Transcripts For CSPAN3 Senate Panel Looks At Stopping Flow Of Synthetic Drugs To U.S. 20170526

Its a crisis. It doesnt discriminate. Its in every corner of my state. Earlier this month a Police Officer named chris green in east liverpool, ohio, had a near fatal fentanyl overdose following a routine traffic stop. He went up to a car and noticed there was white powder spread around the car. He put on his mask and gloves, arrested some individuals, went back to the police station, and noticed that on his shirt there was some powder. He reached up like this and brushed the powder off his shirt. This guy is 63, 225 pounds, big man. And he fell to the floor unconscious and overdosed. They administered narcan immediately but it wasnt enough. They had to rush him to the hospital, where two more narcan doses were administered. And luckily his life was saved. His police chief said he would have died he had been alone. His police chief said, what if he had gone home with that powder on his shirt and hugged his kid . Thats just an example of what were facing. Its an obvious its obviously devastating our families and communities but also creating quite a danger for our Law Enforcement and other First Responders. Fentanyl is 30 to 50 times more powerful than heroin, 100 times more powerful than morphine. We had some floor speeches this week about it, we were able to show just a tiny amount of fentanyl that can be deadly. We also know about carfentanil and other synthetic drugs coming into our country. This issue is getting worse. As i said, the number of overdoses and deaths have increased dramatically. You may have seen dan coats, our former colleague, actually included opioids in his worldwide threat assessment. He noted deaths have increased 73 just between 2014 and 2015, the last year for which they have records. So sadly, that dead toll continues to climb. Well hear about that this morning. In one county in ohio, for instance, fentanyl was responsible for 394 Overdose Deaths in 2016. One county. Tom gilson, youll hear from him later, the medical examiner, he is projecting 551 fentanyl deaths, in other words fentanyl is by far our biggest killer. A lot of these are deaths from mixing fentanyl with heroin and other drugs, leaving the user with no idea what theyre taking. A new opioid cocktail called gray death includes a mixture of fentanyl, heroin,carfentanil. Fentanyl is the weakest drug in that mix. Think about that. You can get this cocktail on the street for as legal as 10 to 20. Fentanyl has an extremely high profit margin, making it appealing to the drug dealer. The Drug Enforcement agency estimates a kilogram of infinfel can be used to make hundreds of thousands of pills with profits in the millions. We need to stop this flow of illegal, illicit fentanyl. Unbelievab unbelievably, it comes through the u. S. Mail system. This is a shock to many of my constituents and others who are learning about this. While some of this fentanyl is smuggled into the United States from mexico and canada, primarily it comes directly into the United States. And according to Law Enforcement, including some folks who are here this morning who will tell us about this, it primarily comes from one place, which is china. Its produced in laboratories there. And our understanding from Law Enforcement is that most of that fentanyl produced in china is intended for export to one place, and thats the United States of america. There are a number of chinese websites ready to ship. Do a Google Search for fentanyl for sale. It produces a number of websites where the drug and many others appear to be readily available. On one website you can purchase a grahm for 250 bucks, but they offer discounts for larger volumes. To ease any concern about whether the purchaser will receive his order, the website guarantees discreet shipment with, quote, undetectable packages. While shipment is available to a number of companies, the website offers express delivery to the United States. Many of these websites are so sure their seizure will not be stopped by Law Enforcement that theyll guarantee you that if the original somehow gets lost or seized, theyll send you another one for free. Several websites we reviewed made it clear that they exclusively used express mail service or ems as their courier. Ems of course is the International Postal service offered by members of the universal postal union or upu. Packages delivered through ems are passed to the United States Postal Service as they enter the United States. So look, our shared goal today is to try to stop these drugs from exploiting our own streams of mail into our country. And every member around this dais this morning has been involved in this issue on prevention and education, on treatment and recovery. Weve actually passed two significant new legislative initiatives in the lasting year in this congress focused on this issue. We understand its much broader than just interdicting. But weve got to do a better job of interdicting. Following 9 11, Congress Identity weaknesses in International Shipping standards as a significant problem and made clear that requiring advanced electronic data would make our country safer. This was 15 years ago. When Congress First legislated, it did so, however, it left a gang loophole. The trade act of 2002 mandated that commercial carriers provide advanced electronic data that could be used to identify certain packages shipped into the United States. In that 2002 legislation, Congress Asked the secretary of Homeland Security and the post master general to decide if the Postal Service should be subject to the same requirements they were putting in place for all private carriers. To date, no determination has been made. And our country is less safe as a result. As such, the difference between the information to private commercial carriers are required to provide is very different than from the Postal Service. Both serve the same function, delivering packages into our communities. At the same time the Postal Service handles a much higher volume than the commercial carriers combined. Prior to any shipment arriving in the United States, commercial carriers are required to electronically provide data to Law Enforcement including custo customs and Border Protection with the basic information including what the shipper name and address is, the name and address of the person receiving the package, a description of the contents, the piece count, the weight, and the value of the contents. This information is then transmitted to customs and border proxy and 47 other agencies at the national targeting center. Based on this information, cpb then targets suspect shipments for additional scrutiny and selects the packages it wants to inspect when they arrive in the United States. Commercial carriers are also charged 1 per package by cpb which most commercial carriers pass on to the shipper. None of this applies to the Postal Service, and the Postal Service handles hundreds of thousands of packages every day. On our national packages shipped through the Postal Service are routed through five International Service centers which jfk airport receiving the overwhelming majority of those packages. How those packages are processed is completely different at each of these centers. Cpb is tasked with identifying packages or shipments it wants to inspect if the Postal Service locates those packages for shipments and presents them to cpb. However it isnt that easy. Due to the hundreds of thousands of packages, the Postal Service is left to manually sort through large shipments trying to identify what cpb is looking for. All internationallily shipped packages are required to have information attached to them, including sender, recipient, weight and volume. The problem is the information is not electronic and its not transmitted in advance, so its not useful to Law Enforcement. Essentially its useless. The upu indicated it will require member countries to place a bar code on every package starting in 2018. Thats fine, however the shipper is not required to load any electronic information on that bar code until 2020. Meanwhile, we have a crisis. Realistically, the target date to implement this requirement is closer to 2022, were told, but theres no guarantee it will even happen by then. For is15 years, the postal serve has been on notice of the need to collect advanced electronic data about its packages. We cant wait any longer. As americans are dying every day from these poisonous drugs flowing into our country, we must act. And weve got to stop this fentanyl, carfentanil, other synthetics from coming in. The Postal Service is trying to use electronic information at jfk to help cpb identify these packages. Its a Pilot Program. Postal service is providing electronic data to cpb for packages that way less than 4. 4 pounds, socalled epackets. Once the postal information shares the information, cpb uses the information to identify the packages it wants to inspect. The Postal Service locates these packages for inspection. This is a step in the right direction in my video view. The results are lacking, however. In 2016, december of 2016, late last year, the Inspector General found that the Postal Service failed to inspect all the packages cpb selected for inspection. I understand the Postal Service is starting to take steps to remedy this issue, presenting packages for inspection. I look forward to headache the details of that death penalty. But without advanced electronic data well continue to miss a significant portion of these packages. Further, the Pilot Program is only happening at one location. At the other four centers, the Postal Service is stuck sifting through millions of packages, like trying to find a needle in a haystack. We cant continue like this, we need the electronic data and we need it now. Weve been working on a bipartisan way to solve this problem. Thats why we introduced legislation, the coauthor is with us today and shell speak in a moment, aimed at providing advanced information the Postal Service should be providing through International Mail. We have 16 cosponsors in the senate, eight democrats, eight republicans. In the house there is companion legislation that has 128 bipartisan cosponsors. Our focus today is getting input from this panel of witnesses so we have a clear understanding from all the Key Stakeholders as we move forward on this. Again, thank you all very much for being here. I thank my colleagues for being here. I would like to turn to Ranking Member senator carper. We talk about special moments, we call them all hands on deck. This is an all hands on deck moment for not just us in this room, not just in the senate, not just in delaware or ohio, or any other states that are represented. This is an all hands on deck moment for our country. We welcome the panel and the second panel. I want to thank our panel. I want to thank Amy Klobuchar for the great work that they have done and other members on this committee have done to get us ready for this day. The focus on todays hearing is more about at least one of the ways these drugs are getting into communities. And what we can do to stop them. I look forward to hearing from our witnesses. We look forward to hearing from our witnesses on first panel, to better understand the processes used by the Postal Service, by private shippers and by cpb to Screen International mail shipments and to identify and stop potentially illicit packages. I also look forward to learning more about where the coordination between shippers and federal agencies is working well, while identifying areas where we need to push for improvements. Joining in todays discussion is the Postal Service which in partnership with cpb is our first line of defense in preventing the flow of Illegal Drugs and contraband into our country. As some of you may recall, protecting and improving the mail system in our country has been one of our biggest priorities, certainly one of my biggest priorities on this committee for an a number of years. The Postal Service is vital to our economy, a linchpin of a trillion dollar mailing industry. Yet the agency is facing insolvency if congress does not act in the coming months to pass comprehensive postal reform. Enacting that legislation will free up billions of dollars that the Postal Service can use not only to invest in the future and improve Customer Service but also shore up mail security. Its worth noting that despite the financial uncertainty facing the Postal Service, its Inbound International package volume has grown significantly in the past three years. In fact, its nearly doubled. Going from 150 million pieces in 2013 to more than 275 million pieces in 2016. There is no question that handling that increased volume, in addition to the increase in domestic packages were seeing, we welcome that, but its putting a strain on our already stretched resource. Unlike private carriers, the Postal Service is required to deliver all mail, all mail it receives from foreign posts in a timely manner. This is due to our membership in the universal postal union which sets International Mailing standards. It also ensures that we can send mail ourselves to friends, to families, to Business Partners overseas. The state department represents the United States, somebody called universal postal union, and theyre going to be with us here today to discuss our involvement, their involvement in this key organization. And we look forward to hearing from our Postal Service and state Department Witnesses about our commitment to promoting the exchange of advanced electronic dot among the unions 192 member countries as a means to combating the shipment of drugs and other illegal goods. While our packages are screened initially by cpb before being presented to the Postal Service, the cpb can and often does target packages for additional screening. Cpb, which is also joining us here today, can target packages based on the country of origin or scans done by the Postal Service. Recently the Postal Service and cpb have been working closely together on a private program that allows cpb to use advanced electronic data on small packages from china arriving at jfk airport. While the Postal Service provides other countries with advanced electronic data about mail originating in the United States, we dont always get the same information from other countries. This makes it harder for cpb to do its job. As packages arrive here, the Pilot Program at jfk is a rare exception. So i hope we can learn today whether there are any recommendations to improve and expand this program. As my colleagues here say many times, find out what works, do more of that. Private carriers like ups, which is also joining us here today, already provide cpb with advanced electronic data on packages destined for our country. And unlike the Postal Service, private carriers have integrated systems in locations around the world and can refuse to accept a package at origin that does not contain any shipping manifest data. Learning how this process is yielding success in interdicting shipments of illicit drugs can hopefully help us cover the gaps exploited by smugglers. I also look forward to identifying ways that congress can ensure that federal agencies as well as our state and local partners have the resources that they need to combat the Opioid Crisis on the ground. Specifically, im eager to hear from our witnesses on the second panel, each of whom serve on the front lines of the nations Opioid Epidemic in various capacities from Law Enforcement to medical doctors to interdiction efforts. They will give us firsthand perspectives on the challenges we face in fighting opioid addiction and the strategies that have proved effective, particularly in delaware, ohio and nationwide. While a look forward to a discussion of ways to reduce americans access to and the use of synthetic opioids, this is only a part of the occasion. We must knot lose sight of the need to focus on the root causes of our nations considerable demand for drugs. Not just on the symptoms but on the root causes for the considerable demand for drugs. Until we do that, the crisis will only continue to worsen and smugglers will continue to look and find ways to go around the defenses we put in place to block the supply of dangerous drugs. Todays Opioid Crisis is arguably the worst in american city. According to the centers for disease control, over 33,000 americans suffered an opioidrelated death in 2015. Thats roughly the population of our capital in delaware, dover, delaware. My home state of delaware has not been immune. None of our states have been immune. According to delawares division of forensic science, there are 222 Overdose Deaths in delaware in 2014, 222. In 2015, 228. Last year, 308. These numbers are for a little state, staggering. Unfortunately theyre even worse in some communities in ohio and other states that are represented on this panel. Substance abuse is a complex problem with consequences for everyone. And we cannot Pay Attention only to the symptoms of the problems without trying to address the underlying cause. We know that Overdose Deaths are preventible. So as the crisis worsens, we need to Work Together to provide robust funding to help save lives. In closing, i believe its critical to note that access to health care plays a pivotal roll in combating addiction. Unfortunately, current proposals to repeal the Affordable Care act threaten to undermine much of the recent bipartisan progress in addressing the nations Opioid Epidemic and strengthening our nations Mental Health system. Medicaid is the single largest payer of Substance Abuse assistance in the nation, paying for onethird Substance Abuse treatment. Caps threaten to make this Opioid Crisis worse as millions will be in danger. Just at the time we need those services the most. Going forward, i look forward to working even more effectively with our colleagues on both sides of the aisle to address the underlying causes of this epidemic and to learn what we can do and how we can bring about substantial lasting change. Thank you so. Thank you, mr. Chairman. I thank the Ranking Member. We have someone today not on the committee, senator Amy Klobuchar, coauthor of the stop act. We welcome her participation. I would like to ask unanimous consent that even though shes not a member of the committee, she be allowed to participate in todays hearing. And without objection. Thats why i was moving quickly, i was worried. Thats what were giving her for her birthday. Thank you, very nice. Todays her birthday. You chose to spend your birthday with us. I would like to recognize senator klobuchar, senator carper and i talked about this in advance, and other members who would like to make an Opening Statement, thats all right, but i know she has another markup shes supposed to be at right now. If you would make a few remarks, i would appreciate it. Thank you very much, mr. Chair, thank you, senator carper. It is a celebratory moment to be here with the subcommittee for my birthday, thank you. And it was really an amazing moment to meet some of the witnesses out there, and i think youll all really learn a lot from hearing about them. Ive never heard the coroner speak about this but to have the medical examiner hits home, how dangerous this is. We take this personally in my statement, we lost prince to fentanyl. That investigation is still going on, on where he obtained that bridge. It wasnt just prince. It was a mom in rochester, minnesota, a student in duluth. Like in every state, we see opioid deaths on the rise with now exceeding homicides in our state. I look at this in three ways. When we pass this framework that i think started us thinking that way, and i want to thank