[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
THE TRUMP ADMINISTRATION'S RESPONSE
TO THE DRUG CRISIS, PART II
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HEARING
BEFORE THE
COMMITTEE ON
OVERSIGHT AND REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
MAY 9, 2019
__________
Serial No. 116-21
__________
Printed for the use of the Committee on Oversight and Reform
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available on: http://www.govinfo.gov
http://www.oversight.house.gov
http://www.docs.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
36-437 PDF WASHINGTON : 2020
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COMMITTEE ON OVERSIGHT AND REFORM
ELIJAH E. CUMMINGS, Maryland, Chairman
Carolyn B. Maloney, New York Jim Jordan, Ohio, Ranking Minority
Eleanor Holmes Norton, District of Member
Columbia Justin Amash, Michigan
Wm. Lacy Clay, Missouri Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts Virginia Foxx, North Carolina
Jim Cooper, Tennessee Thomas Massie, Kentucky
Gerald E. Connolly, Virginia Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois Jody B. Hice, Georgia
Jamie Raskin, Maryland Glenn Grothman, Wisconsin
Harley Rouda, California James Comer, Kentucky
Katie Hill, California Michael Cloud, Texas
Debbie Wasserman Schultz, Florida Bob Gibbs, Ohio
John P. Sarbanes, Maryland Ralph Norman, South Carolina
Peter Welch, Vermont Clay Higgins, Louisiana
Jackie Speier, California Chip Roy, Texas
Robin L. Kelly, Illinois Carol D. Miller, West Virginia
Mark DeSaulnier, California Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands W. Gregory Steube, Florida
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan
David Rapallo, Staff Director
Lucinda Lessley, Counsel
Laura Rush, Clerk
Christopher Hixon, Minority Staff Director
Contact Number: 202-225-5051
C O N T E N T S
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Page
Hearing held on May 9, 2019...................................... 1
Witnesses
The Honorable James W. Carroll Jr., Director, Office of National
Drug Control Policy
Oral Statement............................................... 5
Ms. Triana McNeil, Acting Director, Homeland Security and
Justice, Government Accountability Office
Oral Statement............................................... 6
Ms. Karyl Thomas Rattay, M.D., M.S., Director, Delaware Division
of Public Health
Oral Statement............................................... 7
Mr. Wayne Ivey, Sheriff, Brevard County, Florida
Oral Statement............................................... 9
Written statements for witnesses are available at: https://
docs.house.gov.
INDEX OF DOCUMENTS
----------
The documents listed below are available at: https://
docs.house.gov.
* ACA article; submitted by Rep. Hill.
* Fentanyl article and charts; submitted by Mr. Roy.
* CNN articles on fentanyl; submitted by Mr. Hice.
* Roundtable Statement; submitted by Ms. Shauntia White.
* Statement for the Record; submitted by Mr. Bill Sternberg.
THE TRUMP ADMINISTRATION'S RESPONSE.
TO THE DRUG CRISIS, PART II
----------
Thursday, May 9, 2019
House of Representatives
Committee on Oversight and Reform
Washington, D.C.
The committee met, pursuant to notice, at 11:06 a.m., in
room 2154, Rayburn House Office Building, Hon. Gerry Connolly
presiding.
Present: Representatives Connolly, Maloney, Norton,
Krishnamoorthi, Raskin, Rouda, Hill, Sarbanes, Welch, Speier,
Kelly, DeSaulnier, Plaskett, Khanna, Ocasio-Cortez, Pressley,
Tlaib, Jordan, Amash, Massie, Meadows, Hice, Grothman, Comer,
Cloud, Gibbs, Higgins, Roy, Miller, Green, Armstrong, and
Steube.
Mr. Connolly. The committee will come to order.
The Chair is authorized to declare a recess of the
committee at any time.
The full committee hearing is convening to continue our
review of the Administration's response to the drug crisis. We
previously held a hearing on March 7. This hearing is a
followup continuing our examination of ONDCP's coordination of
national drug control efforts, including efforts to expand
access to treatment.
I now recognize myself for five minutes to give an opening
statement.
Earlier today, members of our committee had the very
important opportunity to meet with four extraordinary
individuals who have lost loved ones to our Nation's crippling
substance abuse problem. We heard from Mr. Kevin Simmers, Ms.
Shauntia White, Mr. Bill Sternberg, and Mr. Mike Cannon. They
told us about the challenges their families endured while
trying to get help for their loved ones in their hours of
greatest need. They turned their unbearable pain into an
inspiring passion to help save other lives and spare other
families from the terrible ordeal that they went through.
They are all here with us now, and I would like to ask each
of them to stand and be recognized for their courage.
[Applause.]
Mr. Connolly. Thank you so much. Thank you.
On behalf of this entire committee, we thank you for
sharing your stories and for bringing the commitment you have
and your dedication to this very important battle that affects
all too many families across America.
I know your determination and urgency are shared by
countless other families also struggling to help their loved
ones, and thank you again for everything you have done and
continue to do.
Today, the committee is holding our second hearing on the
Trump Administration's response to the opioid crisis. At our
first hearing in March, we heard testimony about the Trump
Administration's failure to issue a national drug control
strategy for two years while tens of thousands of people
succumbed.
We also examined the unsatisfactory strategy that the
Administration finally issued earlier this year in January, and
we heard the Government Accountability Office testify that this
strategy is deficient; in fact, did not really add up to a
strategy, and does not comply with the basic legal requirements
Congress has set.
The strategy or so-called strategy lacked enough detail for
the committee or GAO to exercise even minimal oversight or to
ensure accountability for the tens of billions of dollars we
spend annually on national drug control efforts.
For these reasons, we told the Office of National Drug
Control Policy they had to do better, and we told them that we
would have them back today to gauge that progress since our
earlier hearing.
The good news is that there have been some improvements. In
response to the committee, ONDCP has now provided several
supplements to the paper it issued earlier this year. These
materials are certainly more useful than what we saw in
January, and I thank Director Carroll and the dedicated public
servants at ONDCP for the progress they have made.
Unfortunately, the goals in these documents are, to use the
most charitable description, all too modest, especially in
light of what we heard this morning at the roundtable. For
example, there were approximately 70,000 overdose deaths in
2017. But the Administration's plan seeks to reduce overdose
deaths by only 15 percent over five years. At that pace, more
than 200,000 Americans will lose their lives between 2019 and
2022, even if ONDCP meets all of its goals. That is a
frightening projection and one, I think, on a bipartisan basis,
we cannot accept.
Here is another one. Right now, only about 10 percent of
people who need addiction treatment can get access to it across
the country. The Administration does have some ideas here. Its
plan says, ``Evidence-based addiction treatment, including
medication-assisted treatment for opioid addiction, is now more
accessible nationwide.'' But when you look at the details, the
Administration's plan is to have only 20 percent of specialty
treatment facilities provide this type of medication-assisted
treatment by 2022. In fact, we know that most rehab facilities,
in fact, are not medication-assisted treatment facilities, even
though we know medication-assisted treatment is the only
efficacious treatment for opioid addiction.
We must do better. We have to fight harder. The opioid
crisis is the most devastating health emergency our Nation has
faced in over a generation, and we need a bold strategy to meet
this challenge head on.
That is why every Democratic member of the committee joined
together yesterday to introduce the CARE Act, which stands for
the Comprehensive Addiction Resources Emergency Act. This
landmark bill would finally provide stable and sustained
resources to expand treatment for those who so desperately need
it.
The CARE Act has now been endorsed by more than 200
organizations, including the American Medical Association, the
American Society of Addiction Medicine, the National Nurses
United, the National Association of Counties, the March of
Dimes, the American College of Physicians, and the AFL-CIO. It
is supported by doctors, nurses, mental health experts,
organized labor, local governments, public health experts, and
tribal organizations.
The CARE Act will finally start treating the opioid
epidemic like the public health emergency it is, and it will
help people in red states, blue states, and purple states who
are suffering without adequate access to treatment.
Opioid addiction does not know partisanship. These include
people just like the loved ones and the family members who were
lost by Mr. Simmers, Ms. White, Mr. Sternberg, and Mr. Cannon.
I want to thank you all again for being here, and we all
look forward to what we hope is a more productive session this
morning.
I now turn to the Ranking Member for his opening statement,
Mr. Jordan.
Mr. Jordan. Thank you, Mr. Chairman.
I, too, want to thank our guests and Director Carroll for
coming back as well for a second time here.
Our country is a country that values community and civic
engagement. It is now being devastated by drug dependency. It
is a crisis that hits close to home for every single family,
and it has hit especially hard for Americans like Ms. White,
Mr. Simmers and Cannon and Sternberg, who are joining us today
in the audience. I, like the Chairman, want to thank you for
your story. The last hour we just spent upstairs hearing your
story was so compelling. Thank you for bravely sharing your
compelling experiences with us this morning, your stories about
your loved ones, and all too similar stories felt by an Ohio
family, the Riggs family, who lost their young daughter to
heroin use at the age of 20. In the face of such grief, Ms.
Riggs speaks with students and their families about her
daughter's struggle to bring awareness and shatter stigma in
hopes of preventing such devastation to other families.
Our home state of Ohio, over the course of a single year,
witnessed almost 5,000 fatal drug overdoses, nearly 14 deaths
in a single day. But this crisis does not strike each community
in the same way. What prevention, treatment, or enforcement
efforts may be effective in one area may not work in another.
This is not a problem that funding alone can solve, even $100
billion. We need to thoughtfully empower each community to
address its unique need to reduce drug supply, prevent illicit
drug use and, most importantly, get the needed treatment for
these individuals.
Sheriff Wayne Ivey is with us today from Brevard County,
Florida. He is making great strides for his community. Sheriff
Ivey, who relies on ONDCP for standardized and timely data
about drug trends and emerging threats, recently led the arrest
of nearly 100 traffickers of meth and nearly three pounds of
fentanyl. That is enough fentanyl to kill every single person
in this country.
But it was something else about Sheriff Ivey that struck
me. Sheriff Ivey has recognized an important aspect of this
cyclical crisis. When those battling substance abuse disorders
are climbing out of despair, they are in need of support;
treatment, yes, but also purpose. Sheriff Wayne connects his
inmates in jail for drug use with training and jobs on release
into the community. Now the cycle might have a chance of being
broken.
Under the Trump Administration, the strength of our economy
is creating tons and tons of new jobs, good-paying, dignified
jobs that can be filled by those who may have struggled with
the drug problem. Lifting every single member of a community
and giving them a job, responsibility, and accountability gives
them purpose.
I look forward to hearing from Director Carroll, who leads
the Office of National Drug Control Policy, a recently
revitalized office that is playing a newly enhanced role in
coordinating this effort. Director Carroll, the Chairman and I
want your office to succeed. I look forward to hearing from you
on the progress of ONDCP and the Trump Administration, and I
remain optimistic about the support of the committee for
continued progress.
I also look forward to hearing from the experts on the
ground who battle this problem daily. Thank you all for taking
the time to be here this morning to discuss this office and
help us all find solutions to the public health crisis of our
time.
With that, Mr. Chairman, I yield back.
Mr. Connolly. Thank you, Mr. Jordan, and thank you for
sharing that data on Ohio. It is gripping and disturbing and,
unfortunately, not unique.
Mr. Jordan. Not unique.
Mr. Connolly. I know we have an opportunity in this
committee, on a bipartisan basis, to move forward, and I
certainly commit to you in wanting to do that.
Now we want to welcome back ONDCP Director James Carroll,
as well as Triana McNeil, the Acting Director of Homeland
Security and Justice of the Government Accountability Office.
She is accompanied by Mary Denigan-Macauley, the Acting
Director of Health Care at GAO. And I would also like to
welcome Dr. Karyl Thomas Rattay--am I pronouncing that
correctly?--the Director of the Delaware Division of Public
Health and Safety; and Sheriff Wayne Ivey of Brevard County,
Florida. I want to thank them all for participating in today's
hearing.
