 Well, I have the unenviable task of interrupting all these conversations that are going on. It's always nice to host one of these events and see people mingling and meeting people that they want to meet and talking about issues they want to talk about. Before our next speaker comes on, I have the job to introduce a video that we wanted to show you. First, I just wanted to call out, in all of your packets, you've heard me talk about feedback-informed care. You heard Glenda talk about measurement-based care. I think Chuck mentioned it as well. In our packets is a one-page that says feedback-informed care. That just describes our approach to what we're talking about here, measurement-based care and the idea that we can bring intentionality and measurement to mental health care. I thought Glenda put it very well, which is we need to know what works in order to know where to devote our resources. The good news about that is that that is now. That's not a future state. We do know how to measure that, and we do know what we can do with that data, and we're learning more all the time. Take a look at that. This video is just a short video on October 13th as part of Kaiser Permanente's efforts to raise the profile of mental health in our communities. We hosted a forum in Northern California where we had about 250 community partners, as well as Kaiser Permanente providers and other key employees, and it was about building resilience in our communities and focused on mental health. We had our chairman, Bernard Tyson, who many of you have mentioned to me. He is really out there forward on this issue. If you look at his LinkedIn pages, he's posting things about mental health all the time. It's really exciting for us to have the CEO say this is an important issue among all the issues that he has to pay attention to, so we appreciate that. We also had our Northern California health plan president, Janet Liang there. We had Patrick Kennedy, as you'll see. We had Gayatri Ramprasad, who's a mental health advocate. Some of you may have seen it, the California NAMI statewide meeting. We had Daryl Steinberg. Somebody had actually mentioned the billion dollars a year that we have in California for mental health. Daryl Steinberg, when he was in the California Senate, authored Prop 63, which generated that income on an ongoing basis. We did panels on resilience through family and peer support. How do you develop resilience in the workplace? We also had a youth panel, which was really fun. You'll see a little bit of that as well. At the end, we talked about a $2 million grant that we're supporting to sponsor investment in stigma reduction, trauma-informed care. That's just in our Northern California region. If we could roll that video, we will keep going. We all know somebody, love somebody, care about somebody, work with somebody, or are somebody who is dealing with a mental health or addiction condition. We want people with mental health conditions and the people who care about them to find their words and break the silence together as a community. Part of our work is simply to reconnect the head to the rest of the body. And for us to be able to talk about mental health and mental issues as fluidly as we talk about heart disease and cancer and kidney disease. We are not prepared in this country to address the epidemic that is surrounding us all across this country of mental health needs. And what we need to do is prepare to repurpose the rest of medicine to do mental health care. Kaiser Permanente is going to set the model for what kind of health care system we really want. We at Kaiser have been working not only in how to advance prevention, early detection, and promotion within the mental health space. And recently we've been talking about the way to engage everyone is through a public health campaign and that's why we chose to focus on resilience and stigma. Kaiser sets the model which you absolutely can do because you're already culturally aligned to do integrative care, to do population health. It's in your DNA. I mean we are ground zero in terms of really establishing the new paradigm and thank you for being a leader in this. Many of us find great success in our own care when we use our voice and we tell our story and we open up to others. My journey began when my daughter was 12. She began cutting at school, self-harming, and it affected our entire family. Since this was a family problem, we all needed family therapy. Most policymakers don't take on these sets of issues because they fundamentally believe that it's too hard, that it's too hard, that there's no way you can actually make a big difference. If we can demonstrate to people through real outcome-based measures that prevention and early intervention around mental health is the most successful way to avoid all the terrible consequences of untreated mental illness, we will improve homelessness. We will reduce the crime rate. We will help families and we will make for a much more peaceful and healthy California and United States of America. At 18 when panic pounded my heart, anxiety coursed through my veins and my soul was darkened by depression, I had no words to describe my horror. Ignorant about mental health issues, my parents and physicians could not understand my pain. Were in my wildest dreams did I imagine that I would have the opportunity to give hope to thousands of people like myself and my family around the world. Training is lecture. Focus your attention on your breath. Mental health is a huge issue, it impacts your emotional state, it impacts the way I show up in the world, the way I go for something or not. If I can imagine something happening, then I can achieve it. Keith Palmer is a modern voice for a modern world. I wish to break the curses of ignorance in my family, especially in terms of mental health. The passion grew not only through my love for my family, but my love for people. Social media truly allowed me to see that so many young