Transcripts For CSPAN2 Senate Judiciary Hearing On Opioid Epidemic 20240713

Dive into our witness testimony as well. Since 1999 more than 700,000 people have died from a Drug Overdose in the United States. Increased opioid addiction and the production of deadly synthetic opioids have exasperated americans staggering death rate. In 2017 more than 70,000 people died from Drug Overdoses making it the leading cause of death in the United States. Of those 60 involved prescription opioids such as fentanyl. American. Up better against the Opioid Epidemic in 2018 when more than 10 Million People aged 12 or older abuse to opioids. 2 Million People suffered from an opioid use disorder and on average 130 americans die each day from an opioid overdose. We know the untimely death from widespread abuse of prescription and nonprescription opioids but they know from our familys neighbors and friends of the Opioid Crisis is not over. We must continue contending with this crisis. That being said we have made Great Strides in the past three years to help combat this crippling epidemic. Congress has passed t landmark legislation directed at combating the Opioid Crisis. Most of sadly the conference of addiction and recovery act and the 21st century cure at also known as the cures act both of which i proudly supported were signed into law in 2016. Combine these two bills provided over 1 billion in funding to combat the opioid t crisis. With an emphasis on increasing drug abuse prevention and treatment programs for two yeart Later Congress passed the bipartisan support for patients and communities act which is the most conference of antidrug addiction legislation in modern history. We crafted a support act to address every element of the Opioid Epidemic for manufacturers and distributors prescribers to users to First Responders and recovery professionals the date congress has dedicated nearly 11 billion to tackle the Opioid Crisis with the largest portion of that hunting granted to the department of health and Human Services. Today well hear from the administration and the executive Branch Members that shape e and execute the Government Strategy for combating the opene guide epidemic. The office of National Drug control policy and the department of justice the Drug Enforcement administration and the department of health and Human Services. This hearing is especially important when we think about the oversight role we have in congress and executive branch are distributing the funding we provided them to tackle the Opioid Crisis. That said the federal government is one aspect of combating this epidemic. We do not stand alone. Curbing the Opioid Crisis relies on widescale integrated solutions from all impacted. Today during the hearing we will have the opportunity to hear from key components of the private sector including the Health Care Distribution Alliance National committee of Pharmacists Association community antidrug coalition of america and drug policy from the rand corp. But together we anticipate a close and cooperative review of ourio collective effort to curb the supply of illicit opioids and unnecessary prescription opiates to approve access to evidencebased prevention treatment and Recovery Services for opioid use disorder to identify future needs of federal state and local levels and to develop sophisticated and tailored solutions for this destructive and deadly crisis. Before he turned to our Ranking Membere 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 amphetamine abuse has remained persistent problem. Nationwide in 2017 was 1 Million People have a methamphetamine use disorder and that has been reportedly clinically significant impairment including help albums disability and failure to meet responsibilities at work or school or home as a result of their drug abuse. This number significantly is higher than the 684,000 people who reported having methamphetamine use disorder a n 2016. Ed in 2016 alone my home state of iowa reported over 1500 confirmed child abuse reports relating to methamphetamine notches in theth home but foundn the childs body. Ultimately americans suffering from drug dependency. I loved ones are dying from drug abuse at alarming rates. Opioids are a priority today but methamphetamine and other dangerous substances have been attacking our urban arra committees and should and will be addressed going forward. Thank you and now ill turn to Ranking Member feinstein for her Opening Statementnt. Thanks very much madam chairman. I think her Opening Statement dovetails each other and i suspect it will dovetail with every member of the committee thinks. The question is what to do about it. Just last year overdoses created 48,000 deaths. To meet that number is stunning. In 2015 Life Expectancy in the United States has fallen for the third year largely due to opioid related Overdose Deaths in the economic costs are just unbelievable, 700 billion a year. One of the reasons that grew so much im told is a lack of education among medical professionals which has led to overprescribing. We saw in many cases pharmacies where pill mills with churning out of millions of pills to smaller communities regardless of the medical necessity. It opioids manufactures and distributors i believe had a responsibility to identify and report the suspicious t orders t they did not. This problem was compounded by inadequate responses from the federal, state and local governments. The Trump Administration declared the Opioid Epidemic a Public Health emergency in 2017 but has only used three of the 17 authorities triggered by that declaration, limiting its effect. The office of National Drug control policy failed to issue National Drug control strategies in 2017 and 2018. Its 2019 strategy did not include concrete goals for fiveyear projections for programs and Budget Priorities both of which are required by law. According to the october 2019 department of justice ig report the Justice Department and dea did not initially use all of their existing authorities and resources. Reduced quotas for opioids or whole registrants adequately accountable to 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 any solution must include a whole of 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. Another bill, the support act was signed into law last year. It builds on the 2016 legislation by authorizing critical agencies as well as prevention, Treatment Recovery and enforcement programs and expanding research. This act alsoer included a provision called the using data to prevent opioid diversion. This part of the law is designed to ensure that opioid manufactures andha distributors are held criminally and civilly liable for identifying and reporting suspicious orders of opioids. I happen to be the one that offered that and im very much concerned that it has never been really enforced. Today i am introducing new legislation to strengthen this laww and the legislation will requirean 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. Ondcp is establish a number of interagency working groups including the national oil opioids in synthetic cord nation group to monitor emerging trends in data. The Justice Department created the opioid enforcement anden prevention efforts division and thats an opioid fraud and abuse detection unit under a new initiative, focused on disrupting the on line sale of illicit drugs. For its part dea has increased its tactical diversion squad, enforcement and administrative actions against negligent distributors and manufacturers. As a result of these efforts for the First Time Since 1990 Prescription Drug related Overdose Deaths decreased. Thats really good news. There are things that we can do to save lives and reduce addiction. The centers for Disease Control and prevention have warned us a fourth wave of Drug Overdose epidemic is upon us. Most of those suffering from addiction they tell us use more than just opioids. In u 2018, cocaine, methamphetamine and benzodiazepines were present in nearly 60 of all opioid related Overdose Deaths. That is a stunning figure to me. We have got to take a good look at it and see what we need to do i would encourage her 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 beenay ravaged y an addiction epidemic and it costs tens of thousands of lives every year. Failure should not be an option. This is an important hearing and i so look forward to hearing from her witnesses hopefully with new ideas and constructive thoughts of thank you very much madam i chairwoman. Thank you Ranking Member and i recognize senator durbin for open opening comments as well. Thank you bed and chair for this m hearing. I called senator graham several weeks ago and asked him to consider this and i think a menu for making am possible today. I would like to state again with already ben stated we are in the Worst Epidemic in the United States losing 130 people each day. Small or suburb to wealthy to escape this drug epidemic. Its not the first epidemic in our history. The crackcocaine epidemic showed that we learned we cannot incarcerate our way out of this addiction crisis. In the prevention, intervention and treatment on the front end not just prosecution on the backend. Theres a growing bipartisan consensus that harsh prison sentences for lowlevel drug offenders have not only failed to stop drug addiction but if created many unjust and disastrous outcomes. Im proud of those committees spearheading the first atbat to right these wrongs. Now we need to make sure that the f combat current drugs on te market and the spread of synthetic fentanyl analogs that we do not impede Scientific Research that can save people who overdose on these drugs and we do not criminalize any harmless substances in the process. Let me ask you to consider just this fact. A recent study of fentanyl overdoses in massachusetts from 2014 to 2016 found that 83 of patients required more than two miloxone doses. Why . Because naloxone no longer Strong Enough to stop an overdose. Researchers have not yet identified an antidote that is. Many researchers believe a more powerful antidote may include the drug fentanyl. Thats why proposing legislation that will allowha truly harmful analogues to be added to schedule one but not at the expense of facilitating Vital Research to discover lifesaving antidote. Unfortunately there isnt an effort to bypass this conversation about the Research Aspects of the help hope hume returned to be the second pointed like to make is this. We can learn an c important lesn from the 1990 Tobacco Settlement agreement. The msa was a landmark 246 billion settlement to hold big tobacco responsible for hooking americans a nicotine and contributing to millions of deaths. I might add that they are at it again with vaping readonly of the dollars paid under that settlement were devoted to Public Health harms of nicotine addiction. 8 . Most of the money was spent on unrelated itemsic like stadiums. Many states cities and counties have sued theds opiate industry is a large there mass of lawsuit underway in cleveland today that could produce a large settlement. I think its critical that a substantial portion of the settlement be dedicated tos funding opioid addiction. The third is this. It was in june of 2016 in his hearing room at this very table that i learned the first time from acting director of the Drug Enforcement administration revealed on theor record it was actually the dea that approved the animal of opioids to be produced in the United States. Opioid addiction starts with prescription painkillers made by pharmaceutical companies, regulated by the Drug Enforcement administration however the Inspector General of the department of justice recently found that i quote dea was slow to respond to the dramatic increase in opioid abuse and needs to fully utilize its regulatory enforcement resource. Forhi years dea permitted, dea permitted pharma to produce enormous evergrowing amounts of opioid pills each year even though dea had the ability to set quotas limiting that protection. Foretim example and 2017 the drg Enforcement Administration of the government of the United States of america allowed pharma to produce 13 billion opioid doses to be put on the market. How much would that be . It would be a threeweek prescription for every adult in america approved by the Drug Enforcement administration. For years have been calling on them to set lower quotas. Mr. Senator kennedy of louisiana and i joined in a bipartisan effort to reform the law and require the Drug Enforcement administration to suggest opioid quotas to reflect whats happening in america. Madam chair im sure you are well aware of the county in your state, we 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 10co years. Harden county illinois by the least populated counties in my state of 4300 people, between 2006 in 2012, 2. 