Transcripts For CSPAN2 Federal Officials Testify On Fentanyl Addiction 20170322

Minutes. Good morning, welcome to this hearing. Called fentanyl the next wave of the Opioid Crisis. America is a full on Opioid Crisis. Two decades ago it started with the overprescribing of opioid drugs. Then it shifted more to heroine. Today, the subcommittee examines the next wave of the Opioid Crisis in a more dangerous threat to our streets, fentanyl. Since all is made in a lab and for many years that has been a powerful pain medication with patient for cancer. I would add to this when i remembered when i was injured in iraq a few years ago, Battlefield Medicine meant in recovery, they give me lots of fentanyl patches and i know what its like to have the reaction to it. Its 50 times more potent than heroin. One hundred more times quoted than morphine. Now fentanyl has become an additive to even counter. Prescription drugs. Drug dealers increase supply, get more addicts sort of like mst and foods. Users often dont even know that fentanyl is in the heroine. Fentanyl crisis is exceptionally dangerous because of its high potency, the speed with which it reaches the brain. Two mg of fentanyl until, whether swallowed, and inhaled, or through the skin. Appreciate how small amount 2 milligrams is. A sweetener packet that you see at your restaurant table is about a thousand milligrams. 2 milligrams of fentanyl until you. Those suffering from an overdose involving fentanyl may require both higher doses and multiple administrations of the lock so to to stabilize. Even the police and First Responders are at risk from inadvertently and touching or inhaling the top powder at the crime seems forceful helping in overdose victim. In 15 the Drug Enforcement administration or dea issued an alert on fentanyl is alert to public safety. The dea sent another flirts called it an unprecedented threat. Custom orders show an 83 and added challenge is that there are many chemical variations known as analogs. There are about 30 known analogs, however none none of them are controlled substances under federal law. Since 2013, overdoses have death have served with no end in sight. Fentanyl and have contributed to at least 5000 overdoses death in the United States including the death of music star prince, last year. In my district alone fat and all related deaths exploded since 2014, last year 86 last year 86 people in west born county died from Drug Overdose link in part fentanyl. Even these statistics undercut the fentanyl threat nationally because most states and localities are not testing or tracking fentanyl and Drug Overdose cases. We are flying blind. At this case the capacity of Law Enforcement in the Healthcare System will be overwhelmed. China is a primary source of fentanyl and there are thousands of labs making illicit peer fentanyl as well as the source of ingredients or precursors needed to manufacture and all. Topic or sip these ingredients to secret labs in mexico, run by drug cartels and smuggled pounds of that and all over the southwest border through our porous borders, launching it to catapults and into the us. Chinese labs are also a primary source of fentanyl order on the open internet and down the dark web. Peer fentanyl is delivered through the mail or express carriers. Finally, china is the main source of pill processors that can make thousands a pill in our support fentanyl operations. Im pleased to add that china is taking some actions to reduce this and we look forward to working with them because it is so deadly. The fentanyl problem is spreading and going to get worse because the profit is enormous. According to the data from dea a kilogram of color and can be purchased for roughly 6000. An sold hotel for 80,000. Over a kilogram of pure fennel can be purchased for less than 5000 and is so potent that it can be stretched into using cutting agents as talcum powder or camping. Therefore while the each kilogram to be sold for sale for 80,000 it can result in a total profit of the neighborhood of 1. 6 million. Thats about 20 times more profit. We need a federal strategy dedicated to combat and fennel is a clear and present danger that it presents for National Security and Public Health. We welcome our panel of witnesses today, we salute you for your work. Thank you for appearing today and i look forward to working with people to stop the spread of this epic dominic. I recognize my friend from colorado. Thank you, mr. Chairman. Every every day somewhere in this country there is an account about how opiate addiction has wracked a small town or family. Personal stories about americans who become addicted to pain pills and then they get hooked on heroin. These are heartbreaking stories about americans dying and leaving loved ones. Often their children to pick up the pieces. The Opioid Epidemic is unprecedented and it is escalating and i think we all agree that we need a copy of the strategy to confront it. In 2015, more than 33000 americans died of an overdose involving a prescription or illicit opioid and more than 2 Million People had an opioid distributor. Its an Even Deadlier layer to this crisis. It can be up to 50 times more potent than harridan. And a hundred more times than morphine. It leaves even the tiniest amount and anyone exposed to it can have it detrimental. Illicit fentanyl is not a new problem. What is new is its growing prevalence. This 2010 that number covered by the american Law Enforcement nationwide enters in 20 fold from 640 samples tested to 13000 samples tested in 2015. According to information from the da. Us Law Enforcement as the chairman said believes china is the primary source of illicit but small and precursor chemicals. 20s producers shipped fentanyl and chemicals to make it directly into the United States. The precursor chemicals shipped to mexico and canada where traffic across our border in pure form or mixed with other illicit drug like karen. Today, we want want to ask the panel some tough questions about Law Enforcement and diplomatic efforts to extend from china and whether there sufficient. Were also going to ask which drug traffickers use to ship this drug into our country like, express consignment care is an international nail. I think this is another important step that the Second Committee has taken to address the Opioid Epidemic and for the record, i want to to continue this bipartisan work. That said, mr. Chairman i also think we need to find a way to address the treatments that this epidemic and this is sadly where i have significant differences with my majority colleague. Passage of the Affordable Care act has led to nearly 20 million americans Getting Health Care coverage. In addition, the aca has been able to governors to expand the Medicaid Services they offer, which is critical in states that were overwhelmed by the Opioid Epidemic. Studies estimate that since 2141. 6 million uninsured americans gain access to Substance Abuse treatment across the 31 states like mine, when expanded medicaid coverage. This is particularly important for states like kentucky where one Study Reports that residents saw 700 increase in medicaid beneficiary seeking treatment for Substance Abuse. Two weeks ago, the majority rushed through this committee a bill to repeal the aca that many believe will threaten the progress that Medicaid Expansion has made in getting people suffering from addiction and to treatment. Its an assessment of the bill last week that the Congressional Budget Office said that millions of americans, 2,424,000,000 of them will Lose Health Coverage at many of those will be people currently receiving medicaid assistance which includes people receiving treatment for opiate addiction. In january, healthcare aspects from harvard and nyu wrote a thing to the hill about repealing the aca would reverse Important Health gauge. They focus primarily on my baby, the 21st century care act which i did with this Care Committee that we approved unanimously but we could have a full hearing just about how badly the gop, aca repeal bill will half of the progress that we just passed in 21st century cares. I i just want to draw attention to one part where the authors wrote quote repealing the aca and its Behavioral Health positions will have dark effect on those with Behavioral Health and insist. We estimate that approximately 1,253,000 people with serious mental disorders and about 2. 8 million americans with Substance Abuse disorder of about 222,000 have 22000 having opioid disorder will lose some or all of their insurance coverage. The end of the day we dont know what kind of bill will reach the president s desk desk but if we really want to address the Opioid Crisis we i suggest we dont pass the severely poorly thought out piece of legislation. I yelled back. I recognize mr. Walden for five minutes. Thank you, first hearing this Opioid Crisis. If you touch every part of our nation. Like my colleagues i met with community leaders, physicians, Law Enforcement, and families on this issue. Each share their heartbreaking stories on the effect of this crisis in our communities. See addiction doesnt understand politics. It doesnt understand income, doesnt understand race, where someone is from, its an its an equal opportunity destroyer. This crisis has hit close to home for all of us. Last congress, this committee worked in a pipe parts a way to pass legislation to fight the way we avoid epidemic. In an effort that began in the subcommittee that held a series of communities about the growing problems of Prescription Drug inherent abuse. We should be proud of those efforts but as he will discuss today there is a new threat emerging. Last year, there were encouraging reports that the prescriptions for the opioid had finally decline. That was good news. For the first time in 20 years, that it happened. Yet, we saw the overdoses and overdoses death continuing to search upward. We ask why . Emerging data strongly suggest that the main driver is bentall. And its chemical variations. Fentanyl essentially represents a third wave of the Opioid Crisis. If i were here. Fentanyl is a more challenging threat within the ip droid crisis in comparison to the threat of prescription rights inherent in. The fentanyl threat is multifaceted and produces legitimate pain medication and Drug Companies for decades but it is also produce it illicitly and blackmarket art in china. Illicit fentanyl is hard to detect and like to unlike pain is not diverted from the main market. Nor is it comparable to the black market of heroine. It can be purchased over the dark web or the internet openly. The chemicals used to make fentanyl are produced in china and shipped to clandestine labs in mexico. Drug cartels are smuggling massive amounts of fentanyl with other narcotics from mexico across the southwest border. Traffickers in the United States not only are getting deliveries from fentanyl from china through the mail or through express carriers but theyre also getting through indirect segments from china to the can make thousands of pills in our to appeal our operations into our towns our communities and the lives of our citizens. Peer fentanyl is not considered a replacement drug for oxycontin or heroin it is to put in. It is two to 3 milligrams until end of individual. More often than not it is added into heroin, cocaine or other counterfeit drugs to increase the likelihood of addiction. With even scarier is that people taking these drugs do not even know that theyre taking that no, let alone what it is. Fentanyl makes the deadly threat of opioid abuse Even Deadlier. In 2014 and in 2015, in, in my home state of oregon, 49 people died from fentanyl. The number of deaths from fentanyl appears to be rising and thats just what we know. As we work to combat this quickly Public Health threat there is an important question be asked. How can we fight this threat when we dont know how quickly it is spreading . Combating this threat will require more drug control strategies aimed at prescribing opioid is a global problem that requires urgent response. I commend the efforts of her government, dea and the state department particularly for their success in gaining cooperation with china and the united nations. We need to continue the support of an International Engagement to be successful. Like our work on the Opioid Epidemic last congress, combating that no requires an all hands on deck attitude. We need to think outside of the box to stop the surge of the