Transcripts For CSPAN Senate Panel Looks At Stopping Flow Of Synthetic Drugs To U.S. 20170526

State. This month, a Police Officer in ohio had a near fatal sentinel overdose facing overdose following routine traffic stop. ,e put on his mask and gloves arrested some individuals, went back to the playstation and the police station, noticed there was powder on his shirt, he brushed it away. He is a big man, and he fell to the floor unconscious and overdose. Canadministered nor immediately, but he was not enough, they had to rush into the hospital where two more narc an doses were administered and luckily his life was saved. He would have date have died if he had been alone. He also said, what if you got home and hugged his kid . This, it is devastating our communities and causing danger for Law Enforcement and First Responders. Isntanyl hundreds of times more potent than heroin. It can be deadly. We also know about other synthetic drugs coming into our country. This issue is getting worse. As i said, the number of overdoses and deaths have increased a medically dramatically. You might have seen a colleague include synthetic opioids in his worldwide threat assessment. He said his comments the deaths have increased 33 just between 2014 and 2015. Sadly, the death toll continues to climb. We will hear about this this morning. Fentanylunty in ohio, was responsible for over 200 deaths in 2016. One county. Later, you will hear from a medical example and medical examiner and he will cut you is our biggest killer. Often the user has no idea what they are taking. There is a new opioid cocktail called ray death. Death. Y it includes a mixture of various drugs. Heroin is the weakest drug in the mix. And about that. It is available on the street, this cocktail, for as little as 20. O even of these drugs are selling inexpensively, there is a high profit margin, making fentanyl appealing to the drug deal appeared it is estimated that a purchased for a few thousand dollars and can be used to make hundreds of of with profits into millions. Unbelievably, it comes to the u. S. Mail system. This is a shock to many of my constituents and others learning about this. Fentanyl is ahe smuggled into the United States from mexico and canada, primarily comes directly into the United States, and according to Law Enforcement and folks who were here this morning who would tell us about this, it primarily comes from one place, china. It is produced in laboratories and my understanding from Law Enforcement is that most of the fentanyl is intended for export one place, the United States. The number of chinese websites ready to ship, do a Google Search for fentanyl for sale, it produces a number of sites for the drug appears to be readily available. You can purchase a grant for 250, but it says the more you buy, the less you pay. To ease any concern about whether the purchaser will receive his order, the website guarantees discrete shipment with undetectable on careful packaging and careful packaging. The website with audience and offered express delivery to the United States. Many of these websites are so bee their seizure will not stopped by Law Enforcement, they will guarantee if youre it if the original gets seized, they will send you another one for free. Websites we viewed many clear if exclusively used express mail service as their career. That is the International Postal Service Operated by members of the International Postal union. Delivered through ems are passed through the United States Postal Service as the internet United States. Our goal today is to stop the strokes from exploiting our streams of mail into our country. Has beenber around us involved in this issue, on education and treatment and recovery. Weve passed two significant legislative initiatives in the last year in congress focused on this issue. Much broader it is than just interdicting, but we have to do a better job of interdicting. 9 11, congress identified weaknesses in International Shipping centers as a significant problem, and believe that advanced electronic data would make the country safer. When Congress First legislated, it left a loophole. 2002 mandatedof that commercial carriers provide advanced electronic data that could be used to identify certain packages being shipped in the United States. In the 2002 legislation, congress as the secretary of Common Security and the postmaster general to the side of the Postal Service should be subject to the same requirements as private carriers. Today, no determination has been made. Our country is less safe as a result. As such, the difference between privatermation commercial carriers are required to provide is very different from the Postal Service. They both serve the same function delivering packages to our communities. The Postal Service handles a hiring handles a higher volume of International Packages than the private carriers combined. The name and address of the person receiving the package, description of the conference, the weight and the value of the contents. This information is transmitted to customs and Border Protection. Based on this information, cpb targets suspect shipments for additional scrutiny and selects packages of mustard packages it wants to inspect upon entrance in the United States. None of this applies to the Postal Service. The Postal Service handles hundreds of thousands of packages every day. Services ional packages shipped to the Postal Service are shipped through Service Centers. How these packages are processed are completely different at each of the centers. For the most part, cbd is tasked with identifying packages for shipment it wants to inspect. If the Postal Service locates those packages, it percent from the cbd. It isnt that easy. Due to the hundreds of thousands of packages, the Postal Service is left to manually shift through sift through the packages. All International Packages are required to have certain information attached to them including the sender, recipient, description of the contents, weight and value. But the information is not electronic and not transmitted in advance. It is not useful to Law Enforcement. Essentially, is useless. The upu says it will require Member Companies never countries to have a barcode. That is fine. Information beg on the barcode until 2020. Were told mad closer to 2022, but there is no cure guarantee we are told is closer to. 022, but there is no guarantee americans are dying every day from these poisonous drugs and we must act. We have to stop this fentanyl and other synthetics are coming in. The Postal Service is trying to use electronic information at jfk to help cpb identify these packages. It is a Pilot Program. The Postal Service is providing iectronic data that for that weigh less than four pounds. Once the Postal Service shares the information, cpb uses the information to identify packages wants to inspect. The Postal Service locates and present these packages for inspection. This is a step in the right direction, in my view. Notr nearly 15 years of doing this, the results today are lacking. In 2016, december 2016, the Inspector General found the Postal Service failed to present all of the packages cpb request for inspection and there was no draft electronic data associated with it. I understand the Postal Service is taking steps to remedy this issue, sending packages from inspection. I look forward to hearing details about that today. Without this electronic data, we will miss a significant portion of these packages. This Pilot Program is on having at one location. Serviceeas other stations are sifting through packages like a needle in a haystack. We need this information now. Weve been working in a bipartisan way to solve this problem. It is why we introduced. Egislation it is aimed at providing the postalformation service should be providing for International Mail. We have 60 cosponsors in the senate. And the house, theres companion legislation that has 128 bipartisan cosponsors. Our focus today is getting input from this Pattern Panel of witnesses. Again, thank you all for being here. I think my colleagues for being here. I would like to turn to the Ranking Member. This is an all hands on deck moment for our country. We welcome the members of the panel. Those of thenk committee for the good work they have done to get us ready for this day. The focus on todays hearing is more about at least one of the ways these drugs are getting into communities. And what we can do to stop them. I look forward to hearing from our witnesses, we look forward to hearing from our witnesses so that we can better understand the processes used by the Postal Service, private shippers and identify packages and stop alyssa packages. I look for to learning more about the relationship between shippers and federal agencies, while identifying areas where we need to push for improvements. Joining in todays discussion is the Postal Service, which in partnership with the cbp is our first line of defense in preventing the flow of Illegal Drugs and contraband into our country. As a some of you may recall, protecting and improving the mill system in this country has been one of our biggest priorities, certainly one of my biggest priorities were a number of years. The Postal Service is vital to our economy. Trillion dollar mailing industry. The industry is facing solvency if congress is not pass copperheads of reform. And i can that legislation will free of liens of dollars that the Postal Service can use not only to invest for the future and improve customer service, but also shore up mail security. It is worth noting that despite financial uncertainty, the Postal Service rectify them has grown significantly in the past three years. In fact, it has nearly doubled. Growing from 150 million pieces and 2013 to more than 275 million pieces in 2016. There is no question that handling that increase volume addition to domestic strain onis putting a our stretched resource. Unlike private carriers, the Postal Service is required to mail it receives in a timely manner. This is due to our International Postal union. It also ensures we can mail overseas. The state department represent does represent the universal postal union, they will be here with us today to discuss their involvement in this key organization. Look forward to hearing from our Postal Service and state Department Witnesses about our commitment to promoting the exchange of advanced electronic member countries as a means to combat shipment of drugs and other illegal goods. All packages are screened initially before being presented to the Postal Service, cbp can and often does target packages for additional screening. Cbp, which is also joining us screened based on country of origin or scanned by the Postal Service. The Postal Service and cbp have been working closely together on a Pilot Program that allows them to use advanced electronic data on small packages from china arriving at jfk airport. While the Postal Service provides other countries with advanced electronic data about mail originate in the United States, we dont always get the same information from other countries. This makes it harder for cbp to do its job. Its packages arrive here. At jfk is aogram rare exception. I hope we can learn today whether there are recommendations to improve and expand this program. As my colleagues have heard me many times, find out what works and do more of that. Private carriers are also joining us here today, and have the fencedb with electronic data. Unlike the Postal Service, private carriers have integrated Automated Systems throughout the world and can refuse to accept the package and origin that does not contain any shipping manifest data. Learning how the process is used can hopefully help us fill in the gaps exploited by smugglers. I also look forward to identifying ways covers can ensure federal agencies as well as our state and local partners have the resources they need to combat the Opioid Crisis on the ground. Specifically, im eager to hear from our witnesses on the second panel, each of whom serve on the front lines of the nations Opioid Epidemic in capacities from Law Enforcement to medical doctors and addiction expert. They will give us firsthand perspectives on the challenges we face in fighting opioid addiction and the strategies that have proven effective. , ohioularly in delaware and nationwide. I look forward to a discussion of ways to reduce americans access to end the use of synthetic opioids, this is only part of the equation. You must not lose sight on the need to focus on the root causes of our nations considerable demand for drugs. Not just the symptoms. It will onlyhat, continue worsen and smugglers around ourays to get blocking of dangerous drugs. According to the centers for disease control, over 33,000 americans suffered an opioid related death in 2015. That is roughly the population of our capital in delaware. My home state of delaware has not been immune. None of our states of been immune. Delaware to the division of forensic science, in 2015. E 222 lester, 308. Last year, there were 308 deaths. These numbers are staggering. Substance abuse is a Conference Problem with consequences for everyone. We cannot Pay Attention only to the symptoms of the problems without trying to address the underlying cause. Overdose deaths are preventable, so is the crisis worsens need to Work Together to provide funding to help save lives. In closing, i believe it is google to note that access to health care plays a pivotal role in combating addiction. Unfortunately, proposals to repeal this Affordable Care act in people to the progress in addressing the nations Opioid Epidemic. As well know, medicaid is the single largest payer of Substance Abuse services in our nation. Paying for one third of all medication assistance treatment. Current plans to repeal the Medicaid Expansion and add program caps threatened to make the Opioid Crisis worse as millions will be at risk for losing coverage for Substance Abuse prevention and Recovery Services just of the time we need the most. Tong forward, i look forward working even more effectively with colleagues on both sides of the aisle to it address the underlying causes of the epidemic and learning what we can do and how we can bring about substantial, lasting change. Thank you so much. Thank you. we have a college who is not on the committee today. She is the coauthor of the stop acts. Even if she is not a member of the committee, would like consent that should be allowed to participate. [laughter] mr. Portman without objection. Today is her birthday. Mr. Portman you chose to spend your birthday with us. I would like to recognize the senator. We would like to other members would like to make a brief Opening Statement, i know she has some real keen be. If you would like to make some remarks. Thank you. It is a celebratory moment to be with you on the subject subcommittee on my birthday. It was amazing to meet some of the witnesses out there, and i think youll learn a lot from hearing about them. Ronernever heard the corn become this, but the medical examiner was very mining. We are still investigating the death of prince in my state, but it is not just him, it is moms and others. I look at this in three ways. This framework i think the start of us thinking that way, and i want to thank senator portman for his leadership on the bill. We worked in a bar person bipartisan way. , trying to reduce the number of people getting hooked on legal opioids, that means everything from Prescription Drug monitoring bill to the work we are trying to get changes in how Prescription Drugs are given out and how many are given out for simple things like wisdom teeth. The second is treatment, we did and we willl of us have to continue to do work with the budget. I appreciate your leadership on the republican sign in objecting to these cuts we heard from the house. I think that will be really important. The third is that we know people are migrating to the Illegal Drugs because they are cheaper or easier to get. We will see more of these kinds of overdoses from things like fentanyl. In my state in the last few months, we have had 11 people , it is 100r fentanyl times more potent than fentanyl. A dose the size of two grams of salt can be fatal. Judiciary committee, we heard from customs just last week. The numbers we heard is that in 2013, fentanyl seizures were at two pounds, now it is 440 pounds. Thats what i am proud to be the lead democrat on our bill. Senator portman and i have the stop act, i think it is really important we start using modern technology and so we are as sophisticated in tracking down these perpetrators as the ones that are being our kids hooked and killing people in our country. The second thing that i wanted saltntion is the fault act, it makes it easy to prosecute these kinds of cases. I know other senators were here who haves people worked as prosecutors. They see that as a real issue is well. Arehave drug dealers who changing the components in these drugs and they are doing it with as well. They make it harder for us to prosecute them, especially in rural areas where it is not easy to call a medical expert up like we have here today in washington. We are feeling good about the bill because senator grassleys on it, feinstein, the leads on the judiciary committee. If something makes it easier to in a locks when they change the composition of synthetics. Senatorant to thank portman for his leadership and willingness to work across the aisle on this really important issue, and thank you as always senator harper. Mr. Portman thank you. Any other members would like to make a brief Opening Statement . James . All right, we will go to our first panel of witnesses. We have a very distinguished panel, some of them here for a when thee last year stop act first originated. We were able to identify this problem. Would like to call the witnesses individually first. Director of the bureau of International Affairs of the state department, which works to advance u. S. National interests. Prior to during the state department in 1991 here in washington, he held Senior Foreign