It is our custom to swear in witnesses. So, if you would
all rise and raise your right hand?
[Witnesses sworn.]
Mr. Connolly. Thank you. You may be seated.
Let the record show that the witnesses answered in the
affirmative.
The microphones are sensitive, so I would ask each of you
to please speak directly into them when you turn on the button.
Without objection, your written statement will be made part
of the record.
With that, Director Carroll, you are now recognized to give
an oral presentation.
STATEMENT OF JAMES W. CARROLL, JR., DIRECTOR, OFFICE OF
NATIONAL DRUG CONTROL POLICY
Director Carroll. Thank you, Chairman Connolly, Ranking
Member Jordan, and members of the committee. Thank you for the
opportunity to appear before you again to discuss the critical
work the Office of National Drug Control Policy has been doing
to address the challenges America faces from the opioid
epidemic and the broader addiction crisis.
I want to especially thank the committee for their
leadership on this issue, and I appreciate the invitation to
return and have the opportunity to talk with you all about the
work that has been going on since we last met.
It has been my pleasure since our last hearing on March 7
to bring the GAO into ONDCP to see the great work my team has
been doing and making them familiar with our critical role.
Moreover, I ensured GAO has received all of the supplementary
information they requested from ONDCP, including 1,501 pages of
documentation, in response to the additional request from GAO.
I am incredibly proud of my team, and I believe our GAO
colleagues have gained a great deal from the time they spent
with the most senior members of my staff in meetings on at
least 10 different occasions since our last hearing.
I would also like to thank the committee staff for joining
us for several routine interagency engagements over the past
month, which I hope gave them additional context for a few of
the issues that were raised at the hearing.
The time since my last hearing has given us the opportunity
to continue issuing the supplementary materials of the National
Drug Control Strategy, as planned, that fulfill our statutory
requirements. As we continue the process of formally
implementing the 2019 Strategy, several of our interagency
partners have provided us valuable positive feedback on its
clarity, focus, and utility as the right framework to guide
broad control activities in the years ahead.
In addition to the main Strategy document, its three
companion documents provide valuable context on today's drug
trafficking and use environment, and the means to measure our
progress and effectiveness as we advance the Strategy going
forward. These include the Budget and Performance Summary,
which provides details on the drug control budget that supports
the implementation of the Strategy and provides performance
metrics for each drug control program agency; the Data
Supplement, which provides more than 150 tables presenting data
on which ONDCP relies to formulate, implement, and assess
progress toward achieving the goals and objectives of the
Strategy; the Performance Reporting System, which provides the
goals and objectives for the Strategy; plus the two-and five-
year targets and metrics for tracking progress and achieving
them. All of these documents are the constituent parts of the
National Drug Control Policy Strategy, and they have been
submitted to Congress and posted on ONDCP's website.
I am proud to say that during this entire period, my team
has been focused on delivering tangible results for the
American people. We are tackling the addiction crisis head-on,
and we are beginning to see results.
Since the beginning of this Administration, the total
number of opioid prescriptions has declined 34 percent. The
number of naloxone prescriptions has increased by 484 percent.
Twenty percent more people who have a substance use disorder
are now receiving treatment.
ONDCP's ad campaign, ``The Treatment Box,'' just this week
won a daytime Emmy for compellingly bringing adults face to
face with the opioid addiction. More importantly, the campaign
has over 1.4 billion impressions from 18-to-24-year-olds, and
has 92 million total online views.
As a result of all of these efforts and others, preliminary
data suggests that the total number of drug-involved deaths has
stabilized and for the first time in decades might be beginning
to decline.
As I discussed with you before, I have made saving lives
the central focus of our efforts, and it is the true measure of
success not only for the agency but for the American Government
as a whole. Every one of us at ONDCP knows that saving lives is
the only criterion that really matters, and we will continue to
advance that mission as we go forward every day.
I appreciate the committee's ongoing interest in working
with ONDCP on this issue, and I look forward to answering your
questions today.
Mr. Connolly. Thank you, Mr. Carroll.
Ms. McNeil?
STATEMENT OF TRIANA MCNEIL, ACTING DIRECTOR, HOMELAND SECURITY
AND JUSTICE, GOVERNMENT ACCOUNTABILITY OFFICE
Ms. McNeil. Chairman Connolly, Ranking Member Jordan, and
members of the committee, I am pleased to be here today to
discuss GAO's ongoing work on ONDCP's strategies and programs,
as well as our prior work on treatment for people who misuse
opioids.
When I was here in March, I made some key points.
One, in 2017, 70,000 people died from drug overdoses.
My next set of points related to ONDCP's 2019 strategy.
Based on our preliminary observations, it did not include a
number of requirements such as a performance measurement system
to track progress and specific assessments to provide a
baseline of illicit drug use.
Since that time, ONDCP staff have met with us without delay
and provided some previously requested materials. ONDCP staff
also met with other GAO staff to obtain information on best
practices related to strategic planning and coordination. We
have also met with a number of drug control agencies during the
past few months, in addition to White House counsel, to discuss
the opioid cabinet.
Moving forward, we will continue to conduct a thorough
assessment of the documents that ONDCP recently published that
they said, in combination with the Strategy, comport with the
provisions of the 2006 statutory requirements. These documents
include the 2019 Data Supplement, the 2019 Performance
Reporting System, and the 2019 Budget and Performance Summary.
Can GAO say that these three documents, plus the Strategy,
adhere to the 2006 statutory requirements? Not at this time.
But we will include a thorough assessment and our own
conclusion in our upcoming report. We are working to finalize
our design and begin to draft our report. Before we do that, we
still need some key pieces of information to ensure we can
answer questions from the Congress.
For example, we have asked for the budget funding guidance
that ONDCP provided to drug control agencies. We need this to
understand how they certified budgets when there was no
strategy.
We also have a forward-looking aspect to our work, and we
will continue to look at how ONDCP plans to address the
requirements set forth in the Support Act.
This is a two-part statement. So, the other part of GAO's
statement focuses on prior work that we have done on MAT,
medication-assisted treatment, for opioid addiction. It is a
combination of therapy and medications. GAO has issued two
reports on this, one in 2016, one in 2017.
In 2016, we reported that several factors, including the
availability of qualified providers, could affect patient
access to this treatment. In 2017, we found that HHS needed to
establish measures to better determine progress toward goals.
HHS has partially implemented this recommendation. Moreover,
further action to measure the capacity of providers would help
HHS determine whether patient needs can be met.
My colleague, Mary Denigan-Macauley, from GAO's health care
team, is here to answer any questions that you have related to
this treatment, and I can provide any further information on
our ongoing work looking at ONDCP's efforts.
Chairman Connolly, Ranking Member Jordan, and members of
the committee, this concludes my prepared Statement.
Mr. Connolly. Thank you, Ms. McNeil.
Dr. Rattay?
STATEMENT OF KARYL THOMAS RATTAY, M.D., M.S., DIRECTOR,
DELAWARE DIVISION OF PUBLIC HEALTH
Dr. Rattay. Chairman Connolly, Ranking Member Jordan, and
distinguished committee members, thank you for the opportunity
to appear before the committee today.
State, territory, and local health agencies are on the
front lines responding to the current addiction crisis. As
Delaware's state health official for the past decade, and as a
pediatrician and epidemiologist, I have witnessed many facets
of this devastating, complicated, and evolving crisis.
We first sounded the alarm and declared our epidemic in
Delaware in 2011. Our data showed a steady incline over the
previous two decades, going from five overdose deaths in 1990
to 100 in 2009. Importantly, the epidemic is evolving. In 2009,
nearly all our overdose deaths were due to prescription drugs.
Now, illicit fentanyl and other synthetic opioids are the major
driver of overdose deaths, causing 72 percent of the 400 deaths
we experienced in our state this past year.
And behind these data are real people whose lives are
forever changed because of this epidemic. Opioid addiction
affects a wide array of individuals, from high school athletes
to blue-collar workers and highly educated professionals. Yet
stereotypes about those afflicted with addiction still exist,
and one of the greatest barriers to treatment is the stigma
experienced by individuals with opioid use disorder. We must
view addiction as a chronic health disease that affects the
brain, and just like asthma or diabetes, if we apply
appropriate evidence-based strategies, addiction is both
preventable and treatable.
For example, in my state we have had the pleasure of
getting to know Alyssa, who was struggling with opioid
addiction. However, she accepted help when her baby was born.
She has received treatment and recovery services and has been
successful with the use of buprenorphine.
Also, through our home visiting program, we were able to
provide the necessary supports so she could appropriately care
for her newborn baby. Alyssa and her now three-year-old
daughter are thriving.
Although we would all love an easy fix to address this
problem, no single public health tactic or policy will end the
opioid crisis. The complex nature of this epidemic and its
broad, pervasive, and substantial impact on communities and
society at-large justify a multi-pronged set of strategies and
solutions. Preventing and identifying addiction, connecting
people to evidence-based treatment and recovery services, as
well as reducing harm are critical pieces to the multifaceted
response required.
With that in mind, I would like to emphasize three key
points today. Federal, state, and local governments must take a
comprehensive and sustained approach to not only address the
current crisis but we must focus upstream to prevent
individuals from becoming addicted in the first place. We
strongly encourage the committee to include primary prevention
as a core component of opioid-related legislation moving
forward. Any resources going to public health should not cap
primary prevention efforts. We must have the ability to have
flexible resources to meet the needs of our communities and the
populations we serve.
No. 2, it is crucial for the Federal and state, working
with local governments, to continue expanding access to
evidence-based treatment. The ideal system is engaging,
comprehensive, coordinated, high-quality, and person-centered.
It meets people where they are in their communities and
provides an immediate connection to treatment when they are
ready, no matter the setting. It addresses mental and physical
health, as well as social needs like housing and occupational
skill development. It is constantly improving, using real-time
data and evaluation to drive decisionmaking.
As it relates to treatment that will lead to recovery, I
strongly urge Congress to approve legislation to modify the
three-day rule. As an example, under the current rule a non-ex-
waivered emergency physician who is providing care for an
individual who has overdosed can only administer and not
prescribe buprenorphine one day at a time for the purpose of
relieving acute withdrawal symptoms while a person is awaiting
admission into treatment.
The Association of State and Territorial Health Officials
is deeply concerned that the requirements of the three-day rule
are preventing providers from appropriately managing
withdrawal, and we are missing opportunities to successfully
engage people into treatment. Our members have explored many
alternative options, but we are told by Federal officials that
the only way to address this is through legislation. I implore
the committee to address this immediately.
In closing, we work tirelessly to save lives, but we must
also work to improve the lives of people who are impacted by
the disease of addiction, and we must do all we can to prevent
addiction.
Thank you again for the opportunity to speak today.
Mr. Connolly. Perfect timing. Dr. Rattay, thank you very
much.
Sheriff Ivey?
STATEMENT OF WAYNE IVEY, SHERIFF, BREVARD COUNTY, FLORIDA
Sheriff Ivey. Mr. Chairman, Ranking Member Jordan, and
members of the committee, my name is Wayne Ivey, and I have the
honor of serving as the Sheriff of Brevard County, Florida. We
have a population of almost 600,000 citizens and are blessed to
be called the gateway to space, as we are home to the Kennedy
Space Center.
I would like to personally thank you for allowing me to
speak to this committee today in furtherance of our national
strategy to combat the opioid epidemic.
Government's one and only responsibility is to protect its
citizens, and this epidemic is without question the most
impacting challenge law enforcement has faced for decades. For
those that have been in this business for a while, we remember
thinking that crack cocaine was the worst thing we had ever
faced. Sadly, we were mistaken. This epidemic far exceeds those
realities and without question will destroy our communities if
we do not aggressively intervene without delay.
As has already been said, this epidemic has no boundaries
and does not discriminate. This nationwide epidemic is having
devastating effects on individuals, families, and entire
communities. In fact, in my county alone, we have felt the
devastation at levels that none of us believed possible.
