Transcripts For CSPAN2 Senate Judiciary Hearing On Opioid Epidemic 20240713

Good morning, everyone. I would like to welcome you to todays judiciary. On encryption excuse me thats not the right one. Tackling the Opioid Crisis a whole government approach and ill go ahead and start with Opening Statements from the Ranking Member and myself and i believe senator durbin has opening remarks and will die then to eyewitness testimony as well. Since 1999 more than 700,000 people have died from a Drug Overdose in the United States. Increased opioid addiction and a production of deadly synthetic opioids have exasperated american staggering overdosed death rate. In 2017, more than 70000 people died from Drug Overdoses making it the leading cause of injury related death in the United States. Of those, 60 involve prescription opioids and illicit opioid such as fentanyl. Americans fared no better against Opioid Epidemic in 2018 when more than 10 Million People aged 12 or older of abused opioid in 2 Million People suffered from an opioid use disorder and on average 130 americans died each day from an opioid openers. We did not know that some cost and disrupted lives or untimely deaths from widespread misuse of prescription and nonprescription opioids but we know from our family, our neighbors and our friend who bear the enduring lost loved ones that the opio crisis is not over. We must continue contending with this crisis. That being said, we made Great Strides over the past three years to help combat the epidemic, congress has passed landmark Bipartisan Legislation directed to combating the opio crisis and most notably, the comprehensive addiction and recovery act in the 21st century care act both of which i proudly supported were signed into law in 2016. Combine these two bills provided over 1 billion to combat the opio crisis. With an emphasis on increasing Prescription Drug abuse prevention and treatment programs, two years later Congress Passed the bipartisan support for communities act which is the most comprehensive antidrug addiction and trafficking legislation in modern history. We cracked the support act to address every element of the Opioid Epidemic for manufacturers and distributors to prescribers and it users to First Responders and recovery professionals. To date congress has dedicated 11 billion to tackle the opio crisis. With the largest portion of that funding granted to the department of health and Human Services. Today we will hear from the ministration and the executive Branch Members that shape and execute the Government Strategy for combating the opiate epidemic. The office of National Drug control policy, the department of justice, the Drug Enforcement administration and the department of health and Human Services. This hearing is important we think about the oversight where we have in congress to ensure the executive Branch Partners are properly stewarding the funding we have provided to them to clearly tackle the opio crisis. That said the federal government is just one aspect to combating the epidemic and we do not stand alone. Curving opio crisis relies on widescale integrated solutions from all impacted impactors. So today during the hearing we have an opportunity to hear from key components of the private sector including the healthcare distribution alliance, National Community Pharmacists Association community anticoalition of america and drug policy expert from the corporation. Together we anticipate a close and comprehensive review of our collective efforts to curb the supply of opioids and unnecessary prescription of opioid for evidencebased prevention, treatment and Recovery Services for opioid use disorder to identify future needs as state and local level and developed sophisticated and tailored solutions to the destructive and deadly crisis. Before i turned to the Ranking Member and witnesses i like to take a moment to remind us all that americas drug abuse problem did not begin with opioid misuse, and will not and with the Opioid Crisis. In my home state of iowa, methamphetamine abuse has remained a persistent and problem. Nationwide in 2017 almost 1 Million People had a methamphetamine use disorder and reportedly clinically significant impairment including health problems, disability and failure to meet responsibilities at work, school or home as a result to drug use. This number is significantly higher than the 684,000 people who reported having methamphetamine use disorder in 2016. In 2016 alone my home state of iowa reported over 1500 child abuse reports relating to methamphetamine. Not just in the home but being found in the childs body. Ultimately americans are suffering from drug dependency. Our loved ones are dying from drug abuse at alarming and distinct rates. Opioids are priority today but methamphetamine and other dangerous substances impacting urban and Rural Community should and will be addressed going forward. Thank you and now i will turn to Ranking Member feinstein for her Opening Statement. Thank you very much. I think your Opening Statement up tale each other and i suspect the up to what i remember of the committee thinks. The question is, what to do about it. Just last year, overdoses were 48000 deaths. To me that number is stunning. In 2016 Life Expectancy in the United States has fallen for the third year, largely due to opioid related Overdose Deaths. In the Economic Cost are just unbelievable, 700 billion a year. One of the reasons it grew is because a lack of education among medical professionals which has led to overprescribing. So we saw in many cases pharmacies were pill mills with turning out millions of pills to smaller communities regardless of medical necessity. Opioid manufacturers and distributors, i believe, had a responsibility to identify and report the suspicious orders. But they did not. This problem was compounded by an adequate responses from the federal, state and local governments. The Trip Administration declared the Opioid Epidemic of Public Health emergency in 2017 but has only used three of the 17 authorities triggered by the declaration, limiting its effect. The office of National Drug control policy omd cp, failed to issue National Drug strategies in 2017 and in 2018. The 2019 strategy did not include concrete goal for a fiveyear projection for a program and Budget Priority both of which are required by law. And according to the october 2019, department of justice id report, the Justice Department and dea did not initially use all of their existing authorities and resources. Reduced quotas for opioids are whole registrants adequately accountable. The result was an Opioid Epidemic that evolved from Prescription Drugs to heroin and ultimately to fentanyl. There is little question in my mind that the initial response to the opioid situation was ineffective. How do we get back on track . I very much believe that any solution must include a whole government approach and we have got to use all available resources. The comprehensive addiction and recovery act enacted in 2016 laid the foundation for this approach. In another bill, the support a act, was signed into law last year. It built on the 2016 legislation is by authorizing critical agencies as well as prevention Treatment Recovery and enforcement programs and expanding research. This act also included a provision called the using data to prevent opioid diversion, this part of the law is designed to ensure that opioid manufacturers industry routers are held criminally and civilly liable for identifying and reporting suspicious orders of opioids. I happen to be the one offer that and im very much concerned that its never been really enforced. So today, i am introducing new legislation to strengthen this law. And this legislation will require data on all controlled substances to be reported. Not just opioids. In order to better identify suspicious orders, it will also require pharmacies to report all transfers of controlled substances to the dea each month. There is so much to do, the federal government has begun to do this, omdcp has established a number of interagency working groups including the National Opioid synthetic Coronation Group. To monitor emerging trends and data. The Justice Department created the opioid enforcement and prevention effort to division and thats the opioid fraud and abuse detection unit under a new initiative known as j code focused on disrupting the online sale of illicit drugs. For its part, dea has increased its tactical diversion squad enforcement and administered of actions against negligent distributors and manufacturers. As a result of these efforts for the First Time Since 1990 Prescription Drug related Overdose Deaths decreased. That is really good news. So there are things that we can do to save life and reduce addiction. The center of Disease Control and prevention has warned us of wave Drug Overdose epidemics is upon us. Most of those suffering from addiction they tell us use more than just opioids, and 2018, cocaine, methamphetamine and benzodiazepines were present in nearly 60 of all opioid related Overdose Deaths. That is a stunning figure to me. So we have to take a good look at it and see what we need to do and i would encourage our Witnesses Today to comment on this and if you have a solution or a thought, i think wed be very interested in hearing them. Our country has been ravaged by an addiction epidemic and it cost tens of thousands of lives every year. So failure should not be an option. This is an important hearing and i so look forward to hearing from our witnesses and hopefully with new ideas and constructive thought. Thank you very much. Thinking Ranking Member and i would recognize senator durbin for opening comments. Thank you, madam chair for this hearing. I called seven a graham several weeks ago to consider this and i think him and you for making a possible today, i will not state again whats been stated, we can accept it, or in the worst drug epidemic in the history of the United States and losing an average of 2017 of 130 people each day. There is no time to smaller suburb to wealthy to escape this drug epidemic in my state across the nation. But its not the first drug epidemic in our history. The crack cocaine epidemic showed, i hope we learned that we cannot incarcerate our way out of this addiction crisis, weenie prevention, intervention and treatment on the front and not just prosecution on the back end. There is a growing bipartisan consensus that harsh prison sentences have not only failed to stop drug addiction but created unjust and disastrous outcomes. Im proud this committee spearheaded the First Step Act to right these wrongs. Now we need to make sure as we combat current drugs on the market and the spread of synthetic fentanyl analogs that we do not impeach Scientific Research that can say people who overdose on these drugs and we do not criminalize any harmless substances in the process. Let me ask you to consider this fact. A recent study of faunal overdoses in massachusetts from 2014 2016 found 83 of patients required more than two doses. More than two, why, because more lax on is no longer Strong Enough to stop and overdose. Researchers have not yet identified an antidote that is. In a research and a more powerful antidote may include the drug fentanyl or some analog. Thats what im proposing legislation that will allow the truly harmful analog to be added to schedule one but not at the expense of facilitating vinyl research to discover lifesaving antidote. Unfortunately theres been an effort to bypass this conversation about the research aspect but i hope we can return to it. The second point is this, we can learn an important lesson from the 1990 tobacco master settlement agreement. The msa was landmarked 246 billion settlement to hold big tobacco responsible for hooking americans on nicotine. And get your bidding to millions of death, i might add there at it again with vaping. But only 8 of the dollars paid under that settlement were devoted to Public Health forms of nicotine addiction. 