Transcripts For CSPAN Senate Judiciary Hearing On Opioid Epidemic 20240713

And i believe senator durbin has some opening remarks. We will dive into the witness testimony as well. 1999, more than 700,000 people have died from a Drug Overdose in the United States. Increased opioid addiction in the production of deadly synthetic opioids has exasperated americans staggering overdose death rates. Than 70,000 people died from Drug Overdoses, making it the leading cause of injury related death in the United States. Of those, 68 involved prescription opioids and illicit opioids such as fentanyl. Americans fared no better against the epidemic in 2018 when more than 10 Million People aged 12 or older abused opioids. 2 Million People suffered from an opioid use disorder, and on average 130 americans tied each day from an opioid overdose. Cost and know the disrupted lives and untimely deaths from widespread misuse of prescription and nonprescription opioids. We know from our family, our neighbors and our friends who bear the enduring imprint of lost love ones that the Opioid Crisis is not over. We must continue contending with this crisis. That being said, we have made Great Strides in the past three years to help combat this crippling epidemic. Congress has passed and mark Bipartisan Legislation directed at combating the crisis. Most notably the conference of the dictionary recovery act, and the 21st century cure act, both of which i proudly supported and were signed into law in 2016. Probably supported and signed into law in 2016. Combined, the two bills provided over 1 billion in funding to combat the Opioid Crisis. Later, Congress Passed the bipartisan support for communities act, which is the most comprehensive antiDrug Trafficking act in modern history. To addressthe act every element from manufacturers to distributors to prescribers, dispensers, users, First Responders, and recovery professionals. Nearlys has dedicated 11 billion to tackle the Opioid Crisis with the largest portions about funding grants to the department of health and Human Services. Today we will hear from the administration and the executive Branch Members that shape and execute the governments strategy for combating the Opioid Epidemic. National drug control policy, the department of justice, the Drug Enforcement administration, and the department of health and Human Services. This hearing is especially important when we think about the oversight role we have in congress to ensure the executive Branch Partners are properly stewarding of the funding we have provided to them to clearly tackle the Opioid Crisis. The federal government is just one aspect of combating this epidemic. We do not stand alone. Opioid crisis relies on widescale integrated solutions on all impacted sectors. Today during the hearing, we will also have the opportunity to hear from key components and including the health care abuse alliance, community antidrug coalitions of america, and drug policy experts from the rand corporation. Comprehensive review of our collective efforts to curb the supply of illicit opioids to improve access for preventativebased treatment and Recovery Services for opioid use disorder, to identify needs at federal, state, and local level, and to develop sophisticated and catered solutions to this destructive and deadly crisis. I would like to take a moment to remind us all the americas drug abuse problem did not begin with opioid misuse and will not end with the Opioid Crisis. In my home state of iowa, methamphetamine abuse has remained a persistent and perilous problem. Almost one Million People had a methamphetamine use disorder, and they reportedly had significant impairment including health problems, disabilities, and failures to meet responsibly it is at work, school, or home as a result of their drug use. This number is significantly higher than the 684,000 people who reported having methamphetamine use disorder in 2016. Confirmedy home state over 1500 child abuse report related to methamphetamine, not just in the home but being found in the childs body. Ultimately americans are suffering from drug dependency. Dying at ones are alarming rates. Todays are our priority but methamphetamine and other dangerous substances impacting urban and Rural Communities should and will be addressed Going Forward for thank you and now i will turn to Ranking Member feinstein for her Opening Statement. Feinstein i think our Opening Statements dovetail each other and i suspect they dovetail what every member of the committee thinks. The question is what to do about it. Werelast year, overdoses creating of 48,000 dabs. Deaths, and 2016, Life Expectancy in the u. S. Has fallen for the third year largely due to opioidrelated overdose dabs. Arethe economic costs unbelievable. 700 billion a year. Lackf the reasons is the of education among medical professionals. Overprescribing and so we saw in many cases, pharmacies were pill mills with churning out millions of pills to smaller communities. Regardless of medical intensity. Opioid manufacturers and astributors, i believe, have responsibility to identify and report the suspicious orders. But they did not. This problem was compounded by inadequate responses from the federal, the state, and local governments. The Trump Administration declared the Opioid Epidemic a 2017c Health Emergency and has only used 3 three of the seven authorities triggered by that declaration, limiting its effects. To issue failed National Drug control strategies in 2017 and 2018. 2019 its 2019 strategy did not include fiveyear goals or projection for Program Budget priorities, both of which are required by law. 2019ding to the october department of justice ig report, the Justice Department and dea did not initially use all of the resources and authorities. Reduced quotas for opioids or hold registrants adequately accountable. The result was an Opioid Epidemic that evolved from Prescription Drugs to heroin and fentanyl. , to there is little question in my mind that the initial response to the opioid situation was ineffective. How do we get back on track . I very much believe that any solution must include a whole of government approach and we have to use all available resources. The comprehensive addiction and recovery act enacted in 2016 laid the foundation for this approach. , the support act, was signed into law last year. The 2016 legislation by authorizing critical agencies as well as prevention, treatment, recovery, and resource programs. Included aso provision called the using data to prevent opioid diversion. This part of the law is designed to ensure that opioid manufacturers and distributors are held criminally and civilly liable for identifying and reporting suspicious orders of opioids. I happen to be the one that authored that, and i am very much concerned that it is never been enforced. Today, i am introducing new legislation to strengthen this law. This legislation will require data on all controlled substances to be reported, not just opioids. In order to better identify suspicious orders. It will require pharmacies to report all transfers of controlled substances to the dea each month. There is so much to do. The federal government has begun to do this. P has established a number of interagency working groups including the National Opioid Coordination Group to monitor trends and data. The Justice Department created the opioid enforcement efforts and division and that is a opioid fraud and abuse detection unit under a new initiative focused onode, disrupting the online sale of illicit drugs. For its part, dea has increased its tactical diversion squad, enforcement, and administrative actions against negligent distributors and manufacturers. Efforts,lt of these for the First Time Since 1990, Prescription Drug related Overdose Deaths decreased. That is really good news. So there are things that we can do to save life and reduce addiction. Centers for Disease Control and prevention has warned us for wave of drug epidemics is upon us. Most suffering from addiction they tell us use more than just opioids. In 2018, methamphetamine, benzodiazepines was opioidt in 60 of all overdose related deaths. That is a stunning figure to me. We have to take a look at it and see what we need to do. I would encourage our Witnesses Today to comment on this, and if you have a solution or thought, we would be very interested in hearing them. Our country has been ravaged by an addiction epidemic, and it costs tens of thousands of lives every year. Failure should not be an option. This is an important hearing and i so look forward to hearing from our witnesses hopefully with new ideas and constructive thoughts. Thank you, madam chairman. I recognize senator durbin for opening comments. Sen. Durbin thank you for this hearing and i called senator graham several weeks ago and asked him to consider this, and i think him and to you for making this possible. I will not state what has already been stated. Thean accept that we are in worst drug epidemic in history of the u. S. , losing an average 201717, an average in of 138 people a day. There is no town too small to escape this drug epidemic in my state and across the nation. It is not the first drug epidemic in our history. The crack cocaine epidemic showed and i hope that we learned we cannot incarcerate our way out of the addiction crisis. We need prevention, intervention, and treatment on the front end and not just prosecution on the backend. There is a growing bipartisan consensus that harsh prison sentences have not only failed to stop drug addiction but have created many unjust and disastrous outcomes. Communitythat this spearheaded the action of the First Step Act to right these wrongs. Now as we combat current drugs on the market and the spread of synthetic fentanyl analogs that we do not impede Scientific Research that can save people to overdose on these drugs and that we do not criminalize substances in the process. Let me ask you if you have consider just this fact. A recent study of fentanyl overdoses in massachusetts in 2014 to 2016 found 83 of patients required more than two naloxone doses. Why . Because naloxone no longer is Strong Enough to stop an overdose. Many researchers believe a more powerful antidote make include the drug fentanyl or some analog. That is why i am proposing legislation that will allow the truly harmful analogs to be added to schedule 1, but not at the expense of facilitating Viral Research for facilitating antidotes. There has been an effort to bypass this conversation about the research aspects. I hope we can return to it. We can learn an important lesson from the 1998 tobacco master settlement agreement. Was a landmark to hold big tobacco responsible for hooking americans on nicotine and contributing to millions of deaths. I might add, they are added again with vaping. Only 8 of the dollars paid under that settlement were devoted to Public Health harms of nicotine addiction. Most of the money was spent on unrelated items like roads, stadiums. Many states, cities, and counties have sued the opioid industry and there is a massive lawsuit underway in cleveland today that could produce a large settlement. It is critical that a substantial portion of the settlement to be dedicated to fighting opioid addiction. It was in june 2016 in this hearing room at this very table the i learned for first time that the acting director of the Drug Enforcement administration revealed on the record that it was actually the dea that approved the annual quota of opioids to be produced in the United States. Opioid addiction starts with prescription painkillers made by pharmaceutical companies, regulated by the Drug Enforcement administration. The Inspector General of the department of justice dea was slow to respond to the dramatic increase in opioid abuse and needs to more fully utilize its Regulatory Authority and resources. For years, dea permitted pharma to produce enormous, evergrowing amount of opioid pills each year. Abilityugh dea had the to set quotas limiting that production. For example, in 2017, the Drug Enforcement administration of the United States of america allowed pharma to produce 13 billion opioid doses to be put on the market. How much would that be . It would be a three week prescription for every adult in america approved by the Drug Enforcement administration. For years, ive been calling on them to set lower quotas. Last year, senator kennedy of louisiana on the others and i joined in a bipartisan effort to reform a law and required the dea to adjust opioid quotas to reflect the reality of what is happening in america. Madam chair, i am sure you are well aware of accounting in your state that is on the border of iowa and illinois. 