people like myself are struggling with anxiety, depression, BPD, borderline personality and have no idea or even know their trigger points. Thank you so much for being here and being so open. What made you decide to use your platform for this particular purpose? My message would be that you're not alone, I know it feels that way and it really really feels so real. You could be in a room full of people and you feel completely and utterly alone, but you're not and that it gets better. The whole point is sticking in there for another day and allowing yourself the opportunity to see that it gets better. Either your immediate family or your extended family, priority. All that you've gone through. This issue does not stop when we leave the room. So I am really pleased to announce that in 2018 Kaiser Permanente will be investing $2 million in communities across Northern California to address the issues of reducing stigma and increasing the public awareness of mental health. Well I feel like it gets a little bit harder with each panel, each video that we've had. I'm Murray Ross, I lead the Institute for Health Policy at Kaiser Permanente. I'd like to echo my colleagues thanks to everyone for participating in this meeting, thanks particularly to the speakers and the panels that we've had. It's been a powerful morning hearing from patients and families and providers about the challenges and frankly also about some of the successes that are out there. We're now going to pivot to talk about challenges and opportunities at the federal level and we are very pleased to have our keynote speaker and guest of honor, Dr. Eleanor McCants-Catts who is the first assistant secretary for mental health and substance use. She leads SAMHSA, she advises the secretary of HHS on behavioral health. She has a PhD from Yale University in Infectious Disease Epidemiology and a medical degree from the University of Connecticut School of Medicine. She's been a prolific author, she has been in academia, she has been in government. We're going to learn about her experience in the first few months of a, I don't know how to put it, reconfigured job and administration and hear about the challenges and opportunities that she sees going forward. So without further ado, Dr. McCants-Catts, welcome. You're going to go a little bit free form here, so can we make sure the clicker is live? Okay, thank you. Well thanks for inviting me to be here this afternoon to talk for a few minutes about the challenges of serious mental illness and the opioid crisis as we face them today in the United States. I've called this talk a course correction because there are some changes that are coming. So there are some changes that are here and my agency, the Substance Abuse and Mental Health Services Administration or SAMHSA, is an agency that is undergoing change in the service of addressing these challenges. I thought I would start out by talking a little bit about our national survey on drug use and health because it tells us about the prevalence of mental and substance use disorders in our country today. This is data from 2016, which is the most recent year that we have that data and not that old. This came out just a few weeks ago and what we learned is that seven and a half percent of Americans over the age of 18, that's over 20 million people, had a substance use disorder in our country. And when we looked a little more closely, we found that a third of them are people who have problems with illicit drugs. 75 percent of those folks struggle with alcohol misuse and abuse and 11 percent meet criteria for both a substance use disorder from illicit drugs and an alcohol use disorder. And then when we look at people with mental illness, over 18 percent of Americans over the age of 18 right now meet criteria for a mental disorder. And if you look more closely, 25 percent of those people have a serious mental illness. And by serious mental illness, we mean a mental illness that is of such a severity that it impacts a person's ability to carry out their roles in their lives. And when we look at the absolute numbers, over 44 million people and then another 8 million people have both a substance use and a mental disorder. Important to keep in mind as we talk because these are very, very prevalent conditions. And so they create a couple of the major challenges of our time. Serious mental illness affects over 4 million Americans. And serious mental illness, we usually think about psychotic disorders, so schizophrenia, schizoaffective disorder, bipolar disorder, serious major depression, and 35 percent of them get no treatment at all. Jails and prisons have become the de facto mental institutions in this country. Over 2 million Americans are in jail or prison on any particular day in this country, and 50 percent of them have substance use disorders. Another up to 20 percent have serious mental illness, and both of those groups are unlikely to get the care and treatment that they need within the correctional system. The opioid crisis, as you know, is one that is a serious emergency. The president about 10 days ago declared this to be a public health emergency, and we know that over 2 million Americans are addicted to prescription pain medications or heroin. And last year, we saw over 63,000 Americans die of drug overdoses. 