[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
AN UNSECURE BORDER AND THE OPIOID CRISIS: THE URGENT NEED FOR ACTION TO
SAVE LIVES
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON
BORDER AND
MARITIME SECURITY
of the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
MAY 30, 2018
__________
Serial No. 115-67
__________
Printed for the use of the Committee on Homeland Security
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
32-928PDF WASHINGTON: 2018
COMMITTEE ON HOMELAND SECURITY
Michael T. McCaul, Texas, Chairman
Lamar Smith, Texas Bennie G. Thompson, Mississippi
Peter T. King, New York Sheila Jackson Lee, Texas
Mike Rogers, Alabama James R. Langevin, Rhode Island
Lou Barletta, Pennsylvania Cedric L. Richmond, Louisiana
Scott Perry, Pennsylvania William R. Keating, Massachusetts
John Katko, New York Donald M. Payne, Jr., New Jersey
Will Hurd, Texas Filemon Vela, Texas
Martha McSally, Arizona Bonnie Watson Coleman, New Jersey
John Ratcliffe, Texas Kathleen M. Rice, New York
Daniel M. Donovan, Jr., New York J. Luis Correa, California
Mike Gallagher, Wisconsin Val Butler Demings, Florida
Clay Higgins, Louisiana Nanette Diaz Barragan, California
Thomas A. Garrett, Jr., Virginia
Brian K. Fitzpatrick, Pennsylvania
Ron Estes, Kansas
Don Bacon, Nebraska
Debbie Lesko, Arizona
Brendan P. Shields, Staff Director
Steven S. Giaier, General Counsel
Michael S. Twinchek, Chief Clerk
Hope Goins, Minority Staff Director
------
SUBCOMMITTEE ON BORDER AND MARITIME SECURITY
Martha McSally, Arizona, Chairwoman
Lamar Smith, Texas Filemon Vela, Texas
Mike Rogers, Alabama Cedric L. Richmond, Louisiana
Lou Barletta, Pennsylvania J. Luis Correa, California
Will Hurd, Texas Val Butler Demings, Florida
Clay Higgins, Louisiana Nanette Diaz Barragan, California
Don Bacon, Nebraska Bennie G. Thompson, Mississippi
Michael T. McCaul, Texas (ex (ex officio)
officio)
Paul L. Anstine, Subcommittee Staff Director
Alison B. Northrop, Minority Subcommittee Staff Director/Counsel
C O N T E N T S
----------
Page
STATEMENTS
The Honorable Martha McSally, a Representative in Congress From
the State of Arizona, and Chairwoman, Subcommittee on Border
and Maritime Security:
Oral Statement................................................. 1
Prepared Statement............................................. 4
The Honorable Raul Manuel Grijalva, a Representative in Congress
From the State of Arizona...................................... 6
The Honorable Kyrsten Sinema, a Representative in Congress From
the State of Arizona........................................... 7
WITNESSES
Panel I
Hon. Douglas A. Ducey, Governor, State of Arizona:
Oral Statement................................................. 8
Prepared Statement............................................. 10
Panel II
Mr. Guadalupe Ramirez, Acting Director of Field Operations, U.S.
Customs and Border Protection--Tucson, U.S. Department of
Homeland Security:
Oral Statement................................................. 16
Prepared Statement............................................. 18
Mr. A. Scott Brown, Special Agent in Charge, Homeland Security
Investigations--Phoenix, U.S. Department of Homeland Security:
Oral Statement................................................. 23
Prepared Statement............................................. 25
Mr. Douglas W. Coleman, Special Agent in Charge, Phoenix Field
Division, Drug Enforcement Agency, U.S. Department of Justice:
Oral Statement................................................. 30
Prepared Statement............................................. 32
Mr. Timothy Roemer, Deputy Director, Department of Homeland
Security, State of Arizona:
Oral Statement................................................. 39
Prepared Statement............................................. 40
Panel III
Dr. Cara M. Christ, Director, Department of Health Services,
State of Arizona:
Oral Statement................................................. 53
Prepared Statement............................................. 55
Dr. Glorinda Segay, Health Director, Division of Health, The
Navajo Nation.................................................. 65
Ms. Debbie Moak, Co-Founder, NotMyKid:
Oral Statement................................................. 67
Prepared Statement............................................. 69
Mr. Jay A. Cory, CEO and President, Phoenix Rescue Mission:
Oral Statement................................................. 71
Prepared Statement............................................. 73
Mr. Wayne Warner, Dean of Men, Teen Challenge Christian Life
Ranch:
Oral Statement................................................. 75
Prepared Statement............................................. 77
FOR THE RECORD
The Honorable Raul Manuel Grijalva, a Representative in Congress
From the State of Arizona:
Statement of Anthony M. Reardon, National President, National
Treasury Employees Union..................................... 43
APPENDIX
Questions From Honorable Kristen Sinema for Douglas A. Ducey..... 87
Questions From Honorable Raul Grijalva for Guadalupe Ramirez..... 88
AN UNSECURE BORDER AND THE OPIOID CRISIS: THE URGENT NEED FOR ACTION TO
SAVE LIVES
----------
Wednesday, May 30, 2018
U.S. House of Representatives,
Committee on Homeland Security,
Subcommittee on Border and Maritime Security,
Phoenix, AZ.
The subcommittee met, pursuant to notice, at 9:30 a.m., at
Building 2 Virginia G. Piper Auditorium, University of Arizona
College of Medicine--Phoenix, 550 E. Van Buren Street, Phoenix,
AZ, Hon. Martha McSally [Chairman of the subcommittee]
presiding.
Present: Representative McSally [presiding] and Lesko.
Also present: Representatives Grijalva, Schweikert, Sinema,
and Gallego.
Ms. McSally. The Committee on Homeland Security,
Subcommittee on Border and Maritime Security, will come to
order.
The subcommittee is meeting today to examine the impact an
unsecure border has on the opioid crisis.
Before we proceed any further, as Chair I need to make a
few important announcements.
It takes a tremendous amount of work putting this hearing
together, and I appreciate the interest that is shown by the
number of people who are in attendance today. I would also like
to thank the University of Arizona for hosting us today and for
allowing us to use this excellent facility.
Because this is an official Congressional hearing as
opposed to a town hall meeting, we must abide by certain rules
of the Committee on Homeland Security and the House of
Representatives. I kindly wish to remind our guests today that
demonstrations from the audience, including applause, verbal
outbursts, as well as the use of signs or placards, are
violations of the Rules of the House of Representatives. It is
important to respect the decorum and the rules of the
Committee.
I would also like to remind everybody that photography and
cameras are limited to accredited press only.
I also ask unanimous consent that Mr. Schweikert, Ms.
Lesko, Mr. Grijalva, Ms. Sinema, and Mr. Gallego be allowed to
sit on the dais and participate in today's hearing. Without
objection, so ordered.
I now recognize myself for an opening statement.
Opioid abuse has become an epidemic across the entire
Nation, affecting all 50 States.
One hundred and fifteen Americans die every single day from
an opioid overdose. These victims come from all walks of life.
They are teachers, business professionals, ranchers, students,
Government officials, and retirees. Here in Arizona there have
been at least 800 lives lost just last year alone.
Some estimates conclude that more than 2 million of our
fellow Americans are addicted to opioids. Chances are every
single one of us knows someone struggling with opioid
dependence. No State, no neighborhood, no socioeconomic group,
no family is immune from the destruction and carnage that it
brings.
Too many lives have been lost, too many families have been
destroyed, and communities all over the Nation are asking what
more can be done to stop this devastating opioid addiction
epidemic?
I have called this hearing today to not only highlight the
crisis but to discuss both law enforcement and non-law
enforcement solutions that will ultimately save lives.
Thankfully, this is not a partisan issue.
I am grateful to see my colleagues here today, both
Republicans and Democrats, so we can work together to identify
the challenges and enact solutions to help families in our
communities.
Actions to address this crisis will require multiple State,
Federal, local, and Tribal governments to work together, in
concert with non-profit entities and the faith-based community.
No one can go it alone, because this issue will require a
whole-of-society approach.
Addiction often begins after powerful opioids are routinely
prescribed out of a genuine need to manage pain after surgery.
However, patients quickly become hooked, often unaware of how
addicting they are.
In addition, even after the risks were well-known,
unethical doctors continued to write prescription after
prescription, becoming pill mills that now sustain the flow of
opioids to those who are addicted.
Last year, four of Arizona's top opioid-prescribing doctors
were located in the sparsely populated Mohave County. Together,
they wrote prescriptions for nearly 6 million pills over a 12-
month period.
An unsecure border enables and exacerbates this crisis by
providing a strong supply of illicit versions.
Securing the border is more than just stopping illicit
movement of people and contraband between the ports of entry,
which is often the focus. But since I have been Chair of this
subcommittee, I have also focused on modernizing
infrastructure, technology, and additional manpower at our
Nation's ports of entry. In fact, my first bill signed into law
was fast-tracking our veterans for these critical manning
positions at the ports.
It is well-known that the overwhelming majority of drugs,
maybe as high as 90 percent, that enter our country come in
through the Nation's ports of entry such as the ones in Nogales
and Douglas. Illicit opiates are no exception.
Deep concealment within vehicles or in cargo is the
preferred method of the drug cartels, and they are very
successful despite the best efforts of the men and women of
U.S. Customs and Border Protection.
To ensure the speedy movement of commerce that powers our
economy, we can only X-ray a fraction of the vehicles and
trucks that cross the border every day. We need more detection
equipment and more tools for CBP to effectively combat the
illicit drug flow hidden in legitimate travel and commerce.
I am proud to announce that I will be hosting the Secretary
of Homeland Security, Secretary Nielsen, tomorrow at two of our
ports of entry, Douglas and Nogales, so that she can see first-
hand the needs that we have at these ports in Arizona.
I have been a tireless advocate for the expansion and
modernization of Douglas not just because of its importance to
economic growth, but because of its importance to security.
In addition to the challenges at the ports, fentanyl, an
opioid 100 times stronger than morphine, is being produced
illicitly in large quantities, chiefly in China, but also
increasingly in Mexico. The primary smuggling route from China
into the United States is through our mail system, where
vulnerabilities in the postal system are exploited.
In order to mitigate these illicit pathways, we must secure
the border and strengthen our postal system. In addition, we
must increase the detection capabilities of law enforcement on
every level as they respond to this disaster.
However, this is just one part of the solution. Law
enforcement and increased border security alone will never be
enough. We cannot enforce our way out of this problem.
We must also tackle this crisis with treatment and recovery
options that help restore individuals to health and break the
cycle of addiction.
Educating patients on the risks of taking properly
prescribed opioids must be standard medical practice. With
respect to those doctors who unethically prescribe these
medications, they must be held accountable.
Most of all, we must support all those who suffer from
addiction, their families and loved ones, to ensure that they
get the help they so desperately need.
I am very proud to say that the State of Arizona has been a
National leader in addressing these challenges head on.
Faced with a growing crisis, Governor Ducey declared the
opioid crisis a public health emergency in June of last year.
Then the Governor called a 4-day special session of the State
legislature at the beginning of this year and signed the
Arizona Opioid Epidemic Act.
The legislation takes aggressive steps to address opioid
addiction, hold bad actors accountable, expand access to
treatment, and provide life-saving resources to first
responders, law enforcement, and community partners.
On the Federal level, Congress has been engaged in tackling
this problem as well.
Legislation that passed the Homeland Security Committee and
later became law provided additional fentanyl and synthetic
opioids detection equipment to the front-line CBP officers in
the INTERDICT Act.
Over the last few months, 57 bills that address this public
health crisis are making their way through the House of
Representatives. These bills would provide new authority to:
Spur urgently-needed research on new non-addictive pain
medications; ensure medical professionals have access to a
consenting patient's complete health history when making
treatment decisions; provide resources for hospitals to develop
protocols for discharging patients who have presented with an
opioid overdose; establish comprehensive opioid recovery
centers that will serve as models for comprehensive treatment
and recovery; and direct the FDA to work with manufacturers to
establish programs for efficient return or destruction of
unused opioids.
The fiscal year 2018 appropriations bill provided over $4
billion in funding for the development of opioid alternatives,
grants for States to respond to the challenge, new funds for
equipment to inspect more incoming mail packages, as well as
more X-ray devices at the ports of entry.
This is a complicated and multi-faceted problem. There are
no quick or easy solutions. I have invited witnesses today who
deal with this issue from many different angles to testify.
On the following panels we will hear from law enforcement
and border security experts, as well as experienced
professionals from the public sector, those with a family
member or who were themselves addicted and found the support
they needed to get and stay clean.
I look forward to the testimony from our witnesses today as
we search for solutions to this grave crisis that affects too
many of our fellow Americans.
[The statement of Chairwoman McSally follows:]
Statement of Chairwoman Martha McSally
May 30, 2018
Opioid abuse has become an epidemic across the entire Nation,
affecting all 50 States.
One hundred fifteen Americans die every single day from an opioid
overdose. These victims come from all walks of life, they are teachers,
business professionals, ranchers, students, government officials, and
retirees. And here in Arizona there have been at least 800 lives lost
just last year alone.
Some estimates conclude that more than 2 million of our fellow
Americans are addicted to opioids. Chances are every single one of us
knows someone struggling with opioid dependence.
No State, no neighborhood, no socioeconomic group, no family is
immune from the destruction and carnage that it brings.
Too many lives have been lost, too many families have been
destroyed, and communities all over the Nation are asking what more can
be done to stop this devastating opioid addiction epidemic?
I have called this hearing today to not only highlight the opioid
crisis, but to discuss both law enforcement and non-law enforcement
solutions that will ultimately save lives.
Thankfully, this is not a partisan issue.
I am grateful to see my colleagues, both Republicans and Democrats,
here today so we can work together to identify the challenges and enact
solutions to help families in our communities.
Action to address this crisis will require multiple State, Federal,
local, Tribal governments to work together, in concert with non-profit
entities and the faith-based community.
No one can go it alone, because this issue will require a whole-of-
society approach.
Addiction often begins after powerful opioids are routinely
prescribed out of a genuine need to manage pain after surgery; however,
patients quickly become hooked, often unaware of how addicting opioids
are.
In addition, even after the risks were well-known, unethical
doctors continued to write prescription after prescription becoming
``pill mills'' that sustained the flow of opioids to those who are
addicted.
Last year, four of Arizona's top opioid-prescribing doctors were
located in the sparsely populated Mohave County. Together they wrote
prescriptions for nearly 6 million pills over a 12-month period.
An unsecure border enables and exacerbates this crisis by providing
a strong supply of illicit versions.
Securing the border is more than just stopping illicit movement of
people and contraband between the ports of entry. Since I have been
Chair of this subcommittee, I have also focused on modernized
infrastructure, technology, and additional manpower at our Nation's
ports of entry.
It is well-known that the overwhelming majority of drugs, maybe as
high as 90 percent, that enter our country come in through the Nation's
ports of entry such as the ones in Nogales and Douglas.
Illicit opiates are no exception.
Deep concealment within vehicles, or in cargo is the preferred
method of the drug cartels. And they are very successful, despite the
best efforts of the men and women of U.S. Customs and Border
Protection.
To ensure the speedy movement of commerce that powers our economy,
we can only X-ray a fraction of the vehicles and trucks that cross the
border every day. We need more detection equipment and more tools for
CBP to effectively combat the illicit drug flow hidden in legitimate
travel and commerce.
I'm proud to announce that I will be hosting Secretary of Homeland
Security Nielsen tomorrow at two ports of entry--Douglas and Nogales,
so that she can see first-hand the needs that we have at ports in
Arizona.
I have been a tireless advocate for the expansion and modernization
of the Douglas port of entry because our economic growth and National
security rely on well-equipped ports.
In addition to the challenges at ports of entry, Fentanyl, an
opioid about 100 times stronger than morphine, is being produced
illicitly in large quantities, chiefly in China, but also increasingly
in Mexico. The primary smuggling route from China and into the United
States is through our mail system, where vulnerabilities in the postal
system are exploited.
In order to mitigate these illicit pathways, we must secure the
border and strengthen our postal system. In addition, we must increase
the detection capabilities of law enforcement, on every level, as they
respond to this disaster.
However, this is just one part of the solution. Law enforcement and
increased border security alone will never be enough.
We cannot enforce our way out of this problem.
We must also tackle this crisis with treatment and recovery options
that help restore individuals to health and break the cycle of
addiction.
Educating patients on the risks of taking properly prescribed
opioids must be standard medical practice. With respect to those
doctors who unethically prescribe these medications, they must be held
accountable.
And most of all, we must support those who suffer from addiction,
their families, and loved ones--to ensure that they can get the help
they so desperately need.
I am very proud to say that the State of Arizona has been a
National leader in addressing the challenges of opioid abuse head-on.
Faced with a growing crisis, Governor Ducey declared the opioid
crisis a public health emergency in June of last year. Then, the
Governor called a 4-day special session of the State legislature at the
beginning of this year and signed The Arizona Opioid Epidemic Act.
The legislation takes aggressive steps to address opioid addiction,
hold bad actors accountable, expand access to treatment, and provide
life-saving resources to first responders, law enforcement, and
community partners.
On the Federal level, Congress has been engaged in tackling this
problem as well.
Legislation that passed in the Homeland Security Committee and
later became law provided additional fentanyl and synthetic opioids
detection equipment for front-line CBP officers--the INTERDICT Act.
Over the last few months 57 bills that address this public health
crisis are making their way through the House of Representatives. These
bills would provide new authority to:
Spur urgently needed research on new non-addictive pain
medications.
Ensure medical professionals have access to a consenting patient's
complete health history when making treatment decisions.
Provide resources for hospitals to develop protocols for
discharging patients who have presented with an opioid overdose.
Establish Comprehensive Opioid Recovery Centers that will serve as
models for comprehensive treatment and recovery.
Direct the FDA to work with manufacturers to establish programs for
efficient return or destruction of unused opioids.
And the fiscal year 2018 appropriations bill provided over $4
billion dollars in funding for the development of opioid alternatives,
grants for States to respond to this challenge, new funds for equipment
to inspect more incoming mail packages as well as more X-ray devices at
ports of entry.
This is a complicated, and multi-faceted problem.
There are no quick, or easy solutions. I have invited witnesses who
deal with this issue from many different angles to testify this
morning.
On the following panels we will hear from law enforcement and
border security experts, as well as experienced professionals from the
public sector, those with a family member or were themselves addicted
to opioids and found the support they needed to get and stay clean.
I look forward to the testimony from our witnesses today, as we
search for solutions to this grave crisis that affects too many of our
fellow Americans.
Ms. McSally. The Chair now recognizes the gentleman from
Arizona, Mr. Grijalva, for any statement you may have.
Mr. Grijalva. Thank you very much, Madam Chair, and my
appreciation to all the panelists that are going to give
testimony today and respond to the questions from my
colleagues.
The subcommittee hearing that the Chair stated was
entitled: ``An Unsecure Border and the Opioid Crisis and the
Urgent Need for Action to Save Lives.'' Saving lives indeed.
With a daily death toll of 116 in this country from overdoses
and increasing addiction and uses of opioids, both prescription
and illicit, continues to grow in this country.
The deaths and addictions have shattered lives, shattered
families, led to more incarcerations, and the economic and
community losses are dire in not only the State of Arizona but
across the country. It is tragic here, and it is tragic
everywhere.
I believe, as the reason for this hearing, saving lives
must be the focus.
I wondered, Madam Chair, why we don't have a top-level
pharmaceutical CEO here to give testimony as to their role in
igniting the demand and use of prescription opioids and what
they are doing to assist us in stemming this demand and this
use.
I hope that in this hearing, because the premise is to save
lives, that we don't politicize the real crisis with fanciful
demands and proclamations about walls that cost $30 billion,
about maximum sentencing as a deterrent, including the death
penalty, as was mentioned by the Attorney General, and spending
all the time in this hearing blaming immigrants and
undocumented people, including moms of children, as the cause
for this crisis. I think leaving that rhetorical political
posturing aside, it would be important to talk honestly and
realistically about the demand and use, cause and prevention,
and treatment.
The ports of entry where over 80 percent of seizures of
opioids have occurred have been historically underfunded in
terms of personnel, understaffed, with less than the optimum
technology and infrastructure, as was outlined by the Chair,
that is needed in that border.
Bipartisan letters have gone to Homeland Security, to this
administration, by both senators and a bipartisan group of
Congressmen from Arizona time and time again to ask for
additional resources to deal with the people in blue with the
same emphasis that we are dealing with Border Patrol and ICE.
Since 57 percent of the seizures in this country occur between
San Diego and Tucson, it would only seem logical that that
should be a focus.
I think we need a strategy that provides a singular focus
on this issue, a strategy to deal with the organized and
wealthy crime syndicates whose market is the United States of
America, where 5 percent of the population consumes over 80
percent of the opioids, be it prescription or illegal.
Yes, saving lives hopefully is what this hearing is about.
Securing the border with fanciful proclamations is not going to
deal with this issue. If we are going to save lives, it is
going to require hard work, it is going to require cooperation
across lines and across political parties. I prefer to do that
hard work.
At this point, Madam Chair, with the remaining time, I
would yield to my colleague, Congresswoman Sinema, for the time
left on my opening statement.
Ms. Sinema. Thank you, Congressman Grijalva, for yielding a
moment of time. Thank you to Chairwoman McSally for holding
this field hearing.
Like all Arizonans, we share a commitment to a more secure
border and to addressing the opiate crisis. Washington needs to
get serious about taking action. In the past year, more than
8,000 Arizonans overdosed on opiates. Over 1,200 of those lives
couldn't be saved.
Congresswoman McSally, we have worked together to help stop
the flow of dangerous drugs into our communities. We have
offered three bills together to identify the greatest threats
to Arizona's border, improved deployment of new border
technologies, and prevent spotters who facilitate illegal
crossings. We have also worked across the aisle to support and
pass the recent Government funding bill which invests billions
in border security resources, including counter-drug missions,
and in treatment, prevention, and law enforcement efforts
targeting the opiate crisis.
It is important that we put politics aside so we can
protect and help Arizona communities and families. Our work
should support work at the State level to win this fight.
Recently I co-introduced the COMPASS Act with Republican
Congressman Roskam to help doctors cut down on over-prescribing
and to help Arizonans better manage their medications. My
bipartisan bill, which is expected on the House floor in June,
reinforces the great work done by Governor Ducey and the State
legislature through the Arizona Opiate Epidemic Act. I look
forward to continuing to work with everyone here today to
protect our communities, secure our border, and address the
opiate crisis.
Thank you, and I yield back.
Ms. McSally. The gentle lady yields back.
Does the gentleman yield back?
Mr. Grijalva. I yield back.
Ms. McSally. We are honored on our first panel today to
have Governor Ducey. Governor Doug Ducey became the Governor of
Arizona in January 2015. Previously he served as Arizona's 32nd
State treasurer, a position he held since his appointment in
January 2011. Mr. Ducey, Governor Ducey joined Proctor and
Gamble and began a career in sales and marketing. Then he was
trained in management, preparing him for his role as a partner
and CEO of Cold Stone Creamery. Governor Ducey also served as
the Chairman of Arizona's State Board of Investment and State
Loans Commission.
I now recognize Governor Ducey to testify.
STATEMENT OF HON. DOUGLAS A. DUCEY, GOVERNOR, STATE OF ARIZONA
Governor Ducey. Chairwoman McSally, Congressman Grijalva,
distinguished Members of the subcommittee, and other Members in
attendance, thank you for this opportunity to appear before you
to discuss one of the most significant public health and safety
emergencies our Nation and the State of Arizona has faced in a
generation, the opioid crisis and the interrelated priority of
securing our Nation's borders.
Let's start with the need to secure the border.
From the earliest days in my administration, I have had the
opportunity to spend time with Arizona's border sheriffs and
numerous everyday residents, citizens, and ranchers in our
border communities. The concerns they have expressed for their
safety and security are real, and it is our job to listen and
take action.
I am grateful for the strong partnerships our State has
with local law enforcement, and we have established these as
well with the U.S. Department of Homeland Security over these
many years.
In 2015, Secretary of Homeland Security Jeh Johnson was in
town helping to coordinate security efforts for the Super Bowl.
We had such great success working together that I thought, why
can't we continue this type of collaboration to also secure our
border?
Working with that cooperative spirit in partnership with
the Department of Homeland Security, in 2015 we established the
Arizona Border Strike Force. This intra-agency team has,
without a doubt, made Arizona and our entire country safer.
One example of many large-scale efforts by the Border
Strike Force is Operation Organ Grinder, which resulted in the
seizure of more than 4,000 pounds of marijuana and the arrest
of 73 felons.
To date, the Border Strike Force has kept 15.3 million hits
of heroin off our streets.
It is not just drugs. What began as a traffic stop in
Cochise County led to the discovery of a juvenile runaway who
was the victim of horrific sex trafficking crimes. The primary
suspect was sentenced to 20 years in prison and will face a
lifetime of supervised probation and sex offender registration.
We are grateful that the new administration has amplified
these efforts even further. President Trump's deployment of the
National Guard has brought additional boots on the ground to
our border. They are needed and they are welcomed.
Both General John Kelly and current DHS Secretary Kirstjen
Nielsen have not only visited our State to tour the border with
me, but they have delivered on both support and resources. They
are finally making Washington, DC listen. After recently
visiting all four of our border counties, I can tell you that
the residents in these communities could not be more grateful.
When it comes to the opioid epidemic, overdoses and deaths
have indeed reached crisis levels. Last year alone, 800 Arizona
moms, dads, brothers, sisters, family members, and friends were
claimed by this scourge. This is why we are all here today,
from across the State and from both political parties, because
we have all seen the consequences, and we all know this is not
a partisan issue.
The collaborative process under which our plan was
developed, with stakeholders from across the State, and the way
Democrats and Republicans came together to pass it unanimously
is an example to our Nation of what can be accomplished when we
do put politics aside.
The public health state of emergency I declared last June
began a process of collaboration between the Arizona Department
of Health Services, law enforcement, hospitals, medical
professionals, addiction specialists, and other community
stakeholders to fight this crisis head on.
The declaration allowed us to collect information on opioid
overdoses, deaths, cases of newborns experiencing withdrawal
from opioids, and naloxone use on a 24-hour basis, something no
other State has done.
From there, our Department of Health Services worked to
analyze the data and identify solutions focused on prevention
and treatment.
For Arizonans dealing with chronic pain and participating
in a responsible treatment plan, we know how critical these
medications are. So we made sure that they were involved every
step of the way, too.
During a special session last January, we addressed every
facet of this fight, from the need to protect Good Samaritans
and end pill mills, right down to the physical packaging of the
drugs themselves. In fact, all opioid prescription bottles in
our State will now have red caps to alert patients to the high
risk of these drugs and the need to keep them away from
children.
One of our most significant accomplishments was a result of
bipartisan collaboration to improve access to treatment with a
$10 million investment that will help uninsured and
underinsured people get the treatment they need.
Since declaring a State of emergency last June, we have
come a long way. In fact, every directive I gave in that
declaration has been completed.
New reporting and information-sharing procedures are now
codified in policy and rule.
Almost 1,000 law enforcement officers State-wide have been
trained to provide naloxone. We have also seen a 355 percent
increase in the number of naloxone doses dispensed by
pharmacists to communities.
Our health care institutions now have rules for opioid
prescribing and treatment.
Arizona Opioid Prescribing Guidelines have been updated and
distributed.
Our comprehensive Opioid Epidemic Act went into effect in
Arizona on April 26.
The 12 recommendations of our Opioid Action Plan will be
fully implemented by the end of June.
With these items completed, our emergency declaration has
served its purpose.
That is not all the positive news we have to report.
March and April 2018 saw a 33 percent reduction in the
number of opioid prescriptions State-wide compared to March and
April 2017.
Since last June, we have seen a 38 percent increase in the
number of people referred to behavioral health treatment from
hospitals after an overdose.
Since July 2017, we have seen a 60 percent reduction in the
number of patients potentially doctor shopping through our
CSPMP threshold report.
Since this April, over 200 prescribers have utilized our
newly-established Opioid Assistance and Referral Line to get
expert advice on treating patients.
In addition, we have worked with 100 percent of Arizona's
academic partners who train prescribers to develop a State-wide
curriculum on opioid prescribing, treatment of opioid use
disorder, and management of chronic pain. This could be
implemented in our schools as early as this coming fall.
We have certainly made progress, but we know that this
fight remains deadly and that it is far from over. Continuing
to work with each other and across the aisle as we have done, I
know this is a fight we can win.
Again, thank you for having me here today.
[The prepared statement of Governor Ducey follows:]
Prepared Statement of Douglas A. Ducey
May 30, 2018
Chairwoman McSally, Congressman Grijalva, distinguished Members of
the subcommittee, and other Members in attendance, thank you for this
opportunity to appear before you to discuss one of the most significant
public health and safety emergencies our Nation and the State of
Arizona has faced in a generation--the opioid crisis and the
interrelated priority of securing our Nation's borders.
Let's start with the need to secure the border.
From the earliest days in my administration, I've had the
opportunity to spend time with Arizona's border sheriffs along with
numerous everyday residents, citizens, and ranchers in our border
communities.
The concerns they have expressed for their safety and security are
real and it's our job to listen and take action.
I am grateful for the strong partnerships our State and local law
enforcement have established with the U.S. Department of Homeland
Security over many years.
In 2015, former Secretary of Homeland Security Jeh Johnson was in
town helping coordinate security efforts for the Super Bowl. We had
such great success working together that I thought, ``Why can't we
continue this type of collaboration to secure the border?''
Working with that cooperative spirit, in partnership with the
Department of Homeland Security, in 2015 we established the Arizona
Border Strike Force.
This intra-agency team has without a doubt made Arizona and our
entire country safer. One example of many large-scale efforts by the
Border Strike Force is Operation Organ Grinder which resulted in the
seizure of more than 4,000 pounds of marijuana and the arrest of 73
felons.
To date, the Border Strike Force has kept 15.3 hits of heroin off
our streets.
And it's not just drugs. What began as a traffic stop in Cochise
County led to the discovery of a juvenile run-away who was the victim
of horrific sex trafficking crimes.
The primary suspect was sentenced to 20 years in prison and will
face a lifetime of supervised probation and sex-offender registration.
We are grateful that the new administration has amplified these
efforts even further. President Trump's deployment of the National
Guard has brought additional boots on the ground to our border--they
are needed and welcomed. And both General John Kelly and Current DHS
Secretary Kirstjen Nielsen have not only visited our State to tour the
border with me, but they have delivered on support and resources.
They are finally making Washington, DC. listen. And after recently
visiting all four of our border counties--I can tell you: The residents
in these communities could not be more grateful.
When it comes to the opioid epidemic, overdoses and deaths have
indeed reached crisis levels.
Last year alone, 800 Arizona moms, dads, brothers, sisters, family
members, and friends were claimed by this scourge.
It's why we are all here today. From across the State, and from
both political parties--because we've all seen the consequences, and we
all know this is not a partisan issue.
The collaborative process under which our plan was developed, with
stakeholders from across the State, and the way Democrats and
Republicans came together to pass it unanimously, is an example to our
Nation of what can be accomplished when we put politics aside.
The Public Health State of Emergency I declared last June began a
process of collaboration between the Arizona Department of Health
Services, law enforcement, hospitals, medical professionals, addiction
specialists, and other community stakeholders to fight this crisis
head-on.
The declaration allowed us to collect information on opioid
overdoses, deaths, cases of newborns experiencing withdrawal from
opioids, and naloxone use on a 24-hour basis--something no other State
has done.
From there, our Department of Health Services worked to analyze the
data and identify solutions focused on prevention and treatment.
For Arizonans dealing with chronic pain and participating in a
responsible treatment plan, we know how critical these medications are.
So we made sure that they were involved every step of the way too.
During a special session this January, we addressed every facet of
this fight, from the need to protect Good Samaritans and end pill
mills, right down to the physical packaging of the drugs themselves.
In fact, all opioid prescription bottles in our State will now have
red caps to alert patients to the high-risk of these drugs and the need
to keep them away from children.
One of our most significant accomplishments was a result of
bipartisan collaboration to improve access to treatment with a 10
million dollar investment that will help uninsured and underinsured
people get the treatment they need.
Since declaring a State of Emergency last June, we've come a long
way. In fact every directive I gave in that declaration has been
completed:
New reporting and information-sharing procedures are now
codified in policy and rule.
Almost 1,000 law enforcement officers State-wide have been
trained to provide naloxone. We have also seen a 355 percent
increase in the number of naloxone doses dispensed by
pharmacists to communities.
Our health care institutions now have rules for opioid
prescribing and treatment.
Arizona Opioid Prescribing Guidelines have been updated and
distributed.
Our comprehensive Arizona Opioid Epidemic Act went into
effect on April 26.
And the 12 recommendations of our Opioid Action Plan will be
fully implemented by the end of June.
With these items completed, our Emergency Declaration has served
its purpose.
And that's not all the positive news we have to report:
March and April 2018 saw a 33 percent reduction in the
number of opioid prescriptions State-wide compared to March and
April 2017.
Since last June, we have seen a 38 percent increase in the
number of people referred to behavioral health treatment from
hospitals after an overdose.
Since July 2017, we have seen a 60 percent reduction in the
number of patients potentially doctor shopping through our
CSPMP threshold report.
And since this April, over 200 prescribers have utilized our
newly-established Opioid Assistance and Referral Line to get
expert advice on treating patients.
In addition, we have worked with 100 percent of Arizona
academic partners who train prescribers to develop a State-wide
curriculum on opioid prescribing, treatment of opioid use
disorder, and management of chronic pain. This could be
implemented in our schools as early as this coming fall.