8 . Most of the money was spent on unrelated items like roads, stadiums, many states, cities and counties sued the opioid industry in a massive lawsuit underway in cleveland today. That could produce a large settlement. I think its critical that a substantial portion of the settlement be dedicated to fighting opioid addiction. Third point is this, it was in june of 2016 in this hearing room at this very table that i learned food for the first time when the acting director of the Drug Enforcement administration revealed on the record it was actually the dea that approve the annual quota of opioids to be produced in the United States. Opioid addiction starts with prescription keep painkillers made by pharmaceutical companies regulated by the Drug Enforcement administration. However, the Inspector General and department of justice found, dea was slow to respond to the dramatic increase in opioid abuse and needs more fully utilized this regulatory resource. For years, dea permitted format to produce enormous evergrowing amount of opioid pills each year even though dea had the ability to set quotas limiting the production. For example, in 2017 the Drug Enforcement administration of the government of the United States of america allowed pharma to produce 13 billion opioid doses to be put on market, how much would that be . That would be a three week prescription for every adult in america approved by the Drug Enforcement administration. For years ive been calling on them to set lower quotas, last year senator kennedy in louisiana on the other side and i joined in a bipartisan effort to reform the law and required the Drug Enforcement administration to adjust opioid quotas to reflect the reality of whats happening in america. Madam chair, im sure youre well aware of the county in your state, lee county on the border of iowa and illinois, lee county iowa averaged 45 opioid pills per person for nearly a decade dispensed by one pharmacy in that county. 45 opioid pills per person for every person living in that county for ten years. In Hardin County illinois one of the least populated counties in my state about 4300 people, between 2006 and 2012, 2. 7 million opioids were shipped to a fingal pharmacy in Hardin County enough to provide every resident with 90 painkillers pills a year. The Drug Enforcement ministration is supposed to monitor this so that approve a massive production on the front end and no monitoring on the bakken, as we see these areas and counties being swamped with opioids. For years weve been calling on them to lower quotas now they have legislative authority and no excuses, unconcerned the dea is not taking this seriously as it should and will ask questions when we reached the point. Dea has lowered and the quarters of years, dea proposed 2020 coders do not take into account drug addiction, overdoses and deaths in other words, the former production quotas dont look at the reality of the worst drug epidemic going on in america today. I look forward to working with my colleagues to continuing on a bipartisan basis to do with this. Thank you. We will start with our panel one and we will introduce our witnesses and we will start with witness statements. With us today on panel one we have mr. Chester, assistant director of National Opioid and synthetic Coronation Group of the office of National Drug control policy. In this capacity he leaves enter Agency Efforts to reduce the availability of fentanyl and synthetic drugs in the United States by distracting the Global Supply chain and we also have ms. Amanda, she is director of opioid enforcement and prevention efforts for the United States department of justice. She is responsible for correlating the strategic responses to the Opioid Crisis including all investigative and prosecutorial efforts. We also have tim mcdermott, he was appointed as an assistant administrator of the Diversion Control Division on july 24, 2019. He served as the principal advisor to the ministry or on all matters pertaining to the regulation and coronation of programs with the diversion of produce controlled substances. And please help me with your name, doctor period he serves as the chief medical officer as a Mental Health services administration. Hes familiar with the development and utilization of medical services and nuance of regulation and across various state and provider perspective as he delivers direct patient care. Thank you very much. We will go ahead and start with her witness statements and we will start with you mr. Chester. Chairwoman urns, Ranking Member feinstein and members of the committee, thank you for inviting me too testify on the dynamic and challenging opioid environment we continue to face in the United States. In the whole government approach to addressing it. The office of National Drug control policy under the leadership of director jim carroll is uniquely positioned within the executive office of the president to courtney they ministration apprehensive approach to drug policy development and implementation. It began in the opioid issue the dominant threat was heroin. A relatively low crisis which allowed for not intervening use and heroin enabled an easy transition from prescription opioids to listen opioids. Fentanyl emerged as a major overdose driver in 2015 initially as an adulterer to heroin but by mid 2070 many states have experienced or crossover were mo people were overdosing and dying from fentanyl then heroin exclusively. Today we see more diversification across the opioid environment with a variety of fentanyl and nonfentanyl synthetic opioids readily available. Some highly sophisticated counterfeit pills sold on the darknet and delivered direct to consumers. This is further complicated by user transfer among different drug types and across both synthetic opioids and nonopioid drugs like methamphetamine. Combating illicit availability demands president ial leadership, strong bipartisan support from the congress and the synchronization of international state, local and tribal partners across the public Law Enforcement National Security and intelligence communities. This allows us to deeply understand the environment in its complexity and identify and rapidly close gaps and capabilities as they emerge. Over the last four years the government made lifesaving gains the synchronized approach first laid out in 2016 heroin availability Reduction Plan and the final report on the commissioning drug addiction in 2017. President trumps initiative to stop opioid abuse in 2018 and the 2019 National Drug control strategy. We have the answer policy objectives along three clear lines of effort. Prevent drug use before it starts, improve access to treatment for longterm recovery and reduce the availability of illicit drugs in the United States. Most important, the strategy guides and synchronizes government actions on the entirety of the drug problem to achieve the singular goal of saving american lives. This is the only criteria that truly matters by which the American People will measure the success of our efforts. These foundational documents and the efforts they articulate have enabled significant a commish meant over the last few years. The creation of the apartment of justice joint criminal opioid our teams within the fbi to target the internet trafficking synthetic opioids. The training and deployment of k9 teams throughout custom and Border Protection and office of Field Operation specifically trained to protect fentanyl. The establishment of the 24 hour, seven day capability for cpp under the act for new synthetic opioids as they emerge in the marketplace and the passage of the historic support act which recently authorized new Medicare Part b benefits the law opioid treatment programs to build further Services Including counseling and medication next month. However, the illicit opioid environment continues to present a daunting challenge. Synthetic opioids shipped in small quantity make detecting and seizing the drugs monumentally difficult as they move through the mail, express across the borders. The increasing prevalence of drug users, counterfeit pills and the rapid emergence of highly addictive deadly and readily available opioids for prevent efforts. As chinas efforts to elicit classwide fentanyl scheduling take hold new production sources and distribution are emerging. These challenges are not insurmountable. Now more than ever our efforts must remain synchronized across antigovernment with estate partners, our partners in the private sector and others to produce the complementary effects to in the crisis. I would like to think this committee for your foresight and leadership in addressing this conical National Security Law Enforcement and Public Health challenge. On behalf of the ministration we look forward to continue to work with you to confront the extreme complex issue. Thank you for the opportunity to testify today and i look forward to your questions. Thank you mr. Chester. Chairwoman urns, Ranking Member feinstein and members of the committee, thank you for the opportunity to discuss the department of justice to combat the Opioid Epidemic. Im the director of prevention efforts. My position in the Deputy Attorney General Office was created for the sole purpose of ensuring the department is properly formulating and nipple Mining Resources to the full six deck with the express goal of combating up your crisis. I also have 13 years of experience as a drug prosecutor working as an assisting United States attorney and a deputy section chief and the department criminal division. I know firsthand that the department is not simply paying lip service when the leadership expresses commitment to stem the tide of the epidemic. It is responding aggressively and intentionally with every tool at his disposal. One such tool is focused on the department effort of darknet websites. These websites allow prolific drug suppliers to sell fentanyl on the market places. Dismantling them is a priority for the department which is why in 2018 the fbi established the joint criminal opioid darknet enforcement team. Since the launch there have been too successful largescale takedowns that have taken dozens of accounts off the web and hundreds of kilograms of drugs off the street. The department has also been diligently working to prosecute Mexican Cartel to traffic fentanyl and fentanyl analogs into the United States. The Mexican Cartel are not only producing their own fentanyl but mixing it with other drugs such as methamphetamine, heroin and cocaine which is contributing to the staggering numbers of voters death throughout the country. The department is using all the tools at his disposal to combat the cartels winning the conviction of Cartel Leader El Chapo Guzman who is certain to life of 30 years in july of this year. Another noteworthy initiative is operation synthetic opioid search or sos that focuses on illicit opioids that have obtained the highest overdose death rate in the country. The prosecutors in the district worked towards prosecuting cases involving synthetic opioid. The first to the program alone over 300 cases were charged in the ten districts. Additionally the department has created the regional prescription opioid strikeforce. Also known as our poet, a joint Law Enforcement effort the holds resources and expertise of multiple agencies to identify, investigate and prosecute Healthcare Fraud scheme in the region one of the most hardhit by the epidemic. Since october 2018 establishment the strikeforce has charge more than 70 defendants were collectively responsible for disturbing over 40 million pills. These medical professionals were charged with drug offenses was to penalties for the diversion of opioid. It has also worked handinhand with hhs to ensure when there is a takedown of the medical professionals patients are not left out in the cold. Rather they are met by a team of Public Health officials who can refer them to legitimate medical providers or Addiction Recovery services. The department recognizes we cannot put it out of its crisis and using resources to help prevent opioid abuse before it takes place. This occurs through school and community outreach, partnership with american tribes, Public Service announcements and training for medical professionals. Additionally the department has a robust Grant Network established for opioid abuse and Overdose Prevention. This includes plans to facilitate treatment, prevention