75 percent of those drug overdose deaths involved opioids. Congress has been looking at this issue for several years, and the 21st Century Cures Act was passed in December of 2016. And that act created an assistant secretary for mental health and substance use, and the administrator of SAMHSA position went away. The assistant secretary position is now the person who heads SAMHSA, but also has several other roles across government. So the assistant secretary is to maintain a system to disseminate research findings and evidence-based practices to providers in order to improve prevention and treatment services for Americans with mental and substance use disorders. The assistant secretary is to ensure that grants that are awarded are subject to performance and outcome evaluations, and we do conduct ongoing oversight of grantees. The assistant secretary is to work with stakeholder groups to improve community-based and other mental health services for people living with serious mental illnesses, and to collaborate with other departments across the federal government to assure that people living with serious mental illnesses, substance use disorders, are benefiting from all of the federal programs that are put in place to assist them. That can include agencies like the Veterans Administration, the Department of Defense, Housing and Urban Development, the Department of Labor, the Department of Education, the Department of Justice. I can tell you that I work with those agencies already looking at issues related to improving the care and treatment and recovery services available to Americans. And the assistant secretary is to work with stakeholders around workforce issues, which I'll speak a little bit more about in just a moment. Our president has also recognized that there are major problems in the United States with how we have gotten to the point of an opioid crisis and serious mental illness issues as well. From the time the president took office, HHS was told to develop a plan of action, and we have done that, and that plan has been implemented very steadfastly, predating me. I've been in my position for a little over two months. I can tell you that HHS has been working on this issue for quite some time and with special emphasis since the president took office. Around the issue of serious mental illness, there is a recognition of need for treatment and the need for expansion of court-ordered treatment in some cases, as well as the need to address medical communication needs with families. And so some of you may know that our Office of Civil Rights came out with guidance to the field just about 10 days ago, I think, and in that talked about medical emergencies such as those related to opioid overdose and how those were not protected by 42 CFR confidentiality requirements for people receiving substance abuse treatment. Those are medical emergencies, and in a medical emergency, HIPAA applies and allows communication with families and will be working. And our agencies within HHS will be working to make sure that health care providers understand that so that we can assist families because the reality is that families provide most of the care for people living with these serious disorders. It's not the government. It's not health care providers. It's families, and we as health care providers need to recognize that and work with families as best we can. And so we've had to undertake an internal review of SAMHSA and to refocus SAMHSA in a number of ways so that we can meet the requirements of the law and of the direction from the Trump administration. SAMHSA is really, as federal agencies go, we're a small agency. We have a small budget, about $3.8 billion a year. Most of that is in the form of block grants to the states to cover services related to substance abuse and serious mental illness. And so in looking at what needs to be done to address the issues of those living with these very serious disorders, we need to refocus our agency so that it is addressing people living with serious mental illness and their needs as well as the opioid crisis. And Congress also has helped us in thinking through how to do that. The 21st Century Care Act put in place something called the Interdepartmental Serious Mental Illness Coordinating Committee in federal, federalese, we call this ISMIC. This is a public federal partnership whose job it is to review current issues addressing serious mental illness within the federal government to look at federal programs that provide services to people with serious mental illness and to make recommendations to Congress for better coordination of these services at SAMHSA and at other agencies. We want to assure that programs incorporate best practices and evidence-based practices into all of their programs and specifically address issues related to psychotropic use, evidence-based psychotherapies, the use of assertive community treatment, forensic assertive community treatment, crisis intervention services. We know that patients with serious mental illness do not do well in standard emergency medical settings. And so crisis intervention services can be very helpful to keeping people out of the hospital, getting the services and care they need to be able to return to their communities rather than to be hospitalized. This committee will look at hospital bed needs and where those beds should be placed in order to best serve Americans with serious mental illness and assisted outpatient treatment as well as criminal justice diversion and expansion of programs that do divert people from the justice system who have serious mental illnesses. Peer supports and supported employment and supported housing. We also got direction in the 21st Century Cures Act around developing a national mental health and substance use policy laboratory. Now SAMHSA is a services agency. We are not a research organization, but we were directed in the 21st Century Cures Act to establish a policy laboratory and that policy laboratory has a very, a very well-defined role as relates to research and that is to promote evidence-based practices and service delivery models through evaluation of existing models in the United States and determining which models should be scaled up, expanded to better assist Americans with various types of mental and substance use disorders. The main focus of this laboratory is on serious mental illness, but also we will be looking at evidence-based practices and service models for substance use disorders with a focus on opioid use disorder. This policy laboratory, we expect to help us establish closer relationships with the National