Transcripts For CSPAN Federal Officials Testify On Fentanyl Addiction 20170414

The National Institute on drug abuse. This is two hours and 15 minutes. Good morning. Welcome to this hearing called fentanyl the next wave of the Opioid Crisis. America is in a full on Opioid Crisis. It started with the overprescribing of opioid drugs and then shifted more to heroin. Today, the subcommittee examines the next wave of the Opioid Crisis and fentanyl. Fentanyl is made in the lab and for many years, it has been a powerful pain medication used by patients with cancer or for those with extreme pain. When i was injured in iraq a few years ago, Battlefield Medicine they, and recovery, gave me lots of fentanyl patches. It is 50 times more potent than heroine and 100 times more potent than morphine. Now, fentanyl has been a powerful additive. This is the way the drug dealers increase profits and expand the number of addicts, by juicing the potency of heroine or other street drugs, like people have done with msg in foods. Users often do not know that fentanyl is in the heroine. The fentanyl crisis is exceptionally dangerous because of its high potency and the speed with which it reaches the brain. Two milligrams of fentanyl can kill. To appreciate how small an amount of two milligrams, a at ecier packet here your restaurant table is 1000 milligrams. You see at your restaurant table is 1000 milligrams. It may require higher doses and multiple administrations of mo brooks on to reverse the overdose and to become stabilized. Even the police and First Responders are at risk from inadvertently touching or inhaling fentanyl powder at a crime scene or helping an overdose victim. In march 2015, the Drug Enforcement administration or dea issued a nationwide alert on fentanyl as a threat. A year later, the dea sent it anr alert calling unprecedented threat. Customs and Border Protection data shows and 83 fold increase andhe amount of fentanyl she is in three years. There are many chemical variations of fentanyl commonly referred to as analogs. There are 30 known analogues however only 19 of these analogs are controlled substances under federal law. Since 2013, overdoses and deaths have surged with no end in sight. Fentanyl and its an all caps intruded into at least 5000 Overdose Deaths in the United States including the death of music star prince asked year. Last year, 86 people in west county died from Drug Overdoses linked to fentanyl. Statistics seriously undercut the fentanyl threat nationally because most states and counties are not testing or tracking fentanyl in Drug Overdose cases. So we are flying blind. Of Law Enforcement and the healthcare care system will be overwhelmed. China is the primary source of fentanyl and there are thousands making illicit cure for general as pickers is needed to manufacture fentanyl. Traffickers shift these ingredients to secret labs in mexico run by drug cartels and smuggle pounds of fentanyl over the southwest quarter through our porous borders, launching it through catapults or drones. Into the u. S. Chinese labs are also a primary source for fentanyl ordered on the open internet and only dark web. Your fentanyl mail or express is ordered through carriers. Finally, china is the main source of pill processors that can make thousands a pill in our support fentanyl operations. Im pleased to add that china is saying they are taking some actions to reduce this and we look forward to working with them because it is so deadly. The fentanyl problem is spreading and going to get worse because the money and profit is enormous. According to the data from dea a kilogram of color and can be a kilogram of heroine can be purchased for roughly 6000 and sold hotel for 80,000. However a kilogram of pure , fennel can be purchased for less than 5000 and is so potent that it can be stretched into using cutting agents as talcum powder or caffeine. Therefore, while the each kilogram can be sold wholesale for 80,000, it can result in a total profit of the neighborhood of 1. 6 million. Thats about 20 times more profit. We need a federal strategy dedicated to combat and fennel fentanyl as the clear and present danger that it presents for National Security and Public Health. We welcome our panel of witnesses today. We salute you for your work. Thank you for appearing today , and i look forward to working together to stop the spread of this epidemic. I recognize my friend from tte. Rado, miss dege thank you, chairman. Ms. Degette every day somewhere in this country there is an account about how opiate addiction has wracked a small town or family. Personal stories about americans who become addicted to pain pills and then they get hooked on heroin. These are heartbreaking stories about americans dying and leaving loved ones. Often their children to pick up the pieces. The Opioid Epidemic is unprecedented and it is escalating and i think we all agree that we need a copy of the strategy to confront it. In 2015, more than 33000 americans died of an overdose involving a prescription or illicit opioid and more than 2 Million People had an opioid use disorder. It adds an Even Deadlier layer to this crisis. It can be up to 50 times more potent than heroine, and 100 times more potent than morphine. Lethal at even the tiniest amounts and anyone , exposed to it can have it detrimental. Illicit fentanyl is not a new problem. What is new is its growing prevalence. Since 2010, fentanyl recovered by american Law Enforcement nationwide has risen 20 fold from 640 samples tested to 13000 samples tested in 2015, according to information from the dea. U. S. Law enforcement, as the chairman said believes china is , the primary source of illicit fentanyl and precursor chemicals. Producers shipped fentanyl and chemicals to make it directly into the United States. Precursor chemicals or finished fentanyl, is shipped to mexico and canada where traffic across our border in pure form or mixed with other illicit drug like heroine. Today we want want to ask the , panel some tough questions about Law Enforcement and diplomatic efforts to extend stem the tide of fentanyl flowing from china and whether they are sufficient. We are also going to ask which vectors drug traffickers use to ship this drug into our country like express consignment care is carriers and International Mail. I think this is another important step that the Second Committee has taken to address the Opioid Epidemic and for the record, i want to to continue this bipartisan work. That said, mr. Chairman i also , think we need to find a way to address the treatments that this treatment side of this epidemic, and this is sadly where i have significant differences with my majority colleagues. Passage of the Affordable Care act, as you know has led to , nearly 20 million americans gaining health care coverage. In addition, the aca has been able to governors to expand the Medicaid Services they offer, which was critical in states that were overwhelmed by the Opioid Epidemic. Studies estimate that since 2014, 1. 6 million uninsured americans gained access to Substance Abuse treatment across the 31 states, like mine, when expanded medicaid coverage. This is particularly important for hardhit states like kentucky where one Study Reports , that residents saw 700 increase in medicaid beneficiary ies seeking treatment for Substance Abuse. Two weeks ago, the majority rushed through this committee a bill to repeal the aca that many believe will threaten the progress that Medicaid Expansion has made in getting people suffering from addiction and to treatment. In its assessment of that bill last week, Congressional Budget Office said that millions of americans, 24 million of them, will lose health coverage. Many of those will be people currently receiving medicaid assistance, which includes people receiving treatment for opiate addiction. In january, healthcare aspects experts from harvard and then why you wrote an oped for the hill about how repealing the aca would reverse important Public Health gains. They focused primarily on my baby, the 21st century care act which i did with fred upton, and all of this whole committee. Thatprove it unanimously, we could have a whole hearing gopsbout how badly the aca repeal bill will hamper the progress that we just passed in 21st century cares. I just want to draw attention to one part of this op ed where the authors wrote, repealing the aca and its Behavioral Health physicians will have stark effects on those with Behavioral Health. We estimate that approximately 1,253,000 people with serious mental disorders and about 2. 8 million americans with substance have disorders, of whom opioid disorders will lose some coverage. Their the end of the day, we dont know what kind of bill will reach the president s desk desk but if we really want to address the Opioid Crisis we i suggest we dont pass the severely poorly thought out piece of legislation. I yelled back. Mr. Walden for five minutes. Mr. Walden the opiate crisis as we know, has touched every corner of our nation. If i colleagues, i met with community leaders, physicians, First Responders, law on thisent and families issue. Each share their heartbreaking stories on the effect of this crisis in our communities. You see addiction doesnt , understand politics it doesnt , understand income, doesnt understand race, where someone is from. It is an equal opportunity destroyer. This crisis has hit close to home for all of us. Last congress, this committee worked in a bipartisan way to pass legislation to fight the way we avoid epidemic. The Opioid Epidemic. In an effort that began in the subcommittee that held a series of communities about the growing problems of Prescription Drug inherent abuse. We should be proud of those we will discuss us today. There is a new threat emerging. Last year, there were encouraging reports that the prescriptions for the opioid had finally declined. That was good news. For the first time in 20 years, that it happened. Yet, we saw the overdoses and overdose related deaths continuing to surge upward, and we ask why . Emerging data strongly suggest the main drivers fentanyl and its chemical variations. Fentanyl essentially represents a third wave of the Opioid Crisis. It is why we are here. Fentanyl is a more challenging threat within the Opioid Crisis in comparison to the threat of production opioid and heroine. The fentanyl threat is multifaceted. It has been produced as a legitimate pain medication and Drug Companies for decades but it has also been produced illicitly in black Market Applications in china. Illicit fentanyl is hard to detect. Nor is it comparable to the black market of heroine. It can be purchased over the internet openly or on the dark web. The chemicals used to make fentanyl are produced in china and shipped to clandestine labs in mexico. Drug cartels are smuggling massive amounts of fentanyl with other narcotics from mexico across the southwest border. Drug traffickers in the United States are not only getting deliveries of sentinel through the mail, but getting direct or indirect shipments from china Phil Presseys that can fuel fuel thises that can epidemic. Fentanyl is not a replacement drug for heroin or oxycontin. 2 to 3 milligrams can kill an individual, and has. Added into cocaine or heroin to boost the likelihood of an addiction. Those taking these drugs may not know that they are taking fentanyl, linda known what it is let alone what it is. And 2015 in oregon, 49 people died from fentanyl. The number of deaths appear to be rising. That is just what we know. As we work to combat this threat, there is an important question to ask, how can we find this threat when we dont know how quickly it is spreading . Threatng the fentanyl will require more than strategies on overprescribing. Fentanyl is a global problem that requires an urgent response. I commend our government efforts for their success in gaining cooperation with china andt he united nations. We need to support this International Engagement to be successful. Requires anntanyl all hands on deck effort. We have to think outside of the box. I look forward to your testimony in solving this problem. D peeled the balance i yiel the balance of my time. Thank you mr. Chairman. This issue is of concern to me. I have been on the Health Subcommittee long enough. In 2005 we were having a hearing about why doctors were not prescribing adequately for pain. Now we have been concerned about the Opioid Epidemic. Fentanyl has been around for some time. The analogues to fentanyl are relatively new. It is the feeling of Illicit Trade with the ability to get things over the internet that has been the crux of this problem. We have problems with the overseas market. I hope we can hear some insight this morning on additional things to stop the flow. Thank you mr. Chairman and i will yield back to the gentleman from oregon. I recognize the Ranking Member of the committee for 5 minutes. The Opioid Epidemic continues to grow at an alarming rate. In 2015 more than 33,000 americans died of overdoses. According to the center for disease control, 91 americans die every day from an opioid overdose. We are focusing on fentanyl, a synthetic opioid that is 100 times more potent than morphine. Because of its potency, fentanyl results in frequent overdoses that can cause respiratory depression and death. The number of Overdose Deaths is rapidly increasing. The death rate from synthetic opioids increased 72 from 2014 to 2015. This substantial increase from synthetic opioids is largely attributable to the increase of illicit fentanyl. I want to thank our witnesses on this important issue. Fentanyl is dangers not only to users dangerous not only to users but Law Enforcement officials on the front lines. I look for better ways to extend the supply plaguing our communities. Stem the supply plaguing our communities. Rushed ago, republicans trumpcare through the committee. The aca has been instrumental in addressing the Opioid Crisis. Inexcusably, trumpcare would exacerbate the crisis. Thanks to the aca 1. 