fentanyl crisis. I look forward to working with you. I yield my time to mr. Burgess. Thank you, mr. Chairman. Thank you for holding the hearing. I want to thank the dea and you been into my office to talk about this issue in the past 101. It. It is a concern to me. Ive been on the Health Summit committee long enough that in 2005 we were having a Committee Hearing about why doctors were prescribing adequately for pain and now the past two congress is me big concern the appearance of the Opioid Epidemic. But small is not new product, it has been around for some time but on the other hand it is the fueling of the Illicit Trade with the ability to get things over the internet which i think has been probably the crux of this problem. We do have problems with the overseas market with the way the supply comes into our country so i hope we can hear insight this morning into the additional things that might be done to stop the flow. Thank you, mr. Chairman. I yield back my time. We recognize mr. Thank you mr. Chairman. The Opioid Epidemic continues to grow at an alarming rate. In 2015 more than 33,000 americans died of an opioid overdose. More than 2 million individuals hadnt opioid disorder. According to the center for disease control, 91 americans die every day from opioid overdose. Today were focusing on fentanyl but is 50 times more put then haired heroin. Because of its potency fentanyl is a dangerous substitute for heroin and results in frequent overdose that can close respiratory, depression and even death. The number of overdoses is rapidly increasing. If death rate from synthetic other than methadone increases by 72 from 2014 to 2015. The substantial increase in the. The substantial increase in the death rate from synthetic opioid is largely attributed to the increase availability of fentanyl. I want to think our witnesses for their testimony and work on this very important issue. Fentanyl is dangerous, not only to users but also to our Law Enforcement and Public Health officials on the front lines of this epidemic. I look forward to working together to create ways to confront supply that is plaguing our communities. I would also like to talk today about the treatment side of the Opioid Epidemic. Two weeks ago, many republicans rushed care to the committee, a bill that would repeal the Affordable Care act. The aca has been instrumental in addressing the current Opioid Crisis and in especially, to compare would only exaggerate the crisis. The Medicaid Expansion under the aca, 1. 6 1. 6 Million People with Substance Abuse disorders can receive treatment that they need in the 31 states. Care effectively and Medicaid Expansion in 2020. According to the cbo trump care also cost 880 costs for medicaid over the next ten years which will severely. Were taking care from millions of americans especially those with substance care treatment. Care also states were no longer have to offer benefits like Substance Abuse, Mental Health services or Prescription Drugs to millions of americans rely on such care. Repealing the essential benefits package effectively repeals the mental and subterfuge provisions of the aca. It would remove approximately 5. 5 billion annually from the treatment of low income people with mental and Substance Abuse disorders. Repeal will take away the care from those were actively seeking treatment and Preventative Services and we simply cannot afford to eliminate this care and what is often called a life and death situation. Trump care threatens access to lifesaving treatment for more than 1 Million People with opioid disorders. Our hearing today explores the pencil problem. I would argue that today this issue is a much Brighter Program than were filing. Addresses probably we must help americans with Substance Abuse problems to find treatment. Mr. Chairman i want to work with you to confront fentanyl in the larger opioid problem, however, in my opinion, repealing the aca and putting medicaid in nearly trillion dollars over the next ten years will do nothing but undermine our efforts to treat americans who are suffering opiate addiction. We will not be able to arrest a way out of this problem. Without adequate Treatment Options for those suffering from an opiate addiction this problem will only worsen and so will the death of discussion we seem play out across the United States. I dont know if anyone wants my extra minute. If not, ill yield yield back to thank the gentleman. He yield back. Before we get i want to off the record read an article from the Washington Post where fentanyl kills people. It has interesting maps where these occur out across the country, the static opiate in kentucky and pockets in New Hampshire, massachusetts, rhode island and it tells us that theres not one opiate epidemic but several. There is no Silver Bullet and will have to make sure whatever this committee does from our esteemed witnesses were going to have to work to get flexibility and maximum flexibility to work this out. I ask a unanimous consent for this statement to be. Id like to introduce our panel. Federal witnesses for todays hearing. Well start with a mr. Kam chester, acting director. Mr. Policeman leone, assistant. Mr. Matthew allen, the honorable william brown, doctor debra, doctor wilson compton. Thank you all id like to think all of our witnesses and i look forward to a productive hearing. Let me charge you with this moment i usually dont do. More people are dying of Drug Overdose death then guns. We have reached a. When more people are dying then Drug Overdose that been the entire vietnam war. Almost a. Year basis. What youll tell us today is only nine years that are open to anything you can offer us. The families in america and youve heard the story from members here, stories of the deep concerns of the number of deaths that devastate communities and what youre saying here is extremely important. We look forward to hearing you on this growing threat offend all. Were holding an investigative hearing and we take testimony under oath. Do you have any objection to taking testimony under oath. The chair then advises you are you are under the rules of the committee. None, in that case will you please raise your right hand. Do you swear that testimony are about to give is the truth the whole truth and nothing but the truth. Thank you. You are now under oath and subject to the penalty set forth. Will call upon you each to give a fiveminute summary of your written statement. Watch the light. Chairman murphy, ranking memories of the committee thank you for inviting me and my colleagues to discuss the Opioid Epidemic, particularly that of illicit fentanyl. What the federal government is addressing this problem. I appreciate the committees strong support of our work to reduce drug use and its consequences. I currently serve as the acting director of the office of National Drug control policy witchcraft the president s drug policy and oversees the government counter drug and related funding. This is a Critical Mission because as you are aware more than 52000 americans died from a Drug Overdose in 2015. Thats an average of 144. Day, with 91 of those deaths involving opioid such as prescription pain medication, heroin, and illicit fentanyl. Overdoses involved opioid had nearly quadrupled since 2000 between 2013 and 2015 the number of deaths involved in synthetic other than methadone our statistical category that includes retinol is more than tripled. Reaching more connect this number is likely low because not every investigation looks more fentanyl. The majority of the illicit fentanyl in the us is smuggled in after being produced in mexico or china. Both heroin and clandestinely produced retinol can be manufactured, packard and by the same drug organization. The reemergence of illicit fentanyl creates a problem. It create more powerful than heroin, its precursor chemicals are not fully controlled in other countries, its been added into the heroin supply and pain pills. Users are often unaware theyre taking panel. Because of potency can be shipped in small packages and transactions that that involve relatively low dollar amounts making it much harder to detect. First responders and Police Officers report that they need to use much more than the standard doors in the allotted zone two and overdose with strain resources. We also have a limited capacity to treat those that habitually use illicit opioids. Only one in nine people in the us need treatment are receiving it. Weve seen outbreaks in many states were fennel, and other fentanyl analogs have played a role in the way overdose death the devastate communities. In short, illicit illicit fentanyl is exacerbating an already challenging problem that the federal government is working hard to address. The reality is of the academic weve adopted new ways of a adopting drug use and trafficking. The heart of our effort is a partnership between Public Health and Law Enforcement. Some of whom are represented here today to help address the problem in communities across the country. We are also working with our state department and colleagues to engage foreign partners to stop being brought into United States. In terms of Public Health we are working to prevent new initiates by encouraging, prescriber and public education, encouraging prescribers to use the cdc guidelines and the state Prescription Drug Monitoring Programs and emphasizing prevention efforts to try and use initiation. Were also working to expand access to treatment, including evidencebased treatment for opioid use disorder and help people sustain longterm recovery. In this regard, we deeply appreciate congresss support for treatment expansion through the funds authorized for the 21st century cares act. Another critical innovation is that were building new partnerships between local Law Enforcement and the Public Health community to end this crisis. We need to establish routine cooperative work between the state and government. The federal governments efforts are centered on stopping illicit drugs before they cross our borders and dismantling the organization that traffics drugs into and through archimedes. With an o and dcp the National Coordination group was created in october of 2015 in partnership with the National Security council to synchronize federal build of heroin and a little fat to caption redundancies in the department of agencys activities through with interagency cord writers which addresses heroin and fentanyl is a single problems. On dcp also fund the high intensity Drug Trafficking the coordinates anti Drug Trafficking, state, local, tribal drug communities. An internationally we are working with foreign partners like mexico, china, canada to reduce the supply of illicit fentanyl precursors and is analogs issues across north america. While were working diligently the tide on this epidemic and perhaps making some progress we continue to work through numerous challenges. Such as texting in the mail and parcel system and at our borders and working with International Partners to reduce the manufacturing and finding and disrupting the internet marketplaces were illicit fentanyl is purchased and delivered. As the federal Government Works to reduce the opioid using populations through treatment your support for these efforts is critical to our success. Thank you. I look forward to answering your questions. Your rec and ice for thank you, mr. Murphy. I want to put these overdose death numbers in context. Major League Baseball will kick off their season next month. Picture the mlb stadium and any of your respective cities. More than 52000 americans we lost in 20152 Drug Overdoses Drug Overdoses would overflow any of those mlb stadiums we all agreed on unimaginable tragedy. For the dea the frontal threat in the broader Opioid Epidemic is the number one drug threat facing our country. This you have substances many times more patent than heroin, sold as heroin, mixed with hair done and pressed into pill form without being sold by criminal networks on our streets as prescription painkillers. There are five pills that represent five counterfeit. Based on Laboratory Analysis on these counterfeit pills one in every five will contain three times the lethal amount of fentanyl. For the unsuspecting user, death is lurking in just one of these bills. Sadly, but not unexpectedly, mexican cartels are exploiting this academic and producing it from china we need a bounce holistic approach that attacks supply and reduces demand