Individual, went back to the Police Station and noticed on his shirt was some powder. He brushed the powder off the shirt, he is 6 foot 3, 225 pounds am a big man, he fell to the floor unconscious from overdose. They administered antidote immediately but it wasnt enough, rushed him to the hospital where two more doses were administered and luckily his life was saved. He would have died had he been alone. What if he had gone home with that power on his shirt and hugged his kid . That is just an example of what we are facing. Obviously a devastating to our communities and families but also creating quite a danger for Law Enforcement and First Responders. Sentinel is 35 to 50 times more powerful than heroin, a lethal dose to of 20 mg, we were able to show a tiny amount of fenton all can be deadly and we know about other synthetic drugs, this is getting worse as i said, the number of overdoses and deaths have increased dramatically, the director of National Intelligence included synthetic opioid in his worldwide threat assessment and noted in his comments the deaths have increased 70 from 2014 to 2015, sadly the death toll continues to climb and we will hear about that this morning. In one county in ohio fentanyl was responsible for Overdose Deaths in 2016, in one county. Tom gilson, the medical examiner will tell you he is projecting 581 fentanyl related deaths. Fentanyl is the biggest killer. And leaving the user with an example. Called gray death which includes a mixture of heroin, fentanyl, heroin is the weakest drug. This is available on the street, by 10 to 20. Even though these drugs are selling expensively fentanyl has a high profit margin making available to the drug dealer, estimates a kilogram of fentanyl can be purchased for a few thousand dollars a kilogram for 2000 to be used to make hundreds or thousands of pills which profit in the millions. We need to stop this flow of illegal illicit fentanyl and it comes from the us mail system. This is a shock to many of my constituents and others learning about this. Some of this fentanyl is smuggled into the United States from mexico and canada primarily it comes in the United States and according to Law Enforcement, some folks will tell us about this, it comes from one place which is china, produced in laboratories there and understanding from Law Enforcement is most of that fentanyl is intended for export to one place, the United States of america. A number of chinese websites ready to ship. Do a google search, it produces a number of websites where the drug is available and one website, 250, the more you buy the less you pay, discounts for larger volumes. To ease concern whether the purchaser would receive his or the website guarantees discrete human, quote, with undetectable packaging. While sherman was available in a number of countries the website new its audience had often express delivery to the United States. Many of these websites are so sure their seizure will not be stopped by Law Enforcement that they guarantee you if it gets lost or seized they will send another one for free. Several websites we reviewed made clear they exclusively used express mail service as their career. Ems is the International Postal service offered by members of the universal postal union delivered through ems, past the United States Postal Service as they enter the United States. Our shared goal is to stop these drugs from exploiting our own streams of mail into our country and every member has been involved in this issue on prevention and education, treatment and recovery. We passed new legislative initiatives in the last year, focused on this issue. We understand it is broader. Following 9 11 congress identified weaknesses in International Shipping standards as a significant problem making clear advanced electronic data would make the country safer. This was 15 years ago. When congress legislated, it left a gaping loophole. The trade act of 2002 mandated commercial carriers provide electronic data that could be used to identify certain packages making shipment to the United States. And the 2002 Legislation Congress asked the secretary of Homeland Security and postmaster general to decide if the Postal Service should be subject to the same requirements they are putting in place for private carriers. To date no determination has made in the country is less safe as a result. The difference between information, private commercial carriers provide is very different from the Postal Service. They serve the same function delivering packages into our communities. The same time the Postal Service has higher volume of International Packages and commercial carriers. Prior to arriving in the United States they will provide data to Law Enforcement including customs and Border Protection, name and address of the person receiving the package, discussion of the contents, the value of the context, this information is transmitted to customs and Border Protection at 47 agencies. Based on this information cpb targets shipments for additional scrutiny and select packages it wonts to inspect in the United States. Commercial carriers, one dollar per package which most commercial carriers has to the shipper. And handled hundreds of thousands every day. And International Service centers at jfk airport receiving overwhelming majority in the packages. How this packages is different from these centers. Cpb, packages or shipment it wants to inspect, in the postal office, locating this package and prevents them to cpb. It isnt that easy. Due to the hundreds of thousands packages the Postal Service left to sort through large shipments, what cpb is looking for. And the postal union to attach to them. The description of contents, information is not electronic. It is not useful to Law Enforcement. It will require member countries to place a barcode on every passage in 2018. That is fine but shipper is not required to load any electronic information until 2020. Meanwhile we have a crisis. Realistically the target date is closer to 2022 or so with no guarantee it will happen by then. For 15 years the Postal Service has been on notice with a need to collect advanced electronic data. We cant wait any longer. As americans are dying every day from these drugs flowing into our country we must act. We got to stop this fentanyl and other synthetics from coming and. The Postal Service is trying to use electronic information at jfk to identify these packages to Pilot Programs, Postal Service providing electronic data for packages that way less than 4. 4 pounds. Once the Postal Service shares the information cpb uses the information to identify the packages it wants to inspect. Postal service locates and presents these selected packages for inspection, this is a step in the right direction in my view. After 15 years of not doing this the results are lacking. In 2016 december of 2016 the Inspector General found Postal Service failed to present the packages selected for inspection and substantial number of packages lack any advanced electronic data with it. I understand the Postal Service is taking steps to remedy this issue presenting packages for inspection and look forward to hearing details of that today but without advanced electronic data we continue to miss a significant portion of these packages. The Pilot Program is only happening in one location. The other centers the Postal Service stopped sifting through millions of packages like trying to find a needle in haystack. We need electronic data now. We have been working on a bipartisan way to solve this problem which is why we introduced legislation like stop pack, she will speak in a moment. Advanced information, Postal Service should be providing for International Mail. 16 cosponsors in the senate, eight democrats, eight republicans, separate legislation, companion legislation with 128 bipartisan cosponsors. Our focus is getting impact from the panel of witnesses, a clear understanding from Key Stakeholders as we move forward on this. Thank you very much for being here. Thank my colleagues were being here. I would like to turn to Ranking Member senator carver. We talk about special moments, all hands on deck. For not just those in the senate, through other representatives, all hands on deck moment for our country and we welcome our witnesses. Want to thank the chairman for the good work they have done and others on this committee to get ready for the state. They focus on todays hearing, more ways to use drugs getting into communities and how to stop them. We look forward to hearing from our witnesses to better understand processes used by the coastal service, private shippers to Screen International shipments, for illicit packages. And shippers and federal agencies, how to push forward improvements. And the first line of defense, into the country. And one of the biggest priorities, on this committee. And the linchpin of 1 trillion industry, in of congress does not act for postal reform. Enacting legislation free of billions of dollars, to shore up, to shore up security. And Inbound International package volume has grown significantly in the past three years. In fact it is nearly doubled going from 150 million pieces in 2015 to 275 million pieces in 2016. No question they havent got increased volume in addition to increasing domestic packages, we welcome that but putting a strain on an already stretched resource. Unlike private carriers the Postal Service is required to deliver 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 Standards and ensures that we can send mail ourselves to friends, family, Business Partners overseas. The state department represent the United States universal postal unions that will be with us today to discuss our involvement in the key organization. And looking to the Postal Service and state Department Witnesses about our commitment to promoting the exchange of economic data, 192 member countries as a means of combating the shipment of drugs and other illegals. Packages are screened initially by cbp before being presented to the Postal Service, it can and often does target additional screening, cvp joined us here today, targeting packages based on the country of origin or scans done by the Postal Service. Recently the Postal Service has been working closely on a Pilot Program that allows them to use advanced electronic data and small packages from china arriving at jfk. Postal Service Provides other countries with advanced electronic data about male originating in the United States. We dont always get the same information from other countries. It is harder to do its job as packages arrive here. The Pilot Program at jfk is a rare exception. I hope we can learn today if there are any recommendations to improve and expand this program. As my colleagues heard me say many time, it works for more of that. Private carriers like ups are joining us today providing advanced electronic data on packages destined for our country. Unlike the Postal Service private carriers have Automated Systems in locations around the world and can refuse to accept a package at origin that does not contain any shipping data manifest data. Learning how this process for illicit drugs can hopefully help us cover the gaps exploited by smugglers. It also i look forward to identifying ways to ensure federal agencies and our state and local partners have the resources they need to combat the Opioid Crisis on the ground. Specifically to hear from our witnesses on the second handle each of whom serve on the front lines of the Opioid Epidemic in various capacities for Law Enforcement to addiction experts and these witnesses will get firsthand perspective on the challenges we face in fighting opioid addiction and a strategy that has proven effective, particularly in delaware, ohio, a discussion of ways to reduce for access of synthetic opioids, we must not lose sight on the need to focus on root causes of the nations considerable demand for drugs not just on symptoms but root causes for considerable demand for drugs. And look at find ways for defenses to block supply of dangerous drugs. Todays Opioid Crisis is the worst in american history. 33,000 americans and n delaware. My home state of delaware has not been immune in none of our states. And unfortunately, in ohio, on this panel. Substance abuse is a complex program for everyone. We cannot Pay Attention to the symptoms of the problem without addressing the underlying cause. We know Overdose Deaths are preventable, we need to provide funding to save lives. And and the Opioid Epidemic, as we know, medicaid is the largest payer of Substance Abuse services, and the treatment, current plans to appeal the Medicaid Expansion program, the Opioid Crisis were says millions be at risk of losing coverage for Substance Abuse Prevention Recovery Services as we need those services the most. Going forward i look forward to working effectively with colleagues on both sides of the aisle to learn what we can do and bring about substantial lasting change, thank you so much. As senator carver noted, one of our colleagues is not on the many, senator klobuchar, coauthor of the stop act, appreciate interest in the topic. Even though she is not a member of the committee, and very nice. Chose to spend your birthday with us. I would like to recognize senator klobuchar, and a brief Opening Statement, another markup she is supposed to be with. If you would make a few remarks. Thank you, it is a celebratory moment with the subcommittee, it was amazing to meet the witnesses out there, i never heard the coroner speak on this but the medical examiner hits home how dangerous this is. We lost prince to fentanyl and that investigation is going on. And in rochester, minnesota, and opioid death on the rise with homicide in the state. Passing this framework, started thinking that way, i think senator portman, and worked in a bipartisan way. And trying to reduce the number of people getting hooked on opioids, from Prescription Drug monitoring that we are trying to get changes in how prescriptions are given out and how many drugs are given out, simple things like wisdom teeth and we did good work with the cures act, i appreciate the leadership on the republican side objecting to the use medicaid cuts we heard from the house and that will be important and the third is people are migrating to the Illegal Drugs, but we are easier to get and we see more of these overdoses from things like fentanyl. We had 11 people die from car fentanyl, the most powerful form of fentanyl. It is more potent than fentanyl, the dose is 5 two grams of salt can be fatal. We heard from customers last week yet the numbers we heard, at two pounds, last year 440 pounds to give a sense of the tremendous increase, the lead democrat on the bill, senator portman and i have the stop act described wealth, it is really important to use modern technology, sophisticated in tracking down these perpetrators as the ones getting our kids hooked and killing people in our country. The second thing i want to mention is the salt act, a bill with senator Lindsey Graham that makes it easier to prosecute these cases. Senator heitkamp and mccaskill were here earlier, they see this as a real issue as well because drug dealers changing some types over the internet, they are doing it with walorski, harder for us to prosecute them, it is not easy to, senator grassley, the two leads on the judiciary committee, to look at the bill, it is easier to prove analogs to change composition, what i want to think senator portman for his leadership across the aisle. Thanks. Any other members make brief Opening Statements . The first panel of witnesses, very distinguished panel, for a roundtable at this very location last year, it first originated to identify this problem, i call the witnesses, the director of the bureau of International Organizations in the state department which works to advance National Interests but prior to joining the state department in 1991 here in washington, he held Foreign Service positions and other countries. Robert cintron is Vice President of Network Operations, 31 years ago in rochester, new york, he oversees the Postal Service Distribution Network including Overall Network design policies and programs for processing sites, statistics required to move mail that support the postal network. We have robert perez, acting assistant commissioner at the Border Protection. Previously served as director of the new york field office, and 240 million in imported goods but over the course of his distant wrist career mister perez represented cpb as a board of security all over the world at Different International conferences it with a guest lecture security expert. We have tammy whitecomb, from the Postal Service, Audit Director in the deputy Inspector General. And worked at International Revenue service, Inspection Service and Inspector General for tax administration. Finally we have norm schenk, Vice President of Global Customers policy and public affairs, with ups, spent the last 30 years working directly on reducing trade barriers. And it previously testifies, currently serves on advisory committees for the World Customs Organization to the us service and and i appreciate, and. Do you swear your testimony will be the truth, the whole truth and nothing but the truth so help you god . Please be seated. I noticed all the witnesses, the witnesses were prepared to testify under oath. And i keep your oral comments to 5 minutes, i would like to start with you. Thank you, chairman portman, good morning and thank you for the opportunity to appear to discuss illicit drugs. In International Mail. The supply side of the Opioid Crisis prevents a completed picture with multiple pathways for drugs to enter the country. In addition to shipments that find their way to the United States from across our land borders and expert delivery services, illicit fentanyl and other illicit drugs Enter International mail. Small simmons purchased online, individual customers. That the permit of state is where these small shipments propose unique challenges to Border Protection, challenges the exchange of advanced electronic data can