue to expand access to opiate antagonists to reduce incidents of overdose deaths, further ex-
32 

pands access to treatment and diversion programs so people addicted to opiates can get the help they need in lieu of incarceration. 

And, we have expanded the use of Wisconsin’s Prescription Drug 

Monitoring Program (PDMP), so instances of overprescribing become less common. 

It is our hope that these important pieces of legislation will reduce the number of people who become addicted to legal prescription opiates, and in turn, reduce the number of people who eventually turn to heroin and other dangerous substances. 

here are 17 HOPE Agenda bills total, and all of them were approved unanimously by both houses of the Wisconsin State Legislature. Governor Walker has signed 16 of these proposals into law, 

and we are expecting the 17th to be signed very soon. 

Once again, it is important to note, this is not a Republican 

issue, this is not a Democrat issue. When people contact my office 

to bare their soul about their personal stories, we never ask what 

their party affiliation is; but rather, this is a public health and 

safety issue. 

I am proud that there has been such widespread support for 

these pieces of legislation from people throughout our State, including the medical community, law enforcement, my colleagues in the 

legislature, the Governor, attorney general, and countless addiction 

advocates. 

Now it is time to start combating this devastating problem. I am 

proud that Wisconsin is leading the way with efforts like the 

HOPE Agenda and confident that other States will begin to look 

to us for guidance as far as what can be done. 

The laws that make up the HOPE Agenda are not a silver bullet 

that will solve this epidemic, but each proposal is an important 

step in the right direction. With that, I look forward to continuing 

our work to further build upon the HOPE Agenda in the future. 

Future efforts look to reduce current barriers to treatment, as well 

as provide additional access to treatment. 

I appreciate the opportunity to testify before your Committee 

today on the HOPE Agenda and the State of Wisconsin’s efforts, 

and I hope to be able to be a resource for your work as we continue 

to address this problem nationally. 

Thank you. 

Chairman JOHNSON. Thank you, Representative Nygren. We do 

have—— 

[Applause.] 

We do have about 15 minutes with the Commissioner, so let me 

start asking questions, then I will turn it over to you, Senator 

Baldwin, for the Commissioner, and then we will move on to the 

rest of the panel. 

Commissioner, on Tuesday, when we held a hearing in D.C., we 

had the former head of Southern Command, General John Kelly, 

testify before the Committee, and in previous testimony, the other 

15 hearings we have had, and you have participated in a number 

of those as well, we certainly found that the vast majority of drugs 

that move into America through the southwest border actually 

come through our ports of entry. I believe that is true, I will let 

you comment on that, but General Kelly, I was surprised when he 

said we have visibility of about 90 percent of the flow of illegal 
33 

drugs. We have visibility of it—we just, simply, cannot interdict it. 

Is that kind of your understanding? I understand you are Customs 

and Border Protection at the border. General Kelly is Southern 

Command in Central America, but I know DHS is cooperative 

down there as well. Can you just kind of lay out what the reality 

is in terms of our visibility of the flow, our inability to interdict, 

and just the problem we have. 

These drug traffickers are very sophisticated in their use, and I 

have been to the border, the use of dogs, the use of imaging technology, it is extensive, and yet, according to testimony with former 

drug Czar General Barry McCaffrey we only interdict between 5 

and 10 percent of illegal drugs coming in through the southwest 

border. So, just can you speak to that, the difficult nature of the 

task? 

Commissioner KERLIKOWSKE. Sure, Mr. Chairman. I would separate out two things that General Kelly said. One is certainly the 

drugs that come across through the waterways in the Caribbean, 

et cetera. I think he is very clear that we have a lot more visibility 

on that than we have ever had, for a variety of reasons. 

Customs and Border Protection flies the Airborne Warning and 

Control System (AWACS). We do that in conjunction with our partners in the Coast Guard. We have an incredible center in the Joint 

Interagency Taskforce (JIATF) South in Key West, Florida and we 

have a lot of information, a lot of visibility, et cetera. What we do 

not have are the assets to go after that. 

Now, what we are talking about here mostly is cocaine, either 

destined for the United States, but frankly, given the appetite that 

Europe and Africa and others have for cocaine, this is cocaine going 

all the way across. It would be like when I was a police chief and 

we had a call of a robbery at a 7-Eleven, and I would say thank 

you for the information, but I do not have anybody to send. We 

could actually use more assets to be able to respond because we do 

have very good information, both technology and also informant information. 

On the other hand, the drugs that flow, and we are talking here 

mostly heroin, the drugs that flow into the United States from 

Mexico, again, speaking about heroin, is almost always interdicted 

through our ports of entry. We do not see many backpackers or others coming between the ports of entry, and when we do interdict 

drugs, it is almost always marijuana being done in those 

backpacks. 

So, it is coming through the ports of entry, whether it is John 

F. Kennedy International Airport (JFK) or the San Ysidro POE, 

and it is people that are carrying it on their person, it is people 

that have swallowed it, and it is hidden inside of vehicles, and of 

course our best deterrence to that has been able to interdict. 

I will tell you that I look at a lot of data, and I have seen that 

testimony and heard that testimony from General McCaffrey, who 

is a friend and a colleague and a mentor, but I would be very reluctant to cite to you the percentage of drugs that we either seize or 

do not seize. That being said, if we seized 50 percent or 70 percent, 

your earlier statement in the opening about our appetite for drugs 

and the fact that this is such a high profit area is going to make 

it extremely difficult if we seized 80 percent. 
34 

Chairman JOHNSON. I mean, the percentage is neither here nor 

there. The supply is meeting the demand and then some. To have 

the prices go from $3,000 a gram to $100 a gram, there is a real 

problem. 

Oftentimes we hear that the use of drugs is a victimless crime, 

and I think we have heard in testimony there is no such thing, the 

broken families, the broken lives. Again, these are the drug cartels, 

they are businesses. They expand their product line into human 

trafficking and sex trafficking. 

I do want you to speak to the brutality of these drug cartels, but 

I do want to talk a little bit about what we saw in Guatemala, 

where we visited a shelter—no address on it because they are trying to protect themselves from the drug cartels—the sex traffickers, 

but a shelter for sex-trafficked little girls. The youngest was 11, the 

oldest was probably about 16—average age is about 14—and they 

have cribs because they, obviously, get pregnant. So, anybody who 

thinks this is a victimless crime, go down to Guatemala and see 

just one sliver of that type of victimhood. 

But, again, you are on the front lines. You see the brutality. General Kelly was talking about anybody in public safety that would 

even begin to think of going up against the drug cartels, they get 

a little compact disc (CD) with their pictures of their family and 

their little girls. I mean, can you speak to what you know of why 

there is such impunity on the part of drug cartels, because they are 

simply untouchable because they are so brutal? 

Commissioner KERLIKOWSKE. And, I think we are talking mostly 

then about Central America, because I have visited Guatamala. We 

certainly know the statistics in those three Central American countries, Honduras, El Salvador—— 

Chairman JOHNSON. Well, Mexico is quite bad as well, is it not? 

Commissioner KERLIKOWSKE. Well, although, actually, in the last 

year of President Calderon and continuing through President Pena, 

we have seen a decrease in their violent crime. It is still significantly higher than that of the United States. 

But, in those visits and in looking at that data, the level of violence, Honduras and El Salvador have homicide rates that 

oftentime top the world in the per capita killings, and I think that 

is what we have seen in the number of unaccompanied children 

(UAC) and others that have come across the border. 

But, it is driven by gang violence. And, I would go back and say 

that as much as the work that has been done by the Department 

of State (DOS), International Narcotics and Law Enforcement to 

provide rule of law training, to provide technology, to provide training for professional law enforcement, until, as Secretary John 

Kerry mentioned, in Davos, Switzerland, recently, until the corruption issue is addressed in these countries, you are not going to find 

people that are going to want to pick up and go to a local law enforcement official and say, I want to report something, I need help. 

So, I would say corruption drives part of this. 

Chairman JOHNSON. But, can you talk about specifically the 

techniques the drug cartels use to gain the impunity with which 

they operate? 

Commissioner KERLIKOWSKE. Well, I think they are going—— 
35 

Chairman JOHNSON. This is not just gang violence. I mean, this 

is a very dedicated effort on their part to be incredibly brutal 

against the family members of public safety officials, beheadings, 

those types of things. 

Commissioner KERLIKOWSKE. Yes, we have seen time after time 

after time, and including in Mexico, very high level law enforcement officials, many of whom have reputations that have been 

brought in to essentially improve things, to do public safety, they 

have been killed, their families have been killed. The mayor, just 

outside of the city of Mexico City, within the State of Mexico, was 

murdered only several days after her election. The intimidation 

and the threats to prosecutors, to law enforcement officials, et 

cetera. 

Which often then comes back to why in the United States we 

have not seen anywhere near that level of intimidation or violence. 

And, that is because, quite frankly, we have law enforcement officials that are not corrupt, we have prosecutors that will not back 

off from prosecuting, at the greatest and most severe level, people 

that would do that type of intimidation or threats. 

But, you are absolutely correct. The better things that would improve in those countries for safety, security, etc., the better we 

would be when it comes to our drug issue. 

Chairman JOHNSON. So, my final point, and I will turn it over 

to Senator Baldwin, the breakdown of those public safety institutions, that impunity, that is driven by our insatiable demand for 

drugs, and it is important for us to recognize that. Senator Baldwin. 

Senator BALDWIN. Thank you. Commissioner, I want to hear you 

elaborate a little bit more about the pilot with regard to training 

your officers to administer naloxone. 

As I understand it, the beginning of Phase II implementation of 

that pilot is going to begin in the next couple of months. I would 

like to hear about when the initial pilot project will be complete 

and your thoughts about whether this pilot needs to be further expanded. 

Commissioner KERLIKOWSKE. We should actually—— 

Senator BALDWIN. Perhaps describe it, because many in the audience might not be familiar with it. 

Commissioner KERLIKOWSKE. When I served as the president’s 

drug policy adviser starting in 2009, the issue of prescription drugs 

was known in the medical community; it was basically unknown 

anywhere else, unless people had been adversely affected. They 

knew about it, but frankly, you could count on one hand the number of articles about prescription drug overdoses. It is on the tip of 

everyone’s tongue. It is knowledgeable. It is the subject of these 

hearings and many others. And so, one of the things that we saw 

very clearly was that if we can save people’s lives, and, frankly, the 

first responders are often law enforcement, although the medical 

community does respond very quickly, the use of naloxone can reverse overdose. 

I think when the doctor testified about the concern that, well, 

naloxone is only going to encourage someone because they know 

they are not taking the chance, I also heard from the young woman 

at the end of the panel when she talked about, look, people cannot 
36 

stop. If they could make a decision and say, you know what, I am 

going to quit, by heaven, I think they would have made that decision and quit. 

So, we wanted to see naloxone in the hands of every local law 

enforcement, State troopers, deputy sheriffs, and police officers, but 

we also wanted to see it in the hands of our people because we deal 

with a million people a day coming into the country. 

And, when I was in Boston this morning, they talked about people who were overdosing in the restroom of Boston Logan International Airport, and the State troopers there have naloxone and 

are able to use it. We need the same thing. I can assure you, Senator, that when the pilot is over, we will make sure that naloxone 

is at every one of our ports of entry. 

Senator BALDWIN. Thank you. 

Chairman JOHNSON. Again, Commissioner, thank you for your 

service to the country and thank you for coming again. Your dedication to these hearings on a local basis is really much appreciated, 

and thank you. 

Commissioner KERLIKOWSKE. Thank you. 

[Applause.] 

Chairman JOHNSON. So, it is down to three. 

General Schimel, you talked a little bit about the problem businesses are having. Coming from a manufacturing background myself, I can tell you that we have been drug testing, and as I have 

traveled around the State now and talked to manufacturers, who, 

cannot hire enough people, not one, for a variety of reasons. 

One of the reasons is that so many drug tests, 50 percent of people that come in for an application do not show up for the drug 

test—and these are just basic anecdotal percentages—another 50 

percent that actually take it, fail. So, this is an enormously difficult 

problem. 

You talked a little bit about the purity. Does anybody on the 

panel really understand the issue of fentanyl now? Is that being 

blended with heroin? I mean, this is kind of a new drug on the 

scene in the last year and a half, correct? 

Mr. SCHIMEL. Well, it is gained a lot more attention. It has been 

working its way through for some time now, but fentanyl is extraordinarily frightening because it is exponentially more powerful 

than heroin and exponentially more deadly, and when it is laced 

in with heroin, the user may not have any idea that it is in there. 

Chairman JOHNSON. What is the pricing of fentanyl? 

Mr. SCHIMEL. I do not know the answer on that. I am sorry. 

Chairman JOHNSON. Why would they lace that into heroin? If 

you are saying heroin now is so cheap, it can be so pure, why would 

they blend? Anybody know? 

Mr. SCHIMEL. There is a competition for who has the best heroin, 

who has the drug that gets you the most high, that you can use 

the smallest amount to get to where you want to be. That is actually not a fair way to put it. I do not think they want to be there, 

but the place they need to be. 

As I have heard, many people who are in recovery from addiction—or are still struggling—talk about this, and once they 

progress very far into their addiction, they no longer get high. They 

simply are taking the drug to not get sick. There is not even the 
37 

joy of feeling good from using it anymore. There is no joy left in 

their lives. 

So, by making the drug more powerful, they can maybe shoot 

past getting around being sick and still have some joy. It is incredibly dangerous, and we are seeing really shocking numbers of 

deaths from fentanyl. 

Chairman JOHNSON. Do people take it on their own? And, is this 

injectable, is this snortable, or how is fentanyl administered? 

Mr. SCHIMEL. Like the more potent heroin, you can take it in all 

the different manners now. That is one of the major differences, is 

several decades ago, with the 5 percent pure heroin, the only way 

to really get high was to shoot it up. Now, with the higher purity 

heroin, you can start by smoking it or snorting it, and that is less 

frightening a move than strapping a tourniquet around your arm 

and searching for a vein. 

Chairman JOHNSON. You talked about methamphetamine. I 

think in your testimony you talked about it is really prevalent 

more on the western side of the State. Is that just simply a supply 

issue, that it is just more readily available through markets in 

Minneapolis or Minnesota? 

Mr. SCHIMEL. It used to be very much a northwest phenomenon 

in our State. That has changed, and the southwestern part of our 

State is—law enforcement there is howling for help. Treatment 

providers there are very concerned about what they are seeing. 

Southeastern Wisconsin avoided it because there had always 

been a steady supply of cheap crack cocaine from the Chicago area, 

and that seemed to offset that demand. But, methamphetamine is 

on the move, and it is moving across our State. It will be everywhere soon. 

Chairman JOHNSON. But, again, we used to manufacture here. 

You shut down those meth labs, and now it is just coming in, 

again, flowing freely into the United States from Mexico. 

Mr. SCHIMEL. The only kind of labs we have in the State anymore are what—we call them ‘‘one pots,’’ and it will be an individual who is cooking up enough for themselves and maybe a 

girlfriend or boyfriend, but that is it. No more commercial manufacturing. 

Chairman JOHNSON. OK. Senator Erpenbach, you mentioned the 

drug Nivitrol. Can you tell me a little bit more what you know 

about that? You said the price is high. If it was more widely—— 

So, if we administered more of it, would that price come down? 

I mean, could you just—— 

Senator ERPENBACH. That I do not know. Not being a pharmacist, I can tell you that I have read that it blocks certain receptors that lead to the high. It is expensive because the pharmaceutical companies can make it that way, I guess. They can charge 

whatever it is they choose to charge. 

But, the point is, if somebody really, truly wants to make that 

step and has truly decided that, yes, I am done with drugs, we, as 

a community, need to be there for them. And, one of the ways we 

can be there is to try and make Vivitrol as prevalent as we possibly 

can to those who do need it. 

And, again, in the situation in Sauk County when they are identifying inmates who want to be part of this program and we have 
38 

that gap coverage where Medicaid shuts off for people that we incarcerate in jails and then there is a wait to get back on, if they 

can get back on at all, that Vivitrol, that shot of Vivitrol, once they 

are out and they have made that decision to change their life, has 

to be available to them. 

Because if it is not, shortly after they are out, if they do not get 

the support they need, the help they need, and the community is 

not behind them and government is not behind them, they are 

going to end up right back in jail because they ended up stealing 

something because they needed the money to go out and buy some 

heroin or do whatever. I mean, that was the case with my brother. 

Senator BALDWIN. Can I just—— 

Chairman JOHNSON. Sure. 

Senator BALDWIN. So, I am one of those people who just learned 

a little bit more about this issue recently, and so, dangerous with 

the knowledge, but I had a chance to visit with participants in a 

Vivitrol program in Dane County, seven or eight people who were 

quite successfully being treated on the drug. 

It is particularly useful in that hand-off between jail and the 

community, because you have had to—and doctor, you can let me 

know if I have said anything incorrectly—but you had to have been 

free of opioid use for about 14 days beforehand. And so, reaching 

that 14 days is extremely challenging for addicts in the community. 

But, when you are in jail—— 

Senator ERPENBACH. It is there. In my brother’s situation, 

whether it was a county jail, Waupun, Green Bay, or 

Oshkosh—whatever prison he happened to be in, services, things 

that he needed, they were available. When he was out, they were 

not. 

And, it got to the point where, much like Tyler and Ashleigh’s 

mom and dad basically saying to Tyler, you are out of here. I mean, 

we went through that process with my brother, Will. But, at the 

same time, you are still always holding out hope. 

So, as a community and as a government, whether we are State 

government officials or Federal Government officials, if there is 

funding available to help somebody who, again, has made that decision and they are transitioning out of a county jail, and we are saying, sorry, you do not qualify for this shot, good luck out there on 

the streets, we are going to see them right back there again. 

And, I ended my comments by saying, you want to talk dollars 

and cents, because a lot of us talk tough on taxes, you want to save 

money, you start investing in programs that work, and we will be 

saving a tremendous amount of money here in Wisconsin and nationally. 

Chairman JOHNSON. Let us face it, it costs somewhere between 

$30,000 and $50,000 per year to incarcerate somebody. But, talking 

to the Lyberts, they thought that the one treatment for Tyler was 

about $78,000 worth. 

Senator ERPENBACH. About how much? 

Chairman JOHNSON. About $78,000. And, when you hear the 

other—I do not know what the exact stats are, but one in 20, one 

in ten. I mean, that is part of the problem, is this is enormously 

expensive, unfortunately. So, 10 percent or 5 percent effective. I 

mean, it is one of those problems we have to be honest with, in 
39 

terms of what is actually going to work. That is why something like 

Vivitrol, if it really blocks those receptors—— 

Senator ERPENBACH. Yes. And, I know it is expensive, and I saw 

my parents write checks when I was growing up once insurance 

ran out, and I have seen other families go through it as well. But, 

again, there are programs out there that work, and that is what 

we need to invest in. 

Chairman JOHNSON. And, that is what we need to explore, which 

is why I have the hearing. 

Representative Nygren, you did not really mention Cassie—other 

than just the name—in your testimony. You have talked about her. 

Would you be willing to share a little bit more of that experience 

before I turn it over to Senator Baldwin? Because it is these examples—it is that courage. 

And, by the way, my nephew overdosed a couple months 

ago—and the family wants to keep that private—I have a buddy 

that I played softball with, his daughter has been struggling with 

heroin for 5 years. He heard about this hearing, texted me, and 

said, ‘‘Boy, use that as an example anonymously.’’ 

So, I mean, I understand the problem and the pain, and this is 

very hard to make public, but, we have to address the demand side, 

we have to take the glamour out of it, and the way you take the 

glamour out of it is this kind of testimony—it is so powerful. 

So, if you do not want to, just tell me, I will turn it over to Senator Baldwin, but if you are willing to share, it is helpful and it 

is very powerful. 

Representative NYGREN. Well, we have talked about it before. As 

I said, initially, families typically deal with this privately, especially when you are a little bit more in the spotlight—and besides, 

it was a private, personal issue, family issue. 

But, Cassie’s involvement with drugs began with probably—I 

should not say probably, I know it first began with alcohol, then 

marijuana, and—— 

Chairman JOHNSON. Just at what age? 

Representative NYGREN. Well, I would say alcohol, probably, but 

she did not like alcohol. That started probably around 13 and 14. 

Marijuana started around 15 or 16 and prescription drugs started 

around 17. 

Now, I mean, we have not really talked about the legalization of 

marijuana. That is one of those movements that is out there, and 

I know the attorney general has talked about this before, but there 

is people that will argue that marijuana is not a gateway drug, but 

I would argue that each of those are gateway drugs for some people. 

I grew up in the generation where a lot of people probably 

smoked marijuana, and those are the people in decisionmaking positions today, and they think, well, it did not affect us, so it would 

be OK to legalize it. But, as the attorney general, who has more 

knowledge on this, has talked about, we are talking about marijuana that is probably six or seven times stronger than what it was 

back in the 1970s. 

Chairman JOHNSON. I think it is more than that, isn’t it? 

Representative NYGREN. So, I mean, this is not your daddy’s 

marijuana we are talking about, but—— 
40 

So, that was kind of her progression. And, as a family, we went 

through all the—if you sat somebody—Lauri Badura or, somebody 

else who has had a loved one with an addiction right next to me, 

we could probably tell a pretty similar story. Tell you a story about 

robberies in your home, or break-ins in your home, missing dollars, 

missing valuables, those type of things, things that began to disappear. All those things were difficult as a family. 

Seeing somebody who was once a straight-A student not graduate from high school was difficult. Seeing her eventually, in orange in county jail or eventually prison was difficult. 

But, the most difficult thing as a parent was when they are in 

active addiction, waiting for that phone call to come. That phone 

call came for me. I got there, was able to try to help her breathe 

until the paramedics arrived and administered Narcan. If it would 

have been the basic-level emergency medical technicians (EMTs) in 

Marinette, they could not administer Narcan at that point in time; 

we have changed that. But, waiting for that to happen. She has an 

opportunity today to lead the life that we dreamed for her. Unfortunately, she is still struggling. 

But, Tyler mentioned it earlier, there is a certain amount of guilt 

when you talk about this, because it is difficult for me to talk to— 

dramatically about the challenges my family has faced when I 

know of so many others who their children do not have that opportunity for hope. 

Chairman JOHNSON. They are gone. 

Representative NYGREN. They are gone. So, I try to be that voice 

for them. There is so many people working very hard on this issue 

throughout our State. It was talked earlier that we all need to 

work together, and we do. 

We tried to create a website recently to try and bring all those 

different links, all those different resources together, HOPE Agenda website, but there is so many people trying, and I do believe we 

are making progress, but there is so much more work that needs 

to be, and for Cassie there is a lot of work that needs to be done 

as well. 

Chairman JOHNSON. God bless you and her, and we, obviously, 

are praying for her. 

First of all, thank you for sharing that, and thank you for all 

your efforts. 

And, with that, Senator Baldwin. 

Senator BALDWIN. Thank you. 

Attorney General, I would like to hear your thoughts on the 

most pressing gaps that still exist. Your testimony you talked 

about—well, you gave a real strong voice to the need to have, basically, a seamless interaction between law enforcement and public 

health systems in order to tackle this emergency. Your expertise, 

of course, is on the law enforcement side, but you have seen both. 

You talked about the fact that the Edward Byrne Memorial Justice Assistance Grants (JAG) program keeps shrinking, you talked 

about the treatment courts and the fact that new counties are unlikely to start them if there is not a Federal contribution, and you 

talked about the importance of innovation that is happening 

around this State, that competitive grant programs would also be 

of great importance. 
41 

As well as I do, about the fiscal constraints we face nationally, 

statewide, but where do you see the most profound gaps that would 

benefit from greater Federal attention to better grapple with this 

emergency and acknowledging it is a crisis and an emergency? 

Mr. SCHIMEL. The biggest future challenge we face is going to be 

availability of treatment resources. It is now already. But, as we 

have great collaboration with our medical community in Wisconsin, 

and as a result, combining that with some law changes, we are 

going to see prescribing of opioids decrease, and probably dramatically. That is going to limit the amount of prescription narcotics 

that are available for diversion and abuse, and those who are already addicted are going to turn to heroin then. 

Numbers from 2013 already suggested then 163,000 people in 

Wisconsin were abusing opiates in some manner. We cannot treat 

those. We cannot treat that many. We cannot even come close. We 

are going to have to be prepared for that. 

It is something that I am very proud of our medical community 

in Wisconsin, because they get this, and they are working on it. 

They are working to change education for doctors, they are working 

to change the conversation between doctors and patients, and they 

are working to make sure there are more Suboxone providers. 

One of the things we could do is address right now what many 

assert is an artificial limit for the number of patients that a 

Suboxone-certified doctor can see. 

Senator BALDWIN. Yes. 

Mr. SCHIMEL. They can see more, and many recommend that we 

eliminate those artificial limits, or at least raise them, because 

Suboxone will be—and as Tyler Lybert described, not every kind of 

treatment works for everybody, it is all different, but we need to 

have it available, and that does work for many people as a support 

while they are also getting treatment. 

These are medication-assisted treatment; it is important to remember that. It still will always circle back. But, we can stretch 

our treatment capabilities if we have the medication assisting 

someone in getting through treatment as well. I believe treatment 

providers can serve more people if their patients are stabilized with 

some kind of medication assistance. And, prevention dollars are so 

important. 

And, I want to expand a little bit on drug treatment courts. In 

Waukesha County, our drug treatment court costs about $2,700 a 

year to have an individual in that court. That included all of their 

treatment, drug testing, case management, constant trips to court. 

Did I say drug testing? I meant to. Everything. They did not have 

to come up with any money to be in the program. $2,700, I cannot 

keep somebody in the county jail for 3 months. $2,700, I cannot 

keep them in the State prison for one month. $2,700 will not pay 

for an autopsy and the toxicology reports that are necessary. 

All of the people that enter into the drug treatment courts in our 

State are coming there with two destinations that were awaiting 

them otherwise. They were either going to overdose and die, or 

they were heading to prison, and drug treatment courts are interfering with that path, and it is the best thing we’re doing. 

Senator BALDWIN. One quick additional question. As you have 

taken a journey from being the head law enforcement official in 
42 

this county, to a statewide perspective, I have also gone from representing a part of the State to representing the whole State, are 

there any geographical gaps that you would want to bring to my 

attention? I know I get calls from constituents who talk about the 

distances that they need to travel to seek treatment, to seek support, to seek help. 

Mr. SCHIMEL. Treatment resources are taxed severely everywhere, but in the more rural communities, it is most profound. People sometimes have to travel a hundred miles or more to get to a 

treatment provider, and many of these individuals do not have 

money left to have a reliable car. They may have—— 

Senator BALDWIN. They may not have a license. 

Mr. SCHIMEL [continuing.] Lost their driver’s license a long time 

ago, and there is certainly no bus. 

We are seeing innovations in the treatment community, where 

treatment providers are utilizing videoconferencing for it, and I am 

told by treatment providers that it is demonstrated to be as effective or can be as effective as in-person treatment provided, but it 

needs to be—the person receiving that videoconferencing should be 

in some kind of a medical facility where they can get help and advice face-to-face as well. 

But, these are some of the things that we are attempting to do 

to expand these resources to meet a demand that, frankly, we hope 

will become overwhelming. We hope that these tens of thousands 

of people that need to be in treatment, we are hoping that more 

and more of them will be ready to accept treatment. 

Senator BALDWIN. Thank you. 

Senator Erpenbach, I want to continue this discussion about the 

nexus between law enforcement and public health and care and 

treatment for those with addiction based on your testimony about 

the incredible work that is being done in Sauk County. 

You talked a little bit about some of the treatment that begins 

in jail and how there are often interruptions when a person leaves 

and tries to seek that same treatment in the community. I think 

the Vivitrol example is a key example. How is the treatment funded when it is offered in a jail setting? How is it not being covered 

when it becomes an issue of community treatment for the profile 

of people who are needing it? 

Senator ERPENBACH. Well, I do know that in Sauk County, with 

St. Vincent de Paul, who first stepped up and started paying for 

it, and, obviously, they cannot afford it, they have had about 30 

people who have gone through the CARE program and gone 

through it successfully. And, obviously, you identify who would be 

good candidates while people are serving their time in Sauk County Jail. 

And, again, if we, as a State, decided to suspend, as opposed to 

terminate, Medicaid services for folks who are sitting in county 

jails, that would go a long way. That would be a very first good 

step. 

The next step, again, would be, in my opinion, to taking the Medicaid expansion, because somebody who is making minimum wage 

is not eligible for BadgerCare in Wisconsin, and there is 13 percent 

of those who would be eligible from the 100 percent to the 138, 13 

percent of those or so who have addiction-related issues that are 
43 

costing society and their families and themselves ultimately, in 

many cases the ultimate in their death, when they die. 

So, one thing we should do in Wisconsin, and, I am going to talk 

with Representative Nygren about this at some point when we 

head into the next session, is what we can do in working with DHS 

to just suspend, not terminate, those services for those folks who 

lose their Medicaid eligibility. 

Senator BALDWIN. Thank you. 

Representative Nygren, I just want to commend you on your 

work on the HOPE Agenda, the work that we have talked about, 

in terms of coordinating at the State and Federal level. I would 

love it if you could spend a few moments further talking about the 

agenda pieces that improve access to Narcan, or naloxone, and 

whether you are already hearing any feedback about how those are 

working in communities across the State. 

Representative NYGREN. Sure. So, you know what, we in Wisconsin, I think we are a true citizen legislature. We all bring different experiences to the table. My background in insurance, finance, the restaurant business, as a small business owner—so I 

kind of thought that would be my area of expertise, but God had 

a different plan in addition to that, having a daughter with an addiction. So, a lot of the experiences that I have already went 

through with Cassie have enabled us to turn some of those experiences into legislation. 

So, the day that we got that phone call and we found her purple, 

struggling to breathe, needle in her arm, and I tried to help her 

breathe until the paramedics arrived—or EMTs. Marinette we have 

both basic-level EMTs, who are emergency rescue squad, which is 

all volunteer; and we have paramedics assigned to Bay Area Medical Center. 

The paramedics showed up first. I did not know the difference, 

necessarily. But, they administered naloxone and brought her back 

to life. So, that experience began to get me thinking about it. It is 

like, well, what happens if I am in a rural area, and it is a police 

officer that shows up first? At that time, basic-level EMTs, the rescue squad folks, or police and fire, unless they have advanced EMT 

training, did not have the ability to carry and administer naloxone. 

So, we changed that. 

In addition to that, this session we also expanded access to 

naloxone through what is called a standing order. There are a 

number of pharmacies, Walgreens, CVS, Aurora in our State that 

are allowing for naloxone to be purchased with some simple training through what is called a standing order with the local pharmacist. 

There is not a lot of data yet on that, but I have been kind of 

pushing my folks in the administration, my staff, to try and get 

data on that first piece. And, I can tell you that we recently got 

a graph, actually an outline of the State of Wisconsin, showing the 

number of administrations of naloxone during the last year. And, 

the total was, I believe, nearly 4,000. 

So, you know that oftentimes we pass legislation that we do not 

necessarily know or have a good idea of what the immediate effects 

are, but it has been argued by some that putting naloxone into 

more hands enables that behavior. The objective here is getting 
44 

more people in recovery so they can be productive, tax-paying citizens living the American dream. Sorry for that, spouting that ideal. 

Well, they cannot do that, they cannot recover, they cannot get into 

recovery if they are dead. So, the more access to that, the better. 

Senator BALDWIN. Thank you. 

Chairman JOHNSON. Would you like to just do a closing statement, because people have been very patient. So, just have a couple 

closing comments before we close out the hearing? 

Senator BALDWIN. I just think it has been an extraordinary opportunity to hear from Wisconsinites who tackle this issue from 

various perspectives, some having faced tragedy. Frankly, even 

those who were coming to speak because of the office they 

held—everybody has a personal experience with this. 

But, we have an extraordinary amount of education due to make 

everyone aware that this is an epidemic, that this is an emergency. 

And, I think that the better job we can do of understanding the 

root causes from cartels in Central America to well-intentioned 

physicians and prescribers in communities across America, who are 

just trying to alleviate pain, but are not prescribing in manners 

that are safe, with the guidance they need, once we understand 

that, we can do a much better job, and I think we are with these 

State leaders, we are moving in the right direction. But, boy, this 

epidemic is far ahead of us right now, and we need to catch up, 

and we need to do it fast. 

Thank you again. Thank you to the audience members who sat 

through—I suspect everyone in here is here because you have a 

passionate belief in getting this right. So, thank you for that time 

and attention and any help you can give us to get the job done. 

And, Chairman Johnson, thank you for having this hearing. 

Chairman JOHNSON. Thank you. 

I am an accountant. I got some numbers. Let me just run a couple numbers by before I do my closing statements. 

What we are witnessing here, obviously, are tragedies to individuals and to families, and what we are seeing here is, I think, some 

pretty extraordinary, but I would say probably not uncommon, cooperation at the local and State level, trying to grapple with a very 

difficult problem. 

One of the issues we have, when we talk about funding, is there 

are always limited resources. Just so you understand, on a Federal 

Government level, for fiscal year 2016, we will spend about $30 billion on the war on drugs, about half of it on the demand side, half 

of it on the supply side. 

This hearing is just one in a series, and one of the things we will 

definitely do is try and delve into that $30 billion that we spend 

and see if there a better way to deploy it. Are we better off, rather 

than spending $30,000 or $50,000 per prisoner, looking at using 

that in terms of treatment? But, again, the treatment costs are 

high, and we just really do have to really figure out a better way 

of addressing these problems. 

It is very complex. There is the supply side, there is the demand 

side, there is the treatment side. From the Federal Government’s 

standpoint, we do need to concentrate on that supply side, and, the 

fact that we do not have those secure borders, the fact we have 
45 

those drug cartels creating such barbarity and evil in the world. I 

mean, we definitely have to address that. And so, we will do that. 

But, again, I commend you folks for working together in a very 

bipartisan fashion. I commend you for taking the time to be here 

today. Hopefully, the public does take a look at this and go, it is 

possible, we do do it, we do like each other, we do try and work 

together, and the approach to be used is try and find areas of 

agreement. 

There are plenty of things that divide us. I mean, even in this 

hearing, there are some differences, no doubt about it, but we are 

all human beings. There is no one political party that has a monopoly on compassion. We want to solve these problems. If we concentrate on those areas of agreement, it is just a whole lot easier 

finding common ground. 

And, if you will indulge me for 2 seconds. I was not going to do 

this, but prior to this hearing, my wife did reach out to her brother 

and got a text. And, I did not want to bring in anything like that, 

but I just have to read some—there is a text with probably about 

20 different lines in it. 

Talking about the autopsy report, ‘‘he could not read it. Too sad. 

I am still crying. Just tears to me now, big tears’’. 

That is what is affecting people’s lives, these tragedies on an individual basis. 

So, again, Senator Baldwin, thank you for your involvement in 

this issue, things you are trying to work on. Gentlemen, thank you 

for what you are doing. Again, the audience members, you are 

probably here because you have been touched, you have been affected by this. 

This is not going to end. This is a big problem, it is a complex 

problem, many components to it. But, if we work together, if we 

concentrate on areas of agreement, the shared goal of trying to rid 

this country, quite honestly this world, of this scourge, we just 

might start finding some commonality. 

So, with that, let us close it out. The hearing record will remain 

open for 15 days, until April 30 at 5 p.m., for the submission of 

statements and questions for the record. 

Thank you all. This hearing is adjourned. 

[Applause.] 

[Whereupon, proceedings were adjourned at 4:57 p.m.] 

(47) 

A P P E N D I X 
48 

unanimously passed 17 bills as part of the Heroin Opiate Prevention and Education (HOPE) 

Agenda, 16 of which have been signed into Jaw. At a federal level, I was happy to support the 

Comprehensive Addiction and Recovery Act to battle the opioid epidemic in March and earlier 

this month I introduced legislation to reduce the pressure doctors currently face that may lead to 

overprescribing painkillers. These bills will go a long way in addressing our public health crisis, 

but until we increase the security at our borders, the problem will persist. 

I thank all of our witnesses for appearing today and for sharing their stories, and I look forward 

to your testimony. 
49 

Opening Statement of Senator Tammy Baldwin 

Border Security and America's Heroin Epidemic: The Impact of Trafficking and Abuse of Heroin 

and Prescription Opioids in Wisconsin 

AprillS, 2016 

Thank you, Chairman Johnson, and thank you to all of the witnesses for being here today. Each of you 

are on the front lines of Wisconsin's heroin and opioid abuse crisis. For many, this issue has directly 

touched your family- so I look forward to hearing from you on how we can improve the health and 

safety of our communities. 

Heroin use and the abuse of opioid painkillers in the U.S. has now reached epidemic levels. In 2014, 

28,000 people died from opioids, including heroin, which is tragically a new record high. Today we are 

facing the grim fact that more Americans die every year from drug overdoses than they do in motor 

vehicle crashes. 

Particularly troubling in Wisconsin is a surge in deaths tied to Fentanyl, a potent painkiller 50 times 

more powerful than heroin. According to a recent report from the Milwaukee County medical 

examiner's office, Fentanyl killed 30 people in 2015 an increase of 500% from 2012. 

But Milwaukee County is not alone in facing this crisis. Communities across Wisconsin struggle with 

this epidemic every day. I recently heard from Leonard, from Colfax, Wisconsin, whose grandson, 

Nathan, was killed in a car accident when he was just 16 years old. The driver of the other car was under 

the influence of heroin at the time. 

I have also heard from a mother from South Milwaukee, whose son suffered from addiction for 20 years. 

While he is now in recovery, at one point, she found him unconscious from a heroin overdose on their 

bathroom floor. And, another mother from Mukwonago wrote to tell me how her son's life was saved by 

paramedics who administered naloxone during his overdose. 

We are now in the midst of a public health emergency and we have a responsibility to guarantee that our 

communities and families have the resources they need to fight this. 

I am proud that Wisconsin has already made progress in addressing this crisis. State leaders, led by State 

Representative Nygren as well as Senator Erpenbach who we'll hear from today have already 

advanced several measures to help prevent opioid abuse and improve access to mental health services. 

And, our medical provider community is leading the country in improving safe opioid prescribing 

education. 

But, this crisis requires both our state and our .federal leaders to step up and take action. That is why I 

have championed several important reforms in Congress to fight opioid and heroin abuse. 

I recently introduced the Heroin and Prescription Drug Abuse Prevention and Reduction Act with my 

colleague Senator Brown of Ohio. This bill outlines a comprehensive approach to tackle the epidemic in 

four key areas: prevention, crisis, treatment, and recovery. This bill would: 

improve access to lifesaving opioid reversal drugs, like naloxone; 

expand access to medication-assisted treatments; and 

provide for greater treatment and recovery services for our hardest hit communities, like 

adolescents. 
50 

I was pleased that several of these provisions passed the Senate HELP Committee last month. 

As we've seen from the tragic events at the Tomah VA facility here in Wisconsin, opioids and addiction 

have hit our veterans extremely hard. In the Senate, I have authored bipartisan legislation- named in 

honor of Marine veteran Jason Simcakoski -that would provide safer and more effective pain 

management services to our nation's veterans. 

My bill would require stronger opioid prescribing guidelines for VA providers, give veterans and their 

families a stronger voice in patient care and hold the VA system accountable for providing appropriate, 

quality care. This bill recently passed out of the Senate Veterans' Affairs Committee, and I will continue 

to fight to see that it is enacted into law. 

However, our efforts to combat this epidemic will only be effective if we have a federal commitment to 

invest resources in our state and local communities. I have been proud to support bipartisan legislation 

that would supply emergency funding for prevention, treatment and recovery efforts. Unfortunately, this 

legislation has stalled in Washington because not enough Republicans joined Democrats to support this 

investment. It is my hope that today's discussion can send a strong message that more must be done. 

In addition, as a member of the Senate Appropriations Committee, I will continue to champion increased 

funding for programs to take on this epidemic, including the funding requested by President Obama. 

The impact of opioid and heroin abuse knows no political party. Nor is it a problem that either law 

enforcement or the health care system can tackle alone. The federal government can't solve this problem 

by itselt; just as we can't expect states or local communities to address it alone. It is an issue that unites 

us all and we need to work as partners. 

So, !look forward to learning more about how we can help our Wisconsin communities recover and stay 

healthy, and how we can work together to tackle a big problem with bold solutions. Thank you. 
51 

U.S. Senate Committee on Homeland Security and Governmental Affairs 

Border Security and America's Heroin Epidemic: The Impact of the 

Trafficking and Abuse of Heroin and Prescription Opioids in Wisconsin 

t\pril14, 2016 

Senator Kelly Ayotte Statement for the Record 

I want to thank Chairman Johnson and Ranking Member Carper for holding today's 

hearing to discuss the most urgent public health and safety issue facing my home state 

of New Hampshire-the fentanyl, heroin, and prescription opioid abuse epidemic. I 

know this is an issue of grave concern to Wisconsin, as well, and I am pleased that the 

committee has again taken its work on the road to hear from those who are being 

directly affected by this public health and safety crisis. 

Last September, we held a field hearing in Manchester, New Hampshire, and invited 

top federal officials from Washington to hear first-hand from members of our 

treatment community, local law enforcement, and families affected by this 

epidemic. I especially appreciated that Commissioner Kerlikowske traveled to New 

Hampshire to also take part in that hearing. 

In New Hampshire, the number of drug overdose deaths is staggering: In 2015, there 

were over 430 drug overdose deaths -159 of which could be attributed to fentanyl 

alone. These tragic statistics arc more than just numbers. They arc family members, 

friends and neighbors. I've had too many families tell me that they've lost a daughter, 

or a son, or mother- this epidemic is touching every community in our state. 

Solving this crisis requires a comprehensive approach. Over the past two years, I've 

spent a lot of time meeting with families, treatment providers, law enforcement, first 

responders, health professionals and individuals in recovery to better understand what 

they're seeing and to identify ways that we can help at the federal level. 

Whether it's speaking with families, hosting community forums, or riding along with 

first responders when they respond to overdose calls, these experiences have all 

served to reinforce my commitment to work with anyone to find effective solutions to 

this problem. That is why I am proud to be an original cosponsor of the 

Comprehensive 1\ddiction and Recovery Act-bipartisan legislation that has the 

support of over 130 groups across the nation, including the National District 

1 
52 

Attorneys Association, the Major County Sheriffs' Association, Community AntiDrug Coalitions of America, and the National Association of Attorneys General. 

The Comprehensive Addiction and Recovery Act would expand opioid abuse 

prevention and education efforts, expand the availability of naloxone to first 

responders and law enforcement, support additional resources to identify and treat 

incarcerated individuals struggling with substance usc disorders, expand drug takeback efforts to promote safe disposal of unused or unwanted prescriptions, 

strengthen prescription drug monitoring programs, and launch a prescription opioid 

and heroin treatment and intervention program. 

CARA would be a strong step towards combatting this epidemic, both in my state and 

across the country. Last month, the Senate passed the legislation by a vote of 94-1, 

and I am hopeful that the House of Representatives \vill pass this legislation quickly. 

Pinally, I want to touch on the role of fentanyl in drug overdose deaths. Fentanyl 

continues to cause more drug overdose deaths in New Hampshire than heroin. Eric 

Spofford, CEO of the Granite House and New Freedom Academy in New 

Hampshire, has said that fentanyl is a "serial killer." It should be treated as the deadly 

drug we know that it is. 

In September of last year, I introduced the Stop Trafficking in Pcntanyl Act to reform 

trafficking penalties for fentanyl, ensuring that the law appropriately reflects the 

potency of this drug-which is estimated by the DEA to be up to 50 times more 

powerful than heroin-and takes into account its increasing prevalence in drug 

overdose deaths. 

Law enforcement is working tirelessly to take these drugs off the streets. But we can't 

simply "arrest our way out of' this problem. I've heard from law enforcement in 

New Hampshire that key pieces they need to confront this public safety issue are 

more prevention efforts, more treatment options and more support for individuals in 

recovery. CARA would address all of these priorities. 

I thank Chairman Johnson and Ranking Member Carper for their strong leadership 

on this issue and for holding this field hearing. 

2 
53 

STATEMENT 

OF 

JAMES F. BOHN 

EXECUTIVE DIRECTOR 

WISCONSIN HIGH INTENSITY DRUG TRAFFICKING AREA PROGRAM 

BEFORE THE 

UNITED STATES SENATE 

COMMITTEE ON HOMELAND SECURITY 

AND GOVERNMENTAL AFFAIRS 

"WISCONSIN'S DRUG THREAT ASSESSMENT AND THE HIDTA PROGRAM'S RESPONSE" 

APRIL 15, 2016 
54 

Statement of 

James F. Bohn 

Executive Director 

Wisconsin High Intensity Drug Trafficking Areas Program 

(Wisconsin HIDTA) 

Before the U.S. Senate Committee on 

Homeland Security and Governmental Affairs 

"Wisconsin's Drug Threat Assessment and the HIDTA Program's Response" 

April15, 2016 

Chairman Johnson, Senator Baldwin, and distinguished Members of the 

Committee: 

It is my privilege to address you today on behalf of the Executive Board of the 

Wisconsin High Intensity Drug Trafficking Areas (HIDTA) program concerning the 

statewide drug threat assessment of Wisconsin, and in particular, the HIDTA 

designated region. My name is James F. Bohn and I have been the Director of the 

Wisconsin HIDTA since February 2015. Prior to that time I was employed as the 

U.S. Drug Enforcement Administration's (DEA) Assistant Special Agent in Charge 

responsible for overseeing DEA's three offices in Wisconsin. The HIDTA program 

in Wisconsin incorporates seven (7) counties around the state. In particular, the 

HIDTA designated counties include Milwaukee, Racine, Kenosha, Waukesha, 

Dane, Rock, and Brown counties, which thereby incorporate approximately 46% 

of the state's population. 

As I am sure you area aware, the HIDTA program is designed to support and 

encourage federal, state, local, and tribal law enforcement agencies to work 

together in Task Force situations to target identified drug threats in the local 

HIDTA-designated areas. Each year the Wisconsin HIDTA Investigative Support 

Center (ISC) conducts a comprehensive assessment of the drug threats in our area 

to identify and prioritize any new and continuing trends or threats affecting 

Wisconsin. It is also designed to provide the HIDTA participating agencies with 

2 
55 

strategic intelligence to assist in the development of drug enforcement and 

prevention strategies. The Wisconsin HIDTA currently has a total of 28 

participating federal, state, local, and tribal agencies. In addition, the Wisconsin 

HIDTA program assists numerous other non-member agencies throughout the 

state with investigative and intelligence support. 

Due to Wisconsin's geography, location, and population, Wisconsin can be 

described as a "destination" state for illegal drugs and drug activity. By 

"destination" state, I am referring to the fact that in most instances, once illegal 

drugs enter Wisconsin's borders, they are almost always going to be used and/or 

re-sold within the state. Wisconsin's proximity to the major source cities of 

Chicago and Minneapolis has a direct and significant impact on the presence of 

illegal drugs and drug activity in Wisconsin. Within Wisconsin, Milwaukee is 

considered a source area for illegal drugs for other Wisconsin cities in other parts 

of the state. While Wisconsin is geographically located on the norther border of 

the United States, our investigations and intelligence reports of any significant 

seizures being sourced by drug trafficking organizations from the northern border 

(which are relatively few) confirm that their initial entry into this country occurred 

in some other northern border location, such as Detroit or one of the more 

western states, or via the U.S. Postal or some commercial delivery service, before 

making its way into Wisconsin. While there is often speculation about the 

possibility of drug smuggling via watercraft transiting the Great Lakes into 

Wisconsin, there have been no seizures or credible intelligence reports that this 

type of smuggling activity has occurred, or is presently occurring. 

The latest Wisconsin HIDTA Threat Assessment found that, just as in years past, 

the vast majority of drugs entering Wisconsin are via passenger vehicle on one of 

the major highways intersecting the state, such as 1-94 that goes northwest across 

the state all the way from Chicago to the south, through Milwaukee, through 

Madison, and on to the Minneapolis area. In addition, 1-90 is also used to 

transport drugs from Chicago to the Madison area with connections to Wisconsin 

cities in the northern part of the state. 1-43 is a major transit point for Green Bay 

area drug traffickers to travel to Milwaukee to buy their drugs, or to continue on 

to Chicago. 

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The Wisconsin HIDTA is currently in the process of completing its 2016-17 annual 

Drug Threat Assessment. The preliminary indications are that there are some 

notable differences from last year's Threat Assessment; however, what is the 

same is that opioid abuse, including both heroin and prescription drug abuse, 

remain the number one drug threat in Wisconsin- mirroring the trend of much of 

the rest of the country. Wisconsin's drug trends often mirror the country's drug 

trends, albeit sometimes in a delayed status, or on a somewhat smaller scale. For 

years, Wisconsin experienced relatively low levels of methamphetamine-related 

activity, while much of the rest of the country struggled with both 

methamphetamine from Mexico, as well as domestic clandestine laboratories. 

Unfortunately, methamphetamine is now beginning to show a much larger 

presence all around Wisconsin. 

For years, most of the methamphetamine activity in Wisconsin was concentrated 

along the western portions of the state due to its proximity to Minneapolis. 

However, within the past year, larger quantities of methamphetamine are 

showing up all around the state, but particularly in northeastern Wisconsin 

(around Green Bay), and also in southern Wisconsin (around the Madison area), 

as well as the western and northwestern portions of the state, such as in the Eau 

Claire area. Most of the seizures have been directly linked to groups out of 

Minneapolis. However, in late 2015, a joint Kenosha County investigation with 

ties to Chicago resulted in the seizure of 17 kilograms of methamphetamine being 

seized just over the Wisconsin border. This seizure resulted in the arrest of four 

Hispanic male defendants who are suspected of adulterating it in such a way as to 

give it the appearance of cocaine so that it could be criminally marketed as such. 

In the northeast, around Green Bay, the methamphetamine trafficking has been 

between Asian (primarily Hmong) groups both in Wisconsin and Minneapolis. In 

Eau Claire, on the western edge of Wisconsin, methamphetamine trafficking and 

abuse is significantly more prevalent than heroin. The methamphetamine from 

Minneapolis is usually sourced from Mexico, and distributed by a number of 

criminal retail groups, including the Asian groups with ties to the Brown 

County/Green Bay area. Minneapolis continues to be a distribution center for 

large amounts of Mexican produced methamphetamine coming directly from the 

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southwest border by Mexican cartel/drug trafficking organizations (DTOs) into the 

Minneapolis area. 

Much of the heroin abuse in Wisconsin stems from users transitioning from 

prescription opioid abuse to heroin. In 2015, 100% of the Wisconsin survey 

respondents listed heroin as their number one drug threat which was up from 

41% of respondents as recently as three years ago. For 2015, Milwaukee County 

alone reported 109 heroin-related overdose deaths. The vast majority of the 

heroin in Wisconsin is sourced from Chicago-based traffickers with connections to 

the southwest border and the major Mexican cartels. Wisconsin traffickers, in 

particular Milwaukee-based traffickers, will often travel 90 miles south to the 

Chicagoland area several times per week and return with 100-150 gram quantities 

of heroin, usually of the Mexican or South American variety. The traffickers rely 

on passenger vehicles, often rental vehicles, to transport their drugs across the 

border. Some of these vehicles contain hidden compartments to further secret 

their illegal drugs and/or proceeds. 

Over the course of the past two-three years, the majority of heroin present in 

Wisconsin is one of the several types of high purity Mexican heroin (with the 

exception of Mexican black tar heroin), as opposed to the high purity South 

American heroin that was seen routinely for the decade or more prior to that. As 

I'm sure the Committee is aware, the ultimate sources for the heroin are one or 

more of the major Mexican cartels with distribution cells based in Chicago. In 

2015, Wisconsin HIDTA associated or led Initiatives seized a total of over 10 

kilograms of heroin, including the seizure of three kilograms of heroin from a 

Milwaukee residence, indicating the presence of much larger quantities than 

previously experienced locally. That Wisconsin investigation traced the source 

back to Chicago. In that instance, like in most instances of Wisconsin traffickers, 

the Chicago source was within the same ethnic and/or racial group, or they will 

have familial ties. Ultimately, the Chicago-based drug trafficking organization 

(DTO) at some point will have ties to a Mexican source associated with one or 

more of the major cartels. 

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In addition, in Milwaukee in particular, the growing heroin problem has led to 

increased violence and challenges for law enforcement; not only by having to deal 

with the ever-increasing number of overdoses and deaths, but also due to the 

change in how the retail market has evolved. In Milwaukee, "mobile drug 

houses" have become commonplace and have presented law enforcement with a 

new and more dangerous challenge. Retail distributors will travel around the city 

and region in passenger vehicles with heavily tinted windows, delivering retail 

amounts of illegal drugs (usually heroin) to dozens, sometimes hundreds, of 

customers daily. These transactions literally take just seconds to complete. These 

perpetrators then brazenly refuse to stop for law enforcement. These traffickers 

are almost always armed and there will often be more than one violator and more 

than one weapon inside the vehicle if and when they are stopped; posing an 

increased level of danger not only to law enforcement, but also to the public with 

their reckless driving and disregard for their own safety and the safety of the 

innocent public as they are fleeing. 

Of growing concern during 2015 and continuing into 2016 is the increased 

presence of fentanyl, which has also contributed to the record number of 

overdose deaths in Milwaukee County. This most recent increase in fentanyl 

abuse appears not to stem from the diversion of pharmaceutical fentanyl, such as 

transdermal patches, but rather from fentanyl that is most-likely clandestinely 

produced and mixed in with quantities of heroin being smuggled into the region. 

In addition to all types of illegal drugs sourced from cartel distribution cities and 

hubs such as Chicago, Wisconsin is also the destination state for a large number of 

parcel packages that contain all types of illegal substances. In 2015, the 

Wisconsin HIDTA Interdiction Initiative, based in Milwaukee, interdicted a total of 

289 parcels containing a variety of substances, the most common of which was 

high-grade marijuana. Most of these packages were from western and southwest 

border states such as California, Colorado, Washington, Arizona, and Texas. The 

packages range in size from relatively small amounts up to 50 or more pounds. 

They are usually addressed to vacant lots or buildings. The majority of these 

packages are sent through the U.S. Postal Service, as well as other commercial 

delivery companies. Due to the geographical distances between Wisconsin and 

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the west coast and/or the southwestern border, many drug trafficking 

organizations find it more economically feasible and less risky to ship numerous 

parcels to Wisconsin rather than driving larger loads that long distance. 