Service positions in other countries. , the vicetron is here president of Network Operations of the Postal Service. He began his Postal Service career 31 years ago as a clerk in rochester, new york. In his current role, he oversees the Postal Service dissertation networks, including Overall Network design policies and processes required for moving mail and services that support the network. Third, robert perez. He is the acting assistant u. S. Border at protections. Previously he served as director of Field Operations for the new york field office. Lester, he saw the arrival of more than 21 million and 41ional travelers million in imported goods. Over the course of his career, mr. Perez represented cpb as a Border Expert all of the world of many combatants and as a guest lecturer. We have tammy would come, the Inspector General for the Postal Service. She served as deputy Inspector General starting in 2011. Prior to the post office, she worked at both the National Revenue service, Inspection Service and the u. S. Department of treasury. Snally, we have norm he is with ups, and he works directly with government leaders around the world on simple find customs most riesling with supply Chain Security issues. He previously testified on a Drug Enforcement issues before on advisory served committees to the World Customs Organization and department of congress. She also currently chairs the International Chamber of department of trade. We thank all of you for being here this morning and we look forward to hearing your testimony. To swear an witnesses, so i would ask you to stand and raise your right hand. Qs where the testimony will give will be the truth, the whole truth and nothing but the truth, so hope you god . Please be seated. Te. Portman i would no all the witnesses said they were prepared to testify under oath and let the record reflect the answered in the affirmative. Your written testimony will be part of the record, i would ask you to try to keep your oral comments to five minutes each so we can get to the questions. Mr. Tommy, i would like to start with you. Thank you. Good morning and think you for the opportunity to appear to discuss the issue of illicit drugs including synthetic opioids in International Mail. Site of they Opioid Crisis hit the complicated picture with multiple pathways for the drugs into the country. In addition to ship is the find the way to the United States through land borders and express delivery services, illicit drugs also enter the country through International Mail. Typically in small shipments purchased online i individual customers. The department of state is where these small shipments pose unique challenges to customs and Border Protection, challenges that the exchange of electronic data can help mitigate. The department of state works closely with the cbp and postal vice to increase the International Mail. Before discussing these efforts, i should explain that the postal accountability and enhancement act of two thousand six identifies the department as the lead agency for International Postal policy. The main forum for our work is the universal postal union, upu. It is an intergovernmental he organization of 92 countries that have committed to delivering one anothers mail on the basis of reciprocity. The upu congress and its 40 member Postal Operations Council or poc, write and adopt the x of the union, which are the rules of the road for International Mail exchange. 2012, the congress of u. S. Was successful in submitting amendments that required each number state to adopt Security Strategy which included requirements for providing aed. In 2016, the United States was reelected to the poc and sellers to a selected to cochair the supply chain. Workcommittee oversees all on customs, security and transportation standards. The United States also chairs the Committee Standing group on postal security. These leadership roles position is extremely well to ensure that highprotein Security Issues move forward as quickly as possible. We have made significant process toward that goal. With active participation and technical input from the United States, the upu collaborated to develop an electronic data system. In february of lester, the poc adopted a new Regulatory Framework for aed the roadmap called the roadmap for aed implementation. It includes final adoption of the technical messaging standard for item level data. Adoption of the standard should take place at this falls poc meeting. Thesenificant as achievements are, they are only part of the picture and there are open to goals obstacles to overcome. The main impediment is the limited ability of most Postal Services to collect and transmit aed. The plan adopted in 2016 calls for all Postal Services to have capability to Exchange Item level data or the end of 2020. However, the technical ability to exchange this data is not translate directly into the ability to collect or enter it. In thest offices developing world do not have Internet Connectivity or even reliable sources of electricity, which makes collection of data and transmission of data difficult. Even in developed countries, some Postal Services have been slow to invest in the needed info structure for item Level Electronics exchange of data. Currently few if any countries have the ability to provide for 100 of their mail required in customs declarations. To supporth is been the upu to provide Capacity Building that enables aed. The upu is devoting half of its cooperation budget over the next four years to a project designed to position Postal Services in developing countries to obtain this capacity. The major focus of this program is aed. We will continue to support and encourage these efforts but recognize that rapid acceleration and investment and data will be driven by the Business Needs of postal operators themselves. Postal operators now understand the delays caused by necessary customs processing are a major impediment to their own ability to grow their Business Model and adopt the rapid growth of ecommerce transactions. Exchange of aed is the only real problem. To this consequently, while the United States was once a voice in the wilderness almost alone in calling for aed exchange, we are now leading a course of countries, developing and developed, that demand aed. Another Significant Development with invocations for aed is the upus decision to launch the integrated product plan, which aims to modernize upu product operations. This farreaching effort has clear benefits for the customs processing of mail. Phase one begins in january of 2018 and will introduce segregation of mail and items containing into items containing documents and those containing goods. This will split customs requirements. Mail one also requires items containing goods to have a standard barcode label, which is critical to enabling aed. Thermore, upu regulations upu approved regulations in 2016, which will allow members to impose aed requirements on items containing goods, providing they ticketed account whether the requirements can be met to whom they apply. The thinking behind this regulation was that demanding something that is impossible immediately as a condition for delivering and other countries mail is the same as refusing to receive it at all. Such requirement would undermine the reciprocity at the heart of the upu. In conclusion, i would like to assure the committee that the state department Say Department is emitted to state department is committed. Swiftt to ensure implementation of the aed roadmap. We are confident the number of countries able to provide aed and the portion of their mail stream it covers will continue to grow. Chairman. Mr. Of the forward to answering your questions. Good morning, chairman. Members of the subcommittee. Thank you for calling this hearing. Cintron, i amert the Vice President of Network Operations for the United States Postal Service. I oversee the Postal Service National Distribution network, including its international operations. Congress has given the u. S. Customs and Border Protection the authority to screen items at first entry into United States. At entry, customs has the authority to open and inspect all inbound items without a warrant to identify prohibited items. Inbound International Mail from foreign postal operators arrives i playing at one of our International Service centers, cs. N as is they normally arrive in large bags packed in containers. Received anments initial receipts can buy the Postal Service. At this point, items requested by customs are presented for further inspection. For those items which advance known as aed,a, is furnished, customs has an enhanced ability to target items for inspection. Servicehe postal collects aed for more than 90 of its outbound International Packages and receives 40 50 of this information for inbound packages geared to put this into perspective, comparing data from fiscal year 2015 to the present, aed for inbound International Packages has increased from approximately 1 to present range between 40 and 50 . In other words, the Postal Services receives data on a substantial amount of inbound shipments. Including those originating in china did the percentage of inbound items with aed is expected to continue to grow, especially as more countries develop their capacities. In an effort to further expand the provision of aed for International Inbound falling in, the Postal Service is 80 fromzing obtaining the largest flame foreign postal operators, which collectively account for over 90 of all inbound volumes. For example, we have entered into Bilateral Agreements that require aed with foreign postal operators of china, korea, hong kong and australia. We have entered into voluntary data sharing agreements with more than 34 and posts 30 foreign posts for his mentation of aed. To use allowed customs 84 more advanced targeting. Were working with customs to expand this approach to other biases. Iscs. Other the Postal Service does not control the induction of foreign mail destined for the United States, so we cannot control the collection of aed abroad. However, the Postal Service in collaboration with the state department and customs, place a leadership role in advocating for the Global Collection and exchange of aed. Through negotiation and efficacy and by targeting nations with greater capacity like china, inbound aed has grown enormously in the past few years. In conclusion, we share your concerns about americas Opioid Epidemic, and we continue to work with customs to enhance the interdiction of Illegal Drugs and contraband. The Postal Service is committed to taking all practical measures to ensure our nations mail security and provide the American Public the best and most Efficient Service possible. Again, thank you for this chance to testify and i look forward to your questions. Good morning, chairman. Distinguished members of the subcommittee. Thank you for the opportunity to appear today to discuss the role of u. S. Customs and border can Border Protection in combating the inflow of dangerous synthetic opioids, eagerly fentanyl. The majority of sentinel smuggled into the u. S. Is done through International Mail facilities, express consignment facilities or through ports of entry through the Southern Land border. In fiscal year 2016, cbp officers seized or disrupted more than 3. 3 Million Pounds of narcotics. Fentanyl has significantly increased over the past three years. Two pounds a seized in 2013 to over 400 pounds of seized in 2016. Fentanyl is the most frequently seized illicit synthetic opioid. Along the southern border, heroin is often spiked with fentanyl. Fictional is also sometimes spiked with other substances and sold as synthetic heroin. Drug trafficking organizations continually adapt to evade detection and interdiction by Law Enforcement. Cbp uses the same drug interdiction methods to seize fentanyl as it does to detect other drugs moving across the border. But the detection of fentanyl remains challenging because of limited field testing abilities and the variety on the market. In the express consignment of army, cbp can place an electronic cold and notify carriers a parcel needs to be presented for inspection. Cbp is working to implement the same system in the International Mail environment. Together with the United States Postal Service, we have been conducting an advanced that a pilot on express mail and e packets from some countries. He continued to work with the u. S. Postal service. Thanks to the support of commerce, cpb has made significant investments in improvements in our Group Detection technology and targeting capabilities. For exfo, the national targeting example, ther national targeting center, we are able to identify smuggling trends and identify shipments that might contain shipments being diverted for illicit use. In addition to their experience, training and intuition, cbp officers and agents used areas forms of technology and clement to detect synthetic drugs hidden on people, in Cargo Containers and in other conveyances. Data from substances believed to be or to contain fentanyl and found in the mail or an express courier package is transmitted to cbps laboratories and Scientific Services for interpretation. T land ports of entry, we provided readouts for agents and officers. Usually only about 7 of substances at the border make detection difficult. 9s are also a valuable part of our process to combat nakata spewed combat narcotics. Cbp has also implemented a program to provide training and equipment to keep our frontline employees a safe from accidental opioid exposure. Cbp officers are trained to recognize the signs and symptoms of an opioid overdose and administer naloxone, essentially a potentially lifesaving drug. We continue to do all we can to refine our process of detection of fentanyl and other synthetic opioids in the mail and across our nations borders. Distinguished members of the subcommittee, thank you for the opportunity to testify today and i look forward to your questions. Good morning, chairman. Embers of the subcommittee. Me toyou for inviting discuss our work on inbound International Mail. Let me provide some context. We started examining this area two years ago after we received complaints that the Postal Service was not as a gmail to customs and border section for screening is required. After looking into it, we determined audit work was needed. Given our role as the office of Inspector General for the Postal Service, we focused on the Postal Service procedures and coordination with cbp. We did not review cbps operation, but we did talk to their staff together information. Both cdp and the Postal Service provided information used in a report. They consider some details sensitive and requested reductions in the public persons with posted on our website. International mail primarily interest at five Service Centers across the country. It is subject to inspection by the cbp and the Postal Service must present all the mail cdp request. Postal Service Received in 2016, almost half are packages. The growth of ecommerce has caused inbound packets volumes to nearly double in the last three years. It causes challenges for managing the flow of traffic. More than half of the package file you is from small, tracked packages under 4. 4 pounds. Given the growth of International Package close to the Postal Service, there is a need to find more effective ways to manage inbound traffic. Advanced customs data includes details. This data helps with the ofcessing and inspecting inbound mail. International postal regulations are beginning to change in recognition of the importance of providing advanced customs data. The Postal Service can require this data through Bilateral Agreements and makes with foreign postal operators. Audit work found instances of Bilateral Agreements for the Postal Service and not requested this data. The Postal Service has been piloting has had a Pilot Service with cpb. You are using advanced data to target packages for inspection. AndPostal Service and cbp 10 to expand this pilot to new locations before the end of the fiscal year. Issued five reports on inbound International Mail operations since september 2015 and found several problems with the presentation of inbound packages to cbp. First, Postal Service employees sometimes begin processing packages before arrival scan had been input into the system. This could result in missing custom screening or unknown shipments. Second, problems with scanning during processing into and out of customs meant the Postal Service cannot always determine whether package was in cbps custody or its own. Third, and most significant, at times the Postal Service did not present packages to cbp for inspection when requested. Instead, the packages were processed directly into the mail stream. These failures are accounted for several reasons, by several reasons, including human error. The Postal Service and to cbp do not have a formal written agreement about the appropriate sieges. To address our findings, we have made 11 recommendations and areas such as enhancing systems, providing employee training and oversight, improving scanning data, ensuring items are presented to cbp, requesting advanced electronic customs data , andforeign posts coordinating with cpb to establish a formal Agreement Regarding presentation requirements. The Postal Service agrees with these recommendations and has taken sufficient action to close five of them. Six recommendations are still outstanding. Including establishing a formal agreement with cbp. Ensuring the safety and security of inbound International Mail is a critical challenge for the Postal Service and cbp. More effort is needed to quickly fix problems in the current process and make sure cbp receives this much electronic customs data as possible. My office will continue to monitor this issue and we will continue to work with our callings of the department of Homeland Security office of Inspector General on any lidded works they conduct. Thank you. Thank you, chairman. Distinguished members of the committee. I appreciate the opportunity to appear before you today to discuss