6 Million People with Substance Abuse disorders can receive the treatment they need. Trumpcare eventually ends Medicaid Expansion in 2020. Bo,ording to the c trumpcare cuts medicaid over the next 10 years, which severely undermines our efforts to fight the Opioid Crisis. These will russian care for millions of americans, including Substance Abuse treatment. Essentialreveals Health Benefits for Medicaid Expansion enrollees at the end of 2016. Offer no longer have to Prescription Drugs to americans that rely on such care. Repealing the essential benefits remove would approximately 5. 5 billion annually for the treatment of low income people with mental and Substance Abuse disorders. The repeal would take care from those seeking services, and we cannot eliminate this care and what is often a life and death situation. Tompcare threatens access lifesaving treatment for one Million People with lifesaving disorders. I would argue this issue is part of a much wider problem we are battling. We must make sure americans with Substance Abuse disorders can access the effective treatment. Andnt to confront fentanyl the larger opioid problem. In my opinion, repealing the aca and cutting medicaid by 1 trillion will do nothing but undermine our efforts to treat americans that are suffering from opioid addiction. We cannot arrest our way out of this problem. Without adequate treatment options, this problem will only worsen, and so will the death and destruction we have seen play out across the United States. I dont know if anyone wants my extra minute. I yield back. I want to offer for the record a article from the washington post, where opiates kill the most people in 2015. Ps where these occurred throughout the country. Synthetic opioid rates in West Virginia, rhode island, and other aspects. There is not one opiate epidemic, but several. There is no silver bullet. Whatever this committee finds, we have to give maximum flexibility to the states to work this out. I ask unanimous consent that the opening members statements be entered into the record. I would like to introduce our panel of federal witnesses. Chester,tart with mr. Deputy acting officer of the National Drug control policy. Assistant administrator at the diversion control division, within the dea. Assistant director of Homeland Security investigative programs at u. S. Immigrations and Customs Enforcement. The honorable william brumfield, assistant secretary of state. Director of the National Center for injury prevention and control. Deputy director at the National Institute on drug abuse within the National Institute of health. I want to thank our witnesses for the testimony. Let me turned you with this. More people are dying of drug Overdose Deaths and guns then than guns. More deaths than the entire vietnam war. What you will tell us is falling on ears that is open to whatever you can offer us. What you will tell us are the stories what youre saying is extremely important. We look forward to hearing from you. This committee is holding investigative hearing. Have any objection to your testimony under oath . Seeing none, your under the rules of the committee. Seeing none, would you all please rise and raise your right hand and i will swear you in. Do you swear that the testimony you are about to give is the truth, whole truth, and nothing but the truth . You are subject to the oath of title 18. We will call upon each of you to give a summary. Is recognized for 5 minutes. Mr. Chester thank you for inviting me in my interagency colleagues to talk about the issues surrounding the Opioid Epidemic, particularly illicit fentanyl and what the government is doing to address this problem. I appreciate the support of our work to reduce drug use and its consequences. I serve as the acting director of the office of National Drug control policy, which crafts the president s control policy and overseas all government counter drug activities and related funding. This is a Critical Mission because more than 52,000 americans died from a Drug Overdose in 2015, an average of deaths day with 91 involving prescription pain medications, heroin, and elicit fentanyl. Theeen 2013 and 2015, number of deaths involving synthetic opioids other than methadone, a statistical category that includes fentanyl has more than tripled, reaching 10,000 in 2015. This number is likely low because not every overdose investigation looks for fentanyl. The majority is smuggling after being produced in mexico and china. Fentanyl can be manufactured, package, and smuggled by the same Drug Trafficking organizations. The reemergence of fentanyl represents a complex problem and is considerably more powerful than heroine. Its precursor chemicals are not fully controlled in other countries. It is being added into the heroines of life or compressed pain pills, which means users are unaware they are taking fentanyl. Because of its potency it can be shipped in small transactions that involve relatively low dollar amounts, making it harder to detect. Report theyders need to use much more than the standard dose of naloxone to produce an overdose death from fentanyl, which drains resources. We have a liberty a limited capacity to treat those on opioids. One in nine people in the u. S. Are receiving it. We have seen outbreaks instant outbreaks in states where fentanyl has played the role of Overdose Deaths that devastate communities. Illicit fentanyl is exacerbating an already challenging problem the federal government is working extremely hard to address. This epidemic led us to new ways of drug use and trafficking. Our effort is to partner between Public Health and Law Enforcement, some of whom represented here today, to address the problem throughout the country. We are working with our state illicites to prevent drugs from being manufactured and trafficked into the u. S. In terms of Public Health, we are working to prevent new initiates to drug use by encouraging prescribers to use the cdc guidelines and state Prescription Drug Monitoring Programs and emphasizing prescription efforts to determine drug use initiation, including a drugfree communities program. We are working to expand access to treatment including evidencebased assistance treatment for opioid abuse disorder and longterm recovery. Congress ppreciate support for Fund Expansions under the 21st century cures act. Another innovation is building new partnerships between local Law Enforcement partners in the Public Health community to end this crisis and establish routine cooperation between the government and state, tribal, and local levels. In terms of reducing availability of these drugs, government efforts are on stopping illicit drugs before they cross our borders, and dismantling the organization that traffics them through our communities. With the National Heroine Coordination Group paraded in october 2015 in partnership with the National Security council to synchronize federal government efforts to reduce the availability of heroin and innocent fentanyl and address gaps and redundancies through its interagency coordinated havilland availability production plan heroin availability reduction plan. Drug africanhigh program that organizes intelligence against state, local, tribal, and lawenforcement trinitys. A coordinatedd effort across 20 states and d. C. In response to the heroin and fentanyl crisis. We are working with International Partners to reduce the supply of illicit fentanyl, its precursors in and across north america. We are working diligently to turn the tide and are making some progress, we continue to work through numerous challenges, such as detecting illicit fentanyl on our borders, mail, reducing manufacturing and trafficking of fentanyl and disrupting the internet marketplaces where illicit fentanyl is marketed. As the federal Government Works to reduce the size of opioid through prevention and treatment and reduce availability of these drugs in our communities, your support for these efforts is google super success. Is critical to our success. I want to put these overdose death numbers into context. Major League Baseball will kick off the season next month. Icture the mlb is anre we agree this unimaginable tragedy. The broader Opioid Epidemic are the number one threats facing our country. With fentanyl you have substances many times more heroin and increasingly pressed into pill form as prescription painkillers. Here are five pills that represent counterfeit painkillers. Analyses, one of every five will contain the lethal amount of fentanyl. Deathe unsuspecting user, is working in one of these bills. Mexican cartels are excluding the epidemic and aggressively purchasing illicitly produced fentanyl from china, shipping it to mexico, mixing it with heroin and other substances and shipping into the u. S. Where it is sold in our communities. Illicitly made fentanyl is being shipped across our northern border. It is being shipped from china into the u. S. For domestic distribution cells. Why are they doing this . Grade and disregard for human life. There is a massive profit potential with fentanyl. One pure kilogram costs in china 3500. If project if you project that to the distribution level, yield3500 kilogram can hundreds of dollars in revenue. We need a balanced holistic approach that attacks supply and reduces demand. We must be proactive. We must use any and all investigative techniques to identify, infiltrate, capture, and convict all members of these organizations domestic and foreign. Home offices, dea is well positioned to engage in this fight. Throughout deas history, our our greatest successes have come through collaboration with our counterparts. This approach is no different. We will continue to have successes against members of these fentanyl tradition networks. Heres the most frustrating part. Foreignbased fentanyl manufacturers and domestic pied piper operate with impunity. They exploit loopholes in the controlled substances act and capitalize on the lengthy resource intensive reactive process to schedule these dangerous substances. As we speak, criminal chemists are tweaking the molecular analogues,f fentanyl keeping the same dangerous properties as the controlled substances, but helping distributors avoid exposure because of a molecular structure. 5nce july 2015 dea scheduled illicitly produced fentanyl. 