In response to Wisconsin's identified drug threats, the Wisconsin HIDTA program 

uses a multi-faceted approach to address the identified threats. In particular, the 

Wisconsin HIDTA has a multi-agency task force made up of federal, state, and 

local investigators specifically targeting heroin DTOs operating in and around 

Wisconsin. In the past year, several additional investigators from numerous 

departments, many of which from smaller suburban departments, have joined 

the task force due to the prevalence of heroin abuse and trafficking in their areas. 

However, almost all of the Wisconsin HIDTA enforcement initiatives routinely 

conduct some level of heroin or opioid focused investigations due to the scope of 

the problem all around the state. 

In addition, our ISC works closely with many departments and agencies around 

the state to assist with analyzing evidence, in particular, communication devices 

found at overdose death crime scenes in order to find links between traffickers at 

all levels. With HIDTA funding and support, our ISC supports numerous 

intelligence programs and investigative efforts that are specifically designed to 

encourage collaboration and intelligence sharing so as to identify connections and 

close intelligence gaps between jurisdictions and agencies. 

The Wisconsin HIDTA has been actively and routinely involved in training and 

education related specifically to the heroin and opioid abuse problem. Wisconsin 

HIDTA participating agencies regularly conduct heroin-specific training for law 

enforcement, as well as awareness-type training for the public. During the past 

several years, the Wisconsin HIDTA has participated in numerous "heroin/opioid 

summits" all around the state to raise community and public awareness of the 

problem. The Wisconsin HIDTA funds and supports six full-time collocated local 

prosecutors, one of which is dedicated solely to prosecuting heroin and 

pharmaceutical diversion cases. 

Our prevention initiative, Safe & Sound, also works closely with residents, youth, 

and law enforcement in and around Milwaukee's most affected neighborhoods to 

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assist with the prevention of future detrimental behavior and activity. In 2015, 

the Wisconsin HIDTA received some discretionary funding from ONDCP that will 

enable the Safe & Sound program to assist other Wisconsin communities by 

replicating its unique approach toward improving the quality of life for 

communities negatively impacted by drugs and the associated violence and 

crimes. 

The Wisconsin HIDTA is committed to facilitating cooperation among federal, 

state, local, and tribal law enforcement and prevention efforts through the 

sharing of intelligence, and by providing support to coordinated law enforcement 

efforts toward identified drug threats. 

On behalf of the Wisconsin HIDTA Executive Board, I want to thank you for the 

opportunity to appear before the Committee today, and for your continued 

support of the HIDTA program. 

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TESTIMONY 

OF 

TIM WESTLAKE, MD, FFSMB, FACEP 

VICE CHAIRMAN, STATE OF WISCONSIN MEDICAL EXAMINING BOARD 

CONTROLLED SUBSTANCES COMMITTEE CHAIRMAN 

BEFORE THE 

UNITED STATES SENATE 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENT AFFAIRS 

FIELD HEARING 

"BORDER SECURITY AND AMERICA'S HEROIN EPIDEMIC: 

THE IMPACT OF THE TRAFFICKING AND ABUSE OF 

HEROIN AND PRESCRIPTION OPIOIDS IN WISCONSIN" 

PEWAUKEE, WISCONSIN 

APRIL 15, 2016 
62 

Chairman Johnson, Ranking Member Carper, Senator Baldwin and other distinguished 

Members of the Committee: 

It is an honor and privilege to testify, and I thank you for the opportunity to address you today on 

behalf of the patients and doctors in the State of Wisconsin. 

I serve as Vice Chairman of the State Medical Examining Board, where I am also the Controlled 

Substance Committee Chairman. I work as a full-time Emergency Physician, and have over 15 

years of practice in the suburban Milwaukee area. I am also EMS medical director for many of 

the EMS agencies in the communities surrounding my hospital. In these roles, I have been both 

in the trenches intimately involved in the treatment of heroin and prescription drug abuse, as 

well as helping lead the State's response on a regulatory and policy level. I would like to share 

some of my experiences on this complex issue, what we are doing in Wisconsin in the battle, 

and finally propose a few small changes to federal code that you as federal legislators could do 

to help support our communities in battling this scourge. 

As is now becoming common knowledge, there is an epidemic occurring from the use of 

prescription opioids almost invariably followed by heroin in this country. Across the United 

States you are statistically more likely to die of an accidental prescription drug or heroin 

overdose than from a motor vehicle crash. In my practice as an emergency physician in a small 

suburban hospital in it is not uncommon for me to see one or more opioid overdoses per week, 

and of the 20 or so patients I see per day, usually 3-4 are on chronic opioid medications. The 

diagnosis of opioid use disorder has a mortality and long term survival prognosis similar to a 

diagnosis of cancer. Over 80% of the heroin use in general and nearly all of the teenage and 

young adult use starts with prescription drugs. The direct and indirect costs to our society is 

astronomical, but is easily dwarfed by the the impact of the pain and suffering experienced by 

the users and their families. On average across America, someone dies from an opioid 

overdose every 24 minutes. Quite simply, It is the public health crisis of our times. 

To speak frankly, there can be no doubt that the sources of the supply of opioids stem from the 

ease of availability of prescription opioids due to over-prescription by doctors themselves. We 

physicians need to own our part in the problem. It is incontrovertible that over 80% of heroin 

users start first with prescription opioids. Almost inevitably, when the pills are too expensive and 

the person is opioid-dependent, the next step is to move into heroin use. With the relatively 

cheap cost of heroin trafficked over the southern border and with synthetic opioids such as 

fentanyl and other synthetic opioids coming by mail order, Wisconsin is awash in opioids. 

As an emergency physician, I unfortunately see the carnage up close and intimately, and on a 

far too frequent basis. I have been witness to heartbreak beyond comprehension and have had 

to tell innumerable families that their beloved family member will never come home. I will never 

forget sitting next to and telling a good friend and nurse colleague from my very emergency 

department that the patient in room 3 was dead. I could not save her own son from a 

prescription drug overdose. My friend Carolyn's son Josh had started on prescription opioids, 

then moved to heroin, and went back and forth based on what he could beg, borrow or steal. 

Eventually one morning Josh was found dead in his underwear in the front yard of a drug house 

and brought to the ER at which his mom and I worked. The paramedic that was called to the 

scene and tried to resuscitate him and was a close family friend and knew Josh from when he 

was a baby. What can be said to a mom who just lost her child? Sometimes all I can do as an 

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emergency doctor is to bear witness to the pain and suffering in my community. As far too many 

reading this are aware, there are almost no families untouched by the scourge of addiction. 

It is very important when looking for the cure of a disease, to understand the causative factors 

that led to the development of the disease in the first place. To be honest, as long as healers 

have been using opioids to relieve pain, there has been abuse. As physicians, it is a fine 

balance we walk while attempting to alleviate the suffering of our patients while at the same time 

being responsible prescribers and not enable the devastation and destruction of addiction. The 

surge in abuse was and is made possible by the increased availability of prescription drugs 

directly related to regulatory changes that occurred in the late 1990's. The origins come from 

the idea that pain was under-treated and physicians should be more generous with opiate 

prescriptions. You will all recognize one outcome as the pain scale that is incessantly asked of 

you when you visit your doctor. As with many regulatory mandates in healthcare, it started as a 

well intentioned idea, but has had devastating unintended consequences. 

Traditionally, and up until the early 2000's, opiates had not been used in cases of chronic noncancer pain. But then the "Pain as the fifth vital sign" initiative was released federally 

(coincidentally first by JCAHO, CMS and at the VA), which artificially alters literally all patient 

encounters and keeps patients focused on their pain. It is well established that patients can be 

comfortable while having moderate pain, and the pain scale itself has never been proven 

scientifically to be an empirically sound tool for guiding pain treatment and management. At the 

same time the pain scale was federally mandated, there was also a very effective legislative 

push by pain advocacy groups, pain specialists, and drug companies to alter state statutes that 

prohibited the use of opiates for chronic non-cancer pain. Also occurring concurrently new 

extremely potent and potentially addictive long acting pain medications like Oxycontin and MSContin were released to market. All of these lobbying effects were extremely successful, and by 

2003 there were only 5 States that had not changed their regulations and/or statutes to allow 

more permissive use of opiates in cases of chronic non-cancer pain. The effect was to open the 

flood gates and the amount of prescribed opiates has increased explosively since. The 

scourge of the prescription drug epidemic is a direct unintended consequence of these changes. 

I cannot state strongly enough that the urge to try to do something and address this crisis by 

federal legislative solutions needs to be resisted. The lions share of healthcare regulation 

occurs at the State and local level, and as such, most of the responsibility for addressing the 

prescription drug epidemic will come from the States, hospital systems, and physicians 

themselves. It is very important to remember that in the first place, most agree that the spark 

that ignited and continues to fuel the epidemic was born out of federal regulatory effort. 

In Wisconsin, we are blessed to have the insightful leadership of State Rep. John Nygren and 

Attorney General Brad Schimel. They understand that the most useful role of government is to 

provide and encourage the best environment where the healthcare providers and systems 

themselves can find the solutions that work in their own communities-for both the prescription 

opioid as well as other problems. We have been involved in the NGA Best Practice Policy 

Academy for Reducing Prescription Drug Abuse, and have extensively studied what other states 

have done and looked at what legislative and regulatory reform has worked and what has not, in 

order to come up with the best possible regulatory reform for our state. State Rep. Nygren has 

led the state with phenomenal innovation and insight in crafting and shepherding the passage of 

wise legislation that really addresses the root of the problem while remaining as least-invasive 

as possible. Rep. Nygren has real skin in the game with a daughter who's battled opioid 

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addiction, and he's committed to finding and implementing the best possible solutions. He has 

sought out stakeholders from all areas of what his legislation touches and asked real questions 

and listened and adjusted his legislation accordingly. Attorney General Schimel has been 

visionary in attempting to find real solutions to this crisis, not just lay on the heavy hand of law 

enforcement. I remember when he was the Waukesha County District Attorney almost 7 years 

ago and came to my hospital and was educating the doctors and staff about the crisis that was 

occurring in prescription opioid and subsequent heroin abuse, a proverbial canary in a coal 

mine. He has always said we can't arrest our way out of the epidemic, a comprehensive 

approach was needed. He made impacting the opioid crisis a plank of his campaign for election 

to the Attorney Generals office and it is a cornerstone of his work to this day. 

At the State policy level, under the leadership of AG Schimel, Rep. Nygren and me, we have 

established the Wisconsin State Coalition for Prescription Drug Abuse Reduction. This is a 

collaborative impact practice model that leverages the strengths of the members of the coalition 

to position the state's resources in a way to best address the prescription drug abuse issue and 

any intended and unintended consequences from the regulatory and legislative changes. 

Members of the coalition represent all the stakeholders in healthcare: Legislature, Attorney 

Generals office, Medical/Nursing/Dental Exam Boards, Wisconsin Medical/Nursing/Dental/ 

Pharmacy Societies, Hospital Association, addiction community, treatment community, public 

health community, Department of Human Services/Medicaid, insurance providers, rural hospital 

cooperatives, and most importantly representatives from almost all the health systems across 

the state large and small. We are looking at what can be done to provide support to the doctors 

in the trenches and the patients to whom they are giving care. We are looking at ways to find 

and share best practices system to system and implement the reform from within the systems 

and medical community ourselves with the least collateral damage to those already addicted. 

We understand that the true solutions will come from within the communities and health 

systems themselves and have worked to engage stakeholders from every level. 

In looking at causes of over-prescription we have seen that we are dealing with 2 main types of 

prescriptive behavior. The first and by far most common is the 99% of prescribers that are 

meaning well, but whose arguably "overly generous/loose" prescriptive practices have helped 

lead to patient addiction directly and also indirectly by "leftovers" that are then abused. On the 

other hand, there are the prescribers that know what they are doing and intentionally profit from 

the prescribing--! see them as the "doctor dealers". Both groups are completely different and 

require different measures to address them effectively. The "doctor dealers" will and should be 

addressed by law enforcement and state medical examining boards. State legislative and 

regulatory reforms are being instituted across the country at the state and local level which are 

significant improvements. 

We have come up with 2 areas that could significantly help in fighting the scourge of 

prescription drug abuse, that would require a change to US statutory code. I will go into detail 

below. 

1 )The biggest "bang for the buck" federal legislative solution that would likely have the largest 

impact in curbing excessive prescriptive behavior would be for some type of legislative change 

that would restrict federal agencies/entities from being able to fiscally mandate use of the pain 

scale. It has been my privilege to work with Senator Johnson's staff in helping determine what 

federal legislative changes would be most effective in this battle. We are extremely excited to 

hear that Senator Johnson has just released a bill last week that does exactly that! The bill 

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already has broad bipartisan Senate support and is the PROP act (Act to Reduce Pressure to 

Overprescribe Painkillers). Sen. Ron Johnson was joined by his colleagues Sens. Joe Manchin 

(D-W.Va.), John Barrasso (R-Wyo.) and Richard Blumenthal (D-Conn.) in introducing the bill. 

Johnson's bill is the Senate companion to H.R. 4499, a bipartisan measure introduced by Rep. 

Alex Mooney (R-W.Va.) that has been endorsed by the American Medical Association, American 

Hospital Association, American Society of Addiction Medicine, American Academy of Neurology, 

American Osteopathic Association, Physicians for Responsible Opioid Prescribing, Hazelden 

Betty Ford Foundation, Friends of NIDA, and American Association of Orthopedic Surgeons. 

Let me explain how the use of "the pain scale", "pain as a fifth vital sign", and the use of painrelated quality metrics in medical/hospital system reimbursement has significantly altered the 

physician patient relationship and led to over prescription. It has literally altered every single 

doctor patient interaction. As it stands, CMS is responsible for the 2 main parameters that are 

used to measure "Quality" but also have the unintended consequence of increasing the amount 

of opiates prescribed overall. The main item is the PQRS (Patient Quality Reporting System) 

item 0420- Pain Assessment and Followup. It looks at the percentage of patients aged 18 years 

and older with documentation of a pain assessment through discussion with the patient 

including the use of a standardized pain tool(s) on each visit and documentation of a follow-up 

plan when pain is present. The second CMS parameter is from the HCAHPS (Hospital 

Consumer Assessment of Health care Providers and Systems) --item 0166-Question on Pain 

Control. These have very significant downstream impact on prescriptive practices. 

The effect of these financial reimbursement based mandates has been the unintended 

consequence that pain is brought up again and again in every single patient encounter in the 

country. Pain is a completely subjective symptom, and is highly variable. When a provider is 

artificially forced to ask all patients again and again to rate their pain, this causes the patients to 

focus on their pain unnecessarily increasing the subjective experience of it. When you add in 

making the provider responsible for formulating a plan to address this elevated non-scientific 

pain measure, this completely changes the encounter. It is invariably skewed to the almost 

inevitable outcome that more narcotics will be prescribed. Having to use the pain scale 

introduces questions in a way they would not normally be asked. It is not useful to me, nor is it 

my natural practice, to be forced to always ask patients repetitively what their pain level is. It is 

much more natural to instead ask about pain without making focusing completely on it. I prefer 

to ask about how comfortable the patient is, and if they need/want anything else done to be 

more comfortable. Many patients when asked if they want anything more for their pain will 

respond "No", even with a pain rating of 7. The current federal reimbursement pain measures 

mandate that we address the patients pain and establish a plan to bring it down if it hasn't 

numerically changed after treatment, even if the patient is comfortable enough with the 

treatment and doesn't ask for further pain treatment. 

Having to use the pain scale is like having a federal regulator in the room of every single patient 

encounter asking the patient over and over what their pain level is. I have given the example of 

6 research studies that back up the idea that not only does the pain scale not symptomatically 

improve pain control, it is actually responsible for significant problems with over medication and 

over-prescription. Again, another example of unintended consequences to a well-intentioned 

idea. Now that we know how ineffective and potentially damaging it actually is, it is time to do 

away with the pain scale. Below I point to several evidence-based research with some 

interesting titles:(1 )"Increased Adolescent Opioid Use and Complications Reported to a Poison 

Control Center Following the 2000 JCAHO Pain Initiative", (2) "Kindness Kills:The Negative 

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Impact of Pain as the Fifth Vital Sign", (3)"Measuring Pain as the Fifth Vital Sign Does Not 

Improve Quality of Pain Management", (4)"Government Regulatory Influences on Opioid 

Prescribing and Their Impact on the Treatment of Pain of Nonmalignant Origin", (5)"Has The 

Pendulum Swung Too Far in Postoperative Pain Control?" .... These articles are eye opening 

and give credence to what almost every provider instinctively knows. I can provide links to the 

articles as needed. Just ask any doctor, nurse or medical assistant--It is well past time to do 

away with the pain scale! Thank you Senator Johnson for starting the process! We have had 

more than enough of the harmful consequences of over-regulation. 

That being said, it will also be very important to address the role and effects that JCAHO has 

played and continues to play in this epidemic. JCAHO is an abbreviation for Joint Commission 

on Accreditation of Health care Organizations. Only hospitals that have been accredited by 

JCAHO can receive payments from government plans like Medicare and Medicaid, making the 

group's standards highly influential. is a vital accreditation to have, and not having it could mean 

going out of business. 

To me in an eerie coincidence, I will use the emergency department I work at (Oconomowoc 

Memorial Hospital) as an example of the how this JCAHO issue plays out. Our emergency 

department has been able to achieve 10 consecutive years of patient satisfaction in the 95th 

percentile or above (usually the 99th) -every quarter in a row for the past 40 quarters measured 

by the Press Ganey company. There is literally no other ED in the entire US that has been able 

to accomplish this. I'm not saying it to brag, just to underscore that our patients are most likely 

very satisfied with how their pain is being managed. But in November, we had our routine 

JCAHO survey. They found that we were not documenting having asked our patients follow-up 

questions after pain medications were given, and we were cited for not being compliant. 

Coincidentally this measure comes directly from the Affordable Care Act, it is actually the piece 

about pain quality measures that Sen. Johnson's bill would repeal. Our hospital was given one 

quarter to get our compliance up to 90%. As you can imagine, providing emergency care is 

crazy most of time, and we are constantly running around time-managing what we really need to 

do to address the patients true needs. Well, we did not meet the 90% compliance goal, and we 

were just told that due to our 75% compliance, we did not meet the pain reassessment 

documentation requirement. Due to that alone, our JCAHO accreditation is at risk for the entire 

hospital. If we don't get the accreditation, it would likely cost the hospital huge resources (from 

tens to hundreds of thousands of dollars) to undergo a new survey and get reaccredited. This is 

for an emergency department that literally has the highest patient satisfaction in the country. 

Incidentally, our patient satisfaction continued to remain 99% for that same period. Isn't it 

common sense that our patients are most likely getting their pain management needs 

addressed? And the threat is to lose accreditation for the entire hospital. That is just one part of 

the craziness of the current state of excessive bureaucratic regulation in the day to day work of 

medicine, fighting the regulatory requirements to provide the care our patients deserve. We are 

seeing the bureaucratization of medicine as never seen before. 

Coordination with JCAHO and healthcare quality and patient satisfaction measuring companies 

is also vital to help reverse the unintended consequences that the emphasis on pain measures 

has had, and needs to be concurrently undertaken along with prompt passage of the PROP Act. 

It is time remove the government from the middle of the doctor-patient relationship. In a related 

note, more than five dozen nonprofit groups and medical experts sent a letter this Wednesday 

to the Joint Commission asking it to revisit its standards for pain management. The medical and 

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addiction community are unifying behind the dismantling of the "pain as a fifth vital sign" 

movement. 

2)The second area of potentially very useful federal legislative change I'd like to address is a 

way to decrease the supply of "leftover medications". One of the most impactful ways to 

address the current opioid crisis is to simply decrease the availability/supply of opiate pills 

prescribed. It is estimated that 80% of heroin users start by using prescription opiates first. It is 

also estimated that over 50% of prescription opiate abusers obtain their pills by diverting them 

from a relative. Many times kids end up stealing them from pill bottles kept from old 

prescriptions (ie raiding mom and dad's or grandma's medicine chest). There are over 9 billion 

(with a "B") individual Vicodin pills prescribed in America alone every year. It is estimated that 

only 1/3-2/3 of these pills are taken. That leaves 3-6 billion leftover Vicodin pills lying around, 

waiting to be mis-used. Any change in prescriptive practice that would decrease the amount of 

excess opiate pills and hence downstream supply, would go a long way in addressing the 

current epidemic. 

This is where a legislative tweak to the federal Controlled Substances Act could further such a 

change. As current federal law (and state law that mirrors federal) stands, it is not legal to 

provide a refill for schedule II narcotics, a physical prescription must be taken to the pharmacy, 

and cannot be phoned-in or faxed. And now with the recent change to reclassify hydrocodone 

medications as schedule II, this makes it even all the more difficult to prescribe. 

The unintended consequence of not allowing refills is that proceduralists (surgeons, dentists, 

and doctors that perform procedures with painful after-effects) and providers that treat acute 

pain are usually going to err on the side of over-prescription. They are more likely to prescribe 

more than they think the patient will likely need. This is done to make sure the patient doesn't 

suffer from unnecessary pain, and so the patient will not have to call the doctor (or perhaps the 

doctor's on call covering partner) back at night or on the weekend or during the busy daytime 

asking for a little more pain medicine. I think of this as the "hassle factor"--it is real. By 

prescribing a larger amount in this way, the patient and the doctor aren't likely to be 

inconvenienced by having to get a physical prescription refill. But, this almost always ensures 

there will be leftover opiate pills, in many cases in significant numbers. Almost everyone you 

talk to has stories of something like getting a tooth pulled or breaking their hand and then having 

48 vicodin left over, sitting in the medicine cabinet. Therein is the excess supply that enables 

and is a catalyst for abuse. 

For example, the way this plays out for a surgeon who performs a hand surgery is that he 

expects the patient to be in pain for 4-5 days afterwards, so he estimates at maximum the 

patient would need 20 vicodin. But some patients are more sensitive to pain, so not being able 

to write for a refill, he is likely to give a quantity of pills that would be likely more than most 

patients would need--like 40 pills. If he could instead write a time-limited small-volume refill that 

would expire after one week, then the patient would be able to control the amount dispensed, 

and there would be significantly fewer "left-overs". If most patients need less than 20-which is 

likely, then that many less would be in circulation. Again, it is estimated that there are 3-6 billion 

leftover Vicodin pills every year! 

So what we propose as a solution would be to amend USC Title 21 Section 829 which states no 

refills of schedule II drugs . The statute is found here https://www.law.cornell.edu/uscode/text/ 

21/829. We have extensively looked at ways to decrease this over-prescribing behavior. I 

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would propose a change to allow an exemption for one refill of hydrocodone based prescriptions 

that would expire in 1 week for quantities of less than 20 intended only for cases of acute pain 

management. After that time, if the patient had more symptoms he would need a physical 

prescription for any further quantities-as is the case now. 

There would be no change to chronic pain management. It would not touch how those 

medicines are currently prescribed, or how those patients are currently treated. Medications for 

chronic pain would continue to be prescribed for as is, and still require new prescriptions every 

single time with no refills allowed (as is the law now). The argument that this change would 

negatively affect chronic-pain patients has no validity, because there would be no restrictions to 

or changes in the way prescriptions are currently handled. There would just be the new 

availability for prescribers to write for less than 20 pills with a one time refill limited to a week. 

We think this would go a long way to help meet the goal of decreasing the availability of 

prescription opiates and keep them out of the hands of our children and adolescents. 

There are things that the federal government is doing that are working well and where federal 

legislation can have a significant impact in the battle. It is in the ability to bring resources to the 

states themselves to use for grant programs for health and law enforcement efforts. Wisconsin 

lawmakers are helping lead the way in this critical area. The most recent example other than 

the PROP Act is the Comprehensive Addiction and Recovery Act (CARA). It is a great example 

of the bipartisan legislative action in the battle against prescription drug abuse. I applaud both 

Wisconsin Senators Johnson and Baldwin for their support of this important bill, as well as 

Wisconsin Congressman Sensenbrenner for releasing it. 

Senator Baldwin has also done some very good work in this area of prescription drug abuse 

reform. She has authored the Jason Simkakoski Memorial Opioid Safety Act, which passed a 

Senate Committee hearing and has some very good reforms to affect change in prescriptive 

practice within the VA. It mirrors what we have done in Wisconsin with our reforms, taking what 

has worked at the state level and applying it in the VA system. It has emphasis on best-practice 

prescribing guidelines, targeted opioid continuing medical education for prescribers, 

encouraging use of prescription drug monitoring programs, and oversight by the regulatory body 

to ensure minimum standards are met, among other things. 

Senator Baldwin also has authored a bill the Heroin and Prescription Drug Abuse Prevention 

and Reduction Act which covers prevention, crisis, treatment and recovery. In it are great 

pieces that cover expanding access to buphrenorphine to help with medication assisted 

treatment, and also increasing availability of naloxone to reverse opioid overdoses,as well as 

expanding access to treatment. 

The question of justifying expenditures and funding is a very important one, and I feel the 

money put into prevention, management and treatment will deliver a significant return on 

investment as far as total costs/benefits to society and the quality of life in America. I have 

heard of an economic impact analysis that was done on a buprenorphine program in Peoria 

Illinois. They spent $600,000 on the program. Sadly, as is common the case with medication 

assisted treatment and treatment opioid treatment in general, the compliance/success rate was 

less than 20%. Even with that compliance rate, the estimated savings to society in Peoria was 

estimated to be $12,000,000 due to money that wasn't spent on incarceration, medical costs, 

and losses from crime associated with continued abuse related crimes. Truly the case seems to 

be strong that the the return on investment is likely worth the expenditure. 

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In closing, I applaud the efforts that Wisconsin federal and state legislators and leaders, and for 

that matter the government in general is taking in battling the scourge of prescription opioid and 

heroin abuse. We are seeing some great energy and interest in understanding and looking at 

how to best address this epidemic. The legislation so far has been thoughtful and not overreaching. The legislation Sen. Baldwin has been leading would be very useful in helping the 

Veterans Affairs system, the states and our communities in battling this epidemic. I literally 

cannot say how excited I am about Sen. Johnson's PROP bill -(the Act to Reduce Pressure to 

Overprescribe Painkillers). It puts us on a simple, straightforward and commonsense path. It 

moves us back towards allowing the medical community to do what we do best, take care of our 

patients without artificial interference. 

I think it is wise to remember that legislation and regulation is difficult to repeal and filled with 

unintended consequences that can be worse than the problem that is being addressed. The 

case in point is taken from the movement and follows federal policy in the 1990's that was trying 

to address the perceived problem that pain was being under-treated by health providers, which 

was the spark for the current prescription drug epidemic. This quote is from a press release 

taken from Surgeon General Murtha that was released just this last Tuesday, April 8th. "I came 

across a training document from the early 1990s that was directed at nurses and doctors. And 

one of the lines stood out to me clearly," he said. "It said, 'If your patient is concerned that they 

may develop dependence on opioids, you can safely reassure them that addiction to opioids is 

very rare in patients who have pain." ''That one line haunts me" he said. "I remember being 

taught that during my training and having to unlearn it. And I know there are many clinicians who 

were taught the same and still practice based on this teaching - with the best of intentions." 

The last opioid overdose death that I treated was this past week. I could not resuscitate him. 

He was in his early 20's. He told his friend he was going to shoot up and to give him narcan if 

he wasn't breathing. His friend came in 30 minutes later and he was flatline. He was the 4th kid 

to die from opioids in his high school class, from the local high school that sits next to my 

hospital. The police couldn't locate his family, and he was taken to the morgue with no family 

having said goodbye. The coroner who took him away said the Milwaukee County Medical 

Examiner's office was seeing about 2 opioid deaths per day. There have been 30 fentanylrelated deaths in Milwaukee County alone so far this year. There were 5 fentanyl-related deaths 

in 2012. This is the public health crisis of our times. It is not easy work we are doing in setting 

policy and regulations, but it will make a difference if we do it right. 

Thank you for the opportunity to contribute and testify in this hearing. 

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Lybert Family Story 

Tyler's Perspective 

My name is Tyler Lybert and I am a recovering drug addict. I started experimenting with 

drug and alcohol at the very young age of 11 years old. Alcohol was introduced to me by older 

people in 61

h grade and the only reason I started was because I wanted friends. I saw alcohol as 

an opportunity to make those friends so I started to drink and party on the weekends. 

Eventually I was introduced to weed in ?'h grade and saw it as not that harmful so I started to 

smoke. I quickly became an everyday user and started to make really bad choices. I was 

arrested when I was 12 for underage drinking and ended up getting arrested 16 more times 

after that for the same reason. 

Once I got into high school it opened up my world of partying to a lot more people who 

were doing the same things as I was. So dugs and alcohol became a way of life to me. Nothing 

else seemed to matter. Grades, school, football, and family became less and less important as 

drugs and alcohol where more the focus. Pills, more specifically OxyContin, were introduced to 

me when I was 15 and I couldn't resist. It was something new and exciting and I didn't have the 

will power to say no. Once I had said yes to my first hard drug, I rarely ever said no to anything. 

Acid, mushrooms, cocaine, or anything put in front of me was never refused. 

I ended up getting expelled from Arrowhead High School, and Devine Redeemer, and 

eventually landed back at Arrowhead's alternative program. There I graduated with and HSED. 

Once I got out of high school! had a new freedom to party more and do more of what I 

had grown to love so much. I had tried Heroin in high school but it had always scared me so I 

stuck to pills. At this time in my life I was already a drug addict and had that constant need to 

use all the time. The pills were becoming too expensive so I did what most people who can't 

afford to do pill anymore do, I switched to heroin. 

The cost of drugs out weighed what I was making at work so I had to result to different 

sources of income. The easiest source I saw at the time was to steal. So that what I did, I 

started to rob people and steal anything I could. The sad part is that the easiest people to steal 

from was my family. I stole and forged personal checks, business checks, cash, jewelry, and 

even TV's. Anything I could steal I would. I didn't like doing it but I had to. The voice inside my 

head was too loud and the only way to quite it down was to get high. 

This went on like this for years. Everyday I woke up hating myself, asking myself how 

can I keep doing this. Every morning I would avoid life because I didn't want to face it anymore. 

I hated my life, I hated everything about it. I had crushed every opportunity that was ever put 

in front of me, I had gone nowhere in life, and I was destroying my family. I hated what I was 

doing but I couldn't stop. I was an addict and drugs where more important. 

Eventually it came to a point where I hated my life so much that I couldn't find a reason 

why I was still living. I started to wake up praying that I wouldn't wake up anymore. I started 

praying that I would die. Every morning I woke up was a disappointment that it hadn't 

happened yet. We had tried multiple different treatments, inpatient, lOP, Methadone, 

Suboxone, and nothing worked. So my conclusion was that being sober wasn't possible, and 

that my only way out of this would be death. I figured maybe if I died my family could finally 

get some peace, maybe if I die my family can finally lead the lives they where supposed to lead 

without me having to drag them down anymore. 

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My family was at the point where they couldn't take it anymore either. They had been 

living this hell for 10 years and had tried everything. So they decided there was nothing more 

they could do for me and they kicked me out. I went down to Milwaukee and lived in a drug 

house for a bit. I was done, I couldn't take life anymore. 1 hated everything about my life and 

couldn't see a way out of it. It was then that I wanted to finally end it all and take my own life. 

I was in a dark room by myself with knife ready to end it all, when I got a phone call from my 

mom. She said "you have 2 options; you can keep doing what your doing but we never want to 

see you again. You're not welcome at our house, you can't call us, if you choose this we never 

want to see you again. Or you can go inpatient and we will support you %100." 

I went into inpatient and spend 5 and a half months in inpatient. There I had to learn 

how to live again. I had to relearn how to do everything. I had grown up learning to lie and 

steal, and manipulate. They had to undo all that and teach me how to live again. 

My family has been here every step of the way and I am proud to say that I have ben 

sober for 7 years. 

Ash leigh's Perspective 

My name is Ash leigh Nowakowski and I am Tyler's older sister. When Tyler and I were 

little, we were inseparable, we played video games, Ninja Turtle's and house. As we got older 

and more involved in our own sports and activities, while I was doing really well, Tyler started 

making bad choices including drinking and using drugs. 

At first, I thought he was just being a teenage boy and he would grow up and grow out 

of it. But he did not and I began to hate him. I hated him for my parents fight all the time. I 

hated him for my mom crying every day. I hated the fact that every time the phone would ring 

at our house everyone would jump thinking is this phone call that he is never coming home 

again. I hated even coming home from school because I didn't know what I was going to come 

home to, were the cops going to be there, were my parents going to be fighting? I wasn't 

known for my academic merits or my great horseback riding ability, I was known as the drug 

addict's sister. The thing I hated the most was how someone I loved so much could turn around 

and hurt me so badly. 

As a sibling, I felt like I had to be perfect. I felt that if I could get the best grades and be 

the best at my sports, maybe I could keep my family together. I often felt like the middle man in 

my parent's fights. I did everything I could possibly think of to keep my family somewhat 

normal. 

Our family never took trips to the Dells or camping or family vacations because of the 

fear of what Tyler would do. Tyler robbed me and himself of having those experiences. 

I also felt neglected by my parents. They were so focused on Tyler 100% of the time that 

they forgot about me. They would come to my horse shows and cheer me on, but they were 

never 100% there. They were always concerned about where Tyler was and what he was doing. 

In the deepest darkest times, I would secretly wish that he would die. I thought that if 

he did die, he wouldn't have to fight the demons anymore. I also felt that if he did die, then we 

would have to worry about him 24/7. 

Tyler didn't go into treatment until after my wedding. Tyler's drug use was so bad during 

the planning of my wedding that I couldn't even have him stand up. I didn't believe he would be 

alive to see me get married. I thought if I had him stand up and he died, then I would have had 

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72 

to explain to everyone at my wedding why there was a missing groomsman and I didn't want to 

have to that. 

When Tyler decided to go into treatment, I thought it would not work because it hadn't 

worked before. So it took me a good year and half to trust him and want to be around him 

again. I had to figure out how to separate Tyler the drug addict from Tyler my brother because 

they were two completely different people. 

Today, Tyler and I are closer than ever before. I am so lucky and grateful that he is sober 

and alive. But, there will always be that fear that at any day he could go back to using. 

Rick's Perspective 

My name is Rick Lybert and I am Tyler's father. I am not the same man I was 10 years 

ago. Back then, I was a very angry man and it was because of what Tyler was doing to my 

family. I watched Sandi for many years in a deep depression. It got so bad she couldn't even get 

out of bed. And I was mad at Tyler because he just couldn't stop, no matter what I did. The 

fighting, the yelling, the so-called house arrest, he just wouldn't stop. 

I was brought up to believe that as a father it was my job to protect my family. But 

Tyler's addiction was out of my control and I could no longer protect them. Even Ash leigh could 

no longer take it and she moved out of the house, I wish I could have gone with her. 

It wasn't until we me Charlie, Charlie was Tyler's drug and alcohol councilor in inpatient. 

Charlie told us that Tyler couldn't stop, he was an addict. What he told me next was something 

I'll never forget. He said "In order for Tyler to change, you have to change to." I can remember 

thinking, "why do I have to change? He's the one with the problem." What he was trying to tell 

me was that if nothing changes nothing can change. So we did start to change, and we saw a 

change in Tyler. 

I honestly never thought we would be in the place we are today. Tyler was an SO-pound 

heroin addict. I used to call him the walking dead. Sandi even had his funeral planned. Today, 

we are so very proud of Tyler and the man he has become. We have met so many families that 

are not as fortunate as we are. 

Sandi's Perspective 

My name is Sandi Lybert and Tyler is my son. Tyler was a great kid growing up. He was 

always happy and outgoing. When Tyler started to hang around different friends and using 

drugs and alcohol, he changed. He became withdrawn and angry. I watched my son dissolve in 

front of my eyes into a drug addict, a monster. 

I feel guilty because I missed the signs of drugs use. When I finally caught on to what he 

was doing and did start to see the signs, I ignored them because I didn't know what to or where 

to go for help. I felt that if !loved him enough and did everything for him he would quit. I began 

to enable him. I lied to my husband because I didn't want to fight anymore. I lost who I was as 

a person, a wife and a mother because I was so consumed with fixing Tyler. 

Tyler destroyed my life, his dad's life and Ash leigh's life for 11 years. We can never get 

those 11 years back. Tyler would yell scream, swear at me at the top of his lungs about what a 

terrible pathetic mother I was and how much he hated me because I was the fault of all of his 

problems. He would push me against the wall and punch holes around me and verbally abuse 

me until I gave him what he wanted. And even as I was crying, curled up, scared of my own son 

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73 

and his anger, he would walk away and not care as long as he got what he wanted. Then there 

was the soft side of Tyler when he would try to stop using. It was very hard to watch him 

withdraw; the sweating, shaking, vomiting, the begging to make it all stop. That broke my heart. 

When Tyler received his third DUI, I went to the jail to see him. He was in an orange 

jumpsuit and I couldn't touch him. I looked in his eyes and I saw nothing, he had nothing left. I 

left the jail that day and said "I am loving my son to death." So I went home, told Rick all the 

secrets I had been keeping and we made the hardest decision of our life, to kick Tyler out of the 

house. 

When I called Tyler, who was living in the drug house, to give him the ultimatum, I 

honestly didn't know if he would accept the offer of help. But, he did and we as a family, 

worked on his recovery together. I am so very proud of the person Tyler has become today. 

Wisconsin Barriers 

1) There needs to be more treatment options for adolescents and people who cannot 

afford treatment. We send most adolescents out of state because treatment centers 

here won't take them unless they have a dual diagnosis. Also, for those who don't have 

insurance, they have to go to Health and Human Services where the wait time to be 

seen can be 6 weeks or more. 

2) Adolescents can refuse and walk out of treatment at the age of 14. This leaves families 

hopeless. If their child has a drug/alcohol problem, and they refuse treatment, what are 

parents supposed to do? They continue to live in a vicious cycle until their child turns 18 

and they can kick them out. 

3) Funding for prevention. The average age of first use in Wisconsin is 12 years old. Kids 

need to hear clear and consistent prevention messages from 6th grade unti112'h grade. 

In an age where everything is real life, reality shows, facebook, snapchat, etc, kids want 

the same prevention messages, from real people who have lived it. Where prevention 

has the most impact is in schools where everyone hears the same message. Currently, 

schools don't have funding for prevention. We have teachers who pay out of their 

pocket to bring us in. Our greatest chance to stopping this problem is to educate them 

before they make that first choice to use. Thank you for your time. 

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74 

Testimony of La uri A. McHugh-Badura 

"Border Security and America's Heroin Epidemic: The Impact of the Trafficking and 

Abuse of Heroin and Prescription Opioids in Wisconsin" 

Apri115, 2016 

Good Afternoon, 

I'm consumed with grief as yet another overdose death in our small town community, of 

Oconomowoc, WI. This was no ordinary boy, this was someone dear to my own heart that I 

treated as my very own and loved. 

This was someone that I chose to carry the casket at my late son, Archie Badura's funeral just 

under two years ago, of heroin. 

For you see, yesterday I received the terrible news that Archie's childhood best friend John Paul 

G., had overdosed on heroin late Sunday afternoon. When I heard the news I buckled over was 

stunned with disbelief for a moment and silently prayed. 

I immediately left my office and raced to the G. Family home with some food and no words. 

I simply cried and held John's sobbing mother and reopened the wounds that will never 

completely heal--for no parent will ever get over the loss of their child--ever! The room was 

tilled with sorrow and disbelief. J finally wiped her tears and promised her I would fight for our 

boys, that they would not die in vain. To cling to her faith and our Lord-the boys knew Jesus and 

were now in a joyous place--free at last from the chains of addiction! 

I assured her it was no one's fault as these drugs take over an addicts body and demand more--

even though he was clean, and in recovery she thought doing so well, but that is when they arc 

most vulnerable. This family was in total shock, was trying to see what they could have done 

differently .. .if only ... 

When I stood to leave John's mother asked that I help gather pictures of her son so I have spent 

most of today organizing pictures for the upcoming funeral--I'm devastated, their family is 

forever shattered and so is our entire community. 

When I got home several teens/early twenties, from all over (one even from CO) contacted me 

last night, as they each had heard the news to jucry and share their utter disbelief of John Paul's 

passing. Each one saying, "Please make it stop Mrs. Badura, J can't take this anymore!!" For 

your see, another close friend of theirs is now forever gone. 

I promised each of them that I would continue to fight this battle and help implement changes in 

policy and legislation at county, state and at a national level. 

Please take a good long look at these two beautiful boys pictured below--now lost to this 

epidemic. Two kindred souls tangled in the mess of addiction that lost their battle. I know we are 

not alone, WI and our entire nation is sadly plagued and paralyzed by the epidemic/addiction and 

the fear of this possibly creeping into to their own individual families. 
75 

This truly must stop. I can only hope and pray that after this hearing on April 15th, that we can 

implement some new measures for border control and tighten drugs from crossing in and help 

save lives and give hope back to all our nations precious families. 

We are losing an entire generation, --that is why I'm so very driven and full of raw emotion to 

make a difference. 

Thank you -- L.A.M.B. 

My Archie on the left died May 15,2014 at age 19, his best friend John Paul, pictured middle, 

died 4-4-2016 at age 22, Augie my surviving son on the right is 20, is devastated by yet another 

blow of such a deep loss due to this epidemic. 
76 

TESTIMONY OF 

R. GIL KERLIKOWSKE 

Commissioner 

U.S. Customs and Border Protection 

Department of Homeland Security 

For a Field Hearing 

BEFORE 

United States Senate 

Committee on Homeland Security and Governmental Affairs 

ON 

"Border Security and America's Heroin Epidemic: The Impact of the Trafficking and Abuse of 

Heroin and Prescription Opioids in Wisconsin" 

April IS, 2016 

Milwaukee, Wisconsin 
77 

Introduction 

Good morning, Chairman Johnson, Ranking Member Carper, and distinguished Members of the 

Committee. Thank you for the opportunity to appear today in Wisconsin to discuss the role of 

U.S. Customs and Border Protection (CBP) in combating the flow of dangerous drugs into the 

United States. 

The use and availability of heroin and other illegal opioids, as well as the nonmedical use of 

prescription opioids in the United States, have been increasing at an alarming rate. The situation 

is one of the most important, complex, and difficult challenges our Nation faces today. According 

to a recent report from the Centers for Disease Control and Prevention, between 2002 and 2014, 

the rate of heroin-related overdose deaths quintupled, and more than 10,500people died in 2014. 

There is no single entity, nor a single solution, that can address this problem. Tackling this 

complex threat involves a united, comprehensive strategy and aggressive approach by multiple 

entities- from law enforcement, science, medicine, education, social work, and the public health 

sector- across all levels of government. While continued efforts to interdict heroin and other 

drugs at the border are a key aspect of addressing this crisis, interdictions, arrests and convictions 

alone cannot mitigate the far-reaching effects of nonmedical prescription opioid and heroin use. 

We need to focus on prevention and treatment, and identify the characteristics of developing cases 

of opioid use disorder before they escalate. We must also concentrate on deterring opioid 

trafficking by transnational criminal organizations (TCO). 

To do this effectively, we must better integrate our efforts, share information, and partner with 

federal, state, local and tribal communities as well as the private sector. In 2015, the Office of 

National Drug Control Policy (ONDCP) announced the High Intensity Drug Trafficking Areas 

(HIDT A) Heroin Response Strategy, 1 which fosters a collaborative partnership between public 

health and law enforcement entities. The strategy seeks a comprehensive response to this complex 

epidemic by addressing the broad range of efforts required- on the international, national, and 

local levels- to reduce the use, distribution, and trafficking of this dangerous substance. 

As America's unified border agency, CBP has a critical role in the efforts to keep dangerous drugs 

like heroin and other opioids out of the hands of the American public. Interdicting drugs at and in 

between our ports of entry (POE), and combating TCOs, are key components of our multi-layered, 

risk-based approach to enhance the security of our borders. This layered approach to security 

reduces our reliance on any single point or program, and extends our zone of security outward, 

ensuring that our physical border is not the first or last line of defense, but one of many. 

Secretary Johnson's Unity of Effort initiative has put in place new and strengthened management 

processes to enable more effective, integrated DHS component operations to address TCOs, drugtrafficking, and other cross-border threats. In addition, DHS-wide border and maritime security 

activities are guided by the new Southern Border and Approaches Campaign Plan and complement 

the Administration's National Drug Control Strategy, and the National Southwest Border 

Counternarcotics Strategy. Aimed at leveraging the range of unique Department roles, 

1 https://www. whitehouse .gov /the-press-office/2015/08/17/wh ite-ho use-drug-policy-office-funds-new-project· 

s high-intens ity-d rug 

Page 1 of9 
78 

responsibilities, and capabilities, the Campaign enhances our ability to work together in a more 

unified way to address these comprehensive threats. In support of this new Campaign, on 

November 20,2014, the Secretary announced the creation of three new joint task forces (JTF) to 

coordinate the efforts of the combined resources ofDHS component agencies. Joint Task ForceEast is responsible for the maritime approaches to the United States across the southeast, from the 

Gulf of Mexico to the Caribbean. Joint Task Force-West (JTF-W) is responsible for the Southwest 

land border from Texas to California. And, supporting the work of the other two task forces is a 

standing Joint Task Force for Investigations (JTF-1). These three JTFs reached full operational 

capability on July 30, 2015. 

Interdictions and Trends 

In Fiscal Year (FY) 2015, CBP officers and agents seized 3.3 million pounds of drugs across the 

country, representing a four percent increase from FY 2014 in overall nationwide seizure events, 

but a six percent decrease in drug seizures by weight. Additionally, heroin total seizure amounts 

for FY 2015 increased 23 percent to more than 6,000 pounds. CBP seizures of synthetically made 

opioids like fentanyl, while relatively small compared to heroin, have also significantly increased 

from 2.4 pounds in FY 2013, to 8.2 pounds seized in FY 2014, to 197.8 pounds seized in FY 2015. 

These figures demonstrate the continued effectiveness of CBP's detection and interdiction 

abilities, but also attest to the significant increase in heroin production in Mexico. 2 

Mexican manufacturers and traffickers continue to be major suppliers of heroin to the United 

States. Heroin is most commonly brought to the United States across the Southwest land border3 

or transported by couriers on commercial airlines. 4 With regards to fentanyl, the most significant 

source countries are Mexico and China. Fentanyl is smuggled into the United States across the 

Southwest border, and also shipped to a variety of locations within the United States via mail 

services. 

The reach and influence of Mexican cartels, notably the Sinaloa, Gulf, and Jalisco New 

Generation Cartels, stretch across and beyond the Southwest border, operating through loose 

business ties with smaller organizations in communities across the United States. The threat of 

TCOs is dynamic; rival organizations are constantly vying for control, and as U.S. and Mexican 

anti-drug efforts disrupt criminal networks, new groups arise and form new alliances. 

CBP Resources and Capabilities to Counter Drug Trafficking Organizations 

CBP, responsible for America's frontline border security, has a significant role in the Nation's 

efforts to combat the cross-border criminal activity of cartels and other drug trafficking 

organizations. In the past decade, DHS has deployed more resources, technology, and tactical 

infrastructure for securing our borders than at any other time in history. Technology and detection 

capabilities significantly contribute to identifying and deterring the entry of potentially dangerous 

people and contraband. 

2 "Drug Trafficking Across the Southwest Border and Oversight of US Counterdrug Assistance to Mexico", Caucus 

on International Narcotics Control, United States Senate, November 17, 2015, Statement of Michael P. Botticelli, 

Director, ONDCP http: ·

1

W\\'\V. drut:.caucus.senatt.:.l!.ov. s.itesldci1ndt.'fi le~ Michaclr~-020P. (~·O:::OBotticclli.pdC 

3 Heroin intercepted at the Southwest land border is most often from Mexico, but sometimes from South America. 4 Heroin intercepted in the international commercial air travel environment is from South America, Southwest Asia, 

and Southeast Asia. 

Page 2 of9 
79 

At Our Nation's Ports of Entry 

At POEs, the Office of Field Operations (OFO) utilizes technology, such as non-intrusive 

inspection (Nil) x-ray and gamma ray imaging systems, and canine teams to detect the illegal 

transit of drugs hidden on people, in cargo containers and in other conveyances. Since September 

11,2001, Nil technology has been a cornerstone of the CBP multi-layered enforcement strategy. 

As of October 15,2015,315 Large-Scale (LS) Nil systems are deployed to, and in between, our 

POEs. In FY 2015, LS-NII systems were used to conduct more than 7.2 million examinations 

resulting in more than 2,400 seizures and more than 390,000 pounds of seized drugs and more 

than $4 million in U.S. currency. 

Smugglers use varying and innovative tactics to conceal heroin. For example, on January 21, 

2016, CBP officers at the Port ofNogales, in Arizona, discovered almost 29 pounds of heroin 

concealed within a hidden compartment of a privately owned vehicle. And, on July 18, 2015, CBP 

officers at the Port of Hidalgo, in Texas, seized !51 pounds of heroin concealed within the back 

wall of a commercial bus. While vehicles may be a popular conveyance for smuggling, DTOs 

also move heroin in smaller quantities to try to evade detection. Just recently, CBP officers 

working at the express consignment facility in Cincinnati intercepted a package manifested as 

"candy." The package, which contained a tub of chocolate icing, showed some irregularities 

during an x-ray examination. After conducting a physical inspection, CBP officers determined that 

smugglers had placed a sealed bag of approximately two and a half pounds of heroin in the 

chocolate. And, on March 12,2016, CBP officers at the Orlando International Airport discovered 

six pounds of heroin concealed in the lining of a traveler's backpack. 

OFO deploys 478 specialized detection canine teams throughout the nation, trained to detect drugs 

and concealed humans. The majority of the canine teams are concentrated in four field offices 

along the Southwest border. Canine operations are an invaluable component of CBP's 

counternarcotic operations at POEs. For example, on December 17,2015, at the DeConcini POE, 

in Nogales, Arizona, a canine team conducting post-primary inspections resulted in the referral of 

a 31-year-old Phoenix woman for a further search of her Chrysler sedan. Officers then discovered 

nearly 44 pounds of heroin, valued at nearly $617,000, hidden within the rocker panels. During 

FY 2015, OFO canine teams were responsible for the seizure of 603,283 pounds of drugs, 

$34,991,253 in seized property, and $39,323,455 in currency. 

Responding to the upsurge in heroin use across the Nation, and increased seizures at POEs, in 

October 2015, CBP completed Phase I of a pilot program to train and equip CBP officers with 

Naloxone, a potentially life-saving drug for the treatment of opioid overdoses. During Phase I, 

CBP officers, at seven participating POEs 5 received training in recognizing the signs and 

symptoms of an overdose, administering Naloxone, and were certified as CPR instructors. Over 

the next few months, CBP will initiate Phase 2 of the Naloxone Initiative Pilot Program, 

expanding the pilot to an additional eight P0Es. 6 CBP was the first federal law enforcement 

agency to implement such a program. 

5 Phase 1 Naloxone Pilot Program POEs include El Paso; Laredo; Fort Lauderdale International Airport; John K. 

Kennedy International Airport; San Luis: San Ysidro; and Seattle/Blaine. 

'Phase 2 Naloxone Pilot Program POEs include Miami Int'I/Miami Seaport; Boston; Buffalo; Detroit; Newark; 

Chicago; Houston Int'I/Houston Seaport; and Dallas. 

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Along the Southwest Border 

Along the Southwest border, between the POEs, CBP has deployed capable resources to increase 

our situational awareness, identify changes in the border environment, and rapidly respond, as 

appropriate, to emerging threats and areas of increasing risk or illegal cross-border activity. The 

use of tactical infrastructure and advanced surveillance and detection technology in the border 

environment is an invaluable force multiplier to increase situational awareness. 

For example, CBP's Tactical Aerostats andRe-locatable Towers program, originally part of the 

Department of Defense (DoD) Reuse program, uses a mix of aerostats, towers, and electrooptical/infra-red cameras, to provide U.S. Border Patrol (USBP) with increased situational 

awareness through an advanced surveillance capability over a wide area. This capability has 

proven to be a vital asset in increasing CBP's ability to detect, identify, classify, and track activity. 

As of December 2015, USBP agents seized 122 tons of narcotics with the assistance of existing 

aerostats and towers. 

In addition to the hundreds of canine teams OFO deploys to the POEs, the USBP Canine Program 

deploys over 808 specialized detection canine teams- trained to detect narcotics and concealed 

humans throughout the nation. The majority of the canine teams are concentrated in the nine 

Sectors along the Southwest border. During FY 2015 USBP canine teams were responsible for the 

seizure of 432,761 pounds of narcotics, $3,073,313 in currency, and 39,942 human apprehensions. 

Just last month, canine teams in the San Diego Sector aided in the detection and seizure of 

narcotics valued at more than $1.2 million, including 14.35 pounds of heroin valued at $172,200, 

on a single day. 

Through the deployment of these complementary and effective resources, CBP gains more 

coverage and situational awareness of surveillance gaps, and increases its ability to adapt to 

changing conditions to effectively detect, identify, classify, track, and interdict potential threats 

along the borders. 

From the Air and the Sea 

CBP's Air and Marine Operations (AMO) is an essential component of a successful integrated 

strategy for border security, as well as a significant contributor to the national security and 

emergency response efforts of various Federal, state, tribal, and local agencies. AMO operates 

aerial and marine assets including unmanned aircraft systems and strategic and tactical aerostats 

-providing critical surveillance coverage and domain awareness for counternarcotic efforts on the 

ground, in the air, and at sea. Nationally, AMO contributed to the seizure of225 pounds of heroin 

in FY 2013; 724 pounds in FY 2014; and 627 pounds in FY 2015. 

In the maritime domain, AMO employs high speed Coastal Interceptor Vessels that are 

specifically designed and engineered with the speed, maneuverability, integrity and endurance to 

intercept and engage a variety of suspect non-compliant vessels in offshore waters, as well as the 

Great Lakes on the Northern border. 

AMO P-3 Orion Aircraft (P-3s) have also been an integral part of the successful counternarcotic 

missions operating in coordination with Joint Interagency Task Force South (JJATF-S). The P-3s 

patrol in a 42 million-square mile area known as the Source and Transit Zone, which includes 

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81 

more than 41 nations, the Pacific Ocean, Gulf of Mexico, Caribbean Sea, and seaboard approaches 

to the United States. In Fiscal Year 20!5, AMO's P-3 aircrews contributed to 198 seizure, 

disruption, or interdiction events in the transit zone, resulting in the interdiction of213,000 pounds 

of cocaine. 