7 million opioids were shipped to a single pharmacy in harden county enough to provide every resident with 90 painkiller pills a year. The Drug Enforcement administration is supposed to monitor p this so they are provg massive production on the front end and no monitoring on the backend as we see in these areas Rural Counties being swamped with opioids. For years have been calling on them to lower quotas and now they have the legislative authority and no excuses. Im concerned that dea has not taken this as seriously as a should and i will ask questions when we reach that point. Well dea his lowered the indefensible quotas of recent years dea has proposed 20 quotas do not take p 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. There will be some questions on that. Look forward to working with myn colleagues in continuing on a bipartisan w basis to deal with this. Thank you madam chair. Opioids and synthetic Coronation Group of the office of National Drug control policy. In this capacity mr. Chester leads interagency efforts to reduce the availability of heroin fentanyl and synthetic drugs in the United States by disrupting his global applied chain. We also have ms. Miss amanda luscombe. She is director of ovoid enforcement prevention efforts for the United States department of justice. This system is responsible for odaining Department Strategic response to the Opioid Crisis including all investigative and efforts. They also have mr. Williams government printed to mcdermott. Mr. Mcdermott was appointed as the assistant administrator to dea diversion control on july 24th, 2019 pretty starts that the principal advisor to the administrator on all the matters pertaining to the regulation printed and coronation programs associated with the diversiongu of legally produced controlled substances. And also listed chemicals. Please help me with an incumbent doctor neeraj, control him. This is the chief medical officer the Substance Abuse and Mental Health Services Administration he is unfamiliar with the development and utilization of medical budgets, nuances of n regulation and code across various states printed and provided perspectives as he delivers direct patient care. Thank you very much. Well go ahead and start with our witness statement spread will start with you mr. Chester. Chairwoman Ranking Member feinstein members of the committee. Thank you for inviting me to testify in the dynamic and challenging illicit opioid environment we continue to face in the United States and our whole government approach to addressing it. The office of National Drug drug control policy on the leadership of director jim carroll, is uniquely positioned within the executive office of the j president to cordate the admin stations cover hasnt to policy and implementation. Join this began work on the opioid issue, the dominant threat heroin. It was a relatively low prices and impure are forms allowed for non intravenous use. Carolyn enabled an easy transition from prescription opioids to illicit opiates. Hudnall emerged as a major edoverdose driver and 2015. Initially as an adulterer into heroin one but by mid 2000 something many states had experienced a crossover clear more people were overdosing and dying from fennel than from heroin exclusively. Today was even more diversification across the illicit opioid environment with a variety of fentanyl analogues in nontechnical synthetic takes opioids readily available. I live for sophisticated counterfeit bills, sold on the darknet and delivered directly to consumers. This is further complicated by use ofth transference among different drug types. And across both synthetic opioids and non op ui drugs like methamphetamines. Combating illicit wellplanned availability and use demands of president ial leadership, strong bipartisanship by the congress and second injection off International Federal state local and tribal partners, across the Public Health Law Enforcement national security, intelligence communities. This allows us to deeply understand the environment and all of its complexity, and quickly identify and then rapidly close gaps in our capability as they emerge. Over the last four years, the federal government has make lifesaving gains through the synchronized approach first laid out in the 2016 heroin availability reduction plan. Then the final report of the president News Commission on drug addiction opioid abuse in 2017, President Trump News Initiative to stop or avoid abuse in 2018, and the 2019 National Drug control strategy. We advance our policy objectives along three clear lines of effort. Prevent drug use before it starts, improve access to treatment leading to longterm recovery, and reduce the availability illicit drugs in the uniteden states. Most importantly, the strategy guides and synchronizes federal government actions on the entirety of the drug problem to achieve our singular goal of saving american lives. This is the only criterion and that truly matters and by which the American People will measure the success of our efforts. This foundational documents and the others they are to regulate have been able to significantly accomplishments over the past few years. The creation of the department of justice joy crime criminal darknet enforcement Art Deco Team within the fbi, get the unit trafficking of synthetic opioids. The training of deployment of canine throughout customs and Border Protection news office of fields. Operations specifically trained to detect fennel. The establishment of a 24 hour seven day telephone forensic capability for cb on the enter dictate act to identify new synthetic opioids is the emergent in the marketplace, and the passage of the historic support act was recently authorized new Medicare Part b benefits that allow opioid treatment programs to bill for their Services Including counseling and medications beginningd next month. However, the illicit opioid environment continues to president a daunting challenge. Synthetic opioids ship in small quantities, make detecting and seizing these drugs monumentally difficult as they move through thein mail, express consignment carriers and across our borders. The increasing prevalence of polydrug users, counterfeit bills, and the rapid emergence and highly addictive deadly and readily available synthetic opiates are impacting prevention and treatment efforts. As chinas efforts to address the reductionen to last live scheduling begins to take hold, new production sources and distributional factors are emerging. These challenges are not insurmountable. And no more than ever, our efforts must remain synchronized across the entire government. With our state partners, our partners in the private sector, and others to produce the complementary effects we need to end thisrt crisis. I would likeo to thank this committee for your foresight and leadership in addressing this Critical National security Law Enforcement and Public Health challenge. On behalf of theon administratin on dcb looks forward to continuing to work with you and to confront this extremely complex issue. Thank you for the opportunity to testify today. I look forward to your questions. Thank you mr. Chester. This was come. If. Chairwoman arts, Ranking Member feinstein, and members of the committee, thank you for the opportunity to discuss the department of justice news work to combat the Opioid Epidemic. Im in the Department News director of opiate investment in preventionpi efforts. My position in the Deputy Attorney general news office was created for the sole purpose of ensuring that the department is properly formulating and plummeting resources to the fullest extent on the express of combining the Opioid Crisis. I also have 13 years of experience as a drug prosecutor working on as an assistant United States attorney, and also as a deputy second section chief in the Department News criminal division. I know firsthand that the department has brought simply paying lip service join his leadership expresses its commitment in this epidemic. It is responding aggressively and and and and check potential he with every chill that has at its disposal. One such tool is focused on the Department News effort to dismantle darknet websites. These websites allow some of the most prolific and drug suppliers that sell fennel in the marketplaces. Dismantling them is the priority for the department. Which is why a 2018, the fbi established a code, or the joy criminal who pointed at darknet enforcement team. Since jake is launched, there is been to successful largescale takedowns that have taken darknet accounts off of the web in hundreds of kilograms ofs drugs off of the streets. The department has also been diligently working to prosecute Mexican Cartels through traffic fennel and fentanyl analogues into the United States. The Mexican Cartels are not only producing their own fennel, mixing it with other drugs such as methamphetamine, heroin and cocaine. It is contributing to the staggering numbers of Overdose Deaths throughout this country. The department is using all of the tools that just disposal to combat these cartels. Winning the convictions of low cartel leader, walking to a sentence whose live years in july of this year. Another noteworthy initiative to operation from synthetic opioid search, and focuses on illicit opioids and ten districts that have seen some of the highest overdose death rate in this country. Prosecutors know districts have worked towards prosecuting out readily approval cases and by involving synthetic opioids. In the first year alone, over three and her kisses were charged in these ten districts. Additionally the department has created the regional prescription opioid track for sprint also known as arco. Laa joy lie Enforcement Effort that pulls the resources and expertise of multiple agencies to identify investigate and prosecute healthcare front screams in the adolescent reason. One of the most hardhit by thit epidemic. Since october 2018, establishment the strikeforce has charged more than 70 defendants for collectively responsible for distributing over 40 million pills. These medical professionals were charged with Drug Trafficking offenses with stiff penalties for the diversion of opioids. The strikers has also worked handinhand with hh i to ensure that join there is a takedown of these medical professionals, patients are not left out in the cold. Rather they are met by a team of Public Health officials whom there for them to legitimate medical providers or addiction services. The department recognizes that we cannot at sibley cross a way out of this crisis way. The abuse before it takes place. This occurs through school and community outreach, partnership with the native american tribes, Public Service announcements, and training for medical professionals. Additionally, the department has a Robust Network that establish exclusivity for over an inch and it prevention. This includes grants to facilitate treatment and prevention and victim services. And i have state and local Law Enforcement better investigate heroin, and prescription opioid distribution. Finally, i want to remind you of what i spoke with you about in june. Thend importance of a legislatie solution for fast white scheduling a fit not like substances. While the nation and see the usage of prescription opioids decrease, the number of overdose nests in the United States has reached record levels. One of the chief causes is the proliferation of fentanyl, and its analogues. As you know, in february 2018, the dea responded to the proliferation of fennel and log my scheduling the entire class of fit not like substances on a temporary emergency basis. In response to this order, we seen a significant decrease in encounters of fennel like substancesny and reduced production of the substances by traffickers. Classwide scheduling isr workin. But the temporary emergency scheduling order expires in just 51 days. The prosecutor, i can tell you the legislation to permanently schedule fennel like substances is an important and necessaryry step to continue countering this epidemic. We are running out of time and ras the solution has brought found prosecutors will undoubtably be hundred. And traffickers will undoubtedly be held. Af we cannot afford to move in the wrong direction on battling this crisis. Thank you for the opportunity to testify today and we look forward to continuing to work with congress to find solutions necessary to address the threats posed by this epidemic. Or mr. Mcdermott. Thank you for the opportunity to discuss our response to the Opioid Crisis. In the past several years, our nation has been increasingly devastated by anov epidemic that was over by over Prescription Drugs. The increase of over spurs driving from the late 1990s of the first decade of the 2000 was fueled by fund mental belief that pain was undertreated in the United States. Indiscriminate prescribing during this time, created a generation of opioid users. Presently estimated at more than 3m americans. Unfortunately, as prescription rates have declined over the last fourun years, we have seena dramatic disturbing shift. Mexican drug cartels are filling the void with cheap, highly potent, white powdered heroin. He continued to mix it with a illicit fentanyl, and la it to users and with a traditional forum, and on many cases, into counterfeit pills made to resemble illicit pharmaceuticals. Dea is now staying chinese and mexican nationals working together to move massive amounts of heroin, fentanyl, fentanyl related substances across the southwest border. Osthe process is that the organizations are collecting are astounding. The kilogram of fentanyl can be purchased for less than 5000 and can yield potential profits from it sells. In excess of 1. 