Transcripts For CSPAN Drug Policy Experts Testify On Fentanyl Overdose Deaths 20220903

At this point, we will leave this program. Watch the rest on cspan dot org. Drug policy experts are getting ready to give an update on the rise of fentanyl Overdose Deaths, especially among minorities. They are testifying before members of the Senate Health committee. You are watching live coverage, here on cspan three. Good morning, so that health education, labor, and health will please come to order. Today we are having a hearing on the fentanyl crisis that is decimating our communities. I will have an Opening Statement followed by senator cassidy, and then we will introduce our witnesses. After they gave their testimony, senators will each have five minutes for a round of questions. Again, while we are unable to have this hearing fully open to the public, live video is available on the Senate Health committee. If you need of accommodations please reach out to the committee at the office of congressional accessibility services. Last week in Washington State, county declared fentanyl a Public Health crisis, and it is painfully obvious why. This year, king county alone has lost over 270 people to fentanyl overdoses that is in increase of nearly 50 from last year. That is more than one fentanyl death every day, and that is just one county in my state, one corner of our country that lost over 100,000 people to Drug Overdoses last year. That is an alltime high. That number does not just represent a grim record, it represents so many personal tragedies, so many strapped families that are shattered by the loss of a loved one, parents, caregivers, and, increasingly, teenagers. There is no question we had a Mental Health and Substance Use disorder crisis on our hands before the covid pandemic. But, there is also no doubt there things have gotten so much worse due to the trauma of the pandemic. So much more deadly with the sharp rise of illicit fentanyl in recent years. That is because fentanyl is up to 50 times stronger than heroin and 100 times stronger than morphine. Two milligrams can be a lethal dose. From april 2020 to 2021 synthetic open awe its mostly illicit fentanyl were responsible for nearly two thirds of all over the stats. And, the recent rise in fentanyl Overdose Deaths has also reflected the painful, Systemic Health inequities we still need to do so much to address. Black communities, as well as American Indian and alaska native communities have suffered a higher increase in Overdose Deaths than other demographics. There has also been a deeply alarming rise in young people dying from overdoses. In 2019 over 250 teens died from illicit fentanyl. Last year we lost almost 900. Think about that, fentanyl deaths for teenagers more than tripled in two years. My heart goes out to every family touched by this crisis, i have heard from many of them. People who lost a loved one after a long, hard struggle with addiction. And, those who lost a loved one suddenly to a counterfeit bill leased with illegal dose of fentanyl. Our communities are doing everything they can to fight this, but they need help from the federal government to stop these dangerous drugs at the source. Cut off supply lines, and, importantly, get these kids and their families the help they need. The way we do that is to support families on the ground through robust Public Health efforts, and better access to Mental Health and Substance Use disorder care. When it comes to cutting off the supply of fentanyl, fda has been working to cut down on counterfeit drugs being sold online. Something i want to see them continue to make progress on to protect our youth. The dea is working to seize fentanyl laced pills before they can end up in our kids hands. I have been pressing President Biden on this, the same way i press the trump administration. We are seizing more fentanyl laced pills than ever before and i appreciate the hard work that is going into that. Our Law Enforcement and First Responders on the ground are really working to rise to this challenge. To stop these deadly pills and save lives, and ensure people can get the care they need. When i talked to police officers, fire chiefs, First Responders back in Washington State, it is clearly have a lot more to do to build on the progress we are making. To cut off the supply lines that produce these dangerous drugs, and prevent them from ever reaching our communities. Drug trafficking is a serious problem and that is why democrats continue to work with republicans to provide significant funding for Border Security and drug interdiction. Lets get one thing clear, we need to be taking this seriously. And having real conversations about how we address the National Threat of fentanyl use and supply, not playing politics, not scapegoating, not fearmongering, not attacking refugees and immigrants with proposals that are based more on xenophobia than on what will actually work to keep people safe. That is not to say we cannot talk about accountability, especially for opioid manufacturers who feel this crisis to line their pockets. There are enormous corporations that theyll just how dangerous and addictive these products were, and yet decided to ignore the risk for patients, market these pills aggressively, and flood our communities with opioids. We absolutely must hold these Companies Accountable for padding their profits at the expense of countless lives. Of course, stopping the supply of illicit fentanyl and holding Companies Accountable which field the Opioid Crisis is critical. But, we really have to tackle this challenge from every angle possible, with that in mind we have a lot more work to do to help our communities get people the Mental Health and Substance Use disorder care they need. Right now less than 10 of people who need Substance Use Disorder Treatment can get it, that is even harder if you are black, hispanic, American Indian, or alaska native. The painful reality is that most people who died by overdose did not get any Substance Use Disorder Treatment before they passed away. That is unacceptable, we need to do better. A big part of the problem is our Mental Health and Substance Use disorder workforce, it has been woefully overstretched and understaffed. I said this before but it is so important to understand if we are going to get our arms wrong best. Almost 130 million americans live in areas with the Mental Health care provider shortage. Essentially, they do not even have one Mental Health care provider per thousand people. For 30,000 people. In washington eleMental Health Care Workforce is only able to meet 17 of our states needs, if we are going to turn the tide in the fight against fentanyl, that is going to have to change. We cannot lose sight of the fact that a strong Public Health system is easy access to treatment for everyone are some of the most powerful tools in our arsenal. We need to make sure every community has a robust Public Health department, with the help needed to stop overdoses, stop spikes, and the ability to raise Public Awareness about rising threats like counterfeit drugs, laced with fentanyl. And, we need to support programs on the front lines, in our communities that are focused on prevention, treatment, and Recovery Support. I fought hard to invest in our communities to expand Mental Health and Substance Use disorder care, through helping build our Mental Health and Substance Abuse workforce in our Rural Communities, to federal grants, which set up dozens of new Treatment Centers across our states, and the American Rescue plan, which included critical funds for this work. But to talk to anyone on the front lines of this for two seconds, and understand we have a lot more to do, talk to the fire chief in seattle, who told me a few months ago, they responded to four overdoses every day. Talk with the university of washington researcher who told me how 80 of people, who could benefit from surfaces to keep him alive cannot access them. Talked with the nurse, who told secretary the sarah how there are just not enough beds to get people treatment. And the mom who told them about how she lost their job, her house and her child while she was struggling with fentanyl addiction. Talk to jason cochrane, at the Second Chance foundation in everett, who talk about the challenge of trying to get kids the treatment they need, or the many people who desperately tried to help find an open treatment bed, for a 15 year old earlier this year, calling context, posting to facebook, all to no avail. It is so clear that leaders like jason, who are on the frontlines of this crisis, mean so much more for our federal agencies and from this congress. More when it comes to getting fentanyl off of the streets, and more when it comes to getting people the health care they need. Which is why i am as determined as ever to continue the progress that senator burr and i our making on a bipartisan package on Mental Health and Substance Use disorder. We need to support the programs on the ground, in our communities that are already doing lifesaving work to identify people who are at risk and prevent Substance Use disorders in the first place, to get people treatment, and to support people and recovery. We need new programs, especially when it comes to addressing the new challenges we are seeing, with fentanyl, and with heartbreaking increases in overdoses among young people. So i will continue to press for us to advance as an expensive a package as possible, as quickly as possible. And i believe that we can do it because we have done it before. In 2016, and again in 2018, democrats and republicans worked together to pass some of the most comprehensive legislation, to respond to the Opioid Crisis in our countrys history. That has made a big difference. That legislation is undoubtedly saved lives. But ive traveled to just about every part of Washington State to talk about this crisis, from everett, seattle, long view to the try cities, spoken and more. And the challenges we deal with are not the same challenges that we faced in 2018. So now, it is on all of us to build on the bipartisan progress that we have made, and it is painfully clear that our communities cannot wait. They need us to meet this moment with serious action and life saving support for families. With that, i will turn it over to sanity cassidy for his opening records. Thank you, chair. And Ranking Member burr who allowed me to leave this meeting. As a physician, i took care of patients with addiction. But it does not take a physician taking care of those with addiction, to know that we have a fentanyl crisis. Everyone here, and everyone watching those of someone who has died, or suffered from addiction related to opioids. If you read of a young person who died, a teenager, or in college, most often it is related to a Drug Overdose. And you think about the tragedy of that child, whose whole future was before she or he, and now it has ended. Not just affecting their lives, but all the generations that would come after them, from that wonderful person. It is incumbent upon us to address this issue. Now the statistics. Fentanyl is killing over 200 americans a day. In 2021, we saw the largest annual increase in opioid deaths in 50 years. In the 35 years between 1979 and 2016, 600,000 americans died of an overdose, and 100,000 died last year. I will speak of my own state. Louisianas drug Overdose Deaths hit a record high of 2100 in the 12 months leading up to march of 2021. Overdose mortality increased statewide by over 56 , from 2020 to 2021. New orleans was up 51 in 2020, with 365 Overdose Deaths. Jefferson paris, 69 . Santana, 35, in saint bernard, up 64 . And we know the cause of this, it is fentanyl. Illegal fentanyl and fentanyl related substances are flooding into our market from our southern border, in unprecedented amounts. The bulk of this, ultimately originating from a handful of manufacturers in wuhan, china. Fentanyl accounted for 64 of 100,000 Overdose Deaths from last year. Two out of every three people who died from opioids, it is from fentanyl or fentanyl like drugs. No congress has to continue to pass tools to fight this from multiple fronts. First we need to make the classification of fentanyl analogues, as a schedule one drugs, permanent. Several of my colleagues and i introduced the halt lethal trafficking of fentanyl act last year to do just that. Secondly, we must educate americans, on just how deadly fentanyl is. Two milligrams is enough to kill someone. I was proud to join senator marshall and other doctors in the congress to record a psa, informing americans about the risk of fentanyl. Health experts and Public Officials need to continue with such efforts. Thirdly, the border. Last year the dea sees 20 million fake bills, and 50,000 pounds of fentanyl. Enough for 440 million lethal doses. When i went to the border, i saw this big cage of illegal drugs. I said, how much do you think you are getting . They probably think we are getting a third of it. So, if we seize this much, that much more went through. We must recognize that a policy of the border, which has been feckless and ineffective as it has had, does not allow people to have, people who are illegal Illegal Immigrants but it allows people to come across as well. We have got to control that border give is a message in which the administration will get use your tools to control. Force