Transcripts For CSPAN3 Federal Officials Testify On Fentanyl

Crisis. Around two decades ago, it started with the overprescribing of opioid drugs and shifted more to heroin. Today, the subcommittee examines the next wave of the Opioid Crisis and even more dangerous threat on our streets, fentanyl. Fentanyl is made in the lab and for many years it has been a powerful Pain Medicine used by patients with cancer or for those with extreme pain. I remember when i was injured in iraq a few years ago, Battlefield Medicine meant in recovery, they gave me lots of fentanyl patches. I know what its like to have the reaction to that. Its 50 times more potent than heroin. And 100 times more potent than morphine. Now, fentanyl has become a potent adticate to heroin, cocaine, or Prescription Drugs. This is way drug dealers stretch out their supply and spread out the number of addicts, sort of what people have done with msg in fruit. Users aunch dont even know that fentanyl is in the heroin. The fentanyl crisis is exceptionally dangerous because of its high potency and the speed with which it reaches the brain. Just two milligrams of fentanyl can kill, whether swallowed, inhaled or absorbed through the skin. To appreciate how small the amount of two milligrams. A sweetener packet here that you see at the restaurant table is about 1,000 milligrams. Two milligrams of fentanyl can kill you. Those suffering from an overdose involving fentanyl may require both higher doses and multiple administrations of naloxone to reverse the overdose and to become stabilized. Even the police and First Responders are at risk from inadvertently touching or inhaling fentanyl powder at a crime scene while helping an overdose victim. In march 2015, the Drug Enforcement administration or dea issued a nationwide alert on fentanyl as a threat to health and Public Safety. A year later, the d erka sent another alert calling the spike in fentanyl seizures an unprecedented threat. Customs and boarding protection data shows an 83fold increase in the amount of fentanyl seized in three years. An added challenge is there are many chemical variations of fentanyl currently referred to as analogs. There are about 30 known analogs. However, 19 of these are controlled substances under federal law. Since 2013, fentanyl overdosed and deaths have surged with no end in sight. Fentanyl and its analogs have contributed to at least 5,000 Overdose Deaths in the United States, including the death of music star prince last year. In my district alone, fentanylrelated deaths have exploded since 2014. Last year, 86 people in Westmoreland County died from drug oefr dosed linked add least in part to fentanyl. Even these statistics seriously undercut the threat nationally because most states in the counties are not testing or tracking fentanyl in Drug Overdose cases. So were flying blind. At this case, the capacity of Law Enforcement and the Health Care System will be overwhelmed. China is the primary source of fentanyl, and there are thousands of labs making illicit pure fentanyl as well as the source of ingredients or precursors needed to manufacture fentanyl. Traffickers ship these ingredients to secret labs in mexico run by drug cartels and then smuggle pounds of fentanyl over the southwest border through our porous borders, launching it through cat pults or drones and into the u. S. Chinese labs are also a primary source for fentanyl orders on the open internet and on the dark web. Pure fentanyl is delivered through the mail or air express carriers. Finally, china is the main source of pill presses that can make thousands of pills an hour to support fentanyl pill press organizations. I might add im pleased china says theyre taking action in helping to reduce this. We look forward to working with them because its so deadly. The fentanyl problem is spreading and is going to get worth. A kilogram of heroin can be purchased for roughly 6,000. And sold wholesale for 80,000. However, a kilogram of pure fentanyl can be purchased for less than 5,000 and is so potent that it can be stretched into 16 to 24 kill agrams of product when using cutting agents such as talcum powder or caffeine. Tlefrb, while each kill agram of fentanyl can result in a profit of 1. 6 million. Thats about 20 times more profit. We need a federal strategy dedicated to battling fentanyl as the clear and present danger it presents to our National Security and Public Health. We welcome our panel of Witnesses Today. We salute you for your work. Thank you for appearing today and look forward to working together to stop the spread of this epidemic. I recognize my friend from colorado, ms. Degette. Thank you. Every day somewhere in this country, theres a news account about how opioid addiction has racked a small town or family. Personal stories about americans who become addicted to pain pills and then they get hooked on heroin. These are heartbreaking stories about americans dying and leaving loved ones. Often their children, to pick up the pieces. The Opioid Epidemic is unprecedented and its escalating, and i think we all agree that we need a comprehensive strategy to confront it. In 2015, more than 33,000 americans died of an overdose involving a prescription or illicit opioid, and more than 2 Million People had an opioid use d disorder. Fentanyl is an Even Deadlier layer to this crisis. It can be up to 50 times more potent than heroin and 100 times more potent than morphine. Its lethal at even the tiniest amounts. And anyone exposed to it can be can have its detriments. You know, illicit fentanyl is not a new problem. What is new, though, is its growing prev lnls. Since 2010, fentanyl recovered by american Law Enforcement nationwide has risen 20 fold from 640 samples tested to 13,000 samples tested in 2015. According to information from the dea. U. S. Law enforcement, as the chairman said, believes china is the primary source of illicit fentanyl and precursor chemicals. Chinese producers ship fentanyl or chemicals to make it directly into the United States. Precursor chemicals or finished fentanyl is shipped to mexico and canada, where its trafficked across our borders in pure form or mixed with other illicit drugs like heroin. Today, we want to ask the panel some tough questions about Law Enforcement and diplomatic efforts to stem the tide of fentanyl flowing from china and whether theyre sufficient. Were also going to ask which vectors drug traffickers use to ship this drug into our country, like express consignment carriers and International Mail. I take this as another important step that this subcommittee has been taking to address the Opioid Epidemic, and for the record, i want to continue this bipartisan work. That said, mr. Chairman, i also think we need to find a way to address the treatment side of this epidemic and this is sadly where i have significant differences with my majority colleagues. Passage of the Affordable Care act, as you know, has led to nearly 20 million americans gaining Health Care Coverage. In addition, the aca has enabled governors to expand the Medicaid Services they offer, which was critical in states that were overwhelmed by the Opioid Epidemic. Studies estimate that since 2014, 1. 6 million uninsured americans gained access to Substance Abuse treatment across 31 states, like mine, that expanded medicaid coverage. This is particularly important for hard hit states like kentucky where one Study Reports that residents saw a 700 increase in medicaid beneficiaries seeking treatment for Substance Abuse. Two weeks ago, the majority rushed through this committee a bill to repeal the aca that many believe will threaten the progress that Medicaid Expansion has made in getting people suffering from addiction into treatment. In its assessment of the bill last week, the Congressional Budget Office said millions of americans, 24 million of them, will lose health coverage. Many of those will be people currently receiving medicaid assistance, which include people receiving treatment for opioid addiction. In january, Health Care Experts from harvard and nyu wrote an oped about how repealing the aca would reverse Important Health gains. They focused primarily on my baby, the 21st century cures act, which i did with fred upton and all of this whole committee. We approved it unanimously. But it really we could have a whole hearing just about how badly the gops aca repeal bill will hamper the progress that we just passed in 21st century cures. I just want to draw attention to one part of this oped, though, where the authors wrote, quote, repealing the aca and its Behavioral Health provisions would have stark effects on those with Behavioral Health illnesses. We estimate that approximately 1,253,000 people with Serious Health disorders and about 2. 8 million americans with a Substance Abuse disorder of whom about 222,000 have an opioid disorder would lose some or all of their insurance coverage. The end of the day, we dont know what kind of bill is going to reach the president s desk, but if we really want to address the Opioid Crisis, i suggest that we dont pass this very poorly thought out piece of legislation. I yield back. The gentle lady yields back. I recognize mr. Walden for five minutes. I thank the gentleman and thank you for holding this very important hearing. The Opioid Crisis as we know it touched every corner of our nation. Just like my colleagues, i met with community leaders, physicians, First Responders, Law Enforcement, and families on this issue. Each have shared their heartbreaking stories on the effects of this crisis on our communities. Addiction doesnt understand politics. It doesnt understand income. It doesnt understand race or where someones from. Its an equal opportunity destroyer. This crisis has hit close to home for all of us. Last congress, this committee worked in a bipartisan way to advance sweeping legislation to fight the nations Opioid Epidemic. An effort that actually began in this subcommittee which held a series of hearings to examine the growing problems of Prescription Drug and heroin abuse. We should be proud of those efforts, but as we will discuss today, theres a new threat emerging. Last year, there were encouraging reports that showed the number of prpgs for opioids in the United States had finally declined. That was good news. For the first time in 20 years, that had happened. Yet, we saw the number of opioid related overdose said and overdose related deaths continuing to surge upward. We ask why. Thats why were having the hearing today . Emerging data strongly suggests the main driver is fentanyl and its chemical variations. Fentanyl represents a third wave in the nations ongoing Opioid Crisis. Its why were here. Fentanyl is a more challenging threat within the Opioid Crisis, in comparison to threats of prescription opioids and heroin. The fentanyl threat is multifaceted. Its been produced as a legitimate pain medication by companies for decades but its also produced illicitly in china. Illicit fentanyl is hard to detect and unlike prescription pain killers it is not primarily diverted from the legitimate market. Nor is it strictly comparable to the black market of heroin. It can be purchased over the internet. Precurses chemicals used to produce fentanyl are shipped to labs in mexico. Drug cartels areali smuggling massive amounts of fentanyl across the southwest border. Drug traffickers in the United States not only are getting deliveries from fentanyl from china through the mail or express carriers but theyre also getting direct or indirect shipments from china pill presses that can make thousands of pills an hour to fuel their operations and Distribution Networks into our towns, our communities, and the lives of our citizens. Pure fentanyl is not considered a replacement drug for oxycontin or heroin. It is too potent. Just two to three milligrams can kill an individual. More often than not, its added into heroin, cocaine, or counterfeit drugs to boost the potency and increase the likelihood of addiction. Whats even scarier is people taking these drugs may not even know theyre taking fentanyl. Let alone what it is. Fentanyl makes the deadly threat of opioid abuse Even Deadlier. In 2014 and 2015 in my home state of oregon, a reported 49 people died from fentanyl. The number of deaths from fentanyl appears to be rising, and thats just what we know. As we work to combat this quickly evolving Public Health threat, theres an important question to be asked. How can we fight this threat when we dont even know how quickly it is spreading . Combatting this growing multifaceted threat will require more than drug control strategies aimed at opioid overprescribing and heroin. Fentanyl is a global problem that requires an urgent response. I commend the efforts of our government, ondcp, dea, and the state department particularly for their success in gaining cooperation with china and the united nations. We need to continue to support this International Engagement to be siuccessful. Like our work on the Opioid Epidemic last congress, it requires an all hands on deck effort. We need to think outside the box to find ways to top the surge of the fentanyl crisis. I look forward to your testimony and working with all of you to solve this problem and i yield the balance of my time to mr. Burgess. Thank you, mr. Chairman. Thank you, mr. Chairman for holding the hearing. I want to thank the dea and i think you have been into my office to talk about this issue in the past oneonone. It is of concern to me. I have been on the Health Subcommittee long enough that in 2005, we were having a hearing about why doctors werent prescribing adequately for pain. And now, the past two congresses, we have been concerned about the appearance of the Opioid Epidemic. Fent null not a new product. It has been around for some time. On the other hand, the analogs of fentanyl are relatively new, and its the fueling of the Illicit Trade with the ability to get things over the internet which i think has been probably the crux of this problem. We do have problems with the overseas market, with the way the supply comes in to our country. So i hope we can hear some insight this morning on perhaps some additional things that might be done to stop that flow. Thank you, mr. Chairman. I will yield back to the gentleman from oregon, who then yields back. Thank you. I recognize the Ranking Member, mr. Pallone, for five minutes. Thank you, mr. Chairman. The Opioid Epidemic in our country continues to grow at an alarming rate. In 2015, more than 33,000 americans died of an opiate overdose, and more than 2 million individuals have an opiate use disorder. 91 americans die every day from an opioid overdose. Today, were focusing on fentanyl, a powerful synthetic opioid that is 50 times more potent than heroin and up to 100 times more potent than morphine. Its a dirjs substitute for heroin and it results in frequent overdoses that can cause respiratory depression and even death. The number of Overdose Deaths is rapidly increasing. The death rate from synthetic opioids other than methadone increased by 72 from 2014 to 2015. This substantial increase in the death rate from synthetic opioids is largely attributable to the increased availability of illicit fentanyl. I want to thank our Witnesses Today for their testimony and work on this very important issue. Fentanyl is dangerous, not only to users but also to our Law Enforcement and Public Health officials on the front lines of this epidemic. I look forward to working together to explore ways we can better confront the supply of fentanyl now plaguing our communities. I also would like to talk today about the treatment side of the Opioid Epidemic. Just two weeks ago, Committee Republicans rushed trumpcare through the committee. A bill which repeals the Affordable Care act. The aca has been instrumental in addressing the current Opioid Crisis and inexcusably, trumpcare would only exacerbate the crisis. Thanks to Medicaid Expansion under the aca, 1. 