4 currently in progress. We are tracking 19 more. Scheduling actions are reactive, resource intensive processes. W well continue to do everything we can on the scheduling fronte. Shortterm this esteemed body could provide dea and Law Enforcement immediate relief by putting fentanyl and other substances into schedule 1. This will bring to justice the egregious domestic and foreign traffickers preying on our youth. Twould like to end with opposite but interconnected images, sunlight and shadows. Dea will always operate in the sunlight. Weve always follow the rule of law. We have to also operate in the shadows. We have to infiltrate these dangerous transnational organizations wherever they are. We need to develop and collect necessary evidence to bring those that exploit human frailty forprofit out of the shadows into the sunlight of our judicial system for prosecution in the u. S. Deabrave women and men of will continue to do the dangerous work to combat this threat. I look forward to answering any of your questions. You are recognized for 5 minutes. Thank you for the opportunity to discuss the heroine and fentanyl crisis and efforts of u. S. And immigrations Customs Enforcement to target, investigate, disrupt, and bring to justice the criminal elements responsible for smuggling dangerous opioids. As the largest Investigative Agency within dhs, ice investigates more than 400 criminal statutes. Ice agents use authority to investigate all types of crossborder criminal activity and work in coordination with u. S. And customs Border Protection and the dea in a unified effort to target Transnational Criminal Organizations that are supplying heroin and fentanyl to the United States. I would like to highlight efforts to reduce the supply of heroin and fentanyl United States and our operational challenges. The u. S. Is in the midst of a fentanyl crisis that is multifaceted and deadly. Fentanyl is a schedule two synthetic opioid used for synthetic pain relief and is 50 to 100 times more potent than morphine. Two primary sources of the illicit threat are china and mexico. China is a Global Supplier of illicit fentanyl. Chinese laboratories openly sell fentanyl. Chemists work around government control efforts by modifying chemical structures to make analogues not recognized as it was in china, but having the same deadly effects. While there is collaboration ongoing with china, these analogues is one of the challenges we face in stemming the flow. Illicit drug cartels obtained fentanyl for china and primarily use fentanyl as an adulterer and in heroin produced in mexico. Cardinals have discovered the drug cartels have discovered that fentanyl is more efficient than cultivating opium poppies. Fentanyl seems on the u. S. Southwest border is typically five and 10 in purity. Once fentanyl is distributed in local American Drug markets, most that use drugs are unaware potentpresence of more fentanyl. This often leads to overdosing. This is how lawenforcement learns that fentanyl has been introduced into a local drug market. The demand combined with the potency used in opium production has led competition for the part of the u. S. Illicit drug market. Illicit fentanyl is not only dangerous for those who use drugs, but Public Health workers First Responders that could come into contact. Accidental skin contact or inhalation during field testing is one of the Biggest Challenges we face in Law Enforcement. Dramaticse to the increase in availability of opioids, in close correlation with other agencies, we have developed the heroine availability and production plan. I. C. E. Has been supporting this since its inception. We are coordinating with International Partners to provide Field Training to highlight collaboration efforts. We have identified shipment routes, and fentanyl related substances and manufacturing materials that make pills in the United States. Is committed to combating the fentanyl crisis that demands immediate action in conjunction with experts in the Scientific Health communities. Thank you for the opportunity to appear before you. Thank you chairman murphy. The opportunity to appear before you today. This broad Interagency Panel demonstrates this is a Law Enforcement issue and international issue. This Opioid Crisis is perhaps the worst in 30 years. It kills tens of thousands of fellow citizens every year. Illicit fentanyl is responsible for virtually all of these deaths, sourced abroad through Drug Trafficking organizations. To solve the problem we must cut off international supply. That is where my bureau comes into play. Our strategy is threepart, work with the neighbors, china, and united nations. First we realize that the most illicit opioids enter through next canada. Through mexico and canada. Mexican heroin Trafficking Networks introduced fentanyl into the supply chain. Since the start of cooperation in 2008 we have developed a close relationship with Mexican Federal Law Enforcement. We have delivered hundreds of millions of dollars in border inspection and Law Enforcement equipment, training and capacity building, and intelligence exchange. Every invests 20 for one of ours. We recently agreed to extend those efforts further. Canada is suffering its own Opioid Crisis, although most of his heroine comes from afghanistan. We address a shared crisis, assuring both governments have Statutory Authority and sharing realtime Law Enforcement intelligence. All 3 governments cooperate through the new north American Drug dialogue, where we share information on narcotics research, exchange best practices, and actions to protect our citizens. Second we have expanded cooperation with china,a major fentanyl source country. In 2015, china moved to regulate 116 new synthetic drugs and added 4 fentanyl critical analogues to its domestic carb fentanylding , described as fentanyl on steroids, 100 times more potent than fentanyl. I acknowledge these steps by the chinese government. They improve our ability to track and control fentanyl and other synthetic drugs entering the United States. We are using targeting and sanctions programs like the narcotics reward and kingpin authorities to target fentanyl traffickers. For 20 years the u. S. And china have coordinated policy through the group lawenforcement and that dialogue produces valuable cooperation. We are working through the u. N. To regulate dangerous opioids and precursors around the world. I was in vienna for the annual mission on narcotic drugs. Cnd vote of 510, the approved our proposal to regulate two fentanyl precursors. The process took 4 months rather than 2 years. Be more difficult for criminals to obtain the chemicals needed to make it an easier for countries to prosecute them. We support programs by the. U. N yrogram to eliminate popp cultivation in afghanistan, mexico, and guatemala. It takes decades to get into a drug crisis. It will take years of patient persistent effort to get out. Perfect thats so it cannot be improved. I forward to the suggestions. Thank you for inviting me here. At the cdc for injury prevention and control, i think the committee for your interest in preventing opioid misuse and overdose. As an emergency physician i have seen firsthand this devastation. Have nearlye deaths tripled in the last 15 years. In 2015, there were approximately 250,00 drug Overdose Deaths. The large increase is driven from heroin and synthetic opioids. Fentanyl is 80 times more potent than morphine and is administered for painful conditions. Soldn be mixed with or with heroin and is fastacting. Is morese from fentanyl difficult to reverse because it is so powerful. Increase, thethis Massachusetts Department of Public Health with cdcs assistance ended epidemiological investigation. 74 of those deaths in involve fentanyl. I reached a highrisk groups recently released from incarceration. The rise intentional, heroine, and prescription Drug Overdoses are not unrelated. In ohio, cdc found approximately 62 of internal heroin Overdose Deaths were preceded by at least one opioid prescription during seven years prior to death and one in five people have had died from a fentanyl overdose had an opioid prescribed to them at the time of their death. Dr. Houry the cdc is committed to three strategies to comprehensively protect the Public Health and provide all opioid and fentanyl deaths. The first approach is the quality and timeliness to better track trends, identify communities at risk, and evaluating preventive strategies. Cdc funds 12 states in tracking reporting of illicit opioids , overdoses, including fentanyl. Improved surveillance is crucial for states to facilitate faster identification in response to spikes in overdoses leading to quicker, more tailored interventions. The second approach is supporting states in their efforts implement Effective Solutions and interventions. The cdc has funded 44 states and washington d. C. For prevention efforts in surveillance act to these. For example, we have funded ohio to use their Prescription Drug Monitoring Program to identify highrisk patients, and they have achieved full Data Integration with kroger pharmacies as part of their integration of the Electronic Health records. Our third approach is to equip Health Care Providers with the data and tools needed to improve the safety of their patients. To aid primary care providers and evidencebased prescribing practices, cdc developed and published the cdc guidelines for prescribing opioids for chronic pain. In addition to the Critical Partnership with states, cdc knows the epidemic requires partnerships across the sectors and we have been working , sidebyside with Law Enforcement. We are working with Drug Enforcement agencies to implement Prevention Strategies and initiate the personnel exchange. The heroin Response Strategy and deployed by in eight high intensity Drug Trafficking areas involve Public Health and public safety. Cdc is working to coordinate Public Health workers on the ground. Successfully addressing this problem requires efforts and focused efforts in prevention. All three components, Law Enforcement, treatment, and prevention must Work Together to reduce this threat. We each have a Critical Role to play. Without effectively preventing more americans from developing opioid use disorder in the first place, will never get ahead of the problem. Without prevention more , americans will require treatment, often for the rest of their lives, and more will overdose. Thank you again for the opportunity to be with you today , and for your continued support of cdcs work in protecting the Public Health to or to your Public Health. I look forward to your questions. Members of the subcommittee, thank you for inviting me to provide an overview of how science can prevent overuse deaths. Dr. Wilson compton, and im the happy director of the National Institute on drug use. As a physician and researcher ive seen firsthand the , devastating impact of the opiate crisis on families and communities and conducted numerous studies and trends on opioid use and waste to respond. And ways to respond. What is fentanyl and its relationship to the Opioid Crisis . Fentanyls high potency and solubility allow it to rapidly enter the brain and lead to a fast onset of effects to increase the risk for overdose. Emergence of higher potency synthetic opioids creates enormous challenges for controlling supply. A small amount can cause largescale damage. Fentanyl is one part of the ongoing opioid overdose epidemic which also includes prescription opioids and heroin. While recent federal and state efforts have begun to help curb overprescribing of the prescription opioids, overdoses continue to rise mainly due to the rise in heroine and fentanyl related deaths. Efforts in this area part of a Broader Initiative of the office of National Drug control policy and the department of health and Human Services. The population of people using fentanyl largely overlaps with those using heroin, so the strategies being implemented to address the ongoing Opioid Crisis are expected to help address fentanyl addiction and overdoses. Nida, along with fda, cochairs the opioid subcommittee of the department for health and Human Services Behavioral Health coordinating council, and in this role, we help to coordinate interagency efforts. So how is research helping to address the Opioid Crisis . Nida has supported the development of the dedications that the fda approved to treat opiate production. Methadone, all have strong evidence of effectiveness. Despite this effectiveness, only a fraction of people at opioid use disorders are being treated with these medications due to limited treatment capacity, stigma, lack of provider training, and cost. Therefore, nida research is helping to develop strategies to promote wider adoption of these medications. For example, initiating treatment in Emergency Departments has been shown to help ensure the people who overdose are effective engaged in ongoing treatment with their underlying opioid use disorder. Other studies have found that providing methadone while awaiting admission to a Treatment Program reduces opioid use and increases the likelihood of engaging in treatment. How can research and former how can research specifically inform our response to fentanyl . Through nidas Early Warning system, we are supporting research to better understand fentanyl use patterns and trends in hotspots such as ohio and New Hampshire. In the first age of the New Hampshire study, for example, researchers reported that about one third of fentanyl users knowingly used the drug and may seek out a certain dealer or a product when they hear about overdoses, because they think