Institutes of Health whose job it is to conduct research across these various health areas and we expect that there will be cross fertilization if you will with SAMHSA informing NIH about services in the United States and research that they may want to take on to determine if something should be scaled up and NIH will inform SAMHSA about evidence-based practices coming in from original research that's being conducted by NIH grantees. And so we have a number of priorities as they relate to serious mental illness at SAMHSA. These are different from SAMHSA's priorities if you were to look at SAMHSA's leading change 2.0. And let me just mention them to you briefly. The first is there will be increasing focus on early intervention and ongoing support to individuals with serious mental illness. These include our first episode psychosis programs which are covered in our block grants and that we plan to scale up over time. New programs in assertive community treatment and crisis intervention programs. We will be supporting integrated care to meet both physical and mental health needs in one setting. We have diversion programs that work within the justice system both on the serious mental illness side and on the substance use disorder side. We will be looking to work with our colleagues in HHS to help to increase access to care through enforcement of parity legislation and we will be also looking at transitional age youth. We know from our national survey on drug use and health that transitional age youth are a particularly vulnerable group. 18 to 25 year olds have substantial rates of misuse of illicit substances, opioids, alcohol and they have increasing rates of serious mental illness including suicidality. So this is a group that we plan to put some additional resources and attention to. We will be focusing on effective medical treatment of psychotic illnesses through technical assistance and centers of excellence which we are in the process of forming right now. They will look at a variety of issues not the least of which is the is the use of clozapine for treatment refactory psychotic disorders such as schizophrenia and schizoaffective disorder. The use of long acting medications to help people with adherence and focus on adverse events that can occur with particularly with second generation anti-psychotics which are so widely used now and can be associated with metabolic syndromes as well as issues related to tobacco. Other medical illnesses that frequently occur in vulnerable populations with serious mental illness and co-occurring substance use disorders. We also will have an increasing focus on suicide prevention particularly in American adults. We have a new program in Zero Suicide and that focuses on the training of healthcare providers to address suicidality within the healthcare system. We know that most people who do go on to make an attempt to even successfully complete suicide have had a doctor's visit in the months leading up to that event. So we are focusing on healthcare providers. We're also focusing on veterans and service members because of the high, the disproportionately high rates of suicide in this group and we also will be focusing on understanding the links between poorly treated pain, the development of depression, addiction and suicidality. This is an area that I think is not looked at enough and one that I expect we will see more issues with particularly as we have our healthcare providers not prescribing opioids as liberally as they once did. And this is something that will be very important for us to be aware of and to be able to help providers to deal with. I want to move now to the opioid crisis and talk just a little bit about the five point strategy that the Department of Health and Human Services has had really since the beginning of the Trump administration. It has five components. One is strengthening public health surveillance, advancing the practice of pain management, improving access to treatment and recovery services, targeting the availability and distribution of overdose-reversing drugs, naloxone, the antidote for opioid overdose, and supporting cutting-edge research. And SAMHSA has a number of these points that we work directly on. And so I thought it might be useful for you to see what SAMHSA is doing to address the opioid crisis because we are doing quite a lot. We support evidence-based prevention, treatment and recovery services for opioid use disorders. We have been very pleased to work with Congress on additional funding that has been made available to increase access to prevention, treatment and recovery services for individuals with opioid use disorder through what is called the STR Grants the State, targeted response for the opioid crisis and through block grants to the states. We have technical assistance programs that we provide training to healthcare professionals that are working in the area of opioid use disorder. These include treatment, evidence-based practices in medication assisted treatment, psychotherapies, use of prescription drug monitoring databases and toxicology screens, of course, the backbone of treatment of substance use disorders, including opioid use disorder. So we have programs, the ATTCs, the provider clinical support system, and the Center for Integrated Health Services, which train clinicians. But we also provide technical assistance to states and to other federal agencies that provide direct services. So for example, HRSA, Indian Health Service and Department of Justice, we work very closely with making our technical assistance programs available to them so that they can also disseminate those practices to clinicians within their systems. We have programs that address naloxone access and the training of first responders and peer outreach workers on recognition of opioid overdose and use of the naloxone antidote. We have special emphasis programs on pregnant and postpartum women who are opioid dependent, as well as the care and