6 Opioid Crisis<\/a> and even more dangerous threat on our streets, fentanyl. Fentanyl is made in the lab and for many years it has been a powerful Pain Medicine<\/a> used by patients with cancer or for those with extreme pain. I remember when i was injured in iraq a few years ago, Battlefield Medicine<\/a> meant in recovery, they gave me lots of fentanyl patches. I know what its like to have the reaction to that. Its 50 times more potent than heroin. And 100 times more potent than morphine. Now, fentanyl has become a potent adticate to heroin, cocaine, or Prescription Drug<\/a>s. This is way drug dealers stretch out their supply and spread out the number of addicts, sort of what people have done with msg in fruit. Users aunch dont even know that fentanyl is in the heroin. The fentanyl crisis is exceptionally dangerous because of its high potency and the speed with which it reaches the brain. Just two milligrams of fentanyl can kill, whether swallowed, inhaled or absorbed through the skin. To appreciate how small the amount of two milligrams. A sweetener packet here that you see at the restaurant table is about 1,000 milligrams. Two milligrams of fentanyl can kill you. Those suffering from an overdose involving fentanyl may require both higher doses and multiple administrations of naloxone to reverse the overdose and to become stabilized. Even the police and First Responders<\/a> are at risk from inadvertently touching or inhaling fentanyl powder at a crime scene while helping an overdose victim. In march 2015, the Drug Enforcement<\/a> administration or dea issued a nationwide alert on fentanyl as a threat to health and Public Safety<\/a>. A year later, the d erka sent another alert calling the spike in fentanyl seizures an unprecedented threat. Customs and boarding protection data shows an 83fold increase in the amount of fentanyl seized in three years. An added challenge is there are many chemical variations of fentanyl currently referred to as analogs. There are about 30 known analogs. However, 19 of these are controlled substances under federal law. Since 2013, fentanyl overdosed and deaths have surged with no end in sight. Fentanyl and its analogs have contributed to at least 5,000 Overdose Deaths<\/a> in the United States<\/a>, including the death of music star prince last year. In my district alone, fentanylrelated deaths have exploded since 2014. Last year, 86 people in Westmoreland County<\/a> died from drug oefr dosed linked add least in part to fentanyl. Even these statistics seriously undercut the threat nationally because most states in the counties are not testing or tracking fentanyl in Drug Overdose<\/a> cases. So were flying blind. At this case, the capacity of Law Enforcement<\/a> and the Health Care System<\/a> will be overwhelmed. China is the primary source of fentanyl, and there are thousands of labs making illicit pure fentanyl as well as the source of ingredients or precursors needed to manufacture fentanyl. Traffickers ship these ingredients to secret labs in mexico run by drug cartels and then smuggle pounds of fentanyl over the southwest border through our porous borders, launching it through cat pults or drones and into the u. S. Chinese labs are also a primary source for fentanyl orders on the open internet and on the dark web. Pure fentanyl is delivered through the mail or air express carriers. Finally, china is the main source of pill presses that can make thousands of pills an hour to support fentanyl pill press organizations. I might add im pleased china says theyre taking action in helping to reduce this. We look forward to working with them because its so deadly. The fentanyl problem is spreading and is going to get worth. A kilogram of heroin can be purchased for roughly 6,000. And sold wholesale for 80,000. However, a kilogram of pure fentanyl can be purchased for less than 5,000 and is so potent that it can be stretched into 16 to 24 kill agrams of product when using cutting agents such as talcum powder or caffeine. Tlefrb, while each kill agram of fentanyl can result in a profit of 1. 6 million. Thats about 20 times more profit. We need a federal strategy dedicated to battling fentanyl as the clear and present danger it presents to our National Security<\/a> and Public Health<\/a>. We welcome our panel of Witnesses Today<\/a>. We salute you for your work. Thank you for appearing today and look forward to working together to stop the spread of this epidemic. I recognize my friend from colorado, ms. Degette. Thank you. Every day somewhere in this country, theres a news account about how opioid addiction has racked a small town or family. Personal stories about americans who become addicted to pain pills and then they get hooked on heroin. These are heartbreaking stories about americans dying and leaving loved ones. Often their children, to pick up the pieces. The Opioid Epidemic<\/a> is unprecedented and its escalating, and i think we all agree that we need a comprehensive strategy to confront it. In 2015, more than 33,000 americans died of an overdose involving a prescription or illicit opioid, and more than 2 Million People<\/a> had an opioid use d disorder. Fentanyl is an Even Deadlier<\/a> layer to this crisis. It can be up to 50 times more potent than heroin and 100 times more potent than morphine. Its lethal at even the tiniest amounts. And anyone exposed to it can be can have its detriments. You know, illicit fentanyl is not a new problem. What is new, though, is its growing prev lnls. Since 2010, fentanyl recovered by american Law Enforcement<\/a> nationwide has risen 20 fold from 640 samples tested to 13,000 samples tested in 2015. According to information from the dea. U. S. Law enforcement, as the chairman said, believes china is the primary source of illicit fentanyl and precursor chemicals. Chinese producers ship fentanyl or chemicals to make it directly into the United States<\/a>. Precursor chemicals or finished fentanyl is shipped to mexico and canada, where its trafficked across our borders in pure form or mixed with other illicit drugs like heroin. Today, we want to ask the panel some tough questions about Law Enforcement<\/a> and diplomatic efforts to stem the tide of fentanyl flowing from china and whether theyre sufficient. Were also going to ask which vectors drug traffickers use to ship this drug into our country, like express consignment carriers and International Mail<\/a>. I take this as another important step that this subcommittee has been taking to address the Opioid Epidemic<\/a>, and for the record, i want to continue this bipartisan work. That said, mr. Chairman, i also think we need to find a way to address the treatment side of this epidemic and this is sadly where i have significant differences with my majority colleagues. Passage of the Affordable Care<\/a> act, as you know, has led to nearly 20 million americans gaining Health Care Coverage<\/a>. In addition, the aca has enabled governors to expand the Medicaid Services<\/a> they offer, which was critical in states that were overwhelmed by the Opioid Epidemic<\/a>. Studies estimate that since 2014, 1. 6 million uninsured americans gained access to Substance Abuse<\/a> treatment across 31 states, like mine, that expanded medicaid coverage. This is particularly important for hard hit states like kentucky where one Study Reports<\/a> that residents saw a 700 increase in medicaid beneficiaries seeking treatment for Substance Abuse<\/a>. Two weeks ago, the majority rushed through this committee a bill to repeal the aca that many believe will threaten the progress that Medicaid Expansion<\/a> has made in getting people suffering from addiction into treatment. In its assessment of the bill last week, the Congressional Budget Office<\/a> said millions of americans, 24 million of them, will lose health coverage. Many of those will be people currently receiving medicaid assistance, which include people receiving treatment for opioid addiction. In january, Health Care Experts<\/a> from harvard and nyu wrote an oped about how repealing the aca would reverse Important Health<\/a> gains. They focused primarily on my baby, the 21st century cures act, which i did with fred upton and all of this whole committee. We approved it unanimously. But it really we could have a whole hearing just about how badly the gops aca repeal bill will hamper the progress that we just passed in 21st century cures. I just want to draw attention to one part of this oped, though, where the authors wrote, quote, repealing the aca and its Behavioral Health<\/a> provisions would have stark effects on those with Behavioral Health<\/a> illnesses. We estimate that approximately 1,253,000 people with Serious Health<\/a> disorders and about 2. 8 million americans with a Substance Abuse<\/a> disorder of whom about 222,000 have an opioid disorder would lose some or all of their insurance coverage. The end of the day, we dont know what kind of bill is going to reach the president s desk, but if we really want to address the Opioid Crisis<\/a>, i suggest that we dont pass this very poorly thought out piece of legislation. I yield back. The gentle lady yields back. I recognize mr. Walden for five minutes. I thank the gentleman and thank you for holding this very important hearing. The Opioid Crisis<\/a> as we know it touched every corner of our nation. Just like my colleagues, i met with community leaders, physicians, First Responders<\/a>, Law Enforcement<\/a>, and families on this issue. Each have shared their heartbreaking stories on the effects of this crisis on our communities. Addiction doesnt understand politics. It doesnt understand income. It doesnt understand race or where someones from. Its an equal opportunity destroyer. This crisis has hit close to home for all of us. Last congress, this committee worked in a bipartisan way to advance sweeping legislation to fight the nations Opioid Epidemic<\/a>. An effort that actually began in this subcommittee which held a series of hearings to examine the growing problems of Prescription Drug<\/a> and heroin abuse. We should be proud of those efforts, but as we will discuss today, theres a new threat emerging. Last year, there were encouraging reports that showed the number of prpgs for opioids in the United States<\/a> had finally declined. That was good news. For the first time in 20 years, that had happened. Yet, we saw the number of opioid related overdose said and overdose related deaths continuing to surge upward. We ask why. Thats why were having the hearing today . Emerging data strongly suggests the main driver is fentanyl and its chemical variations. Fentanyl represents a third wave in the nations ongoing Opioid Crisis<\/a>. Its why were here. Fentanyl is a more challenging threat within the Opioid Crisis<\/a>, in comparison to threats of prescription opioids and heroin. The fentanyl threat is multifaceted. Its been produced as a legitimate pain medication by companies for decades but its also produced illicitly in china. Illicit fentanyl is hard to detect and unlike prescription pain killers it is not primarily diverted from the legitimate market. Nor is it strictly comparable to the black market of heroin. It can be purchased over the internet. Precurses chemicals used to produce fentanyl are shipped to labs in mexico. Drug cartels areali smuggling massive amounts of fentanyl across the southwest border. Drug traffickers in the United States<\/a> not only are getting deliveries from fentanyl from china through the mail or express carriers but theyre also getting direct or indirect shipments from china pill presses that can make thousands of pills an hour to fuel their operations and Distribution Networks<\/a> into our towns, our communities, and the lives of our citizens. Pure fentanyl is not considered a replacement drug for oxycontin or heroin. It is too potent. Just two to three milligrams can kill an individual. More often than not, its added into heroin, cocaine, or counterfeit drugs to boost the potency and increase the likelihood of addiction. Whats even scarier is people taking these drugs may not even know theyre taking fentanyl. Let alone what it is. Fentanyl makes the deadly threat of opioid abuse Even Deadlier<\/a>. In 2014 and 2015 in my home state of oregon, a reported 49 people died from fentanyl. The number of deaths from fentanyl appears to be rising, and thats just what we know. As we work to combat this quickly evolving Public Health<\/a> threat, theres an important question to be asked. How can we fight this threat when we dont even know how quickly it is spreading . Combatting this growing multifaceted threat will require more than drug control strategies aimed at opioid overprescribing and heroin. Fentanyl is a global problem that requires an urgent response. I commend the efforts of our government, ondcp, dea, and the state department particularly for their success in gaining cooperation with china and the united nations. We need to continue to support this International Engagement<\/a> to be siuccessful. Like our work on the Opioid Epidemic<\/a> last congress, it requires an all hands on deck effort. We need to think outside the box to find ways to top the surge of the fentanyl crisis. I look forward to your testimony and working with all of you to solve this problem and i yield the balance of my time to mr. Burgess. Thank you, mr. Chairman. Thank you, mr. Chairman for holding the hearing. I want to thank the dea and i think you have been into my office to talk about this issue in the past oneonone. It is of concern to me. I have been on the Health Subcommittee<\/a> long enough that in 2005, we were having a hearing about why doctors werent prescribing adequately for pain. And now, the past two congresses, we have been concerned about the appearance of the Opioid Epidemic<\/a>. Fent null not a new product. It has been around for some time. On the other hand, the analogs of fentanyl are relatively new, and its the fueling of the Illicit Trade<\/a> with the ability to get things over the internet which i think has been probably the crux of this problem. We do have problems with the overseas market, with the way the supply comes in to our country. So i hope we can hear some insight this morning on perhaps some additional things that might be done to stop that flow. Thank you, mr. Chairman. I will yield back to the gentleman from oregon, who then yields back. Thank you. I recognize the Ranking Member<\/a>, mr. Pallone, for five minutes. Thank you, mr. Chairman. The Opioid Epidemic<\/a> in our country continues to grow at an alarming rate. In 2015, more than 33,000 americans died of an opiate overdose, and more than 2 million individuals have an opiate use disorder. 91 americans die every day from an opioid overdose. Today, were focusing on fentanyl, a powerful synthetic opioid that is 50 times more potent than heroin and up to 100 times more potent than morphine. Its a dirjs substitute for heroin and it results in frequent overdoses that can cause respiratory depression and even death. The number of Overdose Deaths<\/a> is rapidly increasing. The death rate from synthetic opioids other than methadone increased by 72 from 2014 to 2015. This substantial increase in the death rate from synthetic opioids is largely attributable to the increased availability of illicit fentanyl. I want to thank our Witnesses Today<\/a> for their testimony and work on this very important issue. Fentanyl is dangerous, not only to users but also to our Law Enforcement<\/a> and Public Health<\/a> officials on the front lines of this epidemic. I look forward to working together to explore ways we can better confront the supply of fentanyl now plaguing our communities. I also would like to talk today about the treatment side of the Opioid Epidemic<\/a>. Just two weeks ago, Committee Republicans<\/a> rushed trumpcare through the committee. A bill which repeals the Affordable Care<\/a> act. The aca has been instrumental in addressing the current Opioid Crisis<\/a> and inexcusably, trumpcare would only exacerbate the crisis. Thanks to Medicaid Expansion<\/a> under the aca, 1. 