and Victim Services and state and local Law Enforcement better investigate heroin and prescription opioid distribution. Finally, i want to remind you of what i spoke in june. Importance of legislative solution for classwide scheduling of fentanyl like substances. The nation has seen the uses of prescription opioid decreased the deaths in the United States has reached record levels. One of the causes of the proof relation of fentanyl in the analogs. As you know invertebrate 2018, the dea responded to the proof elation of fentanyl analog by scheduling the fentanyl like substance on a temporary emergency basis. In response to the scheduling order we saw a significant decrease encounters a fentanyl like substance and reduced production of the substance by traffickers. Classwide scheduling is working. But the temporary emergency scheduling order expires in 51 days. As a prosecutor i can tell you that legislation to permanently schedule fentanyl substances is important and necessary step to continue countering this epidemic. We are running out of time and if the solution is not found prosecutors will be hindered and traffickers will be helped. We cannot afford to move in the wrong direction while fighting this crisis pretty thinking for the opportunity to testify and we look forward to continue to work with congress to find solutions necessary to address the epidemic. Thank you. Mr. Mcdermott. Chairwoman urns, rank them over feinstein and distinguished members of the committee on behalf of the 9000 men and women, thank you for the opportunity to discuss a response of your crisis. Over the past several years our nation has been devastated by an epidemic that was fueled by the overprescribing potent Prescription Drugs and the increase in prescribing for the first decade of 2000 was fueled by a belief that pain was undertreated in the United States. Prescribing during this time created a generation of opioid users presently of more than 3 million americans. Unfortunately, as prescription rates have declined over the last four years we have seen a dramatic and disturbing shift, the mexican drug cartels are filling the void with cheap highly potent white powder heroin they continue to mix it with fentanyl and selling in the traditional and in many cases counterfeit pills made to resemble pharmaceuticals. The dea is seen chinese, mexican nationals working together to move massive amounts of heroin, fentanyl, fentanyl related substances across the southwest border. The prophet that these are collecting are sounded. A kilogram of fentanyl is produced for less than 5000 and can have a yield in excess of 1. 5 million. Dea believes the sale of the cartel will continue to be the primary Mexican Cartels controlling the illegal Drug Distribution throughout the United States. To these cartels do not have boundaries or laws of mexico, the United States or any other country. Dea will focus its attention and effort on the command and control component of these major Drug Trafficking organizations to protect our citizens from the devastation that they bring a violence and drugs. With respect to addressing the diverse of control substances and Prescription Drugs, i oversee the activities of dea converging control program roughly eight 80 of her workforce. Less than 1 , less than a fraction of 1 have disproportionately impacted the epidemic. In fact, for 5 new heroin users state they started the cycle of addiction on prescription opioids. Within the Diversion Program we have realigned criminal investigators and embedded them alongside the diversion investigators in an effort enforcement groups we call tactical diversion squad groups currently we have 86 of the groups nationwide who are dedicated to investigating, disrupting and dismantling individuals and organizations involved in teams. These groups along with the additional 87 groups are using all tools administrative, civil and criminal to pursue the registrants who violate the law. We also remain focused on the limits dea establishes for manufacturing of scheduled one into controlled substances appeared with the publication of the 2020 quarters on december 2 the dea has decreased quarters for the six most frequently misused opioid by 55 on the level established at the end of 2016. We been able to break down the quarters because doctors nationwide are writing less prescription to opioid, a 30 decline since january 2017. Despite the decline, let me show the committee that we recognize the opioids are essential medicines especially with those of pain in dea will continue to work with fda, the center for medicare and medicaid services, cdc and the state office to ensure their adequate supply for those in need. The division continue the robust Outreach Program aimed at improving communication and cooperation. In closing, i want to thinking for the opportunity to be here today and i look forward to your question. Thank you. Doctor please. Chairwoman ernst, Ranking Member feinstein and distinguished members of the committee, thank you for inviting me too discuss the approach to the pure crisis. I am chief medical officer, im an addiction psychiatrist with expertise in multistate operations provider supervision and the treatment of Mental Illness and Substance Use disorders in vulnerable and underserved population. The omission is to reduce the impact of substance misuse and Mental Illness in communities across the country. We are the Agency Within hhs that leads Public Health efforts to improve the lives of individuals living with Mental Illness and Substance Use disorders as well as their families. The number one priority in combating the open your crisis is expansion of prevention, treatment and Recovery Support services, we do this by providing a range of grants targeting a pure crisis. The state opioid response gramps and the rest of the crisis including prescription opioids, heroin to fentanyl and fentanyl analogs by increasing access to medication treatment or mat using the three fda approved medication for the treatment of opioid use disorder producing opioid Overdose Deaths to the provision of prevention, treatment and recovery activities for opioid use disorder. We partner with Many Community providers another stakeholder organizations for appropriate evidencebased opioid prevention strategies. These include drug takeback and disposal programs and overdose education as well as distribution activities and Marketing Media campaigns and strategies to reduce stigma. In order to ensure individuals receive a comprehensive array of services they also provide Recovery Support services one of the most common approach to implement Recovery Support services by grantees is utilization of support, individuals who are then in recovery. Another common Activity Development enhancement and expansion of Recovery Community organizations as well as the use of recovery residency. Peers are engaged in a number of settings for individuals with opioid use in the border initiate and maintain recovery. They strongly believe that the expansion of comprehensive a systematic care and continued partnership between federal government, state communities we will continue progress in combating the Opioid Crisis. American indians and alaska natives have been especially hardhit by increasing rates of prescription and illicit opioid use. Addiction and overdose as well. These populations have the secondhighest overdose death rates from heroin and the third from synthetic opioids. An effort to address the Opioid Epidemic in indian countries, they have established the tribal opioid response or tour program the resource. It aims to address the crisis and tribal communities by increasing access to culturally appropriate and evidencebased treatment. It is also been a leader to reduce overdose by increasing availability and use to reduce overdose to funding and technical assistance. Its Overdose Prevention toolkit released in 2013 is one of the most resources. The toolkit provides information on recognizing the risk of ope overdose, the signs of overdose and how to provide Emergency Care and an overdose situation is intended for community members, First Responders, prescribers, people who have recovered from an open unit overdose, family members as well as communities and local government. The opioid prevention targeting scripture drug misuse have shown positive outcome in the strategic prevention framework Prescription Drug program to target the priority issue a Prescription Drug misuse. The Program Works and pharmaceutical communities on the risks of overprescribing too young adult and brings Prescription Drug abuse prevention activity, education to schools, communities, parents, prescribers and patients. All grantees are required to have an operational state run Prescription Drug Monitoring Program called pdm p. And our supporters in developing capacity and expertise in the use of data from these pdm ps. The National Survey on drug use and health also known is providing key national and state level data on a variety of Substance Use and Mental Health topics including opioid misuse. Its a vital part of surveillance efforts related opioids. It is also building existing partnership with nih a partner in implementation of healing communities project. To improve Research Practice pipeline and committed to promoting evidencebased practices in Service Delivery models. Thank you for the opportunity to testify on the issue, i look forward to answering any questions you may have. Thank you to our witnesses and we will start with five minute rounds within the members. Doctor, id like to start with you please. According to the u. S. Census bureau rural areas cover approximately 97 of the nations land area and approximately 56 of iowans live in the Rural Communities and we heard from senator durbin outlining his Rural Communities. And your written testimony you highlighted the Substance Abuse and Mental Health administration worked in those Rural Communities and thank you for doing that. Can you describe a key challenge to reducing the impact of Substance Abuse use and Mental Illness in Rural Communities especially when it comes to opioid and if you can also talk about methamphetamine as well. Thank you for the insightful question. I believe the focus is treatment capacity. We do have a great number of providers that need to be in the right places. Treatment capacity is addressed by a variety of different techniques. Telehealth is one of the areas we are exploring to increase capacity to the rural areas. As well as provider expansion, and collaboration the dea has certified a large number of wavered physicians at providers including expansion for Nurse Practitioners to mid levels increasing provider limits so they would be able to treat a greater number of patients. Unde have to attack this problem from different angles as well as including primary care colleagues as well. Certainly have a lot of resources we are devoting towards that and we think the congress for the appropriation with a substanceabuse block Grant Funding in particular. The block Grant Funding can be utilized for the treatment of any Substance Use disorder. In addition to the grants but also can be used to treat opioid use disorder and any co occurring mental on this or Substance Abuse disorders. A great number of enrollees to have substance elements and funds can be appropriated for that as well. The nations frontline to illicit controlled substances weve just recently marked the oneyear anniversary of Bipartisan Legislation support act which combats the Opioid Epidemic, and i worked in that measure to strengthen drug takeback programs and their efforts and a safe disposal of drugs. How can good dea work to increase the participation in those drug takeback programs . Twice a year they do a takeback and its been very productive. The most important thing i can say is typically when an adolescent is involved with the abuse of opioids could typically starts in the medicine cabinet and thats the most important thing to get out of your house. If we can get the message out and we ar are doing a much bettr job i can tell you now with the participation of tribal areas as well and the addiction rates are tremendous. I was back in the denver area and we