In addition, DHS Science and Technology Directorate (S&T) is working with CBP to develop, 

test, and pilot new technology for securing and scanning cargo, improving surveillance of the 

Southwest border, and enhancing detection capabilities for radar-evading aircraft. S&T is also 

pursuing and fielding new technology to monitor storm drains, detect tunnels, track low-flying 

aircraft, monitor ports, and enhance current mobile/fixed radar and camera surveillance systems to 

increase border security. Recently, S&T-developed technology was put into operational use at the 

US-Mexican Border. These technologies included a new general aviation aircraft scanner in 

Laredo, TX, and a new Brownsville-Matamoras Rail Non-Intrusive Inspection Microwave Data 

Transmission System. 

Intelligence and Information Sharing 

Criminal intelligence sharing is a key component of countering drug-trafficking along the 

Southwest and Northern borders at and in between the POEs. CBP contributes to several 

initiatives to improve the combined intelligence capabilities of Federal, state, local, tribal, and 

international partners. 

CBP hosts monthly briefings/teleconferences with Federal, state and local partners regarding the 

current state of the border the Northern border and Southwest border in order to monitor 

emerging trends and threats and provide a cross-component, multi-agency venue for discussing 

trends and threats. The monthly briefings focus on drugs, weapons, and currency interdictions and 

alien apprehensions both at and between the POEs. These briefings/teleconferences currently 

include participants from: the Government of Canada; the Government of Mexico; JTF-W; U.S. 

Immigration and Customs Enforcement (ICE); U.S. Coast Guard (USCG); Drug Enforcement 

Administration (DEA); Federal Bureau of Investigation (FBI); U.S. Northern Command; Joint 

Interagency Task Force-South; Bureau of Alcohol, Tobacco, Firearms, and Explosives (A TF);; 

U.S. Attorneys' Offices; Naval Investigative Command; State and Major Urban Area Fusion 

Centers; and other international, Federal, state, and local law enforcement as appropriate. 

Substantive and timely information sharing is critical in targeting and interdicting individuals that 

move drugs and illicit merchandise from the POEs to their destinations throughout the United 

States and Mexico. CBP contributes to the whole-of-government effort to combat drug-related 

threats by sharing critical information on travelers and cargo with investigative and intelligence 

partner agencies to identify and disrupt sophisticated routes and networks. Recognizing the need 

for open and sustainable channels to share information with our law enforcement and intelligence 

partners, CBP co-locates interagency personnel at its National Targeting Center (NTC) to support 

efforts to combat drug and contraband smuggling by integrating real-time tactical intelligence into 

CBP targeting efforts and enforcement actions. This whole-of-government counter network 

approach has resulted in TCOs being identified and dismantled, and their smuggling routes shut 

down. An example of this successful collaboration can be seen in the aggressive targeting of 

heroin transiting, or destined for, the United States. In FY 2015, CBP efforts at the NTC, in 

conjunction with increased cooperation from foreign and domestic law enforcement partners, 

resulted in 40 seizures of heroin and several arrests. 

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Physical evidence gathering and forensic analysis is also valuable to the information sharing 

effort. Improved technology and enhanced capabilities have also expanded the collection, analysis, 

and dissemination of information between law enforcement partners working to dismantle DTO 

networks. For example, CBP's Laboratories and Scientific Services Directorate (LSSD) uses 

advanced techniques to provide qualitative identification and quantitative determination as well as 

pollen analysis of heroin, cocaine, marijuana, and methamphetamine to assist with identifying 

potential drug smuggling routes. In November 2014, CBP launched a new program that involves 

the close collaboration of CBP chemists in the laboratories and CBP officers on the 

frontlines. The purpose of the program is to rapidly identify questionable materials through 

presumptive chemical testing, while simultaneously allowing for the quick release of nonoffending, detained importations. The key to the success of the program is the rapid turnaround 

time of presumptive chemical testing of questionable materials. Through the end of2015, over 

7,300 items were examined. During this period, ICE's Homeland Security Investigations (ICEHSI) executed a significant number of controlled deliveries based on CBP' s presumptive 

findings. The most noteworthy takedown resulted in the seizure of $2.5 million in cash, tens of 

millions of dollars in assets, and 14 indictments. 

CBP exchanges information with our partners within the Government of Mexico. This 

information sharing, facilitated by the CBP Attache office in Mexico, has allowed for an 

unprecedented exchange of real-time information through deployments of personnel between our 

countries. Today, Mexican Federal Police personnel sit with our personnel in Tucson, Arizona, 

and Laredo, Texas, where they assist us with targeting criminal activity through the sharing of 

Mexican criminal history database information. Likewise, CBP personnel are assigned to Mexico 

City under the Joint Security Program where we exchange alerts on suspicious TCO movements 

through the monitoring of our Advance Passenger Information System. This information sharing 

has also Jed to numerous seizures and cases within Mexico that serve to disrupt the activities of 

TCOs throughout the Western Hemisphere. 

Enhancing counternarcotic operations in the air and maritime environments, AMO's Air and 

Marine Operations Center (AMOC), a state-of-the-art law enforcement radar surveillance center, 

integrates data from multiple sensor sources to provide real-time information on suspect targets to 

responders at the Federal, state, and local levels. AMOC's capabilities are enhanced by the 

continued integration of DHS and other Federal and Mexican personnel to increase efforts to 

identify, interdict, and investigate suspected drug trafficking in the air and maritime domains. 

Operational Coordination 

A whole-of-government approach that leverages interagency and international partnerships as a 

force multiplier has been and will continue to be the most effective way to keep our border secure. 

Providing critical capabilities toward the whole-of-government approach, CBP works extensively 

with our Federal, state, local, tribal, and international partners to address drug trafficking and other 

transnational threats at POEs and along the Southwest border, Northern border, and coastal 

approaches. Our security efforts are enhanced through special joint operations and task forces 

conducted under the auspices of multi-agency enforcement teams. These teams are composed of 

representatives from international and U.S. Federal law enforcement agencies who work together 

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83 

with state, local, and tribal agencies to target drug and transnational criminal activity, including 

investigations involving national security and organized crime. 

Under the Secretary's Unity of Effort initiative and with the three new DHS JTFs, CBP is 

enhancing our collaboration with other DHS components- specifically ICE and USCG to 

leverage the unique resources, authorities, and capabilities of each agency to more effectively and 

efficiently execute our border security missions against TCOs, drug-trafficking and other threats 

and challenges. JTF operations also increase information sharing with Federal, state and local law 

enforcement agencies, improve border-wide criminal intelligence-led interdiction operations, and 

address transnational threats. 

For example, the JTF-W's integrated intelligence, interdiction, and investigation efforts in the 

South Texas Corridor recently led to coordinated enforcement actions against a TCO, significantly 

disrupting the organization's ability to smuggle their commodity. Under Operation Fusion OneFive, multiple members of the Brewster Criminal Organization, to include the leader of the 

organization, were targeted and arrested. This investigation resulted in an additional 22 criminal 

arrests, the apprehension of 497 undocumented aliens, and the seizure of various types of 

narcotics. On August 10,2015, members ofthe Brewster Organization appeared in federal court 

and received a cumulative sentence of 12.5 years for their roles in human smuggling. This was an 

HSI-led investigation with support from CBP assets. 

CBP is a critical partner in the ICE-led Border Enforcement Security Task Forces (BESTs), which 

are composed of Federal, state, local, and international law enforcement and intelligence 

stakeholders working together to counter TCOs and enhance border security. BESTs currently 

operate in 38 locations, including 14 along the Southwest border. In FY 2015, BESTs made more 

than 3,700 criminal arrests and 960 apprehensions for immigration violations; seized more than 

276,000 pounds of drugs, 800 weapons, and $29 million in currency and monetary instruments; 

and federal prosecutors obtained more than 2,300 indictments and 1,800 convictions in BESTinvestigated cases. 

Other investigative agencies such as ICE-HSI, DEA, and FBI utilize AMO specific skills for air 

and marine relevant investigations to help identify and dismantle the organized flow of narcotics 

and TCOs. This leads to significant intelligence and seizures, and the critical information gained 

is often crucial to identifying TCO suspects, associates, and accomplices. The threat in the air and 

maritime domains requires specialized skills and tactics tailored to the specifics of each of those 

environments. In the maritime domain, AMO personnel routinely augment vessel crews from 

investigative partner agencies when air and marine investigative skills and technical expertise are 

needed for investigation or operation of these maritime assets. 

Because DTOs are also known to use legitimate commercial modes of travel and transport to 

smuggle drugs and other illicit goods, CBP partners with the private sector to increase awareness 

and enforcement of international and domestic drug smuggling activities. In the air domain, AMO 

detects, identifies, investigates, and interdicts potential air threats to the United States, including 

general aviation (GA) aircraft involved in the aerial transit of contraband. The AMOC monitors 

complex airway traffic to identify illicit use of aircraft and those attempting to blend in with 

legitimate traffic. AMO, through its national SKY PRO initiative and in collaboration with ICEHSI, the Federal Aviation Administration, and state, local, and tribal law enforcement agencies, 

Page 7 of9 
84 

works to enhance law enforcement interactions with the GA community to increase awareness and 

intelligence on international and domestic smuggling activities. CBP also partners with the 

private sector to provide anti-drug smuggling training to air, sea, and land commercial transport 

companies (carriers) to assist CBP with stopping the flow of illicit drugs; to deter smugglers from 

using commercial carriers to smuggle drugs; and to provide carriers with the incentive to improve 

their security and their drug smuggling awareness. Participating carriers sign agreements stating 

that the carrier will exercise the highest degree of care and diligence in securing their facilities and 

conveyances, while CBP agrees to conduct site surveys, make recommendations, and provide 

training. 

Heroin trafficking is a global problem, and CBP continues to work with our international partners 

to share information and leverage resources to combat this threat. Through the 21st Century 

Border Management Initiative, the U.S. Government and Government of Mexico (GOM) are 

working to strengthen our collaborative relationship and efforts to secure and facilitate the crossborder flows of people and cargo. CBP also has Border Patrol International Liaison Units (ILU) 

who facilitate cooperation between U.S. and Mexican law enforcement authorities as part of a 

multi-layered effort to target, disrupt, and dismantle criminal organizations. During FY 2015, 

USBP and GOM conducted multiple joint bi-national operations targeting TCOs. During these 

operations, and as a direct result of intelligence sharing with GOM, USBP and GOM were able to 

locate more than 30 illicit tunnels, and seize approximately 80,000 pounds of drugs. 

AMOC's coordinating efforts with the GOM and the deployment of shared surveillance 

technology has enabled the GOM to focus aviation and maritime enforcement efforts to better 

combat TCO operations in Northern Mexico and the contiguous U.S./Mexico border. For 

example, in January 2015, officers working at the AMOC detected a suspicious aircraft travelling 

north towards the United States. AMOC subsequently alerted GOM of the activity, and both the 

Mexican Federal Police and Air Force responded to investigate. The abandoned aircraft was 

located by Mexican officials a short time later, where 27 bags containing approximately 858 

pounds methamphetamine, 174 pounds of cocaine, 174 pounds of white heroin, and 3.3 pounds of 

black tar heroin were discovered and seized. Also, AMO actively participates in Operation 

Martillo, an international counter illicit trafficking initiative whereby U.S. and regional partner 

nations' military and law enforcement agencies patrol the air and sea environments in the 

Caribbean Sea, Gulf of Mexico and the Eastern Pacific on a year-round basis. 

CBP's Office ofinternational Affairs (INA) Technical Assistance Division (INA/IT AD) conducts 

International Border Interdiction training, funded by Department of State, for various countries 

worldwide. These courses provide instruction on multiple aspects of border security, including 

targeting and risk management, interdiction, smuggling, search methodologies, analysis, canine 

enforcement, and narcotics detection identification. Within the last six months, INA/ITAD has 

conducted anti-smuggling training in heroin and opiate source countries such as Panama, 

Guatemala, Columbia, Ecuador, Peru, Mexico, Indonesia, India, Thailand, Afghanistan, Kenya, 

Cambodia, and Philippines. 

Lastly, it is important to acknowledge the significant strides that Mexico has taken in recent years 

to address transnational organized crime generally, and drugs smuggling specifically. Overall, 

CBP's relationship with its Mexican counterparts is stronger today than it has ever been. We 

receive information from Mexican authorities on a daily basis that helps us better target drugs 

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85 

smugglers at the border. Last October, I participated in a high level bilateral and interagency 

security cooperation meeting in Mexico City, where senior Mexican officials committed to 

working with the U.S. Government even more closely-including expanding efforts to combat 

heroin cultivation, production, and trafficking, and sharing more information on smuggling routes 

and networks, and crafting a binational action plan specifically focused on heroin smuggling. 

CBP will continue to work closely with our Mexican counterparts as we seek to identify, interdict, 

and take down the cartels. 

Conclusion 

CBP, through collaboration and coordination with our many Federal, state, local, tribal, 

international government, and other partners, has made great strides with regard to the integrity 

and security of our borders. 

With continued support from Congress, CBP, in coordination with our partners, will continue to 

refine and further enhance the effectiveness of our detection and interdiction capabilities to 

combat transnational threats and the entry of heroin into the United States. We will continue to 

work with the Intelligence Community and our law enforcement partners to improve the efficiency 

of information sharing with relevant partners, to guide strategies, identify trafficking patterns and 

trends, develop tactics, and execute operations to address the challenges and threats posed by 

TCOs to the safety and security of the American public. 

Chairman Johnson, Ranking Member Carper, and distinguished Members of the Committee, thank 

you for the opportunity to testify today. I look forward to your questions. 

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86 

JON ERPENBACH 

STATE SENATOR 

Aprill5, 2016 

Testimony before the United States Senate Committee on Homeland Security and 

Governmental Affairs 

BORDER SECURITY AND AMERICA'S HEROIN EPIDEl\1/C: THE IMPACT OF THE 

TRAFFICKING AND ABUSE OF HEROIN AND PRESCRIPTION OPIOIDS IN WISCONSIN 

Chairman Johnson, Senator Baldwin, Fellow Speakers and Guests: 

Thank you for allowing me the opportunity to speak with you today regarding an epidemic that is 

devastating our Wisconsin communities and the nation at large. 

The problem is well-documented. According to the Wisconsin Department of Health Services 

Division of Mental Health and Substance Abuse Services. the proportion of drug deaths where 

heroin is mentioned has drastically increased from 5% in 2006 to 33% in 2014. And according to 

the Centers for Disease ControL there has been a 200% increase in opioid drug overdoses 

nationally since the year 2000. 

The solution must be comprehensive. If we are to be successful, the State of Wisconsin and the 

federal government need to be partners in the fight. We have made great strides with the 

introduction and passage of the HOPE package. Representative Nygren and the people he 

worked with to develop HOPE, are to be commended tor all of their hard work. We can't stop 

there, there is more to be done. 

I am proud to represent Sauk County, Wisconsin. Sauk County has a growing population of 

about 60,000 residents. It is heavily impacted by the tourism industry, followed closely by trade 

and manufacturing. Its unemployment rate is about 5%. In 20 l 0, law enforcement and the 

medical community started noticing a growing problem. There were 20 heroin and opiate deaths 

in a 2 year period. Ambulance companies and first responders reported over 80 uses ofNarcan, 

an opiate antidote used during suspected incidents of overdose, in that same period. 

Law enforcement, the medical and legal community and local businesses joined together to 

address what they saw as a community crisis. They had the foresight to recognize that this 

problem couldn't be solved by Jaw enforcement alone. They knew they needed a more 

comprehensive approach. They developed the CARE program. 

CARE, or Community Activated Recovery Enhancement is an integrated system putting each 

individual at the center of their treatment. which empowers the individual to make better life 

choices. CARE recognizes that addiction can be treated and overcome using an integrated multi-
87 

disciplinary approach that requires medical treatment, mental health services, social services, and 

healthy support systems. It is a program that recognizes addiction is a disease that not only 

negatively affects the individual struggling with the condition, but also significantly impacts 

family. friends, and the community. 

CARE is a collaboration that is made up of many public and private entities including: St. 

Vincent DePaul- Sauk Prairie/Robury, Sauk Prairie Police, Sauk Prairie Healthcare, Prairie 

Clinic, Ho-Chunk House of Wellness, Sauk County Department of Health and Human Services, 

Sauk Prairie EMS, Sauk Prairie School District, Sauk County UW-Extension, Sauk County 

District Attorney's Office, Sauk County Public Defender's Office, Sauk County Probation and 

Parole, and private business owners. 

The program began in Sauk Prairie, it worked-and people noticed. The program served 87 

people. Soon, the state of Wisconsin and the CARE project received a grant totaling $3 million 

over three years from the Substance Abuse and Mental Health Services Administration. The 

grant funding allowed them to expand the program county-wide and it is now serving an 

additional 20 participants and more interested individuals call each day. 

An important piece of the CARE program is Vivitrol, a drug that is injected monthly and blocks 

the receptors in the brain responsible for an opiate high. It helps to stem the body's biological 

need to use opiates. In short, it makes it nearly impossible for a user to get high. Thanks to St. 

Vincent DePaul, Vivitrol was made available to inmates in the Sauk County Jail. Those who 

agree to the CARE program and the use of Vivitrol, must commit to a year of monthly injections 

and counseling. 

In 2013, Dr. John McAuliffe, a fan1ily practice doctor at the Prairie Clinic, was the first and only 

doctor who participated in the Vivitrol protocol for inmates in the Sauk County Jail. Through his 

leadership there are now 7 doctors who have joined the cause. 

Vivitrol is expensive. The average cost of the monthly shot is $1200. St. Vincent DePaul was 

the first to step up in Sauk Prairie to cover the cost of the drug for inmates who agreed to the 

program but could not afford it. The grant money will help offset the cost for others. It is here 

where we begin to see where the state and federal government can step in, where we can do 

better, where we can go further in the fight against opiates. 

While enrolling inmates in the CARE program, Sauk County realized that Medicaid-eligible 

inmates leaving jail were experiencing a gap in coverage, jeopardizing their ability to continue to 

receive the expensive Vivitrol injections. Wisconsin is a state that chooses to terminate, 

rather than suspend Medicaid coverage for those that are incarcerated. That needs to 

change. 

According to the National Conference of State Legislatures, at least 18 states currently suspend 

rather than terminate Medicaid coverage for people who are incarcerated. The suspension 

approach yields administrative savings related to the reapplication and eligibility determination 

process, which can take as long as 45 to 90 days. This period of time is absolutely critical to the 

people in the CARE program receiving Vivitrol injections. Suspension instead of termination 
88 

would allow for the continuity of care, and a better chance at a successful community re-entry. 

There are several organizations, including Community Advocates Public Policy Institute, that are 

leading the advocacy efforts for this Medicaid policy change in Wisconsin. 

The Wisconsin Department of Health Services has, to its credit, developed a health coverage 

enrollment assistance program for inmates upon their release, and that is very important. 

However, the eligibility determination process can be complicated, and can take a long time. A 

simple policy change could give these offenders a better chance to stay sober, and a better 

chance at a successful life post-incarceration. 

In choosing to terminate Medicaid instead of suspend it, Wisconsin also loses out on federal 

grant money that is available. We need more funding to combat our opiate problem, and should 

not turn our backs on any pot of money that is available to us. 

I would be remiss if I did not also take this opportunity to advocate for Wisconsin to take 

the federal Medicaid Expansion dollars that are available to it. Our Legislative Fiscal 

Bureau estimates that Wisconsin is losing out on $320 million over the biennium to help more 

individuals, many of whom are offenders seeking successful re-entry into our communities, pay 

for health insurance. 13.4% of people in Wisconsin that qualify for Medicaid under the 

expansion have substance use disorders. 

People who are earning minimum wage make too much money to qualify for Medicaid in 

Wisconsin. These people are then forced into a Federal Marketplace that was never intended for 

people of their income level. It is just plain wrong to see our tax dollars going to give people in 

other states the health insurance that people in Wisconsin deserve and paid for. 

There are 30 people in Sauk County who have successfully completed the CARE program and 

have re-integrated into the community. When those folks went and got jobs and changed over to 

employer-sponsored health insurance, a notable success by many standards, they encountered yet 

another problem. Private health insurance has required that a person first have a "FAIL" on the 

pill form of the "opiate-high blocker" before they will cover the injectable Vi vitro!. This too, is 

absolutely ridiculous. To require that someone "FAIL" in their recovery before covering a drug 

that has kept them sober is just plain wrong. Another place that we can make a difference is 

by discouraging this fail-first practice of the insurance industry. 

A key part of the success of the Sauk County CARE program was the fact that law enforcement 

professionals like Sauk Prairie Police Chief Jerry Strunz recognized that the heroin epidemic was 

a community issue. We must engage our criminal justice partners in the fight. Chief Strunz is an 

advocate for law enforcement education programs that help officers on the street recognize 

addiction as a disease and help them look at the issue through a different lens. Wisconsin should 

adopt statewide training standards for law enforcement officers on how to deal with people 

they encounter that are struggling with addiction. 

Chief Strunz also gives his officers a card they are able to hand out to anyone on the street that 

they feel might benefit from the services of the federal grant program. It lists a phone number 

that people can call and talk to a live person 24 hours a day about getting help. 
89 

And, in 2016, Sauk County started a Drug Court. Since January they have had 7 participants. 

The Drug Court team is reviewing applications on a weekly basis. Their goal in the first year is 

to provide services to 30 people. Drug courts, and others like them, work to provide services to 

the individuals involved and get them the help they need while still holding them accountable for 

any criminal actions they might have engaged in. There are currently over 70 drug courts in 

Wisconsin. Expanding treatment courts is a very cost-effective way to address the burden 

drug addiction is putting on our criminal justice system. 

I am proud to represent Sauk County and I firmly believe that the CARE program could serve as 

a model of success for Medication Assisted Treatment around the state and the nation. 

Wisconsin also faces a critical shortage of treatment professionals. Nationally, nearly one in four 

substance abuse clinicians chooses to leave the job each year, with bum-out and low pay cited 

most frequently as the reason they choose a new career. While the Affordable Care Act went a 

long way toward increasing access to mental health and substance abuse treatment 

services, we need to find a way to encourage more people to enter the field so those people 

get the help they need, not put on a waiting list for services. 

Pew Charitable Trusts reports that "Of the estimated 18 million adults potentially eligible for 

Medicaid in all 50 states, at least 2.5 million have substance use disorders. Ofthe 19 million 

uninsured adults with slightly higher incomes who are eligible for subsidized exchange 

insurance, an estimated 2.8 million struggle with substance abuse, according to the most recent 

national survey by the U.S. Substance Abuse and Mental Health Services Administration." 

Research conducted by Jeff Zornitsky ofthe Advocates for Human Potential using 2010 data 

from the Department of Labor Statistics and Substance Abuse and Mental Health Services 

Administration indicates that in Wisconsin there are 30 treatment professionals per 1,000 nonelderly adults with a drug or alcohol addiction. That is just below the national average. Nevada 

is the worst with 11 and Vermont is the best with 70. 

We have to find a way to eliminate waiting lists for treatment, encourage mental health and 

substance abuse professionals to practice in underserved areas, encourage more people to do this 

important work, and address the reasons that so many people are leaving the field. These 

shortages have created treatment bottlenecks, especially in rural areas. 

At the federal level, support and passage of legislation like the Opioid and Heroin Epidemic 

Emergency Supplemental Appropriations Act (S. 2423 and H.R. 4447), co-sponsored by 

Senator Baldwin, will make great strides in assisting the efforts that Wisconsin is currently 

undertaking to battle its heroin and prescription drug abuse problems. It would help fund 

the community policing efforts like the ones that Chief Strunz supports, provide support for the 

Medication Assisted Treatment programs like the CARE program, and help pay for the 

improvements we've made to our Prescription Drug Monitoring Program through the HOPE 

legislation. 
90 

Mr. Chairman, in order to confront this horrible epidemic head on, in order to begin to win this 

fight, we must break down barriers. We must change the way we look at addiction and treat it as 

a disease instead of a choice that people make. We must eliminate the hurdles placed in the way 

of those who seek treatment. We must more appropriately value our treatment professionals and 

the important work they do every day. We need to adequately fund the people on the front lines 

of the crisis. We need to take a community approach to the problem, to work together toward a 

shared goal- stemming the tide of the opiate epidemic. 

Thank you again for the opportunity to be here today. 
91 

Co-Chair, Joint Committee on Finance 

Wisconsin's Heroin and Opioid Epidemic 

State Rep. John Nygren 

Friday, AprillS, 2016 

Thank you Senator Johnson and the members ofthe Committee on Homeland Security and 

Governmental Affairs for holding a hearing on the impact of trafficking and abuse of heroin and 

prescription opioids in Wisconsin. 

Our country is currently facing a prescription opioid and heroin epidemic. This problem knows no 

boundaries; all demographics of people are affected in one way or another, no matter their income 

level, race 1 or how urban or rural their communities are. Many of us know too well that Wisconsin is no 

exception to this epidemic. It is for this reason that I am proud of the legislative steps my colleagues and 

I have taken over the past three years to combat this devastating problem in our state. 

In 2013, we began what has become the foundation of Wisconsin's Heroin, Opioid Prevention and 

Education (HOPE) Agenda. This foundation was laid with seven bills that aimed to fight heroin use and 

addiction in our state. We expanded access to drug treatment opportunities, made opioid antagonists 

like Narcan more readily available to first responders, and enacted a Good Samaritan law. However, 

after the 2013~141egislative session ended, it was clear that there was much more work to be done to 

combat Wisconsin's heroin and opioid epidemic. 

As the 2015-16 session began, we continued our work to build upon the HOPE Agenda. Instead of 

specifically targeting the devastating effects of heroin, we took the opportunity to focus on what many 

believe is the root of Wisconsin's heroin epidemic: prescription opioid misuse, abuse, and addiction. 

Studies show that, in many cases, heroin addiction begins with an addiction to prescription painkillers. 

Whether these medications are obtained legally or not, we need to do our best to curtail the illegal use 

of these dangerous substances. 

As a continuation of the HOPE Agenda this session, we have passed ten additional bills- nine of which 

have already been signed into law by Governor Walker. These bills continue to expand access to opioid 

antagonists to reduce instances of overdose deaths, further expand access to Treatment and Diversion 

(TAD) programs so people addicted to opioids can get the help they need in lieu of incarceration, and 

expand the use of Wisconsin's Prescription Drug Monitoring Program (POMP} so instances of 

overprescribing become less common. It is our hope that these important pieces of legislation will help 

reduce the number of people who become addicted to legal prescription opioids and, in turn, reduce 

the number of people who eventually make the switch to heroin and other dangerous illegal substances. 

There are 17 HOPE Agenda bills total, and all17 of them were approved unanimously by both Houses of 

the Wisconsin State Legislature. Governor Walker has signed 16 of the proposals into law, and we 

expect him to sign the final HOPE Agenda bill into law in the near future. It's important to note that this 

is not a Republican or a Democrat issue, but rather a public health and safety issue. I am proud that 

there has been such widespread support of these pieces of legislation from people around the state 

----------------R\\\ll@li %W lii WJ I;; J 8$1 ~ ~wmiM-HM!Wm--@IWllii®M<IIUWIWNJWilUIJIIiWI4>*--~ 

Capitol: ro. Hnx R01) "' \·1ddMr\ WM01hln 5570!l·fl()15 • (GOfl) 2G&·234) • Toli-Frt·r· (888) S~HlOB9 • Fax: (600) 282-.%89 

Rep.Nygren@legis.wi.gov 
92 

Co-Chair, Joint Committee on Finance 

including the medical community, law enforcement, my colleagues in the legislature, the governor, the 

attorney genera!, and countless addiction advocates. 

As I mentioned before, the heroin and opioid epidemic knows no boundaries, and now is the time to 

start combatting this devastating problem. I am proud that Wisconsin is leading the way with efforts like 

the HOPE Agenda, and I'm confident that other states will be able to look to us for guidance on what can 

be done nationwide. The laws that make up the HOPE Agenda are not the silver bullet that will solve this 

epidemic, but each proposal is an important step in the right direction. With that said, ! look forward to 

continuing our work to further build upon the HOPE Agenda in the future. 

I appreciate the opportunity to testify before your committee today on the HOPE Agenda and the state of 

Wisconsin's heroin and opioid epidemic. Please don't hesitate to contact me with any comments, 

questions, or concerns. 

Capitol: P.O. Box RfJ53 * Mddl)()n, W1swnsm 15708·895!1 * (608) ?56·2343 * To!I-Frer· (888) 554·008l"l .. rax· (608) 282·3689 

Rep.Nygren@legis.wi.gov 
(93) 

1The prepared statement of Senator Portman appears in the Appendix on page 139. 

EXAMINING THE IMPACT OF THE OPIOID 

EPIDEMIC IN OHIO 

FRIDAY, APRIL 22, 2016 

U.S. SENATE,

COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, 

Cleveland, OH. 

The Committee met at 10:13 a.m. in the Ruhlman Conference 

Center, University Hospitals of Cleveland, 11100 Euclid Avenue, 

Cleveland, Ohio. Senator Rob Portman presiding. 

OPENING STATEMENT OF DR. SIMON, PRESIDENT OF 

UNIVERSITY HOSPITALS CASE MEDICAL CENTER 

Dr. SIMON. Good morning. My name is Dr. Dan Simon. I am the 

president of University Hospitals (UH) Case Medical Center. Welcome to Ohio and to the flagship hospital of the University Hospitals system. 

On behalf of our Chief Executive Officer (CEO) Tom Zenty, our 

senior leaders, our 26,000 doctors, nurses and employees and the 

community we serve, we are honored to host this important hearing. 

We are grateful to the U.S. Senate Committee on Homeland Security and Governmental Affairs (HSGAC) for confronting the 

opioid crisis. 

I would like to thank Chairman Johnson and Ranking Member 

Carper for their leadership on the Committee and their staffs for 

being here this morning. 

I would also like to thank our fine Ohio Senators Sherrod Brown 

and Rob Portman for honorably representing Ohioans in Washington. 

We were privileged to host Senator Portman for a round table 

event last January to discuss his legislation, the Comprehensive 

Addiction and Recovery Act (CARA). We are pleased that it passed 

the Senate and hope for speedy consideration in the House. 

Thank you for your strong leadership on a very complicated 

issue. 

Now I would like to turn things over to Senator Portman. 

OPENING STATEMENT OF SENATOR PORTMAN1

Senator PORTMAN. Dan, thank you very much. I appreciate that. 

And, I am now going to officially call this hearing to order. 
94 

I appreciate everybody being here. This is a distinguished group 

of Cleveland area citizens and a really distinguished panel, two 

panels, in fact. We look forward to hearing from them in a moment. 

This is a critical hearing, because it is an opportunity to draw 

attention to an issue that all of us face in the State and in our 

country, which is this epidemic of opioid addiction and overdose 

prescription drugs and heroin. 

It has devastated communities here in Ohio. It has torn families 

apart. But, this is happening all over the country. 

And, as we will talk about in a moment, the fact that our legislation called the Comprehensive Addiction and Recovery Act passed 

with a 94 to 1 vote in the United States Senate, which never happens, which is evidence of that. I do look forward to the expert testimony we are going to receive today. 

And, Dan is right, I was here in this very room in a round table 

discussion where I learned about some of the expertise that resides 

right here at University Hospital and also at our other great medical institutions in town. And so, we thought this would be an appropriate place to hold this hearing. 

It also happens to be a beautiful room for a hearing. You may 

find many Congressional hearings now coming to this room. 

[Laughter.] 

The staff is here from the offices of Chairman and Ranking Member and they are equally impressed. So, I think they may want to 

come back, if you will offer it for free. [Laughter.] 

I want to thank Sherrod for being here. Senator Brown and I 

have worked on this issue together, as we have on so many other 

issues for the good of Ohio. 

And, this is one that crosses every line. There is no zip code that 

is immune from it. It also crosses every party line. 

We have really tried with the CARA legislation over the last 3 

years, as we developed it, to make it not just bipartisan, but nonpartisan. It is not caring where the ideas come from, but if they 

are good ideas, to try to promote them. 

And, it is urgent. Every day we lose 120 Americans to drug 

overdoses. Think about that. 120 people lost every day. The rate of 

overdose over the last 14 years has doubled, leaving about a half 

a million Americans dead from overdoses. 

And, the tragedy of a death from overdose, as terrible as it is, 

tells only part of the story. And, many people in this room are 

working on this issue every day and understand what that means. 

But, it is about the families being torn apart. It is about that 

drug being more important than anything, whether it is family, 

work or faith. It is about communities being impacted dramatically. 

When I talk to prosecutors in Ohio, they think by far most of the 

crime in their communities are connected directly to this issue. It 

is about individuals getting off track and not being able to pursue 

their God given purpose in life. 

So, it is horrible that people are dying from drug overdoses. But, 

sometimes I think we forget this broader issue that is affecting everybody. 

It is hitting us especially hard here in Ohio unfortunately. We 

are probably they say one of the top five States in the country, 

maybe the top State now, in fentanyl, at least heroin overdoses. 
95 

So, it is something that is appropriate for a hearing, to raise the 

visibility of it, and you get extra testimony. 

I do not think it is getting better. And, we will hear from witnesses today about this. But, there is a troubling report this last 

week about a survey that was taken. It is called the Ohio Issues 

Poll. In 2014, they reported that two out of every 10 Ohioans knew 

someone who was abusing prescription drugs. In the latest poll, it 

is 3 out of 10. And, out of those 3 out of 10, 4 in 10 know someone 

who had overdosed. 

Sherrod and I were talking earlier at a town hall meeting. I 

asked how many people have been affected, friends or family, and 

half the hands in the room go up. And, people look around, and 

they cannot believe it. They cannot believe that others are experiencing it, too. 

Because there is not enough discussion about it. There is too 

much stigma attached to addiction. And, it is a disease. And, it is 

treatable. And, one of the problems in getting people into treatment 

is to break down that stigma, which I think is part of the reason 

this hearing is important. 

By the way, about 5 of those 120 persons dying every day are 

dying in Ohio. 

As Sherrod talked about earlier, drug overdoses have killed more 

Ohioans than car accidents, actually every year in Ohio since 2007. 

Overdose deaths have tripled from 99 to 2010. 

We were told that 200,000 Ohioans now are addicted to opioids. 

200,000. That is roughly the size of the city of Akron. We do have 

20,000 overdoses a year. Several thousands will probably lose their 

lives again this year. 

So, I do not think it is slowing down. I do not think we have any 

time to waste. 

The U.S. Senate response has been this Comprehensive Addiction and Recovery Act—again it passed by an overwhelming vote. 

I think it is a critical step in the right direction. It was not just 

3 years in the making. We had five conferences in Washington. 

A number of the experts you will hear from today actually came 

and testified or talked to us on this legislation. I want to thank 

them for that. 

Local Ohio happens to have a lot of smart people who are experts 

in this area. We also just have a big problem here in our State. 

We made it bicameral from the start. So, it was not just not partisan, it was the House and the Senate working together. We actually introduced identical legislation. 

And, the House bill, the CARA legislation in the House, has 120 

plus cosponsors. So, the one reason that we believe that the House 

can act quickly is because they have been working with us for 3 

years. We did not just take Senate ideas. We took House and Senate ideas and more importantly ideas from experts around the 

country. And, they do have over 120 cosponsors. 

So, we are urging them to simply pass that legislation, get it to 

the president who will sign it and get it to our communities where 

it will begin to help immediately. 

Are there other things we should do? Of course. And, we will 

hear some about that today. And, should they pass additional legislation? Of course. Should there be more funding? Of course. 
96 

All of these things can and should happen. But meanwhile, let 

us get this specific response, it has passed the Senate, through to 

our communities. 

The House did move on some small bills earlier this week, and 

I applaud them for that. 

By the way, 3 of the 12 bills are identical to CARA, language 

identical that is in the CARA legislation. So, again, we can work 

with the House on additional ideas. Well, let us pass CARA now. 

Cleveland is one of the regions in Ohio that has been hard hit. 

The statistics are heartbreaking, and they are a call to action for 

all of us. 

There is some city council members here. The city medical director is here. There are members of the Cuyahoga County Task Force 

who are here. You all have been in the middle of this. 

But, as some of you know very well, from March 10, the day that 

the Senate passed CARA, March 10, until March 27, 29 people died 

of overdoses. That is one 17 day period in one city. One long weekend, 12 people died, fentanyl-laced heroin. And, we will hear some 

about that later today. 

Attorney General (AG) DeWine has been involved in this issue 

as well with regard to fentanyl. And, I know the Drug Enforcement 

Administration (DEA) is here with us today. We appreciate you all 

being here. We have other law enforcement folks from the High Intensity Drug Trafficking Area (HIDTA) folks. And, we had a hearing on fentanyl this week in Washington. It is one of those issues 

that has unfortunately really hit Cleveland hard. 

By the way, of the 12 people who died, they ranged in age from 

21 years old to 64 years old, white, African-American, rich, poor. 

This knows no boundaries and certainly no zip code. As we talked 

about, it is not just a Cleveland inner-city problem. This is a problem in our suburbs and our rural areas. In fact, per capita use in 

the rural areas may be greater. 

Fentanyl, again it is 100 times more potent than heroin. And, depending on the dose of fentanyl and how it is produced—it is a synthetic drug. 

We had five people die in Cleveland from fentanyl in 2013. A 700 

percent increase in 2014. More than doubled the next year. This 

year, probably doubling again. 

So, we are just on a steep climb. I am looking at the medical director who has to deal with this every single day. 

Last month, as some of you know, in Fairview Park, not far from 

here, you had a man overdose at McDonald’s. And, it was of course 

immediately online and went viral. 

Luckily, someone was there administering Narcan to save his 

life. But, there were kids there. And, this is increasingly happening 

in public places and in broad daylight. 

We have learned a lot here in Cleveland over the last few years, 

again speaking with advocates, doctors, patients. I have had an opportunity to tour Rainbow Babies and Children’s Hospital here and 

see the incredible work that doctors and nurses are doing. What 

compassion they have for these kids who are born with addiction. 

750 percent increase in babies born with addiction in the last 12 

years in our State. Whether it is at St. Rita’s Hospital in Lima or 
97 

1The prepared statement of Senator Johnson appears in the Appendix on page 145. 

2The prepared statement of Senator Ayotte appears in the Appendix on page 146. 

3The prepared statement of Senator Brown appears in the Appendix on page 142. 

whether it has been nationwide or Cincinnati Children’s Hospital, 

it is the same story. 

And, we will hear about that today from some real experts, talking about how we can ensure that this Neonatal Abstinence Syndrome (NAS) can be addressed both in terms of prevention, education, but also with effective treatment. 

Effectively these nurses and doctors take these babies, of course, 

through a withdrawal process. And, the long term consequences to 

these children we will hear more about today, but it is very difficult to know. It is such a new phenomenon. And, of course, that 

concerns all of us. 

So, I think Cleveland has a lot to teach the country about how 

serious this threat is, as well as effective prevention and treatment 

ideas. And, that is why this hearing is important. 

Again, there is a lot to do in addition to the Comprehensive Addiction and Recovery Act. And, we should continue to listen to the 

experts as we develop our ideas, because this issue is just too important not to. 

I do think today we will hear from some really important testimony from some really compassionate and gifted people who work 

here in this facility and experts in the field. I look forward to hearing from them. 

We also have a statement that I want to enter into the record 

from Senator Johnson, who is the chair of this Committee,1 from 

Senator Ayotte,2 and also testimony that has been submitted by 

Dr. Jason Jerry, who is with us this morning from the Cleveland 

Clinic. 

Where are you, Doctor? There he is. 

Thank you and thank you for the Clinic for being here. 

I also want to thank the staff from Senator Johnson and Senator 

Carper. Senator Carper is the ranking Democrat on the Committee—his staff is here as well—for helping not just put this together, but also for being here and helping us substantively to pull 

information out of this hearing to use it for legislation. 

And, again, I want to thank Senator Brown for his participation 

in this hearing today and for his passion for this issue. He has 

been involved all over the State and had hearings all over the State 

or round table discussions all over the State. 

And, again, it is an issue that, as he will talk about, affects our 

entire State. And, therefore, we have to work together to solve it. 

Now, I will turn it over to Senator Brown for his opening statement. 

OPENING STATEMENT OF SENATOR BROWN3

Senator BROWN. Thank you, Rob. Thank you, Senator Portman. 

Thank you to UH, Dr. Simon, and all of you. 

It took Rob Portman coming to my home town to get to do something in this room. I have never been in this room. [Laughter.] 

I have been to UH like 25 times, including visiting family members—— 

Senator PORTMAN. They never let you in. 
98 

Senator BROWN [continuing]. Doing hearings and doing discussions and past conferences. But, it took the other guy to come in 

town to get the use of this room. So, thank you, I appreciate that. 

And, I thank Senator Portman to allow me to be at this hearing. 

Because I do not sit on this Committee in Washington. And so, I 

am kind of an honorary member or something today sitting in. So, 

thank you for that. 

And, to Senators Carper and Johnson and their staffs, thank you 

for arranging this, for the room and the witnesses, and the second 

panel especially too. 

Rob talked about this upcoming a couple of times. And, if you 

look out this window, you will see zip codes that have some of the 

highest infant mortality rates in the country, and certainly in the 

State and maybe in the country. 

You will see some of the highest foreclosure rates in the country. 

The zip code my wife and I live in, 44105, south of Slavic Village, 

had more foreclosures than any zip code in the United States of 

America in 2007. 

So, this is a public health crisis—opioid addiction—as so many 

of these other things are—and how related they are. 

As Senator Portman pointed out, this is not a city problem, this 

opioid addiction. 

I first started hearing a lot about this when I came to the Senate 

in 2007, and especially in places like Adams and Brown County of 

the Ohio River. Attorney General DeWine has been working on this 

a long time, a lot of us have. 

And, it started off with Oxycontin and oxycodone and Percocet 

and Vicodin and legally prescribed drugs. And, it has spread obviously. 

And, we know that addiction—when you think about addiction, 

and you think about the biases and the prejudices people have 

about addiction, years ago addiction, when it was confined to certain areas and certain cities, look out this windows, it was considered a character flaw or it was considered an individual problem. 

We know it is not. 

We know addiction is—some people are just more predisposed toward addiction than others. We know it is not a character flaw. It 

is not a personal problem. It is an illness. And, it is a chronic disease. And, that is why this hearing is so very important. 

Fundamentally—and I want to thank the people. I did not do 

this. I thank the people in this room who are some of the best activists, as Rob has pointed out, some of the best activists in our 

State fighting against this. 

The numbers are just overwhelming. The availability is amazing. 

I have done, as Rob said—and he has, too—I have done round tables, town halls all over the State. 

I remember one in Southern Ohio. I said, how easy is it to get 

heroin? They said, you know where the McDonald’s is out on Route 

23? I said, yes. They said, go out there. Walk around for 3 minutes, 

and you will be able to buy some. 

We know what a round table I did in the Mahoning Valley—the 

Youngstown area. A woman, affluent, she said because of the 

money her family had, they could keep their son alive. 
99 

He was addicted at 14, because he went into the—I think, if I 

recall, they were taking care of their grandmother, as I did with 

home care and my brothers did some 10 years ago in Mansfield. 

And, there was morphine in the cabinet, because they were helping 

her be comfortable in her last months or last weeks and even last 

days. And, their 12—14 year old son began to take the morphine. 

And, he has been addicted in and out treatment for 12 years. 

And, she talked about the family is just turned upside down, because this son has siblings. And, they are not getting the attention 

that they deserve and they demand and the parents and all the 

things that happen. 

So, we know how excruciating this is in every city, county, innerring suburb, more far flung suburbs, every county in the State. 

And, that is the importance of what we do. 

But, the other thing that really came through to me on this is 

how every community is crying out for dollars to help us on this. 

And, we cannot get Congress to—neither the State nor the Federal 

Government has come up even close to the dollars we need to scale 

out these programs. 

Almost every community in the State, people have come together. 

They are very good, as Rob said earlier today, they are very good 

not for profits. They are very good county-funded—all the different 

ways we fund treatment. Those exist. But, none of them can scale 

up without a lot of help from Columbus and Washington. 

And, when you think—because nobody predicted this opioid epidemic to explode the way it did. So, no community is prepared to 

scale out. It just does not have the resources to do that. 

And, that is where we come in. CARA, the work that Rob has 

done, is very important and impressive with CARA. We need to get 

it through the House. He is working on that. We are all working 

on that. 

We also though need Senator McConnell to begin to support 

much better funding. And, we need the Governor and the legislature to support much better funding. You just cannot do this on the 

cheap. 

The reason though I am optimistic is, I have seen what our country has done in public health for generations. So, it was our country that led the eradication of small pox, where hundreds of millions of people in the 20th Century died of small pox. It is pretty 

much eradicated. 

Look what we did with polio in the 1940s to 1950s—1930s, 

1940s, and 1950s to eradicate polio in this country and most places 

around the world, almost every place. What we did with Ebola 2 

years ago. When the alarmists in our country said, ‘‘thousands of 

people are going to die from Ebola.’’ Well, do you know how many 

people died from Ebola—contracted in the United States and died 

here? Zero. 

We are facing the public health threat of the Zika virus now. We 

are accelerating the research for vaccine and an antiviral for cure, 

for vaccine and cure. And, this is, at least for us in this State, an 

even bigger public health threat with opioid addiction. 

So, we have risen to the occasion as a community, as a Nation. 

I think we will today. This hearing that Senator Portman called is 

a step toward that. Thank you. 
100 

1The prepared statement of Mr. DeWine appears in the Appendix on page 148. 

Senator PORTMAN. Thank you, Sherrod, great points. 

We will now go to our first panel. And, we are going to discuss 

here the Federal, State and local collaboration to combat opioid addiction. We have three really distinguished panelists. 

First, we are going to hear from Attorney General Mike DeWine. 

As I said earlier, Mike DeWine has been a leader on this issue, not 

just focusing on the law enforcement side of it, which you might expect from an attorney general, but also on the prevention side and 

the community outreach. He is also going to talk about fentanyl 

and his effort to prevent drug abuse. 

Next, we are going to hear from Carole Rendon. Carole is the acting U.S. Attorney for the Northern District of Ohio. She’s gone well 

beyond the call of duty to actually lead the task force here in Cleveland on opioid addiction. And, I thank her for that and her continued passion. 

She is going to talk about strengthening partnerships across government to address this problem in her role as part of the task 

force. 

Finally, we are going to hear from Tracy Plouck. Tracy is the director of the Ohio Department of Mental Health and Addiction 

Services (MHAS). She was a key resource as we developed CARA, 

as you can imagine, as one of those people I talked about earlier 

from Ohio who actually gets it and has a lot of expertise on the 

ground. 

She is going to talk about what the State has done to expand addiction treatment, including efforts to respond to the Neonatal Abstinence Syndrome (NAS) we talked about earlier, the addicted babies. 

So, with that, I would ask all three witnesses if they are willing 

to stand, please, we can swear you in. 

Please raise your right hand. Do you swear the testimony you 

will give before this Committee will be the truth, the whole truth 

and nothing but the truth, so help you, God? 

Mr. DEWINE. I do. 

Ms. RENDON. I do. 

Ms. PLOUCK. I do. 

Senator PORTMAN. Excellent. Let the record show that the witnesses all answered in the affirmative. And, with that, again thank 

all three of you for being here. 

And, Attorney General DeWine, thank you for your passion and 

expertise on this issue. We would like to hear from you. 

TESTIMONY OF THE HONORABLE R. MICHAEL DEWINE,1

ATTORNEY GENERAL, STATE OF OHIO 

Mr. DEWINE. Mr. Chairman and Senator Brown, thank you for— 

not just for doing this hearing today, but thank you for your long 

time focus on this particular issue. You have traveled the State, 

both of you have traveled the State extensively and really I think 

understand what this problem is all about. 

You mentioned, Chairman, about fentanyl. There is just one statistic. In 2015, in our crime lab, it was brought in to us and we 

dealt with, the amount of fentanyl that year was—exceeded what 
101 

it was in our labs for five previous years combined. And, this year, 

2016, we are seeing it go straight up as well. So, there is absolutely 

no change in that. 

The number of deaths, we all cite statistics. I do not think we 

know exactly how many people we are losing in Ohio. I would simply say this. That if it was not for naloxone and Narcan, those 

numbers would just be much worse. 

And, what that tells you though I think is it is not just the 

deaths. It is the families that are destroyed, the moms and dads 

who get up every day and worry about their kid all day long, because their child is now in the 22nd day of recovery, and they do 

not know how long that that is going to last. 

You are absolutely correct, this is a very different drug epidemic. 

I started looking at the drug problem when I was an assistant 

prosecuting attorney in the 1970s. This is very different. It is everywhere. It is the rural areas, cities, and suburbs. The face of heroin is really the face of the State of Ohio. And, it does cover every 

single demographic group. 

I do not really know why we are seeing this huge problem. But, 

I will note two things that I think are significant that have come 

together. 

First of all, the marketing of heroin is fundamentally different 

than it has ever been before. They are much more sophisticated. It 

is much more user friendly or consumer friendly. 

Poppies are grown generally in Mexico. The heroin is made, processed in Mexico. It comes across our Southern border. It comes into 

Ohio and other States. 

And, the groups that are selling it really use what I call the 

pizza delivery system. It is very similar. The price is about the 

same, and you can get it just about as quickly as you can get a 

pizza. It is $10. It is $15. Sometimes they will give it away, because 

they want to get someone hooked. 

It is a perfect business model, because you start off at this level 

of heroin for $15 a day. In 6 months or a year, you may be clear 

up here. Some doctors have told me the ratio could be as high as 

100 to 1. So, what starts as a $15 a day habit can be a $1,500 a 

day habit. 

Thus the comment by almost every law enforcement officer that 

we see around the State of Ohio, that 80, 90 percent of the crime 

in the county, every county, is due to this particular problem. 

The second thing that I think is different today is we have a culture problem. And, I think we can do something about that. 

When I was a county prosecuting attorney, you would, after a 

while, you would sort of get to know the drug dealers in your county. You would arrest them. And, some of them you got almost on 

speaking terms with. 

And, after we would arrest someone, I would ask them, what 

drugs are you selling? Or in some cases with the user, what drugs 

are you using? And, they would mention a number of different 

things. 

But, if I would ask, well, what about heroin? The answer would 

be, no, I am not crazy. I do not do that. That is other people. We 

do not do that. I do not put that needle in. 
102 

There was some psychological barrier that was there. That psychological barrier for whatever reason is just down. It is gone. And, 

we have to culturally resurrect that. 

We cannot arrest our way out of this problem. What we do in law 

enforcement—we work with this every day. We have a special heroin unit that works with local law enforcement on the law enforcement side, the investigation side. But, we cannot arrest our way 

out of this problem. 

I want to compliment you, Senator Portman, for the CARA Act, 

and, you, Senator Brown, for your work in support of it. 

This takes a holistic approach. I think we have to have a holistic 

approach. We have to have education. We have to have prevention. 

We have to have treatment. And, we have to have the law enforcement side. 

Let me just mention a couple things. The bad news is the nature 

of this problem and how bad it is and how horrible it is. 

The good news is we are starting to see some maybe not progress 

in the numbers, but we are starting to see some communities that 

have figured out how to fight back. 

When we first started looking at the pain med problem, one of 

the things I noticed was that the communities that who were starting to make progress in this area—and I think this still is true as 

well for heroin—are communities that have come together, pulled 

together. 

It is usually led by a mom, sometimes a dad, but usually a mom 

of someone who has died, a boy, girl who has died. And, they sort 

of rise up in the local community. 

And, the ones that work involve the business community. They 

involve the faith based community, the churches. They involve law 

enforcement. They involve education. And, they have to come together. 

I was so impressed by this model, that a few years ago we put 

together a small group in our office. We now have six young ladies 

who work every single day to work with local communities to try 

and help them. Not to tell them what to do, not to tell—every community is different. But, rather to share what other communities 

have done. 

And so, I always mention that in any group. And, we have many 

times people who will take us up on it. Again, we do not pretend 

to be experts. But, what we do know is what is happening in other 

places in the State and what works. 

So, I would encourage us to look at this from the local point of 

view. Those of us at the Federal level and those of us at the State 

level, we can help. 

Ultimately, we are not going to solve this problem. We can help. 

We can help give people resources. We can help give them ideas. 

But, ultimately, it is going to have to be done at the individual 

community level, which is why I put this group together. 

Let me mention a couple other places. Sheriff John Tharp, the 

Sheriff in Lucas County, has a program that we have partnered 

with him. He came to me over a year ago and said, ‘‘I have an 

idea.’’ And, I thought he was going to talk about law enforcement. 

And, he said, ‘‘No, that is not what I am taking about.’’ 
103 

He says that we have to get people into treatment more quickly. 

And, we have to, once they are in the treatment, make sure they 

stay in treatment. 

And so, what the sheriff has done with the help of local—some 

local money and some money that we gave him, he has a program 

that is over a year old now, and we begin to see some real results, 

where they will go out—if the emergency room is ready, when the 

emergency room has somebody who comes in and actually survives 

an overdose, the sheriff is called. The sheriff has a very small unit 

of dedicated people. They move. They come out. 

One individual will come and see the family and see the addict 

and see if maybe that is a teachable moment. See if that addict is 

ready at that point. And, if they do, that sheriff’s deputy becomes 

really the advocate or the sponsor of that person. 

I talked to a few of the addicts who were recovering in this program a few weeks ago in Lucas County. One recovering addict 

pointed over across the room to the sheriff’s deputy. He said, ‘‘Do 

you see that sheriff’s deputy over there? ’’ And, I said, ‘‘Yes.’’ He 

said, ‘‘I call him five or six times a day.’’ I said, ‘‘Why do you call 

him five or six times a day? ’’ He said, ‘‘I have to in order to get 

through the day. But, he has always been there for me.’’ He said, 

‘‘Without him, I would not still be in recovery. I would have relapsed.’’ 

So, there are programs out there. Senator Portman, down in your 

area, Colerain Township, they have a similar program that is going 

on. So, I think there is a lot of very good things that are going on. 

I do not think we can forget education. As a country, we have 

to do more in the area of prevention and in the area of education. 

I was on President Reagan’s National Commission on Drug-Free 

Schools when I was in the U.S. House of Representatives in the 

1980s. A little different in some ways and in some ways the same— 

a drug problem. 

The one that every expert who came in on education and drug 

prevention said to us is, you have to do something every single 

year. You have to start in kindergarten. You have to have something that is age appropriate. And, you have to go all the way 

through the 12th grade. 