most importantly must be proactive. And use any and all available investigative techniques to identify and book. Site capture and convict all members of these criminal organizations both domestic and foreign. The 221 domestic offices and 21 field divisions and 92 foreign officers in 70 countries dea working with the federal state local International Partners is wellpositioned to engage in this fight. Throughout deas practiced their greatest successes have come from a collaborative effort to the u. S. Interagency and our foreign counterparts. Our approach to this thread is no different that we have had success and we will continue to have success against members of these fentanyl manufacturing Distribution Networks but heres whats the frustrating part great foreignbased manufactures and domestic pied Piper Service poison operate with impunity because they exploit loopholes and they controlled substance attack and capitalize on the lengthy resource intensive raqqa process required to temporarily or permanently scheduled these dangerous substances. As we speak criminal and or country art tweeting thunder snow analogs keeping the same dangerous pharmacologic property as the controlled substances that help manufacturers and distributors avoid criminal exposure because of it altered molecular structure. Since july of 2015 deas emergency fentanyl some progress. We are tracking 19 more. Scheduling actions are critically important that they are react if resource intensive properties. Well continue to do everything we can on the schedule in front in the shortterm this the sistine body to provide the ian Law Enforcement partners immediately by placing the identified fence mall and other dangerous synthetic substances in the schedule wasnt. This would allow us to keep these drugs out of our country bring to justice the egregious domestic and foreign traffickers preying on our youth and flooding our country with these dangerous drugs. I would like to end with two opposite but interconnected images. Sunlight and shadows the dea will always operate in the sunlight. Will always follow the rule of law. We will work to reduce demand with our Community Outreach and prevention efforts are of the country but we have to also operate in the shadows. Wouldnt infiltrate the secretive dangerous Transnational Criminal Organizations wherever they are here in the United States or in Foreign Countries. We need to develop a gluckin this is very evidence to bring those that exploit you with browser forprofit out of the shadows and into the sunlight of our transparent judicial system for prosecution in the u. S. Brave men and women of dea will continue to do the difficult and dangerous work to address this threat. Thank you for the opportunity to appear before you and i will be happy to answer your questions. Your accurate weather expert five minutes. Sammy Ciaran Murphy rank member degette and members thank you for the opportunity to appear before you to discuss the heroin and fentanyl crisis in the United States and the upper u. S. Customs enforcement to bring to justice the criminal elements responsible for manufacturing the distribution of dangerous opioids. As the largest Investigative Agency within dhs security investigations and enforcement or the boehringer federal criminal statutes. Special agencies to investigate crossborder criminal activity and work in close quarters with u. S. Customs and Border Protection and the Drug Enforcement administration and the unified effort both domestic and international Law Enforcement partners to target criminal organizations that are supplying heroin and fence mall to the United States. I would like to highlight our efforts in the operational challenges that we encounter. The United States as you have heard already is in the midst of the fence mall crisis that is multifaceted and deadly. That analysis is scheduled to opioids used for medically severe pain relief and is 50 to 200 more times potent than morphine. We have identified two primary sources of u. S. Fence about threats china and mexico. China is a Global Supplier of the illicit fentanyl in chinese laboratories sell fentanyl. In china criminal chemists work around government control efforts by modifying structures to create substances referred to as analogs now recognize as illicit in china but have the same deadly affects bravo theres collaboration with chinese delacca plaza prohibit analog manufacturing for export is one of the challenges we face in stemming the flow of illicit fentanyl from china. Mexican drug cartels obtained illicit fentanyl in the cursory fence mall related substances from china and primarily use fentanyl as an adulterer into heroin produced in mexico that a cartels have discovered manufacturing fentanyl is much more costeffective efficient and draws less Drug Enforcement attention than heroin. Their southwest border is typically five to 10 in purity. Once solicited fentanyl is sold in the drug market and many people who use drugs or their heroin or prescription pain pills are unaware of the presence of more prominent fentanyl in their narcotic. As fentanyl users suspect heroin or counterfeit is more potent than the drugs they resembled readily leads overdosing and this is often how Law Enforcement learns that fence now or in analog has been introduced into a local drug market. The demand for opiates paired with a low cost and high potency affronts all using counterfeit production has led to compete for a portion of the illicit u. S. Drug market. Listed fentanyl is not only dangers dangerous for people who abuse drugs but also for Law Enforcement Public Health workers and First Responders who could unknowingly come into contact with it. Accidental skin contact or an inhalation of the substance during Law Enforcement activities are field testing of the substance is one of the biggest dangers and challenges we face in Law Enforcement. In response to the dramatic increase in the availability of opioids and drug policy in close coordinate with other federal departments and agencies develop a heroin availability Reduction Plan to reduce supply of heroin and the risk of fence on their sites. I. C. E. Has been supported since its inception. We are coordinating with domestic and International Partners in providing Field Training to highlight officer safety and collaboration efforts. I. C. E. Is the linkage with the dea special Operations Division and the cbp National Targeting Center to identify shipment routes marketing parcels that may contain heroin and illicit fentanyl and fence mall related substances and manufacturing materials that go into making those in the United States be fully exploiting financial analogies along the way. The crisis demands urgent and immediate action across Law Enforcement and interagency lines in conjunction with experts scientific medical and Public Health communities. Thank you for the opportunity to appear before you today and i look forward to your questions. Thank you very much. Make sure your microphone is on please. Thank you chairman murphy rank and member sub by the members of subcommittee thank you for the opportunity to appear before you today. The broad Interagency Panel here today demonstrates that this is a health issue a Law Enforcement issue and an International Issue this Opioid Crisis is perhaps our worst drug crisis in 30 years. He kills tens of thousands of our fellow citizens every year. Illicit fentanyl is responsible for many of those deaths and virtually all of that fentanyl is sourced from abroad. Foreign Drug Trafficking organizations. To solve a problem we must cut off international supply. That is where my inl hero comes into play. Our strategy is threepart. Work with the neighbors work with china work with the united nations. First, we realize that most illicit opioids reaching the United States enter through mexico and canada. Mexico produces more than 80 of the heroin consumed in the u. S. And mexican heroin Trafficking Networks introduced fentanyl into the supply chain. Since the start of the Merida Initiative corp. In 2008 we have developed a close relationship with Mexican Federal Law Enforcement. We have delivered hundreds of millions of dollars in border inspections and Law Enforcement equipment training and Capacity Building and intelligence exchange. Mexico invest 20 for every one of ours. Mexico has increased efforts to eradicate opium poppy and we recently agreed to expand those efforts further. Canada is severing its own opiate Opioid Crisis although most of its heroin comes from afghanistan. We coordinate with candidates to address the sheer crisis ensuring both governments have Statutory Authority to address the problem and sharing realtime Law Enforcement intelligence. And all three governments cooperate through the new north American Drug dialogue where we share information on Narcotics Research Exchange Best Practices and develop actions to protect our citizens. Second we have expanded cooperation with china from major fentanyl source countries. 2015 china moved to regulate 116 new synthetic drugs and on march 1 at this year it added for critical fentanyl analogs its domestic controls including sometimes described as fentanyl on steroids 100 times more potent than fentanyl. We asked china to do more but id knowledge these steps by the chinese government. They improve our ability to track and control fentanyl and other synthetic drugs entering the United States. We are also using targeting and sanctions programs like the narcotics drug. King pin authorities to target fentanyl traffickers. For nearly 20 years in china have coordinating Law Enforcement policies with the u. S. China joint teams on Law Enforcement and the dialogue produces valuable cooperation. Third and finally we are working through the u. N. System to regulate dangerous opioids and precursors throughout the world. I was in indiana for the annual meeting of the commission on narcotic drugs the governing body for all u. N. Drug policy. By a vote of 510 this cmd approved our proposal to regulate to essential fentanyl precursors. The entire process took four months rather than the normal two years but while the regulation will not stop illicit fentanyl production will be more difficult for criminals to obtain the chemicals to make it an easier for countries to profit. We also support programs for the uns Drug Control Organization to eliminate Opium Poppy Cultivation and heroin production in afghanistan Mexico Colombia and guatemala. Mr. Chairman and members of the committee we have an international strategy. You are committed to that strategy they do Welcome Ideas to improve that strategy. Ive learned two lessons in 25 years in engagement in interNational Drug policy. First it takes decades to get into a drug crisis and it will take years of patient persistent efforts to get out. Second no strategy is so perfect it cannot be improved. Thank you mr. Chairman and i look or to your committee suggestions. Thank you. Dr. Opioid and you are recognized. Chairman murphy Ranking Member degette at like to thank you for inviting me here today to discuss this very important issue. As the director of the National Center for injury prevention and control at the cdc that would like to thank the committee for their continued interest in the fentanyl and opioid misuse in prevention and overdose. As an emergency physician ive seen firsthand the devastation all over the country. Drug Overdose Deaths in the United States have nearly tripled in the last 15 years. In 2015 there were approximately 52,000 Drug Overdose deaths and of those 63 involved in opioids. Large increase in deaths seems to be primarily driven from heroin and synthetic opioids such as fentanyl. Fence dollars and opioid analgesic 80 times more potent than morphine is often administered in hospitals. Illegally manufactured fentanyl can be mixed with or sold with heroin and is fast acting. Overdoses can occur in seconds after consumption and that overdose from fentanyl is much more difficult to reverse because it is so powerful. Their rate of Drug Overdose deaths were than doubled from 2013 to 2014 in some states have seen a dramatic effect of this drug much more so than others. For example massachusetts experienced a surge in opiate related deaths from 698 in 2012 to 1747 and 2015. To examine this increased the Massachusetts Department of Public Health with cdcs assistance ended epidemiological investigation. Over 70 74 of those deaths in