treatment of infants that were prenatally exposed to opioids. We have justice programs where we encourage the use of medication assisted treatments and we have programs that place recovery coaches in communities in the service of ongoing care and resources to individuals struggling with opioid use disorders. We also will continue to work with the field health care providers around issues of family inclusion and medical emergency, specifically as they relate to opioid overdose. I also want to mention some of our other divisions within the Department of Health and Human Services because, as I said, there really is a lot going on as it relates to the opioid crisis. The Centers for Disease Control and Prevention and the Office of the Assistant Secretary for Health have a number of initiatives, including consumer communication campaigns. The CDC is really responsible for the prescription drug monitoring databases helping the states to establish those, integrating into electronic health records, making sure that there is interoperability between states so that if I'm writing a prescription in Rhode Island, which is my state, and I will be able to know whether that person is also getting prescription in Massachusetts or Connecticut. We hope to expand that interoperability over time as well and then the flagging of people who are at increased risk for opioid overdose. CDC also works on safe and appropriate opioid prescribing. They have put out, as you know, the guidelines for the use of opioids in chronic pain and are in the process, again through the CARA Act now, putting together a committee that will address additional pain management issues in the United States. They are involved in prescriber education around safe opioid prescribing, as is SAMHSA, and they have just been able to get the National Center for Health Statistics to release more timely data. Now they're doing monthly release of overdose data to help states to be able to target response within their jurisdictions to the opioid crisis. HRSA and the Indian Health Service are providing direct clinical services. They do work with CDC. They work with SAMHSA around technical assistance and training two providers in their systems. And NIH is focusing on research for new treatments for opioid use disorder, as well as the development of non-opioid analgesics. Workforce development is a critically important issue. It doesn't... It's only half the problem to put money into programs if we don't have enough qualified treatment providers. And so at SAMHSA, we will continue our training activities with the Addiction Technology Transfer Centers and the Provider Clinical Support System type programs. My own personal goal is to see the data waiver training go into all pre-graduate settings so that medical students advance practice nurses, pharmacists, physician assistants, nurses, counselors, that everybody gets that exposure to addiction medicine and how to assess and treat opioid use disorder. We want to encourage national certification programs for the peer workforce because we do believe that peers are an essential part of the total health picture for individuals affected by these serious illnesses. And with HRSA, we continue to work with them around the National Health Service Corps. This is basically an incentive program that can pay student loans for individuals in healthcare professions. We would like to see them go into addiction treatment types of programs and we hope that this will be a way to bring more people into the field and we will continue to work to integrate behavioral healthcare including opioid use disorder treatment into primary care facilities, community health centers and federally qualified health centers. We also have additional priorities. As I mentioned, we work with states on program development and establishment of evidence-based practices. So we want to see evidence-based practice approach to opioid use disorder be uniform across this country and we are working to develop enhanced technical assistance that will include clinicians and state government partnerships so that we can tailor the healthcare response to the needs of specific communities and we can't forget about other substances. So SAMHSA will continue to look at other substances stimulants, cocaine, marijuana and in doing so we hope to be able to avoid another epidemic with another substance. So how will we know what we're doing is working? Again, Congress has provided really through the 21st Century Care Act in CARA they really have provided us a blueprint for how to do things. I think it's great. And so we will use our Center for Behavioral Health Statistics and Quality at our policy lab to take on internal reviews of data collection systems and to review the process of how our evaluations are conducted. We look to our colleagues at the NIH, CDC, the Assistant Secretary for Planning and Evaluation to assist us with evaluations of our programs to make sure that our programs are meeting the needs of the American people that we are meeting the goals that every program is put in place to address. And we will begin the process of approval to look at outcome metrics at an earlier time than we do right now to make it possible for us to collect this data from the outset of programs. It's really important that SAMHSA has strong relationships with stakeholders. The stakeholders are really essential to Americans getting the resources and the care and services that they need. And so SAMHSA will continue to work with stakeholders but expanding our sphere of stakeholders to groups that have not been our usual folks that provide us guidance and insights. We will continue to work with behavioral health stakeholder groups and we will encourage them to all work together collegially because we don't have enough providers and we need every provider that we can get with these really urgent issues. But we will bring in new stakeholders. One of the things that I'm doing is working with