Brevard County is one of three counties leading the state
of Florida in overdose deaths. In the past 24 months, my
community has lost 172 dads, moms, sons, daughters, husbands,
and wives to opioid deaths. That is 172 members of our
community who were taken from us way too soon.
As if that were not bad enough, that number grows to 300 in
the past 48 months, and sadly over 650 in the past 10 years.
In addition to those we have lost to death, we have also
had to consider the impact on families who now have a family
member in jail because they targeted the addictions of others
for their own greed.
Opioids are also coming at an enormous financial cost. In
fact, the financial impact does not stop at government. It
extends to entire communities, including a significant impact
on health care and employment. Communities like ours are not
only losing friends, family, and loved ones, which is the
ultimate loss, but we have suffered a great financial burden
due to this epidemic. The rising cost of medical treatment for
those suffering addiction and overdoses, for newborns born
dependent on opioids, for counseling and rehabilitation, and
for law enforcement and first responders, the cost of
combatting this abuse, distribution, and death caused by this
epidemic is significantly increasing every day.
As an example of that statement, I would offer to this
committee that in 2018, the Brevard County jail had 3,737
inmates who required medical detox treatment while incarcerated
in our facility for opioid addictions. In addition, my agency
alone has expended well over $200,000 this past year in Narcan
deployment and investigative costs relating to investigations
of deaths and crimes. Just last week, our agency culminated one
of the most significant single drug investigations in the
history of our community, resulting in the issuance of over 100
arrest warrants for dealers of fentanyl, heroin, and
methamphetamine. These killers known as white powder, brown
powder, China white or black tar, are historically manufactured
and refined in Europe, Mexico, and China, laced with fentanyl,
and floated into the streets of our communities. The drugs in
our investigation were being delivered to the organization from
California, Las Vegas, and Georgia by car couriers and U.S.
Mail.
As a result of that investigation, our agents, in
partnership with the Drug Enforcement Administration, Central
Florida HIDTA, the United States Attorney's Office, the Brevard
State Attorney, and our Florida Attorney General, seized
kilogram quantities of fentanyl, heroin, and methamphetamine.
As our committee members are aware, fentanyl can be a threat to
anyone who comes into contact with it, as it can be absorbed
through the skin, eyes, or accidentally inhaled. It is 50 to
100 times more potent than morphine, and 30 to 50 times more
potent than heroin.
The Drug Enforcement Administration estimates that there
are approximately 500,000 lethal doses in a single kilogram of
fentanyl. The Drug Enforcement Administration further estimates
that a 2-milligram dose is lethal for most people.
Using that formula, the amount of fentanyl seized in our
investigation was enough to kill every single resident of
Brevard County. This epidemic is not isolated to Brevard but
instead is impacting communities in the same fashion across our
great Nation. That is exactly why we must address this epidemic
collectively at the local, state, and Federal levels, as well
as in partnerships with our health care providers and
lawmakers.
Based upon my experience as a 39-year veteran of law
enforcement, I believe that we have to take a multi-dimension
approach to stabilizing and eradicating this epidemic. To truly
protect our citizens, we must shield them with a bulletproof
vest that is designed to protect each citizen. If you know
anything about a bulletproof vest, it is layer after layer of
material that, when woven together, becomes so strong it will
stop a bullet or edged weapon. If one layer fails, the next
layer is standing ready to intervene. This type of strategy
will be paramount in ending this deadly threat to our Nation.
If we take a single-dimension approach to this issue, we will
not be successful. And let there be no doubt, we must execute
our plan right now, before another citizen is taken from us. We
cannot delay or we will be effectively writing off a generation
eliminated by addiction, prison, and death.
As such, I believe that we should construct our bulletproof
vest with the following layers: education and awareness;
aggressive enforcement; partnership enhancement; enhanced
prosecution and sentencing; life-saving tools; and
compassionate care and rehabilitation.
In the interest of time, I included the substance of each
of those areas in my written statement, and if you would like,
I would be glad to share more detail.
Mr. Connolly. Thank you, Sheriff Ivey. We know you and your
colleagues are in the front lines of this battle as well. Thank
you so much for your service.
The Chair now recognizes himself for five minutes of
questioning.
Mr. Carroll, Director Carroll, the Trump Administration's
Drug Control Strategy says addiction is a chronic medical
condition that affects the brain by causing distinct cognitive,
behavioral, and physiological changes; correct?
Director Carroll. Yes, sir.
Mr. Connolly. And the Strategy goes on to state, quote,
``Increasing the availability of treatment services for
substance use disorder will lead to a greater number of
Americans achieving sustained recovery and reduce the size of
the illicit drug market and demand in the United States.''
Correct?
Director Carroll. Yes, sir.
Mr. Connolly. And yet there is a significant unmet need, is
there not, for treatment in the United States? According to the
Strategy issued in January, your office points out in 2017 an
estimated 20.7 million Americans age 12 or older needed
treatment for substance use disorder, but only 4 million of
those 20.7 million received any kind of treatment, and only 2.5
million received that treatment at a specialty facility. And,
of course, we could add to that that many of those so-called
``specialty facilities'' with respect to opioids are not
appropriate, the treatment is not efficacious. So, that number
even overstates how many people got efficacious treatment, and
that is from your report, which is really stunning data in
terms of capacity and cost apparently being such important
factors in people getting treatment.
Director Carroll. Yes, sir. Thank you for the question. I
think it is important to note a few things at the outset.
Undoubtedly, there are millions of people--as we said, the
estimates are 18 to 20 million people who have an addiction.
Sadly, not all of them, only a few percent that actually
recognize and accept the fact, and we heard about it this
morning, are willing to go get treatment. That is the estimate
that we talked about of the people who are willing to get
treatment.
So, certainly, one of the things that we need to do is
decrease the stigma to make sure that more people are willing
to get treatment. Right now, the estimates are 10 percent or so
of that 20 million even seek treatment. So, first off, we need
to increase the number that are accessing treatment. That is
one of the things that we have successfully been able to do.
You talked about effective treatment, and as I said in my
opening statement, I am very happy to report to the public and
to the committee the number of people seeking treatment in the
last year-and-a-half or two years has gone dramatically up. But
you are right, it is not up as high as we need.
And the types of treatment--and we heard a little bit this
morning from one of the parents--every individual is different.
We have to recognize the relationship between a patient and a
provider, and one of the goals of the National Drug Control
Strategy is to increase the number of treatment centers that
offer medication-assisted treatment, MAT, by 100 percent. At
the same time, we do have to recognize, as we heard this
morning, some people who have this addiction do want to go to a
facility where it is total sobriety----
Mr. Connolly. I am going to have to interrupt because my
time is limited, but thank you, good point. If you read
Dopesick, by Beth Macy, she points out that two-thirds of all
the treatment centers for opioid addiction in the United States
still do not allow medical treatment, other drugs to take you
down. That is a sure-fire recipe for getting on heroin or
something worse. It just does not work. The success rate is in
the single digits with that kind of treatment.
What we do know is that the AA approach, go cold turkey,
absolutely is life-threatening when it comes to opioid
addiction. It might work for alcohol; it does not work for
opioids. And that is why----
Director Carroll. And--I am so sorry.
Mr. Connolly. No, go ahead.
Director Carroll. I mean, I could not agree more, but there
are many patients who are suffering from an addiction to
opioids who have found that MAT does not work, and they want to
go to a 12-step method. We should just make sure that we do not
force MAT on a patient. I think the doctor would understand
this, and we heard this morning from a father. Again, let's
find the right treatment for them.
Mr. Connolly. We want to stay flexible, but we also have
data.
Director Carroll. Absolutely.
Mr. Connolly. And we know that MAT works three or four
times better than cold turkey, and there are real risks with
cold turkey.
Real quickly, Dr. Rattay, you talked about people in your
state, which has a little more than half the population of my
home county, having 6,000 people who are not receiving
treatment. Given the size of Delaware, that is a pretty
stunning statistic in terms of what we are talking about here
in terms of people being able to get treatment, having access
to clinics and rehab facilities that are efficacious.
Dr. Rattay. Correct. Although we have been able to increase
the treatment capacity in our state, we know we are not where
we need to be yet with treatment capacity.
But also, as the Director mentioned, engaging individuals
into treatment is also incredibly important. So, one of our
focuses in our state is using what we call reachable moments
such as when somebody has overdosed, when somebody is involved
in the criminal justice system, or when a mother has had a baby
as three prime examples of when individuals are most ready to
become engaged into treatment, and then engage them very
quickly into a system that really meets their own personal
needs.
Mr. Connolly. Thank you. I hope we have a chance to pursue
that.
Final question. My time is up.
Director Carroll, I understand you had a conversation with
the Chairman of this committee, Mr. Cummings. Have you had a
chance to look at the CARE Act being introduced recently, and
any reactions to it you want to share with us?
Director Carroll. First off, I would like to appreciate the
bill itself in that it is very clear that we share a mutual
goal of saving lives, and I think the bill speaks to that, and
I would love to be able to work with you, Chairman Cummings,
and the rest of the committee to make sure that we are doing so
in a way that is the most effective and efficient way to get
help to people. So, I commend the heart and spirit of this
bill.
Mr. Connolly. Well, I just want to say I hope we can work
on this on a bipartisan basis, Mr. Jordan, because this affects
every one of our states. The stories, tragically, are the same.
It knows no socioeconomic boundaries. It respects none, and we
have got to save lives. We have got to try to get quick,
effective treatment and try to turn this around. So, it has to
be done on a bipartisan basis, and it has to be done with the
cooperation of the Administration. So, thank you for that
reaction.
I now call upon the Ranking Member, Mr. Jordan. I think you
want me to recognize the gentle lady from West Virginia. The
gentle lady is recognized for five minutes.
Mrs. Miller. Thank you, Mr. Chairman.
I would like to thank all of you all for being here today,
and I particularly want to thank the families who came and
talked to us during the roundtable. My heart goes out to all of
you.
I also hazard a guess that there is not an individual in
this room who has not been affected by addiction. If you are
standing in the line at the grocery store, sitting in a pew at
church praying with someone, a family member, we are all
touched by addiction.
I have spoken to this committee before about the opioid
crisis and the devastating effect it has had on my community.
My hometown of Huntington, West Virginia is considered the
epicenter of the crisis, and I must give out my respect and
heartfelt gratitude to my mayor, my fire chief, my police
chief, all of those first responders, the faith community, and
anyone who is in recovery, because we are all working together
to solve this problem.
I have visited hospitals and centers where babies are
treated because they have been exposed to addiction. They are
not considered addicted. They are exposed to drugs. I have seen
them laying inconsolable, writhing in pain and crying. It is a
terrible thing. I have sat with their mothers who are being
treated while they are trying to restart their lives. I have
talked to teachers and principals who are now dealing with
young people in school who are the result of the opioid
addiction, and we are learning that teachers have more issues
that they have to deal with with these children.
Addiction is heart-wrenching. It is a minute by minute,
hour by hour struggle for those who have lived with it and face
it every day.
I was pleased recently that the Huntington Police
Department reported that they saw a drop of 60 percent in the
heroin seizures between 2017 and 2018.
What is alarming to me is recently what we have seen is
that the seizures of meth are up. They were up 366 percent.
That number is alarming. Regardless of how many grams are
seized, we have to recognize that trend is going on and that
meth is also on the rise.
Huntington as a community has come together and has
implemented some amazing programs to help those struggling with
addiction, to assist their families and respond quickly to the
overdoses. There is no silver bullet. We need to focus on
treatment for those who are struggling with addiction and stop
the flow of drugs once and for all.
Director Carroll, the Justice Department recently charged
60 doctors, pharmacists, and others in opioids pushing through
Appalachia. The case involved more than 350,000 prescriptions,
encompassing more than 32 million pills.
This is unacceptable. How can we work together to prevent
problems like this?