me to combat the drug cartels to finance the production of smuggling of illicit fentanyl into the United States. Selling synthetic opioids, laced with fentanyl is a major source of revenue for cartels, drugs gangs criminal organizations and for organizations such as hezbollah. They use a financial process, including one known is trade based money laundering, to disguise their activities and illegally move this country in and out of the country. It is a use of Financial Exchanges that look like legitimate trade to serve as cover for illicit flows of money. If we can stop the financing of the drug trade we can stop the trade of drugs. We need to look at loopholes in our system. Cartels will ship chinese made fentanyl into our mail saying that the contents of the package is worth less than 800, which is the threshold preparing tariffs. Because it is declared the less than 800, customs and Border Protection does not inspect the package and it passes through. It is a delay glaring loophole in our customs system. I look forward to discussing these solutions and more in todays hearing, Congress Failing to address this crisis threatens our National Security, and risks the safety of individuals who do not know that one pill laced with fentanyl can kill. Which means that there will be one more obituary of an 18 year old child whose life is gone forever. With that, i yield. Thank you, senator cassidy, i will now introduce todays witnesses. Mr. Kemp chester is the Senior Policy Adviser for supply reduction and international issuance in the office of National Drug control policy. Doctor miriam e. Delphinrittmon is the assistant secretary for Mental Health and Substance Use, and head of the Substance Abuse and Mental Health service administration. Miss Carole Johnson is the administrator of the Health Resources and services administrator. And, dr. Christopher jones is acting director of the National Center for injury prevention and control at the centers for Disease Control and prevention. Thank you, all of you, for joining us today for this urgent crisis, this discussion on this urgent crisis. I really do appreciate all of your sharing of time and expertise. We look forward to your testimony, mr. Chester, we will begin with you. Thank you, chairwoman, and Ranking Member cassidy, and members of the committee. Thank you for inviting me to testify today on the dynamic illicit drug environment we face in the United States and the administrations approach to addressing it. Drug poisonings and overdoses claimed 108,809 lives in 2021 alone. Which represents an American Life lost every five minutes around the clock. Behind these fatal overdoses are millions of individuals experiencing non fatal overdoses, that are overwhelming our First Responders and taxing our health care system. While these fatalities and non fatal overdoses are the most visible manifestations of our crisis, along with them are tens of millions of americans suffering from a Substance Use disorder. And underline these heartbreaking numbers is the impact on our economic prosperity. The cost of this epidemic is estimated to be a trillion dollars a year, and up to 26 of the loss in our Labor Force Participation can be attributed to people suffering from addiction. The administration is approaching this crisis with a keen sense of urgency and with action that is bold, farreaching, and innovative. The president s National Drug control strategy is an evidence based blueprint designed to save as many lives as possible in the near term. While building our capacity to deal with untreated addiction in the profit driven trafficking of illicit drugs in the long term. The director of National Drug control policy has further identified for immediate priorities that cut across the strategies goals to achieve these outcomes. First is to have naloxone, the opioid reversal medication, in the hands of everyone who needs it. Especially now, when three out of every four Overdose Deaths involve an opioid like fentanyl. Second is tackling the enduring issue of americans with a substitute disorder not getting the treatment they need. Fewer than one out of ten people in the United States who need treatment are able to get it. We simply cannot accept that, and we are committed to ensuring universal access to medication for opioid use disorder by 2025. Third, we must disrupt and dismantle the Transnational Criminal Organizations who produce and traffic illicit drugs like fentanyl buy commercially disrupting the entire global illicit business of drug production and trafficking. Including its illicit financial networks, supply chains, and a holistic and coordinated fashion. Finally, we need to close the existing gaps in Data Collection and analysis. We need to drive and evaluate drug policy decisions, especially for non fatal overdoses, which are the most accurate predictors of a fatal overdose in the future. Taken together, this represents a new era of drug policy that is precisely what we need to address an environment of Drug Trafficking and use. That is more dynamic than at any time in history. This is the first time the federal government is embracing high impact armored action to reduce overdoses and deaths. Commercial disruption is a new approach that brings together our efforts and illicit finance, supply chain targeting, and International Engagement to target drug traffickers, theyre operating capital, and their profits. The strategy is the first in which we focused on improving data to deliver lifesaving resources to the people who need it, particularly those who interact with the criminal Justice System and those who are incarcerated. This is the first time we have emphasized Adverse Childhood Experiences and social determinants of health. As key elements of our prevention efforts. This is the first time we have called for making access to Substance Use Disorder Treatment universal, or have removing outdated barriers to prescribing medications for opioid use disorder, and providing workforce opportunities for people in recovery. In todays environment, dominated by opioids like illicit fentanyl, we must reduce Overdose Deaths, ensure people can get access to the help they need, and disrupt the flow of illicit drugs across our borders, and into our communities. On behalf of dr. Gupta and the men and women of the office of National Drug control policy i want to thank this community and your colleagues in congress for your leadership on this critical issue. We look forward to work with you to address this complex National Security, Law Enforcement, and Public Health challenge with the urgency that so desperately demands. Thank you, i look forward to your questions. Thank you, doctor delphinrittmon . Good morning, thank you chair murray, Ranking Member cassidy, and members of the committee for inviting me to testify during this hearing focused on fentanyl and its impact on overdoses across the nation. I am pleased to be here, along with my colleagues from the White House Office of drug control policy, the Health Resources and Services Administration, and the center for Disease Control and prevention to discuss the efforts. The overdose crisis continues to be a challenge across the country. Synthetic opioids like illicitly manufactured fentanyl and the use of other substances, particularly stimulant such as cocaine and methamphetamines, have led to significant increases and Overdose Deaths. The covid19 pandemic exacerbated and already a tragic situation, with drug Overdose Deaths reaching a historic high. Devastating families and communities. Provisional data when the cdc reported that more than 107,000 americans died due to overdose in the 12 month period ending january 2022. Moreover, preliminary findings from the analysis of 2021 data from the drug related Emergency Departments visits show that fentanyl related Emergency Department visits rose throughout 2021. That is why addressing addiction and the overdose epidemic is one of the four pillars of the unity agenda the president outlined in the state of the union address. Additionally, last year the secretary released a comprehensive hhs Overdose Prevention strategy. Which is designed to increase access to a full range of care and services for individuals who use substances that cause overdoses and their families. This strategy prioritizes for key areas, primary prevention, Harm Reduction, evidencebased treatment and support. We have several efforts underway across this continuum. First responders comprehensive addiction and Recovery Program trades and equips First Responders and other volunteer organizations on how to respond to overdose related incidents. Including how to administer overdose reversal medication. During the programs recent project period each state developed a strategic action plan for combatting opioid misuse and death related to heroin and illicit fentanyl. This year, we launched the first ever harm or doctrine Grant Program, then issued 30 million in grant awards. This opportunity authorized and funded by the American Rescue plan acts is increasing access to a range of Community Harm Adoption Services and supports harm Adoption Service providers as they work to help to prevent Overdose Deaths and reduce the health risk associated with drug use. We are increasing access to evidencebased treatment to more americans by allowing practitioners to treat more patients with putin morphine through the revised people morphine practice guidelines. This is given over 17,000 more providers the ability to provide this lifesaving treatment. These programs are Critical Resources to fight this epidemics. They can purchase Fentanyl Tests which are disposable, singleuse tests to protect the presence of fentanyl in the substance. We are flooding the involvement of people with lived experiences, and fostering relationships with internal and external organizations, with Mental Health Addiction Recovery field. On behalf of my families at sam s i want to thank you for your interest in support of our programs and for supporting the nations Behavioral Health. I would be pleased to answer any questions and look forward to our discussion, thank you. Thank you, miss johnson . Chair mary, senator cassidy, and members of the committee thank you for the opportunity to speak with you about the work of the Health Resources and Services Administration to address the Opioid Crisis. Which, as is hearing demonstrates, is increasingly a fentanyl crisis. I am Carole Johnson administrator of the house resources and Services Administration, the agency in the department of health and Human Services that is home to the federal office of rural health policy, Community Health centers, the hiv aids program, federal Behavioral Health Workforce Training Programs, and our federal investments into maternal and child health. Across our work we are seeing the impact of fentanyl use in the historically underserved communities that we serve. Including urban, rural, and tribal communities. And, we are committed to improving access to Mental Health and Substance Use Disorder Treatment. And, growing the Behavioral Health workforce. I want to focus my remarks today on three key issues related to the crisis that this work aims to respond to. First, as the chair mentioned our investments in training and growing the Mental Health and Substance Use disorder workforce. Listen clued psychiatrists and psychiatric nurses, social workers, Substance Use disorder counselors, psychologists, and support paul specialist with lived experience. They are trained and funded through programs like our Behavioral Health Workforce Training Program that supports direct training and stipends to build a next generation of Mental Health and Substance Use disorder providers. The national Health Service quarter where we offer loan repayment and scholarships to Behavioral Health students and providers in return for protesting in the high impact areas. And other programs like the Substance Use Disorder Treatment and recovery loan repayment program, our addiction medicine fellowship program, and our opioid impacted Family Support program. We believe it is critical to expand our investment in this training and deployment of a Mental Health and Substance Use disorder workforce that can respond to the prevention, treatment, and recovery needs of individual struggling with fentanyl use. That is why the president s budget includes a nearly 400 Million Dollar investment into growing the number of Mental Health and Substance Use disorder providers. It is also why the American Rescue plans unprecedented investment in the national Health Service corps has allowed us to see the largest cohort in the programs 50year history, including thousands of Behavioral Health providers. Second, i want to speak to our work to expand access to Substance Use Disorder Services in Rural Communities across the country. The Rural Communities Opioid Response Program reaches over 1500 Rural Communities in 47 states. We are funding whats Rural Communities tell us they need. Including more access to treatment for individuals using fentanyl. In fact, in june we announced a new 10 Million Dollar rural investment to including fentanyl and fentanyls Drug Overdoses. That is with the goal of creating new Treatment Access points in Rural Communities. In june we also announced an announcement focused on stimulants like methamphetamine. Particularly