senator portman for his leadership on that bill. We worked in a bipartisan way with senator ayotte and senator whitehouse and myself. Trying to reduce the number of people getting hooked on legal opioids, and that means everything from our Prescription Drug monitoring bill to the work that were trying to get changes in how prescriptions are given out and how many drugs are given out for simply things like wisdom teeth. The second of course is treatment. And we did some good work, all of us did, with the cures act, and were going to have to continue to do work with the budget. And i appreciate your leadership on the republican side, senator portman, in objecting to these medicaid cuts that we heard from the house, i think thats going to be really important. The third is that we all know as people are migrating over to the Illegal Drugs because theyre either cheaper or easier to get, were going to see more of these kinds of overdoses from things like fentanyl. Just in the last few months in my state weve had 11 people die from carfentanil, which is an even more powerful form of fentanyl. Its a hundred times more potent that fentanyl. The dose is the size of two grams of salt can be fatal. On our judiciary committee, we heard from customs just last week. And the numbers we heard is that in 2013, that fentanyl seizures were at two pounds, and now last year 440 pounds, to give you a sense of this tremendous increase. Thats why i am proud to be the lead democrat on our bill, senator portman and i have the stop act, which he has described well. I think its really important that we start using modern technology. And so that we are as sophisticated in tracking down these perpetrators as the ones that getting our kids and killing people in our country. The second thing that i wanted to just mention is the salt act thats a bill with senator lindsey graham. It makes it easier to prosecute these cases. I know senator heitkamp appear mcafcle were here earlierier as people who worked as prosecutors. They see this as a real issue as well. Because youve got drug dealers basically changing, sometimes over the the internet, the components in drugs. Doing it with fentanyl as well. They make it harder to prosecute them especially in the rural areas wheris not easy to call a medical expert like we have today in washington. We feel good about it because senator grassley and feinstein are on the the committee and but it makes it easier to prove up analogs when they change the composition of synthetics. So its another thing id suggest. But i also want to thank senator portman for leadership and willingness to work across the aisle on this really important issue. And thank you as always senator carper. Thanks. Thank you senator. Any other members like to make brief Opening Statements . James . All right were going to the first panel of witnesses. Weve got a very distinguished panel. Some of you were here for round table in this location last year where frankly the s. T. O. P. Act first original eighted because we were able to identify this problem. Id like to call the the witnesses individually first. Gregory thome, director of the bureau of International Organization affairs at the state department. United states interests through multilateral engage mts but prior to being here in 1919. He held positions in other countries. Robert cintron is the Vice President of Network Operation attention at the Postal Service. Mr. Cintron began his Postal Service career 31 years ago a clerk in rochester new york if in the current role oversees the Distribution Network including network resign policies and programs Action Logistics required to move mail and maintenance policies and programs that support the postal network. Third we have robert perez. Robert is the acting assistant commissioner Border Protection. Mr. Perez served as director for cpb new york office last year he oversaw the arrival of 21 Million International travelers and 240 million imported goods over the course of his career he represented cpb as a Border Security expert all over the world at International Business offers and as a Border Security expert. Tammy whitcomb moua is the acting Inspector General or the u. S. Perforatele service. Miss whitcomb came to the Postal Service as Audit Director served as deputy Inspector General. Prior to her time poefs post office me the Internal Revenue and u. S. Treasury for tax administration. Finally we have norm schenk with us. Norm isnt the Vice President of global customs policy and Global Affairs for the united Postal Service ups. Fl schenk worked with government leaderers on reducing trade barriers simplifies customs processes and supply Chain Security issues. He profile testified to congress on Drug Enforcement issues currently serves on dividesry committees to the World Customs Organization and the u. S. Department of commerce. He chairs the International Chamber of commerce on custom and trade. I appreciate every one of the witnesses being here today. We look forward to your testimony. Its the custom of the subcommittee to swear in witnesses at this time id ask you to please stand and raise your right hand. Do you swear the testimony you will give before in committee will be the truth, the whole truth and nothing but the truth so help you god . [ all answer affirmative ]. I would note all of the witnesses indicated that they were prepared to testify under oath. And the record reflect that they all answered in the affirmative. The your written will be made part of the record and i would ask to you keep oral comments five minutes each so we can get to the question mr. Thome id like to start with you. Thank you chairman portman Ranking Member carper members of the subcommittee good morning and thank you again for the opportunity to appear today to discuss the issue of lfts st. Lts o illicit drugs. The supply side of the synthetic Opioid Crisis presents a complicated picture with multiple path way to sbreer the country np in addition toment those that find they are way in i willis elicit fentanyl enter flew International Mail sipically in small shichlts purchased online by individual customers. The department of state is aware the small shipments propose unique challenges to customs and Border Protection. And advanced electric data can mitigate this. Sequencely the Department Works close with which to take steps global level to increase the availability of a aed for International Mail within we are committed to committing to enhas cpb countries ability to interdikt channels pmt i would i should explain the postal accountability and enhancement of 2006. Identifies cpb as the main forum for the work is universal postal union, the upu. The upu is an Intergovernmental Organization of 92 countries that have committed to delivering one anothers mail on the basis of reciprocity. The upu congress and 40 member Postal Operations Council or poc write and adopt the acts of the union which are the rules of the road for International Mail exchange. At the upu congress of 2012, the United States was successful in securing amendments to the u puchlt u convention that committed each member state to adopt appear implement Security Strategy which included complying with requirements for providing aed. At the most recent upu congress in 2016 the United States was reelected to the president barack obama and was selected to cochair the president Barack Obamas committee on supply chain. This committee overseas all upu work on customs, security transportation and standards. These leadership the United States also chairs the committees Standing Group on postal security. These leadership roles position uls extremely well to ensure that high priority security issues, especially aed move forward as quickly as possible. And we have made significant progress toward that goal. With active participation and technical input from the United States, the upu cooperated with the World Customs Organization to develop an electronic data system to allow for the capture, transmission and receipt of aed. In february of last year, the poc adopted a new Regulatory Framework for the exchange of aed called the road map for aed implementation. The United States now leads the Steering Committee coordinating the work required to reach the road maps milestones which include final adoption of the technical messaging standard for item level data. Adoption of that standard should take place at this falls poc meeting. As significant as these achievements are they are only part of the picture. And there are obstacles to overcome. The main impediment to widespreadated is the limited analyst of most Postal Services to collect and transmit. The up Business Plan adopted in 2016 calls for all Postal Services to have the capability to Exchange Item level data by the end of 2020. However, the technical ability to exchange this data does not translate directly into the ability to collect or enter it. Many post offices in the developing world does not internet connect ifrt or even reliable sources of electricity which makes collection of data and transmission of data extremely difficult. And even in developed countries some Postal Services have been slow to invest in the needed infrastructure for item Level Electronics exchange of data. Currently few if any countries have the ability to provide it for 100 of the mail requiring customs declarations. Our approach has been to support the upu to provide Capacity Building that enables aed. The upu is devoting half of its cooperation budget over the next four years to a project designed to position Postal Services in developing countries to obtain this capacity. And the major focus of this program is aed. We will continue to support and encourage efforts but wrens are recognize that rapid acceleration in investment and use of electronic data for customs on security will also be wrifen by the Business Needs of postal operators themselves. Postal operators now understand the delays caused by necessary customs processing are a major impediment to their own ability to grow their Business Model and adapt to the rapid growth of ecustomers transactions. Exchange of aed is the only solution to this problem. Subsequently while the United States was once a voice in the wilderness, almost alone in calling for aed exchange we are now leading a chorus of countries dwelling and tweld that demand aed. Another Significant Development with implications for aide is the upu decision to launch the integrated product plan which mains to modernize upu proved offering with an i eye forward ecommerce. This has clear benefits for the customs processing of mail. Phase one beginning in january of 2010 will introduce segregation of mail into items containing documents and those containing goods. This splits facilities compliance with skmls requirements including aed. Phase one also rierz mail items containing z goods to have a strt up standard barcode label which is critical to enabling aed. Furthermore, upu regulations upu approved regulations in february 2016 which will allow members to impose aed requirements on items caning goods provided they take into account whether the requirements they are imposing can be met by those to whom they apply. The thinking behind behind the regulation was that kbrand command nanoseconding something impossible immediately agency a condition for receiving another countrys meats is the same as refunding to receive it. Such a requirement would undermine the reciprocity. In conclusion i would like to assure the subcommittee the state department is fully committed to accelerating all countrys ability to provide aed. To that end we will spare no effort to ensure swift implementation of of the upu road map and integrated product plan. As these programs move forward, we are confident the number of countries able to provide aed and the portion of their mail stream that it covers will continue to grow. Thank you, mr. Chairman. I look forward to answering questions. Good morning, chairman portman, Ranking Member carper, and members of the subcommittee. Thank you chairman portman for calling this hearing. My name is Robert Cintron i am the Vice President Network Operations for the United States Postal Service. I oversee the Postal Services national Distribution Network, including its international operations. Congress has given u. S. Customs and Border Protection the responsibility and authority to screen items at the first entry into the United States. At entry, customs hands the authority to open and respect all inbound items without a warrant to identify prohibited items. Inbound International Mail from foreign postal operators arrives by plane at one of our International Service centers, known as isc aes typically arrives in large bags packed in containers. After initial bulk screening by customs inbound shipments receive an initial receipt scan by the Postal Service. At this point, items requested by customs are presented for further inspection. For those items which advanced electronic data known as aed, is furnished, customs has an enhanced ability to target items for inspection. Today the Postal Service collects aed for more than 90 of its Outbound International pack js and receives 40 to 50 of this information for inbound packages. To put this in perspective comparing data from fiscal year 2015 to present aed for Inbound International packages has increased from approximately 1 to present range between 40 and 50 . In other words, the Postal Service currently receives data on a substantial amount of inbound shipments, including those originating in china. The percentage of inbound items with aed is expected to continue to grow, especially as more countries develop their capacities. In an effort to further expand the provision of aed for International Inbound volume, the Postal Service is prior advertising obtaining aed from the largest volume foreign postal operators which collectively account for 90 of all inbound volumes. For example, we have entered into Bilateral Agreements that require aed with foreign postal operators of china, korea, hong kong within the australia. And we have entered into voluntary data sharing agreements with more than 30 foreign posts to facilitate the exchange of aed. Additionally the Postal Service has a Pilot Program in our new york i. S. C. That allows customs to use inbound aed for more advanced targeting. With the Lessons Learned from the pilot, we are working with customs to expand this approach to our other iscs. Unlike private companies, the Postal Service must accept and deliver mail from nearly every country in the world. The postal tfs does not control the induction of mail destined for the United States we cannot control the collection of aed broad. However the Postal Service in collaboration with the state department and customs place a leadership role in advocating for the Global Collection and exchange of aed. Through negotiations and advocacy and by targeting nations with greater capacity like china, inbound aed has grown enormously in the past few years. In conclusion we share your concerns about americas Opioid Epidemic and we continue to work with customs to enhance the interdiction of Illegal Drugs and contraband. The Postal Service is committed to taking all practicable measures to ensure our nations mail security and provide the American Public the best and most Efficient Service possible, again, thank you for the chance to testify. And i look forward to your questions. Thank you. Good morning, chairman portman, Ranking Member carperer, distinguished members of the subcommittee. Thank you for the opportunity to appear today to discuss the role of u. S. Customs and Border Protection and combatting the flow of dangerous synthetic opioids, particularly fentanyl into the United States. The majority of fentle smugland into the u. S. Is done sew arthroInternational Mail facilities, express consignment carrier facilities or through ports of entry along the Southern Land border. In faskle year 10u6r cpb officers and agents seized or disrupted more than 3. 3 Million Pounds of narcotics. Cvp seizure of fentanyl remain small but have significantly increased over the past few years from 2 pounds seized in 30u to over 400 pounds in 2016. Fentanyl is the most pretty quickly seized illicit synthetic opioid. Along the southern border her ien is spiked with funnienle. Fenton is spiked with pore substances and sold at synthetic her i know. Drug tasking organizations adapt to eye evade detection and interdiction. We use the same interdiction nods to seize fentle as used to detect other drugs. However the detection of fentanyl remains challenging due to limited field testing capabilities and the variety of analogs on the market. In the express consignment environment cbp places electric hold and notifies a carry your parcel eye need to be presented for inspection. Cvp is working to implement the same systematic system in the International Mail environment. Together with the United States Postal Service we have been conducting an advanced data pilot on express mail and epackets from some countries. We continue to work with the u. S. Postal service to address the issue of electronic advanced data. Thanks to the to support of congress cbp has made significant advancement in drug Detection Technology and targeting capability for example the narnl targeting center leverages advanced information longside Law Enforcement and intelligence records, to identify smuggling trends, and target shipments that may contain illicit substances or related equipment being diverted from illicit use. Such as pill presses, tablet machines, or precursor chemicals. In addition to the experience training and intuition, cbp officers and agents use various forms of technology and equipment to detect synthetic drugs hidden on people in Cargo Containers and in other conveyances. Data from substances believed to be or to contain fentanyl and found in the mail or in express courier packages is transmitted to the laboratories and Scientific Services for interpretation. At land ports of entry instruments provide a readout directly to officers and agents. The low purities of fentanyl found along the southern border usual ily only about 7 of controlled substance or content make the detection difficult. Canine operations are another invaluable component of narcotic efforts. Cbp is working to safely and effectively add fentanyl as a trained odor to deployed narcotic detection canine teams. Cbp also implemented a program to provide training and equipment to keep ourp employees safe from exposure. Through the Ongoing Program cbp officer are trainsed to recognize opioid overdose and administer a life saving drug for the treatment of opioid overdoses. Cbp will continue to do all we can to refine and enhance the effectiveness of interdiction of fentanyl and other dangerous synthetic opioids through the mail and across borders. Chairman aband members of the committee thank you for the opportunity to testify today and i look forward to your questions. Good morning chairman portman Ranking Member carper and members of the subcommittee. Thank you for invite meeting to discuss our work on inbound International Mail. First let me provide some context. We started examining this area two years after we received complaints that the Postal Service was not presenting mail to customs and Border Protection for screening as required. After looking into it we determined audit work was feetded. Given the role as office of Inspector General for the Postal Service we focused on the Postal Services procedures and coordination with cbp. We did not review cbps operations although we did talk to staff to garrett information. Also both cbp and Postal Service provided information used in reports. They considered some details sensitive and requested redactions in the public versions we posted on the website. Inbound International Mail primarily enters the postal system at five International Service centers around the country. Generally all inbound International Mail is subject to inspection by the cbp and the Postal Service must present for inspection all the mail that cbp requests. The Postal Service receives 621 million pieces of inbound International Mail in fisk alyear 2016, almost half were packages. The growth of ecommerce has caused inbound package volumes to nearly double in the last three years causing challenges for managing this flow of traffic. More than half of the package volume is from epackets, small track pack j ajs under 4. 