Director Carroll. Thank you very much. I do want to commend
you and the work that is going on in Huntington. You mentioned
the mayor and the fire chief, and it is hard not to ask people
to watch the documentary on Huntington of ``Heroine,'' with an
``e'' on the end. It is a very compelling story to watch.
In terms of the prescriptions, we have, working hard with
HHS, cut down on the number of prescriptions. But importantly,
one of the things that we are developing is a National
Prescription Data Plan to make sure that there is insight not
only for physicians when they write prescriptions but also for
law enforcement when they are out there, to make sure that they
can see spikes and trends in terms of where a particular
community is seeing a sudden spike in the increase of
prescriptions being written and making sure that that does not
trigger a red flag that we might have one of those 60
physicians or health care providers.
In reading the charging documents for those 60 individuals,
it is horrifying. These are the people that we talk about who
are preying on people with an addiction, asking them to do
horrific things, knowing that they need the medication to
sustain their addiction. So, I was very happy to work with DEA,
as well as the state and local members of our High-Intensity
Drug Task Force that participated in making sure that we are
getting help to people through appropriate physicians, but we
are not hurting them either. Thank you.
Mrs. Miller. Mr. Chairman, may I ask for a few more
minutes, please?
Mr. Connolly. The gentle lady's time has expired. It may be
possible when we come back that somebody could yield you some
time.
I now call upon the gentle lady from the District of
Columbia, Ms. Norton, for five minutes.
Ms. Norton. Thank you very much, Mr. Chairman.
I want to thank all of the witnesses. This is critical
testimony, especially after the roundtable we had. We just held
a hearing with families of victims.
On the one hand I must say, Director Carroll, I am pleased
that the Administration, after two years without a specific
strategy, has developed since January a strategy so that the
budget will enable a strategy.
So, if you look at first glance, the President's budget
appears to put a priority on public health priorities. But if
you take a second look, and you had better take a second look
very quickly, you see that the President has very inconsistent
policies here. He is gutting the very programs that are
critical to the objectives of confronting the opioid epidemic.
I say that because so many of those caught in the opioid
epidemic depend upon Medicaid, four in ten adults struggling
with this addiction. Indeed, we find that those struggling with
this addiction are more likely to be on Medicaid than on
private insurance.
So, I am trying to find the real deal on the resources that
are committed to this program, and you have $1.5 trillion in
Medicaid cuts over the next 10 years.
So, let me ask you, because I noticed something in your
testimony, Dr. Rattay, in which you said that Medicaid had been
critical to allowing individuals to get access to treatment,
and that the expansion allowed the state--and I am quoting here
from your testimony--``to free up treatment dollars to increase
treatment capacity, including wrap-around services.''
So, I would like to ask you, since we only look at one part
of the policy without looking at what we are actually doing,
let me ask you, Dr. Rattay, what would it mean in your own
state if Medicaid expansion were repealed? How would this
affect your ability, the ability of your state, to respond to
the opioid epidemic?
Dr. Rattay. Thank you for that question, Congresswoman.
Having access to effective treatment is so critical to turning
this crisis around. And as you mentioned, in our state
expanding Medicaid has been, we believe, a critical piece to
not only increasing access to individuals who are Medicaid
recipients but also allowing us to use those additional state
dollars to be able to expand capacity or support wrap-around
services, as well as paying for peer recovery coaches, which is
also an important piece to addressing treatment as an
individual. Additionally, Medicaid has been at the forefront
for allowing naloxone and buprenorphine to be available in our
state.
So, going backward and reversing the expansion I believe
would be incredibly detrimental, and probably we would--I
should not say ``probably.'' We would lose lives because of
that.
Ms. Norton. What if the Medicaid program were converted to
a block grant with a per-capita cap? How would that affect what
you are doing now, and what would be the effect in Delaware?
Dr. Rattay. I do not oversee the Medicaid program in our
state, and I do not want to answer for our Medicaid director,
and I would say it really depends on the amount in that block
grant. Flexibility can be a good thing, but if from a dollar
perspective that limited----
Ms. Norton. What about a per-capita cap?
Dr. Rattay. Again, it depends on the amount. If the amount
is too low----
Ms. Norton. So, you have no cap now. There is no cap now to
what you can spend with someone who has this addiction.
Dr. Rattay. Right. I mean, we do all we can to take a
person-centered approach, and since everyone's journey is
different, some individuals do great on outpatient therapy,
some require more intensive treatment. So, a cap could be very
detrimental to appropriate treatment.
Ms. Norton. Thank you, Mr. Chairman. I just want to say
that you cannot begin to help somebody and then say, ``I'm
sorry, we have reached the limit of what we can spend on your
addiction.'' Thank you very much.
Mr. Connolly. Well, I would also just note your question
about block grants. It depends on the size of the state.
Delaware has three counties. My state has 95, and the suburban/
urban counties in a block grant system that goes to the state
capital always get the short end of the stick. So, it really
depends on how big the state is, maybe, how you view block
grants.
The gentleman from Kentucky is recognized for five minutes,
the other gentleman from Kentucky.
Mr. Massie. Thank you, Mr. Chairman. I am going to yield my
time to the gentle lady from West Virginia, who represents
Huntington, West Virginia, the city where I was born and where
a lot of my family reside.
Mr. Connolly. The gentle lady is recognized, and I would
just say to the gentle lady I am sorry I could not accommodate
her request, because I know she was on a line of questioning,
and we will restore the full five minutes to the gentle lady
from West Virginia.
Mrs. Miller. Thank you, Mr. Chairman. And I thank the
gentleman from Kentucky.
Director Carroll, quickly, how is the approach to tackling
the rise in meth in the United States different from addressing
heroin or opioids?
Director Carroll. One of the things, I think, it is
important to remember as we were talking at the beginning of
this hearing about medication-assisted treatment, I think we
need to put the marker out there that, sadly, right now there
is no MAT for people who have a meth addiction. And some
states--when I was in Oklahoma a few weeks ago, Oklahoma has
just been ravaged by meth. California is also hit particularly
hard. There are a lot of rural places where methamphetamine
really is on the rise. So, MAT does not work for those
individuals.
One of the things that we need to do is to stop the flow of
meth coming into this country, and it is all coming in from
Mexico. The vast majority used to be made here in the United
States. Through our law enforcement efforts such as Sheriff
Ivey and the Drug Enforcement Agency, they have done a great
job in stamping out the meth that was being made here. Since
that time, it has been moved to Mexico. The purity of meth
coming across the border is at an all-time high, 90-some
percent. And meanwhile, because it is flowing into the country,
it is less than half the price.
Mrs. Miller. Okay. Thank you very much.
Sheriff Ivey, in my state we have had great success working
with HIDTA, and I would like you to speak on your experience in
working with the ONDCP and its program. How is it working in
your county?
Sheriff Ivey. It is working very well. We have a great
relationship with the Central Florida HIDTA Task Force. In
fact, they were deeply embedded in this last investigation that
we just conducted.
One of the things that I think makes that task force work
so well is that the governing committee of the HIDTA Task Force
is people such as myself that sit there and understand what is
happening in that particular region. The data that we
continually get from ONDCP is paramount in us being able to do
what we do, understanding the trends that are taking place,
understanding the intelligence from other aspects or other
areas of the country.
So, everything, where we sit right now versus where we
previously were on this epidemic, I think, is working,
certainly in partnerships. I am a big believer--I always tell
everybody there are all sorts of ships in the ocean, but
nothing calms rough seas like partnerships. We have a great
partnership with HIDTA. We have a great partnership with ONDCP.
We could not do what we are doing, boots on the ground, without
them.
Mrs. Miller. Is there more that you see that they could be
helping you with?
Sheriff Ivey. At the surface, not for us. We are getting
everything we need. Obviously, all of us would like to have
more fiscal input to help us with these issues and combatting
it because of the investigative cost. But from an intel
perspective, from a resource perspective, even to the
relationship we have with the United States Attorney's Office
in prosecuting these cases and making sure that we are keeping
those who are preying on the addictions of others off the
street where they cannot do that, it is working.
Mrs. Miller. Thank you very much.
Mr. Chairman, I yield back the rest of my time to the
gentleman from Kentucky.
Mr. Massie. Thank you, Ms. Miller. Thank you for being a
leader on this issue. Thank you for representing my family
there in West Virginia, and for taking this issue up for our
region. As somebody who represents eastern Kentucky, we are all
interconnected there in southern Ohio and West Virginia. So, I
appreciate very much what you are doing on this, and I yield
back the balance of my time.
Ms. Hill.[presiding] Thank you so much.
I would like to recognize Mr. Sarbanes for five minutes.
Mr. Sarbanes. Thank you, Madam Chair.
I want to thank the panel for being here, and I want to
also thank those who came and spoke at the roundtable earlier
for sharing your stories, which I think had a tremendous impact
on us.
Mr. Carroll, I want to thank you for coming and thank you
for your Office putting forth the nine priorities now in terms
of the goals for addressing the opioid crisis. Among them is
the goal of increasing the percentage of Federal prescribers
who undergo continuing medical education on prescribing
practices, getting that up to 50 percent by the year 2022,
which I think is a good goal. Certainly, those providers need
to be informed on the most up-to-date education information, so
their practices are safety-driven and evidence-based.
We should be nearing those safety standards, I think, as
well in other aspects of our Federally-driven policy when it
comes to the opioid crisis, and I am concerned that is not
happening with respect to these high-dosage opioids. So, I
wanted to discuss that with you for a moment.
The CDC's 2018 guidelines for prescribing opioids state
that clinicians should avoid increasing dosage to what is
called 90 morphine milligram equivalents, MME, a day, or over.
So, that is the standard, 90. Despite that, FDA has approved
opioids that exceed this limit. Let me give you an example.
Oxycodone, the generic version of OxyContin, is available in
immediate-release 30-milligram tablets. This form is FDA-
approved for use every four to six hours. So, in other words,
the FDA has approved a frequency of dosage which, in
combination with what that dosage is, means that a patient
following that prescription and taking four of those tablets a
day is actually consuming 180 MME per day, morphine milligram
equivalents per day, which is double what the CDC is
recommending.
So, I guess the question is, as we are warning prescribers
to avoid prescribing over these limits, does it not make sense
that we also kind of look at what is happening at FDA in terms
of that approval and whether that approval needs to be
revisited with respect to these high-dose opioids?
Director Carroll. Thank you for the question. Quite
frankly, you are absolutely right. We need to take a hard look
at what is allowable and recommended in terms of what we know
about the impact it can have. We know that opioid prescription
for someone who is taking a high dose in a week or less can
become addicted. So, when we are going forward and making these
prescriptions, or going forward and talking to doctors about
this, we have to work with the health care experts to determine
what is the right amount of dosage.
One thing, though, I want to make sure we keep in mind, and
I hear it from the community quite a bit, are those people who
are suffering from chronic pain. We want to make sure that they
continue to have access, whether it is for a physical
condition, or whether it is for cancer or some other life-
threatening disease. We want to make sure that we are not
stigmatizing them or making it harder for them to get their
pain medication.
But you are right, we are trying to work together to make
sure, and we are evaluating the pain management actually as we
speak.
Mr. Sarbanes. I appreciate that answer, and I do take your
point that we need to strike the right balance. We want to make
sure that there is the opportunity for physicians to prescribe
pain medication in those instances where that is really the
alternative option that is available to deal with that chronic
pain situation. But I think there is going to be emerging
evidence, as we look harder at this question of the high-dosage
opioids, that the availability of that in combination with what
the FDA prescribing limits are can create situations and
potentially frequent situations where the dosage that that
patient or that consumer is taking is well beyond what is
actually needed to address the particular pain and make sure
that that therapy is working.
So, I am very interested in pursuing better alignment of
the CDC guidelines with respect to what is considered safe in
dosage over a 24-hour period, aligning that with what the
currently FDA-approved prescribing and dosage levels are. So,
we hope to work with your office on that going forward.