as royal communities have reached out to us for help with their critical needs, as they say drugs like math and cocaine becoming even more dangerous due to contamination with highly potent fentanyl. We also fund other Work Programs in Rural Communities, such as grants to reduce the incidence and impact of neonatal absent syndrome and our World Centers of excellence on Substance Use disorder. We are committed to continuing to help Rural Communities respond to this crisis. For our third and final point i want to emphasize the work to help ensure there is no wronged or forgetting Mental Health and Substance Use disorder help. We want to do that by integrating Behavioral Health and two primary care. With this committees leadership to important steps on that path were included in the bipartisan Safer Communities act. The bill gave us new tools and resources to expand Mental Health training, primary care providers, and the funding needed to grow our pediatric Mental Health Access Program. That is to help our work with pediatricians as well as work beyond pediatricians offices and into schools an Emergency Departments. We want there to be no wrong door for those seeking Mental Health and Substance Use disorder care, which is why we aim to expand the capacity of the primary Care Workforce to respond to the Mental Health and Substance Use disorder needs of the community. Including family medicine, pediatrics, maternal care, internal medicine, and others. And, we are committing to building on the primary care footprint of the 1400 Community Health centers we fund in communities across the country, to help reach this goal. We know there is much more work to do and are grateful to the committee for the opportunity to work with you on the next steps. Thank you for the opportunity to discuss this work and i look forward to your questions. Thank you, doctor johnson . Chair marie, senator cassidy, and distinguished members of the committee it is an honor to appear before you today to discuss the centers for v Disease Control and prevention efforts to address the overdose crisis. Thank you for the committee for your attention to this Public Health challenge. This is a complex issue that requires a coordinated approach and i am happy to be here with my colleagues. The overdose crisis continues to escalate, that is due to the proliferation of highly potency netted opioids like illicit fentanyl and the resurgence of stimulants. In fact, we have never seen an illicit drug supply that is so potent, unpredictable, or lethal. According to the latest cdc provisional data, of the more than 100,000 Overdose Deaths in 2021 75 involved at least one opioid. With 66 involving synthetic opioid and 50 involving stimulants, often in combination with synthetic opioids. They started recognize the urgent need for action. The cdc is confronting this crisis through five key strategies that comment the work of our sister agencies in hhs and across the federal government. Our first gratitude focuses on data, which are foundational to prevention efforts. Cdc uses data to stay on the leading edge of overdose trends to ensure that communities have the information they need to respond to the evolving crisis. To our overdosed a tattoo action program, cdc administers two Key Data Systems to improve the timeliness and comprehensiveness above non fatal and fatal overdose data. The Drug Overdose surveillance and epidemiology or dose system collects near Realtime Data in non fatal overdoses an Emergency Departments. States participating have immediate access to their data and can quickly mobilize a Community Response to surges an overdose. The state unintentional Drug Overdose supporting system reds detail contextual information on the circumstances of Overdose Deaths, in the specific substances involving us to inform prevention strategies. To make these data more readily available for decisionmaking we recently launched public facing dashboards for both dos and suitors. I second strategy is building state, tribal capacity, in addition to 47 days and d. C. We find 19 cities, counties, and territories. And, we fund 26 tribal and todays thriller cooperative agreements. And this Program Funding is used to drive action, support the implementation of evidence based strategies to reduce overdose. Our third strategy is to support employers. And the strategy way support efforts to produce safer prescribing and maximize the use a Prescription Drug monitoring programs. Advance, ensure Health System interventions, and label to care and services across health care, community, and criminal justice settings. Our fourth strategy focuses on partnering with Public Safety and community organizations. For example, the Overdose Response strategy, and you need collaboration between cdc and oh and d. C. Peace Program Helps Communities Reduce overdose by connecting Public Health and Public Safety agencies in all 50 states. Cdc also partners with them on the Drug Free Communities Program to provide grants and supports to hundreds of Community Coalitions across the country, to advance youth Substance Use prevention. Our fifth strategy is raising Public Awareness and reducing stigma, to advance the strategy we recently launched a campaign called a stop overdose. Which focuses on raising awareness about fentanyl, naloxone, poly Substance Abuse, and decreasing stigma. Todays top overdose has reached over one billion views. Finally, cdc recognize the importance of preventing Adverse Childhood Experiences as a key part of the production tragedy. These are potentially traumatic events that happened during childhood, decades of Research Show they are strongly linked to risk for Substance Use, addiction, and overdose. As well as risk for Mental Health challenges and suicide, among other leading causes of death. By focusing on prevention we can make substantial progress in preventing substances and overdose and addressing the Behavioral Health challenges facing our nation. As a person in long term recovery, i know firsthand the pain and devastation that addiction can inflict on individuals, families, and communities. But, i have also seen a transformative power of recovery and im grateful to be one of the millions of americans in recovery that can serve as a beacon of hope to others struggling with Substance Use. This work is very personal to me. And, at cdc we are committed to advancing a comprehensive, committed german approach to save lives today, good head of the crisis by identifying emerging threats, and supporting upstream prevention so that next generation does not have to experience this overdose crisis. Thank you for the opportunity to be here, i look forward to your questions. Thank you very much to all of our witnesses today, and, for sharing your expertise. We will now have an opening round of questions from senators, please, again keep your remarks our questioning to five minutes. Mr. Chester, let me start with you. As you know, fentanyl has been devastating for all of our communities, including in my home state of washington, over 2000 people died from a Drug Overdose in Washington State in 2021. That is an increase of nearly 70 over 2019, and, half of those deaths involve fentanyl. So, those numbers are very hard hitting. In king county we saw a record high fentanyl death in 2021. Spoken county reported 186 increase in fentanyl overdose. It is devastating, because of the Transnational Criminal Networks that traffic fentanyl it is only becoming more prevalent. The Drug Enforcement administration recently reported a 264 increase in counterfeit pills seizures in Washington State alone. Law enforcement officials and First Responders are working hard to intercept and stays fentanyl before it reaches our communities and respond to the increased use. But, the federal government really has to do more. Mr. Chester, share with us what steps owe and the cpp is taking to coordinate the activities of the federal Law Enforcement agencies, department of justice, dea to make sure that our efforts to disrupt fentanyl trafficking is as effective as possible. Thank you for the question, senator. In your question was a great deal of the answer. That is, going after the transactional criminal organizations before the drugs can even get across our borders and into our communities. It is what we referred to as commercial destruction. What we are dealing with is a global illicit business that has all of the hallmarks of a Trans National business organization. They have access to resources, they have productive element, they have the ability to not make money and move it across borders with a credible efficiency. They are free riding on the back of the legitimate commercial network that keeps the economy alive. But, it has critical vulnerability. And so, what we are focused on, and this is across the agency and across the federal government, focusing our efforts on those critical vulnerabilities where we can get the greatest amount of effect. One of them is obviously, as discussed, illicit funds. That is their operating capital and it is the profits. Another one is the precursor chemicals that are used in order to manufacture these drugs. In many cases the technology is at the point where precursor chemicals are no longer regulated. Some of them are so legitimate that they cannot be regulated. The third one is going after the commercial shipping that moves things around the country. The fourth one is the pill process and the dye molds that are used to make them. And so, what we are doing to the National Drug control policy is not only working across the federal government, but, working bilaterally with Key Countries like china, like mexico, and like india in order to be able to disrupt a reduction of these drugs at their source. And, to prevent them to get into our borders and into our communities in the first place. That is truly an inter Agency Effort and it is where the bulk of our efforts live right now. Thank you very much, let me turn to dr. Delphinrittmon. For a lot of parents it is hard to help their kids navigate teenagers anyway, especially when it comes to drug and alcohol. The fentanyl crisis has made keeping our kids safer a lot harder. I am a mom, i am a grandma, i understand exactly how scary this is for parents today. Counterfeit pills with fentanyl are extremely dangerous, and extremely easy fourteens to find. Often accidentally on social media platforms. They stories from parents, family members, and loved ones are heartbreaking. Kids by what they think are prescription opioids on line, only to get lethal fentanyl laced pills instead. In fact, the problem is so widespread that the Drug Enforcement administration issued its first Public Safety alert and six years warning about the dangers of those pills. We have to protect our communities, especially our kids, from fentanyl. It is vital that we invest in Substance Use disorder prevention treatment and recovery for youth. Talk to us about how this community can support the efforts, especially in our upcoming reauthorization package. Thank you, chair murray, for that question. You are right, this is such a challenging area, i also want to thank you for your bipartisan work to reauthorize our programs. We do have a specific program, the strategic prevention framework, for private Prescription Drugs that is geared towards helping to increase awareness of the dangers of sharing substances, of Substance Use. It is geared towards raising Awareness Among youth, families, and communities. So, this program does also include information and training. And Technical Assistance related to the dangers of buying substances, period. But, also through the web. And, particularly focuses on youth. So, some of the goal is to raise awareness and to change youth behaviors through that awareness raising. Thank you, i am out of time, doctor jones i wanted to ask you, what efforts is cdc doing and how can we support that . If you can give that to me and writing or if i can get that back to the second round of questions i will ask you that question. Senator cassidy . Thank you, madam chair. Mr. Chester, i have that feedback, can you turn that off . Thank you. Still getting feedback, still getting feedback. Oh well. It is irritating me lets try that. Mr. Jester. I am struck that i can speak about chemical providers in wuhan sending chemicals here that are precursors for fentanyl, that are used by mexican cartels or shipped directly, you can acknowledge it in your testimony. Now, we think of china as an area where they have surveillance cameras on every corner. In which at any point someone may be arbitrarily in prisons. I could go on but you know whats going on would be. How much collaboration are we getting from the chinese in terms of this . Someone has suggested this is a form of bio terrorism. Yes, senator, thank you very much for the question. I continue that we engage regularly with the peoples republic of china on the specific issue. Although, as you know, we have a very complicated relationship with china this is an area where the u. S. And prc interests align. We have made progress in the past, one notable one was our work up to 2000 11 let me stop, if the. I am sorry, yes sir. If we know the Chemical Manufacturers are, the chinese know who they are. Yes, there may be collaboration but there is a fundamental breakdown, right . Yes, sir, the first thing is ensuring