We have certainly made progress, but we know that this fight
remains deadly and that it is far from over. Continuing to work with
each other, and across the aisle as we have done, I know this is a
fight we can win.
Thank you again for having me today.
Ms. McSally. Thanks, Governor Ducey. I really appreciate
it. I understand you have a hard stop in just a few minutes,
but you are willing to graciously take some of our questions.
In order to be mindful of your schedule, we will reduce the
time that each member has to 2 minutes. That means short
questions and allowing the time for answers.
You have taken bold action here in Arizona. We appropriated
$4 billion this year at the Federal level. What else can the
Federal Government do in order to support your efforts in
Arizona?
Governor Ducey. I am proud of the efforts that we were able
to take in the State of Arizona on a bipartisan level in terms
of urgency and action and thoughtfulness and thoroughness on
the opioid epidemic. I do think a wide open and unprotected
border is a reality in this State, and law enforcement efforts
in coordination, along with health care professionals and
prescribers who understand this epidemic and the scourge that
we are fighting in the State, will help us continue to improve
not only for Arizona but for the rest of the United States,
which is where many of these drugs are transported through our
State, unfortunately.
Ms. McSally. Great. Thanks.
I am going to yield back for time.
The Chair now recognizes the acting Ranking Member, Mr.
Grijalva.
Mr. Grijalva. Thank you very much.
Thank you, Mr. Governor, for being here, appreciate it very
much.
The point of security that you made, and I noted in my
opening statement that the overwhelming majority of seizures of
opioids entering this country illegally happen at the ports of
entry. There has been a persistent issue, especially in Tucson
and the other ports of entry, a persistent issue of
understaffing, a persistent issue of infrastructure and
technology not being up-to-date, efforts time and time again.
As part of the security umbrella that you mentioned in your
talk, where do you see ports of entry in this fight?
Governor Ducey. Mr. Grijalva, I agree with you. I think
this is an all-of-the-above solution that we need to bring to
this. So it is not only the ports of entry and the brave men
and women who wear the blue shirts in our Federal Government,
it is also the border agents and the people that wear the green
shirts.
You are talking about the amount of drugs that are seized
at the ports of entry, and that is a fact. But what we don't
know are about the drugs that are not seized and that are
getting to our cities and streets and high schools across the
country. Those are ones that are somehow either evading the
technology that is at the ports of entry, or it is coming
through the border.
So I would be for an all-of-the-above approach in terms of
law enforcement.
Mr. Grijalva. I yield back, Madam Chair.
Ms. McSally. The gentleman yields back.
The Chair now recognizes Mr. Schweikert for 2 minutes.
Mr. Schweikert. Governor Ducey, I always have to break the
habit of not calling you Doug.
Look, your office has always been incredibly good reaching
out to ours when we are working on the reimbursements, the
mechanisms, the prior authorization, and we appreciate that
because it is complicated, and for a lot of us here, my hunger
is for a holistic approach. Yes, there is a problem on the
border. Yes, there is a health care problem. There is a problem
with the mail. How do we get our heads around something that is
this complicated?
You said something that both brings me joy but I would love
to understand. You were saying that in the beginning of this
year, in a couple of those months, you were seeing almost a
one-third fall. I know a couple of months is really hard to get
data from, but do you have a perception of what are we doing
right to actually create that one-third fall, and how do we do
more of it?
Governor Ducey. Thank you, Mr. Schweikert.
Mr. Schweikert. You can call me David.
Governor Ducey. The same temptation, David.
I think this idea of our State legislature taking action on
this, the people that you will hear after me who will provide
testimony focusing on this epidemic, and understanding that
these drugs, for someone who is in chronic pain, these can be a
miracle solution. But the way that they were being distributed,
the way that they were being sold, the way that they were being
prescribed provided a tremendous problem in our State.
One thing I want to give credit to is to Secretary Jeh
Johnson, because it was that cooperation that we saw when
Arizona hosted the Super Bowl in 2015 that we could work
together in partnership with the Federal Department of Homeland
Security, and I want to credit President Trump and Secretary
Nielsen, who is working with Colonel Frank Milstead, our border
sheriffs and sheriffs across the State, along with local law
enforcement.
I do think this is a holistic solution that we have to come
at from a standpoint of not only the rule of law, but then the
best medical practices in how we handle these prescription
drugs, and other drugs. I know that fentanyl was mentioned. The
rise and spike in heroin is a result of this opioid epidemic.
So this is an all-hands-on-deck. It is not just for border
States, because it may be border States where these drugs come
through, but they are being distributed all across our Nation.
Mr. Schweikert. Governor, forgive me. It is the tyranny of
the clock.
I yield back.
Ms. McSally. The gentleman's time has expired.
The Chair now recognizes Ms. Sinema for 2 minutes.
Ms. Sinema. Thank you.
Governor Ducey, as you know, Medicaid ensures access to
treatment and recovery services for 4 in 10 adults suffering
from opioid addiction in Arizona. It is one of the reasons I
voted against bills that threaten Medicaid benefits that more
than 400,000 Arizonans count on via our AHCCCS program.
Could you tell us about the role that AHCCCS plays in your
State-wide plan to ensure that Arizonans have access to the
services and treatment that they need?
Governor Ducey. Thank you, Ms. Sinema. Of course, AHCCCS in
Arizona is a safety net for those that need it most and the
most vulnerable, but it is not just about Medicaid. As I
mentioned, we added $10 million to help those that the
Affordable Care Act left behind, those that were uninsured or
underinsured; also with providing dollars for those that need
health care inside of our prisons.
I am concerned with what is happening with the Affordable
Care Act from the standpoint of providers that are in the State
of Arizona. If we were to go back a decade ago, we would have
had 24 providers available in our 15 counties. Today we have
one provider available in 14 of our 15 counties. So this is
something that I will challenge Congress to act on. It is
something that as a Governor and as an AHCCCS department and a
department of health services, we will be a partner in
reforming what is necessary for access to affordable and
accessible health care in Arizona.
Ms. Sinema. Thank you.
Ms. McSally. The gentle lady yields back.
The Chair now recognizes Ms. Lesko for 2 minutes.
Ms. Lesko. Thank you, Madam Chair.
Thank you, Governor Ducey. I had the privilege of serving
with the Governor while I was in the State legislature, and I
was on the health committee, so we actually got to listen to
testimony on this very important issue of opiate addiction. I
applaud you and the State legislature for your work on this. It
is very important, a very devastating problem in Arizona and
throughout our country.
I know that, if my memory serves me correctly, in the
Senate Health Committee, one of the things that we did in the
legislature and that you promoted was having pharmacists check
a registry of sorts to make sure that the patient wasn't
getting over-prescribed with opiates. I think, if I remember,
it was a balancing act of not over-regulating pharmacists and
doctors and that type of thing.
Can you update us on what transpired on that and what the
success has been with that program?
Governor Ducey. Sure. Thank you, Ms. Lesko. We miss you
very much in the Arizona State legislature, but Arizona's loss
has been our United States Congress' gain.
This focus on the use of technology has reduced doctor
shopping. This was what was happening oftentimes with people
that were addicted, and this is a different type of drug
because it is found behind the pharmacy window.
The addition of the red caps that are there so that people
understand that this is a medicine to be taken seriously,
should not be available to children or left in medicine
cabinets. I think while it has only been a few months, the
trend is incredibly positive, and it is a result of these
actions.
You will also have some experts that will follow me--
Director Cara Christ, Debbie Moak--that helped put these
regulations in place that would allow us to provide the best
possible health care, but to protect Arizonans' health and
safety. To lose 800 Arizonans in the last 16 months, those were
avoidable deaths, far too many. Then Tim Roemer will also be
testifying from a law enforcement perspective, and I do think
it is that partnership of health care and law enforcement that
can best address this epidemic to our country.
Ms. Sinema. Thank you.
I yield back.
Ms. McSally. The gentle lady's time has expired.
The Chair now recognizes Mr. Gallego for 2 minutes.
Mr. Gallego. Thank you, Madam Chair.
Governor, it is good to see you again.
Definitely one of my proudest moments was working with
Governor Brewer and other Republicans to pass Medicaid
expansion, something that I think has been beneficial to this
State, especially our critical care hospitals in urban areas,
as well as our rural areas, which also are being harder hit
when it comes to the opioid epidemic.
What we have heard so far is that we need a whole
Government approach to this. But at the same time, the actions
of the Arizona government and some of your proposals are
actually to diminish Medicaid expansion and try to get people
off Medicaid when we just heard that many of them actually end
up using Medicaid to deal with their addiction.
So what I am kind of trying to bring together is how can we
fight opioid addiction, how can Arizona take it seriously while
at the same time we are taking efforts to gut Medicaid?
I will give you a good example. One of the efforts that you
are pushing is to deal with the retrospective Medicaid
eligibility, RME, specifically if you are Medicaid-eligible and
you go to a hospital, that hospital will not only treat you
that day, make you Medicaid-eligible, you go back 3 months
beyond that to actually be able to bring in funds for any type
of fees that you incurred in the hospital, which is very
important, as you know, for a lot of these rural hospitals. But
under your proposal, you have actually asked to get rid of
that.
So how are you balancing this out? Make me understand, if
we are really serious about the opioid addiction on the
enforcement side, how come we aren't actually dealing with it
on the Medicaid side? Bring this all together.
Governor Ducey. Well, I don't think these two issues are
mutually exclusive. I think when you talk about the reform of
Medicaid, I have been outspoken that I don't want to see any
Arizonan have the rug pulled out from underneath them.
Now, I expressed the very real issue that we only have one
provider in 14 of our 15 counties in the State of Arizona.
Mr. Gallego. That is ACA. Medicaid has nothing to do with
that. Medicaid is separate from ACA.
Governor Ducey. When we are trying to move people off of
Medicaid into work and private insurance, I think that is a
preferable structure when it can be done. We have had a growing
economy here in the State of Arizona, so we have tried to put
policies forward that would incent people to take employment so
that they could have private insurance, and we will continue to
do that.
Ms. McSally. The gentleman's time has expired.
Mr. Gallego. Thank you.
Ms. McSally. I thank the Governor for his testimony and the
Members for their questions. The Members of the committee may
have some additional questions for the witnesses. We would ask
that you respond to these in writing.
With that, I will dismiss this first panel.
We will quickly take a recess. I request the Clerk prepare
the witness table for the second panel.
[Recess.]
Ms. McSally. Our first witness is Mr. Guadalupe Ramirez,
who is the acting director of field operations for U.S. Customs
and Border Protection in the Tucson Field Office. Previously he
served as the assistant director of field operations trade, and
oversaw cargo and agricultural operations within the Tucson
Field Office. The Tucson Field Office annually collects $30
million in revenues and processes 380,000 commercial trucks
that transport $20 billion in trade.
Scott Brown is a special agent in charge of Homeland
Security Investigations, or HSI, in Arizona. Mr. Brown has
oversight of the full spectrum of Immigration and Customs
Enforcement, or ICE, investigative activities in the State of
Arizona. He has more than 500 personnel assigned to offices in
Phoenix, Tucson, Douglas, Nogales, Yuma, Costa Grande, and
Flagstaff.
Doug Coleman is the special agent in charge of the DEA's
Phoenix Field Division. In this position, Special Agent Coleman
is responsible for the leadership and management of all DEA
operations in the State of Arizona. A 27-year veteran of the
DEA, Special Agent Coleman began his law enforcement career in
1988.
Mr. Tim Roemer--did I pronounce that correctly? Tim Roemer
currently serves as the State of Arizona's deputy director of
homeland security and is Governor Ducey's public safety policy
advisor. Prior to joining Arizona Department of Homeland
Security, Mr. Roemer served in the Central Intelligence Agency
for over 10 years.
I now recognize Director Ramirez to testify.
STATEMENT OF GUADALUPE RAMIREZ, ACTING DIRECTOR OF FIELD
OPERATIONS, U.S. CUSTOMS AND BORDER PROTECTION--TUCSON, U.S.
DEPARTMENT OF HOMELAND SECURITY
Mr. Ramirez. Thank you, Chairwoman McSally, Ranking Member
Grijalva, and distinguished Members of the----
Ms. McSally. Can you pull the microphone a little closer so
we can hear? Thank you.
Mr. Ramirez. How about there?
Ms. McSally. Thank you.
Mr. Ramirez. Chairwoman McSally, Ranking Member Grijalva,
and distinguished Members, thank you for the opportunity to
appear today and discuss the role of U.S. Customs and Border
Protection, CBP, in combatting the flow of illicit opioids,
including synthetic opioids such as fentanyl, into the United
States.
My name is Guadalupe Ramirez. I am the acting director of
field operations for CBP's Office of Field Operations in
Tucson.
Since I began my career in Government in 1985, I have
worked to facilitate legitimate trade and travel and protect
our borders. In my more than 30 years of Federal service, I
have seen a great deal of change. I began serving in the Tucson
Field Office in 2009. Since then, I have seen a marked increase
in the volume and potency of drugs interdicted at the ports of
entry by CBP. I have seen interdictions of heroin,
methamphetamine, and fentanyl increase dramatically; 357
percent more heroin was seized in the Tucson Field Office ports
in 2017 than in fiscal year 2009. The number of heroin seizures
has increased five-fold since 2009.
In fiscal year 2009, there were 23 heroin seizures at the
Arizona ports, averaging 8.3 pounds each. In fiscal year 2017,
there were 114 heroin seizures, averaging 10.1 pounds each.
Today, heroin seizures are currently 28 percent ahead of last
year's pace. Seizures of fentanyl in 1 year increased 458
percent from 2016 to 2017.
In the land border environment, my area of experience,
smugglers use a wide variety of tactics and techniques to
conceal drugs. CBP officers regularly find drugs taped to
individuals' bodies, hidden inside vehicle seats, gas tanks,
tires, dashboards, as well as commingled in commercial
shipments and concealed in commercial conveyances.
Seizures like these often involve the use of technology,
canines, or both. CBP officers utilize non-intrusive inspection
equipment, NII, including Z-Portal, high-energy mobile, and
gamma ray imaging systems to detect the illegal transit of
synthetic drugs hidden in passenger vehicles, cargo containers,
and other conveyances entering the United States.
Canine operations are also an invaluable component of CBP's
counter-narcotics operations. For example, on May 1, 2018, a
CBP narcotics detection canine at Nogales, Arizona port of
entry alerted officers to almost 11 pounds of heroin wrapped
around the mid-section of an individual entering the United
States. The heroin had an estimated street value in excess of
$188,000. Officers seized the drugs and turned the arrested
subject over to Homeland Security Investigations.
We are also actively engaging with our Federal, State,
local, Tribal, and international partners to streamline our
counter-narcotics efforts. Tucson Field Office is actively
engaged with the Joint Port Enforcement Group alongside
Homeland Security Investigations to ensure higher rates of
contraband prosecution by assigning CBP officers to HSI to
assist with casework. By working together to respond to,
investigate, and prosecute illicit contraband seizures at the
Arizona ports of entry, prosecution rates have increased to 97
percent.
We are also working with the government of Mexico in
implementing unified cargo processing at commercial facilities
in Nogales, Douglas, and San Luis. This brought Customs
inspectors from Mexico into U.S. commercial facilities for
joint processing and joint inspection of cargo coming from
Mexico. Currently, 16 percent of all commercial cargo processed
at the Arizona ports of entry is tied to this program, with
expectations for increase. This has significantly changed cargo
processing and is considered a best practice along the
Southwest Border ports.
In coordination with our partnership, and with the support
of Congress, we will continue to refine and enhance the
effectiveness of our detection and interdiction capabilities to
prevent the entry of opioids and other illicit drugs into the
United States.
Chairwoman McSally, Ranking Member Grijalva, and
distinguished Members, thank you for the opportunity to testify
today. I look forward to your questions.
[The prepared statement of Mr. Ramirez follows:]
Prepared Statement of Guadalupe Ramirez
May 30, 2018
introduction
Chairwoman McSally, Ranking Member Vela, and distinguished Members
of the subcommittee, thank you for the opportunity to appear before you
today to discuss the role of U.S. Customs and Border Protection (CBP)
in combating the flow of dangerous opioids, including synthetic opioids
such as fentanyl and fentanyl analogues, into the United States. The
opioid crisis is one of the most important, complex, and difficult
challenges our Nation faces today, and President Trump ordered the
declaration of a National Public Health Emergency to address the opioid
crisis in October of last year.\1\
---------------------------------------------------------------------------
\1\ https://www.whitehouse.gov/briefings-statements/president-
donald-j-trump-taking-action-drug-addiction-opioid-crisis/.
---------------------------------------------------------------------------
As America's unified border agency, CBP plays a critical role in
preventing illicit narcotics, including opioids, from reaching the
American public. CBP leverages targeting and intelligence-driven
strategies, and works in close coordination with our partners as part
of our multi-layered, risk-based approach to enhance the security of
our borders and our country. This layered approach reduces our reliance
on any single point or program, and extends our zone of security
outward, ensuring our physical border is not the first or last line of
defense, but one of many.
opioid trends, interdictions, and challenges
In fiscal year 2018 to date, the efforts of Office of Field
Operations (OFO) and U.S. Border Patrol (USBP) personnel resulted in
the seizure of more than 545,000 lbs. of narcotics including over
38,000 lbs. of methamphetamine, over 35,000 lbs. of cocaine, and over
2,700 lbs. of heroin.\2\ CBP seizures of illicit fentanyl have
significantly increased from approximately 2 lbs. seized in fiscal year
2013 to approximately 1,131 lbs. seized by OFO and USBP in fiscal year
2017.\3\ Approximately 1,218 lbs. of illicit fentanyl have already been
seized in fiscal year 2018.\4\ Fentanyl is the most frequently seized
illicit synthetic opioid, but CBP has also encountered 18 fentanyl
analogues.\5\
---------------------------------------------------------------------------
\2\ https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics.
\3\ https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics.
\4\ https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics.
\5\ These include: acetylfentanyl, butyrylfentanyl, b-
hydroxythiofentanyl, a-methylacetylfentanyl, p-fluorobutyrylfentanyl,
p-fluorofentanyl, pentanoylfentanyl (a.k.a. valerylfentanyl), 2-
furanylfentanyl, p-fluoroisobutyrylfentanyl, n-hexanoylfentanyl,
carfentanil, benzodioxolefentanyl, acrylfentanyl, 2,2-
difluorofentanyl, methoxyacetylfentanyl, benzoylfentanyl,
cyclopropylfentanyl, and hydrocinnamoylfentanyl.
---------------------------------------------------------------------------
Illicit drug interdiction in the border environment is both
challenging and complex. Drug Trafficking Organizations (DTOs) and
Transnational Criminal Organizations (TCOs) continually adjust their
operations to circumvent detection and interdiction by law enforcement,
quickly taking advantage of technological and scientific advancements
and improving fabrication and concealment techniques.
DTOs seek to smuggle opioids, most commonly heroin, across our land
borders and into the United States at and between our Ports of Entry
(POEs), and Mexican manufacturers and traffickers continue to be major
suppliers of heroin to the United States.\6\ The reach and influence of
Mexican cartels, notably the Sinaloa, Gulf, and Jalisco New Generation
Cartels, stretch across and beyond the Southwest Border, operating
through loose business ties with smaller organizations in communities
across the United States. The threat of these cartels is dynamic; rival
organizations are constantly vying for control, and as U.S. and Mexican
anti-drug efforts disrupt criminal networks, new groups arise and form
new alliances.
---------------------------------------------------------------------------
\6\ Heroin is also sometimes transported by couriers on commercial
airlines. Heroin intercepted in the international commercial air travel
environment is from South America, Southwest Asia, and Southeast Asia.
---------------------------------------------------------------------------
Smugglers use a wide variety of tactics and techniques for
concealing drugs. CBP officers regularly find drugs concealed in body
cavities, taped to bodies, hidden inside vehicle seat cushions, gas
tanks, dashboards, tires, packaged food, household and hygiene
products, in checked luggage, and concealed in construction materials
on commercial trucks. For example, during the weekend of May 4, 2018
CBP officers at Arizona's San Luis POE arrested two individuals in
connection to separate failed drug smuggling attempts in personal
vehicles. In the first case, CBP seized approximately 113 lbs. of
methamphetamine, worth nearly $338,000, and approximately 5 lbs. of
heroin, worth more than $86,000, which the officers discovered hidden
throughout the vehicle. During a second vehicle inspection, CBP
officers discovered nearly 35 lbs. of methamphetamine, worth almost
$105,000, concealed in the vehicle's seats and rear door. CBP officers
turned the drugs, vehicles, and arrested subjects over to U.S.
Immigration and Customs Enforcement--Homeland Security Investigations
(ICE-HSI).\7\
---------------------------------------------------------------------------
\7\ https://www.cbp.gov/newsroom/local-media-release/san-luis-cbp-
officers-seize-529k-meth-and-heroin.
---------------------------------------------------------------------------
While most illicit drug smuggling attempts occur at Southwest land
POEs, the smuggling of illicit narcotics in the international mail and
express consignment courier (ECC) environments also poses a significant
threat. Illicit narcotics can be purchased from sellers through on-line
transactions and then shipped via the United States Postal Service
(USPS) or ECCs. DTOs and individual purchasers move drugs such as
illicit fentanyl and fentanyl analogues in small quantities, making
detection and targeting a significant challenge. However, these are
often significantly more potent and therefore more deadly than the
shipments seized along the border. Follow-on investigations, which are
conducted by ICE-HSI, are also challenging because these shippers are
often not the hierarchically structured DTOs we encounter in other
environments. To combat this threat, CBP operates within nine major
international mail facilities (IMF) inspecting international mail
arriving from more than 180 countries, as well as 25 ECC facilitates
located throughout the United States.
Between the POEs, DTOs and TCOs strategically send smugglers to
vulnerable spots along the Southwest Border with limited infrastructure
and technology to gain access into the illicit drug market. CBP plays a
key role in the DHS and U.S. Government strategy to combat TCOs at home
and with our international partners. We must combat these criminal and
drug trafficking organizations with a systematic approach to border
security. Our approach includes interagency coordination, legislative
reform, as well substantial investments in impedance and denial
capabilities, surveillance technology, access and mobility, mission
readiness, and personnel.
cbp resources and capabilities to detect, target, and interdict opioids
CBP, with the support of Congress, has made significant investments
and improvements in our drug detection and interdiction technology and
targeting capabilities. These resources, along with enhanced
information sharing and partnerships, are critical components of CBP's
ability to identify and deter the entry of dangerous illicit drugs in
all operational environments. Additionally, thanks to the support of
Congress, the International Narcotics Trafficking Emergency Response by
Detecting Incoming Contraband with Technology Act, or the INTERDICT
Act, authorized the appropriation of $9 million to CBP to ensure that
CBP has sufficient resources and personnel, including scientists and
chemical screening devices, to enhance CBP's drug interdiction mission
and provide for additional scientists to process lab tests
expeditiously.
Advance Information and Targeting
An important element of CBP's layered security strategy is
obtaining advance information to help identify shipments that are
potentially at a higher risk of containing contraband. Under section
343 of the Trade Act of 2002 (Pub. L. No. 107-210), as amended, and
under the Security and Accountability for Every Port Act or SAFE Port
Act of 2006, (Pub. L. No. 109-347), CBP has the legal authority to
collect key cargo data elements provided by air, sea, and land
commercial transport companies (carriers), including ECCs and
importers.\8\ This information is automatically inputted into CBP's
Automated Targeting System (ATS), a secure intranet-based enforcement
and decision support system that compares cargo and conveyance
information against intelligence and other enforcement data. CBP, in
conjuncture with our Federal and international partners, is working to
expand the availability of advanced electronic data (AED) to enhance
our targeting in the international mail environment as well.
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\8\ Under TSA requirements, inbound international mail destined for
the United States is treated similar to other cargo and subject to
security controls. These security controls, which include screening for
unauthorized explosive, incendiary, and other destructive substances or
items in accordance with TSA regulations and security program
requirements, are applied to international mail prior to transporting
on aircraft at Last Point of Departure locations to the United States.
49 U.S.C. 44901(a) states: ``The Under Secretary of Transportation for
Security shall provide for the screening of all passengers and
property, including United States mail, cargo, carry-on and checked
baggage, and other articles, that will be carried aboard a passenger
aircraft.'' Under 49 C.F.R. 1540.5, Cargo means property tendered for
air transportation accounted for on an air waybill. All accompanied
commercial courier consignments whether or not accounted for on an air
waybill, are also classified as cargo. Aircraft operator security
programs further define the terms ``cargo''. These requirements are not
dependent on advance electronic manifest data, as provided by ECC
operators and other participants in the Air Cargo Advance Screening
(ACAS) pilot program.
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At CBP's National Targeting Center (NTC), advance data and access
to law enforcement and intelligence records converge to facilitate the
targeting of travelers and items of cargo that pose the highest risk to
our security in all modes of inbound transportation. The NTC takes in
large amounts of data and uses sophisticated targeting tools and
subject-matter expertise to analyze, assess, and segment risk at every
stage in the cargo/shipment and travel life cycles. The NTC leverages
classified, law enforcement, commercial, and open-source information in
unique, proactive ways to identify high-risk travelers and shipments at
the earliest possible point prior to arrival in the United States.
To bolster its targeting mission, the dedicated men and women of
the NTC collaborate with critical partners on a daily basis including
ICE-HSI, the Drug Enforcement Administration (DEA), the Federal Bureau
of Investigation (FBI), members of the intelligence community, and the
United States Postal Inspection Service (USPIS). Investigative case
data is fused with CBP targeting information to bolster investigations
targeting illicit narcotics smuggling and trafficking organizations.
Moreover, NTC works in close coordination with several pertinent task
forces including the Organized Crime Drug Enforcement Task Force, the
High Intensity Drug Trafficking Areas, and the Joint Interagency Task
Force-West, as well as the Department of Homeland Security's (DHS)
Joint Task Forces (JTF).
Some of the precursor chemicals that can be used to synthesize
fentanyl and fentanyl analogues are currently non-regulated and many
have legitimate uses. However, CBP has sufficient authority to seize
precursors if they can be identified as having illicit end-use
intentions, including the production of illicit drugs. CBP targets
precursor chemicals transiting the United States with destinations to
Mexico and other countries. When these shipments are identified through
interagency collaboration as having illicit end-use intentions, the
shipments are offloaded for further inspection and enforcement action
by external agencies such as DEA and ICE-HSI.
In addition to targeting illicit substances directly, CBP also
targets related equipment such as pill presses and tablet machines. DEA
regulates pill press/tablet machines and there is an ICE Diversion
Coordinator assigned to the DEA Special Operations Division who
oversees the investigations of pill press and tablet machine imports
being diverted for illicit uses. The Diversion Coordinator works
closely with the NTC to identify and target individuals importing and
diverting pill presses and tablet machines to press fentanyl, fentanyl
analogues, and other synthetic drugs into counterfeit pills. In fiscal
year 2014, 24 seizures of pill presses and tablet machines were made by
OFO. The number increased to 92 in fiscal year 2017.
Non-Intrusive Inspection Equipment
At our POEs and in the international mail and express consignment
environments, CBP utilizes technology, such as non-intrusive inspection
(NII), X-ray, and gamma ray imaging systems to detect the illegal
transit of synthetic drugs hidden on people, in cargo containers, and
in other conveyances entering the United States. Since October 2010,
CBP has conducted more than 83 million NII examinations, resulting in
more than 18,500 narcotics seizures, and more than $79 million in
currency seizures. For example, on April 15, 2018 CBP officers at the
Veterans International Bridge in Brownsville, Texas utilized NII
technology to discover 12 lbs. of heroin and 1.3 lbs. of
methamphetamine in a personal vehicle. The combined estimated street
value of the narcotics from the seizure is $348,000. CBP officers
seized the narcotics along with the vehicle, arrested the driver, and
turned him over to the custody of ICE-HSI for further investigation.\9\
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\9\ https://www.cbp.gov/newsroom/local-media-release/brownsville-
port-entry-cbp-officers-seize-over-300k-heroin-and.
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CBP is committed to continuing to improve its ability to interdict
illicit narcotics and is currently joining with the DHS Science and
Technology Directorate (S&T) to evaluate existing detection solutions,
such as the Handheld Illicit Drug Explosives Trace Detector (HID-ETD)
and the X-ray imaging contract, and to develop advanced capabilities
through a prize challenge for inventors to create or modify existing
technology capable of accomplishing this.
Canines
Canine operations are an invaluable component of CBP's
counternarcotic operations. The CBP Canine Training Program maintains
the largest and most diverse law enforcement canine training program in
the country. At our Nation's POEs and at preclearance locations abroad,
CBP officers utilize specially-trained canines for the interdiction of
narcotics, firearms, and undeclared currency, as well as in support of
specialized programs aimed at combating terrorism and countering human
trafficking. Concealed Human and Narcotic Detection Canines are trained
to detect concealed humans and the odors of marijuana, cocaine, heroin,
methamphetamine, hashish, ecstasy, fentanyl, and fentanyl analogues.
The use of canines in the detection of narcotics is a team effort.
CBP's Laboratories and Scientific Services Directorate (LSSD) produces
canine training aids and provides analytical support to the CBP Canine
Training Program, including controlled substance purity determinations,
pseudo training aid quality analyses, and research on delivery
mechanisms that maximize safe vapor delivery during training exercises.
Most recently, OFO's National Canine Program, in coordination with
LSSD, assessed the feasibility of safely and effectively adding
fentanyl as a trained odor to deployed narcotic detection canine teams.
On June 23, 2017, the Office of Training and Development's CBP Canine
Training Program successfully completed its first Fentanyl Detection
Pilot Course. This added the odor of fentanyl and fentanyl analogues to
6 OFO canine handler teams in the international mail and ECC
environments. Beginning October 1, 2018, all-new OFO canine handler
teams graduating from the CBP Canine Training Program will have
successfully completed a comprehensive CBP Canine Detection Team
Certification to include the odor of fentanyl and fentanyl analogues.
Today, all OFO Concealed Human and Narcotic Detection canine teams
across all of OFO's operational environments have completed fentanyl
training.
During fiscal year 2017, OFO canine teams were responsible for
$26,813,863 in seized property, $1,905,925 in fines, $36,675,546 in
seized currency, $29,674,839 in Financial Crimes Enforcement Network
(FINCEN) actions, 197 firearms and 22,356 rounds of ammunition, 79
concealed humans, and 384,251 lbs. of narcotics. In fiscal year 2018 to
date, OFO canine teams have been responsible for $7,322,522 seized
property, $411,073 in fines, $7,951,376 in seized currency, $9,178,971
in FINCEN actions, 150 firearms, 5,418 rounds of ammunition, 105
concealed humans, and 187,409 lbs. of narcotics.\10\
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\10\ Effective 4/24/18.
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For example, on May 1, 2018, a CBP Concealed Human and Narcotic
Detection canine at the Nogales, Arizona POE alerted officers to almost
11 lbs. of heroin wrapped around the midsection of an individual
entering the United States. The heroin had an estimated street value in
excess of $188,000. Officers seized the drugs, and turned the arrested
subject over to ICE-HSI.\11\
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\11\ https://www.cbp.gov/newsroom/local-media-release/nogales-cbp-
officers-seize-188k-heroin.
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Laboratory Testing
As the narcotics seized through the international mail and at ECC
facilities usually have a very high purity, CBP officers at IMFs and
ECC facilities use various field testing devices to rapidly screen
suspected controlled substances and obtain presumptive results. Using
CBP's LSSD Field Triage Reachback Program, CBP officers can transmit
sample data directly to LSSD for scientific interpretation and
identification. When any synthetic opioids are detected by the
Reachback program, LSSD notifies key CBP personnel at the NTC, as well
as our liaisons at DEA. CBP is working to expand the field testing
program, along with the scientific assets and personnel who are able to
provide real-time chemical composition determinations.
In 2016, a CBP pilot program tested four hand-held tools and a new
test kit to provide immediate presumptive testing for fentanyl. Based
on the results of the pilot, OFO procured 12 systems for further
testing across San Diego, Tucson, El Paso, and Laredo Field Offices.
Last year, CBP purchased over 90 handheld analyzers for deployment.
Handheld analyzers improve officer safety, and provides a near-real
time capability to increase narcotic interdiction.
information sharing and operational coordination
Substantive and timely horizontal and vertical information sharing
is critical to targeting and interdicting illicit drugs. CBP works
extensively with our Federal, State, local, Tribal, and international
partners and provides critical capabilities toward the whole-of-
Government approach to address drug trafficking and other transnational
threats at POEs, in our IMFs and ECCs, and along the Southwest Border,
Northern Border, and coastal approaches. Our targeting, detection, and
interdiction efforts are enhanced through special joint operations and
task forces conducted under the auspices of multi-agency enforcement
teams that target drug and transnational criminal activity, including
investigations involving National security and organized crime.
Additionally, CBP hosts monthly briefings/teleconferences with
Federal, State, and local partners regarding the current state of the
border--the Northern Border and Southwest Border--to monitor emerging
trends and threats and provide a cross-component, multi-agency venue
for discussing trends and threats. The monthly briefings focus on
drugs, weapons, and currency interdictions and alien apprehensions both
at and between the POEs. These briefings/teleconferences currently
include participants from: The government of Canada; the government of
Mexico; ICE, U.S. Coast Guard (USCG); DEA; FBI; U.S. Northern Command;
Joint Interagency Task Force-South; Bureau of Alcohol, Tobacco,
Firearms, and Explosives (ATF); U.S. Attorneys' Offices; Naval
Investigative Command; State and Major Urban Area Fusion Centers; and
other international, Federal, State, and local law enforcement as
appropriate.