mitigate. Consequently the department of state works closely with cdp and the u. S. Postal service to take steps at the global level to increase the availability for International Mail. We are committed to helping enhance cdps ability to interdict drugs in this channel. We should explain the enhancement act of 2006, the postal policy, the main forum is the universal postal union, the Governmental 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, right and adopt the acts of the union which are rules of the road for International Mail exchange. The congress of 2012, and securing amendments, committed each member state, included complying with requirements for aed. The most recent upu congress in 2016 the United States was reelected to the poc to cochair the Poc Committee on supply chain. This committee oversees all work on customs, security, transportation and standards. The leadership the United States chairs the committee have Standing Group on postal security. These leadership roles possession us extremely well to ensure high priority Security Issues move forward as possible, we made significant progress toward that goal. And the upu cooperated with the customs organization, with capture and receipt of aed. In february last year. And coordinating the work required for the roadmap milestones. And it took place at this poc meeting. They are obstacles to overcome. And to recommitted. The upu Business Model plan adopted in 2016, and the ability to change this data, and many do not have Internet Connectivity or reliable sources of electricity which makes collection of data extremely difficult. In developed countries some Postal Services have been slow to invest in needed infrastructure for item level Electronic Exchange of data. Few if any countries have the ability to provide 100 of their mail for customs information. Our approach is to support the upu to provide capacity building, the upu is devoting half of its cooperation budget for the next four years to a project to position Coastal Services in developing countries to obtain this capacity. A major focus is aed. We encourage these efforts but recognize rapid acceleration in investment and use of electronic data for custom security will also be driven by the Business Needs of postal operators themselves, they now understand the delays caused by necessary customs processing are a major impediment to their own ability to grow their Business Model, for rapid growth of transactions. It is the only solution to this problem. When the United States was a voice in the wilderness almost alone in calling for aed exchange we are now leading a course of countries developing and developed that demand aed. Another Significant Development with implications for aed is the decision to launch the integrated product plan which aims to modernize Product Offerings with an eye toward ecommerce was this effort has clear benefits for the customs processing of mail. Phase i which begins in january 2018 will introduce segregation of mail for documents and those containing goods. This split will facilitate compliance for customs required including aed. Phase i requires mail items pertaining goods to have upu standard marker which is critical to enabling aed. Furthermore, upu regulations, approved regulations in february 2016 which would allow members to impose aed requirements on items containing goods provided they take into account whether the requirements can be met by those to whom they apply, the thinking behind the regulation was demanding something impossible as a condition for delivering a countrys mail is the same as refusing to receive it at all. That would undermine the reciprocity at the heart of the upu. In conclusion i would like to assure the subcommittee the state department is fully committed to accelerating all countries ability to provide aed. We will spare no effort to ensure swift implementation of the roadmap and integrated product plan. As these programs move forward we are confident the number of countries able to provide aed and portion of their mail stream it covers will continue to grow. Thank you, mister chairman, look forward to answering your questions. Good morning, chairman portman, Ranking Member carper, members of the subcommittee. Thank you for calling this hearing. I am the Vice President of Network Operations for the Postal Service, i oversee the Postal Services national Distribution Networks, and customs and Border Protection, with the entry into the United States, entering customs and the authority to open and inspect all inbound items without a warrant to identify prohibited items. Inbound International Mail for foreign postal operators with Service Centers known as iscs. And with box screening by customers and measurements receive initial receipts can by the Postal Service. Items requested by customs are presented for further inspection. For those items, advanced electronic data furnished customs has an enhanced ability to target items for inspection. Today the Postal Service collects aed from 90 of its outbound International Packages and receives 40 to 50 of this information for inbound packages. To put it in perspective, comparing data from fiscal year 2015 to the present aed for inbound International Packages increased from approximately 1 to present range between 40 to 50 . In other words the Postal Service currently receives data on a substantial amount of inbound shipments including those originating in china. 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 prioritizing obtaining aed from the largest volume foreign postal operators which collectively account for 90 of all inbound volumes. For example, we have answered Bilateral Agreement that require aed with foreign postal operators of china, korea, hong kong and australia. We have entered into voluntary data sharing agreements with 30 facilities to facilitate the exchange of add. Additionally the Postal Service has a Pilot Program in our new york isc that allows customers to use inbound aed for more advanced targeting. With Lessons Learned from this pilot we are working with customs to expand approach to other iscs. The Postal Service must exactly deliver mail from 90 countries in the world. The Postal Service does not control the induction of foreign mail destined for the United States so we cannot control the collection of aed abroad. However the Postal Service in collaboration with the state department and customs plays a leadership role with advocating for the Global Collection and exchange of add. Through negotiation and advocacy and by targeting nations with greater capacity like china inbound aed has grown enormously, in conclusion we share your concerns about americas Opioid Epidemic and continue to work with customs to enhance 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. Thank you for this chance to testify. I look forward to your questions. Good morning, chairman portman, Ranking Member carper, dismissed members of the subcommittee. Thank you for the opportunity to discuss the role of Customs Border protection in combating the flow of dangerous synthetic opioids particularly fentanyl into the United States. The majority of fentanyl fentanyl is done through International Mail facilities, carrier facilities, or through ports of entry on the southern land. In fiscal year 2016 cbp officers and agents seized or disrupted more than 3. 3 Million Pounds of narcotics. Seizures of fentanyl remain small but typically increase over the past few years. Fentanyl is the most frequently seized synthetic opioid. Apps is spiked with fentanyl. And spiked with other substances and folders synthetic heroin. Drug trafficking organizations continually adapt to evade detection and end interdiction by Law Enforcement. Uses the same drug interdiction methods to seize fentanyl to detect other drugs coming across the border. It remains challenging due to limited field testing capabilities. And a variety of fentanyl analogs in the market. It can place an electronic hole that notified carriers that a parcel needs to be presented for inspection. It implements the same system for the International Environment with the United States service to conduct advanced data pilon express mail and packets, to address the issue advanced data. And the significant investments, with targeting capabilities. For example the National Targeting Center leverages advanced information along Law Enforcement and intelligence records with targeting a friends and shipments of illicit substances, and for this abuse like pill presses, tablet machines and training and information, agencys various forms of technology, synthetic drugs and nonpeople, and conveyances. Found in the mail and express courier packages, for laboratories, and Scientific Services for interpretation. At ports of entry, for officers and agents, and low purity is on the southern border, with controlled substance current, to make it difficult. Canine operations are another invaluable component of counter narcotic efforts. Fentanyl as a trained odor, for detection and canine teams. It up into the program for training and equipment, with opioid exposure. Officers recognize signs and symptoms of an opioid overdose administering the lockdown of potentially lifesaving drugs for the treatment of opioid overdoses. To enhance effectiveness, and opioids through the nations the borders. With distinct members of the subcommittee, i look forward to your questions. Reporter good morning members of the subcommittee, thank you for inviting me to discuss our work on Inbound International mail. We started examining this area two years ago after receiving complaints the Postal Service was presenting mail to customs and Border Protection for screening is required. After looking into it we determined audit work was needed. Given our role as the office of Inspector General for the Postal Service we focus on the Postal Service procedures and coordination with cdt. We did not review the operations although we did talk to their staff to gather in formation. The Postal Service provided what is used in a reports. And requested reductions in public versions we posted on our website. Inbound International Mail enters the postal system at five International Service centers around the country, generally all Inbound International mail is subject to inspection by the cvp and the Postal Service must present for inspection all the mail cdp requests. The Postal Service received 621 million pieces of Inbound International mail in fiscal year 2016. Growth of ecommerce caused inbound package volumes to double in the last few years causing challenges for managing the flow of traffic was more than half of the package volume, small tract packages under 4. 4 pounds. Given the 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 advanced electronic Customer Data which includes information on the sender, addressee and content of the mail piece. This data helps both the processing and inspecting inbound mail. International postal regulations are beginning to change in recognition of the important of posts providing advanced electronic Customer Data. The Postal Service can require this data through Bilateral Agreement it makes with foreign postal operators. Our audit work found instances of Bilateral Agreement where the Postal Service had not requested this advanced customs data. Since november of 2015 the Postal Service has been piloting a joint initiative in new york. Integrating the systems with the Postal Service, to use advanced data to target packages, the Postal Service and cvp intend to expand the pilot to new locations before the end of the fiscal year. We issued 5 reports on Inbound International mail operation since september of 1 to 15 and found several problems with presentation of inbound packages. First Postal Service employed sometimes processing packages before arrival stand and put into the system. This could result in pieces missing custom screening for the acceptance of inappropriate unknown shipments. And processing into and out of customs, and determine whether a package for custody and its own. Third and most significant at times the Postal Service did not present packages for inspection and instead the packages into the mail stream. And human error and Electronic Systems and additional factor, Postal Service and cvp do not have formal the written Agreement Regarding appropriate procedures. We have made 11 recommendation recommendations in areas such as enhancing systems providing employee training and oversight, with scanning data insuring items are presented to cvp, electronic Customer Data from foreign posts and coordinating establishment of formal Agreement Regarding presentation requirements. The Postal Service agreed with these recommendations and taken significant actions to close six recommendations related and still outstanding including establishing formal agreement with cvp. Ensuring the safety and security of Inbound International mail is a critical challenge for the Postal Service and cvp. More effort is needed to quickly fix problems in the current process to make sure cvp, with Customer Data as possible. We monitor this issue and work with colleagues at the department of Homeland Security office of Inspector General on any related work they conduct. Thank you, chairman portman, and established members of the committee i appreciate the opportunity to appear before you today to discuss help for providing necessary data to customs and Border Protection and Government Agencies for contraband, seeking to import dangerous in the us. My presence today the thursday before memorial day weekend is literally deja vu. I provided similar testimony on this very same day 17 years ago in the year 2000. And human resources. How can it be stopped . I was asked to do the same thing, walk through the processes ups files to provide advanced data to cvp to scan for highrisk packages, and since 2000, the problem with illicit goods being imported into the us has grown worse and enabled by the internet, bad actors are getting smarter and smarter using every avenue available to send illicit goods into the us. The issue of illicit drugs was centered out for amphetamines, and hightech opioids, the volume of parcel coming, and packages into the country. Ups delivers 19 million packages and documents every day, 220 countries and territories around the world. We work hard to be united problem solvers with our business processes are complex and are technology advance, we work closely with cvp and at our own expense to comply with and exceed existing legal requirements. The key to making this work is the advanced electronic data we provide which enables cvp and 47 other Government Agencies to target high risk embellishments and screen them out of the networks and that is as much as 36 hours in advance. This data can be used to screen counterfeit products and contraband, another growing problem. We applied technology and technologically advanced Network Capabilities enable us to locate any suspects package in the system at any given time so it can be retrieved for legal authorities for additional screening. In 2000 when i testified before the House Government Oversight Committee there were 21 million package shipment entering the us annually. About 10 million through the private sector which were accompanied by electronic data, and there were no electronic data, even 17 years ago it was clear that other federal agencies could not manually screen packages purely because of volume and the most effective way was through the use of advanced electronic data. The volume of packages entering the us has increased many times over. 2016 for post likely sent 400 million packages to the us and the volume is growing. We have been using advanced data for years even before it was required by the trade act. Bob and i have worked 20 years on these things, to provide item level detail about each and every shipment entering the country. This helps us reduce the potential for Dangerous Goods entering the us. Is important to note ups and other carriers submit for all Foreign Countries both developed and developing. I could take out my smart phone even in the remote places, take a picture and transfer it with that. In conclusion if i could take off my ups had for 30 seconds, i do a lot of International Travel to work with customs agencies around the world with the same issue. I dont look around for passengers for suspected of terrorism but the bags and bags of foreign post packages loaded in the belly of the aircraft, no one has any idea what is in those packages, none whatsoever. The government doesnt 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 packet of the day into this country with no requirements for information that will allow cvp to do their job more effectively. I urge you to take action on this important issue, thank you. Thank you, mister schenk. And thank all the witnesses. Senator carper has generously agreed to delay his questions so we have an opportunity for members who are here to ask questions. People have other committees to do so, i will do the same. I would like to start with senator lankford. Appreciate that very much. Tell me about where we are as far as moving and advanced electronic data and for developing countries why this is taken so long when there are straightforward solutions. Why cant they get the data. Thank you for your question. We have been working with the upu to develop this more quickly but the issues we face in developing countries, i would say previously there was lack of will and lack of understanding for them to catch up with their Business Models and take part in the ecommerce boom, the major advance we made, it is a change of mindset that countries regardless of their level of development, and enhance their economies by taking part in this. The encouragement from this congress would be to say packages dont come in behind it. It isolates a lot of people. The most straightforward way we can deal with that is to put a clear deadline out there and say we dont allow packages to come into our country unless there is more data in advance. As described in my testimony