involve fentanyl. I reached a highrisk groups recently released from incarceration. The rise of internal heroin and prescription Drug Overdoses are not unrelated. In ohio cdc found approximately 62 of internal heroin Overdose Deaths were preceded by at least one opioid prescription during seven years prior to death and one in five people have had died from a fentanyl overdose had an opioid prescribed to them at the time of their death. The cdc is committed to three strategies to comprehensively protect the Public Health and provide all opioid and fentanyl deaths. The first approach is the quality and timeliness to better track trends identify communities at risk and evaluating preventive strategies. Cdc tracks reporting of illicit opioids overdoses including fentanyl. Improved surveillance is crucial for states to facilitate faster identification in response to spikes in overdoses leading to quicker more tailored the second approach is supporting states in their efforts implement Effective Solutions and interventions. The cdc has funded 44 states and washington d. C. For prevention efforts in surveillance act to these. For example we have funded all ohios Prescription Drug Monitoring Program to identify highrisk patients and they have achieved full Data Integration as part of their integration of the Electronic Health records. Our third approach is to equip Health Care Providers with the data and tools needed to improve the safety of their patients. To aid primary care providers and evidencebased prescribing practices cdc developed and published the cdc guidelines for prescribing opioids for chronic pain. In addition to the Critical Partnership with state cdc knows the epidemic requires partnerships across the sectors and we have been working sidebyside with Law Enforcement. We are working with Drug Enforcement agencies to implement Prevention Strategies and initiate the personnel exchange. The heroin Response Strategy which is funded by deployed eight high intensity Drug Trafficking areas involve Public Health and public safety. Cdc is working to coordinate Public Health workers on the ground. Successfully addressing this problem requires efforts and prevention. All three components Law Enforcement treatment and prevention must Work Together to reduce this threat. Wed have a Critical Role to play. Without effectively preventing more americans from developing opioid disorder in the first place will never get ahead of the problem. Without the invention more americans will require treatment often for the rest of their lives and more will overdose. Thank you again for the opportunity to be with you today for your continued support of cds sees work in protecting the Public Health to or to your questions. Dr. Company were recognized by ms. Fehr chairman murphy Ranking Member degette and members of asraff nasir thank you for inviting me to provide an overview of how science can help the stress my name is dr. Wilson compton and im the happy director of the National Institute on drug use. As a physician and researcher ive seen firsthand the devastating impact of the opiate crisis on families and communities and conducted numerous studies and trends on opioid use and waste to respond. What is fentanyl and its relationship to the Opioid Crisis . Fentanyl high potency and solubility allow it to rapidly enter the brain and lead to a fast onset of effects to increase the risk for overdose. Emergence of months now higher potency synthetic opioids creates enormous challenges for controlling supply. A small amount can cause largescale damage. Fentanyl is one part of the ongoing opioid overdose epidemic which also includes prescription opioids and heroin. While recent federal and state efforts have begun to help curb overprescribing of the prescription opioids overdoses continue to rise mainly due to the rise in heroin and in small related deaths. Efforts in this area part of a Broader Initiative of the office of National Drug control policy and the department of health and Human Services. The population of people using fentanyl largely overlaps with those using heroin so the strategies being implemented to address the ongoing Opioid Crisis are expected to help address fentanyl addiction and overdose. Nida along with fda cochairs the opioid subcommittee of the department for health and Human Services Behavioral Health coordinating council and in this role we help to coordinate interagency efforts. In research helping to address the opiate crisis nida has supported the development of the dedications that the fda approved to treat opiate production. All have strong evidence of effectiveness. Despite this effectiveness only a fraction of people at opioid use disorders are being treated with these medications due to limited treatment capacity stigma lack of provider training and cost. Therefore neither with researchers helping to develop strategies to promote wider adoption of these medications. For example initiating treatment in Emergency Departments has been shown to help ensure the people who overdose are effective engaged in ongoing treatment with their underlying opioid use disorder. Other studies have found that providing methadone while awaiting admission to a Treatment Program reduces opioid use and increases the likelihood of engaging in treatment. How can research and former response to fentanyl . Through nida Early Warning system we are supporting research to better understand fentanyl use patterns and trends in hotspots such as ohio and New Hampshire. In the first age of the New Hampshire study for example researchers reported that about one third of fentanyl users knowingly used the drug and may seek out a certain dealer or product when they hear about overdoses because they think it must be highly potent. What about overdose treatment . Although naloxone can rapidly reverse an opioid overdose the current standard dose of naloxone is likely not adequate to refer some overdoses from hype potency overdoses like vince an app in response we are supporting research to develop new longerlasting naloxone warm elation and new administration protocols. Nida supports research on prevention and treatment. For instance in partnership with the cdc samhsa and Appalachia Regional Commission nidas testis opioid misuse in rural america. Dishware Planning Research initiative to study treatment expansion models resulting from the Additional Resources provided the states by a 21st century care act. Research involves a way to develop a vaccine for fentanyl to keep fentanyl from entering the brain thereby protecting against addiction and overdose. In summary over 33,000 deaths from opioid overdoses occurred in 2015 with nearly 10,000 of synthetic opioids like fentanyl precise Bass Solutions are available. Neither will continue to work closely with the other federal agencies both those that are here today and many Others Community organizations and private industries to address these complex challenges. Thank you and i look forward to your questions. Thank you doctor. I recognize myself for five minutes. Mr. Chester does the omb believe the fentanyl as the fentanyl is another way the Opioid Epidemic . Yes sir it really is two things. It is an outgrowth of the heroin crisis and once fentanyl has found its way into the supply chain it represents a unique aspect of that particular. Do we have a comment, does the federal government have a Strategic Plan to discuss this unique issue . The heroin availability Reduction Plan included here on intentional as part of its problem set and that synchronizes federal activities against opioid problems and specific specifically heroin and fentanyl. Mr. Milione do believe we have a federal plan in place . I would think theres more to do based on this data in the level of threat. Deas priority and we have programs in place to deal with it but as ambassador brownfield said there is always room for improvement based on the need of the threat. Based on the data that our Law Enforcement looks at International Facilities at nine different airports in 2015 and 2016 i find it amazing that not one of fentanyl was detected. Is it more difficult than coming up with the target profile for fentanyl shipments and we know about it what can be done to improve it . Detection of fentanyl at the land border andpackages in the mail is a challenge that the continued deal with but i think we have Better Success in certain challenges than we do and others. Because customs and Border Protection gets advanced information from the express consignment companies their ability to target packages and bound to the United States is much better than our ability to target the mail coming from the United States because universal postal union that we operate under does not mandate international including china and others provided as information about packages and the mail. Would requiring that information help from the Postal Service . Can have to ask him who can answer this question for me . Wears a coming over the border in mexico. What do we know specifically . The two areas we have seen it most prevalent lady is in Southern California and southern arizona. The vast majority has been detected. How do they bring it across the border . And personally owned vehicles or people coming as pedestrians across the land border at ports of entry. Some people walk across . Some people come through legally through ports of entry, legally or illegally they are coming through . Where we are not detecting this between the ports of entry to at least take a minute designated points of entry and arrests are made by Border Protection. But another with places we are not seeing it. On the land border we are not seeing it detained the ports of entry. The other fentanyl is through express mail detected at consignment hubs where consignment packages are cleared through International Mail facilities around the essay. Most recent data comes from 2015. Am i correct or do you have more recent data from 2016 . We have data from 2016 at a Quarterly Report for 2016 to the National Center for Health Statistics and i think what is really helpful is the funding they receive this past year we have stood up surveillance in 12 states that looked at nonfatal data also. Thats been in place for six months. Do you think its recovery is not instantaneo instantaneous. Sometimes it changes the chemistry of the brain so that sometimes you need other types of tools to treat this, is that right . Yes it was really demonstrated that. And some of the states that it been hit hard the Medicaid Expansion has been able to help them target Addiction Treatment would that be fair to say . Treatment expansion is a shared goal for all of us in making sure the research we support is better than the Healthcare System is essential. After the passage of the Affordable Care act there are not able to pay 50 and medication treatment. In some of the states. Is that right . [inaudible] lets talk about ohio for example. In ohio, republican governor, john kasich recently said thank god we expanded medicaid because that medicaid money is helping rehab people. In fact, february 6, 2017 report noted that ohio added 700,000 medicaid recipients under its expanded program and roughly a third were diagnosed with a Substance Abuse disorder. According to the cbo the republican ac repeals proposal will cut 880 billion in federal medicaid over the next ten years. Would you disagree with any of those figures . Were interested in research that to look at changes in the Healthcare System. By what you disagree that ohio added 700 and medicaid recipients under its expanded program . A third were diagnosed with Substance Abuse disorders . Those figures unreasonable. So what im worried about is clear, if you reduce the Medicaid Expansion in states like ohio, kentucky, West Virginia, other states that have been hardhit by federal, opiate and harrowing, thats also going to reduce the Treatment Programs were able to give them. Thank you. Your rights, we cannot arrest our way out of this. As a followup, do we have enough providers . Does anybody know . We know that half the counties dont have psychologist and psychiatrist and social workers. We have enough trained drug treatment providers in america . We do not have enough to fully meet the needs and were not spread across the country. Thats why we want to address the shortages in rural areas. Treatment is important but preventing people from needing Addiction Services in the first