4 pounds. Given growth of International Package flows to the Postal Service there is a need to find more effective ways to manage inbound traffic. Some foreign posts in the Postal Service advance electronic customs data which include information on the sender addressee and contents of the mail piece. In data helps both with the processing and inspecting inbound mail. International postal regulations are beginning to change and recognition of the importance of posts providing advance electronic customs data. The Postal Service can also require this data through Bilateral Agreements it makes with foreign postal operators. However, our audit work found instances of Bilateral Agreements where the Postal Service had not requested this advanced customs data. Since november 2015 the Postal Service has been piloting a joint initiative with cbp in new york. Cbp is basing data systems with the Postal Service systems to use advanced data to target packages for inspection. The Postal Service and cbp intend to expand this pilot to new locations before the end of the fiscal year. We have issued five reports on inbound International Mail operations since september 50u and found several problems with the presentation of inbound packages to cbp process. First Postal Service employees sometimes began processing packages before arrival scans had been input into the system. This could result in pieces missing customs screnock or in the acceptance of inappropriate or unknown shipments. Second problems with scanning during processing into and out of customs men the Postal Service could not always determine whether a package was in cbp custody or its own. Third and most significant, at times the Postal Service just did not present packages to cbp for inspection when requested. Instead of packages were processed direct i into the mail stream. The failures occurred for several years including human error and Electronic System problems process. An additional factor is that the Postal Service and cbp do not have a formal written Agreement Regarding the appropriate procedures. To address our findings we have made 11 recommendations in areas such as enhancing systems, providing employee training and oversight, improving scanning data, ensuring items are presented to cbp, requesting advance electronic customs data from foreign posts and coordinating with cbp to establish a formal Agreement Regarding presentation requirements. The Postal Service agreed with these recommendations and has taken sufficient action to close five of them. Six recommendationless are still outstanding. Including establishing a formal agreement with cbp. Ensuring the safety and security of inbound International Mail is a critical challenge for the Postal Service and cbp. More effort is quickly needed to fix problems in the process and make sure cbp receives as much electronic customs data as pb. My office will continue to monitor this and work with our colleagues at the department of Homeland Security office of Inspector Generalen on any related work they conduct. Thank you. Thank you, chairman portman, Ranking Member carper and distinguished members of the committee. I appreciate the opportunity to appear before you today to discuss how providing the necessary data to customs and Border Protection and other Government Agencies can help target contraband and weed out bad actors seeking to import Dangerous Goods and counterfeit items in the u. S. Mr. Chairman, my presence here today, the thursday before memorial day weekend is quite literally did he jaw view. I provided similar testimony on this very same day 17 years ago in the year 2000 to the house subcommittee on criminal justice, drug policy and human resources. The hearing then was titled, drugs in the mail. How can it be stopped . For this that hearing i was asked to do the same thing walk through the processes that ups follows to supply advanced data to cbp that will enable them to screen for high risk packages imported in the u. S. Unfortunately, since 2000, the problem of importing illicit goods into the u. S. Has only grown worse. Enabled by the internet, bad actors are getting smarter and smarter, using every avenue available to send illicit goods into the u. S. Back in 2000 the issue of illicit drugs in the mail was centered on amphetamines and ecstasy today the threat panned to fentanyl and high tech opioids. The volume of parcels coming in the u. S. Mass increased particularly from foreign posts which send almost 90 of all packages into the country. Upsss delivers more than 19 million pack analysis in over 220 countries and territories around the world. We work hard to be united problem solvers. Our business processes are complex and our technology advanced. We also work closely with cbp a at our own expense to comply with the and even exceed existing legal requirements. The key to making this bjork is the advanced electronic data we provide which enables c. P and 4 other Government Agencies to target high risk inbound shipments and screen them out and sometimes thats as much as 36 hours in advance. This data can also be used to screen for counterfeit products and contraband another growing problem. We also apply technology technologically advanced Network Capabilities that enable to us locate any suspect package in our system at any given time so it can be retrieved and tepd tendered to legal authorities tor additional screening. In 2000 when i testified before the House Government Oversight Committee there were about 21 million package shipments entering the u. S. Annually. About 10 million through the private sector, which were accompanied by advanced electric data, and 11 million through the International Mail system, which did not have any electronic data. Even 17 years ago it was clear that cbp and other federal agencies could not manually screen packages purely because of volume. And that the most effective way of interdikting bad shipments was through the use of advanced electronic data. The volume of packages entering the u. S. Has increased many times over in 2016 foreign posts cents over 400 million packages to the u. S. And the roll is rapidly growing. We have been used advanced data for years. Even before it was required by the trade act. Bob and i have worked together probably over 20 years on some of these things to provide cbp with item level detail about each and every shipment entering the country. In helps us reduce the potential for Dangerous Goods entering the u. S. Its also important to note that ups and other express carrier obtain and submit data for all Foreign Countries both developed and developing i could take out my smartphone phone most reechlt places take a firkt and transfer it on with that. In conclusion, if i could take off my ups a hat for 30 seconds i do a lot of International Travel and work with customs agencies around the world on this same issue. When i border a flight back to the u. S. I dont look around the passengers looking for suspected controverts. I think about the bags and bags and of foreign post packages loaded in the belly of the aircraft. No one has any idea whats in those packages, none whatsoever. The government dont allow passengers on a plane without personal information or back into our country without a passport or screening. Why do we allow over 1 million and potentially more dangerous packages day into this country with no requirements for information that will allow cbp to do their job more effectively . I urge you to take action on this important issue. Thank you. Thank you mr. Schenk and thank all the witnesses. Senator carper has generously agreed to delay his questions so that we have an opportunity for the two members here to ask questions. I know everybodys got other committees to go to i will do the same and like to start with senator lankford. Thank you mr. Chairmanwork ranging member i appreciate that very much. Tell me about where we are as far as moving on advanced electronic data and why for developing countries this has taken so long when there are some straightforward solutions if they can get the mail to the spot to be able to get it out why cant they get the data . Thank you, senator for your question. Wove been working very closely with the upu to try to move this process along more quickly but the issues that we face in developing countries i would say previously there was a lack of will and a lack of understanding that for them to catch up with their Business Models and take part in the ecommerce boom thats occurring worldwide. There wasnt an understanding that aed was the key to that. I think the major advance we made and its not a statistic but its a change of mindset within the upu that countries now understand regardless of their level of development they have a lot to earn and a lot to gain and can even enhance economies by taking part in this global. All right so the encouragement from this congress would be at some point to say packages doesnt come in without it. Obviously that ice lates a lot of countries and ice lates a lot of people from being alk to get materials in the most straightforward way we could do that was just put a dleer clear deadline saying we dont allow passages into our country unless there is some electronic Data Collection of that in advance. Thank you. Well with, as i described in my testimony, the global postal system simply isnt able to exchange aed comprehensively at this time. And a requirement to a requirement that it do so immediately as a precondition to our accepting its mail it would severely restrict the inflows of mail into our country and probably preclude the acceptance of mail not covered by a Bilateral Agreement. If we stop accepting cold other countries mail immediatelily on shari short notice wed have to anticipate many would stop. I would assume by the way i would be surprised if anything that congress could do on short notice. But i would assume that we would set a Firm Deadline to say about this date certain so that this is not being negotiated in the days ahead this seems to slip year after year. And my concern is how do we actually get a date certain thats sitting out there on the horizon that we know this is resolved for in because this is only one element of trying to be able to stop the illicit movement of drugs in. Clearly notify individuals shipping fentanyl are not going to label the package as containing fentanyl. Were very aware of that this is only one element to be able to help deal with this so this should be a straightforward element. I agree that it should be straightforward. I think the challenge we face is that other countries just are working on other time tables. I think weve made good progress. Up up. Again i think that the the question of their own needs they now understand. Again, the upu is putting forward half of its cooperation budget to helping the countries install the capabilities they need. But electricity and the internet are not available everywhere. But in countries there are. Were still dealing with germany and frans the last i heard do have electricity. The uk does. We can go on and on and on through places this should be pretty straightforward. So for us we have to be able to get this resolved. Let me ask a separate question. Customs and Border Patrol and usps worked on mou relationship quite a while to try to establish consistent methods how to Exchange Data how is that working and where are we in the. Process of getting a clear mou of exchanging information . The mou regarding the just the general operations, senator, and how that functions at our International Mail facilities and how that mail is delivered. Yes. Is with cbp we expect to give that back with our comments to the u. S. Postal Service Within the last or within the next two to three weeks. Good. I checked on that before i got fleer. Thats been outstanding about a year. Indeed, senator. The the mou really puts into place best practices that have already been in place in a lot of field locations including jfk back in new york on how the mail is handled. That is the ones coming from countries of interest for cbp. Im not aware that it specifically gets into the detail of the electronic data. That is more so under the confines of pilot thats being run. Any other compensate on that mr. Cintron. I wanted to add on to exactly what was said here. You know its been a year. And certainly weve been working and we do at each one of you are oh ises work closely with Customs Border protection to make sure the processes procedures supposed to be in place we have been working through those. Its not like weve been waiting for the m. O. U. To get that finalized certainly work and glad to hear well have it back in a few weeks and get it finalized. Assuming that gets finalized rapidly after this comes back. You can assume that to be accurate. That will be traffic trivg. Just basic operation to be able to help increase efficiency in the process on this. On the Inspector General size of things tell me where we are as far as the things we can provide the greatest oversight on to ma make had sure they get checked from usps you you gave us a list items worked through. Top items for congressional oversight what would you list. I think the m. O. U. Is critical. I also think the encouragement for the Postal Service to work these Bilateral Agreements with the countries to receive the data i think theyre making good progress. When we first started our work in 2015 it dsh and mr. Cintron mentioned it there was not much data at all available. Significant progress sidekick made and has been made in the last two or three years. But its its one of those things that you have to continually work on ensure every Bilateral Agreement has the requirement in it. So those are two things that i would encourage. I would only say to this group i appreciate the diligence and the focus on this. Its been seen and noted already for commercial entities, this has been something thaefr been very persistent on for a while. Obviously they have more a Seamless Network theyre not receiving every single pack j coming from every single country they can monitor that through their system. But it is a system achievable in the process. I would note for customs and Border Patrol we appreciate very much the work youre doing mp incredibly dangerous as already noted by the chairman in the Opening Statement even the smallest amount that gets on any individual as theyre doing inspection is a life or death issue. And sew o so from our is committee to all of your team we express our gratitude for what youre protecting american citizens from thank you. I yield back. Thank you. Senator carper. Thanks. Thanks so much. Sometime which with we have a Diverse Panel like this but the people that are knowledgeable highly knowledgeable about a particular issue were trying to address, i asked them to help us solve the problem. I ask you to and im going to ask you today to help us solve the problem. Im going to ask each frp you to say if you dont do anything else do at least this, you congress, this committee, congress what is one thing we ought to do right away. I want to call you thome because of a jim thome a great Baseball Players pleases excuse you now do you pronounce floor name. I pronounce it thome. But i answer to anything. My name used to be pronounced tommy as well. Mr. Tome for god sake do there, one idea. Thank you senator karper. This is all hands on dk im old ghaef guy. All hands on deck. Trying to convey a sense of urgescy. God knows when we go homepeople folk at hemiskon va a sense of urgescy. Thank you, senator. As we talked about this is a difficult problem that needs a lot of solutions. In terms of the remit of the state department and our interactions with the upu, as i said before, weve turned the corner in the countries wanting aed. I think we have to all Work Together to give a realistic time frame to it. There is urgency in our country im first to admit that we have a an epidemic that cant wait years and years. But with the momentum we have over i would say since the 2012 upu congress, its really accelerated. And countries want this. But if they find themselves in a situation where they have a sort of dam clees over their head with a date certain which is why i hesitated to put one on in response to the senators question previously p. We run the risk of losing that momentum in that if the mail shipments are threatened to stop in the United States that could virginia devastating. Thats not my question. Im sorry. Give me one take away one thing we ought to be doing to expedite this move it. I think if we put efforts behind what the upu moving and keep that moving along with the bilateral efforts we can playbook this happen. We is us. Give us some advise. Give us some advice. What can we do to get this moving. I think i think the in my personal opinion the act that youve put forward is on the right track. And it will certainly contribute to this. We just need to craft it in a way thats naes realistic to get it done with countries that we cant order to do things but we need to negotiate and help them see the benefit of doing it. All right mr. Cintron. Yes, i guess for us. There must be some dsh must be some way we can incentivize these folks. Particularly James Lankford mentioned some of the nations still arent doing their share. Theyre not third world nations theyre not third world. Must be some which we can incentivize them. One thing weld ask support support around our strategy to target, focus in on targeted countries right so we understand that that part we we look at the whole picture for us four our strategy has been to stay focused where we see the largest volume coming in. Thats where were looking for that cooperation certainly. To take that step as was noted here one of the concerns is some of the conditions that we might find in some of these other developing countries. But for us, our strategy really is going to be to stay very focused and prioritize. And what he to wg the pilot at jfk we we could push this along. You havent answered my question. All right i asked both of you same question. What does the Congress Need to do to help move this along to expedite this what do we need to do. Well one other thing i might ask is certainly around the passage of comprehensive post the reform for us there are a lot of things that anything you can do to help us with that regard helps overcome initiatives. One of the things a number of of us has have been boring on this a while we want additional postal revenues in order that they can among other things modernize mail processes centers three hundred needing modernization buying new equipment new veegs for delivery. Modernize the post offices sound like this might be some another use for the additional revenues it Postal Service thank you thats a good take away. Mr. Perez for us good advise for us. First let me say thank you senator for the ongoing support not just of this committee but the entirety of the congress for everything that