5 million. Dea believes that the Singalong Cartel and. Cga will continue to be the primary Mexican Cartels controlling the illegal, and Drug Distribution throughout the United States. These cartels do not observe boundaries or United States or mexico or any other country. D8 a will continue to focus his attention and they efforts on the commandandcontrol components of these major Drug Trafficking organizations in order to protect our citizens from the devastations that they bring in the forum of violence and drugs. And with respect to addressing the diversion of controlled substances, and Prescription Drugs, i oversee the activities of dea news divergent control program. Roughly 18 percent of our workforce. The difference in a prescription or appearance small number of practitioners, less than 1 percent and less than a fraction of 1 percent have disproportionately impacted this epidemic. In fact, four to five new heroin users see that they started their cycle of addiction on prescription opioids. Within the diversion program, we have realigned criminal investigators with embedded them alongside diversion investigators. In an effort and enforcement groups with tactical diversion squad groups. Currently we have 86 of these groups nationwide, or solely dedicated to investigating, disrupting and dismantling individuals and organizations involved in diversion kings. These groups along with an additional 87 diversion groups, are using all tools administrative, civil, and criminal to pursue those registers who violate the law. We also remain focused on the limits the dea establishes with domestic manufacturing of scheduled one and into controlled substances called quotas. The recent publication of the 2020 quotas, on december 2nd, the dea has decreased quotas for the six most frequently misused opioids by 55 percent. From the levels established at the end of 2016. Weve been able to bring down these quotas because doctors nationwide, aree writing less fr opioids. A 30 percentna decline since january of 2017. Despite these declines, let me share with this committee and we recognize that opioids are essential medicine especially for those with acute pain. In dea will continue to work in the centers for medicare and Medicaid Services and cdc, and the state 80 offices to ensure that there are adequate supplies for those in need. The Division News continuous robust outreach program, west registrants aimed at improving communications and cooperation in tilting. I want to thank you for the opportunity to be here today and i look forward to your questions. Thank you. Chairman, thank you for inviting me here today to discuss his approach the Opioid Crisis. In the chief medical officer for samsung. On addiction psychiatrist and multisite and multistate operations provider supervision news, and the treatment of both Mental Illness and Substance Use disorders. An vulnerable and underservedia populations. Simpson our mission is to reduce the impact of substance misuse and mental innocent readers across this country. We are the Agency Within hhs that leads Public Health efforts to improve the lives of individuals leaving with Mental Illness and Substance Use disorders as well as their families. Samson news number one priority in combating the Opioid Crisis is the expansion of prevention, treatment, recovery, support services we do this by providing a full range of grants targeting the Opioid Crisis. The state opioid response planse are a program, addresses the main crisis including prescription opiates, heroin, and illicit and no analogues by increasing access to medications since the treatment or mat, using the three fda approved medications for the treatment of opioid disorders. In reducing opioid overdose related deaths through the provision of prevention,n, treatment, and recovery activities for opioid use disorder. The partner with Numerous Community partners and stakeholder organizations to ensure this dissemination of appropriate evidencebased of weird prevention strategies. These includes drug takeback and disposal programs, and overdose education, as well dsp as description activities and marking the immediate campaigns and strategies to reduce stigma. In order to ensure that individuals receive a comprehensive array of services. We suffer serve. One of the most common by smart grantees is pierced supports. Individuals who themselves, are in recovery. Another common activity for development and enhancement and expansion of Recovery Community organizations, as well as the use of recovery residencies. Peers are engaged in a number of settings or individuals with opioid use disorder, initiate and maintain recovery. Samson strongly believes in the expansion of comprehensive ststems of care, through continued partnership between federal governments and state and communities, we will make continued progress in combating the Opioid Crisis. American indians and alaska natives have been especially hardhit by increasing rates of prescription and illicit opioid use. Addiction and overdose as well. These populations have a secondhighest overdose death rates from heroin and a third highest from synthetic opioids. In an effort to address the Opioid Epidemic in an country, samson has established a triable opioid response. Tort program through a source subside. The tort program aims to address the good crisis in tribal communities by increasing access to culturally appropriate and evidencebaseded treatment. Samson has also been a leader to reduce deaths by increasing availability and use of new oxen to reverse overdose through funding it technical assistance. Samson is Overdose Prevention toolkit released in 2013 is one of our most downloaded resources. The toolkit provides information on recognizing the risks off opioid overdose and the signs of overdose, and had to provide Emergency Care in an overdose situation. Toolkit is intended for community members, First Responders, prescribers, people have recovered from an opioid overdose, family members, as well as communities and localty governments. Sims is opioid prevention efforts targeting Prescription Drug misuse have also shown positive outcomes. Samson strategic prevention framework Prescription Drug programs assist grantees to target the priority issue of Prescription Drug misuse. The Program Works of pharmaceutical communities and the risk of over prescribing to young adults and brings Prescription Drug abuse prevention activity education, to schools and communities parents prescribers and patients. On the grantees, are required to have an operational state run Drug Monitoring Program called pmp. They are supported in developing capacity and expertise in the use of data from these pda mps. Samson National Survey on drug use and help also known as nasa provides key national n and stae loophole data. On a variety of Substance Use and Mental Health topics including misuse. As a vital part of the efforts related to opioids. Sims is also building a primary partner implementation of healing communities project. To improve Research Practice but in this committed to promoting evidencebased practices in Service Delivery models. Thank you for the opportunity to testify in this issue and i look forward to answering any questions you may have. Thank you again to our witnesses and we will start with five minute rounds now within the members. In doctorn deanda i would like o start with you please read according to the u. S. Census bureau, rural areas cover approximately 97 percent of the nation news land area and approximately 6 percent of iowans live in those Rural Communities and we heard from of course an undercurrent as well outlining some of hisbi Rural Communities. Doctor gano you written testimony you Substance Abuse and Mental Health services and those Rural Communities and thank you for doing that. It gave describe some of the key challenges to reducing the impact of substance misuse and Mental Illness and Rural Communities especially join it comes to opioids and then if you been also speak to us about methamphetamine as well. Abutting the focuses treatment capacity and we certainly do have a great number of providers and they need to be in the right places. Treatmentbe keep cassidy is certainly addressed by a variety of different techniques. Telehealth is one that we are certainly exploring to increase capacity to these rural areas. As well as provider expansion, sam set in collaboration with dea and certified a large number of wavered physicians and providers including expansion for our Nurse Practitioners and fishes in subsistence and mid levels and increasing provider limits so that they would be able to treat a greater number of patients. So we are understanding that we have two attack this problem from different angles as well as including provider education or primary care colleagues as well. I would comment that Art Addiction Technology Transfer center is provided over 50000 providers with expertise and attacking this problem as well. Education, and treatment expansion as well as the scoring opportunities with telehealth would be the ways we would most likely proceed. A. Excellent i appreciate that. In iowa i have visited very Community Health centers and expanding the reach through telehealth. I really appreciate you speaking to them. And the Opioid Epidemic, Linda Sampson news longterm strategy than for addressing substance misuse Mental Illness and those Rural Communities. The issue of addressing Substance Abuse, we certainly have a lot of resources that we are devotingre towards that ande thank congress for the appropriation block Grant Funding can be utilized for the treatment of any Substance Use disorder. In addition to the rants, which also can be used to treat opioid use disorder any occurring, Mental Illness or substitute disorder, a great number enrollees to have co occurring Substance Use and Mental Illness and certainly itd can fund news can be and are appropriated for the as well. Very good and mr. Mcdermott, d. A. Is our nation news hotline defense to elicit controlled substances and we just recently mark the oneyear anniversary of our Bipartisan Legislation support act which comebacks the Opioid Epidemic and worked in that measure to strengthen drug takeback programs efforts and drugsse safe disposal of how can dea work to increase the participation in those drug takeback programs. Hit a button again. Its is it too much money can tell you is that twice a year the d. A. Doesnt takeback was iw the spring and washe in the fall and is has been very productive. Most important think i can see about that is this, typically join an adolescent is involved with abuse loophole. Then typically it starts ine the medicine cabinet. That is the most important think to get out of the house. Heavy steel parties at schools and so forth he probably heard about. So if we could get the message out and were doing it much better job i can tell you now with participation from tribal areas as well and the addiction rates there are tremendous. I was a second at denver area we we covered montana and had serious concerns there. So takeback is been very productive we have more participation from state and local loophole of participation from coalitions away participation from hospitals, you name it. We are out and its been a very productive at the end of the day, there sometimes there is criticism to see we only get x amount of open eyes but i can tell you any amount of work is that you take out of your house, or off of the streets, that is beneficial. Thank you. Ranking member feinstein. Thanks very much. I believe that the chairman of this committee and t i, very muh believe if it no should be made in schedule one drug. And hopefully will proceed to do that. I cant believe 48000 overdoses deaths, can you in anyway shape shape or forum give us a constituency for that or those 40000 deaths. In other words who is dying and what is their edge and what is the race. How do we know who they are printed. Yes center, i will tell you one of the defining features of the opioid prices and specifically Overdose Deaths due to illicit opioids are the fact that it cuts completely crossed racial economic, geographic, and gender lines. A lot of the Drug Overdose and use patterns that we saw in years past, are defined by the phenyl crisis because it is introduced into the marketplace and users in mucho different ways. Sometimes, and as it mixed and as an adult drink into heroin, it lands in the existing and remained just drunk you using population. It is pressedti into a highly sophisticated counterfeit bill, and sold on the a internet perhs into ang unknowing is that think theyre just getting cut rate opioids from another country, and as a prisoner does not understand or know that they are being part of the illicit environment that they are i can take a bill pressed into her getting up and no bill being presented as a counterfeit drug. So it cuts across all racial geographic and demographic lin lines. That is one of the defining features of this particular crisis. A. What anyone on the panel not support that no being mayday schedule one drug. So i assume the answered is yes and madame, i believe there he strongly than chairman and i have discussed is that pension old beat mayday schedule one drug as soon as we possibly can. I think 48000 people dying from it, is it too many. Can anyone give us a description of the deaths and the majority of use involved in those deaths. I can start. One of the things that weve seen in the evolution of phenyl and i think i have touched on this in my Opening Statement is that in 2006, there was a small break the phenyl Overdose Deaths in illinois. That was tracked back to a one single app. In mexico, was neutralized and it didnt and phenyl didnt completely go away but it certainly decrease. I really wasnt until developed 2015 that we started to see and be a regular feature in toxicology testing done in drug seizures. And by that time, asian drug traffickers principally from china and entered the scene were bringing it into the country principally being ordered over the darknet. And then sent trammell an express express assignment. The reason i see that, is because, rather than having individuals having to go to drug traffickers and make a facetoface catch transaction, it was now able to beat diffuse across the country andss anyone with access to a laptop, and the dark web and crypto currency could buy it have it delivered directly to the house and this kind of speaks to the proliferation of illicit opioids and phenyl news across the country what was originally started in the northeast as an involved intravenous drug using population, and expanded across the country to where we are