6 Million People<\/a> with Substance Use<\/a> disorders now can receive the treatment they need in the 31 states and washington, d. C. That expanded the program. But trumpcare effectively ends Medicaid Expansion<\/a> in 2020. According to the cbo, trumpcare also cuts 880 billion in federal outlets for medicaid over the next ten years, which will severely undermine our efforts to fight the Opioid Crisis<\/a>. These drastic cuts in medicaid made possible by republican plans to end Medicaid Expansion<\/a> and cap the program will ration care for millions of americans. It also repeals essential Health Benefits<\/a> for expand enrollees at the end of 2019. States would no lodger to have offer Substance Abuse<\/a> help, or Prescription Drug<\/a>s to millions of americans who rely on such care. Repealing the essential benefits package effectively repeals the mental and Substance Use<\/a> disorder provisions of the aca and would remove approximately 5. 5 billion annually from the treatment of lowincome people with mental and Substance Use<\/a> disorders. Repeal will take away care from those who are actively seeking treatment and preventive services. We simply cannot afford to eliminate this care is what is often times a life or death situation. Trumpcare threatens access to life saving treatment for more than 1 Million People<\/a> with opioid disorders. Our hearing today explores the fentanyl problem. However, i would argue this issue is part of a much wider opioid problem were battling. To address this problem, we must make sure americans with Substance Abuse<\/a> disorders can access effective treatment. I want to work with you to confront fentanyl and the larger opioid problem. However, in my opinion, repealing the aca and cutting medicaid by nearly a trillion dollars over the next ten years will do nothing but undermine our efforts to treat americans who are suffering from opioid addiction. Will not be able to arrest our way out of this problem. Without adequate Treatment Options<\/a> for those suffering from an opioid addiction, this problem will only worsen, and so will the deaths and destruction we have seen play out across the United States<\/a>. I dont know if anybody wants my extra minute. If not, ill yield back. I thank the gentleman. He yields back. I want to offer for the record, an article from the Washington Post<\/a> called where opiates killed the most people in 2015. Has interesting maps of where these occur throughout the country. For example, synthetic opioid rates in West Virginia<\/a>, kentucky, and pockets in New Hampshire<\/a>, massachusetts, rhode island, and other aspects, which kind of tell us theres not one opiate epidemic but several, and no silver bullet. Were going to have to make sure whatever this committee does and finds today from our esteemed witnesses, we have to work in a way to give flexibility, maximum flexibility to the states to work this out. I ask unanimous consent that the members Opening Statements<\/a> be introduced in the record. Now, i would like to introduce our panel of federal witnesses for todays hearing. We start with mr. Kemp chester, acting Deputy Director<\/a> in the office of National Drug<\/a> control policy. Mr. Louis milione, for the Diversion Control Division<\/a> in the Drug Enforcement<\/a> direction. Matthew allen at the u. S. Immigration and Customs Enforcement<\/a> division, within the department of Homeland Security<\/a> or dhs. William brownfield, of state and National Narcotic<\/a> affairs. Dr. Debra houry, at the centers of Disease Control<\/a> and prevention. And dr. Wilson compton, Deputy Director<\/a> at the National Institute<\/a> on drug abuse within the National Institute<\/a>s of health. Thank you all. I want to thak all our witnesses for being here and providing testimony. Let me charge you with this, though, which i usually dont do. More people are dying of drug Overdose Deaths<\/a> than of guns. We have reached the point where more people are died of drug Overdose Deaths<\/a> than more deaths than the vietnam war. What youre going to tell us today is falling on ears that are open to anything you can offer us. The families in america, and you have heard the stories, the passionate stories from members here, stories of deep concerns, the numbers of deaths, the devastation in communities. What youre saying here is extremely important. We look forward to hearing from you on this growing threat of fentanyl. As youre aware, the committee is holding an investigative committee. Do any of you have any objection to giving testimony under oath . Seeing no objections, the chair then advises you youre under the rules of the house and the rules of the committee. Do any of you advise to be advised by counsel . I see none. Please rise and raise your right hand. Do you swear the testimony youre about to give is the truth, the whole truth, and nothing but the truth . Thank you. Youre under oath and subject to the penalties enforced. The United States<\/a> code. Well call upon you each to give a fiveminute summary of the written statement. Just watch the lights. Well begin with mr. Chester. Youre recognized for five minutes. Chairman murphy, Ranking Member<\/a> deget and members of the subcommittee, thank you for inviting me and my colleagues to discuss the Public Health<\/a> and Public Safety<\/a> issues surrounding the Opioid Epidemic<\/a>, particularly that of illicit fentanyl and what the federal government is doing to address this problem. I appreciate the committees strong support of our work to reduce drug use and its consequences. I currently serve as the acting director of the office of National Drug<\/a> control policy, which crafts the president s drug control policy and oversees all federal government counterdrug activities and related funding. This is a Critical Mission<\/a> because as you are aware, more than 52,000 americans died from a Drug Overdose<\/a> in 2015. Thats an average of 144 per day, with 91 of those deaths involving opioids such as prescription pain medications, heroin, and illicit fentanyl. Overdoses involving opioids have nearly quadrupled since 2000, and the number of deaths involving synthetic opioids other than methadone, a statistical category that includes fentanyl, has more than tripled, reaching nearly 10,000 in 2015. And this number is likely low because not every overdose Death Investigation<\/a> looks for fentanyl. The majority of the illicit fentanyl in the u. S. Is smuggled in after being produced in mexico or china. Both heroin and clandestinely produced fentanyl can be manufactured, packaged, and smuggled by the same Drug Trafficking<\/a> organizations. The reemergence of illicit fentanyl represents a complex problem. Its considerably more powerful than heroin. Its precursor chemicals are not fully controlled in other countries. Its being added into the heroin supply or pressed into counterfeit prescription opioid pain pills meaning users are often unaware theyre taking fentanyl. And because of its potency, it can be shipped in small packages and transactions that involve relatively low dollar amounts, making it much harder to detect. First responders and Police Officers<\/a> report that nay need to use much more than the standard dose of naloxone to reverse an overdose by fentanyl, which strains resources. We also have a limited capacity to treat those who habitualy abuse illicit opioids. Only one in nine people in the United States<\/a> who need treatment are receiving it. We have seen outbreaks in many states where fentanyl and other analogs have played a role in the waves of Overdose Deaths<\/a> that devastate communities. In short, illicit fentanyl is exacerbating an already challenging problem that the federal government is working extrely hard to address. The reality of this epidemic has led us to adopt new ways of addressing drug use and trafficking. Thats why the hard of our effort is the partnership between Public Health<\/a> and Law Enforcement<\/a>. Some of whom are represented here today to help address the problem in communities across the country. Were also working with our state Department Colleagues<\/a> to engage foreign partners to prevent illicit drugs from being manufactured and trafficked into the United States<\/a>. In terms of Public Health<\/a>, we are working to prevent new nishts to drug use by encouraging prescribers to use the cdcs guidelines and their state Prescription Drug<\/a> Monitoring Program<\/a>s, and emphasizing prevention efforts to deter drug use initiation, including the drugfree communities program. Were also working to expand access to treatment, including evidencebased medication assisted treatment for opioid use disorder and help people sustain longterm recovery. In this regard, we deeply appreciate congress support for treatment expansion through the funds authorized under the 21st century cures act. Another critical innovation is were helping to build new partnerships between local Law Enforcement<\/a> partners and the Public Health<\/a> community to end this crisis and establish routine cooperation between the federal government and the state tribal and local levels. In terms of reducing the availability of these drugs in the United States<\/a>, the federal governments efforts are centered on stopping illicit drugs before they cross our borders and dismantling the organization that traffic drugs into and throughout our communities. With omdcp, the National Heroin<\/a> Coordination Group<\/a> was created in october 2015 in partnership with the National Security<\/a> council to synchronize federal government efforts to reduce the availability of heroin and illicit fentanyl across the country and address gaps in redundancies and department and Agency Activities<\/a> through its interagency coordinated heroin availability Reduction Plan<\/a>, which addresses heroin and fentanyl as a single problem set. Ondcp also funds the high intensity Drug Trafficking<\/a> program that coordinates antiDrug Trafficking<\/a> intelligence across state, local, tribal, and federal Law Enforcement<\/a> communities, and in 2015, they developed the heroin response strategy, a coordinated effort across 20 states and the district of columbia in response to the heroin and fentanyl crisis. Internationally, were working with foreign partners like mexico, china, and canada to reduce the supply of illicit fentanyl, its precursors and its analogs into and across north america. While were working diligently to turn the tide on this epidemic, and perhaps are making some progress, we continue to work through numerous challenges such as detecting illicit fentanyls at our borders and our mail and parcel system. Working with our International Partners<\/a> to reduce the manufacturing and trafficking of heroin and fentanyl and finding and disrupting the internet marketplaces where illicit fentanyl is purchased and delivered. Could you finish up . Yes, sir. As the federal Government Works<\/a> to reduce the size of the opioid using population through prevention and treatment and reduce the availability of these drugs in our communities, your support for these efforts is critical to our success. Thank you, and i look forward to answering your questions. Thank you. Youre recognized for five minutes. Thank you, Committee Chair<\/a> murphy, Ranking Member<\/a> degette, distinguished members of the subcommittee. I want to put these overdose death numbers in some context. So spring is here today, and Major League Baseball<\/a> will kick off their season next month. Picture the mlb stadium in any of your respective cities. More than 52,000 americans we lost in 2015 to Drug Overdose<\/a>s would overflow any of those mlb stadiums bar one. Im sure we all agree this is an unimaginable tragedy. For the dea, the fentanyl threat and the broader Opioid Epidemic<\/a> are the number one drug threats facing our country. With illicitly produced fentanyl, you have substances many more times more potent than heroin, sold with heroin, mixed with heroin, and increasingly pressed into pill form on our streets as prescription pain killers. Here are five pills that represent five counterfeit pain killers. Based on Laboratory Analysis<\/a> of the thousands of seized counterfe counterfeit pills. 1 of every 5 will contain three times the lethal amount of fentanyl. Lethal at two milligrams. For the unsuspecting user, death is lurking in just one of these pills. Sadly, but not unexpectedly, mexican cartels are exploiting the opioid use epidemic and aggressively purchasing illicitly produced fentanyl from china, shipping it to mexico, mixing it with heroin and other substances and shipping it back into the United States<\/a> through established Distribution Networks<\/a> where its sold in our communities. Illicitly made fentanyl is also being shipped from china into canada for distribution across our northern border. Its also being shipped directly from china into the United States<\/a> for domestic distribution cells. Why are they doing this . Greed and a complete disregard for human life. There is a massive profit potential with fentanyl. One kilogram of pure fentanyl costs approximately in china about 3500. If you project it all the way through the supply chain to the distribution level, that 3500 kilogram will potentially yield millions of dolls in revenue. For the dea and broader u. S. Government to deal successfully with this threat, we need a balanced holistic approach. Most importantly, we must be proactive. We need to use any and all investigative techniques to identify, identify, and capture and convict all members of these criminal organizations both domestic and foreign. With 221 domestic offices and 21 field divisions and 92 foreign offices in seven countriecountr is well positioned to engage in this fight. Throughout deas proud history, our greatest successes have come from our collaborative efforts with our foreign counterparts. Our approach to this threat is no different. We have had success and we will continue to have success against members of these fentanyl manufacturing and Distribution Networks<\/a>, but heres the most frustrating part. Foreign based fentanyl manufacturers are the domestic pied pipers of this, often operate with impunity, because they exploit loopholes and capitalize on the lengthy resource intensive reactive process required to temporarily or permanently schedule these dangerous sebstances. Criminal chemists are dweek tweaking the structure of the fentanyl analogs keeping the same dangerous properties as the controls substances, but helping the manufacturers avoid criminal exposure because of an alters chemical structure. The dea has scheduled five. Four are currently in process. Were tracking 19 more. Scheduling actions are critically important, but theyre reactive, resource intensive processes. We will continue to do everything we can on the scheduling front, but in the short term, this esteemed body could provide dea and our Law Enforcement<\/a> partners immediate relief by placed the identified fentanyls and other dangerous substances into schedule one. This would allow us to keep these drugs out of our country and bridge to justice the egregious foreign traffickers preying on our youth and flooding the country with these dangerous drugs. I would like to end with two opposite and interconnected images. Sunlite and shadows. We will always operate in sunshine, we will reduce demand of our Community Outreach<\/a> and prevention efforts throughout the country, but we also have to operate in the shadows. We need to infiltrate these secretive organizations wherever they are here in the United States<\/a> or in foreign countries. We need to develop and collect the necessary evidence to bring those that exploit human frailty for profit out from the shadows and into the sunlight of our system for prosecution in the u. S. The brave men and women of dea will continue to do the necessarily difficult and dangerous work to address this threat. Thank you for the opportunity to appear before you, and i look forward to answering any of your questions. Thank you. Now mr. Allen, youre recognized for nooiv minutes. Chairman murphy, and distinguished members, thank you for the opportunity to appear before you today to discuss the heroin and fentanyl crisis in the United States<\/a> and the efforts of u. S. Immigration and Customs Enforcement<\/a> to target, investigate, disresult, and dismantle and bring to justice the criminal elements responsibility for manufacturing, smuggling, and distribution of dangerous opioids. As the largest Investigative Agency<\/a> in dhs, we enforce over 400 criminal statutes. Special agents use their authority to investigate all types of cross border activity and