covered montana and had serious concerns for the takeback has been very productive and we have more participation from state and local symbols of participation from the coalitions and participation from hospitals, you name it. So we are out there and its been a bit very productive and at the end of the day there is sometimes criticism to say we only get x. Amount of opioids that any amount you take out of your house or off the streets is beneficial. Ranking member feinstein. Thanks very much, madam chair. I believe that the chairman of the committee and i very much believe that fentanyl should be made a schedule one drug and should proceed to do that. I cant believe that in 48,000 Overdose Deaths can you in any way, shape or form gives the constituency for those 48,000 deaths . In other words, who is dying, d, what is their age, race. One of the defining features of the crisis is the fact that it cuts completely across racial, economic, geographic and gender lines. A lot of the Drug Overdose patterns that we saw in the years past are defined by this crisis because it is introduced into the marketplace into that users in much different ways. Sometimes as it is fixed up a jet lands in the existing drug use population and is sold on the internet perhaps to an unknowing user who thinks that they are just getting opioids from another country. Its a person that doesnt understand or know they are being part of the illicit environment but they are getting a pill can being presented as a counterfeit drug. So it cuts across all racial geographic and demographic lines and thats one of defining features of this. With anyone on the panel not support fentanyl being made a schedule one drug . I assume the answer is yes and armchair, i believe very strongly coming into the chair and i have discussed the fentanyl should be made a schedule one drug as soon as we possibly can. I think 48,000 people dying from it. Can anyone give us a description of the deaths and the majority of usage involved in those deaths . Senator, i can start and then others can fill in if they would like to. One of the things we have seen in the evolution and i think i touched on this in my Opening Statement is that in 2006 there was a small outbreak in illinois and was tracked back to mexico. Mexico. It was neutralized an and defend the ball didnt completely go away but it did decrease and it wasnt until 2015 we started to see it as a regular feature in postmortem toxicology testing and drug seizures. By that time, drug traffickers principally from chin china entd the scene and were bringing into the country order for the dark mac through mail. The reason that i say that is because rather than having individuals have to go drug traffickers and make a facetoface cash transaction, it was now able to be diffused across the country and anyone with access to a laptop or the dark lab and crypto currency could have it delivered directly to their house and this speaks to the proliferation of illicit opioids and fentanyl across the country. What was originally started in the northeast as it involved intravenous dru drug use in populations expanded across the country to where we are today. So any newly discovered the fentanyl substance should be added to the controlled substances act i name; but everybody support that . Anybody disagree . Madam chair, i think we have our work laid out for us and i know senator durbin has thoughts on this, but we work to make fentanyl a schedule one drug and try to reverse these deaths. Is there any common denominator of people in the 48,000 racially, economically, age wi wise . Not too many common denominator is. I think some of our state partners that we deal with providproviders a lot of informn and have spoken to perhaps an increase in the Africanamerican Community about what he saw and other opioids. The only other common denominator for anyone that has doubted the availability of the drug and availability we know leads to increased first use and first use leads to chronic use with opioids perhaps more so with any other drug. To use for picking a schedule one drug . Yesmen can absolutely. Does everyone on the Panel Support taking it a schedule one drug . Would like to comment . Senator, id have to take that back to the department and have i dont want you to get in trouble. [laughter] i would agree. I also would like to take that question back. If you would, i certainly would appreciate an answer because that is where i am going and that is what i deeply believe. Thank you madam chair. Senator grassley. The office of Inspector General recently reviewed the efforts to control the diversion of opioids and the report, quote, the dea was slow to respond to the significant rise since the early 2000s. So mr. Mcdermott, the Inspector Generals report states that, quote, the department and the dea agreed with all the recommendations. How is the dea prioritizing and meeting these recommendations . As we speak today, we are working on those. One of them is there was criticism pertaining to the work plan for the diversion investigators. They changed the plan and weve implemented the recommendations as we speak today. And then i think the next question is easy to answer what you commit to update congress on the progress of meeting these recommendations . Yes sir. Okay. Thank you. Last year Congress Passed landmark legislation addressing the opioids crisis. We call that the support act and im proud to have cosponsored and moved through a number of bills that are part of the wall. The report states that because of support act is relatively new, the Justice Department is, quote, i made sure to be fun able to measure the effect on the opioids crisis or the opioid enforcement efforts. While that may be the case, the opioid enforcement protection efforts that is your position. Can you provide anecdotal evidence of success of the federal governments efforts to end the crisis . Witwith the sport to respect support act . The dea implemented a member of the acts specifically the suspicious order database that was implemented in october 23 of this year, and i know they are still working through a number of other components within the support act to include their work with the database that has been invaluable to the department with respect to our opioid investigations. I can tell you firsthand how these type of databases have been used to successfully prosecute the diversion of opioids both with what we refer to as dirty doctors, opioid manufacturers and distributors and so we are working with the dea to ensure we are able to hit those benchmarks with this support act. Since im going to ask this question of the entire panel, and it deals with fentanyl is well known about fentanyl and its dangerous analogues coming into the United States, and they told china issued a classwide control of fentanyl analogues and earlier this year bu this is from dea witnesses commented that the Judiciary Committee hearing that they are monitoring chinas actions and ensuring followthrough. To all of you, but Significant Developments at each of your agency should the American People that we are winning the fight against chinese fentanyl entering our country. I will start with you mr. Tester. I think a couple things have come together to bring some tangible outcomes from chinas efforts to schedule. First is the president s appeal to ask him the Class Schedule was an absolute game changer. Ambassador prince of leadership and coordination with the administration i think has been incredibly important. And that resulted in china not only for living through fallingy on its commitment, but also taking some tangible steps such as two months ago inviting u. S. Officials to the convention of the individuals for trafficking coming through china which was a major step forward. As you know director carroll traveled over in september and spoke with the Chinese Government about some tangible steps that they could take moving forward to include greater Law Enforcement cooperation and policy coordination, and we believe that the staff in china or positive endquotes because of a path where they will begin to reduce the flow of fentanyl coming into the United States. For the rest of you, if you have an answer make it short because my time is almost out and i dont want to infringe upon the other people. Just briefly it is my understanding we have seen a significant dropoff in the droe amount of fund all to be 56 fentanyl and analog coming through the mail. I would just remind the committee that since the temporary scheduling order went into effect, we have in the United States seen a significant dropoff of analogues in this country. I believe thereve only been two that have been encountered in this calendar year that shows both chinas actions and the actions here in the United States are working with respect to fentanyl analogues. I ago those comments and also we have two offices in china right now, one in beijing and the working relationship has been excellent. Do you have anything else to add to be 56 to add . Certainly over a quarter million of the kids have distributed across the country with reversible over 14,000 overdoses. Thank you. Madam chair. Thank you, senator durbin. Ive automate sure the record is clear in 2016 when we had a hearing before the committee, we established the Drug Enforcement administration approved the production of 14 billion opioid doses that here in the United States. 14 billion. That meant that every adult in america could take a onemonth prescription of opioids based on the improved production quota from the Drug Enforcement administration. We were in the midst of the worst drug epidemic in the country. Opioids were driving into heroine and sentinel and they had 14 billion of these doses requested by the pharmaceutical industry. A number of us started asking questions. What is going on here. Why are we producing all these opioid is dramatically more than is necessary for america and as a consequence, the testimony today is that the quota productions have gone down. Some 55 . I dont know what the exact number is. I estimate its around 8 billion at this point. 8 billion opioid doses a year. What is that the equivalent to . Equivalent of a twoweek dosage for every adult in america. That is what we are Still Producing as we talk about all the consequences of the opioid drug epidemic. Senator kennedy and i said whats going on here, is the dea paying any attention to what is happening to these pills once they are produced, and the response to me was if you want us to pay attention, put it in the mall and we did and we said from this point forward when they set a quota to take into account the deaths in America Related to opioids the diversion of the pills from the ordinary commerce and the following. So we waited to see what would happen if you know what the response was from the dea, we just cant find that information, we cant take that into consideration. They basically told us they determined due to the grouping of drug classes that they cant estimate Peter Gershon for the purpose of setting the quote us. What does it take . How do we get them to acknowledge that 8 billion opioid doses is dramatically more than could possibly be used for legal purposes, for medical purposes . Senator, thank you for your question. As previously discussed by the former acting administrator, the dea realizes we could have done things differently. We are doing things differently. Ive been in this position almost three months. I read your letter and senator kennedys brother and i sat down with our folks and went over the numbers again. I assure you it is a priority for me and a priority for the administrator to ensure that we have a balanced approach and we are looking at those. If you look at the numbers i think we are doing exactly what you asked us to do. 8 billion, enough for every adult in america to have an opioid dose for two weeks, every adult in america, you think that is a good response in the midst of a drug epidemic . We work with hhs and fda and cdc and the state Attorney Generals Office to ensure theres adequate medical supply and research to ensure that and we will continue to work with your office to limit those numbers and to ensure we have