And, if you think you are going to do something in the fifth grade 

and the ninth grade, and that is all you are going to do, I suppose 

that is better than nothing. But, it is not going to really get the 

job done. 

So, I think we have to kind of rethink how we are approaching 

this. We cannot put all the burden on the schools. But, we have to 

figure out some way, so that young people are getting the information they need in something that has been tested and we have data 

behind that it actually works as far as prevention. 

I was in Boardman a few weeks ago and talked to school officials. 

They have a program there they are just starting. They took a program basically off the shelf. They bought it, a proprietary program. 

They have inserted it into kindergarten all the way through 12th 

grade. And, they are just starting it. They actually put it into their 

science program. So, they work with their science teachers. 

So, it is a way maybe to get around the problem that we are always looking to schools to do everything. Well, let us figure out 
104 

1The prepared statement of Ms. Rendon appears in the Appendix on page 151. 

how to put that in. They do it through their science classes. It is 

basically nine periods a year, in kindergarten all the way through 

12th grade. 

It will be a long time before we have the data. But, I think it 

looked very promising. And, I think that is something we need to 

look at in other communities. 

Again, thank you both very much for holding this hearing. It is 

very important. 

We have looked at the members of the panel, and we have looked 

at the people in the room. Mr. Chairman, as you said, we have a 

lot of great talent here. 

So, thank you for giving me the opportunity to talk about what 

I see, how I see this problem, at least from the Attorney General’s 

view. 

Thank you. 

Senator PORTMAN. Thank you, Attorney General DeWine. 

Acting U.S. Attorney Rendon, we will hear from you. 

TESTIMONY OF CAROLE S. RENDON,1 ACTING U.S. ATTORNEY, 

NORTHERN DISTRICT OF OHIO, UNITED STATES ATTORNEY’S OFFICE, U.S. DEPARTMENT OF JUSTICE 

Ms. RENDON. Chairman Portman and Senator Brown, thank you 

so much for the opportunity to discuss how we here in Northeast 

Ohio are addressing the heroin, opioid and fentanyl overdose epidemic that we are all experiencing. 

Here, in Northeast Ohio, we have a really innovative program. 

It is the Northeast Ohio Heroin and Opioid Task Force. And, if you 

look out into this room, you will see many members of our task 

force from all different walks of life, all working together to help 

to solve this problem. 

The rise of heroin and fentanyl and the misuse of prescription 

opioids threatens our communities, our families, our safety. And, 

these things are all interrelated and they have to be addressed together. And, that is why the Department of Justice (DOJ) and the 

Administration are working closely with our Federal, our State, our 

local law enforcement officers to fight this growing epidemic 

through a combination of enforcement, prevention, education and 

treatment. It is truly a four legged stool, and without any one of 

those legs, the stool will not stand. 

And, this is truly a crisis in Northeast Ohio. We have heard a 

little bit of some of the statistics. But, let me fill you in on what 

we are seeing here in Cuyahoga County, and with thank you to our 

Medical Examiner, who I have to tell you was the first person to 

sound the alarm on this epidemic here in our county. So, heroin 

overdose deaths increased in Cuyahoga County by more than 400 

percent between 2007 and 2012, when 161 people died of heroin 

overdoses. But, sadly, the number of heroin overdoses has increased year by year. And, recently, it has gotten dramatically 

worse with the introduction of fentanyl, which, as you mentioned, 

Chairman Portman, is incredibly potent and extremely deadly. So, 

according to the Cuyahoga County Medical Examiner, while there 

were only five overdose deaths in 2013 attributable to fentanyl, in 
105 

2014 that number rose to 37, and last year it was 91—91 overdose 

deaths attributable to fentanyl or a combination of heroin and 

fentanyl. 

And, last year 228 people, just in Cuyahoga County, died of an 

overdose of either heroin or fentanyl—or a combination of the two. 

And, this year we have already seen 125 fatal overdoses in Cuyahoga County, and it is only April. So, the devastation that this is 

wreaking throughout our community cannot be overstated. 

But, the crisis is not limited to Cuyahoga County. So, as you 

know, there are 40 counties in the Northern District of Ohio. And, 

we are seeing waves of overdose deaths everywhere in our district; 

Lorain, Summit, Stark, Lucas, Marion. It is everywhere throughout 

the Northern District of Ohio. 

And so, faced with this crisis, what we did is we assembled this 

task force. And, it brought together a wide diverse group of stakeholders to identify and implement comprehensive solutions to this 

growing crisis. 

And, in 2013, we held a summit to focus on the heroin epidemic. 

We had more than 700 people at that summit from all walks of life, 

from all aspects of our community; treatment providers, doctors, 

parents who had lost children, law enforcement, across the board. 

The result of that summit was the creation of a heroin and opioid 

community action plan. And, let me emphasize the word community action plan. 

This is the plan that guides the work of our task force. And, it 

addresses the heroin and opioid crisis from four different perspectives; law enforcement, health care policy, education and prevention and treatment. 

I want to take a minute just to highlight a few of the successes 

we have had, because the news is all so grim. But, there have been 

some successes, and they are worth noting. 

So, law enforcement. We created a heroin involved death investigation team. And, what this is, is a group of dedicated law enforcement officers who roll out to every overdose scene. And, they 

treat it like what it is, a crime scene, and they are there to gather 

evidence that we can then use in our criminal prosecutions. 

To date, the United States Attorney’s office has brought nine 

death specification indictments, which carry a 20 year minimum 

mandatory term of incarceration for the dealers who are killing 

people in our community. And, there have been a dozen more manslaughter cases brought in the State court system, because we partner, of course, with the attorney general and all of our local county 

prosecutors. 

Health care policy. So, members of the task force, many of whom 

are sitting in this room, have worked to increase the physicians’ 

use of the Ohio Automated Rx Reporting System (OARRS), which 

is the statewide prescription drug monitoring program. And, they 

have helped to develop really important increased training and 

education for doctors about the dangers and the unintended consequences of over prescribing opioids. And, I will note that a recent 

Centers for Disease Control (CDC) report showed that the total 

doses of opioids prescribed in Ohio decreased by 11.6 percent from 

2012 to 2015, in no small measure as a result of the work of the 

members of our task force. 
106 

Education and prevention. Members of the task force have organized town hall meetings and presentations at schools and with 

labor unions and community organizations throughout Cuyahoga 

County. And, through this, task force members have reached literally thousands of people. And, they have also spearheaded two 

significant media campaigns to raise very importantly awareness of 

this crisis. 

And then, finally, last but not least, I am looking at Dr. Jerry, 

treatment. So, the task force members have led the effort to expand 

the availability of the opioid overdose reversal drug naloxone to 

first responders and relatives of those who have substance use disorders. And, that work has literally saved hundreds of lives. 

And, they are continuing that work, while also addressing what 

you mentioned, which is the critical shortage of treatment facilities 

in our District and throughout the United States. 

These efforts, in my opinion, they are an incredible example of 

what we always talk about in the Department, a multi-faceted approach, that really is what we mean when we talk about being 

smart on crime. And, our task force, because of its success, is now 

a model that is being replicated at U.S. Attorney’s offices all across 

the country. 

But, while we have had some successes, we are keenly aware 

that this problem just continues to grow and get worse by the day. 

And, it is morphed, as we have discussed, from painkillers to heroin to now an incredibly deadly new drug, fentanyl. 

And, as you have noted, Chairman Portman, we cannot arrest 

our way out of this problem. But, we have to aggressively prosecute 

the drug dealers who are bringing this poison into our community. 

And, we have to find a way to choke off the supplies of the drugs 

into our community. 

And, of course, simply getting treatment for everyone who has 

suffered through addiction, that is not going to solve the problem 

by itself either. 

But, given the number of people who we know are already addicted to opioids in our communities, we have to find a way to 

make treatment readily available to those who need it. 

And, of course, changing prescribing practices alone, that is not 

going to curb the problem either. But, we have to start impacting 

the way that doctors are prescribing opioids. 

And, we have to address the underlying incentives that cause 

that to happen in the first place. 

And, education is critical. And, that is why the Administration 

is now championing a practice that requires people who are seeking 

a DEA registration to get specifically trained on prescription 

opioids and the dangers and the need to carefully prescribe. 

And then, finally, every one of us has to continue to talk to our 

children, to our friends, to our colleagues about the dangers of 

opioids. Because no one is immune from this threat. 

As you mentioned, Chairman, Senator Brown, opioid addiction 

knows no boundaries. It is an equal opportunity killer of men and 

women, young and old, city, suburban, rural, wealthy and poor, 

white, black and Hispanic. It is everywhere. And, it is killing people in our community every day. We are all at risk. 
107 

1The prepared statement of Ms. Plouck appears in the Appendix on page 157. 

And, you mentioned, Senator Brown, Ebola and the Zika virus— 

sometimes I wonder if people were dropping dead at this rate of 

Ebola or Zika, how would we all be responding? And, would it look 

like the response that we are seeing to this crisis? And, if not, why 

not? How do we get to the stigma that underlies our failure to address this crisis with every single tool in our tool kit? 

And so, from my perspective, this is going to take what we have 

all come to talk about as the ‘‘all of the above’’ approach. Everyone 

has to work together in concert. We have to roll up our sleeves to 

address what from my perspective, in my little corner of the world, 

is one of the worst public health crises I have ever seen and one 

that I hope never to see again. 

So, thank you. 

Senator PORTMAN. Thank you, Ms. Rendon. Director Plouck. 

TESTIMONY OF TRACY PLOUCK,1 DIRECTOR, OHIO DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES 

Ms. PLOUCK. I really appreciate the opportunity to present at 

this hearing today. 

And, as you are aware, the opioid epidemic has hit all States. 

And, Governor John Kasich and his administration has worked 

tirelessly in the last 5 years with both State, local and Federal 

partners to curb the tide, and yet the storm just continues to rage. 

I know you both share the same concerns that the Governor does. 

And, I would like to talk to you a little bit today about Ohio’s overall efforts and where we still have work ahead of us. 

Unintentional drug overdose deaths in Ohio reached an all time 

high of 2,482 in 2014, which is the most recent year available. That 

is 2,482 families that have been affected by a death related to overdose in our State just in one year. Opiate related deaths, which include both heroin and prescription painkillers, peaked at 1,988 

deaths in 2014, up from only 296 in 2003. With 502 fentanyl-related drug overdose deaths in this State in 2014, fentanyl was a 

significant contributor to the rise in drug overdose deaths according 

to the preliminary data that has been released by the Ohio Department of Health (ODH). By comparison in 2013, just 84 deaths involved fentanyl. As a result, Ohio proactively requested assistance 

from the Center for Disease Control’s EpiAid to better analyze our 

opiate related deaths. We are currently reviewing the recommendations and determining what should be implemented in Ohio to 

build on our effort. This continues to be a pressing issue for the 

State. 

Governor Kasich has made the fight against opiates a priority 

and is one of the nation’s most outspoken advocates on the issue. 

Early in his administration, the Governor announced the establishment of the Governor’s Cabinet Opiate Action Team (GCOAT) to 

fight opiate abuse in Ohio. GCOAT is comprised of directors from 

multiple cabinet agencies that touch the opiate issue. And, it is designed to foster collaboration across public health, treatment, law 

enforcement, education and other agencies that touch some facet of 

this complex challenge. 
108 

I know you understand the importance of taking this issue in a 

multi-pronged way because of your work on CARA. Senator 

Portman, I would like to thank you for your sponsorship of the bill, 

and I would like to thank you, Senator Brown, for your support as 

well. CARA takes a similarly comprehensive approach and addresses on a national level several things that Ohio has demonstrated 

we know are working and making some progress. 

I would like to talk a little bit about some specific areas. And, 

I am going to start with prescribing practices and prescribing 

guidelines specifically. 

In its ongoing efforts to combat drug abuse and save lives, the 

Governor’s Cabinet Opiate Action Team developed comprehensive 

prescribing guidelines for outpatient management of acute pain 

this past January. The acute guidelines follow previous prescribing 

guidelines for emergency departments, which were released in 

2012, and the management of chronic pain in 2013. All three of 

these guidelines were developed in conjunction with clinical professional associations, health care providers, State licensing boards 

and State agencies. I know that CARA also addresses this issue 

from a national perspective. And, I applaud efforts to limit the 

number of opioids prescribed nationally to ensure that these powerful drugs are only used in the course of appropriate medical care. 

As a result of the prescribing guidelines and the increased utility 

of OARRS, our prescription drug monitoring system in Ohio, the 

number of prescriber and pharmacist queries using OARRS increased from 778,000 in 2010 to 9.3 million in 2014. And, Ohio is 

making further progress. 

The number of prescription opiates dispensed to Ohio patients in 

2014 decreased by more than 40 million doses relative to the previous year. 

The number of individuals doctor shopping for controlled substances, including opiates, decreased from more than 3,100 in 2009 

to approximately 960 in 2014. 

From 2013 to 2014, there was a nearly 11 percent decline in the 

number of patients prescribed opiates at a dose higher than the 

current guidelines that are recommended. Ohio patients receiving 

prescriptions for opiates and benzodiazepine sedatives at the same 

time dropped by 8 percent. So, we are seeing some progress related 

to these interventions. 

I want to say a little bit about prevention, which has been mentioned by both of the other panelists. In 2014, the Governor and 

the first lady launched ‘‘Start Talking,’’ which is a statewide youth 

drug prevention initiative based on the premise that youth are up 

to 50 percent less likely to initiate drug use if an adult who cares 

about them talks directly with them about this issue and the risks 

involved. Understanding that this is not an easy discussion to 

begin, the program aims to help parents and other adults communicate better with kids on these topics. ‘‘Start Talking’’ offers three 

free tools for parents and other youth leaders to approach children 

and young adults. 

Nearly 57,000 adults are receiving these biweekly messages via 

e-mail to help start important conversations. 

‘‘Parents360Rx’’ is the second component of the program. It is a 

national program that Partnership for Drug-Free Kids established 
109 

that is designed to help educate adults about the dangers found in 

their own medicine cabinets. This is a good topical source for community meetings to help draw attention to some precautions that 

every household can take in the fight against the opiate epidemic. 

And then, finally, ‘‘5 Minutes for Life’’ is a program that is led 

by the Ohio State Highway Patrol, the National Guard and local 

law enforcement in partnership with high schools. Troopers, law 

enforcement officers and National Guard members talk directly 

with students, usually student athletes, to encourage them to become ambassadors and lead peer-to-peer conversations about the 

importance of healthy choices. During this school year alone, over 

260 events have been hosted with more than 35,000 students participating. 

I want to say just a moment about criminal justice initiatives 

and our support for court involved individuals. 

Established in 2014, we launched the addiction treatment program. This supports drug courts in establishing a program to provide addiction treatment, including medication assisted treatment, 

to non-violent adult offenders with dependence on opiates, alcohol 

or both. The first phase of the program reached 410 men and 

women, two-thirds of whom also had a co-occurring mental health 

disorder. According to a Case Western Reserve University evaluation of the program, past months drug use among program participants decreased by almost 70 percent, while crimes committed 

dipped 86 percent. At the same time, employment increased by 114 

percent, while stable housing increased by nearly 29 percent. 

Among participants, 60 percent had a job, and 91 percent had stable housing upon completion of the program. This program is funded with $11 million over the current biennium in 14 Ohio counties. 

CARA emphasizes the importance of treatment as an alternative to 

incarceration, and we are seeing that work here in Ohio is effective 

in that regard with the drug court model. 

I want to say just a little bit about expanding the availability 

and the use of naloxone or Narcan, as has been noted earlier. 

Our department administers grants for first responders across 

the State. We know that through State emergency medical services 

(EMS) data, naloxone was administered to 18,438 patients in 2015. 

That is more than 18,000 deaths avoided as a result of this lifesaving measure. Without this important overdose antidote, Ohio’s 

already two large number of overdose deaths would be much higher. The most recent State budget included $1 million to purchase 

naloxone for first responders, including police and fire. A concerted 

effort has been made to convince local agencies of the importance 

of carrying naloxone, oftentimes as an overdose victim cannot wait 

for EMS to arrive. And, we have seen many communities sign on 

to this. CARA also addresses this issue, and we support your efforts. Naloxone use is critical to saving lives and getting people into 

treatment. 

I would like to say a little bit about Neonatal Abstinence Syndrome. In 2013, the Kasich administration launched an effort to 

address the epidemic among the smallest of Ohioans, babies born 

to mothers who are addicted to prescription painkillers, opiates and 

heroin. By engaging expecting mothers in a combination of counseling, medication assisted treatment and case management, the 3- 
110 

year project is estimated to reduce infant hospital stays by 30 percent among those enrolled moms and babies. One of the goals of 

CARA is to improve addiction and treatment services for pregnant 

and postpartum women. And, we believe Ohio is developing a 

model that can be replicated nationally. 

Across the State, I continue to hear stories of waiting lists and 

difficulty accessing treatment, in part due to the Federal Institutions for Mental Disease (IMD) exclusion. Treatment works, but it 

is not easy. I recently read of a couple who, after multiple relapses, 

found themselves homeless, involved in criminal justice and lost 

custody of their young daughter. Through treatment received 

through extended Medicaid benefits, they have over a year of sobriety. They have regained custody of their daughter, and they are 

now employed. We know that approximately 400,000 additional 

Ohioans were able to connect with mental health and/or drug addiction treatment as a result of the Medicaid expansion when it 

was extended to adults up to 138 percent of poverty. Capacity and 

workforce continue to be a challenge. And, the IMD exclusion poses 

a barrier to treatment access. I appreciate that CARA sets up a 

way to take a serious look at the IMD exclusion and its impact on 

treatment. 

Thank you again for inviting me to testify on this very important 

topic today. I want to commend both of you on your work on this 

issue. And, I especially commend you, Senator Portman, on your 

leadership on this issue through your career. Again, as I described 

in my testimony and at length in my written statement for the 

record, a number of the provisions in the CARA bill are activities 

that Ohio is undertaking. And, we fully support the expansion on 

a more national scale of these efforts. 

I stand ready to work with you as we move forward. And, we 

look forward to any questions that you might have. 

Senator PORTMAN. Great. Thank you, Director Plouck. I appreciate it. And, we will have some questions. I am going to ask Senator Brown to go first. 

I want to just make one comment that is pretty obvious to everybody in the room. If we can get CARA passed, because of the programs that all three of these panelists talked about, we will be in 

a good position to access some of these grants, whether it is with 

regard to prevention, education or treatment, medication assisted 

treatment or, as you mentioned, the Neonatal Abstinence Syndrome, working with pregnant women. Our veterans, of course, in 

Ohio are great. And, they are funded in here. 

So, there is the diversion programs, drug courts. So, there is a 

lot of opportunity here for Ohio. We play a leading role thanks for 

the additional help that will come from CARA going forward. 

I will ask Senator Brown to go first with questions—and I want 

to ask you some myself. 

Senator BROWN.. Mr. Chairman, thank you. 

And, Director Plouck, let me start with you. First of all, you were 

some years ago, in addition to what you are doing now, some years 

ago you were a Medicaid director in the State, right, so you know 

this issue pretty well. 

On March 30, an Akron Beacon Journal editorial discusses the 

role that Medicaid expansion, when the Governor made his decision 
111 

1The editorial submitted by Senator Brown appears in the Appendix on page 233. 

as part of the Affordable Care Act (ACA) to expand Medicaid, and 

discussed in part Ohio’s battle of its addiction. 

I would like, Mr. Chairman, to enter into the record this editorial,1 if I could. 

Senator PORTMAN. Yes. No objection. 

Senator BROWN. Folks who have health insurance are better able 

to access critical mental health, of course, mental health and substance abuse services, including medication assisted therapy, as we 

talked about. 

I would like to focus on a different benefit of Medicaid expansion, 

if I could, because the expansion localities around the State are 

now able to use money they would have spent on health care for 

other critical services. 

For example, Summit County’s Alcohol, Drug Addiction & Mental 

Health (ADM) services board used to rely on a local tax levy to help 

pay for basic health costs for the disadvantaged. Now, after the expansion of Medicaid, the board can utilize these levy dollars to 

meet other urgent needs in Summit County. That is funding recovery coaches, Project Deaths Avoided with Naloxone (DAWN), funding detox, both to the local community. 

Medicaid expansion enabled Summit County to save more than 

$4 million last year, and is projected to save the county more this 

year, money that is being used to address other urgent needs. 

My question is this: The new ‘‘Healthy Ohio’’ plan out for comment through the Ohio Department of Medicaid, out for comment 

from the Senators from Medicare and Medicaid Services, would require nondisabled adults, including some pregnant women, to pay 

premiums for coverage that is free today, would impose new limits 

on how many times Ohioans can go to the doctor or get care they 

need each year, or require patients to pay out of pocket, as I think 

you know, when they go to the doctor, pick up prescriptions, on top 

of monthly premiums that they may face. And, additionally, if individuals cannot afford to pay the premium or they get locked out of 

coverage, they have to again rely on help from local counties. 

Walk through, if you would, what ‘‘Healthy Ohio,’’ if the Medicaid waiver is granted to the State from Center for Medicare, Medicaid services, how ‘‘Healthy Ohio’’ would affect folks who rely on 

Medicaid for addiction treatment? 

Ms. PLOUCK. Chairman Portman and Senator Brown, I am not 

the lead cabinet director on this issue. And, I would want to defer 

to any clarification that Director McCarthy from Ohio Medicaid 

would want to bring to this. 

I think the general philosophy behind ‘‘Healthy Ohio,’’ when it 

was added into the last biannual budget, was a philosophy of personal responsibility for individuals. And, Medicaid is following the 

law to request the waiver that was stipulated in the budget bill. 

As far as access to addiction and mental health services, those 

are named services in the Ohio Medicaid benefit. And if, those 

would be subject to the same requirements related to call sharing 

or anything that would be required as a part of ‘‘Healthy Ohio’’ 

waiver. 
112 

So, I do not believe that addiction treatment is approached any 

differently than other Medicaid services in that regard. 

Senator BROWN. Understanding you are part of an administration with the legislature that is asking for the waiver. But, does 

that make sense to you, when dollars that would have been available now may be used for other things, when we know how every 

community is starved for dollars on treatment programs? 

Ms. PLOUCK. The Ohio Department of Medicaid is following the 

law that was enacted in the budget bill to request the waiver from 

the Federal Government. 

Senator BROWN. And, I understand they are following the law. 

I want your opinion of that law. Granted I understand you are part 

of the administration. Does that make sense to you? If you can step 

in that other role, and it is probably unfair to ask you to step in 

the other role. But, can you kind of talk that through? 

Ms. PLOUCK. As an advocate for individuals and families that are 

struggling with mental health and addiction challenges in their 

lives, I think that we should work to try to overcome any barrier 

to access to treatment that exists. 

Senator BROWN. OK. 

Ms. PLOUCK. I recognize that to an individual, the waiver, if enacted as it has been proposed pursuant to the budget bill, does create some obstacles that would need to be overcome on an individual 

basis depending on the resources of the individual. 

Senator BROWN. Thank you. And, I ask that in part—I mean, I 

opposed the waiver pretty obviously. 

But, I also ask in part, because the Centers for Medicare and 

Medicaid Services (CMS) in Washington can make a determination 

to choose parts of that waiver to grant and parts to deny. I think 

they should deny the entire waiver. I understand they may not. 

And, I know that hospitals around the State are concerned about 

the waiver period, because they so applaud it when the Governor 

expanded under the ACA Medicaid, I will not speak for others. But, 

the ones that have talked to me think that this is backsliding and 

particularly with the acute needs we have now. 

But, thank you for your candor there. I appreciate that. 

For General DeWine and again U.S. Attorney Rendon, an easier 

question than I would asked Director Plouck. [Laughter.] 

Senator BROWN. I just really wanted to kind of flush out some 

of the things you already said. 

We know that the opioid crisis is not just law enforcement. Senator DeWine, you said you cannot arrest your way out of it. We 

have all said that. We all understand that. And, we kind of made 

those mistakes in the war on drugs in the past. 

You cannot arrest your way entirely out of this, we know. So, we 

know it is not just the law enforcement. As you said, it is law enforcement, not just law enforcement. 

It is not just treatment. It is a problem that requires something 

more comprehensive, as Senator Portman has mentioned many 

times with CARA overall. 

But, what can regular people do to help address this crisis? And, 

we have some of the State’s best experts here. We have people that 

devote much of their workday and beyond that to doing this. Talk 

more about the general public, what people can do? 
113 

Mr. DEWINE. Chairman and Senator Brown, I think that is an 

excellent question. 

Because I truly believe that the success that we have achieved 

so far and that we can achieve in the future is going to be very 

much depending on what occurs at the local level. 

We all have a role. We do what we do. U.S. Attorney does what 

they do in regard to law enforcement. We try to help with the six 

individuals who I told you about who will go out and help in the 

local community. 

The communities that have started to change the culture, to 

change how we look at it, communities that have begun to really 

assist people with not only getting in treatment, but what happens 

when we get out of treatment, those communities—where we have 

seen that happen is because the local community got together. 

I know you had a lot of town hall meetings. Senator Portman has 

had town hall meetings. I suspect you found what I found when I 

did this. 

We did a number of town hall meetings over a year ago. And, to 

me the interesting thing, but also kind of scary thing was, that we 

would have a lot of people, a lot of just citizens who came. And, 

we would have a panel of experts. But, we would have a roomful 

of citizens. And, we encouraged just a conversation. 

And, what I found was that you would get someone who would 

stand up on one end of the room and say, well, in this community 

we need such and such. We do not have that. Somebody else on the 

other side of the room stands up and says, yes, we do. 

So, a lot of it is I think pulling people together and getting people 

out of their normal area where they work and communities coming 

together. 

And, when you have a grass roots effort in the local community, 

what happens is, people in that community start talking to each 

other more. That is how we are going to do this. 

I think the other thing average citizens can do is to say, hey, 

look, in this community, somehow we have to have education at 

every grade level. And, we have to work with our schools, who we 

ask to do all kinds of a million things. And, they are overburdened. 

But, we have to work with our schools. And, the community has 

to say to the school, this is very important. 

If we are going to deal with this problem in the future, if we are 

going to have some success 5 years, 10 years, or 20 years from now, 

we have to start in kindergarten. And, we have to work all the way 

through. 

So, I am a great believer in the local community and where the 

local community comes together, where the business community is 

involved, where the church faith based community is involved. I 

think we can see some progress. That is what the individual can 

do. 

Ms. RENDON. Senator Brown, I think that is an excellent question. Because I think there are things that every single person in 

our community can do to help with this crisis. 

And so, what you are doing here today is a huge step, because 

we all need to be educated about what is happening. And so, the 

more we get the word out, the more people know that this is out 
114 

there, the more they can figure out where their piece is, where they 

can help. 

But, for the average citizen, what I tell people when I am at 

these town hall meetings, there is a ton that everyone can do. 

So, you can start by going home and opening your medicine cabinet and figuring out what is in there that should not be there that 

you were prescribed a year and-a-half ago. 

And then, on April 30, you can see my good friends at the DEA 

on their drug take-back day, and take that medication safely to a 

drug drop box and get rid of it before somebody accidentally tries 

it, some young kid who thinks it is safe because it is in a medicine 

bottle, somebody who happens to be in your home. 

You can do that on a daily basis in many of our police stations. 

And, I know some of our pharmacies are now starting to agree to 

have drug drop boxes in the pharmacy, which I think is phenomenal. So, that is something you can do. 

You can talk to your kids, to your family, to your friends. My oldest son is here. And, he can tell you, I think maybe because of my 

career, I have been talking to my children about the dangers of 

drugs since they were toddlers. 

So, just as we have taught all of our children to buckle their seat 

belt and not smoke cigarettes and not drink and drive, we have to 

have on that list, do not use drugs. You do not know, that first 

time that you take it, you have no idea how it is going to impact 

you. And, then we all have to look at ourselves in the mirror and 

figure out when we became a culture that has to be pain free at 

all times. Right? 

So, when I had my wisdom teeth out, I got Tylenol, and I think 

I got to stay home from school for a day. Now, you take your children to get their wisdom teeth out, and they want to give you 

Percocet. Percocet. We as parents, we as citizens, need to stand up 

and say, no. I am not taking that prescription. I do not need that 

prescription. 

My husband had his elbow operated on—not removed. We do not 

need a 60 day supply of Vicodin. I want three. Right? 

But, I found out you can do the same thing at the pharmacy. So, 

if they do give you the prescription for 30 Vicodin, you do not have 

to take 30 Vicodin. You can talk to your pharmacist and say, how 

many of these do I actually reasonably need to address this problem? And, they will tell you, two, three. And, you can walk home 

from the pharmacy with just what you need. 

So, it has to start with each one of us in our homes with the 

things that we care about, with our commitment to this next generation and the future of our community. And so, there is a role 

for every single person in our community to help with this. And, 

getting the word out is the first step. 

So, thank you. 

Senator PORTMAN. Thank you. Thank you, Senator Brown. 

I could not agree you with more. And, tragically, we are going 

to hear from a witness in a little while about wisdom teeth extraction and the specific issue that you raised and how that led to an 

addiction and eventual overdose and death. 

But, and you are right, everybody has a role. One of the things 

we tried to do in this legislation, drop boxes, for instance, we do 
115 

provide for them to be at pharmacies and at long term care facilities and in hospitals that have pharmacies. 

I must tell you, I have a frustration on the prevention and education side, because, 22 years ago, I started this group in Cincinnati. Officially, we were having our 20th year anniversary I 

think in a couple weeks. I founded it. I chaired it for the first 9 

years. I was on the board until I joined the Senate. 

It is called Coalition for a Drug-Free Greater Cincinnati. Now, it 

is called Prevention First. And, we are considered a model coalition. I was the author of the Drug Fee Communities Act of 1997. 

We have spawned 2,000 coalitions throughout the country. 

As all three of you have acknowledged, we are still not able to 

persuade so many of our fellow citizens, not just kids, this is not 

just about young people, of the dangers. And, the best research 

shows that it is this recognition of the danger that kept those people from trying heroin. In the 1990s when we started our coalition, 

it was not an issue. Now, we have 13 year old kids in Ohio trying 

heroin, first time, shooting up. 

Parents, all the evidence shows parents or other caregivers, when 

there is not two parents at home—which unfortunately is the case 

in many of our communities. And, in many situations you do not 

have a parent who is available, even if the parent is in the family. 

But, parents make a huge difference. 

The single largest difference as a parent, when I had three teenagers, well, all three are passed teenagers now barely, you kind of 

wonder sometimes. But, it is incredibly important, as you say. 

But, on the issue of community coalitions and this whole issue 

of prevention and education, we are going to hear from Rob Brandt 

later, who has become an expert on this by necessity. 

But, what should we be doing differently? The CARA program 

starts a national awareness campaign, specifically on this issue of 

the connection between prescription drugs and opioid addiction, 

and the fentanyl and the heroin connection. 

Because four out of five people who are addicted to heroin start 

on prescription drugs. That is what they say. And, we need to— 

people do not know that. So, they do not know when they go to 

have a relatively small procedure that they should not be asking 

for the Percocet. Instead they should be asking for the Toradol or 

the Tylenol. So, that specifically is in here. 

But, what would you say? And, Attorney General DeWine, again 

you have been active on this, Ms. Rendon and Director Plouck, if 

you would like to jump in. But, what would you do differently in 

terms of the prevention and the education side of this, something 

different and new? 

Mr. DEWINE. No. You go ahead. 

Ms. RENDON. Well, so one of the things that I think is an example that is really incredible to me from our task force here in 

Northeast Ohio is the partnership between law enforcement, treatment, education and regular community members, which has allowed us in some respects to get a little bit ahead of the curve. 

So, I talked earlier about our Medical Examiner (ME) sounding 

the alarm on this problem as it came on the horizon. So, they were 

the first to see fentanyl in pill form in our district. They sent out 

an alert, and it came to us, because we are on this task force. 
116 

And so, it went immediately to the DEA. And, within weeks, the 

DEA had made a massive seizure of fentanyl in pill form, just shy 

of 1,000 pills. And, we were able to charge that individual in Federal court within days and address this problem and get the word 

out very publicly. 

And, what was so important about that is the fentanyl pills were 

shaped and dyed to look like oxycodone. And so, if you are an 

oxycodone user, and that is what you think you are taking, and it 

is fentanyl, it is an overdose waiting to happen. I mean, every one 

of those pills was an overdose waiting to happen. 

But, we were able, because of this group that we have together 

and the constant communication that we have, both when we are 

sitting together in our office and then also on a regular basis by 

e-mail and phone, we were able to sound a really loud alarm bell 

and get the word out to the drug using population. 

Joan Synenberg was here earlier. She is a common pleas court 

judge. She has one of the drug courts. There she is, back there. She 

is a member of our task force. And, told us a really heart-breaking 

story of one of her graduates—I was at the graduation—who 2 days 

after graduation overdosed and died. 

And so, that caused us to realize that we have to get to her graduates as they are walking out the door to make sure that they understand how dangerous the world has become while they have 

been sober. 

Because the heroin users do not know how deadly and dangerous 

the fentanyl is. And, when you are taking an illegal drug, unlike 

a drug that you get at the pharmacy, you have no idea what it is 

you are about to put in your mouth. 

And so, unless you can get the word out, really actively, really 

publicly through the media, through one on one meetings, through 

this combination of people working at all levels, you cannot impact 

the problem. 

But, all of us together, that is why the stool has to have the four 

legs, all of us together, we can make a difference. And, we are. It 

is disheartening when it is not going in the direction that you want 

it to. But, I am telling you every day we are saving lives and will 

continue to do so. 

Mr. DEWINE. I have a couple of comments. Mr. Chairman, you 

are absolutely right. There is a natural progression from opiates to 

heroin. 

One of the things that we partnered with Governor John Kasich’s 

office, right after he took office and I took office, was to really crack 

down on doctors who are really nothing more than drug dealers. 

We have taken, and I say we, because we are the lawyers for the 

State Medical Board, and we pushed this. But, the State Medical 

Board has really stepped up. For many years they were not frankly 

doing what they needed to do. 

They have taken I believe 70 doctors’ licenses in the State of 

Ohio. I was involved in some of the raids. And, I will not take your 

time to tell you the horror stories. But, we had one doctor who was 

on the circuit, basically. He would spend one day—and he had 10 

offices around the State. 
117 

And so, that—if we can stop people from—change the culture regarding an opiate, we are going to see some progress in the heroin 

as well. Because one flows, one flows from the other. 

We had a real pendulum swing, in regard to the culture of prescribing pain meds. And, if you recall, 15 years ago or so, the concern was that doctors were not treating pain. And, that was probably a correct comment, that we needed to do a better job, particularly people who have long term retractable pain. But, we went too 

far the other way. We are now starting to move back. 

But, I will tell you, I had the same experience as I have experienced with a granddaughter who had her wisdom teeth taken out 

and was given dozens and dozens of pills. That was what the prescription was. Our daughter, we told her not to take any of them. 

She did not take any of them. 

So, we are not there with changing the culture with the medical 

community. We have come a long way. 

As to the second thing, I will go back to what I said, Mr. Chairman and Senator Brown, we have not done a very good job in this 

country in regard to education. I think you have to be—we have 

to be careful, is what some of the experts will—I do not intend to 

be an expert. But, will tell me is, there is some things we do—we 

could be doing that we might think is the right way in education, 

and it may be exacerbating the problem. So, I think whatever we 

do, it would have to be evidence based. And, we have to have that 

tested. 

But, you all will remember when I was about leaving, and when 

Senator Brown was about coming, I think, in the Senate, you were 

in the House, but, killed the national funding. It was not very 

much in education. But, every school got some of it. Every school 

got something. And, that just went away. I lost that fight. And, 

those who were fighting on our side also lost. We lost that. 

So, I think we have to look at that more and see what the Federal Government can do. I think candidly we have to do something 

in this State, so that we are doing something with education K 

through 12 every year. Nothing less than that is acceptable. Nothing less than that is going to begin at least to deal with this problem. 

We are not doing that. And, I am not blaming anyone. But, we 

have to start doing that again. 

Senator PORTMAN. Thank you. 

I have so many other questions. And, I am going to continue the 

discussion with all three of you and then with Senator Brown on 

these issues. 

But, we do have another panel that is patiently waiting. And, I 

want to get them up here, too. 

Thank you to all three of you for not just coming today and sharing your views with this distinguished group of people who are in 

the trenches, but for what you do every single day to help to save 

lives and to pull lives back together. So, we look forward to continue to work with you. And, thank you for your testimony. 

Ms. RENDON. Thank you. 

Senator PORTMAN. I would now like to call the next panel up, if 

we could, please. Dr. Michele Walsh, Dr. Kotz, Emily Metz and Rob 

Brandt. 
118 

OK. We are on to the next panelists here. I would like to get 

started. Why do we not start by swearing in the panel, since this 

is the custom of this Committee to do this. So, please stand and 

raise your right hand. 

Do you swear the testimony you will give before this Committee 

will be the truth, the whole truth and nothing but the truth, so 

help you, God? 

Thank you. Let the record show that all the answers were in the 

affirmative. 

We appreciate each of you coming today and look forward to the 

opportunity to hear from you and also to get some questions in. 

I was probably negligent in not mentioning for the last panel 

that we are asking for five minute opening statements. And, I 

know you all know that. But, try to stick to 5 minutes, if you can, 

because that will give us more time to have interaction between 

yourselves and we will be able to ask you direct questions. 

Again, we have an amazing group here. First, is Dr. Michelle 

Walsh, who is right here. I mentioned earlier the Rainbow Babies 

and Children’s Hospital work. It is incredible. She has given the 

opportunity to tour it a couple times, I think, maybe a few times, 

but more recently with regard to this issue of babies who are born 

with Neonatal Abstinence Syndrome. So, thank you for being here. 

Dr. Michele Walsh is division chief of neonatology right here at 

UH. She will talk about that issue. After Dr. Walsh, we will hear 

from Dr. Nancy Young. Dr. Young is an expert in the issue of substance abuse and its impact on children. She is going to expand on 

the broader impact of the Neonatal Abstinence Syndrome we mentioned earlier. 

In particular, Dr. Young is going to discuss the correlation of 

substance abuse and children entering the child welfare system. 

Again these are areas that she has testified about before. In fact, 

she came to our Finance Committee, where Senator Brown both 

and I serve, and testified before the U.S. Senate. I appreciate her 

willingness to come here to Cleveland. 

Dr. Margaret Kotz is here. Dr. Kotz is an addiction expert. She 

is a specialist right here at University Hospital. And, she told me 

this in our round table discussion last year. We got to talk to her 

about some of her work. 

And, she is going to discuss the merits of medication assisted 

treatment. That is one we did not get a chance to get into as deeply 

as I wanted to in the first panel. We look forward to that. 

Emily Metz is here from project DAWN. She is going to speak 

about the work in the community to get naloxone out to prevent 

these overdoses. We talked a lot about that today. 

I think I am going to be with you later this afternoon and be able 

to see some of your good work directly at the free clinic. And, also 

I know you work with MetroHealth, their facility here in Cleveland. So, we look forward to hearing from you. 

And then, last but not least, Rob Brandt is here with us. And, 

I was looking at Rob when there was discussion about this issue 

of prescribing to our kids prescription drugs that are addictive, in 

the case of a wisdom tooth extraction. 

And, unfortunately, Rob is an expert. He is a business leader. He 

got involved with prevention because of his family—his son, Robby. 
119 

1The prepared statement of Dr. Walsh appears in the Appendix on page 170. 

He has a group called Robby’s Voice. They are awesome, because 

they are out there in the schools. We talked about doing it at young 

ages. He is there in the elementary schools. And, he works to bring 

the message of drug education and drug prevention to students and 

families. 

So, again, thank you all for being here. 

And, Dr. Walsh, we look forward to your testimony. 

TESTIMONY OF MICHELE WALSH, M.D.,1 DIVISION CHIEF, 

NEONATOLOGY, UH CASE MEDICAL CENTER, UH RAINBOW 

BABIES AND CHILDREN’S HOSPITAL 

Dr. WALSH. Thank you, Chairman Portman, Senator Brown and 

distinguished guests. I am Michelle Walsh. I am the Chief of 

Neonatology here at Rainbow. I thank the Committee for holding 

this field hearing in Cleveland. And, we are proud to host you at 

the UH Case Medical Center. I thank the Committee for holding 

this field hearing in Cleveland. And, we are proud to host you at 

the UH Case Medical Center. I have been privileged to care for the 

tiny babies of Northeastern Ohio for over 25 years. And, I appreciate the opportunity to speak on their behalf. 

Never have I seen a public health epidemic of the severity of the 

current opioid epidemic among our citizens. And, as others have 

said, Ohio unfortunately has the unfortunate distinction of being 

among the lead in the entire country. We must focus our efforts on 

a cohesive national strategy that attacks every facet of this complicated problem. In the same way, as Senator Brown alluded, that 

we came together as a nation to combat Acquired Immunodeficiency Syndrome (AIDS) and more recently Ebola, the same urgent epidemiologic methods and prevention are needed to combat 

this scourge. The Comprehensive Addiction and Recovery Act 

championed by you, Senator Portman, and so many others is exactly the right direction to address the complexities of addiction 

treatment, the inadequate numbers of programs, inadequate numbers of trained physicians and addiction specialists and the critical 

shortage of facilities to address this exploding issue. 

As others have highlighted before me, and I will not repeat, the 

epidemic is staggering. And, I entered into the record data on the 

explosive growth from 2001 to 2011 of the number of citizens in 

Ohio. Which the data from the Ohio multi-agency community report documented that in 2001, there were only eight counties that 

had a significant problem with opioid addiction. But, by the last 

available report in 2011, there were only eight counties—— 

Senator PORTMAN. That will be entered into the record. 

Dr. WALSH [continuing]. That was not at the highest levels of addiction. 

The fentanyl problem is exploding. And, unfortunately, the epidemic among adults has led to a corresponding epidemic among 

newborns. A recent publication from Tennessee analyzing Medicaid 

data indicated that 27 percent of pregnant women were prescribed 

one or more opiates during their pregnancy. 

So, it does have to start with education, not just of our children, 

but also more education of physicians. And, as has been high-
120 

lighted here, it is not just physicians. It is dentists. It is emergency 

room physicians who in the interest of being compassionate are 

over prescribing these drugs. 

The tragic occurrence of a newborn addicted to narcotics causes 

a syndrome similar to what is seen in adults—jitteriness, fever, diarrhea, poor feeding, and, if not treated, seizures. 

About half of the babies that are narcotic exposed in the womb 

require pharmacologic treatment. The problem is that the strategies were largely unstudied. And so, there is huge variation in the 

amount of drugs used and the duration of the treatment. 

Governor Kasich challenged Ohio children’s hospitals to work together to come up with a better approach to this. And, we were 

able to publish our research that showed a significant improvement 

in the treatment of the newborns. Working together, we identified 

best practices for caring for the family and the infant and improving the integration of care between obstetricians, neonatologists 

and addiction medicine specialists. 

From the earliest days of our work in 2011 to today, we have decreased the number of opiate-exposed newborns who received opiate treatment from 60 percent to 45 percent—and decreased the 

length of their treatment from 25 days to 16 days and the total 

hospitalization from 31 days to 19 days. 

As we took that, we moved from the six children’s hospitals, and 

with funding from the Ohio Department of Medicaid, we moved 

this into our statewide Ohio Perinatal Quality Collaborative 

(OPQC). And, I am privileged to lead that group. And, we are now 

active in all 105 maternity hospitals in Ohio. And, in fact, on Monday, we will have our third learning session where over 500 health 

professionals will meet together to share lessons learned and further improve our treatment course. 

While embracing the cohesive approach that you have heard 

from the first panel, we are just beginning to see the tide turn on 

the amount of narcotics prescribed in Ohio. And, for the first time, 

the data comparing 2012 to 2014, the amount of opiates prescribed 

decreased for the first time. And, we hope that this will be a harbinger that as prescribed opiates decrease, the epidemic of addiction will decrease as well. 

I believe Ohio’s approach to be a model for the Nation. And, I respectfully urge additional approaches like the CARA Act to continue efforts to educate physicians and dentists and all other prescribers on appropriate pain treatment, especially the limited role 

of narcotics in acute pain and the science of addiction. 

All of the efforts limiting illegal prescribing practices and requiring the mandatory use of our OARRS prescription platform is beginning to make inroads. 

We do need to create new programs within our opioid maintenance clinics, encouraging mothers to focus on their recovery and 

consider delaying pregnancy until the mother’s health and dependence are improved. 

We also, as has been emphasized, need to enhance programs that 

encourage women to seek prenatal care and avoid criminalizing 

pregnant women with narcotic addiction. Some States have 

criminalized using opiates during pregnancy. And, what we are 

seeing, as some of those States are adjacent to us, we are seeing 
121 

1The prepared statement of Dr. Young appears in the Appendix on page 173. 

increasing numbers of those women seeking care in Ohio, rather 

than seeking care in their home State. 

We need to create incentives for new methadone treatment providers to enter into the field and eliminate barriers to prescribing 

Suboxone replacement therapy during pregnancy, which will decrease the severity of newborn withdrawal and allow certified providers to increase the number of patients they are treating. 

Lastly, we need additional residential treatment programs that 

welcome both the mother and her infant and can comprehensively 

support the recovery. 

Pregnancy is a teachable moment, where women are highly motivated to change and improve their lives and the lives of their children. And, among all of those who are treated for addiction, the 

success rates are higher in pregnancy than they are in other populations. 

And finally, as was alluded by Senator Brown, we need to fund 

research at the National Institutes of Health (NIH), as we do not 

know what the long term consequences to these infants are going 

to be, and whether there are going to be impacts on their intellectual development in the future or in their vulnerability to addiction 

themselves in the future. 

Thank you again for the opportunity to testify. And, I stand 

ready to support your efforts in any way possible. Thank you. 

Senator PORTMAN. Thank you, Dr. Walsh, you already have. Dr. 

Young. 

TESTIMONY OF NANCY K. YOUNG, M.D.,1 DIRECTOR, CHILDREN 

AND FAMILY FUTURES, INC. 

Dr. YOUNG: Thank you. And, thank you, Senator Portman and 

Senator Brown, for having the hearing and your continued support 

on these issues and the CARA Act. 

Each year the number of infants who have been prenatally exposed to illicit drugs, binge drinking and heavy alcohol is about 

360,000, the population of Butler County, each year. 

I would like to emphasize four points from my written statement. 

In the past three decades, our country has experienced at least 

three major shifts in substances of abuse that have had a dramatic 

impact on children and families, but particularly on the child welfare system. 

While the increase of opioid misuse has been described as having 

the worst effects, unfortunately, as reported in governing just last 

week, we have to begin to anticipate the synthetics, such as bath 

salts and spice, which are beginning to kill people in a very different way than the overdose, but are increasingly being manufactured, marketed and used. 

The point is that irregardless of the drug of the decade, child 

welfare agencies see some of its worst effects. And, despite the history and the known cost of substance use disorder on child welfare, 

the response has not been systemic. It has not been with funding 

changes to adequately address the problem. Instead, we have offered demonstration grants and pilot programs. 
122 

While worthwhile, to understand what works, we need to be at 

that systemic level of understanding how to take these initiatives 

statewide. 

My second point is that the current opioid crisis, as is all too 

well-known in Ohio, means that young people are dying at astonishing rates too often leaving young children. Grandparents and 

other kinship providers are taking in these children—sometimes 

with little support or assistance. 

We recently analyzed the Federal Adoption and Foster Care 

Analysis and Reporting System (AFCARS) data set and found that 

children who were placed in protective custody, because of their 

parent’s alcohol or drug problem, are most frequently placed in kinship placements, rather than other type of foster care or group 

homes. 

Another effect of opioids on child welfare services is the alarming 

increase in infants who are coming into protective custody. In 2014, 

45,000 infants were placed in protective custody, the most recent 

year that data are available. 

Specific to opioids, thank you again for your support of protecting 

our Infants Act. I understand the report to Congress is underway 

in the administration. 

But, the Federal law intended to protect these infants, the Child 

Abuse Prevention and Treatment Act (CAPTA), requires medical 

providers to notify child protective services of infants identified as 

affected by prenatal substance exposure. However, it is not consistently implemented. And, child welfare agencies do not have clarity 

about how best to meet these families’ needs. 

Last week, the Administration on Children, Youth and Families 

(ACYF) issued program instructions for States to more fully describe their State laws and policies and then procedures for these 

infants. Clearly a view of the current legislation and funding mechanisms to provide safe care for these infants is now essential. 

But, we also need to recognize that CAPTA funding for this provision is approximately $25 million nationwide, which in some 

States, it is about half of one State employee. 

The response to the effects on these infants is essentially an unfunded mandate that to date has not been implemented and in the 

wake of increasing NAS no longer seems adequate. 

The urgent policy issues here are clarifying how to implement 

the CAPTA law, expanding treatment access by appropriating 

funds for CARA, for example, and most important, ensuring that 

child welfare financing is flexible enough to allow keeping infants 

with their families whenever possible by ensuring treatment access 

and in-home preventive services. 

My third topic is the good news on what we know about what 

works. Federal investments over the past decade have tested collaborative strategies in nearly 100 communities. And, those investments consistently produced better outcomes for these families. 

To simplify, we have determined that there are seven core common strategies implemented in communities which lead to improved outcomes in five Rs. 

Recovery. The children remain at home. They reunify. We have 

dramatic decrease in recurrence and decrease of return to care, 
123 

1The prepared statement of Dr. Kotz appears in the Appendix on page 201. 

about a third of standard services. These positive results are detailed in my written statement. 

Implementing these priority strategies is underway in Ohio as a 

result of a grant from the Department of Justice’s Office of Juvenile and Delinquency Prevention (OJJDP) as a grant to the Ohio 

Supreme Court. OJJDP selected five States to show how these ingredients of better practice can be implemented on a larger scale 

by creating systems change throughout the juvenile court docket. 

I have been privileged—I feel like Ohio is my second home. I am 

here about every other month and on the phone every week with 

a State team that is devoted to expanding these kinds of practices 

across the State, with 12 communities that have been selected as 

pilots. 

And, over this past 18 months, we have been focused on implementing these seven key ingredients and working on the data systems to monitor outcomes. Next spring, Ohio will be one of those 

five States that will compete for funds for full implementation of 

the plans that they have made in the last 2 years. Finally knowing 

that Federal investments have generated a knowledge base of effective approaches and demonstration grants, pilot programs and Title 

IV–E waivers, we now have clear policy choices. 

Improving data collection and monitoring. Building on the lessons from the prior Federal investments to take these initiatives to 

scale in the States. Solve the current gap in timely treatment access. 

Funding CARA, as you know, is critical, as well as providing 

child welfare with the resources they need to pay for substance 

abuse and mental health treatment for parents, including those 

families with a baby affected by prenatal substance exposure. 

And, preventing future crises and costs as substance abuse patterns change over time, by providing the flexible funding that is 

needed by child welfare to meet the needs of families before infants 

are removed. When we assure timely access to effective treatment, 

families recover, kids stay safe at home, and we save money. Now, 

we can and we must move beyond these pilots and demonstrations 

and take these lessons into systemic changes across agencies for all 

of our children and families. 

Thank you so much for your time. 

Senator PORTMAN: Thank you, Dr. Young. Dr. Kotz. 

TESTIMONY OF MARGARET KOTZ, D.O.,1 DIRECTOR, ADDICTION RECOVERY SERVICES, UH CASE MEDICAL CENTER, 

UNIVERSITY HOSPITALS 

Dr. KOTZ: Chairman Portman and Senator Brown, thank you for 

the privilege of being here today. 

I am an addiction psychiatrist at University Hospitals. And, my 

background is, is that I have been in the field of addiction psychiatry for over 30 years. Recently, I have been heavily involved with 

national agencies, such as the Substance Abuse and Mental Health 

Services Administration (SAMHSA), and Center for Substance 

Abuse Treatment and recently spoke with Agent Jess, and worked 
124 

with professional organizations to develop regulations and guidelines, as well as policies for treatment of opioid disorders. 

I share the concerns of all of our previous speakers and legislations that opioid addiction is destroying the lives and communities 

of many Ohioans. 

You have heard previously, too, that this disease was previously 

thought to mainly affect impoverished males in inner-cities. However, the current epidemic affecting suburban women, well to do 

professionals and adolescents in privileged environments has reminded us that the disease of addiction does not discriminate. 

I would like to discuss the role of medication assisted treatment. 

Studies show that when heroin addiction is treated only with abstinence and psychosocial treatment, that most fail. 

Our 50 years of experience with methadone to treat heroin addiction confirms that counterintuitively the use of a selected opioid to 

treat opioid addiction results in decreased unemployment, criminality and infectious diseases such as Human Immunodeficiency 

Virus (HIV) and hepatitis C. 

However, while effective, methadone is not an option for the 

overwhelming majority of patients with opioid addiction. It requires 

daily visits to specially licensed facilities, typically only found in 

large urban locations. It is completely inaccessible to rural patients 

and relatively so to those living at a distance in the cities, especially when transportation is limited. The daily visits are a barrier 

to employment. 

Since the Drug Addiction Treatment Act of 2000 (DATA 2000), 

Office Based Opioid Treatment (OBOT), has been available, the 

partial opioid agonist buprenorphine can be prescribed by qualified 

primary care providers, by a physician, in the patient’s neighborhood, making it significantly more accessible. Daily visits are not 

needed, so that the patients can work more easily. 

Research demonstrates that it is as effective as methadone and 

far safer in case of overdose or child exposure. Even so, access remains severely limited, due to inadequate numbers of physicians 

prescribing buprenorphine. 

An alternate medication based strategy for treatment relies not 

on opioids, but rather an antagonist medication that blocks opioids. 

Only one—naltrexone—is currently available as a daily pill or a 

monthly injection. While less acceptable to many patients than 

buprenorphine, for those willing to take it or who have monitored 

administration, it can be a valuable tool for increasing long term 

sobriety. 

Although opioid agonist and antagonist medications are important additions to our treatment armamentarium, they are not in 

and of themselves sufficient for successful treatment. This is especially true when a primary care provider has 15 minutes to provide 

addiction treatment, while also complying with requirements to ensure that other issues, such as vaccinations and colonoscopies are 

up to date. 

So, what we need is support for extended office visits and for associated behavioral services to be and to have essential favorable 

outcomes. 
125 

1The prepared statement of Ms. Metz appears in the Appendix on page 211. 