work in close communication with the Drug Enforcement<\/a> administration, in a unified effort with both domestic and international Law Enforcement<\/a> partners to target organizations supplying heroin and fentanyl to the United States<\/a>. Today, i would like to highlight our efforts to reduce the supply of heroin and fentanyl to the u. S. And the operational challenges we encounter. The United States<\/a>, as you have heard already, is in the midst of a fentanyl crisis that is multifaceted and deadly. Fentanyl is a schedule two synthetic opioid used medically for severe pain relief and its 50 to 100 times more potent to morphine. The United States<\/a> Law Enforcement<\/a> has identified two primary sources of the u. S. Illicit fentanyl threat. China and mexico. China is a Global Supplier<\/a> of illicit fentanyl, and chinese laboratories openly sell fentanyl. In china, criminal chemists work around their governments control efforts by modifying chemical structures to create substances referred to as analogs not referred to as illicit but having the same deadly effects. Although there is ongoing collaboration with china, there lack of current chinese laws that prohibit export is one of the challenges we face in stemming the flow of islicit fentanyl from china. Mexican cartels also require the fentanyl to manufacture fentanyl related substances from china and use fentanyl as an adulterant in heroin produced in mexico. The cartels have discovered manufacturing fentanyl is much more cost effective, efficient, and draws less Law Enforcement<\/a> attention than cultivating opium poppies to produce heroin. Fentanyl seized at our u. S. Southwest border is typically 5 to 10 in purity. Once illicit fentanyl is distributed in American Drug<\/a> markets, many people who use drugs, whether heroin or prescription pain pills are unaware of fentanyl in their narcotic. As fentanyl users and uses are more potent than the drugs they resemble, it readily used to overdosing. Its how we learn that fentanyl has been introduced to the local drug market. The demand for drugs along with fentanyl used in opioid production has led tcos to compete for a portion of the u. S. Drug market. Illicit fentanyl is not only dangerous for people who use the drugs but also for Law Enforcement<\/a> and First Responder<\/a> whose can unknowingly come into contact with it. Accidental skin contact or inhalation of the substance in Law Enforcement<\/a> activity or field testing of the substance is one of the biggest dangers and challenges we face in law f enforcement. In response to the dramatic increase of the opioids in close coordination with other departments and agencies developed the heroin availability and Reduction Plan<\/a> to reduce the supply of heroin and illicit fentanyl in the United States<\/a>. I. C. E. Has bib supporti harp since its inception. We have been coordinating with domestic and International Partners<\/a> and highlighting collaboration. Were engaged with the National Targeting Center<\/a> to identify shipment routes, targeting parcels that may contain fentanyl and fentanyl related substances and manufacturing materials that go into making pills in the United States<\/a>. Fully exploiting financial and other investigative analysis along the way. I. C. E. Is committed to battling the u. S. And fentanyl crisis that demands urgent and immediate average across Law Enforcement<\/a> in conjunction with experts in the scientific and Mental Health<\/a> communities. Thank you for the opportunity to appear before you today. Thank you very much. Now, mr. Brownfield, youre recognized for five minutes. Make sure your microphone is on, please. Thank you, chairman murphy. Ranking member degette. Members of the subcommittee. Thank you for the opportunity to appear before you today. The broad Interagency Panel<\/a> here today demonstrates that this is a health issue, a Law Enforcement<\/a> issue, and an international issue. This Opioid Crisis<\/a> is perhaps our worst drug crisis in 30 years. It kills tens of thousands of our fellow citizens every year. Illicit fentanyl is responsible for many of those deaths and virtually all of that fentanyl is sourced from abroad through foreign Drug Trafficking<\/a> organizations. To solve the problem, we must cut off international supply, and that is where my inl bureau comes into play. Our strategy is threepart. Work the neighbors, work china, work the united nations. First, we realize that most illicit opioids reaching the United States<\/a> enter through mexico and canada. Mexico produces more than 80 of the heroin consumed in the u. S. , and mexican heroin Trafficking Networks<\/a> introduce fentanyl into the supply chain. Since the start of the Initiative Cooperation<\/a> in 2008, we have developed a close relationship with Mexican Federal<\/a> Law Enforcement<\/a>. We have delivered hundreds of millions of dollars in border inspection, in Law Enforcement<\/a> equipment, training and capacity building, and intelligence exchange. Mexico invests 20 for every 1 of ours. Mexico has increased efforts to eradicate opium poppy, and we recently agreed to expand those efforts further. Canada is suffering its own Opioid Crisis<\/a>, although most of its heroin comes from afghanistan. We coordinate closely with canada to address a shared crisis insuring both governments have Statutory Authority<\/a> to address the problem and sharing realtime Law Enforcement<\/a> intelligence. And all three governments cooperate through the new north American Drug<\/a> dialogue. Where we share information on narcotics research, exchange best practices, and develop actions to protect our citizens. Second, we have expanded cooperation with china. A major fentanyl source country. In 2015, china moved to regulate 116 new synthetic drugs, and on march 1st of this year, it added four critical fentanyl analogs to its domestic control, including car fentanyl, sometimes described as fentanyl on steroids, 100 times more potent than fentanyl. We asked china to do more, but i acknowledge these steps by the Chinese Government<\/a>. They improve our ability to track and control fentanyl and other synthetic drugs entering the United States<\/a>. We are also using targeting, sanctions programs like the narcotics reward and drug kingpin authorities to target fentanyl traffickers. For nearly 20 years, the u. S. And china have coordinated Law Enforcement<\/a> policy through the u. S. china joint Liaison Group<\/a> on Law Enforcement<\/a>, and that dialogue produces valuable cooperation. Third and finally, were working through the u. N. System to regulate dangerous opioids and precursors throughout the world. I was in vienna last week for the annual meeting of the commission on narcotic drugs. The governing body for all u. N. Drug policy. By a vote of 510, the cmd approved our proposal to regulate two essential fentanyl precursors. The entire process took four months rather than the normal two years. And while the regulation will not stop illicit fentanyl production, it will be more difficult for criminals to obtain the chemicals needed to make it and easier for countries to prosecute them. We also support programs by the u. N. s drug control organization, unodc, to eliminate Opium Poppy Cultivation<\/a> and heroin production in afghanistan, mexico, colombia, and guatemala. Mr. Chairman, members of the committee, we have an international strategy. Were committed to that strategy. We Welcome Ideas<\/a> to improve that strategy. I have learned two lessons in 25 Years Engagement<\/a> in interNational Drug<\/a> policy. First, it takes decades to get into a drug crisis. And will take years of patient persistent effort to get out. Second, no strategy is so perfect it cannot be improved. Thank you, mr. Chairman. I look forward to the committees suggestions. Thank you. Doctor, youre recognized for five minutes. Chairman murphy, Ranking Member<\/a> degette, i would like to thank you for inviting me here today to discuss this very important issue. As the director of the National Center<\/a> for injury prevention and control at the cdc, i would also like to thank the committee for your continued interest in the prevention of opioid misuse and prevention. And overdose. As an emergency physician, i have seen firsthand the devastation all over the country. Drug Overdose Deaths<\/a> in the i year 2015, there were approximately 52,000 drug Overdose Deaths<\/a>, and of those, 63 involved an opioid. The large increase in deaths seems to be primarily driven from heroin and syntheticopeioids such as fentanyl. Fentanyl is an opioid analgesic 80 times more potent than morphine. Illegally manufactured fentanyl can be mixed with or sold as heroin and is fast acting. Overdoses can occur in seconds after consumption and an overdose is much more difficult to reverse because its so powerful. The rate of drug Overdose Deaths<\/a> involving fentanyl more than doubled from 2013 to 14 and some say its the dramatic effects of this drug more than others. Massachusetts experienced a surge ofope yod related deaths from 698 in 2012 to 1,747 in 2015. To examine this increase, the Massachusetts Department<\/a> of pub lg health requested cdcs assistance and an investigation. Cdc determined over 74 of the recent drug Overdose Deaths<\/a> involved fentanyl and recommended conducting outreach to high risk groups such as people recently leased from incarceration. The rise in overdoses are not unrelated. In ohio, cdc found 62 of fentanyl and heroin Overdose Deaths<\/a> were presided by at least one opioid prescription in the seven years prior to death and 1 in 5 people who died from a fentanyl overdose had an opioid prescribed to them at the time of their death. Cdc is committed to three strategies that comprehensively protect the Publics Health<\/a> and prevents all opioid misuse and Overdose Deaths<\/a>. The first approach is improving data quality and timeliness to better track trends, identify communities at risk, and evaluate prevention strategy. Cdc funds 12 states to improve tracking reporting of illicit opioid overdoses including fentanyl. Improved surveillance is crucial to identify faster identification, a response to spikes and overdoses leading to quicker, more tailored interventions. The second approach is supporting states and their efforts to implement Effective Solutions<\/a> and interventions. Cdc has funded 44 states and washington, d. C. For prevention efforts and surveillance activities. For example, we have funded ohio to use their Prescription Drug<\/a> Monitoring Program<\/a> to identify highrisk patients, and they have achieved full Data Integration<\/a> with kroger pharmacies as part of their integration of Electronic Health<\/a> records. Our third approach is to equip Health Care Providers<\/a> with the data and tools needed to improve the safety of their patients. To aid primary care providers in evidencebased prescribing practices, cdc developed and published the guidelines for prescribing opioids for chronic pain. In addition to the Critical Partnership<\/a> with states, cdc knows the epidemic required partnerships across specters andee have been working side by side with Law Enforcement<\/a>. We are working with the Drug Enforcement<\/a> agency to implement strategy and a personnel exchange. The heroin response strategy, which is funded by ondcp, and employed eight high Drug Trafficking<\/a> areas sets out for Public Health<\/a> and safety. Cdc is working to coordinate Public Health<\/a> workers on the ground. Successfully addressing this problem requires focused efforts in prevention. All three components, Law Enforcement<\/a>, treatment, and prevention, must Work Together<\/a> to reverse this dangerous threat. We each have a Critical Role<\/a> to play. Without effectively preventing more americans from developing opioid use disorder in the first place, we will never get ahead of the problem. Without prevention, more americans will require treatment, off often for the rest of their lives, and more will overdose. Thank you again for the opportunity to be here with you today, and for your continued support of cdcs work in protecting the Publics Health<\/a>. I look forward to your questions. Thank you. Dr. Compton, youre recognized for five minutes. Chairman murphy, Ranking Member<\/a> degette and members of the subcommittee, thank you for inviting me to provide an overview of how science can help us address the rise in fentanyl deaths. My name is dr. Wilson compton. As a physician and researcher, i have seen firsthand the devastating impact of the Opioid Crisis<\/a> on families and communities and have conducted numerous studies to better understand trends in opioid use and ways to respond. What is fentanyl and its relationship to the Opioid Crisis<\/a> . Fentanyl is high potency and fat solubility allow it to rapidly enter the brain, leading to a fast onset of effects, which increases the risk for addiction and overdose. Addiction in overdose. The emergence of fentanyl and higher synthetic opioids for control and supply. Since very small amounts can cause largescale damage to users as well as to Law Enforcement<\/a> and First Responders<\/a> who may come into contact with the drugs. Fentanyl is one part of the ongoing opioid overdose epidemic which also includes prescription opioids and heroin. While recent and federal and state efforts curb overprescribing of the opioids, and opioids continue to rise in fentanylrelated deaths. Efforts in this area are part of the broader initiatives are part of the office of drug control policy and the department of health and Human Services<\/a>. The population of people using fentanyl largely overlaps with those using heroin and the strategy is implemented to address the ongoing Opioid Crisis<\/a> to address fentanyl addiction in overdoses. Cochairs the opioid subcommittee of the department of health and Human Services<\/a> Behavioral Health<\/a> coordinating council and in this role, we help to coordinate inner agency efforts. So how is research helping to address the Opioid Crisis<\/a> . Nilea in support of the three medications that have been approved to treat open yoed addiction, all have strong evidence of effectiveness. Despite this effectiveness, only a traction of people of opioid addictions are treated with these medications. Due to limited treatment capacity, stigma, lack of provider training and cost. Neither research is helping to develop strategies to promote wider adoptions of the medications in a variety of settings. Number yating in Emergency Departments<\/a> has been helped to ensure that people in overdose are effectively engaged for the underlying opioid use disorder. Other studies have found that methadone while awaiting admission to the Treatment Program<\/a> reduces opioid use and increases the like hely hood of treatment. How can research specifically include our response to fentanyl. Through nileas Early Warning<\/a> system were supporting system to federal trends and hot spots such as ohio and New Hampshire<\/a>. In the first phase of the New Hampshire<\/a> study, for example, researchers reported that about onethird of fentanyl users knowingly used the drug and may seek out a certain deal or product when they hear about overdoses because they think it must be highly potent. What about overdose treatment . Although noloxone the crept standard dose is likely not adequate to reverse some overdoses from some opioids like fentanyl. In response were supporting research to have nal ox informulations and protocols. For instance, in partnership with the cdc, samhsa and the an latch an Regional Commission<\/a>, nilea is addressing opioid misuse in rural america. In addition, we are planning a Research Initiative<\/a> to study treatment expansion models resulting from the Additional Resources<\/a> provided to states via the 21st century cures act. Research is also under way to develop a vaccine for fentanyl, to keep fentanyl from entering the brain, thereby protecting against addiction and overdose. In summary, over 33,000 deaths from opioid overdoses occurred 2015 with nearly 10,000 involving synthetic opioids like fentanyl. Sciencebased solutions are available. Nida will continue to work closely with other federal agencies, both those here today and many