45 county, iowa averaged opioid pills per person for nearly a decade, dispensed by one pharmacy in that county. 45 opioid pills per person for every person living in that county for 10 years. In harden county, illinois, one of the least populated counties in my state, 4300 people, but between 2006 and 2012, enough opioids to provide every resident with 90 painkiller pills a year. The dea is supposed to monitor this. They are proving massive production on the front end, and no monitoring on the backend. As we see these areas, Rural Counties being swamped with opioids. For years, we have been calling on them to lower quotas and now they have the legislative authority and the no excuses. I am concerned the dea is not taking it as seriously as it should and i will ask questions we reach that point. While the dea has lowered the indefensible opioid quotas in recent years, the proposed 2020 quotas do not take into account drug addiction, overdoses, and death. In other words, the pharma production quotas do not look at the reality of the worst drug epidemic going on in america today. Withk forward to working my colleagues to continuing on a bipartisan basis to deal with this. Ourow we will start with panel 1. We will introduce our witnesses and then we will start with witness statements. With us today on panel 1, we chester, the assistant director of National Opioids and synthetics Coordination Group of the office of National Drug control policy. Capacity, mr. Chester leads interagency efforts to reduce the availability of , andn, fentanyl synthetic drugs in the u. S. By disrupting the supply chain. And shemiss lipscomb, is responsible for coordinating the departments strategic responses to the Opioid Crisis including all investigative and prosecutorial efforts. We also have mr. William mcdermott. Mr. Mcdermott was appointed as the assistant administrator to deas diversions control division. He serves as the principal advisor to the administrator on all matters relating to and listed, chemicals. Niraj, serving as the chief medical officer of Substance Abuse and Mental Health services. He is familiar with the development and utilization of medical services, budgets, nuances, regulations and code across states and provides perspective as he delivers care. Thank you for being with us. We will start with our witness statements and we will start with you mr. Chester. Ernstester chairwoman and members of the committee, thank you for inviting me to testify in the illicit opioid environment we continue to face in the United States and the government approach to addressing it. The office of National Drug control policy under the leadership of jim carroll is uniquely under the office of the president. Began work, the dominant drug was heroin. Nonintravenous use and heroin enabled an easy transition for prescription opioids to elicit opioids. An overdoserged as driver in 2015. By 2017, many states experienced a crossover were more people were overdosing and dying from fentanyl than heroin exclusively. Today we see even more diversification across the opioid environment with the variety of fentanyl and nonfentanyl. Pills sold onnto the darknet and delivered directly to consumers. Complicated by user transference of different typesypes and not opioid like methamphetamine. By president ial leadership, strong bipartisan support in congress, and across the Public Health, Law Enforcement, national security, and intelligence communities. This allows us to deeply understand the environment and all the complexity and quickly identify and then rapidly close gaps and arcade abilities as they emerge. Over the last 40 years, the federal government has made lifesaving gains through the synchronized approach first laid out in the 2016 heroin availability reduction plan, then the final report of the ,residents commission on drugs president trumps initiative to stop opioid abuse in 2018, and the drug control strategy. We advance our policy objectives along lines of effort. Lead to longterm recovery, and reduce the availability of illicit drugs in the u. S. The strategy guides and synchronizes federal government actions on the entirety of the drug problem to achieve the singular goal of saving american lives. This is the only criterion that truly matters and by which the American People will measure the success of our efforts. These foundational documents and the efforts that they articulate has been enabling significant accomplishments over the last few years. Targeting the internet trafficking of synthetic opioids. The training and deployment of k9 teams across the border Enforcement Office field teams specifically trained to find fentanyl. Syntheticntify new opioids as they emerge in the marketplace, and the passage of the historic support act which recently authorized new medicare allow benefits that opioid treatment programs to build further bill for their services. However, the illicit opioid environment continues to present a challenge. Synthetic opioids ship in small quantities making detecting and seizing these drugs difficult as they move through the mail and across our borders. Of increasing prevalence polydrug users, counterfeit pills, and the rapid emergence of highly addictive, deadly, and readily available synthetic opioids are impacting prevention and treatment efforts. Address efforts to new factors are emerging. These challenges are not insurmountable. Now more than ever, our efforts must remain synchronized across the entire government with our state partners, our partners in the private sector, and others to produce the complementary effects we need to end the crisis. I would like to thank the committee for your foresight and leadership in addressing this Critical National security, Law Enforcement, and Public Health challenge. On behalf of the administration, we continue to look forward to work with you to confront this extreme the complex issue. Thank you for the opportunity to testify today. I look forward to your questions. 0 thank yo cspanwj thank you. Thank you for the opportunity to discuss the department of justices work to combat the Opioid Crisis. My position in the Deputy Attorney Generals Office was created for the sole purpose of ensuring the department is properly with the express goal of combating the Opioid Crisis. I also have 13 years of experience as a drug prosecutor and also as a deputy chief in the criminal division. I know firsthand that the department does not simply paying lipservice. It is responding aggressively and intentionally with every tool it has at its disposal. One such tool is focused on the departments effort to dismantle darknet websites. These websites allow some of the most prolific drug suppliers to sell. Dismantling them is a priority for the department which is why in 2018, the fbi established the joint criminal opioid and darknet enforcement team. Since the launch, there have been two successful, largescale takedowns that have taken dozen of darknet account off the web. The department has been diligently working to prosecute mexican cartels who traffic fentanyl and analogs into the u. S. The mexican cartels are not only producing their own fentanyl but mixing it other drugs such as heroin,hetamine, and cocaine. The department is using all of the tools at its disposal to combat the cartel, most notably, earning the conviction chapo, who was sentenced to life this year. And focusing on elicit opioids in 10 districts that have seen some of the highest overdose death rate in this country. The prosecutors in those districts work towards prosecuting all readily provable cases in synthetic opioids. Over 300 cases were charged in these districts. Additionally, the department has created the Appalachian Regional restriction task force. A joint Law Enforcement to pull the resources of multiple agencies to identify and prosecute Health Care Fraud schemes in the Appalachian Region, one of the most hardhit by this epidemic. The jointber 2018, Law Enforcement has charged more than 70 defendants who are responsible for the trip eating million pills. These medical professionals were charged with Drug Trafficking offenses. The strikeforce has worked handinhand with hhs to ensure that when there is a takedown of these medical professionals, patients are not left in the cold. Rather they are met by a team of Public Health officials can refer them to legitimate medical providers or addiction Recovery Services. The department recognizes that we cannot simply prosecute our way out of this crisis and evan using our resources to help prevent opioid abuse before it takes place. This occurs through school and community outreach, partnership with native american tribes, Public Service announcements, and training for medical professionals. Additionally, the department has a network established exclusively for opioid prevention. This helps state and local Law Enforcement today can better investigate heroin and prescription opioid tradition. Finally, i want to remind you of what i spoke with you about in june. A legislative of then for class number of Overdose Deaths in the u. S. Has reached record levels. One of the chief causes is the proliferation of fentanyl and its analogues. As you know, and february 2018, the dea responded to the proliferation of fentanyl analogs by scheduling the entire class of substances, and the scheduling order, we saw the significant decrease of encountering fentanyllike substances. Classwide scheduling is working. The temporary emergency scheduling order expires in 51 days. As a prosecutor, i can tell you that legislation to permanently schedule fentanyl like is an important and necessary step to continue encountering this epidemic. We are running out of time and if a solution is not found, prosecutors will be hindered and traffickers will be helped. We cannot afford to move in the wrong direction while battling the crisis. Thank you for the opportunity to testify today and we look forward to continuing to work with congress to find solutions necessary to address the threats posed. Chair ernst thank you. Ott on behalf of the 9000 men and women of the dea, thank you for the opportunity to discuss a response to the Opioid Crisis. Over the past several years, the nation has been increasingly devastated by an epidemic that was field by the overprescribing of Prescription Drugs. The 2000 wass to fueled by a fundamental belief that pain was undertreated in the United States. It created a generation of opioid users. Presently estimated at more than 3 million americans. Unfortunately, as prescription rates have declined over the last four years, we have seen a dramatic and disturbing shift. Mexican drug cartels are filling cheap,d with chief highly potent, white powdered heroin. They continue to mix it with fentanyl and pressed into counterfeit pills made to look like listed pharmaceuticals. The dea is now seeing chinese and mexican nationals working together to move massive amounts of heroin, fentanyl across the southwest border. The profits are astounding. Can beram of fentanyl purchased for less than 5,000 and can yield potential profits in excess of 1. 