Director Carroll. I am happy to, and I am happy to have
some of our pain experts and health care professionals work
with you and the committee staff going forward.
Mr. Sarbanes. Thank you.
I yield back.
Ms. Hill. Thank you.
I recognize Mr. Roy for five minutes.
Mr. Roy. Thank you, Madam Chair.
I appreciate you all taking the time to be here and
visiting with this committee, and for all the work that you all
do to address this particular problem. I appreciate everybody
who is coming here and people who have been affected by this
dreaded crisis that we face in dealing with the opioid
epidemic.
A question for Director Carroll. I have a study here in the
Journal of American Physicians and Surgeons from the spring of
2018, so a year ago, estimating the actual death rate caused by
prescription opioid medication and illicit fentanyl. What the
author, John Lilly, posits is that, from his closing: ``As more
constraints are placed on legal prescriptions, it appears that
market competition is driving opioid misusers from prescription
opioid medication to illicit fentanyl because of its high
potency and the variability of dosing of legally obtained
drugs. Illicit fentanyl is far more likely to result in
death.''
Would you agree with that characterization?
Director Carroll. Thank you for the question. I think we do
have a careful balancing here. One of the things that we need
to do to address it is to make sure that we are not starting
down that path of prescribing opioids when a patient does not
need it. That is one of the goals, to reduce opioid
prescriptions. The goal was a third by four years. We are
actually already ahead of schedule on that.
The other thing that we do need to keep in mind is the
education that we are doing in the communities through our
Drug-Free Communities and with our partners to make sure that
we are getting the message out to people----
Mr. Roy. But would you agree that a significant amount of
the problem right now is illicit fentanyl?
Director Carroll. Is illicit fentanyl? Absolutely.
Mr. Roy. Yes, illegally obtained illicit fentanyl.
Director Carroll. It is terrifying. HIDTA last year alone
removed a ton-and-a-half of fentanyl alone, which we heard how
deadly it is.
Mr. Roy. So, without objection, I will ask that this report
be introduced in the record.
Ms. Hill. So, ordered.
Mr. Roy. A graph that is in there is hard to see because I
have not put it up, but you will see if you look at this, the
blue being the prescription opioids and the red being the
illicit fentanyl. This is only through 2016. You will see some
pencil chicken scratch on the right, my numbers looking at
2017. This shows upwards of--these numbers here take you to
35,000 almost total deaths as a result of overdose. That red
number, that red being the illicit fentanyl, seeing the spike
that we are seeing from 2013 to 2016, that number is
progressing. Would you agree with that?
Director Carroll. It is progressing and it is terrifying.
That is one of the reasons the President has made it a goal to
stop the flow of fentanyl from China. We got an agreement from
the President. Now we have to enforce it and we have to make
sure it is not coming through the mail or across the border.
Mr. Roy. Great. Would you, Director Carroll, or maybe
Sheriff Ivey could jump in, would these data points make sense
to you? According to Border Patrol's most recent data through
the end of April, they have seized 136.09 pounds of fentanyl
between ports of entry since October, 98.9 percent of that
being seized on our southwest border. Does that sound like an
accurate statistic to you?
Director Carroll. Could you repeat the number again? I am
just looking to my page.
Mr. Roy. Sure. This is data released for April, 136.09
pounds of fentanyl between the ports of entry since October.
This is according to CBP yesterday.
Director Carroll. That is correct, essentially what I have.
I do not have April, but I have March.
Mr. Roy. Through March, okay, sure, 98.9 percent of which
was seized on our southwest border. Does that sound correct?
Director Carroll. Absolutely.
Mr. Roy. In Fiscal Year 2018, the United States Border
Patrol seized 388 pounds of fentanyl, and this year's numbers
are following a similar trend. Fentanyl is a powerful opioid,
as you know. It is 50 to 100 times more potent than morphine.
Is the flow across our southern border a significant portion of
the problem that we are dealing with with narcotics in our
country?
Director Carroll. Absolutely, positively, without question.
And I think all you have to do is actually go back to the data
from 2017.
Mr. Roy. Right.
Director Carroll. It was 181. Now in 2018, in the data we
have for 2018, it is right, as you said, at 388. It is
doubling. It doubled in a year. This is where it is coming from
in terms of Mexico, and it is coming from China either directly
from Mexico or through the mail. But the southwest border
between the ports of entry is terrifying.
Mr. Roy. And are we aware that a significant reason that
this is happening is because of the influence of cartels at our
border? They are profiting by moving people and moving
narcotics; true?
Director Carroll. Absolutely. I will try to be quick. The
drug cartels, they are an incredibly dynamic, organized group.
These are not individual people out there. If you go down to
the border, you will see forward scouts on the Mexican side
with binoculars. They see where CBP is, they flood the zone
with immigrants until CBP is preoccupied with individuals. Once
they know CBP is over here with these immigrants, they flood
the zone with the drug trafficker.
Mr. Roy. And I have 12 seconds left. Would the opioid
epidemic be further enhanced in our country, improved, if we
were to target cartels and stop the flow across the border and
secure our southern border?
Director Carroll. We absolutely--that has to be one of our
many, but has to be one of the priorities.
Mr. Roy. Thank you.
Ms. Hill. Thank you.
I recognize Ms. Tlaib for five minutes.
Ms. Tlaib. Thank you so much, Chairwoman.
I wanted to personally thank the families from this
morning. It was incredibly powerful to hear what the human
impact of doing nothing looks like. I talk about that a lot,
and I talked to Mike Cannon, Kevin Simmers, Bill Sternberg, and
Shauntia White. Thank you again so much for sharing. I heard
this sense of urgency from all of you of really having us do
something.
So, Director Carroll, you have been very clear that we
cannot end the epidemic without expanding treatment to those
individuals suffering from the disease of addiction, and the
National Drug Control Strategy recognizes, quote, ``Addiction
is a chronic medical condition.''
I could not agree more, and what I heard this morning, it
really was a testament that they do not want any more talk.
They want to talk about the need for treatment and that we must
dedicate resources to expanding those treatments. And then we
have to make sure that it is actually working.
The Performance Reporting Supplement recognizes that in
2017 only 10 percent of specialty treatment providers offered
medication-assisted treatment. However, the Administration sets
a very modest goal of doubling the number of specialty
treatment facilities within five years. Even if we reach that
goal by 2022, only one in five specialty treatment providers
would offer the medication-assisted treatment, and the vast
majority still would not.
Director Carroll, how was this goal chosen? Why did your
agency aim for only 20 percent when 70,000 Americans are dying
each year from overdoses?
Director Carroll. Thank you, Congresswoman. I would love to
have that number be 100 percent. I think you would, too. And I
think that is what the American people deserve. But what we are
trying to do is--and we could put that in the strategy
document, but what we have to do is set aggressive goals that
we think we can actually meet once we have an understanding of
what is going on.
This crisis, sadly, took us years to get here. There is a
recent Washington Post article that talked about how long and
how many years we could see this coming. I think we have to be
realistic with people to say how long it is going to take to
get us out of this crisis. That is why we have to rely not only
on----
Ms. Tlaib. But it takes a strategy, Director, and----
Director Carroll. We have a strategy. Yes, ma'am.
Ms. Tlaib. I know. Well, then tell me how many more people
with opioid use disorder will be receiving medication-assisted
treatment.
Director Carroll. What we want to be able to do is double
that number as quickly as possible.
Ms. Tlaib. What is that number?
Director Carroll. Right now, the number of people receiving
treatment is about 10 percent of the 20 million who had it. We
do not have it broken down by specialized treatment. That is
not the way HHS tracks the number in terms of facilities that
provide MAT, but I am happy to try to work with you to get that
HHS number, if they provide specialized treatment.
Ms. Tlaib. We know that addiction is a chronic disease,
like diabetes. If only one in five diabetes clinics offered
treatment with insulin, would that be acceptable?
Director Carroll. I am not a health care professional, so I
cannot tell you about diabetes.
Ms. Tlaib. But the point is, right, Director, that----
Director Carroll. The point is that people are individuals,
and we have to treat them as that and not raw numbers.
Ms. Tlaib. But we already know medication-assisted
treatment is one of those elements that needs to be fully
funded and the resources available to the families that need
this.
Director Carroll. I could not agree more.
Ms. Tlaib. So, I want to turn for a minute to the
President's budget, because we cannot reach these goals without
dedicated Federal resources. For my colleagues, it always will
take resources, no matter how much we try to fix border issues.
It is here now, and we cannot fix it without resources.
So, Director Carroll, what resources are needed to reach
the Administration's stated goal of doubling specialty
treatment centers offering, again, medication-assisted
treatment within five years?
Director Carroll. The President's budget included an
additional $6 million last year, and I appreciate Congress' and
this committee's support of getting additional treatment. The
total budget that we spend on this issue is about $35 billion.
And everyone--maybe not everyone, but a lot of people have the
misconception that the vast majority of that goes to law
enforcement interdiction attempts. It is patently untrue. It is
almost a dead-even split of half of that money going toward law
enforcement and interdiction, and the other half going to
prevention and treatment, with 90 percent of that $18 billion
going for treatment alone.
I appreciate the committee's interest in making sure that
those treatment centers have the resources to get help to
people.
Ms. Tlaib. So, as a member, and a new member, which agency
is going to be responsible for achieving this objective?
Director Carroll. That is part of the implementation
process now, to work with the agencies. Obviously, at the end
of the day, HHS on the treatment side has the largest part of
that. But one of the things that we also have to remember is we
have to have fewer people addicted in the first place to make
sure we are cutting down on the availability of prescriptions,
illicit drugs, and God willing we will have fewer people that
are addicted. So, it really is--we cannot look at this too much
in isolation, but obviously on the treatment side alone, the
key partner for that will be HHS.
Ms. Hill. Thank you. Your time is up. Sorry.
I would like to recognize Mr. Higgins for five minutes.
Mr. Higgins. Thank you, Madam Chairwoman.
Ladies and gentlemen, thank you for appearing today.
I believe we face a cultural crisis in our country, and one
of the major impacts of that crisis is an opioid challenge. A
cultural crisis requires a cultural response, so let's talk
about the genesis and the direction of this epidemic.
A decade ago, as a patrol officer, part of my job in
communicating with the citizens that I served was greeting new
residents, and I will briefly advise of one story that ended
tragically because of prescription opioid addiction.
A lady moved into the neighborhood with her daughter, a
young adult who had a child. So, the lady, her daughter, her
grandchild moved in, were very happy. They were greeted by the
community, and over the course of one year I watched this life
deteriorate. The daughter left. The lady went from being very
friendly to being rather mean and very aggressive, continually
had her lights turned off, complaints from neighbors, et
cetera, constant interaction from law enforcement, and my
observations were that she was addicted to Lortabs.
We warned her. I told her. I said one night I am going to
get a call here and you are going to be gone, from your
daughter, your granddaughter. And indeed, that is exactly what
happened. About a year after they had moved in, we got a call
from the daughter that she had not talked to her mom in a
couple of days. She had moved out some time before but she was
worried; would I go check? I went and found the lady deceased
with empty bottles of Lortabs next to her.
The Nation responded to this by restricting easy access to
Lortab prescriptions and other opioid prescriptions, cracking
down on doctor shops, et cetera, and this was largely
effective. At the same time, our Nation was dealing with
crystal meth. You remember, Sheriff, we had crystal meth labs,
shake and bake labs, home labs all over the place. The Nation
responded by restricting access to the primary ingredients of
crystal meth, Sudafed, et cetera, took it off of the shelf and
the aisles. You had to document who was buying this stuff.
So, the Chinese created fentanyl. A decade ago we were not
dealing with fentanyl; now we are.
So, my concern is that this body looks beyond our actions
and stays ahead of the curve of what can happen with the drug
trade and the consumption of dangerous narcotics by our
citizenry.