groups like the national social work groups, the national physician assistant groups, counseling groups, peer groups to bring everybody in because we need all of these folks to help us address these issues. And I have a little wish list. The assistant secretary for mental health and substance use is a position that many people will hold. While I hold it, I hope to accomplish a few things. One is to increase access to evidence-based behavioral health care timely without delays and to have our community behavioral health centers really focus on serious mental illness. To develop strong partnerships between psychiatric medicine and community recovery supports and peers, I think this is very important to patients getting the care and treatment that they need. To increase SAMHSA's assistance to families with focus on serious mental illness and opioids being what we start with but broadening that to other areas. Families, as I said, are really very important and we want to emphasize that now at SAMHSA. I would like to see the prioritization of supported housing for people affected by serious mental illness and substance use disorders. I think we can do this with the ISMIC to eliminate criminal records for minor drug offenses so that people can be employed and be housed and be able to get on with their lives because we know that treatment works but it's difficult for treatment to work and for people to recover if they can't be housed and they can't have jobs. And we want effective interventions. I want effective interventions and behavioral health for transitional age youth. This is really very worrisome what goes on with some of our transitional age youth and to control the swing of the pendulum as it relates to the opioids too far to the liberal prescribing but we can't go too far the other way. People with pain must have that pain relieved and so we want to be very judicious about how we take this issue on and make sure that all Americans can get the care and services that they need and now I will stop there. Well I think you had us at small agencies, small budget, big job so that sums it up. That was pretty impressive to-do list that's on your desk there. I'm going to encourage people we have a few minutes here for questions so I'll again encourage people to go to the mics at the front of the room or the back of the room and I'll just kick things off with a question around workforce. Because we've heard some of the challenges this morning we've heard about reimbursements we've heard about people going into programs not going into programs but at the end of the day we have a sort of a short run issue and a long run issue and the short run issue is we're going to have a hard time getting more bodies on the job and I know the VA is working a lot in the telehealth space in this are you thinking- well what are you thinking to try and expand the people we have? So telehealth certainly especially for rural areas areas difficult to reach telehealth is certainly one resource but what I want to see is that every healthcare professional gets training on the recognition and treatment of mental and substance use disorders this does not occur this does not occur in standard education for certainly not for medical students and I can tell you that because I've been doing this for a long time and I'm a doctor but also I know this is true from talking to my colleagues in nursing and pharmacy in psychology so if we can do that and we can do that we have good technical assistance programs right now we need to fund we need to fund the ability to expand that training and we are going to do that particularly as it relates to the opioid epidemic and we'll be following to see whether putting more funding into training results in increased workforce and qualified workforce Then we had a question earlier this morning on the timing of or I guess the progress on ISMIC if I can use the acronym I understand you have a preliminary report due in December It's not a preliminary report it's the report It is the report Yeah so there are two there are two reports due as a result of the 21st Century Cures Act one is on December 13th of 2017 and then the other is in five years Okay So the first report we'll go to Congress on time and we have a committee of really very dedicated stakeholders and people family members people living with these these disorders who have worked very hard on developing that report that report is is I can tell you it's now in the process of being reviewed by the other agencies that have a footprint in behavioral health and then we will get that to Congress But what has to happen is it can't stop there We have to have a plan and we do to move this forward and so what will happen after that is that we will have at least two meetings a year and I can see because I read the report myself this weekend that the committee would like to have four meetings a year and I think that's a great idea that will advise us within the federal government about what we should be doing and how we should be doing it Bringing public input into this process is really I think going to be an effective way to change the course of what we do so that we serve Americans better I'm going to ask my colleagues that are on this committee to tell us what they think about how we should be implementing We of course will be sharing all of that with Congress and hopefully making change from a variety of vantage points We may be able to influence legislation and congressional intervention going forward but also directly affect how the different departments that have behavioral health care programs or services for people living with serious mental illness and substance use disorders undertake those programs Great, thank you Let me go to the mic Yeah, I'm Nathaniel Councilman of Health America and I was curious what your advice would be for us in trying to translate evidence-based practices into pre-service training so that the pre-service training so