today. Any newly discovered fayetteville substance should be added to the controlled substances act by name. But everybody support that. Anybody disagree. Cementum chairman, i think we have artwork laid out for us. Senator durbin, i know has thoughts on this but we work to make note schedule one drug. We try to reverse these deaths. Is there any common denominator of people in the 48000 racially, economically, edge wise, not is it too many common denominators. They some of our shaped partners with whom wert deal and provides a lot of information have spoken to perhaps an increase in africanamerican communities above what we saw in other opioids. The only common denominator for everyone who has died and the availability of the drug. And availability, we know, leads to increase first use and first use use to chronic use of opioids and perhaps more so than any of them. That is the common denominator. A. E do you support making it a schedule one drug. A. Absolutely. A. Does everyone on the Panel Support making it a schedule one drug. A. Would you like to comment. Senator, id would have to take that back to the department. I dont want to be in trouble thats fine. Among i agree with missus m. I would also like to take that question back to my team. Assuming if you want, i would certainly appreciate an answered because thats where imap goin. I may not be successful but its what i deeply believe. Thanks madame chairman. Senator grassley. The office of Inspector General, recently reviewed the deas efforts to control the diversion of opioids. Dsthe report did this conclusion in the dea was slow to respond with a significant rise in the use and diversion of opioids since the early 20000 news. So mr. Mcdermott, Inspector General news report states but the quote the department and dea agreed with all of the recommendations how is dea prioritizing and meeting theseri recommendations. Senator, as we speak today, we are working on this. One of them is, there was criticism or the dea pertaining to our work plan for diversion investigators. We have change the work plan and we work with yg. Join implemented the recommendation as we speak today. A. And then i think the next question to you is easy to answered. Would you commit to updateo congress on the u progress of meeting these recommendations. So i guess her prince mike thank you. Last year Congress Passed landmark legislation the Opioid Crisis, we call that the support act and proud to have cosponsored and moved through the Judiciary Committee chairman at the time. A number of bills that are part of that law, the oig report states that because the sport act is relatively new to the Justice Department is quote unable to measure read and predict its effect on the Opioid Crisis or deas opioid Enforcement Efforts. Question, mother may be the case, and may be legitimately theop case the director of opiod enforcement and prevention efforts of the Justice Department, but your position, can you provide net a double. With respect to the support act. So dea has implemented a number ofea the act from the support act and specifically that database credit that was implemented in october 23rd of this year. And another that they are a stil working through a number of other components within theth support act to include their work with the database which has been invaluable to the department with respect to our opioid investigations. I can tell you i seen firsthand, how the types of databases avenues to prosecute diversion of opioids both with what we refer to as dirty doctors to nationwide opioid manufacturers in disparate distributor so we are working with d. A. To ensure that we are able to hit those benchmarks with the support act. Since i am going to assess question to the entire panel, it deals with that no, and hope it doesnt cause crossover with senator feinstein asked. It is wellknown about fentanyl and it is dangerous and logs, coming to the United States from china and enables china to issue a class wide control of phenyl and logs. Also earlier this year witnesses from dea, the Justice Department, only a dcp, commanded that Judiciary Committee hearing hasnt been monitoring transactions and ensuring followthrough. Do all of you, or was significantni developments of eh of your agency show the American People that we are winning the fight against chinese phenyl injuring our country. Ill start with you mr. Chester. A. Senator, i think a couple of things have come together to bring some tangible outcomes from chinas efforts to schedule panels as a t cause. The first one is the president s direct appeal to president jake asking him was that game changer and grandstandser leadership in coronation with the administration of the inner agency as been incrediblyon ported. That resulted in china not only following through completely on its one commitment, but also taking some tangible steps such as two months ago, by inviting u. S. Officials to the conviction of nine individuals forfeit no trafficking coming from china. It was ahi major step forward. As you know director carol traveled over to china in september, spoke with the Chinese Government about some tangible steps that they could take moving forward to include greater Law Enforcement cooperation and greater policy ordination, and we believe that the steps in china are positive and will take uspo in the path where it will begin to reduce the flow of phenyl coming into the United States. For the recipe if you havent answered, make it short because my time is s run out. And i want to infringe upon the other people. Just briefly, its my understanding that we seen a significant drop off in the amountnt of phenyl and analog to china in the mail. That shows the positive steps that have been taken from china classwide scheduling. And i would remind the committee that sensitive or scheduling order went into effect women the United States significant drop off of analogs in this country. I believe its only been to analogs have been encountered in this calendar year which shows that both chinas actions in the actions here in the notices are working with respect to phenyl analogs. A. I have caught her comments and also we have twoom offices n now. Right they won in beijing and one joke. And the working relationship is been excellent. Anything abductor. He looked simply that senses approaches meant for prevention we distributed blocks and kids and to certainly over a quarter million of them of distributed to across the country with reversal of over 14000 overdoses. 1 thank you. On the nature of the record is clear that in 2016 join we hearing for this committee be established the Drug Enforcement administration had approved the productionrc 14 million opioid doses that year in the United States. 14 billion. That meant that every adult in america could take a one month prescription of opioids based on the approved production quota from the Drug Enforcement administration. In the midst of the worst drug epidemic in d our country and we suffice it. Opioids were driving it to him and one in fenton on the dea was approving the production of 14 billion of these doses. Requested by the pharmaceutical industry. A number of us started asking questions. What is going on here. By reproducing all these opioid arpills dramatically more than s necessary for the health of america. And as a consequence, mr. Mcdermott news testimony today, is that the corn of productions have gone down. So 55 percent, unknow with the exact number is im estimating is around 8 billion at this. 8 million opioid doses here. Join is the equivalent to. Is equivalent to a two week dosage for every adult in america and that is what we are Still Producing and opioids as we talk about the opioid drug epidemic. And so mr. Mcdermott, senator kennedy and i said what is going on here is de eight paying any attention to what is happening to these opioid pills. Once they are produced. And the response to me was, sinner, if you want us to pay entention, put in the law. We did. It was that from this. Forward join theai septic code is an dea taken into account the deaths in americaa related to opioids, the diversion of these opioid pills, from the ordinary medical and of Course Congress and the following. As we waited to see mr. Mcdermott what would happen you know what the response was we just cant find that information where we cant really take that into consideration bring back the d. A. Basically told us, and determine the dude in the grouping of the drug classesro n all sources provided the data cannot be used just might diversion for the purpose of sending the production quotas. One is the take. How do we get the dea to acknowledge that 8 million opioid doses is dramatically more than can possibly be used for legal purposes. For medical purposes. Center, thank you for your question as previously discussed by the former acting administrator, dea realizes that we couldve done things differently. We do think differently and have been in this position for almost a mr. Read your letter and senator kennedy news letter and i would tell you that i sent down to the s folks that do the quota and went over the numbers again. I assure you thats a priority for me and i sure you that is a priority for the administrator to ensure that we have a balanced approach printed aware or looking at those and if you look at the. Numbers were doing exactly what you asked us to do. 8 billion. Enough for every adult in america to have a whole. Toys for two weeks print every adult in america. You think that is a good response in the midst of it drug epidemic. So we work with fda and the cdc, and the state attorney general news office to ensure there is adequate medical supply research to ensure that and will continue to work with yourr office to let those and to those numberso into ensure that we hae a proper medical supply out there. It. Start with this, if our government, doesnt start by and reasonable regulation of the production, it will continue to ask for more and more and more and more. Far beyond what is medically necessary far beyond was need it for chronic pain and ordinary uses. So if the Drug Enforcement administration has brought in on the program, we are going nowhere with this conversation. And i hope that changes soon. So far we havent had a response from the dea thatt i think is appropriate. And as doctor bulger a question. Is there an antidote to phenyl. In your initial statement you had mentioned that you had heard anecdotal reports where people have required more than windows of norwalk news own as a reversal for opioids. At this time that is our fda approved option in the lock soon has been used to reverse opioid overdoses however long acting substances like fentanyl may require more than one dose and that is whyhy even after someone has had had administered in the had been resuscitated adequate medical supervision so to answered your question, it is the option we have right now. Cemex is the point i like to get to. On the scheduling, phenyl analogs gubelli discusses in a separate meeting. I am not opposed senator feinstein and others, take that no analogs on a schedule one as tha are. And it will expect higher in 51 days. Join they worry about and i am concerned about is we do not have an antidote. What i worry lou put it onto a schedule one process which prohibits Production Units is because of the possibility of research into an antidote for phenyl which i think should be underway. It would be i think, ludicrous for us to believe the phenols going to disappear even if the import numbers are coming down. Join im asking you to do it all im asking you to do news and putting these had no analogs on schedule one, give us some process so that researchers can look for that fentanyl antidote which could literally save lives today. The lock soon, is the guess and some value really doesnt have hthe effect of application that could make a difference. Mr. Chester missus lipson if you like to respond. News center i am proud to see, then dcp, the department of justice and have him Human Services have been working throughout the somber on the very balance that you talk about which is the balance between controllinghe substances that ae ydangerous and they come into te United States but allowing adequate researcher access and we believewe we struck the balae and enjoyed working with the committee on this. To ensure that as substances are gathered up that are more than reasonably dangerous and potentially dangerous that we provide an unprecedented loophole of researcher access to be able to pull them out of the schedule for Research Purposes to do two things. To determine their medical merit as you discussed maybe the next generation not determine that they have no active effect in the body or that the nondangerous and think they should be beat reschedule. We believe the work we have done between both of those departments actually strike that balance very well with the unprecedented loophole of researcher access, but at the same time an unprecedented loophole of control for the substances that are dangerous to americans. Lets continue that conversation. S l is that im looking forward to further. Senator blackburn. His stomach thank you madame chairman and thank you to each of you for being here. I think you can hear the bipartisan frustration. Inner voices we have an issue that continues to get worse. Not better and in tennessee, we have seen an increase in our drug related deaths. 