the proper medical supply out there. Lets start with this, if our government doesnt start by a reasonable regulation of the production, pharma will continue to ask for more and more and more far beyond what is medically necessary, far beyond what is needed for chronic pain and ordinary users. So if the Drug Enforcement administration isnt in on the program, we are going nowhere in this conversation and i hope that changes soon. We put in a bill and so far have not had a response from the dea anthat i think is appropriate. Is there an antidote to fentanyl . In your initial statement you mentioned you had heard anecdotal reports where people require more than one does as a reversal for opioids. At this time, that is our fda approved option. Its been used to reboot gave to reversreverse theoverdoses howeg substances may require more than one dose. Thats why even after someone has had this administered and they have been resuscitated, they still require adequate medical supervision. So, to answer your question is the option we have right now. This is the point id like to get to on the scheduling of the analogues as we discussed in a separate meeting i am not opposed of putting analogues of the scheduled one as we currently are and as you mentioned will expire and 51 days. What i worry about and im concerned about is we do not have a really effective antidote of fentanyl and im worried wore are putting onto the scheduled one process that prohibits production in the United States is going to close out the possibility of research into an antidote for fentanyl which should be underway. In putting these analogues on the schedule, give us some process other researchers can sn look for that antidote which could literally save lives today. I guess it has some value that really doesnt have the effect of the application that could make a difference. Senator, thank you very much. I am proud to say that the department of justice and the health and Human Services have been working throughout the summer on a very balanced talk about which is the balance between controlling substances that are dangerous as they come into the United States and allowing adequate researcher access. We believe we struck the balance and weve enjoyed working with the committee on this to ensure that the substances were gathered up that are more than reasonably dangerous and potentially dangerous that we provide an unprecedented level of Research Access to be able to pull them out of the schedule for Research Purposes to do two things, to determine the medical merit as you discussed. Maybe the next generation or to determine that they have no active effect on the body or that they are not dangerous and that they should we be scheduled. We believe the work that we have done betweewevedone between boe departments actually strikes the balance very well with an unprecedented levels of researcher access but at the same time unprecedented level of control for the substances that are dangerous to americans. Lets continue the conversation. That is the balance and looking for. Absolutely. Senator blackburn. Thank you madam chair and thank you to each of you for being here. I think you can hear the bipartisan frustration in our voices. We have an issue that continues to get worse, not better. In tennessee, we have seen the increase in our drug related deaths. We are let at sea, 1,837 last , that was up from 1776. We know from our national Law Enforcement community that fentanyl related deaths are increasing. Our tdi director has said that he is seeing a continued increase. So, it is something we are facing statewide. We seem to have a problem with fentanyl on the streets and with methamphetamines i in upper east tennessee, and we engage regularly caught constantly with Law Enforcement and health care professionals. This is why we need you all to really collaborate with us in a timely manner to find answers to this. Senator feinstein and i sat down and talked a little bit yesterday about how drugs and Mental Illness and how that affects the homeless issue which is what they are struggling within california. Many of our cities are. So, we need to move past these discussions. Weve bee been asked to been ate especially with the opioids and look at what is going to be a coordinated longterm strategy, look at how we are going to get resources to Law Enforcement in some of these hardest hit areas around our country. We have a task force that the doj has commended and we commend them for the good work that they are doing. And when it comes to the hhs, what are we going to do to promote treatment for the thousands of addicts . People that are causing the revolving door situation with Law Enforcement and that are not receiving the treatment that they need . I want to come to you first cant talk about what youre doing to get resources to Law Enforcement, and i would like for you to talk a little bit about treatment and what you all are changing to make treatment and recovery available, what are you doing to train doctors, to educate pharmacists and as senator durbin just said the number in the system independent being able to achieve the balance approach, the people that need it didnt take the rest of it out of the system comes up to you first and please be mindful of the clock. I will be very quick, senator. When you talk about resources from the office of the National Drug control policy, principally it is the high intensity Drug Trafficking Areas Program that funds Law Enforcement task forces at the state level that our state, local and federal and that is the principle in a combined effort absolutely. The thing about the task force is that they are unique to the particular area and focused on the particular drug threat in that area. They are given the flexibility. At doj we have a number of strike force is where we utilize the same methodology in terms of combining the resources of local and state Law Enforcement like the reachable strike force. They are focused on efforts in the Appalachian Region and while they do have the dea, fbi and hhs, oig involved, they also rely on the local and state park is in order to combat the diversion of opioids in that area. We are anchored in the evidencebased practices and certainly promoting those to the provider education. We have two main initiatives. The provider clinical support system which implements the materials and medical School Curriculums as well as provider education for Substance Use disorder education as a whole in Healthcare Settings and education. Healthcare settings are certainly the place that we can improve our scope for educating the next level and next generation of providers. How utilized are those programs . I believe over 157,000 individuals have been trained through both programs. Thank you. I will yield back. Senator whitehouse. Thank you very much. Let me start with a question about the Perdue Pharma case. I dont know that either of you were involved in that from the doj, but more than a year ago in august of 2018, the senator and i sent a letter to the department of justice asking about why the case against Perdue Pharma was being proposed as a federal criminal indictment out of the Western District of virginia once it got to the political side of the department of justice suddenly got turned into a misdemeanor prosecution for a find in the context of the litigation isnt very significant and operated not against perdue but against a Holding Company so that they could continue to do business with medicaid and other federal programs. The fact that mr. Giuliani was involveinvolved the position ths involved in the department of justice on other matters as an extra to the disappearance of the prosecution and the political level. I can look into that later i dont have a lot of specifics to share with you but i can tell you that apartment is very actively looking into the nationwide manufacturer distributors. We recognize the role that many of the companies played including the executives and companies, and in contributing to the Opioid Crisis we filed a letter in that litigation that is correct. What assurance can we have that in your role in the district litigation the department of justice will actually take a serious position in favor of the plaintiffs when the record so far is that you called in the right lawyer and go to the political appointees at the doj in your case disappears into a misdemeanor against a Holding Company. We are not a party to builda district litigation. We are there to provide guidance to whether it is the court or the plaintiff in that case. I think it depends on what the issue is and what help they need. I know right now weve been involved in helping with the positions of the dea in the current reform and weve been assisting in putting together the data that has been requested as a part of the litigation. When you take a position, will the same people that scorched the Western District of the prosecution be making the decision as to what position the department should take substantively . Im not sure what position the department is going to take or what the issue is going to be that i can tell you that again. Great the department does have open investigations that i obviously cant comment on but t is actively looking into this space to hold people accountable for their involvement in creating this. I hope you do a better job than you did the last time. The last question i have this more of a technical question but as youve heard today, there is broad bipartisan support for scheduling fentanyl as an unlawful drug. However, and all of you seem to agree with that however, when we go to the hhs, this Administration Says no we shouldnt do that because the chemistry in this question is very complicated and if you ban fentanyl analogues, you will likely get into potentially damning drugs that could actually help with addiction or response to an overdose. So it seems to me the most important thing that you all could do is get the administration outlined behind a program for healthy schedules until without the objection from hhs and perhaps you can leave with that because you are trying to coordinate the effort. We have been coordinating between the hhs and its departments, fda, cdc, nih. Is there a common position . Guess there is. It was captured and transmitted to the kenned the ce as i discussed and doe in thosek about sensibl fentanyl, i do wae clear what we are talking about is fentanyl analogues which are additions or substitutions to the skeletons of that is how it is defined that are reasonably assumed the active in the body on a structural relationships with the substances come in they are captured. The other side of that and this is the hhs portion is to be able to have an unprecedented level of access to access the substances and do research on them, to determine what their actual activity is and to determine if theres any medical merit. Thats what weve been able to do in the department of health and Human Services and the department of justice bringing them together to get an agreement that we struck the righhe struck theright balance l and access and thats what we have presented to the committee. My time has expired. More to follow. We talk about opioids and that is an envelope term that includes Prescription Drugs, heroin, fentanyl, is that the universe of what we consider to be opioids . It certainly would include all of those synthetic and natural all the way to Prescription Drugs as well. In your experience, is an addiction specialist when people cant get Prescription Drugs, to the opt in for a cheaper alternative by carolyn . Heroine . Not everyone but a subset was. Hispanic figures last year were 15,000 heroin related death deas although i know the numbers get kind of murky because frequently as several of you mentioned, you have a cocktail at a variety of drugs sometimes mixed together which is deadly obviously. You mentioned the locks administered by First Responders and others when somebody is suffering a Drug Overdose. I think you mentioned there were 14,000 roughly applications of the drug last year, successfully. But that just saves the persons life from the overdose at that moment. That doesnt cure the addiction, correct . Correct. We believe