we have open lines of communication. The information that we have, that we understand about seizures in the western hemisphere, can be sent to the chinese so that they can take action on it. The second part of that is, and something we have clearly communicated to the chinese, and you mentioned in your Opening Statement. I think you brought up a important point. Three simple things. Agree with us on a list of unregulated chemicals that are used to create precursor chemicals that bear increase scrutiny. The second thing is to properly label the chemical and equipment shipments in accordance with the world trade organization. The third one is that they know their customer and put know your customer procedures into place. Those are the things we should expect from any responsible country, we have asked other countries to do this as well. We look forward to working with the chinese to implement these procedures to reduce the flow of precursor chemicals in the western hemisphere. We have been raising this issue with the chinese for years now. I guess what i do not think im getting is the level of true collaboration as opposed to, hey, we are with you. As opposed to we are knocking down doors, shutting down people and throwing them in jail. I would tell you that in relationship to the way we have with the chinese and the prc has given us uneven progress. I think there are areas where the Chinese Government is giving quick and Decisive Action at the request of the United States and it has had good results. I think there are other times that we have differences with the government of china, procedurally on certain things that we asked them to do, we have to ensure that we continue to communicate with them and impress them how incredibly important this is. Not just to the United States but to the rest of the world. Other countries, secretary blinken brought this up in his speech about china. Other countries should expect to great countries like the United States and the prc to Work Together on this global mission. They understand that. Looking at mexico, you have the sense that mexico is always teetering on whether not is in control or not. Several states are not in control of the central government. But, to what degree has the Mexican Government collaborated with us if these cartels are bringing small drugs from china to bring across our border . To what degree are we are in collaboration, there . We have a good and longstanding relationship with the government of mexico, which was solidified in the bicentennial framework for security that was assigned just a few months ago and replaces the previous initiative. That is a little bit more holistic, and, now takes it more of the contributing factors within mexico. Not just the Security Side of the house. On the ground we have a large embassy, we have deep Law Enforcement relationships with the government of mexico. We have had cooperation in the past and most recently the apprehension of the is a good example of the government of mexico collaborating that bears fruit. I had a sense that recently there was some increased liability for some of our agents that might be down there should something go wrong. I also had a sense that the president of mexico has less affection for the u. S. Than some of his predecessors. Any comment on that . What you are referring to is the National Security law that was put in place in january of last year that created a bunch of increased procedures for cooperation between mexican and u. S. Law enforcement agencies. On the ground that has been worked out in practical terms, it has not had a devastating effect on Law Enforcement cooperation in mexico. That is not uniform across all agencies but i think in general terms the National Security law is not a barrier. Not a barrier for us working with mexico. I think it is clear that president lopez sees two things. One is, he wants to go after the root causes of criminality. The second thing is he a continually looks at the u. S. Mexico relationship in terms of mexicos interest as much as United States interests. And so, it has caused a recasting of a relationship with mexico. But, we have made some progress on this specific problem when working with the government of mexico. I yield. Thank you, senator murphy . Thank you very much, madam chair. Thank you for this hearing, you are all doing very important work and i appreciate the testimony. Doctor dave delphinrittmon i wanted to talk to you about the genesis of the Opioid Crisis. Which, of course, is first in rooted in americas penchant to survive opioids and addictive pain medication at a rate that is unparalleled in the rest of the world. We have made a lot of progress when it comes to the overall number of opioids that are described in this country. There is a direct line between individuals that become addicted to these pain medications and those that end up seeking illicit drugs. Im black markets, they often end up having fentanyl attach them. We have seen this drop in the number of opioids that have been prescribed. We have pounded ourselves on the back and yet, when you look at our numbers, even with this drop, compared to the rest of the world we are still a crazy outlier. We are still 5 of the worlds population and 70 to 80 of the worlds opium prescriptions. Even with a 40 drop in the overall number of prescriptions that are being made. So, just talk for a second and above that. As we are talking about the fentanyl crisis, here, the work that we still have to do to alter prescribing patterns as a means to stop people from getting on this pathway to fentanyl. Yes, thank you for that question, senator. They prescribing patterns and ultimately ensuring that people have access to evidence based services and supports is so critical. We know that the evidence based practices and treatment such as medication assisted treatment, whether be eaten or foreign or methadone can help people. People who are struggling with opioidrelated substance challenges. In terms of prescribing patterns one thing we are working on is to increase that access for individuals that might be struggling. Two allowed individuals prescribe ors to trade up to 30 individuals with buchen or fiend. We have revised the buprenorphine practice guidelines, such that those individuals can treat individuals struggling with opioid addiction with buprenorphine. I guess im talking about pain management, im talking about the fact that it we are still prescribing far more pain medication, addictive pain medication than the rest of the world. From your perspective you have to focus on trying to find alternative ways to manage pain so that people never get in the position of being addicted to pain medication that then becomes an addiction to heroin, fentanyl, et cetera. Yes, we actually have grants to do that type of training, our state opioid response grant does train providers on alternatives to pain management, such that Prescription Medications are not the first course. Other strategies to manage pain, lack of help to alter and change some of the prescribing practices that we are seeing. Mr. Chester, i want to talk to you a little bit about how fentanyl and other illicit substances come into the United States through the southern border. It is still true, correct, that the lions share, the vast majority, not all but almost all the product coming into the United States comes through our ports of entry. We have made, through the appropriations committee, i chair the subcommittee that writes the budget for the ses, some significant investments in technology at those ports of entry. But, there is sometimes an impression here that a lot of this product is being moved across in the dead of the night through the desert. The reality is we still do not catch as much as we should, walking through straight through public ports of entry. Additional investments that we can make to try to catch more of it and ultimately determine more of that activity. Yes, senator, you are correct. The preponderance of the droughts that come through the existing ports of entry, the technology that they have available is very impressive, the men and women of customs and Border Protection are our most experienced folks on the ground. It is the most efficient way to be able to move them across and then have access on the other side to unavailable network to get them quickly across the country. They do come through most of the ports of entry, but there is obviously more than we can handle. The president s budget asked for 300 million in enhancement for customs and Border Protection for that very region. This is an evolving threat, there are other places through the mail system, through maritime advances that these drugs get into the country as well. I just make that point, madam chair, because a lot of our colleagues think that by putting up a wall on the border they are going to stop fentanyl confirming into the country. The reality is is coming through the ports, we can make investments but the idea that it is the on walled portions of the border where the fentanyl is pouring in its just not with the facts bear out. Thank you, madam chair. Thank you, senator marshall, doctor jones you consider the fentanyl crisis to be a Public Health emergency . Yes, theres currently a Public Health emergency declared for the Opioid Crisis. Okay, thank you, like my state the home state of kansas is now a border state. As you can see from this map behind me, kansas is literally at the crossroads of fentanyl trafficking. With three major arteries coming out of mexico pierce in the heart of our great state, and all three bisecting the nations busiest east to west byway. We are now at ground zero, in fact, just recently officers in kansas city, kansas, and sees nearly 15,000 fake pills laced with fentanyl during a two day bust. Fentanyl is now killing a kansas resident almost every day. It is killing over 250 americans every day. Sadly, fentanyl is now the number one killer of young adults. Poisoning deaths, and i mention, and i stress that these are poisoning deaths from synthetic opioids, particularly fentanyl have increased by more than 600 . Where does it come from and why is it so cheap . As we all know, the fentanyl precursors are made in china. Yes, you could call this chinas revenge on the west for the opium war. In mexico, chinas catalysts and their cartels and work the precursors into fentanyl and lace fake bills like adderall, xanax, and percocet. They mix them with illicit drugs like masks, cocaine, or they sell in various pure forms. Unfortunately, this is one supply chain from china that is not broken. It goes without saying, with an open, porous southern border of the supply is abundant, driving the street price down. From the oxycontin can tablets cost maybe 60, you can pay two to 6 for fentanyl tablet. One final point i want to go back to, returning to this fake pills concepts. Dying from fentanyl is poisoning. It is not an overdose, that is poisoning, if an unsuspecting student takes a fake adderall pill they purchased online, or wherever they purchased and dies that is poisoning. The criminal should be tried for murder. That is how i see it. Mr. Chester, with securing borders and decreasing smuggling impact the fentanyl crisis . Yes, senator. As i said in response to senator murphy as well, the men and women that we have at arson and border are the finest in the world. Youre great would have a significant effect. Doctor johns, same question. Whats securing our borders and decreasing the smuggling and easy access to fentanyl impact the crisis . I would reiterate, mr. Chesters points about the efforts of the National Drug control strategy to address. But they are not working . You can reiterate the points but obviously with a 600 increase in deaths whatever we are trying to do, reiterating the points, forming committees, talking to people, something is not working. Doctor jones, do you believe we should apply title iv to drug smuggling across the southern border . Title 42 is rooted in protecting Public Health from communicable diseases, while there is a declared 319 Public Health emergency for the Opioid Crisis falls outside of the scope of title 42. Okay, mr. Chester, you stated that first the most important action we can do right now is to get more naloxone out. As a physician that is like telling me to give people with brain tumors tylenol. Do you really feel that giving out naloxone would have a bigger impact than securing our borders . Senator, by most important thing what i meant was most important thing in saving lives now. Because it can reduce and opioid overdose. That is not exclusive all of the work that is being done at the southern border and with other countries, and with the coastal inspections of us, and all of the other means to keep drugs out of our communities. The naloxone is designed to reduce an overdose death and save a life immediately. What we are doing right now is putting a finger in the dike and the antarctic is giving away. If we do not scarab orders this epidemic will get worse. Mr. Chester, you stated that the u. S. Engages with the peoples republic of china to address shipments. You say that the prcs impact is less of a direct impact. How can you objectively, quantitatively substantiate your statement we are seeing a 600 increase in deaths . I know you are talking to them, i know there is