the global postal system is not able to exchange at this time but the requirements that it do so immediately as a precondition to accepting its mail it would severely restrict inflows of mail into our country and preclude the acceptance of mail not covered by the Bilateral Agreement. If we stop accepting cold, the countrys mail around short notice, we would anticipate they would stop accepting. Anything that congress would do on short notice, i would assume we would set a firm deadline, by this date, not being negotiated in days ahead. This slips year after year. My concern is how to get a date certain on the horizon. This is only one element to stop the illicit movement of drugs, most individuals are not going to label their package containing fentanyl. One element to deal with this, this should be a straightforward element. It should be straightforward, other countries are working on other timetables. We made good progress, the question of their own needs they understand. Half of the cooperation budget, helping countries install the capabilities they need. The electricity and internet are not available everywhere. We are dealing with germany and france, and the uk does, we can go on and on and on through places this should be pretty straightforward. For us we have to be able to get this resolved but let me ask a separate question. Customs and Border Patrol worked on m ou relationship to establish consistent methods of how to exchange data. How is that working and where are we in the process . The m ou regarding general operations, how that functions at International Mail facilities and how it is delivered, we expect to give that back with comments to the u. S. Postal Service Within the next two or three weeks. I checked on that just before i got here. The mo you really put into place best practices that have already been in place and a lot of field locations including jfk in new york on how the mail is handled, that is the ones that are coming from countries of interest for cvp, not aware it specifically gets into the detail of the electronic data. That is under the confines of the pilot itself. Any comment on that . Exactly what was said here. It has been a year, we have been working at each of these, working closely with customs, Border Protection and made sure the processes and procedures, we have been working through those, not the we have been waiting for them to get that final item. Glad to hear we will have it back in a few weeks. Assuming it gets finalized rapidly. You can assume that to be accurate. Basic operations to be able to help increase efficiency in the process on this. When we first started our work in 2015 and mr. Cintron mentioned it there was not much of that at all available pick significant progress is being made and has been made in the last two or three years. One of those things yet to continue work on and enter every Bilateral Agreement has a requirement in it. So those are two things that i would encourage. I would say i appreciate the diligence and the focus on this as it is been seen and noted already for commercial entities. This is an something they have been very persistent on for a while. They have more a Seamless Network and are we not receiving every single package from every single country theyre able to monitor that to the system. It is a system that is achievable and the process. I would know for customs and Border Patrol we appreciate the work you were doing. This is incredibly dangerous work. Has been noted by the chairman in Opening Statement even the smallest amount they gets on any individual as are doing an inspection is a life or death issue. And so from our committee to all of your team we express our gratitude for what to protecting the american citizens from. Thank you. Yield back. Senator carper. Thanks so much. Sometimes who have a Diverse Panel like this, people are knowledgeable about it, a a particular issue, i asked them to help us solve the problem. I ask you, im going to ask you today to help us solve the problem. I will ask each of you, if you dont do anything else do at least this, congress, this committee. One thing we ought to do like right away. I want to call you tomme. How do you pronounce your name . I pronounce it tommy, but it answer to anything. [laughing] my name used to be pronounced tommy as well. Mr. Thome, for god sake, do this. Thank you, senator carper. I said earlier this of all hands on deck. We are trying to convey a sense of urgency. God knows when they go home, the folks were represented convey a sense of urgency so were trying to convey that as well. Go ahead. Thank you very much. I think as weve talked about this is a difficult problem that needs a lot of solutions, but 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 want aed. I think we have to all Work Together to give a realistic timeframe to it. Theres urgency to this in our country. Im the first to admit that and as been discussed with an epidemic that cant wait years and years. But with the momentum we have or i would say since the 2012 upu congress, its really accelerated. Countries want this. But if they find themselves in a situation where they have a damocles over their head with a date certain which is why hesitate to put one on in response to the senators question previously, we run the risk of losing that momentum in that if their mail shipments our staff or threatened to stop in the United States they could have devastating effects of on their income. Thats not my question. I was asking give me one particularly, one thing we ought to be doing to expedite this, to move it. Give me one. If we put our efforts behind with the upu is doing and keep it moving along with efforts bilaterally that are happening, we can make this happen . Give us some advice. What can we do to get this moving . I think emma personal opinion the act that you put forward is on the right track and it will certainly contribute to this. We just need to craft it in a way that is realistic to get it done with countries that we cant order to do things that we need to negotiate and help them see the benefit doing. Mr. Cintron. I guess for us there must be someone we can incentivize these folks, particularly some of the nations that still are not doing their share. They are not third world nations. There must be someone we can incentivize them. Go ahead please. One thing we would certainly ask, support around our strategy to target, focusing on targeted countries. So we understand it, that part, when we look at the whole picture for us, our strategy has been to stay focused when we see the largest volume coming in and i think 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 we might find in some of these other developing countries. But for us our strategy will he is going to be state very focused and prioritized it we believe through that and to our efforts and what were doing with the pilot at jfk we can push is a lot of in customs or you have an answer to my question. I asked both is a question. What does cokes need to do to help move this along, to expedite this . What we need . One of the thing i might ask is certainly around the comprehensive pulse reform for us. Theres a lot of things tied up in that and anything to do to help us with that regard certainly helps our overall initiative with everything we do. One of the things, we have been worked on this for a while as you know, we want to have additional postal revenues in order that they can, among other things, modernize their Mail Processing centers. They can buy new equipment, new vehicles for delivery, modernize their post offices. Sounds like it might be another use for additional revenues of the Postal Service. That might be helpful as well. Thats a good particularly. Mr. Perez. For us, good advice for us. First let me say thank you, senator, for the ongoing support not just of this committee but of the entire Congress Everything that cbp does in the entirety of effort that we put forth to combat illegal narcotic trafficking. Thats why but specifically ask ever so respectfully that that support continue for all things narcotic trafficking. Cbp frankly, we are not waiting and dont wait for the evolution of the different types of threats and enhancements we need to lean forward and do everything we possibly can to interdict, to detect, to deter and dismantle those who would do us harm in this fashion. And so whether were talking about that or talking about tools and technology that were trying to deploy and even the personnel. That ongoing support that this body continue to provide cbp on the overall drug mission is absolutely critical that we push it that. Ms. Whitcomb, same question. I think focusing oversight on ensuring that the m. O. U. Ms. Ford quickly, and also i just heard a minute ago the m. O. U. Does not necessarily cover the Pilot Program. I think that pilot, theres lots of Lessons Learned through the pilot, but expanding that pilot quickly across the country to the other International Service center 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. If we have a cigarette i want to come back and talk about the pilot and those Lessons Learned. Please, last witness, please. Past the stop act. The reason i say that is, as discussed her 17 years ago and nothing tangible has changed and it just is moving at a snails pace and we think the right way is passed legislation to we appreciate all the fine work that is been on that. We work with cbp four years before the trade act and i dont know how they do the job that they do on the mail. Because we have our own challenges with all the data, but were talking about the minimum surpass the stop act. Thank you, mr. Chairman. Senator mccaskill. So i understand that, first of all, thank all of you. We are all hands on deck, as senator carper said on this, and this committee is doing an investigation into another piece of this which is the sales and marketing technique that have been employed by the opioid manufacturers. We are also going to be looking at the distributors in terms of that issue interlinked in our country. I want to focus in on my time here on the fact that we are having some of this that no produced in china sent to the United States fentanyl where then it is sent to mexico. Are you all aware that this is commonly occurring . We have a large amount of opioids that are moving to our country in that regard. Does anybody disagree with that analysis . If i can comment, i would share that my understanding is that much of the fentanyl coming out of china, win in its actual form, will come directly into the u. S. What weve seen, that moves from china typically into the latin, mexico, theyre deluding, crating analogs and then racing heroin shipments with the fentanyl as well, is precursors and moving directly from china into mexico. Not aware of at least at this current time of the movement south bend from the u. S. Into mexico, but gladly take that back. My staff has looked into this and believes that there is a significant amount of this that is moving from china to the United States, the precursors, and then going from the United States to mexico for them to process in their labs. If we are getting wrong information, i can live with that. If you dont have that information, is accurate, unworried. Because i think its really important that we understand where this is flowing. Mr. Cintron, would you agree that you will believe that some of this is coming to the United States and then being shipped to mexico as a precursor to be used in the labs to cut hair with . I can specifically respond to that but certainly the Inspection Service part of the organization we can provide you at the thing i can provide you information on that. So i understand that mail from china is not covering the cost to the United States Postal Service to handle this meal, correct . Again, i apologize but i would certainly as proving to provide any of that information. Post hearing. Once again my staff tells me that we are underwriting, the United States Postal Service is underwriting the cost of mail coming here from china. That just seems crazy to me. How in the world is that happening . Well again, unfortunately, i am not able to enter that specific question but i can provide the information after the hearing, senator. We are obviously struggling to keep the is Postal Service out of bankruptcy. Its one thing to be getting fedex and ups, a deal on the last month of Package Delivery which ive been writing about in this committee for many, many years, but if we are actually making it cheaper for china to use of the United States Postal Service because where underwriting our costs, that is really outrageous. Im anxious to get to the bottom of it so if you follow this quick as possible we would really appreciate it. Absolutely. Okay. So for the trade act, it is my understanding in terms of the private deliveries that they are not actually, they are supposed to be having the information on the packages they send, the name and the address of the recipient coming into this country from other countries. But i understand many times all they get is the address of a processing facility where its coming to and not the address of who the actual recipient is. Is that accurate, mr. Perez . Indeed, in the context of u. S. Postal service, the general mail, that is true but that is the type of data that would were pursuing for the pilot to begin to get more of that. On talking about phase two of the trade act requiring the name and address of the recipient from the private carriers. Has that been fully implemented . Arent we getting the address and recipient from u. P. , not from the Postal Service but from fedex and the of the private carriers . To my knowledge yes, but i would take that back to make sure we can confirm that for you. But from those of the commercial entities, carriers, we typically get pretty comprehensive list of information in advance with respect to those particular shipments. Well once again, my information based on staff preparation for this as a preparation i done for this unit 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 that package is coming. I would really like to know why we are, why my information is different from yours. And the other information that i have is that we are not even imposing the fines they need to be imposed on the carriers who are not following the law. And by the way this is the trade act that was imposed after 9 11 when were trying to get after the security of our ports and the security of the entry ports in terms of her country, in terms of goods, people and services. I will be anxious to hear you follow up about that. Phase three of trade publication was supposed to be penalties. Its my understanding that phase three has not been implemented. Does anybody know the answer to that question . I dont have the details on phase three of the trade act implementation at this time. Gladly take that back and get it back to you and your staff. Okay. If we are not getting the address where the package is going and we are not finding the carriers ahead of time so we can actually look to see if this is an address that has popped up before, Law Enforcement needs to be all hands on deck, if were not getting that and were not even knowledge about whether or not we as amended the part of the lower penalties are enacted, our Research Indicates sometimes penalties have been imposed that had been negotiated down by the carriers lawyers from thousands of dollars to 50 bucks. If thats occurring thats a huge problem. Im a little worried that folks and have the answers to these questions at this hearing understand the subject matter of this hearing about four to getting the incident as quickly as possible. Yes, mr. Schenk. Senator, if im a response to that. Certainly from ups perspective, weve been providing that information full information the shipper, the description, value, country of origin since we started bringing International Imports into the u. S. In 1985. The program was developed with cbp. I would also say that weve gone well beyond the trade act working with cbp, with the air cargo advance screening process which is a voluntary program that was implemented after the attempted yemen bomb attempt where we not only transmit the shipper and the consignee, we transmit multiple consignees when his ecommerce shipment. Speaking for ups, we do, not only required but we go beyond the requirement. In your opinion as phase three been implemented . Do you believe there are penalties that would apply to you if you somehow, its amount of package came to the United States through your company for didnt have the address of the recipient on it . The answer to that one is i dont know how we could because our processes and systems are developed that he package cant enter our system and last but information has been entered in and it cant move through because our systems interconnect between ups and cbp. Practically speaking, it couldnt happen. Okay. We will follow up on information we have acted information from all of you and go forward from there. Thank you very much. Im going to ask my questions now and we will have another route as well. I know senator hassan has agreed to stick around. I appreciate that 11 of the college who has joined us. First of all, i think we need to back up and talk about what this and that is is it helpful, mr. Perez, i expect your aunt on this, but all of you come is it helpful to have advanced electronic data to identify these packages that have this poison in them, which is what were focus on today, which is synthetic opiates that he come into our country, killing more and more of our citizens every day. Do you want to have that advanced electronic data and is at helpful for you to be able to stop some of this poison for come in to our communities . Yes or no . Unquestionably, mr. Chairman, having advanced electronic data as we do we see for all of the types of cargoes is a key tool in our ability to manage and assess risk. To focus and target those threats that may warrant greater inspection, potential threats may warrant greater inspection to