5 million. The dea think that the cartel primary will be the mexican cartels. They do not observe boundaries or laws in mexico, United States, or any other country. To focuswill continue its attention and efforts on the commandandcontrol components of these major Drug Trafficking organizations in order to protect our citizens from the devastation they bring in the form of violence and drugs. With respect to address the divergence of substances, i oversee the program with roughly 18 of our workforce. Prescriptione of opioids by a small number of practitioners, less than a fraction of 1 have disproportionately impacted this epidemic. In fact, four out of five new heroin users state that they started their cycle of addiction on prescription opioids. Within the diversion program, we have realigned criminal investigators and embedded them alongside diversion effort andrs in an enforcement groups we call technical and we have 80 of these groups nationwide who are solely dedicated to investigating and dismantling individuals and organizations involved in diversion schemes. Toolsgroups are using all of administrative, civil, and criminal to pursue those registrants that violate the law. We also remain focused on the limits dea establishes for domestic manufacturing of controlledand 2 substances called quotas. With the recent publication of the 2020 quotas on december 2, the dea has decreased quotas for the six most frequently misused opioids by 55 from the levels established by the end of 2016. We have been able to bring down these quotas because doctors nationwide are writing less prescription for opioids. Januarycline since 2017. Wepite these declines, recognize that opioids are essential medicines, especially for those with acute pain. Workea will continue to with the fda, the senators for medicare and medicaid services, cdc, and the state ags office is to ensure there are adequate supplies are those in need. The division will continue its robust Outreach Program with registrants, aimed at improving. I look forward to your questions. Chair ernst thank you. Chairwoman and the stingless members of the committee, thank you for inviting me today to discuss approach to the Opioid Crisis. I am the chief medical officer for samsung. Samsa. I am an addiction psychiatrist with expertise in the treatment of both Mental Illness and Substance Abuse services and vulnerable and underserved populations. I mission is to reduce the impact and Substance Abuse issues. We lead Public Health efforts to improve the lives of individual living with Mental Illness and Substance Abuse disorders as well as their families. Samsas number one priority is the expansion of prevention, treatment, and recovery, and support services. We do this by providing a full range of grants targeting the Opioid Crisis. The Program Addresses the Opioid Crisis including prescription opioids, heroin, and fentanyl , usingtanyl analogues the three fda approved medications for the treatment of opioid abuse disorder, reducing unmet need, and reducing opioidrelated deaths through prevention, treatment, and recovery. Community with providers. Drug takeback and disposal programs, overdose education, and naloxone distribution activities and strategies to reduce stigma. To ensure that individuals receive a comprehensive array of services, they also provide Recovery Support services. One of the most common approaches to implementing Recovery Support services is utilization of peer supports. Individuals who themselves are in recovery. Another common activity is the development, enhancement of Community Recovery organizations as well as use of recovery residencies. Ofrs are engaged in a number settings where individuals with opioid abuse disorder initiate and maintain recovery. Thea strongly believes that consistent care with the continued partnership with federal governments, state, and communities, we will make continued progress in combating the Opioid Crisis. American indians and alaska natives have been especially hardhit by increasing rates of prescription and illicit opioid use. Addictions and overdoses as well. These populations of the secondhighest overdose death rates from heroin and the from overdose opioids. The tour program aims to address the Opioid Crisis in tribal communities by increasing access to culturally appropriate and evidencebased treatment. Leader tolso been a depthsoverdose through funding and Technical Assistance. Overdose prevention toolkit released in 2013 is one of our most downloaded resources. Provides information on recognizing the risks of opioid overdose, the signs of overdose, and how to provide Emergency Care and an overdose situation. Samsas opioid prevention efforts targeting Prescription Drug misuse is also shown positive outcomes. Assistategic Framework Program works the with pharmaceutical and medical communities on the risk of overprescribing to young adults and bringing Prescription Drug use prevention and activity to schools, communities, parents, prescribers, and patients. All the grantees are required to have an operational state run official Drug Monitoring Program , and are supported in developing capacity and data from these pdmps. Sda provides key data on a variety of Mental Health drug topics including misuse. We are also building existing partnerships with nih and implementation of healings communities healing communities, and committed to delivery models. Thank you for the opportunity, and i look forward to answering the questions you have. Chair ernst thank you to our witnesses. We will start with five minute rounds now with the members. Gandotra, i would like to start with you. According to the u. S. Bureau, rural areas cover about 97 of the land areas and 56 of islands live in those Rural Communities. We heard from senator durbin outlining some of his Rural Communities. Testimony, you highlighted the Substance Abuse and Mental Health services in ways they work and those Rural Communities. Can you describe some of the key challenges to reducing the impact of substance misuse and Mental Illness and verbal communities as well as when it comes to opioids and then if you have also been speaking to us about methamphetamine as well. Dr. Gandotra thank you. Thank you for the insightful question. I believe the focus is treatment capacity. We certainly do have a great number of providers and they need to be in the right places. Treatment capacity is certainly addressed by a variety of different techniques. Areasalth is one of the we are certainly exploring to increase capacity to these rural areas. As well as provider expansion, inan samsa collaboration with the dea has provided a short number of providers, increasing provider limits so that they would be able to treat a greater number of patients. We are understanding that we have to attack this problem from different angles as well as include provider education from our primary care colleagues as well. I would comment that Art Addiction Technology Transfer 50,000has provided over providers with the expertise in attacking this problem as well. Education, and treatment expansion as well as exploring opportunities with telehealth would be the ways we would most likely proceed. Chair ernst i appreciate that. I have visited various Community Health centers and they are expanding their reach through telehealth. I appreciate you speaking to that. Beyond the Opioid Epidemic, what is samsas longterm strategy misuseressing substance and illness in Rural Communities . We certainly have a lot of resources that we are devoting towards that and we thanked congress for the appropriation with the Substance Abuse block Grant Funding in particular. Block Grant Funding can be utilized and any Substance Abuse disorder. Being treated with Substance Abuse disorder any of Mental Illness. Ands can be appropriated are appropriated for that as well. Chair ernst mr. Mcdermott, dea is our nations front line defense to control illicit substances. We recently marked the oneyear anniversary of Bipartisan Legislation of the support act which combats the appleyard the Opioid Epidemic. I worked to strengthen the Drug Takeback Program efforts and include the safe disposal of drugs. How can the dea work in those drug taebaek programs Drug Takeback Program . Maybe here button again. Twice a year, dea does a takeback, and it has been very productive. Most important thing i can say about that is this, typically when adolescents are involved with abusive opioids, typically it starts in the medicine cabinet. That is the most important thing to get out of your house. They have these pill parties at schools and so forth that you probably heard about. If we can get the message out and we are doing a much better job with participation from tribal areas as well, and the addiction rates there are tremendous. Area, wehe denver covered montana and we had serious concerns. Take back has been very productive. We have more precipitation participation from state and locals, we have participation from hospitals, you name it. We are out there and it has been a very productive and at the end of the day, there is criticism to say we only get x amount of opioids, but i can tell you any opioid to take off of your house or off the streets, that is beneficial. Chair ernst Ranking Member feinstein. Sen. Feinstein i believed that chairman of this committee and i very much believe that fentanyl will be made a schedule one drug. Hopefully we will be able to do that. Believe that 48,000 dabs. Ses, overdose overdose deatsh. Can you give us the constituency for that 48,000 deaths, in other words, who is dying . What is their age, race, how do we know who they are . The defining features of the Opioid Crisis and specifically opioid deaths due to illicit sources is that it racial,pletely across economic, geographic, gender lines. A lot of the Drug Overdose and use patterns that we saw in the past are defined by the fentanyl crisis, because it is introduced into the marketplace to users in much different ways. Sometimes as it is mixed in, and lands into the intravenous drug using population. If it is pressed into a highly sophisticated counterfeit pill , it isd on the internet a person that does not understand or know that they are being a part of the illicit environment, that they are getting a pill pressed into fentanyl pill being presented as a counterfeit dog. Counterfeit drug. Geographicoss all lines. Anyone feinstein what on the panel not support would anyone on the panel not support fentanyl being a schedule one drug . I assume the answer is yes and chairwoman, i believe very strongly that fentanyl should be made a schedule one drug as soon as we possibly can. , can0 people dying from it giveive and us a description of the deaths and the majority of use involved in those deaths . I can start and then others can fill in. One of the things we have seen in the evolution of fentanyl and i think i touched on this in my Opening Statement is that, in 2006, there was a small outbreak Overdose Deaths in illinois and that was tracked back to a