The flow of drugs across the southern border, to me the
biggest thing we can do to fix this thing is to secure our
southern border. With all due respect to my colleagues that
have alternate opinions, I respect their opinions, but as a
former cop I am going to ask you, Sheriff, if you would share
with us, what would your jurisdictional authority look like?
How would it impact Florida if we could just stop the flow of
illegal drugs across the border with aggressive law enforcement
and change in our laws?
Sheriff Ivey. Well, I do not think there is any doubt that
securing our borders is going to not only impact this in
controlling this epidemic but also impact us in the gangs, in
the gun running, everything else that goes along with that. We
work very closely with our partners from ICE and just recently
partnered with the 287(g) Program in Brevard County to be able
to help in that aspect.
I can tell you that in working closely with them, we see
the information, the data that Director Carroll was talking
about earlier, the massive amount that is flooding into our
country and that ultimately floods to communities like mine. It
lands in communities where you are from, and that----
Mr. Higgins. Regarding those numbers, not to interrupt but
my time is short, did 400 or 500 pounds of fentanyl last year,
100-something pounds thus far this year--I think those numbers
are light, don't you?
Sheriff Ivey. I do. I believe those numbers are--the
numbers that we actually----
Mr. Higgins. In my remaining time, would you respond, sir?
Would there be positive ancillary impact if we could stem the
tide, if we could hold this--would there be positive ancillary
impact by being able to devote your assets to other services
for your community, as opposed to----
Sheriff Ivey. Without question it would do that, it would
have that major impact, and it would give us the ability to
further our investigations in other areas.
Ms. Hill. The gentleman's time has expired.
Mr. Higgins. Mr. Carroll, yes or no, is the President
serious about this?
Director Carroll. Yes, sir.
Ms. Hill. The gentleman's time has expired.
Without objection, a study from the American Journal of
Public Health, entitled ``The Affordable Care Act:
Transformation of Substance Use Disorder Treatment,'' is
entered into the hearing record.
Ms. Hill. And I would like to recognize Mr. DeSaulnier for
five minutes.
Mr. DeSaulnier. Thank you, Madam Chair and Ranking Member.
Thanks for having this hearing.
I would like to ask my questions from the perspective,
given that all of us participated in the amazing testimony--I
believe all of us. Maybe, Ms. McNeil, you were not there; maybe
you were--of Mr. Steinberg, Ms. Simmers, Ms. White, and Mr.
Cannon, all of who are still here.
So, both professionally and personally, having heard what
they said and having negotiated similar personal issues and
tried to see them from a professional standpoint at the county
and state level in California, and now at the Federal level,
for multiple generations in my family, I have watched AA and
now neuroscience and behavioral health, and I am going to
direct the question first to Dr. Rattay.
But for family members, and we heard this from a
journalist, a police officer, someone who struggled with the
social service safety net, it very much resonates with me. So,
I have heard family members take the approach to parents, to
children, siblings, you need to do this, you shall do this,
sort of the hierarchical ``We can just say no.''
Well, we know the neuroscience, we know the behavioral
health, and that is not the right way to get a return on
investment, and it is nice to hear a bipartisan ``let's do
evidence-based research and have really good outcomes,'' and
the GAO, I think, has done a marvelous job at trying to
establish that. I am reminded of that quote often used,
supposedly attributed to Einstein, that the definition of
insanity is approaching a difficult-to-solve problem the same
way and expecting different results. This, to me, is the
epitome of it.
So, why can we not be more client-based, taking the
evidence-based research--I do not know why we do not just give
this to the Centers for Disease Control. This is what they do,
with all due respect to Mr. Carroll. We had this conversation
last time. To be perfectly honest, Kaiser in my area, in Walnut
Creek, California, has an opening for substance abuse director.
They have over 400,000 clients in my county. You would not
qualify from a paper standpoint. So, I appreciate your passion.
The National Institute for the study of cancer--I am a survivor
of cancer. The NIH's evidence-based research to develop the
directors.
So, my point is client-based, but then have professionals
develop the evidence-based research.
In your experience, do family members in Delaware go
through what family members in California and what we heard
this morning? And how can we help the family members get the
resources they need given the urgency? I think the testimony by
the police officer was amazing. I mean, how many times does a
family have to spend that kind of emotional and mental strain
to get through the bureaucratic process?
Dr. Rattay. Thank you for that question. We agree
completely. The system was in no way at all ready for a crisis
like this. This experience has certainly led us to rethink all
of how we provide these services for individuals, as well as
supporting families.
Treatment must be evidence-based. That is why access to
medication-assisted treatment is so critically important, and
we see at times where families really want their loved ones to
try treatments that are not evidence-based, so there is
education for everyone. Taking the stigma away from MAT is
really important.
But then also that person-centered approach, as you
mentioned, really is so important because everybody's journey
is so different. One person may really want to do outpatient
treatment, which works very well, so they can continue their
job. Other individuals may really need residential----
Mr. DeSaulnier. Doctor, if I could stop you there. But as a
family member, the challenge is we rely on the professionals to
say that. I have had family members go into residential
treatment and be outpatient. I expect the experts to make the
assessment based on evidence-based research, and I want to
support them. But my personal experience, like our witnesses
today, from very divergent backgrounds, they have all had the
same problem. The point of entry does not support you.
I just want to switch because I have very little time.
Ms. McNeil, we have to change the process. So, how could
you look at not just performance standards for outcomes, which,
Director Carroll, I appreciate you making a very real effort,
but how can we look at what we did for cancer, for instance, to
have the professionals do the work, but then what we missed in
cancer is exactly what the families are having a problem with.
And last, it would be wonderful if GAO looked at our
policies in the Federal Government and the state government
that have reinforced the stigma and have put up obstacles, so
that we do not just spend money on it and give it to someone
else. This committee should look and evaluate the policies we
have enacted that reinforced the system we currently have,
whether it is HIPAA or anything else.
Ms. McNeil?
Ms. Hill. The gentleman's time has expired.
You can answer, briefly.
Mr. DeSaulnier. Thank you, Madam Chair.
Ms. McNeil. GAO would agree that evidence-based
policymaking and decisionmaking is key. So, in the work that we
have that we will be starting up soon, I think that is one of
the things that we will consider - looking at programs that
have worked well and bringing that to bear and making sure that
that information is provided to you all.
Ms. Hill. Thank you.
I recognize Mr. Hice for five minutes.
Director Carroll. Madam Chairwoman, I know I do not get to
reclaim 30 seconds, but for the sake of parents and family
members out there, may I just make sure that they are aware of
a website where they can go for treatment?
Ms. Hill. Yes, please.
Director Carroll. Thank you.
In working with HHS, ONDCP did put out a website for
parents to go and find a locator, so thank you for that. For
any parents or individuals who have an addiction, they can go
to www.samhsa.gov/findtreatment, so they can find centers.
Thank you. I apologize.
Ms. Hill. Thank you.
Mr. Hice?
Mr. Hice. Thank you, Madam Chair.
I would ask unanimous consent to have submitted into the
record a CNN article about how the Trump Administration won a
major policy shift from the Chinese on fentanyl.
Ms. Hill. So, ordered.
Mr. Hice. Thank you very much, Madam Chair.
Director Carroll, from what I am hearing, is it accurate to
say that you are continuing to track the increases of fentanyl
coming across the southern border? Is that correct?
Director Carroll. Yes, sir. We have to.
Mr. Hice. And you described it as frightening.
Director Carroll. Yes, sir. Scary for the parents and the
kids out there.
Mr. Hice. Absolutely, for our entire Nation.
Now, the flow that is coming across the southern border is
not by any stretch limited to our ports of entry; correct?
Director Carroll. Absolutely not, not at all.
Mr. Hice. Okay. So, there is no question while we are
seizing a significant number of illegal drugs at our ports of
entry; correct?
Director Carroll. Yes. We are seizing it all along the
border.
Mr. Hice. All right. But a lot of it at the ports of entry,
I would assume, primarily, because we have the resources there,
the manpower, the dogs, those types of resources and others?
Director Carroll. We are able to concentrate law
enforcement at those areas, at the POEs.
Mr. Hice. That is right, and just because we have those
types of resources there, it is safe to assume that we have
tons of illegal drugs coming in-between our ports of entry.
Director Carroll. Absolutely. I think it is key to note
that seizures do not indicate flow, and we know from the flow
that we are able to capture between the ports of entry that
that is a fraction of what is coming across.
Mr. Hice. That is right, and that is because we do not have
the resources in-between the ports of entry, or the manpower;
correct?
Director Carroll. That is correct.
Mr. Hice. All right. So, besides your conversation with Mr.
Roy a while ago talking about the importance of addressing the
cartel issue between the ports of entry primarily, would you
also agree that securing the border, the entire southern
border, would stem the flow of illegal narcotics?
Director Carroll. We have to secure the country, and that
starts with securing the southwest border.
Mr. Hice. Now, you mentioned also that fentanyl is coming
largely into this country from China, that they are a major
producer, I think 160,000 chemical companies in China, and they
are going to Mexico or whatever, and then across our southern
border. How important is the article? I do not know if you saw
the article that I just had submitted, but China now referring
to fentanyl as a controlled substance, how significant is that?
Director Carroll. What we have to do is make sure that
China understands that they are about to become the drug dealer
of the world, and we have to make sure that they are
aggressively enforcing the class scheduling that became
effective May 1. Both on the intel side in the classified
setting, as well as in the public space, we are going to be
able to track what China is doing to actually live up to their
agreement. We have to.
Mr. Hice. And what kind of impact will that have?
Director Carroll. I think it is going to have a significant
impact. Congressman Roy held up the map or the graph that
showed the amount of fentanyl. While we are here today talking
about American lives, this is really a global problem. If you
were to see the graph for Canada, which was just put out
publicly this week, it is almost the exact same. I mean, this
is becoming a worldwide problem. We have to take care of
Americans, but China has got to stop.
Mr. Hice. I could not agree with you more.
Sheriff Ivey, let me go to you with this same question.
What kind of impact do you think the Chinese now referring to
fentanyl as a controlled substance, what kind of impact will
that have on you?
Sheriff Ivey. I would go back to what you were saying
earlier about the ability to deploy resources in other
capacities. Right now, fighting this opioid epidemic is
draining my resources. My team, for example, just in one case
was committed for six months to this lengthy investigation. So,
being able to stop it at the border, being able to stop
incoming into our country would give me the ability to shift my
resources to do the other crime prevention efforts that we need
to be focused on.
Mr. Hice. Well, I hope we are succeeding, going to succeed
in doing that.
Director, coming back to you, probably for my final
question, you say we have got to enforce this with China. What
type of things do we need to keep our eye on as it relates to
China, whether they are serious on this?
Director Carroll. There are two things that I think we can
see right off the bat in the public space. One is having them
talk about it publicly, having the government officials there
do what you all are doing and having hearings on this, talking
about this. The other thing that we will see in the public
space is actually prosecution and enforcement of drug
traffickers, of those who are producing fentanyl. If we see
those two things in the public space, we will be able to get a
sense that China is taking this seriously.
Mr. Hice. Thank you.
Ms. Hill. The gentleman's time has expired.
Mr. Khanna, I recognize you for five minutes.
Mr. Khanna. Thank you, Madam Chair.
Thank you to the witnesses.
Thank you, Director Carroll, for your service. As you know,
buprenorphine has been crucial to the treatment of disease for
opioid addiction. Currently, about six percent of doctors have
the authorization to do that. I appreciate that you have called
for increasing that goal to 10 percent in five years.
I guess my question is, when you look at France's
experience when they had a major epidemic in the 1980's and
early 1990's, they eliminated completely the similar waiver
requirement, and my understanding is opioid overdoses dropped
by nearly 80 percent after they did that. Why have a goal of
only 10 percent? Why can we not be more aggressive in that?
Director Carroll. Buprenorphine is a very effective
medication for those suffering, but it is not without its own
dangers. So, we do need to make certain that the people who are
prescribing it are properly trained. The original cap for
doctors was to make sure that they are able to focus in on the
patients instead of just writing prescriptions, are not out of
control.