how providing the necessary data to customs and Border Protection and other Government Agencies can help target contraband and weed out bad actors seeking to import Dangerous Goods and counterfeit items into the United States. Mr. Chairman, my presence here today, the thursday before memorial day weekend, is quite literally deja vu. I provided similar testimony on this very same day 17 years ago. , to thehe year 2000 house subcommittee on criminal justice, drug policy and human resources. The hearing then was titled drugs in the mail, how can it be stopped . I was asked to do the same thing, walked to the process in ups follows to provide advanced data to cbp that allows them to screen for highrisk passages. Unfortunately, since 2000, the problem of importing of goods into the u. S. Has only grown worse. Enable the internet, that actors are getting smarter and smarter, using every avenue available to send illicit goods into the u. S. Back in 2000, the issue of illicit drugs in the mail was centered on amphetamines and accuracy ecstasy. Today it is extended to fentanyl and hightech opioids. Volume has increased substantially, particularly from foreign posts, which now send on this tiny percent of all packages into this country. Ups delivers more than 19,000 packages every day around the world. We work hard to the united problem solvers. Our business processes are complex and our technology advance. We also work closely with cbp at our own expense to comply with and even exceed existing legal requirements. The key to making this work is the advanced electronic data we provide which enables cbp and other Government Agencies the target highrisk inbound , andents and screen sometimes that is as much as 36 hours in advance. This data can also be used to screen for counterfeit products and contraband, another growing problem. We also apply technologically advanced Network Capabilities that enable us to locate any suspect package in our system at any given time so that it can be retrieved and tendered to legal authorities for additional screening. In 2000, when i testified before the house government oversight committee, there were about 21 million package shipments entering the u. S. Annually. About 10 million through the private sector, which were accompanied by advanced electronic data, and 11 million through the International Mail system, which did not have any electronic data. Even 17 years ago, it was clear that cbp and other federal agencies cannot manually screen packages purely because of volume, and the most effective interdicting bachelorettes is through advanced electronic data. In herume of packages and the u. S. Has increased many times over. In 2016, 4 post entries and over 400 million packages to the u. S. And the volume is rapidly growing. Weve been using advanced data for years, even before it was wired to the trade act spirit required by the trade act. Bob and i have worked on these things for close to 20 years. On each andetail every shipment entering the country. This reduces the potential for Dangerous Goods in her and the u. S. It is also important to note that ups and other express carriers obtain data for all Foreign Countries, both developed and developing. I could take up my smartphone, because even in the most places, take a picture of it and transfer it on like that. Offonclusion, if i can take my ups had for 30 seconds, i do a lot of International Travel and work with customs agencies around the world on this very same issue. When i board a flight back to at u. S. , i dont look around passengers looking for suspected terrorists. I think about the banks and backs of four post packages loaded in the belly of the aircraft. No one has any idea what is in those packages, none whatsoever. The government does not allow passengers on a plane without personal information or package your country without a passport or screening. Over a million and potentially more dangerous packages a day into this country was no requirements for information that will allow cbp to do the job more effectively . I urge you to take action on this important issue. They do. Thank you to all the witnesses. Senatorenter has carpenter has agreed to delay his questions. To ask an opportunity are questions. And appreciate that very much. Tell me about where we are as far as moving on advanced electronic data and why for developing countries this has taken so long when there are some straightforward solutions. If they can get the mail to the spot to get it out, why cant they get out . Thank you for your question. We have been working very movely with the upu to this process along more quickly, but the issues we face in developing countries, i would say previously, there was a lack of will and elective understanding with them to catch up with their Business Models and take part in the ecommerce boom. There wasnt an understanding that aed was the key to that. I think the major advance we have made is not a statistic but a change of mindset that country is now understand that regardless of their level of development, they have a lot to learn and gain, and can even enhance their economies are taking part. The encouragement from the congress would be at some point to say packages dont come in without it. Obviously that isolates a lot of countries and a lot of people who may not be able to get materials in. But the most straightforward way we can do with it is just to put a deadline out there and say we dont allow packages to come into our country in less there are some electronic Data Collection in advance. Thank you. As i described in my testimony, the global postal system simply isnt able to exchange aed conference of the at this time. Requirement to do so immediately as a precondition to our accepting its mail, it would severely restrict the inflows of mail into our country, and probably preclude the acceptance of mail covered by a Bilateral Agreement. If we stopped accepting other countries mail on short notice, we have to anticipate that many would stop accepting our spirit i would be surprised if anything that congress could do on short notice. But i would assume that we would set a Firm Deadline to say, by the state certain, this is not being negotiated in the days ahead, this seems to slip your after year. My concern is how do we get a date certain that is sitting on the horizon that we know it will be resolved, at least for this, because this is just one element of trying to be able to stop the Alyssa Milano of drugs in. Clearly, most to stop the illicit movement of drugs in. This is only one element to be able to help deal with this. It should be a straightforward element. I agree that it should be straightforward, i think the that othere face is countries just are working on other timetables. I think weve made good progress. Again, i think the question of their own deans phone needs we now understand. Halfpu is putting forward of its Corporation Budget to helping these countries install the capabilities they need, but electricity and the internet are not available everywhere. But in countries where there are. We are still dealing with germany and france, the last i heard they have electricity. We can go on and on, but this should be straightforward. For us, we have to be able to get this resolved. Let me ask a separate question. Customs and Border Patrol and establishingked on consistent methods of how they will exchange data. How is that working right now and where are we in the process of getting a clear and will you of exchanging mou of exchanging information . Regarding general operations, when and how that functions at our International Mail facilities and how it is , with cbp, we expect to get that back within the next two to three weeks. I caps on that just before we got here. I appreciate that. Weve been waiting for that for a year. Indy. The indeed. Mou puts in the place how the mail is handled, coming from countries of interest, not aware that it specifically gets into the details of the electronic data. That is more so under the confines of the pilot itself. A comment on that . I wanted to add on to what was said. It has been a year and we have been working and we do it at each one of our iscs and we make sure that the processes and procedures that is put in place, we have been working through this. Ot just in waiting for the mou for we are certainly glad we will have it back in a few weeks. A semigets finalized fairly rapidly after it comes back in. Yes, you can assume that is accurate. Great. Operation and it will increase efficiency in the process. On the Inspector General site, tummy where we are as far as the things we can provide the greatest oversight on to make sure they get checked off from usps. Itemsve us a good list of that are being works through, top items for congressional oversight, what would you lift . List . Is criticalhe mou and the encouragement to work these Bilateral Agreements with countries to receive data, i think there taking the process progress. When we first started our work and mr. Cintron nottioned it, there was much data available. Significant progress has been made in the last two years, but it is one of those things we have to continually work on in a short every Bilateral Agreement has been determined in it. Those are two things that i would encourage. That weld only say appreciate the diligence and focus on this, it has been seen and noted already for commercial entities. This is been something they have been very persistent on for a while. Obviously they have a more seamless networks, they are not receiving every single package in every single country. But it is a system that is achievable in the process. I would also note for customs and Border Patrol, we appreciate very much the work you are doing. It is incredibly dangerous work. As was already noted by the chairman in the Opening Statement, even the smallest amount to gets on and individual as they are doing inspection is a life or death issue. From our committee to all of your team, we express our gratitude for what you are protecting american citizens from. I feel back. Thank you. Thanks so much. Sometimes we have a Diverse Panel like this, but people that are highly knowledgeable about a particular issue we are trying to address, i asked them to help solve the problem. Today to to ask you help us solve the problem. I will ask each of you, if you do nothing outcome of do at least this, this committee. Tell us one thing we should do right away. Tony becausell you of jim tommy, the great is the player. Great baseball player. Tommy, for god sakes do this. I said earlier, this is all hands on deck, it is all hands on deck. We trying to convey a sense of urgency. When we go home, the folks we represent convey a sense of urgency. Thank you very much. As we have talked about, this is a difficult problem that needs a lot of solutions, but in terms of the remit of the state department in our interactions with the upu, as i said before, were turned the corner with the countries that want 80, i think well all have to Work Together to give a realistic timeframe. We have an epidemic here that cannot wait years and years. But with the momentum we have, i would say since the 2012 upu congress, it has really accelerated. Countries want this. If they find themselves in a situation where they have a , we run over the head the risk of losing that momentum in that it the mail shipments are stopped or threatened to stop to the United States, that could have devastating effects on the economy. Give me one takeaway, one thing we ought to be doing to move it . I think if we put our efforts behind what tp was doing and keep that moving along with the efforts bilaterally that are happening, we can make it happen. All right. Give us your advice. What can we do to get this moving . Opinion, irsonal think the actual forward is on the right track and it will move this forward. It will we need to craft it in a way that is we listed get them with countries we cant order to do things that we need to negotiate and help them see the benefit. Mr. Cintron. There must be some way to incentivize these folks. Thatially the nations start doing their share. Theyre not work third world nations. I would say our strategy, focusing in on targeted countries. We understand that part, only look at the whole picture, and strategies to say focused on the receive the largest volume coming in. I think that is where we are looking for that cooperation. To take that step was noted here, one of the concerns is some of the conditions we might find in some of these other evolving countries. For us, our strategy really is to be stay very is to be staying very focused and prioritize. Doing that, and with the pilot at jfk, we can push the salon. Answerent action my question. What does Congress Need to do to expedite this . What do we need to do . One other thing i might ask is a certainly run the passages conference of postal reform for us. You are a lot of things tied up and that, in anything you can do to help us with that regard helps us with everything we are doing. One of the things weve been working on for a while as you know, we want to have additional thatl revenues in order they can, among other things, modernize Mail Processing centers. They can buy new equipment, new vehicles for delivery and modernize post offices. Sounds like this might be another need for revenues for the Postal Service. That is a good takeaway. Mr. Perez. Good guys for us advice for us . For your say thank you ongoing support and everything n the entiretyi of what we do to combat illegal or chronic trafficking. That is what i would ask, that that support continues. Cdp, friendly, we are not waiting and dont wait for the evolution of the different types of threats and enhancements we need to lean forward and do everything we possibly can to interdict, to detect, deter and dismantle those who would do us harm in this fashion. So whether we are talking about that or talking about all the technology we are trying to deploy and even personnel, that ongoing support that this body continues to provide cbp and overall drug mission is absolutely critical. Thank you. Same question. I think focusing oversight on movesng that the mou toward quickly, and i just heard that the mou does not cover the Pilot Program. I think that pilot, there is lots of Lessons Learned through the pilot, but expanding the pilot quickly across the country to the other International Service centers so that the data that is being received from these countries can be used to target specific and dangerous packages. Oversight in that area. We have a second i want to come back and talk about the pilot and those Lessons Learned. Last witness, please. 17 years ago today. Past the stop act. The reason i said that is because we discussed the 17 years ago and nothing tangible has changed. It is moving at a snails pace. We think the right way is to pass the legislation. The fine work is been done on that. We have worked with cbp for years before the trade act and i dont know how they do the job they do on the mail. We have our own challenges with all the data, we are talking about a minimum. So pass the stop act. So, i understand that first of all, think all of you. We are all hands on deck, as was said. This committee is busy doing an investigation into another piece of bass, which is the sales and marketing technique that is been employed by the opioid manufacturers. We are also going to be looking at the distributors in terms of that issue internally in our country. I want to focus my time on the fact that we are having some of this fentanyl produced in china sent to the United States, where then it is sent to mexico. Are you all aware that this is commonly occurring . That we have a large amount of opioids are moving through our country in that regard . Does anybody disagree with that analysis . If i can comment, i would share that my understanding is that much of the fentanyl coming out of china, wen in its actual form, will come directly into the u. S. What we have seen that moves m china typically into the into mexico, they are diluting it and lacing harrowing with the fentanyl heroin with fentanyl. Moving directly from china into mexico. Not aware at this current time of the movement southbound from the u. S. And mexico, but i will gladly take that back. Ed at staff has look this and believe there is a significant amount moving from china to the United States, the precursors, and going from the united dates to mexico for them to process in their lap. Lab. Ir if you dont have that information that is accurate, i am worried. I think it is really important that we understand where this is flowing. Mr. Cintron, would you agree that you all believe that some of this is coming to the United States and then being shipped to mexico as a precursor to be used to cut heroin . I cantecifically specifically respond to that, but the inspection part, i can provide you information on th at. It mail fromnd china is not covering the cost to handle this mail, is that correct . But i wouldze, certainly ask your permission to provide any of that information after the hearing. Once again, my staff tells me that we are underwriting, the United States Postal Service is underwriting the cost of mail coming here from china. That just seems crazy to me. . Ow the world is that happen unfortunately, i am not able to answer that specific question, but i can provide the information after hearing. We are obviously struggling to keep the Postal Service out of bankruptcy. It is one thing to be getting fedex deal on last mile of delivery, which ive been railing against, but if we are making it cheaper for china to use the United States Postal Service, that is really outrageous. I am anxious to get to the bottom of it, so if you would follow up as quickly as possible, we would appreciate it. Absolutely. For the trade act, it is my understanding in terms of the private deliveries that they are not actually they are supposed to be having the information on the packages they send. Address of the recipient coming from other countries. I understand that many times all thinking