It is imperative that we train more doctors to include medication 

assisted treatment, and that we ensure that there is payment for 

both medical and behavioral services. 

In Northeast Ohio, there are simply not enough facilities or behavioral services to treat addiction for those who need it. And, 

when space is available, insurance often fails to pay for it. Or, perversely, patients are required to fail a level of care or a medication 

before the appropriate treatment will be considered. 

In summary, a current epidemic, our current epidemic is having 

a catastrophic impact on many lives in our communities. We are 

fortunate that both of our Ohio Senators are taking action to address this scourge. Senator Portman was a co-author of the act. 

And, Senator Brown has been a ferocious supporter of it. 

I am a proud member of our Heroin Task Force in Northeast 

Ohio. However, I also think that it is likely that an approach at 

the Federal level will be necessary to stem the tide of opioid addiction. 

Thank you. 

Senator PORTMAN: Thank you, Dr. Kotz. Ms. Metz. 

TESTIMONY OF EMILY METZ,1 PROGRAM COORDINATOR, 

PROJECT DAWN 

Ms. METZ: Senator Brown, Chairman Portman, fellow speakers, 

and guests, thank you for allowing me to speak to you regarding 

the opioid epidemic and its devastating impact on Cuyahoga County. The MetroHealth System is an essential hospital system committed to leveraging its expertise, resources, and relationships to 

respond to this public health crisis. I serve as Program Coordinator 

for MetroHealth Cuyahoga County Project DAWN, a lifesaving 

overdose prevention program sponsored by the health system, the 

Alcohol, Drug Addiction and Mental Health Services Board of Cuyahoga County and the Ohio Department of Health (ODH). I am 

also speaking to you as a member of the Cuyahoga County Opiate 

Task Force and our local U.S. Attorney Opiate Action Plan Committee. 

These committees convene many local experts, such as Project 

DAWN Medical Director, Dr. Joan Papp, the Cleveland Clinic’s Dr. 

Jason Jerry, County Drug Court Judges David Matia and Joan 

Synenberg, Dr. Gilson, our County Medical Examiner, and even 

Erin Helms who manages recovery housing in our community and 

many others in order to address this crisis by collaborating with 

government, law enforcement, education and prevention and addiction experts. 

Our country is in the grips of an opiate addiction and overdose 

epidemic. We are at risk of losing a generation of Americans to disease that devastates lives, families and entire communities. In 

2014, 2,482 Ohioans died as a result of a drug overdose, where 80 

percent of these fatalities involved an opioid. In large part, our 

country’s epidemic is iatrogenic. Our liberal prescribing of opioids 

has created a generation of Americans who are addicted to opioids 

and require help. As a nation, we must mobilize to curb and fix 

this crisis. 
126 

At Project DAWN, we work to reduce opioid overdose mortality 

by helping to expand community access to the opioid overdose antidote naloxone. We train community members on risk factors for 

overdose, how to recognize an overdose and how to respond to an 

opioid overdose. The most critical aspect of our program is the free 

provision of naloxone to our patients. Since Dr. Joan Papp founded 

our county program in March 2013, we have provided over 3,300 

kits to community members resulting in over 430 overdose rescues 

that we are aware of alone. 

Ohio’s streets are saturated with fentanyl-laced heroin, which 

has contributed to the loss of 502 Ohioans during 2014, as compared to 84 during 2013. Because fentanyl is an opioid that is up 

to 50 times stronger than heroin, the dose of naloxone needed to 

revive the victim must be increased. This development is impacting 

our intervention efforts and budget because it is increasingly necessary to provide additional take home doses to our patients. 

We and other alcohol, drug and mental health service providers 

in our country do not have the adequate resources to meet the 

emerging needs of communities struggling with substance use disorders. Cuyahoga County Project DAWN is actually considered one 

of the largest Project DAWN programs in Ohio. We have expanded 

to include 3 to 4 hour walk-in clinics 3 days a week. And, also, 

started to provide naloxone kits in other community settings, such 

as the county jail, MetroHealth emergency departments and the 

Free Medical Clinic of Greater Cleveland’s syringe exchange program. Without these strong community collaborations, we would 

not be able to save as many lives. Currently Project DAWN’s efforts are shouldered by one full-time employee, me. In Ohio, we are 

one of 37 Project DAWN programs in a State of 88 counties. The 

reality is that many of these programs do not have full-time staff 

members, and some are only able to operate once a month. And, 

often, there are programs that run out of funds to purchase 

naloxone before the year’s end. 

Project DAWN programs are essential to curbing opioid overdose 

mortality at the community level, because we equip those most 

likely to witness an overdose with the proper lifesaving tools. While 

we strongly support increasing access to naloxone for first responders, including police, fire and EMS, we know that the most likely 

individuals to witness an overdose are actually drug users, their 

family and their friends. 

We strongly support the Comprehensive Addiction and Recovery 

Act and request funding be considered to help lay responders who 

are connected to Project DAWN models. This investment will sustain and expand community based naloxone programs that have a 

proven track record in reaching people in the community before 

they intersect with the first responder system. 

We applaud our Congressional leadership for recognizing that increasing naloxone access in our country does not alone fix the 

opioid epidemic. The CARA legislation is promising, in that it promotes evidence based and innovative strategies, interventions and 

treatments at the community level. Project DAWN welcomes Federal funding in support of community networks focusing on connecting treatment, housing, education and employment opportunities to those struggling with addiction. 
127 

1The prepared statement of Mr. Brandt appears in the Appendix on page 214. 

Finally, the stigma that is present in our country for individuals, 

as you have heard from others, is no small issue to tackle. We commend CARA’s focus on public awareness campaigns, which would 

educate the public on the risk of prescription drugs and heroin 

abuse. We hope these campaigns will also educate the public that 

addiction is a chronic disease. And, we should support those in recovery, just as we rally behind those who face other diseases. Individuals with substance use disorders are not bad people trying to 

get good. Instead they are sick people trying to get well. 

Thank you for your time and allowing me to serve on this panel. 

Senator PORTMAN. Thank you, Ms. Metz. Mr. Brandt. 

TESTIMONY OF ROB BRANDT,1 FOUNDER, ROBBY’S VOICE 

Mr. BRANDT: So, I want to thank Senator Brown and Senator 

Portman for the opportunity to present this testimony today, as 

well as for your work on the CARA legislation. 

On October 20, 2011, my son Robby passed away from a heroin 

overdose. His addiction started with a prescription for pain medication after he had his wisdom teeth taken out. It grew because of 

the availability of prescription pain medications in school. And, it 

ultimately led to his addiction to heroin. As a family, we battled 

the disease as best we could. But, we lacked information. We 

lacked education. We lacked awareness to the resources that may 

have been available that may have helped us save his life. But, our 

deficit of education really began well before his addiction. And, it 

began with the lack of education in the schools, to the students, 

where they do not fear the drugs or that the stigma is not scary, 

and the lack of awareness at the community level, which allows us 

as parents to continue to live under the false pretense that it is not 

going to be our kid. 

In May 2012, we started Robby’s Voice in an effort to raise 

awareness at schools and efforts to raise awareness in the communities. And, since then, we have spoken to over 75,000 people in the 

schools, in communities, in rehabs. And, we are currently working 

on turnkey programs for schools, as well as developing a center for 

continued recovery for post treatment. 

But, the reality of it is—it is not why we started Robby’s Voice. 

We started Robby’s Voice because it was his dream. We started 

Robby’s Voice because, when we went on this road of addiction, we 

had no clue. We did not know what to do. We did not know where 

to turn. We did not know how to deal with it. 

And, it does split the family. And, the only thing worse than living with an addict is the death of a child. And, you cannot fix that. 

So, today, I speak to you as a parent who has lived with an addict, as a parent who has lost a child, and as a parent who has 

been on the front lines for the past 4 years fighting the battle. 

Robby did not want to be an addict. He said it over and over. He 

could not escape it. We could not protect him. And, in the end, we 

lost him. And so, because of that, we believe strongly that prevention is the ultimate answer. Prevention strikes at demand. Law enforcement strikes at supply. Prevention strikes at demand. If there 

is no buyer, there is no one for the seller to sell to. 
128 

Prevention means that we have to take a good hard look at causation—things like pain as a vital sign. Pain is subjective. And, 

pain can be traced back to the beginning of this epidemic. We have 

to look at things like the Affordable Care Act and the payment 

structure that promotes prescribing because of patient satisfaction 

surveys. We have to be able to sever payment from pain. 

Prevention addresses the concepts of choice and consequence. 

And, it is going to allow us to escape this epidemic, and it is going 

to allow us to avoid the next one. To that, education is the cornerstone of a prevention strategy. Education will drive a critical 

change in culture. And, education will drive the change in the stigma that we deal with every day in society. Education has to be 

comprehensive. It has to be Kindergarten through 12th grade. It 

has to expand beyond just science in other classrooms and other 

curriculums. It has to extend to the teachers. It has to extend to 

the support staffs. It has to extend to the parents who are the 

missing link in this. 

We speak at schools all the time. And, what we hear is, we do 

not have the time, because we have standardized tests. We do not 

have the money. We do not have the resource. And, as a result, 

most of the schools that we speak in do not have comprehensive 

sustainable education plans. We have to educate across the spectrum. We have to educate in the communities. We have to educate 

in law enforcement. 

We still get mixed messages from the police department. Are the 

police departments in the arrest and prosecute mode or are they 

in the treatment mode? And, it is mixed in the communities. We 

only have 46 police departments in the State of Ohio that are carrying Narcan. And, I can tell you it is not because of just the cost. 

I have had police officers look me in the eye and tell me, we just 

do not know if we should save these people. 

We cannot miss our opportunity to educate at the point of origin, 

whether it is the point that the prescription is written or at the 

point of dispense at the pharmacy. We also have a 70 to 90 percent 

failure rate in treatment. And, that frankly is a support issue. 

As a society, we provide support for chronic diseases like cancer 

and diabetes and obesity. Yet with addiction, we do not have the 

necessary resources, nor the necessary funds to provide the support 

that is needed to sustain sobriety. And, as a result, we unknowingly continue to enable relapse. 

Support also has to extend beyond the addict to the family. We 

call addiction a family disease, yet we focus our treatment and our 

treatment dollars solely on the addict, while the families are at 

home enabling relapse, enabling addiction. 

So, the question really becomes is what can the Federal Government do to help us? And, in our opinion, we believe the Federal 

Government can help us not only create, but employ a comprehensive strategy. This is a national issue. And, you have a national 

perspective. But, more importantly than that, we believe that the 

Federal Government can help us move with the sense of urgency, 

a sense of purpose. The cost of addiction we measure in billions of 

dollars. But, the cost of addiction is not the dollars. It is the cost 

of the community, and it is the cost to the fabric of our families. 
129 

We are going to lose 120 Americans today. We are going to lose 

120 Americans every day until we move. And, we measure that statistic as well. See, that is not a statistic. But, those 120, they are 

moms and dads. They are brothers, they are sisters, and they are 

sons and daughters. And, that is what has to stop. 

Thank you. 

Senator PORTMAN. Thank you, Mr. Brandt. I really appreciate 

your willingness to be here and channel your grief that you and 

your family have experienced into something so constructive. I am 

going to start with a question about these kids. And, Dr. Walsh, 

you talked about the fact that we need more research into what the 

long term effects are. 

Do you agree that we also need more research into how to try 

to avoid those long terms effects? 

In other words, although I know your neonatal unit here is at 

the cutting edge—one of the best in the entire world—I have also 

been at other hospitals that do not have that expertise, here, in 

Ohio. And, I know you have been generous to bring in babies from 

not just this region, but from around the State and, indeed, across 

State lines. 

But, what do you think needs to be done in terms of the research, first, to determine what the long term impact is, and, second, how to avoid these impacts? 

Dr. WALSH. Well, Chairman Portman, as usual you ask the salient question. The babies are the downstream. They are just the 

tiniest part of this horrible epidemic. And so, prevention is what 

it is all about. And, moving upstream to have more comprehensive 

treatment programs is, I think, the appropriate method. And so, 

using public health language, a primary prevention strategy 

through education in the schools. But, also then, if a woman has 

a substance abuse disorder, urging a life planning process, so that 

they avoid pregnancy while they are seeking treatment and in recovery. 

The research that we need on the infants, obviously, is long term. 

So, we need to understand how are they doing in early childhood 

and at school age. It is not difficult. 

Sadly, we have way too many babies in Ohio to be able to do this 

study. In the 18 months that we have been working throughout the 

State, we have treated over 4,000 newborns with opiates for NAS. 

And, another 4,000, who we were able to manage without opiate 

exposure. 

The bigger question that concerns me is that, if you have a genetic predisposition to addiction—and the baby shares those same 

genetics as the mom—are these infants then—have they been 

changed, in the womb, to even enhance that genetic predisposition? 

And, that is going to take even decades of research to be able to 

answer that question. 

Senator PORTMAN. As you say, this is only, not, relatively, a new 

phenomenon—and it is overwhelming in our neonatal units. But, 

it is time for us to do this research, immediately, to be able to save 

these kids. So that they do not have to go to school unable to concentrate or to learn, which is some of what I hear, anecdotally, 

from some of the teachers—elementary school teachers—who are 
130 

experiencing these kids coming into their classrooms. And, how do 

we help with that? 

Dr. Young, you talked a little about this. And, one of the things 

that has always concerned me is this coordination you mentioned 

in your testimony between child protective services and the neonatal abstinence syndrome. Just to be clear, because I am not sure 

I understand this, are child protective services (CPS) contacted 

when there is a child who comes out of the hospital and has been 

diagnosed with neonatal abstinence syndrome? 

Dr. YOUNG. The Child Abuse Prevention and Treatment Act, it 

says that they are to. But, we know that there are vast discrepancies in how that is implemented. 

Last week was the first time that there were program instructions to ask the child welfare agencies to describe what their policies and procedures are once that referral is made. 

We have six States with the National Center on Substance Abuse 

and Child Welfare (NCSACW)—six States that we are working 

with, specifically, on this coordination between hospitals, obstetricians, child welfare agencies, the courts, and treatment agencies. 

And, we have detailed some of the reasons that obstetricians, in 

particular, and hospitals tell us, in terms of why those reports are 

not made. 

Two States—New Jersey and Virginia—are in the process of surveying all of their birthing hospitals in order to get a better handle 

on what those issues are, as to why infants are either not detected 

or not referred or not followed up with. 

So, there is a host of issues. And, I would be happy to follow up 

with some of those details from those States that we are working 

with. 

Senator PORTMAN. We would love to see that data. 

CARA, as you know, authorizes and reauthorizes some programs 

in this area for pregnant women and postpartum women. And, I 

know you have been supportive of that. And, you have testified 

about that, and even in the Senate Finance Committee. But, it 

seems to me, this is an opportunity, I guess, to go past—to not just 

provide—— 

Dr. YOUNG. Right. 

Senator PORTMAN [continuing]. More of those services, but more 

research into those. 

Dr. YOUNG. Right. 

Senator PORTMAN. Because we have a real problem. And, I agree 

with what Mr. Brandt said about prevention and education. Again, 

I have been at this for many years. But, we have these kids. 

Dr. YOUNG. Right. 

Senator PORTMAN. And, they are moving their way through the 

system right now. 

Dr. YOUNG. Correct. Several years ago, we looked at the independent living programs, because we know that these are kids that 

are at a substantial higher risk of developing their own substance 

use disorder. And, sadly, we did not find information about addiction, about being the child of a person with a substance use disorder in the independent living programs. 
131 

So, I think foster youths tell us over and over, first I wish you 

would have helped my parent. And, second, I did not know what 

I was dealing with. 

So, much of what we are looking at when communities come together and actually try and work across these systems is 

parent/child interventions that address both of those issues. 

Senator PORTMAN. Try to keep the child in the home, ultimately? 

Dr. YOUNG. Keep the child in the home. But, also, after unification—or if they are at home—that the parenting class is a two generation program. That it is prevention for the child at the same 

time that it is a parenting program for the parent. 

And, if I could just follow up on the long term consequences. It 

is an area that I looked at pretty extensively, previously. And, most 

of the research would say that alcohol and tobacco are the two substances that have the most long term developmental consequences, 

particularly related to alcohol related neurodevelopmental disorders. 

So, when you hold those things constant, even the things that we 

thought were going to happen with cocaine and methamphetamine—and the prior research from the prior heroin epidemic in 

the 60s followed kids up to about 5 and 6 years old. And, when you 

controlled for those other substances, poverty and change in out of 

home placement, it does not look like there is an effect of that substance in and of itself. 

What we have to be mindful of are first substances and the 

neurodevelopmental effects of alcohol. And, second, what that postnatal environment is, and the continuity of care for the postnatal 

environment, particularly for kids who are placed in out of home 

care and the frequent changes in foster care placements. 

Senator PORTMAN. That data is needed. I have heard this as 

well. That fetal alcohol syndrome has had more—— 

Dr. YOUNG. Oh, yes. 

Senator PORTMAN [continuing.] Evidence of long term—— 

Dr. YOUNG. Oh, yes. 

Senator PORTMAN [continuing.] Impacts on brain development. 

Dr. YOUNG. We know that clearly now—— 

Senator PORTMAN. Attention span and so on. 

Dr. YOUNG [continuing.] From all the prenatal exposure studies 

that were done during the cocaine epidemic, in particular. 

Senator PORTMAN. That might be a slice of better news, and the 

ability to really be able to—— 

Dr. YOUNG. Right. 

Senator PORTMAN [continuing.] Post-withdrawal to be able to get 

these kids in the right environment. 

Dr. YOUNG. Correct. 

Senator PORTMAN. And, to be able to make their lives full. 

Dr. YOUNG. Right. 

Senator PORTMAN. In a lot of bad news, that is the relatively better news. 

I have a couple other questions. But, I am going to ask Senator 

Brown if he would want to ask some questions. I know he has another commitment, as do all of you I am sure. But, again, thank 

you all for being here. I may come back for a second round. 

Senator BROWN. Thank you. 
132 

And, Ms. Metz, I loved your comment—not bad, not trying to get 

good, but, simply, trying to get well. 

Mr. Brandt, I think the real heroes in our society are those who 

have lost so much, as you have. And, we do not want that to happen to other families. And, you devote much of your life to that, so 

thank you for that. And, what you said about the satisfaction surveys in the Affordable Care Act, I am hopeful that with the new 

president next year that we can go back and begin to instead of 

having votes to repeal the Affordable Care Act or not, whichever 

side you vote, that we can actually go back and begin to make 

changes against. Anything that broad obviously has some shortcomings. And, that is, certainly, one of the things that we will look 

at, the satisfaction surveys and the impact that has on pain medication. Thank you. 

Mr. Brandt, what do we get wrong in our conversations about addiction? And, as you answer that, elaborate on some of the work 

you have done to help change that dialogue. 

Mr. BRANDT. I think one of the biggest things we get wrong is 

this perception. We just had this conversation the other night. 

When you look at the news coverage of addiction—and it is on 

every day—what do we see? We see death. We see crime. We see 

arrests. 

And, it continues to paint the picture of these addicts as bad people—bad kids. And, they are not. These are good people. These are 

good kids that are being driven to these actions out of a sense of 

desperation—driven by a disease that they could not comprehend— 

that has changed their brain chemistry and that is driving this 

desperation. So, we create this stigma in society. And, as a result, 

it drives our perceptions. And, that is, I think, one thing that is 

critical. 

Then, the other thing is, again, it is cohesion strategy. It is parent involvement. I was at an event last night in a community of 

10,000 people. About 200 plus people showed up—really good showing. We had Drug Abuse Resistance Education (DARE) officers 

from multiple communities there. 

And, you know who was not there? Not one single representative 

from the schools. Not one. So, we lack some cohesion relative to our 

strategies. 

But, I think really one of the biggest deficits we have are the 

parents. We did a parents event in a community one evening. And, 

we had two parents show up. The next day we did the high school. 

And, nine kids went to guidance and asked for help. That is a disconnect. So, we have to do a better job of getting the information 

out. 

So, relative to the work we do, we spend a lot of time going into 

schools—whether it is elementary schools or high schools. And, we 

have a program for the schools that focuses on choice and consequence and information. 

We are working on sustainable messaging, because it cannot be 

one time hits. It cannot be once a year. So, we are developing posters, things that the students can do to have student leadership. We 

do the same thing with parents organizations. 

But, really our big focus right now is recognizing that we have 

a massive relapse rate. We have a massive relapse rate. 
133 

So, we are in the process of jumping on board with the recovery 

communities and looking at a center for continued community, 

where we can allow recovering addicts to have a place to come 

where they fit, where they feel comfortable. They are not sitting at 

home alone. Where we can help them with that, secondary education, post secondary education, coping skills, goal setting schools, 

resume writing, dressing for interviews, interview skills. We want 

to get down the road to develop sober employees. And so, much of 

that is just linked to helping communities lift the stigma off 

through education. 

Senator BROWN. Thank you. 

Dr. Walsh, thank you for the work you do at Rainbow—one of 

the great hospitals in the State. 

You have said something so obvious and so important—that we 

should avoid criminalizing pregnant women. What do we do to encourage pregnant women to get help? 

Dr. WALSH. So, through the Ohio Perinatal Quality Collaborative 

(OPQC), we worked with an advertising firm that only does public 

health messaging. And, we have created a number of informational 

pieces that are directed at the pregnant women and encouraging 

them to seek help. 

And, we have some messaging that we are partnering with the 

treatment programs, maintenance treatment programs to have that 

information there, and say, this is where you are entitled to free 

prenatal care. This is how you can sign up for Medicaid, for coverage. Because it is Medicaid that covers over 85 percent of these 

births. And, just reaching out to encourage them to get into care. 

The States that have made that criminal have seen about a 60 

percent drop in the number of women seeking prenatal care. And 

so, now you have only the hit of substance exposure, but now you 

do not even have the routine prenatal care and prevention that any 

pregnant woman would have. And so, those babies are doubly affected. 

Senator BROWN. Thank you. 

Dr. Kotz, as I have done these round tables around Ohio and listened to the—you heard people talk about the difficulty of getting 

access to treatment, both on the provider side and from the patient 

side—and especially the families—I, primarily, hear two things. 

One is that it is just a dollar figure—they cannot scale up 

enough. The other I hear is that the limit that Congress put on 

providers, on the number of patients they could have. That might 

have made sense a decade and-a-half ago, but does not make sense 

now. 

That is what we are trying to do with the Recovery Enhancement 

for Addiction Treatment (TREAT) Act. We hope we can fix that, 

particularly, in centers where they have had a history of providing 

care. And, doctors can go do more than 30 the first year and 100 

the second and beyond. But, could you just—if you would give me 

your thoughts on what more do we do to address treatment options 

I would appreciate it. 

Dr. KOTZ. I think it is a complex situation. And, I was at the 

Senate hearing that I think, in 2003, asked that the limit be moved 

from 30 to 100. 
134 

The problem is that over half of the physicians in this country, 

who are waivered and eligible to prescribe, are not. And, that is 

based on several reasons. 

One, is that there are not behavioral services that are paid for 

to go along with it. 

And, the other thing is, for a primary care physician—again, as 

I said, if they are to get involved with medication assisted treatment, like buprenorphine, they have to be able to, one, refer, which 

is not happening. And, two, they have to be able to be paid for the 

time that they are taking to do it. So, again, I think addiction 

treatment is terrifically underfunded. And, that is why there is 

such a huge barrier to access. 

My opinion in some of the professional national organizations I 

am involved with that have been working with the Federal agencies—there has to be a sensible number. 

The numbers that have been thrown out there, like one physician 

to be capped at 500, I think is going to lead to a lot more diversion. 

And, one—even one physician without an infrastructure cannot 

take care of 100 patients. 

So, when you are talking about increasing the cap or the limit, 

currently I think the Department of Health and Human Services 

(HHS) is—what they are proposing is increasing it to 200. 

I think that even a tiered approach, where if you are a physician 

that has an infrastructure with nurse practitioners and with counselors and behavioral services, then you could definitely take care 

of perhaps more than 100. But, if you do not have that infrastructure, then you are not really going to be providing evidence based 

care. So, I think there needs to be a reasonable approach to it. 

Senator BROWN. I mean, that is the difficulty in picking a number. But, I mean, I have been to clinics, treatment centers around 

the State which clearly have the, as you say, the infrastructure to 

be able to do—if they had the dollars. Some do. Some have more 

than others. But, to scale up because they have all the ancillary 

services. 

And, that is a difficult way to write the law or regulation that 

way. But, we have to figure it out. Thank you. 

Senator PORTMAN. Just a quick follow up on that. I think you are 

right, I think it is a complex issue. 

I was at a treatment center in Dayton, Ohio on Friday talking 

about this issue. It was a methadone clinic with some suboxone, so 

it was not one of these physicians. But, I think there is a concern 

about diversion. And they, as you know, take very careful steps at 

these treatment centers, including here in Cleveland, to avoid that 

diversion. But, there is plenty evidence of that happening. 

So, we do want to continue that, that discussion with you. And, 

it is not part of the legislation as a result. 

We do have a study on the issue of how many beds in a residential treatment center, which is another issue I think that needs to 

be addressed, and we need to expand that. But, the question is 

bringing in the extras—and that is something that again needs discussion. 

On medication-assisted treatment, you did not mention Vivitrol 

or the difference between, sort of, methadone, Suboxone, and 

Vivitrol—and what works and what does not work. 
135 

Do you have thoughts on that? Have you had experience with 

Vivitrol? 

We have about 12 pilots around Ohio now. And, some of the drug 

courts are using it. And, from what they have told me, some have 

had very good experience. 

I have also been at round tables with recovering addicts who 

have acknowledged to me that they have used Vivitrol—and then 

used other substances—not opioids, but, specifically, cocaine—and 

it did not work for them. What are your views as an expert? 

Dr. KOTZ. So, when I mentioned agonist, that included methadone and buprenorphine. And, the antagonist I mentioned was 

naloxone, which is the injectable form of Vivitrol. 

Senator PORTMAN. Yes. 

Dr. KOTZ. So, I think, Vivitrol is definitely a good alternative to 

agonist therapy. I think it should be used more widely. 

Again, a lot of it originally had to do with cost. The cost when 

I first started giving Vivitrol was $1,500. And, most insurances 

were not paying for that. 

And, more recently, payers have said that you have to fail oral 

naloxone before they will consider giving you Vivitrol. So, the 

preauthorization hassle is enormous. And, also, even the 

preauthorization for buprenorphine has gotten to be an enormous 

burden to prescribers. 

Senator PORTMAN: Actually, I know that it is still considered 

more expensive. Although, when it is once a month as an injection—if it works—it could arguably be less expensive. 

And, the timeframe obviously the average time on methadone, 

for instance, is much longer than Vivitrol. But, on the other hand, 

it is new. So, we do not have a lot of experience. 

I appreciate your input on that. 

And, Ms. Metz, I know we are going to have a chance to talk 

about this later, and I look forward to seeing your work firsthand. 

But, this whole issue of Narcan has been talked about a lot today. 

And, as you know, naloxone, Narcan is a part of this legislation. 

In other words, not just the firefighters and our police officers, but 

your organization would benefit from some of the trainings and 

some of the grants to provide more immediate assistance to save 

lives. And, that is important. 

The one thing that troubles me—and I went to Kroger. They 

asked me to come for their announcement that Kroger was going 

to go to over-the-counter. And, all I asked them was, ‘‘Well, what 

are you doing in terms of the consultation or providing people with 

some information on treatment options? ’’ 

Mr. Brandt talked about frustration he hears from some police 

officers. And, he did not say this, but I will tell what you they tell 

me, which is that, sometimes, they are administering it to the same 

person three, four, or five times. And, their thought is, ‘‘How do you 

get the person into treatment? ’’ 

That, to me, is the good intention here. How do you actually shift 

from the safety net—we talked about the guy at McDonald’s within 

a few miles from here. How do you get that person motivated to 

go into a program to get the treatment—to get the long term recovery that is needed? How do you respond to that? 

Ms. METZ. Sure. So, that is definitely a valid question. 
136 

With regard to relapse, unfortunately, relapse is a part of addiction. So, if people do not survive their relapse, they could never 

have the opportunity to get into recovery. From my personal experience with this program for about 3 years, most of my patients actually end up saving their friends, who are also drug users. Sometimes I do see, maybe, some folks who have overdosed multiple 

times. 

But, most of my patients, when I see them, they are asking me, 

‘‘Where do I go for detox and treatment? ’’ And, that is information 

that I have readily available for folks. The problem is, the treatment waiting list for detox—for inpatient are months long. And so, 

we are going to expect people to continue to have an overdose. We 

want to make sure that they survive to get to that point. 

We also see folks who are getting out of inpatient treatment programs and are having a relapse almost immediately after getting 

out of treatment. Because, as Rob mentioned, some of our programs 

are failing our patients. The relapse rate from inpatient treatment 

is 90 percent. Now, that is a very high risk individual for overdose 

and overdose death, because they have no tolerance anymore. 

If it is heroin that they are going to have an overdose on—perhaps, it is heroin that they use when they have a relapse—but all 

too often it ends up being fentanyl. So, that is something that we 

are continuing to be concerned about. And, unfortunately, as I said, 

relapse is a part of this disease. 

With regard to our pharmacies, I was involved in actually training all of our Discount Drug Mart pharmacists, who are now carrying naloxone. It is mandated as part of the law for pharmacists 

to be able to furnish naloxone, that they go through the training 

similar to what we do. 

And so, one of the important things that I emphasize in that 

training is, you want to have all of these treatment resources available to folks. Because, especially with the syringe exchange patients I see, I might be their first entry into the health care system. 

They might never have been comfortable with asking someone for 

help. And, they see someone like myself who sees them as an individual and has that information available to them. 

So, I think that we are actually going to find more opportunities 

for folks when they go into the pharmacies to be able to ask for 

treatment. And so, they should be ready with that information. So, 

I hope that answered your question. 

Senator PORTMAN. It does. And, I commend you for that. And, I 

am glad that in your training that, you help them to find the local 

treatment and detox center information. And, as you said, one of 

the big issues we have in Ohio is some of our detox centers do get 

filled up. 

Having, ridden with the police officers on this issue, from their 

perspective, that is their big issue often is that they do not have 

anyplace to send people. They do not want to arrest our way 

through this issue. On the other hand, they have to find a place 

for these people who they pick up who have overdosed. 

And then, if you are not doing what you are doing, which is to 

provide these options, I think we are really missing an opportunity. 

We talked a lot about teachable moments today. That is a teachable moment. And, I have talked to many recovering addicts, who 
137 

have told me that is when it happened for them—when they 

overdosed—and two people told me they died. They literally feel 

like they died. And, I guess in some respects, medically, they might 

have. 

One guy told me he saw his father in heaven and came back. 

And, when he came back, that is when he finally decided he needed 

to seek treatment. 

So, I thank you for doing that. And, I hope that we will have a 

chance to see it today later, but I think that is really important to 

interact with their pharmacists. I have so many other questions. 

And, again, I will continue in touch with everybody here. 

But, just one final one for you, because you have mentioned this. 

I am not sure everybody picked up on it. But, to use Narcan in its 

normal dose for fentanyl is not always effective, is that accurate? 

Ms. METZ. Yes. The problem with fentanyl, because of its extreme potency, the onset of the overdose is quicker. So, overdoses 

can occur up to 2 hours or so after somebody uses an opioid with 

fentanyl. You hear of folks, unfortunately when we have lost our 

community members, you will hear the needle was still in their 

arm, something like that. That is a case when it is more likely that 

it is a fentanyl overdose. Because, literally, the person falls out into 

the overdose immediately. And so, the response time needs to be 

quicker. All too often in most cases, the dose of the naloxone must 

be increased. 

So, typically sometimes we will find that one or two doses of our 

two milligram intranasal naloxone might revive somebody who is 

having just a heroin overdose. We have seen people that need 10 

doses of this medicine. Now, that is very important for our program, because we are already stretched in our funding. And, I have 

patients pretty much every day that I have decided this person is 

an extremely high risk, they should have more doses. 

We are at risk of running out of funds through our program now. 

If you think of a rural community, it takes a long time for the ambulance to get there, if a person is even willing to call 911. Because 

there is that fear of being arrested or being charged with a drug 

charge or maybe even being charged with manslaughter, that they 

supplied that drug to their friend or family member. So, it is an 

increasing concern for us. 

Senator PORTMAN. Well, it is a new challenge. At least, it is a 

greater challenge than it used to be—particularly, here in Cleveland—and in other areas that have been specifically targeted with 

fentanyl. 

And, again, I thank all the witnesses. This is great information 

here today. I think we have learned two things. One, the comprehensive approach is the only approach. 

And, I appreciate the fact that many of you helped us get to this 

point on this one bill, CARA—into our communities quickly. It will 

help. It will help Emily. It will help Dr. Kotz and Dr. Walsh with 

what they are doing. It will certainly help Mr. Brandt in what he 

is courageously doing. And so, we have to get that done. 

But, then, there is more to do. And, funding has to follow. We 

did a good job in sort of providing evidence based grant making. 

But, now you have to have funding that actually follows it. And, 
138 

I think that is going to be successful this year. But, we have to just 

keep the pressure on. 

And, as with every issue, again, I started working on this many 

years ago—the substance that is being abused will come and go— 

as is talked about by the experts here today. We tend to take our 

eye off of the ball. We will never solve the problem entirely. The 

tide continues to come in. And, to turn that tide requires consistency. So, I got that today, too. 

And then, finally, the sense that this is a crisis. This is not just 

we are talking theoretically about stuff we should be doing. This 

is stuff we have to do in order to save lives and repair our communities and get families back together. 

So, thank you very much for your testimony. Thank you University Hospital and all of us who are still here for allowing us to use 

this beautiful room, which will now become the official hearing 

room for the United States Congress. Thank you. 

This hearing record will remain open for 15 days until May 7 at 

5 p.m. for the submission of statements and questions for the 

record. And, the hearing is adjourned. 

[Whereupon at 12:35 p.m., the Committee was adjourned.] 
(139) 

A P P E N D I X 
140 

use it. I have repeatedly urged my colleagues in the House to pass CARA, and I will continue to 

speak out, even if that means going against leaders in my own party. 

We're here in Cleveland, which is arguably one of the regions in Ohio that is hardest hit. The 

statistics are heartbreaking, and they are a call to action for us as legislators. In Cleveland, from 

March 1 0-the day the Senate passed CARA 94 to 1-to March 27, 29 people died of overdoses. 

That's just one 17-day period in just one city. 

In one long weekend, eight men and four women died of overdoses. Twelve Ohioans. That 

includes a 21 year old and a 64 year old. Some of the victims were white; some were AfricanAmerican. This is affecting all of us. 

And increasingly overdose deaths are being driven by fentanyl, which we're told can be up to 

100 times more potent than heroin. In 2013, 5 people in Cleveland died of overdoses of fentanyl. 

In 2014, that number increased more than 700% to 37. The next year, that number more than 

doubled, to 89. These rapid increases are alarming, and there does not appear to be any sign that 

they are slowing down. 

In Fairview Park, which is not far from here, we had one case last month where a man overdosed 

at a McDonalds-in a public, busy place. I thank God that someone was able to save his life with 

naloxone. But it just shows the extent of the problem: this is happening in broad daylight, and in 

places where children are present. 

I've spent a lot of time in Cleveland speaking with advocates, doctors, and patients. My wife, 

Jane, and I have toured the Rainbow Babies and Children's Hospital right here. We saw firsthand 

babies who were born to mothers who are addicted, babies who were addicted in the women and 

were born addicted. They're so small that they could fit in the palm of your hand, and they have 

to go through the drug withdrawal process. Doctors don't fully know the long-term consequences 

of this process. 
141 

Cleveland has a lot to teach the country about how serious the threat of addiction is, as well as 

about effective prevention and treatment. 

There is still much more to do after CARA. We ought to inform our future efforts by listening to 

the experts. That is the approach we took to developing CARA, and that is why it is such an 

effective piece of legislation. 

Cleveland has suffered so much from this epidemic, but also possesses some of the best doctors, 

nurses, and caregivers, some of the most passionate advocates, and some of the most effective 

coalitions with whom we could consult, so I am grateful for this field hearing. That includes, 

especially, some of the compassionate and gifted people who work in this facility. 

!look forward to hearing from our witnesses, who represent a broad spectrum of experience and 

backgrounds- we will hear more about neonatal abstinence syndrome, fentanyl related overdoses, 

medication-assisted treatment, the use of naloxone, and what we can do to prevent drug abuse in 

the first place. 
142 

Opening Statement of Senator Sherrod Brown 

"Examining the Impact of the Opioid Epidemic in Ohio" 

Friday, April22, 2016 

As preparedfor delivery: 

Thank you, Senator Portman, for inviting me to be an honorary member of the Homeland 

Security and Government Affairs Committee for the purposes of this field hearing today. 

Thank you also to Senator Carper and Senator Johnson and their staffs for their help in 

organizing this important hearing on the Opioid Epidemic in Ohio. 

But thank you most of all to those of you who are spending your Friday mornings here with us to 

testify on an issue about which you know all too well. 

It's about time members of Congress come together in a bipartisan way and take action on the 

opioid addiction epidemic that is devastating communities across our country. 

We have failed to sufficiently invest in mental health care and treatment for addiction and 

substance abuse for too long. Now that we are experiencing a record number of fatal overdoses, 

it is impossible to ignore these issues any longer. 

As everyone here knows all too well, in one year alone, nearly 2,500 Ohio families lost a loved 

one to addiction- and thousands more continue to struggle with opioid abuse or with a family 

member's addiction. 

Addiction isn't an individual problem or a character flaw- it's a chronic disease. And right now, 

it's placing an unbearable burden on our families, our communities, and our health care system. 

This issue has hit every community across the country, but it is particularly acute here in 

Northeast Ohio. 

Last year in Cuyahoga County, at least one Ohioan died every day from a drug overdose. 

While deaths related to heroin decreased, deaths as a result of Fentanyl [fen-tan-ill], a powerful 

synthetic opiate, increased. 

We cannot continue to make progress against one drug but have another more dangerous and 

more lethal version pop up in its place. 

And as we work to fight against this epidemic, we cannot afford to forget the human cost of 

inaction. 
143 

I am proud that we are starting to tackle this epidemic at the national level, and I am encouraged 

by the Senate's passage of Senator Portman's bill the Comprehensive Addiction and Recovery 

Act (CARA), which included a provision I authored with Senator Toomey from Pennsylvania. 

But CARA even if it gets passed into Jaw- is not enough. This bill, which we are all hopeful 

the House will take up soon, is just a first step. 

On its own, this legislation is not nearly enough to put a dent in this epidemic. 

The initiatives in CARA are going to mean very little without additional funding to back them 

up. 

We need to ensure our communities have access to affordable naloxone, which reversed 166 

heroin- or fentanyl-related overdoses in Cuyahoga County in 2015. 

This requires funding, yes. But to truly fight this epidemic, we need to do more. 

We need funding but we also must build upon the community-based structures and supports 

that already exist to do more prevention, educate our children on the danger of these drugs, 

give our health providers the tools they need to fight pain without opioids, and- most 

importantly- increase access to treatment. 

I have held several roundtables around the state of Ohio to learn from communities and health 

professionals on what they need to make progress in this fight. 

During a roundtable I held in Chillicothe, Ohio, we heard over and over how important funding 

is for prevention. The community organizations and local governments are already stretched thin 

-in both time and resources- dealing with the increasing number of residents who struggle with 

addiction. 

They don't have the time or the resources they know that they need to educate their communities 

about prevention. 

We need real investment in prevention progran1s. We need real investment in treatment options 

that help patients not just get clean, but stay clean. 

In public health emergencies, we are somehow always able to come up with the necessary mone) 

-whether it's Swine Flu or Ebola. Hopefully, we will now provide money to address the 

emerging Zika virus. 

But while we support these important efforts, we must recognize that addiction is also a public 

health emergency. You can't look at the spike in the number of deaths and conclude anything 

else. 

I am disappointed that Congress has been unwilling to come together to invest in this epidemic 

and give our communities the support they need to tight this epidemic. 
144 

It's time for us to get serious, and call this what it is- a public health crisis that demands real, 

immediate investment. 

We look forward to hearing the witness testimony today so that Senator Portman and I can bring 

back your stories and suggestions to our colleagues in Washington and urge them to do more. 

Thank you. 
145 

Opening Statement of Chairman Ron Johnson 

"Examining the Impact of the Opioid Epidemic in Ohio" 

Friday, April22, 2016 

As prepared/or delivery: 

During this congress, the committee has spent a great deal of time uncovering and 

defining the problems occurring at our borders. Today will mark our 17th hearing on border 

security and our fourth hearing focusing specifically on the rising heroin and opioid epidemic 

across this country. These topics are closely related, as one root cause-perhaps the primary 

cause--{)f our unsecure border is America's insatiable demand for drugs. 

The information our committee has gathered from all this work indicates that America's 

borders are not secure. The declining price of heroin-from a nationwide average of$3,260 per 

gram of pure heroin in 1981 to as low as $100 per gram on the streets of Milwaukee today-is a 

metric that proves the point. Today, the committee will explore how our unsecure southwest 

border has become a gateway for drug traffickers to distribute illicit drugs across the country. 

I want to thank Senator Portman, a trusted and valuable member of the committee, for 

proposing and organizing this very important hearing in Cleveland. Ohio stands at the center of 

the heroin and opioid epidemic. In 2014, unintentional drug overdoses continued to be the 

leading cause of injury-related death in Ohio, ahead of motor vehicle crashes-a trend that began 

in 2007. Unintentional drug overdoses caused the deaths of2,744 Ohio residents in 2014-the 

highest number of deaths on record from drug overdoses. The increased illicit use of a powerful 

opioid, fentanyl, was a significant contributor to this rise in drug overdose deaths. 

My home state also has been greatly aftected by this epidemic. While Wisconsin 

averaged only 27 heroin deaths a year from 2000 to 2007, by 2014 there were more than 250 

heroin-related deaths. In Milwaukee County alone, 109 heroin-related deaths occurred in 

2015. In fact, last November, six people died in Milwaukee in a 24-hour period due to 

prescription medication or heroin overdoses. 

During a committee hearing last week in Wisconsin, we heard from not only a former 

addict, but from a sister, father, and two mothers, reminding us that drug addiction harms not 

only those who use the drug, but also their friends and family. 

Today the committee will hear very important local perspectives defining the opioid 

epidemic in Ohio. This hearing will provide a voice for those that do not have one: babies born 

physically addicted to heroin due to their mothers' use. This phenomenon is known as neonatal 

abstinence syndrome (NAS), and Ohio has seen a 740 percent increase in it since 2004. Today's 

witnesses will describe how the rising heroin and opioid epidemic in this country is giving rise to 

NAS cases. 

I thank the witnesses for their willingness to provide these important insights. I would 

also like to again extend a special thanks to Senator Portman for his leadership on this issue and 

for convening a hearing to examine much needed solutions to this growing public health crisis. 
146 

U.S. Senate Committee on Homeland Security and Governmental Affairs 

"Examining the Impact of the Heroin Epidemic in Ohio" 

April 22, 2016 

Senator Kelly Ayotte Statement for the Record 

I want to thank Senators Portman and Brown for holding today's hearing to discuss 

the most urgent public health and safety issue facing my home state of New 

Hampshire-the fentanyl, heroin, and prescription opioid abuse epidemic. I know 

this is an issue of grave concern to Ohio, as well, and I am pleased that the committee 

has again taken its work on the road to hear from those who are being directly 

affected by this public health and safety crisis. 

Last September, we held a field hearing in Manchester, New Hampshire, and invited 

top federal officials from Washington to hear first-hand from members of our 

treatment community, local law enforcement, and families affected by this 

epidemic. I especially appreciated that Commissioner Kerlikowske traveled to New 

Hampshire to also take part in that hearing. 

In New Hampshire, the number of drug overdose deaths is staggering: In 2015, there 

were over 430 drug overdose deaths -159 of which could be attributed to fentanyl 

alone. These tragic statistics are more than just numbers. They are family members, 

friends, and neighbors. I've had too many families tell me that they've lost a daughter, 

or a son, or mother- this epidemic is touching every community in our state. 

Solving this crisis requires a comprehensive approach. Over the past two years, I've 

spent a lot of time meeting with families, treatment providers, law enforcement, first 

responders, health professionals and individuals in recovery to better understand what 

they're seeing and to identify ways that we can help at the federal level. 

Whether it's speaking with families, hosting community forums, or riding along with 

first responders when they respond to overdose calls, these experiences have all 

served to reinforce my commitment to work with anyone to ftnd effective solutions to 

this problem. That is why I was proud to join Senators Portman, Whitehouse, and 

Klobuchar in introducing the Comprehensive Addiction and Recovery Actbipartisan legislation that has the support of over 130 groups across the nation, 

including the National District Attorneys Association, the Major County Sheriffs' 
147 

Association, Community Anti-Drug Coalitions of America, and the National 

Association of Attorneys GeneraL 

The Comprehensive Addiction and Recovery Act would expand opioid abuse 

prevention and education efforts, expand the availability of naloxone to first 

responders and law enforcement, support additional resources to identify and treat 

incarcerated individuals struggling with substance use disorders, expand drug takeback efforts to promote safe disposal of unused or unwanted prescriptions, 

strengthen prescription drug monitoring programs, and launch a prescription opioid 

and heroin treatment and intervention program. 

CARA would be a strong step towards combatting this epidemic, both in my state and 

across the country. Last month, the Senate passed the legislation by a vote of 94-1, 

and l am hopeful that the House of Representatives will pass this legislation quickly. 

Finally, I want to touch on the role of fentanyl in drug overdose deaths. Fentanyl 

continues to cause more drug overdose deaths in New Hampshire than heroin. .Eric 

Spofford, CEO of the Granite House and New Freedom Academy in New 

Hampshire, has said that fentanyl is a "serial killer." It should be treated as the deadly 

drug we know that it is. 

In September of last year, I introduced the Stop Trafficking in Fentanyl Act to reform 

trafficking penalties for fentanyl, ensuring that the law appropriately reflects the 

potency of this drug-which is estimated by the DEA to be up to 50 times more 

powerful than heroin-and takes into account its increasing prevalence in drug 

overdose deaths. 

Law enforcement is working tirelessly to take these drugs off the streets. But we can't 

simply "arrest our way out of' this problem. I've heard from law enforcement in 

New I Iampshire that key pieces they need to confront this public safety issue are 

more prevention efforts, more treatment options and more support for individuals in 

recovery. CARA would address all of these priorities. 

I thank Senator Portman for his strong leadership on this issue and for convening this 

field hearing. 

2 
148 

TESTIMONY AS PREPARED 

OHIO ATTORNEY GENERAL MIKE DEWINE 

U.S. SENATE COMMITTEE ON HOMELAND SECURITY 

AND GOVERNMENTAL AFFAIRS 

CLEVELAND, OH 

APRIL 22, 2016 

Thank you, Senator Portman, for presiding over this very important field hearing today, as we 

discuss the opioid epidemic in Ohio. 

Ohio is facing the worst drug epidemic I've seen in my lifetime. Every county, city, and village 

in Ohio is affected by the opioid problem. Quite candidly, the face of Ohio is becoming the face 

of heroin. 

According to the Centers for Disease Control, nearly half a million persons in the United States 

died from drug overdoses between 2000 and 2014. But, in 2014 alone, 47,055 Americans died 

from drug overdoses, which was the highest number than in any prior year on record. For 

perspective, almost that same number of Americans-- 47,434 --died in battle during the 

Vietnam War. 

Since 2007, dmg overdose deaths in Ohio surpassed deaths from motor vehicle crashes. The 

Ohio Department of Health reports that 2,482 Ohio residents died from unintentional drug 

overdoses in 2014. This is the highest number of deaths from drug overdoses on record- a 

number that reflects a 17.6 percent increase over the 2,110 drug overdose deaths in 2013. 

Opioids, whether it's heroin or a prescription opioid, are involved in the majority of these deaths. 

Tragically, we are seeing the impact of the drug epidemic in babies born to moms addicted to 

heroin or other opioids. The Ohio Hospital Association reported in 2013 that nearly $100 

million in healthcare related costs and 25,000 days in Ohio hospitals were connected to treating 

newborns impacted by neonatal abstinence syndrome. 

We've also seen the evidence as it comes in to my office's state crime lab- the Bureau of 

Criminal Investigation (13CI). Heroin cases began increasing dramatically in mid-2012, and 

since then, we've experienced an unprecedented number of heroin submissions. In fact, one out 

of every four cases coming through BCI lab involves testing for heroin. 

The psychological barrier that stops someone from taking heroin is simply gone. And, the drug 

Mexican drug cartels have created the perfect business model to make it all the easier to feed 

someone's addiction. Their door-to-door delivery system makes calling for and getting heroin 

easier and cheaper than ordering a pizza! 

True impact of our heroin epidemic is measured in lives lost, families devastated, and 

communities diminished. That's why my office is trying to combat the problem on several 

fronts. 

1 
149 

In 2013, we established a heroin unit in my office that includes lawyers, investigators, and 

community outreach liaisons. We restructured some existing resources, added others, provided 

our law enforcement partners with new tools, and expanded our community prevention and 

education outreach. 

Our community outreach team works with law enforcement, prosecutors, grass roots 

organizations, schools, clergy, and other citizens to help form a plan specific to that community 

to address the drug problem. This team helps communities identify needs and give 

recommended resources to address those needs. Recommendations include anything from 

implementing a school based prevention program that's working in another area of the state, 

accessing naloxone, or connecting the community with state resources. 

Additionally, my office provides grants for law enforcement officers for drug use prevention 

education programs in schools. However, in most cases, limits on grant dollars and manpower 

usually allow these programs to be in one or two grade levels at most. In the 1980s, I served on 

President Reagan's National Commission on Drug Free Schools. The experts we had contact 

with routinely told us that repetitive, comprehensive, school-based education was necessary to 

successfully combat drug addiction. 

Some schools today have implemented alternative programs, such as the National Institute on 

Drug Abuse's "Brain Power" curriculum in science courses or Generation Rx from the Cardinal 

Health Foundation and Ohio State University College of Pharmacy. I'm encouraged by these 

efforts and support the expansion of evidence-tested school-based prevention education 

programs. Our hope is that we can help put that psychological barrier back up so our children 

will understand the dangers of drug abuse. 

Many addicts got hooked on heroin by first misusing prescription opioids. To address this issue, 

we partnered with the Ohio Department of Health and Drug Free Action Alliance to provide free 

drug collection bins to a number of local law enforcement agencies. We've also gone after those 

doctors who overprescribe painkillers. Since I took office in 20 II, a total of 73 doctors and 22 

pharmacists have had their licenses revoked or permanently revoked for violations involving 

improper prescribing or handling of controlled substances or illegal drugs. 

I've also been very supportive of expanding access to naloxone for first responders. Naloxone 

was administered at least 74,000 times in Ohio between 2003 and 2012. More than 17,000 doses 

were administered in just the past two years. I'm pleased to report to you that we've renewed 

our agreement with Amphastar Pharmaceuticals, Inc.-- a manufacturer of naloxone-- to provide 

rebates to consumers, such as police departments and other non-federal government agencies that 

distribute the drug in Ohio. So far, almost 60 Ohio agencies have applied for more than 

$151,000 in rebates. 

In 2015, the law changed in Ohio to allow pharmacies to sell Naloxone over the counter without 

a prescription. Since then, we worked with several Ohio retail stores, including CVS, Kroger 

and Walgreens, who have agreed to sell Naloxone. This will also help families and friends who 

know someone who is addicted by letting them keep this life-saving medication on hand. 

2 
150 

As Ohio's Attorney General, I am proud to be one of38 Attorneys General who signed on to 

support passage of your 2016 Comprehensive Addiction and Recovery Act (CARA). As you 

know well, there is no magic bullet solution, but CARA's comprehensive approach would be a 

tremendous help to address the heroin problem in our state. 

Government can't solve the heroin problem. And, we know that we cannot arrest or convict our 

way out of it, either. The truly effective solutions will come from citizens on a county by 

county, village by village, congregation by congregation basis. My office will continue to 

support families, schools, law enforcement, the faith-based community and others to bring hope 

and healing to those who struggle with substance abuse and addiction. 

Thank you for the opportunity to testify here today. I'm happy to answer any questions. 

3 
151 

i!leparlment of Justite 

STATEMENT OF 

CAROLE S. RENDON 

ACTING UNITED STATES ATTORNEY 

NORTHERN DISTRICT OF OHIO 

BEFORE THE 

COMMITTEE ON HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

FOR A FIELD HEARING IN CLEVELAND, OHIO 

ENTITLED 

EXAMINING THE IMP ACT OF THE OPIOID EPIDEMIC 

PRESENTED 

APRIL 22,2016 
152 

Statement of Carole S. Rendon 

Acting United States Attorney 

Northern District of Ohio 

Committee on Homeland Security and Governmental Affairs 

United States Senate 

Cleveland, Ohio 

April 22, 2016 

Chairman Johnson, Ranking Member Carper, and Members of the Committee, thank you 

for the opportunity to discuss the most pervasive drug problem facing the Northern District of 

Ohio today: the heroin, prescription opioid, and illicit fentanyl overdose epidemic. I appreciate 

the opportunity to testify today to discuss how we, in Northeast Ohio, are addressing this crisis 

through our innovative Northeast Ohio Heroin and Opioid Task Force. 

The rise of heroin and the misuse of prescription opioids in Ohio - and across the United 

States- is one of our biggest challenges to public health and safety. It threatens our 

communities, families, and children. Heroin use and the prescription drug misuse are 

intertwined and both must be addressed. Although a small percentage of those prescribed 

opioids misuse them, 80% of new heroin users previously misused prescription pain 

medications. 1 The Department of Justice and the entire Administration arc working closely 

together with our federal, state, local, and tribal partners to fight this growing epidemic through a 

combination of enforcement, prevention, education, and treatment. 