cargoes, people, conveyance of all types. So unquestionably. Having that dated and working towards getting that advanced data and making sure it is of high quality and reliable for us to do that work is a high priority. The reason why were working so closely with our colleagues to get to that point. Of the wisest like the needle iin the haystack i talked about earlier. I meet with your folks back home and they use exact words you just use. This is a tool we desperately need, otherwise which is not effective at stopping the stuff. And its othe of the contrabands well but were focus here on a crisis. I appreciate the state Department Perspective on diplomacy and trying to work with other countries and i really appreciate you, mr. Thome, sandy think the stop act is on the right track with the notion of the country working on the own timetables and some countries dont have electrici electricity. China has electricity and we know where this stuff is coming from. Some of it is coming from indy as well. They have electricity. This notion i will say, and mr. Cintron, i understand your concern about having to apply this to all countries and you noted in your comment you prefer it to be targeted to countries that are known to be sending us this poison. Let me just follow up on that a little bit. We talked about this yesterday. We are working on this issue of countries that circumvent our trade laws does have a care attached because of a dumping order and they simply shall the product to another country. Simply ship. Why would that happen here . If we say were only going to target a few countries of interest why wouldnt they just ship it to another country say vietnam or malaysia or indonesia and sundays poisons come into our country . Can you answer that question . What i would say is of this. Our focus and strategy is to prioritize the list, so take a look, make a Risk Assessment and target those particular countries. Certainly i think as a work, the inspection Service Working in collaboration with other Law Enforcement agencies i think its probably the other key. As you collaborate, share information, if those events occur i think then we refocus and do that. Our point is theres a starting point. Our peace was around where is the highest risk, where do we see the highs followed and had to be go to your point on capacities . Those particular countries that havent we should really be focus on those and get that information. No question its a crisis but unfortunate what weve seen is theres transshipment of the step and it will simply be shipped to other countries, evidence we have. If we dont have this broadly applying, and you noted earlier that its voluntary now. I guess i would ask you, do you have enough data . Your aunt is going to be no because you would like more advanced electronic data from these other foreign posts. So again what our legislation says is its time to follow up on what congress past 15 years ago, which was asking the thin cabinet secretary in charge, now Homeland Security, and the Postal Service and the commissioner to come up with a plan. Norm said he testified 20 years ago, even before that, i soon those in the context of preparing for the 2002 trade act. I would just make it. Broadly that we do have a crisis. We all acknowledge that and this is not business as usual and for the country work on their own timetable that doesnt work. That dog dont hunt because its an epidemic. You noted, mr. Thome, is interesting that advanced electronic data is in their interest, too, and theres a consensus now, you said, among countries around the world that they need to provide it. Lets get moving on it. Another question i would have is for mr. Perez. He talked about canines. I just have to ask because i asked the same questions of labor colleagues a roundtable discussion at this response about a year ago and i was told dogs to work because the dogs could die from sniffing a package or a letter with fentanyl in it. Whats the situation with regard to monitoring generally and screening many of the support among legislation to provide more funding for more inspection by specifically with regard to k9s, does it work or is it too dangerous . Thank you, mr. Chairman a. On the k9 front we are currently in a test phase to train the k9s for the specific odor. As you probably know they are train for a variety 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 were specifically training them in a very safe way with the types of odors that are generally emitted from fentanyl and such. Not with actual fentanyl but with our laboratory and Scientific Services folks to make sure were doing so in a safeway but nevertheless, enabling that tool along with the other technical and or electronic tools that are at our disposal where were actually taking readings from the suspect packages and sending the spectra back to our labs to determine whether or not there is a presence of fentanyl and other opioids. Id like to think it could be done safely. The dogs dont have the masks we talked about earlier and the clothes that they can put on. I would suspect theres a huge danger to them. Much better jeff targeted packages where you have reason to suspect a package by having advanced electronic data. Im sure you would agree with that. Absolutely, mr. Chairman. You talked about the Pilot Program, the lack of correlation between the Postal Service and cbp and the need for memorandum of understanding and a written agreement is necessary picky subject 11 recommendations, six of which are still outstanding. You said we ought to expand this pilot quickly. Have you look at our legislation . Do you think the stop act would help to expand their pilot quickly . We did look at the legislation. We didnt do a Detailed Analysis of the impact of the legislation on the Postal Service. We are supportive of the general idea of the legislation about increasing the amount of advanced electronic data. However, the impact of that on the Postal Service something we havent done a Detailed Analysis of. We do believe, as we said in a statement, that Additional Data would be really helpful and i think the pilot is moving in that direction as well. Again thats what this topic is about about is making that mandatory moving away from just making at the pilot but making it a requirement. Mr. Schenk, quickly do you and venable turned to my colleagues, you talked about having testified in 2000 on this. The fact you get your data to the cbp sometimes 36 hours in advance, 36 hours in advance gives them timetable to respond to it. Tell us how you do that. I mean, how do you do with the post office has not been able to do over the last 15 years since the trade act . Thank you, chairman. It really starts with the collection of the data and it depends on the sides of the customer, but the bottom line is for the large multinationals we have software and direct interfaces with them. But even in the individuals that walk into one of our ups stores, it can be input. We get information into the system immediately. As soon as the package is picked up, thats what is the indicator. 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 a collaborative effort that i think from the business side we have a shared responsibility do that. And then depending on whats going on with the shipments, communicate back with whats going on but our whole principle and foundation of what we do for cbp is, lets get the data above to get it to you as soon as possible so that you can begin theres a couple of transmissions that gets a little technical, but its a very i think good process. When the package is picked up the daily kos and the Law Enforcement folks, the 47 agencies have access to. Chairman, can i clarify . Yes. I want to get to senator hassan. If you dont mind will do a cigarette and ill be happy to speak with you as much as you like. Thank you, senator portman and Ranking Member carper for a limey diversity in the subcommittee and for your leadership on the stop act. I do want to just take a minute also to echo senator carvers reminder that while we are focused today on the supply of illicit drugs and especially the precursors to the synthetic type fentanyl and carfentanil, and we have to continue to also focus on the demand side here at home which is when Medicaid Expansion and continuing work to make sure people can get treatment and we will work on prevention as well which is so important. As you all probably know, enhances one of the state that is been hit hardest by the good epidemic. Last year 70 of her Overdose Deaths involve fentanyl. 80 so far this year involve fentanyl. We are seeing an analog of fentanyl and just in the last six weeks or so weve seen deaths from carfentanil. So to echo what my colleagues are saying, everywhere we go we are talking to people from all walks of life whose lives have been taken or ruined or impacted, and its drained on not on our lives and communities but our economy as well. I wanted to focus just a minute because in my last briefing with the dea at home, they recounted to me in very graphic and vivid details how dangerous fentanyl and carfentanil is for our Law Enforcement and First Responder personnel. That obviously extends to people who may be handling the substances through the postal system. We know you can overdose by touching this stuff with a bare finger or breathing it in. Carfentanil in particular has change the way our Law Enforcement is dealing with everything about the way the interface aspects home to a crime scene afterwards. So we also know we dont want to put third parties like usps personal at risk. Let me to start, mr. Cintron, with you. What has the Postal Service and help address these risks to usps employees . How can we both protect our workers who make sure that Law Enforcement has of the tools that need to investigate and crack down on the supply of these things that ask . The usps has over 600,000 employees, so from processing to delivering the mail, transporting the mail, all of our employees are involved, and on a regular basis whether its International Service centers or other Processing Centers around the country, delivery operations, we do a lot of training with our folks around hazardous type conditions. Weve seen tragedy in the past in this organization so we are very well aware of effects of what i can do. Our focus really is to constantly and consistently train employees, and we do the same with our Inspection Service which does a lot with our processing facilities as well for oversight and investigating and addressing issues that we find in the mail. Thank you, and ill ask mr. Perez to comment. You discussed debs cbp has taken to protect its personal and id love it if you could expand, and again talk about the balance here. You know, i know of an agent in New Hampshire is doing everything right. She was all massed and club and that she took off her gloves to handle the suspects cell phone and she od, brought back by multiple doses of narcan. I am very concerned about it. Thank goodness, senator, thank you. Beginning in 2015 in fact, we begin a very comprehensive training and instruction that was deployed to all our frontline officers and agents, the people who would typically potential come into contact with the substances. With its a great depth of proper handling, what they need to wear and if and when they encounter a partial or person that may be carrying a vehicle as well where they believe the presence of these dangers opioids may be. So when addition to that, we began our Naloxone Program as well so that we have those countermeasures deployed in over 34 locations over the past two years. Those locations include all the busiest express consent of facilities, all the the basis International Mail facilities and locations along the southwest border where we see the most trafficking in these types of opioids. The last point i will make in addition all that is what deployed over 600 doses of narcan in addition to the naloxone throughout the country. And as a side note, the officers and agents that are typically trained in actually utilizing these are ems certified cbp officers and or agents. So that is pretty much what were doing and we continue to make sure that that training, that awareness is ongoing and that we do absolutely everything we can, to go with the uptick in our encounters with these drugs. Mr. Schenk, ongoing acid at the same thing. Obviously the concern here is if, for instance, nonenforcement thinks that theyre putting third parties at risk to undercover operation and theyll stop doing. We need to be able to continue investigations. So its helpful to hear that training is ongoing, but how do gps address this issue . Ill be honest with you, i really dont know the answer but i would get back to you on that. They used to be certain kinds of undercover operations that i think Law Enforcement has taken a look at because risk people handling a package that they may not know has an illicit and deadly substance. It would be great if you look at it. The one of thing i want to ask mr. Thome, you discussed in your testimony that fentanyl at other synthetics are bought online and we know that both on the open web and the dark web. So what efforts are being made internationally to crackdow cran illegal purchases of the synthetic drugs and the precursor chemicals that are used . I know a lot of what were doing here, but whats happening internationally . The state department is engaged in extensive negotiations with countries that we feel our sources for these kind of things. I cant give you a conference of ads across the board, but i did talk with our bureau of narcotics and Law Enforcement and they did give me some information on whats happened with china, which is of great concern and is been brought up so i can share that with you. In response to repeated u. S. Requests made to the bilateral joint group we have with china on Law Enforcement, china has in fact, domestically controlled now more than 134 synthetic drugs including carfentanil. This is in advance was made in getting them to see this. Chinas decision to domestically control carfentanil, which is cause the desk and the United States that you mentioned, is a welcome measure and we hope we can continue working with the chinese. In many cases the chinese argue to us that these are not causing problems in their country, and we have succeeded in convincing them that even if that may be something they claim, they are causing problems in our country and want them to take measures. Again, we continue the process. Theres a lot of work left to do but weve had that success. Given much. And thank you, mr. Chair. Thank you, mr. Chairman. So for you, mr. Schenk, the packages are dropped off at a ups facility, whether its here or in some of the foreign country, youre able to track those with a code to electronically track and share information with the customs and Border Protection, thats pretty much a system, correct . Thats correct. Okay. And the Postal Service, tell me why you cant do the same thing. With inbound package is coming in, you know, so foreign shippers who ship to a form post and then they tender into the yes the ups we do not have that direct connection. Okay. So the state department, why cant we require that from the shippers in Foreign Countries, their equivalent of the post office . Well, as my colleague from the Postal Service says, unlike the express shippers that control both ends of the transaction, we dont control both ends. But why cant we tell them that they cant utilize our post office in less they have an electronic tracking number on it that we can track and share with cbp to cut down on this baloney . Our treaty obligations at the upu which is in or position based on reciprocity for the exchange of International Mail do we do that for them by the way . Do we give them an electronic tracking if the requested . We have offered and we would like to be able to share data with them if they had the capacity, yes, we what. Heres the problem. The Ranking Member and the chairman talked about the fact we have a problem in this country and we have a problem in this country. So i gave it. They do want to do it. I dont want to do on a lot of things im told to do. So why d dont we hold their fet to the fire . The truth this would have some impacts on the country . Im telling you now doing it have having economic impacts. Is there any way people could roll up their sleeves and say look, weve people dying every day in every state in the union from this crap and its time to say enough . Senator cohen i would argue we are doing our level best to hold th their feet to the fire d to demonstrate to them has the threat pinnate you will not be able to ship to the Postal Service if you dont do the . We have not made that explicit threat. Vatican would be outside of our treaty obligations. Its not a threat. Its a real life situation. I mean, look, i mean, we can pat people on the back and say please, but that hasnt worked. Im not in the negotiation so i dont know what you guys are faced with but i do know it we are faced with in this country, a pile of money and winning a lot of lies. I would just encourage you the next time upu meets, buckle down and do it. Otherwise, we might have to do something pretty dr. Cohen as this it and im not sure we want to go that direction. I take your message and want to assure you that we are working very hard to do with shady urgency. And i appreciate that. Its not you by the way. Its a general overall thing. I appreciate you all being here, by the way. The Inspector General, that might be you, miss would come, came up with some audit reports on Inbound International mail to the Postal Service. This question is for you, mr. Central or perez, or both. There were 11 recommendations, by those have been closed. If my math is correct, six are still open. One of the recommendations was the Postal Service establish m. O. U. With cbp to better clarify inspection of packages and sit down to establish the process. Why arent we doing this . Earlier today we did speak, my colleague, is to perez indicated within the next three weeks we will have the