CBP is a critical member in the S&T-led interagency Illicit Drug
Detection Working Group. This Working Group assists in coordinating
communications between various Government stakeholders inside and
outside of DHS, including four other DHS components, the Department of
Defense, DEA, and the Department of Justice (DOJ), on synthetic opioid
information, such as seizure and profile data, and approaches for
detection and best practices for safe handling. The Working Group, with
the specific support of the National Institute of Standards and
Technology, is also working on the development of detection standards
for illicit drugs to allow the consistent test and evaluation of
detection equipment and inform protocols for operational use. Further,
these illicit drug detection standards generated by the Working Group
will guide industry in their development of detection equipment that
will meet the operational needs of DHS.
CBP is a key participant in the implementation of the Office of
National Drug Control Policy's (ONDCP) Heroin Availability Reduction
Plan (HARP). CBP also utilizes the DOJ's Nation-wide Deconfliction
System operated by DEA, conducting interagency deconfliction and
coordination, and is working with the Heroin and Fentanyl Working Group
at the DEA Special Operations Division, alongside ICE-HSI.
Collaboration with our partners yields results. For example, the
Chicago Field Office Tactical Analytical Unit initiated ``Operation Mad
Dog'' in February 2017 to target international mail shipments suspected
of containing illicit fentanyl and refer those shipments to law
enforcement partners across the country--including ICE-HSI and State,
local, and Tribal partners--for action. Targeted suspect shipments were
intercepted and examined in IMFs based on information provided by our
law enforcement partners and the NTC, as well as open-source
information. Controlled deliveries have resulted in 37 arrests.
Successes attributed to this operation to-date also include the seizure
of over 57 lbs. of fentanyl, firearms, cash and crypto-currency, and
the disruption of a major domestic dark web distributor of illicit
fentanyl.
International Collaboration and Cooperation
USPS receives international mail from more than 180 countries. The
vast majority of this mail arrives via commercial air or surface
transportation. An increasing number of foreign postal operators
provide AED to USPS, which is then passed on to CBP. CBP is working to
expand the availability of AED globally to enhance the security of the
international mail. For international mail arriving from foreign postal
operators who do not provide AED, CBP officers utilize experience and
training to identify items that potentially pose a risk to homeland
security and public safety, while facilitating the movement of
legitimate mail. CBP and USPS now have an operational AED targeting
program at five of our main IMFs with plans for further expansion. USPS
is responsible for locating the shipments and delivering them to CBP
for examination. Thus far in fiscal year 2018, CBP has interdicted 186
shipments of fentanyl at the John F. Kennedy International Airport
(JFK) IMF, a participant in the AED program. One hundred and twenty-
five of those interdictions can be attributed to AED targeting. CBP and
USPS continue to work with foreign postal operators to highlight the
benefits of transmitting AED.
CBP, in close coordination with USPS and U.S. Food and Drug
Administration, provided technical assistance on the ``Synthetics
Trafficking and Overdose Prevention (STOP) Act'', which were largely
incorporated into the pending ``Securing the International Mail Against
Opioids Act of 2018'', which was recently reported favorably by the
House Committee on Ways and Means. This legislation seeks to address
these challenges in a multi-phase process which emphasizes risk-
assessment, technology, and collaboration across the Federal Government
and with our international partners. We support efforts to expand the
ability of USPS to greatly increase the availability of AED (which is
the foundation of a sound targeting mechanism) for international mail,
to develop new scanning technology, and to collect fees to help cover
the cost of customs processing of certain inbound mail items.
Because DTOs are also known to use legitimate commercial modes of
travel and transport to smuggle drugs and other illicit goods, CBP
partners with the private sector to provide anti-drug smuggling
training to air, sea, and land commercial transport companies
(carriers) to assist CBP with stopping the flow of illicit drugs; to
deter smugglers from using commercial carriers to smuggle drugs; and to
provide carriers with the incentive to improve their security and their
drug smuggling awareness. Participating carriers sign agreements
stating that the carrier will exercise the highest degree of care and
diligence in securing their facilities and conveyances, while CBP
agrees to conduct site surveys, make recommendations, and provide
training.
The trafficking of synthetic opioids like fentanyl and fentanyl
analogues is a global problem, and CBP continues to work with our
international partners to share information and leverage resources to
combat this threat. CBP's Office of International Affairs International
Technical Assistance Division (INA/ITAD) conducts International Border
Interdiction training, coordinated and funded by the Department of
State, for various countries world-wide. These courses provide
instruction on multiple aspects of border security, including targeting
and risk management, interdiction, smuggling, search methodologies,
analysis, canine enforcement, and narcotics detection identification.
INA/ITAD has conducted anti-smuggling training in opiate source
countries such as Panama, Guatemala, Colombia, Ecuador, Peru, Mexico,
Indonesia, India, Thailand, Afghanistan, Kenya, Cambodia, and the
Philippines. CBP also provides an Identification of Drugs and Precursor
Chemical training course to Mexico and other drug source and transit
countries to provide important insight to foreign Customs Officers on
the vast resources of precursors available to narcotics producers and
traffickers world-wide.
Through the 21st Century Border Management Initiative, the U.S.
Government and the government of Mexico are working to strengthen our
collaborative relationship and efforts to secure and facilitate the
cross-border flows of people and cargo. We receive information from
Mexican authorities on a daily basis that helps us better target drug
smugglers at the border and continue to work closely to expand joint
efforts to combat illicit drug cultivation, production, and
trafficking, and sharing more information on smuggling routes and
networks. This information sharing, facilitated by the CBP attache
office in Mexico, has allowed for an unprecedented exchange of real-
time information through deployments of personnel between our
countries. Today, CBP personnel are assigned to Mexico City under the
Joint Security Program where we exchange alerts on suspicious DTO
movements through the monitoring of our Advance Passenger Information
System. This information sharing has also led to numerous seizures and
cases within Mexico that serve to disrupt the activities of DTOs
throughout the Western Hemisphere.
conclusion
In coordination with our partners and with the support of Congress
CBP will continue to refine and enhance the effectiveness of our
detection and interdiction capabilities to prevent the entry of opioids
and other illicit drugs into the United States, including strengthening
our ability to detect and interdict drugs entering via the mail and
express consignment systems. Chairwoman McSally, Ranking Member Vela,
and distinguished Members of the subcommittee, thank you for the
opportunity to testify today. I look forward to your questions.
Ms. McSally. Thank you, Mr. Ramirez.
The Chair now recognizes Mr. Brown to testify for 5
minutes.
STATEMENT OF A. SCOTT BROWN, SPECIAL AGENT IN CHARGE, HOMELAND
SECURITY INVESTIGATIONS--PHOENIX, U.S. DEPARTMENT OF HOMELAND
SECURITY
Mr. Brown. Good morning, Chairwoman McSally, attendees from
the Arizona congressional delegation. Thank you for the
opportunity to appear before you today to discuss the opioid
crisis in the United States, particularly along the border here
in Arizona, and the efforts of U.S. Immigration and Customs
Enforcement to target, investigate, disrupt, dismantle, and
bring to justice the criminal elements responsible for the
manufacturing, smuggling, and distribution of dangerous
opioids.
As the largest investigative agency within the U.S.
Department of Homeland Security, or DHS, ICE Homeland Security
Investigations, or HSI, investigates and enforces more than 400
Federal criminal statutes. HSI special agents use their broad
authority to investigate all kinds of cross-border criminal
activity and work in close collaboration with U.S. Customs and
Border Protection and the Drug Enforcement Administration in a
unified effort with both domestic and international law
enforcement partners to target transnational criminal
organizations, or TCOs, that are supplying illicit substances
to the United States.
Today I would like to highlight our efforts to reduce the
supply of illicit opioids such as heroin and fentanyl from
coming into the United States along the Southwest Border in
Arizona and the operational challenges we encounter.
The United States is in the midst of an opioid epidemic
that is being fueled by the smuggling and trafficking of heroin
and illicit fentanyl. Based on our investigative efforts, U.S.
law enforcement has identified China and Mexico as primary
sources of the U.S. illicit opioid threat.
Illicit fentanyl, fentanyl analogues, and their immediate
precursors are most often produced in China. From China, these
substances are shipped primarily through mail carriers directly
to the United States or are alternatively shipped directly to
the TCOs in Mexico.
Once in the Western Hemisphere, often in Mexico, fentanyl
or its analogues are mixed with other narcotics and fillers
and/or pressed into pill form, then moved to the illicit U.S.
market where demand for prescription opioids and heroin remain
at epidemic levels.
Mexican cartels have seized upon the profit potential of
opioids, including synthetic opioids, and seem to have invested
in growing their share of this illicit market. We are even
seeing an increased number of instances in which precursors
originating in China and smuggled into the United States have
traveled through the United States, destined for the Southwest
Border locations to include here in Arizona. The Mexican
cartels then attempt to smuggle the precursors out of the
United States, allowing them to synthesize them into fentanyl
in Mexico, with the intent to smuggle the finished product back
into the United States for distribution and consumption. The
final product is sold as heroin or as a prescription opioid,
and the end-user may not be aware of the presence of fentanyl.
The vast majority of heroin and fentanyl entering and
transiting Arizona is smuggled across the shared border with
Mexico via the land border ports of entry. Like other narcotics
supplied by Mexico, heroin and fentanyl are often smuggled
utilizing deep concealment in passenger vehicles as the TCOs
exploit the high volume of legitimate cross-border traffic at
our ports of entry as part of the concealment of their
smuggling efforts. Heroin and fentanyl loads are also smuggled
by pedestrians into the U.S. ports of entry, often concealed on
their person or in their bags or backpacks.
Almost all the Mexico-sourced drugs entering the United
States via the border in Arizona can be attributed to the
Sinaloa Cartel. HSI continues to investigate and identify the
leadership of the Sinaloa Cartel and attack the critical
organizational nodes of smuggling facilitators and financial
networks that sustain their operations. It is imperative that
we continue to focus our efforts on disrupting and dismantling
the Sinaloa Cartel, which not only smuggles opioids but other
narcotics like methamphetamine and cocaine that also have a
devastating impact on our communities.
HSI has made significant strides in fiscal year 2017 in
combatting the fentanyl epidemic in the United States as
evidenced by a 400 percent increase in fentanyl-related
seizures. However, even with these advances, there is no single
solution or Government entity that can stop the flow of
dangerous and illicit opioids like fentanyl into the United
States or keep them from harming the American public. Tackling
this complex threat involves a united, comprehensive, and
aggressive approach across law enforcement in collaboration
with experts in the medical, science, and public health
communities.
HSI will continue to work with our Federal, State, local,
and Tribal partners to improve the efficiency of information
sharing and operational coordination to address the challenges
and threats posed by illicit narcotics smuggling into the
United States.
Thank you for the opportunity to appear before you today. I
will answer any questions you have.
[The prepared statement of Mr. Brown follows:]
Prepared Statement of A. Scott Brown
May 30, 2018
Chairman McSally, Ranking Member Vela, and distinguished Members:
Thank you for the opportunity to appear before you today to discuss the
opioid crisis in the United States, particularly along the border here
in Arizona, and the efforts of U.S. Immigration and Customs Enforcement
(ICE) to target, investigate, disrupt, and dismantle the criminal
networks responsible for the manufacturing, smuggling, and distribution
of dangerous opioids.
As the largest investigative agency within the U.S. Department of
Homeland Security (DHS), ICE Homeland Security Investigations (HSI)
enforces more than 400 Federal criminal statutes to include the
Immigration and Nationality Act under (Title 8), U.S. Customs laws
under (Title 19), general Federal crimes under (Title 18), and the
Controlled Substances Act under (Title 21). HSI Special Agents use this
authority to investigate all types of cross-border criminal activity
and work in close coordination with U.S. Customs and Border Protection
(CBP), the Drug Enforcement Administration (DEA), the United States
Postal Inspection Service (USPIS) and our State, local, Tribal and
international partners in a unified effort, to target the Transnational
Criminal Organizations (TCOs) that are supplying illicit substances, to
include opioids, to the United States.
Today, I would like to highlight our efforts to reduce the supply
of illicit opioids, such as heroin, fentanyl, and fentanyl analogues
from coming into the United States along the Southwest Border in
Arizona and the operational challenges we encounter.
introduction to illicit opioid smuggling
The United States is in the midst of an opioid epidemic that is
being fueled by the smuggling and trafficking of heroin, illicit
fentanyl, and fentanyl analogues. Based on investigative efforts,
United States law enforcement has identified China and Mexico as
primary sources of the U.S. illicit fentanyl threat.
Illicit fentanyl, fentanyl analogues, and their immediate
precursors are most often produced in China. From China, these
substances are shipped primarily through international mail or express
consignment carriers (such as DHL, FedEx, or UPS) directly to the
United States or, alternatively, shipped directly, via express
consignment, postal or commercial carriers to TCOs in Mexico. Once in
the Western Hemisphere, fentanyl or fentanyl analogues are prepared and
mixed with other narcotics and fillers and/or pressed into pill form,
and then moved to the illicit U.S. market where demand for prescription
opioids and heroin remain at epidemic levels. In some cases, regional
distributors smuggle industrial pill presses and components into the
United States to operate fentanyl tableting operations domestically.
Mexican cartels have seized upon the profit potential of synthetic
opioids, and seem to have invested in growing their share of this
illicit market. Low cost coupled with high potency (one kilogram of
fentanyl can be purchased in China for $3,000-$5,000) can generate
upwards of $1.5 million in revenue on the illicit market. We are now
seeing instances in which precursors originating in China and smuggled
into the United States have traveled through the United States,
destined for the Southwest Border locations, to include Arizona. The
Mexican cartels have then smuggled the precursors out of the United
States, synthesize them into fentanyl, and imported the finished
product back into the United States for distribution and consumption.
The final product may be advertised as heroin, and the end-user may not
be aware of the presence of fentanyl.
illicit opioid shipments via international mail and express consignment
facilities
Though fentanyl seizures made at land border ports of entry are
higher in number and larger in volume, the fentanyl seizures from mail
and express consignment carrier (ECC) facilities are much higher in
purity. Laboratory results of tested fentanyl has identified that the
majority of illicit fentanyl seized in the international mail and ECC
environments is shipped in concentrations of over 90 percent, whereas
the majority of fentanyl in the land border port of entry environment
is seized in concentrations of less than 10 percent. Illicit opioids
like fentanyl can be purchased easily through open source and dark web
marketplaces.
Just as TCOs attempt to hide illicit smuggling attempts at the land
border ports of entry by blending into the voluminous daily legitimate
cross-border traffic, TCOs are exploiting the great volumes of mail and
parcels entering and crossing the United States as a means to conceal
their criminal activity. In an effort to combat opioid trafficking
through the mail and express consignments, HSI is targeting supply
chain networks, coordinating with domestic and international partners,
and providing field training to highlight officer safety, trends, and
collaboration benefits with partners such as CBP, DEA, and the USPIS.
In April 2017, CBP officers assigned to an express consignment
facility in Memphis, Tennessee intercepted a parcel from China found to
contain more than two kilograms of a white powder, which after lab
testing was found to be the fentanyl precursor 4-ANPP. The parcel was
destined for a warehouse in Nogales, Arizona. The CBP officers
coordinated with HSI special agents assigned to the Memphis Border
Enforcement Security Task Force (BEST), who in turn coordinated with
HSI Nogales to conduct a controlled delivery of the parcel. Through its
investigative efforts, HSI Nogales identified the unwitting courier
hired to pick up the parcel, and developed significant information
about the organization in Mexico that was coordinating the smuggling
effort. While this investigation is on-going, the intelligence
developed from interviewing the courier about his likely conspirators
has permitted HSI to impede operation of a precursor pipeline feeding
fentanyl production in Mexico.
HSI is fully engaged with the DEA Special Operations Division (SOD)
and the CBP National Targeting Center (NTC) to identify shipment routes
and to target parcels that may contain illicit opioids and
manufacturing materials. Full financial and investigative analyses are
also conducted. While this is a good start, we recognize much more
needs to be done.
Recognizing the need for greater action, HSI, CBP, and the USPIS
are collaborating in the development of a more robust, Nation-wide
effort to interdict illicit opioids transiting through mail facilities
including by obtaining advanced data to improve our targeting. HSI is
expanding the number of its trained investigators assigned to
international mail facilities. These additional investigators will be
seeking to conduct long-term, complex, criminal investigations into
opioid trafficking activities, with the goal of achieving additional
significant seizures and arrests. These seizures and arrests will help
disrupt the movement of illicit opioids and opioid precursors
transiting through the mail and ECCs, and will aid in the dismantling
of distribution networks. The ultimate goal of course, is to reduce
overdose deaths in the United States.
smuggling of fentanyl and heroin across the arizona/mexico border
The vast majority of fentanyl and heroin entering or transiting
Arizona is smuggled across the shared border with Mexico via the land
border ports of entry. Like other narcotics supplied by Mexico, heroin
and fentanyl loads are often smuggled utilizing deep concealment within
passenger vehicles, as the TCOs exploit the high volume of cross-border
traffic at our ports of entry as part of their smuggling efforts.
Heroin and fentanyl loads are also smuggled by pedestrians entering the
United States at ports of entry, often concealed on their person, or in
their bags or backpacks.
Loaded vehicles often contain multiple types of illicit drugs,
which we refer to as ``poly loads'' or ``mixed loads''. It seems that
the traditional drug supplying organizations have diversified their
illicit product inventory to include increased amounts of heroin and
fentanyl while also continuing to source methamphetamine, cocaine, and
other drugs. HSI, as the investigative agency responsible for
investigating smuggling at the ports of entry, works closely with CBP
every day, to ensure that every smuggling incident is vigorously
investigated, and expanded to the networks behind the smuggling
attempt. Additionally, intelligence developed through HSI's
investigative efforts is shared with CBP to enhance and refine their
targeting and interdiction efforts at the ports of entry.
Almost all the Mexico-sourced drug supply entering the United
States via the border in Arizona can be attributed to the Sinaloa
Cartel. HSI continues to investigate and identify the leadership of the
Sinaloa Cartel and attack the critical organizational nodes of
smuggling facilitators and financial networks that sustain their
operations. However, every law enforcement success against the cartels
is challenged by the fact that the cartels are highly networked
organizations with built-in redundancies that adapt on a daily basis
based on their intelligence about U.S. border security and law
enforcement. Mexican cartels, notably the Sinaloa Cartels, stretch
across and beyond the Southwest Border, where they have strategically
situated people in cities across the United States who have established
networks and loose affiliations with smaller organizations for the
purpose of smuggling.
Our vigorous response to these threats must include increased
border security infrastructure, personnel, and technology; a system of
systems if you will. Effective physical barriers, advanced technology,
and strategic deployment of law enforcement personnel is essential, but
it should be bolstered by interior enforcement and administration of
our immigration laws in a manner that serves the National interest.
ice's collaborative lines of effort in arizona
There is no single entity or solution that can stop the flow of
dangerous illicit drugs such as fentanyl and fentanyl analogues into
the United States or keep them from harming the American public.
Tackling this complex threat involves a united, comprehensive strategy
and aggressive approach by multiple entities across all levels of
government. Therefore, ICE, through its investigative arm, HSI, has
long had inter-agency collaboration as one of its operational pillars.
Law enforcement partnerships in Arizona are strong, and all agencies
are committed to doing everything they can to defeat the heroin and
fentanyl crisis that is gripping our Nation. Through partnerships
across Arizona, across the Nation, and across the globe, HSI's
commitment to collaboration is having a significant and positive
impact.
Border Enforcement Security Taskforces (BESTs)
Border Enforcement Security Taskforces (BESTs) are DHS's primary
platform to investigate opioid smuggling domestically. ICE currently
operates BESTs in 62 locations throughout the United States. During
fiscal year 2017, the number of BESTs increased 30 percent in response
to the President's Executive Order 13773, Enforcing Federal Law with
Respect to Transnational Criminal Organizations and Preventing
International Trafficking. BESTs leverage the participation of more
than 1,000 Federal, State, local, Tribal, and foreign law enforcement
agents and officers representing over 100 law enforcement agencies to
target opioid smuggling. In Arizona, HSI oversees 7 BESTs, one in each
of all our front-line border offices: Douglas, Nogales, Sells, and
Yuma, as well as Tucson, Casa Grande, and Phoenix. BESTs not only
leverage the abilities and authorities of the participating agencies by
unifying all under a single DHS effort; but they also provide a common
case management and intelligence platform, which greatly increases the
speed, completeness, and transparency of investigative and intelligence
information sharing.
This level of information sharing is critical for combatting the
TCOs that smuggle fentanyl and other drugs across the Arizona Border
and distribute it in our heartland. The common case management and
intelligence platforms enable the information obtained from a port
seizure in Nogales, to be shared immediately with a BEST investigating
a transportation cell in Phoenix, and a BEST investigating at a
distribution network in Ohio.
So, to cite a real-world example, in support of an on-going
investigation of a Nogales Sonora-based cell of the Sinaloa Cartel that
smuggles opioids and other hard narcotics through the Nogales ports of
entry, HSI agents and Maricopa County Sheriff's Detectives were able to
identify a recipient of the narcotics in Phoenix. During a traffic
stop, the recipient was found to be in possession of 175 grams of
fentanyl in pill form. Agents were also able to detain a package the
recipient had dropped off at a post office, and working with U.S.
postal inspectors, obtained a search warrant for the package, which was
found to contain 1.3 kilograms of methamphetamine. HSI special agents
were able to immediately and effectively coordinate with their
counterparts in Little Rock, Arkansas, where the package was destined,
and ultimately effected the arrest of the intended recipient. Both
subjects have been charged Federally with Possession with Intent to
Distribute Narcotics and Conspiracy to Possess and Distribute
Narcotics.
Joint Port Enforcement Groups (JPEGs)
Across Arizona and now expanded across the Southwest Border, HSI
and CBP have formed collaborative partnerships designated as Joint Port
Enforcement Groups (JPEG) to more effectively address smuggling, to
include opioid smuggling, at the ports of entry, while addressing
staffing challenges and breaking down historical stovepipes. Under HSI
supervision, CBP officers and Border Patrol agents have been trained on
port response investigations. This ensures, particularly at remote
ports of entry, that investigative efforts are started promptly, and
information is shared quickly. The JPEGs also ensure clear and
unfettered information sharing between ICE and CBP, breaking down
historical barriers between DHS component agencies. This dramatically
improves our ability to arrest and prosecute those who would attempt to
smuggle opioids or other contraband into the country, while freeing up
limited HSI resources to pursue more complex investigations targeting
the entire smuggling network.
High Intensity Drug Trafficking Areas (HIDTAs)
Created by Congress through the Anti-Drug Abuse Act of 1988, the
HIDTA program provides assistance to Federal, State, local, and Tribal
law enforcement agencies operating in areas determined to be critical
drug trafficking regions of the United States. The Office of National
Drug Control Policy administers the HIDTA program, providing funding
and working with Congress to designate localities eligible for the
program. Like the BESTs, the HIDTA Task Forces ensure that the concerns
of all the participating agencies, to include the State, local, and
Tribal agencies, are included in investigative priorities; which
certainly includes the impact of heroin and fentanyl on their
communities. HSI works very closely with all Arizona HIDTA member
agencies. In Nogales, HSI leads and houses the Santa Cruz County HIDTA
Investigative Task Force.
On the Tohono O'Odham Nation, HSI houses and predominantly staffs
the Native American Targeted Investigation of Violent Enterprises
(NATIVE) Task Force. The HIDTA and NATIVE task forces then apply the
full force of the participating agencies' authorities and abilities to
disrupt and dismantle the threat. In collaboration with Border Patrol,
and in close coordination with the U.S. Attorney's Office, the NATIVE
Task Force has led a multi-layered initiative to disrupt and dismantle
the extensive scouting and re-supply networks that have long enabled
prolific smuggling in Arizona's West Desert Region. For years, law
enforcement operating in the West Desert has been hampered by scouts
for the drug cartels who sit on the highpoints and relay law
enforcement movement to smuggling groups moving across the remote
terrain. Challenges have included bringing effective prosecutions to
the scouts, as they are geographically separate from the drugs they are
helping to smuggle. By employing a comprehensive strategy, that
identified and attacked the critical nodes that have made the West
Desert one of the Nation's most notorious smuggling corridors, these
on-going efforts have already resulted in a significant degradation to
operations of the Sinaloa Cartel in the area.
Joint Task Force--West Arizona Corridor
HSI is a critical participant in the Joint Task Force--West (JTF-
W)--to include in the Arizona Corridor. JTF-W is a collaborative effort
across DHS components in support of the DHS Secretary's Southern Border
and Approaches Campaign. In the Arizona Corridor, JTF-W conducts an
annual cross-component threat assessment to ensure that DHS is aligning
its resources and operating within a unity of effort to address cross-
border threats, to include heroin and fentanyl smuggling.
Alliance to Combat Transnational Threats
The Alliance to Combat Transnational Threats is similar to the JTF-
W, but expands the collaborative structure to include other Federal,
State, local, and Tribal partners. Through this forum, joint operations
to promote border security and counter the threat of smuggling are
prioritized and planned. Additionally, intelligence and best practices
are shared. One recent Unified Command meeting featured a presentation
on personal protective equipment and fentanyl testing procedures to
minimize the risk of exposure to fentanyl to law enforcement officers.
ice's use of collaboration centers outside of arizona to attack the
threat in arizona
National Targeting Center--Investigations (NTC-I)
ICE HSI participates at CBP's NTC program through the National
Targeting Center--Investigations (NTC-I), which leverages intelligence
gathered during HSI investigations and exploits it using CBP data sets
to target the flow of drugs into the United States. The NTC-I works to
share information between CBP and ICE HSI entities world-wide.
ICE HSI has assigned special agents to work within the NTC Cargo
(NTC-C) Narcotics Division. These special agents serve as liaisons
between the NTC and ICE HSI personnel in both domestic and
international posts. HSI investigative case data is fused with CBP
targeting information to bolster investigations targeting illicit
opioid smuggling and trafficking organizations. HSI and CBP in Arizona
share all heroin and fentanyl seizure data and intelligence with the
NTC to ensure the maximum exploitation of our combined efforts, more
complete targeting, and more robust and impactful investigations. HSI
in Arizona has consistently detailed special agents to the National
Targeting Center to assist in these efforts.
NTC-I conducts post-seizure analysis based on ICE seizures in the
field and CBP seizures at the ports of entry. The analysis is critical
to identifying networks that transport illicit opioids throughout the
United States. The resulting products are then shared with the affected
HSI offices in the form of investigative leads. Another key component
of the post-seizure analysis is the financial investigation. The NTC-I
focuses on the financial element of the smuggling organization by
exploiting information gathered from multiple financial databases.
Cyber Crimes Division
The ICE HSI Cyber Crimes Division provides support and assistance
to field cyber investigations targeting dark net illicit marketplaces,
where fentanyl and chemical precursors proliferate. This includes
support to active investigations in Arizona. Recognizing the need to
proactively target on-line opioid trafficking, the ICE HSI Cyber Crimes
Division is identifying on-going investigations and facilitating the
coordination of on-line and in-person undercover operations conducted
in furtherance of dark net illicit marketplaces.
As criminal activity, and especially the trade of illicit opioids,
continues to migrate to the on-line world, ICE HSI faces growing demand
for cyber investigative assistance. Through the Human Exploitation
Rescue Operative (HERO) program, the Cyber Crimes Division is training
former warfighters to continue their service to the Nation in the field
of computer forensics. HSI in Arizona currently has one HERO intern,
and has converted four former HERO interns, all of whom completed their
internships in Arizona, to full-time computer forensic agents to
bolster our ability to fight cyber-enabled crimes.
Special Operations Division (SOD)
The DEA's Special Operations Division (SOD) Heroin and Fentanyl
Task Force (HFTF) is supported by ICE, CBP, DEA, USPIS, and several
other Federal agencies. The SOD-led, interagency task force exploits
electronic communications to proactively identify, disrupt, and
dismantle the production, transportation, and financial networks behind
the heroin and illicit fentanyl distribution organizations that impact
the United States.
The HFTF focuses on the collaborative authorities and efforts of
each invested agency's resources, in order to better share and
deconflict information. The HFTF works together to target international
and domestic organizations by proactively working with field offices.
The task force also assists in coordinating and linking investigations
from the street-level dealer to the international supply source.
HSI in Arizona has consistently detailed special agents to SOD.
These special agents advance the mission of SOD through their unique
and in-depth knowledge of the Sinaloa Cartel. This expertise, honed
through their investigative experience in Arizona, combined with the
resources of SOD and the HFTF, contributes significantly to
investigations, not only by HSI, but by other agencies, in Arizona and
beyond.
Financial Division
Identifying, analyzing, and investigating the payment systems that
facilitate the purchase and smuggling of opioids is critical to the
disruption and dismantlement of networks that smuggle fentanyl and
other illicit opioids into the United States. ICE HSI conducts
proactive investigations that focus on the two key payment systems,
which support illicit procurement of opioids: Money service businesses
(MSBs) and cryptocurrencies. Generally, illicit opioids that are
purchased on the ``indexed'' internet are paid for through licensed
mainstream MSBs. On dark net marketplaces and other ``unindexed''
websites, purchases are often paid for with cryptocurrencies such as
Bitcoin. In support of its diverse financial investigative efforts, ICE
HSI uses undercover techniques to infiltrate and exploit peer-to-peer
cryptocurrency exchangers who typically launder proceeds for criminal
networks engaged in or supporting dark net marketplaces. Furthermore,
ICE HSI leverages complex Blockchain technology exploitation tools to
analyze the digital currency transactions and identify users. Several
HSI special agents assigned to Arizona have received Blockchain
technology training which gives them the tools necessary to pierce the
anonymity relied upon by dark net users.
ICE HSI created the Money Service Business Initiative to enable the
application of advanced data analytics across large amounts of MSB data
to isolate criminal networks, highlight suspicious transactions
indicative of illicit activity, and provide predictive intelligence.
The power of this type of advanced analytics truly shines when MSB data
is integrated with additional Government data holdings, open-source and
social media information, and communication records such as phone toll
records, internet protocol (IP) address activity records, email search
warrants, and Title III wire intercepts.
With support of its headquarters Financial Division and NTC, HSI in
Arizona regularly pursues complex investigations of the cartels'
exploitation of our legitimate financial systems, and the laundering
and movement of their illicit proceeds via trade-based money
laundering. Given the volume of legitimate trade between the United
States and Mexico that occurs in Arizona, the ability to launder funds
through the movement of goods versus dollars is a particular
vulnerability here. In a joint effort to combat this threat, on May 25,
2017, on behalf of ICE HSI, I entered into a Memorandum of
Understanding with the CBP Office of Field Operations, Tucson,
officially launching the Nation's first land border Trade Enforcement
Coordination Center in Nogales.
international collaboration
ICE HSI in Arizona recognizes that all of our investigations have
an international nexus. With ICE HSI's international presence of 67
offices in 50 countries, we are constantly looking to push our
investigations beyond our borders. In Arizona this means near-daily
collaboration with our ICE HSI attache and assistant attache offices in
Mexico. Through strategic and targeted intelligence sharing, and joint
investigative efforts, the impacts of our investigations are magnified.
Whether through bi-national operations to arrest cartel leadership, or
through sharing a piece of intelligence that may illuminate a
previously unknown network, the building and strengthening of these
partnerships is key to our efforts to combat the cartels and to stop
threats, to include illicit opioids, before they reach our borders.
conclusion
Thank you again for the opportunity to appear before you today and
for your continued support of ICE HSI and its law enforcement mission.
ICE HSI is committed to battling the U.S. opioid crisis. This includes
ICE HSI's collaborative efforts to reduce and ultimately stop the flow
of these dangerous drugs across the border here in Arizona and tackling
the significant challenges we see in increased smuggling through the
mail and express consignment systems. ICE HSI will continue to
vigorously pursue the cartels that bring not only heroin and fentanyl
to the United States, but other narcotics that have a dangerous, and
too often deadly, impact on our communities. The opioid crisis is an
epidemic that demands continued urgent and immediate action across law
enforcement agencies and in conjunction with experts in the scientific,
medical, and public health communities. I appreciate your interest in
this important issue and look forward to your questions.
Ms. McSally. Thank you, Mr. Brown.
The Chair now recognizes Mr. Coleman to testify for 5
minutes.
STATEMENT OF DOUGLAS W. COLEMAN, SPECIAL AGENT IN CHARGE,
PHOENIX FIELD DIVISION, DRUG ENFORCEMENT AGENCY, U.S.
DEPARTMENT OF JUSTICE
Mr. Coleman. Distinguished Members of the committee, on
behalf of Acting Administrator Patterson and the men and women
of the Drug Enforcement Administration, I appreciate your
invitation to testify today about the growing threat of opioid
trafficking across the Southwest Border and the impact that
these activities of narco-trafficking organizations are having
on Arizona.
For DEA, the opioid crisis is and unfortunately will
continue to be the top drug threat facing our Nation. This
epidemic includes not only prescription opioid medications but
also the proliferation of heroin, illicit fentanyl, and
fentanyl analogues. Despite record numbers of overdose deaths,
nearly 64,000 in 2016 alone, we are making progress on the
prescription drug front. However, we are witnessing a
fundamental shift toward cheaper, easier-to-obtain heroin and
illicit fentanyl and its related analogues.
Over the last few years, Mexican drug cartels have
exploited the increased demand for heroin and boosted their
heroin production, transportation, and trafficking operations
to get more heroin into the United States, predominantly across
the Southwest Border. In addition, Chinese manufacturers began
to produce fentanyl and fentanyl analogues and ship them to the
United States via mail, or to Mexico, to be mixed into the U.S.
domestic heroin supply, or pressed into a pill form and then
moved to the illicit U.S. market where demand for prescription
opioids and heroin remain at epidemic proportions.