collaboration, but what is your objective evidence that says that china is doing anything to slow this machine down . The best example i can give you as the work that we did with china prior to may of 2019, when china class scheduled all fentanyl related substances. As a result, they direct shipment of fentanyl and fentanyl related substances from china to the United States went down to almost zero. That was in 2019 . That was in 2019, yes, sir. The traffickers moved from producing finished fentanyl into precursor chemicals. Which they supplied to mexican suppliers, that speaks to the dynamic and interactive nature a very determined, profit driven quantitatively, what have you done that can show me that we have impacted that . What is there any objective evidence that we have impacted chinas supplies . They are sending it to us like we send it to them. The number of seizures of precursor chemicals and pray precursor chemicals in the western hemisphere has been consistently high, in many of those cases that was due to cooperation with chinese officials. Or, subsequent to the seizure the information was sent to the chinese officials that they could take action on hold the individuals responsible. Thank you, madam chair, i yield back. The point is this is yours are going up because, objectively, china is not stopping the supply of these precursors. Thank, you i yield back. Senator nelson . Thank you, madam chair, thank you to all of our witnesses for being here today. I want to start with a question to mr. Chester. Deaths from fentanyl among teenagers more than tripled between 2019 and 2021. As chair murray mentioned, many of these teens or not seeking fentanyl. They purchased what they thought was percocet, ox eco, down or adderall, only to take a fatal dose of fentanyl. The stories are truly heartbreaking. How are young people getting exposed to these fentanyl laced drugs . Thank you for the question, senator, i think the distinction was made between poisonings and Overdose Deaths. I think it is an important one because you bring it up in your question. Unfortunately they are being exposed to these deaths in a greater variety of memes than they ever were before. And in many cases, and dr. Gupta has said this several times. Getting access to these drugs is as simple as in the palm of your hand through a social media app. And so, when you are dealing with global drug traffickers who want to reduce their risk and reduce their overhead, and increase their Customer Base and increase their profits it is in their interest to make it available from a variety of means. The first thing is to have access to them through social media apps and the dark web. Sometimes through the clear web, sometimes through their own personal interactions. Second thing is, how those drugs move across the borders and into the United States. In some cases it is the southwest or border but sometimes it is through consignment. The work we have done with the Postal Inspection Service where the number of seizures has increased has been admirable, in being able to disrupt that vector coming into the country. Thank you, another question for you, last Years National Defense Authorization act included a bipartisan bill that senator toomey and i offered to block deadly fentanyl imports act, this law require the government to publicly identify countries that are major producers or traffickers of illicit fentanyl and cut off foreign aid to those countries if they failed to increase efforts to fight Drug Trafficking, mr. Chester, what steps is the administration taking to evaluate whether we should cut off foreign aid to countries due to the production or trafficking of fentanyl, and fentanyl analysts within their borders . Thank you for the question, im sure you understand i cannot take a position on pending legislation, but i can tell you is that the current process that we have, that we apply under the majors process for plantbased drug producing countries has been effective over the years and we welcome any tool that gives us the ability thank you, i appreciate that, how is our audio, here . Okay, we are good. I can hear you, im not sure we can hear the witnesses. Is it off . I think we are right, right now, i want to turn to miss johnson for another question and i appreciate mr. Chesters response to the last one. Miss johnson, according to the department of health and Human Services the country must add more than 100,000 general psychiatrists and 43,000 addiction psychiatrist to meet the current need. The surest impact states like New Hampshire where patients may have to drive hours to find treatment for a Substance Use disorder. As part of funding, i helped advocate for, the department of health and Human Services awarded a 1. 4 Million Dollar grant to dartmouth hitchcock in january to train health and other residents of rural New Hampshire committees to address the Substance Use disorder needs of residents. Miss johnson, how will these Grant Programs help build the Behavioral Health workforce over the long term . How will they help rural areas in particular . Thank you, senator, and thank you for your leadership in supporting and developing these critical programs that are really a part of what it is going to take for us to confront this crisis. For us to be able to build critical programs that my colleagues across the table have identified, we need a workforce to be able to deliver on that and it is the types of programs that you have helped create that give us the tools to be able to recruit people into the field, to get them the training that they need, and that you deploy them into the communities where they are needed most, we are looking forward to the work that will happen at dartmouth under the Grant Program. Thank you for that, quickly i have a question for doctor arctic delphinrittmon. We know that medication assisted treatment is a Gold Standard for opioid use disorders access to treatment is limited by the requirement that providers obtained a special waiver known as the ex waiver in order to prescribe buprenorphine. About 40 or counties cross the United States in 2018 last even a single wavered practitioner who was able to provide this treatment. Doctor li delphinrittmon, if the waiver concern is how the lack of treatment providers offering medication assisted treatment impact fentanyl overdose rates . Yes, thank you for that question, senator, and for all of your work in this critical area. We know that it is vital that people have access to medication assisted treatment when they are struggling with opioid use disorder, data shows that, it can help people move into long term recovery along with other services and supports, in terms of increasing the number of providers, we have removed from of the barriers and we are in full support of removing barriers to additional providers so that they can prescribe buprenorphine. That is why we have changed the training requirements, along with the guidelines, as you know. That did bring an additional 17,000 prescribe ors into the field. That is since we put that in place. That is important, but we have more to do. I have introduced the bipartisan mainstream Addiction Treatment act which would eliminate the waiver and expand access to treatments that we know will save lives. Thank you so much, madam chair. Thank, you senators know a vote has been called, i am going to call on senator moran and then i will go vote and come back. Senator casey will hold the gavel im gone. Chairwoman, thank you very much for your presence today. Let me start with administrator johnson, in your testimony you mentioned that you are working on better connecting Substance Abuse Disorder Treatment with access to Mental Health care. I come from a state but i also come from a nation in which access to Mental Health care is limited for a number of reasons. Particularly the rural part of our state with the inability to attract and retain Health Care Professionals is a huge issue. I see this in my Veterans Affairs committee where we are trying to see steps necessary to prevent veteran suicide, the services, if they exist are a distance away. Senator smith and i recently introduced a bill authorizing a Grant Program to help primary care practices in Behavioral Health Care Services into their offices. Designed to take those circumstances in which you do have a hometown position, a Family Practice doctor and bring Mental Health Care Services to that practice do you think better integrating behavioral Health Services into private primary care settings for adults and children make sense . Would that help address the substance cbos crisis that our country is facing . Thank you, senator, and thank you so much for your leadership on this issue. I think integrating Behavioral Health, Mental Health and Substance Use Disorder Services in primary care is essential for us to confront this crisis, we are not going to be able to solve this problem unless people can get the care and services they need. That means we have to deploy all available assets. That means there needs to be no wrongs or forgetting and to get Mental Health of Substance Use Disorder Services. That is why we are very focused on trying to average the programs and are grateful for the support of this committee to identify ways we can continue to help the primary Care Workforce, understand and treat, and identify Mental Health and Substance Use disorders. Thank you, 9 20 is your endorsement and our efforts to get the legislation passed, dr. Dolphin richmond. ,. In your testimony you touched on the First Responders comprehensive addiction and recovery act Grant Program, which helps to train and equip First Responders to respond to overdose related incidents, this Grant Program, as you note included a rural set aside for many rural departments, the loss of man or woman power while an officer or deputy is off training is almost as prohibitive as the lack of funding. What is your department doing to make training and other resources more accessible, such as through Online Training courses to small and understaffed apartments . Thank you for that question, it is so important to be able to have multiple modalities, to be able to offer training, we do have a number of training and technical system centers, we have addiction training and sectional assistance center, as well as the provider clinical support system. That provides a range of Technical Assistance, training, and education for prescribe hours as well as other behavior and Health Providers in the field. Those include both in person, as well as remotely through webinars and online strategies and means as well. I might suggest to you that at least in our state we have a number of Law Enforcement training Centers Across the state geographically, you may want to integrate your program or share the opportunity for training in those settings and utilize the services that generally Law Enforcement the community has already created for ongoing training for members of Law Enforcement. I also appreciate your attention to ensuring that Rural Communities have the resources needed to fight fentanyl and Substance Abuse, there are two issues, these two issues are often associated with urban areas. I can assure, as you know, it is not an urban or suburban issue, it is not solely that. Rural america is battling the epidemic and we are doing so as i indicated earlier with a more Strained Health care delivery system, and limited workforce. One particular program you talk about in your testimony that kansas is utilizing well is the Certified Community Behavioral Health clinic programs, in 2021 kansas became the first state to establish the model on the state level and by 2024 we have 26 state certified ccbhcs. Would you speak further to the role of localize care like these community Mental Health centers have in fighting Substance Abuse that we are talking about today . Yes, absolutely, i want to commend kansas for having that number of ccbhcs, it is a wonderful model that provides both Mental Health, Substance Use services as well as coordination and connection and linkage to primary Care Services. It is a model that also provides wraparound prevention, treatment, and Recovery Services and supports. It is critical in terms of being able to connect people who are struggling with opioid use disorders, as well as other Substance Use disorders to include Recovery Services and supports as well. Thank you both responding to my questions. Senator lujan . There we go, thank you very much mister chairman, madam chair for this important hearing i do want to start by echoing something from my colleague from connecticut and bring attention to our ports of entry, somehow this keeps getting politicized, if the United States wants to be serious about stopping the flow of illicit substances into the United States, we must remember there is a southern border and a northern border and there are two water borders. And then you go down and member of the gulf of mexico with the water ports. Do not forget modern airports, the screening or lack thereof that is done at our ports should allow all of us. Five or 6 to 10 with passengers graining into the southern border is embarrassing. The United States must adopt 100 screening into the United States with commercial goods, and with passenger traffic at all of our ports of entry, only then will we start to understand how these