that most addiction professionals treatment has to continue for an extended period of time. Simply one intervention wont be effective whether it be reversing the overdose and i would highlight that this administration is evidencebased practice. Certainly it is something that we promote as a wonderful option for reversing opioid overdose. Certainly been a lifesaver, but my point is, and you just made it as well, that the person remainbut the personremains adds additional treatment and health, correct . Correct. Treatment should extend on the full spectrum from if the person requires detox, president ial, outpatient. We know when they stay, we have better outcomes. Do they get moved to other drugs like methadone clinics thank you for bringing that up. Medication assisted treatment is the Gold Standard for opioid use disorders. Whether it be methadone, deep in our theme, they are all fda approved medications that have been found to decrease the overdose and improve social capital in particular for the criminal justice involvement, homelessness and engage another treatment seeking an behaviors consistently getting the patients in treatment is our goal. You mentioned the chairman and you discussed by Mental Health issues. Do you see Substance Abusers who are people suffering from a Mental Health crisis who seek to self medicate . Is that a phenomena that you see . That again would be one subset of individuals. Certainly the Substance Use disorders reenforced typically when one gets worse adherence to the other treatment gets worse as well. But when one gets better and effectively treated it can provide a conduit for the other. Certainly there is a subset of individuals that have co occurring for Mental Illness and Substance Use disorders and others that dont as well. The one source that we havent really talked that much about so far is the mexican drug cartels at the border, something that your agency specializes in combating. I know that there is a lot of justified outrage of the pharmaceutical manufacturers over the prescription opioids but a substantial amount of opioids comes across the southern border from the mexican drug cartels, correct . Correct. And the transit through mexico from china maybe not all of it at a substantial amount of it, correct . Correct. If we want to get serious about combating the Opioid Crisis in america we have to get serious about Border Security and intervening or interdicting those drugs before the cartels are able to smuggle them into the United States do you agree . And of course the proceeds of these drugs that the cartels manufacture are used to subsidize other illicit activities like Human Trafficking is that inaccurate statement in your experience . That is accurate. Madam chair, i see that my time has run out. Thank you madam chair and thank you for the witnesses. One of the things i wish the average american had the time to hear is the broad bipartisanship of the approach of the members of this panel to working with the administration and trying to address the nations Opioid Crisis. 48,000 americans died of overdoses last year. That has ravaged every state, every community at every level. Any senator that has getting the job has been to funerals, pin and groups, engaged with the community and has tried their best to tackle this and you have heard broadly shared frustrations about how slow some processes are moving like scheduling fentanyl and how much we still seem to have failed to grasp this crisis and act in a corresponding way. You are the assistant administrator for the diversion control of the dea, is that correct . Thats correct. Im grateful for what the dea does in delaware and across the country, but we lost 400 people to overdoses last year. It was a 15 increase over the year before that and increase over the year before that and that. In a bipartisan effort to try to find something more that needs to be done, ive worked with Senator Cory Gardner of colorado on a simple issue, knowing where the drugs are going. And as youve heard from several of my colleagues, senator durbin forcefully pointed out that weve had a system thats now for years since literally millions of opioids to towns that have tiny little populations where pharmacies or interdicting that the diversion and would strike me as a pressing gold. We live in a roadway or you can order a pizza or package from amazon and know in real time by text or call or email if you want them exactly where your package is and when its going to arrive. Weve worked with the dea now for months and months to try to get consensus on whether or not they want realtime knowledge of where the deliveries of the opioids that are likely to be diverted or happening. All of us are familiar with the story of a small town in West Virginia that ended up with millions and millions of doses for a town that had just a few thousand president s. If i could, does the dea have the ability now to track shipments as they move from the manufacturer to the distributor to the pharmacy that placed the order, do you have the ability to monitor that in real time . We do. We enhanced our data so we havee done that and we also as a part of the support act, we have the source in october of this year we had that coming in but to answer your question about the realtime data, a monthly would be better at this point right now. Its not realtime now to answer my question. It doesnt monthly now. When do you get data about how largish attempt has been made at a particular town or pharmacy . By statute 30 of the manufacturer and vista peters, 30 on a monthly basis, 70 on a quarterly basis and that is by statute. By statute, the vast majority of the data but if i were in your shoes as a Law Enforcement officer i would want to get months after the deliveries. Thats correct. Senator gardner and i have introduced a bill, the suspicious identification act that would help you collect and analyze the data in realtime to ensure that youve got knowledge you can act on that state Law Enforcement can act on and pharmacies can act on them we see different manufacturers and distributors old honing in on one town and delivering millions and millions of doses. Last year in math were shipped to my state of delaware to allow every single president to have 45 a year and i did the vast majority were not on the opioids last year. But 400 enough to die. One of the issues that has been focused on is three quarters died because of a mixture with fentanyl and i commend both our efforts to try to accelerate the scheduling of fentanyl and the steps china has taken, but there is so much more we have to do. Let me ask about the ways we can and should be innovative around developing new methodologies for treating pain and addiction. Ive also introduced with senator gardner of colorado the act that would support and fund Critical Research into the Science Behind opioid addiction thatthats already passed out e house and it was unanimously voted out of the Senate Commerce committee. I hope we will see a full senate vote on that soon. Can you speak to which aspects of the crisis would benefit the most from Additional Research and before you answer i will mention we all just learned on t on a bipartisan basis there will be more funding for brain research, for the nih and more funding this coming year. Where do you think we can make the biggest impact with more research . Certainly anchored in evidence with the Research Support in all aspects, prevention efforts certainly have yielded through, treatment with the evidencebased practices that we already have, expanding one of the biggest ones we would promote as well as Recovery Services because treatment isnt just investing in the clinic also recovery communities. Thats where the evidence lies and where i would expect the greatest to be yielded. Im also pleased that the outcome it seems now the outcome of the appropriations process will be vetoing the cp will be received at the that they will have a modest i think disturbing increase in the height o of the fundinfunding and the drugfree community funding. Folks, this is a Genuine National crisis that demands all hands on deck at all of us engaged in finding the best ways we can to deliver the resources for the research, Law Enforcement and coordination of the federal and state level. Thank you madam chair. I want to start by saying that for the state of misery, this is is a crisis that has been truly devastating. Missouris Life Expectancy in the state as a whole has actually been declining now for years on end because of the surge in Drug Overdoses, because of the surge in deaths and despair often linked to opioid addiction and other drug addictions. Its taking an enormous toll of courts around the country but in many ways it is groun ground zer this epidemic, so thank you all for being here and for the work that you are doing. Let me start with you as the attorney general i brought suit against the manufacturers into the second or third state to do so. It was very early on, two and a half years ago ar were close to three years ago now. I understand that the district of new yordistrictof new york nn criminal probe of opioid makers and distributors and im wondering if you can get a sense of the scope with a stage of that investigation and anything you might know about where it stands. I cant comment on open investigations but i can point you to public indictments of manufacture distributor executives as of late with the executives of the other was a Rochester Drug corporation. We made a point of holding the executives in charge of these companies who helped contribute to the crisis responsible. I think thats very important to do and if that hypothetical or possible for the individual executives and some of these companies and major distributors may be investigated or charged. We will go where the evidence takes us but that is always a possibility. Im glad to hear that and i hope that they will look very closely at that because i do think that if we are going to be charging opioid and heroin dealers and putting them in prison, and he showed, we absolutely sure that that is going to go all the way up the supply chain and i know from our own investigations in the state of missouri county outright deception of many of these companies, they knew that they were addictive, they knew what the side effects were, they knew that the data didnt support prescriptions and the mass numbers they were being prescribed and yet they deliberately misled the public sometimes doctors and veterans and other atrisk communities deliberately did so over a number of years and made literally billions of dollars and theres got to be an accountability in the wall for this. I want to come back to the question of drug smuggling and maybe i will address this to you. In the state of missouri and no, the supply of prescription opioids, the blackmarket supply i should say is being rationed down which is generally a positive thing, very positive. However we are seeing drug addiction continues to surge in the state and in the wake of prescription opioids we are seeing the blackmarket fentanyl and weve been talking about also methamphetamines. Now those products are not produced in the state of miseryy and methamphetamine isnt produced in the state of missouri at mexico and it comes across the southern border and its no to say every single one of our counties, 114, every single one of them is a wash in these Illegal Drugs and if you cannot go into a school in my state and not find these drugs with the snap of the finger so tell me about what our latest efforts are on the border, how are we doing it and protecting the drugs and what more do you need from congress because this is truly a crisis for my state. I was in missouri before i came back and so forth, so i totally agree with you 100 . I can tell you we are working with cbp. We have some of the highest seizures rightparen the United States on methamphetamine coming and i can tell you the men and women of the st. Louis Division Work everyday to ensure the safety and wellbeing of the estate and i can tell that you have great professionals there and actually one of the best supervisors i had was right down to your area. We are adding additional bodies as well