single lab, and fentanyl did not completely go away but it certainly decreased. Wades not until 2015 that saw it be a regular feature and regular feature in most not until 2015 that we side to be a regular feature in postmortem autopsies. Sent over the darknet and then sent through the mail. Rather than having individuals having to go to drug traffickers and make a facetoface it was now able to be diffused across the country and anybody with access to the laptop and cryptocurrency could have it delivered to their house. What was really originally started in the northeast as that involve the intravenous drug using population, that expanded across a country to where we are today. Sen. Feinstein any newly substance fentanyl should be added to the controlled substances act by name. Would everyone support that . Anybody disagree . Madame chairwoman, i think we have our work laid out for us, and senator durbin i know has thoughts on this, but we work to make fentanyl a schedule one drug, and try to reverse these deaths. Is there any common denominator of people in the 48,000, racially, economically, age wise . Not too many common denominators. Some of our state partners who we deal and provide us a lot of information have spoken to perhaps an increase in the Africanamerican Community above what we saw another opioids. The only common denominator for everyone who has died is the availability of the drug. We know leadshat to increased first use and first use leads to chronic use with opioids, perhaps more so than any other drugs. Sen. Feinstein you support making get a schedule 1 drug . Yes maam. Sen. Feinstein is everyone on support making get a schedule one drug . I would have to take that back to my department. Sen. Feinstein ok, i dont want you to get in trouble. I agree with ms. Liskamm. Dr. Gandotra i would also like to take the question back. Like annstein i would answer, that is where i am going. The office of Inspector General recently reviewed the deas efforts to control the diversion of opioids and came to this conclusion, the dea was slow to respond to the significant rise and use and diversion of opioid since the early 2000s. Mr. Mcdermott, the Inspector Generals report states the department and dea agreed with all the recommendations. How is d8 prioritizing and meeting these recommendations . Mr. Mcdermott as we speak today, we are working on those. Criticismm, there was of dea pertaining to our work plan for diversion investigators. We have changed the work plan, we have worked with oig, and we have implemented their recommendations as we speak today. Questionsley the next for you, would you could would you commit to update congress on the meeting of these recommendations . Mr. Mcdermott yes sir. Sen. Grassley thank you. Passedar, congress landmark legislation addressing the Opioid Crisis, and i am proud to have cosponsored and that moved through the judiciary. Amm, the oig report states that because the support act is relatively new, the Justice Department is unable to predict its effect on the Opioid Crisis or deas opioid enforcement efforts. While that may be the case and may be legitimately the case, the director of opioid enforcement prevention efforts of the Justice Department, that is your position. Can you provide anecdotal evidence of success of the federal governments efforts to end this crisis . Ms. Liskamm with respect to the support act or in general . Sen. Grassley with respect to the support act. Askedskamm the dea has typically the suspicious order database that was ever lamented october 23 of this year. They are still working through a number of other components within the support act to include their work with the database which has been invaluable to the department with respect to our opioid investigations. I can tell you firsthand how these types of databases have been used to successfully prosecute the diversion of opioids both with what we referred to as dirty doctors, to nationwide attribute and manufacturers. Since im going to ask this question of the entire panel, and it deals with fentanyl, and i hope it does not cross over what senator feinstein asked. It is well known about fentanyl and its dangerous analogues coming to the u. S. From china. In april, china issued a classwide control of fentanyl analogues. Earlier this year, witnesses from dea, the Justice Department commented at the Judiciary Committee hearing that they are monitoring chinas actions and ensuring followthrough. Of you, what Significant Developments to each of your agency show the American People that we are winning the fight against chinese fentanyl entering our country . Mr. Chester i think a couple of things have come together to bring some tangible outcomes from chinas efforts to schedule fentanyl as a class. The first is the president s direct appeal to president xi, asking for the Class Schedule with an absolute game changer. The coordination with the administration and the agency has been incredibly important. That resulted in china not only following through completely on its commitment but also taking some tangible steps such as two months ago, and writing u. S. Officials to the conviction of nine individuals for fentanyl trafficking coming from china which is a major step forward. Director carol traveled over to china in september, spoke with the Chinese Government about some tangible steps that they could take moving forward to include greater policy coordination, and we believe the steps are positive and will take us in a step where it will reduce the flow of fentanyl coming into the u. S. Sen. Grassley the rest of you, if you could make your answers short, i dont want to infringe upon the rest. Ms. Liskamm we have seen a significant drop of fentanyl and analogues coming through the mail from china, which has shown the positive steps taken from chinas classwide schedule link, and i would remind the committee that since the temporary scheduling order went into effect, we have seen a thing of can drop off of analogues in this country. I believe there have only been two analogues that have been encountered in this count this calendar year which shows that the china action as well as the actions in the states are working. Sen. Grassley mr. Mcdermott . Echo hermott i comments, and we have two offices in china right now. The working relations present excellent. Simply, samsas approach has been for prevention so we have distributed naloxone kids, and over a quarter million have been distributed across the country with reversal of over 14,000 overdoses. Chair ernst thank you senator durbin. We establish the Drug Enforcement administration had approved the production of 14 billion opioid doses that year in the United States. 14 billion. That meant that every adult in america could take a one month prescription of opioids based on the improved production quota from the Drug Enforcement administration. We were in the midst of the worst drug app adamic and our country and we still face it. Opioids were driving into heroin and fentanyl, and the dea was approving the production of 14 billion of these doses requested by the pharmaceutical industry. A number of us started asking questions. What is going on here . Why are all of these opioid pills, more than is necessary, for the health of america . And as a consequence, mr. Mcdermotts testimony today is that the quote of productions have gone down. Estimating itam is around 8 billion at this point. 8 billion opioid doses year. It is equivalent to a twoweek dosage for every adult in america. That is what we are Still Producing in opioids as we talk about all of the consequences of the opioid drug epidemic. Senator kennedy and i said what is going on here . Is the dea paying any attention to what is happening . The response to me was, senator, if you want us to pay attention, put it in the law. And we did. We set from this point forward, when they set the quote at dea, take into account the deaths in America Related to opioids, the diversion of the opioid pills from the ordinary medical course of commerce and the following. We wanted to see what would happen and you know what the response was from the dea . We just cannot find the information. We cannot really take that into consideration. The dea told us that the dea determined that due to the grouping of subclasses, the data cannot be used to set the production quotas. What does it take . How do we get the dea to acknowledge that 8 billion opioid doses is dramatically more than can possibly be used for legal purposes for medical purposes. As discussed, dea license we couldve done things differently and we are doing things differently. I have been in this position for three months. I read your letter and i will sell you that i sat down with our folks and went over the numbers. A priorityu it is for me and the administrator to ensure that we have a balanced approach. If you look at the numbers, i think we are doing exactly what you asked us to do. 8 billion . Enough for every adult in america to have an opioid dose for two weeks . You think that is a good response in the midst of a drug academic epidemic . Host we mr. Mcdermott we work with the state attorney general to make sure theyre ours adequate research. We will continue to link those numbers and ensure that we have proper medical supply out there. Lets start with this. If our government doesnt start by a reasonable regulation of the production, it will continue more and more, far beyond what is medically necessary. Far beyond what is needed for chronic pain. Dea is not onthe the program, we are going nowhere with this conversation. I hope that changes. Senator kennedy and i put it in the bill. Had a, we have not response that we think is appropriate. Is there an antidote to fentanyl . Statement,initial you had mentioned that you had heard anecdotal reports were people had required more than one dose of naloxone. As a reversal for opioids. Time, that is our fda approved option. Naloxone has been used to reverse opioid overdoses. Substances may require more than one dose. That is why even after doc after someone has naloxone administered and they have been resuscitated, they still require medicale adequate supervision. It is the option we have right now. Sen. Durbin this is a point i would like to get to on scheduling fentanyl analogs. We discussed this in a separate meeting. I am not opposed to putting fentanyl analogs on schedule one and will expire in 51 days. What i am concerned about is we do not have a really effective antidote for fentanyl and i am worried we are putting onto a schedule one process which prohibits production in the United States is going to close out the possibility of research into an antidote for fentanyl, which i think should be underway and would be ludicrous for us to believe fentanyl is going to disappear even if the import numbers are coming down. All i am asking you to do is in putting these analogs on schedule one, give us some process so that researchers can look for the fentanyl antidote which could save lives today. Value,e i guess has some but does not have the effective application that could make a difference. If you would like to respond. Chester i am proud to say that Human Services have been working throughout the summer on that balance you talk about. Which is the balance between controlling substances that are dangerous but allowing adequate researcher access. We believe we struck a balance and we have been working with the committee on this to ensure that as substances are gathered up that are more than reasonably dangerous and potentially dangerous, that we provide an unprecedented level of researcher access to be able to pull them out of the schedule for Research Purposes to determine their medical merit. Maybe the next generation of naloxone they have no active effect or should bd schedule. We believe that the work we have done between both of those departments strikes that balance very well and unprecedented level at researcher access but at the same time, unprecedented control over the substances that are dangerous to americans. Sen. Durbin that is the balance i am looking for, too. Sen. Blackburn thank you for being here. I think you can hear the bipartisan frustration in our voices. We have an issue that continues to get worse. We have seen an increase in our drug related deaths. 