cartels and other entities are throwing product of the problem. I hope that we can at least comes together and Work Together to get something done by the way, one of the last pieces of legislation that was signed by President Trump was a Bipartisan Initiative challenging the department of Homeland Security to Tell Congress how to get to one hunted percent screening of our ports. Lets find a way to Work Together. Second, mr. Chester i appreciate the attention to the illicit Financial Markets. The United States should be embarrassed by the lack of process that we have with prosecuting against Financial Markets that are elicit, not just democrat or republican American American administrations, it is both, one major Financial Institutions in the United States are found to be laundering money for cartels, and the outcome is that no one goes to jail, someone gets a fine, that is just the new cost of doing business. If someone can make that much money and only get fined it is going to continue. If theres one thing all of these bad people have in common and is happening is that they are making money. Until you stop the flow of that money you are not going to stop any of this. I am hopeful that these are some areas, i know we are not in the committee of jurisdiction but there are some areas where we can find some Common Ground to go after these enemies that are not politicized. Now, the questions that i have, i want to echo a statement that was made earlier pushing on the buchen or fraying or improving screening at ports of entry in america. Dr. Delphinrittmon, does the United States need to adopt both access to treatments as well as trying to stop these movements of these illicit substances from around the world into the United States . Thank you for that question, senator, i can certainly speak to the work of samsung, i know mr. Chester has comments in terms of over, it seems like we are taking a multi level approach, certainly there is quite a bit of work underway to increase access to medication assistance treatment, as well as other vital prevention and Recovery Services and supports as well, it does sound like there is quite a bit of work in terms of borders as well, but in terms of our programs and initiatives in place, birth through the state operated response, as well as the Substance Abuse treatment block brand, there are a range of services and reports available across the country to help individuals that are struggling with opioids,. So include the dissemination of Fentanyl Test strips, which allow for the testing of substances and the testing for the presence of fentanyl. Dr. , would access to Fentanyl Testing strips save more lives . So, what we are seeing is that Fentanyl Test strips allow for the identification of fentanyl in substances that is helpful for individuals that are not able to take fentanyl, often we find armored auction programs also disseminate information about how to Access Services, often people are connected with a recovery coach or programming, the Harm Reduction offered an opportunity to disseminate the Fentanyl Test strips, but also to disseminate information about how to Access Services and supports. I believe access to the ships will save lives. It alarms me that in some states those strips are treated as illegal use or traded in a way where people cannot abuse them. I think that one thing we can do is come together to ensure that access to strips, things of that nature is something that can be accessible across the United States. I do have other questions for the record that i will submit, one point that i wanted to raise is according to the cdc, only about one and every ten American Indian alaskan native and hispanic people with Substance Use disorder reported receiving treatment. The number is about 70 of the 2 million folks around the country who are not getting treatment. Nominally in rural and native american communities, hispanic communities, black communities, and other communities of color as well. I appreciate that there was more tension to be brought to these, but again, whats been happening . The data shows where this is occurring and there is still no response. Madam chairman, mister chairman, im certainly hopeful that as we are having this conversation and moving to new legislation to encourage and demand more access to methods we understand with the data is based on the number of folks that we are losing. Probably also to stop these illicit Financial Markets and improve significantly the security at our borders to make the drastic steps necessary to get our hands ready. Thank you senator collins. Thank you mister chairman. Members of the panel, i say this with Great Respect for each of you. I know that you care deeply and that the policy programs that you are implementing our wellintentioned, but i think we have to face the very unpleasant truth that what we are doing is not working. The data, overwhelmingly, demonstrate that. But there you look at National Data or data from the state of maine. Maines leading Drug Overdose drug death researcher, doctor marcy sort from the university of maine recently called mains overdose epidemic, quote, the worst it has ever been. And quote. Tragically we have lost a record high 627 main in 2021 and the data from the first part of this piece year shows a 9 increase over comparable period of last year. The number, of total, oh devices in maine exceeded 9900 last year. Fentanyl was involved in a 77 of deadly overdoses in maine. That is a dramatic increase. So i want to talk to you about two issues. One, endorsement and interdiction. The second, prevention and education. In 2021 the Drug Enforcement agency in maine sees more than 10,000 grams of fentanyl, that is a 67 increase. They tell me they cannot possibly keep up. They are overwhelmed. Mains overdose crisis is primarily driven by the increased supply of illicit fentanyl, originating in china and smuggled through mexico. Into our country. I have been to the border with mexico. I have seen the cartels smuggling people across the border. I have talked with the Border Patrol officers out on their midnight shift and they have expressed such frustration that they have had to divert their resources to handling the tremendous influx of people crossing the border, rather than focusing on illicit drug interdiction. Like my colleagues, i cannot help but conclude that our inability to secure the southern border has an adverse impact in and contribute directly to our inability to stop the flow of drugs into this country. I have also talked to the coast guard in their efforts and how frustrated they feel. So my first question mr. Castor is do you agree that the unprecedented surge of people illegally entering the United States has diverted limited Government Resources away from drug interdiction. Thank you for your question senator. I know marcy sorkin, ive worked with her in past years and shes an incredible professional and understands this issue just about better than anybody. There is no doubt that there is a number of challenges at the southwest border of the United States. When i ask that we all bear in mind is a couple of things, the first one is, that these are very determined drug traffickers. They will find any means get these drugs into our country. That is whether its the southwest border, male, express consignment, maritime, air conveyances. I think that is the first thing. The second thing is our focus, that we have not only in commercial disruption by going after the illicit finance. Not only the profits that are the motivation for doing this, but the operating capital that allows it to happen is an overarching way to deal with his very frustrating problem. The last thing i would tell you, man, is that this is a very dynamic problem. A very dynamic situation. What you are saying that but we are doing is not worth it working, what is easier to say is that what we have done is not working and quickly we can identify what new vulnerabilities are there when traffickers change either do business and close those vulnerabilities as quickly as we can. That is what we are in the process of doing right now. Thank you. I am going to submit my next question for the record because my time has expired, dr. Dolphin, rick this is for you. I want to tell you about hannah flaherty, a 14 Year Old Girl from portland. She was a straight a student with no drug history of drug abuse who died from a suspected fentanyl poisoning last month. My question for you is going to be, for the record given the time, what more can we do to reach young people . Im not just talking about high school, i am talking about middle school students. To educate them about the dangers of drug use so that they dont think uphill is harmless and its injecting yourself, which is dangerous. I think that is common, a columnist perception. I would like to follow up and talk with you about that. I remember very well when i was growing up in caribou, northern maine, that we had a recovered heroin addict come in and talk to us. It was so powerful. It was incredibly powerful. I am wondering what more we can do to educate students at a young age who have to know about the dangers. I know about the time, but thank you. Thank you. Its a critical question and we all look forward to answering that in response. Senator baldwin . Thank you madam chair. I am listening to my colleagues, as well as the responses, and there is sort of a pattern that i have observed over time. When we were talking this committee about the opioid epidemic, just several years ago, it was much more the conversation was much more focused on prescribe arrears and over prescribing. You know, 30day supply after dental surgery instead of something that would be much more appropriate to avoid subsequent abuse. Now we are talking a lot about accidental overdose and getting folks who have gotten fentanyl laced pills, it said era. I am, like my colleagues, i want to share the stories about several wisconsin families and ive gotten to know this year. They have gone through this crisis themselves. Kate running ten was a graduate of warnecke Community High school, a student at you w milwaukee, a kid who was full of life and energy, and excitement. On november 4th of last year caid died last year in a storm room after taking what he thought was a percocet pill. That hill contained fentanyl. Combatting fentanyl is a critical task for this committee and this entire administration. Im concerned that we are not doing enough to warn our nations young people about the dangers of counterfeit pills. Doctor jones, i want to just draw your attention to the work that im sure you know about. The work that the dea has been doing to spread the word that, quote, one pill can kill. This message, in my mind has not yet been shared widely enough. I wonder how the cdc is working with the dea to elevate this particular message and make sure that this information is being shared with young people . Thanks so much for the question. We work closely with the before that campaign was launched, because we have experience over the last several years with multiple campaigns we have done at the cbc about prescription opioids, transitioning to recovery, and now the illicit fentanyl market. We have learned lessons along the way about how to communicate and wanted to make sure that we could assist the dea in their messages. So, we worked with them prior to the launch and we certainly work across agencies here, with the dea, to help disseminate those messages. I think that campaign is an important one because it is very catchy. One pill can kill, that makes sense. Its not something that is lost on people. It does reflect the tossup city of the illicit drug market, as many senators here have mentioned today. The issue of poisoning versus overdose. I recently participated in an dea offense that brought Families Together who had lost individuals through those exact scenarios. Taking counterfeit pills i thought were xanax, percocet, but was actually pressed fentanyl. I will highlight two things at the cdc that i think compliment the work of the dea and things continue to spread those messages. The first is our stopover this campaign which i mentioned in my Opening Statement which focuses specifically on fentanyl and the toxicity of the illicit drug market, the availability of naloxone, probably Substance Abuse which is contributing to overdose and unintentional exposure. People think they were using Something Else and actually getting fentanyl, that increasing stigma. We know that is barrier for people to seek help. That campaign was tested among at young adults, 18 to 34 years old. We know that something thats freely available, people can take that and applied in their communities. I think that is a new asset that is available to help spread the message about the toxicity of the drug market. The last thing i will say is that there is a real opportunity to focus on upstream primary prevention. We need to get messages out about the toxicity of the drug market, but fundamentally as a long run strategy to addressing this issue we need to help instill resilience, life skills, problem solving conflict resolution focus on root causes like adverse drug experiences that really set the trajectory for someone to have risk for Substance Use. We know people with aces a dishy eight Substance Use earlier which increases your risk of having a Substance Use disorder, they are really op powerful opportunity for public interventionalist bases. Thank you dr. Jones. I did not want to cut you off because its very responsive to my question, i will do as senator collins did and submit some questions for the record. I did want to indicate that both caid, who i just told you about, and Nicolas Barrett graves were have passed away a fentanyl poisoning. Nicholas, a boy in wisconsin could have been saved by naloxone as of couldve kate. Thats why been pressing manufactures to get make their products available over the counter and working to make legislation to rig reauthorize the opioid reversal medication access education and Grant Programs. For dr. Dolphin and then again for the record i will be inquiring whats sampson needs to make sure that naloxone is more readily available to First Responders and in key locations such as school dormitories and community centers. That will be submitted for the record. Thank you, senator. Thank you madam chair. The question will be for mr. Casten are. I want to cite a few things that i think most americans would be appalled at what is happening. Since 2021, january, 3. 