cbp does in the entirety of the effort that we put forth to combat illegal narcotic trafficking. Thats where i would specifically ask ever so respectfully that that support continue for all things narcotic trafficking. Because cbp frankly we are not waiting and dont wait for the evolution of the different types of threats and the enhancements we absolutely need to lean forward and do everything we possibly can to interdikt, to detect, deter and dismantle those who would do us harm in this fashion. Whether were talking about that ob tools and technology were try to deploy and even personnel that ongoing support this body continues to provide cbp on the overall drug mission is abilitily critical and we trisht. Miss whitcomb same kwi. Yes i think focusing oversight on ensuring that this the m. O. U. Moves forward quickly. Also i just heard a minute ago ago that the m. O. U. Does not necessarily cover the Pilot Program process. I think that pilot there is lots of Lessons Learned through that pilot. But expanding that pilot quickly across the country to the other International Service centers so that the data that is being received from these countries can be used to target specific and dangerous packages. So oversight in that area. We we come back for nick if we have a second round i want to come back and talk about the tielt and Lessons Learned. Last last witness, please norm. 17 years ago. Pass the s. T. O. P. Ac and the reason i say that discussed here was 17 years and nothing tangible changed. And it just moving at a snails pace and we think the right way is to pass the legislation. We worked with cbp before the trade act i dont know how they do the job they do on the mail we have our own challenges with all all the data. But were talking about the minimum so pass the t. S. T. O. P. Act. Chang chairman. Senator mcakil. So i understand first of all thank you all of you we are all hands on deck, as senator carper said on this. And this committee is busy doing an investigation into another piece of in which is the sales and marketing technique that have been employed by the opioid manufacturers. And we are also going to be looking at the distributors in terms of that issue internally in our country. But i want to focus in on my time here on the fact that we are having some of this fentanyl produced in china, sent to the United States, where then it is sent to mexico. Are you all aware that this is commonly occurring . Is we have a large amount of opioids moving through our country in that regard . Does anybody disagree with that . Analysis . Senator if i can comment i would share that my understanding is that much of the fentanyl coming out of china when its actual form comes directly into the u. S. What we have seen that moves from china typically into the labs in mexico that are diluting creating analogs and laysing her i know shipments as well. Precursers moving directly from mcinto mexico. Not aware at least ootsds current time of the movement southbound from the u. S. Into mexico. But i gladly would take that back and our my staff has looked into this. And believes there is a significant amount of this moving from china to the United States, the precursers, going from the United States to mexico for them to process in in re labs. If if we are getting wrong information, i can live with that. If you dont have the information and its accurate, im worried, because i think its really important that we understand where this is flowing. Mr. Cintron, would you agree that you all believe that some of in is coming to the United States and then being shipped to mexico as a precursor to be used in the labs to cut her i know. Yes, sno senator, i can specifically respond to that but certainly the inspection part of the organization we could provide you after the hearing i could provide you information on that. So i understand that mail from china is not covering the costs to the to the United States Postal Service to handle this mail. Is that correct . Again, senator, i apologize but i would certainly ask your permission to provide any of that information posthearing. Once again my staff tells me that we are underwriting the United States apostle service is underwriting the costs of mail coming to here from china. And that just seems crazy to me. How in the world toes that happen . Well, again, unfortunately im not able to answer that specific question. But i certainly can provide the information after the hearing, senator. Yeah, i mean we are obviously struggling to keep the u. S. Postal service out of bankruptcy. Its one thing to be giving fedex and u. P. S. On the deal a last mile of Package Delivery which ive been railing about in this committee for years. But if we are making it cheaper for china to use the United States Postal Service because were underwriting our costs there thats outrageous im anxious to get to the bottom of it if you would follow up as quickly as possible i would appreciate it. Absolutely. Okay. So for the trade act, it is my understanding in terms of the private deliveries that they are not actually theyre supposed to be having the information on the packages they send, name and address of the recipient coming into this country from other countries. But i understand that many times all cbp gets is the address of the processing facility where its coming to and not the address of who the actual recipient is. Is that act mr. Perez. In the context of the u. S. Postal service the general mail that is true. That is the type of data that were pursuing through the pilot to begin to get more of that senator. Im talking about phase two of the trade act requiring the name and address of the recipient from the private carriers. Are we has that been fully implemented . Are we getting the address and recipient from the dsh not from Postal Service but from fedex and the other private carriers. From the express consignment carriers to my knowledge yes but i will take that back to make sure we can dmirm that but from the other commercial entities and carriers we get pretty comprehensive list of information in advance with respect to the particular shipments. Well, once again, my information based on staffs preparation for this and the preparation ive done for this hearing is that in fact they are not providing the name and address of the recipient and that many times all you get is the address of the ups or fedex processing facility where the package is coming. And i would really like to know why we are why my information is different than yours. And the other information that i have is that were not even imposing the fines that need to be imposed on the carriers who are not following the law. By the way this is the trade act imposed after 911 we wrerp trying to get after security of the ports and security of entry ports in terms of our country in terms of good, people and services. So i will be anxious to hear you follow up about that. Phase three of trade implementation was supposed to be penalties for the bad description. And its my understanding that phase three has not been implemented. Does anybody know the answer to that question . I dont have the details on the phase three of the trade act implementation, senator. At this time. I will gladly take that back and get it back to you and your staff. Okay. If were not getting the address of where the package is going, and were not finding the carriers ahead of time so we could actually look to see if this was an address that has popped up before i mean Law Enforcement needs to be all hands on deck here if were not getting that and not even knowledgeable about whether or not weve complemented the part of the law where penalties are enacted our Research Indicates that sometimes penalties have been imposed but theyve been negotiated down by the carriers lawyers from thousands of dollars to 50. If thats occurring, thats a huge problem. Im im a little worried that folks dont have the answers to the questions at this hearing understanding the subject matter of the hearing ill look forward to getting the answers to them as quickly ago as possible. Yes, mr. Schenk. Senator if i may respond to that certainly from a u. P. S. Perspective. Weve been providing that information full information of the shipper, the consincee oh value oh country of origin since we started bringing International Imports into the u. S. In 1985. And the program was developed with cbp. I would also say that weve gone well beyond the trade act working with c. B. P. With the air cargo advanced screening process, which is a voluntary program that was implemented after the attempted yemen bomb attempt on that where we not only transmit the shipper and the consignee we go the california mile and the transmilt the multiple consinnees. Speaking for u. P. S. We do not only the required but we go beyond the required. In your opinion has phase three been implemented . Do you believe there are penalty that is would apply to you if you did not somehow a package came to the United States through your company that didnt have the address of the recipient on it . I would well the answer to that one is dont know how we could our process and systems is developed that a package cant enter our system unless that information has been entered in there and then it cant move through because our systems enter connect between u. P. S. And cbp practically speaking it couldnt happen. Well we will well follow up on the information we have get information from all you have go forward from there. Thank you very much. Thank you senator. Im asking my my questions now and well have another round as well i know senator hasan has agreed to stick rnd around and we appreciate that with we have another colleague joining us. We need to back up and talk about what the hearing is about. And that is is it helpful mr. Perez i expect your answer on this but all of you is it helpively to have advanced electronic data on this package which is have ac poison which is synthetic op yats coming into the country killing and more and more citizens every day. Do you want to have that advanced electronic data . Is that help for you to be able to stop the poison coming into the communities . Yes or no . Unquestion mr. Mri, mr. Chairman, having the advanced electronic data as we do receive for all types of cargos is a key tool in our ability to manage and assess risk. To focus and target those threats that may warrant a greater inspection potential threats that may warrant greater inspection, cargo, people, conveyances of all types. Unquestionably. Having that data working toward get nag advanced data and making sure it is of high quality and reliable for us to do that work. Is a high priority and the reason were working so closely with the colleagues together to that point. Otherwise its paidle in the hey stack i talked about earlier i meet with your folks back home they use the compact word he use this is a actual we need otherwise were not effective at stopping this stuff. Its other contraband as well but were focused here on a crisis. And you know, i i appreciate the state Department Perspective on diplomacy and trying to work with other countries. And i appreciate you mr. Thome saying you think the s. T. O. P. Is on the right tract but the other notion that the other countries working on time tables and some countries dont have electricity. China has electricity and we know where the stuff is coming from. Some of it coming from india as well they have electricity too. This notion i will say and mr. Cintron, i understand your concern about having to apply this to all countries. And you note in it in the comments you youd prefer it to targeted to countries known to be sending us in poison let me just follow up on that a little bit. Senator carper and i worked on this yesterday were working on issues of countries circumventing because they have a tariff attached to theme because they have a dumping order. They simply sip through another country. Which wouldnt that happen here if we target just certain countries why wouldnt they ship it through another country vietnam, malaysia ob indonesia. What i would say is this. Our focus our strategy as i spoke is to prioritize the list. Look at it make a Risk Assessment and target those particular countries. Certainly as we work certainly the Inspection Service working in collaboration with the other Law Enforcement agencies i think is probably the other key, right. As you collaborate we share information. If those events occur i think we then we refocus and do that. I guess our point is there is starting point. Our piece was around where is the highest risk, highest volume how do we go to your point on capacities, those particular countries that have it we should be focused on those and get that information. No question its a crisis i want you to prioritize. Unfortunately what we seen there is transshipment of the stuff and simply shipped to other countries from the evidence that we have. And if we dont have this broadly applying and you noted earlier that its voluntary now. And i guess i would ask you qb do you have enough data . And your answer is going to be no because youd like more advanced electric data from the other foreign post attention process again our what our legislation says its time to follow up on what Congress Passed 15 years ago which was asking the then cabinet secretary in charge, now Homeland Security, and the Postal Service and the commissioner to come up with a plan. And norm said he testified 20 years ago. Even before that i assume that was in the context of preparation for the 2002 trade act. So i i would i would just make the point broadly that we do have a crisis. Weve all acknowledged that. And this is not business as usual. If other countries are working on their own time table that doesnt work. That dog dont hunt. Because its an epidemic. And you noted, mr. Thome which i thought was interesting that advanced electronic data is in their interest. And there is a consensus you said among countries around the world they need to provide it lets get moving it. Another question i would have is for mr. Perez, you talked about canines i have to ask you this question because i asked the same question of one of the colleagues at a round table discussion at this spot about a year ago. I was told sniffing dogs dont work because the dogs could die from sniffing a package or a letter with fentsenle in it. Whats the situation with regard to monitoring general annually and screening many us im on legislation to provide funding for inspection. Specifically with regard to kay fliens does that worng or is it too dangerous . Thank you, mr. Chairman. On the canine front were kernlt in the test phase to train the canines for the specific odor. As you probably know they are trained for a innovator of narcotic odors. And so depending on the actual form and nature of the narcotic they may detect and or be able to alert to some of the opioids. But we are specifically training them in a very safe way with with the types of odders that are generally emitted from fentanyl and such not with actual fentanyl but with the laboratory and Scientific Services folks make sure were doing so in a safe way enabling that tool, along with the other you know technical and or electronic tools that are at our disposal where were actually taking readings from the suspect packages and sending. Expect ray back to the labs to determine whether or not there is a presence of fentanyl and other opioids. Id like to think it can be done safely. The dogs dont have the masks we talked about earlier and the gloves they can put on. The lack of coordination between the Postal Service and c. B. P. And need of memorandum of understanding and written agreement you said is necessary. Been able to do over the last fif years since the trade act . Thank you, chairman. It really starts with the collection of the data and it depends on the size of the customer but the bottom line is for the large multi nationals we have software and direct interfaces with them but even in the individual that is walk into one of our ups stores it can be input so we get the information into the system immediately. As soon as the package is picked up thats what actually is the indicator and every 15 minutes our system automatically transmits to cbp so that we can get the information to them as early as possible. And that was part of the clabive effort injury from the business side we have a shared responsibility to do that. Then depending on whats going on with the shipments, the you know communicate back with whats going on but our whole whole principal and foundation what we do for cbp lets get the data and get it two to you as soon as possible so you can begin that. Carpers reminder that while we are focused today on the fly of illicit drugs and especially the precursors to the synthetics that we have to continue to focus on the demand side here at home continuing work to make sure people can get treatment while working on prevention as well is so important. New hampshire, 70 of our Overdose Deaths involved fentanyl. 