begets is the address of reprocessing facility where it is coming to and not the address of the actual recipient. If that accurate . Is that accurate . U. S. The context of the Postal Service, the general mail, that is true. That is the type of information were trying to get more appeared im talking about the trade act requesting the name and address from the private carriers. Has that been fully implemented . Are we getting the address and recipient from not from the Postal Service, but from fedex and other private carriers . But imy knowledge, yes, would take that back to make sure we can confirm that to you. From a commercial entities and carriers, we tickly get pretty conference of information comprehensive information in advance. Informationn, my based on the staff preparation for this in the preparation i have done is that in fact, they name androviding the address of the recipient, and that many times are you get is the address of the ups or fedex processing facility where the package is coming. Know whyeally like to we are, why my information is different from yours. The other information i have is that we are not even imposing fines the need to be imposed on the carriers who are not following the law. By the way, this is the trade act that was imposed after 9 11 when we were trying to get after the security of our ports and entry ports in terms of our country, goods, people and services. I will be anxious to hear do followup about that. Phase three of trade implementation was supposed to be penalties for the that description. It is my understanding phase three has not been committed. Does anybody know the answer that question . I dont have the details on phase three. I will gladly take that back and get back to you. Ok. Getting thet address of where the package is going, and were not finding the carriers, fining the so we can see if this is an address that has popped up before. If we are not getting that and we are not even knowledgeable about whether we have implement the part of the long where penalties are enacted, our Research Indicates that sometimes penalties have been imposed but they have been negotiated down i the carrier lawyers thousands of dollars from thousands of dollars to 50. If that is a problem, it is a huge problem. I am a little worried. Have the answers to these questions at this hearing. I look forward to getting the answers as soon as possible. That fromy respond to a ups perspective, we have been providing that information, full shipper, thef the consignee, description, value and country of origin since we started bringing International Import into the u. S. In 1985. The program we developed with cbp. Weve gone well beyond the trade act working with cbp with the air cargo advanced screening process, which is a voluntary program that was implement it after the attempted yemen bomb attempt where we not only transmit the shipper and consignee, we transmit multiple signee when it is multiple international transit. We go beyond the requirement. In your opinion, has faced three been implemented . Whatever the penalties apply to you if a package came to your company that did not have the address of the recipient on it . The answer to that one is i dont know how we could not because our process and systems are developed that a package can enter our system and the set information has been entered in their and it cant move through, because our systems interconnect between ups and cbp. Practically speaking, it couldnt happen. Up and go follow forward from there. Thank you. Im going to ask my questions now and we will have another round. Have another colliculus joined us. First of all, we have another colleague who has joined us. As of all, i think we need to backup to what this committee is about. It helpful to have advanced electronic data to identify these packages that have the us this poison in the, which is what were focused on today, synthetic opioids killing more and more of our citizens every day. Do you want to have that advanced electronic data, and is it helpful to you to help stop this poison from coming into our communities . Yes or no . Unquestionably, have any advanced electronic data is a key tool in our ability to manage and assess risk. Focus and target those threats that may warrant greater inspection, cargoes, people, conveyances of all types. Unquestionably. Having that data in working toward getting that advanced data, and making sure it is of high quality and reliable for us to do that work is a highpriority. Its the reason we are working so closely with our colleagues to get to that point. Otherwise it is like a needle in the haystack. I work with your folks back home, and they use the same words you used, it is a tool, and it needs to be effective. We are focused on a crisis. I appreciate the state Department Perspective on diplomacy and try to work with other countries and i really appreciate you saying you think the stop act is on the right track, but this notion that other countries are working on their own timetables and some countries dont have electricity china has electricity and we know where this stuff is coming from. Some of it is also coming from india, they have electricity. And mr. Ion, i will say, cintron, i understand your concern about having to apply this to all countries and you noted in your comments you prefer to be targeted to countries who known who are known to send us this poison. Let me follow up on that a little bit. We talked about this yesterday, we are working on this issue of countries that circumvent our trading laws. A simply shook the product to another country. Why wouldnt that happened here . We are only going to target a few countries of interest, why wouldnt they just shoot through another country like vietnam or malaysia and still have the poisons come into the country . Can you answer that question . Is to focus and strategy prioritize the list feared take a look at it, make a risk assessment, and target those particular countries. The Inspection Service working in collaboration with other Law Enforcement agencies, i think is probably the other key. We shareborate, information, it doesnt this occur, then we refocus and do that. The point is, there is a starting point. Where is the highest risk, where we see the highest volume . To your point, those particular capacities that have that, we should be focused on them. Unfortunately what we have seen is there is shukman of the stuff and it will simply to be shipped was something be shipped to other countries if we dont have this broadly applying. You noted earlier, its voluntary. I guess i would ask, do you have enough data . Your answer is going to be no, because you would like more advanced electronic data from foreign post. It is timetion says to follow up on what Congress Passed 15 years ago, which was charge,hen secretary in , and theand security Postal Service and the commissioner to come up with a plan. Testified 20 years ago. I would just make the point broadly that we do have a crisis, we are volatile much that, and this is not business as usual. If other countries are working on their own timetable, that does not work. That dog dont hunt. It is an epidemic. Something that was interesting, advanced electronic data is in their interest, too. Amongis a consensus now the countries around the world that they need to provide it. Get moving on it. Another question i would have is for mr. Perez, you talked about k9s. I asked the same questions of a colleague of yours about a year ago, and i was told that sniffing dogs dont work because they could die. What is the situation with monitoring generally and supportg many of us more funding for inspection, but specifically with regard to k9 s, does it work . We are currently in a test phase to train the dogs for the specific order. Specific odor. Theyre trained for a number of ors. Otic od they may detect or be able to ,lert to some of the opioids but we are specifically training them in a very safe way with the types of odors generally admitted from fentanyl and such. Not with actual fentanyl that our laboratory folks make sure we are doing in a safeway but enabling that tool but along with the other alleged tronic tools at our disposal, where we are actually to determine whether or not there is a presence of fentanyl and other opioids. I would like to think it could be done safely. And the gloves they could put on. I suspect there is a huge danger to them, much better to have targeted packages where you have reason to suspect a package. Absolutely, mr. Chairman. Have you talk to somebody about the Pilot Program, about the lack of coordination between the Postal Service and the need for understanding and a written agreement you said is necessary. You said you had 11 recommendations, six of which are still outstanding. The said we should expand this pilot quickly. You think the stop act would help to expand that pilot quickly . We did look at the legislation. Iledid not do a deta analysis. We are supportive of increasing the amounts of advanced electronic data. However, the impact of that on the Postal Service is something we have not done a Detailed Analysis of. We do believe that, as we said in our statement, that Additional Data would be really helpful and i think the pilot is moving that direction as well. Again, that is what the stop act is about, making that mandatory and moving away from just making it a pilot, and making it mandatory. Quickly to you, and then i will turn to my colleagues. You talked about having testified in 2000 on this, and the fact that you get your data advance. Pb 36 hours in that gives them time to respond to it. Tell us how you do that. How do you do with the post office has not been able to do over the last 15 years since the trade act. Thank you, chairman. It really starts with the collection of the data and it depends on the size of the cuts. But for the large multinational, we have software and direct interface with them, but even for the manufacturers that walk we get thes stores, information into the system immediately. As soon as the package is picked up, that is what is the indicator and every 15 minutes, our system automatically bp, so we can get the information to them as early as possible, and that was part of the collaborative effort. From the business side we have a shared responsibility to do that. Depending on what is going on with the shipments, we communicate back with what is going on, our principal and foundation of what we do for cbp, is, lets get the data to you as soon as possible. There are a couple transmissions that get a little technical, but it is a very good process. When the packages picked up, the 47 Law Enforcement agencies have access to it. Chairman, can i clarify . Yes, i want to get to senator hassan. If you dont mind, we will do a second round. Thank you, senator portman and Ranking Member for participating in this subcommittee and for your leadership on the stop act. I do want to take a minute to atco senator harpers reminder that while he are focused today on the supply of illicit drugs and especially, the precursors fentanylnthetics like k that we have to continue to focus on the demand side here at home, which is why Medicaid Expansion is continuing work to make sure people get treatment and we are working on prevention as well. As you all probably know, New Hampshire is one of the states that has been hit hardest by the Opioid Epidemic. Last year, 70 of our Overdose Deaths involved fentanyl. 80 so far this year involved fentanyl. We are seeing an analog of fentanyl and in the last six weeks or so we have seen six deaths from carfentanil. To echo what my colleagues are saying, everywhere we go we are talking to people from all walks of life whose lives have been taken or ruined or impacted. And it has drained on not only our lives and communities, but our economy as well. Cus for just a minute because in my last meeting with the dea at home, they recounted to me in very graphic and vivid deatitails how dangerous fentanyl and carfentanil is for our Law Enforcement and First Responder personnel. That extends to people who could be handling these substances through the postal system. We know you can overdose by touching this stuff with a bare finger, or breathing it in. Carfentanil in particular has changed the way Law Enforcement verythingg with e about the way they enter a suspects home to a cvrrime scee afterwards. We dont want to put their parties like you at risk. Let me start, what has the Postal Service done to address employees, to usps and how can we both protect our workers who make sure that Law Enforcement has the tools that they need to investigate and crackdown on the supply of these synthetics . Yes, senator. The usps has over 600,000 employees. So, from processing to delivering the mail, transporting the mail, all of our employees are involved. On a regular basis, whether it is at International Service centers or other processing centers, we do a lot of training with our folks around hazardous type conditions. We have seen tragedy in the past in this organization. We are very well aware. Of what that could do really is to constantly and consistently train employees and we do the same for our Inspection Service, ourh does a lot with processing facilities as well for oversight and investigating and addressing issues we find in the mail. Thank you, and i will ask mr. Perez to comment. You discuss steps cpb has taken to address this. Could you talk about the balance here . I know of an agent in New Hampshire who did everything right. She was all masked and gloved, and she took off her gloves to handle the suspects cell phone and she overdosed, brought back by multiple doses of narcan. I am very concerned about it. Thank goodness, senator. We began an 2015, very comprehensive training and instruction that was deployed to all our frontline officers and agents, people who could potentially come into contact with these substances. They went into great depth on the proper handling, what they needed to wear if and when they contact a parcel or person of any type, where they believe the presence of these dangerous opioids may be. In addition to that, we began our Naloxone Program as well. We have had those countermeasures to put in over 34 locations now over the last two years. Those locations include all the busiest express consignment facilities and the locations along the southwest corridor, where we see the most trafficking with these types of opioids. The last point i will make in addition to that is we have deployed over 600 doses in narcan, in addition to the naloxone throughout the country. As a side note, the officers and agents that are typically trained in actual utilizing these are ems certified cvp officers and or agents. That is pretty much what we are doing and we continue to make sure that that training, that awareness is ongoing and that we do absolutely everything we can, particularly with the uptick in our encounters with these drugs. I will ask you to answer the same thing. Obviously, the concern here is if for instance, Law Enforcement thinks they are putting their parties at risk through certain kinds of undercover operations they will stop doing it. We need to be able to continue investigations. It is helpful to hear that training is ongoing, but how does ups address this issue . I will be honest with you. I really dont know the answer, but i will get back to you on that. Yes, its just now, there used to be certain kinds of undercover operations that i think Law Enforcement has taken a look at because of the risk to people handling a package they might not know has an illicit and deadly substance. So, it would be great if you would look at it. The one other thing i wanted to ask, you discussed in your testimony that fentanyl and other synthetics are bought onli ne, both on the open web and dark web. So, what efforts are being made internationally to crack down on illegal purchases of these synthetic drugs, and the precursor chemicals that are used . What is happening internationally . The state department is engaged in extensive negotiations with countries that we feel are sources for these kinds of things. I cant give you a comprehensive answer across the board, but i did talk with our bureau of narcotics and Law Enforcement and they did give me information on what has happened with china, which is of great concern. I can share that with you. In response to recent u. S. China hasla to mystically controlled now drugs,an 134 synthetic including carfentanil. This is an advance we have made in getting them to see this. Chinas decision to domestically control, for example, carfentanil, which has caused deaths in the u. S. , is a welcome measure and we hope we could continue working with the chinese. In many cases, the chinese argued that these are not causing problems in their country and we have succeeded in convincing them that even if that might be something they claim, they are causing problems in our country and we want them to take measures. We continue the process. There is a lot of work left to do. But we have had that successful step. Thank you. The packages are dropped off at a ups facility, whether it is here or at a foreign facility, youre able to track those with a code to electronically track and share information with the board of protection and that is your system, correct . That is correct. Ok. And the Postal Service, tell me why you cant do the same thing . With inbound packages coming in, so foreign shippers shipped through a foreign post, they are given to the ups. We do not have that direct connection. So, the state department, why cant we require that from the shippers in Foreign Countries, the equivalent of their post office . Well, as my colleague from said, unlikervice the shippers that control both ends of the transaction, we dont control both ends. But why cant we tell them that they cant utilize our post office unless they hvae an electronic tracking number on it that we can track and share with baloney. T down on this this organization is based on reciprocity. Do we do that for them, by the way . Do we give