place will save the Healthcare System a lot of money so making sure we are using say prescribing practices. We have seen opiate and heroin epidemic beverage every part of our country. Even in affluent areas like Orange County, california are struggling with over 200 deaths per year. Now we are witnessing a fall deadlier intervention. This painkiller reserved for the most severe and acute pain are being added to heroin, cocaine, confit drugs. As a mother for young adults, it breaks my heart every time i see or hear of another life loss. Just last year the 19yearold from Orange County overdosed after tanking but not least cocaine. This epidemic again hit home on a dea investigation resulted in four arrest for an alleged fentanyl importation a disparate trade distribution in long beach. They reported the men had over 30,000 acetal fentanyl tablets and 13 kilograms of the narcotic. Mr. Maloney, i want to commend your agency for this investigation and keeping this deadly drug off the streets of Orange County. Mr. Maloney, the making and distributing appeals containing but now has been discussed by molding the pills in a variety of counterfeit brands and colors. What are the most prevalent pill types be discovered . It is a broad range. Oxycodone, they will mimic whatever is popular in the street, depending on the market in area. If there is a market for oxycodone, theyll replicate those. Its more powdery substance they want to capsule because i want to start it . That market will influence other package it. What types of pill making machinery and most commonly associated with his counterfeit drug operations . A broad range. And were from an extensible machine to ones that cost ten or 20000 that can produce 250,000 pills per hour. Some are handheld and can be easily used. Its a broad spectrum. What are the most likely sources of these confit drugs . China is the primary source for the fentanyl, but then going into mexico and the networks are shipping the merchandise into the United States. Were seeing more and more as the pills, the counterfeit bills are being made in the United States at different domestic transportation cells run the country. Doctor, we understand that this typical victim of a fentanyl overdose can be extremely hard to define since it does not follow economic structure or community locales. What can you tell us about Current Trends and tendencies . Your rights. This epidemic increases in all demographics. The most hardest hit and those the 20 to make 44 and those or those 25 44 more seen more and men. Whats important for people in rhode island weve setting one third of the decedents had a prescription within the past 90 days from opiates, third of those had a high dose of morphine equivalent prescription. So weve talked about being cautious of being exposed to opiates and then going on to fulfill their addiction to heroin and fentanyl. Mr. Chester, and recement bunton all was identified as a major problem in the northeast, parts of the midwest, answered states like florida and maryland. What you see is trends or directions of its spray . We have seen indication that is moved west, sacramento, california was the first about a year ago. Weve seen it move further west. But no on its way to the north was because it was easier to mix into the powdered white heroin that was popular the northwest letter northeast part of the United States. I think were beginning to see more the pill form that they were discussing as well. Fentanyl, even though it began being geographically concentrated in the northeast we have seen indicators throughout the United States. A youll back my time. Thank you mr. Chairman for calling this hearing thank you to our expert witnesses for shining a light on this. It does feel like were in the Twilight Zone because thats where talking about the seriousness of the opiate epidemic, we are faced in todays with a vote on a health bill that will receive in this country responsibility and Health Services to families who are addicted, who need Substance Abuse treatment, Mental Health treatment. Mr. Chester, you said only one and nine are receiving treatment who need it. You say that we have to reduce demand as part of a balanced strategy, yet this gop healthcare bill that is coming to the floor will take a hatchet to coverage for millions of americans, plus it will and medicaid Health Services as we know its that provide come in florida and most states, the most important Mental Health and Substance Abuse Health Services. This is very important, but this bill coming up for a vote that would take us backwards when we are talking about opiates. One of my local sheriffs in st. Petersburg in clearwater, we cannot and never will solve this problem at the lawenforcement level. This needs to be treated as an addiction problem, Mental Health problem. We may have had Great Success in beating back the pill mills, but all that meant is were going to see a switch to different drugs and different dealers. I wanted to highlight whats happening in West Virginia. Its startling. Theres a good Investigative Reporter shining a light on. According to a december 2016 article in the charleston gazette, male opiate wholesalers ship mass quantities that seem to be for an excess to what people in West Virginia shouldve received. The article says, and six years drug wholesaler showered the state was 780 million hydrocodone and oxycodone pills while 1728 West Virginians fatally overdosed on those two painkillers. The of feathers shipments much of 433 pain pills for every man, woman, child in West Virginia. This reporting suggests that West Virginia appears to have been receiving quantities of hydrocodone and oxycodone pills that would clearly be more than whats medically necessary. Are you familiar with some of the reporting that suggest West Virginia may have been grossly oversupplied with dangerous prescription opiates . I am. This is shocking. It would appear that addiction to pain pills can come according to the reporting and what you have testified here today, that once you have axiom hydrocodone that takes over someones life, that we quickly lead to the user seeking more powerful opiates such as heroin or counterfeit pills. Both of which may be adulterated with fentanyl. Doctor harry, in your testimony, you say reversing the epidemic requires changing the way opiates are prescribed. Is it therefore reasonable to assume that prescription pain medicines has a connection to the fennel problem in the larger opiate epidemic . Yes. Many the people who have overdosed on fentanyl have had an opiate prescription at the time of their death. I believe all of these fentanyl, heroin and prescription opiate overdosed deaths arlington. Msnbc ran a story about the influx of the opiates in West Virginia on a small town of kermit. It only 392 people. They reported that they received 9 million hydrocodone pills in two years. If this reporting is true, its hard to believe that we have sufficient systems in place to spot dangerous trends. Is the dea familiar with reports regarding what happened in the small town . With the oversupply of addictive pills and what can you tell us about a . I am familiar with the report. Familiar it has happened in many locations across the country. We have an obligation across the supply chain from the manufacturers. What is happening with wholesalers . The wholesalers have to uphold the regulatory obligations. Weve taken action recently against to the big three, mckesson cardinal. I hope is their compliance programs like any good corporate citizens would work to prevent diversion and would uphold those obligations. Such is the wholesalers. We have to go down the supply chain to maintain this distribution. Its complex and challenging. We are well aware of issues across the country. Thank you. My time has run out. Thank you mr. Chairman. Let me start with you, i dont know if we can get this matter of the opiate deaths from 2015 on the screen. The map is almost counterintuitive to me. We talk about, thats not the one, is the total opiate deaths in 2015 just for the purposes of illustration. Thank you. Almost counterintuitive, six of the states with the lowest numbers, go back once i please. Six of the states with a list numbers, of the six, for our border states, texas, california, north dakota, and montana. It would be counterintuitive to what we talked about things that are coming in across the border. Also if you look at the map it seems like there is a bullseye on the midwest. What are you doing to interrupt the supply chains that seem to have targeted a portion of the country . You are right, its not staying at the border where crosses, is going to locations around the country. The midwest is increasingly getting hit. Now the west is also getting hit. We are applying lawenforcement techniques and work with our federal partners infiltrating the supply chain and looking for the distributors in trying to disrupt them with the judicial process. Let me ask a question, thank you for being here today and i just for the record, you are correct the cit state departmen, correct . Thank you for your service to the state department. The secretaries in china or has been in china recently, your testimony today written testimony provided in your verbal testimony kind of indicated that perhaps things were looking up. There were positive developments. I guess im just not feeling positive developments. In fact, please dont arrest me, but i went online and looked at how to order fentanyl online just as were sitting here. There are a lot of opportunities. I suspect those opportunities, many come from asia or china. Mr. Brown phil, do you think were doing enough to interrupt those . I will say that we are starting close to. 0 in terms of our cooperation with china. We have moved in a positive direction. Were dealing with a country that has somewhere between 170,400,000 companies that produce pharmaceutical somewhere in the peoples republic of china. As recently as two or three years ago, there was virtually no control over their production whatsoever. Since then, 116 synthetic drugs are now controlled by the chinese government. Within the last month and a half, for new ones, including important fentanyl analogs are now controlled by the chinese government. We have a dialogue, were talking to one another. Three years ago their answer, which by the was not unusual around the world is, we do not have offense no problem and therefore we are not interested in cooperating with you because it is not being abused in china. Weve gotten abou around that. We are not where we want to be. We have not yet solve the problem but are we ahead of where we were two or three years ago . On that, say yes. I think you for that effort. I agree with you that is a positive development. Given the distribution aspects on our United States map, is it possible, and really for anyone on the panel, is it possible to identify from which laboratories are manufacturing houses overseas, which are causing us the greatest problems in these areas were seen on our United States map . Does anyone have an answer . Thats a great question. To build on what the investor was saying, on the lawenforcement side weve had tremendous success getting leads from the chinese of usbased recipients of the fentanyl. That is a huge step forward and allows us to uncover the network in the United States. We have had successes uncovering what those labs are in china, we been working cooperatively with our lawenforcement counterparts and i please with the direction that is going. From the limited time remaining, both of you talked about fentanyl use patterns, im a big believer in Prescription Drug Monitoring Programs. Its important to have drugs like fentanyl available. We are grateful for their utility in clinical settings. Clearly they have to be used appropriately. Do you have a sense of what i was talking to the dea state department about, do you have a sense where the use patterns are occurring . Are you able to target limited resources so that perhaps we can have Early Intervention progra programs . If youre in the house but i think its a good idea. If youre in texas that might not be as important. In ohio we were able to do that. We did abandon counties that have highest rates and were able to help guide ohio to her to focus their efforts. In massachusetts we also saw there is a high rate of Overdose Deaths in those recently incarcerated about 50 times of other populations. We