it must be highly potent. What about overdose treatment . Although naloxone can rapidly reverse an opioid overdose, the current standard dose of naloxone is likely not adequate to reverse some overdoses from hype potency overdoses like fentanyl. In response we are supporting , research to develop new longerlasting naloxone warm formulums and new administration protocols. Nida supports research on prevention and treatment. For instance, in partnership with the cdc, samhsa, and Appalachia Regional Commission , nidas testing interventions to address opioid misuse in rural america. Planning Research Initiative to study treatment expansion models resulting from the Additional Resources provided the states by the 21st century care act. Research involves a way to develop a vaccine for fentanyl to keep fentanyl from entering the brain, thereby protecting against addiction and overdose. In summary, over 33,000 deaths from opioid overdoses occurred in 2015, with nearly 10,000 of synthetic opioids like fentanyl. Sciencebased solutions are available. The challenges often in their implementation. Nida will continue to work closely with the other federal agencies, both those that are here today and many Others Community organizations and , private industries, to address these complex challenges. Thank you doctor. , i recognize myself for five minutes. Mr. Chester, does the omb fentanyl isthat another part of the Opioid Epidemic . Yes, sir. It really is two things. It is an outgrowth of the heroin crisis, and once fentanyl has found its way into the supply chain, it represents a unique aspect of that particular. Do we have a Strategic Plan does the federal government have , a Strategic Plan to discuss this unique issue . That particular plan guides and synchronizes government activities against the opioid problems, specifically heroin and fentanyl. Yes, sir. Mr. Milione, do believe we have a federal plan in place, as broad as it needs to be . I would think theres more to do based on this data in the level of threat. It is the deas priority, and we have programs in place to deal with it but as ambassador , brownfield said, there is always room for improvement based on the need of the threat. Based on the data that our Law Enforcement looks at International Facilities at nine different airports in 2015 and 2017, i find it amazing that not of fentanyl was detected. Is it more difficult than coming up with the target profile for fentanyl shipments and we know about it what can be done to improve it . Detection of fentanyl at the land border and in consignment packages and mail is a challenge that we continue to deal with. I think we have Better Success in certain challenges than we do with others. Because customs and Border Protection gets advanced information from the express consignment companies, their ability to target packages inbound to the United States is much better than our ability to target the mail coming from the United States because universal postal union that we operate under does not mandate that international shippers, including china and others, provide advanced information about packages and the mail. Would requiring that information help from the Postal Service . Yes, it would. Is it i also asked, where coming from over the border in mexico . Do we know specifically . The two areas we have seen it must prevalently is in Southern California and southern arizona. The vast majority has been detected. How do they bring it across the border . In personally owned vehicles or bodies people coming as , pedestrians across the land border at ports of entry. So people walk across . Or people come through legally through ports of entry, legally or illegally they are coming through . Legal. We are not detecting it between the ports of entry. We are seeing it come in at designated points of entry and it is being protected and seized and arrests are being made by Border Protection. But another with places we are not seeing it. They are not picked up there . On the land border, we are not seeing it detained the ports of entry. It is also through express consignment packages and mail at hubs where all consignment packages are cleared or at International Mail facilities around the United States. Thank you. The most recent data comes from am i correct or do you have more 2015. Recent data from 2016 . We have data from 2016 at a Quarterly Report for 2016 to the National Center for health statistics, and i think what is really helpful is the funding we received this past year. We have stood up surveillance in 12 states that looked at nonfatal data also. Thats been in place for six months. We capture more quickly emerging trends. Rep. Murphy do you think it is still underreported significantly . Significantly underreported because many medical examiners and corners are not testing for fentanyl analogs. Of the 20 of times, the type of drug is not reported to read we are working with the National Association of medical examiners to improve death certificate reporting. Rep. Murphy just a few seconds, it is a scientific challenge. Can you explain how fentanyl is more dangerous than other opioids medically . The key issue is its strength and fast solubility. Not only is it inherently more potent, but it can more rapidly into the brain. That is what kills people. Rep. Murphy all right. We have more later on. Thank you. Thank you very much, mr. Chairman. Mentioned in my opening statement, i think we all agree that the amount of fentanyl recovered by american Law Enforcement has risen from 640 samples tested to 13,000 samples tested in 2015. Would you agree with that statistic . I would. That sounds right. It is really going up in crisis proportions, right . And have arrests for counterfeit pills or sources increased as well . I would have to get back to you as far as if there has been an increase. We have been investigating these networks. The think you would agree amount of fentanyl recovered has been growing at financially. It has. Dr. Compton, i want to ask because other opioids sometimes often lead to fentanyl use. Sometimes suggested that to stem the demand for fentanyl, we also need to treat opioid addition to addiction drives the users to seek those other drugs that contains fentanyl. Would you agree . Dr. Compton it is most closely related to heroin addiction. It is those people who have the most trouble with fentanyl. Rep. Degette and treatment, as we have learned in many hearings is ans subcommittee, important component in the addiction fight, is that right . Dr. Compton absolutely. We think expanding access is a key component of our attempts to address this. Rep. Degette i assume you had experience with opioids and with heroine. You just cannot stop this by arresting people. Would that be fair to say . You have got to also have treatment. Dr. Compton i think it is key to point out that it is the combined Public Health and approaches that most promising. We include criminal justice systems as well as Public Health is reductions in crime and Important Health outcomes. Rep. Degette Health Outcomes are key part of that. Dr. Compton of course. Rep. Degette so this is what i am concerned about. When you are trying to treat opioid addiction, as we have also learned in our many hearings in this subcommittee, it is a comprehensive treatment that is very extensive, wouldnt you agree with that . Dr. Compton yes. We have thoroughly learned the treatment needs to last quite a long time. It takes people long time to turn their lives around and recovery is not instantaneous. Rep. Degette they sometimes change the chemistry of the brain so you have to have medication assisted treatment and other types of tools to treat this, is that right . Dr. Compton yes. Research has demonstrated that. Rep. Degette in some of these states that have been hit hard with the opioid and fentanyl epidemic, the Medicaid Expansion they have been able to get has been able to help them really target populations for Addiction Treatment and prevention, would that be fair to say . Dr. Compton treatment expansion as a shared goal for all of us and making sure the research we support is embedded in the Health Care System is essential. Rep. Degette the past two years after the passage of the Affordable Care act, medicaid was now able to pay up to 50 of medication treatment in some of these hardhit states. Is that right . Dr. Compton i would really want to refer to specific questions to the state officials. Rep. Degette youre not familiar about how some states in the last few years have been able to increase their treatment . Dr. Compton unfamiliar with the state efforts to expand treatment in the last few years. Talk aboute let us ohio. In ohio, republican Governor John Kasich recently said thank god we expanded medicaid because that medicaid money is helping to rehab people. And in fact, february 6, 2017. February 6, 2017 pew report noted that ohio added 700,000 medicaid recipients under its expanded program and roughly a third were diagnosed with a Substance Abuse disorder. According to the cbo, the republican aca repeals proposal will cut 880 billion in federal medicaid over the next ten years. Would you disagree with any of those figures . Certainly, weell are interested in research that can look at changes in the Health Care System. Study thetnering to implementation. Rep. Degette would you disagree by example, that ohio added 700 and medicaid recipients under its expanded program . A third were diagnosed with Substance Abuse disorders . Dr. Compton those figures sound reasonable. Rep. Degette what im worried about is if you reduce the Medicaid Expansion that in states like ohio, kentucky, West Virginia, other states that have been hard hit by fentanyl, opioids, and heroine, that will reduce the Treatment Programs we are able to give them. Thank you, mr. Chairman. We cannot arrest our way out of this. We have to treat our way out of this. Do we have enough providers . Does anybody know . Have the counties in america do not have social workers. Do we have enough trained drug treatment providers in america . We do not have enough to fully meet the needs and they are not evenly spread across the country so that is why we are engaging in the Rural Initiative to address the severe shortages in rural areas. Prevention will save the Health Care System a lot of money to make sure we are using safe prescribing practices is a key component. Thank you, mr. Chairman. We have seen the opioid and heroine epidemic ravaged every part of our country. Even affluent areas like my home of Orange County, california are struggling with over 200 deaths per year. We are witnessing a far deadlier iteration, fentanyllaced jobs. This painkiller, reserved for the most secure and acute pain are being added to heroine, cocaine, and counterfeit drugs. As the mother of four and adults, it breaks my heart every time i see or hear of another life lost. Just last year, a 19yearold from Orange County overdosed after taking fentanyllaced cocaine. This epidemic again hit home when the dea investigation resulted in four arrests for an alleged fentanyl application and distribution conspiracy in long beach. The dea reported that the men fentanyl tablets and 13 kilograms of the narcotic. Mr. Maloney, i want to commend your agency for this investigation in keeping this deadly drug off the streets of Orange County. The making and distributing of pills containing fentanyl has by molding the pills and a wide variety of counterfeit brands and colors. What are the most prevalent pill types being discovered . Thank you for the question. It is a pretty broad range, but oxycodone they will mimic , whatever is popular in the street, depending on the market , depending on the area. If there is a market for oxycodone, theyll replicate those. Its more powdery substance they want to capsule because i want to start it . That market will influence other package it. What types of pill making machinery and most commonly associated with his counterfeit drug operations . A broad range. Anywhere from an extensible 250,000to was that cost 10,000, 20,000, pills per hour. Some are handheld and can be easily used. Its a broad spectrum. What are the most likely likely sources of the counterfeit drugs . China is the primary source for the fentanyl, but going into mexico and the networks, shipping the merchandise up into the United States and what we are seeing more and more is actually the pills, the counterfeit pills are being made in the United States at different domestic transportation cells around the country. Thank you. Doctor, we understand that the typical victim of the fentanyl overdose can be extremely hard to define since