them electronic tracking if they request it . We have offered and we certainly would like to be able to share data with them. So, heres the problem. The Ranking Member and the chairman talked about the fact that we have a problem in this country and we have got a problem in this country. I get it. They dont want to do it. I dont want to do a lot of things i am told to do. So, why dont we hold a ceasefire . Would have impacts on our country . Yeah. But i am here to tell you that not doing it is causing economic impacts. Is there any way that people could roll up their sleeves and say, we have people dying every day in every state in the union from this crap, and it is time to say enough . Mr. Senator, i would argue we are doing our level best to hold their feet to the fire and to demonstrate to them have you told them . Is the threat you have made that you will not ship through the Postal Service . We have not made that specific threat. It would be outside of our treaty obligations. It is not a threat. It is a reallife situation. Look, we cant pat people on the back and say please, but that has not worked. Theim not in negotiations, so i do not know what you are faced with, but i do know what we are faced with in this country. This is costing a pile of money and ruining a lot of lives. I would encourage you, the next time you meet to buckle down and do it. Doerwise, we might have to something draconian at this end, and im not sure we want to go there. I take your message, senator and we are working very hard to demonstrate the urgency. I appreciate that and it is not at you. I appreciate you will being here, by the way. The Inspector General, that might be you, came up with some audit reports on inbound International Mail to the Postal Service. These are questions for you, mr. Cintron or perez. There were 11 recommendations and five of those have been closed. If my math is correct, six are still open. One of the recommendations with the Postal Service better clarify inspection of packages. Why arent we doing this . Speak,ier today we did my colleague mr. Perez indicated that within the next three weeks u sitting at the mo the customs part of production. It will be tendered back to the Postal Service. They will then get that hammered out and get it in place as soon as possible. Just to reiterate for the record, we have not waited for the mou. We work collaboratively with some people locally to get these things in place. I appreciate that. Do you agree with that mr. , perez . That is in effect caught a find as many of the best practices and procedures that are already in place with the International Mail facilities around the country. If i could, mr. Chairman, when you get that mou signed, could you give a copy to the leadership of this committee so we know it is done . We can provide it. Thank you. One more thing, and this goes to mr. Cintron and mr. Perez, or mr. Woulitcomb. If the legislation required for you to take swifter actions to prevent these poisons from coming into this country . Anybody can go . Mr. Cintron . Could you repeat what our time. Do you require further be able to taketo swifter action from preventing these poisons from coming into the country, or do you have enough latitude with the rules on the books now . Legislation that is needed for you to be able to stop these drugs from coming in is the question, or do you have the latitude today . I defer to the state department. Answer. Ms to maybe mr. Perez . Senator, we are very comfortable with our authority. Nevertheless, i would continue to emphasize the unquestionable efforts tofurther the get advanced information. Do youwitcomb, i have anything to add . The timing of rolling out this pilot is critical. I would just ask that if you have any recommendations that need to be changed within the code, dont be afraid to tell us. It would be helpful. Thank you all for being here today. I very much appreciated. Senator daines. Thank you, mr. Chairman. People in ohio and his country would have been proud of what i saw six weeks ago. I was in the chairman in beijing and we had meetings with the chairman in china, the chairman of the mpc. Number three in charge of all of china. Followed by a meeting with the premier. Veryr. Chairman, you were direct in asking for the help from the Chinese Government at the very highest levels to deal with this issue at the source of fentanyl and carfentanil. Thank you. I saw that behind closed doors and thank you for your leadership that extends and influences beyond this country, but around the world, to stop this scourge. Thank you for testifying today before our committee. Homeecent years in my om state of montana we have been facing a meth epidemic. I realize this is something that started with the opioids and has worked northeast across the country. It is in by sky country. Largely, the import of meth is coming from mexico. It is showing the somber signs of the drugs widespread presence. The montanaof 2016, department of justice issued a report that there were 14 children that died in our foster 11 of those 14 children died as a result of Household Drug use. And four of those were specifically linked to meth. That is not the way you are supposed to grow up with a child in our great state. In addition, the Montana Department of Justice Division of criminal investigation has 2015 ance 2010 to tripling of the number of cases they are addressing that relates to meth. Meth has left its mark on montana through increased incarcerations, increased deaths, heartbreak and in straining our Community Resources to keep up to stop the importation of meth at its sour ce. It will go far to begin the healing process in states like montana. Mr. Contron, in your written testimony, you mentor that from the use ofesent, electronic data increased from approximately 1 to 40 to 50 . I know in montana mexico has specifically been identified as an overwhelming source of meth. The question is, what countries have been either collaborative or particularly unresponsive in sharing a advanced electronic data . The second part of that, has mexico been at all helpful in providing the necessary data . Yes, i could provide that information post the hearing. We have many countries we have agreements with. We have out the four bilateral. Many other countries where we are receiving electronic data from that make up that 40 to 50 , but i could certainly provide you with written information after the hearing specific to mexico. And maybe zeroing in on a couple of specific countries. You mentioned mexico and china that are the largest sources of illicit drugs. Have they been responsive in working towards the universal postman unions implementation date fo universallyr providing advanced customs data, or other just grasping at the air on this one . As it relates to china, and i can provide better data. We are think substantial data that comes back from them. I could certainly provide you with that information after the hearing. I would appreciate that. Thank you. Mr. Schink mentioned in testimony that the ups delivers more than 19 million packages and documents each day while providing the advanced customs data. Could you share mr. Schink, one, how many packages containing illicit drugs are removed from delivering by cbp due to the use of advanced customs data . And number two, what percentage might those packages represent . You, senator. For that, the reality is, we are not perfect. We would like to say no bad people are going to use our network, but they certainly attempt to do that. Unfortunately, with the information we have with sharing information, we do find ways to interdict and we do have occasional shipments. We had several shipments of fentanyl over the last year that were seized by cbp. A littleo had actually bit more in terms of numbers of shipments of meth that was mentioned earlier that gets seized with that. In terms of percentage, it is miniscule. One of the reasons we would hope that the bad people dont try to use our network is because of all the programs that we do and actually what we were talking about here was 101 quarter level stuff with that. Plus, our ability to track and trace and work with the local authorities, which we do on investigations. Cintron, to have an idea of the estimate of packages under current practices that are flagged because of illicit drugs . I would have to do for maybe to mr. Perez to answer. I would have to defer maybe to mr. Perez to answer. I could provide you the data after the session. It is a very small percentage, but we can provide that information after the hearing. And small is less than 1 , less than 5 . We dont have that, but i will provide that. Tjhank you. Let me close by saying, i do believe the most effective way to end the meth crisis in a state like montana will be cutting off meth at its source. Yes, well got to work on our demand issues, but we can Work Together here on source. We need a collaboration between bp, and our foreign post stakeholders. And if our foreign post stakeholders decide not to cooperate, i think we need to take stronger action and put America First in this equation. Thank you, mr. Chairman. Thank you, mr. Daines. Thank you, mr. Chairman for taking on this issue. It is critically important. I remember a conversation we had last congress. The dea was in the room and when i suggested that they may want to use drug dogs to detect fentanyl packages, the dea told me that would not be wise given that if they could smell it, the dogs would die. We are dealing with an incredibly dangerous material. And this is moving to the Postal Service and every postal worker who touches a package is at risk. And so, i think this isnt just , for the Postal Service is not just about processing and getting things through, but it really is an issue of care fo ryor your employees. I wanted to raise that. Ms. Witcomb, we know that in your testimony, your audit work on the Postal Service have the ability to request advanced customs data under several Bilateral Agreements, but opted not to do that in certain circumstances. Why did the Postal Service make that determination and what would you recommend in response . Most of the bilaterals that did not have these requirements in them were older Bilateral Agreements. More recently, the negotiations on bilaterals have included this requirement. I believe it is more of a timing issue and a recognizing of the importance of this and overtime i think it has improved over time, i should say. But some of the ones we had reviewed that did not have this requirement where older Bilateral Agreements. Might know aon little bit more about the direction the Postal Service is taking to include this more consistently in the Bilateral Agreements than i do at this point. Yes, and this is for anyone on the panel. It appears one of the arguments being made with regards to the Postal Service being able to utilize the system, similar to the system that has been outlined by private shippers and carriers of the cost issue. I understand other issues also complicate equalizing the shipping requirements, but cost processes and technology seem to be a factor in the Postal Service claims, which are inhibiting their efforts. Is this an accurate statement . If so, how do we bring down the cost of compliance and technology . Is it possible to look at prioritizing the advanced electronic data, upgrades to a system with foreign shippers and under the current method you are using to try and address the situation, how long do you think it would take to get Foreign Countries utilizing higher ra tes . Do you have any plans to have that discussion . Maybe we could start with you, mr. Perez. Through the Pilot Program that we had, senator, with the u. S. Postal service, we are currently getting advanced electronic data from several different countries. Specifically the pilot in jfk has to do with both china and france. We will continue to focus on the and work alongside our Postal Service partners to see you know, what else we could do to make sure we are being able to not only utilizing get that advanced electronic data, but nots our efforts to expand only the volume that we are able to apply, but the quality itself so we can make better and more informed decisions on where we need to focus our efforts. Yes, and i wanted to clarify more on the point earlier. Certainly one of the things we will be looking to do is expand that part of it. That is where those costs come in. The Technology Part of what we can do on our side is a little bit different in regards to aed once we at the data itself. I dont want to prolong this, but if we were happy to which the speed with which the u. S. Postal service was dealing with this issue, you will would not be here. This is not moving fast enough. We see these drugs coming in. We have had numerous deaths in my state because of fentanyl abuse and we know the delivery point of the United States Postal Service. Other point to point in this , the recent investigation and prosecution regarding fentanyl moving in the mail from portland, oregon, but it originally came from canada. This is serious stuff. And it needs to be addressed and we need to have a plan it seems to me with detailed timelines and if resources are a problem, we need to know that. If there is a legal problem with the bilateral, or with the agreements, we need to know that. If there is a resource problem, we need to know that, but we have got to stop jeopardizing the lives of people who move this stuff, whether it is at the post Office People who come into contact with the package unwittingly. But we have got to have a plan. And it is frustrating because we address this last year and the year before. I think im hearing the same things over and over again and pilots are good. But they dont give us a plan. So, i applaud the chairman and Ranking Members for bringing this issue to the committee. This is something we are going to be serious about in terms of oversight and moving forward. With that, mr. Chairman, they yield back the rest of my time. We will not do a very quick second round, lightning round. I agree with my colleagues were saying, that we are not moving fast enough. Let me give you a specific example. A letter was sent in april of 2016 to this committee. In that letter it said, the plan to expand the jfk Pilot Program from china to the Los Angeles International airport is scheduled for the summer of 2016. We are now in the summer of 2017. Has it expanded . It has not expanded no, it has not. Heard what would happen with regard to the universal postal union and with all due respect to our International Partners and the u by 2018,it get done 2020, or 2022 . They keep pushing it back with respect to advanced electronic data. If we did not have a crisis in this country, we could go along with the normal routine, which is as i said earlier, other countries working on their own timetables. We cannot afford to have them work on their own timetables because our people are dying. The question i would ask, is how many more americans have to die before our government gets its act together and makes sure the pilot is working, makes sure it is expanding as it promised, and we are doing everything we can to keep this poison out of our communities . Admittedly, there is not one silver bullet. I will steal a line from my Ranking Member. Everyone of you have acknowledged this silver bb today. My hope is because of the hearing we can move more quickly on this issue and we can get the legislation passed to get you the additional 30 i think you need. Ther. Perez said, to have tools to identify the right packages, to go after them, to stop some of this poison and increase the cost on the street, because right now this stuff is so cheap and so deadly that it is killing more and more people. Still here from the next panel about what is happening in our communities and what is likely to happen this year as compared to last year. The summary is more people dying. Thank you all for being here. I turned to my Ranking Member, mr. Carpenter. Thank you, mr. Chairman. Have of us on this panel worked on postal reform legislation. We have focused on increasing the revenue of the Postal Service so they can replace vehicles that are 25 years old, so they can modernize Mail Processing centers, which are not designed to handle large packages or parcels. Provide those revenues . There is another reason the Postal Service needs revenue. It is to be able to do their job, a better job, with respect to intercepting these highly toxic chemicals. And we are going to use that and remind our colleagues why it is important to move on postal legislation sooner rather than later. This is one of the reasons we need to do that. I want to come back to the pilot. Take me through the pilot, if you will. It is jfk, right . Yes. Why are you not spreading the pilot to the other, i guess, f our other destinations . A couple things. Let me explain the pilot itself. They started in mid 2015. In the recent two months we have made improvements. We eliminated the manual handling of the product itself, right . So, we get the advanced electronic data and provide it to Customs Border protection and they provide us with a list of what they want us to extract. We were doing that in a manual fashion in terms of identifying what we need to do to extract those pieces. In todays environment, when there has not been any expansion, there has been improvement significantly to outfit the process and equipment. We worked very closely with the Inspection Service and our engineering systems and are able to do that on our processing equipment. Things thatey will happen with this it will be on equipment at jfk. We also connected to downflow facilities that are connected to jfk, so we are able to track those now. We do this very well on the domestic side of the network today. We are very good at tracking barcodes. We have the ability now to do that. The expansion and our full commitment is to get those other sites up and running. We need to do this in collaboration with customs and Border Protection and mr. Perez might want to chime in. It is ready to move forward and