are able to use the data for that. Prescription drug Monitoring Programs you can see people at risk for opiate use disorder and how that link. Are you . What were doing another program has been a place for two years. We are in 44 states and getting data that is quicker and better able to be used by states and letting states focus on evidence. Im over time, honestly we authorize in 2005, should be just recently. The shouldve been an ongoing exercise over the past decade in my opinion. Want to put together couple of pieces. The lady from florida West Virginia mention this tremendous prescription rate, massive amount people up another chart here of disability rates in the United States intentional, the county those there is West Virginia one of the highest in the nation. What doctor burgess just point out the deaths occurring there, makes me wonder is youre talking about collecting data how much more dated you have to have . Using these targeted areas where the amount of prescriptions is way out of control. Its way out of control. Yet, these deaths occurring are there any teams going into these places and identifying whos writing these prescriptions in the death second from this . Absolutely. Weve had teams in ohio, massachusetts, rhode island, given specific information to the states. West virginia . I did a site visit myself out there, we been working with each state to look at the Prescription Drug Monitoring Program. If you look at the guidelines, 18 states adopted or implemented aspects for safe prescribing. Were starting to see significant improvement in things like kentucky, thursday to see funding. The Monitoring Program has a alert to if they have a high morphine equivalent to make sure people are getting safer prescriptions. Thank you mr. Chairman. Want to thank all of our witnesses, this is been very important issue. Its an important fight for our communities. Obviously the lawenforcement piece of figuring out how we can stop the entry into our country the components of fentanyl is important. Want to say again and it has been said many times before, this is a very Serious Health issue. To my republican colleagues, we face the smoke coming up on thursday, we have to recognize the importance of the medicaid program. Its a secondbiggest pair of drug abuse treatment in the United States. Offended roughly 25 of public and private spending on drug abuse treatment in 2014. We talk about West Virginia, were talking about a lot of lowincome people. Medicaid is a source of help for them. For my home state of illinois, medicaid has been vital. To address Substance Abuse. Medicaid expansion has provided coverage to 650,000 lowincome adults in illinois, one third of whom have Mental Health or Substance Abuse disorders. Thats just the typical percentage all over the country. Without medicaid these individuals will be marked lead to end up in Emergency Rooms or jails which are drive up costs for states and local budgets. Its clear that in illinois we need to be further expanding access to Substance Abuse treatment. Im sure thats the case in many other states around the country. From 2014 to back 2015 illinois on 20 increase in the number of deaths from Drug Overdoses. So yet the republican childcare proposal would decimate the Medicare Program which serves one in four people in illinois. One in four. The republican bill would have Medicaid Expansion and propose a capital funding. I want to go more on about that. Its been address. Doctor thompson, wouldnt you agree, solving the fentanyl and opiate addiction problem requires that we also ensure that people have access to appropriate Substance Abuse treatment . Given the underlying issues and opiate use disorder, treatment is a key component of solving the problem. And in your testimony stated that the rise in fentanyl, heroin and Prescription Drugs evolved overseas are not unrelated. Im sorry, overdoses, not overseas. The rise intentional Prescription Drug involved overdoses are not unrelated. Would you agree that in order to solve the fentanyl crisis we must also add address the larger opiate Prescription Drug epidemic . Yes, i think a comprehensive approach is needed. Prevention is the key aspect of that. I wanted to ask doctor compton, how harmful would that be for a patient with an opiate disorder to have to discontinue his or her Substance Abuse treatments . One of the key productions is recidivism. When they stop treatment there at high risk of relapse to their addiction problems and criminal behavior and other serious problems. A very concerned and also on the committee, we know they proposed an 18 cut in hhs, 5. 8 billion cut in the National Institutes of health. My understanding is that youre actually doing some research, dont know if the right word is vaccine but some sort of prevention, against opiate addiction, is that true . We have research where it could lead to an approach to keep the fentanyl from getting to the brain. The goal is to keep it in the circulatory system so antibodies attached to the fentanyl keep it out of the brain. Again, i want to thank all of the people who are here today testify how you want to stop it before it starts and understand all the sources. Also interested in the Health Services. I want to thank the witnesses again for your testimony and answers to our questions. The fentanyl threat you describe to us is the third wave of the opiate epidemic. It seems to me in individual states and ive looked at maps theyve seen different a aspects. Some are facing it head on right now. Others are against Prescription Drug or heroin overdoses. So are we better off to look at this is a statebystate basis. I realize theres natural implications but theres some real hotspots in the states. When we think of a strategy to combat it, should be multiheaded and look at this opiate epidemic in that way or look at all of the above or onesizefitsall . We look at it as a complex National Security and health interest. At the same lovers theres unique environmental factors that cause different manifestations of the opiate problem. As you point out there is fentanyl in some states more than others. Theres theres heroin. The factory seen evidence in some places that heroin deaths are prominent and sometimes in the implementation of our planes we do two things, we try to respond to unique aspects of the states environment and also develop a framework to share Lessons Learned from one state to another. So absurd states found to be successful with their aspect of the problem can be shared with other states who may not be facing that particular problem but may sit in the future. Thank you. Ambassador brownfield, i want to commend the state department and the good work that you have done recommend the dea for the recommendation on the march 16 commission for controlling two primary fentanyl precursors. I want to thank the chinese for many with the ambassador we sent a letter thanking them for their work to shut down some of the facilities. What you hope will be the impact from the un recommendation for the fentanyl product in the u. S. . First, the risk of shamelessly pandering to you think it to the letter to the ambassador. It makes my job enormously easier when they hear directly from you. What do they expect from the cmd decision to control the two precursors . We have to wait another 170 or 168 days before its fully implemented. This is a time during which the 185 Member States of the un part of the cmd have endorsed or ratified the treaty spray they have the right to seek a exception. I dont excep expect anyone to k that because the vote was unanimous. When it comes into effect the countries that produced the two precursors, the two most prevalent precursors in the prinproduction of fentanyl in te world will be required to control, register, license, verify production of these precursors there. Which two countries are those . The two precursors. The most important countries china. Which, in fact did support, and assist us to some extent, and lobbying for the passage. What will happen at that point in time, is whenever company, and a company in the world is going to export either of these precursors, the government of the country where it was produced will be required to notify the National Authorities of the country to which it is being exported. Will have to provide the basic data and information. How much, when, who is the receiving party the route by which it will be shipped, that allows national authority, in this case hsi or dea to determine what is coming in doing the Due Diligence to verify this is a legitimate and legal sheet shipment. This is why said my oral statement this is a way to shutdown the diversion of legal and illicitly produced fentanyl. They tried this with it made a big difference when you put pseudoephedrine behind the counter and required a prescription. That change the dynamic in terms of individual cooking operations that we are polluting homes and killing people. I commend you in the state department and the governments of all for taking this step. We look forward to be partners with you going forward. I youll back the balance of my time. Done on. Sorry about that. The problem with the microphone. Thank you mr. Chair. Im satisfied were holding a hearing today because it is literally a a life or death issue for my constituents. My hometown of amsterdam, new york from a Small Community of about 18000 people, we have had for overdose death and another dozen overdoses in the month of december alone. At tha if that rate were maintad for an entire year, one in every 375 individuals in my hometown would perish. These overdoses were all attributed to fentanyl. One in 375. When you drive down the interstate in my district, instead of billboards advertising for taco bell, you see billboards for opiate overdoses. Eyewitness people taking their first steps of recovery in a bilateral i have to pass that race the arbitrary limits on the number of patients a dr. Can treat for opiate use disorder. Bearing witness to the Success Stories fuels my drive to push for policies that will expand the recovery opportunity for everyone. That is why i found it astounding that in all of the witness testimony today, the word medicaid was mentioned just twice. Both times in the context of Prescription Drug Monitoring Programs. We can talk supply reduction all we want, you cannot talk about a federal response to the opiate epidemic without talking about medicaid, which is the largest pair for Behavioral Healthcare services in our country. In your, medicaid pays for 30 of all medication assisted treatment for opiate use disorder. In new jersey, is 22 . Indiana, 17. I could go down the list, but you get the point. As my colleagues have pointed out, theres a huge elephant in the room. The term care bill being asked to vote on will be the single most devastating piece of legislations two individuals struggling with addiction. Trump care would eviscerate treatment for individuals struggling with opiate addiction by ending the Medicaid Expansion, repealing guarantees of Mental Health and Substance Use benefit, and getting medicaid to the tune of 880 billion over the next ten years alone. You dont have to take my word for it. The American Society of addiction medicine, a professional society representing 4300 professionals wrote to congress saying, we are concerned that rolling back the Medicaid Expansion and the requirements in cap a federal support will reduce coverage for and access to Addiction Treatment services. Changes that will be particularly painful in the ongoing opiate epidemic. Rolling back the expansion and fundamentally changing the structure to cap spending will reduce access to evidencebased Addiction Treatment reduce much or all progress made on the opiate crisis last year. The Mental Health liaison group, wrote, and i quote, the hca would leave without coverage 1. 3 million childless non impregnated adults with serious Mental Illness who are able, for the first time to gain coverage under Medicaid Expansion. It would leave uncover the 2. 