1,837 last year, up from 1,776. We know from our Law Enforcement communities that fentanyl related deaths are increasing. Our director has said he is seeing a continued increase. It is something we are facing statewide. We seem to have a problem with. Entanyl on the street in upper east tennessee, we engage regularly, constantly with Law Enforcement and Health Care Professionals. All to why we need you really collaborate with us in a timely manner. To find answers to this. Senator feinstein and i talked drugs and Mental Illness and how that affects homelessness, which they are struggling with in california. Many of our cities are. Fast theo move discussions. We have been at this for a while, especially with the opioids. Look at what is going to be a coordinated longterm strategy. Look at how we are going to get resources to Law Enforcement in some of the hardest hit areas around our country. A task force, doj has commended them and we commend them for the good work that they are doing. To whatever going to do to present treatment for the addicts, people caught up in a revolving door situation with Law Enforcement . They are incarcerated and they are not receiving the treatment that they need. Mr. Chester, i want to come to you first. Talk about what you are doing to get resources to Law Enforcement tra, i would like you to talk about treatment and what you are changing to make treatment and recovery available for physicians. What are you doing to train doctors, what are you doing to educate pharmacists when it comes to this . As senator durbin said, the number of pills that are in the system and being able to achieve that balance, people that need it can get it but get the rest out of the system. Mr. Chester, to you first. Please be mindful of the clock. I will be very quick. When you talk about resources for Law Enforcement, principally it is the high intensity Drug Trafficking Areas Program that funds Law Enforcement task at this state level that our state local and federal. In a combined effort. These taskforces is they are unique to a focusedar area and are on the drug threat over that area. They are given the flex ability. Mr. Chester yes maam. Methodology we have combining resources with local and state Law Enforcement. Particularly the regional appalachian opioid strikeforce. They are focused in the Appalachian Region and while they have the fbi and hhs involved, they rely on local and state partners in order to combat the diversion of opioids in those areas. Dr. Gandotra we are anchored in evidencebased practices. We have two main initiatives, provider clement of provider clinical support system as well as provider education for Substance Use disorder education as a whole in healthcare care settings and education. We believe Health Care Settings are the place we can improve our scope for educating the next level and the next generation. Sen. Blackburn how widely utilized are those programs . Dr. Gandotra i believe over 15 7,000 individuals have been trained. Sen. Blackburn thank you. Chairperson senator whitehouse. Whitehouse thank you very much. Let me start with the Purdue Pharma case. I dont know if you were involved, but more than one year ago, the senator and i sent a letter to the department of why theasking about case against Purdue Pharma that was being proposed as a federal critical criminal indictment out of virginia once he got to the political side of the department of justice suddenly got turned into a misdemeanor prosecution for a find that in the context of this is not very significant. And that operated not against purdue but against a holding couldy so that purdue with medicaid and other federal programs. The fact that mr. Giuliani was when he wast involved in the department of justice adds an extra odor to the disappearance of this at the federal level. I would like to get an answer to my letter from august 2018. I dont think that is asking too much. I would like to know what you know about why that prosecution was made to disappear and turn into a misdemeanor settlement. Can look into that letter. I am not aware of the status but i will be sure to take it back to my colleagues. I was not involved in the litigation so i dont have a lot of specifics but i can tell you that the department is actively looking into nationwide manufacturers and distributors of opioids. We recognize the role that many of those companies played, including executives in those companies, in can contribute into the Opioid Crisis. Sen. Whitehouse so you are at least a participant if not a litigant. Ms. Liskamm we have filed a letter in litigation. Sen. Whitehouse what insurance do we have that in your role as a friend of the court in the litigation, the department of justice will actually take a serious position in favor of the plaintiffs, when the record so far is that you call in the right lawyer, you go to the political appointees, and your case disappears into a misdemeanor against a holding company. Dr. Gandotra ms. Liskamm as a friend of the court, we are there to provide guidance. Wheres theuse guidance going to go . Ms. Liskamm it depends on what the issue is. We are involved with helping the dea, current or former employees. We have been assisting in pulling together data that has been requested as part of that litigation. Supporting the discovery and information gathering phase . Ms. Liskamm thats correct. Sen. Whitehouse when you take a position, will the same people will be makingat a position as to what the department should take . Ms. Liskamm im not sure what Position Department is going to take. I dont know what the issue is going to be. Departmentrate the does have open investigations, which i obviously cant comment on but is actively looking into this space and trying to hold people accountable for their involvement. Sen. Whitehouse i hope you do a better job than you did last time. The last question i have and this can go to either 1 is more of a technical question. As you heard today, there is broad bipartisan support for scheduling fentanyl as an unlawful drug. However, all of you seem to agree with that, however, when we go to hhs, this Administration Says no, we shouldnt do that. Because the chemistry in this question is very complicated. Analogs, yountanyl will likely get into potentially banning drugs that could orually help with addiction with response to an overdose. It seems to me that the most important thing you all could do is get the administration aligned behind a program for how we schedule fentanyl without banging into the objections from hhs. Perhaps mr. Chester, you can lead that. Mr. Chester we have been coordinating between hhs and its departments. Fda, cdc. Sen. Whitehouse is there a common position . Mr. Chester there is. It was captured and transmitted in committee in september, which as i discussed earlier is the balance when we talk about fentanyl, i want to be clear. About isre talking fentanyl analogs, which are substitutions to the fentanyl skeleton. That is how it is defined, that are reasonably assumed to be active in the body based upon a structure activity. These are variations of fentanyl. To beher side of that is able to have an unprecedented level of access to access those substances, do research, determine their activity and determine if there is medical merit. That is what we have been able to do between the department of health and Human Services and department of justice to get an agreement that we have struck the right balance between control and access. That is what we have presented to the committee. Sen. Whitehouse my time is expired. We talk about opioids, that includes it is an umbrella term. It is Prescription Drugs, heroin, fentanyl. Is that the universe a vote considered to be opioids . Dr. Gandotra i would include all of those synthetic and natural. Opium, heroin, all the way through to Prescription Drugs. Experience, in your when people cant get Prescription Drugs, do they opt for the cheaper alternative like heroin frequently . Dr. Gandotra a subset of individuals do. Not everyone would, but certainly a subset. Sen. Cornyn the figure i saw last year, there are 15,000 heroin related deaths, although i know the numbers get murky, because frequently, as several of you have mentioned, you have a cocktail a variety of drugs , which is deadly, obviously. You mentioned naloxone. Something that is administered by First Responders and others when someone is suffering a Drug Overdose. 14,000tioned applications of that drug last year, successfully. That just saves the persons life from the overdose at that moment. That does not cure the addiction, correct . Dr. Gandotra correct. Most most addiction professionals would believe that treatment has to continue for an extended time. One intervention will not be effective, whether it be reversing the overdose, and i would highlight that Naloxone Administration is evidencebased practice. Certainly it is something that we promote as a wonderful option for reversing opioid overdose. Sen. Cornyn certainly a lifesaver, but my point is that the person remains addicted and needs additional treatment and help. Dr. Gandotra correct. Treatment should extend on a full spectrum if the person requires detox, residential, outpatient. Treatment has to continue. We know that when treatments patient stay in treatment, we have better outcomes. Sen. Cornyn do they move to other drugs like methadone . Dr. Gandotra thank you for bringing that up. Medication as a treatment is the Gold Standard for opioid use disorder. Either be methadone or something else. Fda approved medications to treat have been found to improve overdose, social capital. In particular, employment, criminal justice involvement, homelessness, and engage in other treatment seeking behaviors. Reducing hiv spread. Getting patients in treatment is our goal. Sen. Cornyn you mentioned, the chairman and you discussed Mental Health issues. Abusers whoubstance are people suffering from a Mental Health crisis we seek to self medicate . Dr. Gandotra that again would be one subset of individuals. Certainly the Substance Use disorder and Mental Illness are interactive. The other treatment gets worse as well. , oneone gets better provides a conduit for the other. Certainly there is a subset of individuals that have Mental Illness and Substance Use disorders and others that do not. Mcdermott, esther one source of opioids we really have not talked much about so is the mexican drug cartels at the border. Something your agency specializes in combating. I know there is a lot of outrage, justified outrage at manufacturers and doctors who over prescribe prescription opioids, but a substantial amount of opioids come across the southern border from the mexican drug cartels, correct . Mr. Chester correct. Sen. Cornyn and the fentanyl transits through mexico from china. Maybe not all of it, but a substantial amount of it . So if we want to get serious about combating