80 so far this year involve fentanyl. Were seeing acetyl fint mill and weve seen six death from carfint il. To echo what my colleagues are saying, we are talking to talking to all sorts of people. Its drained not only on our lives as a community but our economy as well. In my last briefing with the dea, they accounted to me in graphic and vivid details of how dangerous fentanyl and carfentanyl is for our Law Enforcement and person em. That extends to people who may be handling these substances through the portfolio system. We know you can overdose by touching this stuff with a bare finger or breathing it in. Carfentanyl is changing the way our Law Enforcement is dealing with everything about the way they enter a suspectss home to a crime scene afterwards. We know we dont want to put third parties like usps at risk. What has the Portfolio Service done to help address these risks to usps employees and how can we protect our workers but make sure that Law Enforcement has the tools that they need to investigate and crack down on the supply of synthetics. Yes, senator. The u srvegts ps has over 600 employees. Yeah. From processing to delivering the mail, transporting the mail, all of our employees are involved in that supply change of doing so. On a regular basis, whether its at International Service centers or processes centers around the country, we do a lot of training with our folks around has. Were constantly and consistently training employees. We do the same with our Inspection Service, which is does a lot with our processing facilities as well for oversight and investigating and addressing issues that we find in the mail. Ok. Thank you. And ill ask mr. Perez to comment. You discuss steps cpb has taken to protect its personnel. Id love if you could expand and talk about the balance here. You know, i know of an agent in New Hampshire whos doing everything right. They was masked and gloved and she took off her glove and she overdosed. I was very concerned about it. Thank you goodness, senator. Beginning in 2015, nfltd, we began a comprehensive training and instruction that was deployed to all our front line officers and agents, the people who would typically potentially come in contact with these substances that went into grate depth of the proper handling, the wear they need to don and wear. If and when they uncounter a parcel or a person that may be carrying a vehicle as well where they believe the dangerous opioids may be. We began our Naloxone Program as well. We have those countermeasures deployed in over 34 leaks now, over the past two years. Those locations include all the busiest express consignment fastballs, all the International Mail facilities and the location along the southwest border where we see the most traffic along these opioids. Weve also deployed over 600 doses to narcan. As a side note, the officers and agents that are typically trained in actually utilizing these are ems certified cvp officers and or agents. That is pretty much how were doing it. We continue to make sure that that training, that awareness is ongoing and that we do absolutely everything we can particularly with the up tick in our encounters with these drugs. Im going to ask you to even the same thing. If Law Enforcement thinks that theyre putting third parties at risk through certain kinds of under cover operations, theyre going to stop doing it, we need to be able to continue investigation. Its helpful to hear that training is ongoing. How does ups address this issue . Ill be honest with you. I really dont know the answer but ill get back to you on it. There used to be certain kind of undercover operations that i think Law Enforcement is taking a look at because of the risk to people handling a package a that they may not know has an elicit and dead ly contents. The other thing i wanted to ask mr. Tommy. You discussed in your testimony that fentanyl and other synthetics are bought on line, bought on the open web and the dark web. So what efforts are being made internationally to crack down on illegal purchases of these synthetic drugs, but whats happening internationally . The state departments engaged in extensive negotiations with countries that we feel are sources for these kind of things. I cant give you a comprehensive answer across the board but i did talk with our Bureau Narcotics and they reported on china, so i can share that with you. In response to repeated u. S. Requests made through the Bilateral Group we have with china, china has, in fact, domestically controlled now more than 134 synthetic drugs including car fentanyl. This is an vant weve seen in getting them to see this. Chinas effort to control it is a welcome measure. We hope we can continue working with the chinese. The chinese say they are not causing trouble in their country, theyre causing problems in our country and we want them to take measures. Theres a lot of work to do but we have had that success. Thank you very much and thank you mr. Chairman. Thank you mr. Chairman. For you, mr. Shank, the packages are dropped off at aups facility whether here or in some other country, youre able to electronically track and share information with the customs and Border Protection and thats essentially your system, is that correct . Thats correct. And the Portfolio Service, tell me why you cant do the same thing. Inbound packages coming in, you know, so foreign shippers, ship to a foreign post and then they enter into the usps. We do not have that direct connection. Ok. So state department, why cant we require that from the shippers in Foreign Countries, theyre give lent of their post office . Well, as my colleague from the Portfolio Service says, unlike the expression shippers that control both end of the transaction, we dont control both ends. But why cant we tell them that they cant utilize our payoffs unless they have an electronic tracking number on it that we can track and share with cbp to cut down on this baloney . Our Treaty Organization based on reciprocity would we give them an electronic tracking the they requested . We have offered and we certainly would like to be able to share data with them. If they have the capacity we would. The Ranking Member and the chairman talked about the fact that we got a problem in this country and we got a problem in this country, so i get it. They dont want to do it. I dont want to do a lot of things im told to do. So why dont we hold their feet to the fire . Home run. Would it have an Economic Impact . Not having it is an Economic Impact. Street any way people could roll up their sleeves and say wie got people dying from there crap and its time to say enough. Were doing our level best to hold their feet to the fire an to demonstrate to them. Has the threat been made that youre not going to be able to ship it via the Portfolio Service . Actually its not a threat. Its a reallife situation. We can pat people on the back and say please, but that hasnt worked. Im not into negotiation, so i dont know what you guys are faced with. I do know that this is hurting a lot of people and costing a lot of money. Next time you meet, buckle down and do it. Otherwise, we have to do something draconian here. We narchd the urgency. Its not you. I appreciate yall being here. The Inspector General, that might be you, ms. Whitcomb came up with some audit reports on inbound International Mail to the Portfolio Services. These are questions for you, mr. Perez or sentron. If my math eats correct, six are still open. One of the recommendations was that the Portfolio Service establish that process. Why arent we doing in . Yeah. Earlier today we did speak. My colleague mr. Perez indicated that within the next three weeks we will have the mou sitting up now at Customs Border protection. We will then get that hammered out and get it in place as soon as possible. Ok. Just to reiterate for the record, we havent waited for the mou. A lot of these things we work collectively, collaboratively. Glad to hear that. Do you agree, mr. Perez . Yes. The getting it delivered and codifying, if you will, many of the best practices and procedures in International Facilities around the country. Mr. Chairman, when you get that mou signed would you send off a copy to this committee so we know id done . We can provide it. Thank you. One more thing, and this goes to any of you three gentlemen, is there legislation that is required in order for you to take swifter, stricter actions to prevent these poisons from coming into the country or do you think you can do it with whats on the books now. Anybody can can go. Mr. Sentron. With you repeat . J the question is do you require further legislation to take swifter and stricter actions to prevent these poisons from come into the country or do you have enough latitude with the rules that are on the books now . Yeah. Is there legislation thats needed for you to stop these drugs coming in is the question. Yes. Or do you have the latitude to do it today . I would defer to the state department, maybe customs to maybe answer. Mr. Perez . Senator, were very comfortable with our authorities. Good. Nevertheless, again just would continue to emphasize the unquestionable need to further the efforts to get advance information. Good. All right. Miss whitcomb do you have anything ultimate like to add . I would just piggy back on what mr. Perez set, concerning the roll out timing. If you have any recommendations that need to be changed within the code, dont be afraid to tell us. It would be helpful. All right . Thank you all for being here today. Very much appreciate it. Thank you, senator. Senator danes. Thank you, mr. Chairman. I want to thank you for your personal leadership on this issue. People of ohio and the people of this country would have been very proud of what i saw six weeks ago. I was with the chairman in beijing. We had meetings with the chairman in china, chairman of the mpc. Number three in charge of all of china. Followed by a meeting with the premiere and mr. Chairman, you were very direct in asking for the help from the chinese government, the very highest levels to deal with the source of fentanyl and car fentanyl. I saw that behind closed doors and thank you for your leadership that extends and fluchbss beyond this country and around the world to stop this discourage. Thank you, senator. Thank you for testifying today before our committee. In recent years in my home state of montana, we have been facing a meth epidemic. I realize its something that started with the opioids and meth starting in the northeast working its way across the country. Its in big sky country as we speak. Largely the import of meth is coming from mexico. It has gripped my state and is showing somber and sad signs that its present. The Montana Department of justice issued a report that there were 14 children that died in our foster care system. 11 of those 14 children died as a result of Household Drug use and four of those were specifically linked to meth. Thats not the way youre supposed to grow up with a child in our great state. In addition, the Montana Department of Justice Division of criminal investigation has seen since 2010 to 2015 a tripling of a number of cases theyre addressing as it relates to meth. Meth has left its mark on montana through increased incarcerations, increased death, heartbreak, and its straining our Community Resources to keep up. To stop the importation of meth at its source would go far in the healing process in states like montana. Mr. Centron in your written testimony you mention that the use of advanced trovrng data for inbound International Mail increased from approximately 1 to somewhere in the 40 to 50 range. And i know in montana, mexico has specifically been identified as an overwhelming source of meth. Question is, what countries and which countries have been either collaborative or particularly unresponsive in sharing advanced electronic data . And the second part of that, has mexico been at all helpful in providing the necessary data . Yes, i can provide that information post hearing. We have many countries that we have agreement with like, i talked about the four we have bilaterals, many other countries were receiving advanced trovng data from them make up 40 to 50 but i can provide you better information after the hearing. Specific countries, mexico, and china that are the large efs sources of illicit drugs. Have they been responsive to working toward the 2020 implementation date for providing advanced customs deet or are we just grasping on the air . Absolutely were seeing substantial data that comes back that bans electronic data to them. I can certainly provide you with that after the hearing. Ok. Thank you very much. Appreciate that. Mr. Schenk mentioned in testimony that theups delivered more than 19 million packages and documents each day while providing the electronic advance data. Would you estimate how many packages containing illicit drugs are caught due to the advanced customs data. And number two, what percentage might those packages represent . Thank you, senator. For that the reality is were not perfect. Wed like to say that no bad people are going to use our network but they certainly attempt to do that. Fortunately, with the relationship that we have with customs and Border Protection in sharing information, we do find ways to interdict it and we do get some occasional shipments. We have had several shipments of fintd nil over the past year that were seized by cvp. Weve also had a little more in terms of numbers of shipments of meth that was mentioned earlier that gets seized with that and we work with cvp. In terms of percentage of it, its many. One of the reasons that we would hope that the bad people dont try and use our network is because of all the programs that we do and actually what were talking about here is kind of 101 border level stuff with that and plus our ability to track and trace and work with local authorities as we do on investigations. Mr. Sedo you have any estima of packages that are flagged because of illicit drugs. I can provide you the data after the session. Its a small percentage but we can provide that information after the hearing. Small i guess less than 1 , less than 5 . Any sense of how small is small . Dont have that. Ok. But il provide it. Thank you. Just close by saying i do believe the most effective way to end the meth crisis in a state like montana and allowing the healing process to begin is cutting off the source of meth. We can Work Together here on source. Well need collaboration between the usps, cpb and our foreign post stake holders. If the foreign stake holders refuse, we shool put America First in this situation. Thank you mr. Chairman. Thank you mr. Danes. Senator high camp. Thank you so much for taking on this issue. Its critically important. I remember a conversation we had last congress. Dea was in the room. When i suggested that they may want to use drug dogs to detect finltd nil package, the dea agent told me that if they actually could smell it, the dogs would die, so were dealing with an incredibly dangerous material and this is moving through the Portfolio Service and every postal worker who touches a package is at risk and so i think this isnt just about for the Portfolio Service, its not just about, you know, processing and getting things true but it really is an issue of care for your employees and so i just wanted to raise that. Business whitcomb, we noted in your testimony this the Portfolio Service oig work, your audit work found that the Portfolio Service had the ability to request advance custom data under several Bilateral Agreements but elected not to do that in certain circumstances. Why did the Portfolio Service make that determination and what would you recommend in response . Yes. I think most of the bilaterals that did not have these requirements in them were older Bilateral Agreements. Most recently the negotiations on bilaterals have included this requirement, so i believe its more of a timing issue and a recognizing of the importance of this and over time i think it has improved over time, i should sigh. But some of the ones that we had reviewed that did not have this requirement were older Bilateral Agreement. Mr. Centron may know about the direction the Portfolio Service is taking to include this more consistently in the Bilateral Agreements than i do at this point. Yes. Bilateral agreements require advance electronic data. And this is for anyone on the panel. It appears that one of the arguments being made regarding the Portfolio Service being unable to utilize a system similar to the system that has been outlined by private shippers and carriers is a cost issue. I understand that other issues also complicate equalizing the shipping requirement but cost, prices and technical things matter. How do we bring down the cost of compliance with technology. Is it looking at the prioritization of data. Upgrades with foreign shippers and under the current method you are using to try to address this situation how long do you the think it would take to get Foreign Countries to utilize aed at higher rates . Do you plan to have those discussions, i guess . Maybe we could start with mr. Perez. Through the Pilot Program we have, senator, with the u. S. Portfolio service where currently getting advance electronic data from several different countries, specifically the pilot in jfk has to do with both china and france, and so were going to continue to focus on,000 and work alongside our Portfolio Service partners to see what else we can do to make sure that were being able to not only utilize and get that advanced tropg data but then focus our efforts to expand not only the stlool were able apply but again, the quality itself so we can make better and more informed decisions on where it is we need to focus our efforts. Mr. Centron. Yes. I can clarify. The point earlier is for us with the pilot in jfk, certainly one of the things were going to be looking to do, expand that part of it to the others we have and get better with the amount were generating that is going to and i can speak more about that for later. The costs are really going to be incurred at the foreign post where they really have the technological upgrades and challenges that need to be you know, thats where those costs are going to come in and certainly thats the difference. The Technology Part of what we can do on our side is a little different. In regard to aed once we get the data itself. If we were happy with the speed to which the u. S. Portfolio service were dealing with this issue, you all wouldnt be here. This is not moving fast enough. We see these drugs coming in. We have had numerous deaths in my state because of fentanyl abuse. We know that the delivery point is the United States Portfolio Service, either point to point in the this country. My recent investigation and prosecution regarding fentanyl moving in the mail from portland, oregon. But it originally came in from canada. This is serious stuff. And it needs to be addressed and we need to have a plan, it seems to me, with detailed time lines. If resources are a problem, we need to know that. You cant get if theres a legal problem with the bilaterals or with the agreements, we need to know that. If theres a resource problem, we need to know that but weve got to stop jeopardizing people who move this stuff, whether its at the payoffs or who come into contact with a package unwittingly. But weve got to have a plan. It is frustrating because we addressed this in a round table last year or the year before. Im hearing the same things over and over again. Pilots are good, but they dont give us a plan, and so i applaud the chairman and the Ranking Member for bringing this issue to the committee. This is something we are going to be serious about in terms of oversight and moving forward, so with that, mr. Chairman, ill yield back the rest of my time. Thank you senator highkamp. Were going to do a second round, a lightning round. Let me give you an example of not moving quickly enough. In april 2016 there was a letter sen to this committee. It said the plan to expand the program from china to los angeles internarnlt is currently scheduled for the summer of 20616. Were now in the summer of 2017. Has it expanded . It has not expanded yet. It has not. It has not. The upu. Weve heard about whats going to happen with regard to the universal portfolio union. With all due respect to our International Partners tanned fr upu, well get done by 20818, 2020 or even 2022. Other countries are working on their own time tables. We cant afford to have them working on our own time tables because our people are dying. I guess my question is how many more americans have to die before our government gets its act together, making sure that the plan was working. Make sure that were actually doing everything we can to keep this poison out of our skmunts. Admittedly, this is not a silver bullet. Theres not one silver bullet. Im going to steal a line from with one of my colleagues who says there are a lot of silver bbs. I hope that because of this hearing we can get this legislation passed to give you the Additional Authority i think you need to have as mr. Perez said rightly, the tools,y the tools to be able to identify the right packages, to go after them, to stop some of this poison and also to increase the cost on the street. Right now this stuff is so cheap and so deadly that its killing more and more people. Were going to hear from the next panel about whats happening in our communities and whats likely to happen this year as compared to last year. And the result is more people dying, getting worse and worse. Thank you for being here. I turn to my Ranking Member. Thank you mr. Chairman when senator highkamp was speaking, it reminded me of the portfolio legislation over the years. How do we increase the revenue to the Portfolio Service so they can replace 25yearold fleet, how do modernize payoffs and with our rural letter carriers. How do we provide those services . To be able to do their job, a better job with respect to intersecting the movement intersenting the movement of these highly toxic clalgs. Were going to use that in reminding our colleagues on why its important to move on portfolio regulations and sooner rather than later. The other thing i want to come back to is the pilot. Take me to the pilot. And if you will, its jfk, right . Jfk . Yes. Yeah. And what