others and Community Organizations<\/a> and private industry to address these complex challenges. Thank you. I look forward to your questions. Thank you, doctor. Ill begin with questions and ill recognize myself for five minutes. Mr. Chester, does the ondcp believe fentanyl is another wave of the Opioid Epidemic<\/a> . Yes, sir. It really is two things. I think it is an outgrowth of the heroin crisis and once fentanyl has found its way into the supply chain it represents a unique aspect of that particular so do we have a Strategic Plan<\/a> does the federal government have a Strategic Plan<\/a> to address that as a unique issue . We do. As i mentioned the heroin available Reduction Plan<\/a> included heroin and fentanyl as part of the problem set and that particular plan guides and synchronizes federal government activities against the opioid problem set, specifically fentanyl and heroin, yes, sir. Do you believe that with this unprecedented threat of fentanyl that we have a plan solidly in place as broad as it needs to be . I believe there is more to do based on the level of the threat . Dea has a level of priority and we have programs in place to deal with it, but as ambassador brownfield said theres always room for improvement based on the need for the threat. Based on the data that our Law Enforcement<\/a>s had International Mail<\/a> facilities in nine different airports in 2015 and 2017. I find it amazing that not one pack of fentanyl was detected out of 8,473 that were examined. Is it more difficult to coming up with shipments than we know of and what can be done to improve this . The detection of fentanyl at the land border and in consignment packages and it is a challenge that we continue to deal with. I think we have Better Success<\/a> in certain channels than we do in others. Because customs and Border Protection<\/a> gets advanced information from the express consignment companies, their ability to target packages that are inbound to the United States<\/a> is much better than our ability to target mail thats coming to the United States<\/a> because the universal postal union that we operate under does not mandate that International Shippers<\/a> including china and others provide information about packages and mail. So requiring that would help . Requiring that would help for the postal service. Who can ask this question . Where is it coming over the border in mexico. I understand there are places in california and arizona. Do we know, specifically . The two areas that we see is in Southern California<\/a> and southern arizona. The vast madge orijority has be detected. How do they bring it across . On bodies and people coming across the border at ports of entry. People walk across or people who come through legally through ports of entry, either way, illegal or legal are coming through. Legal. Where we are not detecting it is between the ports of entry. We are seeing it come in at designated points of entry and the arrests are being seen at ports of entry, but in other parts were not seeing it, when theyre across the border and theyre not picked up there. On the land border were not seeing it come into ports of entry and its through express consignment packages which generally is detected in the interior express consignment hubs where theyre cleared by cbp or International Mail<\/a> facilities designated around the United States<\/a>. Thank you. The most recent of febt nilrelated Overdose Deaths<\/a> is in 2014, am i correct . Or is it 2016 . We have data and we have released a Quarterly Report<\/a> through the National Center<\/a> for health statistics, and thats death data. I think that is really helpful with the funding that we received this past year. We stood up the Surveillance System<\/a> that looks at nonfatal data also, and that has been in place for six months that allows us to have data from Emergency Departments<\/a> to capture more quickly emerging trends. With all of that, do you think its underreported significantly . I do think its significantly underreported because medical examiners and reporters arent testing for fentanyl analogs and up to 20 of times and the type of drug is not reported and were working with the National Association<\/a> of medical examiners to improve death certificate reporting. In just a few seconds, its a scientific challenge. Can you explain how fentanyl is more dangerous than other opioids medically. The key issue is both its strength as well as fat solubility. Not only is it inherrently more potently where it exerts the respiratory depression which is what kills people. Well go for five minutes. Thank you. Thank you very much, mr. Chairman. As i mentioned in my opening statement, and i think we all agree the amount of fentanyl recovered for american Law Enforcement<\/a> has risen from 640 samples tested to 13,000 samples tested in 2015, would you agree with that statistic . I would. Not having them in front of me, but that sounds right. Its raised going up in crisis proportions, right . Thats correct. And have arrests for counterfeit pills or sources increased, as well . Id have to get back to you as far as its been an increase and weve been steady and aggressively investigating these networks. Think you would agree the amount of fentanyl recovery has been growing exponentially. It has. Dr. Compton, i want to ask you, because other opioids sometimes often lead to fentanyl use. Some have suggested that to stem the demand for fentanyl, we also need to treat opioid addiction because addiction drives the users to seek those other drugs that contains fentanyl. Would you agree . Yes, i think the fentanyl issue is most closely related to heroin addiction and its the very same people that used heroin that seemed to have the most trouble with fentanyl. And treatment, as we learned in many, many hearings in this Sub Committee<\/a> is important an important component in an addiction fight, is that right . Absolutely. We think expanding Treatment Access<\/a> is a key component of the attempts to address this. Based on i assume that youve had experience with opioids and with heroin, you just cant stop this by arresting people, would that be fair to say . Youve got to also have treatment. I think its key to point out that its the combined Public Health<\/a> and Public Safety<\/a> approaches that look most promising, so we look at models that include criminal justice systems as well as showing reductions in crime as well as Important Health<\/a> outcomes. Okay. But Health Outcomes<\/a> are a key part of that. Of course. And so this is what im concerned about when youre trying to treat opioid addiction as weve also learned in our many hearings in this subcommittee, its a comprehensive treatment that is very extensive. Wouldnt you agree with that . Yes. We certainly learned that the treatment needs to last quite a long time. It takes people a long time to turn lives around and recovery is not an instantaneous process. These drugs sometimes change the chemistry of the brain so that you have to have medicaidassisted treatment and other types of tools to be able to treat this, is that right . Yes. Nida research has demonstrated that. And some of the states that have been hit hard with the opioid and fentanyl epidemic, the Medicaid Expansion<\/a> that theyve been able to get has been able to help them really target populations for Addiction Treatment<\/a> and prevention. Would that be fair to say . Certainly treatment expansion is a shared goal for all of us and making sure that making sure the research we support is embedded in the Health Care System<\/a> thats essential. In the past two years after the passage of the Affordable Care<\/a> act, medicaid was now able to pay up to 50 of medication treatment in some of the hardesthit states. Is that right . I would really want to refer the specific questions about how medicaid is funded to the state officials that implement those programs or to cms. So youre not familiar how some states have been able to increase their treatment . Im certainly familiar with the states efforts to expand treatment in the last few years. Well, lets talk about ohio, for example. In Ohio Republican<\/a> Governor John Kasich<\/a> recently said, quote, thank god we expanded medicaid because that medicaid money is helping to rehab people and in fact, a february 6, 2017 pugh report added that ohio added 700,000 medicaid recipients under its expanded program and roughly a third were diagnosed with a Substance Abuse<\/a> disorder. According to the cbo, the republic and aca appeals proposal cut for medicaid over the next ten years. Would you disagree with any of those figures . Well, certainly, we are interested in research that can look at changes in the Health Care System<\/a>. Were partnering with samhsa to study would you agree, for example, that ohio added 700 new medicaid recipients and a third were with Substance Abuse<\/a> disorders . Those figures sound reasonable. Okay. What im worried about is probably pretty clear, if you reduce the Medicaid Expansion<\/a> that in states like ohio, kentucky, West Virginia<\/a> and other states that have been hard hit by fentanyl and opioid and heroin, that thats also going reduce the Treatment Program<\/a>s were able to give them. Thank you, mr. Chairman. We have to treat our way out of this and just a followup to what youre saying, do we have enough providers. We know that half the counties in america dont have psychologists and do we have enough trained drug treatment providers in america . We do not have enough to fully meet the needs and theyre not evenly spread across the country and thats why were engaging in the Rural Initiative<\/a> to address the shortages in rural areas. Thank you very much. I would just add to that. Treatment is important, and preventing people from needing Addiction Services<\/a> in the first place will also save the Health Care System<\/a> a lot of money and using safe describing practices. Thank you, mr. Chairman. We have seen the opioid and heroin epidemic ravage every part of our country. Even affluent areas of my home of Orange County<\/a>, california, are struggling over 200 deaths per year. Now we are witnessing a far deadlier iteration, fentanyllaced drugs. This incredibly powerful painkiller reserved for the most severe and acute pain are being added to heroin, cocaine and counterfeit drugs. As a mother of four young adults, it breaks my heart every time i see or hear of another life lost. Just last year a 19yearold from Orange County<\/a> overdosed after taking fentanyllaced cocaine. This epidemic again hit home when a dea investigation resulted in four arrests for an alleged fentanyl importation and distribution conspiracy in long beach. The dea reported that the men had over 30,000 esatol, fentanyl tablets and 13 kilograms of the narcotic. Mr. Maloney, i want to commend your agency for the investigation in keeping this deadly drug off the streets of Orange County<\/a>. Mr. Maloney, the making and distributing of pills have been disguised by molding the pills in a wide variety of counterfeit plans and colors. What are the most prevalent pill types being discovered . Thank you for the question. Its a pretty broad range, but oxycodone. Theyll mimic whatever is popular on the street, depending on the market and depending on the area. If there is a real market for oxycodone 30s, theyll replicate those and if its a powder than a capsule because they want to snort the substance that market will influence how they package it. What types of pill making machinery are most regularly associated with the count are fit operations . Theres a broad range to an inexpensive pill machine and ones that can produce 250,000 pills an hour. Some of them are hand heheld th could be easily used and its a broad spectrum. What are the sources of the counterfeit drugs . China is the primary source for the fentanyl and going into mexico and the networks are shipping the merchandise up into the United States<\/a> and what were seeing more and more is actually the pills for the counterfeit pills are being made in the United States<\/a> at different domestic transportation cells around the country. Thank you. Doctor, we understand the typical victim of a fentanyl overdose can be extremely hard to define since it does not follow structure or community locals. What did you tell us about Current Trends<\/a> and tendencies. Youre right. Were seeing it in all, and were seeing it in 25 to 44 and were seeing it in men. What i think is important is those people like in rail and, we saw a third of the decedents had had a prescription within the past 90 days from opioid and a third of those had had a high morphine equivalent prescription, can be cautious and people are getting exposed to opioids and then going on to fuel their addiction through heroin and fentanyl. Thank you. Mr. Chester, in recent months, fentanyl was first identified as a major problem in the northeast. Parts of the midwest and certain states like florida and maryland. What do you see as trends or directions of its spread . We have begun to see some indications that it was moved, and sacramento, california was the first one and that was a year ago and we had begun to see it move west and i think fentanyl found its way into the northeast simply because it was easier to mix into the powdered white heroin that was popular in the northeast United States<\/a>. Were beginning to see a pill form that mr. Maloney was discussing, as well. Fentanyl even though it began being geographically concentrated in the northeast weve seen indicators in the areas throughout the United States<\/a>. I yield back the balance of my time. Mrs. Katz, you are ridiculousoided frecognized for five minutes. It does feel like were in the Twilight Zone<\/a> though because as were talking about the seriousness of the Opioid Epidemic<\/a> we are faced in two days with a vote on a health bill that will recede in this countrys responsibility and Health Services<\/a> to families who are addicted. Who needs Substance Abuse<\/a> treatment and Mental Health<\/a> treatment and mr. Chester, you said that only one in nine are receiving treatment who need it. Mr. Maloney, you say we have to reduce demand as part of a balanced strategy and yet, this Gop Health Care<\/a> bill thats coming to the floor will take a hatchet to coverage for millions of americans, plus it will and medicaid Health Services<\/a> as we know it that provide in florida and most states the most important Mental Health<\/a> and Substance Abuse<\/a> Health Services<\/a>. So this is very important, but boy, this bill thats coming up for a vote would really take us backwards when were talking about opioids. In fact, one of my local sheriffs in pinellas county, st. Petersburg in clearwater says we cannot and we never will solve the problem at the Law Enforcement<\/a> level. This needs to be treated as an addiction problem, a Mental Health<\/a> problem and we may have Great Success<\/a> in beating back the pill mills and all that meant is well see a switch to different drugs and different dealers, and i wanted to highlight whats happening in West Virginia<\/a> because it is startling and there is a good Investigative Reporter<\/a> thats shining a light on it. Mr. Maloney, according to a december 2016 article in the charleston gazette mail, it appears to be in far excess of what communities should have received based on sound medical needs. The article says, quote, in six years drug wholesalers showered the state with 780 million hydrocodone and oxycodone pills while 1,728 West Virginia<\/a>ns fatally overdosed on those painkillers. The shipments aimed to 433 pain pills for every man, woman and child in West Virginia<\/a>. This reporting strongly suggests that West Virginia<\/a> was receiving high quantities of oxycodone pills that would clearly be more than what would be medically necessary. Mr. Maloney are you familiar with West Virginia<\/a> was grossly oversupplied with dangerous prescription opioids . I am. This is really shocking. It would appear that addiction to pain pills can, according to all of the reporting and what you all have testified here today, that once you have oxy and hydrocodone that takes over someones life that that will quickly lead to the user seeking