the Opioid Crisis in america, we have to get serious about Border Security and intervening, or interviewed dictate interdicting, i should say. Do you agree . Mr. Chester correct. Sen. Cornyn of course the proceeds of these drugs that the cartels manufacturer are used to subsidize other illicit activities human trafficking. Is that an accurate statement . Mr. Chester that is accurate. Madame chairman, i see my time has run out. Thank you madam chairman. To the witnesses before us today , thank you. One thing i wish the average american had the time to hear is the broad bipartisanship of the approach of the members of this panel to working with the administration on trying to address our nation Opioid Crisis. Americans died of overdoses last year. That has ravaged every state, every community, at every level. Any senator who is doing their job has been to funerals, parent groups, engaged with Public Health communities and has tried their best to tackle this. You have heard broadly shared frustration about how slow some processes are moving, like scheduling fentanyl, and how much we seem to have still failed to grasp the depth and breadth of this crisis and acted in a corresponding way. Mr. Mcdermott, you are the assistant administrator for a control of the dea. I am grateful for what the dea does in delaware and across the country, but we lost 400 people to overdoses last year. That was a 15 increase over the year before that and over the year before that. Bipartisan effort to try to find something more needs to be done, ive worked with Senator Cory Gardner on a couple of issues. Knowing where the drugs are going. As you have heard from several of my colleagues, senator durbin pointed out that we have had a system that now for years sends toerally millions of opioids towns that have tiny populations or pharmacies and interdicted that diversion would strike me as a pressing goal. We live in a world where you can order a pizza or a package from amazon and know in real time exactly where your package is and when it is going to arrive. And we work with dea now for months and months to try to get consensus on whether or not the dea once realtime knowledge wants realtime knowledge of where massive diversions of opioids are happening. We have heard the stories of small towns that ended up with millions of doses for a town with a few thousand residents. If i could, does the dea have the ability now to track shipments of opioids as they move from the manufacturer to the distributor to the pharmacy . Do you have the ability to monitor that in real time now . Mr. Mcdermott senator, we do. We enhanced our data. Acts, inf the support october 23 of this year, we have that coming in. To answer your question about realtime data, monthly would be better at this point. Sen. Coons so it is not real time now, it is not monthly now. When do you get data about how large a shipment has been made to a particular town or pharmacy . 30 ofermott we receive the manufacturer distributors on a monthly basis, 70 on a quarterly basis. That is by statute. In. Coons so by statute, if were in your shoes the vast majority of the data that i would want to get months after the delivery. So senator gardner and i have introduced a bill that would help you collect and analyze that data in realtime to ensure that you have got knowledge you can act on that state Law Enforcement can act on, pharmacies can act on, when we see different manufacturers and distributors all homing in on one town and delivering millions of doses. Last year, enough opioids were shipped to my state of delaware to allow every single resident to have 45 pills per year and a vast majority of them were not on opioids. 400 took enough to die. Died quarters of them because of a mixture with both ourand i commend efforts to try and accelerate scheduling of fentanyl and steps that china has taken but there is so much more we have to do. The ways inou about which we can and should be innovative around developing new methodologies for treating pain and addiction. I have also introduced with senator gardner of colorado the effort act which would support and fund Critical Research into the Science Behind opioid addiction. It has passed out of the house, unanimously voted in the senate. I hope we will see a full vote soon. Aspectsspeak to which of the crisis would benefit the most from Additional Research . We all just learned that there this coming funding year. Certainly anchored in evidence. Preventionh supports. Prevention efforts have yielded fruit. Treatment with evidencebased practices we already have. Expanding mat is one of the biggest ones. As well as Recovery Services. In thent is not just clinic, but also recovery communities. That is where the evidence lies. That is where i would expect the greatest fruit to be yielded. Sen. Coons i am pleased with the outcome. It seems the outcome of our prices will be that they will receive a National Drug control policy a modest but deserved increase in the height of funding. This is a Genuine National crisis that demands all hands on deck and all of us engaged in finding the best ways we can to deliver resources for research, Law Enforcement and coordination. Thank you. Thank you madam chair. I want to say that for the state of missouri, this is a crisis that has been devastating. Missouris Life Expectancy has been declining now for years on end because of the surge in drug death linked to opioid addiction and other drug addiction. It is taking an enormous toll around the country but to missouri it is in many ways ground zero for this epidemic. Thank you all for being here and thank you for the work you are doing. As attorney general of the state of missouri, are brought suit against major manufacturers. It was very early on, 2. 5 years ago. I understand the Eastern District of new york has started its own criminal probe of opioid makers and distributors. Im wondering if you can give us a sense of the scope of the process. I canttunately, comment on open investigations but i can point you to public indictments of manufacturer and distributor executives. Executives and the other was the Rochester Drug corporation where he made a point of holding the executives in charge who have helped contribute to the crisis responsible. Sen. Hawley i think that is very important. Hypothetically, is it possible that individual executives of these Companies May be investigated and charged . We will go over the evidence takes us. That is always a possibility. Prosecutors i hope will look closely. If we are going to be charging opioid and heroin dealers and putting them in prison, that accountability has to go all the way to the supply chain. I know from our investigation, the outright deception of many of these companies, they knew opioids were addictive. They knew what the side effects were. They knew the data did not support prescription in the numbers they were being prescribed and they misled the public, sometimes doctors and veterans and other atrisk communities. Deliberately did so and made billions of dollars. Has got to be accountability for this. I want to come back to the question of drug smuggling. Maybe i will address this to you. In the state of missouri, the supply of scription opioids, the black market supply, is being ratcheted down, which is a very positive thing. What we are seeing is as drug addiction continues to surge and in the wake of prescription opioids, we are seeing black market fentanyl and methamphetamine. Those products are not produced in the state of missouri. And itroduced in mexico comes across the southern border. It is no exaggeration to say in missouri every single one of our counties is awash in these drugs. You cannot go into a school in the state and not find these Illegal Drugs with the snap of a finger. Whatever latest efforts are on the border. How are we doing in interdicting these drugs. What more do you need from congress, because this is truly a crisis from my state. Missouri before i went to headquarters, so i agree with you 100 . Some of theng with highest seizures right now in the United States on methamphetamine. I can tell you the men and women of the st. Louis Division Work every day to ensure the safety and wellbeing of that state and i can tell you have some great professionals there. Actually one of the best supervisors i had was down in your area. We are adding additional bodies as well as, we were able to get Additional Special agents assigned to st. Louis. I believe we are doing Everything Possible to work with state and local counterparts as well as department of justice and you have an excellent u. S. Attorney in your state. Sen. Hawley what more do we need to do specifically on the border, however. Feel free to chime in. See the to happen to flow of these drugs. We prefer not to have to deal with it in the states. I preferred these drugs not to come to the state and they are pouring in. In springfield, missouri, we have had record overdoses in two months. More overdoses in two months from what looks to be fentanyl and methamphetamine than we had all of last year. It is unbelievable. The drugs are pouring in. What do we need to do to stop the flow across the border . The drugs coming from the cartels, whether methamphetamine or analog are devastating this country. I would refer you to the classwide scheduling. That is our number one priority. Have 51 days left and we need congress to act on this one point. I think that is the number one request. Sen. Hawley thank you. Thank you. I know that we are here talking issues, but as mentioned by other senators, other states have other problems. Leti is mainly still meth me give you a little bit of data on hawaii. Intensity Drug Trafficking areas threat assessment identified meth as posing the greatest drug threat to the hawaii region. Between 2012 and 2018, the number of people who died from meth increased 250 . 