This is truly a crisis in our community in Northeast Ohio. Several years ago, we 

identitled and began responding to a health care and law enforcement crisis that has impacted 

every corner of our state, but was first apparent to us here in Cuyahoga County. Heroin overdose 

deaths increased in Ohio's largest county by more than 400 percent between 2007 and 2012, 

when 161 people died as a result of heroin overdose, in addition to another Ill who died from 

overdose of other opioids. By 2013, that number had increased again, to 194 fatal heroin 

overdose deaths. In 2012, people living in Cuyahoga County were more likely to die from a 

heroin overdose than a car accident or homicide. Sadly, the number of overdose deaths has 

continued to increase, particularly with the introduction of fentanyl, which has proven to be 

incredibly deadly. According to the Cuyahoga County Medical Examiner, while there were only 

five overdose deaths in 2013 involving fentanyl, in 2014 that number rose to 37, and in 2015 to 

91. In 2014, we lost I 77 people to heroin overdoses, 16 to fentanyl overdoses, and 21 to a 

combination of heroin and fentanyl. In 2015, heroin alone resulted in 137 overdose deaths, while 

fentanyl spiked to 44 deaths, with an additional 4 7 people dying of a combination of heroin and 

fentanyl. In 2016, we have had 125 fatal overdoses from heroin and fentanyl in Cuyahoga 

County alone, and it is only April. We were overwhelmed by a death a day in the early part of 

1 Muhuri, P. et. a!., Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States, 

CBHSQ Data Review (August 20 13), retrieved from 

http: 1 \n\ w .samhsa.gov:dnta.'sitesldeElu lt/fj lcs.'DR006ii)R006/nonmed ical-pain-re! iever-use-20 13 .htrn. 
153 

the year. Then, in March, we started to see an average of two overdose deaths a day. The 

devastation is undeniable. 

This crisis, however, is not limited to Cuyahoga County. We are seeing waves of 

overdoses, both fatal and non-fatal, in Lorain, Summit, Stark, Lucas, and Marion Counties. No 

part of our District is safe from this epidemic. Nationally, there were over 47,000 overdose 

deaths in 2014, or approximately 129 per day; 61 percent of those deaths involved either a 

prescription opioid or heroin. These are our family members, friends, neighbors, and colleagues. 

Faced with this crisis, we assembled the Northeast Ohio Heroin and Opioid Task Force 

(Task Force). This Task Force brought together a wide and diverse group of stakeholders to 

identify and implement comprehensive solutions to this growing crisis. There was a lot 

of positive work being done in our community already; our goal was to build upon and expand 

on it. 

A summary of Task Force members speaks to both the breadth of the partnerships as well 

as the multifaceted nature of the problem that we face. Led by the United States Attorney's 

Office for the Northern District of Ohio, members are leaders from all of our major healthcare 

institutions, including: University Hospitals; Cleveland Clinic and MetroHealth Medical Center; 

Cuyahoga County Sheriffs Department; Cuyahoga County Common Pleas Court; the Cuyahoga 

County Prosecutor's Office; Ohio Attorney General's Office; judges from Geauga and Ashtabula 

counties; Robby's Voice; Orca House; WKYC Channel3; Cleveland Division of Police; Drug 

Enforcement Administration, Federal Bureau ofinvestigation; Department of Justice's 

Organized Crime Drug Enforcement Task Forces (OCDETF); Ohio State Medical Board; Ohio 

State Pharmacy Board; Cuyahoga County Board of Health; Cuyahoga County Medical 

Examiner; Alcohol Drug Addition & Mental Health Services Board; Westshore Enforcement 

Bureau; educators; clergy; treatment providers; faith leaders, and others. 

Having hosted a Prescription Pill Summit (Summit) in the Spring of2012, the Task Force 

quickly decided that we needed to host a second community-wide summit to focus on solutions 

and raise awareness of the problem of heroin and opioid abuse in our community. It seems hard 

to believe now, but in 2013 there were many people who were either unaware of the scope of the 

problem or in denial that it was happening in their community. Our goal was to use the Summit 

to create a concerted, coordinated effort to address the problem from multiple fronts and stem the 

tide of death and destruction wrought by heroin and opioid addiction. 

We brought together more than 700 community members and leaders ofNortheast Ohio's 

top institutions, including: doctors from all of our hospital systems; federal, state, and local law 

enforcement; addiction specialists; pharmacists; the medical examiner; parents of children who 

died from heroin or other opioids; educators; and people in recovery. The result of the Summit 

was the creation of a Heroin and Opioid Community Action Plan to guide the work of our Task 

Force. The Action Plan was not set in stone, but was designed to serve as a guide, with goals 

and action items that would and could change as we achieved successes or needed to address 

new problems. 

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The Heroin and Opioid Community Action Plan addresses the heroin and opioid crisis 

from four perspectives: I) law enforcement; 2) healthcare policy; 3) education and prevention; 

and 4) treatment. Here are just a few examples of success we have achieved by implementing 

this comprehensive plan: 

The Law Enforcement Subcommittee: Working with the Cuyahoga County Sheriff and 

Prosecutor, and the Cleveland Division of Police, we created a Heroin-Involved Death 

Investigation Team. Fatal heroin overdoses are now treated as crime scenes, with 

investigators going to every scene to gather evidence that we can use in potential criminal 

prosecutions of the drug dealers who are poisoning our community. To date, the United 

States Attorney's Office for the Northern District of Ohio has filed "death specification" 

indictments against nine drug dealers, and dozens more manslaughter charges have been 

filed in state court. This law enforcement model is now being replicated in Lucas 

County. 

Healthcare Policy Subcommittee: Members of the Task Force, particularly doctors from 

University Hospitals, Cleveland Clinic, and MetroHealth Medical Center, have worked to 

increase physician use of Ohio Automated Rx Reporting System (OARRS), the statewide 

prescription drug monitoring program, and have helped develop increased training and 

education for doctors about the dangers and unintended consequences of overprescribing 

opiates. A recent Centers for Disease Control and Prevention (CDC) report noted that in 

2015, the total doses of opioids prescribed in Ohio decreased to 701 million from a high 

of 793 million in 2012, a decrease of 11.6 percent. 2 While that decrease is the result of 

many factors, we believe the work of the Task Force certainly helped in that effort. 

• Education and Prevention Subcommittee: Members of the Task Force have organized 

town hall meetings and presentations at schools and community organizations attended 

by thousands of people throughout Cuyahoga County. Task Force members also have 

spearheaded two significant media campaigns to raise awareness of this crisis. The Ohio 

Attorney General is also leading an effort to get a science-based drug education program 

into our middle school curriculum. 

• Treatment Subcommittee: Dr. Joan Papp, Dr. Jason .Jerry, and other Task Force members 

led the effort through administrative and state legislative action to expand the availability 

of the opioid overdose-reversal drug naloxone to first responders and relatives of people 

with substance use disorders. Dr. Papp's Project DAWN (Deaths Avoided with 

Naloxone) has provided overdose prevention training and naloxone kits to persons with 

opioid use disorders and their loved ones throughout Cuyahoga County. Their work has 

literally saved hundreds of lives. They are continuing that work while also addressing the 

critical shortage of treatment facilities in our region. 

2 Spies, E., et. a!., Undetermined Risk Factors for Fentanyl-Related Overdose Deaths, EpiAid 2016-003, Trip Report 

Epi2 (March retrieved from 

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The Heroin and Opioid Action Plan that serves as the master plan for Northern Ohio's 

attempt to address this crisis, and the sustained Task Force efforts to implement that plan, are 

excellent examples of what it means to develop a multi-faceted approach that is smart on crime. 

Our Task Force model is now being replicated in United States Attorney's Offices throughout 

the country, including in Georgia, Illinois, Minnesota, New Mexico, Montana, Maine, and 

Kentucky. 

While we have had many successes, the Task Force is keenly aware that the death rate 

has only increased as the threat has morphed from prescription painkillers to a combination of 

heroin and fentanyl. A recent CDC report further examines the increase in unintentional 

fentanyl-related drug overdose deaths in Ohio and notes the dangers of injection drug use 3 

Rather than discouraging us, the on-going crisis has underscored the need for all aspects of our 

community to come together and continue to implement a comprehensive approach to this 

problem. 

These efforts have had an impact on local communities. Thanks to Task Force member 

Dr. Papp and Project DAWN, the number of people who died last year from heroin and fentanyl 

was nearly half as high as it otherwise would have been (228 dead vs. 398 without DAWN) in 

Cuyahoga County. Similarly, our Medical Examiner recently sounded the alarm in a widely 

issued press release on the appearance of fentanyl in pill form, dyed blue to look like oxycodone, 

but far more potent and deadly. That alarm led Jaw enforcement to focus its efforts on fentanyl, 

resulting in the seizure last month of more than 900 fentanyl pills and the arrest of the dealer who 

was selling the pills. 

Nationally, to enhance synchronization and coordination of Federal efforts, in October 

2015, the Office ofNational Drug Control Policy (ONDCP) in coordination with the National 

Security Council, established the National Heroin Coordination Group (NHCG). The NHCG, a 

multidisciplinary team of subject matter experts within ONDCP focused exclusively on working 

the heroin and fentanyl problem set, helps guide and synchronize the interagency community's 

efforts to reduce the availability of heroin and fentanyl in the United States by disrupting the 

global supply chain. The NHCG is the hub of a network of interagency partners who can 

leverage their home agency authorities and resources with the desired result of significantly 

reducing the heroin-involved deaths in the United States through a disruption in the heroin and 

fentanyl supply chains, a detectable decrease in the availability of those drugs in the U.S. market, 

and the complementary effects of international engagement, law enforcement, and public health 

efforts. The Department is also working to address this crisis. OCDETF has established a multiagency, national heroin initiative to facilitate rapid collection and sharing of relevant information 

across agencies, jurisdictions, and disciplines, to maximize the effectiveness of the Department's 

holistic approach. DEA is using all available criminal and regulatory tools- both domestically 

and internationally- to combat this threat by identifying, targeting, disrupting, and dismantling 

individuals and organizations responsible for the illicit manufacture and distribution of 

pharmaceutical controlled substances. DEA also is targeting the Mexican-based criminal 

organizations that are supplying heroin to the United States. Finally, the office of Community 

Oriented Policing Services (COPS) program recently announced that it is accepting applications 

3 /d. 

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for COPS Anti-Heroin Task Force (AHTF) grants. The 2016 Anti-Heroin Task Force Program 

is a competitive grant program that assists state law enforcement agencies in states with high per 

capita levels of primary treatment admissions for both heroin and other opioids. AHTF funds 

will be used for investigative purposes to locate or investigate illicit activities related to the 

distribution of heroin or the unlawful distribution of prescription opioids. 

We see a continued need to aggressively prosecute drug traffickers and disrupt the supply 

of illicitly manufactured fentanyl and heroin into the United States. Simply getting treatment for 

everyone suffering from substance use disorders will not solve the problem, because not 

everyone is ready to enter treatment and treatments are imperfect, but given the size of the 

existing population of heroin and opioid users, we must make sure we have enough treatment 

capacity so that when someone says enough and wants help, treatment is immediately available. 

Changing prescribing practices alone also will not cure the problem, but we must continue to 

curb the rate at which doctors are prescribing opioids and address the underlying incentives that 

have led to that practice. Education is a key component. That's why the Administration has 

supported requiring practitioners (such as physicians, dentists, and other authorized prescribers) 

who request DEA registration to prescribe controlled substances to be trained on responsible 

opioid prescribing practices as a precondition of registration. Finally, every one of us must 

continue to talk to our children, our friends, and our colleagues about the dangers of opioids and 

how no one is immune from the threat. Opioid addiction knows no boundaries. It is an equal 

opportunity killer of old and young, men and women, urban, suburban, and rural, rich and poor, 

black, white, and Hispanic. We are all at risk. 

I believe it will take what we have come to call the "all of the above approach," that 

requires everyone to work together in concert to push back on what appears to be, at least in our 

corner of the world, a public health and law enforcement crisis. 

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Promoting well ness and recovery 

John R. Kasich, Gowrnor. Tracy J. Plou,k, Dire( tor • 'lOE.Ilroad St • Columbw., OH 4'121'l • (614) 4M·259ri • mha.ohio.gov 

Director Tracy J. Plouck 

Ohio Department of Mental Health and Addiction Services 

Testimony before the U.S. Senate 

Committee on Homeland Security and Governmental Affairs 

April 22, 2016 

Good morning Senators Brown and Portman. It is my pleasure to speak before the Senate 

Committee on Homeland Security and Governmental Affairs. Senator Portman, as chair of the 

committee today, I appreciate the invitation you extended to me. As you are aware, the opiate 

epidemic has hit all states hard, including Ohio, and the Kasich Administration has worked 

tirelessly over the last five years to curb the tide, yet the storm continues to rage. I know that 

you both share the same concerns about this as the Governor does. I would like to talk to you 

today about Ohio's efforts, including what is working and where there is work that still needs to 

be done. 

Unintentional drug overdose deaths in Ohio reached an all-time high of 2,482 in 2014, which is 

the most recent year available. Opiate-related deaths, which include both heroin and 

prescription painkillers, peaked at 1,988 deaths in 2014, up from 296 in 2003. With 502 

fentanyl-related drug overdose deaths in Ohio in 2014, fentanyl was a significant contributor to 

a rise in drug overdose deaths, according to preliminary data released by the Ohio Department 

of Health (ODH). (Note: the 502 fentanyl related deaths number is also included in the 1,988 

total for heroin and prescription painkillers.) By comparison, in 2013 just 84 deaths involved 

fentanyl. As a result, Ohio proactively requested assistance from the Center for Disease 

Control's EpiAid to better analyze our opiate related deaths. We are currently reviewing the 

recommendations and determining what should be implemented in Ohio to build on our current 

effort. This issue continues to be a pressing one for the state. 

Governor John Kasich has made the fight against opiates a priority and is one of the nation's 

most outspoken advocates on this issue. Early in his administration, the governor announced 

the establishment of the Governor's Cabinet Opiate Action Team (GCOAT) to fight opiate abuse 

in Ohio. GCOAT is comprised of directors from the multiple cabinet agencies that touch the 

opiate issue and is designed to foster collaborative efforts across public health, treatment, law 

enforcement, education, and other agencies in recognition that the problem is a complex one 

that needs attacked from many different angles. 

One of the key documents that GCOAT has produced is a toolkit for local communities that are 

interested in convening their own cross-agency efforts. That toolkit can be found on our GCOAT 

webpage at http://mha.ohio.gov/gcoat. It outlines the best practices that every community 

should embrace, such as increased availability of naloxone, establishment of drug courts, and 

coordinated prevention efforts. At the state level, we have worked closely with communities, 

such as Ross and Trumbull counties, to provide assistance in bringing together local partners 
158 

and offering technical help to develop a plan to leverage local resources and collaboration to 

combat the crisis. 

I know that you understand the importance of taking this issue on in a multi-pronged way 

because of your work on the Comprehensive Addiction and Recovery Act (CARA) of 2016. 

Senator Portman, I would like to thank you for your sponsorship of this bill, and I would like to 

thank you, Senator Brown, for your support. CARA takes a similarly comprehensive approach 

and addresses on a national level several things that we know are already working in Ohio. I 

encourage you in your efforts to move CARA forward, and I hope that Ohio's experience can 

offer additional support for passage of this comprehensive legislation to address opiate abuse 

on a national level. 

Prescribing Practices 

Prescribing Guidelines 

In its ongoing efforts to combat drug abuse and save lives, the Governor's Cabinet 

Opiate Action Team developed comprehensive prescribing guidelines for the outpatient 

management of acute pain in January 2016. The acute guidelines follow previous 

prescribing guidelines for emergency departments (April 2012) and the management of 

chronic pain (October 2013). All three guidelines were developed in conjunction with 

clinical professional associations, healthcare providers, state licensing boards and state 

agencies. The prescribing guidelines are designed to prevent "doctor shopping" for 

prescription opiates, to urge prescribers to first consider non-opiate therapies and pain 

medications, to reduce leftover opiates that can be diverted for abuse, and to encourage 

prescribers to check Ohio's Automated Rx Reporting System before prescribing opiates 

to see what other controlled medications a patient might already be taking. I know that 

CARA also addresses this issue from a national perspective, and I applaud efforts to limit 

the number of opioids prescribed nationally to ensure that these powerful drugs are 

used only in the course of appropriate medical care. 

OARRS Improvements 

Ohio Automated Rx Reporting System (OARRS) is a tool created to track the dispensing 

of controlled prescription drugs to Ohio patients. It is designed to monitor suspected 

abuse or diversion (i.e. diversion of legally prescribed drugs for illicit purposes), and can 

give a prescriber or pharmacist critical information regarding a patient's controlled 

substance prescription history. This information can help prescribers and pharmacists 

identify high-risk patients who would benefit from early interventions such as pharmacist 

consultation with the prescriber regarding a patient's controlled substance use, switching 

to alternative non-opiate therapies, further assessment of addiction risk or mental health 

concerns and, when appropriate, referral to an addiction medicine specialist. While Ohio 

is seeing record use of OARRS, it is cumbersome for prescribers and pharmacists to 

switch from their computer system to OARRS to check past opiate history. That is why 

Governor Kasich recently invested up to $1.5 million to integrate OARRS directly into 

electronic medical records and pharmacy dispensing systems so prescribers and 

dispensers can automatically check past opiate history within the same system they use 

day-to-day. 

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Results 

As a result of the prescribing guidelines and the increased utility of OARRS, the number 

of prescriber and pharmacist queries using OARRS increased from 778,000 in 2010 to 

9.3 million in 2014 and Ohio is making impressive progress in curbing painkiller 

prescriptions, including: 

o The number of prescription opiates dispensed to Ohio patients in 2014 decreased 

by more than 40 million doses (5.27 percent) compared to 2013. 

o The number of individuals "doctor shopping" for controlled substances including 

opiates decreased from more than 3,100 in 2009 to approximately 960 in 2014. 

o From 2013 to 2014, there was a nearly 11 percent decline in the number of 

patients prescribed opiates at a dose higher than the current guidelines 

recommend to ensure patient safety. 

o Ohio patients receiving prescriptions for opiates and benzodiazepine sedatives at 

the same time dropped 8 percent. 

Prevention Efforts 

Start Talking! 

In 20134, Governor John Kasich and First Lady Karen W. Kasich launched the Start 

Talking! statewide youth drug prevention initiative based on the premise that youth are 

up to 50 percent less likely to use drugs when their parents or other trusted adults talk 

with them about drug use and abuse. Understanding that this is not an easy discussion 

to begin, the program aims to help parents and other adults communicate better with 

kids. Start Talking! offers three free tools for parents and other youth leaders to 

approach children and young adults: 

o Know! delivers free tips and tools to parents (Parent Tips) and teachers 

(TEACHable Moments) to increase communication between parents and their 

children about substance abuse. Currently, nearly 57,000 adults are receiving 

these messages that help start important conversations. 

o Parents360Rx is a national program from the Partnership for Drug-Free Kids that 

is designed to educate adults about the dangers found in their own medicine 

cabinets. 

o 5 Minutes for Life is a program led by the Ohio Highway Patrol, the Ohio National 

Guard and local law enforcement in partnership with high schools. Troopers, law 

enforcement officers and National Guard members talk to student athletes to 

encourage them to become ambassadors who lead peer-to-peer conversations 

that promote healthy lifestyles. During this school year, over 260 events have 

been hosted with over 35,500 students participating. 

• Community Based Coalitions 

In Ohio, we are seeking to elevate local drug coalitions by offering designation to local 

prevention coalitions as an Ohio Coalition of Excellence. The recognition illustrates that a 

coalition is using local data and evidence-based prevention strategies to create 

meaningful change in a community. Many coalitions across the state receive funding 

through OhioMHAS and the Substance Abuse Prevention and Treatment Block Grant. 

CARA places an emphasis of the importance of community-based coalitions and we 

support that effort because this issue is most impacted through local efforts. 

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Youth Led Prevention Network 

The Ohio Youth-Led Prevention Network is a joint initiative between the Drug Free 

Action Alliance and OhioMHAS. It consists of youth-led substance abuse prevention 

providers and youth across the state who are committed to the cornerstones of youthled prevention, peer prevention, positive youth development and community service. 

These teens plan an annual rally at the Statehouse to declare "We Are the Majority"-

meaning that most youth live their lives drug and substance free. This year's rally is next 

week -April 28 - and more than 1,700 teens are expected to attend. I encourage 

anyone to attend feel free to reach out to my office for more details. 

Criminal Justice 

Addiction Treatment Program for Court Involved Individuals 

Established in 2014, this program supports drug courts in establishing a program to 

provide addiction treatment, including medication-assisted treatment, to non-violent 

adult offenders with a dependence on opiates, alcohol, or both. The first phase of the 

program reached 410 men and women, two-thirds of whom also had a co-occurring 

mental health disorder. According to a Case Western Reserve University evaluation of 

the program, past-month drug use among program participants decreased 69.4 percent, 

while crimes committed dipped 86 percent to 3.7 percent. At the same time, 

employment increased 114 percent, while stable housing increased by nearly 29 

percent. Among participants, 60 percent had a job and 91 percent had stable housing 

upon completion of the program, compared to 27 percent and 70 percent, respectively, 

before enrolling in the program. The program is funded with $11 million over the current 

biennium in 14 counties. CARA emphasizes the importance of treatment as an 

alternative to incarceration, and we are seeing that work here in Ohio through the drug 

court model. 

Specialized Dockets Payroll Subsidy Project 

This program provides assistance to drug courts and other specialized docket programs 

with funding to effectively manage offenders in the community, thereby reducing 

commitments to Ohio's prisons and jails. The funding supports payroll for the 

administration of the docket, in an effort to encourage communities to create new 

dockets and sustain existing ones. Currently, the state is funding 136 specialized 

dockets. 

Recovery Services Partnership with the Ohio Department of Rehabilitation and 

Correction 

The most recent state budget proposed a new partnership between OhioMHAS and the 

Ohio Department of Rehabilitation and Correction (DRC) to improve addiction services 

within the state prison system. According to DRC, approximately 50,495 individuals are 

incarcerated within DRC facilities. Of these, 80 percent have histories of addiction. 

Nearly 30,000 of those incarcerated have a considerable or moderate treatment need. In 

order to make improvements and expand the reach of recovery services in the prisons, 

this initiative leverages the clinical expertise and recovery-oriented mission of OhioMHAS 

partnered with DRC's success in keeping recidivism rates low to provide quality addiction 

services to more people within the walls of the state prisons. Enhanced care inside the 

prison walls includes adding to the recovery services staff to provide individual and 

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group treatment and adding two therapeutic communities, a proven model of treatment 

that uses the influence of peers to promote recovery. Additional programming will 

encourage a seamless transition to services upon release to further lower the rate of 

recidivism, including a connection with the Medicaid program to ensure continued 

clinical services where applicable. Expanded use of medication-assisted treatment will 

further reduce the risk of future relapse. The program will also increase access to 

recovery supports, such as sober housing and employment services, upon release to 

ensure stable recovery and even further lower the recidivism rate. 

Expanding the A va!'lability and Use of Naloxone 

Project DAWN (Deaths Avoided With Naloxone) 

Project DAWN is an initiative of the Ohio Department of Health which encourages local 

programs to offer, free of charge, kits that include two doses of naloxone and training 

on its use to members of the public who may encounter people at risk opiate abuse for 

the purposes of overdose reversal. As you are aware, naloxone is effective at saving 

lives and is easy to administer. It is a critical tool in fighting the opiate epidemic, 

particularly as Ohio is seeing an increase in the very deadly illicit version of fentanyl. 

There are over 40 Project DAWN programs across the state with more being added 

soon. 

Grants for First Responders 

We know through state EMS data that naloxone was administered to 18,438 patients in 

2015. Without this important overdose antidote, Ohio's already too large number of 

overdose deaths would be much higher. The most recent state budget included $1 

million to purchase naloxone for first responders, including police and fire. A concerted 

effort has been made to convince local agencies of the importance of carrying naloxone, 

as oftentimes an overdose victim cannot wait for EMS to arrive, and we have seen many 

communities eager to take this on. CARA also addresses this issue, and we support your 

efforts. Naloxone use is critical to saving lives and getting people into treatment. 

Over the Counter Availability 

Ohio's legislature has rapidly expanded the availability of naloxone across the state by 

putting in place immunity for naloxone administration and making it available over the 

counter at pharmacies that have a standing order with a physician. Legislation recently 

proposed by the Kasich Administration proposes to allow facilities that regularly interact 

with high-risk individuals to have onsite access to naloxone. Facilities that could benefit 

from this measure include homeless shelters, halfway houses, schools and treatment 

centers. 

Treatment and Supports 

Neonatal Abstinence Syndrome 

In August 2013, the Kasich Administration launched an effort to address the epidemic 

among the smallest of individuals - babies born to mothers who are addicted to opiate 

painkillers and heroin. The Maternal Opiate Medical Support Project will improve health 

outcomes and reduce costs associated with extended hospital stays by neutralizing the 

impact of Neonatal Abstinence Syndrome. Treating newborns impacted by Neonatal 

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Abstinence Syndrome was associated with nearly $100 million in healthcare expenses 

and almost 25,000 days in Ohio's hospitals in 2013, according to data from the Ohio 

Hospital Association. The project supports interventions and prenatal treatments that 

improve outcomes for women and babies while reducing the cost of specialized care by 

shortening length of stay in Neo-Natal Intensive Care Units. By engaging expecting 

mothers in a combination of counseling, medication-assisted treatment and case 

management, the three-year project is estimated to reduce infant hospital stays by 30 

percent. One of the goals of CARA is to improve addiction and treatment services for 

pregnant and postpartum women, and we believe Ohio is developing a model that can 

be replicated nationally. 

Medication Assisted Treatment 

Work is on-going to expand the use of medication-assisted treatment across the state. It 

is a proven best practice. In 2011, Governor Kasich signed an executive order 

authorizing its expanded use and making it available through the state Medicaid 

program. In 2013, seed funding was put forward to establish medication-assisted 

treatment in Southern Ohio, specifically Jackson, Ohio. 

Recoverv Housing 

CARA recognizes the importance of recovery supports, and one area in which there has 

been rapid expansion in Ohio is recovery housing. Recovery housing is characterized as 

a safe and healthy living environment that promotes abstinence from alcohol and other 

drugs and enhances participation and retention in traditional clinical treatment. Through 

a $12.5 million state investment, we have been able to increase the availability of 

recovery housing by over 1,000 beds statewide. Additional funds have been committed 

for future years and this work is being supported by Ohio Recovery Housing, an 

organization dedicated to the development and operation of quality alcohol and drugfree living in a community of recovery for people with substance use disorders which 

was created with funding from OhioMHAS. 

Medicaid/Institutions for Mental Disease CIMD) Exclusion 

As I cross the state, I continue to hear stories of waiting lists and difficulty accessing 

treatment, in part due to federal law. Treatment works, but it is not easy. I recently 

read of a couple who, after multiple relapses, found themselves homeless, involved in 

the criminal justice system, and lost custody of their young daughter. Through 

treatment received through extended Medicaid benefits, they have over a year of 

sobriety, regained custody of their daughter, and are employed. We know that 

approximately 400,000 Ohioans have accessed mental health and addiction services 

since Medicaid was extended up to 138% of poverty. Capacity and workforce continue 

to be a challenge, and the IMD exclusion poses a barrier to creating more treatment 

capacity across the state. I appreciate that CARA sets up a way to take a serious look at 

the IMD exclusion and its impact on access to treatment. 

Thank you again for inviting me to testify on this important topic today. I want to commend 

both of you on your work around this crisis and I want to especially commend you Senator 

Portman on your leadership on this issue throughout your career. Again, as I described in my 

testimony and in length in my written statement for the record, a number of the provisions in 

the CARA bill are activities Ohio is undertaking and should be implemented on a national level. 

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That is why we support your efforts and the CARA legislation. I stand ready to work with you 

moving forward, particularly on the issue of the !MD exclusion. I have attached a 

comprehensive document that lists the state's efForts over the past few years and a timeline 

that highlights many of the key changes made. Thank you for your time, and I welcome any 

questions. 

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COMBATTING THE OPIATE CRISIS IN OHIO 

In 2011, Gov. John R. Kasich announced the establishment of the Governor's Cabinet Opiate Action Team to fight 

opiate abuse in Ohio. Ohio is combatting drug abuse through many initiatives on several fronts at the state and local 

levels involving law enforcement, public health, addiction and treatment professionals, healthcare providers, 

educators, parents and many others. New initiatives were developed, then launched in 2013 or later, and it will take 

some time for their full impact to be reflected in reducing the number of drug overdose deaths. For more information 

about GCOAT, visit http:/lwww.mha.ohio.gov/gcoat. 

Law Enforcement: Cracking Down on Drug Trafficking 

Interdiction by law enforcement is a necessary intervention in combatting the opioid epidemic. Yet, the opiate issue 

is one of the more complex drug challenges that law enforcement has ever faced. Coordination across jurisdictions 

and with regulatory boards is a critical step. 

2011: Gov. Kasich signs HB 93 into law to shut down "pill mill" pain clinics that fuel Ohio's opiate crisis. 

2011: The Ohio Highway Patrol reports that it seized more than 38,000 prescription pills and 16,400 grams of 

heroin in calendar year 2011. 

2012: Ohio hosts first statewide Opiate Summit, drawing more than 1,000 addiction, law enforcement, policy 

and medical professionals. 

2012: The Ohio Highway Patrol reports that it seized more than 39,900 prescription pills and 34,800 grams of 

heroin in calendar year 2012. 

2013: A partnership with local law enforcement is strengthened by investing $3 million in behavioral health 

programs through local jails to reduce recidivism. 

2013: Ohio Attorney General Mike DeWine establishes the Attorney General's Heroin Unit, which assists local 

law enforcement in investigating and prosecuting upper-level drug traffickers in Ohio. 

2013: The Ohio Highway Patrol reports that it seized more than 54,200 prescription pills and 46,200 grams of 

heroin in calendar year 2013. 

2014: Ohio Attorney General Mike DeWine awards more than $500,000 to law enforcement in Allen County 

to combat the fiow of heroin along 1-75. 

2014: The Ohio Attorney General's Office launches Heroin Recognition and Investigation Training for law 

enforcement through the Ohio Peace Officer Training Academy. 

2014: The Ohio Highway Patrol reports that it seized more than 37,900 prescription pills and 14,100 grams of 

heroin in calendar year 2014. 

2011-2014: The State Medical Board of Ohio and the Ohio State Board of Pharmacy, working in conjunction 

with the Ohio Attorney General's Office, revokes the licenses of 61 doctors and 15 pharmacists for violations 

involving improper prescribing or dispensing of prescription drugs. 

2015: The Office of Criminal Justice Services contributes $100,000 to the Heroin Partnership Project, a 

collaborative effort of federal, state and local agencies focused on reducing heroin and opiate overdose 

deaths in Ross County. 

2015: The State of Ohio Board of Pharmacy trains local law enforcement agencies on how to conduct drug 

overdose investigations, including the use of the Ohio Automated Rx Reporting System. 
165 

Preventing Youth Drug Use Before it Starts To help prevent youth drug use before it starts, Gov. Kasich launched Start Talking! in January 2014. Start Talking! is 

Ohio's statewide youth drug prevention initiative that brings together proven prevention strategies to promote the 

importance of having drug-free conversations with our youth. Research 

shows that children whose parents or other trusted adults talk with them 

about the risks of drugs are up to 50 percent less likely to use drugs. Start 

Talking! features three components designed to provide parents, teachers, 

Start Talking! a Dtug·Free Future 

guardians and community leaders with simple tools to get the conversation started: Know!, Parents360-Rx, and 5 

Minutes for Life. Visit the Start Talking! website at http://starttalking.ohio.gov for details. 

2013·14: More than 16,500 high school student-athletes participate in 5 Minutes for Life sessions held before 

or after practice, during which Ohio state troopers, local law enforcement officers and National Guard 

members talk about responsible decision-making, leadership and encouraging their peers to live a drug-free 

lifestyle. 

2014: An additional6,400 parents, teachers and employers sign up for Know! tips and TEACHable Moments 

with a total reach of more than 40,000 as a result of organizations sharing the information. They join a 

subscriber base of more than 60,000. 

2014·15: More than 17,700 student-athletes participate in Minutes for Life sessions held before or alter 

practices. 

2014·2015: Start Talking! awards 22 grants totaling $1.5 million to communities to help strengthen school· 

based prevention and resiliency programming for at~risk youth. 

2014: An overview of Start Talking! was presented to approximately 500 nurses at three ODH Regional School 

Nurse Conferences. 

2014: Gov. Kasich signs HB 367 into law, requiring school districts to provide education about prescription 

medication and opiate abuse. 

The Ohio Department of Health releases results of the Ohio Youth Risk Behavior Survey which indicates a 50 

percent decrease in the number of Ohio teens who used a prescription painkiller without a doctor's 

prescription. 

2015: The 5 Minutes for life program is expanded and now available year round. 

2015: Start Talking! is displayed at ODH's annual New School Nurse Orientation. 

Encouraging Appropriate Use and Availability of Pain Medication Ohio officials have worked diligently with the medical community to find the right balance between making sure pain 

interventions are available to patients who need it while taking important steps to limit the number of opioid 

prescription medications that diverted and sold on the street for illicit use. 

2011: The Governor's Cabinet Opiate Action Team develops low dose protocol for buprenorphine and 

Suboxone. 

2012: The Ohio Attorney General's Office, the Ohio Department of Health, the Ohio Department of Mental 

Health and Addiction Services, and Drug Free Action Alliance launch the Ohio Prescription Drug Drop Box 

Program by providing secure disposal bins to more than 60 law enforcement agencies. 

2012: The Governor's Cabinet Opiate Action Team rolls out opioid prescribing guidelines for emergency room 

and acute care facilities. 

2013: The Governor's Cabinet Opiate Action Team introduces prescribing guidelines for Ohio's opioid 

prescribers for safe management of chronic, non-terminal pain. 
166 

2014: ODH provides seed funding for local prescription drug overdose prevention projects in Cuyahoga 

County, Clermont County and the City of Portsmouth with a grant from the Centers for Disease Control and 

Prevention. The projects include coalition development, healthcare prescriber education and healthcare 

system changes for safer prescribing practices. 

2014: The State of Ohio Board of Pharmacy adopts rules authorizing pharmacies to accept unused or expired 

prescription controlled substances from the public. 

2014: The State of Ohio Board of Pharmacy receives a $386,000 federal grant to make enhancements to 

improve the use of the Ohio Automated Rx Reporting System. 

2014: The number of opioid doses dispensed to Ohio patients decreased by almost 42 million from 2012 to 

2014. 

2014: The number of individuals "doctor shopping" for opiates decreased from more than 3,100 in 2009 to 

approximately 960 in 2014, according to data from the State Board of Pharmacy's Ohio Automated Rx 

Reporting System (OARRS). 

2014: To improve care to our veterans and reduce prescription drug abuse, the State of Ohio Board of 

Pharmacy completed a project that allows the Veterans Health Administration (VHA) to report all prescription 

controlled substances dispensed from their Ohio facilities to the Ohio Automated Rx Reporting System 

(OARRS). 

2014: An analysis of OARRS data shows a 10.8 percent reduction in the number of Ohio patients receiving 

prescription opiates (excluding Suboxone) at doses greater than the 80 mg Morphine Equivalent Daily Dose 

since the establishment of Ohio's opiate prescribing guidelines in October 2013. 

2015: Governor's Cabinet Opiate Action Team releases a Health Resource Toolkit for healthcare providers to 

address opioid abuse. 

2015: Use of the Ohio Automated Rx Reporting System by opioid prescribers continued to increase. In the 

second quarter of 2015, OARRS receives more than 2.2 million queries by prescribers compared to 156,289 

for the same quarter in 2010. 

2015: The State of Ohio Board of Pharmacy provides healthcare regulatory boards with the names of more 

than 15,500 clinicians who violated Ohio laws by prescribing opioids and benzodiazepines and not checking 

the Ohio Automated Rx Reporting System. 

201S: Prescription Drug take-back targeted at state employees nets more than 100 pounds of unused, 

expired, unwanted prescription medications (roughly 95,000 pills). 

2015: CDC selects Ohio among 16 states to receive between $750,000-$1 million a year over four years to 

combat prescription drug overdoses. The funding is to be used to enhance prescription drug monitoring 

programs; educate providers and patients about the risks of prescription drug overdose; work with 

health care systems, insurers and hea!thcare professionals to help them make informed decisions when 

prescribing pain medication; and respond to new and emerging drug overdose issues. 

2015: U.S. Department of Justice selects the State of Ohio Board of Pharmacy to receive a $200,000 grant to 

develop new OARRS educational and training resources for healthcare schools, colleges and residency 

programs. 

2015: Governor Kasich announces an investment of up to $1.5 million a year to integrate the Ohio 

Automated Rx reporting System (OARRS) directly into electronic medical records and pharmacy dispensing 

systems across the state, allowing instant access for prescribers and pharmacists. 

2016: The Governor's Cabinet Opiate Action Team launches guidelines for the management of acute pain 

outside the hospital emergency department setting. The guidelines address treatment without drugs, nonopioid drug treatment and safe opioid drug treatment. 

2016: Ohio Board of Pharmacy issues updated rules requiring increased use of OARRS by pharmacists prior to 

dispensing controlled substance medications. 
167 

Saving Lives by Expanding Access to Overdose Antidote Ohio has taken steps to prevent drug overdose deaths through the expanded availability and use of the overdose 

reversal drug naloxone. Ohio's naloxone efforts also serve to educate persons who are addicted on available 

treatment options. 

2012: ODH provides seed funding for a pilot naloxone education and distribution program called Project 

DAWN (Deaths Avoided with Naloxone) in Scioto County. 

2013: ODH funds additional Project DAWN sites in Ross, Stark and Hamilton 

Counties. These sites joined existing sites in Cuyahoga, Scioto and 

Montgomery counties. 

2013: OhioMHAS begins offering Project DAWN kits to patients leaving state 

psychiatric hospitals who are at~risk of overdose. 

2013: Gov. Kasich signs SB 57 into law establishing a one-year naloxone pilot project in Lorain County that 

permits first responders to administer naloxone. 

2014: Gov. Kasich signs HB 170 into law, expanding the use of naloxone so that first responders can 

administer the drug, and allowing family and friends to get prescriptions for loved ones at risk of overdosing 

on opioids. 

2014: The Ohio Attorney General's Office develops an online training course for law enforcement and an 

educational video for the public regarding the administration of naloxone. 

2014: Ohio EMS personnel administer naloxone 16,121 times. 

2014: Fourteen Project DAWN programs provided 2,894 naloxone kits with 190 overdose reversals/lives 

saved. 

2015: Thirty-four Project DAWN community sites operate in 27 counties, and 16 sites operate in drug 

addiction treatments centers and hospital emergency departments. 

2015: Ohio Attorney General Mike DeWine negotiates an agreement with naloxone manufacturer Amphastar 

Pharmaceuticals, Inc. regarding rebates for public entities that purchase Amphastar naloxone. 

2015: Gov. Kasich signs HB 4 into law, further expanding access to naloxone by permitting pharmacists to 

dispense without a prescription this life-saving drug that has the potential to reverse drug overdoses. 

2015: To assist pharmacies in the implementation of HB 4, the State of Ohio Board of Pharmacy has 

developed a dedicated web page, www.pharmacy.ohio.gov/naloxone, which features a number of helpful 

resources, including a guidance document, sample protocol and a listing of all participating pharmacies. The 

Board is also offering printed, no-cost patient educational materials to any participating pharmacy. 

2015: SFY 16-17 budget includes an investment of $500,000 per year to purchase naloxone for distribution to 

law enforcement by local health departments. 

2016: More than 800 Ohio pharmacies in 77 counties offer naloxone without a prescription. 

2016: The Centers for Disease Control and Prevention (CDC) issues a report based on a CDC team's visit to 

Ohio at the Ohio Department of Health's request to help examine the state's increase in fentanyl-related 

drug overdose deaths. The report recognizes Ohio's comprehensive response to combatting the opiate crisis 

and makes recommendations, including further expanding access to and use of naloxone. 

Creating Pathways to Treatment and Recovery 

Making sure that Ohioans have access to treatment-including Medication-Assisted Treatment in combination with 

traditional counseling -along with key recovery supports such as stable housing, employment services, relapse 

prevention and more has been a critical focus in Ohio. 

2011: Gov. Kasich signs Executive Order authorizing the expanded use of Medication-Assisted Treatment 

(buprenorphine, vivitrol, methadone) in responding to the state's opiate crisis. 

4 
168 

2012: Ohio Medicaid introduces coverage of Medication-Assisted Treatment services. 

2012: The Mid-Biennium Budget Review includes $3 million for opiate addiction treatment. 

2012: The Office of the Governor awards $2.1 million to Ohio's children's hospitals to fund several research 

projects. Of that total, $1 million was set aside for the development of a standardized treatment protocol for 

addressing neonatal abstinence syndrome (NAS) in newborns. 

2013: The Ohio Department of Mental Health and Addiction Services receives a $10 million federal grant to 

support implementation of a screening and wellness tool for physicians called SBIRT (Screening, Brief 

Intervention and Referral to Treatment). SB!RT also becomes a 

billable service under Ohio Medicaid. 

2013: New Southern Ohio Addiction Treatment Center is 

established in Jackson County, addressing a gap in local services 

for individuals who are opioid~dependent. 

2014: Extension of Medicaid coverage in Ohio begins, making addiction treatment services available to more 

individuals. 

2014: The Ohio Department of Mental Health and Addiction Services partners with Ohio Medicaid to launch 

the Maternal Opiate Medical Support (MOMS) pilot project to develop best practices for treating addicted 

mothers and for addressing neonatal abstinence syndrome among newborns. 

2014: The Mid-Biennium Budget Review includes funding for drug prevention, recovery housing, and drug 

courts. 

2014: The Ohio Department of Mental Health and Addiction Services launches an Addiction Treatment Pilot 

Project to provide Medication-Assisted Treatment to drug court participants in six counties. 

2014: Gov. Kasich speaks to teams from across Ohio at a Judicial Symposium to encourage collaborative 

efforts to fight drug abuse and promote the drug court model. 

2014-15: Ohio Attorney General Mike De Wine awards a total of $800,000 to Lucas County to develop a pilot 

program aimed at helping those suffering from heroin addiction get the assistance they need to move 

towards recovery. The University of Toledo will study and evaluate the effectiveness of the program for its 

potential use as a model for recovery in other communities across the state. 

2015: The Ohio Department of Mental Health and Addiction Services participated with the Ohio Highway 

Patrol in successful SHIELD details by helping connect drug users intercepted by law enforcement to 

treatment. 

2016-17: The state budget for the biennium calls for the Ohio Department of Rehabilitation and Correction 

and OhioMHAS to expand the availability of treatment within state prisons and upon release; to continue to 

invest in recovery housing; and provides additional funding to expand the Addiction Treatment Pilot Project 

to a total of 15 counties. 
169 

.. 

.. 

0 

N 
170 

University Hospitals 

Testimony of 

Michele Walsh, MD, Chief of Neonatology, University Hospitals, University Hospitals Rainbow 

Babies & Children's Hospital and Case Western Reserve University 

University Hospitals Case Medical Center 

Cleveland, Ohio 

April22, 2016 

Before the United States Senate Homeland Security and Government Reform Committee 

Chairman Portman, Senator Brown and distinguished guests, my name is Michele Walsh, M.D. I am the 

Chief ofNeonatology at Rainbow Babies & Children's Hospital, UH Hospitals and Case Western 

Reserve University. I have been privileged to care for the tiny babies of North Eastern Ohio for over 25 

years. I thank the Committee for holding this field hearing in Cleveland, and UH Case Medical Center 

is proud to serve as host. I appreciate the opportunity to speak on behalf of those babies this morning. 

UH Rainbow Babies & Children's Hospital is a 244-bed, full-service children's hospital and academic 

medical center. A trusted leader in pediatric health care for more than 125 years, UH Rainbow Babies & 

Children's Hospital consistently ranks among the top children's hospitals in the nation. As the region's 

premier resource for pediatric referrals, UH Rainbow Babies & Children's Hospital's dedicated team of 

more than 1,300 pediatric specialists uses the most advanced treatments and latest innovations to deliver 

the complete range of pediatric specialty services for 700,000 patient encounters, annually. 

Never have I seen a public health epidemic of such severity as the current opiate epidemic among our 

citizens. We must focus our efforts on a cohesive national strategy that attacks every facet of this 

complicated problem. In the same way that we came together as a nation to combat AIDS and more 

recently Ebola-the same urgent methods are needed to combat this scourge. The Comprehensive 

Addiction Recovery Act championed by Senator Portman and others is exactly the right direction to 

address the complexities of addiction treatment, and the inadequate numbers of programs, trained 

physicians and facilities to address this exploding issue. 

The epidemic has raced across Ohio and the nation. To illustrate I provide a series of pictures of the 

spread of individuals in Ohio seeking treatment for opiate addiction from 2001-2011. 
171 

We are now facing a new twist that is having deadly consequences. Ohio leads the nation in seizures of 

Fentanyi~Related Deaths by Quarter: January 2013 

to March 2015 

fromJ;wuary 

2013 to March 

201Stherewas 

over a .?,000% 

fentanyl deaths!l! 

illegally manufactured fentanyl: a 

narcotic that is 50 times more 

powerful than heroin or morphine. 

Drug dealers are mixing the fentanyl 

with heroin unbeknownst to their 

clients- and escalating the death toll. 

The problems associated with abuse 

of prescription narcotics and the use 

of illegal opiates has grown and 

continues to get worse. Unfortunately, the epidemic of narcotics (both heroin and prescription narcotics) 

use among adults has led to a corresponding epidemic of narcotic-exposed newborns. This tragic 

occurrence is termed Neonatal Narcotic Abstinence Syndrome (NAS). NAS produces jitteriness, fever, 

diarrhea, poor feeding, and if not treated seizures. After narcotic exposure in the womb, NAS requires 

treatment in most newborns. The problem is that treatment strategies for NAS arc largely unstudied, and 

lead to wide variations in practice, lengths of stay, and cost. 

To combat the issue of disparate treatment ofNAS newborns, Governor Kasich helped to create and 

fund a statewide collaboration of the 6 Children's Hospitals in Ohio to research NAS and determine 

improved courses of treatment. I am honored to lead this research initiative, and to work with my 

colleagues from the other Ohio Children's Hospital Association member hospitals: Akron Children's 

Hospital; Cincinnati Children's Hospital Medical Center; Dayton Children's Hospital; Nationwide 

Children's Hospital; and, Promedica Toledo Children's Hospital. Our objectives were to: 

Describe the maternal and neonatal characteristics of full term infants with NAS; 

Determine the best practice for NAS treatment; and, 

Identify variation and areas for future research. 
172 

Working together we were able to identify best practices for caring for the family, and the infant and 

improving the integration of care between obstetricians, neonatologists and addiction medicine 

specialists, From the earliest days of our work in 20 II to today we decreased the duration of opiate 

treatment from 60% of all NAS exposed infants to 45%, decreased length of treatment from 25 days to 

16 days, and total hospitalization tram 31 days to 19 days, 

While embracing a cohesive statewide approach attacking all aspects of the problem, we are just 

beginning to see the tide turning and for the first time seeing a reduction in the amount of opiates 

prescribed across the state, We hope this will be a harbinger that the epidemic of addiction is slowing. 

I believe Ohio's approach to be a model for the nation. I respectfully urge federal lawmakers to: 

• Continue efforts to educate physicians, dentists and other prescribers on appropriate pain treatment, 

the limited role of narcotics in acute pain and the signs of addiction. 

• Continue efforts to eliminate illegal prescribing practices. 

• Require the mandatory use of state wide opiate prescribing sites before writing an opiate prescription, 

and link theses registries across states. 

• Create new programs within opioid maintenance clinics designed to delay pregnancy until the 

mother's health and dependence are improved. (MOMS grant from CMS) 

• Enhance programs that encourage women to seek prenatal care and avoid criminalizing pregnant 

women with narcotic addiction. 

• Create incentives for new methadone treatment providers to enter the field. 

• Eliminate barriers to prescribing suboxone replacement therapy during pregnancy which will 

decrease the severity of newborn withdrawal, allowing certified providers to increase the number of 

patients that they arc treating. 

• Create additional residential treatment programs for both the mother and infant. Pregnancy is a 

teachable moment where women are highly motivated to change and improve their lives and the lives 

of their children. 

• Fund research at the National Institutes of Health to better understand the consequences ofinutero 

exposure to opiates, and to further refine treatments. 

Thank you once again for the opportunity to testify before the Committee this morning. I stand ready to 

support your efforts in any way possible, and look forward to your questions. 
173 

-ttlta~~~ and 

Family Futures 

Written Testimony of 

Nancy K. Young, Ph.D. 

Director, Children and Family Futures, Inc. 

Before the United States Senate 

Committee on Homeland Security and Governmental Affairs 

Examining the Impact of the 

Opioid Epidemic 

Friday, April22, 2016 

University Hospitals of Cleveland 

Ill 00 Euclid Avenue. Cleveland, OH 44106 

25371 Commercentre Lake Forest, CA 92630 714.505.3525 www.cffutures.org 
174 

Senator Portman, Senator Brown and the other Members of the United States Senate 

Committee on Homeland Security and Governmental Affairs: 

Thank you for conducting this hearing on our nation's opioid epidemic and the effects of opioid 

and other substance use disorders on our nation's child welfare and foster care system. There 

are four primary points I would like to emphasize in this statement for the record: 

1) In the past three decades, our country has experienced at least three major shifts in 

substances of abuse that have had dramatic effects on children and families. However, 

the increase of opioid misuse has been described by long-time child welfare 

professionals as having the worst effects on child welfare systems that they have seen. 

2) The current environment has at least two major differences from our prior experiences: 

(a) young people are dying at astonishing rates; and (b) many states report that infants 

are coming into protective custody at alarming rates. 

3) Federal law requiring medical providers to notify child protective services of infants 

identified as affected by prenatal substance exposure is not consistently implemented 

and a review of current legislation and funding mechanisms has become essential. 

4) Federal investments over the past decade testing strategies to improve outcomes for 

families in child welfare affected by substance use disorders have generated a 

knowledge base of effective programs, which means that we can no longer say we don't 

know what to do to address these problems. 

Brief Summary of the Data 

Data from SAMHSA's National Survey on Drug Use and Health show that between 2007 and 

2014, the numbers of persons who misuse prescription drugs, new users of heroin and people 

with heroin dependence increased significantly (SAMHSA, 2014). As shown in this graph, rates 

of dependence on heroin has doubled and overdose deaths increased 286 percent between 

2002 and 2013 (Leonard, 2015). 

3.,0 3.0 

13 IIIII Past:-year hQrou1 a bus-,;:, or depend0nce 

~ H..,ro•n-rel<lh?d ove-.-dose doal:h<> ~ 

~ 2.5 ~ 

~- = ;il i 2.0 2.0 

~ 

! ~ LS 1.5 ~ ~ 

_g ~ c "' ] 1.0 1.0 ~ 

= ~ ~ ~-

2:. 0.5 0.5 ~ 0 "' ~ a Q.O 0.0 

Year 

3 
175 

According to the 2014 National Survey on Drug Use and Health: 

10.3 million persons used prescription painkillers non-medically in 20141 

Approximately 1.9 million met criteria for prescription painkillers use disorder 

4.8 million people have used heroin at some point in their lives 

212,000 people aged 12 or older used heroin for the first time within the prior 12 months 

Approximately 435,000 people were regular (past-month) users of heroin 

The pattern of initiating heroin use has changed over the past decade. Approximately threequarters of persons who use heroin report prior nonmedical use of prescription opioids, as well 

as current abuse or dependence on additional substances such as stimulants. alcohol and 

marijuana. Conversely, a small percentage, approximately four percent, of persons with 

nonmedical use of prescription drugs become regular users of heroin. However, given the 10.3 

million persons who reported nonmedical use of prescription drugs in 2014, this small 

percentage of conversion to heroin generates two hundred thousand new heroin users in a year 

and 435,000 regular heroin users (Compton, Jones & Baldwin, 2016). 

Persons with 

Heroin Use 

Disorders 

Among pregnant women, the highest rates of use continue to be the legal substances which 

have known detrimental effects on the neurodevelopment of the fetus. Among pregnant women 

aged 15 to 44, 5.4 percent were current illicit drug users based on data averaged across 2012 

and 2013. This was lower than the rate among women in this age group who were not pregnant 

(11.4 percent). In the most recent year for which the data on specific substances are available, 

among pregnant women in 2011-2012, 18% reported using cigarettes, 9.4% used alcohol and 

5% used illicit drugs; heroin use was reported by .2% of pregnant women and .9% nonmedically used prescription drugs (SAMHSA, 2012). 

1 Nonmedical use of prescription drugs includes using medications that are not prescribed for these drugs or using 

them for the effect or feeling rather than the medical purpose for which they were prescribed 

4 
176 

There are two aspects of parental opioid use that affect 

the child welfare system: 

(1) prenatal opioid and other substance use exposure 

when it is determined that there are immediate safety 

factors resulting in the newborn being placed in 

protective custody; and, 

(2) post-natal use that affects parents' ability to safely 

care for their children. 

Congress has been specific that hospital notification of 

cases of prenatal substance exposure is not 

substantiated child abuse or neglect. 2 Rather, when 

these children come to the attention of the child welfare 

system, assessment of risk and safety are to be 

conducted and plans of safe care instituted to ensure the 

newborn's well-being. Unfortunately, as the recent 

Reuters series made clear, often this is not happening 

(Wilson & Shiffman, 2015). 

In April2016, the Administration on Children, Youth and Families (ACYF), issued Program 

Instructions to States for their June 2016, reporting on child welfare programs. This instruction 

includes details on how States are to report their programs and policies specific to this 

population of infants who were identified with prenatal exposure in accordance with the current 

Child Abuse Prevention and Treatment Act (CAPT A). Future analyses of these reports will 

assist in determining what actions may be needed to ensure the well-being of these infants and 

their families. At present, data are not available to report how often infants are referred to child 

protective services resulting from prenatal substance exposure. Clearly however, the CAPT A 

State grants at approximately $25 million dollars for the entire country are inadequate to provide 

services and supports for this population. The policy focus should be on the need for legislative 

changes and sufficient funding, including links to other child welfare and treatment funding, in 

order to implement the congressional intent of the CAPT A legislation. 

In addition, there has been a lack of clarity on the requirements and components that should be 

included in a plan of safe care for these infants. Our agency has issued a discussion draft to 

clarify how States and local communities should be addressing the implementation of plans of 

safe care. It includes a two-pronged approach: (1) a Governor-appointed task force that works 

across the multiple administrative agencies and the family courts to set State policies and (2) a 

local implementation committee that clarifies practice components such as screening tools, 

assessment, referrals and communication protocols. This draft is being circulated to gather input 

from multiple stakeholders to assist States and communities. A plan of safe care must address 

a two-generation approach to the needs of the parents and the child. 