it does not follow economic structure or community locales. What can you tell us about Current Trends and tendencies . You are right. This epidemic increases in all demographics. The most hardest hit and those ose 25 to 44. We have seen it more and more. Whats important for people in rhode island, weve setting one third of the decedents had a prescription within the past 90 days from opiates, third of those had a high dose of morphine equivalent prescription. People are getting exposed to opioids and billing on to fuel their addiction through heroine and fentanyl. Thank you. Mr. Chester, in recent months, fentanyl was first identified as a major problem in the northeast, part of the midwest, and certain states like florida and maryland. What do you see as trends or directions of its spread . Mr. Chester we have begun to see indications that it has moved west. Sacramento, california was the first one about a year ago that we have begun to see it move further west. Fentanyl found its way to the northeast because it was easier to mix in with the powdered white heroin that was popular the northwest part of the United States. I think were beginning to see more the pill form that mr. Milione was discussing as well. Fentanyl, even though it began being geographically concentrated in the northeast we have seen indicators throughout the United States. Thank you. I yield back the balance of my time. Miss kaster, you are recognized for five minutes. Thank you, mr. Chairman, for calling this hearing thank you for shining a light on this. It does feel like were in the Twilight Zone because thats we are talking about the seriousness of the Opioid Epidemic, we are faced in two days with a vote on a health bill that will receive in this countrys responsibility and Health Services to families who are addicted, who need Substance Abuse treatment, Mental Health treatment. Mr. Chester, you said only one and nine are receiving treatment who need it. You say that we have to reduce demand as part of a balanced strategy, yet this gop healthcare bill that is coming to the floor will take a hatchet to coverage for millions of americans, plus it will and will end medicaid Health Services as we know it. Rep. Castor this is very billtant, but boy, this that is coming up for a vote would really take us backwards when we are talking about opioids. In fact, what of my local sheriffs in st. Petersburg in clearwater, we cannot and never will solve this problem at the lawenforcement level. This needs to be treated as an addiction problem, Mental Health problem. We may have had Great Success in beating back the pill mills, but all that meant is were going to see a switch to different drugs and different dealers. And i wanted to highlight whats happening in West Virginia. It is startling. Theres a good Investigative Reporter that is shining a light on it. Mr. Malia any mr. Milione according to a december 2016 , article in the charleston charlestone gazette mail, opiate wholesalers ship mass quantities that seem to be for an excess to what people in West Virginia shouldve received. The article says, in six years drug wholesaler showered the state was 780 million hydrocodone and oxycodone pills , while 1728 West Virginians fatally overdosed on those two painkillers. The unfettered shipments amounted to 433 pain pills for every man, woman, child in West Virginia. This reporting strongly suggests that West Virginia appears to have been receiving quantities of hydrocodone and oxycodone pills that would clearly be more than what would be medically necessary. Mr. Milione are you familiar , with some of the reporting that suggests West Virginia may have been grossly oversupplied with dangerous prescription opiates . Mr. Milione i am. Rep. Castor i mean, this is really shocking. It would appear that addiction to pain pills, can, according to reporting and what you have testified here today, that once you have axiom hydrocodone that takes over someones life, that would quickly lead to the user seeking more powerful opiates such as heroin or counterfeit pills both of which may be , adulterated with fentanyl. Doctor harry, in your testimony, you say reversing the epidemic requires changing the way opioid are prescribed. Is it therefore reasonable to assume that prescription pain medicines has a connection to the fentanyl problem and the larger Opioid Epidemic . Yes. Dr. Houry many of the people who have overdosed on fentanyl have had opioid prescriptions at the time of their death, so i believe all of these fentanyl, heroin, and prescription opiate Overdose Deaths arlington. Deaths are linked. Rep. Castor msnbc ran a story about the influx of the opiates in West Virginia on a small town called kermit. Which i understand has only 392 people. They reported that kermit received 9 million hydrocodone pills in two years. If this reporting is true, its hard to believe that we have sufficient systems in place to spot dangerous trends. Is the dea familiar with reports regarding what happened in the small town . With the oversupply of addictive pills and what can you tell us about it . I am familiar with the report. Familiar it has happened in many locations across the country. We have an obligation across the supply chain from the manufacturers to the district eaters. Rep. Castor what is happening with wholesalers . Mr. Milione the wholesalers have to uphold the regulatory obligations. Weve taken action recently against two of the big three, and my hope is their compliance programs like any good corporate citizens would work to prevent diversion and would uphold those obligations. We have to go down the supply chain to maintain this distribution. Its complex and challenging. We are well aware of issues across the country. Rep. Castor thank you. My time has run out. Thank you. Thank you, mr. Chairman. Mr. Milione, let me stay with you if i can. I dont know if we can get this map of opiate deaths from 2015 up on the screen. The map is almost counterintuitive to me. We talk about, thats not the one. It is the total opiate deaths in 2015, just for the purposes of illustration. Almost counterintuitive, six of the states with the lowest members go back one slide please. Six of the states with a list numbers, of the six, for our border states, texas, california, north dakota, and montana. It would be counterintuitive to if we talked about things that are coming across the border, but also, if you look at the map, it seems like there is a bullseye on the midwest, and what are you doing to interrupt those supply chains that seem to have targeted a portion of the country . Great question. So, you are right. It is transiting in, not staying at the border where it crosses. It is going to locations around the country. The mideast is getting hit. The midwest is increasingly getting hit. Now the west is also getting hit. We are applying lawenforcement techniques, working with our federal partners infiltrating supply chains and looking for , the distributors in trying to disrupt them with the judicial process. Ambassador, let me ask you a question. Thank you for being here today record, youor the are with the state department, correct . I am. Rep. Burgess thank you for your service to the state department. The secretaries in china or has been in china recently, your testimony today written testimony provided in your verbal testimony kind of indicated that perhaps things were looking up. Things were there were positive developments, and i guess im just not feeling that there are positive developments, and in fact, mr. Milione, please dont arrest me but i went , online and looked at how to order fentanyl mine just while we are sitting here, and there are a lot of opportunities. I suspect those opportunities, many of them come from asia or the country of china. Do you think were doing enough to interrupt those . Congressman, i will say we are starting very close to. 0 in terms of our cooperation with china. We have moved in a positive direction. Were dealing with a country that has somewhere between 170000 and 400,000 companies that produce pharmaceutical somewhere in the peoples republic of china. As recently as two or three years ago, there was virtually no control over their production whatsoever. Mr. Brownfield since then within the last month and a , half, for new ones, including important fentanyl analogs are now controlled by the chinese government. We have a dialogue, were talking to one another. Three years ago, their answer which by the way is not unusual around the world is, we do not have offense no problem and therefore we are not interested in cooperating with you because it is not being abused in china. Weve gotten about around that. Are we where we want to be . No, of course not. We have not yet solved the problem but are we ahead of where we were two or three years ago . On that, say yes. Rep. Burgess i thank you for that effort. I agree with you that is a positive development. Given the distribution aspects on our United States map, is it possible, and really for anyone on the panel, is it possible to identify from which laboratories or manufacturing houses overseas, which are causing us the greatest problems in these areas we are seeing on our United States map . Does anyone have an answer . Congressman, that is a great question. Ambassador what brownfield was saying on the , lawenforcement side weve had tremendous success getting leads basedhe chinese of u. S. Recipients of the fentanyl. That is a huge step forward and allows us to uncover the network in the United States. We have been working cooperatively with our Law Enforcement counterparts over there, and very pleased with the direction that is going. Rep. Burgess just on the limited time i have remaining, compton, and dr. I am a big believer in drug Monitoring Programs. It is important to have drugs like fentanyl available. We are grateful for their utility in clinical settings. They have to be used appropriately, but do you have a sense of what i was talking to the dea and state department about . Do you have a sense of where they use patterns are occurring . If you are in a hotspot, i think that its a good idea. If you are in texas, that may not be as important. Dr. Houry in ohio, we were able to do that. We found eight counties that had highest rates. Ohiore able to help guide on where to focus their efforts and in massachusetts, we saw there was a high rate of Overdose Deaths in those recently incarcerated about 50 times of other populations. We are able to use the data for that. With Prescription Drug Monitoring Programs, you can see people at risk for opiate use disorder. Are you . Dr. Houry what were doing another program has been a place for two years. We are in 44 states and getting data that is quicker and better able to be used by states and letting states focus on evidencebased interventions. Rep. Burgess im way over time, but honestly we authorized the program in 2005. This should have been an ongoing exercise over the last decade in my opinion. Thank you, mr. Chairman, i yield back. I want to put together a couple of pieces we just said. The lady from florida in the gentleman from texas mentioned this tremendous prescription rates, massive amount. I put up a chartier of disability rates in the United States. Andt you know, mingo county other areas of West Virginia one , of the highest in the nation. What doctor burgess just point ed out was the deaths occurring there. It makes me wonder what you are talking about, collecting data. How much more data do you have to have . It is way out of control. Yet, these deaths occurring are. Are there any teams going into these places and identifying who is writing these prescriptions and the deaths from this . Absolutely. Weve had teams in ohio, massachusetts, rhode island, given specific information to the states. West virginia . West virginia, we have been funding the program, working with it states to work with the Prescription Drug Monitoring Programs. Dr. Houry if you look at the guidelines, 18 states adopted or limited aspects of the guidelines implemented aspects of the guidelines for sake prescribing. We are starting to see significant improvement in things like kentucky, thursday to see funding. The Monitoring Program has a alert to if they have a high morphine equivalent to make sure people are getting to first prescriptions getting safer prescriptions. Want to thank all of our witnesses. This is been very important issue. Its an important fight for our communities. Obviously, the lawenforcement piece and figuring out how we can stop the entry into our country of the components of fentanyl is very important, but i want to say again, and it has been