More recently, Mexican DTOs are acquiring precursor
chemicals and manufacturing fentanyl and its analogues to
compete with the Chinese suppliers. The DEA in Arizona has been
at the forefront of recognizing and responding to this
increased heroin and fentanyl trafficking from the Mexican
cartels. The Sinaloa Cartel is the primary drug threat to
Arizona, as its organization influences and controls virtually
all transportation and entry point importation along the
Arizona-Mexico border. Additionally, the Sinaloa Cartel directs
command-and-control cells in Phoenix and Tucson who are the
choke points for both the drugs coming into the United States
and the illicit proceeds returning to Mexico.
DEA's Phoenix Field Division's response has been multi-
layered and comprehensive. No group in American law enforcement
knows the Sinaloa Cartel and their operations better than the
DEA in Arizona, and our strategy was developed based on this
long-term knowledge of how this organization operates.
The first pillar of the strategy involves increasing our
focus on the command-and-control cells operating in Phoenix and
Tucson. These cells are often difficult to penetrate and
require lengthy, complex investigations targeting communication
facilities and cartel members who direct operations throughout
the United States and coordinate with high-level cartel
leadership in Mexico.
Working with our State, local, Tribal, and Federal
partners, we have increased these types of complex conspiracy
investigations targeting opiate trafficking by more than 60
percent over the last 3 years, resulting in the arrests of
hundreds of high-level traffickers and the seizure of thousands
of pounds of heroin and fentanyl, as well as the disruption and
dismantlement of many of these cells.
The next pillar of our strategy was to increase our ability
to directly support State and local law enforcement efforts
targeting overdose deaths and community impact. To do this, we
created a Heroin Enforcement Action Team, or HEAT, to directly
respond to local area opioid-related overdoses, attempting to
expand overdose investigations to identify and target those
directly responsible for supplying heroin/fentanyl to the
overdose victims. By doing this, HEAT is a force multiplier to
any State and local heroin investigation and allows us to
target and bring to justice those individuals having the
greatest negative impact in the local community.
Since its inception, the HEAT team has expanded to include
relationships with over 40 governmental law enforcement
agencies in Arizona and has arrested and prosecuted many
individuals who were directly responsible for distributing
opioids resulting in overdoses. The HEAT has been an incredibly
beneficial program to local law enforcement, and we continue to
expand both its footprint and operations throughout the State.
The final pillar of our strategy involves a robust and
comprehensive public awareness and education campaign. In 2015
and 2017, we partnered with Arizona State University on two
``Hooked'' television specials about the dangers of heroin and
diverted controlled prescription drugs that reached over 2
million Arizonans. We also conducted over 135 community
outreach events over the past 3 years, educating thousands of
Arizona residents about the dangers of heroin and opioid abuse.
Finally, DEA officials have appeared on Arizona media--TV,
radio, and newspaper--over 100 times in the past 3 years
discussing the opioid addiction issue in a variety of forums.
While DEA in Arizona has a robust and comprehensive
strategy to combat opioid abuse and trafficking in our State,
we realize that our efforts, while having a significant impact
and many successes, must be maintained and expanded to continue
to best serve the citizens of Arizona and the United States.
Rest assured that the men and women of DEA in Arizona will
never relent, and we will continue to do everything in our
power to do our part to help end this deadly epidemic.
On behalf of DEA, I thank the committee for the opportunity
to speak today, and I am happy to answer any questions.
[The prepared statement of Mr. Coleman follows:]
Prepared Statement of Douglas W. Coleman
May 30, 2018
Chairman McSally, Ranking Member Vela, and Members of the
subcommittee, on behalf of the approximately 9,000 employees of the
Drug Enforcement Administration (DEA), thank you for the opportunity to
discuss the threat posed by the flow of heroin, fentanyl, and fentanyl
analogues across our borders, specifically in Arizona, and DEA's
efforts, along with our Federal, State, and local partners, to combat
this crisis.
Today, Mexican Transnational Criminal Organizations (TCOs) remain
the greatest criminal drug threat to the United States; no other group
can challenge them in the near term. These Mexican poly drug
organizations traffic heroin, fentanyl, fentanyl analogues,
methamphetamine, cocaine, and marijuana throughout the United States,
using well-established transportation routes and distribution networks.
They control drug trafficking across the Southwest Border (SWB) and are
moving to expand their share of distribution and sales in U.S. domestic
illicit drug markets, particularly heroin markets. At the same time, we
face significant challenges with the emergence of fentanyl being hidden
in the enormous volume of international parcel traffic by mail and
express consignment couriers.
Drug overdoses, suffered by family, friends, neighbors, and
colleagues, are now the leading cause of injury-related death in the
United States, eclipsing deaths from motor vehicle crashes or
firearms.\1\ According to the Centers for Disease Control and
Prevention (CDC), there were nearly 64,000 overdose deaths in 2016, or
approximately 174 per day. Over 42,200 (66 percent) of these deaths
involved opioids. The sharp increase in drug overdose deaths between
2015 to 2016 was fueled by a surge in fentanyl and fentanyl analogues
(synthetic opioids) involved overdoses.\2\ Maricopa County is the most
populated county in Arizona and encompasses the Phoenix metropolitan
area. The Maricopa County Office of the Medical Examiner (MCOME)
reported that in 2016 there were 647 overdose deaths while preliminary
reporting for 2017 reflects an increase of opioid-related drug overdose
deaths to 674. That number is expected to rise as toxicology reports
are retuned and investigations finalized.
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\1\ Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, & R. Matthew
Gladden. Increases in Drug and Opioid Overdose Deaths--United States,
2000-2014 Morbidity and Mortality Weekly Report, 2016;64:1378-1382.
\2\ CDC WONDER data, retrieved from the National Institute of
Health website; http://www.drugabuse.gov as reported on NIDA's website.
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The incidence of misuse of controlled prescription drugs (CPDs) and
the growing use of heroin, fentanyl, and fentanyl analogues are being
reported in the United States at unprecedented levels. According to the
Substance Abuse and Mental Health Services Administration (SAMHSA) 2016
National Survey on Drug Use and Health (NSDUH), an estimated 6.2
million people over the age of 12 misused psychotherapeutic drugs
(e.g., pain relievers, tranquilizers, stimulants, and sedatives) during
the past month.\3\ This represents 22 percent of the 28.6 million
current illicit drug users, and is second only to marijuana (24 million
users) in terms of usage.\4\ There are more current misusers of
psychotherapeutic drugs than current users of cocaine, heroin, and
hallucinogens combined.\5\
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\3\ Substance Abuse and Mental Health Services Administration.
(2017). Key substance use and mental health indicators in the United
States: Results from the 2016 National Survey on Drug Use and Health
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD:
Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
\4\ Substance Abuse and Mental Health Services Administration.
(2017). Key substance use and mental health indicators in the United
States: Results from the 2016 National Survey on Drug Use and Health
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD:
Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
\5\ Substance Abuse and Mental Health Services Administration.
(2017). Key substance use and mental health indicators in the United
States: Results from the 2016 National Survey on Drug Use and Health
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD:
Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
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The increase in the number of people using heroin in recent years--
from 373,000 past year users in 2007 to 948,000 in 2016--is
troubling.\6\ More alarming is the proliferation of illicit fentanyl
and fentanyl analogues. DEA investigations reveal that fentanyl and its
analogues are increasingly being added to heroin and frequently pressed
into counterfeit tablets resembling CPDs. Because of its high potency,
the more illicit fentanyl and fentanyl analogues are introduced to the
11.5 million people that misused a pain reliever in the previous year,
the more likely that drug overdoses will continue to climb.\7\ In
short, we are witnessing the transition from CPDs to heroin, fentanyl,
and fentanyl analogues as the primary killer and peril within the
opioid epidemic.
---------------------------------------------------------------------------
\6\ Center for Behavioral Health Statistics and Quality. (2017).
2016 National Survey on Drug Use and Health: Detailed Tables. Substance
Abuse and Mental Health Services Administration, Rockville, MD
\7\ Center for Behavioral Health Statistics and Quality. (2017).
2016 National Survey on Drug Use and Health: Detailed Tables. Substance
Abuse and Mental Health Services Administration, Rockville, MD
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DEA's focus is targeting the most significant, sophisticated, and
violent trafficking organizations that profit from exploiting persons
with substance use disorders. DEA's strategic priorities include
targeting Mexican Consolidated Priority Organization Targets (CPOTs)
and Priority Target Organizations (PTOs), which are the most
significant international and domestic drug trafficking and money-
laundering organizations.
controlled prescription drugs (cpds)
Black-market prices for sales of opioid CPDs are typically 5 to 10
times their retail value. DEA intelligence reveals the ``street'' cost
of prescription opioids steadily increases with the relative strength
of the drug. For example, hydrocodone combination products (a Schedule
II prescription drug and also the most prescribed CPD in the
country)\8\ can generally be purchased for $5 to $10 per tablet on the
street. Slightly stronger drugs like oxycodone combined with
acetaminophen (e.g., Percocet) can be purchased for $7 to $10 per
tablet on the street. Even stronger prescription drugs are sold for as
much as $1 per milligram (mg). For example, 30 mg oxycodone (immediate
release) and 30 mg oxymorphone (extended release) cost $30 to $40 per
tablet on the street. The costs that ensue with greater tolerance make
it difficult to purchase these drugs in order to support a developing
substance use disorder, particularly when many first obtain these drugs
for free from the family medicine cabinet or from friends.\9\
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\8\ On October 6, 2014, DEA published a final rule in the Federal
Register to move hydrocodone combination products from Schedule III to
Schedule II, as recommended by the Assistant Secretary for Health of
the U.S. Department of Health and Human Services.
\9\ Substance Abuse and Mental Health Services Administration.
(2017). Key substance use and mental health indicators in the United
States: Results from the 2016 National Survey on Drug Use and Health
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD:
Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
---------------------------------------------------------------------------
heroin
The vast majority of heroin consumed in the United States is
produced and distributed by powerful Mexico-based TCOs, such as the
Sinaloa Cartel and Jalisco New Generation Cartel, and transported to
the United States across the Southwest Border. These TCOs are extremely
dangerous, violent, and will continue to leverage established
transportation and distribution networks within the United States.
Not surprisingly, some people who misuse prescription opioids turn
to heroin. Heroin traffickers produce high purity white powder heroin
that costs approximately $10 per bag, and usually contains
approximately 0.30 grams per bag. This makes heroin significantly less
expensive than CPDs. Heroin produces a ``high'' similar to opioid CPDs,
and can keep some individuals who are dependent on opioids from
experiencing painful withdrawal symptoms. For some time now, law
enforcement agencies across the country have been specifically
reporting an increase in heroin use by those who began misusing
prescription opioids.\10\
---------------------------------------------------------------------------
\10\ U.S. Department of Justice, Drug Enforcement Administration,
2016 National Heroin Threat Assessment Summary, DEA Intelligence
Report, April 2016, available at: https://www.dea.gov/divisions/hq/
2016/hq062716_attach.pdf.
---------------------------------------------------------------------------
According to reporting by treatment providers, many individuals
with serious opioid use disorders will use whichever drug is cheaper
and/or available to them at the time.\11\ Heroin purity and dosage
amounts vary, and heroin is often adulterated with other substances
(e.g., fentanyl and fentanyl analogues). This means that heroin users
run a higher risk of unintentional overdose because they cannot predict
the dosage of synthetic opioid in the product they purchase on the
street as heroin.\12\ Additionally, varying concentrations found in
diverted or counterfeit prescription opioids purchased on the street
have led to increased unintentional drug overdose deaths. Roughly 75
percent of heroin users reported nonmedical use of prescription opioids
before initiating heroin use.\13\ The reasons an individual may shift
from one opioid to another vary, but today's heroin is high in purity,
less expensive, and often easier to obtain than illegal opioid CPDs.
---------------------------------------------------------------------------
\11\ U.S. Department of Justice, Drug Enforcement Administration,
2014 National Drug Threat Assessment Summary, November, 2014.
\12\ Stephen E. Lankenau, Michelle Teti, Karol Silva, Jennifer
Jackson Bloom, Alex Harocopos, and Meghan Treese, Initiation into
Prescription Opioid Misuse Among Young Injection Drug Users, Int J Drug
Policy, Author manuscript; available in PMC 2013 Jan 1, Published in
final edited form as: Int J Drug Policy, 2012 Jan; 23(1): 37-44.
Published on-line 2011 Jun 20. doi: 1016/j.drugpo.2011.05.014. and;
Mars SG, Bourgois P, Karandinos G, Montero F, Ciccarone D., ``Every
`Never' I Ever Said Came True'': Transitions From Opioid Pills to
Heroin Injecting, Int J Drug Policy, 2014 Mar; 25(2):257-66. doi:
110.1016/j.drugpo.2013.10.004. Epub 2013 Oct 19.
\13\ Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. (2014). The
changing face of heroin use in the United States: a retrospective
analysis of the past 50 years. JAMA Psychiatry.71(7):821-826.
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Overdose deaths involving heroin are increasing at an alarming
rate, having increased more than fivefold since 2010.\14\ Today's
retail-level heroin costs less and is more potent than the heroin DEA
encountered two decades ago. It is also not uncommon for heroin users
to seek out heroin dealers claim is ``hot,'' meaning it is likely cut
with fentanyl or its analogues. Users seeking ``hot'' heroin is an
indicator that as higher opioid tolerance levels develop, users will
seek out ever more potent forms of opioids.
---------------------------------------------------------------------------
\14\ CDC WONDER data accessed on 10/15/17, as reported at NIDA's
website: 3,036 heroin overdoses in 2010; 15,446 overdoses in 2016.
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-
death-rates.
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fentanyl and fentanyl analogues
Fentanyl is a Schedule II controlled substance produced in the
United States and widely used in medicine. It is an extremely potent
analgesic indicated for use anesthesia and pain control in people with
serious pain problems, and only for individuals who have high opioid
tolerance.
Illicit fentanyl, fentanyl analogues, and their immediate
precursors, are often produced in China. From China, these substances
are shipped through private couriers or mail carriers directly to the
United States, or alternatively shipped directly to TCOs in Mexico,
Canada, or the Caribbean. Once in the Western Hemisphere, fentanyl or
fentanyl analogues are prepared to be mixed into the U.S. domestic
heroin supply, or pressed into a pill form, and then moved to the
illicit U.S. market where demand for prescription opioids and heroin
remain at epidemic proportions. In some cases, traffickers set up
Chinese pill presses in the United States, and press fentanyl pills
domestically. Mexican TCOs have also seized upon this business
opportunity because of the profit potential of synthetic opioids, and
have invested in growing their share of this illicit market. Because of
its low dosage range and high potency, one kilogram of fentanyl
purchased in China for $3,000-$5,000 can generate upwards of $1.5
million in revenue on the illicit market.\15\
---------------------------------------------------------------------------
\15\ U.S. Department of Justice, Drug Enforcement Administration,
2017 National Drug Threat Assessment Summary, October 2017.
---------------------------------------------------------------------------
According to the DEA National Forensic Laboratory Information
System (NFLIS), from January 2013 through December 2016, over 58,000
fentanyl exhibits were identified by Federal, State, and local forensic
laboratories.\16\ During 2016, there were 36,061 fentanyl reports
compared to 1,042 reports in 2013,\17\ an exponential increase over the
past 4 years. The consequences of fentanyl misuse are often fatal and
occur amongst a diverse user base. According to a December 2017 CDC
Data Brief, from 2015 to 2016, the death rate from synthetic opioids
other than methadone, a category that includes fentanyl, doubled from
9,580 (age adjusted rate 3.1) to 19,413 (the age-adjusted rate of drug
overdose deaths involving synthetic opioids other than methadone [drugs
such as fentanyl, fentanyl analogs, and tramadol] doubled between 2015
and 2016, from 3.1 to 6.2 per 100,000).\18\
---------------------------------------------------------------------------
\16\ U.S. Department of Justice, DEA, NFLIS, actual data queried on
October 13, 2017.
\17\ U.S. Department of Justice, DEA, NFLIS, actual data queried on
October 13, 2017.
\18\ Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, & R. Matthew
Gladden, Hedegaard, H., Margaret Warner, and Arialdi M. Minio. Drug
Overdose Deaths in the United States, 1999-2016 Increases in Drug and
Opioid Overdose Deaths--United States, 2000-2014 Morbidity and
Mortality Weekly Report NCHS Data Brief, 2016; 64:1378-1382 No. 294,
Dec 2017. https://www.cdc.gov/nchs/data/databriefs/db294.pdf.
---------------------------------------------------------------------------
More disturbing is the production of fentanyl pills disguised as 30
milligram oxycodone pills. In 2017, over 100,000 such pills were seized
in Arizona.\19\ Alarmingly, intelligence reflects that traffickers may
be changing their methods and pressing fentanyl into the form of other
prescription drugs, as they have experienced success in disguising
fentanyl as oxycodone. Fentanyl-related deaths have been reported in
Florida where fentanyl was made to look like Xanax pills; and in
California, where pills were made to look like Norco.\20\ In addition
to the fake oxycodone pills, 22 kilograms of fentanyl were seized in
Arizona in calendar year 2016 and 125 kilograms were seized in calendar
year 2017.\21\ In July 2017, the first carfentanil seizure occurred in
Arizona, by the Salt River Police Department, where 397 blue tablets
were also designed to resemble pharmaceutically manufactured
oxycodone.\22\
---------------------------------------------------------------------------
\19\ EPIC National Seizure System.
\20\ DEA Intelligence Brief/(U//FOUO) Counterfeit Prescription
Pills Containing Fentanyls: A Global Threat--May 2016.
\21\ EPIC National Seizure System.
\22\ Joint Arizona HIDTAS/DEA Officer Safety/Situaltional Awareness
Report--First Carfentanil Seizure in Arizona--May 2018.
---------------------------------------------------------------------------
current assessment of the threat
Threats at the Southwest Border
Based on active law enforcement cases, the following Mexican TCOs
are operating in the United States: the Sinaloa Cartel, Beltran-Leyva
Organization (BLO), Jalisco New Generation Cartel (Cartel de Jalisco
Nueva Generacion or CJNG), the Los Cuinis, Gulf Cartel (Cartel del
Golfo or CDG), Juarez Cartel, La Linea, Michoacan Family (La Familia
Michoacana or LFM), Knights Templar (Los Caballeros Templarios or LCT),
and Los Zetas. While all of these Mexican TCOs transport wholesale
quantities of illicit drugs into the United States, the Sinaloa Cartel
remains the most active supplier and is the primary source for
wholesale traffickers impacting Arizona. The Sinaloa Cartel leverages
its expansive resources and organizational structure in Mexico to
facilitate the smuggling and transportation of drugs throughout the
United States.
Mexican TCO operations in the United States typically take the form
of a supply chain system that relies on compartmentalized operators who
are only aware of their own specific function, and who remain unaware
of other operational aspects. In most instances, transporters for the
drug shipments are independent third parties who work for more than one
Mexican TCO. Since operators in the supply chain are insulated from one
another, if a transporter is arrested, the transporter is easily
replaced and unable to reveal the rest of the network to law
enforcement.
The foundation of Mexican TCO operations in the United States is
comprised of extensive and well-entrenched transportation and
distribution networks based throughout the United States. Frequently,
members of Mexican TCOs are sent to important U.S. hub cities to manage
stash houses containing drug shipments and bulk cash drug proceeds.
While operating in the United States, Mexican TCOs actively seek to
maintain low profiles and avoid violent confrontations with other,
rival TCOs, or U.S. law enforcement.
Mexican TCOs transport illicit drugs over the SWB through ports of
entry (POE) using passenger vehicles or tractor-trailers. In Arizona,
the Nogales POEs are the primary entry points for heroin and fentanyl,
and along with other drugs, are typically secreted in hidden
compartments when transported in passenger vehicles, or comingled with
legitimate goods when transported in tractor-trailers. Once across the
SWB, Mexican TCOs will initially utilize stash houses in a number of
hub cities, including Dallas, Houston, Los Angeles, Atlanta, Phoenix,
and Tucson. The illicit products will then be transported via these
same conveyances to distribution groups in the Midwest and on the East
Coast. Mexican TCOs also smuggle illicit drugs across the SWB using
other methods, including tunnels, maritime conveyances, aircraft, and
body-carriers through pedestrian lanes at POEs.
Importation vs. Domestic Production and Use of the Internet
Fentanyl, fentanyl analogues, and other synthetics, are relatively
inexpensive, available via the internet, and are often manufactured in
China. From there, they may be shipped (via U.S. mail or express
consignment couriers) to the United States, or alternatively directly
to transnational criminal organizations in Mexico, Canada, and the
Caribbean. Once in the Western Hemisphere, fentanyl and fentanyl
analogues in particular are combined with both heroin or binders and
pressed into counterfeit pills made to look like controlled
prescription drugs containing oxycodone or hydrocodone, and then sold
on-line from anonymous dark net markets and even overtly operated
websites. The combination of: The questionable legal status of these
substances, which are not specifically named in the Controlled
Substances Act (CSA) itself or by DEA through scheduling actions; the
enormous volume of international parcel traffic by mail and express
consignment couriers; and the technological and logistical challenges
of detection and inspection, make it extremely challenging for the U.S.
Customs and Border Protection (CBP) to effectively address the threat
at ports of entry and pave the way for non-cartel-affiliated
individuals to undertake fentanyl trafficking. DEA is working with CBP
to increase coordination on seized parcels.
Use of Freight Forwarders
Traffickers often use freight forwarders to ship fentanyl, fentanyl
analogues, and other new psychoactive substances (NPS) from China.
Several DEA investigations have revealed that the original supplier
will provide the package to a freight forwarding company or individual,
who transfers it to another freight forwarder, who then takes custody
and presents the package to customs for export. The combination of a
chain of freight forwarders and multiple transfers of custody make it
difficult for law enforcement to track these packages. Often, the
package will intentionally have missing, incomplete, and/or inaccurate
information.
significant enforcement efforts
Heroin Fentanyl Task Force
The DEA Special Operations Division (SOD) Heroin/Fentanyl Task
Force (HFTF) working group consists of several agencies using a joint
``whole-of-Government'' approach to counter the fentanyl/opioid
epidemic in the United States. The HFTF consists of personnel from DEA,
U.S. Immigration and Customs Enforcement, Homeland Security
Investigations (HSI) and CBP; supplemented by the Federal Bureau of
Investigation and the U.S. Postal Inspection Service. HFTF utilizes
every resource available, including support from the Department of
Justice's Organized Crime Drug Enforcement Task Forces (OCDETF), OCDETF
Fusion Center (OFC), and the Criminal Division, the Department of
Defense (DOD), the intelligence community (IC), and other Government
entities, and provides field offices (all agencies) with valuable
support in their respective investigations.
The HFTF mission aims to:
Identify, target, and dismantle command-and-control networks
of national and international fentanyl and NPS trafficking
organizations.
Provide case coordination and de-confliction on all domestic
and foreign investigations to ensure that multi-jurisdictional,
multi-national, and multi-agency investigations and
prosecutions have the greatest impact on targeted
organizations.
Provide direct and dynamic operational and investigative
support for domestic and foreign field offices for all
agencies.
Identify new foreign and domestic trafficking,
manufacturing, importation, production, and financial trends
utilized by criminal enterprises.
Analyze raw intelligence and documented evidence from
multiple resources to develop actionable leads on viable
target(s) involved in possible illicit pill production and/or
distribution networks.
Educate overall awareness, handling, trafficking trends,
investigative techniques, and safety to domestic and foreign
field offices for all law enforcement, DOD, IC, and
Governmental agencies.
Facilitate, coordinate, and educate judicial districts
during prosecutions of fentanyl and other NPS-related cases.
Close interagency cooperation via the HFTF has led to several large
enforcement actions, including the first-ever indictment, in two
separate OCDETF cases, of two Chinese nationals responsible for the
manufacturing and distribution of illicit fentanyl in the United States
in October 2017. On October 17, the deputy attorney general and the DEA
acting administrator announced the indictments of the Chinese
nationals, who were the first manufacturers and distributors of
fentanyl and other opiate substances to be designated as CPOTs. CPOT
designations are of those who have ``command-and-control'' elements of
the most prolific international drug trafficking and money laundering
organizations operating in the world.
In addition, SOD's HFTF played an integral role in the July 2017
seizure and shutting down of the largest criminal marketplace on the
internet, AlphaBay. As outlined by the attorney general and the DEA
acting principal deputy administrator, AlphaBay operated for over 2
years on the dark web and was used to sell deadly illegal drugs, stolen
and fraudulent identification documents and access devices, counterfeit
goods, malware and other computer hacking tools, firearms, and toxic
chemicals throughout the world. The international operation to seize
AlphaBay's infrastructure was led by the United States and involved
cooperation and efforts by law enforcement authorities in Thailand, the
Netherlands, Lithuania, Canada, the United Kingdom, and France, as well
as the European law enforcement agency Europol. Multiple interagency
OCDETF investigations into AlphaBay revealed that numerous vendors,
including many in China, sold illicit fentanyl and heroin on the site,
and that there have been a substantial number of overdose deaths across
the country attributed to such purchases.
Cooperation with Mexico
DEA's presence in Mexico represents our largest international
footprint. The ability to have DEA special agents assigned to 11
different offices throughout Mexico is a reflection of the level of
cooperation that we continue to enjoy with our Mexican counterparts.
DEA supports bi-lateral investigations with the government of Mexico by
providing information and intelligence to develop investigations that
target leaders of TCOs throughout Mexico. The United States and Mexico
have established a strong and successful security partnership in the
last decade and, to that end, the U.S. Government stands ready to work
with our Mexican partners to provide any assistance, as requested, to
build upon these successes.
DEA Phoenix Field Division Response
DEA's Phoenix Field Division response has been multi-layered and
comprehensive. No group in American law enforcement knows the Sinaloa
Cartel and their operations better than DEA in Arizona, and our
strategy was developed based on this long-term knowledge of how this
organization operates.
The first pillar of the strategy involved increasing our focus on
the command-and-control cells operating in Phoenix and Tucson. These
cells are often difficult to penetrate and require lengthy, complex
investigations targeting communication facilities and cartel members
who direct operations throughout the United States and coordinate with
high-level cartel leadership in Mexico. Working with our State, local,
Tribal, and Federal partners, we have increased these complex
conspiracy investigations targeting opiate trafficking by more than 60
percent over the last 3 years, resulting in the arrest of hundreds of
high-level traffickers, the seizure of thousands of pounds of heroin
and fentanyl, and the disruption and dismantlement of many of these
cells.
The second pillar of the strategy is enhancing DEA's ability to
directly support Arizona State and local law enforcement efforts
targeting overdose deaths and community impact. In 2016, the DEA
Phoenix Field Division created the Heroin Enforcement Action Team
(HEAT) in response to the growing opioid epidemic in Arizona. HEAT is
an intelligence-driven enforcement approach partnered with our law
enforcement, first responders, community outreach programs, and State
health officials. DEA built a relationship with the Maricopa County
Office of the Medical Examiner to receive nearly real-time
investigative reports, leads, and statistics--information previously
collected, but rarely utilized. This information led HEAT intelligence
analysts to review overdose cases and then disseminate leads based on
objective enforcement criteria. Further, the HEAT program also
conducted overdose investigation training for our Task Force Officers
(TFOs) and their local departments, then used these TFOs as ``force
multipliers''--conduits for both potential cases and evidence
collection. For the first time in the Phoenix Division's history, DEA
investigators responded directly to heroin and fentanyl overdose scenes
in order to identify the source of supply. To date, DEA investigations
in Arizona have resulted in the Federal indictment of three subjects
for Distribution of a Controlled Substance Resulting in Death and
Serious Bodily Injury 21 USC 1A 841(a)(1) and 841(b)(1)(C), and one
plea to a State negligent homicide charge (ARS 13-1102) in Pima County.
In addition to the HEAT, DEA in Arizona hosts two Tactical
Diversion Squads (TDS) in Phoenix and Tucson. TDS investigate suspected
violations of the CSA and other Federal and State statutes pertaining
to the diversion of controlled substance pharmaceuticals and listed
chemicals. These unique groups combine the skill sets of special
agents, diversion investigators, and a variety of State and local law
enforcement agencies. They are dedicated solely toward investigating,
disrupting, and dismantling those individuals or organizations involved
in diversion schemes (e.g., ``doctor shoppers,'' prescription forgery
rings, and DEA registrants who knowingly divert controlled substance
pharmaceuticals). Between March 2011 and present, DEA increased the
number of operational tactical diversion squads (TDSs) from 37 to 77.
In addition, DEA established two mobile TDS that can deploy quickly to
``hot spots'' around the country in furtherance of the Diversion
Control Division's mission. Last year, the Phoenix TDS shut down two
pharmacies and arrested a pharmacist engaged in the distribution of
controlled substances,\23\ and the Tucson TDS, in partnership with the
Arizona Attorney General's Office, recently indicted a Tucson doctor on
26 State charges for unlawfully prescribing opioids.\24\
---------------------------------------------------------------------------
\23\ https://www.dea.gov/divisions/phx/2017/phx070717.shtml.
\24\ https://www.dea.gov/divisions/phx/2018/phx040518.shtml.
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Community Outreach
The final pillar of DEA's strategy in Arizona involves a robust and
comprehensive public awareness and education campaign. DEA and the
Southwest Border High Intensity Drug Trafficking Area (HIDTA)--Arizona
Region, joined efforts to organize the first Arizona Opioid Summit:
Turning the Tide in January 2017, followed by a second summit in
February 2018. The summits promoted the communication between
traditionally isolated professions and furthered the collaboration
between law enforcement, treatment, and prevention specialists. This
past February, DEA and HIDTA partnered with the Institute for the
Advancement of Behavioral Healthcare, who provided their National
expertise and sponsorship of an additional 2 days of educational
courses for medical professionals following the second summit. Over 400
law enforcement representatives, treatment and prevention specialists,
medical practitioners, and community advocates attended this year's
event. Additionally, the Phoenix Field Division has issued three alerts
to the media and the public regarding new trends observed by DEA in
Arizona,\25\ including warnings of the first overdose fatalities
attributed to the synthetic opioid U-47700, the prevalence of overdoses
attributed to blue fentanyl pills, and the first report of an overdose
death attributed to the powerful opioid carfetanil. These alerts were
significant in fostering communication with the community as citizens
themselves observe and subsequently report information to DEA's Tip
Line. Furthermore, DEA routinely engages with the media in an effort to
continue educating the public about the opioid crisis and its impact on
the State, as well as the Nation. DEA in Arizona has been featured in
over 100 media broadcasts related to the opioid crisis, most notably,
two 30-minute investigative reports regarding heroin and diverted CPDs
produced by Arizona State University's Walter Cronkite School of
Journalism and Mass Communication. In a unique collaboration with local
media entities, both reports, Hooked: Tracking Heroin's Hold on Arizona
and Hooked Rx: From Prescription to Addiction, aired commercial-free
and during prime time hours and reached over 2 million Arizonans.
---------------------------------------------------------------------------
\25\ https://www.dea.gov/divisions/phx/2017/phx011017.shtml,
https://www.dea.gov/divi- sions/phx/2017/phx032117.shtml, https://
www.dea.gov/divisions/phx/2018/phx041618.shtml.
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conclusion
Mexican TCOs remain the greatest criminal drug threat to the United
States. These Mexican poly drug organizations traffic heroin,
methamphetamine, fentanyl, cocaine, and marijuana throughout the United
States, using established transportation routes and distribution
networks. They control drug trafficking across the SWB and are moving
to expand their share of U.S. illicit drug markets. Their influence up
and down the supply chain, their ability to enter into new markets, and
associations with gangs, are of particular concern for DEA. DEA will
continue to address this threat domestically and abroad by attacking
the crime and violence perpetrated by the Mexican-based TCOs, which
have brought tremendous harm to our communities. In addition, DEA will
extend its on-going public awareness campaign about the dangers of
opioids and other drugs as part of its efforts to educate the community
and other stakeholders who combat, treat, or are otherwise affected by
this crisis every day. DEA will also work with our partners to address
the significant challenge presented by new trend of deadly synthetics
entering our country through the mail and express consignment systems.
Ms. McSally. Thank you, Mr. Coleman.
The Chair now recognizes Mr. Roemer for 5 minutes to
testify.
STATEMENT OF TIMOTHY ROEMER, DEPUTY DIRECTOR, DEPARTMENT OF
HOMELAND SECURITY, STATE OF ARIZONA
Mr. Roemer. Good morning, Chairwoman McSally, Ranking
Member Grijalva, Congressman Gallego, Congresswoman Lesko, and
Congressman Schweikert. Thank you for the opportunity to
testify today on Arizona's efforts to combat the opioid
epidemic and to combat illegal activity happening on our
Southern Border.
Illegal activity perpetrated across the Southern Border of
the United States infiltrates communities across Federal,
State, local, and Tribal jurisdictions, making it absolutely
necessary for law enforcement agencies at every level to work
together in order to stop these threats.
Arizona's border county sheriffs, police chiefs, and their
teams are on the front lines, protecting their communities
every day. No one knows the effects of transnational crime on
our citizens better than they do. They see the devastation of
human trafficking on victims and their families. They see the
destructive power that illegal drugs, overdoses, illegal
weapons, and ammunition have on human lives, and they are
dedicated to stopping it.
Formed in 2015, Arizona's Border Strike Force, led by the
Arizona Department of Public Safety, is truly unique in the
United States in that it harnesses the expertise and dedication
of our local law enforcement and combines it with the power of
the Federal Government to keep America safe. This team's intra-
agency collaboration is unparalleled, and they have results to
prove it.