1837. Last year that was up from 1776. We know from our national Law Enforcement communities that the deaths are increasing. Our dr. Said he is seeing a continued increase so it is something that we are facing citywide. We seem to have a problem with fentanyl on the streets. And with myth. In the upper east tennessee and we engage regularly and constantly with Law Enforcement and Healthcare Professionals. And this is why we need you all, to really collaborate with us in a timely manner. Defying answers to this and 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 they are struggling within california. Many of our cities are. Need to move past these discussions. Weve been at this for a while. Especially with the opioids. And look at whatt 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 and weve got, attack scores, doj has commended them and we commend them. For the good work that they are doing. Join it comes to hhs, what are we going to do to promote treatment for the thousands that exclude people that are caught up in a revolving door situation with Law Enforcement. They are incarcerated and they are not receiving the treatment that they need it. So mr. Chester, and missiles come, i want to come to you first. Talk about what you are doing to get resources to Law Enforcement and i would like for you to talk about a little bit about treatment and what you all are changing to make treatment and recovery available for physicians. What are you doing to try to train doctors and what you doing to educate pharmacists. When he comes of this and senator durbin just said, the number of pills, that are in the system, and then being able to achieve that balance approach for people that need it to get it. To get it out of the system. So mr. Chester, do s you first. Please be mindful of the car. Will be very quick w senator. Law enforcement principally, it is a Drug Trafficking programs. That fund Law Enforcement task forces at the state loophole that our state and local and federal and that is the principal and a combined effort. Absolutely. And the think about the height of test horses is that they are unique to the particular areas and focus on the particular drug threat in that area rather than one of the country. The giving the flexibility if necessary. Likewise at doj we are number of stark were we utilize the same methodology in terms of combining resources of local and statement law and enforcement they like the prescription strikeforce. There focus on efforts in the ablation region and while they do have the daf you in each edge is the live g, he also very much rely on the local and state partners. In order to combat the diversi diversion. Sue might evidencebased practices and certainly promoting evidence based practices too provide education. If two main initiatives. The provider clinical support system which implements data waiver materials into medical schools curriculums as well as provider education for Substance Abuse disorder in education as a whole within. We believe that Healthcare Settings is certainly the place where we can improve art scope for educating the next loophole in the next generation of providers. Widely utilized programs. I believe over a hundred and 57000 individuals have been trained through growth programs. Thank you very much and let me start with a question about the purdue former case and i dont know if either of you guys were involved in that from doj but more than a year ago in august, 2018, we sent a letter to the department of justice asking about why the case against Purdue Pharma that was being proposed as a federal criminal indictment and the Western District of virginia, wincing onto the political side of the department of justice, suddenly got turned into a misdemeanor prosecution for a find that in the context of this litigation has brought very significant and that that operated not against purdue but a holy company so that purdue could continue to do business. With medicaid and other federal programs. And the fact that mr. Giuliani was involved with the same time that he is involved with the department of justice on other matters, huds and asked her owner to the disappearance of this prosecution of the political loophole. Personal i would like to try to get an answered from a letter from august of 2018. Dont think thats asking is it too much. Second i would like to know let you know about why that prosecution was made to disappear and turn into a misdemeanor settlement. I can look into that letter senator im unaware of that the statuses but ill be sure to take that back to my colleagues. I was not involved in that litigation so i dont have a lot of specifics to share with you but i can tell you that the department is very actively looking into nationwide manufacturer into speed strip readers of opioids. We recognize the brawl that many of those companies played including the executives in those companies and contributing to the Opioid Crisis. Semi surfing the multidistrict litigation. Right. You are like to participate in it if not leaving it. We have a friend of the quote letter. That litigation is correct. What is stressing me out that in your brawl, as a friend of the quote in the district litigation, the department of justice will actually take those serious position in favor of the plaintiffs join the record so far is that your call in the right lawyer of thehe political appointees at doj and the uks disappears into a misdemeanor against the holding company. So as a friend of the quote were not a party to that litigation recently hit there to help provide guidance. Depends on what the issue is. Now i know weve been involved with helping the depositions of the dea either current or former employees weve been assisting in pulling together the requested as part of that litigation. Supporting the discovery phase in the information gathering phase of the effort. Assuming thats correct. We do take those position, while the same people scotched the Western District be making the decision as to what position the department should take substantively. I am not sure what position the Department News going to take. I dont know what the issue is going to be butng i can tell you again, but reiterate the department has opened an investigation was i obviously cant, and on but is very actively looking into the space and trying to find to hold eopeople accountable for their involving in creating this crisis. His stomach hope you do a better job than he did the last time. The last question i have a has to do with this particular. It is more of a technical question but as youve heard today, there is broad bipartisan support for scheduling sentinel as a unlawful drug. However, in all of you seem to agree with that however join we go to hhs, this administration hssays no we shouldnt do that because the chemistry in this question is very complicated. And if you man sentinel analogs, you will likely get into potentially banning drugs that could actually help with addiction or with response to an overdose. E. So it seems to me that the mot important think that you all could do is get the administration alondra Piano Program for how we schedule until that went out bringing into the objections from hhs. Perhapsan mr. Chester you can le with that. T probably trying to cordate this effort. We have been coordinating between hhs and his departments and night at fda cbc nih, and also excuse me sir credits mike is the common position yet. Yes or there is. It was captured and transmitted in the committee in september which i discussed earlier the balance between gathering and we talk about fictional i d want to be clear, what we are talking about is sentinel analogs which are additions or substitutions to the fennel skeleton and thats how we define based on an activity in the body. As these substances come in they are captured. And the other side of that and this is the hhs program is to have an unprecedented loophole of access to be able to access the substances and be able to do oresearch on them and determine what their actual activity is to determine if theres any medical merit. That is what weve been able to do between the department of health and Human Services and the help department of justice bringing them together to get into an agreement that we have struck the right balance between control and access. And that is what we have presented to the committee. My time is expired. Want to follow. We talk about what fluids, this is an umbrella term right. With crisp Prescription Drugs, heroin, fentanyl, is that the universe of what we consider to be opioids . Certainly that it would include all of those synthetic and natural. Opium and heroin all of the way through to Prescription Drugs as well. His. In your experience as an addiction specialist, join people cant get Prescription Drugs, do they opt in for a cheaper alternative like heroin. It. A subset of individuals do. Not everyone would but certainly a subset would. Think the figure i saw was about 15000 heroin related deaths off of i know the numbers get kind of murky, because frequently as several of you have mentioned, you have a cocktail of a variety of drugs sometimes mix together which is deadly obviously. The applications of that drug last year but that just saves the persons life. From the overdosee at that moment. That does not cure the addiction, correct . Correct. We believe that sam set in most addiction professionals that treatment has to continue for an extended period of time. Simply one intervention wontt be effective. Whether it be reversing the overdose and i will say the administration is using best practice. It is certainly something we promote is a wonderful option for reading reversing opioid. It has certainly been a lifesaver and you have just made it, the person remains addicted and needs additional treatment and help. Correct . Corrects. Cttreatment should extend on the full spectrum. If the person requires detox, residential, outpatient. Treatment has to continue. We know inpatient stay in treatment that we have better outcomes. Do they o get moved to other drugs like methadone . Thank you for bringing that up. Or medications in the treatment is a Gold Standard for opioid use disorder. Whether it be a methadone, mall truck sewn, their fda approved medications. These have been treatments that have been found to decrease overdose, increase social capital, criminal justice involvement, homelessness, and engage in other treatment seeking behaviors. Reducing hiv spread, so certainly getting patients in treatment is our goal. You mentioned chairman ernst and you discussed 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 phenomenon you see . That again is one subset of individuals. Certainly the Substance Abuse disorder and Mental Illness are interactive reinforcing when one gets worse, and 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 individualss who have co occurring for both Mental Illness and Substance Abuse disorders. And others that dont as w well. Mr. Mcdermott, the one source of opioids that we really havent talk that much about so far is the mexican drug cartels and the border. That is something your agency specializes in combating. I know there is a lot of outrage, justified outrage at pharmaceutical manufacturers that over manufacture and doctors who over prescribe prescription opioids. But a substantial amount of opioids come across our a southern border from the mexican drug cartel, correct . Correct. And the fence and all, transits through mexico from china. Maybe not all that but a substantial amount of it correct . Correct. Sophie want to get serious about combating the Opioid Crisis we have to gets serious and intervening are interdicting those drugs before the cartels are able to start smuggle them into the United States. Do you agree . Corrects. Of course the proceeds of these Illegal Drugs that the cartels are manufactured is used to substitute sought subsidize their other activities such as human track faking. Is that an accurate estate statement . Yes. Madame chairman i see my time is run out. Senator, thank you to the witnesses before us today. One thing i wish the average american had the time to hear is the broad bipartisan of the approach of the members of this panel to working with the administration and trying to address our nations Opioid Crisis. 