m. O. U. It is sitting at the custom for protection and will be back to the Postal Service. We will then give that hammered out and get it in place as soon as possible. Just to reiterate for the record, we havent waited for the m. O. U. A lot of these things, we work collaboratively, collaboratively with custom oakle vocally to gee things in place. Appreciate that. Do you agree with that, mr. Perez . Yes. I mentioned earlier the timeline of getting the delivered and that is in effect putting, codifying many of the best practices and procedures that are already in place with the International Episode about the country. If i might, mr. Chairman, when you get that m. O. U. Signed, could you write full copy off to the leadership of this committee so we know it is done . We could provided. Thank you. One more thing and this goes to mr. Cintron, perez or ms. Whitcomb. And that is is a legislation that is required in order for you to take swift or strict action to prevent these poisons and come into this country, or do you think you the ability to do with what is on the books now . Anybody can go. Mr. Cintron . Could you repeat one more time . The question is, do you require further legislation to be able to take swift and strict action to prevent these poisons from coming into the country, or do you have enough latitude with the rules that are on the books now . Is their legislation thats needed for you to be able to stop these drugs from coming in, is a question, or do you have the latitude to do it today . I would defer to the state department may be to, or to customs to maybe answer. Mr. Perez. Senator, we are very comfortable with our authorities. Nevertheless, again, just would continue to emphasize the unquestionable need to further the efforts to get the advanced information. All right. Ms. Whitcomb, do you have anything youd like to add . Let me piggyback of what mr. Perez said. The timing of rolling at this point i think is critical. I would just ask that if you have any recommendations they need to be changed within the code, dont be afraid to tell us. That would be helpful. All right . Thank you all for being here today. Very much appreciate it. Thank you, senator tester. Senator daines. Thank you, mr. Chairman. Mr. Chairman, i want to thank you for your personal leadership on this issue. The people of ohio and the people of this country would have been very proud what i saw six weeks ago. I was with the chairman in beijing. We had meetings with the chairman in china, chairman of the nbc, number three in all of china. Followed by beating with the premier and mr. Chairman, you were very direct in asking for the help from the chinese government, the very highest levels to do with this issue of the source of fentanyl and carfentanil. And thank you. I saw that behind closed doors and thank you for your leadership that extends and influences beyond this country but around the world to stop this scourge. Thank you for test line today before our committee. In recent years in my home state of montana, and we had been facing meth epidemic. I realize its something so with the opioids in the northeast work its way across the country. It is in big sky country as we speak. Largely, the import of math is coming from mexico. Its gripped my state and it has shown the somber and sad signs of the drugs widespread presence. In fact, in december 2016 the Montana Department of justice issued a report that there were 14 children that died in our foster care system, 11, 11 of those 14 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 as a child in our great state. In addition, the Montana Department of justice of a criminal investigation has seen since 20102015 a tripling of the number of cases they are addressing that relates to meth. Math has left its mark on montana through increased incarcerations, increased deaths, heartbreak, and in straining our Community Resources to keep up to stop the importation of math at its source would go far to begin the healing process in states like montana. Mr. Cintron, in your written testimony you mentioned that from fy 15 depressant, the use of advanced electronic data for Inbound International mail increased from approximately 1 the summer in the 4050 range. I know in montana mexico has specifically been identified as an overwhelming source of math. The question is what countries and which countries have been either collaborative or particularly unresponsive ensuring 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 injury. We have many countries that we have agreement with. I called up the four we are bilateral scope many of the countries that we are receiving advanced electronic data from that make up the 4050 . But i can certainly provide you some better information after the hearing specific to mexico. Zeroing in on a couple of specific countries, you mentioned mexico and china that are the largest sources of illicit drugs. Have they been responsive in working toward the universal postman unions implementation date for universally providing advanced customs data, or of which is grasping at the error on this one . No. As relates to china we, and i can provide better data, absolutely we are seeing substantial data that comes back from advanced electronic data from the. I can provide you information after the hearing. Thank you. Would appreciate that. Mr. Schenk, you mention in testimony at the ups delivers more than 19 million packages and documents each day while providing the advanced customs data. Could you share, mr. Schenk, one, how many packages containing illicit drugs are removed from delivery by cbp due to the use of advanced customs data . And number two, what percentage might those packages represent . Hanky senator, for that. The reality is we are not perfect. Wed like to say that know that people are going to use our network but they certainly attempt to do that. Fortunately with relationship that we have with customs and Border Protection and sharing information, we do find ways to interdict it and we do get some occasional shipments. Weve had several shipments of fentanyl over the last year that were seized by cbp, and we also had actually a little bit more in terms of numbers of shipments of math that was mentioned earlier that gets seized with that, and w will work with cbp. In terms of percentage of it, its minuscule. 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 one on one border level stuff with it. Plus our ability to track and trace and work with the local authorities, which we do on investigations. Mr. Cintron, do you share, given idea to estimate, the percentage of packages under current practices that are flagged because of illicit drugs . I have to defer maybe to mr. Perez to answer. I think. I can provide you the data after the session. Its a very small percentage that we can provide that information after the hearing. And small as a guess less than 1 , less than 5 . Any sense of how small is small . Dont have that but i will provided. Thank you. Let me close by saying i did leave the most effective way to end the meth crisis in a state like montana and allow the healing process to begin is going to be by cutting off meth at its source. Yes, we have to work on our demand issues, but we can Work Together here on source. We will need the collaboration between the usps, cbp and our foreign posts stakeholders. And if our foreign post stakeholders decide not to cooperate, i do think we need to take stronger action and do put America First in this equation. Thank you, mr. Chairman. Thank you, mr. Daines. Senator heitkamp. Thank you so much, mr. Chairman, for taking on this issue. Its critically important. I remember a conversation with last congress on dea was in the room and when i suggested that they may want to use drug dogs to detect fentanyl packages, the dea told me that were not be wise, given that if they actually could smell it, they would die, the dogs would die. So we did with an incredibly dangerous material, and this is moving through the Postal Service, and every postal worker who touches a package is at risk. And so i think this isnt just about for the Postal Service here its not just about processing and getting things through, but it really is an issue of care for employees and such is wanted to raise that. Ms. Whitcomb, we noted in your testimony that the Postal Service report, your audit work, found the Postal Service has the ability to class advanced customs of data on december Bilateral Agreements, but opted not to do that in certain circumstances. Why did the Postal Service make that determination, and what would you recommend in response . Yes, i think most of the bilateral that did not have these requirements in them are older Bilateral Agreements. More recently the negotiations on bilateral have included this requirement. So i believe its more of a time issue and a recognizing of the importance of this, and over time i think it has improved over time, i should say. Some of the ones we had reviewed that did not have this requirement were older allowed agreements. And mr. Cintron may know a little more about the direction the Postal Service is taking to include this more consistently in the Bilateral Agreement than i do at this point. Yes. All new Bilateral Agreements require advanced electronic data. Okay. And this is for anyone on the panel. It appears one of the arguments being made regarding the Postal Service being unable to utilize the system so much of the system that has been outlined by private shippers and carriers is a cost issue. I understand other issues also complicate equalizing the shipping requirements, but cost, processes and technology seem to be a factor in the Postal Service claims, which are inhibiting their efforts. Is this an accurate statement . If so, how do we bring down the cost of compliance and technology . Is a possible to look at prioritizing events electronic data, upgrades to assist with four shippers, and under the current method you are using to try and address the situation, how long do you think would take to get Foreign Countries utilizing aed at higher rates . Do you have any plans to have that discussion i guess . Mably concert with you, mr. Perez. To the private program we have, senator, with the u. S. Postal service, we are currently getting advanced electronic data from several different countries, specifically the pilot at jfk has to do with both china and france and we continue to focus on that and work alongside our Postal Service partners to see what else we can do to make sure that were being able to not only utilize and get that advanced electronic data but then focus our efforts to expand not only the volume that were able to apply, but again the quality itself so that we can make better and more informed decisions on where it is we need to focus our efforts. Mr. Cintron . Yes. I wanted to, and i can clear find more the point earlier, is that for us with the aed and the pilot in jfk, one that things will be looking to do, expand that part of it to the other that we have and get better with the amount that we are generating that is going to and i can speak more about that later. In regards to the cost, the cost relook on to be incurred at the foreign post where they will have the technological upgrades and challenges that we need to be, thats with the cost of going to come in. And certainly thats that different. The Technology Part of one can do on our site ethel bit different in regards to aed one to ask a get the data itself. I dont want to prolong this but i will tell you if we were happy with the speed which the u. S. Postal service were dealing with this issue, you all wouldnt be here. This is not moving fast enough. We see these drugs coming in. We had that numerous deaths in my state because of fentanyl abuse, and we know that the delivery point is the United States Postal Service. Either. 2. In this country, recent investigation and prosecution regarding that no moving in, the meth 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 timelines. And if resources are a problem, we need to know that. If you cant if theres a legal problem with the bilateral or with the agreements can we need to know that. If theres a resource problem we need to know that but weve got to stop. Jeopardizing the lives of people who move the stuff, whether its at the post office or people who come in contact with the package unwittingly. But weve got to have a plan. It is frustrating because we address this in a roundtable last year or the year before. I think im hearin having the se things over and over again, and 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, i will yield back the rest of my time. Thanks, senator to hype cant. We will do a very quick segment, lightning rent. I agree with what my colleagues were saying, that we are not moving fast enough. Let me give you a specific example of this. There was a letter sent april of 2016 within a year ago to this committee. In the letter it said, the plaintiff spent just a Pilot Program from china to Los Angeles International airport is truly scheduled for the summer of 2016. We are now in the summer of 2017. Has it expanded . It has not expanded. It has not. The upu, weve heard today about whats going to happen with regard to the universal postal union, and with all due respect to our International Partners and the upu, will he get done by 2018, 2020 or even 2022 . They keep pushing it back with respect to this electronic data. If we didnt have a crisis in this country, we could cannot go along with the normal routine which is as a set earlier and i quote, other countries are working on their own timetables. We cant afford to have been working on own timetables because our people are dying. The question i would ask is how many more americans have to die before our government gets its act together, make sure the plan is working, makes sure it is expanding as it was promised, and has not occurred, and make sure we are actually doing everything we can to keep this poison out of our communities. Admittedly there is not one silver bullet. Im going to steal a line from my Ranking Member who said theres a lot of silver bbs but this one of the one of you have acknowledged that today. My hope is that because of this hearing will be able to move or close on this issue, we can get this legislation passed to give the Additional Authority i think you need to have as mr. Perez said, rightly the tools, the tools built identify the right packages to go after them, to stop some of this poison can and also increase the cost on the street. Because right that this stuff is so cheap and so deadly that its killing more and more people. We will hear from the next panel about whats happening in our communities and whats likely to happen this year as compared to last year. The summary is, more people dying. Getting worse and worse. So thank you all very much for being you. I now turn to my Ranking Member, mr. Carper. Thank you, mr. Chairman. Send it to high camp was speaking a moment ago. Im reminded of the work were done, a lot of this on to spell have done pulse reform legislation. One of the things we focus on his how to increase the revenue flow to the Postal Service so they can replace vehicles that are 25 years old, so they can modernize mill Processing Centers which are not designed to handle large packages or parcels. Number three, how do we modernize the post office to provide Better Service with rural letter carriers . How do we provide those . Another reason why the Postal Service needs revenue and it is to be able to do their job, a better job with respect to intercepting these highly toxic chemicals. We are going to use that, you set and remind our colleagues why its important to move our postal legislation sooner rather than later. This is one of the reasons why we need to do that. The other thing i would come back to is the pilot. Take me to the pilot. If you will. We were doing that in a manual fashion in terms of identifying what we need to do to extract those pieces and in todays environment when there hasnt been expansion that has improved significantly to put that on processing and equipment, working closer with the Inspection Service and our Engineering Service to do this on our processing equipment. One of the things that will happen is there will be equipment at jfk, ifc and we connected the down float facilities connected to jfk where we trot trap those pieces now. We do this well on the domestic side of the Network Today we are very good at tracking bar codes so we have the ability to do that. That expansion is to get those other sites up and running now that we have flushed through this. As quickly as we can get them up we need to do collaboration with bustout Border Protection. We are focused to get moving and its ready to move forward and get expanded to the other four sites. We are committed to getting that done. Final three seconds, a great take away. You are here 17 years ago and i want to make sure you are here 17 years from now. Give us a great take away in terms of our to do lists. The key thing is passage of the stop pack and not only will it help with the problem as a whole we also think it will help the postal operators in their negotiation with upu that they will have language that says we have a mandate and we have to do it any other thing is if there is a way to make an increasing the amount amount of information shared, we have a great working relation with cbp, but there are limitations in terms of if we knew more about who the bad people were we could build that into our systems. That would be the two things. I will be asking for the record if there is any amendments or changes that should be made to the stop act and what changes if any. Sweater prioritize those for us and that will be a question for each of you. We are halfway home and its been a great first half. Thank you. Let me conclude by thanking our witnesses again and think everyone 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 are working on this issue. As i said, we have to figure out how to do it effectively and faster. Let me end with a story. Yesterday, we