Neonatal abstinence syndrome (NAS) occurs in about half of babies with exposure to opioids 

during pregnancy. At this time, there are not clear data as to why babies do or do not 

experience the withdrawal syndrome. In a national study on the use of methadone and 

buprenorphine during pregnancy, researchers found that NAS did not appear to be related to 

2 The exact language is that " ... such notification shall not be construed to- (I) establish a definition under Federal 

law of what constitutes child abuse or neglect; or {I!) require prosecution for any illegal action." 

5 
177 

the dose of these medications that are used to treat opioid dependence. But there were data 

suggesting that experiencing NAS was related to mothers who also smoked during pregnancy 

(Jones, 2015). 

Dr. Stephen Patrick and colleagues (2015) have analyzed hospital data to monitor the trend of 

infants who are diagnosed with Neonatal Abstinence Syndrome. There is variation across 

regions in rates of NAS, with the north-east and mid-south central regions experiencing the 

highest rates of diagnosed cases in hospital births. 

D o.o.s.o D s.o-10.0 1!11110.0-15.0 

-15.0-20.0 

While there is not a clear relationship of rates of NAS and the dramatic increase of infants being 

placed in protective custody, the trend of younger children in care and particularly the number of 

infants is alarming. After a decade of decreasing numbers of children in out-of-home care, that 

trend began to reverse in 2012-2013. The total number of children in care are both new intakes 

as well as children who are remaining longer in care. 

424,658 

Number of Children in Out~of~Home Care 

2009-2014 

400,~89' 

397,153 .. > ••••• 

1{11:1 

415,129 

6 
178 

Of the nearly 265,000 children who entered care in 2014, the largest group were infants. The 

data are not available on the percentage of those infants who also experienced prenatal 

substance exposure, since they are not collected at the federal level nor by the majority of 

states. One might suggest however, that there are few underlying factors other than a parent's 

substance use disorder that would disrupt the ability of a parent to care for their infantparticularly in areas of the country that are experiencing a profound opioid epidemic. 

Number of Children who Entered Foster Care by Age 

2013/2014 (N=264,746) 

lllllllllllllllh 

These trends are resulting in an increasing shift toward younger children making up a larger 

percentage of children in out-of-home care with children under six representing nearly 40% of 

children in care. These data indicate a short window of time for intervention with these children 

and families. This alarming rate of young children coming into care is especially troubling, as 

children ages 0-3 are especially vulnerable. Infancy and toddlerhood is a time of rapid 

development across all domains of functioning. The brain of a newborn is about one-quarter the 

size of an adult's and by the age of three, the brain has developed to about 80 percent of its 

adult size (Nowakowski, 2006). It is imperative that the development of that child take place in a 

stable environment with a caregiver who fosters mutual attachment with the child. 

Unfortunately, I cannot report reliable data that would indicate to what extent parental opioid or 

other substance use disorders are associated with the number of children in out-of-home care. 

The nation's data system to monitor these factors does not require collection of parental 

substance use as factors in child removal, since those are voluntary collection items in the data 

system. However, our agency has been monitoring the available data for 15 years, and there 

has been a steady increase in reports of removals due to substance use by parents. The graph 

on the following page shows that since 2009, states report a 19.4% rate of increase in parental 

alcohol or drug use as factors in the child's removal. 

7 
179 

Pon:;Qnt of Children with Pamntal Akoho1 or Orug U~€! a:ii hctor in 

Out·of"H-ome P!a~Qment, 2009~2014 

'''\ 

Thera h~:~s b£-en l:.lti lncreas.lngtr~od lt'l the: pettt!rttage of ehlld placement cases w1th parental alcohol or dr1..1g use as 

factor$ m the orotectivec\l$tcdv p!ar:ement over the p;nt 15 years D\Je to ldt!ntiflcatlon and data entry c,omple~itle:>-, 

there 11 gre3t vanabllttyacross. stCJteswlth St<!t~">s.ri:!'POrhng l~s! th.an 10% to s.ome rep.ori.Jng more tfum &O''ll', 

However, we have been to all the States in the country and asked child welfare professionals if 

they believe these data represent the prevalence of parental substance use in their cases. Not a 

single state believes these data accurately reflect their experience and nearly all tell us that 

these numbers greatly understate the vast majority of cases in which a child is placed in 

protective custody for causes related to parental substance use disorders. 

As shown in the graph on the following page, these data vary substantially across states. We do 

not believe that these data reflect true variation in incidence; rather they reflect states' systems 

of identification and specifics of how these data are recorded in each state's automated data 

system. Only a handful of states have a standardized screening tool that is used to detect 

parental substance use disorders during investigations of child abuse and neglect. Very few 

states have consistent policy and protocols on how the results of investigations regarding 

parents' substance use are to be recorded in the automated information system. 

8 
180 

Parental Alcohol or Drug Use as a Reason for Child Removal, 2014 

We do not believe that these data reflect true variation in states' incidence; 

rather they reflect states' systems of identification and specifics of how these data 

Alabama 

Alaska 

Arizona 

Arkansas 

California 

Colorado 

Connecticut 

Delaware ~ 

are record 

District of Columbia j~~~~~~~~~~~:::::-• Florida 

Georgia 

Hawaii 

Idaho 

Illinois ..., 

Indiana Iowa ~§§§§§::=::=- Kansas 

Kentucky 

Louisiana 

Maine 

Maryland 

Massachusetts 

Michigan 

Minnesota 

Mississippi 

Missouri 

Montana 

Nebraska 

Nevada 

New Hampshire 

New Jersey 

New Mexico 

New York 

North Carolina 

North Dakota 

Ohio 

Oklahoma 

Oregon 

Pennsylvania 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Texas 

Utah 

Vermont 

Virginia 

Washington 

West Virginia 

Wisconsin 

Wyoming 

Puerto Rico 

0% 10% 20% 30% 40% 50% 60% 

U.S. D{'partment of Health nnd Human Services, Administration for Children and Fami!1es, Administration on 

Children, 

70% 

9 
181 

Among all reasons for child removal, drug abuse by parents showed the largest rate of increase 

over the past five years. In addition, child welfare professionals often tell us that neglect is the 

category that is checked in the data system but that neglect is almost always associated with 

parents' substance use disorder. 

Percent C~ange from ~009 to l014 in Orug Abuse •• a Reason for Removal 

Physical Abuse 

!t1JbiHt'? C0pr 

B-ehavior t'rL\blcm -

- 0.0% 

The p~rcentage of children enterin:g t:are th~t had 

parent drug llbusen!porttd M a nlason for removol 

.increas-ed from 22-1% in :2009 to 2.9,7'X, in 2:0l4. 

This is the largest increase of any 

reason for removal. 

3.0% 10.000 

These data are reflected in statements by child welfare agency professionals from around the 

country. I have had the privilege to work with the State of Ohio over the past year and a half. 

Recently, I was told by a child welfare administrator from a county that borders Kentucky that 

2015 was the first time ever that there were more children whose parents' rights were 

terminated than were reunified. That small county had 70 terminations attributed to parents' 

opioid use disorders. Child welfare officials reported that this trend is evident across the state. 

They report that over the past five years, parents with opioid use disorders have increased the 

number of children placed in care at the same time that overall resources to serve families have 

decreased. 

To summarize: 

Infants are the largest age group of children entering foster care; however, it is not currently 

known how many of these infants were referred due to prenatal substance exposure 

Overall removals of children due to parental substance abuse have increased significantly 

as reported by the states 

Child welfare professionals across the country, particularly in the north-east and 

Appalachian states, report that parental opioid use disorders are having a major impact on 

increasing child removals, preventing reunification and increasing termination of parental 

rights 

10 
182 

What Works for Families Affected by Opioid and other Substance Use Disorders 

Families and child welfare agencies have been affected by multiple drug epidemics over the 

past several decades-cocaine in the late 1980s, methamphetamine in the early 2000s and 

now opioids. This month an article in Governing reports that the next trend in drug epidemics is 

on the horizon with bath salts and "synthetic marijuana," "K2" or "Spice." Synthetic marijuana is 

dried plant leaves that are sprayed with a synthetic cannabinoid similar to THC. Alabama in 

particular has reported increases in overdoses and deaths associated with these synthetics 

(Buntin, 2016). 

During the cocaine epidemic, Congress enacted 

legislation to expand specialty treatment programs for 

women and their children and required that the 

Substance Abuse Prevention and Treatment Block 

Grant prioritize treatment admissions for pregnant and 

parenting women. 

During the methamphetamine epidemic, Congress 

made the largest ever investment in demonstration 

grants linking child welfare, treatment agencies, and the 

courts to find out what works to improve outcomes for 

these families and ensure child safety, permanency in 

caregiving relationships, and child and family wellbeing. A key shift in policy was that many of the 

communities that received these grants worked to prevent removal of children by providing 

services to children and their families while the children remained safely at home. States use 

different labels to refer to these "in-home" cases-protective supervision, for example. But they 

represent the majority of the caseload of families in child welfare services, often about 70% of 

the state's caseload. 

Across child welfare programs, approximately 85% of children stay home, or go home, or in the 

case of children who are not reunified, they find homes when they age out of foster care or 

become adults and access their adoption records. These realities make evident the imperative 

that child welfare service agencies, substance abuse treatment providers, courts, and 

community partners work together to address the needs of parents to prevent placement, 

reunify with their children or potentially play another supportive role in their child's life. 

The demonstration grants included the Regional Partnership Grant Program (RPG) and 

SAMHSA's Children Affected by Methamphetamine Program (CAM). The RPG and CAM 

programs documented a set of common ingredients and strategies leading to positive outcomes 

for families affected by substance use disorders. These strategies include: 

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183 

Implementation of these common strategies for collaborative policy and practice has shown five 

core outcomes. the 5Rs: 

Regional Partnership Grants 

The Child and Family Services Improvement Act of 2006 reauthorized the Promoting Safe and 

Stable Families program and provided a competitive grant program with funding over a five-year 

period to implement regional partnerships in states, tribes and communities to improve 

outcomes for children and families who were affected by parental substance use disorders. 

In October 2007, the Administration on Children Youth and Families (ACYF). Children's Bureau 

(CB) awarded grants to 53 partnerships across the country, including 7 tribes. Family Drug 

Courts were part of the initiative in 21 of the grantees. The outcomes of the grants were 

measured in a performance measurement system focused on documenting child safety. 

permanency, and well-being; systems improvement; and treatment-related outcomes such as 

timeliness of treatment access, length of stay in treatment, and parents' recovery. 

12 
184 

In September 2012, ACYF/CB awarded 17 new RPGs and 2-year extension grants to 8 of the 

53 original grantees. This was made possible by Child and Family Services Improvement and 

Innovation Act (Pub. L. 112-34) signed into law in September 2011. In September 2014, four 

additional 5-year grants were awarded. 

The original 53 grantees served a total of 17,820 adults, 25,541 children and 15,031 families. 

Key positive outcomes across sites include: 

Parents achieved timely access to substance abuse treatment (36.4% entered treatment 

within 3 days), stayed in treatment (65.2% stayed in treatment more than 90 days), and 

reported reduced substance use. 

The majority of children at risk of removal remained in their parent's custody- 92.0% of 

children who were in custody of their parent or caregiver at the time of RPG program 

enrollment remained at home through RPG program case closure. The percentage of 

children who remained at home significantly increased through program implementation 

from 85.1% in Year 1 to 96.4% in Year 5. 

Most children in out-of-home placement achieved timely reunifications with their parent(s) 

- 83.0% of children discharged from foster care were reunified 

-63.6% reunified within 12 months 

-17.9% were reunified in less than 3 months 

- 72.7% of infants reunified within 12 months. 

After returning home, very few children re-entered foster care 

-only 4.2% of children had a substantiated maltreatment within six months versus 5.8% 

subsequent maltreatment rate based on state data. 

13 
185 

Children Affected by Methamphetamine Grants 

Funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), 

the Children Affected by Methamphetamine (CAM) Grant Program focused on expanding and 

enhancing services to children and their families who are affected by methamphetamine and 

other substance use disorders. The Public Health Service Act of 2000 Section 509 provided 

funding from 2010-2014 to 12 Family Drug Courts to improve the well-being, permanency, and 

safety outcomes of children, who were in, or at-risk of out-of-home placement as a result of 

parental methamphetamine or other substance abuse. The primary focus of the grant program 

was to provide services directly to the children and to provide supportive services for parents, 

caregivers, and families. 

Outcome data from across all12 sites indicated that children enrolled in the CAM program 

services were kept safe with lower rates of repeat maltreatment than in the general child welfare 

population. Outcomes included: 

More than 90% of children remained in their home with their parenUcaregiver throughout 

program participation and the majority of children exiting out-of-home care were discharged 

to reunification 

Over two-thirds (68.2%) of CAM children were reunified in less than 12 months 

Less than 6% of reunified children re-entered foster care within 12 months after being 

returned home. This is about a third of the national average with standard services. 

The CAM grantees' experience increased our knowledge about the timing and type of parenting 

classes that should be delivered to parents in early recovery. These grantees experimented with 

when to start and what type of parenting classes these families need. They found that they 

could increase retention in treatment when they engaged parents early in their recovery in 

parenting programs specifically developed for parents with substance use disorders, focusing 

on teaching effective parenting skills, and providing opportunities for children and parents to 

repair their relationship. 

14 
186 

The other good news about these projects is that they saved money. Not only did they reduce 

foster care costs, but they also kept parents in treatment long enough for treatment to have a 

lasting effect. And in the long term, these programs are keeping children out of higher-end, 

higher-cost mental health, special education, and juvenile justice programs when they get older. 

These programs proved that they could save millions of dollars, justifying the increase in 

enhanced services for children and their parents. 

Although these grant programs operated in different drug epidemics than the current opioid 

wave, there is much that can be applied to today's crisis. We do know that access to 

medication-assisted treatment is imperative for success in today's population. But, as important 

as access to effective treatment has proven to be in prior eras, access to medication-assisted 

treatment for this population is not being provided on a timely basis. For example, months of 

wait lists for treatment are the norm across the country. 

In Ohio last month, I was told that in a FDC model that includes facilitating treatment access, it 

still takes approximately one month to get access to medication assisted treatment. Without 

participation in the specialized drug court docket, it takes at least three months to access 

medications. When children's safety and well-being are at stake, parents need to access 

treatment much faster than that. 

While some states have access to Medicaid funding for some families involved with child 

welfare, it's important to recognize that the health-related criteria for accessing treatment and 

the outcomes measured in the health care system may not always relate to the needs of 

families in child welfare. Medical criteria to access a certain level of care with Medicaid or 

private insurance does not include the safety or impact on the child as criteria for residential or 

intensive out-patient levels of care. Similarly, outcomes for substance abuse treatment for adults 

in the Medicaid or private insurance system do not typically count family safety and child wellbeing in their performance measures. Rather, these outcomes are the responsibility of the child 

welfare system in collaboration with substance abuse treatment agencies and courts. 

Another factor affecting the expansion of treatment resources in a family-centered approach is 

the restriction on residential programming under Medicaid due to the Institutions for Mental 

Disease (IMD) exclusion on treatment access for individuals with a substance use disorder. We 

note that the Comprehensive Addiction and Recovery Act (CARA) legislation would require a 

GAO report on the implications of this restriction and would urge that specific attention to its 

impact on families involved in child welfare be included in that report. 

We would suggest that referral to a wait list does not meet child welfare's legal standard of 

reasonable efforts, and in the case of Native American children the higher standard of active 

efforts, to prevent placement and to reunify children. Merely referring does not connect parents 

and children with services; ensuring access to treatment and treatment availability is what is 

needed. 

In summary, we can no longer say we don't know what to do. We can build on the track record 

of dozens of fine, smaller-scale programs in your states and communities. That's a big 

difference in this epidemic, compared with prior eras. We can take what works into system 

change approaches, instead of helping only a few families at a time. 

15 
187 

Opportunities to Take What Works into System-Wide Reform 

The impact of opioids on children and families in the child welfare system must be placed in 

context of the history of parental substance use disorders, the need to comprehensively address 

the current epidemic, and the potential to mediate the effects of future shifts in drug use patterns 

from severely impacting children and their families. These efforts should focus on: 

Building on lessons from prior federal investments; 

Resolving the current gap in timely treatment access; 

Improving data collection and monitoring; and, 

Prevent future crises and costs as substance use patterns change over time. 

In Fiscal Year 2015, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) funded 

five states to take the lessons from effective family drug courts and implement those on a larger 

scale. The states are Alabama, Colorado, Iowa, New York and Ohio. Another solicitation to add 

a small number of additional States is currently underway. The first round of States were 

awarded two years of planning grants and in 2017, it is anticipated that the States will compete 

for implementation awards. In addition to a grant award, each State receives significant 

resources in technical assistance and training through OJJDP's FDC Technical Assistance 

contract with Children and Family Futures. 

In Ohio, an Executive Oversight Committee has been created with membership from the 

Supreme Court of Ohio, the Ohio Department of Job and Family Services and the Ohio 

Department of Mental Health and Addiction Services. The Executive Committee and its 

representatives are working on several key strategies: 

A Memorandum of Understanding across these agencies and the court to specify 

agreements related to their working together including data sharing agreements. 

Various working groups and committees are developing implementation plans on: 

o Cross-system training; 

o Data collection; 

o Resource development; 

o Expanding the number and penetration rate of family drug courts to reach more 

families; and, 

o Determining how to best take the components of effective practice into the larger child 

welfare court docket. 

Eleven performance measures have been agreed upon by the State team and a code 

book has been developed to assist counties in clarifying how to track parents and children 

in the separate data systems. 

A contract is in development that will create a data warehouse at Ohio State University so 

that performance measures can be monitored across the state agencies and the court; this 

action is necessary, since the existing data systems do not have variables to track 

families' progress across treatment and child welfare services. 

Counties applied and two waves of six demonstration counties have been selected. The 

pilot sites are being provided technical assistance via the OJJDP grant and small incentive 

awards are being developed to assist with some of their direct costs in participation. The 

demonstration sites are currently working on the following priorities: 

o Developing local governance structures with representatives from the local 

dependency court, child welfare and treatment agencies; 

16 
188 

o Testing strategies to implementing universal substance abuse screening protocols for 

all families within the child welfare system; 

o Developing standardized information sharing protocols across the three systems that 

include formal information-sharing agreements that address the issues of 

confidentiality; and 

o Identifying local performance measures needed to measure outcomes for families 

affected by substance use disorders within the children welfare system and developing 

strategies to engage in data sharing across the three systems. 

The map below indicates the 20 counties currently operating Supreme Court-certified family 

drug courts, with Cuyahoga in is the process of certification. There are 12 counties that have 

been selected to pilot and implement the SSRP initiative, as well as four counties that are 

currently pilot testing the M.O.M.S. program. 

Materna!OpiateMedica! • 

Support(M.O.M.S) 

State System Reform Round 1 * Program(SSRP) 

DemonstratlonSites Round2* 

In addition to the key programmatic strategies being implemented to prevent child placement, 

there are system changes that are also needed to effectively monitor effects over time, ensure 

staff are prepared to work effectively with these families, develop state-specific financing 

strategies to maximize recent changes in substance use disorder treatment, fill gaps in 

treatment access for these families, and build collaborative efforts that cross agency boundaries 

and support communities. Specific system reforms that are needed include: 

Improve data collection and reporting to monitor the effects of parental substance 

use disorders on the child welfare system and the outcomes achieved by addressing 

treatment needs. States' information technology challenges include recording alcohol and 

drug use factors in case files, requiring standardized reporting of alcohol and drug use 

factors in federal child welfare reporting systems and requiring existing outcome monitoring 

to report on the differential child welfare outcomes for children and families due to parental 

17 
189 

substance use disorders. No state at present is able to report the child welfare outcomes of 

all families referred to and enrolled in its treatment systems. 

Improve access to quality substance use disorder treatment. The need for access to 

substance abuse treatment cannot be over-emphasized. When we refer parents to 

treatment as a condition of keeping or reunifying with their children, we must make sure that 

the treatment is state-of-the-art. comprehensive, meets the needs of the entire family, and 

that treatment, including medications for opioid use disorders, is available and timely. 

Funding of the Comprehensive Addiction and Recovery Act (CARA) is critical. including the 

provisions that will expand services to pregnant and parenting women. However, it is also 

imperative to ensure that child welfare funding is shifted to allow children, particularly infants 

and young children, to remain at home with parents while their parents receive substance 

abuse and mental health treatment to prevent the trauma of child removal and the higher 

costs associated with foster care. 

Improve collaborative practice. This can be achieved through implementation of practical 

strategies, such as staff development and training programs and cross-systems 

communication protocols. Ensuring that these strategies include a focus on infants with 

prenatal substance exposure will develop a workforce that is prepared to work in today's 

environment. Staff training and communication protocols must provide concrete and 

pragmatic information, such as guidance in developing comprehensive plans of safe care 

that keep infants with birth families whenever possible and provide interventions to address 

the needs of both the infant and mother. 

When we ensure timely access to effective treatment, families recover, 

kids stay safe at home, and we save money. Now we can and must move 

beyond pilots and demonstration grants and take these lessons to into systemic 

changes across agencies to help children and families. 

18 
190 

References 

Buntin, J. (2016). Synthetic Drugs: An Emerging, Evolving Threat. Governing. Accessed April18, 2916 at: 

blUd/ www .gave rn in g. com/to pi cs/p ubI i c -justice-s afety/gov-syn th eti c-d rugs-states. ht m I 

Compton, W.M., Jones, C.M. & Baldwin, G.T. (2016). Relationship between nonmedical prescriptionopioid use and heroin use. New England Journal of Medicine, 374(2), 154-163. 

Jones, H. (2015). Treatment of Opioid Use Disorder in Pregnancy and Infants Affected by Neonatal 

Abstinence Syndrome. A Webinar presented for the SAMHSA Women's Health Week. May 15, 2015. 

Accessed February 20, 2016 http://www.cffutures.org/files/webinars 

Leonard, K. (2015). Heroin Use Skyrockets in U.S. US News and World Report. July 7, 2015. Accessed 

February 21, 2016. http://www.usnews.com/news/blogs/data-mine/2015/07/07/heroin-useskyrockets-in-us-cdc-says 

McDonald, T. & Brook, J. (2013). Description of the State of Kansas Regional Partnership Grant and 

Evaluation Findings. Accessed February 21, 2016. 

http://www. cffut u res. o rg/fi I es/ rpg p rofi I e s/ A rra yofSe rvic esC I uste r I Kansas De p a rtm e ntofSocia Ian d R e h a 

bilitationServices. pdf 

Nowakowski, R.S. (2006) Stable neuron numbers from cradle to grave. Proceedings of the National 

Academy of Sciences of the United States of America. 103(33):12219-12220. 

Patrick, S. W., Davis, M. M., Lehmann, C. U. & Cooper, W. 0. (2015). Increasing incidence and geographic 

distribution of neonatal abstinence syndrome: United States 2009 to 2012. Journal of Perinatology, 

35(8): 650-655. 

Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on 

Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication 

No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics 

and Quality (201S). Behavioral health trends in the United States: Results fram the 2014 National 

Survey on Drug Use and Health HHS Publication No. SMA 15-4927, NSDUH Series H-50. Retrieved from 

http://www .sam hsa .gov /d ata/sites/d efa u lt/files/NS DU H-FRR 1-2014/NS DU H-FR R1-2014.pdf (accessed 

February 19, 2016). 

Wilson, D. & Shiffman, J. (2015). Helpless and Hooked. A Reuters Investigation. December 7, 2015. 

Accessed February 21, 2016 http://www .reuters.com/investigates/special-report/baby-opioids/ 

19 
191 

Children i!rlcl ' Farni1y Futun;s 

Via Email (Megan Harrington@portman.senate.gov; Abigail Duggan@brown.scnatc.gov) 

May 3, 2016 

Senator Robert Portman 

Committee on Homeland Security and Governmental Affairs 

340 Dirksen Senate Ot1icc Building 

Washington, DC 20510 

Senator Sherrod Brown 

713 Hart Senate Office Building 

Washington, DC 20510 

Re: Longer-Term Effects of Prenatal Substance Exposure 

Dear Senator Portman, Senator Brown, and Committee Members: 

Thank you for the opportunity to participate and testify before the Committee on Homeland 

Security and Governmental Affairs at the recent hearing titled "Examining the Impact of the 

Opioid Epidemic" on Friday, April 22, 2016 at the University Hospitals of Cleveland in Ohio. 

In follow-up to our discussion, I have provided a brief summary of the literature on the longerterm effects of prenatal substance exposure to opioids and other substances (i.e., alcohol and 

nicotine). 

Introduction 

According to the American Co11egc of Obstetricians and Gynecologists (ACOG), "Neonatal 

abstinence syndrome is an expected and treatable condition that follows prenatal exposure to 

opioid agonists (2012)." Neonatal abstinence syndrome (NAS) is the term used to represent the 

pattern of effects that are associated with opioid withdrawal in newborns (Wachman et a1., 

2013 )- The section on Prenatal Exposure to Opioids below provides additional information on 

NAS. 

A complex interplay of prenatal and postnatal [actors affect the developmental trajectory of the 

infant that is exposed to opioids. Although numerous studies have identified the various factors 

that can affect the long-term outcomes of children with prenatal substance exposure-whether 

the mother is able to access prenatal care, substance use treatment and the range of additional 

services that may be necessary to address the range of psychosocial, health and socioeconomic 

issues that the family may face-poly-substance use, particularly alcohol and tobacco, must be 

addressed. Use of multiple substances in itself presents a challenge, making it difficult to 

separate analyses of any one substance's effects. 

25371 Cornmercentre Drive, Suite 140 • Lake Forest, CA 92630 

Phone: 714.505.352S • Fax: 714.505.3626 • Toll Free 866.493.2758 

w_ww.cffutures.ora 
192 

Some studies have demonstrated that some of the long-tenn effects of prenatal exposure to 

alcohol and tobacco arc independent of other risk factors. There is a growing body of evidence 

that suggests these long-term effects include a predisposition to developing a substance use 

disorder for the child with prenatal exposure (Behnke & Smith, 2013). The following table from 

the American Academy of Pediatrics summarizes 40 years of data examining the effect of 

prenatal exposure to drugs and alcohol (Behnke & Smith, 2013). 

Across all substances, alcohol and tobacco exposure have the highest risk for poor outcomes in 

regard to challenges across multiple domains related to both short-term effects (e.g. bitth 

outcomes) and long-term effects. Alcohol exposure has been found to have a strong effect across 

all long-term domains of growth, behavior, cognition, and achievement. Nicotine exposure has 

been associated with challenges across long-tenn domains of behavior, cognition, language and 

achievement. 

The following summarizes various studies tbat examine the long-term outcomes of children 

prenatally exposed to opioids, alcohol and nicotine. Discussion on the short-term (e.g. neonatal 

abstinence syndrome) effects ofopioid exposure is also provided. 

Prenatal Exposure to Opioids 

Some distinctions among women who usc opioids during pregnancy are paramount to 

understand because the potential risks to the infant can vary. Generally, women who use 

opioids during pregnancy can be categorized within one of the following groups: 

• Are receiving pain management with medications under the care of a physician. 

• Are under the care of a physician and undergoing treatment for an opioid use disorder 

with medications, such as methadone or buprenorphine. 

• Are misusing or abusing opioid pain medications with or without a prescription (e.g.} 

obtaining pills illegally for a nonmedical usc, "doctor shopping,~· obtaining a prescription 

illegally). 

• Are using or abusing illicit opioids, particularly heroin. 

The use of medication-assisted treatment (MAT) during pregnancy is a recommended best 

practice for the care of pregnant women with opioid use disorders (ACOG, 2012). The use of 
193 

MAT, in combination with counseling and behavioral therapies, and access to a range of 

supportive services, such as housing and employment services, assists the mother in achieving 

a more stable life (Newman & Kagen, 1973). MAT stabilizes the intrauterine environment and 

avoids subjecting the fetus to repeated episodes of withdrawal, which place the fetus at higher 

risk for morbidity and mortality (Kaltenbach & Finnegan, 1998; Jones et al., 2005; CSAT 

2005). 

Methadone has been accepted as a treatment for opioid use disorders during pregnancy since 

the late 1970s (Kaltenbach & Finnegan, 1998; Kandall et al., 1999; CSAT 2005). In 1998, a 

National Institutes of I lealth consensus panel recommended methadone maintenance as the 

standard of care for pregnant women with opioid use disorders (National Consensus 

Development Panel on Effective Medical Treatment of Opiate Addiction, 1998). The use of 

buprenorphine for the management of opioid use disorders in pregnancy is becoming more 

widely used, with the emergence of data from randomized clinical trials that demonstrate its 

safety and efficacy (Jones et al., 2005; Fischer et al., 2006; Jones et al., 2010). 

Between 2005 and 2008, A National Institute on Drug Abuse (NIDA)-supported clinical trial, 

the Maternal Opioid Treatment: Human E<perimental Research (MOTHER) study, examined 

the use of both methadone and buprcnorphine maintenance therapy during pregnancy, The 

study found that infants exposed to buprenorphine required shorter treatment duration and less 

medication to treat the symptoms ofNAS and experienced shorter hospital stays when 

compared to infants exposed to methadone. No significant difference was found with respect 

to any serious maternal or neonatal adverse events, including abnormal fetal health or 

neurologic symptoms (Jones ct al., 201 0). 

• Jones, H. E., Kaltenbach, K .. lleil, S., Stine, S.M., Coyle, M.G., AITia, A.M., O'Grady, 

K., Selhy. P., Martin, P., & Fischer, G. (2010). Neonatal abstinence syndrome after 

methadone or buprenorphine exposure. New England Journal of Medicine, 363, 2320-

2331. Retrieved from http://www.nejm.org/doi/full/1 0.1 056/NEJMoal005359. 

Neonatal abstinence syndrome (NAS) symptoms are affected by a variety of factors, including 

the type of opioid the infant was exposed to, the point in gestation when the mother used the 

opioid, genetic factors, and exposure to multiple substances, particularly nicotine (Velez & 

Jansson, 2008). Non-pharmacological treatment is the standard of care for the infant with NAS 

and should start at birth and continue throughout the infant's hospitalization and beyond. Both 

non-phmmacological and phannacologica1 treatment (e.g. methadone, buprenorphine, morphine) 

seek to soothe the infant's symptoms, while encouraging the mother-inHmt bond. The course of 

treatment required by the infant depends on the severity of symptoms and response to treatment. 

The mean length of hospital stay for newborns diagnosed with NAS is approximately 1-3 weeks. 

depending on the type of treatment (Hudak & Tan, 2012). 

Sudden Jnfimt Death Svndrome/Sudden Unexplained Infimt Death 

Studies have examined the association between prenatal opioid exposure and risk of Sudden 

Infant Death Syndrome/Sudden Unexplained Infant Death (SIDS/SUID). A study found that 
194 

Children and ' family f1.1ture~ 

smoking during pregnancy and lack of prenatal care contribute to a high risk for SJDS/SUID 

among women who received methadone treatment-controlling for those two factors almost 

halved the risk. Another study found the mortality rate of infants prenatally exposed to opioids 

via MAT for opioid dependence to be similar to that of the general population. 

o Burns, L., Mattick, R.P., Lim, K., & Wallace, C. (2007) Methadone in pregnancy: 

Treatment retention and neonatal outcomes. Addiction, 102(2): 264-270. 

o Kelly, L.E., Rieder, M.J., Bridgman-Acker, K., Lauwers, A., Madadi, P., & Koren, G. 

(2012). Are infants exposed to methadone in utero at an increased risk for mortality? J 

Popul Ther C/in Pharmacal, 19(2): el60-1655. 

Developmental Outcomes 

A seminal review of two decades worth of literature examining the impact of prenatal exposure 

to opioids found no difference in the linguistic, cognitive, social-emotional and motor skills of 

children who had been exposed to opioids via methadone maintenance treatment. Although some 

studies found differences in the motor development of infants and toddlers, potentially 

confounding factors-such as exposure to multiple substances, use of prenatal care, and length 

of participation in methadone maintenance treatment-were not controlled for and the 

differences could not be directly attributed to methadone exposure. The potential effect of other 

risk factors was also demonstrated in studies that examined the developmental outcomes of pre~ 

school aged children. A study comparing the outcomes of three groups of children-those born 

to mothers who received methadone treatment; those born to mothers who used heroin during 

pregnancy and did not receive methadone or any other type of medication assisted treatment; and 

those born to mothers who did not use any substances-found comparable findings across the 

blTOUpS in terms of cognitive development. However, 95% of women in the methadone treatment 

group continued to use illicit or prescribed medications. The three groups were also comparable 

in terms of the presence of physical and psychosocial risk factors. These findings indicate that 

the degree of opioid exposure was not a factor and instead, predictors of cognitive development 

are much more influenced by a range of [actors, including access to prenatal care, exposure to 

multiple substances and other risk factors related to continued substance use, and the presence of 

mental health issues or domestic violence. 

• Kaltenbach, K.A. (1996). Exposure to opiates: behavioral outcomes in preschool and 

school-age children. NIDA Res Monogr, 164:230-41. 

o Kaltenbach, K., Finnegan, L. P. (1987). Perinatal developmental outcome of infants 

exposed to methadone in utero. Neurotoxicol Terata!, 9, 3 ll-313. 

o Kaltenbach, K., & Finnegan, L. P. (1984). Developmental outcome of children born to 

methadone maintained women: A review of longitudinal studies. Neurobehavioral 

Toxicology Terato/, 6(4), 271-275. 

A 2014 meta-analysis review found no significant impairments in cognitive, psycho-motor or 

behavioral outcomes [or children prenatally exposed to opioids. Although the review did find a 

trend toward poorer outcomes for children with prenatal exposure, the study did not control for 

whether multiples substances were involved and variation in the type of exposure (e.g. heroin or 
195 

methadone). The study discusses additional risk factors such as maternal mental health, parental 

attitude towards parenting. parent-child interaction and stressful life vents. It is not the sole 

presence of prenatal exposure to oploids or the presence of one of the other potential risk factors 

that contribute to poor outcomes. Instead, it is the presence of multiple and inter-related variables 

that cumulatively influence the infant's development. 

• Baldacchino, A, Arbuckle, K., Petrie, D. J., & McCowan, C. (2014). Neurobehavioral 

consequences of chronic intrauterine opioid exposure in infants and preschool children: A 

systematic review and meta-analysis. BMC Pscyhiatry, 14, 104. 

Visual Impairment 

One study found that infants prenatally exposed to methadone are at higher risk for developing 

visual problems, especially infants who experience severe NAS requiring pharmacological 

treatment. The authors acknowledge that it is uncertain whether the visual and other issues 

experienced by children in the study arc directly attributed to methadone exposure, or, whetber 

other factors, such as prenatal exposure to other substances-55% of children were exposed to 

benzodiazcpines and 40% exposed to heroin-also contributed. 

• Hamilton, R., McGlone, L., McKinnon, J. R., Russell, H. C., Bradnam, M. S., & Mactier, 

H. (2010). Ophthalmic, clinical and visual elegrophysiologicallindings in children born 

to mothers prescribed substitute methadone in pregnancy. Br J Ophthalmol. 94(6): 696-

700. 

Prenatal Exposure to Alcohol 

'·Prenatal alcohol is predictive ofdecreased executive functioning in early childhood that could 

not be attributed to environmental jitctor (Noland eta!., 2003). " 

Alcohol is a teratogen, meaning that it is a substance known to be hannful to human 

development (Kaufman, 1997). Children prenatally exposed to alcohol can suffer from serious 

cognitive deficits and behavioral problems as well as from alcohol-related changes in brain 

structure. Brain imaging studies have identified structural changes in various brain regions of 

children \Vho were prenatally exposed to alcohol. The affected regions may account for the 

cognitive deficits experienced by affected children. Fetal Alcohol Spectrum Disorders (PASD) is 

an umbrella tem1 describing the range of lifetime physical, mental, behavioral and learning 

disabilities experienced by children who are prenatally exposed to alcohol 1

• 

Several studies have found that the long-term effects of prenatal exposure to alcohol are 

independent of the other risk factors (e.g. environmental risk factors) that influence the 

development of children who are exposed to otber substances. These effects are due to the 

changes in brain structure caused by alcohol exposure. 

• Baer, J., Sampson, P. D., Barr, H. M., Connor, P. D., & Streissguth, A P. (2003). A 21-

year longitudinal analysis of the effects of prenatal alcohol exposure on young adult 

drinking. Arch Gen Psychiatry, 60(4), 377-385 
196 

' Chlldr(1n <HH:I Family future~ 

• Mattson, S.N., Schoenfield, A.M., & Riley, E.P. (2001). Teratogenic Effects of Alcohol 

on Brain and Behavior. Alcohol Research & Health, 25(3), 185-19!. 

• Merrick, J., Merrick, E., & Kandel, I. (2006). Fetal alcohol syndrome lmd its long-term 

effects. Minerva Pediatrica, 58(3), 211-218 

Prenatal Exposure to Nicotine 

Tobacco smoke contains over 4,000 different compounds, of which approximately 30 have hcen 

associated with adverse health outcomes (Behnke & Smith, 20 13). Multiple studies have 

demonstrated that prenatal exposure to nicotine exacerbates NAS, resulting in a higher likelihood 

of the infant requiring pharmacological treatment, thereby resulting in longer hospital stays. Any 

nicotine exposure has been found to significantly increase the risk of poor fetal growth, 

prematurity and low birth weight. (Bakstad, eta., 2009; Burns, et al.. 2008; Chao, et al., 2004; 

Jones, et al., 2014; Jones, et al., 2012; Kaltenbach, et al., 2012; & Winklbaur. et al., 2009). 

In addition to exacerbating the symptoms ofNAS, prenatal exposure to nicotine affects the fetus 

in numerous ways including low birth weight and abnormalities to the brainstem-both of which 

are risk factors for SIDS/SUID. Up to 70% of SIDS/SUID involve brainstem abnormalities 

(American Academy of Pediatrics IAAP], 2011). The brainstem operates numerous functions, 

including respiratory and autonomic ftmctions, both of which are related to SIDS/SUID. 

Exposure to tobacco smoke in the postnatal period continues to affect the infant's respiratory and 

autonomic development and functions, putting the infant at further risk. An estimated one third 

of SIDS/SUID cases can be prevented if smoking during pregnancy were to be eliminated (AAP, 

2011). 

After controlling for a variety of potentially confounding factors, studies have demonstrated the 

behavior effects, such as impulsivity and attention problems, of prenatal tobacco exposure to be 

long-term in nature. 

• Fried, P.A., Watkinson, B., & Gray, R. (1992). A follow-up study ofattentional behavior 

in 6-ycar-o!d children exposed prenatally to marijuana, cigarettes, and alcohol. 

Neurotoxicol Terata/. 14(5): 299-311. 

• Kris\iansson, E.A., Fried, P.A., & Watkinson, B. (1989). Maternal smoking during 

pregnancy a!Tccts children's vigilance perfonnance. Drug Alcohol Depend, 24(1): 11·-19. 

• Thapar, A., Fowler, T., & Rice. F. (2003). Maternal smoking during pregnancy and 

attention deficit hyperactivity disorder symptoms in offspring. Am Journal Psychiatry, 

160(11): 1985-1989 

Summary 

Prenatal exposure to substances is a major health concern with significant new visibility due to 

the current opioid epidemic. Understanding how to appropriately and effectively treat infants 

prenatally exposed to opioids and to develop a long-term care plan requires an understanding 

of: 
197 

Children ' and Family futures 

The type of opioid exposure: Exposure to heroin and related risk factors (e.g. HIV, 

hepatitis, drug-seeking behavior) demonstrates significantly poorer outcomes than 

exposure to medications used to treat opioid use disorders 

• Access to treatment: Improved outcomes related to the usc of MAT in pregnancy is 

associated with the concurrent usc of counsc1ing, other behavioral interventions and a 

range of additional supports to address the other psychosocial and health concerns 

faced by the family. 

• Exposure to multiple substances: Teaqing out the effects of specific substances is often 

difficult as individuals with substance use disorders generally use multiple substances, 

particularly alcohol and nicotine, which have been shown to have adverse consequences 

for children. In ali situations of opioid use during pregnancy, identifying whether 

alcohol and nicotine are also involved is critical due to the effects of smoking on the 

frequency and severity of the NAS experience of the infant and the potential of lifetime 

challenges related to gro\\'th, behavioral, cognitive, and language development. 

In closing, I would like to thank you for your interest in the opioid issues and again for the 

invitation to testify before the United States Senate Committee on Homeland Security and 

Governmental Affairs. We are happy to assist you with any questions you may have regarding 

this summary and to provide you with any additional information you may require regarding 

these critical issues. 

Sincerely, 

Nancy K. Young, Ph.D. 

Executive Director 

cc: Laura Kilbride (Via Email Laura_Kilbride@hsgac.senate,gov) 

Benjamin Grazda (Via Email Benjamin_ Grazda@hsgac.senate.gov) 
198 

References 

American Academy of Pediatrics. (201 1). Technical Report, SIDS and Other Sleep-Related 

Infant Deaths: Expansion of Recommendations for a Sate Infant Sleeping Environment. 

Pediatrics, 128(5), cl341-el367. Retrieved from 

bttp:i ipcdiatrics.nappublicatiolls.on.~konh::_Q1{_pediq_trics/ 12R/5/e l34l . .ful1Q.d.f 

American College of Obstetricians and Gynecologists Committee on Health Care for 

Undcrserved Women, & American Society of Addiction Medicine. (2012). Opioid abuse, 

dC(Jmdentce, and addiction in pregnancy. ACOG committee opinion no. 524. Obstetrics and 

Gynec:olc>gy, I !070-1076. Retrieved from !lU,IldY00~"'-QJ;&J:!lJ~Ql!!~l:l.l!lll:: 

Bakstad, B., Sarti, M., Welle-Strand, G., & Ravndal, E. (2009). Opioid maintenance treatment 

during pregnancy: Occurrence and severity of neonatal abstinence syndrome: A national 

prospective study. European Addiction Research, 15(3), 128-134. 

Behnke, M., & Smith, V. C. (2013). Technical Report. Prenatal substance abuse: short and longterm e!Tects on the exposed fetus. American Academy of Pediatrics, !31(3), e1009-el024. 

Burns, L., Mattick, P. & Wallace, C. (2008). Smoking Pattems and Outcomes in a Population of 

Pregnant Women with Other Substance use Disorders. Nicotine Tob Res. 10 (6): 969-974 

Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid 

addiction in opioid treatment programs: Treatment Improvement Protocol (TIP) Series 43. 

HilS Publication No. (SMA) 12-4214. Rockville, MD: Substance Abuse and Mental Health 

Services Administration. Retrieved 

Choo, R. E., Huestis, M.A., Schroeder, J. R., Shin, A. S., & Jones, H. E. (2004). Neonatal 

abstinence syndrome in methadone-exposed infants is altered by level of prenatal tobacco 

exposure. Drug and Alcohol Dependence, 75(3), 253-260. 

Fischer, G., Ortner, R., Rohmeister, K., Jagsch, R., Baewert, A., Langer, M., & Aschauer, H. 

(2006). Methadone versus buprenorphine in pregnant addicts: A double-blind, double-dummy 

co1nnaw;on study. Addiction. 275-281. Retrieved from 
199 

Chfldren :;;~nd FamJly Futures 

Jones, H. E., Johnson. R. E.. Jasinski, R., O'Grady, K. E., Chisholm, C. A., Chao, R. E .. & 

Milio. L (2005). Buprenorphine versus methadone in the treatment of pregnant opiolddependent patients: Effects on the neonatal abstinence syndrome. Drug and Alcohol 

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Jones, H. E., Kaltenbach, K., Heil, S., Stine, S.M., Coyle, M.G., Arria, A.M., O'Grady, K .. 

Selby, P ., Martin, P., & Fischer, G. Neonatal abstinence syndrome after methadone or 

buprcnorphine exposure. New Journal of Medicine, 363, 2320-2331. Retrieved from 

Jones, H. E., Heil, S. H., Baewert, A., Arria, A.M., Kaltenbach, K., Martin, P.R., Coyle, M.G., 

Selby, P., Stine, S.M., & Fischer, G. (2012). Buprenorphine treatment of opioid-dcpendent 

pregnant women: A comprehensive review. Addiction, 107,5-27. 

Jones, H. E., Dengler, E., Garrison, A., O'Grady, K. E., Seashore, C., Horton, E., Andringa, K., 

Jansson, L.M., & Thorp, J. (2014). Neonatal outcomes and their relationship to maternal 

buprenorphine dose during pregnancy. Dmg and Alcohol Dependence, 134, 414-417. 

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Kaltenbach, K., & Finnegan, L. ( 1998). Prevention and treatment issues for pregnant cocainedependent women and their infants. Annals of the New York Academy of Sciences, 846.329-

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Marin, P.R., & Jones, H. E. (2012). Predicting treatment for neonatal abstinence syndrome in 

infants born to women maintained on opioid agonist medication. Addiction, 107,45-52. 

Kandall, S. R .. Doberczak, T. M., Jantunen, M., & Stein, J. (1999). The methadone-maintained 

Clinics in 173-183. Retrieved from 

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and its influence on the chromosome constitution of the pre-ovulatory egg. Alcohol Alcohol, 

2(2):113-28. 
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(1998). EtTective medical treatment of opiate addiction. Journal of the American Medical 

Association. 280 1936-1943. Retrieved from 

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program after two years: An overview. Proceedings, National Conference on Methadone 

Treatment, (1 ):794-801. 

Noland, J. S., Singer, L. T., Arendt, R. E., Minnes, S., Short, E. J., & Bearer, C. F. (2003). 

Executive functioning in preschool-age children prenatally exposed to alcohol, cocaine, and 

marijuana. Alcoholism: Clinical and Experimental Research, 27(4), 647-656. 

Velez, M., & Jansson, L. M. (2008). The opioid dependent mother and newborn dyad: 

Nonpharmacologic care. Journal of Addiction Medicine, 2, 113-120. 

Wachman, E. M., Hayes, M. J., Brown, M.S., Paul, J., Harvey-Wilkes, K., Tcrrin, N., Huggins, 

G. S., Aranda, J. V., & Davis, J. M. (2013). Association ofOPRMl and COMT singenucleotide polymorphisms with hospital length of stay and treatment of neonatal abstinence 

syndrome. Journal of the American Medical Association, 309(17), 1821-1827. 

Winklbaur, B., Baewert, A., Jagsch, R .. Rohrmeister, K., Metz, V., Jachmann, C. A., Thau, K., & 

Fischer, G. (2009). Association between prenatal tobacco exposure and outcome of neonates 

born to opioid-maintained mothers: Implications for treatment. European Addiction Research, 

15(3), 150-156. 
201 

University Hospitals 

Testimony of 

Margaret Kotz, DO, Director of Addiction Recovery Services, UH Case Medical Center 

University Hospitals Case Medical Center 

Cleveland, Ohio 

April 22, 2016 

Before the United States Senate Homeland Security and Government Reform Committee 

Chairman Portman, Senator Brown and distinguished guests, my name is Margaret Kotz, D.O. 

am the Director of Addiction Recovery Services at University Hospitals Case Medical Center. I 

thank the Committee for holding this field hearing in Cleveland, and UH Case Medical Center is 

proud to serve as host. 

University Hospitals is a Cleveland-based super-regional health system that serves more than I 

million patients in 15 Northeast Ohio counties. The hub of our 18-hospital system is University 

Hospitals Case Medical Center, a 1,032-bed academic medical center that encompasses 

University Hospitals Rainbow Babies & Children's Hospital; UH Seidman Cancer Center; UH 

MacDonald Women's Hospital and a medical-surgical complex boasting world-renowned 

excellence in every specialty. 

As we are all aware, the disease of addiction has reached epidemic proportions. One need only 

turn on the television or open a newspaper on any given day to see reports of the alarming 

increases in opioid pain medication and heroin use and associated overdoses and death. Opioid 

pain medication addiction and more recently, heroin addiction, have skyrocketed with the death 

rate for opioid pain medication increasing 3.4-fold and heroin deaths increasing 6-fold from 2001 

-2014. Nationwide, 78 people die of opioid or heroin overdose each day. Right here in 

Cuyahoga County we saw heroin and fentanyl kill 12 people in a matter of 6 days, just last 

month. Although we may see heroin and opiate addiction in the headlines these days, the rate of 

alcohol dependence has remained steady. It is estimated that 17 million Americans over the age 

ofl2 are actively addicted to alcohol and more than half of households in the United States are 

affected by an alcoholic family member. Beyond the flashy statistics and the headlines, we must 

always remember that each number represents a person and a family suffering every day from 

this horrible disease. The only effective remedy for this enormous public health problem is 

adequate treatment for addiction. 

I want to commend Senator Portman for his diligent work in drafting and working to pass the 

Comprehensive Addiction Recovery Act. I am confident that many provisions in the bill will 

help address the current shortfalls in treatment options and get more people the help they need. 
202 

am pleased it had such strong support in the United States Senate and hope the House of 

Representatives swiftly moves to pass the bill. 

It is a simple fact that the vast majority of individuals who need addiction treatment do not get it. 

According to the National Survey on Drug Use and Health (NSDUH) conducted by the 

Substance Abuse and Mental Health Service Administration (SAMHSA), only about II% of 

individuals who needed treatment for alcohol or drug use problems in 2013 received treatment at 

a specialty facility (defined as inpatient hospital stays, inpatient or outpatient drug or alcohol 

rehabilitation facilities, or mental health centers). This translates to approximately 20 million 

people who needed treatment for alcohol or dmg use problems but did not receive it in 2013 

alone. The most common reason given by individuals who recognized a need for treatment but 

did not receive it was a lack of health coverage or the ability to afford it, comprising 3 7% of 

respondents. This reason was followed by not being ready to stop using (24.5%), not knowing 

where to go for treatment (9%), health coverage did not cover treatment costs (8.2%), and a lack 

of convenient transportation (8%). It is imperative that we make treatment more accessible and 

widely available to people of all socioeconomic statuses and improve insurance coverage and 

costs for addiction treatment. 

The stigma attached to alcohol and dmg addiction continues to loom large in society. Often, it is 

heard "just lock them up in jail, treatment doesn't work anyways." This less than humane 

attitude about people needing treatment for a chronic and often fatal disease is not only entirely 

inaccurate, this sentiment has contributed to a sense of shame where one's disease is depicted as 

criminal. Shame about one's alcohol or drug use affects the individual's decision to seek 

treatment or not, as well as recovery and relapse rates. Individuals with addiction are more likely 

to have higher levels of shame compared to the general population as well as individuals with 

other mental health conditions. Early intervention on shame is a worthy goal, as children who are 

more shame-prone may be more likely to use drugs by age 18, compared to lower shame-prone 

children. Shame is associated with poorer functioning in multiple domains, including recovery 

from alcohol and drug addiction. Higher levels of shame about one's past drinking is associated 

with higher relapse rates, more severe relapse, as well as worse physical health in general. 

Despite typically having a faster course of illness and more severe physical and mental health 

consequences, women are less likely to go to addiction treatment compared to men. This is 

particularly alarming as women are among the fastest growing groups to be atllicted by 

addiction. The rates of overdose death from prescription painkillers among women have risen 

400% from 1999-2010. We have seen a 100% increase in heroin use among women from 2002 

2013. 

The most common barriers to treatment for women are issues related to chi1dcare. The stigma 

associated with substance use is one contributor, with research indicating that mothers who abuse 

substances are judged more harshly by the public and even by healthcare providers. On a 

practical level, women often fear that reporting problems with alcohol or dmgs and entering 

treatment would jeopardize custody ofthe children. Women who are primary caretakers of their 

children often do not enter treatment at all, and among those who do, many leave treatment early 

due to childcare constraints. When addressing the addiction epidemic in this country, we must 

also include the very real concerns and barriers to care for women with addiction. 
203 

Treatment must include the use of state of the art medications, prescribed by properly 

credentialed physicians. It must also include evidence-based behavioral and psychosocial 

treatment (in conjunction with proper medications) to be effective and to assist patients in 

maintaining long term abstinence. Further, we must educate the public, including healthcare 

providers that evidence-based addiction treatment is effective and essential. Research has shown 

that individuals in treatment, over extended periods of time, will stop using drugs, decrease their 

criminal activity, and improve their occupational, social and psychological functioning. At the 

same time, it is important for patients and family members to have a realistic view of the chronic 

nature of this disease and the associated, expected treatment outcomes. Relapse does occur in the 

treatment of addiction. However, relapse should not be deemed a "failure". Relapse rates for 

addiction resemble those of other chronic diseases such as diabetes, hypertension, and asthma. If 

relapse occurs, this does not indicate failure. Rather, it indicates the need for treatment to be 

adjusted, or that alternate treatment is needed. 

Specialized programs certified by their State's accrediting body have the most positive 

outcomes. Unfortunately, there is a dearth of treatment programs and addiction specialists in the 

United States providing evidence-based treatment. In order to adequately address the growing 

addiction epidemic, it is imperative that treatment be available and readily accessible by those 

who need it. 

Beyond saving lives and healing families, treatment is quite simply cost effective. Alcohol and 

drug addiction yield an enormous financial burden on society, with costs of up to $600 billion 

per year. Conservative estimates indicate that every dollar invested in addiction treatment 

programs yields $4 - $7 in reduced drug related crime, criminal justice costs, and theft. As 

mentioned above, in lieu of treatment, addicts often end up in jail. In addition to the questionable 

morality of this practice, treatment is much more cost-effective than incarceration. For instance, 

on average, a year of medication for opiate or heroin addiction (methadone) costs approximately 

$4,700, compared to $18,000 for imprisonment. If for no other reason, investing in drug and 

alcohol treatment is a cost-saving measure in the United States. 

Drug and alcohol addiction does not discriminate based on race, gender or socioeconomic class. 

In a time and country filled with great medical and technological advances, it is tragic that 

overdose death rates are not only rising, but rising at a tremendous rate. We whole-heartedly 

endorse the passing of the CARA as it will serve to make treatment more available to those in 

need. For too long, there have been insurmountable barriers for many to receive adequate 

treatment. CARA is an important step towards addressing this growing public health concern 

which devastates lives and families. 
204 

Margaret Kotz, DO, Ashley Braun-Gabelman, PhD., Ray lsackila, LPCC, LICDC 

April22, 2016 

As we are all aware, the disease of addiction has reached epidemic proportions. One need 

only tum on the television or open a newspaper on any given day to see reports of the alarming 

increases in opioid and heroin use with associated overdoses and deaths. Addiction to opioid 

analgesics and more recently heroin, has skyrocketed with the death rate for prescription opioids 

increasing 3-fold and heroin deaths increasing 6-fold from 2001-2014 (NIDA, 2015). 