48000 americans died of overdose just this last year. That has ravaged every state, every community at every level. Any senator who is doing their job, has been to funerals, has been to parent groups, has engage with their Public Health community, and is tried their best to tackle this. And you have heard broadly shared frustration about how slow some processes are moving. Like scheduling fentanyl and how much we still seem to grasp the breadth and depth of this crisis and acted in a corresponding way. Mr. Mcdermott, you are the assistant administrator for diversion controlled the dea. Is that correct . That is correct. And i am grateful for what the dea doesnt delaware and across the country. But we lost 400 people to overdoses last year that was a 15 increase over the year before that and increase over the before that common increase with the over there before that. And its a bipartisan effort to find something more that needs to be done. I have worked with senator gardner from colorado on a simple issue. Knowing where the drugs are going. And as you have heard from several of my colleagues, senator durbin forcefully pointed out that weve had a ersystem that now for years since literally millions of opioids to townsio that have tiny little populations or pharmacies and interdicting that diversion which strike me as a pressing goal. We live in a world where you can order a pizza or package from amazon and know in real time by text or calls, or emails if you want them to exactly where your package is. And when its going to write. And we worked with dea now for months and months to try and get consensus on whether or not the dea wants realtime knowledge of where massive hadeliveries of opioids that are likely to be diverted are 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 town that just had a few thousand residents. So if i could, mr. Mcdermott. Does the dea have the abilityou now to track shipments of opioids as they move from the manufacturer to the distributor, to the pharmacy who ordered it. You have the ability to monitor that a real time now . Senator we do. We enhance our data, we have also as a support act we had the source, in october of 23rd of this year we have that coming in. But to answer your question about realtime data, we monthly would be better at this. Right now. So its not real time now to answer the question. Its not monthly now, when do you get data about how large of a shipment has been made to a particular town or pharmacy. By statute we received 30 of the manufacturers and distributors on a monthly basis. M 70 on a quarterly basis and thats by statute. Sell by statute the vast majority of the data that if i were near shoes was a lawenforcement officer i would want. You get months after the deliveries. Of that is correct so senator gardner and i i have introduced a bill that would help you collect and analyze that data in realtime to ensure that you have knowledge that you can act on. That state Law Enforcement can act on, that pharmacies can wact on when we see different manufacturers in different distributors all homing in on one town. Andn they are delivering millions and millions of doses. Last year enough opioids were shipped to my little state of delaware to allow every single resident to have 45 pills a year. And i bet you the mass majority do not use opioids last00 year. But 400 took enough to die. One of the issues this has been focused on his three quarters of them died because of a mixture with fentanyl and i commend both our efforts and tried to accelerate the scheduling of fentanyl on the steps china has taken, but theres so much more we have to do. Doctor kendo trapay can ask about the ways we can and should be innovative about methodologies on treating pain and addiction i have also introduced the effort act which supports and funds the Science Behind opioid tradition. It was unanimously voted out the Center Commerce committee i hope we will see a full senate vote on it soon. Can you speak on the aspects which would benefit most from Additional Research . And i will like to say on a bipartisanan basis there will be more funding for Brain Research for thefu nih, and more funding for the nsf this coming year. Where do you think we can make the biggest impact on opioid addiction with research . Certainly anchoredin in evidence over the research and it supports all aspects, prevention, prevention efforts ouhave yielded fruit. Treatment with the evidencebased practices that we already have expanding mat is probably one of the biggest ones. As well as Recovery Services. Because treatment is not just a setting in the clinic, but recovering communities. Shats where the evidence lies, thats where i would expect the greatest fruit to be yielded. Im also pleased that the outcome, it seems now that the outcome that our appropriation process will be that on dcp will receive the National Office of drug control policy will have a modest but it deserved increase funding. Folks this is a Genuine National crisis that demands all hands on deck, and all of his engage in finding the best ways to deliver resources for research, for Law Enforcement, and for coordination at the and state levels. Thank you madam chair. Senator holling. Thank you madam chair, i would like to start by saying for the state of missouri, this is a crisis that has been truly devastating. Life expectancy as a whole has been declining now for years on end because of the surge in Drug Overdoses. Because of the surge of death andai despair are often linked to opioid addiction and other drug addiction. I just taking an enormous toll around the country, but to missouri it is unfortunately in many cases ground zero for this epidemic. So thank you all for being here. Thank you for the work youre doing. Let me start with you, as attorney general for the state of missouri i brought suit against major opioid manufacturers inn the second or third state to do so. Its veryte early on, the student half years ago almost three years ago. I understand the Eastern District w new york has now start its own criminal probe of opioid makers and distributors. Im wondering if youen could give us some information about the scope of that investigation. You know where it stands . Unfortunately i cannot comment on opening investigations. But i can. You to public indictments of manufacturing and distributor executives as ofh late, one was the executives of miami lucan, and the other was of Rochester Drug corporation were we have made a. Were holding the executives who in charge of these countries to help continue to the crisis responsible. As i think thats very important in speaking of executives is that hypotheticals think that some of these major distributors may be investigated and charged . Is that potential . We will obviously go over us. Evidence takes it is always a possibility. Good, well im glad to hear that i hope the other prosecutors look very closely thatin because i do think if we are going to be charging opioid and heroin dealers and putting them in prison, and we should. The absolution. But that accountability ability haskell although if the supply chain. I know from our own investigation and the state of missouri the out rank deception of these pharmaceutical deception that they knew opioids were addictive theyrt knew the data did not support subscriptions in the massive doses they are prescribing. And yet they deliberately misled the public. Sometimes doctors and veterans and other atlas communities delivery did so they made literally billions of dollars on that. There has to be accountable in the law for this. Plumbing come back to the question of drug smuggling. Mr. Mcdermott maybe ill dress this year. In the state of missouri now, the supply of prescription opioids, the black market supply, is being ratcheted down. Which is generally a positive thing. A very positive thing. However, overseeing as a drug addiction seems a surge in the state. And in the wake of prescription opioids we are seeing fenton all in black market fennel, and also methamphetamine. Now those products aremt not produced the state of missouri and methamphetamine is in mexico and it comes across the southern border. Ou and it is no exaggeration to say in missouri every single one of our counties we have hundred 14, every single one of them is a wash in these Illegal Drugs. And i mean awash in them. You cannot go into a school in my state and not find these Illegal Drugs with a snap of the finger. So tell me about what our latest efforts are on the border . How are we doing in interdicting these drugs . What more do you need from congress. Because this is truly a crisis for my state. Senator i was in missouri before i go back and forth to had crisper so i totally agree with you one 100 . I can tell you were working with cvp and we have some of the highest seizures rightp now and the United States andit methamphetamine and i can tell you the men and women of the st. Louis Division Work every day to ensure the safety and wellbeing of that state. And i can tell you have some great professionals there, and actually one of the best supervisors i had went right down to your area. Adding additional bodies as well as when i was a sect there we weree able to get special agents assigned to the stainless division. So i believe we are doing everything we possible to work with your state and local counterparts in the departmentic of justice. And you have an excellent u. S. Attorney in your state. What more do we need to do specifically on thehe border however. Ms. Luscombe feel free to chime in here. What has to happen to see the flow of these drugs change. Its one thing we prefer to not have to deal that in the astate. I prefer these drugs not come to the state. But they are pouring into the state. In Springfield Missouri weve had record numbers of overdoses just in the two month period, more overdoses in a two month. What looks like fennel and methamphetamine that we had all of last year. Its just unbelievable. The drugs are just pouring in. What do we need to do to stop the flow across the border . Senator you are absently correct. The drugs coming from the Mexican Cartel whether its fentonth all nixon i just want to push you back with 51 days left, we very much need congress to act on this one point in so i think thats the number one request at this. Thank you very much thank you manager. Senator ono. Thank you. I know that we are here talking about opioid issues, as mentioned by senator ernst that other states have other problems in hawaii is still mainly meth. So i would like to ask you, will let me give you a little bit of data on hawaii. The high intensity Drug Trafficking area in 2019 assessment identified math is closing the greatest drug. In 2018 who died increased over 250 . And over 70 of drug related deaths in hawaii are the result of math. And the meth problem is not isolated to hawaii, data from the centers for Disease Control and prevention shows that meth overdoses nationwide increased fourfold between 2012 and 2016. What resources are your organizations, this is for the full panel. Are your organizations committing to addressing the increased use of math in states like hawaii and obviously itsdr in missouri, its in iowa. And what Additional Resources do you need . Senator i can start on we can work or we down. At the beginning of this year, doctorct carol had spent so much time traveling around the country and had heard from some of the members of congress ended realized he put so much effort into the opioid crack crisis and rightly so, but that we have learned a lot and had developed a lot of architecture and we should apply that too methamphetamine as well. We have been on a deliberate effort now to gather the information,me bring the inter agency, and come up with some tangible solutions that we can do for methamphetamine. I had a goodat conversation talking about methamphetamine where he believes its coming from a what the patterns are as well. Thats not on the problem with the drug itself, but the associated criminality around the methamphetamine track trafficking thats deeply affecting hawaii. And so we are working to find tangible solutions whether that is using grants money that is specifically been for opioids and expanding that to methamphetamine as well. As was mentioned earlier, the drugfree communities Prevention Program and the haida programs are always that we can understand that this is a clear problem, across the country. Its not geographically located. And we can take aoc lot of the stuff that we learn from the Opioid Crisis and apply it to methamphetamine as well. Any of the other panelists once at answer. Thank you, senator, i echo what mr. Chester said when in respect to the grants. There are many grants out there that are focused on the Opioid Crisis as they should be. But we have been hearing increasingly thatt there is a need to get money to help address methamphetamine which i also spoke with the u. S. Attorney there and recognize what a huge issue it is in your district. I just cannot. Enough to what is happening with the Mexican Cartel and they have been for several years. They continue to produce methamphetamine, its very profitable and easy for them to make. Theres a huge profit market and the rates we are seeing is through the roof in close to one 100 purity so it is evan epidemic and something we are continuing to work with. And i think the ae can spoke to some of the programs i know youre looking at domestic track at faking routes. We are looking at how we can best attack the cartel as they are bringing this into the country. Do you know how most of the meth comes into hawaii is coming to the mail is that the reports . Do you know . What ive heard it from speaking with the u. S. Attorney there its coming in through both routes. And they are doing what they can to address it. My understanding is theres very little opioids in hawaii and that is primarily meth. Relatively speaking. Compared to these other districts. So were working on ways to help that since stopping the flow of methamphetamine into that state. Still have and you come up with something very specific with regard to the stopping the meth coming into hawaii . And also what kind of Treatment Options are prevention options are they firstaid like hawaii . Anything specific . The dea could talk about the great work they are doing with the government in to talk about whats going on down there. Two things to answer any previous questions we have, these cartels or drugs. So they must ration 2018 provide us with the dea with funding for over 400 task force officers. This are from state locals that know the area and know whats happening on the street level. So we have been able to implement that, it was void the Opioid Crisis but however since it was polydrug, they are working cases that are now methamphetamine as well. So we have seen a certain task force positions as well as we are working we have 11 offices in mexico now. A primary offices in mexico city and we are working with the Mexican Government on a daytoday basis to take out these methamphetamine labs. We are working with them on seizures 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 do have, i would like to submit a question regarding prevention. Because its one thing to keep all of these drugs were coming into our country but its another once they get here and what are we doing to prevent the usage of these drugs especially among young people . Thank you. Senator kennedy. Mr. Mick derman it