get expanded to the other four sites. We are committed to getting that done. Mr. Schenk, give us a final 30 seconds. I want to make sure we are not here 17 years are now. Give us a great take away with what you would like to do with this. The key t hings passage of the stop act. I only will it help with the problem, we also think it will help the postal operators in their negotiations with their upus with legislative language that says, we have a mandate. If there was a way to increase the amount of information that is shared, we have a great working relationship with cpb, but there are limitations in terms of, if we knew more about who the bad people where, we could build that into our system. Thats great. I will be asking for the record if theres any amendments that should be made to the stop act. And prioritize those for us. That is for each of you. Mr. Chairman, so far, we are halfway home. This has been a great first half. Let me conclude by thanking our witnesses again and thank everyone of you for what you are doing in your own way to push back on this epidemic because each of you in your capacity is working on this issue. Weve got to figure how to do it more effectively and faster. Let me end with a story. Yesterday we had our weekly buckeye coffee. We had a couple hundred i owans come in. Letter carriers were there to talk to me about postal issues from the union. They talked to me about the stop act and the need for more resources for senator carpers efforts. And then two of the four took me aside privately, towo fof the four. They said, i have a Family Member one was a nephew and one was a son, who were addicts. Recovering addicts now. In both cases they had the opiate addiction and are out in and out of recovery. They both said to me, youve got to move forward with this. So, i would just tell you, this is affecting everybody, including our families and friends and neighbors in every zip code and the real letter carriers that came to talk to me on another topic, but focused on a personal topic, their deep concern on this issue. Thank you all for being here, and appreciate being able to work with you on this initiative. Thank you. We are going to move quickly through the introductions. Each of you deserve a 20 minute introduction. The executive director of the great center for addictive medicine at boston medical center. As some of you know, he has been at this for a long time and he was the drug czar until just a few months ago. We are delighted to have you here. The policehave chief for the city of newtown in Hamilton County, ohio. He has been involved in Hamilton County Heroin Task Force and is chair of the task force and everywhere in the southwest the full up to him for his advice on this and he will be able to talk to us about what is happening on the street. We have dr. Thomas gilson, a medical examiner. Previously he was the chief medical examiner for rhode island. I told him today, he provides us with the best information and every month gives us the data on what is happening, broken down by area of the county, rural, suburban, and her city, ethnicity ethnicity, age. It affects everybody. Is also with us and he is the chief of the division of addiction medicine in wilmington, delaware. Previously he served as the director of medicine at the phoenix house. Most recently he helped launch the Opioid Withdrawal pathway. He also found a project engage and has been there involved in delaware as the chair of the Drug Overdose fatality review commission. I appreciate all four of you being here as experts. I would ask for you to stand so we can swear you quicklyi. Do you swear the testimony will give before this testimony will be the truth, the whole truth, so help you god . Yes, sir. You can be seated. Comment. A quick terry is a leader and sitting right behind mr. Perez. He has gone on to be a wonderful leader in our state on a wide range of health care issues. Old and wes 15 years welcome him as well. We will be watching carefully to see if sebastians lips are moving when his father speaks. I am sure you attribute all your success in life to governor, now senator carper. Which he succeeded in spite of my mentoring. The witnesses all answered in the affirmative with respect to the oath. The written testimony will be printed in the record in its whole. It would ask you to keep the oral comments to five minutes. Tom gilson,with if thats okay. Thank you. Good morning, chairman portman, and other subcommittee members. My name is thomas gilson. I am the medical examiner, as well as the Crime Laboratory director. I thank you for a long me to be here to speak on this critical subject. This has killed tens of thousands of people in the u. S. This year. Its a Natural Disaster were to occur, how would fema respond . If this catastrophe was a lot to happen again with more fatalities, coming more hearings would be determined to recall what went wrong . The Opioid Crisis should be thought of as a slowmoving mass fatality that occurred last year, is occurring this year, and will occur next year. Each year it is getting worse than the previous. In my home of Cuyahoga County, we will see approximately 800 anths in 2017, which is increase of last year, when we saw approximately 660 people die from drugrelated deaths. Nearly 90 of these deaths will be due to opioids of some kind, prescribed pills, from which the crisis originated and grew from, heroin, fentanyl. Public healthwide emergency, which is simply out of control. Ohio is one of the hardest hit states. The New England States are also particularly hardhit. 2011, my office alerted the executive to the rise of the heroin associated deaths. We partnered with our county sheriff, the u. S. Attorneys office, the county prosecutor, addiction and Mental Health services and our board of Mental Health to launch a community initiative, which i am proud to say has attempted to combat this Public Health crisis. Partners were quickly added from the major mental institutions. Clinic, a the free prePublic Health Service Provider and this set in motion important pieces of w response. We have created drop boxes. Programxen distribution is one of the county hospital, as well as the free clinic and the board of health. We also issue warning letters to released inmates who are at greater risk of opioids, as well as patientss leaving Treatment Centers. These folks are at risk because of decreased tolerance. The creation also of our heroin Death Review Committee allowed us to look at data from the overdose fatalities in an attempt to plan intervention strategies. We also hosted a heroin summit at the Cleveland Clinic. The Cleveland Clinic hosted the summit in november, 2013. Law enforcement is also creating Specialized Task forces that work with our medical investigators to begin investigations earlier, provides highly accredited, timely and efficient scientific testing. Prosecutors are now levying much stiffer charges against targeting dealers. All of this work continues to implement a communitywide, communitybased strategy that was the result of the Cleveland Clinic summit. When a heroin overdose occurs, individuals typically fall asleep and breathe more slowly and shallowly until at last they stop altogether. During this progression the dying sequence can be relieved by the heroin antidote naloxone which was made more readily available in ohio and is an immediate first step in saving lives and should be applauded. The Metro Health Medical Center partnered to distribute it by prescription, and we have currently documented over 1,000 reversals with it. Police departments and a Pilot Program started in 2014, but ramped up in earnest last year, have documented another 300 reversals. These 1,300 individuals did not have to make a final trip to my office. The introduction of fentanyl and even more potent analogs like carfentanyl, which is initially seen in our jurisdiction, is a large animal tranquilizer, has diminished the efficacy of naloxone. Several doses may be required and the time window is greatly shortened. This is the fundamental reason for the catastrophic mortality rise in 2016. Research conducted at the medical Examiners Office in my county, a collaboration with medical Law Enforcement, 600 people died of heroin overdoses between 2012 and 2014. Some promising intervention points should be considered. At least 72 of all of these overdoses had been prescribed a controlled substance within two years of their death and over 50 for opioids. Several of these people were doctor shopping and with the mandatory implementation of a Prescription Drug monitoring program, or as in our state, we are now moving in a positive direction. To reduce this as an entrywa foe to go into the illicit drug market. The final example of how the valuable information can be gleaned from death certificate and death review data is the fact that many of the individuals who came to my office is been in contact with the legal system and or drug and alcohol treatment programs. Theres a tremendous need for education and these opportunities are needed to maximize us for messaging but its naive to think that education and messaging would be effective if we dont adequately address the need for Treatment Options once the message has been delivered. People can recover from drug addiction with adequate support. While data and information are critical, it has been particular inspiring to see a sense of community in Cuyahoga County that has brought treatment prevention Law Enforcement, prosecution, and medical examiners like myself together for a single purpose, to save lives. At the same time, our local resources are stretched to exhaustion. Investigation system and the forensic laboratories are facing doubledigit caseload increases annually, personal shortages, equipment problems, and increasingly complex processes with the fentanyl increasing. While we have interacted successfully, the sublime delivery of the drugs to the community is unabated. Our community has added millions of dollars to the effort in the past several years. Our estimates are that there in a people in my county to fill a football stadium. Every year, approximately sufficient number of people to fill our basketball arena transition over to the use of prescription opioids to helen and fentanyl. Use of heroin and fentanyl. They usually was a largely caucasian popularity and this is changing now. Cocaine is being mixed into the fentanyl distribution in an effort to introduce these drugs into the africanamerican community. Cocaine had been the only drug that victims in our community were predominately africanamerican. That has changed since the introduction of cocaine into that distribution. It is also of note that we have a rising percentage of africanamerican deaths and our Drug Overdoses crisis. The strategies to combat to this are not a matter of innovative creation, but of sure will, cooperation, and adequate resources. The cooperation we see already that the resources at a local level are depleted and overwhelmed. Treatment beds need to be opened and adequately funded. Our county executive has created an additional treatment exclusion that limits the number of treatment beds to 16 for Substance Abuse Treatment Facilities. Absolutely i salute te bill offered by you as was your colleague senator brown. Theres a National Crisis in my field. Further, there is a National Crisis. I will try not to go over time. But there is a National Crisis in my field. In my field especially, for in is insic pathology, dire need. On my organizations website, 28 offices are seeking to hire pathologists. I have the privilege of heading the oldest training program, training pathologists in the country. There are only 35 such programs in existence and theyre not funded my medicare. Unlike any other medical training specialty. Our Program Graduates one or two doctors a year and a system that can only produce a few dozen pathologists annually. We rely on accurate data around mortality to define this crisis and i think it will serve as a significant measure of success or failure. All of these actions are beyond the ability and authority of a local county like mine. We need your continued and renewed assistance, resources, and commitment to all stages of the fight. Prevention, education, treatment, enforcement, and recovery. I am sorry to go overtime. It is a very important topic for me. Ank you for your time. I would be happy to answer any questions and we provide a packet of information which summarizes even more. I could have talked longer. They give very much. Thank you doctor. Mr. Chair. Just because i have to lead, i would second say for all of you, but i would also like to thank dr. Gilson who was deputy chief medical examiner for New Hampshire for some time. Thank you for your work and continued work and thank you for all of the panelists. I am sorry i am going to miss you, but i have talked to you before and we will talk again. Statementr, your full will be part of the record. Chairman, raking member, thank you for the opportunity and the invitation to be here today and for your ongoing leadership in this epidemic. I think we all know the opioid pressing Public Health issue of our time, and a Public Safety issue of our time. The 2016 National Survey on drug use estimates approximately 2. 1 Million People in the United States have an opioid use disorder. In 2015, we had complete national statistics. 91 people a day died from opioid overdoses. Including prescription pain and orion, heroin, fentanyl. That resulted in 33,000 deaths in 2013 alone. In massachusetts, 1900 people died of an overdose in 2016. That is up from 742 just from 2012, in addition to addiction and death, we know this injection drug use associated has been linked to Viral Hepatitis along with local outbreaks of hiv. A recent analysis done by the cdc show that there are at least 220 counties that are a significant risk of another outbreak similar to the one in scott county, indiana. Over the past two years, we have seen the emergence of synthetic opiods like fentanyl. The cdc estimates that Overdose Deaths estimated to these other than methadone increased by over 72 from 2014 to 2015. Reports from the dea as was state local Law Enforcement indicate that the deaths have been associated with Law Enforcement seizures testing positive for fentanyl. This increase is not a result of internal prescribing indicating this is a largely illicitly prescribed. Analysis is limited to those dates, like ohio, that have had excellent or good reporting. That means Overdose Deaths are reported with a specific drug involved. 26 states reported significant increases from 2014 to 2015. Where states in the northeast and midwest experienced the highest increases. A recent analysis of Overdose Deaths in massachusetts show deaths involving fentanyl rose tom 32 in the 2013 to 2014 of 2016. E first half fentanyl has mixed with heroin or cocaine and with or without the users knowledge. Usually without. As weve seen a highprofile deaths, it can be disguised as Prescription Medication and taken without the users knowing it contain fentanyl. This appears to be largely manufactured in china. Either directly from the United States, via both open and dark web, or mexico where it gets mixed in with the u. S. Before transporting it to the united i will go into details due to lack of time to think you all know the administrations andonse to these efforts underpinning all those efforts is ensuring people that need treatment have highquality care including medication assisted treatment. The Affordable Care act contributed to perhaps the greatest expansion of treatment by answering that it was one of the 10 essential benefits that Medicaid Expansion plans and marketplace plans had to cover. It also ensured that those benefits be offered on par with the federal Mental Health parity and addiction equities. Act. For lack of time i wont go into detail, but im proud of the accomplished we are able to make with congress in terms of the passage of the comprehensive Addiction Recovery act that work rescinding the ban. We accomplished a lot in our time here in washington. But we still have a long way to go. I will focus the remainder of my remarks on what i think the recommendations as i look on how we deal with fentanyl. Continuing to enhance our intelligence and information gathering on the manufacturing and distribution of fentanyl is critical. I was very appreciative of the Intelligence Communitys calls for better information and there are still unanswered questions. I looked at synthetic opioids is a major threat. Quite frankly, i was frustrated during my time that i didnt know we had fentanyl and things like carfentanil until we saw local outbreaks in the United States. Our Intelligence Community is too good for us to because caught unawaree in terms of what is coming at us. Fentanyl is much harder to detect and present a hazard to Law Enforcement, we need to promote better ways to develop detection capabilities. We need to continue to provide find factbased information to Law Enforcement, Border Control and others who may come in contact with it. Need to continue our engagement with china and press them for additional actions to schedule fentanyl analogues and to take down illicit manufacturers and shippers. There is also significant variability of standard testing of fentanyl with Law Enforcement and treatment programs. They need to incorporate fentanyl into their drug testing panels. With Public Health experts, we need to distribute informational material on how users can minimize their overdose risk in areas where fentanyl might be present. We need to expand the use of naloxone for anyone able to witness an overdose. Because of the potency of fentanyl and the pattern of drug users using alone, we need to reverse an overdose is shortened. We need the federal government to deploy Rapid Response teams like other diseases so that the communities have the investigatory tools to examine the outbreaks and the causes behind them. We need to expand Syringe Service programs that engage active drug users to promote safer injecting and minimize