said many times before, this is a very Serious Health to my republican colleagues, as we face this note on thursday, vote on thursday, we have to recognize the importance of the medicaid program. Rep. Schakowsky its a secondbiggest pair of drug abuse treatment in the United States. Roughly 25 of public and private spending on drug abuse treatment in 2014. We talk about West Virginia, we are talking about a lot of low income people, and medicaid is really the source of help for them. Illinois,e state of medicaid has been absolutely vital to address Substance Abuse and providing access to treatment. Medicaid expansion has provided coverage to 650,000 lowincome adults in illinois, nearly one third of whom have Mental Health or Substance Abuse disorders. Thats just the typical percentage all over the country. Without medicaid these , individuals would be more likely to end up in Emergency Rooms or jails which are drive likely to drive up costs for states and local budgets. Its clear that in illinois we need to be further expanding access to Substance Abuse treatment, and im sure thats the case in many other states around the country. From 2014 to 2015, illinois on saw a 120 increase in the number of deaths from Drug Overdoses. And so, you know yet the , republican trumpcare proposal would decimate the Medicare Program which serves one in four people in illinois. One in four people in illinois. The republican bill would have end Medicaid Expansion and propose a drastic cap on funding. I want to go more on about that. It has been certainly addressed. Dr. Compton, wouldnt you agree that solving the fentanyl and opioid addiction problem also ensuret we that people have access to appropriate Substance Abuse treatments . Dr. Compton certainly, given that the underlying issue is an opioid use disorder, treatment is a key component of solving the problem. Rep. Schakowsky thank you. Dr. Houry, in your testimony, you stated that the rise in fentanyl, heroin and Prescription Drugs evolved overseas are not unrelated. Im sorry, overdoses, not overseas. I will say that again. The rise in drug involved overdoses are not unrelated. Would you agree that in order to solve the fentanyl crisis we , we must also address the larger opiate Prescription Drug epidemic . Yes, i think a comprehensive approach is needed. Prevention is the key aspect of that. Rep. Schakowsky i wanted to ask dr. Compton how harmful would , that be for a patient with an opiate disorder to have to discontinue his or her Substance Abuse treatments . Dr. Compton one of the key predictions of relapse is recidivism. When they stop treatment there at high risk of relapse to their addiction problems and criminal criminal behavior and other serious problems. Rep. Schakowsky thank you. Also on concerned, and the budget committee. Been proposedihas an 18 cut in hhs, 5. 8 billion cut in the National Institutes of health, which my understanding is that you are actually doing some research on i do not know if the right word is vaccine, but some sort of prevention. Something that would be against opioid addiction. Is that true . Dr. Compton we have research specifically targeting fentanyl, where it might lead to an approach that would keep the fentanyl from getting into the brain. The goal is to keep it in the circulatory system so antibodies thelop that attached to fentanyl and keep it out of the brain, where deserted dangerous effects. Rep. Schakowsky thank you. I want to thank all the people who are your today, testifying how you are trying to stop it before it starts, and understand all the sources. I also am interested in the Health Services. Thank you. I yield back. Chairman of the committee, mr. Walter. I want to thank the witnesses again for your learned testimony and answers to our questions. The fentanyl threat you describe to us is the third wave of the opiate epidemic. It seems to me that individual states and ive looked at maps theyve seen different a spects. Some are facing it head on right now. Others are against Prescription Drug or heroin overdoses. So i guess my question is, are we better off to look at this as sort of a statebystate basis . It seems like there are real , so whenin the states we think about a strategy here to combat it, it should be multiheaded, and look at this Opioid Epidemic in that way, or look at canon of all of the kind were sort of a one of look at all of the above or onesizefitsall . We look at it as a complex National Security and health issue at the national level, and at the state level, there are unique environmental factors that cause different manifestations of the opioid problem, and as you correctly point out, there is fentanyl in some states more than it is in others were prescription opioids in others, and in others, there is heroine. We have seen evidence in some places that heroin deaths are pondering and in other cases, fentanyl has surpassed heroine as being the preponderant cause of death. We do two things. Number one, we try to respond to unique aspects of that state partial environment, but also develop a framework to share Lessons Learned from one state to another. Certain states have found to be successful in dealing with their particular aspect of the problem can be shared with other states who may not be facing that particular problem but may see it in the future. Rep. Walden thank you. Ambassador brownfield, first of all, i want to commend the state department and the good work you , and commend the dea for your work and helping gain the recommendation of the march 16 effort by the Uns Commission on narcotic drugs in favor of controlling two primary central precursors. I want to thank the chinese, too. We sent them a letter thanking them for their work to shut down some of the facilities. What do you hope will be the u. N. Impacts from their recommendation for the fentanyl product in the u. S. . What can we expect from that . Mr. Brownfield at the risk of shamelessly pandering, i thank you for the letter to the ambassador. It makes my job and enormously easier when they hear directly from you. What do we expect from the decision to control the two precursors . First, we have to wait another roughly 170 or 168 days before it is fully implemented. This is a period of time during which the roughly 185 Member States that are part of the cmd have endorsed or ratified the seekies have a right to an exception. I dont except expect anyone to seek that because the vote was unanimous. It was 510. When it comes into effect, the countries that produced the two precursors, the two most prevalent precursors in the production of fentanyl in the entire world will be required to control, register, license, and verify production of these precursors there. Rep. Walden which two countries are those . Mr. Brownfield the two precursors. The most important country is china which, in fact did , support, not only vote for, did support and assist us to some extent in lobbying for the passage. What will happen at that point in time, is whenever company, any company in the world is , going to export either of these two precursors the , government of the country where it was produced will be required to notify the National Authorities of the country to which it is being exported. And it will have to provide the basic data and information. How much, when, who is the receiving party, route by which it will be shipped, that allows the National Authority in this case, the hsi, dea, ice to determine what is coming in , doing the Due Diligence to verify this is legitimate and legal sheet shipment. This is why said my oral statement this is a way to shutdown the diversion of legal and illicitly produced fentanyl. Rep. Walden statewide and elsewhere they tried this with. It made a big difference when you put pseudoephedrine behind the counter and required a prescription. That changed the whole dynamic in terms of individual cooking operations that were polluting homes and killing people. And so, i commend you and the state department and the governments involved for taking this step. We look forward to being partners with the going forward. I yield back the balance of my time. Tomko, you are recognized for five minutes. The mic is not on. Sorry about that. The problem with the microphone. Thank you, mr. Chair. I am quite satisfied we are holding this hearing today, because it is literally a life or death issue for my constituents. In my hometown of amsterdam, new york, a Small Community of 18,000 people, we had four Overdose Deaths and another in thereated overdoses month alone. If that rate of carnage were maintained for an entire year, one in every 375 individuals in my hometown would perish. Rep. Tonko these overdoses were all attributed to fentanyl. One in 375. When you drive down the interstate in my district, instead of billboards advertising for mcdonalds or taco bell, you see billboards advising you to call 911 in case of an opioid overdose or year, i had the opportunity to visit a clinic where i witnessed people taking their first steps of recovery, aided by a law i had to pass last year that limits the number of patients a dr. Octor can treat for opiate use disorder. Bearing witness to the Success Stories fuels my drive to push for policies that will expand the recovery opportunity for everyone. That is why i found it astounding that in all of the witnesses testimony today, the word medicaid was mentioned just twice. Both times in the context of Prescription Drug Monitoring Programs. We can talk supply reduction all we want, but you simply cannot talk about a federal response to the Opioid Epidemic without talking about medicaid, which is the largest payer for Behavioral Healthcare services in our country. In new york, medicaid pays for 38 of all medicationassist in treatment for opiate use disorder. In new jersey, it is 22 . Indiana, 17 . I could go down the list, but you get the point. As my colleagues have pointed out, theres a huge elephant in the room here. The Trumpcare Bill this house is being asked to vote on later this week would be the single most devastating piece of legislation to individuals struggling with addiction in our nations history. Trumpcare would eviscerate treatment for individuals who are struggling with opiate addiction by ending the Medicaid Expansion, repealing guarantees of Mental Health and Substance Use benefits, and getting gutting medicaid to the tune of 880 billion over the next ten years alone. You dont have to take my word for it. The American Society of addiction medicine, a professional society 4300senting over professionals in the field of addiction medicine wrote to congress saying, we are concerned that rolling back the Medicaid Expansion and the sunsetting of requirements and capping beneficiaries will reduce coverage for and access to Addiction Treatment services. Changes that will be particularly painful in the midst of the ongoing Opioid Epidemic. Rolling back the expansion and fundamentally changing the medicaids financing structure to cap spending on Health Care Services will certainly reduce access to evidencebased Addiction Treatment and reverse much were all progress made on the opiate crisis last year. The Mental Health liaison group, an Umbrella Organization for groups involved in Mental Health and Substance Use service wrote, and i quote the hca would leave , without coverage 1. 3 million childless nonpregnate adults with serious Mental Illness who are able, for the first time to to gain coverage under medicaid , expansion. It would leave uncover the 2. 