Nationwide, 78 people die of opioid or heroin overdose each day (CDC, 2016). In Cuyahoga 

County Ohio, heroin and fentanyl killed 12 people in a period of 6 days this March (MacDonald, 

20 16). Beyond the attention-grabbing statistics and headlines, it is essential to remember that 

each number represents a person and a family suffering every day from this disease that destroys 

lives long before it ends them. The remedies for this epidemic include education, interdiction, 

and especially treatment of those already afflicted. 

The vast majority of individuals who need addiction treatment lack access to it. 

According to the National Survey on Dmg Use and Health (NSDUH) conducted by the 

Substance Abuse and Mental Health Service Administration (SAMHSA), only about II% of 

those who needed treatment for alcohol or drug use in 2013 received specialty treatment, leaving 

20 million people without care in 2013 alone. The most common barrier cited by individuals who 

recognized a need for treatment but did not receive it was financial. This affected 37% of 

respondents. This reason was followed by "not ready to stop using," (24.5%) "did not know 

where to go for treatment," (9%) "health coverage did not cover treatment costs," (8.2%) and "no 

transportation/inconvenient" (8% ). It is imperative that treatment be made more accessible to 

people at all socioeconomic levels. 
205 

Beyond saving lives and healing families, treatment is cost effective. Alcohol and drug 

addiction is an enormous financial burden to society, with costs of up to $600 billion per year 

(NIDA, 20 12). Conservative estimates indicate that every dollar invested in addiction treatment 

yields $4-$7 in reduced crime and criminal justice costs (NIDA, 2012). Without treatment, 

individuals with addictive disorders often end up in jail. This has a disastrous effect on the lives 

of the offenders and falls disproportionately on minorities. It also represents a mal-allocation of 

funds. On average, a year of medication treatment for addiction (with methadone) costs 

approximately $4,700, compared to $18,000 for imprisonment (NIDA, 20 12). If for no other 

reason, investing in drug and alcohol treatment is a cost-saving measure. 

The stigma attached to alcohol and drug addiction continues to loom large in society. A 

common attitude is, "Just lock them up in jail; treatment doesn't work anyway." This response is 

not only inhumane, it is factually incorrect. It contributes to the shame and self-loathing that 

impede treatment-seeking. Those with addiction are even more likely to experience shame than 

are those with other mental health conditions (O'Connor, Berry, Inaba, Weiss, & Morrison, 

1994). 

Despite typically having a faster progression of illness and more severe physical and 

mental health consequences, women arc less likely to receive addiction treatment than arc men 

(Greenfield, Brooks, Gordon, Green, Kropp, McHugh et al., 2007). This is particularly alarming 

as women, historically less likely to become addicted, constitute a large portion of the population 

afflicted by the opioid epidemic. The rates of overdose death from prescription opioids among 

women have risen 400% from 1999 20 I 0 (CDC, 2013 ). There has been a I 00% increase in 

heroin use among women from 2002 2013 (CDC, 2015). 
206 

The most common barriers to treatment for women are scarcity of treatment tacilities, 

lack of funding for treatment, and unavailability of childcare. The stigma associated with 

substance use is one cause of treatment avoidance, as addicted mothers are judged more harshly 

by the public and by healthcare providers than are men. (Castillo & Waldorf, 2008). 

Additionally, women often fear that entering treatment may cost them custody of their children 

(Greentield, Back, Lawson & Brady. 2010.) Women who are primary caretakers of their children 

often do not enter treatment at all, and of those who do, many leave treatment early due to 

childcare constraints (Castillo & Waldorf, 2008). When addressing the addiction epidemic in this 

country, we must also include the very real concerns and barriers to care for women with 

addiction. 

Treatment must include state of the art medications, prescribed by properly credentialed 

providers. Studies show that when heroin addiction is treated only with abstinence and 

psychosocial treatment, most fail. Our 50 years of experience with methadone treatment of 

heroin addiction confirms that, counter-intuitively, the use of a selected opioid to treat addiction 

results in decreased unemployment, criminality, and infectious diseases such as HIV and 

hepatitis. 

However, while effective, methadone is not an option for the overwhelming majority of 

patients with opioid addiction. It requires daily visits to specially licensed facilities, typically 

only found in large urban locations. It is unavailable to rural patients, and relatively so to those 

living at a distance in the cities, especially when transportation is limited. The daily visits are a 

barrier to employment. 

Since DATA 2000. Office Based Opioid Treatment has been available. The partial opioid 

agonist buprenorphinc can be prescribed by a qualified primary care physician in the patient's 
207 

neighborhood, making it significantly more accessible. Daily visits are not needed, so that 

patients can hold jobs. Research demonstrates that it is as effective as methadone and far safer in 

overdose or accidental child exposure. Despite this, access remains severely limited due to 

inadequate numbers of physicians prescribing buprenorphine. 

An alternate medication based strategy for treatment relies not on opioids, but on agents 

(antagonists) that block them. Only one, naltrexone, is currently available as a daily pill or 

monthly injection. While less acceptable to many patients than buprenorphine, for those willing 

to take it or who have monitored administration, it can be a valuable tool for increasing long term 

sobriety. 

Although both opioid agonist and antagonist medications are important additions to our 

treatment armamentarium, they are not sufficient for successful treatment. This is especially true 

when a primary care provider has !5 minutes to provide addiction treatment while complying 

with requirements to ensure that other issues, such as vaccinations, colonoscopies, and 

mammograms are up to date, that state prescription drug monitoring data has been checked, that 

urine drug testing is current, etc. It is apparent that support for extended office visits and for 

associated behavioral services is essential for favorable outcomes. It is necessary that more 

physicians be trained in medication assisted treatment of addiction and that there is sufficient 

payment for requisite medical and behavioral services. 

In Northeast Ohio, there are simply not enough facilities to treat addiction for those who 

need it, even if they could afford it. Perversely, patients may be required to fail a level of care or 

a medication before the recommended treatment will be reimbursed. 

We have focused on treatment of substance use disorders; however, it goes without 

saying that this is only part of a group of essential strategies. We have learned from cigarette 
208 

addiction efforts that a national educational campaign can save many lives. We have learned that 

focusing on a criminal justice approach to the problem is largely ineffective, yet has costs that 

greatly exceed those of treatment. 

In summary, the current addiction epidemic is having a catastrophic impact on many lives 

and communities. We are fortunate that both of our Ohio senators are taking action to address 

this scourge by supporting CARA. It is likely that an approach at the federal level is necessary to 

stem the tide of opioid addiction nationally. 

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Castillo DT, Waldorf VA (2008). Ethical issues in the treatment of women with 

substance abuse. The book of ethics: Expert guidance for professionals who treat addiction, I 01-

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Centers for Disease Control and Prevention. Understanding the epidemic. (2016, March). 

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Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses: a 

growing epidemic, especially among women (2013, July.) Retrieved April!!, 2016 from 

http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html 

Centers for Disease Control and Prevention (CDC). Today's heroin epidemic 

infographics (2015, July). Retrieved April 15,2016 from: 

http://www. cdc. gov /vital signs/heroin/info graphic. html 

Greenfield SF, Back SE, Lawson K, Brady KT (2010). Substance Abuse in Women. 

Psychiatric Clinics of North America, 33: 339 355. 
209 

Greenfield SF, Brooks AJ, Gordon SM, Green CA, Kropp F, McHugh RK., ... Miele, G. 

M. (2007). Substance abuse treatment entry, retention, and outcome in women: A review of the 

literature. Drug and alcohol dependence, 86(1 ): l-21. 

MacDonald, Evan (7 April, 2016). Cuyahoga County heroin, fentanyl overdoses kill 12 in 

six days. Cleveland. com. Retrieved on Aprill5, 2016 from: 

http://www.cleveland.com/metro/index.ssf/20!6/04/cuyahoga _county_ heroin_ fentany.html 

National Council on Alcoholism and Drug Dependence (2015, July). Facts about alcohol. 

Retrieved on April 15, 2016 from: https://ncadd.org/about-addiction!alcohol/facts-about-alcohol 

National Institute on Drug Abuse (20 12). Principles of drug addiction treatment: a 

research-based guide (3'd edition). Retrieved on April 14,2016 from: 

https :/ /www. dru gab use. gov /pub li cations/principles-drug -addiction-treatment-research-basedguide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost 

National Institute on Drug Abuse (2015, December). Overdose death rates. Retrieved on 

April 15, 2016 from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-deathrates 

O'Connor, L. E., Berry, J. W., Inaba, D., Weiss, J., & Morrison, A. (1994). Shame, guilt, 

and depression in men and women in recovery from addiction. Journal of substance abuse 

treatment, 11 (6), 503-510. 

Substance Abuse and Mental Health Services Administration. Results from the 2013 

National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, 

HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health 

Services Administration, 2014. 
210 

Substance Abuse and Mental Health Services Administration (2014). National Survey on 

Drug Usc and Health (NSDUH). Table 5.8A-Substance dependence or abuse in the past year 

among persons aged 18 or older, by demographic characteristics: Numbers in thousands, 2013 

and 2014. Retrieved on April15, 2016 from: 

http://www.samhsa.gov/data/sites/default/files/NSDUH-DctTabs2014/NSDUHDctTabs20 14.htm#tab5-8a 

Stuewig, J., Tangney, J.P., Kendall, S., Folk, J. B., Meyer, C. R., & Dearing, R. L. 

(2015). Children's proneness to shame and guilt predict risky and illegal behaviors in young 

adulthood. Child Psychiatry & Human Development, 46(2), 217-227. 
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MetroHealth 

Statement Of 

EMILY METZ, MPH 

Program Coordinator 

Cuyahoga County Project DAWN (Deaths Avoided With Naloxone) 

The MetroHealth System 

Cleveland, Ohio 

For a Field Hearing 

Before The 

United States Senate 

Committee on Homeland Security and Governmental Affairs 

11Examining the Impact of the Opioid Epidemic" 

Friday, April 22 
212 

MetroHealth 

Chairman Johnson, Senator Baldwin, Fellow Speakers and Guests: 

Thank you for allowing me to speak to you today regarding the opioid epidemic and its devastating 

impact on Cuyahoga County. The MetroHealth System is an essential hospital system committed to 

leveraging its expertise, resources, and relationships to respond to this public health crisis. I serve as 

Program Coordinator for Metro Health Cuyahoga County Project DAWN, a life-saving overdose 

prevention program sponsored by the health system, the Alcohol, Drug Addiction & Mental Health 

Services Board of Cuyahoga County, and the Ohio Department of Health. I am also speaking to you as a 

member of the Cuyahoga County Opiate Task Force and our local U.S. Attorney Opiate Action Plan 

Committee. 

Our country is in the grips of an opioid addiction and an overdose epidemic. We are at-risk of losing a 

generation of Americans to a disease that devastates lives, families, and entire communities. In 2014, 

2,482 Ohioans died as a result of a drug overdose and 80% of these fatalities involved an opioid. In large 

part, our country's epidemic is iatrogenic; our liberal prescribing of opioids has created a generation of 

Americans who are addicted to opioids and require help. As a nation, we must mobilize to curb and fix 

this crisis. 

At Project DAWN, we work to reduce opioid overdose mortality by helping to expand community access 

to the opioid overdose antidote naloxone. We train community members on risk factors for overdose, 

how to recognize an overdose, and how to respond to an opioid overdose. The most critical aspect of 

our program is the free provision of naloxone to our patients. Since the founding of our county program 

in March of 2013, we have provided over 3,300 kits to community members resulting in over 400 

overdose rescues. 

Ohio's streets are saturated with fentanyl-laced heroin, which has contributed to the loss of 502 

Ohioans during 2014 as compared to 84 during 2013. Because fentanyl is an opioid that is up to 50 

times stronger than heroin, the dose of naloxone needed to revive the victim must be increased. This 

development is impacting our intervention efforts and budget because it is increasingly necessary to 

provide additional take-home doses to our patients. 

We and other alcohol, drug, and mental health service providers in our country do not have the 

adequate resources to meet the emerging needs of communities struggling with substance use 

disorders. Cuyahoga County Project DAWN is considered one of the largest Project DAWN programs in 

Ohio. We have expanded to include three-to-four hour walk-in clinics, three days a week and also 

provide naloxone kits in other community settings such as the County Jail, Metro Health Emergency 

Departments, and the Free Medical Clinic of Greater Cleveland's syringe exchange program. Without 

these strong community collaborations, we would not be able to save as many lives. Currently, Project 

DAWN's efforts are shouldered by one full-time employee, me. In Ohio, we are one of 37 County 
213 

MetroHealth 

Project DAWN programs in a state of 88 counties. The reality is that many of these programs do not 

have full-time staff members, some are only able operate once a month, and often there are programs 

that run out of funds to purchase naloxone before the year's end. 

Project DAWN programs are essential to curbing opioid overdose mortality at the community level 

because we equip those most likely to witness an overdose with the proper life-saving tools. While we 

strongly support increasing access to naloxone for first responders including police, fire and EMS, we 

know that the most likely individuals to witness an overdose are drug users, their family and friends. 

We strongly support the Comprehensive Addiction and Recovery Act (CARA) and request funding be 

considered to help lay responders who are connected to Project DAWN models. This investment will 

sustain and expand community-based naloxone programs that have a proven track record in reaching 

people in the community before they intersect with the first responders system. 

We applaud our Congressional leadership for recognizing that increasing naloxone access in our country 

does not alone fix the opioid epidemic. The CARA legislation is promising in that it promotes evidencebased and innovative strategies, interventions, and treatments at the community level. Project DAWN 

welcomes federal funding in support of community networks focused on connecting treatment, housing, 

education, and employment opportunities to those struggling with addiction. 

Finally, the stigma that is present in our country for individuals with substance use disorders is no small 

issue to tackle. We commend CARA's focus on Public Awareness Campaigns, which would educate the 

public on the risk of prescription drug and heroin abuse. We hope these campaigns will also educate the 

public that addiction is a chronic disease and we should support those in recovery just as we rally behind 

those struggling with other diseases. Individuals with substance use disorders are not bad people trying 

to get good, instead, they are sick people trying to get well. 

Thank you for your time. I welcome questions from the committee. 
214 

EXAMINING 

ROBBY'SUU'v 

~ 

THE IMPACT OF THE OPIATE EPIDEMIC 

Testimony 

Presented by 

Robert Brandt, Founder ROBBY'S VOICE 

Frida~April2~2016 

Mr. Chairman and members of the committee, thank you for the opportunity to present testimony this 

and thank you for your focus on this issue. I also want to thank Senator Portman and Senator Brown for 

their efforts relative to the CARA legislation. Once this legislation is passed, it will make a significant 

difference for so many families. 

Before I proceed to my testimony, I want to provide a brief overview of our family's experience, and our 

organization. Five years ago this October, my son, Robby, passed away from an accidental heroin 

overdose. His addiction began with the prescribing of prescription pain medication after the extraction 

of his wisdom teeth, and ultimately led to his addiction to heroin. As a family, we battled this disease as 

best we could. However, we lacked information, we lacked education and we lacked the understanding 

of resources that may have been available; resources that may have saved his life. This included things 

like a real understanding of medication assisted treatment, the probability of relapse, and the role of the 

family in enabling recovery versus addiction. But the real deficit began prior to his addiction. The lack 

of education to students and parents, the lack of community awareness, and the abundance of stigma 

which cast a dark pall over every family struggling with this disease. What scares me to this day is that 

even if there were more awareness, more education, I do not know that I would have escaped the "not 

my kid" mentality that so many parents operate under. 

Our journey with heroin addiction lasted six months. When it ended, it left a wake of devastation 

behind it and darkness ahead. We watched this young man, our son, struggle with this disease. We 

witnessed the battle, and we saw the pain in his eyes as he would say over and over "I did not ask for 

this, I don't want this." We watched as the relationship he had with his brother and sister deteriorated, 

blocked by the drug, by the addiction. We watched as he did unthinkable things; lying, stealing, 

manipulating, things that were just not who he was. We watched as our home was wrought with chaos, 

divided by differences that stemmed from our lack of education and understanding. 

Robby passed away on October 20th, 2011, 68 days before his 21" birthday, 18 days before leaving on 

deployment to Afghanistan. In the wake of his death, our family has been left forever impacted, forever 

incomplete. As parents, we carry the guilt of not being able to save him, questioning every decision we 

made along the way, wondering how we allowed this to happen to our son, why we did not see this 

earlier. His sister lost her best friend. She struggles continually with the guilt of knowing he was 

struggling, but as a good sister does, she kept his secret because he asked her to, and because of the 
215 

lack of education in our schools, she just did not understand the true impacts of addiction. His brother 

lost his idol, the person that he, as little brothers always do, emulated and wanted to be like. To this 

day, Nolan always has something of Robby's with him, and he often talks about not being able to have a 

best man at his wedding. The impact of loss is deep, and it is permanent. 

A few weeks after his death, Carla and I were cleaning up Robby's room, and we found a journal that 

outlined his plan to make a difference. He wanted to speak in schools and he wanted to create an online support group for recovering addicts. His idea was called Live Free. We knew that we traveled this 

road in darkness, confused and unsure of what to do, and we knew we could never let another family 

experience the same thing we had. After reading Robby's journal, we knew that we had to become his 

voice and at that moment, ROBBY'S VOICE was born. 

ROBBY'S VOICE officially launched in May of 2012 with a mission to bring awareness to schools and 

communities. Over the past four years, we have spoken to over 70,000 students and parents. We have 

worked to raise awareness in our communities and we have worked with those communities to develop 

plans to attack the epidemic that has been attacking them. We have worked in private with families 

that have been impacted by this disease, and with families that have suffered the ultimate loss from this 

disease. We continue to develop resources for schools with the goal of delivering a turn-key program 

that makes education on this issue easy and meaningful. We continue to provide resources for parents, 

and have launched our own family support group called Family Matters. We have also announced our 

intention to develop a Center for Continued Recovery which will be a post treatment resource center for 

those in recovery that focuses on helping them develop the skills and relationships to allow for a quicker 

assimilation back into normal life, increases the opportunity for sustained recovery and provides a place 

where recovering addicts are able to fit in. Our place in the world of addiction lies in prevention, both 

on the front end prior to addiction, and what we call prevention part 2, the prevention of relapse. 

In the invitation to testify, there were two main points we were asked to address; the role the Federal 

Government can play, and how we may improve prevention, education, treatment and support. I have 

delineated my thoughts on these subjects in the following testimony, thoughts that are based in part on 

evidence based research done by others, interaction with industry experts as well as families that have 

personal experience, and our personal experience both with addiction and in all the encounters we have 

had through ROBBY'S VOICE. 

As I prepared this testimony, I was challenged to determine how best to articulate my thoughts and to 

convey these thoughts as well as the hearts and souls of those who shared their thoughts with me. I 

will frame this testimony with the following story; 

Last Friday, I had the honor to speak at my alma mater, Padua High School. Robby wanted to look at 

going to Padua, but we discounted that because of cost and distance. Today, we question that decision. 

What if, what if we had said yes; would we be in a different place today? We question every decision 

we made along the way, we carry the guilt of every decision we made along the way because those 
216 

decisions ultimately were not the right ones. We failed to protect our child. We failed to save our child, 

and we carry that every day. Welcome to our world. Welcome to the world of addiction. 

In our opinion, prevention is the key element because those that don't use don't get addicted, and those 

that are not addicted are not at risk for the consequences of the disease. Prevention touches many 

areas, but the foundation of prevention is education which I will discuss later. Yet there are other 

elements that will allow us to be more successful relative to prevention. 

Supply vs. Demand; Some want to attempt to strangle supply, get the drugs off the street. 

While we have been mildly successful at reducing the availability pf prescription pain 

medication, we have not been successful in reducing the availability of illegal drugs. Prevention 

strikes at demand. It does not matter what the product is, if there are no buyers, the seller 

ultimately loses. 

Pain as a vital sign; Prevention means we look at causation and one cause that needs to be 

addressed is pain as a vital sign. Pain is the only subjective vital sign, and that subjectivity is 

exploited by those who continue to abuse prescription medications. Additionally, it forces our 

providers to administer care in a different manner. The adaptation of pain as a vital sign is 

aligned with the beginning of our current epidemic. 

Affordable Care Act; Along with the exploitation of pain as a vital sign is the impact of the 

Affordable Care Act and the focus on patient satisfaction. Pain is the largest driver of poor 

survey results which impact the reimbursements to healthcare providers. We will and we must 

increase education to Residents, increase the use of automated tracking of prescriptions, and 

adopt prior authorization guidelines. These are outlined in CARA and will undoubtedly help. 

However, until we separate the relationship between pain and payment, our providers will 

continue to write. It may be in smaller quantities, but they will continue to write in order to not 

be penalized. 

Funding; If prevention is to be successful, then it has to be a priority and it has to be funded. 

The current funding allocations provide the lion's share of funding to treatment. That funding is 

essential and critical, but it also takes money from prevention. We need to fund prevention so 

that we are able to ultimately spend less on treatment. Yes, we need expanded treatment 

today, but ultimately, we need less addicts. 

Within prevention lies the concepts of choice and consequence. Today, we focus on prescription pain 

medications as well as heroin, but there will always be another drug, there will always be the next drug. 

The concepts of prevention, honest education about choice and consequence, will allow us to have an 

impact not just on this current epidemic, not just on the next potential dangerous drug, but on all the 

different issues facing our kids (bullying, sexting etc.). 

Today, we face a new danger that is far greater than heroin; fentanyl. Virtually no one saw this coming, 

but the devastation is far greater, far more dramatic than anything we have dealt with. A foundation in 

prevention, a real foundation would have allow us to minimize the impact of this drug. A real 

foundation in prevention will allow us to minimize the impact of the next fentanyl. 
217 

Education is the cornerstone of a prevention strategy, and to be effective, must extend to all segments 

of society, all age groups and it must be sustained. 

We have learned that in order for education to be effective, it must have the following elements; 

Sustained over time 

Maintain a frequency that salutes the importance of the subject matter 

Variation of in how it is delivered 

These factors reinforce the importance of the information, account for different learning modalities, and 

enhance the probability of delivering the message at a time when it needs to be heard. 

Education also drives change in two other critical areas; culture and stigma. 

We have created a take a pill feel better mentality, and a culture that glorifies drug use. We may say 

that we don't, but we do, and we deliver these messages to our youth through movies, television, music 

and societal expectations (concert behavior or the "college experience."). We have taken the stigma of 

use and experimentation out of the picture. Education will allow us to change that. 

Stigma still exists across society, and impacts the addicts ability to re-engage into a normal life and drive 

long term sobriety. In my community, Medina, many had worked to bring more treatment options 

forward. It was received with open arms, until it came down to selecting a location. Then, stigma, 

driven by uneducated but understood beliefs slowed the process. Education will allow us to overcome 

stigma. It will help us recognize addiction as a disease entity, and will allow families to more openly deal 

with addiction an engage in treatment earlier. It will assist in sustaining recovery through community 

acceptance and the development of options like sober employers. 

Education must be comprehensive. 

Schools- K-12 science based with adjuncts to different curriculum elements allows us to build student's 

knowledge year over year, it answers the questions why, and how. When we speak at schools, students 

agree that addiction is a bad thing, yet they struggle to articulate how addiction happens. They also do 

not associate their image of an addict (usually a dark, dilapidated image) with themselves, their families 

or their peer groups. This disassociation supports the "It won't happen to me" attitude. K-12 education 

allows us to answer the key questions of how and why, providing a knowledge base for decision making. 

Yet schools struggle to deploy consistent education as they are faced with economic challenges as well 

as the burden of performance test scores. We hear regularly, "we don't have time." Most schools are 

now conducting cursory education, but most that we deal with truly don't have a comprehensive 

approach. 
218 

Included in this, we must not forget teachers and support staff. These teams interact with students on a 

daily basis and have an opportunity to identify a behaviors that fall in line with addiction, as well as 

understanding the impact that addiction in a family has on other children within the household. 

Parental Education- probably the largest gap we see is within the parents groups. These events have 

notoriously low turn-out, so information dissemination is a struggle. We find parents believing that they 

either know the information or that it won't be their kid. We as parents live under false impressions, 

yet, I understand it. Honestly, even if all the awareness that exists today were available when Robby 

was first struggling, I am not certain that I would have been open to it happening to "my kid." Utilizing 

social media tools and a targeted educational campaign, we have the ability to push information to 

parents on a regular and consistent basis. Messages from programs like "Let's Talk" here in Ohio are 

being adopted by schools and used in parental communication. The keys, once again, are sustainability 

and frequency, coupled by the ability to provide incremental resources to parents. Just like students, 

parents need a "why" to get engaged. 

Medical Community-Increased training at all levels of healthcare providers. CARA will address part of 

this. We must ensure that our Doctors receive the training they need both on prevention as well as the 

impacts of dispensing. Here are a few examples of what needs to change; 

My wife underwent a surgical procedure. She was prescribed 60 Percocet post operatively, took 

about 20. At her follow-up visit, the Surgeon asked her about pain and medication. She told 

him that she had 40 left, and he still wanted to write another prescription "just in case." 

A friend's daughter recently had her wisdom teeth extracted. She was prescribed enough 

OxyContin for two weeks. 

A friends daughter, a recovering addict, recently gave birth. She told the Doctor that she was in 

recovery and did not want pain medication. The Doctor replied "it will be administered through 

your IV so it won't affect your recovery." She continually declined, and the Doctor continually 

pushed. 

Law Enforcement- When law enforcement officials say to me, "I don't know if those people are worth 

saving," then I know more education is needed to assist our officers in understanding addiction, the 

addicts perspective and what is driving their behavior, the family impact, and the critical nature of 

Narcan. 

Communities- We focus on failure. Follow the media and we are bombarded by stories of overdoses 

and crime. This perpetuates the stigma associated with addiction and directly impacts efforts toreacclimate to the community and working toward sustained recovery. Part of the education approach 

must be to help society as a whole understand two key elements; 

We must understand the impact that society has relative to influence and messaging to kids. 

This includes the glorification of substance use on television, in the movies, and in music. 

We must help society understand the disease of addiction 
219 

We will always deal with addiction, and as such, we will always need treatment. I will leave more 

detailed testimony to the treatment experts, but I will share a few thoughts based on our experience. 

We must recognize areas that are having success versus areas that provide treatment. Areas like Scioto 

County Ohio, led by Ed Hughes that had dramatic turnarounds should serve as models to be adapted as 

standards. We must; 

Recognize the differences in opiate addiction and other addictions and adapt treatment 

accordingly. THE LCADA WAY in Lorain is a great example of an organization that has developed 

different treatment options and extended treatment to deal with this particular addiction. 

Utilize evidence based treatment, allowing us to identify treatment facilities that produce 

results, either globally or within a certain substance group and/or demographic. Our partner, 

MAP, has developed an algorithm which allows them to identify the best treatment options 

based on historical data married to the specifics of a given addict. Utilizing this type of data 

allows us to not only to save lives, but to reduce the overall cost of treating the disease. 

Availability- Treatment availability is critical, and we should look at multiple options to increase 

access. These options include creative modalities like ambulatory detox. Additionally, funding 

of treatment continues to be a challenge. Private payors do not treat addiction like other 

chronic diseases, leaving the burden of funding on the parents, and in Ohio, even with the 

expanded Medicaid coverage there is still a gap in those that have private insurance that no 

longer covers treatment or covers short periods of treatment. 

Finally, the need to focus on support directly impacts the relapse rate which ranges between 70%- 90%. 

This begs the question; where is the issue, treatment or support? While we must improve treatment 

availability our relapse rate is directly relative to our post treatment support as well as family support. 

Post treatment support is prevention part 2. 

Post Treatment support lacks in many areas, but is critical to reducing relapse rate. We see in recovery 

communities improved outcomes driven by the support that continues to wrap addicts in the support 

that carries them through the time it takes to recover the natural chemistry of the brain and reestablish 

or establish the skill sets needed to manage everyday life. 

This concept of post treatment support provides a pathway to; 

Continuing sobriety through support groups and connectivity to peer support. 

Tele-medicine 

o Utilization of MAP or other tele-medicine providers to provide on-going support and 

early relapse identification 

Development Life Skills 

o Coping skills 

o Goal setting and accomplishment 

o Personal Finance 

o Parenting 

• Education 
220 

o Secondary completion 

o Post-secondary access 

Employment 

o Resume's 

o Interview skills 

o Dressing for success and grooming 

o Employment connections and the development of sober employers 

Additional Concepts 

0 Networking 

0 Nutrition 

0 Cooking 

0 Fitness 

The concept of continued recovery communities is providing the needed continuing support to assist 

addicts in defeating this chronic disease which we currently treat as acute. 

The second element of support that must continue to evolve is family support. Addiction is a family 

disease, but we focus our treatment efforts on the addict while families often fend for themselves. The 

continuing development of resources as well as awareness of those resources will allow families to cope 

with the stigma of addiction, as well as learning how to enable recovery versus addiction. Family 

support is built upon; 

Education to empower the family 

True support group functions 

Connectivity to other resources 

Through our experience in deploying Family Matters, we have uncovered two additional areas where we 

see a need for increased support' 

Expanded support for children and siblings 

o Targeted at ages 7-15, developing teen leaders to assist in generating discussion and 

easing the fears of younger members. 

Expanded support for children of addicts living with relatives 

o Primary focus is on educating the family members on how to deal with the situation 

As a society, we provide support for other chronic diseases like cancer, diabetes and obesity. Yet, with 

addiction, we lack the necessary continued support to sustain sobriety, and through that, we 

unknowingly enable relapse. 

The final point to address is the statement in the invitation to testify that reads "focus on the role of the 

Federal Government and the importance of a cohesive national strategy ... " In my view, we lack a 

cohesive national strategy. In fact, we lack cohesive state and local strategies and as such, we need the 

Federal Government to lead in this arena. This epidemic is a national epidemic, and as such requires a 
221 

national approach. As we have worked within the field of addiction, we have encountered many 

organizations, both public and private sector, that are working diligently to address this issue. However, 

within that same element, we are seeing a lack of cohesion and repetitive efforts across the state. Our 

experience has revealed a disjointed effort in the following areas; 

Schools 

o Focus is on standardized testing and the statement is far too often "we don't have 

time." 

o Schools don't have the financial ability to deploy Preventionalists or Resource Officers 

o Schools that do provide education don't have a sustained strategy; usually a one-time 

speaker, health class and the D.A.R.E program. 

o Lack of a K-lZ approach and a lack of funding for programs like the NIDA program. 

Law Enforcement 

o Community perception that their law enforcement is focused on arrests and punitive 

action and others that are engaged in treatment versus jail 

o Police Departments that are on-board with Narcan and others that either don't have the 

resources or the desire to carry Narcan 

Physician differentiation relative to prescribing and managing pain. 

These are some areas where we see disjointed efforts and inconsistent messages to our communities. 

The Federal Government has an opportunity to bring all parties to the table and to build a national 

strategy that does not focus on walls and enforcement, but rather on a strategic approach with tactical 

execution across the spectrum of players in this field. A coordinated strategy that identifies best 

practices and has education, healthcare, law enforcement and communities all on the same page will 

improve our treatment outcomes, lower costs and lay the groundwork to prevent such epidemics in the 

future. 

We need to focus on a migration of funding from treatment to prevention. We need to support 

treatment, but we must increase focus and funding toward prevention and support. A reduction in 

active addicts, both first time and those who suffer from repeated relapse will have a natural reduction 

in those that need treatment. We have to fix the issue as opposed to treating the symptom if we hope 

to reduce the financial burden and most importantly the human cost of addiction. 

Most important, we need to move with a sense of urgency, and the Federal Government has the ability 

to drive that urgency. We lose an America every thirteen minutes, an Ohioan seven times per day. This 

is the greatest healthcare crisis in modern history, and we must act with urgency; lives depend on it. 
222 

ADDENDUMS 

The following addendum outline the current efforts of ROBBY'S VOICE as it pertains to our education 

based programing. 

ROBBY'S VOICE EDUCATIONAL PROGRAM OVERVIEW 

Education Tenants 

Our approach to education at the school level is based on the following three principles; 

1. Sustained Consistency 

2. Variation 

3. Extension 

Sustained Consistencx 
223 

Due to the pressures facing schools to perform on standardized tests and cover the social 

issues facing students, we only skim the surface of education relative to drugs and 

addiction. The education surrounds three or four factions; 

DARE (4thj5th Grade) ......,. 9th Grade Health ......,. Prom 

If education on this topic is not sustained on a consistent level, the message we deliver is 

simple; it is important, but not that important. In order to change and create a culture that 

focuses on good decision making, education on this issue must be sustained consistently 

over the students' academic career. We need to acknowledge that accidental overdose is 

the leading cause of accidental death in our state and country, and that the first age of 

usage are; 

Marijuana; 12 years old 

Pill abuse; 14 years old 

Our (RV) approach emphasizes a K-12 curriculum as follows: 

K-12; NIDA pre planned curriculum. This program was developed by educators for 

educators and is a pre-planned science based curriculum. It is adaptable outside of science 

to create education throughout the school year and in different classes. Additionally, the 

program is age appropriate, answers the question "WHY," and provides visual support 

materials to support the classroom lessons. 

Core Curriculum Related Classroom Activities- RV is developing classroom based activities 

which tie to the states adaptation to the common core. The activities will provide 

opportunity in creative writing (grammar/research), debate, and physical education. 

grammar, research. Debate, 

Sustaining the consistency of education allows each year to build upon the previous year 

and creates a platform for positive decision making based on facts and information. 

Variation 

Variation of messaging is another facet that we view as important. Recognizing that 

exposure, influence, experience and timing vary by student, we can't predict which 

message will resonate with which students. For example, we have spoken to students who 

were very engaged with the DARE program while others stated that DARE made them want 

to experiment with drugs. Variation provides the following benefits; 

Relatability; Provides a wider variety of relatable messaging to students as well as staff 

members that may be listening. 
224 

Reinforcement; variation improves attention. The same message from the same sources 

tends to tuned out over time. Hearing the same message from different sources allows for 

a stronger attention span as well as reinforcement of the message. 

Differentiation; Variation provides opportunity for perspective and for discussion in the 

classroom after the program as to similarities and differences. Also another opportunity 

for education based activities. 

Perhaps the best reason for variation lies in bringing reality to the discussion. NIDA is a 

classroom activity, but by utilizing outside sources, the classroom application may be 

applied to real life. This again allows for vigorous classroom discussion or assignment. 

Even more critical is the ability to empathize and relate, potentially seeing friends or family 

members reflected in the speaker and triggering a call out for help. We have experienced 

engagements where we are not approached by students afterwards, approached by three 

to five students with legitimate questions and challenges, and having up to nine students 

seeking assistance from guidance after the presentation. 

EXTENT! ON 

Classroom education, while critical for its ability to influence choices, is not enough. 

Education must extend beyond the school to be reinforced and emphasized. With 

addiction, the extension is even more critical as we know that early intervention has a 

greater success rate relative to treatment and recovery. Yet we know that far too many 

parents are truly not aware of the scope, deviance and information needed to understand 

this epidemic. 
225 

We view staff and parents as the key focal points of this activity. 

STAFF- With the educational and social issues facing teachers, keeping up with addiction 

education is a challenge. Most efforts are targeted within the health department, and that 

knowledge doesn't matriculate beyond that. We also need to aknwoledge "staff' t include 

bus drivers, maintenance, cafeteria and so on. All of these Teams are exposed to the 

student environment and should have at least a base understanding of; 

Warning signs 

Terminology 

Paraphernalia 

Furthermore, all staff should have a clear understanding of the tools available through the 

school system and what steps to take if they uncover anything that may present a danger to 

the students in the school. Finally, the forgotten ones in this epidemic are siblings. Staff, 

especially teachers, should understand when siblings are facing challenges at home so they 

may assist in the support network. 

PARENTS- We believe that parental education should be mandatory each school year. 

Again, to create a culture, educating parents should have a cadence of consistency which 

demonstrates the importance of the issue. Parents need to be provided with the tools to 

detect warning signs within their children as well as their children's friends, and that 

education must continually be updated. The awareness campaign may be conducted in a 

way that allows for interaction between parents and students as well as providing 

information and support to assist in having these discussions in the home. 

By extending the educational umbrella, we improve the support for the students, improve 

early detection, and support a strong creation of culture. Let us also not forget that the 

staff of each school are also parents, grandparents and members of the community and we 

should not assume that because they work in the school that they are more educated and 

aware on this issue. 
226 

THE ROBBY'S VOICE PROGRAM 

The RV program is a multi-faceted approach to providing resources and support to our 

schools in an effort to provide more sustained education with greater variation extending 

beyond the classroom. 

RV Support a choice consequence model that extends beyond the "opiate" issue to 

encompass drug usage and addiction overall with values that may be applied to other 

challenges such as bullying, sexting etc. 

Our program is age appropriate and reality based utilizing a multi-media, interactive 

format to keep the students engaged. This is not a scared straight approach, but it also 

does not shirk the realities our kids must understand. 

We are currently working to develop a turn-key portfolio which allows schools to access 

different elements to support their educational efforts. We support our model as follows; 

SUSTAINED- CLASSROOM 

• K-12 NIDA Program 

• 7th Grade Booster with "Anti-Venom" 

• RV tools including posters and CAP cards 
227 

• Developing a weekly "Break The Silence" program for school announcements. This 

may be potentially aligned with the 40 developmental attributes. 

• Common Core alignment is under development 

We are currently involved with student based focus groups to gain a deeper understanding of 

where we may be able to more effectively connect with students. Our common core activities 

are being developed by Teachers. 

VARIATION- SPEAKERS 

• ROBBY'S VOICE 

o Currently adding additional speakers to include recovering addicts that are 

established speakers. 

• Network of partners in law enforcement, medical and treatment. We have 

presented multi-dimensional programs when requested, 

EXTENTION 

STAFF 

• Staff education presentation 

• Conducted an annual seminar utilizing Operation Street Smart for an 8 hour 

educational program. 

PARENTS 

o Currently investigating an annual staff certification via the on-line 

application. 

• Traditional parents presentation 

• Alignment of school program to parents with interactive activities 

Utilization of our web site and Face book as resources 

Contributions to the monthly school newsletter 

• Developing a parents workshop 

Developing a parents support guide 

Support programs like Hidden In Plain Site 

ROBBY'S VOICE SPEAKING PROGRAM 

Multi-Media 

• Interactive 

• Action orientation 
228 

• First Segment 

o Introduction to "why" we are talking 

o Gain student involvement 

o Address societal influences (messaging, TV, movies, music) 

o Review what an addict looks like help them understand it could be anyone 

and build attention to the remainder of the program. 

o Consequences; Students provide and RV reviews using real life young people 

and their path ways. 

• Second Segment 

o Video from Tyler's Light 

Addresses starting with alcohol and marijuana 

Leads to discussion about choice of friends 

Links to the power of addiction 

o The brain and addiction 

Answer how this happens 

Message to physiological changes and loss of personal choice 

o Robby's Story; brings reality closer 

Third Segment 

o Focuses on Action 

o CAP 

Choices and Consequences 

Awareness 

• Illegal, Prescription, Marijuana 

• Warning Signs 

Plan 

Personal Plan for who to call for help 

• Three phrases to get to safety 

What to do if a friend is in trouble 

o Importance of Breaking the Silence making a difference for others 

• Post Program 

o Encourage classroom discussion 

o Options Include 

CAP Card at school or home 

Engaging parents with phone blast and web site connection 

On-going activities and suport 
229 

ROBBY'S VOICE is working to close the loop relative to schools, parents, students and tools. 

Accordingly, we are also have a drug testing partner and a philosophical approach to 

rewards based testing programs. 

Finally, our experience has led us to begin the development of a school checklist. We utilize 

this list (below) to have discussions with school leaders relative to resources they either 

have and deploy, are under-utilized (tip lines), or may want to consider. 

We are also developing a School/Police program to address parties where underage 

drinking and substance abuse takes place. This will include a hand-out for parents to help 

them understand their responsibilities. 

ROBBY'S 

Break the Silence 

SCHOOL PROGRAM CHECKLIST 

' OPPORTUNITY .. · · .. · QEStRWrtONi .... ·. · .... . ow~gRSI-tiP· 

---- District policy for identification Identify the s<:hool districts School 

and management of drug use policy on identification and 

management of drug use, 

inclusive of parental notification 

and resource support. 

Prevention/ Addiction Resource Identification of district School 

Support resources for prevention 

education including Resource 

Professional, Preventlonafist, 

D.A.R.E. deployment, Guidance 

Department 

Staff Education Education ofTeachers, Coaches, School 
230 

Trainers, Nurses, Bus Drivers and 

other district personnel 

District Educational Curriculum Identification of the curriculum School 

the district deploys for the 

students focusing on age groups, 

frequency, consistency and 

variation ofthe message 

' ',, '' ,,'.'' . , c, .,,\ .,. <: .• >' ,, ' .•.•• ,-/ . . .... ,,, } 

Staff Education RV supported education School and RV 

including RV presentations, 

Operation Street Smart and 

D.A.R.E. for the Staff. Create a 

Teachers organization 

responsible for staff education. 

Student Education Grade Appropriate RV RV 

presentations to present the 

issue. 

Student Education Curriculum review ofthe DRUG RV Affiliate. 

AWARENESS & PREVENTIO Program has an implementation 

program providing K-12 and training expense dependent 

curriculum upon scope of deployment 

Sustained Messaging Collaborate on sustained RV 

messaging for the students, 

working with RV Team, 

Administration and Student 

leadership. 

RV Poster Messaging Quarterly deployment of an RV RV- Poster Program under 

poster providing different development 

messaging to the students. This 

will be supported by a weekly 

message that Student Leadership 

may deploy 

"Break The Silence" Fridays Provides sustainable messaging RV/Schools 

within the schools by allowing Utilization of RV approved family 

the students to define the stories are available for this 

themes on Fridays to re-enforce program 

the anti-addiction message 

Volunteer Drug Testing Program focuses on volunteer RV/School 

drug testing in the High School. RV will assist in the identification 

Program is funded either by of a testing organization. 

private sponsorship or by Parental contract/student 

students/parents. Student contract is under legal review 

reward programs need to be 

identified within the individual 

school for those passing the test. 

Rewards Program Working with the County and RV I Administration/Community 

local Prosecutor, a portion of 
231 

seized items from drug raids are 

provided to the schools as a 

reward program. Works well in 

conjunction with the voluntary 

drug testing program. 

Additionally, community 

businesses and school offer 

rewards which may include 

merchandise, discounts an 

special privileges like bonus 

points, popcorn lounges etc. 

Tip Submit Program to allow teachers and RV 

students to submit information 

anonymously regarding drug 

use. This is a program that 

becomes cultural over time, and 

saves lives. It is a smart phone 

app so it fits the new generation 

RV Web Site Utilization of the RV web site as RV 

an educational tool. RV videos Scripts are in development 

may be used by teachers and 

parents to communicate with 

their students about the issue in 

a more in depth manner. Videos 

are pulled from different sources 

to provide a spectrum of 

perspective 

T-Shirt Program Create awareness through School 

apparel. The students are able 

to develop their own messaging 

and shirts to enforce the 

messaging. 

Mentoring Program Development of a student School 

mentoring team which is 

deployed to younger grades in 

order to provide messaging on 

drugs and other key issues as 

well as support for students 

struggling with issues in the 

younger grades 

· .. · .. ·. : .. '·. •· . . . d ; ··. Parents Program RV presentation specifically RV 

designed to educate parents on 

the issue of addiction 

Boot Camp Parents program that is more RV 

focused on helping parents learn 

the tools of prevention 
232 

PTA Messaging Coordinate with the school's PTA RV 

for inclusion in the district 

newsletter, providing 

information to the parents of the 

district 
233 

Submitted for the record by Sen. Brown: 

How the Medicaid expansion helps in addressing the heroin problem 

By the Beacon Journal editorial board 

Akron Beacon Journal 

Published: March 30, 2016-06:48 PM 

John Kasich has received some campaign knocks for his decision to expand Medicaid. To his credit, the governor 

has not backed away. The numbers are compelling, with roughly 600,000 newly eligible Ohioans enrolling in the 

public health-care program. Emergency room traffic has declined as visits to primary care doctors have 

increased. Those with little means struggle less to pay for necessities such as food and housing. 

There is another benefit of much significance. The Medicaid expansion has aided efforts to address the heroin 

problem touching so many Ohio communities. 

How so? Consider Summit County. Before the expansion, the county Alcohol, Drug Addiction and Mental Health 

Services Board used local money, generated through a property tax levy, to help pay for basic health costs of the 

disadvantaged. With the expansion, Medicaid now picks up much of the expense. That allows the ADM board to 

route levy dollars to meet other urgent needs. 

All told, the money newly available totaled $4.2 million last year and is projected to be $5.4 million this year. Not 

all of those funds go to combating heroin addiction. The county Opiate Task Force has routed resources to 

recovery coaches, for instance. The coaches play a crucial role, helping those in recovery to navigate the system, 

accessing aftercare, housing, even employment. 

Such support can be decisive in beating an addiction. That is especially so with recovery housing beds, those 

afflicted residing in a more encouraging environment and more likely to stay clean. 

Similar thinking applies to detox beds, the ADM board working with such partners as Oriana House and the 

Community Health Center. Local levy dollars help ease the strain driven by the need. The money also supports 

Project Dawn, an initiative to train family members and friends about how to recognize and respond to 

overdoses. That includes administering naloxone, a medication that reverses overdoses and saves lives. 

The local effort involves a drug prevention component for the long term, spurred by roughly $800,000 per year. 

For example, these levy funds support equipping teachers with skills to improve management of child behavior 

in the classroom. Already some teachers in the Akron and Coventry schools are using the techniques. Evidence 

from elsewhere shows positive results- fewer disruptions leading to more learning and a greater likelihood of 

success in school and beyond. 

On Tuesday, President Obama highlighted the need for the federal government to do more to help communities 

overcome the heroin epidemic. The U.S. Senate, with Rob Portman of Ohio at the front, recently approved 

additional resources for the effort. Now the House must act, though the bill still does not do enough to meet the 

size of the problem. 

What already has made a difference in Summit and other counties with local levies is the expansion of Medicaid. 

In that way, not only do more Ohioans have health-care coverage. Communities have resources to push back 

against heroin with proven strategies. 
234 

Dr. Jason Jerry, M.D. 

Staff Physician, Alcohol and Drug Recovery Center 

Assistant Professor of Medicine, Lerner College of Medicine 

Cleveland Clinic 

United States Senate Homeland Security and Government Affairs Field Hearing 

"Examining the Impact of the Opioid Epidemic in Ohio" 

April 22, 2016 

Chairman Johnson, Ranking Member Carper, Senator Portman, and members of the 

Committee, thank you for coming to our community to discuss the opioid and heroin 

addiction epidemic that is plaguing many of our communities throughout Ohio and 

across the nation. On behalf of the Cleveland Clinic, we appreciate the opportunity to 

provide a firsthand account of the impact of opiate addiction, as well as the approaches 

we are taking to address this crisis. 

As an Addiction Specialist at the Cleveland Clinic, as well as Chair of the Treatment 

Sub-Committee for the U.S. Attorney's Heroin and Opiate Task Force Group, I have 

advised on community, clinical, and policy solutions to this crisis. The Task Force was 

an outgrowth of an Opiate Summit hosted by Cleveland Clinic and the U.S. Attorney's 

office in 2013. Since then the Cleveland Clinic has been dedicated to addressing the 

opiate and heroin abuse and addiction crisis in Northeast Ohio. Through the Heroin and 

Opiate Task Force, we collaborate with government, local law enforcement, and 

addiction experts - including from our partners at University Hospitals and MetroHealth 

Medical Center- to address the epidemic in local communities. The Task Force has 

been instrumental in developing and implementing community-based approaches to 

combat this crisis, such as increasing access to naloxone through Project Dawn and 

establishing "drop-box" programs with local municipalities to dispose of unused 

prescription drugs. 

Yet it is hard for clinicians to discuss opiate and heroin abuse in Ohio without 

addressing pain. Research has shown that 75% of current heroin addicts were 

introduced to opiates through prescription narcotics. An increased focus on the 

aggressive treatment of pain has led doctors to prescribe narcotics for indications where 

they would never have been considered twenty years ago. 

The rise in opiate addiction, including addiction to prescription pain killers and street 

drugs such as heroin, is influenced by a complex interaction of physical, social, 

emotional, and economic factors. While it is tempting to try to solve the problem with 

simple actions such as limiting access to prescription pain medications, longer-term 

solutions must address all of the contributing causes. 
235 

However, over-prescribing opioids has been implicated in substance abuse patterns 

across the United States. Ohio's Cuyahoga County has recently experienced a dramatic 

increase in heroin mortality as well as a rise in prescription narcotic mortalities. An 

analysis of 2012 deaths indicates that approximately 67% of overdose victims had at 

least one prescription for a scheduled drug and that more than 50% had at least one 

prescription for an opioid analgesic. 

Here is where we need help from our federal policymakers. While the connection 

between increase in use of opiate prescription drugs and the rise in opiate addiction 

state is clear, the Center for Medicare and Medicaid Services (CMS) Hospital Consumer 

Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction 

survey includes broad queries about pain management, setting the expectation that 

control of pain, by any means, is essential to patient outcomes and quality. The surveys 

used by CMS ask a total of 25 questions. These surveys are tabulated and the results 

impact Medicare payment rates for that institution. 

The two pain related measures questions read as follows: 

13. During this hospital stay, how often was your pain well controlled? 

14. During this hospital stay, how often did the hospital staff do everything they could to 

help you with your pain? 

These questions are helping to drive increased patient expectations that pain can and 

will be eliminated by physicians. If the patient's expectations are not met, providers 

could lose significant reimbursement based in part by negative responses to these 

questions. In an op-ed that Dr. Joan Papp, M.D. and I recently wrote for the American 

Medical Association (AMA) Wire, we highlight the practice of CMS utilizing patient 

satisfaction scores that include specific questions regarding pain management to help 

determine hospital reimbursement. (Papp J and Jerry JM. When patient satisfaction is 

bad medicine. AMA Newswire. March 18, 2016.) 

Rather than tying payment to "pain free" care, isn't it more important that the patient 

understand their pain and their role in helping to control it? Isn't the critical issue that a 

patient knows how their pain is going to managed to optimize healing and minimize 

addiction? 

Along with your colleagues in Congress, the members of this Committee can make a 

difference here. We call on you to work with CMS and clinical experts to consider how 

the pain management questions can be revised to better reflect the patient experience 

and quality of care provided, while still holding providers and caregivers accountable for 

the most responsible care possible. 

Cleveland Clinic authored legislative policy alongside the Ohio State Medical 

Association, and members of the Ohio Assembly to encourage CMS to revise the 

HCAHPS survey questions that are related to patient pain management. Just last week 
236 

this state resolution (HCR 16) was passed unanimously by the state Senate and is 

currently awaiting the Governor's signature. 

Addressing the issue of patient satisfaction surveys and pain management will no doubt 

help us tackle this opioid epidemic. Cleveland Clinic would welcome the opportunity to 

partner with you in this effort. 

Opiate addiction is a chronic, lifelong illness that requires ongoing treatment and follow 

up. Addressing the addiction epidemic that continues to grow and spread throughout 

Ohio and across the country requires strategies that hit at it from all angles. Just this 

month, our Ohio Attorney General, Mike DeWine called together community and faith 

leaders for an Opiate Summit. I spoke on behalf of the Cleveland Clinic, but despite 

having become an expert on the issue of substance abuse and addiction, I was touched 

by the stories and was inspired by the commitment of the community to overcome this 

destructive killer. 

From a clinical perspective there is much we can do to help treat those who are 

addicted to heroin or prescription opiates. We have known for decades that evidencebased treatment- specifically, medication-assisted behavioral treatment- is effective in 

keeping this illness in remission but is too seldom employed. Widespread 

misinformation, stigmatization, and, in some cases, poor delivery of these evidencebased treatments has guided many addicts to seek help in abstinence-based programs 

that are only successful in about 10-20% of cases. Opiate addiction simply cannot be 

effectively treated in 28 days. In addition to the well-documented lack of efficacy of the 

acute-care abstinence-based residential programs, is a secondary tragedy-individuals 

returning home from such programs are at increased risk of overdose as their 

physiologic tolerance to opiates has returned to pre-addiction levels. 

Our best strategy is to stop addiction before it starts. On January 1 of this year, 

Cleveland Clinic became one of the few health systems in the US to adopt system-wide 

randomized drug testing of all caregivers. Much like when we established a policy to not 

hire smokers, we determined that for patient safety and caregiver health it is imperative 

to have a drug-free workplace. As part of our pledge to deliver safe, reliable care, 

Cleveland Clinic recognizes that impairment caused by chemical dependency and 

substance abuse/misuse can adversely impact patients and the lives of our caregivers. 

Coping with overwhelming job stress and having access to controlled substances puts 

healthcare workers at increased risk for substance abuse. But admitting there is a 

problem with substance abuse is the first step to overcoming it. In fact, we encourage 

caregivers who believe they have a substance abuse problem to seek help before they 

are selected for random testing. 

We are grateful for the leadership exhibited by Senator Portman, Senator Sherrod 

Brown, and members of the Ohio congressional delegation in advancing legislative 

policies to expand access to evidence-based, life-saving addiction treatments, including 

broad availability of Naloxone to help assist those experiencing opiate-related 
237 

Æ 

overdoses. Senator Portman, your bipartisan legislation, the Comprehensive Addiction 

and Recovery Act (CARA), is one example and a much-needed step in the right 

direction. We support the bill and are hopeful it can be passed by both Chambers in 

Congress and signed into law. Together with Senator Brown, you have worked tirelessly 

to ensure the federal government provides the resources necessary to fight this 

addiction epidemic head on. 

Cleveland Clinic, together with our the leaders testifying at this hearing, helped drive 

policy at the state level to curb the number of opioid-based drugs prescribed in Ohio. 

This work led to the passage of legislation mandating physicians in the state use Ohio's 

Automated Rx Reporting System (OARRS), which resulted in a 6.5% decrease-- nearly 

50 million doses (6.5%) -- in the number of prescription opiates dispensed to Ohio 

patients in 2015 compared to 2014. 

Senator Portman, members of the Committee, thank you for your leadership and 

commitment to solving this public health emergency.