again, why if delay in spreading and extending the pilot to the other, i guess four destinations . Why . Yes. Couple of things. Let me explain the pilot as weve gone through it. Mid 2015 when they started. Until the recent two months weve made some pretty significantle kbrooichlts. We try to eliminate the manual handling of the product itself. Right. So we get the advance electronic data. We provide it to Customs Border protection. They provide us with a list of what they want us to extract. We were doing that in a manual fashion in terms of identifying the sacks and identifying what we needed to do to extract those pieces. When there hasnt been any expansion, theres been improvement to put it on the processing equipment. Weve worked closely with the Inspection Service and our engineering systems b and now to be doing this on our processing equipment. So one of the key things that will happen is it will be on equipment at jfk isc. Weve connected the downrole in facilities where we can trap those pieces now. Mitch the same you heard from the ups service. Were very good at this part of it, tracking bar codes. So we have the ability how to do that. The expansion is and our full commitment is to get those other sites up and running now that weve fleshed through this. We need to do it in collaboration with customsBorder Protection. Mr. Perez may want to dmiem a little bit but were focused on getting moving forward and expanded to the other four sites. Were very committed to getting that done. Give us a final 30 seconds, a glatd stakaway. A last 17 years ago i want to make sure youre not here 17 from now. We probably wont be either. Give us a great take away in terms of our todo list here on our end, the congress end. I think the passage of the stop pact we also think it will help the portfolio operators in their negotiations with the upu that says we have a mandate, they have to do it. If there was a way to increase the amount of information thats shared. We have a great working rim with cvp but there are limitation eggs of the we knew about who some of the bad people were we could put that into our system. Thank you. Im going to be asking for the record if amendments or changes to be made to the stop act. What should we consider and sort of prioritize those for us. That will be a question for the record. If you can do it, that would be great. Were halfway home. This has been a great happen thank you. Certainly. Let me conclude by thanking our witnesses again and thank every one of you for what you are doing in your own way to try to push back on this epidemic, because each of you in your capacities areworking on this issue. Weve got to figure out how to do it more effectively and faers. Yesterday we had our weekly buckeye coffee. We have a couple hundred ohioans come in n and four rural letter carriers were there. There were there from the union to talk about portfolio issues. They talked about the stop act and the need for more resources for senator carpers efforts and hes been a leader in this over the years. Then two of the four took me asietds privately. Two of the four. This is 50 of the rural letter carriers that came to me yesterday who said i have a family member, one was a mother, one was a son, who are recovering addicts. Theyre now in recovery, in and out of recovery which is not unusual. And they both said to me, you got to move forward with this, you got to continue your efforts. I would just tell you this is affecting anybody including our families and friends and neighbors in every zip code and including the rural letter carriers who came to talk to me about another topic but ended up focussing on their concern for this issue. Thank you for being here. The second panel has now joined us. Were going to move quickly here through the introductions. Each of you deserve a 20minute instruction but im going to give you a shorter one today. First is Michael Botticelli executive director of the center for addiction medicine at Boston Medical Center. As some of you know, mr. Botticellis been at this a long time. He was actually the drug czar who will a few months ago. Were happy to have you here mr. Botticelli. Second we have chief thomas cynan police chief of the city of newtown in hamilton county, ohio. Hes been involved in the ohio canadian Heroin Task Force and chair of the task force. Everywhere in southwest ohio people look to hem on his advice for this. Hes going to talk to us about whats happening on the street. We have dr. Gillson, previously chief medical examiner for the state. He provides us the best information because every month he gives us whats happening in Cuyahoga County broken down by the counsel, rural, suburban and its helpful. Bottom line is, it affects everybody. Mr. Cherry horton is here with us. Hes the chief at medical services in delaware. Previously he served in the phoenix house. He developed a program. He founded project engage and has been very involved in delaware as the chair of the Drug Overdose fatality review commission. Really appreciate all you being here. Would like to ask you to stand. Raise your righthand repeat after me. Do you swear the testimony youll give before this committee will be the truth, the whole truth and nothing but the truth so help you god. [ sboresponse [. Large Regional Health care provider, terrys sitting right behind is bettina riveras. Shes gone to be a great liter on a wide range of Health Care Systems. I think sebastian is back there. Hes sa years old, terrys son. We welcome him as well. Well be looking to see if his lips are moving when his father speaks. Im sure you attribute all your success in governor now senator carper. Let the record reflect the witnesses answered in the affirmative in regard to the oath. It will be printed in the record in its whole. Wed ask you to keep your oral comments to five minutes so we have time for questions and a good dialogue. Lets start with tom gillson, if thats ok. Dr. Gillson, lets hear from you first. Thank you, good morning. My name is thomas p. Gillson, the crime lab director. I thank you for allowing me to be here to speak on this critical subject. If i were to tell you a major catastrophe that would kill tens of thousands of people in this country each year, how many people would respond . How much resources would be put into action in this response . If the catastrophe was aloued to happen with more fatalities, what other hearings would be called. It should be thought of as a slow moving mass fatality event that occurred last year, is occurring this year and will continue to occur the next year. Each year is getting worse than the previous. In the my county well see approximately 800 deaths. Last year we saw approximately 660 people die from these deaths. 90 will be open next seven days, pills, heroin, fintd nil and newer an logs of fentanyl. Its a nationwide Public Health emergency thats simply out of control. Its hit all states except an lasha. The New England States are already hard hit. We were alerted to an alarming rise in heroin associated deaths. We partnered with our county sheriff, Cleveland Police department, county prosecutor addiction and Mental Services word to launch a Community Initiative which has attempted to gas this public crisis. Partners were added from major institutions including the cleveland clinic, case western reserve honts and our county hospital as well as the free clinicalic. The free Public Health Service Provider and set in motion some important pieces of response. We have drug drop off boxes in order to take back overprescribed prescriptioned pain pillings. Its run out of the free cling and Public Health. As well as patients leaving Treatment Centers. These folks are at risk because of decreased tolerance. The creation also of our heroin Death Review Committee allowed us to look at data from did overdose fatalities in an attempt to plan intervention strategies. We also hosted a heroin summit at the cleveland clinic. Cleveland clinic hosted the summit in november 2013. Law enforcement has already created Specialized Task forces that work with our medical investigators, scene investigation to begin investigations earlier in our Forensic Laboratory provided timely highly efficient stsk evaluations. Youll of this work continues a community strategy. When a heroin overdose occurs individuals typically fall asleep and breathe more shallowly until they stop altogether. The dying can be reduced by ma locks own which is an immediate solution and should be providing. We have currently documented over 1,000 reversals with naloxone. Ramped up in ernest last year have documented another 300 reversals. These 1300 individuals did not have to make a final the trip to my office. The addition of fentanyl and car fentanyl which was initially seen in akron and sd a large animal tranquilizer. Several doses may be required and the time window for administration is greatly shortened. This is the fl reason. Research conducted at the medical Examiners Office in my county in collaboration with medical, Law Enforcement and forensic partners indicate that nearly six people died between 2012 and 2014. At least 72 of all these overdoses had been prescriptioned, a controlled substance within two years of air death. Several of these people were doctor shopping and with the madonna story Drug Monitoring Program we are moving in a positive direction to prevent this from people going into the illicit drug market. The final example of how valuable information can be gleaned from death certificate data is the fact that many of the individuals in my office had been in contact with the legal system and or drug and alcohol treatment programs. Theres a tremendous need for education and these are intended to do that but its naive to think it would be effective if we dont observe Treatment Options. People can recover from drug addiction with adequate support. While data and information are criticaling in helping to determine effective astros, it has been particularly inspiring to see the sense of community in Cuyahoga County that has brought treatment, prevention, Law Enforcement, prosecution and medical examiners like myself together for a single purpose, which is to save lives. At the same time, however, our local resources have been stretched to the point of exhaustion. The Death Investigation system and laboratories are facingle double digit case load increases annually, increasingly complex processes to support the fight especially now with the fentanyl analogues entering into our country. Its clear that the supply and delivery of the drugs to our communities continues nearly unabated in Treatment Options are severely limited. Our community added millions of dollars to this effort in several years. There are enough people until our county to fill our football stadium every year and approximately a sufficient number of people to fill our basketball arena. That used to be large limb a caucasian majority with up to 85 of the victims. However, its changing now and it seems almost with purposeful intent fentanyl are being introduced into the africanamerican community. Cocaine had been the only drug that victims in our community where victims in our community were predominantly africanamerican. Thats changed dramatically and its also of note that we have a High Percentage of africanamerican deaths in our Drug Overdose crisis. The the incomp race i feel i see already in my county are depleted and overwhelmed. Treatment beds need to be opened and adequately funded. The imd exclusion which limits the number of treatment beds to 16 for Substance Abuse Facility Needs to be lifted and i applaud the bill submitted by you that will double the number of available beds. Interdiction agreements with china, mexico and china need to be strengthened and delivery of these substances needs to be squeezed off. I appreciate your coship of senate bill 7088. Theres a National Crisis in my field in Death Investigation. My field especially is in dire need. There are less than 500 Board Certified Forensic Pathologists performing in the United States. Currently 28 offices are seeking to hire additional Forensic Pathologists. I have did oldest Training Program in the country. There are only 35 such programs, however, in existence and they are not funded by medicare, unlike any other training spermt. We employ one or two doctors a year in a system that can only produce a few dozen scientists annually. That depends on competent Death Investigation. Its essential that Additional Support be given to these Training Programs as well as to doctors already practicing in the field. All of these actions are beyond the ability and authority of a local county like mine. We need continued resources and commitment to enforcement and recovery. Its a very important topic to me. Thank you for your time and consideration. Id be happy to answer any questions. We provided a packet of information which summarizes even more. I could have talked longer. Thank you very much. Thank you, doctor. Mr. Botticelli. Mr. Chair . Yes. Just because i have to leave, i wanted to thank dr. Gillson the medical examiner for the state of New Hampshire for such a long time. Thank you so much for your work and your continued work. Mr. Botticelli im sorry ill miss you but weve talked before and well talk again. Thank you very much. Remember your full statement will be part of the report. Great. Thank you. Chairman portman, senator heston as you leave, thank you for the opportunity to be here today and for your ongoing leadership in this epidemic. We agree that its a Public Safety issue of our time that 2015 National Survey on drug use and health estimates that approximately 2. 1 Million People in the United States have an opioid misuse order. Last year we had statistics. T 1 people a day died from overdoses resulting in over 33,000 deaths in 2015 alone. In massachusetts, 1900 people died of an overdose inning 2016 and thats up from 742 just from 2012. In addition to addiction and death, we know injection drug use associated with this epidemic hack linked to viral help diets across the country along with local break oouts of hiv. There are at least 220 counties mostly in appalachia that are at significant risk for another outbreak similar to the one in indiana two years ago. Over the past few years weve seen the emergence of synthetic opioids. Overdose deaths attributed to other than methadone increase kd by over 72 from 2014 to 2015. Reports from the dea as well as state Law Enforcement indicate that these defts have been soeshltded with Law Enforcement seizures, testing positive for fentanyl. This increase is not a result of fentanyl prescribing, indicating this is largely illegal ly adde. Analysis is limited to those states like ohio that have excellent or very good reporting, which means that overdoughs deaths are reported with the specific drug involved. 26 states reported statistically significant increases from 2014 to 2015 with states in the northeast and midwest experiencing the highest increases. A recent analysis of Overdose Deaths in massachusetts showed that deaths involving fentanyl rose from 32 into the 2013 to 2014 period to 272 in the first half of 2016. Fentanyl is often mixed with heroin or cocaine with r o without the users knowledge, usually without. Its seen in high profile. Its largely illicitly manufactured in china, shipped to the is via open or dark internet to the United States. I wont go into detail for lack of time but i think you all know the administrations response to these efforts. And under all of those efforts is ensuring people who need treatment have access to highquality care, including medicationassisted treatment. The Affordable Care act contributed to assuring Substance Abuse Disorder Treatment was one of the ten essential benefits that Medicaid Expansion plans and marketplace plans have to cover. It also ensured that those benefits be offered on par with the federal Mental Health parity and addiction equities act. Again, for lack of time, i i wont go into detail but im very proud of the accomplishments we were able to make with congress in terms of the passage of the comprehensive Addiction Recovery act rescinding the federal ban on the Syringe Service programs. We accomplished a lot in our time together here in washington. But we still have a long way to go. So ill focus the remaineder of my remarks on what i think are recommendations on how we deal with fentanyl. Continuing to enhance our intelligence and information gathering on the manufacturing and distribution of fentanyl is critical. While i was very appreciative of the Intelligence Communitys calls for better information, theres still many unanswered questions. I was happy to hear that the dni looked at synthetic opioids as a threat. I was disappointed before that i didnt know we had fentanyl until we saw local outbreaks in the United States. Our Intelligence Community is too good for us to be caught unaware in terms of what is coming at us. Since fentanyl is much harder to detect and can present a hazardous to state and federal and local Law Enforcement, we need to expand current drug Testing Technology and continue detection capabilities. We need to continue to provide factbased handling instructions to Law Enforcement, Border Patrol and others who may come in contact with fentanyl. We need to continue our engagement with china and schedule analogs and take down illicit manufacturers and shippers. There is also a significant amount of variability of standard testing of fentanyl with Law Enforcement criminal justice system, coroners and medical examiners and treatment programs. They need to incorporate fentanyl into their drug testing panels. With Public Health experts, we need to develop and distribute informational material on how users can minimize their overdose risks in areas where fentanyl might be present. We need to expand the use of maloxen by someone who witnesses an overdose. Because of the potency of fentanyl, the period of time we have to reverse an overdose should be shortened. We need the federal government to deploy a Rapid Response team to our communities like we do with other diseases so that communities have the investigatory tools that they can to examine some of these outbreaks and the causes behind it. We need to expand Syringe Service programs and others that engage active drug users to promote safer injecting and minimize overdose risks. And more importantly most importantly, we need to encourage the coverage gains, particularly Medicaid Expansion and other federal grant programs. Even with these provisions, timely access to quality care remains an issue for many, particularly in rural communities. Thank you for your time and i look forward to your questions. Thank you. Thank you, chairman and senator carper. First, id like to say i think this issue of addressing fentanyl is important. Fentanyl exacerbates any issue i have to attend to at the hospital in trying to help individuals get into care. It just creates a rapid spiralling of addiction, much more sudden. And in delaware, currently, every 25 of our individuals die have only 25 of our individuals have fentanyl in their blood at the time of death and so when we look at the potential for damage in our state when we reach the levels of massachusetts, you know, i think theres going to be a real catastrophic increase in the coming year. Having said, that i want to share briefly as someone who sits in a hospital and works in an inpatient setting and emergency room and clinics, ive been doing that for 25 years, some of the Lessons Learned, this is a horrific epidemic. It strikes across the board. I take care now of not only Young Mothers who have given birth and High School Kids who are wrestling champions but also grandparents and couples. So all races, all ages. What they share is a horrific addiction. They are their brains have changed. Their motivational circuits have been distorted. As well, they have this new onset of withdrawal, a withdrawal that is really like primal misery. Its a withdrawal that prevents them from moving through that wall to go into care. Theyll stay outside of that care and avoid it at all costs because they cant attend to withdrawal. Thats also a reachable moment. Thats also what we can leverage and weve done that in the hospitals and in jails. So when someones put in a hospital and they can no longer be on the outside and theyre desperate to avoid withdrawal, we can address a withdrawal and treat it aggressively with medications like suboxin. Twothirds of the people that i see in the hospital that are agreeable to go into longterm care, twothirds. They dont come into the hospital looking for that. They have an infected leg or heart and use that opportunity to get into drug treatment. Its really remarkable. Twothirds of individuals that i see are actively looking to go into drug treatment when i offer it and address their withdrawal. Of those individuals, remarkably, nearly 80 show up to the Community Care provider when ive inducted them on to suboxin. The hospital is a reachable moment. 