seems to me that weve got three problems here. People in china are addicting are people in america people in america or rather people in mexico are addicting the American People and they you knighted since government is addicting the American People. Senator durbin talk to you about the current quote of being 8 billion doses of opioid a year is that right . Yes or. Thats 25 mike it in tablets for every man woman and child in america. Now if i take 25 vicodin over two weeks im going to get addicted, arent i . Probably sir. Yeah. So we can agree then that the 8 billion is too hi, right . Sir i would not agree on that. What i can say. Why not . It depends on the medical use. I understand and we know at the medical uses. Is 25 vicodin tablets for every man, woman, and child in america. You dont think thats too high . s quote ised based on what we think his message necessary for the medical use as well as research, as well as a exportation. And you think we need every one of those bike it in tablets. We are trying to do a balanced approach. But i can assure you i will work with your office. Mr. Mcdermott im not trying to be rude, but she read a checkpoint where patients ceases to be a virtue. You are telling me we need 8 billion, thats nine zeros doses of opioids. Year for the American People . Twentyfive vicodin tablets for every man, woman, and china child. We need every single one of them . That your testimony . Served with the quota we have that is what we believe is needed for the United States. So you think thats what we need . The quota we believe is balanced for what we discussed. I believe youre saying yes is that right . Sir. I dont speak bs. You are saying yes correct . Sir we believe the quote is appropriate. Sir let t me ask you this, you get information about what pharmacists are prescribing, right . Quarterly and monthly in some cases. We get information on a quarterly and monthly basis on what the manufacturers are distributing to the pharmacies. I think we just said the same thing. So if you see that a pharmacy and buck snort usa population 1500, just subscribed or prescribed 7000 vicodin tablets last month, that kind of tells you something doesnt it . Thats too many, right . Can we agree thats too many, right . Surf we had that data, which what you are describing is p. M. Pda data we have the data what goes to the pharmacy now what goes out . Why dont you go get it . Sir we dont have that in we have to get that from the e ate. If we could ask for your assistance, we need that. That would be a game changer. It doesnt seem to me that would be very complicated. If a pharmacist is writing scripts for 5000 vicodin tablets and buck snort when there are only 1500 people, weve got a problem. I agree with you. So you send somebody in who in gods name is prescribing all this . And then you stop it. Any fee dont stop it you punish them than the rest of their natural lives. I agree with you. Why dont you do that . Because we dont have that data. You dont have that data. You dont have that data. Doc let me ask you something, noww i look to record up in your smart mad. Yale, you are telling me youve got to go out and educate doctors and pharmacists that if you take too many vicodin tablets you get addicted . You talked about uevidencebased practices, youre telling me that the average doctor in america doesnt understand that if you give somebody six month supply of vicodin theyre going to get addicted . We have to educate them for that . What we are talking about center is enhancing the medical scope curriculum. Provider curriculum. Doc, doc, i barely got through the part where you cut up the frog in biology. And i know that if you give somebody a six month supply of vicodin theyre going to get addicted. Why dont we do something so the doctors that are doing this . They dont need evidencebased training. Theyve been the medical school. Imn over. Senator blumenthal. Thank you madam chair. I think you have sensed there is impatience, and anger, and even fury about this Opioid Crisis and with all due respect i know that you all are the messengers. You are not k the policymakers and you have to take back our message to you, and i think you can sense it is one of frustration. Least. The and as my colleagues have expressed, i dont think its good enough to say, as you have mr. Mcdermott. We will work with you. Because thats what agencies have been saying to us, and may be partly to fault is United States congress, and if so you should tell us. But this crisis has existed for some b time. Its not suddenly reared its head. Its going back two years ago that rays of addiction was rising and so was its rates of death due to overdose in 2018 it was 1017 Overdose Deaths. And that number is expected to rise this year between 2012 and 2018 to 221 increase in opioid related death. Thats in connecticut alone. So i think there has to be an effort to hold accountable, not only the mexicans in the chinese, but the manufacturers and distributors in this country. And senator kennedy raises a valid. Ive raised it numerous times since my four children all had athletic injuries and worse prescribed 30 days worthth of opioids. On the first thing my wife and i did was tell them they werent getting any ofnd it. And i recently had shoulder rotator cuff surgery. And i was prescribed i think about the same length of opioids. And i did not even bother filling the prescription. And yet there are now medical courses, courses in medical school on Pain Management. So the medical profession recognizes its responsibility. And i think that the manufacturers and distributors need to be held accountable to. And in terms of the consciousness about this issue, i know ms. Bliss you have prosecuted mexican and guatemalan corrupt politicians who took bribes from cartels and major cartel heads. In your view, has the level of corruption diminished over recent years . I think depending on the country you are looking at. There are Different Levels of corruption. In one of the reasons i spent a great deal of time and those types of cases is that obviously when theres corruption, it allows the cartel to operate in that country sort of carte blanche. But you have seen no diminishment of the levels of corruption in those countries . I personally have not seen a disk management but i have not n been as actively involved in those investigations in my current role. Had a most of these cartels shipped their drugs into this country . I can speak from my experience, i have had the opportunity to sit down with numerous members are former members of the cartel who are now cooperating witnesses who described routes such as tunnels, that they spend a Million Dollars to build under the border. Two using, whether its a passenger vehicle or a trunk that has hidden compartments in it, to bring drugs and through lawful ports of entry. I have personally prosecuted cases inn california where they called a panga vote which is a fishing vote that has an Outboard Motor is used to traffic drugs to a maritime message along this Southern California coastline. I can say the cartels will do anything and everything they can to get drugs into this country and is making is much profit as possible. A wall is not likely to stopm them, correct . I dont know. I think they utilize every method that is possible for them to get the drugs into the country. So far you mention tunnels, ports of entry, water routes, none of those be prevented by building a wall. And im not going to press you on this. Because i recognize the limits of your appearance here. But i do appreciate your testimony and all those who have been here today. Thank you very much. Senator tele. Thank you madam chair thank you all for being here. I didnt plan on asking us a question but i think i will start with you ms. Lis come. When we think about the wall, which many people describe is just being a big fence or something along those lines, my understanding were trying to work on tunnel Detection Capabilities with technology particular. Over in california and other parts in the southwest. I believe we are talking about updating our legal ports of entry was scanning technology that can get to one 100 scan of vehicles. And then also building structures. Weve also had discussions of running coast guard more so they can beef up their interdiction efforts and secure the border. Do you believe that if we were focusing on those, identifying tunnels for Illicit Trade in human trafficking, and Drug Trafficking. And having 100 scan it ports of entry that that concept of a wall would probably have a beneficial impact on drug intervention . I think the department could use every possible tool available to combat the drugs coming into this country. So i think all of the tools you mentioned would bes beneficial in helping to stem the flow. Yes me too, thank you. Mr. Mcdermott, happy holidays. I actually want to Say Something that i think is positive its coming out of the dea, and that has to do with some of the emphasis on potentially prescribing scheduled three opioids of her because they appeared to be less addictive, and i appreciate you alls efforts on that behalf. I am kind of curious with the data coming out a year agency, and im not saying yes so the same focus at this. With the cdc and other agencies and a the government. Do you have any idea when they will actually catch up . Catch up with some of the policies you have already been moving in trying to provide data . Others share kennedys concern with prescriptions and i know potentially they are opioids but potentially less addictive and may be might make a gateway. Thank you for that work, but whats the rest of the government to try to lessen these addictive drugs. What i can say is we are working on a daily basis with hhs and the fda, and the cdc, the d. O. J. And the ndc p as a whole the united government. I can study what we do is what we ensure for the what the best for the u. S. Citizens. And we are working on that, and i hear senator kennedy and i hear senator dermot and i continue to work on what theyve message us to do. And i think we need all the agencies and catch up. I think youve done some good work they are in you should be commended for. I dont know who to ask this question, maybe the doctor in the house. But i have a its my anderson sanding back when i was speaker the house and we are trying to work on this is a state policy in north carolinas estate that implemented policy to reduce prescribing opioids, or minimizing the amount that they are prescribing with some sort of oversight and check back. Its my understanding a few years ago that one of the leading causes of suicide in this country, are people who are experiencing chronic pain conditions. Disaster accurate . It is a major cause. I wouldnt say its a leading cause, but it certainly. So one of the things wema are trying to balance of its the only medication that has efficacy around these things, for chronic pain. Its one of the reasons we prescribe it. Would you agree that . I would say its a thoughtful perspective that individuals with chronic pain, in particular may develop opioid dependence but not the other behaviors of Substance Abuse disorder. The cdc has issued guidelines in 2016 and i believe they will be in process of refining those guidelines. And when it comes to providing education, i like to provide just a little bit of clarity. Sampsons goal is to provide improvement in those individuals who have Substance Abuse disorder and Mental Illness. We tried to implement efforts of best practices when it comes to our medical school curriculum. For treating Substance Abuse disorder and opioid use disorder. And not necessarily limit to just prescribing practice. Thank you mr. Mcdermott. You her response to one of senator kennedys questions as you said you wanted to get information if psyche called the state and get that information,li you need some sort of statutory support to do that, is that correct . That is correct. And what does that look like in terms of what we need template. What i would ask is that you make the states have to give us this information. Salem mandate that they have to give you that information for the information senator kennedy would you would have. But absence. We have to go on a statebystate basis. We have to see the states to get that information. Senator lahey. Thanknk you and doctor you mentioned evidencebased prevention. I agree with you. We have to have that, we have to have treatment, we have ten recovery programs, Enforcement Actions and actually do things. As vice chairman of the Senate Appropriations committee, the bill that is filed late last night i tried to prioritize these issues. In the budget package weve got 1. 3 billion as of last nights, and the fight against so put epidemic hundred and 10 million for Rural Communities opioids response00 program. 500million for targeted research and opioid addiction and Pain Management. 731. 9million for pregnant and postpartuman women with opioid abuse disorder. 