had our weekly buckeye coffee and we had a couple hundred command couple hundred come in and verbal letter carriers were there from the unit to talk about postal issues and they talked about the stop act and the need for more resources. He has been a leader on this over the years and two of the four took me aside privately, two of the four, 50 of your letter carriers can to me yesterday and said i have a family member, one was a nephew and one was a son who were addicts, recovering addicts out and in both cases they had opioid addiction, now in recovery, in and out of recovery, which isnt unusual and they both said to me you have to move forward and continue your efforts, so i would just tell you this is affecting everyone including families and our friends and neighbors and every zip code including the rural letter carriers letter carriers that talk to me about another topic, but focused on a personal topic which is this issue. Thank you for being here. The second panel has now joined us. We will move quickly through the introductions. Each of you deserve a 20 minute introduction, but im going to give you a shorter one to get to questions. First, executive director of the center for addiction medicine at Boston Medical Center. As some of you know he has been at this a long time and is a expert. He was head of the office of National Drug control policy until a few months ago, so we are delighted to have you here. Second we have thomas sinon, city of newtown in Hamilton County ohio and has been involved in Hamilton County heroine task force and is chairman of the Law Enforcement sector that task force and everywhere in southwest ohio people look to him for his advice and he will be able to talk to us about what is happening. We have doctor Thomas Gilson, medical examiner of Cuyahoga County. Previously medical examiner for the state of rhode island with a lot of experience. Every month he gives us data on whats happening in the county. Broken down by area of the county, rural, suburban, intercity, ethnicity, age and its helpful data. Bottom line, it affects everyone and it knows no zip code. Doctor terry horton is also here with us. Previously he served as medical director of the Phoenix House foundation in new york. Most recently helped develop and launch the opioid pathway to screen and identify opioid addiction patients identified at the hospital. He has been involved in delaware is the chair of the Drug Overdose totality review commission. Appreciate you all being here today as experts and we ask you to stand, so we can swear you in quickly. I ask you to raise your right hand repeat after me. Do you swear the testimony you give will be the truth, the whole truth and nothing but the truth so help you god . Yes. Please be seated. Please make a quick comment cherry jerry horton is here and sitting behind him is patina who at one time when i was governor she was my deputy of legal counsel. Shes a wonderful leader on a wide range of health care issues. Theres a young guy back there, sebastian, and we had trained together. Sebastian is 15 years old and we welcome him. Im sure you attribute your success in life to governor, now senator carpenter carpenter. She succeeded despite my mentoring. Witnesses answered in the affirmative regarding to the of. We ask you to keep oral comments to five minutes and we have time for questions and a good dialogue. Lets start with tom gilson doctor gilson, lets hear from you first. Thank you. Good morning. My name is Thomas Gilson and on the medical examiner from Cuyahoga County as well as Crime Lab Director and i think you for allowing me to be here to speak on this critical subject. If i were to tell you the major catastrophe that would kill tens of thousands of people to share were to occur how it fema respond . How much money, how much resources will be ported to action . If this catastrophe was allowed to happen again with even more fatalities how me more hearings would be called to determine what went wrong in those months . The opiate crisis should be thought of as a slow moving fatality events that occurred last year, is occurring again this year and will continue to occur next year. Each year is getting worse than the previous. In my home we will see approximately hundred drugrelated deaths in 2017, which is an increase from her most devastating year last year 2016, when we saw approximately 660 people die from drugrelated deaths, up from 370 the year before. Nearly 90 of these deaths will be due to opiates of some kind, prescribed pills, heroine, that no. The nationwide Public Health emergency which is something out of control. Ohio is one of the hardest hit states. Midatlantic states in New England States are also particularly hard hits. In the fall 2011 the office alerted county executive to an alarming trend of heroine associated deaths and in the subsequent months and years we have parted with their county sheriffs, us attorney office, county prosecutor, addiction and Mental Health services and our board of health to launch a community initiative, which i am proud to say has attempted to combat this crisis. Partners were added from the Major Medical institutions including the Cleveland Clinic, western reserve University Hospital and county hospital as well as the free clinic, free Public Health Service Provider and set in motion important pieces of response. We have drug dropoff boxes and they also take back over prescribed prescription pain medication in over 50 Police Departments. We also issue warning letters to released inmates who are at greater risk due to overdoses as well as patients leaving Treatment Centers. Of these folks are at risk because of decreased tolerance in the creation also other heroine Death Review Committee allowed us to look at data from the overdose the tallies in an attempt to plan intervention strategies. We also posted a heroine summit at the Cleveland Clinic. Law enforcement has created specialized pass forces working with all medical investigators, scene investigation to begin investigations earlier in our laboratory. Prosecutors at the county and federal level are levying different charges against dealers. This work continues to implement a communitywide communitybased strategy that was the result of the Cleveland Clinic summit. When a heroin overdose occurs individuals fall asleep and breathe more slowly until they stop altogether. During the progression the dying sequence can be relieved by the panicked out a box on made more readily available in ohio as immediate for step in saving lives. Cuyahoga county partnered in 2013 to distribute this drug by prescription and we have currently documented over 1000 reversals. Police department Pilot Program started in 2014, but ramped up last year and have documented another 300 reversals. These 1300 individuals did not have to make a final trip to my office and the introduction of fentanyl, which is initially seen in akron and subsequently in our jurisdiction is a large animal tranquilizer diminishing that efficacy of moyock sound. This is the fundamental reason for that catastrophic mortality rise in 2016. Research conducted at the medical Examiners Office in my county in collaboration with medical Law Enforcement and forensic partners indicate nearly 600 people died of heroine overdose between 2012 and 2014 and promising intervention should be considered, at least 72 of these overdoses had been prescribed a controlled substance within two years of their death and over 50 for opioids. Several word doctor shopping and with the mandatory implementation of Prescription Drug Monitoring Program we are now moving in a positive direction to reduce this as an entryway ideally for people to go into the illicit drug market. The final example of how the information can be gleaned from death certificate and attribute data is the fact that many of the individuals who came to my office had been in contact with the legal system and or drug and and alcohol Treatment Programs with the tremendous need for education in these opportunities to maximize messaging. Its naive to think education and messaging would be effective if we dont adequately address the need for Treatment Options once the message has been delivered. People can recover from drug addiction with adequate support. While data and information are critical in helping to determine effective strategies particularly inspiring to see that the community in Cuyahoga County that has brought treatment prevention, Law Enforcement, prosecution medical examiners like myself together for a single purpose, to save lives. However, our local resources have been stretched to exhaustion. Death investigation system and local forensic laboratories are facing doubledigit caseload increases annually, personal shortages, equipment problems and complex processes to support fight especially now with the trend of six fentanyl entered our country. While we have interacted successfully with federal partners its clear the drums to our community continues. As i mentioned our options are limited. Are committed the added millions of dollars to this effort. Our estimates are that theres enough people in my county to fill our football stadium. Every year and that approximate a sufficient number of people to fill our basketball arena transition over from prescription opioids to heroine and fentanyl picked that used to be largely caucasian majority of up to 85 of victims, but its changing and seems almost with purposeful intent cocaine is being mixed into the fentanyl distribution and analog of fentanyl to distribute these drugs into the Africanamerican Community peer cocaine has been the only drug victims in our Community Work predominantly africanamerican. That has changed since introduction of cocaine into the supply distribution and its also of note that we have High Percentage of African American deaths in our Drug Overdose crisis. The strategy is not a matter of innovative creation, but sheer will cooperation an adequate resources. The willing cooperation i see in my county, but the resources at a local level are depleted. Treatment beds need to be opened and adequately funded. Our county executive in cooperation with our mayor and local alcohol and drug boarded has quitted additional funding. That i am the exclusion which limits the number of treatment beds to 16 for a Substance Abuse Treatment Facility i support the bill currently offered by you that will more than double the number of available beds. Interdiction agreements with china, mexico and canada need to be strengthened and delivery of these substances to the us Postal Services and other Services Needs to be squeezed off. I appreciate your cosponsor of senate bill 708 to this purpose. Further, National Crisis and im sorry to go overtime, the to add this theres a National Crisis in my field and death investigation. My field is especially forensic facility add is in need with less than 500 boardcertified Forensic Pathologists practicing in the us. Currently, my professional Organization Website 28 offices are seeking to hire additional forensic pathologist. I had the privilege of heading the oldest trading Program Training pathologists in the country with only 35 such programs in existence and they are not funded by medicare. Unlike any other medical training specialty. Car Program Graduates one or two doctors a year in a system that can only produce a few dozen pathologists annually. We were relied accurate data to define this crisis and i think it will serve as our success or failure in that depends on competent death investigation. Its essential Additional Support beginning to these programs. All of these actions are beyond the ability and authority of a county like mine. We need your continued and renewed assisted resources and commitment to all phases of this fight. I am sorry to go overtime. It is a important topic and i thank you for your time and consideration and i would be happy to answer any questions and we also provided a packet of information summarizing i could have talked longer. Thank you very much. Thank you. Mr. Chair . Yes. Because i have to leave, ill want to thank doctor gilson who is deputy chief medical examiner for the state of New Hampshire for some time and thank you so much for your work and for your continued work and thank you to all of the panelists. Mr. Botticelli, im sorry i will miss you, but we talked before and we will talk again. Mr. Botticelli and remember your full statement will be part of the record. Thank you for the opportunity and imitation to be here today and for your ongoing leadership in this epidemic. I think we know opioids epidemic is the pressing Public Health issue of our time and in many respects a Public Safety issue. 2016 National Survey on drug use and health estimates approximately 2. 1 Million People in the us have an opioid use disorder. In 2015, the last year we had complete national statistics, 91 people and they died from an overdose of opioid include imprecision pain medication, heroine and or fentanyl resulting in over 33000 deaths in 2015. In massachusetts, 1900 people died of an overdose in 2016 and that is up from 742, just from 2012. In addition to addiction and death we know injection drug use associated with this epidemic has been linked to increases in Viral Hepatitis across the country along with local bricks of hiv. A recent analysis done by the cdc shows there are at least 220 counties mostly in appalachia that are of significant risk for another outbreak somewhere to the one we saw in scott county, indiana, two years ago. Over the past few years weve seen that synthetic opioids like fentanyl and the cd8 cdc estimate overdose drug death other than methadone increased by over 72 from 2014 to 2060 with reports from the dea as well as date Law Enforcement indicate these steps have been associated with Law Enforcement seizures, have been positive for fentanyl in this increase is not a result of fentanyl prescribing indicating this is largely illicitly manufactured. Law enforcement seizures have increased by 426 from 2013 to 2014 and analysis is limited to those states like ohio, that have excellent or very good reporting, which means Overdose Deaths are reported with eight specific drug involved. 2016 reported statistically significant increases from 2014 to 2015 with states in the northeast and midwest experiencing the highest increases. A recent analysis of overdose death in massachusetts, shows death involving fentanyl rose from 32 in the 2013 to 2014 period to 72 in the first half of 2016. Fentanyl is often mixed with heroine and cocaine with her without the users knowledge, usually without. As we have seen in highprofile deaths it can be prescribed as prescription pain medication and taken without the user knowing. The supply as we have discussed appears to be largely illicitly manufactured in china either directorship to the us on both open and dark web sources are shipped to mexico where its mixed in before transporting it to the us. I wont go into details for lack of time, but i think you know the administrative the administrations response to the efforts and under those efforts is ensuring people who need treatment have timely access access to highquality care including medication treatment work of the zero portable care act contribute it to perhaps the greatest expansion of treatment by insuring Substance Abuse Disorder Treatments was one of the 10 essential benefits that Medicaid Expansion plan and marketplace plans had to cover. It also ensures those benefits be offered on par with the federal Mental Health parity and addiction equity act. Again, for lack of time i wont go into detail, but i am proud of the a cop assurance we are able to make with congress in terms of the passage of the conference it Addiction Recovery act, or soon enough ban on the problematic aspect of Sewerage Service programs and we accomplished a lot in our time together here in washington, but we have a long way to go. I will focus the remainder of my remarks on what i think our recommendations as with how we deal with fentanyl. Continuing to enhance our intelligence gathering, manufacturing and distribution of fentanyl is critical and while i was appreciative of the Intelligence Community calls for better information there are still many unanswered questions. I was happy to hear that synthetic opioid was looked at as a major threat. I was frustrated that i didnt know we had fentanyl and things like car fentanyl until we saw local breaks in the us. Our Intelligence Community is too good for us to be caught unaware in terms of whats coming out as. Since that no is harder to detect and can present a hazard to state and local Law Enforcement we need to promote better ways to expand current drug Testing Technology and continued to develop capabilities. We need to continue to provide factbased handling instructions to Law Enforcement, Border Patrol and others you may come in contact with fentanyl continuing our engagement with china and press them for additional action to schedule analog and takedown illicit manufacturers and shippers. There is also significant amount of variability of standard testing of fentanyl with Law Enforcement criminal justice system, medical examiners and Treatment Program incorporating fentanyl into their blood testing panels. With Public Health experts we need to develop and distribute informational material on how users can minimize their overdose risk in areas where fentanyl might be present. We need to expand the use of naloxone. Because of the potency of fentanyl in what appears to be a pattern of drug users injecting alone with a peer in mecca time to reverse an overdose can be shortened. We also need the federal government to deploy Rapid Response teams to our communities as with other kid diseases. We need to expand inservice programs and others that engage active drug users to promote safer injecting, distribute naloxone and minimize overdose risk. More importantly most importantly we need to preserve the gains made through the Affordable Care act to the Medicaid Expansion and other federal grant programs. Even with these provisions