No day or night is routine for this team, and I want to
share a little more of what they have been interdicting on our
behalf. A vehicle is stopped going north on I-17 and 5 pounds,
or almost 225,000 hits of heroin, are found concealed in the
spare tire. Yet another vehicle is stopped going westbound on
I-10. Indicators of criminal activity prove true when 6 pounds
of fentanyl are found wrapped in a gift bag.
To give you some perspective, a 2- to 3-milligram dose of
fentanyl is known to be lethal. So in that one car driving down
I-10 was enough to kill anywhere from 900,000 to over 1.3
million people. Those aren't even the large-scale operations
like Operation Cascabel One and Two that resulted in the
seizure of 131 pounds of meth, 12 pounds of cocaine, 618 pounds
of marijuana, and 32 stolen vehicles, along with the arrest of
39 felons.
I want to emphasize that we can quantify results in a
number of ways, but there is one metric we can't account for,
and that is the number of lives that have been saved. Every
human trafficker caught is one less wreaking havoc in the lives
of their victims. Every dose of narcotics seized is one less
destroying lives within our communities in Arizona.
We are saving lives because the Border Strike Force, and
our Federal partners across two Presidential administrations,
are taking the fight to heavily-armed drug cartels and those
who would do us harm.
Arizona is also doing more, in real time, to prevent deaths
from the scourge of opioid overdoses. Since Arizona's opioid
emergency was declared in June 2017, we have provided over
6,000 kits or more than 12,000 doses of the overdose reversal
drug Naloxone. This has been distributed to 63 law enforcement
agencies across our State.
Nearly 1,000 law enforcement officers have been trained to
recognize and treat an opioid overdose. These officers have
administered Naloxone to 364 individuals, all but 9 of whom
survived the immediate out-of-hospital event. Also since June,
approximately 84 percent of the suspected non-fatal overdoses
received Naloxone pre-hospital from EMS, law enforcement, or
community members.
In closing, I want to say thank you once again to our
Federal partners and everyone at the State, local, and Federal
levels who support our efforts. I am confident that as our
partnerships continue to grow in the form of information
sharing, manpower, and monetary support, more lives will be
saved, and we are grateful for that.
Thank you again for affording me the opportunity to testify
this morning.
[The prepared statement of Mr. Roemer follows:]
Prepared Statement of Timothy Roemer
May 30, 2018
Chairwoman McSally, Congressman Grijalva, distinguished Members of
the subcommittee, and other Members in attendance, good morning and
thank you for giving me the opportunity to testify on Arizona's efforts
to combat the opioid crisis and criminal activity across our Southern
Border.
Illegal activity perpetrated across the Southern Border of the
United States infiltrates communities across Federal, State, local, and
Tribal jurisdictions making it absolutely necessary for law enforcement
agencies at every level to work together in order to stop the threats.
Arizona's border county sheriffs, police chiefs, and their teams
are on the front lines, protecting their communities every day.
No one knows the effects of transnational crime on our citizens
better than they do.
They see the devastation of human trafficking on victims and their
families.
They see the destructive power that illegal drugs, overdoses,
illegal weapons, and ammunition have on human lives--and they are
dedicated to stopping it.
Formed in 2015, Arizona's Border Strike Force, led by the Arizona
Department of Public Safety is truly unique in the United States in
that it harnesses the expertise and dedication of our local law
enforcement and combines it with the power of the Federal Government to
keep America safe.
This team's intra-agency collaboration is unparalleled and they
have results to prove it.
No day or night is routine for this team, and I want to share a
little more of what they interdicting on our behalf: A vehicle is
stopped going north on I-17 and 5 pounds or almost 225,000 hits of
heroin are found concealed in the spare tire.
And yet another vehicle is stopped going west-bound on I-10.
Indicators of criminal activity prove true when 6 pounds of fentanyl
are found wrapped in a gift bag.
To give you some perspective, a 2-3 milligram dose of fentanyl is
known to be lethal. So in that one car driving down I-10 was enough to
potentially kill anywhere from 900,000 to over 1.3 million people.
And those aren't even the large-scale operations like Operation
Cascabel One and Two that resulted in the seizure of 131 pounds of
meth, 12 pounds of cocaine, 618 pounds of marijuana, and 32 stolen
vehicles along with the arrest of 39 felons.
I want to emphasize that we can quantify results in a number of
ways, but there's one metric we can't account for--and that's the
number of lives that have been saved.
Every human trafficker caught is one less wreaking havoc in the
lives of their victims.
Every dose of narcotics seized is one less destroying lives within
our communities.
We are saving lives, because the Border Strike Force, and our
Federal partners--across two Presidential administrations--are taking
the fight to heavily armed drug cartels and those who would do us harm.
Arizona is also doing more, in real time, to prevent deaths from
the scourge of opioid overdoses.
Since Arizona's opioid emergency was declared in June 2017, we have
provided over 6,000 kits or more than 12,000 doses of the overdose
reversal drug Naloxone to 63 law enforcement agencies across our State.
Nearly 1,000 law enforcement officers have been trained to
recognize and treat an opioid overdose. These officers have
administered naloxone to 364 individuals, all but 9 of whom survived
the immediate out-of-hospital event.
Also since June, approximately 84 percent of the suspected non-
fatal opioid overdoses received naloxone pre-hospital from EMS, law
enforcement, or community members.
In closing, I want to say thank you once again to our Federal
partners and everyone at the State, local, and Federal levels who
support our efforts.
I am confident that as our partnerships continue to grow in the
form of information sharing, manpower, and monetary support, more lives
will be saved--and we are grateful for that.
Thank you again for affording me the opportunity to testify this
morning.
Ms. McSally. Thank you, Mr. Roemer.
I now recognize myself for 5 minutes for questions.
Director Ramirez, the INTERDICT Act came out of our
committee and was signed into law in January, which provided
CBP $9 million to procure new opioid and other illicit
substance screening devices, lab equipment, facilities,
personnel, for all operational hours to expedite the testing of
suspected opioids seized at the border and ports of entry.
Have you seen any of that flow into Arizona yet and making
an impact at our ports of entry here?
Mr. Ramirez. Yes, ma'am, Chairwoman McSally.
Ms. McSally. Can you just speak up?
Mr. Ramirez. For some reason this mic really wants to be
very close to me.
We have. We have in a couple of areas. One of the biggest
concerns we have, as you know, with fentanyl, as deadly as it
is, is to ensure that as we dismantle vehicles and get the
narcotics and we test them, that we do not contaminate any of
our officers or the traveling public.
The technology that we are using, now thanks to the support
of Congress, is our testing equipment, which is basically
laser-based. Instead of having to take the narcotics and put it
into a little pouch, you have the Gemini system which will read
it, and we also have the glove boxes, which is a sealed
compartment where you put the narcotics in, and then you put
your hand in through gloves. It is completely sealed, and you
test the narcotics. That, along with X-ray equipment, which is
always welcome at the ports of entry, has been a great help.
Ms. McSally. Great. Thank you.
This whole panel is about the supply, the easy supply that
is out there for people to become addicted. Our next panel will
be talking more about a whole-of-society approach to address
some of the other root issues. But as we are looking to crack
down on the supply, is it fair to characterize it as efforts
have been made to crack down on the over-prescription and the
pill mills and those types of things?
You have people who are addicted that are now going on to
the illicit market because it is cheaper for them to get the
product they need to feed their addiction, and that is where
the dangers are increased because it can be laced with higher
doses than expected, or other drugs, and people are overdosing
and dying because they are being driven to the illicit market.
Is that a fair characterization of what has happened and our
level of awareness has gone up and how the dangers are
increasing? If anybody wants to answer.
Mr. Roemer. I believe so, if I may, Chairwoman. Four out of
every five new heroin users start addicted to a painkiller, a
prescription painkiller. So, as we have seen, as the Governor's
testimony and all the great efforts of the State of Arizona,
Dr. Cara Christ leading the Department of Health Services, as
we have seen those statistics plummet of the number of opioids
prescribed, that is going to make a huge dent in those new
heroin users.
Ms. McSally. Yes. Does anybody else want to comment on
that?
Mr. Coleman. I think you hit it right on the head. The
reality is that as we have seen our prescription drug epidemic
increase, the Mexican cartels, as they always do, have taken
advantage of the fact that we have so many. What has happened
is that the increased heroin has created more competition for
them, which has led to the increased production and
distribution of fentanyl to make a stronger product to compete
against each other to make sure they keep those repeat
customers.
Ms. McSally. OK, thanks.
So, we hear the number often that 90 percent of drugs that
come over the border come through the ports of entry. When we
are talking specifically about opioids, heroin, fentanyl, like
everything that is related to this crisis, I don't know who can
answer this, but do we have a percentage or understanding of
what is coming through the ports of entry and what is coming
through the mail from China?
Mr. Coleman. A difficult question to answer. The answer is
if I knew where all of it was coming from, I would seize all of
it.
Ms. McSally. From what we know, just what we know.
Mr. Coleman. What we know is that the reality is that most
of our large shipments of hard drugs are coming across the
border. We do see a significant portion coming through the mail
of the smaller quantities, especially when it comes to
fentanyl. So I don't know if there is a percentage we could put
on it. Ninety percent probably seems a little bit high, but
there is a very significant portion of it----
Ms. McSally. But of that coming across the border, what
number is coming through the ports of entry versus----
Mr. Coleman. For the hard drugs, it is probably 90 percent,
at least. But marijuana and softer drugs come through--they
walk across.
Ms. McSally. So the reality is, obviously, because it is
still so cheap on the streets, that a lot is getting through
that we are not detecting. What else can we do in order to be
able to detect it? We have some additional non-intrusive
inspection capabilities. Is there anything else, Mr. Ramirez,
that we can do? Because we are missing a lot of it, not related
to the professionalism of your teams here. It is just very
difficult to detect and intercept. So what else can be done?
Mr. Ramirez. I thank the continued support we have seen
from Congress. When it comes to staffing, thank you for your
support with the VRA. Staffing is a huge part of it,
infrastructure and technology. So the continued support in
those areas will absolutely help us dramatically in our efforts
at the ports of entry.
Ms. McSally. OK, great. I am going to yield back my 2
seconds.
The Chair now recognizes the Ranking Member, Acting Ranking
Member, Mr. Grijalva, for 5 minutes.
Mr. Grijalva. Thank you very much, Madam Chair.
Mr. Ramirez, following up on the Chair's question--if I
may, Madam Chair, if there is no objection, enter into the
record a statement by Mr. Anthony Reardon, National President,
National Treasury Employees Union, on the topic of this
hearing.
Ms. McSally. Without objection.
Mr. Grijalva. Thank you very much.
[The information follows:]
Statement of Anthony M. Reardon, National President, National Treasury
Employees Union
May 30, 2018
Chairman McSally, Ranking Member Vela, distinguished Members of the
subcommittee, thank you for the opportunity to provide this testimony
on the role of Customs and Border Protection (CBP) in addressing the
Nation's opioid crisis. As president ofthe National Treasury Employees
Union (NTEU), I have the honor of leading a union that represents over
25,000 CBP officers, agriculture specialists, and trade enforcement
specialists stationed at 328 land, sea, and air ports of entry across
the United States and 16 PreClearance stations.
Any discussion of the opioid crisis and the resources needed to
stop the movement of opioids across the border must include the role of
CBP officers at the ports of entry and the need to hire new CBP Office
of Field Operations (OFO) personnel. Between 2013 and 2017,
approximately 25,405 pounds, or 88 percent, of all international
arrivals of opioids, were seized by CBP officers at the ports of entry.
CBP OFO is the largest component of CBP responsible for border
security--including anti-terrorism, immigration, anti-smuggling, trade
compliance, and agriculture protection--while simultaneously
facilitating lawful trade and travel at U.S. ports ofentry that are
critical to our Nation's economy. CBP OFO has a current need to hire
2,516 additional CBP officers and 721 agriculture specialists to
achieve the staffing target as stipulated in CBP's own fiscal year 2018
Workload Staff Model (WSM) and Agriculture Resource Allocation Model
(AgRAM.) According to CBP's Congressional Affairs Office, as of May 4,
2018, CBP OFO has 23,147 CBP officers on-board at the ports of entry--
1,328 short of the authorized staffing level of 24,475.
Trade and travel volume continue to increase every year, but CBP
OFO staffing is not keeping pace with this increase. New and expanded
Federal inspection facilities are being built at the air, sea, and land
ports, yet CBP OFO staffing is not expanding. For example, in June, a
new Federal inspection terminal will open at the San Diego Airport.
Inspection volume will increase from 300 air passengers an hour to
1,000 air passengers an hour. Currently, there are a total of 53 front-
line officers split between the airport and seaport. CBP needs to hire
and assign an additional 38 officers to the airport alone to staff this
new inspection facility. At the San Ysidro land port, 12 new pedestrian
lanes and 8 new vehicle lanes come on line in June. There are no new
CBP officers assigned to this port and beginning on April 1, 2018, 150
CBP officers have been sent from other short-staffed ports to the
seriously short-staffed ports of Nogales and San Ysidro for 90-day
temporary duty assignments.
To address CBP OFO staffing shortages, and to address the expected,
ever-increasing volume of trade through the ports of entry in the
future, Ranking Member Vela and others recently introduced H.R. 4940,
the Border and Port Security Act, stand-alone, bipartisan legislation
that would authorize the hiring of 500 additional CBP officers, 100 CBP
agriculture specialists, and additional OFO trade operations staff
annually until the staffing gaps in CBP's various Workload Staffing
Models are met. NTEU strongly supports this CBP officer and agriculture
specialist--only staffing authorization bill and urges every Member of
Congress to support this bill.
NTEU also asks Committee Members to request from the House
Appropriations Committee up to $100 million in fiscal year 2019 direct
appropriations for the hiring of 500 CBP officers, 100 CBP agriculture
specialists, and additional needed non-uniformed Trade Operations and
support staff.
The President's fiscal year 2019 budget request does support the
hiring of new CBP officers to meet the current staffing need of 2,516,
but seeks to fund these new positions by increasing user fees. The
President's budget proposal only provides appropriated funding to hire
60 new CBP officer positions at the National Targeting Center. The
President's request seeks no appropriated funding to address the
current CBP officer staffing shortage of 2,516 additional CBP officers
as stipulated by CBP's own fiscal year WSM or to fund the additional
721 CBP agriculture specialists as stipulated by CBP's own fiscal year
2018 AgRAM.
User Fees.--As in the past, the administration's budget proposes
significant realignment of user fees collected by CBP. Currently, 33
percent of a CBP officer's compensation is funded with a combination of
user fees, reimbursable service agreements, and trust funds. The fiscal
year 2019 budget proposes to reduce OFO appropriated funding by
realigning and redirecting user fees, including redirecting the
Electronic System for Travel Authorization (ESTA) fee that would
require a statutory change. The fiscal year 2019 budget proposal would
redirect approximately $160 million in ESTA fees from Brand USA to CBP.
Rather than redirecting the ESTA fees to fund the additional 2,516 CBP
officer new hires needed to fully staff CBP officer positions in fiscal
year 2019 and beyond, as stipulated by CBP's WSM, the budget would in
fact reduce CBP's appropriated funding by $160 million. Therefore,
while the budget proposes to increase the number of CBP officer
positions funded by ESTA user fees by 1,093, it decreases appropriated
funding by $160 million, and reduces the number of CBP officer
positions funded by appropriations by 1,093 positions.
Once again, the President's budget includes CBP officer staffing
numbers that are dependent on Congress first enacting changes to
statutes that determine the amounts and disbursement of these user fee
collections. To accomplish the ESTA fee change in the President's
budget, Congress must amend the Travel Promotion Act of 2009 (Pub. L.
111-145). The President's request also proposes fee increases to the
Immigration and Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) user fees, not a direct up-front appropriation, to fund CBP
officer new hires as stipulated by the WSM. However, Immigration and
COBRA user fees cannot be increased without Congress first enacting
legislation. A proposal to increase user fees has been part of the
administration's annual budget submission since fiscal year 2014 to
fund the hiring of new CBP officers. These user fee increase proposals
are again in the fiscal year 2019 budget request, even though the
committees with jurisdiction have never shown any interest or even held
a hearing to discuss this long-standing legislative proposal, and the
administration has not pressed upon these committee chairs to do so.
Opioid Interdiction.--CBP OFO is the premier DHS component tasked
with stemming the Nation's opioid epidemic--a crisis that is getting
worse. In a report released on May 10, 2019, by the Senate Homeland
Security and Governmental Affairs Committee Minority titled
``Combatting the Opioid Epidemic: Intercepting Illicit Opioids at Ports
of Entry'', CBP officers at the ports of entry were found to ``play a
key role in stopping opioids and that CBP has significant shortages of
Port Officers that may be compromising efforts to seize additional
opioids before they can reach U.S. communities.''
The smuggling of fentanyl and other opioids has increased markedly.
According to the report, ``between 2013 and 2017, approximately 25,405
pounds, or 88 percent of all opioids seized by CBP, were seized at
ports of entry. The amount of fentanyl seized at the ports of entry
increased by 159 percent from 459 pounds in 2016 to 1,189 pounds in
2017.''
The scourge of synthetic opioid addiction is felt in every State
and is a threat to the Nation's economic security and well-being. The
majority of fentanyl is manufactured in other countries such as China,
and is smuggled primarily through the ports of entry along the
Southwest Border and through international mail and express consignment
carrier facilities (e.g. FedEx and UPS).
According to CBP, on March 24, 2018, CBP officers arrested an
individual at Arizona's San Luis port of entry after discovering 3.5
pounds of methamphetamine, worth nearly $11,000, wrapped around his
torso. Also, at San Luis, on April 27, 2018, a CBP canine team alerted
CBP officers to a vehicle that was found to have concealed within its
quarter panels more than 70 pounds of methamphetamine worth over
$210,000.
As the Senate report states, CBP officers are, ``in the majority of
cases, the last line of defense in preventing illicit opioids from
entering the United States . . . CBP's current shortage of over 4,000
port officers is directly influencing operations and staffing these
positions could increase CBP's ability to interdict opioids.''
Also, according to CBP, over the last 3 years, there were 181 CBP
employees assigned to the five Postal Service International Service
Centers and 208 CBP employees assigned to the Private Express Carrier
Facilities.
According to the report, on average, CBP officers only inspect 100
of the 1.3 million in-bound international packages that arrive daily by
international mail. In 2016, 65 million packages arrive via express
carriers, which are required by law to provide advanced electronic
data. However, this data can be incomplete. ``For example, from 2014
and 2016, CBP issued over 5,000 penalties for incomplete manifest
information and assessed over $26 million in fines. However, express
shippers successfully negotiated penalties down to just over $4
million.''
In the past year, the FedEx hub in Memphis processed 38 million
imports and 48 million exports--equaling 86 million in total package
volume. There are approximately 24 CBP officers in total screening all
86 million shipments, and on average, about 15 CBP officers are working
the main overnight FedEx ``sort'' shift. Considering the volume at the
FedEx hub, NTEU has been told that the port requires a minimum of 60
CBP officers to facilitate the flow of legitimate freight and ensure
successful interdiction of these synthetic chemicals. NTEU's CBP OFO
appropriation request supports both the critical need at the air, sea,
and land ports of entry, but also at international postal and express
consignment hubs.
Last, the Nation's busiest land port of entry San Diego, along with
the Tucson area land ports, account for ``57 percent of all opioids
seized by ports of entry, including 75 percent of all fentanyl and 61
percent of all heroin seized.'' These two land ports are also the most
critically understaffed. According to CBP, ``these long-term staffing
shortfalls continue to stretch the limits of operational, enforcement
and training capabilities at the ports of entry.'' To address these
shortfalls, CBP solicits non-supervisory officers to serve in Temporary
Duty (TDY) assignments. Since November 1, 2015 between 80 and 200 CBP
officers per quarter have been TDYed to the San Diego and Tucson land
ports. The continuing lack of CBP officer staffing at these ports of
entry results in forced overtime shifts, multiple deployments away from
home, and low morale.
Agriculture Specialist Staffing.--Despite CBP's release of its
risk-based AgRAM that documents an on-going shortage of CBP agriculture
specialists--by 721--at the ports of entry, the budget request includes
no direct appropriation to hire these critical positions needed to
fulfill CBP's agriculture quarantine inspection (AQI) mission of pest
exclusion and safeguarding U.S. agriculture and natural resources from
the risks associated with the entry, establishment, or spread of
animal, plant pests, and pathogens. NTEU's appropriations request
includes a direct appropriation to begin to hire the 721 agriculture
specialists as stipulated in their fiscal year 2018 AgRAM.
CBP Trade Operations Staffing.--CBP has a dual mission of
safeguarding our Nation's borders and ports as well as regulating and
facilitating international trade. CBP employees at the ports of entry
are the second-largest source of revenue collection for the U.S.
Government. In 2017, CBP processed more than $2 trillion in imports and
collected approximately $40 billion in duties, taxes, and other fees.
Since CBP was established in March 2003, however, there has been no
increase in non-uniformed CBP trade enforcement and compliance
personnel even though inbound trade volume grew by more than 24 percent
between fiscal year 2010 and fiscal year 2014. Additionally, CBP trade
operations staffing has fallen below the statutory floor set forth in
the Homeland Security Act of 2002 and stipulated in the fiscal year
2017 CBP Resource Optimization Model for Trade Positions. NTEU strongly
supports the funding through direct appropriations of 140 additional
positions at the CBP Office ofTrade to support implementation of the
Trade Enhancement and Facilitation Act (Pub. L. 114-125) requirements.
Hiring Contract.--A funding proposal of concern to NTEU is a $297
million contract that CBP recently awarded to Accenture Federal
Services ``to manage the full life cycle of the hiring process from job
posting to processing'' of 7,500 CBP Border Patrol, Air and Marine, and
OFO new hires. NTEU has seen reports that the 5-year contract cost is
approximately $39,600 per hire--nearly the same as the starting salary
of a CBP officer. NTEU strongly believes that these Federal funds would
be better spent actually hiring new CBP employees using CBP's in-house
human resources department rather than in contracting out to a private-
sector consultant ``to augment our internal hiring capabilities.''
The best recruiters are likely current CBP officers. Unfortunately,
morale continues to suffer because of staffing shortages and a
threatened pay freeze, and the administration's proposed cuts to
retirement, health care, and workers' compensation programs. In
addition to being overworked due to excessive overtime requirements,
temporary duty assignments are a major drag on employees, especially
those with families. Based on their experiences, many officers are
reluctant to encourage their family members or friends to seek
employment with CBP. I have suggested to CBP leadership that they look
at why this is the case.
NTEU strongly believes that addressing OFO hiring shortages by
funding needed new CBP officer and agriculture specialist to fill the
fiscal year staffing gap will do more to improve morale and encourage
peer-to-peer recruitment than funding a private contractor to help
recruit and hire new CBP employees.
Increasing CBP officer staffing at the ports-of-entry is an
economic driver for the U.S. economy. According to the Joint Economic
Committee (JEC), ``every day 1.1 million people and $5.9 billion in
goods legally enter and exit through the ports of entry'' and finds
that border delays cost the U.S. economy upwards of $5 billion each
year. CBP estimates that the annual hiring of an additional 500 CBP
officers at the ports of entry would increase yearly economic activity
by $1 billion and result in an additional 16,600 jobs per year to the
U.S. economy.
Thank you for the opportunity to submit this statement on the CBP
OFO resources needed to secure and protect the United States on behalf
of the men and women represented by NTEU at the Nation's ports of
entry. On behalf of our CBP members, NTEU requests are for Homeland
Security Committee Members to cosponsor the bipartisan CBP OFO staffing
authorization bill, H.R. 4940, and to ask the House Appropriations
Committee for $100 million in direct appropriated funding for new CBP
officers, agriculture specialists, and support staff to build on the
CBP OFO staffing advances made in the fiscal year 2018 Omnibus measure.
Mr. Grijalva. To address the CBP staffing shortages, and to
address the ever-increasing volume of activity at the ports of
entry, that involves also the economics of it, as you have
explained to me in terms of trade, import/export at the ports
of entry, not just now but in the future. Ranking Member Vela
from this committee introduced H.R. 4940, a bipartisan bill,
the Border and Port Security Act, that would authorize the
hiring of 500 additional CBP Customs officers, 100 CBP
agricultural specialists, and an additional Trade Operations
staff annually until you begin to close the staffing gaps at
the ports of entry.
Your reaction to that piece of legislation? Do you see that
as part of the deterrence that we are talking about today and
the seizures that we are talking about today?
Mr. Ramirez. Absolutely. That is welcome news, Congressman
Grijalva. When we talk about our complex jobs at the ports of
entry, as you know, it is a balance between facilitating
legitimate trade and travel and interdicting bad people and bad
things. So our job is to encourage travel and trade, not
discourage it.
So obviously, staffing is a big part of it. We have
implemented a huge recruitment effort in our agency where
basically every recruiter Nation-wide at this point is
recruiting for Arizona. Having those extra bodies allows us not
just to open additional lanes but to provide better service to
the traveling public and the trade community, and again operate
more of our canines, our X-rays, and have a stronger
enforcement posture at our ports of entry. So, thank you very
much.
Mr. Grijalva. Thank you.
Mr. Coleman, if I may, the process of coordination of all
these activities, interagency coordination, across
jurisdictions coordination, and with stakeholders in various
communities and others, I know it is rare but there are some
turf issues sometimes. It certainly doesn't happen with Members
of Congress----
[Laughter.]
Mr. Grijalva. But I am sure it is the same experience that
you have.
[Laughter.]
Mr. Coleman. Welcome to my district.
Mr. Grijalva. Tell me a little bit about the DEA, the
principal agency, but also Homeland Security now having broad
authority over the same subject. Tell me about that interagency
issue.
Mr. Coleman. I think that, having been a 30-year law
enforcement officer, I can tell you that--and I have worked all
over the country and the world--I think that the relationships
between Arizona law enforcement agencies at the Federal, State,
and local level is unprecedented in my career. While we
occasionally get into spats over issues, there is nothing that
we haven't been able to solve in the time I have been here,
which is 11 years now. Scott's people are integrated in my
offices, and my people are integrated in his offices. We work
very closely together. We are partners on many task force
groups. I have over 80 State and local officers assigned to my
task forces. He probably has a similar number. So our
integration is complete as much as we can be in the State.
Mr. Grijalva. Thank you.
My last point, Mr. Roemer, you mentioned all those other
things. You mentioned quickly about weapons. Seventy percent,
based on statistics from 2009 to 2014, of weapons seized across
the border, in Mexico primarily, came from the United States.
That is the origin. It is legal, weapons possession in Mexico.
It is legal to have them, and they are primarily in the hands
of cartels, and they have savaged that country as well.
So what do you see in terms of what we are able to do in
terms of what is going from here to there?
Mr. Roemer. Sure. Ranking Member Grijalva, just the Border
Strike Force--it is a huge concern for us from a public safety
perspective. Just the Border Strike Force alone----
Mr. Grijalva. But statistically, you mentioned tonnage and
all that. Have you re-arrested people?
Mr. Roemer. Absolutely. So, 280 firearms have been seized
just by the Border Strike Force during Border Strike Force
operations. But staying up-to-date on a daily basis on what Mr.
Ramirez and all of CBP is doing and the success they are
having, they are interdicting more weapons going south-bound
across the border. I don't have the exact statistics for you,
but I will tell you that I have been very pleasantly surprised
at the number of success stories coming out of CBP on those
weapons going south-bound.
Mr. Grijalva. I yield back, Chairwoman.
Ms. McSally. The Chair will now recognize Mr. Schweikert
for 5 minutes.
Mr. Schweikert. Thank you, Madam Chairwoman.
That is an interesting point. The leaky border basically
devastates people on both sides, and there becomes the
discussion of what do we do to lock it down.
Forgive me, this may be more for Mr. Brown than Mr.
Coleman, a quick thought experiment. Many have been working on
pieces of legislation. We are blessed that they look like they
are going to move, prior authorization for opioids, some
changes within the way opioids are prescribed, the ability for
pharmacies, the data to see it.
What happens if we are successful, that the prescription
level of opioids crashes? Do the bad actors come and say, well,
you are cutting our future profits because the migration we
were hearing before of medical opioids that in the future
potentially becoming a customer for heroin, eventually a
customer maybe for fentanyl, do the bad actors try to find
another way to continue the level of usage and devastation in
our society?
Mr. Roemer. I think over the short term that will happen. I
think there is no question that we have to lower the amount of
these prescriptions that we are writing to get hold of the
actual number of addicted that we have here. I do think that
the cartels will make moves to try to keep that addicted
population addicted so they can continue.
Mr. Schweikert. Do they go out and try to find new
customers?
Mr. Roemer. That is what they do. They recruit customers,
and they also introduce new products into the system, fentanyl
and its analogues and things like that, to get people more and
more hooked.
Mr. Schweikert. OK, that is partially where I wanted to go.
Mr. Brown.
Mr. Brown. I would echo what Doug said, and I would add I
think one of the things we are seeing commonly is they are
pressing fentanyl into a pill form.
Mr. Schweikert. As you know, yesterday there was a large
bust of what we thought was a prescription. It turns out it was
a derivative of a fentanyl product.
Mr. Brown. So I think that is a way of kind of marketing it
to those people that started out with a legitimate opioid
addiction. I think the reality is there are going to be some
people that, when they recognize that I am going to a wholly
illegal source to get my drugs, that will scare a couple of
people away and scare them into the treatment that they need.
To save those couple of lives, I would agree with Doug that we
need to work----
Mr. Schweikert. It is an interesting thought experiment
that will our success on one side, because there we can treat
it as a medical crisis, ends up moving that population into
almost a criminal, much more difficult to identify populations
to help.
Mr. Ramirez, help me understand. I sat through a security
briefing almost a year ago. It was a very small one, a little
geeky. We actually did the chemical compounds that are in
fentanyl, and I think they were using some other derivatives of
fentanyl, and just the stunning addictive, poisonous--how small
it was.
How do you capture--how do you find it when something the
size of your pinky is the death of all of us in this room?
Mr. Ramirez. It is a very scary proposition, Congressman.
At the ports of entry, what we are encountering is large
quantities. It is amazing when I look, as I said, 30 years in.
I remember when I started with Customs in El Paso, if you
caught 1 kilo of heroin back then, you were the man for a year.
Today, when we see 60 or 70 pounds, and what they are
coming in, the packages are coming with multiple pills in the
package----
Mr. Schweikert. My concern, though--and this may be more of
a question for a chemist. Heroin, fentanyl, for the same market
value, or for the same addictive quality, what is my volume
difference?
Mr. Ramirez. We don't know that until we send it to the
labs, including the DEA labs, and have them test it. I believe
that would be a question more suited for Mr. Coleman.
Mr. Schweikert. Mr. Coleman.
Mr. Coleman. Fentanyl is obviously much stronger than
heroin, and what we see is the profit margin on a kilogram of
fentanyl, $30,000 for a kilo, $1.5 million is the profit you
can make off of that.
Mr. Schweikert. So you strain to see a movement away from
heroin products to----
Mr. Coleman. Unfortunately, we see both coming in. We have
seen massive increases in the fentanyl and massive increases in
the heroin to feed that addicted population.
Mr. Schweikert. My understanding is there are some new
chemical derivatives of fentanyl that are even more dangerous
than----
Mr. Coleman. Yes. When you talk about fentanyl, it is a
synthetic opioid, so with just very small chemical changes you
can create different drugs--carfentanyl, U47-700. Some of those
drugs are hundreds of times more powerful than fentanyl.
Mr. Schweikert. The carfentanyl was fascinating chemically.
Madam Chairman, forgive me, I know I am over time. But for
all of us on the panel, it is worth a bit of a thought
experiment--and I don't want to speak out of what was given to
us in the SCIF, but if that type of product ended up in
something we are all publicly consuming, could you imagine the
brutality that comes with that?
Ms. McSally. The gentleman's time has expired.
Ms. Sinema had to go, so the Chair now recognizes Mr.
Gallego for 5 minutes.
Mr. Gallego. Thank you, gentlemen.
Director Ramirez, I am very lucky to serve on the Armed
Services Committee, and in that we have to make decisions
between whether we are going to buy tanks, aircraft carriers, a
whole lot of things. It ranges from bullets to bombs, and I
have to make those decisions every year through the National
Defense Authorization Act.
When it comes to fighting the opioid epidemic, we don't
have an unlimited amount of resources either for this, right?
If you haven't heard, we are in debt. We are going even more
into debt because of this latest tax plan, and we will probably
do that for the next 10 years.
If I had the opportunity to get you $25 billion and you had
to choose between a wall or to put more men at Customs and the
border, men and women, professionals at our Customs and ports
of entry, where would you choose your resources to be in terms
of trying to fight the opioid epidemic?
Mr. Ramirez. That is a little unfair.
Mr. Gallego. I know, that is why I asked it.
[Laughter.]
Mr. Gallego. If it was fair, I wouldn't ask it.
Mr. Ramirez. Because you are not going to find a port
director who is going to say that he cannot do without more men
or women.
Mr. Gallego. OK. I don't want to get you into trouble, so
we will stop there. I appreciate the honesty.
One of the other areas that Congresswoman McSally has
talked about, Congresswoman Sinema has talked at great length
about this also, is because of the understaffing at the ports
of entry, we are actually essentially using temporary personnel
right now to fill those gaps. In terms of operational outcomes,
what is that causing in terms of the consequences of that on an
everyday basis, or just in terms of long-term sustainability?
Mr. Ramirez. Well, long term, with our new recruiting
efforts and the fact that we finally have people in the
pipeline both pre-academy and academy and post-academy, it
looks like there is light at the end of the tunnel. Long term,
it actually benefits the agency when you bring people from
other ports of entry.