The original cap was 100. The Secretary of HHS engaged in
rulemaking and moved that up to 275. So, we are seeing how that
is going. But I think you are right, and that is one of the
goals, to make sure that buprenorphine is more available to
individuals who are suffering from the disease of addiction.
Mr. Khanna. Would you be open to studying what France did
and looking at how they managed to get rid of the waiver and
seeing if there is something we can learn there?
Director Carroll. We are working with HHS, and it is
actually one of the things that they are doing now, is to make
sure that everyone understands the impact and to see if--just
like what we were doing with Huntington, the lessons learned.
Mr. Khanna. Are you supportive if this Congress allocated
$100 billion over 10 years to help you and others fight this
opioid epidemic?
Director Carroll. I am certainly supportive of any
effective, efficient means of taxpayer dollars to save lives.
In terms of the right amount, it is hard to say what the right
amount is, at least in the next two minutes and 45 seconds. But
certainly in the CARE Act the heart is there in terms of what
we need to do to prevent this, treat this, and stop the flow
from coming in.
Mr. Khanna. And that is, of course, our Chairman's bill,
Chairman Cummings. Do you think that could be an area of
potential bipartisan cooperation, that we get something like
that passed?
Director Carroll. I probably should not say this publicly,
but I actually enjoy a good relationship with Chairman
Cummings. Please do not report that back. I hope the mic is
off.
On this issue, it really is bipartisan, and I have good
conversations with Chairman Cummings, his counsel, on the
minority and majority side, to try to figure out how we are
going to do this and save lives.
At the end of the day, that is all I think any of us care
about, if we are going to save lives, how we are going to do
it, how we are going to spend taxpayer dollars wisely. These
are tough questions, though.
Mr. Khanna. Dr. Rattay, I wanted to ask you about the
Vermont model, the hub and spoke system where we have seen
terrific success, where people are not just treated for their
mental health issue and drug addiction but also given
counseling, given a way to reintegrate with society.
What is your view of that hub and spoke model and whether
it could be replicated in other parts of the country?
Dr. Rattay. We really have learned a lot from the hub and
spoke model. One of the ways in which it showed in Vermont to
be helpful is by having primary care providers providing
treatment, learning how to help manage individuals. You could
increase treatment capacity significantly. In Delaware we have
created a similar model that we call the START system. But
really, again, what is so important is that you engage people
in treatment, that it is effective evidence-based treatment,
which includes both the physical, the mental health, and the
wrap-around services that people need, and that it is really
treated as a disease, which is why primary care providers and
buprenorphine play an important role in considering it just a
disease like any other.
Mr. Khanna. I am glad you are making progress in Delaware.
My understanding is in Vermont--and I am not sure of the
statistics in Delaware--opioid injections have actually fallen
almost 90 percent. How much do you think that we can look to
the expansion of Medicaid that helped the Vermont program, and
how important do you think expanding Medicaid is to being able
to deal with the opioid addiction?
Dr. Rattay. It is so important that individuals have access
to treatment, effective evidence-based treatment. In our state,
expanding Medicaid has been very helpful to increase access to
treatment for individuals in that expansion group, but it has
also enabled us to free up funding to be able to increase our
overall treatment capacity, as well as increase some of those
wrap-around and other services that are important, including
peer recovery coaches or working on addressing housing or other
issues.
Mr. Khanna. Thank you.
Ms. Hill. The gentleman's time has expired.
I now recognize Mr. Cloud for five minutes.
Mr. Cloud. Thank you.
Let me again first echo the sentiment of so many others on
this committee to the families who came here and shared their
personal stories. It was truly touching. And to the members
here, and Dr. Carroll specifically, how you keep bringing back
the focus on saving lives, I think that is keeping this
committee in the right spirit, that that is really what we are
trying to do here, is to save lives.
Of course, Sheriff Ivey, I appreciated your analogy about
the bulletproof vest and that this is a multi-layered approach.
We talk about prevention, we talk about treatment, and both are
needed. I was happy to hear that, from a financial standpoint,
we are investing in both of those substantially and need to
continue to do so.
I happen to be from south Texas, and my community is right
in the middle of what is called the fatal funnel, where two
highways converge from the southern border, and then drugs and,
unfortunately, human trafficking is dispersed throughout the
Nation and beyond through that. As my friend from Texas was
talking about meth coming across the border, the majority
across the southern border, we have the issue with fentanyl
coming between the borders.
It is really a mess down there. I have been down to the
border, talked to Customs and Border Patrol, and I asked them,
I said what is the next win for you, and they said we would
like situational awareness. We want the tools and resources
just to have situational awareness. We are not at the point yet
where we are trying to mitigate the problem. We are just trying
to understand what is going on. I think that is a travesty.
A couple of weeks ago I was back in the district and had
the opportunity to sit in on what is a weekly law enforcement
briefing where the law enforcement, Highway Patrol, sheriffs,
police officers from throughout the district that I live in
meet weekly to talk about how what is going on at the border is
affecting what they are dealing with throughout the region, and
it is certainly with the hospitals that are having to deal with
this, the schools that are having to deal with this, it is
certainly having an impact, and there is the lives and friends
and family that we all have that have people who have dealt
with addiction and the consequences of it.
My question is what tools do we need? What are we doing to
disrupt the drug trade, and what tools do we need to mitigate
this crisis? Because treatment is awesome, and we want
treatment. What is even better is if people do not need it.
Dr. Carroll, I guess you can start.
Director Carroll. I realize you could talk to any of us and
we probably all--actually, we probably do not have dissimilar
ideas.
One thing is we need to start at the very beginning, as I
talked about earlier, with the prevention programs that are out
there that are targeting kids to make sure that they
understand. Our drug-free communities, we have 731 plus 55, and
I appreciate the 55 because of Congress. We have 786 Drug-Free
Communities across the country. What we are seeing there is a
rapid decline in past-30-day drug use of kids, and we talked
about kids earlier today, and so that is critical.
The treatment admissions are up. We need more. There is no
question that we need more people accessing treatment, and we
have to make sure that they can find it. That is why the HHS
Treatment Locator is so important.
But then we also need the third pillar, which is the law
enforcement and interdiction side of this. We have all of our
partner agencies working together at the national, state,
local, and tribal levels to make sure we do this. So, it is
with our partners at DEA. I am proud to have my HIDTA, my High-
Intensity Drug Trafficking Area, pin on today. We love our
HIDTAs because they are a combination of law enforcement
working together, as you heard Sheriff Ivey say, and they
actually work at these drug-free communities to make sure the
prevention folks and efforts there work.
One last thing when we talk about what we can do, I would
ask that the members of the committee go back to their
jurisdictions. One of the things that the HIDTAs have developed
is an OD map system. There are many places in Delaware that use
it, and we are trying to get more states. Chairman Cummings was
instrumental in getting an awareness to Maryland so every
county in Maryland now provides real-time data not only to law
enforcement about where overdoses are occurring so that they
know they have a problem, but more importantly it provides it
to the public health officials in the community to get ready,
there is a spike, there is something happening in this area of
town. It is all anonymized so there is no privacy information
concerns, but it allows public health officials to be aware,
schools to be aware, and even in some counties parents who have
a child who is suffering from an addiction. Sometimes they will
get the alert so they will know, oh-oh, I am not going to let
my kid out of the house tonight.
Ms. Hill. The gentleman's time has expired.
Mr. Cloud. Thank you.
Ms. Hill. I recognize Mr. Welch for five minutes.
Mr. Welch. Thank you. Thank you very much.
Dr. Rattay, I want to just ask you a little bit about the
wrap-around services. I am from Vermont, and we heard some
questions from my Silicon Valley friend about Vermont, but I
want to ask you about Delaware and wrap-around services. How
essential are they, and how can we provide them?
Dr. Rattay. They are very essential.
Mr. Welch. Define it, define what that means.
Dr. Rattay. So, when we think about wrap-around services--
well, they are defined differently by different folks. I mean,
when we talk about comprehensive services, we want to make sure
that individuals do not just have their opioid use disorder
treated but also any other mental health conditions, as well as
physical health conditions.
But then also, for a person to be able to be successful in
recovery, they need to have a safe place to live, and they are
going to do much better in recovery if they are either on a
pathway toward a career or they have a job, or both. Whether it
is legal issues that are making it difficult for them to stay
in recovery because they are very anxious, we have to make sure
that we understand what is it that a person needs to be able to
stay in recovery.
We also include peer coaches, peer recovery coaches as a
part of that as well, because they are very important for
people to navigate.
Mr. Welch. Can you talk a little bit about that? Because it
is so hard, if a person gets addicted, it is such a challenge
for that individual to try to stay the course, especially when,
by the time they get to that point, a lot of the supports in
their life have vanished, including people in their lives. Can
you just comment on the challenge that is there for service
providers?
Dr. Rattay. Yes. I mean, first of all, it is a difficult
system to navigate. There are so many different parts to the
system, so just navigating the system itself, most people,
families and individuals, really need help navigating the
system. But because there is so much stigma as well, they need
somebody they can trust who is not judging them to help support
them in their journey for treatment and recovery. This is why
we found peer recovery coaches to be so helpful for
individuals, getting them connected to treatment and
navigating.
Mr. Welch. Thanks.
Let me ask Director Carroll about the peer support. Somehow
that makes an awful lot of sense to me. In our roundtables in
Vermont, the peer coaches just had an immense amount of
credibility with folks who are struggling with an addiction.
Director Carroll. They really do. They are really able to
reach out to people that are struggling and say I have been
there, I will hold your hand, I will help get you through this.
Again, talking about the Democratic mayor in West Virginia
who I am friends with because of this--sadly, it is because of
this. But to go back to the communities, one thing that they
have developed is the QRT, quick response team, and other
communities have it as well. But people who have just had an
overdose and thankfully their life has been saved because of
naloxone, something that most people should carry--I had all my
staff trained on it. The next day, after someone has survived
an overdose, four people go see them because they know at that
point they are most receptive. It is a member of law
enforcement who is not wearing a uniform at the time but to
say, look, I will take any drugs you have, I am not going to
arrest you. It is a member of the public health team. It is a
member of the faith-based community to say I will provide
support if you have family or children. But it is also someone
in recovery, a peer. So, when you go back home and think about
this type of QRT, quick response team, it works.
Mr. Welch. Thank you very much.
Sheriff, what do you think about peer support, and what
frustrations do you and your officers face when you are called
to a scene involving a person that you were called to a week or
two weeks before?
Sheriff Ivey. It is incredibly frustrating and, quite
frankly, heartbreaking, especially when you see the potential
end result, like we heard from many of our parents and family
members today. From the peer support aspect, I cannot speak
enough about that because, as Director Carroll said, having
somebody who has been through it that can help guide you
through it, we use that same aspect or concept, if you will, in
helping officers who have been involved in shootings or other
critical incidents. So, the peer support group is going to be
of great value.
But to speak directly to frustrations, we spend an
incredible amount of time doing just that, responding over and
over again to those who are addicted to this.
Mr. Welch. I yield back. Thank you.
Ms. Hill. Thank you.
I would like to recognize Mr. Grothman for five minutes.
Mr. Grothman. Yes, thanks for being back here again.
I do not remember if I asked this question last time. A
relatively high percentage of American troops used heroin in
Vietnam, and within a few years of returning a very small
percentage of those people were using heroin. What happened
there?
Director Carroll. I am sorry, I am happy to do some more
research into the Vietnam era and get back to your staff. One
thing I am sure about is there was not fentanyl coming over
from China and coming up from Mexico.
Mr. Grothman. That is true. I am just saying--who knows
what to believe on the Internet, but from what I read, about 15
percent of American troops in Vietnam were using heroin, maybe
even described as heroin addicts, and they returned, and in a
relatively short period of time that number almost entirely
disappeared. I wondered whether any of you four experts were
familiar with that or have looked into it.