as when i was there we were able to get Additional Special agents assigned to the st. Louis division, so i believe that we are doing everything we possibly can to work with our state and local counterparts as well as the department of justice, and you have some excellent u. S. Attorneys in your state. What more do we need to do specifically on the border, however come and feel free to chime in here, you mentioned this in your statement. What has to happen to see the flow of these drugs . It is one thing we prefer to not have to deal with it a mistake. I prefer them not to come to the state to begin with and they are pouring into the state in Springfield Missouri for instance, weve had record numbers of overdoses and a twomonth period more than a two month ago from wha from what loe fentanyl and potentially methamphetamine, then we had all of last year. Thats unbelievable. The drugs are pouring in. What do we need to do to stop the flow across the border . You are absolutely correct the drugs coming from the Mexican Cartels whether they are methamphetamine, fentanyl or analog or devastating the country. I would refer you back to the class scheduling of defense and all analog that is our number one priority right now. We have 51 days left and we very much need congress to act on this. I think that is the number one request at this point. Thank you very much and thank you madam chair. Senator hirono. Thank you. I know that we are here talking about opioids issues, but as mentioned by senator hawley and senator ernst other states have other problems in hawaii is mainly still methamphetamines. So, id like to ask you, let me give you a little bit of data on hawaii. The intensity Drug Trafficking areas 2019 threat assessment identifies methamphetamine, not opioids as posing the greatest drug threat to the region between 2012 and 2018 the number of people who die from overdoses increased by over 250 and over 70 of the drugrelated deaths in hawaii or the result of methamphetamine and the problem is not isolated to hawaii. Data from the centers show that overdoses nationwide increased fourfold between 2012 to 2016. What resources are your organizations and this is for the whole panel, or your organizations committing to address the increased use in states like hawaii and obviously in missouri and iowa and what Additional Resources do you need . I can start and then we can work our way down. Its beginning this year director carol have spent so much time traveling around the country and heard from so many members of congress and realized wed have so much effort into the crisis and write so that we learned a lot and developed a love of architecture and we should apply that to methamphetamine is also the ram on a deliberate effort right now to gather the information and bring together the inner agency and come up with some tangible solutions that we can do about methamphetamines coming and i had a good conversation with the u. S. Attorney from hawaii talking about where he beauties it is coming from i and what the patterns are and its not only the problem of the drug itself but its criminality of count of trafficking that is deeply affecting hawaii. So we are working to find tangible solutions, whether that is using grant money that is specifically meant for opioids and expanding that to methamphetamines as well and as it was mentioned earlier the drugfree Communities Program are all ways that we can understand that this is a problem across the country. Its not geographically locatedd and we can take a lot of the stuff weve learned from this crisis and apply it to them for domains as well and they will yield back. With respect to the grants there are many out there that are focused on the Opioid Crisis as they should be but we have been hearing increasingly but there is the need to get money to help address methamphetamine and i recognize what a huge issue it is in your district. I cant point to wha you to whas happening with the Mexican Cartels and they have been for several years and continue to. Its a very profitable and easy for them to make theres a huge profit margin and its through the roof and close to 100 so it is an epidemic and something we are continuing to work with and i think they can speak some of the programs, but i know that we are looking at domestic trafficking routes and how we can best attack the cartels that are bringing this into the country. Do you know how most is comincoming in through the mail, through the ports, do you know . What ive heard is that its coming in through both routes and they are doing what they can to address it. My understanding is that there is very little opioids in hawaii and that it barely methamphetamines compared to some of these other districts and so we are working on ways to help with that in terms of stopping the flow of methamphetamines into that state. Have any of you come up with something very specific with regards to stopping at coming into hawaii and also what kind of Treatment Options there are for the states like hawaii . Anything specific . They can speak to the great work they are doing with the government to identify. Two things to answer one of the previous questions. The administration in 2018 provided us with funding for over 400 Task Force Officers from state and local but know the area and know whats happening on the street level. So weve been able to implement that. As for the Opioid Crisis. However, due to the fact they are working cases now are methamphetamine as well so we have seen the surge in the task force positions as well as we have 11 offices in mexico right now. The primary office is mexico city and we are working with the Mexican Government on a daytoday basis to take out the methamphetamine labs and we are working with them on seizures as i said in the United States and we are also looking at highvalue targets to be brought back to the United States and face justice here. My time is up, but i would like to set a question regarding prevention because it is one thing to keep them from coming into the country but its another one to see what we are doing to prevent the usage of the drugs especially among young people. Thank you. Senator kennedy. It seems to me weve got three problems here. People in china are addicting our people here in america. People in america o are people rather in mexico over addicting the American People, and the United States government is protecting the American People. Senator burr been talked about the current quota being 8 million doses of opioids a year is the right of . By his method, yes. Thats 25 vicodin tablets for every man, woman and child in america. If i take 25 vicodin over two weeks, im going to get addicted car and i . Probably, sir. Yes. So, we can agree then that is too high, right clicks i wouldnt agree on that. What i can say is why not ask because it depends on the medical use. I understand and we know the medical use is come is 25 vicodin tablets for every man, woman and child in america. You dont think that is too high a tax our quota is based on what we think is necessary for the medical and research and you think we need every one of those vicodin tablets . The quota we believe is an appropriate malevolent law balance for what i discussed cinemax you are saying yes . I dont speak be s. You are saying yes . Right quex. We believe that quota is appropriate. Let me ask you this. You give information about what pharmacist are prescribing quarterly and monthly in some cases. We with the distributors that are to the pharmacist. I think we just said the same thing. If you see a pharmacy population 1500 just prescribed 7000 tablets last month that tells you something right . We can agree thats too many. What you are describing is the pmp data we have the data that goes to the pharmacy. Why dont you go get it . We have to get that from the state if we could ask for your assistance that would be a game changer. It doesnt seem like thats complicated. If a pharmacist is running scripts for 5000 vitamin tablets then we have a problem. I agree. You say who is prescribing all this . If you dont stop it. I agree. Why dont you do it . We dont have the data. You dont have the data. You dont have the data. Let me ask you something. You are a smart man. You are telling me you have to go out and educate the pharmacist that if you take too many vicodin tablets you will get addicted. You talked about evidencebased practices so the average doctor in america doesnt understand that if you give somebody six month supply of vicodin they will get addicted . We have to educate them for tha that . We are talking about enhancing the wider curriculum. Stop. I barely got through the part i know if you give somebody a six month supply of vicodin they will get addicted. Why do we do something to the doctors that are doing this . They dont need evidence based training they have been to medical school. I am over. Thank you madam chair. As you can sense there is some anger and a little bit of fury about the Opioid Crisis and with all due respect i know you are the messengers and not the policymakers but our message to you, i thank you can sense it is one of frustration. And as my colleagues have expressed dont think its good enough to say that mister mcdermott will work with you because thats at the agencies have been saying to us if so you should tell us but the crisis has existed for some time going back to connecticuts rate of addiction to overdose 2018 it was 1017 and that number is expected to rise with a 221 percent increase in opioid related death. So i think there has to be an effort not only the mexicans in chinese but the distributors and senator kennedy raises a valid point numerous times since my four children had all athletic injuries they were prescribed 30 days worth of opioids and the first thing my wife and i did was tell them they were not getting any of it. Even rotator cuff surgery i was prescribed about the same length opioid i didnt even bother filling the prescription. But yet now there are courses in medical school on Pain Management so they are recognizing their responsibility. I think the manufacturers and distributors can help but in terms of the consciousness about this issue and politicians that took bribes from cartels. Has the level of corruption diminished . Depending on the country are looking at their Different Levels of corruption. One reason i spent a great deal of time on those cases it allows them to operate carte blanche. But you see no levels of diminishment of corruption. Personally i have not. I have not been as actively involved in those investigations in my current role. How do most of the cartels shift the drugs into the country . From my experience i have had an opportunity to sit down with numerous or former members of cartels that are now cooperating who describe routes such as tunnels they spent 1 million to build under the border, to using a passenger vehicle, a truck with hidden compartments , lawful ports of entry, i prosecuted cases in california a fishing boat with an Outboard Motor is used to traffic drugs through maritime methods through the Southern California coastline. They will do whatever they can to get drugs into this country to make as much profit as possible. A wall is not likely to stop them. I dont know. I think they utilize every method that is possible to get the drugs into the country. You mentioned ports of entry, tunnels, water route routes, none of those would be prevented by building a wall. I will not press you on this point because they recognize the limits of your appearance here but i appreciate your testimony thank you. When we think about the wall which many people describe as a monolithic structure or fence along those lines and in other parts of the southwest i believe we are talking about updating the legal ports of entry and also Building Structures we also have discussions about funding coast guard so they can better beef up their efforts to secure the border do you believe looking at those Drug Trafficking having that scale that concept at one of a wall would have had an impact . The department can use every possible tool available for drugs coming into the countrys all those tools would be beneficial to help stem the flow. Me