2 million migrants across the border illegally. Weve intercepted 1. 2 Million Pounds of illegal drugs, over 16,000 pounds of fentanyl. That is approximately 3. 7 million lethal doses coming in to the population it could kill the population ten times over. We also have 100,000 per year Overdose Deaths nationally. 2000 opioid over to those death in the state of indiana. I dont know that we need to dispute the facts, mostly, look at the background. Its impressive and it has been your job to figure out how to disrupt the supply chain. Yet the main manufacturer is china, the main distributor is mexico, and i was down there in march of 21. Illegal crossings were 40 50, 000, going up 60 70, now they exceed 200,000. We all remember the vivid interception, i think recently, if i dont know how many pounds of fentanyl. Are you confident that what we are doing aggravating the prague problem, encouraging more proportionately from what it was prebiden administration . Im making any headway . Thank you very much, its a very comprehensive question i want to hit all of it. The first thing is, i want to ask that we all bear in mind that there has absolutely been increase in our overdose sea that will not go to traffickers for their benefits. The second thing, is i think ive mentioned this before. Would you have described very accurately is the result of a Global Business enterprise that is driven by profits and is focused on finding vulnerabilities in order to expand their Customer Base and make as much money as they can, which would increase the amount of risk. Synthetic drugs like fentanyl and synthetic opioids can be produced at much lower overhead and sold for much more money. That is the second thing. The third thing is, this is not confined the problem is not begin or end at the southwest border but rather it is deep in a country where that drug is produced and it is the conveyances that move them and the Raw Materials around the world, and they are shipped through multiple means into the United States and into our communities. So, what we cannot do is take individual pieces of that complex and focus our efforts on it and ignore the others. We have to look at it in its totality, we have to determine when there are changes in those environments and focus on those changes. Our ultimate goal, i think you use the right word in disrupting, over time, their ability to be able to move these drugs into our country. Snapshot of time, i absolutely understand it may give certain numbers and indicators i can tell you were approaching this in a holistic fashion which is what it deserves because that is the complex of issues that we are dealing with under this particular Drug Trafficking let me follow up this. That sounds like a good approach in terms of how you are analyzing it, but we had 40 to 60,000 illegal crossings about a year and a quarter ago. Now it is up to over 200,000. Can and what they told us then is at the wall, which i dont think amber was talked about being from see the signing she where it was. It was our most important tool along with the stay in mexico policy. How do you explain why it has gone from 40 to 60,000 illegal crossings to what could be approaching 300,000 and how we could be doing a better job in intercepting the illicit material that is coming along with the illegal crossings. Yes, senator, thank you. Please understand im going to limit my comment to my answers to the issue of illicit Drug Trafficking. When i can tell you is that is precisely why in the president fy 23 budget we ask for 320 million to enhance the capability of cbp to deal with illicit Drug Trafficking across our borders, another 300 million to the Drug Enforcement administration to be able to do its work within the United States and being able to see these drugs as well. As i mentioned before, these are very determined drug traffickers that are going to find a way to get the drugs into the country. We have the greatest professionals on the face of the earth but we can always do more in order to give them the tools that they needed in order to be most effective against this problem. Thank you, i am out of time and one quarter another round of questions but i think carefully about that relationship between how many people are coming across and what is underlying the fact that you are going to be intercepting a lot more illicit materials, as well. Thank you. Thank you, senator thank you madam chair. Mr. Chester, i wanted to ask a question about pyro. Even as fentanyl does its communities, more coming in colorado. We are starting to see pyro, a drug that used to is to be ten times stronger than fentanyl. I know you made disrupting the supply of major drugs a focus of your career. How do illicit like pyro, where did they come from . House and up in colorado and what is the administration doing to try to intercept supply . Thanks for the question, senator. I know that in particular i 75 as a major corridor for you in in the amount of concerns that are involved with the fentanyl movement of drugs through your state and the region on that corridor. That particular drug and others like it, i want to be clear in our character races zeeshan here. So you have fentanyl itself, then you have fentanyl analogues which are alterations, additions, or substitutions to the base fentanyl molecule. An entire class of substances. And you have other non fentanyl synthetic opioids that is the knife is ian family and others that come up. The reason we see the missed two reasons. One is the one of the best excellence of the production of a new drug is actions taken against an existing one, these are profit seeking enterprises that have very smart chemists who want to market new substances, posted on the internet around social media for availability and get people to be up early adopters to them. That is the first time the first way you see them. The secondly you see them is generally product placement, they have the available precursor plate chemicals the chemical formulation they can get on and the advertising and having a certain qualitative effect on the body. All of them are elastic, all of them are dangerous, all the available on the internet, the dark web, to be shipped in either physically tonight states or cross our borders through mail and express consignment. The last thing i will tell you is under the Rocky Mountain hideout very well. Very proud of the height and the Drug Trafficking Areas Program that we administer here we have extended the Overdose Response strategy for the high out program to all 50 states, virgin islands, puerto rico, in d. C. That brings together drug Intelligence Officers and Public Health individuals in order to be able to a better understand the environment, identified the new emerging threats like the one you just mentioned and being able to take action on the. They do very good work. Thank you for the support remarkably effective. Doctor redmond. Fentanyl has killed 1600 colorados in the last three years, its just a few months ago we had the High School Sophomore from during go, colorado an accidental fentanyl overdose. We receive 23 million 22 million and this is prevention treatment grants as part of a rescue program. Does this go out of colorado and do you see that maybe what do you see is the most effective utilization to that funding . One of the best investments we can use to try to go after the fentanyl overdose rates and how is samson working with states to provide that realtime information and data and Technical Assistance to get there . So, often well be finding states will use strategic prevention framework approach to be able to identify approaches and strategies that will work of most vitally within their contacts. So maybe the Community Coalitions will do focus groups, media schools, we were students to be up to develop messaging that will resonate with students and resonate with schools. In some instances the coalitions will work with schools and students to develop some of that messaging. Its really coming from students. I think thats one thing thats helpful. Developing messaging that students will taken and raise awareness with dangers of fentanyl to include social media, access offense in all, just the dangers of fentanyl use. I think another strategy that now is working with schools to raise awareness of the of being able to identify students that maybe struggling with substances or maybe having trouble. Ultimately, being able to adapt those Students Services and supports. Thank you. I think were making progress talks identifying the types of kids that might be likely to experiment, so often with fentanyl it seems like its someone who has almost no experience in drug use. Not always, obviously, but too often. Anyway, out of time. We have a couple of the questions i will file in written form. Thank you. Senator casey. Thank you chairman marina, thank you for calling this hearing i want to thank our witnesses for their testimony and for the expertise that they bring to bear in this awful, awful fentanyl crisis that is consuming the country. Pennsylvanias third in a category that you dont want to be third and, third and Overdose Deaths. Pennsylvania had 5000, 400, 38 deaths in 2021 alone. That is one death every two hours. Just like in so many other places, fentanyl is the dominant, dominant opioid. So, it is consumed so many families in so many communities. Like chair murray im very concerned about the rice rise in fentanyl related deaths in adolescents who, because of the state to development are more vulnerable to opioid use disorder. This particularly the case when a young person has a Mental Health issue like adhd, depression, and anxiety which too often goes undiagnosed and untreated. I will start with doctor dolphin redmon. Can you speak to two things . One, the relationship between opioid use disorder and other Mental Health conditions and, number two, how timely Mental Health care for young people can help prevent opioid misuse . Yes, thank you for that question similar and for all of your work and advocacy in this area. We know for some as well as adults, the use of opioids and other substances is a related to a persons meant of challenges. To the extent that services and supports our, we talk about this a lot that we are able to take a cold curing of how approach that services in sports are able to address both Substance Use and multiple challenges. That is also a problem of identification. We have a program called, for short, the youth family tree. With that program is abouts early identification of youth that may be struggling. Youth, as well as transitioning individuals and other members of families. It is a brand that takes a Community Based approach, family based approach, and really used in some multisystem approach to be able to identify. To do early identification but also early connection to services and supports, such that the addiction doesnt progress. So i think that is one area that is an important area of work, that ranges up for authorizations or certainly appreciate this committees commitment to that area of work. Theres also work in terms of being able to ensure access. You spoke the piece about ensuring that there is timely access to services and supports. I think that is an important part of the system of care work, as well. Ensuring that whether its a school system, family members, that there is awareness around how to access and connect students with families to the services in sports. Thank you very much, doctor, i want to turn to Carole Johnson with whom i have worked in the aging committee. It is great to see you i guess twice in a week. Carol, i wanted to make reference to both screening and access for opioid use Disorder Treatment which are of course in demand and widely out of workforce for caring for adolescents. We have a bill support cross training for pediatric Health Care Workforce to address Mental Health and Substance Use disorders. Even the serious threat of fentanyl to young people, we cant afford to miss any opportunity to screen adolescents for these disorders. How do we increase opioid use disorder competency in pediatric care for us . Thank you so much senator casey and for your leadership on this issue. We think