timely access to quality care remains an issue for many. Thank you for your time and i look forward to your questions. Thank you. First off i would like to say i think this issue of addressing fentanyl is important. It exasperates any issue i have to attend to at the hospital in trying to help individuals, creating a rapid spiral of addiction and much more sudden than we would see otherwise. Currently in delaware in the [inaudible] 20 to 25 of individuals have fatality fentanyl in their blood at the time of death, so when we look at the potential for damage in our state when we reach the level of massachusetts. I think it will be at catastrophic increase in the coming year. I went to share briefly as someone who sits in the hospital works in inpatient setting an emergency room, just some of the Lessons Learned, this is a horrific epidemic, strikes across the board. Ik take care now of not only Young Mothers who have just given birth and High School Kids who are wrestling champions, but also grandparents and couples, all races, all ages. What they share is a horrific addiction. Their brains have changed and their motivational circuits have been distorted. As well they had this new onset of withdraw that is really like primal misery, withdraw preventing them from moving through the wall to go on to care. They stay outside the care and avoided at all costs because they cant attend the withdrawal. Thats also what we can leverage and we had done that in the hospitals and jail, so when someone is put in a hospital and can no longer be on the outside and they are desperate to avoid withdraw and we can address their withdraw, treated aggressively with medications and have been able to leverage that and get them into treatment. Two thirds of the people i see in the hospital are agreeable to go into longterm care. They dont come into the hospital looking for that. They had a affected leg or affected heart, but they use that opportunity to get into drug treatment. Two thirds of individuals i see are actively looking to go into drug treatment. When i offer it, i address their withdraw and of those individuals remarkably nearly 80 show up to their Community Care provider. So, the hospital is a reachable moment and of those individuals 70 are there mostly. What im telling you is that individuals who are addicted to opiates who come into the Hospital System is a reachable moment to address withdraw to leverage that to get them into treatment and they stay there. If you are on drug treatment which block opiates and if you use opiates he won overdose and its really about safety. I tell my patients every day when i see them yesterday i had clinic in this is what i say, take your suboxone today and tomorrow and we wont have to worry about you overdosing. 30 save message. Really critical to what i am trying to do and help it individuals get into care and stay in care so they dont overdose or die is to have access to accurate we are pretty fortunate. In delaware we have been able to expand outpatient slots for primary care, Substance Abuse care by the thousands. For me, i have no difficulty when i identify individual in the hospital to get them into care the next day in the community setting. It has to be that continuous or eight lose them and they relapse. Its remarkable unable to do that. Unable to do that because i care is available. That care is dependent on medicaid. Without medicaid that care would collapse, so i can tell you what i am fearful of is that im fearful id know how to address this epidemic and i know how to treat the patients i have who are addicted to heroin and other drugs and 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 a really fearful some of the cuts that have been proposed will completely gut the system that i rely on to treat my patients and keep them safe and help them get to a better place, so basically im saying, please, its critical dont take away my ability to treat my patients and keep them safe. They depend on me and i depend on you to really preserve the system of care i been able to work with and make improvements. Without it i think this war is lost. Thank you, doctor horton. Thank you chairman, Ranking Member carkner carpenter. In my 24 years of Law Enforcement i never seen a substance cause such damage and devastation with the death of rates that have risen higher than levels in Car Accidents and homicides. I have witnessed the power of drugs in my small community, 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 such as this in july, 2016 i received a call from the greater fusion center, part of Homeland Security, a center originally designed after 911 attacks for lawenforcement to share intelligence on potential terrorist situations which could analyze interlocal federal Law Enforcement, with the public. Recognizing the ability to analyze data and share quickly among agencies we adopted the user heroin tracking overdoses, locations and intelligence to track trends on the street. At 10 00 p. M. That call told me theres a new drug on the street called carfentanil and i asked what is it in the response was we arent sure, its used to knock out large animals and i replied like a pig and he responded no, elephants. We passed this information onto the medical medical examiner trying to obtain as much information as we could to figure out what the introduction of carfentanil on our streets would mean. What we learned about the drug is friday. The top of the fentanyl chain chain. The drug is not intended for humans and so powerful to the equivalent of two grains of salt could kill a human. This drug is 10000 more potent and then heroin concern not only for the user, but police ponders, hospitals, Treatment Center and the public. All could unknowingly be exposed to this synthetic. We were so concerned for the safety of Law Enforcement we recommended stop field testing of heroin, which is a process needed to arrest a person for her when. The officer safety is a priority over enforcement. This warning had reached other states stopping their practice to ensure the safety of their officers. With all the dangers facing Law Enforcement, this danger which could be undetected until it is too late was a danger concerning the most hardened police veterans. We knew this drug westerly controlled and monitored in the us and with the assistance of the dea we determined it was not coming from sources within the us. We could have never anticipated our epidemic would reach levels more along the lines of and become the new normal. In the week of august 19 through the twice seven, 2016, an event occurred when the hardest hit cincinnati experienced nearly 200 overdoses and three deaths in one week. Hearing from dealers and users that there was nothing on the street like fentanyl, trance to carfentanil we expressed a shift from organic opiate of heroin to the synthetic opiate of fentanyl, all of its derivatives and carfentanil. This shipment synthetic is testing the limits of users, First Responders, system of government, hospitals in the spirit of each person drawn in is to the point of breaking. I not only witness the devastation, but the determination of the same people who try to keep up with the new normal, the noon average of 50 to 70 overdoses with four to five deaths a week. 11 people die in one weekend and will multiple overdose at the same time in the same location with at times overdoses reaching nearly 40 in one day stretching resources. Cincinnati in one district with 20 officers had 16 overdoses and four shootings not allowing officers to respond to other calls. In 2012, there were seven fentanyl related deaths in three years it exploded to 238. Though Coalition Using naloxone to every First Responder within 19 months have used over 7500 kits of naloxone. The volume of numbers a young boy walking down the beach picked up a starfish, throat in the single for the next one took an old man seen this stop the points that young man, there are too many to make a difference you cannot save them all. The young dale boy picked up the starfish and replied i saved about one. This description we follow is beautiful in nobility and heartbreaking and reality describing where we are in this epidemic. No matter how great our efforts, the tremendous influx of such powerful synthetics such as fentanyl which are medical Examiner Office has identified at least 10 variations of fentanyl and in the current opiate. [inaudible conversations] carfentanil has forced us to change our beliefs to keep up with the power. The original 2milligram naloxone has made it obsolete having to replace with a higher concentration of 4milligram dose of naloxone reducing the strength of the synthetic. Its more common to hear of users unconscious taken to the hospital placed on a concert naloxone group to keep them alive. These synthetics are so ingrained in our area that when we think a situation can get more difficult, dealers insensitive to the damage they are causing have now began to place these synthetics and other drugs like cocaine causing a more overdoses and death. Carfentanil is now so common in our drug supply and a staple in the heroin supply its expanded. The couple weeks ago for people in cincinnati who bought what they thought was just cocaine overdosed. Two died on the scene and to left in Critical Condition due to the cocaine containing carfentanil. Since i submitted this report last week another person in that incident died, so three have died and one is still hospitalized. That same week a mother drove her 10 monthold baby into a driveway where she got out a collapsed. Neighbors called 911, brought the baby inside and when officers arrived the mother regained consciousness. She believed she had only purchased heroin when she found out she had been given a mixture of cocaine, fentanyl and carfentanil. Since i submitted this there was a 25year old who died at the same location. I commend this committee for taking the time to hear, investigate and look into ways to reduce these powerful synthetics from entering our country, drug supply and our communities and i plead with this panel to do all it can to stop the poison from getting in to the country. This will not stop addiction or stop every supply, but each prevention means First Responders can get relief from the overwhelming numbers which has caused such as stressors on them and our system that we have coined the term called First Responder fatigue. Take this deadly ingredient from those pushing the drugs on our street. Take this tool away from them so our tools we are using can be given a chance to work. Reduction from these devastating synthetics would mean less people would overdose, numbers of deaths reduced which for us is never lost as each one of those numbers is a person. A person was a mother, father, brother sister daughter who will ever grieve the loss of their loved one. Thank you for allowing me to speak and i commend you for your compassion. Thank you and thank you to all four of you for powerful testimony. Im struck by your testimony, chief, about Law Enforcement and trying to keep up with about changing drug mix and specifically the moved to synthetic opioids, fentanyl and carfentanil in particular and im thinking about how Law Enforcement approaches this. Now you have a situation where through the us mail system someone cam at their po box designated pickup fentanyl from china, use it as an individual and there is no drug dealer for you to go after. Some of these individuals also become drug dealers, as you said yet, its a different situation than being able to go after the source because the source is coming in through the us mail. You talked about tools, earlier we were talking to Law Enforcement folks that said the cpb said they want the tool of advanced electronic data to 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 through the mail system, so i guess i would ask you, given your experience and background would it be helpful at a critical chokepoint like these International Service centers we talked about here today to be able to stop this poison in part to be up to keep the volume down to avoid the persons under fatigue, but in part to raise the cost, the risk to the trafficker of it being caught also the cost of this by reducing the supply . Yes. It would definitely help cutting off the supply. There is very little risk of for the dealers right now. Theres quite a bit of reward and the problem 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 collapsed. Here its everywhere with hundreds of dealers and not necessarily in a network in one area, so it makes it difficult for enforcement. I want to say, however, i want to caution we dont repeat history. In ohio we did a great job of shutting down Philip Nelson doctor shopping and inadvertently that created part of this epidemic when he when we had a segment of society left out there opiate dependent and i went to be careful we dont just shut off the supply, which is incredibly important. It would give First Responders a chance to breathe, but also want to make sure why we do that wish still have resources on the backend is part of the problem we are facing with this epidemic is if you can get someone who is opiate addicted to treatment often there is no Space Available plus there is discussion of treatment and the science show that its affected, but we need doctors and nurses with that and facilities, so not only is that chokepoint important, but we need to work on the issue of having people addicted get longterm care in order to reduce the demand, which might believe his once you reduce demand you will reduce supply. Great point and i was impressed with doctor hortons Healthcare System that he has that ability ability to take someone into treatment and within. 4 hours get them into treatment which is frankly not the case in many cases in ohio particularly in rural areas. We have a real issue with that availability and treatment and longerterm recovery, which as you know i have been focused on because i think that leads to better results and i think Law Enforcement can lead to better results by supporting our drug courts more. I know you are involved with that as well. Doctor gilson, you talked about what you are facing a specifically the forensic pathologist being overwhelmed and talked about this prior to the hearing as well. One thing you said to me was that at a death scene where someone had overdosed from fentanyl your people sometimes find a package literally a package from china at the death scene. Again, i think this is a extraordinary change from what you are used to with cocaine or for that matter with heroin coming overland and sold at the Street Corner in cleveland, ohio. I was struck by that. Can you talk to us for second about what you see happening . I think as i told you earlier you have the best data, at least in ohio and for 2016 unfortunately you were pretty accurate that there would be increase in the number of deaths from fentanyl was 399 as i recall. Since you do keep this accurate data on overdoses and fentanyl related deaths, what trends do you predict for 2017, as compared to the 399 . What do you project for 2017 . Senator, i think we are already far enough into 2017 that we can make predictions. One, the crisis will get worse for projecting on increase from 660 total of to close to 800. I think most of that again will be driven by fentanyl and i think the other thing that everyone in the room should be incredibly concerned about is what is going to be intact with analog of fentanyl. We had 54 deaths in 2016 related to fentanyl just a miter section since the beginning of 2016 we have identified at least 16 to 17 different analogs of fentanyl and many of these like carfentanil are far more potent than fentanyl. Fentanyl is already a bad drug. What concerns me is that at some point if these it drugs start to replace fentanyl in our community these numbers will take off again and to echo 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 to cough dramatically and that was our trend until 2015. Heroin deaths started to look like it was going to go down, but then we caught a title wave of fentanyl, another more potent drug and 2016 was a uniform disaster in Cuyahoga County nearly losing twice as many people. These arent hundreds of people dying of Drug Overdoses. If carfentanil becomes the fentanyl of 2017, i hate to think how much worse that will be. Doctor gilson, from your experience is that carfentanil also coming from the mail system . I think this is again partly what i can tell you from death scenes and partly what i gleaned from the collaboration we have with Drug Enforcement agencies. Yes, the answer to that. My investigators by happenstance will sometimes identify computer records, packaging that clearly show these drugs are coming from overseas and the concept that a lot of these drugs are coming from china is something that our dea liaisons completely support. The idea also, that and one of the senators mentioned it earlier and maybe they come to this country and get real to mexico to mexico is also true because in the heroine epidemic heroin production grew up dramatically to where they became the second largest heroin producer in the world and that Distribution System is definitely in place and i think fentanyl can follow the same Distribution System, so i do think these are drugs coming from overseas primarily from china and being nestled in our country really almost on a basis that could be considered an act of terrorism. Thats interesting comment even what we said earlier about and what mr. Botticelli said with regard to the director of National Intelligence listing at this year for the First Time Ever in his world assessment. He put synthetic opioids into National Security contact. Senator peters . Thank you, mr. Chairman and thank you for calling this important herein of opioid abuse in michigan are not growing at an alarming rate and its important to get to the bottom of this and understand how we can deal with it and i appreciate your leadership on this issue. Certainly, thank you to the panelists for your compelling testimony as well in dealing with this. My first question really deals with how we deal with the underlying Substance Abuse and medical treatment necessary to treat this as a medical issue. Certainly its a Law Enforcement issue, but to your testimony, chief, a Public Health issue first and foremost. Whenever we think about Public Health i think about our Health Care Policies and in his signal or act with its expansion of medicated, which has been significant in my state. Medicaid expansion has led to over 600,000 individuals now having healthcare coverage where they didnt have a 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 of more than 1. 