to. Thank you happy holidays. Something that i think is positive coming out of the dea just prescribing opioids over schedule to i appreciate the efforts i am curious with the data coming out of your agency im not seeing the same focus with other agencies and government do we know when they will catch up with the policies you have already been moving sharing senator kennedys concerns with the prescriptions but they are opioids but potentially less addictive so first thank you for that. We are working on a daily basis with hhs with fda and cdc and the whole body government to ensure whats best for the us citizens senator kennedy and senator durbin we will continue to work. You have done good work and you should be commended for it. It is my understanding working on this as a matter of state policy with the states that have implemented policies those that are prescribing opioids minimizing the amount by some sort of oversight its my understanding one of the leading causes of suicide in the country or people experiencing chronic pain conditions. I dont know if it is the leading cause that it is a major cause. The only medication that has efficacy of chronic pain thats why they prescribe it word you agree with that . You take a thoughtful perspective individuals of chronic pain in particular may develop opioid dependence but not those other dependent cdc has issued guidelines and i believe they will be revising those when it comes to provider education i would like to provide some clarity the improvement of those individuals and we try to implement evidencebased practices when it comes to medical School Curriculum with opioid use disorder not just to prescribing practices. You said you would love to get the data from the state is not like you can just call up the Health Department to say you need this information you need statutory support . Thats correct. What does that look like . I would ask you make the states have to provide us because that could provide the insight that senator kennedy would like you to have absent congressional action we dont have that. We do not we have to go state to state and then we have to sue the states to get the information. Thank you. You mentioned evidencebased i agree with you treatment and recovery programs Enforcement Actions and as vice chairman of the Senate Appropriations committee the bill filed late last night in the budget package one. 3,000,000,000. 110 for Rural Communities, 500 million for research of paid management and pregnant and postpartum women 89 for a medication assisted treatment for Prescription Drugs in opioid addiction if you disagree with that money in there please say so i think the senators of both parties we have a lot of progress for my state of vermont we still have problems the university of vermont that is also in the burlington area and in the rural areas two hours each week for a treatment if the Healthcare Professionals prescribed for addiction just like they do medication. Certainly has the treating opioid use disorder we would support any further expansion for all treatments and for vermont one of the first to implement where individuals would initially get treatment at a specialty site then continue had a spoke center so certainly we would want to not only do that but also Telehealth Options as well. We appreciate that because that brought our numbers down considerably. Lets Work Together on this we can talk and agree on this we have to make sure that it happens the Chinese Government took steps to prohibit sentinel coming up on fentanyl targeted sacs sanctions make a difference to fenton now being shipped to north america. Senator we have seed decreased direct from china shipments into the United States at the positive step in the right direction but what we do have to watch is if its coming from another country like canada or a european country and an increase in the production of fentanyl in mexico and the southwest border with other plant based drugs we are putting emphasis on that so all chinas actions have had an effect we have to make sure they contribute to solve the problem. You mentioned the importance of written testimony the administration on the task force of all funding including 5 million for the state Drug Task Force if these are important and why are they considered critical efforts for the epidemic . Senator im not familiar with those figures but i can tell you that ive mentioned a couple of them the task force and initiative that have come out over the past couple years to stem the tide on this epidemic so im not familiar with that specific grant budget but we are trying to put our resources where we see results. I have some followup questions on that to keep that money in the appropriations bill. Thats where the money has to come it started in the president s budget but its more difficult. Senator kennedy asked for an additional 30 seconds. I know you are new but explained to me in english why every man woman and child in America Needs 25 doses of opioids every year. I know you work hard at what you do doctor. I have two brothers who are physicians but doctors need to police themselves. You will not convince me that someone is smart enough to go to medical school doesnt understand that if they give someone a six month supply of vicodin they will get addicted and the doctors need to police themselves. At this time we are ready for our first panel as we set up for the second panel will be the bios of the second panel thank you to our witnesses for being here today thank you very much. With the second panel we have doctor bradley doctor hauser doctor stein is a senior policy researcher for Rand Corporation practicing adolescent psychiatry policy researcher at the Rand Corporation and as a professor of psychiatry at the university of pittsburgh executive Vice President miss kelly oversees all state and federal regulatory and Political Activities doctor hauser is the Vice President of policy and Government Affairs for the National Pharmacist association and over 25 years a private consultant in policy issues related to Substance Abuse to treatment into the witnesses on the second panel i will ask you to hold your statements to one minute and then we will make sure your entire statement is submitted for the record then we will proceed with questioning after that we do have votes that have been called so quickly go to your statements that would be helpful. Good morning and Ranking Member feinstein with the practic seeing child psychologist in pennsylvania many are children of crisis as parents, siblings and aunts and uncles my clinical work is how the Opioid Crisis involves analgesics and treatment and touching multiple systems involving Child Welfare and Public Housing and the systems track very complicated ways to understand these interactions of the unintended consequences if we were to confront this successfully. We have made Great Strides with the pain pills for example some chronic pain patients and others have finding trouble finding a new doctor if theres retires that to make sure that these individuals have access to better Pain Management as well as treatment. Thank you doctor stein. Good morning for the opportunity to discuss and address the Opioid Crisis for the record our industrys primary mention that this effort working with our supply chain partners to regulate our industry and fda and all state regulatory agencies every legitimate entity in the supply chain must be properly licensed and have a valid dea registration look forward to working with committees to address the Opioid Epidemic and we look forward to your questions. Good afternoon chairwoman and members of the committee representing the Community Pharmacist 22000 independents participating in numerous initiatives it includes evaluating prescriptions adopting electronic prescribing taking part dispose my meds utilizing the pharmacist toolkit advocating for greater access i will summarize my recommendations i think continue dialogue and continued Health Care Provider Resources Data sharing including prescriber systems the dea pharmacy may not that been updated since 2010 i would encourage them to do so advancing the role of medication assisted treatment and a medicaid provider to expand the disposal offices. Thank you. Thank you chairman and Ranking Member and the distinguished members of the committee more of this needs to be focused on prevention this is the most Cost Effective way to deal with the epidemic the program meets the reduction of misuse through the implementation that includes those sectors actively involved supply and demand. We train people to implement strategies to reinforce one another including awareness from changing policy and the procedures to change the physical design of the communit community. For those that have undertaken these types of approaches with those Substance Use and other metrics that can be transferred from the program to build and maintain that capacity and then to break down silos. I will yield my time to senator feinstein if you want to ask some questions for the second panel. I actually have no questions. Thank you for coming. I just want to ask a question of the distribution chain i used an example at the outset of 4300 people that received two. 7 million opioids. One pharmacy. One pharmacy. We are very pleased wie new functionality that was put forward. Didnt mr. Mcdermott say that its a matter of months before they get the information . It is. Its either monthly, he said 30 there are some Distribution Companies that have a massive amount sent to the middle of nowhere in illinois. You believe your responsibility ends by contacting narcos . I hope that would mea mean you d contact Law Enforcement and save time out, this isnt right, something just happened here we want to report it. Do you feel the responsibility to do that . Theres got to be some people that look and say they delivered what. Our responsibility is to report to the Prescription Drug Monitoring Programs overseen at the state level so the turnaround time varies, some or every 24 hours but that is the members responsibility to report a. I think we are on a roll call on the floor. I will just wrap up. Youve talked about alternative for the perception of opioids and the barriers that are there for the effective treatment of the misuse. What immediate policy changes to your recommended increase alternatives to prescription opioid medications . I think we need to make sure we are developing, disseminating anit really financially supportg and paying for alternatives both in the shortterm and longterm. In the shortterm we know certain types of procedures such as wisdom teeth being removed, we dont need this. We need to make sure youre using those. For more chronic pain we have things like physical therapy. We need to develop a picture insurance is covering a whole variety of treatments that are effective. Pain isnt going away. It affects 20 of u. S. Adults and in pairs so much they can do their daily activities and we need to be able to manage that. Your testimony if you go through the written testimony that youve provided, there are some powerful prevention success stories. How can Congress Must support this type of programs . Thank you so much. Just by exerting leadership and i think its also important that we have more communities that are trained and have the capacity to get those types of outcomes, tiny bits of federal money, 125,000 a year with a dollar for dollar match is basically all that they get. So it is an amazingly great federal resource and as senator coons said, we have a tiny bump up yesterday, but literally for every million dollars, we end up with another eight to ten rounds. I do apologize we are going to cut you short on your panel today. I think other members have all fled to the floor so we will also flee to the floor, but i do want to thank you for your input and input. We do have your records and those are submitted for the record. We will make sure of that and i appreciate the time and attention is given to us. Thank you so much. And we will keep the record open for one week for any members wanting to submit items for the record. [inaudible conversations] [inaudible conversations] [inaudible conversations]tes