overdose risks. More importantly, most importantly we need to preserve the coverage gains made to the Affordable Care act, particularly Medicaid Expansion and other federal grant programs. Even with these provisions, timely access to quality care remains an issue for many. Particularly in rural communities. Thank you for your time and i look forward to your questions. Thank you chairman. First, i would like to say this issue of addressing fentanyl is important. Fentanyl certainly exacerbates any issue i have to attend to the hospital in trying to help individuals get into care and it just creates a rapid spiraling of addiction that we see otherwise. D in delaware, only 25 of our individuals had fentanyl in their blood. Death. Time of when you look at the potential for damage in our state when we reach goals of massachusetts, i think there will be a real catastrophic increase in the coming year. Having said that, i want to share briefly, as someone in Emergency Rooms and clinics for 20 by years, some of the Lessons Learned. This is a horrific epidemic. Strikes across the board. I take care now of not only, and not only Young Mothers who have given birth in High School Kids who are champions and wrestling champions, but also grandparents, couples, all races and all ages and they share a horrific addiction. Their brains of changed, their motivational circuits have been distorted, and as well, they have this new onset of withdrawal. A withdrawal that is primal misery. It is a withdrawal that prevents them from moving through that wall to go into care. They will stay outside of that care and avoid it at all costs because they cant attend to withdraw. But is not reachable moment. That is what we can leverage. We have done that in hospitals and jails. When someone is put in the hospital and they can no longer be on the outside, and they are desperate to avoid withdrawl, we can address the withdrawal, treat it aggressively with medications like suboxone. Two thirds of the people i see in hospitals are very agreeable to go into longterm care, they dont go into the hospital about the affected leg heart, they use the opportunity to get into drug treatment. It is remarkable. Two thirds of individuals i see are actively looking to go into drug treatment when i offer it or address their withdrawal. Other individuals of those individuals, remarkably, nearly 80 show up to the Community Care provider. Thats when i inducted them in the hospital. The hospital is a reachable moment. Of those individuals 70 are there a month later. What i am telling you is that individuals who are addicted to opiates come into our Hospital System to address withdrawal and we can use that to leverage them into treatment and they stay there. If you are on drug treatment, medicines like suboxone which like opiates, if you use opiates, youre not going to overdose. It is really about safety. My all my state patience when i see them, i say take your suboxone today, and tomorrow, and those days we wont have to worry about you overdosing. Pretty simple, safe straightforward safety message. Its really critical to what im trying to do on helping individuals get into care and stay into care so they dont overdose and die. Its really having access to the care and we are fortunate. In delaware, we were able to expand outpatient slots for Substance Abuse care by thousands. For me, i have no difficulty, when i identify an individual in the hospital, getting them into care the next day. Contiguous orhat i lose them and they relapse. It is remarkable that im able to do that, but im able to because the care is available. The care is entirely dependent on medicaid. Without medicaid, that care would collapse. I can tell you that what i am really fearful of is that i am fearful that i know how to address this Opioid Epidemic, know how to treat the patients i have more addicted to heroin and other drugs, i know how to get them into a safe place, but im fearful that i will lose the tools and the medicines i need to keep them safe. And i am really fearful that some of the cuts that are proposed will completely gut the system that i rely on to treat my patience and help them get to a better place. , dontcally i am saying take away my ability to treat my patients and keep them safe. Basically, im saying, it is critical, dont take away my ability to treat my patience and keep them safe. They depended on me and i depend on you to really preserve the system of care that i have been able to work with and make improvements. Without it, i think the war is lost. Thank you doctor. Thank you chairman for giving the opportunity to discuss this important topic. How synthetic drugs are destroying the lives of people in our communities. In my 24 years of Law Enforcement ive never seen such a substance causes damage with death rates rising higher than levels of Car Accidents and homicides combined. I have witnessed the power of drugs in my community, watching an entire family from the mother to her three sons wiped out. An entire generation gone because of drugs. The last two brothers because of heroin. This comes at a time where we were calling this epidemic with an average of 20 or 25 overdoses and one or two deaths a week and epidemic. In july 2016 i received a call from a fusion center, a part of Homeland Security, originally designed after the 9 11 attacks to share intelligence on potential terrorist situations, which can analyze or share local and federal Law Enforcement along with the public. Recognizing the centers ability to analyze data quickly, we use it to track trends on that street. At that 00 p. M. I got a call saying there was a new drug on the street called carfentanil. They said we are not sure, it is used to knock out large animals. I replied, like a pig . He said no, elephants. We try to obtain as much information as we could to figure out what the introduction of carfentanil on our streets would mean. What we learned about the drug is frightening. It is potentially using chemical weapons and is not intended or for humans it had the potential to kill human. It is now on our streets issuing a public warning, concerned not only worried about user but also the public. Anyone to be unknowingly exposed to a externally data synthetic. Youre so concerned that we recommended stop field testing of heroin. The officers safety is a priority over enforcement. This is reached other states like georgia and florida to ensure the safety of the officers. With all the dangers facing Law Enforcement, this danger, which could be undetected until its too late, is a concern that could we knew the drug was struggling controlled and monitored in the u. S. , and with the dea, we determined it was not coming within the u. S. We could never havent dissipated that our epidemic would reach levels along the line of pandemic. It could be the new normal. In august 19 through the 27th of 2016, an event occur that would forever change the heroin epidemic when the hardest hit in cincinnati experienced 200 overdoses and three deaths in one week. Theres nothing on the streets like this, we experienced a literal shift from the organic opioid of heroin to this and that it opiate of fentanyl, always derivatives, a carfentanil. This is testing the limits of users, First Responders, the system of government, hospitals, and the spirit of each person drawn in to the point of breaking. I not only witnessed the devastation, but the determination of the same people who try to keep up with the new normal. The new average of 50 up to 70 averages of overdose. 11 people died in one weekend in multiple overdoses at the same time and same location. At times, they reached 40 in one day stretching the resources of the even the Police Departments and Fire Departments of cincinnati. We had 16 overdoses and four on shootings causing every officer to be unable to respond to other calls. In 2012, our area had seven deaths fentanyl related and it spiked to over 200. The Coalition Using narcan is given to every First Responder, in 19 months, have used large volumes. A young boy was walking down the beach and picked up a starfish and through it in the seat and moved to the one. In old man stopped and said theres too many to make a difference. The young boy picked up a the matter how great our efforts, the tremendous influx of such powerful synthetics like fentanyl, which corner offices identified 10 variances of, and the current ultimate have rendered each initiative less effective forcing us to change our beliefs in order to keep up with the power. The original narcan now is obsolete. We had to replace it with a higher concentration which, due to the strength of the synthetic, require multiple doses. It is more common to hear users unconscious being placed on a constant narcan drip to keep them alive. The synthetic is so now ingrained in our area thats when we think the situation cant get more difficult, dealers insensitive to the damage have now begin to place these in other drugs like cocaine. This will cause more overdoses and deaths due to the cocaine user bodys not being accustomed to it. It is expanding. For people in cincinnati who bought they thought was ok, overdose. Two died on the scene. Since i submitted this report last week, another person in that incident died. Three have died, one is hospitalized at my last check. The same week, in my community, a mother drove her baby into a driveway where she got out and collapsed. The mother believed she had only purchased heroin, and found out she had given a mixture of cocaine, fentanyl, and carfentanil. I commend this committee for taking the time to hear, investigate, and look into the ways of reducing these powerful synthetics fermenting our country, drug supply and our communities. I plead with this panel to help to stop this poison from getting in to the country. Although this will not stop addiction or stop every supply, each intervention that prevents them from reaching the streets means First Responders can get relief from the overwhelming numbers that has cost such pressure on them and we have coined the term called First Responder fatigue. Take this deadly ingredient from those on the street so they become less powerful. Take this tool away from them so that our tools we are using can be given a chance to work. Reduction from these powerfully devastating synthetics would mean less people would overdose, the numbers of deaths would go down, and, for us, each one of those numbers is a person. A person who is a mother, father, brother, sister, son, or daughter that will forever grieve the loss of their loved one. Thank you for allowing me to speak on the subject and i commend you for the compassion on helping all of us. Thank you. Thank you to all four of you for very powerful testimonies. I was struck by your testimony, chief, as you said, trying to keep up with the changing drug makes and specifically, the mood to synthetic opioids, i am thinking about how Law Enforcement approaches this. Now you have a situation where through the u. S. Mail system , someone can, at their post office box, pickup fentanyl from china use it as an individual and there is no drug dealer for you to go after. Some of these individuals become drug dealers, as you said, and yet, it is a different situation than being able to go after the source because the source is coming into the u. S. Mail. You talked about tools. Earlier, we talked to Law Enforcement folks saying they want the tool of being able to get electronic data so they can identify the packages and you also said you want to take the tool away from the traffickers. The tool of being able to ship this stuff into our communities the mail system. I guess i would ask you, given your experience and your background in this, would it be helpful at a critical chokepoint like these International Service centers that we talk about today, to be able to stop this poison, in part, to be able to keep the volume down, to avoid the fatigue talked about, but also to raise the cost, risk to the trafficker of being caught but also the cost of this by reducing the supply. Yes. It would definitely help cutting off the supply. There is very little risk for the dealers right now. Theres quite a bit of reward. The problem with it coming through the mail is that it is not like 1980s with crack where you had major gangs mostly pushing the crack cocaine. Once you identify the gang, you cut the head off the snake and the rest collapse. Here is everywhere with hundreds of dealers which are not necessarily sourced in one area. It makes it very difficult for Law Enforcement. I want to caution that we dont repeat history. In ohio we did a great job of shutting down doctor shopping and pill mills. Inadvertently that created part of this epidemic when we had the segment of society that was left opioid dependent. I dont want to just cut off the supply because this is an incredibly important part of this. It would give First Responders a chance to breathe, but also, want to make sure that while were doing that, that we have the recess in the back end. The problem were facing with this is, if you get someone into treatment, often, there is not the Space Available and there is discussion about whether it is effective or not and we need and nurses alongside of that and the facility to go with. It. Not only is that chokepoint important, but we need to work on the issue of having those people addicted getting longterm care in order to reduce the demands. Once we reduce demand, we will produce supply. It is a great point. I was impressed with the doctors Healthcare System and he has the ability to take someone in need of treatment and within 24 hours get them into treatment. Frankly, that is not the case in many places of ohio. Particularly in rural areas. We have a real issue with the availability of treatment and longterm recovery, which as you know, i have been focused on because that leads to better results. I think the Law Enforcement system can lead to better results too by supporting our drug courts more. I know you are involved with that as well. Dr. Gilson, you talked about what you are facing and specifically, you talked about the frenzied pathologists being overwhelmed. You talked prior to the hearing as well. One thing you said to me was that at a death scene, where someone had overdosed from fentanyl, your people sometimes find a package from china, literally, at the death scene. Again, i think this is just an extraordinary change from what you are used to with cocaine, or, for that matter, with heroin coming over land and being sold at the Street Corner in cleveland, ohio, i was struck by that. Can you talk to us for second about what you see happening . As a told you earlier, i think you have the best data in ohio, and for 2016, unfortunately, you are pretty accurate that there would be an increase in the number of fentanyls deaths. 399, as i recall. Since you do keep this accurate data on overdoses, what trends are you predicting for 2017 . As compared to the 399, what do you project for 2017 . Senator, i think we are already far enough into 2017 that we can make some predictions. One is that the crisis is going to get worse. Were projecting an increase up to 800. I think most of that is going to be driven by fentanyl. The other thing that everybody in the room should be concerned about is what is going to be the analogues of fentanyl . We had 54 deaths related to carfentanil in just my jurisdiction. Since the beginning of 2016 we have identified 17 different analogs of fentanyl. Many of these are far more potent than fentanyl. Fentanyl is already a bad drug. What concerns me is that at some point, if these drugs start to replace fentanyl, these numbers will take off again. To echo what the chief said, we started with diverted Prescription Drug medication, and about 2011 with my office saw was a transition away from Prescription Drugs which appeared to plateau, and heroin took off dramatically. That was our trend until 2015. Heroine started to look like it would go down. But then we caught a tidal wave of fentanyl. A more potent drug. 2016 was a uniform disaster in Cuyahoga County. These are hundreds of people dying of Drug Overdoses. If carfentanil becomes the new fentanyl in 2017, i shudder to think a much worse that can be. From your experience, is the carfentanil also coming to the mail system . This is partly what i can tell you from death scenes and partly from what i can glean with collaborations with the dea. Yes. My investigators will sometimes identify computer records and packaging that clearly show these drugs are coming from overseas. The concept that a lot of these drugs are coming from china is something that our dea liason completely supports. Maybe they come to this country and get routed into mexico. That is also true. In the heroin epidemic, the mexican production went up dramatically so much that they became the number one producer in the world. That system is definitely in place and i think that fentanyl can follow the same system. These are drugs coming from overseas, primarily from china, and being sold in our country, probably on a basis to be considered an act of terrorism. That is an interesting comment given what we said earlier with regard to the d. N. I. Listing it for the First Time Ever last month in his assessment. He put synthetic opioids into a National Security context. Senator peters. Sen. Peters thank you for calling this very important hearing. Michigan isuse in growing at an alarming rate, as it is around the country. It is good for us to get to the bottom of this. I appreciate your leadership in the months and years that youve been working on this. Thank you to the panelists for your compelling testimony. My first question deals with how we deal with the underlying Substance Abuse and the medical treatment necessary. To treat those. Issue,ly its a medical but with your testimony, this is a Public Health issue that we have to deal with. Whenever we think about Public Health, our health care policies, in particular the Affordable Care act with the expansion of medicaid. Which has been significant in my state. Medicaid expansion has led to 600,000 individuals now having Health Care Coverage where they didnt before. Part of the Affordable Care act is coverage for Mental Health as well as Substance Abuse. Which gets to the heart of the issue with this problem. Since the Medicaid Expansion, 1. 