As you know, the Southwest Border is very unique when it
comes to our jobs, very exciting and action-filled, very
different from someone who sits in an airport or a Northern
Border port. So when they have an opportunity to come and work
side-by-side with the men and women assigned to the ports of
Arizona, it is a learning experience which they take back to
their ports of entry, and in turn it strengthens the operations
at those ports of entry.
I hear it from port directors who are not happy about
having to give up resources for a short time, but when those
resources get back, they are very pleased with what they find.
Mr. Gallego. Then to dive a little deeper, in terms of what
we are looking at in terms of shortages right now for permanent
staff, how many would you say do we need to fill the gap,
especially in the Tucson sector?
Mr. Ramirez. In the Tucson Field Office, I believe we are
still a few hundred positions short. Like I said, we have had
success in hiring, but with attrition, it is a couple of steps
forward, one step back kind of thing. So we are still a few
hundred overall short.
Mr. Gallego. Is the attrition because of Baby Boomers aging
out, or just because people find that the strain of the job is
just too much for their family, or just for personal income
reasons?
Mr. Ramirez. No, it is really more that blood is thicker
than water. A lot of folks, we hire them from other parts of
the United States, and in time they want to get back to family.
We have had some of our officers who have transferred to get
closer to family who have since come back to help us out in
temporary assignments, and they will tell you that they miss
the camaraderie, they miss the esprit de corps at the Arizona
ports of entry, and they actually miss living in Arizona. So
most of it is people rotating out, trying to get closer to home
and family.
Mr. Gallego. So, unfortunately, the cartels, they are very
well-funded themselves. They are innovative. They have a
product they need to sell, and they have a market that wants
it. What are we doing in terms of technology to keep up with
all the ways that they are trying to get their illicit drugs
into this country, and is there more we can do along those
lines to basically ratchet up our levels to make sure we are
matching their levels?
Mr. Ramirez. You know, one of the best X-ray systems that
we have right now, newly implemented, is the Z-Portal
technology, which is actually a low-energy system where the
travelers do not have to get out of their vehicles. You just
drive right through. That is one of the best tools. We just
finished installing the latest one in San Luis. We have one in
Douglas.
Mr. Gallego. How many more of those do we need?
Mr. Ramirez. I would like to see one at every port of
entry, and we are almost there, especially our larger ports of
entry. We already have them in Douglas, Nogales, San Luis, and
in Lucasville. So we are about there.
Mr. Gallego. Excellent.
Mr. Ramirez. But those have been a great addition to our
enforcement posture.
Mr. Gallego. Thank you. I yield back.
Ms. McSally. The gentleman yields back.
The Chair now recognizes Ms. Lesko for 5 minutes.
Ms. Lesko. Thank you, Madam Chair.
I want to say to the panel, thank you for your service to
our country, and thank you to all the law enforcement that
works to protect our communities and our country. I really
appreciate it.
I think you testified--and this is to any of you--that most
of the illicit opioids come through the ports of entry. From
the data that I see here, it mostly is coming through the San
Diego sector, it looks like. Correct me if I am wrong.
My question is if people are being inspected, if they know
they are going through a port of entry and they know they are
going to be inspected, why would they come through the ports of
entry, and how do you know that there is not a bunch of drug
traffickers coming through other parts of the border?
Mr. Coleman. From a DEA perspective I can tell you that the
reality is that they certainly know that some of them are going
to get taken off as they come across, but they will send
multiple people through at a time. When CBP catches them, moves
them away, then four others can sneak in behind them. So they
use a variety of techniques. But they build into their business
model the fact that they are going to lose a significant
portion of them that come across. So they flood us,
essentially, with more people coming across than we can catch.
Ms. Lesko. Thank you for that answer. But my question is
you testified--well, not you specifically, but that they strap
it on their body and that type of thing. But how do you know
that a bunch of people aren't coming through other areas of the
border, not ports of entry, that have strapped-on illicit drugs
because they are not going through a port of entry where there
is going to be any type of inspection?
Mr. Brown. Again, we have procedures made by Border Patrol
that they really aren't encountering hard narcotics between the
ports of entry. The reality is if you cross at a non-port of
entry, if you are detected, you are going to be stopped, you
are going to be apprehended, you are going to be searched.
If you are coming through a port of entry, you are blending
in with a huge volume of traffic, of which we can only inspect
a small portion of those vehicles and pedestrians, so it is
playing the odds. Again, you are automatically doing something
wrong and are going to be more heavily scrutinized if you are
coming across between ports of entry.
Ms. Lesko. Thank you.
Madam Chair and anyone from the panel, I know that you may
not know the exact answer to this, but for every amount of
illicit drugs that you detect, how much do you think is
undetected? It is hard to know, I know, but you probably have a
guess.
Mr. Coleman. There is a significant portion that gets
through, obviously. At DEA we work around the entire world, so
we see the expansion of these drugs coming in and landing in
other States, stuff that we know came through the port of
entry. Our cases lead us from other parts of the country back
to Arizona. So we know that there is a lot that gets through. I
shudder to hazard a guess, but there is a significant amount
that gets through all of us.
Ms. Lesko. Thank you.
I yield back my time.
Ms. McSally. The gentlelady yields back.
I do want to note that the appropriations bill included
$284 million for port and drug inspection technologies within
CBP, and $71 million specifically for opioid detection. So
hopefully we are seeing more flow to the different ports of
entry, more technology flow to the ports of entry for that non-
intrusive inspection.
We have a lot more to talk about, but we don't have a lot
of time, so I just want to say thanks to our witnesses for all
that you do in order to keep our communities safe, and
everything that all of your members do every single day to keep
us safe and to address this issue.
There is a lot more that we can do together to solve, so
this is just really a platform for us, and we look forward to
continuing to work with you moving forward to address this
crisis.
I want to thank all the witnesses for their testimony and
the Members for their questions. The Members of the committee
may have some additional questions for the witnesses. We will
ask you to respond to those in writing.
With that, I will dismiss this panel and request that the
Clerk prepare the witness table for our third panel.
[Recess.]
Ms. McSally. While the last panel was very much focused on
the supply of these addictive opioids and other substances,
this panel is going to be talking more about solutions within
society, civic society, and all elements, what can we be doing
to have early identification and prevention and treatment to
provide wholeness for people who have struggled with
addictions. So, I am really looking forward to the discussion
on this panel.
I am pleased to welcome five distinguished witnesses for
our third and final panel today. First is Dr. Cara Christ, who
serves as director of Arizona Department of Health Services.
She has worked for the agency for more than 9 years in multiple
positions. In May 2015, Dr. Christ was appointed as director by
Governor Doug Ducey.
The second witness is Dr. Glorinda Segay, who became the
health director of Navajo Nation in July 2017. In this position
she is responsible for overseeing the direction of 14 different
programs which include direct patient care as well as the
provision of Medicaid and Medicare for the Navajo people.
Previously she provided psychotherapy and group therapy
treatments, as well as working on suicide prevention.
Ms. Debbie Moak became the director of the Governor's
Office of Youth, Faith, and Family in 2015. She served as
director under Arizona Governor Ducey until June 2017.
Previously she worked as an elementary school teacher for 10
years. In 1999 she co-founded notMYkid, an anti-substance abuse
non-profit, with her husband. The non-profit aims to help young
people make positive choices.
Mr. Jay Cory has served as the president and CEO of the
Phoenix Rescue Mission since September 2011. Mr. Cory has over
25 years of senior leadership experience in religious-based
rescue and recovery ministries, with a proven track record of
success in building ministry and recovery programs.
Mr. Wayne Warner is a graduate of Teen Challenge, a faith-
based program with practical solutions for men and women with
life-controlling issues. I am very familiar with Teen
Challenge. I was a former board member of Teen Challenge.
Initially a skeptic, Wayne graduated in 2014 and is now a firm
advocate for the program which helps people ``become mentally
sound, emotionally balanced, socially adjusted, physically
well, spiritually alive, and employment ready.''
The Chair now recognizes Dr. Christ to testify.
STATEMENT OF CARA M. CHRIST, M.D., DIRECTOR, DEPARTMENT OF
HEALTH SERVICES, STATE OF ARIZONA
Dr. Christ. Chairwoman McSally and other Members in
attendance, thank you for this opportunity to share our
progress toward Arizona's public health emergency, the opioid
epidemic.
The opioid crisis is different than other drug epidemics.
While heroin and other illicit opioids present a problem in our
communities, the start for many who develop opioid use disorder
begins in a doctor's office in an attempt to relieve pain.
It wasn't until recently that medical professionals
realized how dangerous these medications are. Merely taking
them as directed for 6 days or more significantly increases
your chance of dependence. Four out of five new heroin users
started as opioid medication users.
We knew to address this issue our response required a
coordinated, multifaceted approach from all sectors, including
public health and medical professionals, law enforcement,
patients, and many others in our communities.
Last year my agency, the Arizona Department of Health
Services, issued our report on opioid deaths, showing more than
two Arizonans died each day in 2016 from these dangerous drugs.
Upon release of that report, Governor Ducey took decisive
action and declared a public health emergency, mobilizing
resources and allowing us to collect real-time data. Within
hours of the declaration, our Health Emergency Center began
analyzing data, gathering partners, and identifying solutions.
The numbers reported are staggering. Since June 2017, over
1,200 suspected opioid deaths, 8,000 overdoses, and 760 babies
with neonatal abstinence syndrome have been reported to the
Department. After over 50 stakeholder meetings involving over
1,350 partners, the Department issued our Opioid Action Plan.
During the past year, Arizona has been implementing our
plan and completing the activities Governor Ducey directed in
the emergency declaration, and we have made great progress. The
reporting and information-sharing requirements first
established through the enhanced surveillance activity are now
codified in rule. Almost 1,000 law enforcement officers State-
wide have been trained to provide Naloxone, and to date we have
provided over 6,100 Naloxone kits to over 63 law enforcement
agencies throughout Arizona, allowing our officers to save
lives by reversing overdoses in the field.
Our health care facilities now have rules for opioid
prescribing and treatment, ensuring they have policies and
procedures aimed at preventing opioid use disorder. We are also
in the process of developing rules to regulate pain management
clinics and end pill mills.
Our Arizona Opioid Prescribing Guidelines have been updated
to incorporate the newest information from the Centers for
Disease Control and Prevention, encourage a shift in pain care
to avoid unnecessary exposure to opioids, and emphasize the use
of non-stigmatizing language.
We have created a free, 24/7 State-wide consultation opioid
assistance and referral line. This is for prescribers seeking
advice about prescribing opioids and caring for patients with
opioid use disorder.
One hundred percent of Arizona's health professional
schools participated in the development of the Nation's first
State-wide curriculum across all prescriber training programs
for pain and addiction using a whole-person approach.
Integration of this curriculum is said to begin during the
2018-19 school year.
We have also partnered with the Arizona Department of
Corrections to pilot a program that provides free Naloxone for
individuals at high risk of overdose who are released from our
correctional facilities. Multiple State agencies, including
AHCCCS, the State's Medicaid program, the Governor's Office of
Youth, Faith, and Family, and the Arizona Board of Pharmacy
have come together to increase access to peer support, enhance
youth prevention programs, and improve the Controlled
Substances Prescription Monitoring Program.
However, one of the biggest successes is the unanimous
bipartisan passage of the Comprehensive Arizona Opioid Epidemic
Act that went into effect on April 26. The Act consists of a
number of life-saving policy initiatives, including a $10
million investment to enhance access to treatment for uninsured
or underinsured Arizonans, a Good Samaritan law to allow people
to call 9-1-1 for a potential opioid overdose, requiring
insurance companies to make one form of medication-assisted
treatment available without a prior authorization, and limiting
the first fill of an opioid prescription to 5 days for all
opioid-naive patients while protecting chronic pain patients
currently on these medications.
While this legislation just went into effect, we are
already seeing improvements based on our comprehensive efforts.
In addition to the statistics that Governor Ducey presented
earlier, we have also seen a 50 percent decline in the number
of high-dose prescriptions when you look at this since last
April.
Though we have completed all of the directed activities and
the emergency declaration has been terminated, we know that our
work is just beginning. Arizona has an on-going commitment to
continue to identify and implement new solutions to prevent
future overdoses and deaths.
Thank you for allowing me to talk about our progress today.
[The prepared statement of Dr. Christ follows:]
Prepared Statement of Cara M. Christ
May 30, 2018
The Arizona Department of Health Services (ADHS) released the 2016
Arizona Opioid Report on June 1, 2017. This report revealed that in
2016, 790 Arizonans died from opioid overdoses--more than 2 people per
day. Arizona has experienced an alarming increase in opioid deaths of
74 percent since 2012. In the past decade, 5,932 Arizonans died from
opioid-induced causes with death rates starting to rise in the late
teens and peaking at ages 45-54. This data highlighted a need for
action. On June 5, 2017, Governor Doug Ducey declared a public health
emergency to address the increase in opioid deaths in Arizona.
health emergency operations center
The ADHS team immediately sprang into action and activated the
Health Emergency Operations Center (HEOC) within hours of the
Governor's emergency declaration. More than 75 agency staff across ADHS
responded to the Governor's calls to action. As part of the declared
state of emergency, ADHS was given the responsibility to:
Provide consultation to the Governor on identifying and
recommending elements for an Enhanced Surveillance Advisory.
Initiate emergency rulemaking for opioid prescribing and
treatment within health care institutions.
Develop guidelines to educate providers on responsible
prescribing practices.
Provide training to local law enforcement agencies on proper
protocols for carrying, handling, and administering naloxone in
overdose situations.
Provide a report to the Governor on findings and
recommendations by September 5, 2017.
enhanced surveillance advisory
With consultation from ADHS, Governor Ducey issued an executive
order on June 15, 2017 to require the reporting of opioid-related data,
allowing State health officials to receive information within 24 hours
of specific events. This was a first step toward understanding the
current opioid burden in Arizona and building recommendations to better
target prevention and intervention. These reporting requirements
greatly increased the Department's ability to assess and apply timely
interventions in comparison with traditional data sources, which are 6
to 18 months delayed. The specific health conditions required in the
enhanced surveillance advisory included suspected opioid overdoses,
suspected opioid deaths, naloxone doses administered in response to
either condition, naloxone doses dispensed, and neonatal abstinence
syndrome.
To facilitate collection of data, the agency's secure web-based
surveillance systems, Medical Electronic Disease Surveillance
Intelligence System (MEDSIS) and Arizona Prehospital Information & EMS
Registry System (AZ-PIERS), were utilized for designated reporters to
electronically submit mandatory surveillance data. These systems were
quickly modified to accommodate data submitted from 209 unique MEDSIS
reporters and 143 AZ-PIERS reporters. ADHS coordinated a series of
three webinars that trained a total of 171 health care, EMS, and law
enforcement reporters. Arizona State Public Health Laboratory
established the capability to receive postmortem blood specimens from
Medical Examiners Offices to screen suspected opioid overdoses for
opioids and other substances as of April, 2018.
treatment capacity survey
In order to ascertain the current capacity and occupancy for
substance abuse treatment in the State, ADHS requested the completion
of an anonymous behavioral health, substance abuse treatment, and
health care facilities survey. The survey was disseminated through the
Regional Behavioral Health Authority system. Survey data was used to
gain a better understanding of the distribution of services across the
State, understand the utilization and availability of treatment, and
better target future resources for treatment capacity in Arizona.
Overall, the data collected demonstrated that there are not an adequate
number of treatment services available in the State. It was also noted
that when seeking care, many individuals may be turned away or placed
on waiting lists. Starting in September 2018, ADHS will be collecting
treatment capacity data from health care facilities and will issue
quarterly reports noting gaps and recommendations.
emergency rule making
As directed in the emergency declaration, the Department rapidly
initiated emergency rule making for opioid prescribing and treatment
practices in licensed health care institutions. Rules were completed in
coordination with Arizona's Attorney General's Office and approved by
the Secretary of State for immediate implementation on June 28, 2017.
These emergency rules focus on health and safety; provide regulatory
consistency for all health care institutions; establish, document, and
implement policies and procedures for prescribing, ordering, or
administering opioids as part of treatment; include specific processes
related to opioids in a health care institution's quality management
program, and require notification to the Department of a death of a
patient from an opioid overdose. To support the agency's stakeholders
and partners, a series of four webinars on the emergency rules were
held, training a total of 458 attendees.
After the emergency rule implementation, the Department initiated
the regular rule-making process, which included opportunities for
stakeholder input on the final rules through several stakeholder
workgroup meetings and surveys in September and October 2017. An oral
proceeding was held on December 18, 2017. Written comments were
accepted through December 18, 2017. The final rules went into effect
March 6, 2018.
In addition, ADHS drafted and submitted emergency opioid-related
reporting rules to the Attorney General's Office in order to maintain
reporting requirements initiated by the Enhanced Surveillance Advisory.
These rules require continued reporting of suspected opioid deaths,
suspected opioid overdoses, naloxone doses administered in response to
a suspected opioid overdose, naloxone doses dispensed, and neonatal
abstinence syndrome cases. On-going reporting requirements will allow
sustainable and continued collection of timely data throughout Arizona
to better target prevention. Following stakeholder meetings and surveys
through the regular rule-making process, the opioid-related reporting
rules went into effect on April 5, 2018.
opioid prescribing guidelines
ADHS utilized the Arizona Prescription Drug Initiative Health Care
Advisory Team, which has been in place since 2015, to review and update
the Arizona Opioid Prescribing Guidelines published in 2014. The Rx
Initiative Health Care Advisory Team, made up of professional health
care associations, practicing clinicians, and subject-matter experts,
met 9 times since June 2017 to review and update the guidelines. The
Guidelines are a voluntary, consensus document that promotes patient
safety and best practices if prescribing opioids for acute and chronic
pain. Nineteen Arizona healthcare organizations have endorsed the new
guidelines. The content of the guidelines was finalized in December
2017, and the final version is posted at www.azhealth.gov/
opioidprescribing/.
Current updates reflect:
Incorporation of the most recent evidence, National
guidelines (including the VA/DoD Clinical Practice Guideline
for Opioid Therapy for Chronic Pain, 2017 and CDC Guideline for
Prescribing Opioids for Chronic Pain, 2016), best practices
from other States, and Arizona data.
A shift in pain care that avoids unnecessary exposure to
opioids in order to reduce the risk of adverse outcomes.
Previous guidelines focused on the ``safe prescribing'' of
opioid therapy, while these guidelines aim to prevent
initiating unnecessary opioid therapy while addressing
patients' pain from a whole-person perspective.
Emphasis on non-stigmatizing language. Health care providers
can counter stigma by using accurate, nonjudgmental language.
These guidelines employ person-first language (``Patients with
substance use disorder'' instead of ``addicts''), nonjudgmental
terminology (``negative urine drug test'' instead of ``dirty'')
and supportive terms (``recovery'' instead of ``no cure'').
Increased focus on prevention, recognition, and treatment of
opioid use disorder in patients receiving long-term opioid
therapy for chronic pain, given the high risk of developing
opioid use disorder in this population.
Integration into clinical workflow (operationalization). A
key element of success of guideline implementation is how
seamlessly it can be incorporated into a clinician's normal
activities. This revised version includes specific
operationalization actions under each guideline.
expanding access to naloxone
ADHS identified a need to train local law enforcement agencies on
proper protocols for carrying, handling, and administering naloxone in
overdose situations, in order to positively impact the opioid epidemic
through rapid treatment of encountered suspected overdoses.
Approximately 1,000 law enforcement officers have been educated through
training events held throughout the State since June 2017. ADHS is
coordinating continuing requests for law enforcement training with the
Arizona Peace Officer Standards and Training Board (AZ-POST).
Progress on naloxone distribution includes:
ADHS has free naloxone kits available for law enforcement
agencies and first responders who are unable to bill for
naloxone. Agencies can request naloxone by completing the
request form on the ADHS website.
ADHS has provided 6,316 naloxone kits for 63 law enforcement
agencies since June 2017.
ADHS received a SAMHSA grant to support training of first
responders in naloxone administration and conducting screening,
brief intervention, and referral to treatment. AzPOST and the
University of Arizona are partnering with ADHS to implement
grant activities.
Eighty-four percent of people experiencing non-fatal
overdoses since June 15, 2017 when enhanced surveillance was
initiated received naloxone pre-hospital.
Law enforcement officers have administered naloxone 482
times to 364 people since June. In all but 9 cases, the
individual survived the immediate out-of-hospital event.
In order to support increased use of naloxone to save lives in
Arizona, ADHS Director Dr. Cara Christ signed standing orders that
allow pharmacists to dispense naloxone to any individual in the State
and allow ancillary law enforcement, correctional officers, and EMS to
use naloxone for suspected opioid overdoses. A naloxone pamphlet was
developed in both English and Spanish to assist in public education of
opioid safety and naloxone use.
goal council 3: opioid breakthrough project
With Director Cara Christ as the lead of the Governor's Goal
Council 3 on Healthy People, Places, and Resources, the ADHS team
assisted Director Christ in launching several subgroups to recommend
actions that will reduce opioid deaths. On June 26, 2017, partners from
across the State convened to learn more about the opioid emergency and
the work of the Goal Council on Healthy People, Places, and Resources.
Participants were asked to join one or more subgroups to help
define problems, set goals, and determine what actions would be most
impactful to prevent and reduce opioid deaths. Subgroups worked
together in July and August 2017 to identify recommendations and
convened again on August 23, 2017 to share draft recommendations.
Approximately 200 committed Arizonans volunteered their time to
contribute ideas and prioritize recommendations that shaped much of the
content of the recommendations in Opioid Action Plan delivered by ADHS
to Governor Ducey. Over the course of the emergency declaration, ADHS
has held over 50 stakeholder meetings and engaged over 1,350 Arizonans
State-wide.
communication and resources
ADHS has developed several mechanisms to allow for partner
interaction and information distribution. One such mechanism is the
development of a dedicated webpage, azhealth.gov/opioid. This webpage
organizes resources and allows stakeholders to quickly access up-to-
date opioid-related information. Within these webpages the Department
has posted numerous unique resources covering various topics including
FAQs, reporting-related case definitions, publicly released data,
setting-specific guidance and resources, and a 50 State Review on
Opioid Related Policy. A centralized email, [email protected], and
digital interface within the opioid webpage allow for direct
stakeholder communication for concerns and interest in partnering with
the Department.
ADHS recently formed a drug overdose mortality review team, per
A.R.S. 36-198, to develop a data collection system regarding drug
overdoses, conduct an annual analysis relating to drug overdose
fatalities, develop standards and protocols, provide training and
technical assistance to local overdose review teams, and develop
investigation protocols for law enforcement and the medical community.
The first meeting of the State Drug Overdose Fatality Review Team was
held on November 28, 2017.
ADHS is also launching a new approach adopting chronic pain as a
public health issue. In follow-up to a chronic pain summit held in May
2017, ADHS developed a dedicated webpage, azhealth.gov/
chronicpainmanagement, to increase public awareness and utilization of
safe, effective approaches to managing chronic pain. With an emphasis
on promoting non-pharmacological therapies that are proven to ease pain
and increase function, ADHS aims to help Arizonans with chronic pain
resume daily activities and maximize their quality of life. A major
component of this initiative will be a new media campaign emphasizing
options and self-management strategies for addressing chronic pain.
arizona opioid action plan
The public health emergency declaration directed the Arizona
Department of Health Services to submit a report of the accomplished
activities and identify recommendations for combating the opioid
epidemic in Arizona. ADHS submitted the Opioid Action Plan to Governor
Ducey on September 5, 2017. The Opioid Action Plan includes 12 major
recommendations with over 50 actions slotted for completion by June 30,
2018.
Goals to address the opioid epidemic:
Increase patient and public awareness and prevent opioid use
disorder.
Improve prescribing and dispensing practices.
Reduce illicit acquisition and diversion of opioids.
Improve access to treatment.
Reduce opioid deaths.
Recommendations, created through multiple meetings with partner
agencies, impacted stakeholders, Goal Council 3 subgroups, and policy
makers to address the above goals include:
1. Enacting legislation that impacts opioid deaths by addressing
identified barriers;
2. Creating a free, State-wide consultative call line resource for
prescribers seeking advice about prescribing opioids and caring
for patients with opioid use disorder;
3. Requiring Arizona medical education programs to incorporate
evidence-based pain management and substance-use disorder
treatment into their curriculum;
4. Engaging the Federal Government to address necessary Federal-
level changes;
5. Establishing a regulatory board workgroup to identify
prescribing trends and enforcement issues;
6. Encouraging law enforcement agencies to expand the Angel
Initiative and other existing diversion programs and assist the
DEA with filling local vacancies on the Tactical Diversion
Squad;
7. Increasing access to naloxone for high-risk individuals released
from correctional facilities;
8. Pulling together experts into task forces to address identified
barriers by:
Identifying specific improvements to enhance the Arizona
Controlled Substance Prescription Monitoring Program;
Identifying, utilizing, and building upon Arizona's
existing peer recovery support services;
Providing recommendations regarding insurance parity and
standardization of substance abuse treatment and chronic
pain management across the State; and
Identifying and implementing school-based prevention
curriculum, expanding after school opportunities and
identifying resource needs.
------------------------------------------------------------------------
Progress to Date
Goal Recommendations (May 2018)
------------------------------------------------------------------------
Reduce Opioid Deaths........ Enact legislation On January 26, 2018,
that impacts opioid Governor Ducey,
deaths by reducing with unanimous,
illicit acquisition bipartisan support
and diversion of of the Arizona
opioids, promoting Legislature, passed
safe prescribing the Arizona Opioid
and dispensing, Epidemic Act, or
decreasing the risk Senate Bill 1001, a
of opioid use comprehensive
disorder, and approach to
improving access to addressing opioid
treatment. related issues
State-wide.
Improve Prescribing & Establish a ADHS convened three
Dispensing Practices. Regulatory Board meetings of the
work group to Regulatory Board
identify Workgroup and will
prescribing trends submit an Action
and discuss Plan to the
enforcement issues. Governor by June
Establish a task 30, 2018.
force to identify The Arizona Board of
specific Pharmacy convened
improvements that the task force and
should be made to identified a set of
enhance the Arizona initial
Controlled improvements
Substances regarding
Prescription registration of
Monitoring Program prescribers and
(CSPMP). improved outreach,
technical
assistance, and
education. New
training modules
are available on
how to use the
Arizona Controlled
Substances
Prescription
Monitoring Program
on their website.
Reduce Illicit Acquisition & Meet with leaders of ADHS and Homeland
Diversion of Opioids. law enforcement and Security leadership
first responder met with law
agencies to expand enforcement
Angel Initiative leadership in
and other OUD September.
diversion programs Two law enforcement
and assist the DEA agencies are
with filling participating in
vacancies in the the Angel
DEA Tactical Initiative with 136
Diversion Squad. individuals
enrolled.
Improve Access to Treatment. Require all ADHS has worked with
undergraduate and 100 percent of
graduate medical Arizona academic
education programs partners to develop
to incorporate a State-wide
evidence-based pain curriculum on
management and opioid prescribing,
substance-use treatment of opioid
disorder treatment use disorder and
into their management of
curriculum. chronic pain.
Create a call-in The Opioid
line resource to Assistance and
provide Referral Line, a
consultation to free 24/7 call
prescribers seeking resource for
advice about prescribers, has
prescribing opioids been implemented in
and caring for partnership with
patients with Arizona's Poison
opioid use disorder. and Drug
Establish through Information
executive order a Centers.
work group to Arizona's Medicaid
identify, utilize, agency and State
and build upon substance abuse
Arizona's existing authority, AHCCCS,
peer recovery has convened the
support services. peer support work
Convene an Insurance group.
Parity Task Force The Task Force
to research and conducted a survey
provide of current
recommendations insurance coverage
regarding parity related to pain
and standardization management and
across the State. opioid use disorder
Engage the Federal treatment. A report
Government with
outlining necessary recommendations
Federal changes to will be submitted
assist Arizona with to the Governor by
our response to the June 30, 2018.
opioid epidemic. The Governor's
Increase access to office sent the
naloxone and letter requesting
Vivitrol for Federal changes to
individuals leaving assist Arizona's
State and county response to the
correctional opioid epidemic.
institutions and ADHS is working with
increase access to the Arizona
MAT therapy for Department of
individuals with Corrections to
opioid use disorder implement a
while incarcerated. naloxone pilot
program for
formerly
incarcerated
individuals who are
at high risk for
overdose after
release. ADHS has
provided 1,000
doses of naloxone
for Corrections to
distribute to high-
risk inmates being
released. An
overdose prevention
and education video
will be completed
June 30.
Prevent Opioid Use Disorder/ Utilize Public The Governor's
Increase Patient Awareness. Service Office of Youth,
Announcements Faith, and Family
(PSAs) to educate developed new PSAs
patients, that began airing
providers, and the in December and are
public regarding scheduled to
opioid use and continue through
naloxone. 2018. See
Create a youth www.RethinkRxabuse.
prevention task org.
force to identify The Governor's
and implement Office of Youth,
evidence-based, Faith, and Family
emerging, and best has convened the
practice substance youth prevention
abuse prevention/ task force to
early discuss prevention
identification programs. A report
curriculum, expand with
after-school recommendations
opportunities, and will be submitted
identify resource to the Governor by
needs. June 30, 2018.
------------------------------------------------------------------------
arizona opioid epidemic act
On January 26, 2018, Governor Doug Ducey signed The Arizona Opioid
Epidemic Act, the first bill to become law in 2018, following a 4-day
Special Session and unanimous passage in the House and Senate. The
legislation takes aggressive steps to address opioid addiction, hold
bad actors accountable, expand access to treatment, and provide life-
saving resources to first responders, law enforcement, and community
partners. Most provisions of the act went into effect on April 26,
2018.
Specific policy initiatives in the Arizona Opioid Epidemic Act
include:
Identifying gaps in and improving access to treatment,
including for uninsured or underinsured Arizonans, with a new
$10 million investment;
Expanding access to the overdose reversal drug, naloxone,
for law enforcement or corrections officers currently not
authorized to administer it;
Holding bad actors accountable by ending pill mills,
increasing oversight mechanisms, and enacting criminal
penalties for manufacturers who defraud the public about their
products;
Enhancing continuing medical education for all professions
that prescribe or dispense opioids;
Enacting a Good Samaritan law to allow people to call 9-1-1
for a potential opioid overdose;
Cracking down on forged prescriptions by requiring e-
prescribing;
Requiring all pharmacists to check the Controlled Substances
Prescription Monitoring Program prior to dispensing an opioid
or benzodiazepine;
Developing a social media youth prevention campaign;
Requiring emergency departments and hospitals to make
referrals to treatment for overdose patients;
Reducing prior authorization time frames for insurers and
requiring insurers to make at least one form of Medication
Assisted Treatment available without prior authorization;
And, limiting the first-fill of an opioid prescription to 5
days for all opioid naive patients and limiting dosage levels
to align with Federal prescribing guidelines. These proposals
contain important exemptions to protect chronic pain suffers,
cancer, trauma or burn patients, hospice or end-of-life
patients, and those receivingdication assistedeatment for
substance use disorder.
expanding access to treatment
Arizona is expanding access to opioid use disorder treatment and
support resources through Federal and State funding.
Arizona received $24 million dollars through the SAMHSA
State Targeted Response (STR) Grant to use toward opioid use
disorder prevention and treatment. The Arizona Health Care Cost
Containment System (AHCCCS) is expanding access to opioid
treatment programs throughout the State using grant funds from
SAMHSA. The first of five, 24-hour centers for opioid
treatment, including two medication-assisted treatment (MAT)
centers and three crises centers, opened in October 2017 to
address the growing need for access to opioid use disorder
treatment. The 24/7 access to opioid treatment is currently
available in Mohave, Yavapai, Maricopa, and Pima counties.
The Arizona Opioid Epidemic Act provided $10 million in
State general fund dollars for substance use disorder services
for the uninsured and underinsured. AHCCCS conducted community
forums to gather input to target use of the funding and
identify priority needs.
arizona's progress
100 percent (18/18) of health professional schools in
Arizona participated in development of a curriculum for pain
and addiction. This is the Nation's first State-wide curriculum
across all prescriber training programs. All schools agreed to
a shared vision to redefine pain and addiction as
multidimensional, public health issues that require the
transformation of care toward a whole-person approach with a
community and systems perspective. Academic programs are
expected to begin integration of core components of the
curriculum during the 2018-19 school year.
New OARLine: Opioid Assistance + Referral Line for Arizona
Providers: 1-888-688-4222 is available for health care
clinicians to call for free consultation on patients with
complex pain or opioid use disorder. The 24/7 hotline is
staffed by experts at the Poison and Drug Information Centers
in Arizona. The hotline will be expanded in the future to
provide information and referrals to the public.
ADHS is working with the Arizona Department of Corrections
on a pilot to provide released inmates at high risk of opioid
overdoses prevention education and naloxone. Training was
conducted for corrections supervisors on naloxone, and 1,000
naloxone kits have been provided for them to begin distributing
to those inmates who are identified at risk for an overdose
post-release. (High-risk was defined as overdosing while
incarcerated) ADHS is also working on a short educational video
to be completed by June 30.
The Insurance Parity Taskforce conducted a survey of over 50
insurers to assess current coverage of pain management
treatments and substance use disorder treatments. The Taskforce
will make recommendations to Governor Ducey by June 30, 2018.
ADHS and Governor's Office of Youth, Faith, and Family will
be launching a new youth prevention campaign in fall of 2018,
which was authorized and funded by the Arizona Opioid Epidemic
Act.