this is critically important. Making sure that we create sort of norms and standards in the Health Care Workforce that primary care sites, pediatrics offices, primary care physicians, Community Health centers, are places where clinical work force is trained to identify Mental Health and Substance Use disorders and where appropriate, be able to help begin treatment. Thats why we are committed to this work and we appreciate the progress that we have made with the pediatric mental Access Program which has helped us be able to bring mental expertise directly into pga striations offices. We want to continue to look for ways to grow the capacity, that of the primary Care Workforce and pediatricians to address Substance Use disorders directly. Thank you chairman. Thank, you chair marie. Really appreciate holding this very important hearing today. And, of course, the witnesses for all of your work in this area. So many of us are so worried about our communities. The overdose disparities. Especially in nevada in our communities. They synthetic fentanyl crisis has gotten worse in nevada in recent years. It has just utley impacted are growing latino population. Between 2019 and 2020 drug Overdose Deaths amid latinos in nevada increased 120 . The proportion of those involving fentanyl increased 135 . The highest among any demographic group. Compounding this problem is a lack of awareness in our Latino Community about where sources, including harm redactions strategies. As well as a shortage of Substance Abuse disorder providers. Particularly competent Spanish Speaking providers, doctor delphinrittmon what kind of targeted Community Outreach are you doing to ensure latino communities, not just in nevada but across the country have access to evidence based Substance Use disorder resources to help curb addiction, including those harmond Action Strategies . Thank you for that question, senator, this is an area that is a priority for us, it is certainly a priority as well within the secretaries Overdose Prevention strategy. It is one of the Cross Country areas which is equity, one of the things we do is we find the center, which provides a broad range of training and Technical Assistance to providers across the country. That helps to ensure that those providers are able to implement culturally responsive services, services that meet the needs of latino individuals and diverse groups, and so that trainee is available across the country. And all available work we have through the office of behavioral equity through new grantees. And also previous grantees that we have strengthened this program, we now do disparity impact statements so grantees have to identify disparity populations they may be serving and how that grant will be used to address disparities among those individuals or groups, where disparities exist, what we have increased is now we have increased and will be increasing the Technical Assistance to grantees to ensure that they have the resources and support they need. That is in terms of addressing some diverse groups. We are excited about that program, we think it will make a real difference in terms of working across our Grant Programs. To help them to be able to identify disparity populations and also address those disparities to include latino individuals. That is great that you are doing that, we know that you need the resources, that means the workforce, while the Minority Fellowship Program has made strides in increasing provider diversity and boosting cultural competency and Behavioral Health, data suggests people of color still only constitute a significant minority of the Substance Abuse disorder workforce, again, doctor, as the Committee Seeks to reauthorize and enhanced samhsa programs this year, i really want to see how we can expand and improve on these Minority Fellowship Programs to bring people into the workforce, to ensure we are attracting and retaining these providers. Mentoring the next generation. So that they can better serve the trust of latinos. Of course, all of our minority populations are underserved populations across the nation. Yes, thank you for that. That is a program, for one i can say it is near and dear to my heart. I went through the fellowship program. One thing we are doing to expand that program is to increase the number of individuals that can go through at the masters level. Doctoral level fellowships are provided but now we are also offering the masters program. That will help with people who can work in the field sooner, we are very excited about that and we know the program is coming up for authorization. And some of what we will use those resources for. Other programs are around working with hispanic serving institutions around attracting institutions to the Behavioral Health profession. People who are interested and Behavioral Health. That is an Additional Program that works to increase in numbers of individuals from diverse populations who are entering the Behavioral Health fields. Or, individuals working with individual organizations as well. Thank you, i think my time has expired. Thank, you chairwoman, thank you to our witnesses for being here and for your important testimony. My states, like others, i have heard each senator talk about the tragedy of this in their states. There were 2656 Overdose Deaths in virginia in 2021. It was a 15 increase from 2020. Fentanyl was responsible for 77 of those fatal overdoses. We are all grappling with this. I appreciate the testimony and colleagues of mine have asked many questions that i was going to. I wanted to ask a strategy to deal with this issue that we have talked about before. The last time you are here as a question about creating interest noted individuals to treatment services. And, in particular, about drugs. You shared information from sam s us Drug Court Program, those are programs, most of us have them in our states. Work to divert individuals for more involvement with the Justice System into Behavioral Health treatment that is more likely to lead to a successful outcome. When i meet with sheriffs and virginia i always ask them this is the opening question, what percentage of people in your jail should not be there . I do not have to describe my terms, i do not have to define when i mean, they know what i mean. They know that i am asking what percentage of people in jail or not bad people, cooks, or criminals. There people with Substance Use issues that have either been diagnosed and untreated, or not effectively treated in some instances, never diagnosed. I have never had a sheriff give me another less than 40 . Often sheriffs give me numbers like 50, 60, 65 . Since 2017 of virginia has received four supported grants. One in lynchburg, harrisburg, and southwest virginia. I have been to some of the drug courts to talk about what they do. I have been to some graduations, i have been to two in the last couple of years and in one of the drug Corps Program was started by a local Circuit Court judge who his child had died of a Drug Overdose. That led her to spur the effort to start it. And the other one i went to one of the probation officers who worked with the program came up to me and said, and this is my second graduation this week. I said, i thought this county only had one Program Going on at any one time. He said, we do, but my first graduation was that my son graduated from a Drug Court Program in another county. Heres the one where i am the probation officer and im here because i am proud of my graduates. Talk a little bit about the effectiveness of the drug program and samhsa. There are funding issues, do we have enough funding to operate them . I happen to believe the money we invest in this is some of the best investments we make. But, if you would talk about drug core programs. Yes, thank you for that question and all of your work in this area. What we find and what we know is that the programs make a difference. They make a meaningful impact in peoples lives. It has an opportunity to reduce further penetration into the Justice System for individuals who are struggling with Substance Use challenges. It is an opportunity to connect people to evidence based services and supports, to include medication assisted treatment, and to really change your trajectory of an individuals life, because theyre able to get that treatment that is critical. As you know, we also do in reach program. Enraged programming is for individuals that are connected, that are further along. Maybe before release, whether it is from jail or prison we connect them to services that include buprenorphine if necessary. Right after this hearing i will be flying to the National Annual meeting of drug core professionals. We will be doing a series of meetings with Different Court groups related to their work. This is vital, lifesaving work. This program is coming up for reauthorization as well. Certainly appreciated a committee and interest in this area. Please pass on as you go and talk to professionals the respect for we have for the work that they do. Heres a question dealing with fentanyl coming into the United States from abroad. City what can you tell us, particularly those with the National Drug control office. What can you tell us, if there is a part chart by mail, some kind of people smuggled over the border, some come around the borders. I understand that huge percentages of the fentanyl that come to the United States come in across our ports of entry, in vehicles because we only respect one out of however many vehicles, cartels figure they can play the odds and smuggle it right across the border of your ports of entry. Can you share with the data is about that . Yes, senator, is an understandable question, but, im afraid of this on a notable question because the only thing we can calculate is what we see and find. But, your characterization of vehicles is correct for a differently isnt. Our customs and Border Protection do have the ability to be able to do non intrusive detection that is very impressive. I was down in el paso last fall. The non intrusive detective capability that they have is very good. More importantly, those ports are manned with incredibly experienced agents. They can pull a vehicle into secondary just based upon i have seen this before, just based upon intuition. They also have models and algorithms that can determine the right time to pull folks into secondary. There are a lot of reasons why someone can get pulled into secretary. But, your characterization to drug traffickers is absolutely correct. A drug trafficker consent ten vehicles across, knowing that to make it bold aside. But, that is just built into the business model, the amount of profit and knowing that the remainder are going to be able to get through. That is the challenge that we have. Even if we were able to reduce that number to see seven and only three get through. Drug traffickers in pursuit of profits are going to find other ways to be able to circumvent that and get the drugs into the country. What we do by looking at it in a more holistic fashion is determine, when we see changes in the environment and how quickly we can surge in order to address that change as well. That is why when we describe it as a dynamic environment, that is what we mean by that. I am overtime but, madam chair, what that says to me is if any of our efforts on the enforcement side are created people who want to make profit, if there is another way to do. It ultimately we have to tackle this on the demand side. That is prevention, that is the kind of things you have been testifying to. [inaudible] thank you, that will conclude our hearing today and i want to thank all of my colleagues, especially our witnesses today. Tonight, miss johnson and dr. Johns. Thank you for a conversation on such an urgent crisis for all of our communities. There is one thing we take away from todays conversation i hope it is that our communities cannot wait. They need urgent action from the administration and from us in congress to disrupt the supply of dangers, a little illicit fentanyl. To support those on the front lines of this crisis and our communities. Especially to connect people with the prevention, treatment, and Recovery Support services that we know saves lives. That is why it is very important to me, more important to me than ever that we can advance a bipartisan package that makes meaningful progress on these issues. I hope all of my republican colleagues agree, and that we can continue our process of negotiating robust Mental Health and Substance Use disorder bill, that will support the programs we have seen make such a difference and provide additional tools and resources to tackle the new threats and emerging challenges in the space. For any senators who wish to ask additional questions, questions for the record will be due in ten business days. August 9th at 9 pm, and the committee stands adjourned. The status of tomorrows launch. We are about 29 hours until our earliest opportunity to launch our space launch system and orion spacecraft. You see them live on launch pad 39 be at Kennedy Space center. Artemis one will be humanitys return to the moon in almost 50 years. Welcome back for another live briefing of our artemis one mission. Thank you for being with us. This briefing is to update you on how our countdown is going so far. The two hour launch window opens tomorrow, september 3 at