more powerful powerful opiates such as heroin or counterfeit pills both of which may be adulterated with fentanyl. Dr. Harry, in your testimony, you say reversing the epidemic requires changing the way opioids are prescribed. Is it reasonable to assume that addiction to Pain Medicine<\/a>s can be the fept nil problem and the larger Opioid Epidemic<\/a> . Yes. Many of the people who have overdosed on fentanyl have had opioid prescription at the time of their deaths. So i believe all of these fentanyl, heroin, and prescription opioid deaths are linked and mr. Maloney, msnbc ran a story about the substantial influx of opioids into West Virginia<\/a> reported on a small town called kermit which i understand only has 392 people. They reported that kermit received 9 million hydrocodone pills in two years. If this reporting is true, its hard to believe that we have sufficient systems in place to spot dangerous trends. Is the dea familiar with the reports of what happened in this small town with the over supply of addictive pills and what can you tell us about it . Im familiar with that report and its happened in many looks across the country. So we r an obligation across the whole supply chain from the manufacturers. Whats happening with the wholesalers . The wholesalers have to uphold their regulatory obligations and weve taken action recently against two of the big three, mckesson and cardinal. Our hope is that there are compliance programs like good corporate citizens would work to prevent diversion and they would uphold the obligations and its not just wholesalers. We have to go down the supply chain to maintain this closed system of distribution. Its certainly complex and its a challenge and were well aware of the issues across the country. Thank you. My time has run out. Dr. Burgess, you are recognized for five minutes. Let me stay with you, if i can and i dont know if we can get this map of the opioid deaths of 2015 on the map. The map is almost counterintuitive to me. Thats not the one and its the total opiate deaths for the purposes of illustration, thank you. Almost counterintuitive, six of the states with the lowest numbers. Go back one slide, please. Six of the states with the lowest numbers, of those six are border states. Texas, california, north dakota and montana which would be counterintuitive if we talk about things that are coming in across the border, but also if you look at the map, boy, it seems like theres a bullseye on the midwest, and what are you doing to sort of interrupt those supply chains that seem to have targeted a portion of the country . Thats a great question. Youre right. Its transiting in and its not staying at the border where it crosses and its going to locations across the country and the northeast is getting hit and the northwest is increasingly getting hit and the west is getting hit. What are we doing . Were applying Law Enforcement<\/a> techniques and were working with our federal partners and infiltrating the supply chains and trying to disrupt them with the judicial process. Let me ask you a question, and any time we have the panelists thats a good thing, so thank you for being here today. Just for the record, you are career at the state department, is that correct . I am, congressman. Thank you for your service to the state department. Of course, the secretarys in china or has been in china recently. Your testimony today, your written testimony is that you provided in your verbal testimony kind of indicated that perhaps things were looking up, things were there were positive developments, and i guess im just not feeling that there are positive developments, and in fact, mr. Maloney, please dont arrest me, but i went online and looked at how to order fentanyl online just while we were sitting here and there are a lot of opportunities, and i suspect those opportunities, many of them come from asia ore come through china. Do you think were doing enough to interrupt those . Congressman, ill say were starting very close to pointe 0 in terms of our cooperation with china. We have moved in a positive direction. We are dealing with a country that has somewhere between 570,000 companies that produce pharmaceuticals somewhere in the peoples republic of china. Two or three years ago there was no control over their production whatsoever. Since then, 116 synthetic drugs are now controlled by the Chinese Government<\/a> and within the last month and a half, literally, within the last month, four new ones including important fentanyl analogs are now controlled by the Chinese Government<\/a>. We have a dialogue. We are talking to one another. Three years ago their answer which, by the way, was not unusual around the world. We do not have a fentanyl problem and therefore we are not particularly interested in cooperating with you because it is not being abused in china. Weve gotten beyond that. Are we where we want to be . No. Of course not. What you have prove sen we have not yet solved the problem, but are we in fact, ahead of where we were two or three years ago . On that i say yes. I agree with you that is a positive development, but given the distributional aspects on our United States<\/a> map, is it possible, and really, its for anyone on the panel, is it possible to identify from which laboratories or manufacturing houses overseas, which are causing us the greatest problems in these areas that were seeing on our United States<\/a> map . Does anyone have an answer for that . Congressman, thats a great question and to build on what ambassador brownfield was saying. We have on the Law Enforcement<\/a> side in china and the beijing country office, tremendous success getting leads from the chinese of u. S. Based recipients of their fentanyl and thats a huge step forward and it allows us to uncover the network in the United States<\/a>, and yes, weve had successes uncovering what those labs are in china and weve been working with our Law Enforcement<\/a> counterparts over there and were very pleased with the direction its going. Well, and just with the limited time i r remaining, dr. Compton, most of you talked about fentanyl use patterns and im a big believer in the Prescription Drug<\/a> Monitoring Program<\/a>s. Look, i was a physician. Its important to have drugs like fentanyl available and were grateful for the utility and clinical settings and clearly, they have to be used appropriately, but do you have a sense of what i was talking to the dea and the state department about do you have a sense of where the use patterns are occurring . Are you able to target limited resources so that perhaps an er can have one of these Early Intervention<\/a> programs and if youre a hot spot, i think thats a good idea and if youre out in lubbock, texas, that might not be as important. In ohio we were able to do that and we found eight counties that had highest rates and were able to help guide ohio to where to focus their efforts and then in massachusetts we saw that there was a high rate of Overdose Deaths<\/a> and those that were recently incarcerated 50 times than what we saw in other populations and we were able to use the data for that accident Prescription Drug<\/a> Monitoring Program<\/a>s you can very much see opioid disorder and use that to help link. Are you . What were doing right now the program has been in place for two years and we are in 44 states and getting data thats better and quicker able to be better used by states and letting states focus on evidencebased interventions. Im way over time and honestly, we authorized it back in 2005 and it shouldnt have been recently and it this have been an ongoing exercise in my opinion, thank you, mr. Chairman upon. Thank you, i yield back. Thats where you mentioned this tremendous prescription rate, massive amount, and i would put up another chart here of disability rates with the United States<\/a> and dont you know, the areas in West Virginia<\/a>, are among the highest in the nation. What dr. Burgess pointed out, the deaths occurring there, and it makes me wonder if youre talking about collecting more data, how you how much more data do you have to have . Youre seeing these targeted areas where the amount of prescriptions is way, way out of control, and you can see on the map its way out of control and these deaths are occurring. Are there any teams going into these places and identifying who is writing the prescriptions and the deaths that come from this . Weve been sending teams to ohio and massachusetts, and rhode island and giving specific information to the states . I did a site visit myself out there to West Virginia<\/a>. Weve been working with each state to look at the Prescription Drug<\/a> Monitoring Program<\/a> and if you look at the guideline, 18 states have adopted or implemented aspects to help with safer prescribing in their states and we are starting with significant improvements and you see things like kentucky through our cdc funding and with the press dripgz Drug Monitoring Program<\/a> has an alert for high morphine equivalents to make sure people are getting safer prescriptions. You are recognized for five minutes. Thank you, mr. Chairman. I want to thank all of our witnesses and this has been a very important issue and it is an important fight for our communities and obviously, the Law Enforcement<\/a> piece and figuring out how we can stop the entry into our country of the components of fentanyl and very important, but i want to say again, and its been said many times before, this is also a very Serious Health<\/a> issue, and to my republican colleagues, as we face this vote thats coming up on thursday we have to recognize the importance of the medicate program its the second biggest payer for drug abuse treatment in the United States<\/a> and it funded roughly 25 of public and private spending on drug abuse treatment if 2014. We talk about West Virginia<\/a>, were talking about a lot of lowincome people, and medicaid is really the source of help for them. For my home state of illinois, medicaid has been absolutely vital to extend Substance Abuse<\/a> and provide treatment and Medicaid Expansion<\/a> has provided coverage to 650,000 lowincome adults in illinois, and nearly onethird of whom have Mental Health<\/a> or Substance Abuse<\/a> disorders. Thats just the typical percentage over the country. Without medicaid, these individuals would be more likely to end up in Emergency Rooms<\/a> or jails that would drive our cost for state and local budgets and it is also clear that illinois, we need to be further expanding access to Substance Abuse<\/a> treatment, and im sure thats the case in many other states around the country, from 2014 to 2015, illinois saw 120 increase in the number of deaths from Drug Overdose<\/a>s, and so, you know, the Republican Trump<\/a> care proposal would decimate the Medicare Program<\/a> with one and four people in illinois, one in four people in illinois. The republican bill would then Medicaid Expansion<\/a> and impose a per capita cap on funding and i dont want to go on more about that because its been certainly addressed. Doctor compton, wouldnt you agree that solving the fentanyl and opioid addiction problem requires that we also ensure that people have access to appropriate Substance Abuse<\/a> treatment . Certainly given that the underlying issue is an opioid use disorder, treatment is a key component to solving this problem. Dr. Ari, in your testimony you stated that, quote, the rise in fentanyl, heroin and Prescription Drug<\/a> involved overseas are not unrelated. Im sorry. Overdoses, not overseas. Im going to say that again. The rise of fentanyl, heroin and Prescription Drug<\/a> involved overdoses are not unrelated. Would you agree that in order to solve the fentanyl crisis we must also ad and address the larger opioid Prescription Drug<\/a> epidemic . Yes. I think a very comprehensive approach is needed and prevention is a key aspect of that. I wanted to also ask dr. Compton, how harmful would it be for a patient with an opioid disorder to is to discontinue his or her Substance Abuse<\/a> treatment. One of the keyest predictors of relapse and recidivism is stopping treatment and when people stop treatment abruptly, their extraordinarily high risk of the addiction problems as well as criminal behaviors and other serious problems. I am very concerned and im also on the Budget Committee<\/a> and we know that theres been proposed an 18 cut, in hhs and 5. 8 billion cut in the National Institute<\/a>s of health, which my understanding is that youre actually doing some research, and i dont know if the right word is vaccine and some sort of prevention is something that would against opioid addiction. Is that true . We even have research specifically targeting fentanyl where the development of a vaccine might lead to an approach that could keep the fentanyl from getting into the brain. The goal is to keep it in the circulatory system so you get antibodies that attached to fentanyl and keep it out of the game that exerts the dangerous effects. I want to thank all of the people who are here today testifying how youre trying to stop it before it starts and understand all of the sources, but i also am interested in the Health Services<\/a>. Thank you. I yield back. The gentle lady yields back. And the chair recognizes mr. Walter for five minutes. Thank you, mr. Chairman. I want to thank you for your learned testimony and the answers for our questions. The threat mr. Chester described to us is the third wave of the Opioid Epidemic<\/a>. It seems to me that individual states and ive looked at the maps and some are facing fentanyl headon right now, and it looks like in other areas it hasnt hit or at least not in the deadly effect and the Prescription Drug<\/a> and heroin overdoses, so i guess my question is are we better off to look at this as sort of a state by state basis and i realize there are National Implications<\/a> and there are real hot spots in the states and so when we think about a strategy here to combat it, it shouldnt be multiheaded and look at this Opioid Epidemic<\/a> in that way and look at all of the above or a sort of of a one size fits all. What from your experience would work best . Congressman, we look at it as a complex, National Security<\/a> Law Enforcement<\/a> and Public Health<\/a> issue at the National Level<\/a> and then at the state level there are unique environmental factors that cause different manifestations of the opioid problem and as you correctly point out, there is fentanyl in some states more than it is others, and in others there is heroin and weve seen evidence in some places that heroin deaths are preponderant. And in the implementation of our plans we do two things. Number one, we try and respond to unique aspects of that states environment, but also develop a framework to share Lessons Learned<\/a> from one state to another. So things that certain states have found to be successful in dealing with their particular aspect of the problem, can it be shared about other states who may not be facing that particular problem, but may see it in the future. Thank you. Ambassador brownfield, first of all, i want to commend the state department and the good work that you all have done and commend the dea for your work in helping gain the recommendation of the march 16th effort by the u. N. Commission on narcotic drugs in favor of controlling two primary fentanyl precursors, and i want to thank the chinese, too. Ive met with the ambassador and weve sent them a letter thanking them for their work to shut down some of the facilities. What do you hope will be the impact from the recommendation on the problem in the u. S. What can we expect out of that . First, at the risk of shamelessly pandering to you, congressman, may i thank you for your letter to the ambassador. It makes my job enormously easier when they hear directly from you. What do we expect from the cmd decision to control the two precursors . First, wee another roughly 170 and 168 days before it is fully implemented. This is a period of time during which the roughly 185 Member States<\/a> of the u. N. Who are also part of the cnd are have endorsed or ratified the treaties and have the right to seek an exception. I do not expect anyone to seek an