8 million childless, nonpregnant adults with Substance Abuse disorders, who gain coverage under expansion for the first time. Current ohio governor, governor spent, thank god we money for medicaid because that is helping to rehab people. Former arizona governor, no ones idea of a bleeding heart affects are most vulnerable, elderly disabled, childless adults, chronically mentally, ill, or our drug addicted. It will simply devastate their lives and lives around them because theyre dealing with an issue that is very expensive to take care of as a family with no money. I could go on, but you get the point. I would, mr. Chair, like to place into the record this letter from 415 addiction groups nationwide opposing trumpcare for the devastating impact that trumpcare would have on treatment for the opiate epidemic. Without objection. Rep. Tonko thank you, mr. Chair. From my vantage point, there is no one outside a three block radius of this Capital Building thinks that trumpcare is anything better than a raging dumpster fire. Certainly, no one thinks this bathroom bill will improve the kroom bill will improve the lives of those struggling with the disease of addiction. I yield back. Gentleman yield back. I do want to note for the gentleman, the article referenced before, i dont know if you have seen it from the washington post, it says the important take away is theres that one opiate epidemic, but several. For policymakers, that means solving the problem will require a more nuanced solution. Not have any affect on fentanyl deaths in massachusetts. Sure we worke together to make sure state have a lot of flexibility to do what they do, so i will continue to work with you on that. Thank you. Now recognize mr. Carter of georgia, a pharmacist. Mr. Carter thank you for being here on what is obviously a serious subject. About thetalk marketing of fentanyl. We talked about it some during this hearing. One of the questions i have, i know i cannot remember who it was that mentioned you are working with wholesalers and trying to make sure they are doing their part and accurately pointed out you need to follow it all the way through the supply chain. I can tell you, that is very important. We need to make sure that happens. Have you been in contact with any of the manufacturers . Generic, about how much they are able to manufacture and put on the market . What we are not seeing is the largescale widespread diversion of legal fentanyl. It is never did for personal use. We do have engagement from the manufacturers that come up and we are happy to work with them. That is good. That is important for a couple of reasons. Rep. Carter i would be remiss if i did not point out that one of the problems we have is not being above the get enough of the product so people who truly need it, Cancer Patients and those truly in need of it we would run short because they put monthly limits on us or something. That was really a tragedy as well. So i hope we keep that in mind as we go along. One of the things i was involved with as a member of the Georgia Legislature is our yearly update of dangerous drugs. One problem we had was identify trying to identify the analog. I know that has to be a challenge. That has got to be a challenge here. One of my other colleagues mentioned about the precursors to it and how we control that. One of the abuse substances that i was always chasing was synthetic marijuana. You know how to identify it, and add it each year into the dangerous drug list, and in the next year, they came out with something else. I went as far as to try to identify the molecular structure and say anything with this and , still, it was so difficult. Can you address that . Sure. I mean, the synthetic threat outside of the fentanyl threat is massive. Weve identified about 400 different substances. Its a misnomer to cause call it synthetic marijuana. It is synthetic ca nnabinoids. You have a whole series. Its a major problem for us. The same criminals tweaking the structures are doing the same when we schedule those, is a very dangerous one hit can send someone into, or have a violent reaction. Its a big problem for First Responders. It is a devastating problem. Rep. Carter we had deaths in my district, five deaths in glenn county because they were buying it at the convenience store. We cannot keep up pace with the emergency scheduling on it. Rep. Carter absolutely. We are taking our shadow there. First of all, from what i am being told by some of the drug agents, particularly in georgia, part of the problem is just with marijuana coming up. Some of it is laced with fentanyl. That is a big problem. Full disclosure, i am a big, big opponent of the legalization of marijuana. I think it is a gateway drug. Nevertheless, that seems to be a problem, too. Before i run on, i want to get to a subject that is very important to me and that is mailorder drugs, mail order prescriptions, coming to patients houses. One of the biggest culprits, the da. Three out of the five facilities in georgia that deliver drugs through the mail are the v. A. Clinics and that is a concern, and something we need to address. We have opioids coming through the mail, being delivered, left on the front porch of someones it signedeven having for, just leaving the box there. How much of a problem have you found with what the drugs that are coming through our mail system . On the kemp chester virginia issues we have a number of open investigation issues and are trying to work nationally at the headquarters, those are areas of significant concern. Buddy carter i think thats distinguished from the trafficking of counterfeit drugs that often move through the mail. We talked about going online there is a plethora of Online Pharmacies that are appearing to sell legitimate pills when in fact there counterfeit. Those are moved to the system in a daily basis. I want to say that is a tim murphy problem. This committee of this Congress Needs to be looking at mail order prescriptions and was going through our mail now. I yield back. As pharmacists see that, perhaps youd be picking up patterns of prescribing in the community and you would notice the massive amount coming through but you would not see that at a mail order system at all . M i correct . On a mailorder system, in other words, pharmacies that are mailing through, if theyre legitimate, they should be keeping records of whats going on a mailorder system, in out. Saw pharmacy may not ecessarily see if people are getting mailed and. Absolutely specially was more than one. The p bmps helps especially if we can do it over state lines. Just recently started that in georgia but floridas one of the states still not doing it. Just recently thats a problem because its a big problem down there. I recognize the vice chair for five minutes. I want to thank the witnesses for being here today. Very serious subject. I have to refute some things that ive heard today. I think we could. Apples gorgeous will try to bring in fentanyl and open opiate abuse into the debate whether you want obama care, American Healthcare act. What ive heard repeatedly is somehow Medicaid Expansion has helped solve this problem come about the math map of data that doctor burgess put up, and i have a paper copy here shows us thats not the case. I think its apples and oranges. I dont think obama care caused opiate abuse can i dont think its can solve it on its own. Were trying to find the answers today. I dont think the American Healthcare act will be able solve it on its own. When you look at the states where the deaths are, if you just get to play games of numbers, the expansion states have more deaths in the non expansion states. I dont think thats fair, but i think what my colleagues on the other side of the aisle about us causing problems about the American Healthcare act is irrelevant to our discussion today. With that being said, you mentioned the commission that youre working on a project, what are you doing thats my turf in part. I represent the appalachian regions of southwest Wilson Compton m. D. Virginia which border hotspot areas for opiate abuse in kentucky and West Virginia. I remember a meeting in virginia is a lovely town that can be a group to look at this issue several months ago. Ur initiative is a Grant Program to look at demonstration to improve the Public Health Morgan Griffith infrastructure and determine how good a job that will do to address the crisis in rural parts of the country. The commission will be go find in this along with the cdc and others taking the lead on it. We appreciate it. Its a significant problem. One of the issues that we need to look at is whether or not the folks started off because of the higher a for disabilities as well people have done a lot of manual work nd they get a prescription and then they get hooked. Doctor, you indicated in ohio that 62 of the people who died from heroin debra houry m. D. Or fentanyl had come in the last seven years had a Prescription Drug for an piate. Can you tell us more . Weve seen this in many states, like in rhode island a third of the people who had overdosed on fentanyl had an opiate prescription within three months and a third of those had a high dose opiate prescription sure that people that are in prescription opiates get addicted and then can go on an overdose. And sometimes their prescription runs out but there ooked. Is there some way we can connect the doctors recognizing that the patient just got hooked to get them to help . Of this prescription just stands and nobodys alerting are those folks going out buying it illegally on the streets . Thats why we have our cdc prescribing diet guidelines. If you have a patient that you uspect one of the things i have been proud about his although there were funding the states to do whats important each month we do Technical Assistance call to help them with scientific expertise on where to focus resources and where the best evidence based treatments to share best practices. As we see Different Things emerge we can share those. Data does drive action. I heard Morgan Griffith a stock but should this be a national or state approach . New hampshire is number 20, the following your number five. We need to give states the flexibility to deal but we need to have the overall approach. Thank you. I apologize if i messed that up. I would be remiss, why think marijuana is a dangerous drug, think your testimony indicates fentanyl was her number one concern. Its not your jurisdiction so its a rhetorical question. Why dont we let there be more research on marijuana and the ability to help patients weather in uppsala Louis Milione here pain. While i think its a dangerous drug, i dont think its as dangerous as fentanyl or other opiates. We do Frank Pallone jr. Support any approved research along those lines. We will continue to work with researchers on those things always support that. Mr. Chairman the problem is a schedule one drug makes it tougher than if it were scheduled to like fentanyl and other opiates. Thank you mr. Hairman. The affordable character the expansion of medicaid extended Health Insurance coverage to hundreds of thousands of americans in need of treatment. Im concerned that if the money is cut for medicaid which is what the cbo says what happened with the republican bill, patients could lose access to care and this can make the fentanyl problem worse. So doctor compton come in your testimony is states Wilson Compton m. D. Opiate addiction is a chronic condition in patients will need ongoing treatment for many years. But could happen if their treatment was interrupted because the patient no longer had healthcare coverage for Substance Use disorders . We know when treatment is interrupted or stopped whether intentional or unintentional the relapse is extraordinary. Some Health Experts estimate 1. 3 Million People are receiving treatment for Mental Health and Substance Abuse treatment thanks to Medicaid Expansion. Our efforts to curb this could be impacted. Should the aca be repealed to clearly expect the opiate crisis to worsen . Gain, the people who are currently being treated for an opiate abuse disorder were to lose coverage, would we expect the number of overdoses may increase . I hesitate to make a different because theres so many roles here on how things will be generalized. Our goal is to make sure the research we support is implemented the matter the healthcare system. Is the state of West Virginia as an example because it was hard hit by the opiate epidemic. February 6 article reports that West Virginia has the highest piate overdose death rate in he nation. Let me ask doctor, are you aware that West Virginia has one of the highest death rates for opiate overdoses in the u. S. . Yes, and that same article reports Medicaid Expansion as had hundred 73000 people from West Virginia the program. Its about one third of the ntire states population. According to the article, doctor, and 2013 the first year that West Virginia expanded medicaid the number of people in treatment for Substance Abuse fell from 16000 to 17000. Increase use for services with suggest a thousand West Virginia went without needed treatment prior to the Medicaid Expansion. Would that be a fair assumption . We think about states like West Virginia point out the role aspects make it complicated to deliver services. Im proud were able to implement this new Research Program in rural areas. It would appear that medicare is essential in the fight against the addiction which would include the growing problem of fentanyl. My last question is if West Virginia were to lose the services would we expect the open and fentanyl programs were said assuming there were lost medicaid coverage . I cant speak to the coverage issues but individuals were treated if you stop treatment abruptly that could be bad. The republican