6 million americans gaining access Substance Abuse treatment , so mr. Botticelli and doctor horgan, could you speak to how individuals enrolled in medicaid are using the program and whether or not we see an actual impact on folks suffering from Substance Abuse problems . [inaudible] think you. You would think i would know how to do this by now. When National Surveys look at why people are not able to access treatment, not having adequate access to Insurance Coverage and being under underinsured is one of the biggest reason and you are correct about before the care act i think that a number of things as it related to increasing access to care. Its made substance Disorder Treatment and Mental Health treatment one of the essential Health Benefits required by Medicaid Expansion and by ensuring that those benefits were on par with other medical benefits. We have seen remarkable results related to increase access to care under the Affordable Care act and i think your point about the Medicaid Expansion population, which we knew had higher Substance Abuse disorders than the general population, so we have seen remarkable results and quite honestly remarkable results in those states that have been dramatically impacted by this epidemic like west virginia, like kentucky, New Hampshire, massachusetts. We have seen an incredible increase in peoples ability to access care to do that. The other piece i want to make two quick points. The other important point here is that people with Substance Abuse disorders often have Mental Health and quite honestly other health conditions. Its not just accessing care for their Substance Abuse disorder. They need care for hepatitis, Mental Health coverage and the last thing i will say is i really worry about not just people losing coverage, but the stability of our treatment infrastructure. Some of these folks can tell you that these programs operate on thin margins and i worry that we will even have a treatment of the structure for those remaining people who can access care if they are not able to bill insurance. Thank you. Thank you. As i had mentioned in our system we have developed to some very unique partnerships with community providers, so we now screened 30,000 admissions to our medical hospitals, largest in delaware, identify those that are opiate addicted. That care is predominantly medicaid, so our Largest Community provider, a program called connections, has the largest footprint in the state and developed that footprint because they had a reliable funding stream. Not only a funding a stream that cares for medicaid patients, but all patients, a quality provider. The bulk of their revenue and what allows them to exist is that they have a reliable revenue stream and because of that i am able literally and my record is actually 12 hours of identifying someone in getting them into treatment on a medicine and i can do that because the individual is coverage. For the most part that coverage is medicaid. If medicaid goes way that classes and frankly though Substance Abuse structures collapse. I will identify individuals in the hospital, but i will have anywhere to send them. They will leave the hospital, relapse in hours to days and be back in the hospital and we will return to the good old days of the revolving door in the astronomical cost of caring for these individuals. We will never attend to the root cause of the issue. The big difference these days is that the volume of heroin. It used to be once upon a time one, two, five beds a day and now its bundles. Each bundle is 13 bags and i think of it as russian roulette where instead of bullets its bags of heroin and any of those bags that have fentanyl in it, that person dies. Because i have access, ready access to Substance Abuse treatment on demand im able to make a difference and i am clear that those individuals arent overdosing and i know because they coming up week after week. Thank you. Chief. Im sorry, senator or can i add a different prospective . Yes. We dont track it specifically, but, you know, we go out and respond to death scenes and i think one of the most heartbreaking things we see is an individual whos been seen in the er within weeks to sometimes days for a Drug Overdose who is now dead of a Drug Overdose. These are the people, doctor horton doesnt see. They dont make it back to treatment. They died we do have the capacity in my county to send these people when we have captive attention to treatment. We send them back on the street like doctor horton said to see if they can work something out. Anything like Medicaid Expansion being eliminated that limits peoples access to healthcare, i cant see any good coming from that in this crisis especially with its mortality. Thank you. I appreciate those comments and as i said, chief, you are on the front line. Thank you for your service and i assume you would concur . Absolutely. I am proud of my colleagues who have taken the lead on this, but the problem is we are taking the lead on something thats a Public Health issue. You are taking Law Enforcement who is taking programs trying to get Addiction Specialists out there. We have become paramedics and its not uncommon for officers to take users to treatment, so its well outside of our realm to deal with this issue, but for us its become somewhat of Addiction Specialists and for Law Enforcement to talk about that we should not decrease medicaid. Tells you how important it is to us because to reduce the demand which would in return reduce the supply it we had to get people into treatment. One of the programs are teens is doing a signing people up to medicaid to get them into treatment, so these are individuals walking with the user to get them into treatment and if medicaid is gone that it would have a significant impact. Its difficult enough and its not a common to find a user called numerous Treatment Facilities, is told there is a bit open and we drive them out there only to find out the bed is gone. Its difficult enough, but taking away medicaid would make it more difficult and like i said we would be spinning our wheels. We are already like on a mouse on a wheel. Thank you for your testimony, all of you. Thank you. On going to turn the gavel over to my colleague and Ranking Member and ask him to conduct his final questioning and then closes out and again, when to thank the four of you for being here. 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. Mr. Chairman, before you go let me just say thank you for your sustain continued leadership on this run. Maybe we can use the work and effort you have let along with amy and others last year and care and other initiatives and if we can work that well across the aisle on important issues, maybe we can somehow make sure folks that are ready to get treatment that actually have access to treatment. That was the accident. In order to put a person in treatment i have have a person to put them in. We have to develop out patient slots because if they had revenue they could be relied upon. Without it the treatment system wouldnt exist. We are able to leverage reachable moments. We are thinking about how do we partner with our colleagues at ems and police to find those other moments where an individual is so fearful that they will agree to go into treatment, but you have to have the partnership and coordinatio coordination. Emergency room one some these being admitted to the hospital, they are there. It was more about having the institution except that this was an issue and move forward to implement pathways. Were good at that. Were good at creating Electronic Health records and mechanisms to screen. We had the where wherewithal. It was a natural place to do those experiments. And they worked and they can be replicated. By that i mean identify individuals quickly around the issue, address it aggressively and use it as a lever to move them and care. Most of the patients are interested and two thirds of my patients are willing to go and show up. A question really is can we have the same results were someone has been arrested ten times breaking into a garage where the Police Departments are trying to struggle with this. Theyve come up with their own program. Let me use this, i would think of this as a best practic practice, folks from the hospital the ready for treatment and we get them treatment. Maybe each of you could give us an example that we can learn from and implement. This is an area we focused on at the white house by bringing some best practice. Ill give you an example at Boston Medical Center. We opened what i believe is the first opioid Urgent Care Center in the country so that folks came into the Emergency Department were identified coming into the community and could walk in where they were brought into the Emergency Department and we have dedicated staff who are able to work with them and get a bed and get access to care is not easy. They worked to make sure people have the care they need. I have to say, this is really important, massachusetts still has the lowest uninsured rate in the country. It is not an issue for staff at Boston Medical Center in the Emergency Department or any other facility. We have a generous medicaid benefit. And opioid rich care center is something worth looking at. Thank you. Would have to go along with that as well. We are trying to get the hospitals to work with us and allow those people to go in as patients. We are looking at this from a Law Enforcement aspect which is in going to solve, it wont be the answer. What we are also facing from the frontend of the people who dont want to get into treatment which is a significant amount of people. There is a hurdle, not just going to jail or the hospital but how do we get them into those Treatment Facilities. If we had opioid centers how will we get them there. Thats one of the challenges are trying to overcome. If we started treating this like a brain injury or an illness like its defined as a chronic illness, then i think we would have a better solution. Thank you. A lot of ideas come to mind, but i think one of the things we have to do is use the information that can be cleaned from people who die of overdoses to design intervention strategies. We saw 40 of the people who came to my office during the heroin phase of this have been incarcerated within two years or they have been in treatment within two years. I sent each of the people leaving jail or Treatment Facilities a letter spelling out Risk Reduction strategies. Dont use by yourself, good dont go back to the same dose. Theres a tremendous amount of information to be gleaned that if we can take the burden off the epidemic crushing the systems could be potentially used to design very effective intervention strategies. Thank you. Let me add another thought or two and then he will close it out. Thank you again for being here , for those with whom you work and represent, we thank them too. Every now and then we have hearings that are illuminating. Sometimes we have them that are both illuminating and terrifying. This is beginning to be an all hands on deck moment as we wrap this up. One of the things i was asked to do was be the founding vicechairman of something called the American Legacy Foundation. It was created out of the 50 state tobacco summit where the Tobacco Industry provided a lot of money for each of the states for 25 years. They also provided a billion or 2 billion to create something called the American Legacy Foundation which is probably the most Effective Campaign weve seen in this countrys history in terms of convincing young people that if they were using tobacco they should stop. I realize its not entirely comparable, but weve talked a lot about messaging and in the back of my mind we talk about no silver bullets. Given what weve accomplished its one i would not dismiss. Finally we will be asking the questions for the record. The shortlist, things we ought to be doing, sense of urgency. Thank you all for what youre doing. We are in this together. Lets go forward and accomplish things. First i want to concur with all of your comments. Thank you for asking one last final question, going back to the root causes. I appreciated your response on how we have to make sure we have Health Insurance available, medicaid available for Substance Abuse counseling and treatment, but theres also a compelling evidence that prescription opioids are one of the key drivers for what we are seeing here with prescriptions. Doctor gilson in your testimony it struck me that in your county individuals who had beens prescribed controlled substance, within two years of their death, half of them had prescription opioids. I guess just the final question, are we aware of other sorts of treatments that we should be prescribing so we can stop what appears to be over prescription of opioids to patients who then become addicted to this that we need to have different types of treatments and in thinking about how we Practice Medicine , what should we be thinking about Going Forward in trying to basically stop the pipeline that starts with some Prescription Drugs . Thank you for the question. I think you really hit the genesis of the problem, the nail on the head exactly, the culture and medicine tending toward overprescribing, the scientific support for that is minimal and unfortunately that became a standard of practice that has created a large opioid addicted population. If we gave prescription pain medication to everyone in this room, they would become addicte addicted. We have created a substantial, large addictive population through the use and abuse of prescription pain medication. That is absolutely true. How we get back from that is to start the reeducation of our medical community, we have to put 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 detrimental consequence, thats not a good treatment and we should hold accountable the people who promoted that idea. It wasnt very well documented. Im ashamed to say that the part that the medical community played in this crisis isnt stopping. I still have lots of anecdotal information of people getting a months worth of vicodin after they get teeth pulled with refills. We have to stop that and turn that flow off. I think doctor horton and other folks said we have a population of people who are already suffering from the over prescription. We cant turn our back on them. Treatment does work and i think the ways we improve treatment will be more effective for them. During my time we worked at the cdc and i think some the issues we heard in terms of non opioid hairpiece, the challenges are changing the culture of just gettin giving a prescription but i think we also heard insurance reimbursement for physical therapy and acupuncture and often Mental Health therapy. That was an issue that we really got to take a look at in terms of those challenges. I will say, we have had some good evidence in states that have really robust Prescription Drug Monitoring Programs, weve seen some good monitoring where physicians had to register and check each and every time. I know many states have moved to mandatory registration and mandatory checks because it seems like that works. You often get pushback from physicians and i understand that sometimes they are busy, but my response was we are 15 years into this and i dont think its unreasonable for a physician to take education and check the Prescription Drug Monitoring Program. We are losing too many people. In our state think we been able to implement some of those measures and really ratchet up regulation for prescribers. Its a small states were able to make these changes and were seeing the cultural change so there is hope about being able to attend to it. As far as treatment for Prescription Drugs, in many ways the genie is out of the bottle and most of the patients i attend to were exposed to Prescription Drugs. We are 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 is well. Congress supported this, if you talk to the National Institute of health they will tell you we need to do a better job by researching non opioid medication. I think one of the barriers is looking at what the Administration Proposed in terms of nih reduction that are significant damper on the research capabilities, and to come up with non opioid, nonaddictive prescriptions for pain medication and i think it undercuts what Congress Passed as part of the 21st century cares act. Thank you so much. Its a good note to end on. Got a lot of good ideas, the preacher in our church likes to say that preaching to the choir needs to be preached to. Our thanks for coming for the work that your colleagues are doing the record will remain open for 15 days. For any additional questions or comments we ask that you submit them. This hearing is adjourned. Thank you so much. [inaudible conversations] on the hill today president trumps criticism of germany with a tweet that red we have a massive trade deficit with germany plus they pay far less with what they should on nato and the military. Very bad for the u. S. This will change. Before the tweet the german chancellor set her country can no longer completely depend on the u. S. Germanys foreign minister called president trumps policies shortsighted. He said they stand against the European Union interest. You can read more at the hill. Com. Also, in political, president Trumps White House communication director has resigned as the president considers a wider shakeup of personnel to confront controvers
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