8 million childless nonpregnant adults with Substance Abuse disorders who gain coverage under expansion for the first time. Turn Ohio Governor quote, thank god week spent a medicaid because that money is helping to rehab people. Former arizona governor, no ones idea of a bleeding heart affects are most vulnerable, elderly disabled, childless adults, chronically mentally, and a drug addicted. It will simply devastate their lives and lives around them because theyre dealing with an issue thats expensive to take care of the family with no money. I could go on but you get the point. I would, like to order into the record this letter from 415 addiction groups nationwide opposing trump care for the devastating impact that trump care would have on treatment for the opiate epidemic. Without objection. From my vantage point, there is no one outside a three block radius of this Capital Building that thinks that trump care is better than a raging dumpster fire. No one thinks this backroom bill will improve the lives of those struggling with the disease of addiction. I yield back. I do want to note for the gentleman, the article referenced before you seen it from the Washington Post, says important take away is that theres that one opiate epidemic, but several. What that means is it will require a strategy to make sure that we Work Together to make sure states have the flexibility to do what they do. So i will work with you on that. I recognize mr. Carter of georgia. Thank you mr. Chairman. Thank you for being here on this a very serious subject. To start by talking about the leak of marketing fentanyl. One of the questions i have, i cannot remember who it was that mentioned youre working with wholesalers with cardinal, mckesson and trying to make sure theyre doing their part and accurately pointed out you have to follow it through the supply change. As a practicing pharmacist thats very important. Have you been in contact with any of the manufacturers, janssen, or mylan makes a generic, but how much they are able to manufacture and put on the market . Not seen a large scale, widespread diversion fentanyl. Its diverted for personal use mostly. What were doing is the clandestinely used. We have issues that come up and were happy to work with them. Thats important for couple of reasons. Id be remiss if i didnt point out one of the problems we had at the dispensing level is not been able to get enough of the product so people who truly need it, Cancer Patients and those truly in need of it we would run short because they put monthly limits on us or something. That was really a tragedy as well. I hope we keep that in mind as we go along. One of the things i was involved with is a member of the legislatures our yearly update of dangerous drugs. One problem we had was identify the analogs. That has to be a challenge. In one of my other colleagues mentioned about the precursors to it, control that. One of the abuse substances that i was chasing was synthetic marijuana. Identify it and added in to the dangerous drug list and then the next year they came out with something else. I tried to identify the molecular structure and say anything with this and still it was so difficult. Can you address that . Sure. This and that x thread outside the fentanyl threat which is significant is massive. Weve identified about 400 substances. Its a misnomer to cause synthetic marijuana. You have a whole series. Its a major problem for us. The same criminal,s tweaking the structures are doing the same when we schedule those, is a very dangerous one hit can send someone into, or have a violent reaction. Its a big problem for First Responders in a devastating problem as it sold legally. We had deaths in my districts, five death single account cousin that, theyre buying it at the convenience store. We cannot keep up pace with the emergency schedule. Where just chasing our shadows. Real quickly, from what ive been told by some of the drug agents in georgia, part of the problem is with marijuana coming over some of it is laced with fentanyl. Thats a big probe problem, im a big opponent to the legalization of marijuana. I think its a gateway drug. Nevertheless it seems to be a problem. Before i run out of time i want to get to the subject of mail order drugs coming through the mail being delivered to patients houses. One of the biggest culprits, the virginia. In georgia, three out of the five facilities that deliver drugs through the mail other virginia clinics. That is a concern is something we need to dress. We have opiates coming through the mail being delivered and left on the four from porch of someones home not even having to sign for. How much of a problem have you found with the drugs coming through our mail system . On the virginia issues we have a number of open investigation issues and are trying to work nationally at the headquarters, those are areas of significant concern. I think thats distinguished from the trafficking of counterfeit drugs that often move through the mail. We talked about going online there is a plethora of Online Pharmacies that are appearing to sell legitimate pills when in fact there counterfeit. Those are moved to the system in a daily basis. I want to say that is a problem. This committee of this Congress Needs to be looking at mail order prescriptions and was going through our mail now. I yield back. As pharmacists see that, perhaps youd be picking up patterns of prescribing in the community and you would notice the massive amount coming through but you would not see that at a mail order system at all . Am i correct . On a mailorder system, in other words, pharmacies that are mailing through, if theyre legitimate, they should be keeping records of whats going out. Saw pharmacy may not necessarily see if people are getting mailed and. Absolutely specially was more than one. The p bmps helps especially if we can do it over state lines. We recently started that but floridas estate thats not doing it. Thats a problem because its a big problem down there. I recognize the vice chair for five minutes. I want to thank the witnesses for being here today. Very serious subject. I have to refute some things that ive heard today. I think we could. Apples gorgeous will try to bring in fentanyl and open opiate abuse into the debate whether you want obama care, American Healthcare act. What ive heard repeatedly is somehow Medicaid Expansion has helped solve this problem come about the math map of data that doctor burgess put up, and i have a paper copy here shows us thats not the case. I think its apples and oranges. I dont think obama care caused opiate abuse can i dont think its can solve it on its own. Were trying to find the answers today. I dont think the American Healthcare act will be able solve it on its own. When you look at the states where the deaths are, if you just get to play games of numbers, the expansion states have more deaths in the non expansion states. I dont think thats fair, but i think what my colleagues on the other side of the aisle about us causing problems about the American Healthcare act is irrelevant to our discussion today. With that being said, you mentioned the commission that youre working on a project, what are you doing thats my turf in part. I represent the appalachian regions of southWest Virginia which border hotspot areas for opiate abuse in kentucky and West Virginia. I remember a meeting in virginia is a lovely town that can be a group to look at this issue several months ago. Our initiative is a Grant Program to look at demonstration to improve the Public Health infrastructure and determine how good a job that will do to address the crisis in rural parts of the country. The commission will be go find in this along with the cdc and others taking the lead on it. We appreciate it. Its a significant problem. One of the issues that we need to look at is whether or not the folks started off because of the higher a for disabilities as well people have done a lot of manual work and they get a prescription and then they get hooked. Doctor, you indicated in ohio that 62 of the people who died from heroin or fentanyl had come in the last seven years had a Prescription Drug for an opiate. Can you tell us more . Weve seen this in many states, like in rhode island a third of the people who had overdosed on fentanyl had an opiate prescription within three months and a third of those had a high dose opiate prescription sure that people that are in prescription opiates get addicted and then can go on an overdose. And sometimes their prescription runs out but there hooked. Is there some way we can connect the doctors recognizing that the patient just got hooked to get them to help . Of this prescription just stands and nobodys alerting are those folks going out buying it illegally on the streets . Thats why we have our cdc prescribing diet guidelines. If you have a patient that you suspect one of the things i have been proud about his although there were funding the states to do whats important each month we do Technical Assistance call to help them with scientific expertise on where to focus resources and where the best evidence based treatments to share best practices. As we see Different Things emerge we can share those. Data does drive action. I heard a stock but should this be a national or state approach . New hampshire is number 20, the following your number five. We need to give states the flexibility to deal but we need to have the overall approach. Thank you. I apologize if i messed that up. I would be remiss, why think marijuana is a dangerous drug, think your testimony indicates fentanyl was her number one concern. Its not your jurisdiction so its a rhetorical question. Why dont we let there be more research on marijuana and the ability to help patients weather in uppsala here pain. While i think its a dangerous drug, i dont think its as dangerous as fentanyl or other opiates. We do support any approved research along those lines. We will continue to work with researchers on those things always support that. Mr. Chairman the problem is a schedule one drug makes it tougher than if it were scheduled to like fentanyl and other opiates. Thank you mr. Chairman. The affordable character the expansion of medicaid extended Health Insurance coverage to hundreds of thousands of americans in need of treatment. Im concerned that if the money is cut for medicaid which is what the cbo says what happened with the republican bill, patients could lose access to care and this can make the fentanyl problem worse. So doctor compton come in your testimony is states opiate addiction is a chronic condition in patients will need ongoing treatment for many years. But could happen if their treatment was interrupted because the patient no longer had healthcare coverage for Substance Use disorders . We know when treatment is interrupted or stopped whether intentional or unintentional the relapse is extraordinary. Some Health Experts estimate 1. 3 Million People are receiving treatment for Mental Health and Substance Abuse treatment thanks to Medicaid Expansion. Our efforts to curb this could be impacted. Should the aca be repealed to clearly expect the opiate crisis to worsen . Again, the people who are currently being treated for an opiate abuse disorder were to lose coverage, would we expect the number of overdoses may increase . I hesitate to make a different because theres so many roles here on how things will be generalized. Our goal is to make sure the research we support is implemented the matter the Healthcare System. Is the state of West Virginia as an example because it was hard hit by the opiate epidemic. February 6 article reports that West Virginia has the highest opiate overdose death rate in the nation. Let me ask doctor, are you aware that West Virginia has one of the highest death rates for opiate overdoses in the u. S. . Yes, and that same article reports Medicaid Expansion as had hundred 73000 people from West Virginia the program. Its about one third of the entire states population. According to the article, doctor, and 2013 the first year that West Virginia expanded medicaid the number of people in treatment for Substance Abuse fell from 16000 to 17000. Increase use for services with suggest a thousand West Virginia went without needed treatment prior to the Medicaid Expansion. Would that be a fair assumption . We think about states like West Virginia point out the role aspects make it complicated to deliver services. Im proud were able to implement this new Research Program in rural areas. It would appear that medicare is essential in the fight against the addiction which would include the growing problem of fentanyl. My last question is if West Virginia were to lose the services would we expect the open and fentanyl programs were said assuming there were lost medicaid coverage . I cant speak to the