bill with regard to expansion eliminates essential services guarantee. What we have found the swimming you dont have the guarantee the first thing to go is behavioral services, drug treatment, mental Health Services, things that are expensive the states and provide until we set a Medicaid Expansion that they have to. I think between the cutbacks that would occur because states to be getting less money, theyre going to get less money, they dont necessarily have to cover people depending on their income as they reduce Medicaid Expansion population. Even with traditional medicaid if theres no guarantee of essential services the first thing that is cut back his treatment for drugs. Thats my fear. Thats why think this is devastated if we try to deal fentanyl these other opiate roblems susan w. Brooks that we have. Thank you mr. Hairman. The governor yields back. Thank you to everyone on the panel for your important work. I must say that fentanyl is not a new problem. I was u. S. Attorney is several districts from 2001 until 2007. I learned about fentanyl them. You, wouldnt talk about it much. The way we focused on methamphetamine and the dangers to children, the environment, but were not talking about is he danger. We talk about the overdoses but can we talk about truly how dangerous fentanyl is as a product. I realize against icy because we use it in medical procedures. Having just been with Law Enforcement firefighters this past weekend, there are dangers and is that not why youre doing training . Can you talk to us about the dangers of fentanyl and why havent we, for a long Matthew Allen time talked about the danger. I dont think attics and their families really have understood how incredibly dangerous it is. I say the lawenforcement community we have been. Since the recent surgeon fentanyl one of the things weve gotten out largely following the da is making awareness are personal generally what they could be ncountering. Press operationally its changed how we do our work. One of the investigative techniques we have done historically is to purchase drugs, whether online or more domestically. We stop doing that because of officer safety concerns we have that could be inherent to an undercover agent buying drugs or state local officer by drugs and not knowing what theyre purchasing. Changed how we do our work. One of the investigative theres a challenge for us from the perspective of field testing. Gone are the days of agents pulling out of pocket knife and probing that package of suspected drugs and putting that into a test kit. We, ths and susan w. Brooks within Border Protections have taken the lead on trying to examine, explore the field now on intrusive testing that would allow us to go to a test were agents dont have to physically open a package to determine with the substances. Louis milione why is there surgeon fentanyl . What is your, and dea, what would you say was the cause behind the search that we have been seeing . Its a free market principles applied to mass profits that can be made. Cartels and criminal groups are exploiting that. They aggressively market the small amount of fentanyl they dont want to deal the massive bulk of heroin. They can get more profit out of it. They dont care that its killing their customers . Its very callous, but its the cost of doing business. I think some of the medical professionals on the panel would say theres a perverse, sometimes reaction when people overdose from high potency fentanyl. It sometimes attracts more attention to that product. Any idea what the stats are prominent cases we have been charging in the past year susan w. Brooks or two causing death . Federal cases where were actually prosecuted drug traffickers for causing death. Out have to get back to with statistics. We are doing more around the country. Working with u. S. Attorneys offices, were engaging with u. S. Attorneys trying to get hem to lean forward and work cooperatively on that. Its definitely more focused on. Heroin death or fentanyl death. It would be the last distinguish the kind of analog i think also is helpful to have the medical examiner. Was it an intentional overdose or other paraphernalia its really up to the laboratory and the training as tim walberg well. You are doing a great job for us Louis Milione to. Does the dea have precise data on how much fentanyl is coming in directly from canada . E dont know exactly what is coming in that we know we can get those statistics to you. It is in perfect though to be able to get it in so having flown over the entry into seeing the amazing ways eople will find that a significant amount of coming cross. China and canada across the order. Do you have numbers on Matthew Allen how much has been interdicted from canada and are there hot spot among the order . With the components have coming from canada is rarely coming from assignment and not necessarily the physical land border. In your written testimony you mentioned that i i. C. E. Has sent all related nvestigations. Can you talk more about this investigation and extending the coordination with canada . We work with the department in that effort and we are meeting with the mexican counterparts and chinese counterparts as heard today. I think expanding the information with the source and transit countries is going to be part of how we improve what we do and recognizing some of the fentanyl that makes its way to the United States from china think expanding the r other places also is the r other places also is the same stream that makes its way from canada into mexico as ell. Its great to have a border neighbor we can work pretty well with. I would add one of the things that has distinguished is that canadians have come to us to talk about having a very similar problem that we are. The act aims to stop the shipment of the synthetic drugs and those like fentanyl sent into the u. S. The bill would require shipments from Foreign Countries to the system to apply the advanced data like where its coming from, who its going to and crossing the borders into the u. S. How would this information help interdiction by giving the advanced information that they could use at places like the National Targeting Center to be more objective and efficient targeting what is coming into the United States. One of the things that constrains the ability of what information the Postal Service has an advanced my understanding of the act is it would require us to update through negotiations and the state department to provide more timely information in the targeting. Are there are there additional steps congress should consider along with to assist the efforts to stop the shipments . Nyone . Thank you mr. Gus bilirakis chairman. I yield back. Now the member on the full committee for five minutes. Thank you mr. Chairman. Thanks for allowing me to ask the questions and i appreciate the panel being here. This is such a very important kemp chester issue. They want to get the message ut and i think that is the ost important. If you could answer that uestion i would appreciate t. As i stated earlier, the components how we are dealing with this is to provide treatment for those that are addicted to these drugs and stop the flow of those coming into the United States. In terms of prevention, one of the methods used is funded and managed by the Substance Abuse Mental Health administration with thousands of communities around the country as a Prevention Program that is focused on the needs of individual communities to require local solutions in the coalition of the Community Members that are focused on the needs of the particular community not only to raise awareness of the issues but to Gus Bilirakis prevent the primary drugs used focused on the demographics of about 13 to 17yearsold, which is the targeted demographic. Its a very effective program. Ok, very good. Mr. Allen, as you mentioned earlier, china announces the intention to ban the different types of fentanyl. Can you describe the working relationship to prevent Louis Milione and treat and are there mechanisms to hold china types of fentanyl. Accountable . Our relationship on the working level has been tremendous. The administrator was met with the counterparts as a result shortly there after working in the state department they agreed to schedule these and it is more potent than morphine. This is a significant step. The other positive thing is when they initiated the investigation there had been a bilateral sharing to the domesticbased distributors that are ordering fentanyl and that has helped to flesh out the networks and now the investigations are ongoing as we have been pleased and hope it continues and certainly it can kemp chester expand. And i would only echo that on their way to the United States nd weve been able to use that information to identify other individuals and organizations that have received shipments from the same origin in china that has allowed us to begin the investigations. Finally, congressman, if i could add one more. A little over a year ago, we reached a bilateral understanding of the chinese governmentbacked they would control the delivery of products from china to the u. S. Even if they were not controlled in china. If they were controlled in the u. S. For exchange which we Gus Bilirakis made the same commitment to them. It is not enforceable but it is an agreement been reached between ourselves and the governments. Thank you. In your testimony you noted that they are committed to giving providers and debra houry m. D. Health system the tools they need to improve puppy opioids are used and prescribed. Can you discuss the tools and how they can take advantage of the tools . Absolutely. We have an approach one is through the education we have been working with the director of medical schools on the the Clinical Training and effective Pain Management and prescribing practices. We also developed the seven education seminars available for free on the website and with the pipeline itself, i now you have to have something that you can use so we have a checklist thats been downloaded more than 25,000 times by the provider to use, and we also have a mobile app on the phone around the guidelines. How do you talk with a patient about thethe patientabout the difficult decisions on whether or not to give the calculated appropriate opioid to give, and we piloted the Community Education program and awareness about the risks of opioids intensity that were the hardest hit. I would like to talk to you about possibly coming to my area if you havent already. I would welcome that. Thank you. Was yield back. I just want to respond to what the colleague said. Certainly nobody thinks that the shocking increase in opioid ntiheroine is in any way elated to the aca. We recognize and some of those areas we have the Medicaid Expansion rv areas that are read on the map and that is quite disturbing. Our point is if we are to treat these folks getting addicted that its important they have access to medical treatment and we are concerned if the Medicaid Expansion is retracted because in those states Medicaid Expansion has helped many people who need to have Addiction Treatment which is extensive. I have a letter that talks about the Medicaid Expansion and how many people would lose their tim murphy treatment if it passes and i would like to ask you to put unanimous consent that letter in the ecord. Do you have any idea how many federal agencies deal with Substance Abuse tim murphy across all departments . I dont have the answer of the top of my head but i would like to follow up if i could. I know when we asked the gao to do this they said at least 112 probably more but they ouldnt figure it out. I know one of the things the committee did this coordinate he agency efforts. Its a question i wanted you to let us know. What would the administration do do . E will have intense hearings but we are far past the opioids and we need your suggestions to Work Together. We have a shared passion in this area and this is one we have to Work Together. The states have to handle it a different way with the disability rates and unemployment rates would be different for massachusetts or utah or anywhere else. There is a letter that we sent with several questions and maybe we can expect some answers to that . It is in the final clearance we hoped to get it to you this morning that we will get it as oon as possible. Let me just say i want to thank all of the members that articipated in todays hearing and you have ten Business Days to submit questions so the witnesses have time to respond. We look forward to working with you and with the bad, the hearing is adjourned. And you have ten Business Days