89million for medication assistant treatment for Prescription Drug and opioid addiction. So i think that money is going to be out spirit in if any of you disagree with having money in that place, say so because we start voting this afternoon on having it there. House members and centers in both parties to work today on this. Now, weve had a lot of progress in my state of vermont. We have one of the lower percentages of opioid addiction. But we still have problems. The university of vermont, federal and senators great outside of the burlington area. But then we have those in the hardhit rural areas. We dont see them drive two weeks or two hours each week for treatment. Should Healthcare Professionals be able to prescribe morphine for addiction just like they do other medication . I want to know how we reach these rural areas . Certainly sampson is integrals a file model arbiter for the x waiver for those products to treat opioid disorder. Mood certainly appreciate any further expansion of rural treatment centers. Vermont, i would comment was one of the first to implement the hub and spoke model where individuals would initially get treatment at a specialty sites, the hub, and then continue treatment in the community at a spoke center. So certainly we would want to not only do that, but also improve our Telehealth Options as well. I appreciate that because the hubub and spoke has brought our numbers down considerably below what some of the surrounding areas have. Lets Work Together on this, because we can talk about it and agree on it here, but we have to make sure it happens. Now the Chinese Government took some steps to prohibit fentanyl. Are the targeted sanctions that are been put in place terms a difference in of fentanyl is being shipped to north america . Senator i can start an interpretive injustice if they have some thing to add. We have seen a decrease in direct from china shipments of fennelro and fennel analogs and opioids in nine states. And thats a positive step in the right direction. The two things we do have to watch our indirect shipments from china into the United States, which means it comes from another country like canada european country that we are not watching us closely. In the second thing is the increase in the production of fentanyl in mexico and its trafficking across the southwest border along with other plant based drugs. Those that you things are putting a great deal of emphasis on. So while chinas actions have had an effect, we need to make sure that they contribute to actually helping solve the problem. I agree with you. And miss list come, you mentioned the ports of the antiheroine tax force the written task force. Of the administration 2020 budget zero doubt all funding. The antiheroine to ask force had been appropriated 35 million in fiscal year 20. I know in our state, the state task force uses that. If these are important, why is the white house not similarly consider these grants critical to these efforts ofca the Opioid Epidemic. Why is it zero doubt . Senator im actually not familiar with his figures. But i can tell you with five mesh a couple of them we have task source andas initiatives an d. O. J. That have come out over the past couple of years and actually working in our view to help stem the tide on the epidemic. So again i am not familiar with that specific grants, budget, but i can tell you we are trying to put our resources were we are actually seeing results. I will have further questions on that because many of us rub at republicans and democrats want to keep that money in the appropriations bill so we can talk about it here and generality but somewhere the money has toon come. If its not of the president s budget, oftentimes we do added in. But it is more difficult. Thank you. s senator kennedys asked for additional 30 seconds. Mr. Mcdermott i know youre new, id like you to write me a letter explaining to me in english, why every man, one woman, and child in America Needs 25 doses of opioids every year. And doctor im going to say to you, i know you work hard at what you do. I have two brothers who are physicians. But doctors need to police themselves. You are not going to 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 are going to get addicted. And the doctors need to police themselves. Okay thank you, senator kennedy. At this time we will release our first panel for the record and as we are setting up for the second panel, i will go ahead and read the bios of our second panel. I want to thank our witnesses for being here today. Thank you very much. Okay, on our second panel we have doctor Bradley Stein. Mr. Patrick kelly, doctor rhonda hauser, and ms. Sue cowper. And doctor Bradley Stein is a senior physician, policy researcher for reincorporation. Doctor stein is a practicing child and adolescent psychiatrist and senior physician policy researcher. At the Rand Corporation and adjunct associate professor of psychiatry at the university of pittsburg. Mr. Patrick kelly as an hdas executive Vice President of government affairs. Ra. Kelly oversees all hda state and federal legislative regulatory and political activities. And then doctor rhonda hauser, doctor hauser is a Vice President of policy on government affairs. Operations for f the National Community Pharmacists Association. And then ms. Sue cow, is that correct . Ms. Sue thought, for over 25 years miss the ball has a private consultant specializing in policy issues, relating to Substance Abuse prevention andd treatment. And to hour of our witnesses on the second panel, i am d ing to have to ask you to hold your statements to one minutes if at all possible. We will submit your entire statement for the record. And then we will proceed withwi questioning after that. So if you can abbreviate as much as possible, we do have votes that have been called, so if you could quickly move through your statements that would be very helpful. Doctor stein lets start with you please. Good morning chairwoman and establish members of the committee. As chairwoman mentioned in addition to my research im a practicing psychiatrist and many of the children i treat our children of the crisis. Their parents, siblings, and senegal have been affected. Many of our how the this involves multiple symptoms. Many of our policies focus side opioid analogy and treatment. But many defective families touched multiple systems. Parents on probation involving child welfare, public housing. These systems interact in very complicated ways. And i think, understanding these interactions, and the unintended consequences is essential if we are to confront this crisis successfully. We have made Great Strides in curbing clinical subscribing and availability pain pills permit some of these have had on the consequences. So some chronic pain patients are being tapered off of opioids to quickly and other individuals have trouble finding a new doctor when theres retires. Wee need to both focus on continuing to decrease opioids but at the same time making sure these individuals have access to better Pain Management as well as t t treatment. Thank you doctor syed mr. Kelly. Good morning chairman ernst feinstein and the rest look may pray thank you for the opportunity to discuss what we are looking Good Solutions to address the appeared crisis the nine states. For the record distributors dont manufacture describe prescribe, our primary mission is to provide the supply chain. Pharmaceutical supplies regulator entities must notably the Drug Enforcement and the drug in the session. At allstate reg atari agencies. In order to handle controlled substances every legitimate entity in the pharmaceutical supply chain must be properly licensed and have a valid dea registration. We look forward to working with committee as you move forward and looking at forwardlooking solutions and looking at this epidemic and look forward your questions. Doctor hauser. And cpa represents Americas Committee pharmacists include nearly 22000 independent community pharmacies. In cpv members are numerous and to dispense subs controlled substances and to identify possible ovulation. Examples include evaluating prescriptions to attempted tech forgeries, adopting electronic prescribing which is stopped for directors, and dispose my meds, utilizing allied against opioid toolkit and advocating for reader pharmacists. I will summarize my recommendations. I think continued dialogue with all stakeholders and continued health care provided resources are important. Enhanced integration and data sharing, including prescriber systems. Updated dea pharmacist manual, has not been updated since 2010. I would encourage the dea to do d so. Advancing the role the pharmacist and medication assisted treatment. I reckon is the pharmacist is a medicare provider to furnish opioid services. Expanding disposal options and improving supply chain reporting. Thank you. Thank you, senator ernst rankin member find cited other memories. To stem the more focus needs to be put on prevention to stop abuse before it really starts. That is the most costeffective way to deal with the epidemic. The Drug Free Communities Program and nds pc has had major reductions in opioid misuse through the implementation of the model for Community Change that includes 12 required sectors being actively involved and also spans the supply andnv demand split. We train people to implement seven strategies to Community Change. These basically reinforce each other. They include everything from raising awareness through changing policies, practices, and procedures. Providing support for more skills in changing the physical design of the community and communities that have undertaken these types of approaches they have seen traumatic reductions and Substance Abuse and other metrics. Into us the keys to success on the can be transferred the dmc program to mitigate the Opioid Epidemic are building and maintaining multisector capacity, providing Technical Assistant training, ensuring preventions a major focus in breaking downca silos across the plane. Thank you. I will yield my time right now to senator feinstein if you want to add some brief questions for second panel. I actually have no questions, but thank you for coming. Thank you. All right senator durbin. I just basically want to ask a question of the distribution chain and the people represented independent pharmacies here. I use an example here at the onset of accountancy with 4300 people that received 2. 7 million u opioids. One pharmacy received it. There is a process, and arduous process its most keep track of this paper the dea basically told us they get their information late if they get it all. Do you feel any Corporate Responsibility in your businesses to report something that on its face is so outrageous to Law Enforcement . Senator we take our responsibility to report to the state very seriously. Its a very important issue for us. We are very pleased with the new functionality that was put forward in the support. Excuse me didnt mr. Dermot say its a matter of months before they get the information . It is, sir, he said 30 are monthly. Your Distribution Company sends a massive amounts of opioids to a tiny pharmacy in the middle of nowhere illinois, you believe your responsibility ends by contacting them . No, sir we have a responsibility to prevent diversion. Its art obligation. Thank you i would hope that would mean you contact Law Enforcement its a timeout. This is not right. Something just happened here. We want to report it. Do you feel Corporate Responsibility to that . Yesy or in many of our companies do that. The pharmacy itself, theres gotta be some people working at the pharmacy with a look at theat back door and say they delivered what . Yes absently in our responsibility is not important to archive we report to a Prescription Drug monitoring at the state program. Thend turnaround time on those very spirit summer every 24 hours. And cpa does frequent sub reporting as possible. But that is our members responsibility to report those controlled substances their dispensing. I think we are on a roll call on the force, so we may have to cut it short. Its not a roof reflection i respect you being here today. Thank you. And i will just wrap up doctor stein youve talked about alternatives, and adequate alternatives for prescription opioids and the barriers that are there for effective treatment for opioid misuse. What immediate policy changes do you recommend to increase alternative, to prescription opioid medications. I think we need to make sure we are developing, disseminating, and really financially supporting and paying for alternatives both the shortterm and longterm. In the short term we know that certain types of pain such as wisdom teeth being removed we dont need opioids. We need to make sure we are not using this. Forwe chronicle pain we have things like physical therapy. E over the longerterm many tesoro develop and make sure insurance or covering a whole variety of treatments that are effective for people who have pain. Pain is not going away. It affects 20 of u. S. Adults. It impairs one and 12 so much they cannot do the daily activities. R we need to be able to manage that. Yes i appreciate that very much. Missed off you go through your written text testimonial provided t there some powerful prevention Success Stories from drugfree committees. And how can congress do support those types of programs . Thank you so much. Just by exerting leadership, and ink think thats also important that we have more communities that are trained to have the capacity to get this types of outcomes. Tiny bits of federal money, hundred 25000 a w year with a dollar for dollar match is basically all that they get. So its an amazingly great investment of scarce federal resources, and as senator koontz said, if we got a tiny bump up yesterday, but literally for every Million Dollars we end up with another eight to ten. Very good and i do apologize folks we are going to cut you short. Our other members of all floods the floor. So we will also flee to the floor. So i do not thank you for your important inputs, we do have your written records and those are submitted for the record. I will make sure of that. And i appreciate the time and attention you haveia given to us. Thank you so much. [background noises] s panic we will get the record and other items who want to submit for the record. [background noises] [background noises] [background noises] [background noises] [background noises] [background noises] [background noises]