coverage issues but individuals were treated if you stop treatment abruptly that could be bad. The republican bill with regard to expansion eliminates essential services guarantee. What we have found the swimming you dont have the guarantee the first thing to go is behavioral services, drug treatment, Mental Health services, things that are expensive the states and provide until we set a Medicaid Expansion that they have to. I think between the cutbacks that would occur because states to be getting less money, theyre going to get less money, they dont necessarily have to cover people depending on their income as they reduce Medicaid Expansion population. Even with traditional medicaid if theres no guarantee of essential services the first thing that is cut back his treatment for drugs. Thats my fear. Thats why think this is devastated if we try to deal fentanyl these other opiate problems that we have. Thank you mr. Chairman. The governor yields back. Thank you to everyone on the panel for your important work. I must say that fentanyl is not a new problem. I was u. S. Attorney is several districts from 2001 until 2007. I learned about fentanyl them. You, wouldnt talk about it much. The way we focused on methamphetamine and the dangers to children, the environment, but were not talking about is the danger. We talk about the overdoses but can we talk about truly how dangerous fentanyl is as a product. I realize against icy because we use it in medical procedures. Having just been with Law Enforcement firefighters this past weekend, there are dangers and is that not why youre doing training . Can you talk to us about the dangers of fentanyl and why havent we, for a long time talked about the danger. I dont think attics and their families really have understood how incredibly dangerous it is. I say the lawenforcement community we have been. Since the recent surgeon fentanyl one of the things weve gotten out largely following the da is making awareness are personal generally what they could be encountering. Press operationally its changed how we do our work. One of the investigative techniques we have done historically is to purchase drugs, whether online or more domestically. We stop doing that because of officer safety concerns we have that could be inherent to an undercover agent buying drugs or state local officer by drugs and not knowing what theyre purchasing. Theres a challenge for us from the perspective of field testing. Gone are the days of agents pulling out of pocket knife and probing that package of suspected drugs and putting that into a test kit. We, ths and within Border Protections have taken the lead on trying to examine, explore the field now on intrusive testing that would allow us to go to a test were agents dont have to physically open a package to determine with the substances. Why is there surgeon fentanyl . What is your, and dea, what would you say was the cause behind the search that we have been seeing . Its a free market principles applied to mass profits that can be made. Cartels and criminal groups are exploiting that. They aggressively market the small amount of fentanyl they dont want to deal the massive bulk of heroin. They can get more profit out of it. They dont care that its killing their customers . Its very callous, but its the cost of doing business. I think some of the medical professionals on the panel would say theres a perverse, sometimes reaction when people overdose from high potency fentanyl. It sometimes attracts more attention to that product. Any idea what the stats are prominent cases we have been charging in the past year or two causing death . Federal cases where were actually prosecuted drug traffickers for causing death. Out have to get back to with statistics. We are doing more around the country. Working with u. S. Attorneys offices, were engaging with u. S. Attorneys trying to get them to lean forward and work cooperatively on that. Its definitely more focused on. Heroin death or fentanyl death. It would be the last distinguish the kind of analog i think also is helpful to have the medical examiner. Was it an intentional overdose or other paraphernalia its really up to the laboratory and the training as well. You are doing a great job for us to. Does the dea have precise data on how much fentanyl is coming in directly from canada . We dont know exactly what is coming in that we know we can get those statistics to you. It is in perfect though to be able to get it in so having flown over the entry into seeing the amazing ways people will find that waterbor waterborne. A significant amount of coming across. China and canada across the border. Do you have numbers on how much has been interdicted from canada and are there hot spot among the border . With the components have coming from canada is rarely coming from assignment and not necessarily the physical land border. In your written testimony you mentioned that i i. C. E. Has sent all related investigations. Can you talk more about this investigation and extending the coordination with canada . We work with the department in that effort and we are meeting with the mexican counterparts and chinese counterparts as heard today. I think expanding the information with the source and transit countries is going to be part of how we improve what we do and recognizing some of the fentanyl that makes its way to the United States from china or other places also is the same stream that makes its way from canada into mexico as well. Its great to have a border neighbor we can work pretty well with. I would add one of the things that has distinguished is that canadians have come to us to talk about having a very similar problem that we are. The act aims to stop the shipment of the synthetic drugs and those like fentanyl sent into the u. S. The bill would require shipments from Foreign Countries to the system to apply the advanced data like where its coming from, who its going to and crossing the borders into the u. S. How would this information help target for drug shipments. They take the lead on interdiction by giving the advanced information that they could use at places like the National Targeting Center to be more objective and efficient targeting what is coming into the United States. One of the things that constrains the ability of what information the Postal Service has an advanced my understanding of the act is it would require us to update through negotiations and the state department to provide more timely information in the targeting. Are ther are there additional steps congress should consider along with to assist the efforts to stop the shipments . Anyone . Thank you mr. Chairman. I yield back. Now the member on the full committee for five minutes. Thank you mr. Chairman. Thanks for allowing me to ask the questions and i appreciate the panel being here. This is such a very important issue. They want to get the message out and i think that is the most important. If you could answer that question i would appreciate it. As i stated earlier, the components how we are dealing with this is to provide treatment for those that are addicted to these drugs and stop the flow of those coming into the United States. In terms of prevention, one of the methods used is funded and managed by the Substance Abuse Mental Health administration with thousands of communities around the country as a Prevention Program that is focused on the needs of individual communities to require local solutions in the coalition of the Community Members that are focused on the needs of the particular community not only to raise awareness of the issues but to prevent the primary drugs used focused on the demographics of about 13 to 17yearsold, which is the targeted demographic. Its a very effective program. Okay, very good. Mr. Allen, as you mentioned earlier, china announces the intention to ban the different types of fentanyl. Can you describe the working relationship to prevent and treat and are there mechanisms to hold china accountable . Our relationship on the working level has been tremendous. The administrator was met with the counterparts as a result shortly there after working in the state department they agreed to schedule these and it is more potent than morphine. This is a significant step. The other positive thing is when they initiated the investigation there had been a bilateral sharing to the domesticbased distributors that are ordering fentanyl and that has helped to flesh out the networks and now the investigations are ongoing as we have been pleased and hope it continues and certainly it can expand. And i would only echo that on their way to the United States and weve been able to use that information to identify other individuals and organizations that have received shipments from the same origin in china that has allowed us to begin the investigations. Finally, congressman, if i could add one more. A little over a year ago, we reached a bilateral understanding of the chinese governmentbacked they would control the delivery of products from china to the u. S. Even if they were not controlled in china. If they were controlled in the u. S. For exchange which we made the same commitment to them. It is not enforceable but it is an agreement been reached between ourselves and the governments. Thank you. In your testimony you noted that they are committed to giving providers and Health System the tools they need to improve puppy opioids are used and prescribed. Can you discuss the tools and how they can take advantage of the tools . Absolutely. We have an approach one is through the education we have been working with the director of medical schools on the the Clinical Training and effective Pain Management and prescribing practices. We also developed the seven education seminars available for free on the website and with the pipeline itself, i know you have to have something that you can use so we have a checklist thats been downloaded more than 25,000 times by the provider to use, and we also have a mobile app on the phone around the guidelines. How do you talk with a patient about ththe patientabout the din whether or not to give the calculated appropriate opioid to give, and we piloted the Community Education program and awareness about the risks of opioids intensity that were the hardest hit. I would like to talk to you about possibly coming to my area if you havent already. I would welcome that. Thank you. I was yield back. I just want to respond to what the colleague said. Certainly nobody thinks that the shocking increase in opioid antiheroine is in any way related to the aca. We recognize and some of those areas we have the Medicaid Expansion rv areas that are read on the map and that is quite disturbing. Our point is if we are to treat these folks getting addicted that its important they have access to medical treatment and we are concerned if the Medicaid Expansion is retracted because in those states Medicaid Expansion has helped many people who need to have Addiction Treatment which is extensive. I have a letter that talks about the Medicaid Expansion and how many people would lose their treatment if it passes and i would like to ask you to put unanimous consent that letter in the record. Do you have any idea how many federal agencies deal with Substance Abuse across all departments . I dont have the answer of the top of my head but i would like to follow up if i could. I know when we asked the gao to do this they said at least 112 probably more but they couldnt figure it out. I know one of the things the committee did this coordinate the agency efforts. Its a question i wanted you to let us know. What would the administration do . We will have intense hearings but we are far past the opioids and we need your suggestions to Work Together. We have a shared passion in this area and this is one we have to Work Together. The states have to handle it a different way with the disability rates and unemployment rates would be different for massachusetts or utah or anywhere else. There is a letter that we sent with several questions and maybe we can expect some answers to that . It is in the final clearance we hoped to get it to you this morning that we will get it as soon as possible. Let me just say i want to thank all of the members that participated in todays hearing and you have ten Business Days to submit questions so the witnesses have time to respond. We look forward to working with you and with the bad, the hearing is adjourned