6 million americans have now gained access to Substance Abuse treatment. Could you speak to how individuals enrolled in medicaid are using the program and whether or not we are seeing an actual impact on folks suffering from Substance Abuse . [inaudible] you think i would know how to do this by now. We saw for a long time, that when National Surveys look at why people are not able to access treatment, not having adequate access to Insurance Coverage or being underinsured are the biggest reasons. Youre right, the Affordable Care act did a number of things as it related to increasing access to care. It made Substance Use Disorder Treatment and Mental Health treatment one of the essential Health Benefits required by Medicaid Expansion and ensuring those benefits were on par with other medical benefits. And we have seen some results as it related to increased access to care under the Affordable Care act. Your point about the Medicaid Expansion population, which we knew had higher Substance Abuse disorders than the general population. We have seen remarkable results, and quite honestly, remarkable results in those states that have been dramatically impacted by this epidemic. Like west virginia, like kentucky, New Hampshire, massachusetts. So we have seen an incredible increase in peoples ability to access care to do that. The other piece i just want to make two quick points. The other important point here is people with the Substance Abuse disorders often have comorbid Mental Health. Quite honestly, other health conditions. It is not just accessing care for a disorder, but they need care for hepatitis. They need Mental Health coverage. The last thing ill say is i worry about, not just people losing coverage, but the stability of our treatment infrastructure. Some of these folks can tell you that these operate on thin margins. I worry that we will even have a treatment infrastructure if they are not able to bill insurance. Thank you. Anybody else . As i mentioned, in our system, we have developed some very unique partnerships with community providers. We know screen 30,000 admissions to our medical hospital. The largest in deleware. We identify those were dependent quickly. That care is predominantly medicaid. So our Largest Community provider, called connections, has the largest footprint in the state. They developed that footprint because they had the reliable funding stream. It covers all patients. They are a quality provider. But the bulk of their revenue what allows them to exist is if they have a reliable revenue stream. My record is 12 hours, identifying someone and getting them into treatment on a medicine at suboxone. I can do that because that person is covered. For the most part, it is covered by medicaid. If medicaid goes away, that collapses. I will identify individuals in the hospital. I wont have anywhere to send them. They believe the hospital and relapse within hours to days and will be back in the hospital and we will return to the good old days of the revolving door and that cost, that astronomical cost of caring for these individuals. We will never attend to the root cause issue. The big difference these days is the volume of heroin. It is to be one or two bags per day. Now it is bundles. 50 bags a day. I think of it as russian roulette where instead of bullets it is bags of heroin. If any of those bags has fentanyl in it, that person dies. Because i had ready access to Substance Abuse treatment on demand, i am able to make a difference. Im clear that those individuals taking the suboxone are not overdosing. I know because they come in week after week. Im sorry senator, can i add a different perspective on this too . We dont track it specifically, but we go out to respond to death scenes. I think one of the most heartbreaking things we see is an individual who has been seen in an Emergency Department within weeks or days of a Drug Overdose. These are the people dr. Horton doesnt see. They dont make it back to treatment, they die. And we dont have the capacity in my county to send these people when we have their captive attention, they just nearly died, to treatment. Like dr. Horton says, we send them back to the street to see if they can work something else. Anything like seeing Medicaid Expansion being eliminated that access to health care i cannot see anything good coming from that, especially with mortality. I appreciate those comments. You are on the front lines, thank you for your service. I assume that you would concur . Absolutely. As Law Enforcement, im proud of my colleagues who take the lead on this but we are to the lead on something that is a Public Health issue. Youre trying to get Addiction Specialists out there. Narcan has becomg paramedics. It is not uncommon for officers to take users to treatment. Its outside our realm. We had now become something of an addiction specialist. For Law Enforcement to talk about that we should not be decreasing medicaid, because you how important this is for us. To reduce demand which would reduce the supply, we have to get people into treatment. One of the things that our teams are doing is signing people up for medicaid to get them into that treatment. If medicaid is gone, that would have a significant impact. It is not uncommon for us to find a user, call Treatment Facilities, be told there is a bed open, drive up and find that it is gone. It is difficult enough, taking away medicaid would make it even more difficult. Were already like a mouse on a wheel trap spinning as it is. Taking away more tools will keep it difficult and we will continue to dig ourselves into a hole. I am going to turn the gavel over to my colleague. Big mistake. Ask him to conduct his final questioning and close us out. I want to think the four of you for being here and for your work every day. All four of you are in the trenches, on the front lines. Thank you for helping reverse this tide which unfortunately is moving in the wrong direction. Before you walk out, i will say this to your face, not behind your back, thank you for your sustained, continued leadership. Maybe we can use the effort that you have led, along with Amy Klobuchar and others. If we can work that well across the aisle on important issues, maybe we can make sure the folks show up the hospital, that they actually have access to treatment. We have to focus our attention on that. Thank you. I want to come back to dr. Horton. Explain to the folks who might be following this, how is it in delaware when somebody shows up at the hospital and they have had an overdose. For brief moments or hours, theyre ready to go. Theyre ready to start treatment. Within 24 hours we often have the ability to place them in treatment. How are we able to do that in delaware and not in other states . Does it have anything to do with the Medicaid Expansion . In order to put someone into treatment i have to have a treatment to put them into. That treatment is primarily the expansionmedicaid and problems like connections developing those outpatient slots because they had revenue that could be relied upon. Without the revenue, the Treatment Center wouldnt exist. We are able to leverage reachable moments. There are many more than just the hospital. How do we find the other reachable moments cannot lock up, for example that they are so ready to go into that injury that they agree to go into treatment. In the emergency room when someone is being admitted to the hospital, they are there. It is about having the institution accept that this was an issue and implement pathways. We are good at creating Electronic Health records, mechanisms to screen and algorithms to treat. We had the wherewithal. It was a natural place to do those experiments and they worked and can be replicated. By that i mean identify the issues around withdrawal, use that as the lever to move them into care. Most patients are very interested in it and as i said, two thirds of my patients are willing to go and most of them show up at the backend. But what about the lockup . We have the same result where someone had been arrested, breaking into a garage. Im told by my colleagues at New Castle County where the Police Departments are trying to struggle with this, they have come up with their own programs. Thank you for that. Let me this is i would think it is what he describes as a best practice. Folks are ready for treatment and we get them into treatment. Maybe each of you can give them one example of best practice and that the rest of us can learn from and implement. This is an area that we focused on at the white house. I will give you an example at boston medical center. We opened what i believe is the first opioid Urgent Care Center in the country. So that folks who came into the Emergency Department were identified coming into the community could walk in or were brought in to an Emergency Department. We have dedicated staff, some peers, recovery coaches. They are about to work with them. Getting access to a bed and care is not easy. They work to make sure that people have the care that they need. But i have to say because this is important massachusetts still has the lowest uninsured rate in the country. It is not an issue for staff in boston medical center, or the emergency staff department, or any other facility. We have a generous medicaid benefit. Opioid and Urgent Care Center is something worth looking at. Great, thank you. I have to go along that track also. In Hanover County we are trying to get the hospitals work with us. As patients, we are looking at this from a Law Enforcement aspect, which is not going to solve isnt going to be the answer, but part of the problem we are also facing is those people who dont want to get into treatment, which is a significant amount of people. There is a hurdle not just going from jail or to the hospital. But how do we get them into Treatment Facilities. Its one of the challenges we are trying to overcome. If we can ticket to the medical system where they can go to the hospital and received treatment. If we started treating this like a brain injury or illness, that it is defined as, then i think we would have a better solution. Thank you, chief. Thank you senator. You know, a lot of ideas come to my mind. Just give me a really good one. I think one of the things we have to do is use the information that can be gleaned from people who die from overdoses to design intervention strategies. We saw people 40 of people who can to my office that had been incarcerated within two years or had been in treatment within two years. I send each of the people leaving jail or Treatment Facilities a letter spelling out Risk Reduction strategies. Dont use by yourself, dont go back to the same folks. If we can take the burden off the epidemic crushing these systems, it could be used to define very effective intervention strategies. Thank you for each of you. Before i close i add another thought. Then i will turn it over to senator peters. I want to thank you again we want to thank you again for being here for those with whom you work and represent. Every now and then, we have hearings that are illuminating. It is rare we have a hearing that is illuminating and terrifying. This is really both. It is an all hands on deck moment. I am more convinced than ever. My deputy Legal Counsel in my last term as governor, one of the things i was asked to do is to be the vice chairman of the American Legacy Foundation. The American Legacy Foundation was created out of the 50 state Tobacco Settlement where the Tobacco Industry provided a lot of money to each of the states for a period of 25 years. Still does. They also provide about 1 billion to 2 billion to create something called the American Legacy Foundation. It developed a campaign in terms of convincing young people if they were using tobacco to stop and they hadnt started, not to start. I realize it is not entirely a comparable parallel, but we have not talked about messaging. We have not talked about messaging. In the back of my mind i talked about there are no silver bullets, there are a lot of silver bbs. In the back of my mind, that might be one of them. Given what weve accomplished with that campaign, thats something i would not dismiss. Finally, we will be asking questions for the record. The shortlist, the things we should be doing. Asking you to come back to those ideas, repeating some of the things you have said. I think you could feel a real sense of urgency on this. I am sure that we feel it from your side. Thank you for what you are doing. Were in this together, lets go forward together. Senator peters. I want to concur with all of your comments. Thank you for asking one last final question. Going back to the root causes and i appreciated your response about how we have to have medicaid available. There is compelling evidence that prescription opioids are really one of the key drivers for what we are seeing. Dr. Gilson, you mentioned in your county that individuals who had been prescribed controlled substance within two years of their death, over half of them had prescription opioids that led to this. And so, a final question, are we aware of other sorts of treatments that we should be prescribing so that we can stop what appears to be perhaps over prescription of opioids to patients . That we need to have different types of treatment and thinking about how we can Practice Medicine . Are there impediments to preventing that . What should we be thinking about Going Forward to stop the pipeline that starts with some Prescription Drugs . Thank you for the question. You have really hit the genesis of the problem, the nail on the head exactly. The culture in medicine tended toward overprescribing of opioid medication for chronic pain. The scientific support was minimal and that unfortunately became a standard of practice that i think has in large created an opiod addicted population. If we gave prescription pain medication to everyone in this room, they would become addicted to prescription pain medication and opioids. We have created a substantially large addiction population. That is inconvertibly true. How we get back from that is i think we have to start the reeducation of the medical community. We have to put much stricter use and guidelines on people prescribing pain medication. Im sympathetic to people in pain. But if it creates a detrimental consequence, that is not a good treatment. We should hold those people accountable. It wasnt welldocumented. Im ashamed to say that in part the medical community played in this crisis isnt stopping. I still have lots of anecdotal information about people getting vicodin, people getting teeth pulled and a month later getting refills. We have a population of people who are already suffering from that overly liberal prescription. We cant turn our back on them. They will be with us for a while. Treatment does work. One of the ways we improve treatment will be more effective for that. During my time in ondcp, we worked with the cdc unencumbered on comprehensive guidelines. Some of the issues we heard in terms of nonopioid therapies, the challenges were changing the culture of giving out prescriptions, but the other issue we heard was things like insurance reimbursement for physical therapy, acupuncture, and often even Mental Health therapy. I think that is an issue that we have to take a look at. In terms of those challenges. I will say that we have had some good evidence in states with robust Prescription Drug monitoring programs. We have seen some good data on Overdose Deaths where physicians has to register each time. Many states have moved to mandatory registration and checks. It seems like that works. You often get pushback from physicians. I understand that sometimes they are busy. But my response was, we are 15 years into this epidemic. I dont think it is unreasonable for a physician to take a modicum of education and check the prescription. Were losing too many people. Thank you. I appreciate your testimony. Were you going to Say Something . In our state, we were able to implement some of those measures around pnp and have ratcheted up regular nations for prescribers. It is a small state and we are able to make these kind of changes. There is hope about being able to attend to it at the levels that are met. As far as treatment for Prescription Drugs, in many ways the genie is out of the bottle. Yes, most the patients i attent to are exposed to Prescription Drugs. Now most of them are of using heroin. We are seeing two epidemics. The Prescription Drug epidemic has not gone away. Now we have a heroin epidemic as well. If i could add one more thing, i think it is important. Because congress supported this, if you talk to the folks at the National Institute of health, they will tell you that we need to do a better job of researching nonopioid pain medications. I think one of the barriers is looking at what the Administration Proposed in terms of nih reductions. It put a significant damper on nihs Research Capabilities to come up with nonopioid, nonaddictive prescriptions for pain medication. It undercuts what Congress Passed as part of a 21 century cures act. That is a good note to end on. We have a lot of, i think, good ideas. Some of them we have heard before. The pastor of our church, when he knows he is preaching to the choir, says even choirs need to be preached to. We appreciate you introducing us to best practices. Is we know you are introducing best practices, and good ideas, and it makes a lot of sense. The hearing record will be open for 15 days. With that, this hearing is adjourned. Thank you so much. [captions Copyright National cable satellite corp. 2017] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] announcer President Trump met with european leaders in brussels earlier while attending his first nato summit. 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