77 are there a month later. What im telling you is that individuals who are addicted to opiates, its a reachable moment to address around withdrawal and we can use that to leverage them to get into treatment and stay there. If youre on drug treatment or medicine like suboxin, youre not going to overdose. Its really about safety. Yesterday i had clinic and this is what i said. Take your suboxin today and tomorrow and those are the days we dont have to worry about you overdosing. A simple and straightforward safety message. Really critical to what im trying to do and helping individuals get into care and staying into care so they dont overdose and dont die, its really having access to that care. In delaware, weve been able to expand Outpatient Care for primary Substance Abuse care. Really by the thousands. And so for me, i have no difficulty when i identify an individual in the hospital getting them into care the next day and in the community setting. It has to be that close. It has to be that contiguous or i lose them and they relapse. Its remarkable that im able to do that but im able to do that because that care is available and you go its completely dependent on medicaid. Without medicaid, it would collapse. What im fearful of, i know how to address this Opioid Epidemic. I know how to get them into a safe place but im fearful i will lose the tools and medicines i need to keep them safe. And im fearful the cuts will so basically im saying, please, you know, its critical. Dont take away my ability to treat my patients and keep them safe. You know, they depend on me and im depending on you to really preserve the system of care that ive been able to work with and make improvements. You know, without it, i think this war is lost. Thank you, dr. Horton. Thank you for giving me this opportunity to discuss this very important top mcof how synthetic drugs are destroying the lives of loved ones in our communities. In my 24 years of Law Enforcement, ive never seen a substance cause death rates higher than Car Accidents combined. Ive witnessed the power of drugs, watch an entire family, from a mother to her three sons wiped out. Three brothers, an entire generation gone because of drugs. The last two brothers due to heroin. Events like this led us to form a coalition at a time when we were calling this epidemic with an average of 20 to 25 overdoses and one to death as week an epidemic. In july 2016, i received a call from the Greater Cincinnati fusion center, a part of Homeland Security, a center originally designed after the 9 11 attacks to analyze and share local and federal Law Enforcement along with the public. Recognizing the centers ability to analyze data and share quickly among various agencies, we adapted the use for heroin, tracking overdoses and locations and intelligence that could track trends on the street. At 10 00 a. M. , that call told me theres a new drug on the street called carfentanyl. The response was, we are not sure what it is. Its used to knockout large animals. I replied, like a pig . No. Elephants. We passed this on to the county Health Commissioner trying to obtain as much information as we could to try to figure out what the introduction of carfentanyl on our streets would mean. What we learned about this drug is frightening. The top of the opioid chain, the drug not intended for humans, so powerful that equivalent to two grains of salt had a potential to kill a human. 10,000 times more powerful than heroin. So concerned not only for the user but First Responders, hospitals, Treatment Centers and the public. You could unknowingly be exposed to this synthetic. We recommended stop field tests of heroin, a process needed to develop probable cause to arrest a person for heroin. This warning has reached other states such as georgia and florida to ensure the safety of their officers. With all the dangers already facing Law Enforcement, this danger which could be undetected until it is too late is a danger that concerns the most hardened police veteran and led a change to policies to protect their officers. We knew this drug was monitored in the u. S. And controlled and with the assistance of the dea, we determined it wasnt coming from sources within the u. S. We could never have anticipated that our epidemic would reach levels of more along the line of a pandemic. In the week of august 19th to the 27th of 2016, an event occurred that what forever change our heroin epidemic in our area when cincinnati experienced 300 overdoses and two deaths in one week. There was nothing on the streets than synthetic drugs like fentanyl and carfentanyl, we went with a shift from organic opioid heroin to synthetic fentanyl, its derivatives and carfentanyl. Its testing the person drawn in no matter by choice or necessity is to the point of breaking. I not only witnessed the determination of those same people day in and day out to keep up with the new normal, 50 to 70 overdoses with four to five death as week. Moments of spike with 70 overdoses on one weekend, 11 people die in one weekend and multiple overdose at the same time in the same location. At times, overdoses reached nearly 40 in one day stretching the resources of even large police and fire departments, such as cincinnati, who in one district with 20 officers responding to other calls. In 2012, our area had seven deaths fentanyl related. In just three years, that number exploded to 238 in 2015. Heroic efforts such as Quick Response teams try to connect users to treatment, the Coalition Using narcan to every First Responder who in 19 months has used over 7500 kits of narcan. The sheer volume of numbers, a young boy walking down the beach where thousands of star ships have washed up. An old man seeing this stopped the boy and said young man, theres too many to make a difference. You cant save them all. The youngs boy picked up a star fish and replayed, i saved that one. This description we follow is beautiful and heartbreaking in its reality. Describing where we are right now in this epidemic. But no matter how great our efforts, our initiatives and determination, the tremendous influx of such powerful synthetics, such as fentanyl, to even more powerful derivatives, which our Coroners Office has releas uncovered more than ten different kinds of fentanyl. The original two milligram narcan is now obsolete. Having to replace with a higher concentration of four milligram dose of narcan which requires multiple doses. Its more common to hear of users unconscious and taken to the hospital and being put on a constant narcan drip in order to keep them alive. So now ingrained in the user in our area that when we think the situation cant get more difficult, dealers sensitive to the damage there causing to the users and our communities have now began to place these synthetics in other drugs like cocaine. This will not only cause more over do overdoses but deaths. Carfentanyl now so common in our drug supply is now expanding. Just a couple weeks ago, four people in cincinnati who bought what they thought was just cocaine overdosed. Two died on the scene, two left on narcan drips due to it containing fentanyl. Since i submitted this report last week, another person in that incident died. Three have died. Ones still hospitalized, as of my last check. That same week in my small community, a mother drove her 10monthold baby in the driveway where she got out and collapsed. Neighbors called 911 and the mother regained consciousness. She believing she had only purchased heroin. It was found out that she actually had been given a mixture of cocaine and fentanyl and carfentanyl. Two officers stood over the body of a 26 yeerlyearold who diede same drug. I thank the committee for looking for ways to reduce these powerful synthetics from entering our country, drug supply and our communities. I plead with this panel to do all i can to help us stop this poison from even getting into the country. Although this will not stop addiction or stop every supply, each intervention that prohibits these from reaching the streets, First Responders can get relief from the overwhelming numbers which has caused such stress on them working with Ohio Attorney Generals Office called First Responder fatigue. Take this deadly ingredient from those pushing drugs on the street and the potions become less powerful. This would mean less people would overdose, the number of deaths would be reduced, which for us is never lost that each one of those numbers is a person. A person who is a mother, father, brother, sister, son or daughter who will forever grieve the loss of their loved one. Thank you for allowing many he to speak on this subject. I commend you for your compassion to want to help all of us. Thank you. Thank you, chief. And thanks to all four of you for very powerful testimony. I was struck by your testimony, chief, about Law Enforcement and, as you said, trying to keep up with the changing drug mix and specifically the move to synthetic opioids, fentanyl and carfentanyl in particular. Im thinking about how Law Enforcement approaches this. Now you have a situation where, through the u. S. Mail system, someone can at their post office box that is designated, pick up fentanyl from china, use it as an individual and theres no drug dealer for you to go after. Some of these individuals also become drug dealers, as you said. And yet its a different situation than being able to go after the source because its coming in through the u. S. Mail and you talked about tools. Earlier, we were talking to Law Enforcement folks and they said cpb said they want the tool of being able to get advanced electronic data so they can identify these packages and you said you want to take this tool away from the traffickers, the tool of being able to ship this stuff into our communities through the jail system. So i guess i would ask you, given your experience and given your background in this and seeing what is going on, would it be helpful at a critical show point, like these International Service centers weve talked about here today, to be able to stop this poison in part to be able to keep the volume down and in part to raise the cost, the risk to the trafficker of being caught but also the cost of this by reducing the supply . Yes, senator portman. It would definitely help cutting off that supply. There is very little risk for the dealers right now. Theres quite a bit of reward. The problem with it coming through the mail is that its not like in the 80s with the crack where you had major gangs that were mostly pushing the crack cocaine and once you identified the gang, you cut the head off the snake and the rest of it collapsed. Here it is everywhere with hundreds of dealers and not necessary flee a network or sourced into one area. It makes it very difficult for enforcement. In ohio with did a great job of shutting down pill mills and doctor shopping and inadvertently it created part of this epidemic when we had a segment of society left out there opiate dependent. It would give First Responders a chance to breathe. Part of the problem were facing with this epidemic is if you can get someone who is opioid addicted into treatment, often theres not Space Available and then the science shows that theres medicine assisted and not only is that choke point important, we also need to work on the issue of having those people who are addicted get longterm care in order to reduce the demand which my belief is once we reduce demand, then we reduce supply. Its a great point. I was impressed with dr. Hortons Health Care System that he has the ability to take somebody who is in need of treatment and within 24 hours get them into treatment, which, frankly, is not the case in many places in ohio. And particularly in rural areas, we have a real issue with the availability of treatment and longer term recovery, which, as you know, ive been focused on because i think that leads to better results. And i think Law Enforcement system can lead to better results, too, by supporting our drug courts more. I know youre involved with that as well. Dr. Gilson, you talked about what youre facing and specifically you talked about the forensic pathologist being overwhelmed. One thing you said to me was that at a death scene, where someone had overdosed from fentanyl, your people sometimes find a package literally a package from china at the death scene and, again, i think this is just an extraordinary change from, you know, what you were used to with cocaine or, for that matter, with heroin coming over land and being sold at the Street Corner in cleveland, ohio, i was struck by that. Can you talk to us, you said you have the best data, a the least in ohio, and for 2016, unfortunately, you were accurate that there would be an increase of deaths of fentanyl. Yes. Since you do keep this accurate data on overdoses and fentanylrelated deaths, what trends are you predicting for 2017 . What do you project for 2017 . Senator, i think were already far enough in to 2017 that we can make some predictions. One is that the crisis is going to get worse. Were projecting an increase from 660 total deaths up to close to 800. I think most of that will be driven by fentanyl and i think what everybody in the room should be incredibly concerned about is what is going to be the impact of the analogs of fentanyl. We had 54 deaths in 2015 related to carfentanil. Weve identified at least 16 to 17 different analogs of fentanyl and many of these, like carfentanil. What concerns me is that at some point, if these drugs start to replace fentanyl in our community, these numbers will take off again and to echo kind of what the chief said, we started with diverted Prescription Drug medication and about 2011, what my office saw was a transition away from Prescription Drugs, oxycodone, which appeared to plateau, and heroin took off. When heroin got started, it looked like it was going to go down. And then we caught a tidal waive of fentanyl. If carfentanil becomes the new drug in 2017, i shudder about how much worse that will be. Is carfentanil also coming through the mail system . This is what i can tell you partly from death scenes and partly from the Drug Enforcement agency. Yes, the answer to that, my investigators by happenstance will sometimes identify computer records and packaging that clearly shows that these drugs are coming from overseas and the concept that a lot of these drugs are coming from china is something that our dea liasions complete and getting it from mexico is also true. In the heroin epidemic, the mexican production went up dramatically to the point where they became the second largest heroin producer in the world. That Distribution System is in place and fentanyl can follow the same Distribution System. So i think that these are drugs coming from overseas, primarily from china, and being sold in our country really on the basis that can be considered an act of terrorism. Well, thats an interesting comment, given what we said earlier and what mr. Botticelli said with regard to the director of National Intelligence listing it for the First Time Ever this year in his world assessment, he put synthetic opioids into a National Security context. Senator peters . Thank you, mr. Chairman. Thank you for calling this very important hearing. The opioid abuse in michigan is growing at an alarming rate as it is around the country and its important for us to get to the bottom of this and understand how we can deal with it and i appreciate your leadership on this issue over the months and years that youve been working on this and certainly thanks to each of the panelists for your compelling testimony as well in dealing with us. My first question really deals with how we deal with the underlying Substance Abuse and the medical treatment necessary to treat those as a medical issue. Certainly its a Law Enforcement issue but its also a Public Health issue first and foremost we have to deal with. Whenever were thinking about Public Health, i think about our Health Care Policies and, in particular, the Affordable Care act with its expansion of medicaid, which has certainly been significant in my state, Medicaid Expansion has led to over 600,000 individuals now having Health Care Coverage where they didnt have it before and part of the Affordable Care act is coverage for Mental Health as well as Substance Abuse, which gets to the heart of the issue of this problem. Since the acas Medicaid Expansion window, more than 1. 