70 of drugrelated deaths in hawaii are a result of meth and this problem is not isolated to hawaii. Data from the centers for Disease Control and prevention shows that Overdose Deaths nationwide increased fourfold between 2012 and 2016. What resources are your organizations committing to address the increased use of meth in states like hawaii. Obviously it is in missouri and iowa. What other Additional Resources do you need . I can start and we can work our way down. At the beginning of this year, director carol had spent time traveling around the country and heard from members of congress and realized we had put so much effort into the Opioid Crisis but we had developed a lot of architecture and should apply it to methamphetamine as well. We have been on a deliberate effort to gather the information, bring together the interagency and come up with solutions that we can do and i had a good conversation with the u. S. Attorney from hawaii talking about methamphetamine and what the patterns are. It is not only a problem with the drug itself, but the associated criminality that is deeply affecting hawaii. We are working to find tangible solutions, whether that is using grant money that has specifically been for opioids and expanding it to methamphetamine. As was mentioned earlier, the drugfree communities Prevention Program are ways we can understand this is a problem across the country. It is not geographically located. We can take a lot of the stuff we learn from the Opioid Crisis and apply it to methamphetamine. I echo what mr. Chester said. Focused onany grants the Opioid Crisis, as they should be but we have been hearing there is a need to get money to help address methamphetamine, which i also spoke with u. S. Attorney and recognize what a huge issue it is in your district. What is point enough to happening with the mexican cartels. They have been and continue to produce methamphetamine. It is very profitable and easy to make. There is huge profit margin and the rates we are seeing are through the roof. Close to 100 purity. It is something we are continuing to work with and i think dea can work with those programs but we are looking at how we can best attack the cartels that are coming bringing this into the country. Sen. Hirono do you know how most of the meth coming into hawaii is coming. Is it through the mail, the ports, do you know . Ms. Liskamm what i have heard from the u. S. Attorney is both routes. They are doing what they can to address it. My understanding is there is very little opioids in hawaii and it is primarily meth. Compared to some other district. To stoporking on ways the flow of methamphetamine into the state. Sen. Hirono have any of you come up with something specific with regard to stopping the meth coming into hawaii and also what kind of Treatment Options or prevention options there are . Think dea could speak to the great work they are doing with the government of mexico to identify the labs down there. Currently, to answer one previous question, the administration in 2018 provided us with funding for over 400 Task Force Officers that know the area and know what is happening on the street level. We have been able to implement that. It was for the Opioid Crisis. Due to the fact that it is pol ydrug they are working with methamphetamine as well. We have 11 offices in mexico right now. Our primary office is in mexico city and we are working with the Mexican Government daytoday to take out these methamphetamine labs. We are working with them in record seizures in the United States and looking at highvalue targets to be brought back to the United States and face justice. Sen. Hirono my time is up but i would like to submit a question. It is one thing to keep these drugs from coming into the country but another once they get here and whether they doing to prevent the use of drugs. Especially among young people. Sen. Kennedy mr. Mcdermitt, it seems we have got three problems here. People in china are addicting our people in america. America or rather people in mexico are addicting the American People. The United States government is addicting the American People. Senator durbin talked to you about the quota being 8 billion doses of opioids per year. Is that right . Dr. Gandotra by his math, yes. That is 25 vicodin tablets for every man, woman and child in america. If i take 25 vicodin over two weeks, i will get addicted, while i . Dr. Gandotra probably, sir. Sen. Kennedy so we can agree that the 8 billion is too high. Right . Dr. Gandotra i would not agree on that. Why can say is sen. Kennedy why not . Dr. Gandotra it depends on the medical use. Sen. Kennedy we understand the medical use. It is 25 vicodin tablets for every man, woman and child in america. You dont think that is too high . Mr. Mcdermott our quota is based on what we think is necessary for medical use sen. Kennedy i want im not trying to be rude, but you reach a point where patients ceases to be a virtue. You telling me we need 8 billion that is like nine zeros doses of opioids per year pretty American People. 25 for vicodin tablets lets say for every man, woman and child. That is your testimony. We need every single one of them. Mr. Mcdermott sir, i said the quota is appropriate for what we believe for the United States. Sen. Kennedy and so you think that is what we need. Mr. Mcdermott the quota we believe is appropriate for what i have discussed. Sen. Kennedy ok. I think youre saying yes. Is that right . I dont speak bs. You are saying yes. Mr. Mcdermott we believe the quota is appropriate. Sen. Kennedy let me ask you this. You get information about what pharmacists are prescribing, right . Quarterly and monthly in some cases. Getmcdermott we information on what distributors are disturbing to the pharmacist. Sen. Kennedy i think we just said the same thing. See that a pharmacy in a city with a population of 1500 prescribed 7000 vicodin tablets kind of tellsat you something, doesnt it. That is too many. That i mean we can agree that is too many, right . Mr. Mcdermott sir, we have the data that goes to the pharmacy. We do not have the data that goes out. Sen. Kennedy then why dont you go get it . Mr. Mcdermott we have to get that from the state. If we could ask for your assistance, we need that. That would be a game changer. Sen. Kennedy it doesnt seem to me that this is real complicated. If a pharmacist is writing scripts for 5000 vicodin tablets in box port where there are 1500 people, we got a problem. Mr. Mcdermott i agree. Sen. Kennedy so you send somebody in and say who in gods name is prescribing all of this and then you stop it. And if you dont stop it, you punish them the rest of their natural lives. Mr. Mcdermott i would agree. Sen. Kennedy why dont you do it . Mr. Mcdermott because we dont have that data. Sen. Kennedy you dont have the data. You dont have the data. Let me ask you something. I looked your record up. You a smart man. Me you have got to go out and educate doctors and pharmacists that if you take too many vicodin tablets, you get addicted . About evidencebased practices. You telling me theres a doctor in america doesnt understand that if you give somebody a six month supply of vicodin they are going to get addicted . We gotta educate him for that . Dr. Gandotra what we are talking about is enhancing medical School Curriculum. Provider curriculum. Sen. Kennedy i barely got through the part where you cut up a frog in biology. And i know that if you give somebody a six month supply of vicodin they are going to get addicted. Why dont we do something for the doctors that are doing this . They dont need evidencebased training. They been to medical school. Im over. Senatornstein blumenthal. Sen. Blumenthal as you have sensed, there is impatience and anger and fury about this Opioid Crisis. Youl due respect, url all are the messengers, not the policymakers. You have to take our message to you and i think you can sense that it is one of frustration. To say the least. As my colleagues have expressed, i dont think it is good enough have, we will work with you. Because that is what agencies have been saying to us, and may be partly the fault of the United States congress and if so, you should tell us. But this crisis has existed for some time. It is not suddenly rearing its head. Ago, back two years connecticuts rate of addiction was rising. So was its rate of death and overdose. 17 overdose was 10 deaths and that is expected to rise. Between 2012 and 2018, there was increase in opioid deaths in connecticut alone. So, i think there has to be an effort to hold accountable not only the mexicans and chinese but the manufacturers in distributors in this country. Raised a valid point. I have raised it numerous times since my children have all had athletic injuries and were prescribed 30 days of opioids and the first thing my wife and i did was tell them they were not getting any of it. Surgeryly had shoulder and was prescribed about the ime length of opioids and didnt even bother filling the prescription. Yet, there are now medical courses in medical school on Pain Management, so the medical profession is recognizing its responsibility. Andink the manufacturers distributors should be held accountable, too. In terms of the consciousness know you havee, i andecuted mexican guatemalan politicians, corrupt politicians who took bribes from. Artels in your view, has the level of corruption diminished over recent years . Ms. Liskamm depending on the country you are looking at, there are Different Levels of corruption. One reason i spend a great deal of time on those cases is when there is corruption, it allows the cartel to operate in that country carte blanche. But you haveal seen no diminishment of the levels of corruption . Ms. Liskamm i personally have not seen a diminishment that i have not been actively involved in those investigations in my current role. Sen. Blumenthal how to most of the cartels shipped their drugs into this country . Ms. Liskamm from my experience, ive had the opportunity to sit down with numerous members i should say former members of a cartel who are cooperating witnesses who have described routes such as tunnels that they spend 1 million to build under using a passenger vehicle or a truck that has hidden compartments through lawful ports of entry. Cases where ated boat which is basically a fishing boat with an outboard drugsis used to traffic along the Southern California coastline. The cartels will do everything they can to get drugs into this country. Sen. Blumenthal awol is not likely to stop them, correct . Wall is not likely to stop them correct . Ms. Liskamm i dont know. They use every port of entry they can to get drugs into this country. Sen. Blumenthal you have mentioned tunnels, water routes. None would be prevented by holding a wall. I recognize the limits of your appearance here but i do appreciate your testimony and those who have been here. Thank you all for being here. I didnt plan on asking this question, but i think i will start with it. When we think about the wall, which many people described as being this monolithic structure or fence or something along those lines, i understand we are trying to work on tunnel detection, capabilities, technology, particularly in california and other parts in the southwest. I believe we are talking about updating ports of entry with technology that can get to 100 scan of vehicles. Also building structures. Aboute had discussions funding the coast guard so they can beef up their efforts with the border. Do you believe that if we are ,ocusing on those tunnels having 100 scan at legal ports of entry, that concept of a wall would have a beneficial impact . Ms. Liskamm i think the department could use every tool to combat drugs coming to this country. I think all the tools you mentioned would be beneficial. Sen. Tillis mr. Mcdermitt, happy holidays. Something that i think is positive coming out of the dea and it has to do with the emphasis on prescribing schedule three opioids overscheduled to as they appear to be less addictive. I appreciate your efforts on that behalf. I am curious with the data coming out of your agency, i am not saying it is the same focus with the cdc and other agencies, do we have any idea when they will catch up with some of the policies you have already been moving and trying to provide sharehat the prescribers i share senator kennedys concerns. It does look like you are trying to emphasize they are opioids but potentially less addictive and less likely to provide a gateway. What about the rest of government, what is the progress to emphasize specific drugs . Mr. Mcdermott what i can say is we are working on a daily basis doj. Hhs and cdc, dear g what we do is to ensure what is best for the u. S. Citizens and i hear senator kennedy and senator durbin and assure them we will continue to work on it. I think we need all the agencies to catch up. Sen. Tillis you have done some good work there and you should be commended. I dont know who to ask this question. Is it is my understanding as speaker of the house trying to work on this, North Carolina is one of the states that has implemented policy to reduce prescribing opioids or minimizing the amount they are prescribed with some sort of oversight. It is my understanding a few years ago that one of the leading causes of suicide in this country are people experiencing chronic pain. Is that accurate . It is a major cause. I would not say the leading cause. Sen. Tillis one thing we are trying to balance if it has efficacy around this. It is one of the reasons why we prescribed them. It is a thoughtful perspective that individuals with chronic pain in particular may develop opioid dependence but not Substance Use disorder. Cdc has issued prescribing guidelines. Provide a little clarity. The goal is to provide improvement on those individuals who have Substance Use disorder and we are trying to up lament practices when it comes to our medical School Curriculum for treating Substance Use disorder. Not necessarily limited to prescribing practices. In response to one of senator kennedys questions you said you would like to have the data you do not have. Its not like you can just call up the state Health Department and say we need this information. You need some statute to do that. Is that correct . Mr. Mcdermott that is correct. Sen. Tillis and what does that look like . Mr. Mcdermott i would ask that you make the states have to provide us this information. So that would provide the site that you would like to have . Mr. Mcdermott we have to go on a state to state basis. As i said, in colorado, had to sue the states to get that information. Thank you. Evidence based prevention. I agree with that. We have to have treatment. We had to have recovery programs. Enforcement action to actually do that. Of thechairman appropriations committee, i prioritize these issues. 