that the graduate students and medical students of tomorrow become the workforce of the future and they come out knowing integrated practices I think that's consistently the biggest black box for advocates in making change and I love your advice Okay So, there's a lot of latitude within the professions as to how they deliver curriculum So advocates should be putting pressure on these organizations like the Association of American Medical Colleges and the counterparts in other groups that develop the behavioral health workforce that should be they should be hearing constantly about the need What other diseases in this country have this kind of a prevalence that I showed you where you have so little attention in many academic settings so little attention paid to it That has to change Now, here's the good news So we have technical assistance programs at SAMHSA They're modular or they can be taught face to face or they can be taught by webinar or they can be taught online There's lots of ways to do this The schools can tell us what they want will help them do it They need to decide that this is the direction they want to go in I can tell you that So before I came to this job I was a professor at Brown and Brown is very forward thinking and had a nice curriculum a nice curriculum on addiction And so what I did was brought in some lectures on medication assisted treatment and how to use buprenorphine particularly in clinical practice And we used a part of data 2000 that's not been used before But it said that medical boards in states can say what qualifies someone to have a data waiver And so we used that We worked with our medical board to get all of our Brown students will now graduate having met the educational requirement to get the data waiver I think every school should do this There's nothing so high tech about these trainings that certain groups couldn't undertake the training I think everyone And in fact when I've done a lot of data waiver training I always encourage doctors back in the day when it was doctors that got waivers but to bring their staff Why? Because the doctor isn't the person who's really going to do most of the care Most of the care is going to be with the nurse practitioner or the physician assistant the medical assistant the even the office staff And if you don't have everybody on board it isn't going to happen So everybody would come And these folks all could benefit from that training So we can do this Tell me what you need and we'll make that happen for you Yeah Okay My question is about abuse deterrent formulas In 2015 in the state of Maryland we passed legislation that required insurance companies to cover two generic and two brand abuse deterrent formulas as alternatives in treating pain Have you had any information about this? Do you know how effective they've been? Can you share anything about that as a possible solution? Well, I'm not the expert on abuse deterrent formulas My colleague Scott Gottlieb would be a better person I think to answer that question who is the commissioner of the FDA However I think that abuse deterrent formulas does not mean that the medication does not have abuse liability And it does not mean that no longer is this medication non-addictive So there has to be good communication about just what what that formulation what that what that means you know what that designation means I think that it's being studied right now as to the effectiveness and probably is something that that I would I would let other people comment on Okay That permission for one more question Dawn Thank you Thank you for coming to speak to us first of all My question is about whether you can comment on the future of 42 CFR Is somebody who practices in an integrated healthcare system like Kaiser Permanente and I think even for the the disintegrated system that affects most people in the country it it really has come to feel like a hindrance that extra layer over and above HIPAA and yet the recent revision didn't make things easier for us It seemed to make things harder Really? Yeah I mean we had set up a qualified service agreement in some of our regions and that got squeezed in terms of what it could cover and so you know we're left okay we're integrated we can do a great job taking care of these issues primary care specialty care and yet there's this restriction so Right right you know some of the some of the really good work of Connie Weissner came out of Kaiser Northern California because you all have the segregated systems so you didn't know your patients who were getting substance abuse treatment and come over here to their primary care doctor and getting whopping amounts of opioids and benzodiazepines right Yeah so that's the problem So can I tell you what's going to happen with 42 CFR? What I can tell you is my opinion which which isn't really relevant so I won't I won't say anything more than to say as a physician I think it produces safety issues if I can't know as a physician that somebody's in in receiving substance abuse treatment and what would make them vulnerable to certain types of medications I might be considering or I can't know somebody is taking methadone or buprenorphine and what kinds of drug-drug interactions might occur because I might be wanting to prescribe something that they need for some sort of an illness and I don't know because of 42 CFR I think that's dangerous I think it's outdated and stigmatizing and I told you I wasn't going to give my opinion but I just did So we think your opinion may be relevant So having said that 42 CFR is being looked at and there will be additional guidance coming out probably in the next few months that will hopefully address some of the issues that you've just brought up Yeah And I can't I am not able to say more about that except to say that we are aware that there are some continuing issues and we hope that we can address at least some of them with this new guidance Yeah Dr. McCants-Katz Thank you so much