exception to the ruling because the vote was unanimous. It was 51 to zero. When it comes into effect, the countries that produce these two precursors, the two most prevalent precursors in the production of fentanyl in the entire world will be required to control, register, license and verify production of these precursors there. Which two countries are those . I mean, the two precursors and the most important country is china which, in fact, did support not only vote for, but did support and assist us to some extent in lobbying for the passage. So what will happen at that point in time is whenever a company, any company in the world is going to export either of these two precursors, the government of the country where it is produced will be required to notify the National Authorities<\/a> of the country to which it is being exported, and it will have to provide the basic data and information, how much, when, who is the receiving party route by which it will be shipped that then allows the national authority, and in this case it might be hsi or i. C. E. Or dea to determine what is coming in and doing the Due Diligence<\/a> to verify this is a legitimate and legal shipment. This is why i said in my oral statement this is a way to shut down the diversion of legal and illicitly produced fentanyl. The state of oregon and elsewhere tried this with methamphetamine to get it the precursor ingredients and it made a big difference when you put pseudoephedrine behind the counter and required a prescription. Boy, that just changed the whole dynamic in terms of the individual cooking operations that were polluting homes and killing people and so i commend you and the state department and the governments that were involved for taking this step. We look forward to being partners with you going forward, and i yield back the balance of my time. You are recognized for five minutes. Sorry about that. Problem with the mike. Thank you, mr. Chair. I am quite satisfied were holding this hearing today because it is literally a life or death issue for my constituents. In my hometown of amsterdam, new york, a Small Community<\/a> of 18,000 people we had four Overdose Deaths<\/a> and another dozen treated overdoses in the month of december alone. If that rate of carnage were maintained for an entire year, one in every 375 individuals in my hometown would perish. These overdoses were all attributed to fentanyl. One in 375. When you drive down the interstate in my district, instead of billboards advertising for mcdonalds or taco bell, you see billboards advising you to call 911 in case of an opioid overdose. Last year i had the opportunity to witness a clinic where people were taking the first steps to recovery that raised the arbitrary limits on the patients a doctor could treat for opioid disorder. Bearing witness from the Success Stories<\/a> fuels my drive to push for policies that will expand the recovery opportunity for everyone. Thats why i found it astounding that in all of the witness testimony today the word medicaid was mentioned just twice and both times in the context of Prescription Drug<\/a> Monitoring Program<\/a>s. We can talk supply reduction all we want, but you simply cannot talk about a federal response to the Opioid Epidemic<\/a> without talking about medicaid which is the largest payer for Behavioral Health<\/a>care services in our country. In new york, medicaid pays for 38 of all medicationassisted treatment for opioid use disorder. In new jersey, its 22 . Pennsylvania, 29. Indiana, 17. I could go down the list, but youd get the point and as my colleagues have vaguely pointed out, there is a huge elephant in the room here, the Trumpcare Bill<\/a> the house will be asked to vote on later this week will be the single most devastating piece of legislation to individuals struggling with in our nations history. Trumpcare would eviscerate treatment for those struggling with opioid addiction by ending the Medicaid Expansion<\/a> and repealing guarantees of Mental Health<\/a> and Substance Use<\/a> benefits and gutting medicaid to the tune of 88 on 0 billion over the next ten years alone. You dont have to take my word for it. A professional society representing over 4300 professionals in the field of addiction medicine wrote to congress saying we are concerned that rolling back the Medicaid Expansion<\/a> certainly sunsetting the ehb requirements for Medicaid Expansion<\/a> plans and capping federal support for medicaid beneficiaries would reduce coverage for an access for Addiction Treatment<\/a> services and changes that will be particularly painful in the midsts of the finance structure to cap spending on Healthcare Services<\/a> will certainly reduce access to evidencebased Addiction Treatment<\/a> and reverse much or all progress made on the Opioid Crisis<\/a> this year. The Liaison Group<\/a>, an Umbrella Organization<\/a> for groups involved in Mental Health<\/a> ask substance wrote and i quote, the aaha would leave without coverage the 1. 3 million childless, nonpregnant adults with serious Mental Illness<\/a> who were able for the first time to gain coverage under Medicaid Expansion<\/a>. It would also leave uncovered the 2. 8 million childless nonpregnant adults with Substance Abuse<\/a> disorders who gained coverage under expansion for the first time. Current ohio governor, governor kasich, quote, thank god we expanded medicaid because that medicaid money is helping to rehab people. Former Arizona Governor<\/a> jan brewer, no ones idea, of a bleeding heart liberal wrote and i quote, it affects our most vulnerable, our elderly, disabled, our childless adults and our chronically and mentally ill and it would devastate their lives because theyre dealing with an issue that is very expensive to take care of as a family with no money. I could go on, but you get the point. I would, mr. Chair, like to order into the record placed entered into the record this letter from 415 addiction groups nationwide opposing trumpcare for the devastating impact that trumpcare would have on treatment for the Opioid Epidemic<\/a>. Without objection. Thank you. Mr. Chair . From my Vantage Point<\/a> there is no one outside of a threeblock radius outside of the Capitol Building<\/a> that thinks trumcare is better than a raging dumpster fire. Certainly no one thinks this back room bill will improve the lives of those struggling with the disease of addiction and with that i yield back. The gentleman yields back. I do want to reference the gentleman, the article, i dont know if youve seen it from the Washington Post<\/a> , the important takeaway is theres not one Opioid Epidemic<\/a> and solving the problem would require no nuance blanket solutions on the war on drugs and to overdose, and it would have massachusetts. I want to make sure that we working to the so states can have the flexibility to do what they do and i will continue to work with you on that. Thank you. Ill recognize mr. Carter of georgia who is himself a pharmacist. Thank you, mr. Chairman. Thank you all for being here on what is obviously a very serious subject. I want to start by talking about the legal, if you will, marketing of febt nil. We talked about it some during this hearing. One of the questions i have. I know that i cant remember who it was that mentioned that youre working with the wholesalerses with cardinal and mckesson in trying to make sure that theyre doing their part and accurately pointed out that you need to follow it all of the way through the supply chain and i can tell you as a practicing pharmacist thats very important and we need to make sure that happens. Have you been in contact with any of the manufacturers, jansen, or mylan makes a generic about how mauch theyre able to manufacture and put on the market . What were not seeing is a largescale widespread diversion of legal fentanyl. Right. Its diverted for personal use, mostly. Were dealing with the clandestinely produced fentanyls. And we do have it for issues that come up and were happy to work with them. Thats good. And thats important for a couple of reasons and i would be remiss if i didnt point out that one of the problems we had at the dispensing level is not being able to get enough of the product so the people who truly needed it, the Cancer Patients<\/a> and those truly in need of it, we would run short of it because they put monthly limits on it of that sort and we werent able to get it and that wasnt a tragedy and i hope we keep that in mind as we go along. One of the things that i was involved with as a member of the Georgia State<\/a> legislature is the yearly update of the dangerous drugs and one of the problems we always had was trying to identify the analogs and i know that has to be a challenge. Thats got to be a challenge here and one of my other colleagues mentioned about the precursors to it and how we control that. One of the the abuse substances that i was always chasing was synthetic marijuana. I would identify it and add it into the each year into the dangerous drug list and then the next year theyd come out with something else, and i went as far as trying to identify the molecular structure and saying anything with this and still, it is just so difficult. Can you can you address that . Sure. I mean, thats the synthetic threat outside the fentanyl threat which is significant is massive. Weve identified about 400 different substances and its a misnomer to call it synthetic marijuana and a synthetic cannabinoid and a whole other series of synthetics and this is a major problem for us and the same chemists tweaking the molecular structures of fentanyl are doing the same when we schedule those cannabinoids. Very dangerous, one hit can send someone into a coma or have some kind of violent reaction and its a big problem for First Responders<\/a> and its a devastating problem because it is sold legally. Absligolutely. Weve had five deaths in my district, in glen county because they were buying it at the convenience store. We cannot keep pace on the cannabinoid absolutely. Were just chasing our shadow. First ever all, from what im being told from some of the drug agents particularly in georgia, part of the problem, too, is just with marijuana coming over and some of it is laced with fentanyl. Thats a big problem. Full disclosure, i am a big, big opponent to the legalization of marijuana. I think its just a gateway drug, but nevertheless, that seemed to be a problem, too. Before i want out of time i want to get to a subject thats important to me and thats mailorder drugs and mailorder prescriptions coming through the mail and being delivered to patients houses and thats when we find out so much and listen, mr. Chairman, one of the biggest culprits, the va. In georgia, three out of the five facilities that deliver drugs through the mail are the va clinics and that is a concern and something we need to address. We have opioids coming through the mail, being delivered, left on the front porch of someones home not even having them sign for it. Just leaving a box there. How much of a problem have you found with the drugs that are coming through our mail system . Well, on the va issue, we have a number of open investigations and were trying to work cooperatively with the compliance departments at the va nationally and the headquarters also and those are areas of significant concern. And i think thats distinguished from the trafficking of counterfeit drugs that are often moved through the mail when representative burgess talked about going online, there is just a plethora of Online Pharmacies<\/a> that are appearing to sell legitimate pills when, in fact, they are counter fifeit. I see im out of time and i do want to say that that is a problem. Ye need to look at, mr. Chairman, this committee and this Congress Needs<\/a> to be looking at mail order prescriptions and whats going through our mail now and i yield back. Let me ask the gentleman who is a pharmacist along those lines then. As pharmacists who see that, perhaps you would be picking up patterns of as a pharmacist and you would notice as a massive amount coming through and you would not see that on a mail order system at all. You would be completely blinded, am i correct . In other words, pharmacies that are mailing through, if theyre legitimate, they should be keeping records of whats going out, yes. The gentle lady from florida was offering in West Virginia<\/a> which is ground zero for this. That pharmacy may not see it if people are out of the area. Especially if its more than one, and the pbms, and the pdmps, sorry, that helps tremendously especially if we can do it overstate lines. That is a tremendous help. Weve just recently started that in georgia, but florida is one of the states thats still not doing and thats a big problem down there. Thank you. Recognize the vice chairman, mr. Griffith for five minutes. Thank you very much, mr. Chairman and i want to thank thenethe witnesses for being here and i want to refute some things that i heard today and one in particular, and i think were comparing apples to oranges which were trying to bring in fentanyl and opioid abuse into the debate over whether you want obamacare, Medicaid Expansion<\/a> or the American Health<\/a> care act, and in fact, what ive heard repeatedly is that somehow Medicaid Expansion<\/a> has helped to solve this problem, but the map of deaths of opioid use that we saw earlier that dr. Burgess put up and ive got a paper copy here shows thats fsht the case. I think its apples and oranges. I dont think it caused opioid abuse, and i dont think it will solve it on its own and i dont think the American Health<\/a>care act will solve it in and of itself on its own, but when you look at the states where the deaths are, you know, if youre just going to play games with number, the expansion states seem to have more deaths than the nonexpansion states. Do i think thats fair . No, i dont. I think thats horse hockey, but i think that what my colleagues on the other side of the aisle have said about us causing problems by voting for the American Health<\/a> care act is irrelevant to our discussion today. With that being said, you mentioned the an latch an Regional Commission<\/a> and thats my turf, in part, and i represent the Appalachian Region<\/a> and it spills over into my district, as well. I certainly remember a terrific meeting in West Virginia<\/a>. Its a lovely town that convened a group from all across the Appalachian Region<\/a> to improve the Public Health<\/a> infrastructure and determine how good a job that will do to address the Opioid Crisis<\/a> in rural parts of the country. It will be cofunding this along with samhsa, the cdc and of course, nida taking the lead on it. We appreciate it because it is a significant problem and one of the issues there that we have to look at is whether or not the folks started off because its a high area for disabilities, as well and people have done for years and a lot of hard, manual work and they get a prescription and then they get hooked. Dr. Howry, you indicated in ohio, at least, that 62 of the people who died from heroin or fentanyl had in the last seven years had a Prescription Drug<\/a> for an opioid. Can you talk more about that . Sure. Weve been seeing this in many states like in rhode island, a third of the people who had overdosed on fentanyl had an opioid prescription within three months and a third of those had had a high dose opioid prescription showing that people that are on prescription opioids get addicted to opioids and can then go on to overdose from heroin or fentanyl. And sometimes their prescription runs out, but theyre hooked. Is there some way we can connect the doctors recognizing that maybe the patient has gotten hooked to get them the help because if the prescription just ends and nobodys alerting anybody, arent those a lot of the folks going out and buying it illegally on the streets somewhere . I think thats why we have the cdc prescribing guideline where we did talk if you have a patient that you suspect opioid use disorder about the importance of linking them to treatment, and one of the things that ive been really proud about the work cdc is doing is although were funding the state to do whats most important for the states, each month we do Technical Assistance<\/a> calls to help provide assistance on wher to focus resources and what are the best evidencebased treatments and convening to share the best practices. As we are seeing things immerge in different states we can do that. New hampshire was number 20 one year for overdoses. The following year it was number five. We need to give states the flexibility but we need to have that overall approach. Thank you. I would be remiss while i think marijuana is a dangerous drug you say fentynl is your number one concern. Why dont we let there be more research on marriage on whether it is epilepsy or pain. While i think it is a dangerous drug i dont think it is as dangerous as other opiods. In response to that we approve any approved research along those lines. Well konlt to work with researchers and we support that. And if i might the problem is the schedule one drug makes it tougher than if it were a schedule two like opiods. Mr. Malone for five minutes. Thank you. The Affordable Care<\/a> act through the expansion of medicaid extended Health Insurance<\/a> to others in urgent need of treatment for opiod use. Im concerned if the money is cut for medicaid which is what they said would happen with the republican bill patients could lose access to care and it could make the problem even worse. Dr. Compton, in your testimony you state that opiod will need treatment for many years. What could happen to a patient if their treatment was interrupted for example because the patient no longer had Health Care Coverage<\/a> for Substance Use<\/a> disorders. We do know whether it is intentional or unintentional the risk of relapse is extraordinary. Thank you. Some estimate nearly 1. 