ADHS is working with stakeholders to develop new regulations
for pain management clinics. Arizona will license pain
management clinics starting January 2019.
While it is early to evaluate the outcomes associated with
Arizona's response to the opioid crisis, there are some promising
indicators of success.
The 4 & 4 report is a list of patients who have obtained
controlled medications from 4 different doctors and 4 different
pharmacies in a given month. The Arizona Board of Pharmacy
sends any prescriber with a patient on the 4 & 4 list an
unsolicited letter to alert the prescriber of the patient's
possible doctor and pharmacy shopping. There has been a 60
percent decline in the number of patients on this report--from
99 in July 2017 to 40 in April 2018.
The percent of patients receiving referrals to behavioral
health or substance abuse treatment services after an overdose
has increased from 41 percent in June 2017 to 63 percent in
April 2018.
The number of naloxone prescriptions dispensed by
pharmacists has increased significantly in recent months. July-
September 2018, fewer than 900 naloxone kits were dispensed
each month. In April 2018, 3,143 kits were dispensed to the
public. See attachment 1.
The number of opioid prescriptions filled and the number of
prescriptions with high doses exceeding 90 morphine milligram
equivalents has declined, as illustrated in the graphs in
attachments 2 and 3.
lessons from opioid surveillance
ADHS has been collected data on suspected opioid overdoses since
June 15, 2017. Over this period of time, the surveillance has
indicated:
Most overdoses (59 percent) occur among men.
People ages 25-34 years old had the highest percent of
suspected opioid overdoses.
Chronic pain (e.g. lower back pain, joint pain, arthritis)
is the most common pre-existing physical condition reported for
those who had a verified opioid overdose, followed by
depression and history of substance use disorder, including
alcohol.
About 40 percent of people who had a suspected overdose
(between June 15, 2017 and March 26, 2018) had 9 or more
prescriptions for opioids filled.
More than 40 percent of people who had a suspected opioid
overdose were prescribed opioids by 10 or more providers since
January 2017.
Most reported overdoses involve multiple drugs. Polydrug use
was indicated in 2/3 of the overdose fatalities. The charts in
attachments 4 and 5 detail the drugs identified in the reported
opioid overdoses.
number of naloxone kits despensed by pharmacies
controlled substances prescription drug monitoring program data july 1,
2017-may 17, 2018
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
opioid prescriptions filled per month. controlled substances
prescription drug monitoring program data jan. 1, 2017-may 10, 2018
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
number of opioid prescriptions for mme 90 or above filled per month.
controlled substances prescription drug monitoring program data jan. 1,
2017-may 10, 2018
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
oxycodone and heroin were the opiate drugs most commonly noted in
overdoses determined to be due to opioids during review. overdose
surveillance data june 15, 2017-may 17, 2018
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
number of naloxone kits despensed by pharmacies. overdose surveillance
data june 15, 2017-may 17, 2018
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. McSally. Thank you, Dr. Christ.
The Chair now recognizes Dr. Segay to testify for 5
minutes.
STATEMENT OF GLORINDA SEGAY, M.D., HEALTH DIRECTOR, DIVISION OF
HEALTH, THE NAVAJO NATION
Dr. Segay. Thank you, Madam Chair. I am Dr. Segay, Navajo
Nation executive director for Department of Health. The
president and vice president also send their regards. Thank you
for having me here today, and thank you for all that you do for
us.
I just want to also inform you that opioid abuse does exist
on the Navajo Nation. Recently we had created an opioid task
force team, and basically this is a collaboration with our
Indian Health Service. We do have five facilities there on
Navajo, and also our Public Law 93-638 facilities which we also
have there.
Basically, we have been talking about how and what is this
opioid to the Navajo Nation. Our people there have a low health
literacy rate in regards to understanding what is happening in
their health, so that is what we have been talking about, APSA
and creation of educating our Navajo Nation in ways that
opioids that are being used on Navajo, which we discussed, is
the pill form, the smoking, the snorting, mixing with
substances, skin patches. So basically we are working on a PSA
again so that we can educate our Navajo people.
One barrier we do have is our language. Navajo language is
very complex, so it is a lot of descriptive details that we
need to include while we are translating. So we do have issues
with funding there, so we do need and request more funding so
that we can provide adequate services in educating our Navajo
people.
We do have distributors there on Navajo. The main
distributor is Indian Health Service, and also our Public Law
638 facilities. We do have border towns there, such as
Flagstaff and Gallup, so they do have their private
distributors such as Walmart, Walgreens, and Safeway, which we
have no control of, so that is an issue for us.
It is also furthermore requesting as far as Tribal direct
funding. It is very hard when the Government sends money to the
State and then it trickles to the Tribes. There are
restrictions and there is not enough funding.
I also just want to make mention that AHCCCS is
underfunded. So if we can get more funding to AHCCCS to help us
to fight opioid there with Navajo as well as Indian Country. We
have been talking with AHCCCS, and what we do have is a
strategic plan that has been shared with us. Part of the
strategic plan is basically strengthening our public health
data and reporting and collecting. We want to focus on
actionable data for target interventions so that we can provide
services.
I just also want to make mention that with Navajo, one of
our methods of treatment is through our traditional Native
medicine. So we still do use our elders. We still use our
cultural practices through prayers and songs and chants with
our ceremonies, and that is very effective for us. So we do
also want that to be recognized as a form or method of
treatment.
Furthermore, just going on with our strategic plan, we have
an advanced practice of pain management to enable access to
high-quality, evidence-based pain care that decreases the
burden of pain for individuals, families, and society, while
also reducing them in appropriate use of opioids and opioid-
related harms.
So again, going into the crime rate, we do have a high
level of crime, underlying issues with domestic violence. We
also have human trafficking there on Navajo because of opioids,
as well as other substances.
We want to improve access for patients as far as treatment,
prevention, and recovery services so that we can prolong the
life of each of our Navajo people. They are important to us. We
also want to target the availability and distribution of
overdose medication to ensure the provision of these drugs to
people likely to experience or respond to an overdose, with a
particular focus on targeting high-risk population.
I also want to make mention that we also want to support
cutting-edge research that advances our understanding of pain
and addiction that leads to development of new treatment and
identifies effective public health interventions to decrease
opioids. So right now what we are basically doing is a lot of
prevention education. We do have a collaboration with our
community health representatives, who also go out into the
community and pretty much provide education in the Navajo
language, and we also feel our Navajos learn more visually. So
they are out there with their charts, especially with our
elders and speaking about what are the signs and the symptoms,
what are some concerns, because a lot of our people who use
opioids still live with their elderly parents. So we want to
inform the elderly parents because, again, it is a safety
concern. We get a lot of elders who come to us and tell us that
they are afraid of their adult children, especially when they
are on any sort of influence as far as substances go.
I also want to make mention that Navajo Nation president
has made mention several times there in the District of
Columbia that the DEA needs to be involved and that we feel as
Navajo they need to place extreme restrictions on opioids.
Basically, that is what I wanted to share with you all.
Thank you for this time.
Ms. McSally. Thank you, Dr. Segay.
The Chair now recognizes Ms. Moak for 5 minutes to testify.
STATEMENT OF DEBBIE MOAK, CO-FOUNDER, NOT MY KID
Ms. Moak. Chairwoman McSally and distinguished Members of
Congress, thank you for having me here today. It is an honor.
Generally, when we talk about opioid abuse or drug abuse in
general, we think about three different buckets: Supply,
demand, and harm reduction strategies. I am going to focus my
comments primarily on demand and touch on harm reduction
strategies.
In the midst of an opioid epidemic, I want to see people
find access to treatment to save lives while preventing the
next generation from starting down this path. We must do both
simultaneously.
About a decade before we founded notMYkid, drug abuse was
the No. 1 issue on the minds of Americans. This country went to
work, and we made huge strides in and from all sectors. Yes, it
was law enforcement, but it was also everyone else too,
including Hollywood, churches, sports professionals. This
country knows how to take an issue, like we have done with
tobacco use, seriously when it wants to, and in the late 1980's
and early 1990's, we did that.
The results were nearly miraculous. We reduced drug abuse
in this country by over 50 percent by 1993 when we got focused.
We did in this country what we too often do: We felt we solved
it, and we moved on. So we should look back to those years and
look at those strategies of what worked.
I will tell you this: We need to adopt those strategies and
funding consistently and grind them out without gaps year after
year.
Too often I am dismayed because I hear smart, responsible
citizens tell me that it is impossible to turn back our drug
use problem here in the United States, and I say you are wrong.
It must start first with our will to do so. The mass poisoning
of millions can be stopped with a serious effort.
We have addressed drug crises like crack cocaine, crystal
meth, and now must employ similar strategies for the opioid
epidemic. We actually know what to do. We have been here
before. But every single American has a role to play.
Yes, I said substance use, because I don't just single out
opioids, even in the midst of a crisis. America has a drug use
problem. Of course, we see whatever is coming across our
borders, what is coming through our postal system, and what is
being produced here in America. That will trend what we are
seeing that ends up in our homes, depending on what the supply
is. Addressing demand or use of all substances needs to also be
done simultaneously. That is the best evidence-based practice,
versus singling out one substance.
I want to share with you some effective programs that are
happening here in Arizona that can be employed more widely. Our
Arizona Use Survey of 2016 is a road map for us. It tells us
that youth use drugs for the following reasons, and in order:
To have fun, to feel good, to deal with stress, and to avoid
being sad. In other words, youth want to alter how they feel.
Sadly, adults have sent them many messages that impact that
thinking.
We have told kids that things like marijuana is medicine
when we vote to change medicine to recreate with it. We see
commercials every time we turn on the TV that tell us there is
a fix for every feeling that we have.
The survey also gives us a road map, however, for how to
keep kids from using drugs. The top reasons why kids don't use
drugs are: It is of no interest to them; they understand the
harmful effects; they don't want to disappoint their parents;
and that they are illegal. These are all points of data.
Arizona has a campaign unlike the ``Just Say No'' campaign.
Arizona has a campaign called--I call it a ``Just Say Yes''
campaign. Say yes to I have something better to do. We connect
youth to local opportunities in their counties to play sports,
hike mountains, go to a concert, volunteer and, quite frankly,
get reengaged with their own families.
We have to inspire kids to seek out their passions and
dreams and help them to get there. When was the last time we
have seen a great PSA or campaign continued not only throughout
the year without interruption here in Arizona and certainly
across the United States? We can do that, and Arizona already
has a great campaign ready to be scaled.
We also know that talking to our kids with an educated
parent may reduce substance abuse by 50 percent. Yet, the
Arizona Youth Survey shows us that only 50 percent of 8th
graders have had that conversation with a parent in the last
year. Sixty percent of seniors have not had that conversation
with a parent in a year. Fix that. Focus on that. Mandatory
parent, youth, and faculty involvement in prevention
programming that educates youth, parents, and faculty at the
same time exists here in Arizona. However, that program has
great data provided by ASU in its reach, and we won't have
funding for it next year.
SBIR, one of the 56 Opioid Commission recommendations:
Screening, brief intervention, referral to treatment. Yes,
screen all high school students for mental health and substance
use. Ninety percent of all addiction occurs from what kids do
during the teen years. That gives us our target and a bulls-
eye. Screen youth during these years to support and intervene
early when it is easy to turn the situation around, when it is
least costly to youth and society. We used to screen kids for
things like vision or scoliosis, and when we screen all kids,
it is not weird and no one gets singled out or stigmatized.
When notMYkid has a program where kids are being funneled
there who have been caught with first use, and it has tripled
in a year in its size because schools are desperate for this,
it is called Project Rewind.
So on first use of a kid, we work with them. Kids shouldn't
be kicked out of school. We should help them and their families
receive appropriate resources; again, something else that
already exists and we can scale.
Youth feel loved and protected when adults set boundaries
and offer support. Today's youth feel alone, isolated, and
stressed more than ever. This is a place for adults to get
educated and connect, and I am letting you know that embedding
behavioral health in our schools is key.
Ms. McSally. Ms. Moak, can you wrap up your testimony and
we will continue on with the questions?
Ms. Moak. Oh, I am so sorry. Yes, ma'am. I am so sorry.
Ms. McSally. That is OK.
Ms. Moak. As you can see, I am quite passionate.
Ms. McSally. You are.
Ms. Moak. Then in closing I will just say there are five
things I would like you to remember.
Prevention is the healthiest and cheapest.
The Federal Government must provide visible leadership to
convene all parties.
We must recognize behavioral health as important as
education in school settings.
We need on going public- and private-sector commitments.
We must make access to treatment available.
Thank you.
[The prepared statement of Ms. Moak follows:]
Prepared Statement of Debbie Moak
I want to thank this committee for addressing this serious issue,
this most serious of issues. Generally, when speaking to an audience
like this I would address supply, demand, and harm reduction
strategies. Knowing the expertise of the other panel members today I
will focus my comments on demand and touch on harm reduction. In the
midst of an opioid epidemic I want to see people find access to
treatment to save lives, while preventing the next generation from
starting down this path. We must do both simultaneously.
The context for my comments today come from 10 years as a classroom
teacher, behavioral health education, 20 years in non-profit
prevention, previous director for Governor Ducey's Office of Youth,
Faith, and Family and someone who's been in the trenches with her own
family and thousands of other families for 20 years with addiction.
About a decade before we started notMYkid, drug abuse was the No. 1
issue on the minds of Americans. This country went to work and we made
huge strides--in and from all sectors. Yes, it was law enforcement, but
it was also everyone else, too--from schools to churches to synagogues
to Hollywood to professional sports. This country knows how to take an
issue, like we've done with tobacco use, seriously when it wants to and
in the late 1980's and early 1990's we did.
The results were nearly miraculous. We reduced drug abuse in this
county by over 50 percent by 1993. And then we did in this country what
we too often do: We moved on. We should look back to those years and
use those successful strategies. We've done this before, we can do this
again. We must first have the will and focus to grind these strategies
out, year after year without fail. This should be one of our most
diligent efforts and focused priorities as a Nation. Too often I hear
smart, responsible citizens say that it's impossible to turn America's
drug use around and I say, you're wrong! The mass poisoning of millions
can be stopped with a serious effort. Anyone who actually believes that
we can't do this is part of the problem, not the solution.
We have addressed drug crisis before including crack cocaine,
crystal meth, and now must employ similar strategies to the latest
epidemic, opioids. We actually know what to do as we've been here
before. Every single American has a role to be played in reducing
substance use. Yes, I said substance use vs. singling out opioids.
America has a drug USE problem. Of course we see use trends spike as
different drugs make it across our borders, through our U.S. Postal
Service and onto our streets. Yes we must specifically address the
opioid epidemic with urgency, but we must also begin to see the
pattern. Both what comes across our borders and what is produced here,
be it spice, molly, bath salts and more, are what citizens will use. In
short, we have a USE problem in the United States. Addressing demand or
use on-going of ALL substances must be consistent and evidenced based
year after year.
Let's first take a look at some successful prevention strategies
employed here in Arizona, but with intermittent or no continued funding
sources to continue annually. We must prevent future generations from
following the path of drug use and abuse.
The Arizona Youth Survey 2016 tells us that youth use drugs to have
fun, feel good, deal with stress and avoid being sad. In other words,
youth want to alter how they feel through a drug, and adults have sent
them that message in so many ways. We've told kids things like
marijuana is medicine when we vote to change medicine so we can
recreate with it, we see commercials every time we turn on the TV that
tell us there's a fix for every feeling we have just ask your doctor
for this pill. But the survey also gives us a roadmap for how to keep
them from using drugs. The top reasons why kids don't use drugs are:
It's of no interest in them, they understand the harmful effects, they
don't want to disappoint their parents, and they're illegal. All points
of data that we can implement like the campaign we started here in the
State of Arizona. Instead of the ``Just Say No'' campaign Arizona has
created a just say yes campaign. Say yes to ``I've Got Something Better
To Do''. Connecting youth to local opportunities to play sports, hike
the mountains, listen to a concert, or volunteer connects them to their
passions, dreams, and families. When people in our country shame,
stigmatize, and don't want to spend money to help those with a chronic,
relapsing, brain disease, I often think, do they not remember that the
average age of first use in this country is 13. We're talking about
helping people who began their drug use as a teenager. Funding for this
campaign is intermittent at best and must be sustained year-round for
maximum impact.
We all know that talking regularly with an educated parent about
substance abuse can reduce drug use by about 50 percent. Yet, the
Arizona Youth Survey shows us that 50 percent of AZ 8th graders and
their parents didn't talk about drugs in the last year and almost 60
percent of seniors didn't hear from their parents either. Fix that,
focus on that, mandatory parent, youth, and faculty involvement in drug
education like the program we launched in Arizona, Healthy Families
Healthy Youth, prevention programming that educates youth, parents, and
faculty at the same time. These are researched-based and have great
data to support the effectiveness of this program, but as is the norm,
there will be no money to continue this cost effective, data-driven
prevention program next year.
sbirt-screening, brief intervention, referral to treatment
Yes, screen ALL high school students for mental health and
substance use. Ninety percent of all addiction start in the teen years.
Screen youth during these years to support and intervene early when
it's easiest to turn the situation around, when its least ``costly'' to
our youth and society. When we screen all youth in a school setting no
one gets singled out, no one is weird, like vision screening used to
be: It's preventative and helpful to connect youth and their families
to resources. One such intervention program at notMYkid has tripled in
size rapidly through school referrals, Project Rewind. When a kid is
first caught with a substance we need to intervene to stop its
progression vs. kicking them out of school. As we look at our schools
across the country, I don't think anyone can deny that it's about
schools, prevention, early diagnosis and connecting kids to resources.
As we look back at all the school violence, someone or multiple
someones knew there was a problem with the school shooters. We need to
change school culture and create meaningful prevention programs with
access to resources early. Youth feel loved and protected when adults
set boundaries and offer support. Today's youth feel alone, isolated,
and stressed more than ever. This is a place for adults to get educated
and connect to our youth facilitated in school settings.
As we moved on from the early 1990's, the crisis came back and
today we are at epidemic portions with over 64,000 Americans dying a
year from drug overdoses. Every year now, we lose more people to drug
overdose deaths than all the names gathered over 18 years on the
Vietnam Memorial Wall. In the District of Columbia.
That, of course, is the worst of it--we haven't even begun to
account for family breakup, social services being stretched, criminal
activity and costs, workplace accidents, dropouts, and education
deficits, ER admissions, lost productivity. Once we do--we're talking
hundreds of billions of dollars to America on this one problem, this
one problem that drives so many other problems. Please let me be clear,
although I have written my share of checks to organizations to help
someone get off the streets, find a treatment bed, or pay for a meal,
I'd much prefer to invest in a system of prevention which offers the
greatest rewards to the individual and society.
To those of us who know friends and family in rehab we know two
things: (1) Those are the lucky ones, the fortunate ones. Most don't
get to or find rehab. Approximately 23 million people need treatment
for a substance use disorder annually, yet sadly, only about 10 percent
will receive it. (2) Sobriety is a life-long commitment that is
addressed every day. Recovery is not linear, but relapse does not have
to be a part of a person's story. Relapse is all too common and I don't
accept that norm. I have lived through this personally with a son and a
sister. Fortunately my son is with me, but my sister is not.
I have spent, as do others, tens of thousands of dollars on detox
and treatment just to see my investment of love and resources lost with
a relapse. The scariest day of a recovering addict's life is the day
they leave the treatment center. We literally have built and funded a
system for decades that hasn't changed and worse yet, rewards failure
by bad actors. To be clear, there are many wonderful treatment centers
and even more trained and compassionate counselors who want to help
people. But I fear, and my experience has been, that there are far too
many in this field who prey upon individuals and families at one of
their most vulnerable times in life. Most business models would be
rewarded for success and innovation in their fields, but we financially
reward those in this field more when they have terrible outcomes or no
outcomes at all! Let's hold treatment centers accountable for
verifiable outcomes. I know you're thinking that's impossible, but I
assure you it is not. Through technology-assisted care, peer support
programs, drug testing, and more we can and must know which treatment
centers are doing the best job and reward them. This type of
programming actually already exists. In all candor, I share with you
the only technology that does all of this today, that I am aware of,
which was created by my son Steve who is here with me today. That
program is called True After Care. There are likely others in the field
who do something similar and I want to know more about them as well.
The bottom line is, let's fund what works and demand verifiable
outcomes! Recovery needs to be a part of treatment. No one should leave
a 30-day treatment program without a serious support system like True
After Care to complete their journey into long-term sobriety.
So in conclusion I want you to remember five things: (1) Prevention
is the healthiest and most affordable choice we can ever make
decreasing demand for drugs, (2) The Federal Government must provide
visible leadership to create and convene all Americans in this effort,
(3) We must recognize behavioral health as equally important as getting
an education and imbed programs into our schools, (4) We need on-going
public- and private-sector commitments, (5) Last, we must make access
to treatment widely available.
Drugs will always be here, so our message of prevention must be the
louder of the two. We've done this before, we can and must do this
again as it is not an unknown science.
Ms. McSally. Thank you.
The Chair now recognizes Mr. Cory for 5 minutes to testify.
STATEMENT OF JAY A. CORY, CEO AND PRESIDENT, PHOENIX RESCUE
MISSION
Mr. Cory. Thank you, Chairwoman McSally and committee, for
allowing me to be here to share today.
Arizona faces an epidemic of substance abuse that
translates into staggering costs to our State. It is one of the
leading causes of homelessness, poverty, crime, rising medical
costs, incarcerations, repeat offenders, recidivism, child
removal into State custody, and family deterioration.
I am going to dispense with statistics, as we have heard
plenty.
The opioid crisis is a wake-up call. However, substance
abuse, other addictions, and negative behavioral manifestations
such as violence and abuse continue to rise as well. Society
continues to increase its desire for instant gratification,
self-medication, and escape.
The problem is greater than just availability of chemicals.
Our society is declining spiritually. We have seen the
breakdown of the family with more fatherless households and a
growing number of those who cannot sustain themselves and
afford the cost of living.
The problem does not operate in isolation. There is a large
underserved population of men, women, and families facing
poverty, homelessness, and trauma in Arizona, and especially in
the Phoenix metropolitan area.
Poverty. There are over 1.1 million persons, or 16.4
percent of Arizona, below the poverty line.
Homelessness. There are more than 37,000 persons who
experience homelessness in Arizona, and there may be as many as
8,900 homeless on any given night. In Maricopa County there
were 22,000 experiencing homelessness, or 54 percent of the
State's total, with more than 5,600 on any given night.
Lack of affordable housing. There is grossly insufficient
affordable housing in Arizona, and often it is not safe and
healthy. Many leave recovery programs or incarceration and go
right back to use because they can't afford to live.
Recommended solutions. Phoenix Rescue Mission applauds the
efforts to reduce supply and efforts toward prevention of
substance abuse. Phoenix Rescue Mission also supports the
efforts of medication-assisted treatments to reduce cravings
for and effects of opiates.
There is an immediate, drastic need for increased capacity
for cost-effective, comprehensive residential and non-
residential programs that provide pathways out of poverty,
homelessness, addiction, and other life-controlling problems.
Most need more than just temporary relief or short-term
programs and are unprepared for direct placement into housing.
These programs should include a crisis component, crisis
stabilization, get people out of situations that they are in,
bring them to a safe place where they can be assessed and
properly placed.
There needs to be a drastic increase in comprehensive
recovery programs, both short- and long-term, ``comprehensive''
meaning case management services, academic assistance, English
as a second language, vocational development, job placement,
spiritual growth, and counseling.
Reentry. There needs to be expanded capacity for housing
and support services for persons completing residential work.
Recommended solution. Work in partnership with faith-based
providers. Example: Association of Gospel Rescue Missions.
Phoenix Rescue Mission is a member of the Association of Gospel
Rescue Missions. There are seven member missions in Arizona.
Now in its 105th year, the Association is North America's
oldest and largest network of independent crisis shelters and
rehabilitation centers. Each year AGRM members serve more than
65 million meals, 24 million nights of lodging, 36,000 people
find independent housing, and they assist about 45,000 people
in finding employment, and 17,000 people from addiction
recovery programs are placed into productive living.
Just a little experience, recent experience from the
Phoenix Rescue Mission. The first step into admission into all
residential programs is called RAP, which is a 7-day triage
program. Statistics for the last 10 months, ending April 30, we
admitted 542 unduplicated men. The top three presenting
problems were homelessness, financial crisis, and substance
abuse. The top disclosed drugs of choice for substance abusers
were alcohol, stimulants, cannabis, and opioids. Opiates were
38 percent. Three hundred and ninety-two, or 72 percent of the
men were successfully placed in appropriate solution
programming, with 254 or 47 percent being placed in our first
phase recovery program. People are getting off the streets, and
they are getting plugged into treatment programs.
On the women's side, we had 217 unduplicated women, the
same basic breakdown of presenting problems, with a 40 percent
opiate. So we are out on the streets.
A couple of anecdotal points. Because of our street teams
that go out on the street, we have two vans out there every
day. They are younger. Obviously, heroin is increasing as a
drug of choice. It is less expensive. We are seeing that the
results of our efforts to reduce prescription meds on the
street is taking effect because they are becoming more
expensive. However, people are turning to a cheaper alternative
such as heroin.
Thank you for allowing me to share.
[The prepared statement of Mr. Cory follows:]
Prepared Statement of Jay A. Cory
May 30, 2018
the problem
Arizona faces an epidemic of substance abuse that translates into
staggering costs to our State. Substance abuse is one of the leading
causes of homelessness, poverty, crime, rising medical costs,
incarcerations, repeat offenders, recidivism, child removal into State
custody, and family deterioration.
According to AZ DHS website for the period 6/15/17-5/24/18, there
were:
1,238 Suspected opioid-related deaths,
8,022 Suspected overdoses,
766 Neonatal Abstinence Syndrome,
5,262 Naloxone doses administered,
347,816 Opioid prescriptions dispensed last month.
The opioid crisis has been a wake-up call. However, substance
abuse, other addictions, and negative behavioral manifestations such as
violence and abuse continue to rise as well. Society continues to
increase its desire for instant gratification, self-medication, and
escape.
The problem is greater than just availability of chemicals. Our
society is declining spiritually, we have seen the breakdown of the
family unit with more fatherless households, and a growing number of
those who cannot sustain themselves and afford the cost of living.
The problem does not operate in isolation. There is also a large
underserved population of men, women, and families facing poverty,
homelessness, and trauma in Arizona and especially in the Phoenix
metropolitan area.
Poverty.--PRM provides services in some of the most poverty-
stricken areas of our community and Nation. Many lack the
basics needed to sustain themselves and are often only one step
away from homelessness. They are often unaware or unable to
connect to services that may assist them. There are over
1,100,000 persons or 16.4 percent in AZ below poverty line
ranking 43rd in the Nation. More efforts are needed to provide
elevation through vocational development and education.
Homelessness.--According to AZ DES 2017 report, more than
37,000 persons experienced homeless in AZ and there may be as
many as 8,900 homeless on any given night. In Maricopa County
there were over 22,000 experiencing homelessness or 54 percent
of the State's total with more than 5,600 on any given night.
Of those experiencing homelessness, 67 percent were single
adults, 12 percent were adult members of families, and 21
percent were children in families. Causes include economic
factors, substance abuse, mental health issues, and domestic
violence.
Lack of Quality Affordable Housing.--There is grossly
insufficient affordable housing in Arizona and often it is not
in a safe and healthy environment. Many leave recovery programs
or incarceration and go right back into a war zone. Housing is
the fundamental intervention that moves an individual or family
from homelessness to self-sufficiency. Without housing, all
other intervention programs are less effective. There is a
great need to provide healthy supportive housing communities.
recommended solutions
Phoenix Rescue Mission (PRM) applauds the efforts to reduce supply
and efforts toward prevention of substance abuse.
PRM also supports the efforts of medication-assisted treatments to
reduce cravings for and effects of Opioids (example--Vivitrol).
There is an immediate drastic need for increased capacity for cost-
effective comprehensive residential and nonresidential programs that
provide pathways out of poverty, homelessness, addiction, and other
life-controlling problems. Most need more than just temporary relief or
short-term programs and are unprepared for direct placement into
housing. Their life-controlling problems are often complex and need
comprehensive community and residential services. These programs should
include:
Rescue--Crisis Response and Stabilization to prevent further
decline by meeting basic needs, providing stability, support,
assessment, and guidance in developing and executing a solution
plan. Motivated persons must have their immediate needs met or
brought to a safe place so they can be properly assessed and
placed into the right solution pathway.
Recovery from Life-Controlling Problems--Comprehensive
services to address the total person toward solutions and
sustainability. Services such as case management, connection to
services, academic assistance such as GED/High School Diploma,
and English as a Second Language, vocational development and
job placement, spiritual growth, counseling, life skill
development, short- and long-term addiction recovery.
Re-Entry--Expanded capacity for housing and support services
for persons completing residential recovery programs, existing
incarceration, and other populations so that they can continue
forward momentum.
Work in partnership faith-based providers. Many do excellent work
and receive little to no Federal funding. Remove barriers and provide
equal opportunity for funding. An example:
AGRM--PRM is a member of the Association of Gospel Rescue
Missions. There are 7 member missions in Arizona. Now in its
105th year, AGRM is North America's oldest and largest network
of independent crisis shelters and rehabilitation centers. AGRM
has nearly 300 rescue mission members across North America.
Each year AGRM members serve more than 65 million meals,
provide more than 20 million nights of lodging, and help more
than 36,000 people find independent housing, assist about
45,000 people in finding employment, bandage the wounds of
thousands of abuse victims, and graduate nearly 17,000 people
from addiction recovery programs into productive living. Every
year, AGRM members use 300,000 volunteers and 10,000 full-time
staff to serve.
prm's recent experience
Rescue-Assess-Place (RAP) Program.--Is the first step for admission
into all PRM programs and is a maximum 7-day residential triage program
for motivated adult men, women, and mothers with children under the age
of 12 facing homelessness and/or seeking recovery from addiction or
other life-controlling problems. PRM Rescue-Assess Place (RAP) Program
statistics for last 10 months 7/1/17-4/30/18.
PRM admitted 542 unduplicated men into RAP. The top 3
presenting problems disclosed were homelessness (513 or 95
percent), financial (434 or 80 percent), and substance abuse
(337 or 62 percent). The top disclosed drugs of choice for
substance abusers were alcohol, stimulants, cannabis, and
opioids (38 percent). Note: 392 or 72 percent of men were
successfully placed in an appropriate solution program with 254
or 47 percent being placed in PRM's Foundations (phase 1
recovery program).
PRM admitted 217 unduplicated women into RAP. The top 3
presenting problems disclosed were substance abuse (170 or 78
percent), homelessness (103 or 47 percent), and financial (91
or 42 percent). The top disclosed drugs of choice for substance
abusers were stimulants, alcohol, and opioids. (40 percent).
Note: 177 or 82 percent of women were successfully placed in an
appropriate solution program with 117 or 54 percent being
placed in Foundations.
Street Outreach.--PRM's Street Outreach ministries go out in Hope
Coach vans to engage unsheltered homeless individuals to rescue them
off the streets and into appropriate solutions. Basic survival needs
such as water and hygiene kits are provided. Street Outreach partners
with law enforcement and first responders and caseworkers to provide
solutions to homeless individuals and the neighborhoods affected by
homeless camping. PRM's street teams are trained and equipped in the
use of Naloxone (Narcan). From 7/1/17-4/30/18 Street Outreach:
Engaged over 650 individuals for attempted rescue.
95 were engaged off the street and transported off the
street and connected to services.
25 percent of those rescued were admitted opioid abusers.
55 were admitted to PRM's RAP program.
Anecdotal observations from the street teams over the past few
months:
The three greatest segments of those on the streets are
substance abusers, mentally ill, and service resistant.
Particularly among the substance abusers there is a large
number that are responsive to ``hand-up'' options when properly
engaged and the timing is right.
Heroin continues to be prevalent on the streets and is
rapidly ascending as a drug of choice. It is available and less
expensive than many other choices.
There is a growing number of heroin addicts that started as
result to addiction to pain medication. Many of these are
relatively inexperienced in homelessness and are vulnerable.
Pain medication is decreasing in supply and becoming more
expensive. Heroin is a much less expensive option and more
readily available.
Many panhandlers are substance abusers with an increasing
number addicted to heroin.
PRM has experienced success in working with clients in recovery
from opioid addiction particularly in its long-term ``Transformations''
recovery program. Currently both the men's and women's RAP program are
run by graduates each with over 5 years sobriety. Graduates are also in
leadership positions with our Street Outreach and Foodbank operations.
To see many of PRM's stories of success, please visit
www.phoenixrescuemission.org.
PRM has current plans to expand its residential capacity for men's
recovery by over 300 beds with anticipated construction beginning by
the end of 2018.
Ms. McSally. Thank you, Mr. Cory.
The Chair now recognizes Mr. Warner for 5 minutes to
testify.
STATEMENT OF WAYNE WARNER, DEAN OF MEN, TEEN CHALLENGE
CHRISTIAN LIFE RANCH
Mr. Warner. Thank you, Congressman McSally and Ranking
Member Grijalva. I want to thank the distinguished Members of
the subcommittee for allowing us to come today. I also want to
thank the current and past panels for all their efforts. It is
an absolute honor to represent Teen Challenge of Arizona today
as a graduate of the program.
Like Mr. Cory, I will also be dispensing with statistics
and simply share my personal experience with addiction.
My name is Wayne Warner, and I am the dean of men at the
Teen Challenge Christian Life Ranch in New River, Arizona.
Miraculously, I am an ex-opioid addict that has had the
pleasure of not only testifying today but also being alive
after an extensive period of illicit drug use took me down a
path of misery and discontent.