1. 3 billion in the fight against the Opioid Epidemic. 110 million for Rural Communities in the response program. 500 million in targeted opioid assistance. 89 million for medication assisted treatment for Prescription Drug and opioid addiction. I think that money is going to be a help. Disagree, please say so. I think the house members and senators of both parties who worked with me on that. Weve had a lot of progress in my state of vermont. We have one of the lower addiction,of opioid but we still have problems. The university of vermont, federal grant which is great, also in the burlington area. Edn we have those in higher rural areas. We dont want to see them drive two weeks or two hours each week for treatment. Should Health Care Professionals prescribe other drugs for addiction like they do for other medication . Im thinking of how we reach these rural areas. Certainly, it is integral as the final arbiter for products to tree opioid use disorder. We would certainly support any further expansion of rural treatment centers. Vermont was one of the first to implement the hub and spoke model, where individuals would initially get treatment at a treatment specialty site, a hug, then continue treatment in the community at a spoke center. Want to nottainly only do i appreciate that. Numberse brought our down below what some of the surrounding areas in the states have. Lets Work Together on this. We can talk about it and agree on it but we have to make sure it happens. The Chinese Government took some steps to prohibit sentinel fentanyl coming out. The sanctions have been put in place are they making a difference in the amount that is being shipped to north america . I can turn it over to justice if they have something to add. We have been seeing a decrease in direct ship into the United States. That is a positive step in the right direction. The two things we have to watch our indirect shipments into the United States. It comes from another state country like canada that we are not watching closely. An increase in the production of fentanyl in mexico and trafficking across the southwest border. Those of the two things we are placing emphasis on. While chinas actions have had an effect, we have to make sure they contribute to solving the problem. I agree with you. Excuse me. You mentioned the importance of antiheroine task forces. 2020 zerostration in doubt all funding for the antiheroine task force. Appropriated 3. 5 million. Force uses that in our state. These are important. Why have these not been considered in combating the Opioid Epidemic . Why is it zero doubt . I am not familiar with those figures but i can tell you that we have tremendous task forces and initiatives at doj that have come out over the past couple of years. We are working to help stem the tide on the epidemic. I am not familiar with that grant. Trying to you we are put resources where we are seeing results. I have further questions on that. Many of us republicans and democrats what to get that money in the bills. We can talk about it here but somewhere the money has to come. Often times we do add it in. It is more difficult. Thank you. Senator kennedy has asked for an additional 30 seconds. Mr. Mcdermott, i know you are new. I would like you to write me a letter explaining to me, in english, why every man, woman, and child in America Needs 25 doses of opioids every year. Dr. , let me say to you, i know you work hard at what you do. I have two brothers who are physicians. Docotors need to police themselves. You cannot convince me that someone smart enough to go to medical school does not understand that if they give someone a six month supply of vicodin they are going to get addicted. The doctors need to police themselves. Thank you, senator kennedy. We will release the first panel for the record. As we are setting up for the second panel i will go ahead and read the bios of our second panel. I want to think our witnesses for being here. Thank you very much. Dr. Ur second panel we have bradley stein. Patrick kelly, dr. Rhonda hauser, and sue tao. Is a policy researcher for rand corporation. Adolescentcticing psychiatrist and senior physician. Corporation and adjunct associate professor of psychiatry at the university of pittsburgh. Is the eighthlly Vice President of government affairs. He oversees all hda state and federal regulatory and political activity. Viceana hauser, is the president of government affairs. Operations for the Community Pharmacists association. Is that correct . Thaw. She has been involved in Substance Abuse treatment. I will ask you to hold your statements to one minute if possible. We will submit your entire statement for the record. Will proceed with questioning after that. Folks that have been called. If you could quickly move through your statement that would be helpful. Dr. Stein, lester with you. Good morning. In addition to my research i am a practicing psychiatrist in pennsylvania. Many of the children i treat our children of depression. The family has all been affected. Work has opened my eyes to how the opioid problem involves many systems. Many of the affected families have touched multiple systems. Parents on probation child welfare, public housing. The systems interact in complicated ways. I think understanding these interactions and the unintended consequences is essential if we are going to confront the crisis successfully. We have made Great Strides in curbing availability of pain pills. Some efforts have had unintended consequences. Some chronic pain patient from being tapered off quickly. Others have trouble finding a new doctor when theres retires. Decreasingfocus on hope we would spend at the same to making these individuals have access. To better Pain Management and treatment. Thank you, dr. Stein. Dr. Kelly. Good morning. Thank you for the opportunity to discuss how we are addressing the Opioid Crisis. Distributors do not drive demand for medicine. Industrys primary goal is to operate perfectly. The Drug Enforcement administration and Food Administration as well as state regulatory agencies. In order to handle controlled substances all must be properly licensed and have a valid dea registration. We look forward to working with the committee as you move forward to look at solutions. Dr. Has appeared houser. Numbers members identify possible overly utilization. To look at forgers. We disposed of and proper meds. Utilizing ovoid abuse toolkits. Advocating for great pharmacist access. I will summarize my recommendations. Dialogue withued all supply chains and continued Health Care Provider resources are important. Enhanced integration and data sharing. In cluing including prescriber systems. Haveed pharmacist manuals not been updated since 2010. I would encourage the dea to do so. Advancing the role of the pharmacist and medications treatment. Pharmacist should be optional disposal options. Thank you. Thao. S to stem the tide of the open wide epidemic emphasis needs to be focused on prevention. Starts misuse before it it is the most costeffective way. Through the implementation of Community Change that includes 12 required sectors being actively involved and also spans the supply and demand split. Implementeople to seven strategies for Community Change. These basically reinforce each other. They include everything from raising awareness through changing policy, practices, and procedures, providing support, tilting skills, and changing the physical design of the community. In communities that have undertaken these types of approaches they have seen dramatic reduction in Substance Use. The key to success that can be transferred from the dfc program to mitigate the opioid academic our building and maintaining multisector capacity in providing Technical Assistance and training. Ensuring that prevention is a major focus. Thank you. I would yield my time right now. Senator feinstein, if you want to add brief questions. No questions. Have but thank you for coming. Senator durbin. Just want to ask a question the distribution chain and the folks representing independent pharmacies. I used an example at the outset of a county with 4300 people that received 2. 7 million opioids. One pharmacy received it. Good question. The arcos process is supposed to keep track of it. The dea told us they get the information light if at all. Do you feel any Corporate Responsibility in your businesses to report something that on its face is so outrageous to Law Enforcement . We take our responsibility to report to the database seriously. It is a important issue for us. We are pleased with the new functionality that was put forward did mr. Mcdermott say it is a matter of months before they get the information . It is paired he said orr disimpression Distribution Company since so many opioids to the middle of nowhere illinois paired you believe responsibility ends contacting arcos . No, we have a responsibility to submit diversion. I hope that would mean you would contact Law Enforcement and say this is not right. Something just happened. We want to report it. You feel a responsibility to do that . Yes and Many Companies do. The pharmacy itself . There have to be people working there who may look at the back door and say, they delivered what . I will responsibility as to report to arcos. We were support to we report to the state monitoring level. The turnaround time varies. Some are every 24 hours. We support as frequent reporting as possible. Are on a roll call. We may have to chart. I respect you being here today. Thank you very much. Coming up on cspan, Supreme Court justice neil gorsuch. Ae Economic Committee Holding Hearing on the cost of raising a family. Washington journal live every day. Coming up friday morning, as part of office we, University African studies professor, carol anderson, discusses her book one person, no vote. Hugo garden will be on talking about conservatives in the trump presidency. Be sure to watch cspan washington journal live at seven eastern 7 00 eastern. Watch office we call this week starting at 8 a. M. Eastern. Supreme Court Justice neil gorsuch. He discusses the Judicial Branch aubs new book