6 million americans have now gained access to Substance Abuse treatment. So mr. Botticelli and dr. Horton, can you speak to how individuals enrolled in medicaid are using the program and whether or not we are seeing an actual impact on folks who are suffering from Substance Abuse problems . You would think i know how to do this by now. What we saw for a long time is when National Surveys look at why people are not able to access treatment, not having adequa adequate access to Insurance Coverage and being underinsured is one of the biggest reasons. Youre right. What the Affordable Care act did is a number of things related to increasing access to care. And made Substance Use Disorder Treatment and Mental Health treatment one of the essential Health Benefits required by Medicaid Expansion and by insuring that those benefits were on par with other medical benefits. And weve seen some remarkable results as it related to increased access to care under the Affordable Care act. And i think your point about the Medicaid Expansion population, which weve seen remarkable results and quite honestly remarkable results in those states that have been dramatically impacted by this epidemic like west virginia, like kentucky, New Hampshire, massachusetts. So we have seen an incredible increase in peoples ability to access care to do that. So the other piece i just want to make two quick points. The other important point here is that people with Substance Abuse disorders often have comorbid Mental Health and other health conditions. Its not just accessing care for their Substance Abuse disorder, they need care for their hepatitis, they need Mental Health coverage and the last thing ill say, i really worry about not just people losing coverage but the stability of our treatment infrastructure. Some of these folks can tell you these programs operate on very thin margins and i worry that were going to have a treatment infrastructure for those remaining people who can access care if they are not able to bill insurance. Thank you. Dr. Horton . Thank you. As i mentioned, in our system we have developed some very unique partnerships with Community Providers so we now screen 30,000 admissions to our medical hospital, the largest in delaware, identify those who are opioid dependent and treat that and if they are agreeable and go into care. That care is predominantly medicaid. So our Largest Community provider, called connection, has the largest footprint in the state and developed that footprint because they had a reliable funding stream. Its not only a funding stream that cares for medicaid patients. It covers all patients. They are really a quality provider. But the bulk of their revenue, what allows them to exist, is that they have a reliable revenue stream. And because of that, my record is actually 12 hours, identifying somebody and getting them into community and on a medicine like suboxone, and i can do that because the individual is covered. For the most part, the coverage is medicaid. If medicaid goes away, that collapses and, frankly, the structure in delaware collapses. I will identify individuals in the hospital. I wont have anywhere to send them. Theyll leave the hospital, relapse within hours, a few days and end up back in the hospital and we return to the good old days of the resolving door and the astronomical cost of caring for those individuals will shunt to places like my hospital he Health System and well never attend to the root cause issue. The big difference these days is that the volt assume of heroin. It used to be once upon a time individuals were just one, two, five bag as day. Now its bundles. Each bundle is 13 bags. 50 bag as day. Instead of bullets, its heroin. If any of those bags have fentanyl in it, that person dies. Its amazing. So were in the middle of all of this and because i have access ready access to Substance Abuse treatment on demand, you know, im able to make a difference and im clear that those individuals taking their suboxone are not overdosing and i know because they come in week after week. Chief, thank you. Im sorry, senator, can i add a different perspective on this, too . Please. We dont track it specifically, but, you know, we go out there and respond to death scenes and i think one of the most heartbreaking things we see is an individual whos been seen in an Emergency Department within weeks to sometimes days for a Drug Overdose who now is dead of a Drug Overdose. These are the people dr. Horton doesnt see. They dont make it back to treatment. They die and we dont have the capacity in my county to send these people when we have their captive attention, theyve just nearly died, to treatment. We send them back on the street, like dr. Horton said, to see if they can work something out. Anything like Medicaid Expansion being eliminated that limits peoples access to health care, i cant see any good coming from that in this crisis, especially if its mortality. Im sorry. Thanks for the time. I appreciate those comments and chief, youre at the front lines. Thank you for your service on the front lines. I assume you would concur . Absolutely. Law enforcement is very proud of my colleagues that have taken the lead on this. But youre taking Law Enforcement who has taken programs like Quick Response teams trying to get Addiction Specialists out there. Narcan, weve become paramedics. Its not uncommon for officers to take users to treatment. Its well outside of our realm to deal with this issue but weve become somewhat Addiction Specialists and for Law Enforcement to talk about that, we should not be decreasing med candidate, it tells you how important this is to us. We have to get people into treatment. And one of the programs that our team is doing out there is signing people out there to get them into that treatment. These are individuals walking with that user to try to get them into treatment and if medicaid is gone, that would have a significant impact. Its already difficult enough. Its not uncommon for us to find a user, call numerous Treatment Facilities, be told theres a bed open, drive up there and find out the bed is gone. Its difficult enough. Taking away medicaid would make it even more difficult and, like they said, wed be spinning our wheels. Were already like a mouse on a wheel trap spinning as it is. Taking away the tools is just making it more difficult and well continue to dig ourselves in a hole. Great. Thank you for your testimony, all of you. Appreciate it. Thank you, senator peters. Im going to turn this over to my colleague and ask him to conduct his final questioning and then close us out. Again, i want to thank the four of you for being here and for your work every day, all four of you are in the trenches, on the front lines. Thank you for helping to reverse this tide which, unfortunately, right now is moving in the wrong direction. Senator carper . Before you walk out, ill say this to your face, not behind your back. Thank you for your sustained continued leadership on this front. Maybe we can use the work and effort that youve led along with Amy Klobuchar and others for other initiatives. If we can work that well across the aisle on an important issue, maybe we can somehow particularly on the piece about making sure folks show up at a hospital and they are ready to get treatment, that they have access to treatment and how important that is. Weve got to focus our attention on that as well. Thank you so much. I want to come back, dr. Horton. I know weve this has been mentioned before. Explain to the folks maybe not just here in this room but around the country who might be following this. How is it in delaware when somebody shows up in a hospital, they have had an overdose and there for a brief moment, minutes, hours they are willing to they are ready to go, ready to start treatment. Yeah. And we can within 24 hours or so have the ability to place them in treatment. Yes. Are we able to do that in delaware and maybe not in other states. Why is that . Does it have anything to do with the Medicaid Expansion . Yes. Because that was the access. In order to put someone into treatment, i have to have a treatment to put them into and that treatment is primarily the result of Medicaid Expansion and programs like our Program Connections developing those outpatient treatment because they had revenue they could rely on. We were able to leverage reachable moments. There are many more than just the hospital. Were thinking about how do we partner with our colleagues, ems and police to find those other reachable moments, a lockup where an individual is so fearful of going into that primal misery that theyll agree to go into treatment but you have to have that partnership and coordination. In the emergency room, if someone is being admitted to the hospital, they are there. It really was more about having the institution accept that this is an issue and then moving forward to implement pathways and thats were good at that, at creating Electronic Health records and mechanisms to screen and then algorithms. So it was a natural place to do those experiments and they can now be replicated. Identify individuals quickly, address the withdrawal aggressively and use that as the lever to move them into care and as i said, twothirds of my patients are willing to go and most of them show up at the back end. Do we have the same sort of results where someone has been arrested, usually petty crimes, breaking into a garage and the Police Departments are trying to struggle with this. Theyve come up with their own programs on their own. Let me use this as a thank you for that. I would think of what dr. Horton has described as a best practice and the ability to folks up in the hospital and ready for treatment, we get them into treatment. Maybe you can give us an example of this was bringing a good, best practice. Giving you an example of Boston Medical Center. We opened what i believe is the first opioid Urgent Care Center in the country so that folks either came in through the Emergency Department were identified sometimes coming into the community and or they were brought into an Emergency Department. We have dedicated staff, some pier pi peers, recovery coaches who are able to work with them and getting access to care is not easy, unfortunately, and so they work to make sure that people have the care that they need. But i have to say, because this is really important, massachusetts, i still believe, has the lowest uninsured rate in the country so its not an issue for my staff at Boston Medical Center in the Emergency Department or in any other facility and we have a generous medicaid benefit. Okay. So those are opioid Urgent Care Center is something that i think is worth looking at. Great. Thank you. Id have to go along the track with that, also. Were trying to get the hospitals to work with us and allow those patients to go in. Were looking at it from a Law Enforcement aspect which isnt going to solve the answer. Its not going to be the answer. Part of the problem were also facing from the front end line is those people who dont want to get into treatment, which is a significant amount of people. So there is a hurdle, not just going from to jail or to the hospital but how do we get them into the Treatment Facilities and if we have opioid centers, how will we get them there . Thats wuone of the challenges were trying to overcome. If we can get them to the hospital, start receiving medically assisted treatment and if we started treating this like a brain injury or illness, like its defined as a chronic illness, then i think wed have a better solution. Thank you, chief. Thank you, senator. You know, a lot of ideas come to mind. Just give me one, a really good one. I think one of the things that we have to do is use the information that can be gleaned from people who die from overdoses to design intervention strategies. We saw 40 of the people who came to my office during the heroin phase of this epidemic have been incarcerated within two careeyears and i spell out reduction strategies. Dont use by myourself. Dont go back to the same dose. Theres information to be gleaned by medical examiner systems, which if we can take the burden off the epidemic crushing these systems, could be potentially used to design effective strategies. Thank you. In closing, senator peters, hell close it out. I want to thank you for being her here. Every now and then we have a thearg is illuminating. This is illuminating and terrifying. And im more convinced as ever as we wrap this up. And my last term as governor, one of the things that i was asked to do is be the founding vice chairman of something called the American Legacy Foundation and American Legacy Foundation was created out of the tobacco settlement, whether they provided a lot of money for each of the states for 25 years. Still does. We also have a billier or 2 billion which developed a are Truth Campaign which probably is the most Effective Campaign weve seen in this countrys history. In terms of convincing young people, if they were using tobacco, to stop. If they hadnt started, not to start. And i realize its not entirely comparable or parallel here but i think in the back of my mind its going to be no silver bullet, a lot of silver bbs and im thinking this is one that i would not given with the Truth Campaign, one that i would not dismiss. Finally, well be asking the questions for the record and ill be asking for, again, things we ought to be doing, a sense of urgency, and ask you to come back to those items and repeat some of the things that youve said, that would be fine. But i think you could feel a real sense of urgency and im sure we feel it from your side as well. Thank you for what youre doing. Lets go forward and get it accomplished. Senator peters . First, i want to concur with all of your comments, senator carper, for asking one last final question going back to the root causes and i appreciated your response on how we have to make sure we have Health Insurance available, medicaid available for Substance Abuse counseling and treatment. Theres also a compelling evidence that prescription opioids are really one of the key drivers for what we are seeing here with prescriptions. Dr. Gilson, i know in your testimony it struck me that you mentioned in your county that individuals who had been prescribed controlled substance within two years of their death, over half of them had prescription opioids that led to this. And so i guess just a final question, you know, are we aware of other sorts of treatments that we should be prescribing so that we can stop the what appears to be perhaps overprescription of opioids to patients who then become addicted to this so we need to have different types of treatments and thinking about how we practice some medicine and are there impediments to preventing that . What should we be thinking about Going Forward in trying to basically stop the pipeline that starts with some Prescription Drugs . Thank you, senator, for the question. I think that youve really hit the genesis of the problem, nail on the head exactly. The culture in medicine tended towards overprescribing of opiate pain medications for chronic pain. The scientific support for that was minimal and that, unfortunately, became a standard of practice that i think has created a large opiateaddicted population. If we gave prescription pain medication to everyone in this room, they would become addicted to prescription pain medication. They would become addicted to opioids. We have created a substantial, large addicted population per the use and abuse of prescription pain medication. That is absolutely inconvertibly true. How we get back from that, i think we have to restart the education of our medical community, we have to much much stricter use and guidelines on people prescribing pain medication. Im sympathetic to people who have chronic pain, but if its an ineffective treatment that creates an unnecessary and really detrimental consequence, thats not a good treatment and we shouldnt we should hold accountable the people who promoted that idea. It wasnt very well documented and im ashamed to say that the part that the medical community played in this crisis isnt stopping. I still have information of people getting months worth of vicodin after they get teeth pulled with refills. We have to stop that. After horton and other folks here said, we have a population of people who already are suffering from that prescription. We cant turn our back on them. They are going to be with us for a while and i think the ways that we improve treatment will be more effective for that. During my time, we worked with the cdc on comprehensive guidelines and some of the issues we heard in terms of nonopioid therapies, the challenges that i think were changing the culture of just giving a prescription. But i think the other issues that we heard is insurance reimbursement and acupuncture and Mental Health therapy. That was an issue that we have really got to take a look at in terms of those challenges. I will say that we have had some good evidence in states that have really robust Prescription Drug monitoring programs. I think weve seen good data on the reduction in Prescription Drug Overdose Deaths. Where physicians had to register and check each and every time, many states have moved to mandatory checks because it seems like that works and you get a pushback from physicians and, you know, i understand that sometimes theyre busy. But my response was were 15 years into this epidemic. And i dont think its unreason b able for a physician to take education and to check the Prescription Drug monitoring. Thank you. Thank you so much. Doctor, were you going to Say Something . In our state, i think weve been able to implement some of those measures around the use of regulations for prescribers so its its a small state and so we have a cultural change. There is hope about the levels and as far as treatment for Prescription Drugs, in many ways, the jeanngenie is out of bottle and most were exposed to Prescription Drugs. And were starting to see two epidemics, Prescription Drug epidemic hasnt gone away so those measures need to continue and reduce the exposure but now we have a heroin epidemic as well. If i could add one more thing, congress supported this. If you talk to the folks at the National Institutes of health, they will tell you that actually we need to do a better job by researching nonopioid pain medications and i think one of the barrier is looking at what the Administration Proposed in terms of nih reductions and it put a significant damper on nih Research Capabilities and to come up with nonopioid, nonaddictive prescriptions for pain medication and i think it undercuts what Congress Passed as part of the 21st century cures act. Thats a good note to end on. Ive gotten a lot of good ideas. Some of them weve heard before but when hes preaching to the choir, he says even choirs need to be preached to. We appreciate you introducing to us a number of good best practices and new ideas and also some something that makes a lot of sense. Again, our thanks to talking and for coming and for the work that you and your colleagues are doing. The hearing record will remain open for 15 days. For any addition comments or questions by any of our subcommittee members. With that, this hearing is adjourned. Thank you so much. This holiday weekend, on book tv on cspan 2, saturday at 8 30 p. M. Eastern, former u. S. Secretary of state, Condoleezza Rice looks at democracy around the world in her book democracy stories from the long road to freedom. Americans in particular were blessed with Founding Fathers who understood an institutional design that would protect our liberties, our right to say what we think, to worship as we please, to be free from the secret police at night, to have the dignity that comes with asking for consent. But if we were blessed with that, and we believe that we were endowed by our creator with those rights, it cant be true for us and not for them. Sunday at 2 20 p. M. , Columbia University professor on the controversies of sounding black in his book talking back, talking black. I think that we need to get comfortable saying black people have a slightly different sound because they often spend more time with one another just like white people sound more like one another because they tend to spend more time together and thats true of all human groups. Thats not racist. Its true and harmless. And on monday at 4 30 p. M. Eastern, former president george w. Bush on his portraits of courage. The first guy was major chris turner and i said, why are you here . He said because i cant get out of my mind seeing a buddy of mine killed. And i paint from pictures and or photos and as im painting turner, im thinking, that what that must be liked. For more, go to booktv. Org. It resulted in a naval victory for the u. S. Over japan, just six months after the attack on pearl harbor. And on june 2nd, American History tv will be live all day from the mcarthur Memorial Visitor Center for the 75th anniversary of midway. Featured speak ters, the fivesr admirals who won the war at sea. Elliott carlson with his book, the honesty of a code breaker who out witted yamamoto and coauthor of shattered sword and timothy orr, coauthor of never call me a hero, a legendary dive bomber pilot remembers the battle of midway. Watch the battle of midway 75th Anniversary Special live from the Memorial Visitor Center on june 2nd, beginning at 9 30 a. M. Eastern on American History tv on cspan 3. Next, a look at the United States military assets in space and potential National Security threats. A housed Armed Services Committee Heard from the general who heads up the air force space