3 Million People<\/a> receiving treatment for disorders thanks to medicaids expansion. Should it be repealed we would expect the opiod crisis to worsen. Dr. Compton, again, if peemt who are currently being treated were to lose coverage would we expect the numbers including opiod containing fentynl increase . Okay. I just use West Virginia<\/a> as an example because it was very hard hit or is very hard hit by the opiod epidemic. It has the highest overdose death rate in the naks. Let me ask him i dont know if im pronouncing it right right there. Yes. And dr. Compton, that same article has added 173,000 adults to the program. West virginias Medicaid Enrollment<\/a> is now 573,000 people which is about a third of entire states population according to the article. Dr. Compton also reported in 2015 the first year West Virginia<\/a> expanded medicaid the number of people in treatment for Substance Abuse<\/a> jumped from 16,000 to 27,000. The increased use of Medicaid Services<\/a> was suggested thousands of West Virginia<\/a>ns went without needed treatment prior to medicaids expansion. Would that be a fair assumption . Certainly when we think about states like West Virginia<\/a> i point out the rural aspects make it complicated to deliver services. Im proud we are able to implement this in rural areas. It would appear to me medicaid is essential which would include the growing problem. I guess myquestion, again, is if West Virginia<\/a> were to lose these services would we expect that the opiod problems would worsen assuming they were loss of medicaid coverage, those people . I cant speak to the implications of the coverage issues but certainly for individuals who are being treated it could be very dill tear use. The problem that i see is that the republican bill with regard to the expansion eliminates essential services guarantee. What we have found in the past is a lot of times when you dont have that kind of guarantee the first thing to go is behavioral services, things that are expensive. Many states didnt provide until we said that they would have to. I just think that between the cut backs that would occur because states would be getting less money, youre going to get less money. They dont necessarily have to cover people depending upon their income. You know, as they reduce the Medicaid Expansion<\/a> population and then even with traditional medicaid or any kind of population if theres no guarantee of essential services then, you know, the first thing that often is cut back is treatment for drugs. Thats my fear. Thats why i think this is devastating if we are dealing with fentenl. And other problems that we have. Thank you. The way we focused ton dangers to children, to the environment, what we are not talking about in the country is danger. We talk about the overdoses, and now seeing the incredible increase in overdoses. Can we talk a little bit about how truly dangerous fentenyl is. I realize we use it in medical procedures but having just been with Law Enforcement<\/a> and firefighters there are dangers, are there not . Thats part of why youre doing training. I want to z you, can you talk to us about why havent we, far long time now talked about the incredible danger because i dont think addicts and their families really have understood how incredibly dangerous it is. I would say we have been. It is making awareness to our personnel, to Public Safety<\/a> personnel and generally what they could be encountering. It changed how we do some of our work. One of the investigative techniques we have done historically is to purchase drugs, whether it is online or doe mesically we have stopped doing that because of officer safety concerns that could be inherent to an under cover agent buying drugs or state and local officer buying drugs and not necessarily knowing what they are purchasing. There is also for the field testing. Gone are the days of agents, you know, pulling out a pocket knife and probing a package of suspected drugs and putting that into a test kit. We particularly at dhs has taken the lead on trying to examine, explore and field nonintrusive testing that would allow us to go to a place where agents dont have to physically open a package in order to determine what the substance is inside. Why is there a surge . What is your dea and i know you have been at this for a long time, but what would you say is the cause behind the surge that we have been seeing . It is free market principals applied to the opiod epidemic and cartels that are exploiting that. They aggressively market. They dont have to deal with massive bulk of heroin and get so much more profit out of that. So thats one of the things. But they dont care that its killing their customers . In a perverse its very callous but its the cost of doing business. Unfortunately theres a perverse some times reaction when people overdose from high poet si fentenyl. It some times attracts more atengs to that product. Any idea what the stats are how many cases we have been charging, federal cases where we are actually procuting drug traffickers for causing death . I would have to get back with you but we are doing more and more of those, death resulting cases, working with u. S. Attorneys office. We are engaging trying to get them to lean forward and work cooperatively on that. And i guess part of the challenge maybe for a u. S. Attorney is that coroners are not keeping track of and going into that much detail on the cause of death which could be a problem. Should we be asking or requiring coroners to do a better job on that aspect . I think its a resource issue oftentimes they dont have the labs. They have to send it out which is additional funding that they need. Besides the labs what kind of resources would they need to do the testing besides a heroin death or fentenyl death . They would need the lab to distinguish the tine of analog. It is really the testing for the laboratory and training as well. Thank you. I yield back. Thank you mr. Chairman and thank you to the panel. It is clear from your testimony and questions that you live in a world thats difficult, frustrating, challenging, ugly but youre doing a great job for us. We appreciate that. My home state of michigan shares over 700 mile of land and water border with canada as part of the longest border in the world. Does dea have precise data on how much is coming in directly from canada . We have the data as to whats been seized. Theres a certain flaw in that. We dont know exactly whats coming in. We know what we have seized and we can get the statistics to you. There are net wovgs finding any way to get it in. Having flown over the entry into lake erie and seeing the creative and amazing ways that people will find to cross that water border and seeing the efforts by Customs Border<\/a> patrol as well as isis and others to intradikt that i would agree it is probably very difficult. Significant amount coming across in. Significant in that its one of the main threat streams, canada across our northern bo border. Do you have any information how much has entered from canada an are there hot spots along the northern border . What the dhs components have seized the primarily coming in through consignment and mail, not necessarily along the physical land border with canada. Consignment and and mail. Okay. Mr. Allen, in your written testimony you mentioned that isis met with canadian officials to share trends and targeting strategies. Can you talk a little bit more about this effort and does your agency intend to expand the coordination with canada . Well, we work along with the department of state and dea in that effort. We were meeting with canadian counter parts, as you have heard today. I do think that expanding the exchange of information with both source and transit countries is going to be part of how we improve what we do and recognizing that some of what makes its way to the United States<\/a> or other places is in the same stream that makes its way to canada and mexico as well. Its great to have a border neighbor. Generally we can work pretty well with them. One of the things that distinguishes the relationship is that the canadians have come to us and talked about them having a very similar and significant problem that we are. The bill would require shipments through our postal system to provide electronic advanced data and whats in it before crossing our borders into the u. S. Mr. Allen, how would this information help better target illegal drug shipments to keep these dangerous elements out of our communities . It would assist Border Protection<\/a>s by giving them advanced information they could use at places like the National Targeting Center<\/a> to be more effective and more efficient in targeting mail comesiing to the United States<\/a>. My understanding is through negotiation lead to provide more timely information. Are there additional steps congress should consider along with that taking to assist efforts to identify and stop these shipments . Anyone . Thank you mr. Chairman. Thank you for allowing me to ask the questions. This is such a very important issue. It effects all of our districts. A lot of people aware of opiod abuse what resources are available for communities who want to get the message out . I think thats important. If you answer that question i would appreciate it. Yeah. Kind of the components of how we are dealing with this is to prevent issues to provide treatment to those and stop the flow of the drugs coming in the United States<\/a>. It is Prevention Program<\/a> foe cussed on needs of individual communities. Local communities require local issues. It is focused not only to raise awareness but to prevent primary drug use focused on the demographic of 13 to 17 years old. It is a very effective program. Okay. Very good. As you mentioned earlier china announced intentions to ban and manufacture and sell four additional types. Can you discuss our working relationship to prevent entry and sell . Our relationship on the Law Enforcement<\/a> working level has been tremendous. Our administrator met with counter parts. They provided us leads of domestic based distributors with fent fentanyl. Certainly it could expand. I echoed that. It is about seizures made on their way to the United States<\/a>. We have been able to use that information to identify other individuals and organizations that have received shipments from the same points in china. And finally, if i could add one more. Please. A little over a year ago we reached a bilateral understanding with the Chinese Government<\/a> they would control the delivery of products from china to the u. S. Even if they were not controlled in china if they were controlled in the u. S. In exchange for which we made the same commitment to them. It is not enforceable in any sort of organization but it is an agreement we made between ourselves. You mentioned the cdc giving the tools in how opiods are used and prescribed. Can you discuss how communities can take advantage of these tools . Absolutely. One is through education we have been work on safe prescribing practices. We also had continuing education w webinars. With the guidelines itself i know you have to have something you can use. We have a checklist thats been downloaded more than 25,000 times by providers to use and also have a mobile app on our phone and how do you talk with a patient about whether or not to give an opiod a calculator on whats the appropriate and safe dose of an opiod to give. We also piloted a Community Education<\/a> program and awareness around the risks of opiods and cities that were hardest hit. I like to talk to you about possibly coming to my area if you havent already. I would welcome that. Thank you very much. I yield back, mr. Chairman. Closing comments . Certainly nobody thinks that the shocking increase in opiod and heroin use have in any way related to the aca and we recognize some of those areas where we do have the expansion are the areas which are the red on the map. Thats quite disturbing. Our point though is if we hope to treat these folks that are getting addicted to opiods it is important they have access to medical treatment. Thats why we are concerned if the Medicaid Expansion<\/a> is retra retracted i have a letter dated march 20, 2017 which talks about the Medicaid Expansion<\/a> in oregon and how many people would lose their Medicaid Expansion<\/a> and treatment if the republican alternative passed this week. I would like to ask unanimous consent to put a copy of that letter into the record. Without objection. I yield back. Okay. Just a couple of other questions i have. Do you have any idea how many federal agencies deal with Substance Abuse<\/a> across all spectrums, all departments . I do not have that answer off the top of my head. I would like to follow up with you, if i can, on that. You can. I will. They said probably 112 or probably mfrmt i dont know how many there are. I know one of the things this committee did in our Mental Health<\/a> bill was coordinate these. It is a question that i want you all to let us know as well as getting back to us that what you would suggest. And they pointed out disability and unemployment rates may be very different from massachusetts or utah. I wanted to make sure states have full flexibility. I want to say lets get into this. Well get an answer into this together. Thats letter we sent february 23rd with several questions. Any idea when you will expect answers to that . Yes. The letter is complete. It is in final clearance. We hope to get it to you this morning. Thank you for the letter. Yes. Thank you. I want to thank all of the members and remind members you ten Business Days<\/a> to submit questions for the record so the witnesses have time to respond to those. And with that i thank the witnesses. This is a very important hearing and very critically important issue. We look forward to working with you. With that this hearing is adjourned. This weekend on American History<\/a> tv on cspan3 Benjamin Bankhurst<\/a> on how stereo types have","publisher":{"@type":"Organization","name":"archive.org","logo":{"@type":"ImageObject","width":"800","height":"600","url":"\/\/ia600603.us.archive.org\/26\/items\/CSPAN3_20170325_000000_Federal_Officials_Testify_on_Fentanyl_Addiction\/CSPAN3_20170325_000000_Federal_Officials_Testify_on_Fentanyl_Addiction.thumbs\/CSPAN3_20170325_000000_Federal_Officials_Testify_on_Fentanyl_Addiction_000001.jpg"}},"autauthor":{"@type":"Organization"},"author":{"sameAs":"archive.org","name":"archive.org"}}],"coverageEndTime":"20240627T12:35:10+00:00"}