My story begins at 16 years old, when a conflict at school
left me with the ring and pinky appendage of my left hand
severed after a door was closed on them. I cite this experience
not for the trauma or the pain, but the pain management I
received for my injury. I was a 16-year-old handed narcotics to
take when I ``needed'' them to manage the pain in my hand. I
remember this experience vividly, and I still refer to this as
the day I first felt OK with myself.
Although I so enjoyed this feeling, the thought of becoming
a drug addict truly terrified me to my core. It would take a
few years for my addiction to truly take over my life. After a
seemingly slow graduation from marijuana to pills again and
then eventually heroin, I found myself homeless, jobless, and
nearly lifeless. I had been arrested several times, charged
with felonies, and sent on my way time and time again. I was an
angry, injured shell of a human being attempting to carry
around the fragmented pieces of my life from rehab to rehab
until I could get enough rest to find the energy to wake up and
do it all over again.
Life at this point was meaningless and people were
pointless. Love was an idea, abandoned and buried in the
cemetery with my relationships with my family and friends.
People would die around me and I felt like the lone sailor in
the sea, waiting for the shark of addiction to come up and
ambush me from beneath, but I was not afraid of him. I was
afraid that I would have to wake up when the sun rose and the
slow and painful torture of withdrawal would begin to set in
once again.
I was arrested for the last time on October 28, 2012 after
I stole a vehicle from the family member of a friend in order
to pick up a bag of heroin with the last $20 I had to my name.
As I spoke through the bars of the back window of the Peoria
Police Tahoe, I recall giving my mother's name and her number
to my friend and asking him to tell her that I was arrested
once again and to please just leave me in jail this time.
Unbeknownst to me, on that very same day, two men from the
Christian Life Ranch in New River, Arizona would knock on the
door of a woman's house that desperately needed her son to get
help. They gave their testimonies, prayed with her, and
promised her they would pray for her son to get the help he
needed. That woman's name is Tammy, and she is my mother.
I was sentenced, I served my time, and I was released. It
was ordered that one of the conditions of my probation would be
the completion of the Teen Challenge program. It was also made
clear to me that in the State of Arizona I would then and
always carry the legal label of ``felon'' indefinitely.
Over the following years a few major milestones would be
achieved in my life. Teen Challenge and adult probation were
completed. I committed to and completed an internship at The
Ranch and was later hired on as a full-time employee.
This might sound like every other redemptive story you have
heard, and you might be partially correct. There is one thing
that makes me different, and that is the fact that I have had
my immediate family and my Teen Challenge family behind me
every step of the way. They never gave up, never put me down,
and never stopped loving me.
I was baptized, affirmed, counseled, and unconditionally
loved. I owe a debt of gratitude not only to both my family and
my program but also to Jesus Christ, my personal Lord and
savior. If it weren't for these relationships being so strong
and dependable, I would not be where I am today. My life has
now exponentially improved. I get to be part of a team of
leaders that is spearheading the effort to discuss and resolve
the real-life issues that people like me have dealt with and
some of us have died because of. I am sought after for
guidance, support, and even advice.
I will be celebrating 6 years of sobriety this October. I
will be celebrating my 1-year anniversary with my wife Kendra
this June, and we will be celebrating the birth of our newborn
baby boy in July.
It is through the program of Teen Challenge, programs like
it, the people that work there, and the grace of God that I am
able to speak in front of you today.
There is hope for the epidemic our country and our world is
currently facing, and that hope is found in love.
Thank you, and God bless.
[The prepared statement of Mr. Warner follows:]
Prepared Statement of Wayne Warner
My name is Wayne Warner and I am the dean of men at the Teen
Challenge Christian Life Ranch in New River, AZ. Miraculously, I am an
ex-opioid addict that has the pleasure of not only testifying today;
but also being alive after an extensive period of illicit drug use took
me down a path of misery and discontent.
My story begins at 16 years old, when a conflict at school left me
with the ring and pinky appendage of my left hand severed after a door
was closed on them. I cite this experience not for the trauma nor the
pain, but the pain management I received for my injury. I was a 16-
year-old, handed narcotics to take when I ``needed'' them to manage the
pain in my hand. I remember this experience vividly and still refer to
this as the day I first felt ``OK'' with myself.
Although I so enjoyed this feeling, the thought of becoming a drug
addict truly terrified me to my core; it would take a few years for my
addiction to truly take over my life. After a seemingly slow graduation
from marijuana, to pills again and then eventually heroin; I found
myself homeless, jobless, and nearly lifeless. I had been arrested
several times, charged with felonies and sent on my way again time
after time. I was an angry, injured shell of a human being attempting
to carry around the fragmented pieces of my life from rehab to rehab
until I could get enough rest to find the energy to do it all over
again. Life was meaningless and people were pointless. Love was an
idea, abandoned and buried in the cemetery with my relationships with
my family and friends. People would die around me and I felt like the
lone sailor in the sea; waiting for the shark of addiction to come up
and ambush me from beneath; but I wasn't afraid of him. I was afraid
that I would have to wake up when the sun rose and the slow and painful
torture of withdrawal would begin to set in once again.
I was arrested for the last time October 28, 2012 after I stole a
vehicle from the family member of a friend in order to pick up a bag of
heroin with the last $20 I had to my name. As I spoke through the bars
of the back window of the Peoria Police Tahoe I recall giving my
mothers' name and number to my friend and asking him to tell her that I
was arrested once again, and to just leave me in jail.
Unbeknownst to me, on that very same day, two men from the
Christian Life Ranch in New River, AZ would knock on the door of a
woman's house that desperately needed her son to get help. They gave
their testimonies, prayed with her and promised her they would pray for
her son to get the help he needed. That woman's name is Tammy and she
is my mother.
I was sentenced, I served my time, and I was released. It was
ordered that one of the conditions of my probation would be the
completion of the Teen Challenge program; it was also made clear to me
that in the State of Arizona I would then and always carry the legal
label of ``felon'' indefinitely. Over the following years a few large
milestones would be achieved in my life. Teen Challenge and Adult
Probation were completed; I committed to and completed an internship at
The Ranch and was later hired as a full-time employee.
This might sound like every other redemptive story you've heard,
and you might be partially correct. There is one thing that makes me
different; that is the fact that I have had my immediate family and my
Teen Challenge family behind me every step of the way. They never gave
up, never put me down, and never stopped loving me. I was baptized,
affirmed, counseled, and unconditionally loved. I owe a debt of
gratitude, not only to both my family and my program; but also to Jesus
Christ, my personal Lord and Savior. If it weren't for these
relationships being so strong and dependable, I would not be where I am
today. My life has now exponentially improved. I get to be part of a
team of leaders that is spear-heading the effort to discuss and resolve
the real-life issues that people like me have dealt with and some of us
have died because of. I'm sought after for guidance, support, and even
advice. I will be celebrating 6 years of sobriety this October. I will
be celebrating my 1-year anniversary with my wife Kendra this June; and
we will be celebrating the birth of our newborn baby boy in July. It's
through the program of Teen Challenge, the people that work there and
the Grace of God that I am able to speak in front of you today. There
is hope for the epidemic our country and our world is currently facing;
and that hope is found in love
Thank you and God Bless.
Ms. McSally. Thank you, Mr. Warner, for your courage to
share your personal story with us. It is pretty powerful.
Mr. Schweikert needs to leave, so I am now going to
recognize him first for questions.
Mr. Schweikert. Thank you for that.
Being raised by a woman who spent much of her later adult
life in a 12-step program and then became a substance abuse
counselor right down the street here, trying to recruit drug-
addicted prostitutes off the street, you don't sometimes
process the human tragedy substance abuse can be.
I have to leave in a moment, but I do have some questions.
Dr. Christ, just because it bothered me but also was
optimistic, you made a comment that we have a 50 percent
reduction in high-volume prescriptions for opioids.
Dr. Christ. Yes.
Mr. Schweikert. For the remaining 50 percent, how much of
that is palliative, of the remaining 50 percent?
Dr. Christ. So that would be through our Controlled
Substances Prescription Monitoring Program. What we are doing
is the 90. A lot of it is going to be pain management.
Mr. Schweikert. That is actually where I am going. We have
all had this issue in our lives, someone who is in hospice, for
those things. In that case there is going to be pain
management. My concern is 50 percent reduction is miraculous.
What if that remaining 50 percent is still bad actors, and what
if that is just what should be the baseline in our society? I
know I am asking you to speculate, but you are bathing in the
data.
Dr. Christ. Right. We can go back and look. That is a very
interesting question. I don't know that I have the specifics
because we would have to go back and match medical records.
Mr. Schweikert. It is hard, but that is actually one of the
things I am after. If you are making an argument that opioids
are different than other types of addictions in our society,
that this gateway comes through our medical profession, so the
demographics are different, the population looks different than
often the youth and other types, but of our population, how
many should be there? If it is only another 10 percent or so,
we need to solve that other 40 percent. Am I making sense?
Dr. Christ. Absolutely.
Mr. Schweikert. What do we do as Federal policy makers? I
am working on a technology piece that does a prior
authorization. That is bipartisan. That will go through. But is
it a technology solution? Is it a data solution? Is it a human
solution? Help us find one.
With that, Madam Chairman, I yield back. Forgive me, I must
leave.
Ms. McSally. Absolutely.
Dr. Christ, do you want to reply at all?
Dr. Christ. I would say it is probably all three. So it is
probably going to be a technology solution, a data solution,
and a human solution. But out of concern for those who do need
it for hospice or end-of-life or palliative care, that has been
exempted and they are not required to stick to the dose
restrictions.
Mr. Schweikert. We need to understand how much of our
population prescription usage is that population, and then the
rest we need to analyze and understand.
Dr. Christ. Absolutely.
Mr. Schweikert. Thank you.
Ms. McSally. The Congressman yields back.
The Chair now recognizes the acting Ranking Member, Mr.
Grijalva, for 5 minutes.
Mr. Grijalva. Thank you very much.
First of all, Mr. Warner, thank you for sharing with us and
everybody. Your journey, as difficult as it was, it was a
light, and we appreciate you taking the time to be with us
today and sharing that.
Dr. Christ, at the beginning of my opening statement I said
I wish somebody from the pharmaceutical industry was here, and
the reason is that there is no question in terms of linkage
that much of what we are dealing with right now with this
opioid crisis began with the prescription painkillers that
became part and parcel, and now you see an increase in heroin
and fentanyl as substitutes for that.
One of the reasons it is a question is that Naloxone, which
is a life-saving overdose drug was, interestingly enough, in
2014 it was $288 for an injection. Right now it is over $2,000
for an injection. I think somebody recognized a market, and
when local communities, particularly law enforcement and public
health officials, are attempting to get hold of this as a life-
saving opportunity to have out there, the price has been
raised. So I think they need to be part of this.
If you had $76 billion to spend on the opioid crisis
Nation-wide, where would you prioritize the money? What would
be your first priority?
Dr. Christ. I think going back to Ms. Moak's response, I
think this has to be a two-pronged approach. I think you need
to provide access to treatment and improve the ability for
patients that are currently suffering from opioid use disorder
to have access to the treatment they need. But I think in order
to respond and deal with this in the future, you really have to
have targeted prevention and harm reduction efforts.
Mr. Grijalva. Thank you. One of the studies showed that
since 2000 the cost of the opioid crisis has been $1 trillion,
and that in the next few years it could be $500 billion. So I
appreciate your answer, because I think that is one of the
focuses that we need to have when we talk about this.
Mr. Cory, in your experience, in dealing with the fine work
you do, particularly in outreach and retrieving people to try
to provide support, I am glad you brought up the issue of
poverty and other things that are contributing factors that we
don't talk about enough.
Do you believe that the majority of opiate users started
out on heroin and fentanyl?
Mr. Cory. We are dealing with people that are actually
right off the streets, people that are coming into our RAP
unit, which is more like a social detox. I think that there has
been a heroin problem for a very long time, there has been a
substance abuse problem for a very long time. I would say that
there has been an adjustment in the population. We are seeing a
new element enter into the population. Again, we are focused
sort-of at the bottom of the safety net in that they are
younger people that, because of prescription med addiction,
fell into heroin addiction. So they are younger. There are a
lot more females on the street than there used to be.
I don't know if I am answering your question.
Mr. Grijalva. You did.
Ms. Moak, in the limited time that I have, your testimony I
think did a great job of explaining why prevention is so
important and the various techniques that can be employed to
fight substance abuse in all forms and dealing with the opioid
crisis in this hearing.
Where does border security funding fall as a prevention
strategy to end the demand for drugs in this country, and how
do we reconcile the proposed cuts to nutrition, Medicare,
Medicaid, community development in terms of the efforts at
prevention?
Ms. Moak. I think that is a great question. Certainly, that
is prevention, not having these drugs come across our borders.
But for me, I like scaling what is most cost-effective and
makes the most sense, and that is not seeing our youth get
started using any type of drug. We have this crisis right now.
We have had others before. We will have others after this.
So working in the schools and scaling, quite frankly,
behavioral health right now in our school setting is a great
use of funds.
Mr. Grijalva. Dr. Segay and others, my time is up, but I
have written questions, and I appreciate Dr. Segay bringing a
perspective that sometimes at these hearings is not heard often
enough.
Thank you.
Ms. McSally. The gentleman yields back.
I now yield to myself in place of Mr. Schweikert.
Mr. Warner, thanks for sharing your personal story, and
congratulations on the coming birth of your daughter. It is
exciting and hopeful, and I think you know that some decisions
you made and what may have been intended for evil, God has used
for good in your redemptive path. So I am really proud of your
courage to be able to share that story and invest in others.
If you could talk to your 16-year-old self and look back at
that moment in time--you obviously had an injury, you were in
pain--what would you advise be done differently both within
your choices and those around you, whether it is the doctor or
others in your life, friends and family, in order to have you
go on a different path?
Mr. Warner. I am so glad that I have an opportunity to
speak more than just my testimony, because I have a lot of
opinions on this stuff, and so I just appreciate just this
moment in time.
First off, as Ms. Moak was speaking about, preventive
measures have to be taken. We actually do a segment called Stay
Sharp where we go into middle schools, high schools, and
elementary schools, and we give our testimonies to adolescent
children, and the teachers come up to us after and say, hey,
can you stay back and talk to this one person that I really
feel needs help? What that tells me is two things: This person
really doesn't have anybody to talk to at home, and they don't
have anybody to talk to at school. The teacher doesn't know
what to do until we just show up out of the blue and they
think, oh, I am so happy you guys are here, now this person can
speak. But we have a limited amount of time.
So having a representative from some type of organization
that is in the school that has a personal relationship with
these adolescents would be monumental in terms of being able to
sense where a person is and how they can help, No. 1; No. 2,
$76 billion, if we had that--I mean, just being able to fund
that type of thing inside of public schools and private
schools, not only are you going to see the addictions start to
drop because we are heading it off, we are nipping it in the
bud before it can even get to this epidemic, but then also
supply is meeting demand right now, and as long as you have
demand, you will get supply.
I don't want to diminish the task forces that we have heard
from today whatsoever, but the fact is that all of the drugs
that they have taken off the streets, I did not have an issue
finding them. I am letting you know that right now. It wasn't
like, hey, guess what? There was a big bust, we are not going
to get high today, unfortunately. I hate to be crass, but that
is the reality. It was never an impact.
So that was what I would have liked to have known, that
there was somebody there that understood me and that cared
about me. Thank you for your question.
Ms. McSally. Thank you, Mr. Warner.
As we have seen from this panel, we have now two faith-
based organizations and not $1 of Government funding. They are
changing lives and impacting lives, and a non-profit that is
also involved and engaged. Not every school needs to have the
Teen Challenge visitors. Not every school is going to be able
to have notMYkid. But the complementary nature of all of what
you are doing, combined with an appropriate Government role, I
think is really what has come out of this panel a lot, right?
It has to be all of the above.
Is there any sort of collaboration or coordination among
the non-profits with the Government, Dr. Christ, related to,
hey, we are focused over here, but there is really an issue in
this geographic area, or we need to be doing more on the
reservations and cooperating and getting some non-profits
coming in there? Is there some way for there to be that
collaboration in order to address this and identify where the
needs are, an all-of-the-above strategy?
Dr. Christ. I think that is a fantastic question. Through
the Governor's Council we did try to bring together
stakeholders, whether they were patients, associations, faith-
based, non-profits. But I think one of the biggest assets that
the Governor has is the Governor's Office of Youth, Faith, and
Family, because they do a fantastic job convening those
organizations and getting funding to them.
Ms. McSally. Ms. Moak, and then I want to ask Dr. Segay.
Ms. Moak. In fact, since I left the Governor's Office, that
is exactly what I am working on. We know that Federal/State
funds will never be enough to solve this. One example, one
small example, I am currently working with Blue Cross Blue
Shield, and their bottom line was we want to fund what you are
already doing, we don't want to start something from scratch.
So we are taking a look, again, at all the initiatives we
already have that have data and bringing in more private
sector, like Blue Cross Blue Shield, to scale.
Ms. McSally. Dr. Segay, Indian Health Services is,
obviously, critical on the reservation. Are there other non-
profits or others that would be culturally acceptable to be
able to partner with and help on the reservation for those who
are struggling with addiction? Are they present there?
Dr. Segay. Thank you for your question, Madam Chair. The
reality there on Navajo is that we have been trying to pretty
much demonstrate the effectiveness of our method of treatment
with traditional services, and it has been hard. We don't have
an evidence base as far as what ceremonies are effective or
disciplined. We have what is effective-based. So right now, all
of our ceremonies are traditional methods with our traditional
practitioners, and are not reimbursable. So it is really
complicated to say here is an evidence-based ceremony that
needs to be reimbursed.
In reality, we have been going to CMS and letting them know
that this needs to be reimbursable, pretty much. I mean, it
just connects to everything. So collaboration is happening
among our Tribal programs, our Public Law 93-638 facilities,
and IHS as far as their satellite, and then the Tribal
programs, keeping in mind that Navajo is 27,000 square miles,
with 350 enrolled members. Thank you.
Ms. McSally. Thanks.
I am totally out of time. Mr. Cory, I wanted to ask you a
question, but I want to respect everyone's time.
The Chair now recognizes Mr. Gallego for 5 minutes.
Mr. Gallego. Thank you, Madam Chair.
Ms. Moak, I actually missed it, but I was looking through
your testimony. You mentioned a program that was run out of U
of A that ran out of funds. Can you refresh my memory on that?
Ms. Moak. Yes, sir. It was actually a program that was
evaluated by ASU. The program was a prevention program where we
designed the curriculum, scaled it for the past 2 years into
7th grade, has great data, was loved by students, parents, and
faculty, very affordable and easy to scale, and literally we
don't have funding for it this coming year.
Mr. Gallego. So why don't you have funding for it this
coming year?
Ms. Moak. The grants change from year to year.
Mr. Gallego. The grants are coming from the Federal
Government or the State government?
Ms. Moak. Yes, sir. A Federal grant.
Mr. Gallego. Which department is it?
Ms. Moak. I apologize, I am blanking on that right now. But
the grant is not available to us next year.
Mr. Gallego. OK. If you could provide that information
tomorrow, I would greatly appreciate it.
Ms. Moak. Yes, sir, I will.
Mr. Gallego. Director Christ, you heard my comments earlier
to Governor Ducey. As someone who is very knowledgeable on
Medicaid, and someone like me who actually really is proud of
AHCCCS here in Arizona, I am concerned that there is a missing
link here among our Arizona government through the Governor,
that they don't actually quite understand how important
Medicaid is to preventing both opioid deaths and addiction.
Could you just give us some examples of how helpful
Medicaid expansion can be in terms of dealing with our opioid
epidemic?
Dr. Christ. Given the 5-minute limitation, I think that
that is a----
Mr. Gallego. I will give you 2 minutes of the 5 minutes.
Dr. Christ. OK. I didn't get to highlight how engaged
AHCCCS and the Medicaid program have been in Arizona's
response. We have partnered with Director Betlock and his team.
They are responsible for administering the $24 million State-
targeted response grant that came through SAMHSA last year.
They are actually integrating that into the Medicaid program so
that our substance abuse patients and those who are suffering
from opioid use disorder get the same services, and especially
for that $10 million funding that they found for the uninsured
and underinsured. That will be partnered with our AHCCCS
program.
So we are using Medicaid in Arizona as the base for
expanding our medication-assisted treatment and our treatment
options.
Mr. Gallego. To switch gears, in terms of FQHCs--I am
really bad with acronyms--Federally Qualified Health Clinics,
there has been a severe cut in terms of funding for FQHCs,
which deals with a lot of that population. Do you see it as a
good investment in terms of putting money back into FQHCs in
terms of trying to curb the human costs of the opioid epidemic?
Dr. Christ. Absolutely. I think that, luckily in Arizona,
we have a very strong partnership with our FQHCs and their
association, and so we are utilizing them. They are a perfect
resource. They are State-wide. They provide whole-person
integrated care. They are a great partner for our opioid use
disorder patients.
Mr. Gallego. Great. Thank you, Dr. Christ.
Dr. Segay, as you know, the opioid epidemic's impact on
Indian Country has been quite profound. Fully 10 percent of
Native children have used opioids for non-medical purposes,
which is double the rate of Anglo children. In addition, Native
women who are pregnant are nearly 9 times more likely to be
diagnosed with opioid dependency or abuse compared to the
general population.
This epidemic has also strained Tribal governments that
already are facing significant challenges in general.
In the face of so much suffering, what can we do as the
Federal Government to step in? I particularly ask this because
I am going to be the incoming Chairman of the Indian Affairs
next year and would like to make sure that I am ready and
prepared to be helping out Indian Country.
Dr. Segay. Thank you for that. Well, on Navajo, we pretty
much always try to educate our leaders. So we always make the
request to our leaders in Washington at the Federal level that
they come visit Navajo so that they can understand and see how
our health care delivery system is set up.
So, for example, in some areas it is 100 miles to the
nearest facility, and we don't have helicopter service, or even
our safety response is like a 2- or 3-hour response. So that is
where there is the golden hour, and that is where we lose a lot
of our people, especially if there is an opioid overdose.
Mr. Gallego. Not to take too much time, but this is
certainly a problem dealing with East Coast politicians. They
don't understand the concept of a Native American reservation,
because over there the land is the size of a stamp, and tribal
lands are the size of States compared to the East Coast. So I
do agree that we need to have that education for them.
Dr. Segay. Yes, and more funding for AHCCCS. Thank you.
Mr. Gallego. One hundred percent. I like how you got that
in under the wire.
[Laughter.]
Mr. Gallego. Thank you so much. Thank you for all your
testimonies.
Ms. McSally. The gentleman's time has expired.
The Chair now recognizes Ms. Lesko for 5 minutes.
Ms. Lesko. Thank you, Madam Chair.
Thank you, panel, for everything that you do for our
community.
What has become clear to me in this whole hearing today is
we need a multi-faceted approach, which we are taking, to solve
this opioid crisis and drug abuse crisis, and I really thank
you, Mr. Cory, for the work that you do in the community, and
Mr. Warner for sharing your story. I hope you can continue
sharing your story. It is very inspirational, very touching.
What a success story. Thanks for sharing it.
I have a really kind-of common-sense basic question, not
about statistics or anything like that. This is something that
comes up, and I, quite frankly, want to know the answer and see
what your insight is. That is, I see a huge increase in
panhandlers on the streets. My district includes Sun City, and
I am starting to see panhandlers on the streets in Sun City on
Grand Avenue, which hadn't happened before. The number of
homeless, too, really seems to be increasing.
So my first question is do you think that the increase in
panhandlers is due to drug addiction? Are they trying to get
money for drug addiction? My follow-up question is, as an
individual who is compassionate, should I give them money or
should I not? Maybe all of you can answer it, but I have a
feeling that Mr. Cory and Mr. Warner probably are the best ones
to answer those questions.
Mr. Cory. This is a Rescue referral card so we will come
pick you up, we will give you free food, we will take care of
you. So do not give them money is my counsel. I have a bunch of
them with me, be happy to share them with you.
So, yes, there is an increase in panhandling, there is an
increase in homelessness. You see it West Coast. What I see on
the West Coast really scares me. It is not in our statistics
yet, I don't believe, but there are people who are in Phoenix
that actually came from San Diego and different places now. It
is a mess over there. Addiction is 70 percent, in my opinion.
That is because it is complicated with dual diagnosis, but
certainly it is 70 percent substance abuse on the streets. That
is my opinion. People will disagree with that.
I have many clients that are successful coming up through
our program that were panhandlers for years. It is a good
business. One individual I will refer to in Scottsdale got up
in the morning from his camp, got on public transportation,
went to a spot and worked long enough to achieve a target
dollar amount so he could get his fix and some food, and he
went and got high until the next day, and he repeated it all
over.
So panhandling is a good business. I am not saying it is
all that way for everybody. We actually have some efforts that
are in motion. We are launching soon a homeless-to-work program
that will actually be targeted at giving panhandlers the
opportunity to work for the day. But, yes, I think it is very
much related to substance abuse.
Mr. Warner. Yes. So, Phoenix Rescue Mission, this isn't a
secret. This is something that they all know about. I want to
say ``all.'' I want to be very careful with that. The majority
of people that are looking for help know about Phoenix Rescue
Mission. They know about Teen Challenge. They know about these
other organizations that want to help them. What you are seeing
is somebody who is more than likely avoiding the help in order
to do what they want to do.
My advice as a compassionate person, and the practice that
my wife and I have employed in our relationship is if we run
into somebody who seems as if they are in need, we ask them
what their specific need is, and we either take them to go and
get it or we get that thing for them and bring it to them. We
don't give them currency. We don't give them things like that
because if they have a specific need, we will take care of
that. If you need gas in your car, we will go get you gas. If
you need a meal, we will get you a meal. But in terms of just
cold, hard cash, it is not necessary, in my opinion.
Ms. Lesko. I yield back.
Ms. McSally. All right. Well, I want to thank the witnesses
for their valuable testimony, and Members for their questions.
Members of the committee may have some additional questions
for the witnesses. I know we didn't get into all the solutions,
and I am grateful for your time and your passion on this issue.
If we have other questions, we will ask them in writing, and we
would ask if you could respond to them in writing.
Pursuant to Committee Rule VII(D), the hearing record will
be held open for 10 days.
Without objection, the committee stands adjourned.
[Whereupon, at 1 p.m., the subcommittee was adjourned.]
A P P E N D I X
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Questions From Honorable Kristen Sinema for Douglas A. Ducey
Question 1a. An important part of addressing the opioid epidemic is
reducing overprescribing and preventing doctor shopping. The PASS Act,
which I have introduced with support from both parties in Congress,
would require Medicare to notify outlier prescribers--doctors
prescribing outside of established medical guidelines--that they are
potentially overprescribing. Do you believe this will be beneficial to
Arizonans efforts to reduce overprescribing?
Question 1b. What other actions would you recommend Congress take
to support Arizona's efforts?
Answer. The opioid epidemic is a complex problem and there is no
silver bullet to solve it. We have taken action at the State level in
Arizona, but we welcome Federal action. The PASS act aims to prevent
opioid overuse by providing annual notification to outlier prescribers
of opioids compared to other prescribers in their specialty and
geographic level. I strongly support this. This information will help
doctors have a full picture of how their prescribing habits compare to
their peers. While we have taken similar action on a State level, this
is very important in the Medicare space given the July 2017 report by
the Health and Human Services OIG report on high prescribing levels and
potential doctor shopping in the program.
In addition to the PASS Act, there are several other steps the
Federal Government can take to address the epidemic. One of the
greatest barriers Arizona faces is the prohibition of Medicaid
reimbursement for inpatient stays longer than 15 days. This Institute
of Mental Disease (IMD) exclusion impacts approximately 24 facilities
and 1,700 individuals throughout Arizona. The IMD exclusion prevents
Arizonans from getting effective inpatient treatment they need to break
their addiction.
With a Nation-wide shortage of inpatient beds, health care
professionals, and treatment programs, this Federal restriction should
be removed for all States, most critically for substance use disorder,
immediately. Congress should amend the IMD exclusion to ensure that
those in need of treatment are able to access it.
Another critical barrier is the current Medicaid rules restricting
the coverage of Medication-assisted Treatment (MAT) programs for
individuals who are in State or county correctional institutions. In
2017, the Arizona Department of Corrections reported that 77 percent of
the 42,184 inmates assessed at intake had histories of significant
substance abuse. Of those identified only 732 were enrolled into an
addiction treatment program. We must do all we can to help individuals
who are incarcerated overcome their addictions, including providing
evidence-based MAT therapy, in order to reduce recidivism, provide
people with a second chance, and become productive Arizona citizens.
Indeed, these rules are contributing to a cycle of crime, costly
incarceration, and a return to crime and prison because of addiction.
These rules should be suspended and reevaluated to get effective
treatment to those in State or county correctional facilities.
A significant contributor to the over-prescribing of opioid
medication is the Centers for Medicare and Medicaid Services (CMS)
Hospital Consumer Assessment of Healthcare and Providers and Systems
(HCHAP) still utilizes a pain satisfaction score in its overall
hospital ratings which does not align with the current efforts to
reduce opioid use. This score has already been removed from the HCHAP
reimbursement formula but this initial assessment score causes Arizona
to rank below the National average with patients who report that their
pain was ``always well-controlled.'' The HCHAP should eliminate this
scale from the survey to further enhance efforts to reduce the number
of opioids being prescribed. We know that keeping people from getting
addicted is the one sure way to reduce overdose and death, and
eliminating this scale from the survey will help empower health care
providers to make evidence-based decisions.
While Arizona leads the Nation in gathering real-time data on this
crisis, a significant Federal barrier to understanding the scope of the
epidemic are Federal regulations regarding reporting restrictions from
certain facilities. Currently CFR 42, Chapter I, Subchapter A, Part 2
prohibits facilities from sharing substance abuse use disorder data
which is a hindrance to comprehensive health care and surveillance
program in our State. These privacy protections were certainly well-
intentioned, but are impeding turning the tide on the opioid epidemic.
The reporting restrictions should be removed and a requirement of
Federal facilities to meet HIPPA requirements should be instituted.
Last, the presence of Federally-controlled health care facilities,
with no State oversight or State reporting requirements presents
multiple challenges for Arizona. First, we request that Federal health
care facilities maintain State licensure. Currently, Federal health
care facilities do not meet the same requirements as other health care
facilities in our State. This divide creates confusion for our
citizens, and allows a disparate level of care to be delivered to our
veterans and members of our Indian Tribes. Arizona wants to ensure that
members of our community receive quality care regardless ofthe
facility, be it Federal, State, or privately-owned.
We would also request a requirement for Federal health care
providers to input dispensing data into the States' prescription drug
monitoring programs. Without Federal participation in the States' drug
monitoring program, there is an increased risk for over prescribing and
dispensing. This would also include participating in State-based
communicable and non-communicable disease reporting, allowing Arizona's
health care professionals access to information about an at-risk
population and the potential impact to their communities.
Although these requests are spread across the full spectrum of
Federal health care agencies, a unified and cooperative approach from
local, State, and Federal health care providers is the only way that we
can have an immediate and sustainable impact to this ever-growing
crisis affecting not only Arizona but our country as a whole.
Question 2. Here in Arizona, the Sinaloa drug cartel and other
transnational criminal organizations continue to bring heroin and
methamphetamine into our State, in addition to other crime. In March of
this year, the House passed legislation I co-introduced to crack down
on international criminal gangs that threaten our safety. Our bill
requires the administration to develop and execute a strategy that cuts
off funding and other resources for organizations like Sinaloa. As a
border State, what more can we do to enable State and Federal law
enforcement to work together to combat the illicit financing of
transnational criminal organizations, like those smuggling opioids and
synthetic opioids into our State?
Answer. In order to effectively disrupt and dismantle transnational
criminal organizations operating in our State, we must seize their
illegal drugs and prosecute the criminals responsible for trafficking
those drugs. The best way to counter their illicit financing is to
destroy their profits. Although these organizations have been
transitioning to more modern means of currency, the bottom line is that
we must prevent their drugs from coming into the country, then we can
put them out of business. This can be accomplished with increased
interdiction operations in Arizona.
The best way for Congress to help us accomplish this goal is to
provide State and local law enforcement agencies the resources they
need to counter the drug cartels. Arizona is proud of our Department of
Public Safety, Sheriffs, and Police Chiefs, and we know they could be
of greater assistance to the Federal Government on the front lines of
this problem, if they were to receive more funding. Through our Border
Strike Force, Arizona has proven our commitment and capabilities to
counter these criminal organizations, but so much more could be
accomplished with more Federal resources. As the Federal Government
faces many challenges hiring and retaining the workforce they need
within the Department of Homeland Security, State and local agencies
can be major contributors and a force-multiplier for these efforts.
Additionally, more U.S. attorneys are needed to prosecute drug
traffickers. Increased funding to the Department of Justice for more
prosecutors would help ensure that all of these criminals are brought
to justice.
Questions From Honorable Raul Grijalva for Guadalupe Ramirez
Question 1a. CBP has relied on temporary duty assignments to meet
regional staffing demands in recent fiscal years. How many officers
have you needed to bring in from other parts of the country to staff
the Tucson port of entry over the past year?
Answer. For fiscal year 2018 to date, a total of 300 officers have
been temporarily assigned to the Tucson Field Office to assist with
staffing demands at the various ports of entry. This assignment has
been completed quarterly. Each quarter, a total of 100 officers are
assigned to the Tucson Field Office.
Question 1b. How many more do you anticipate needing through the
rest of the fiscal year?
Answer. Seventy-five CBP officers were temporarily assigned to the
Tucson Field Office for the fourth quarter of fiscal year 2018.