Director Carroll. I am not familiar. I am happy to look
into it and get back to you.
Mr. Grothman. Good.
Yes, Sheriff Ivey?
Sheriff Ivey. Yes, sir. The only thing I can speak to is,
in talking with my team, we are seeing an increasing number of
our veterans that are falling into this epidemic, and that is
both accidental and intentional overdoses that are taking
place, and that is one of the things that we are looking at.
Mr. Grothman. Okay, that is okay.
The next question that just popped into my head. As far as
when you are keeping track of these statistics, percent of
people who die of a heroin overdose, do you know what
percentage are married compared to the general population?
Director Carroll. We do not track that. I can ask the CDC
if they have such information and get back to you.
Mr. Grothman. You should track that.
Director Carroll. Sadly, I think what is happening is that
it is more and more kids, younger people who are passing away,
but I am happy to go back and see if----
Mr. Grothman. Yes, see if the number of people who are age
35 die, what percent are married compared to the population as
a whole.
Okay. Of all the programs you are familiar with, and I
think everybody here who has any sort of political career has
voted for all sorts of money to fight this, what is the most
successful program? I mean, what program has, say, the highest
rate of no relapse within five years? What is the best program
you found?
Director Carroll. We really have to be able to look at this
as everything. We cannot--respectfully, I cannot take just one
program. We have to do programs that work on prevention, and
then on the treatment side we know that MAT is incredibly
effective. We also know faith-based. It really is such an
individualized one, it is hard for me to say----
Mr. Grothman. Well, I will put it this way. Before you guys
came up here, we heard some heart-rending stories of parents
and a daughter whose mother or children died, and some of them
just seem to go through this revolving door of treatment,
treatment, treatment. And I just wondered, is there any program
out there that you can say, at least say 70 percent of the
people who go through this program do not relapse within five
years? Is there such a program that exists?
Director Carroll. I will say that probably the most
effective thing that we can do that has almost zero dollars
attached to it is getting rid of stigma, is telling people that
it is okay to----
Mr. Grothman. Is there any program like that? Does anybody
know? For all the time we spend on this, can anybody say if you
go to such and such a program in Columbus, Ohio, 70 percent of
the people do not relapse within five years? Is there any such
program that even exists?
Director Carroll. This issue is so complex that there is
not one single solution for individuals. We have to take this
as a step-by-step process.
Mr. Grothman. Well, I know we do, but we have been studying
this thing forever. I mean, I have done this job for three or
four years. I wish I could keep track of all the hearings I
have spent before this. Do we know of any program that we can
say that, say, I am going to send my son here, whatever, and
say with 70 percent certainty that person will not relapse
within five years? Is there any such program?
Dr. Rattay. There is no magic program like that at this
point. But we----
Mr. Grothman. How about 40 percent?
Dr. Rattay. But we have learned a lot over----
Mr. Grothman. I only have five minutes. Is there a program
that you can even say 40 percent of the people have not
relapsed within five years?
Dr. Rattay. Again, I agree with the comprehensive approach.
If I were to point to one thing, medication-assisted
treatment----
Mr. Grothman. So, there is no program, or you just do not
know.
Dr. Rattay [continuing]. Is critical.
Mr. Grothman. Final question. As far as other countries--
and maybe I will give this to Sheriff Ivey. Some people do not
like to deal with deterrence, you know, let's do treatment but
we cannot deal with deterrence. I went to Taiwan about 14 years
ago, and they have almost no drug problem. Can you tell us what
type of--does deterrence work in some of these southeastern
Asian countries?
Sheriff Ivey. I am assuming by ``deterrence'' you mean the
type of penalties and the incarceration----
Mr. Grothman. Yes.
Sheriff Ivey. I am a strong believer--in fact, I absolutely
advocate the harsher the penalty to these that are dealing--
preying on those addicted, the harsher penalties we can give,
hitting them with racketeering, conspiracy to racketeer,
putting them away for life, is certainly a deterrent. I
absolutely believe it.
Mr. Grothman. Yes, these----
Ms. Hill. The gentleman's time has expired.
I recognize Ms. Pressley for five minutes.
Ms. Pressley. Thank you, Madam Vice Chair.
Structural racism and systemic biases have shaped our
responses to addiction, which has resulted in the criminalizing
and the devastating of whole communities for decades. I do
believe we perpetuate those practices when we ignore and leave
out of the conversation and the profile of who has been
impacted by this public health crisis and epidemic expectant
mothers, when we leave out the black and Latinx communities,
and when we leave out those that are incarcerated.
Again, one of the groups most at risk of opioid-related
deaths--and pregnant women and new moms have been especially
vulnerable. The CDC found that the number of pregnant women
with an opioid addiction more than quadrupled in the last 15
years. And for these new moms experiencing addiction, a year
after childbirth is the deadliest.
Mr. Carroll, what is ONDCP doing to partner with HHS to
improve comprehensive health services, particularly for
postpartum women, who are often most susceptible to relapse and
opioid-related overdoses?
Director Carroll. One of the things that is important to do
is to make sure we are reaching every community that is out
there. You mentioned the incarcerated. Let me start with the
order that you went. You were talking about the population that
is incarcerated, and it----
Ms. Pressley. We can go there, but I would like to stay on
the moms right now.
Director Carroll. I am trying to answer your question.
Ms. Pressley. Okay.
Director Carroll. And I will get there, I promise.
What we are trying to do for the incarcerated population,
sadly, in many communities, those are the facilities that
provide the most treatment for individuals. So, that leads to
change, but the change is at the fundamental level in making
sure that we are not criminalizing addiction and so fewer and
fewer people are going to jail. We are doing that--we did an
additional $4 million in drug court diversion so they are not
going to jail and they can get treatment on the outside.
In terms of----
Ms. Pressley. I am sorry. So, yes or no, does that mean
that ONDCP is working with the Bureau of Prisons to expand
access to medication-assisted treatment for incarcerated
people? Since we know that two-thirds of incarcerated people
suffer from substance abuse disorders, and only one-quarter of
those people receive any drug treatment.
Director Carroll. One of the things that is important when
we talk about----
Ms. Pressley. Yes or no, do you have a partnership? I am
sorry, I have a limited time. I am trying to be respectful.
Director Carroll. And I am trying to be respectful, too.
Ms. Pressley. Okay.
Director Carroll. What we are trying to do is expand the
number of prescribers, because once we have a bigger work
force, we can get more people into an incarcerated population
to provide them the treatment that they need.
Ms. Pressley. So, those reentering society, they are 40
times more likely to die from an opioid overdose.
Director Carroll. And there are some local jails that are
doing this. We are trying to incorporate it at the Federal
level as well.
Ms. Pressley. Okay, very good. Thank you.
Director Carroll. But one thing it is important----
Ms. Pressley. I am short on time. I want to get to my
question about moms.
Director Carroll. In terms of moms, that is one of the
saddest things that you see is when you see a child who has NAS
and they truly have that pain. So, the idea is making sure that
we are having specialized care for them with HHS, to make sure,
such as Lilly's Place in West Virginia that we talked about,
and other places, to make sure we are going right at--we have
to treat these----
Ms. Pressley. Excuse me. I am sorry. But at the same time,
you are intent on overturning the ACA, rolling back protections
for preexisting conditions, and undermining the expansion of
Medicaid, which can be a critical source for addiction
treatment. So, yes or no, will this Administration's attack on
the ACA and efforts to stop Medicaid expansion help tackle the
opioid epidemic?
Director Carroll. The failed policies of health insurance
do not actually mean health care, and I think it is important
that we understand that at the outset. We have to make sure,
and it is my responsibility to advise the President on making
sure that as the reforms go forward, getting treatment to
individuals is the most important thing that I can do in terms
of helping whether it is moms who have an addiction, parents,
children, or anyone. That is my responsibility, to make sure
that we have a health care system that works.
Ms. Pressley. Excuse me. I just want to be clear, because
mothers are dying. Do you believe the Administration's efforts
to undermine the ACA will help in the opioid crisis?
Director Carroll. I believe that the health care policy
going forward will save more lives, absolutely. We are going to
make it a sound policy.
Ms. Pressley. Okay. We disagree on that.
In my home state of Massachusetts, the opioid crisis is
robbing lives at a rate that is two times higher than the
national average, and the death rates in black and brown
communities are spiking at record rates. Yet these communities
most at risk are less likely to have access to critical
services and medication-assisted treatment.
Mr. Carroll, what is ONDCP doing to ensure that black and
Latino communities are not left behind?
Director Carroll. One of the things we have to do, as I
talked about a minute ago, was to make sure that there is not
stigma in terms of the population, the prescribing population,
to make sure that we are getting treatment and facilities that
provide quality, effective care. Sometimes we have seen in
communities, especially in urban areas, our methadone clinics
that are not providing quality care. What we have to do is make
sure that there are qualified individuals out there providing
MAT----
Ms. Pressley. And also culturally competent. I just wanted
to add that.
And then just for the balance of my time, we do not have
much time for you to answer but I just want to say on the
record, your Administration has indicated that they plan to
eradicate and end the HIV and AIDS epidemic in the next decade.
So, I do hope that this is a part of that broader strategy
since we do know a number of the new infections. There is an
overlay in all of these issues.
Director Carroll. God bless you. I hope you are right.
Ms. Pressley. Okay. I yield my time.
Ms. Hill. Thank you so much.
I now recognize the Ranking Member for five minutes.
Mr. Jordan. Director Carroll, what year was the ACA passed?
Director Carroll. Boy, you are probably a better guess.
Four years ago? Five years ago?
Mr. Jordan. It passed in 2010.
Director Carroll. Okay. Time flies. Sorry.
Mr. Jordan. Is it still the law?
Director Carroll. It is.
Mr. Jordan. Yes. And what has happened to the opioid crisis
during that time?
Director Carroll. We have seen the number of deaths just
skyrocket.
Mr. Jordan. Yes. So, the idea that somehow the Trump
Administration and us trying to do what we promised the voters
we were going to do, which is replace, repeal and replace the
ACA, that has not happened. So, the idea that that somehow has
contributed to this terrible crisis across the country is just
crazy; right?
Director Carroll. We need an efficient and effective system
to get help to people.
Mr. Jordan. I agree.
Sheriff, how big is your county?
Sheriff Ivey. A population of 600,000.
Mr. Jordan. Big county.
Sheriff Ivey. Yes, sir.
Mr. Jordan. How long have you been in law enforcement?
Sheriff Ivey. I have been in law enforcement almost 40
years, sir.
Mr. Jordan. Forty years? Most of it in your county?
Sheriff Ivey. No, sir. Actually, I served--the biggest part
of my career is supervisor with the Florida Department of Law
Enforcement across the state.
Mr. Jordan. Across the state. A pretty big state, too.
Sheriff Ivey. Yes, sir.
Mr. Jordan. Yes. So, in 40 years of experience in a county
of 600,000 that you are now the sheriff of, and then I think in
my opening remarks I talked about you had a fentanyl bust of
like--I forget how many pounds. What was the number?
Sheriff Ivey. The investigation yielded three pounds of
fentanyl.
Mr. Jordan. Which is enough, as I think I said, or someone
said, enough to kill----
Sheriff Ivey. In lethal dose form, it would have killed
everybody in my county.
Mr. Jordan. Yes. That is serious. Do you know where that
came from?
Sheriff Ivey. We know that the direct point to us was from
Georgia. That is where the subject picked it up. But according
to our partners with DEA, we see the fentanyl coming in from
China and through Mexico.
Mr. Jordan. Yes, like Director Carroll has talked about and
most of us know.
And I think earlier you talked about what we need to do on
the border. Would you describe the situation on our southern
border as a crisis?
Sheriff Ivey. There is absolutely no question. We need to
secure our southern border. In doing so, we will eliminate and
eradicate a lot of problems that law enforcement faces each and
every day.
Mr. Jordan. And potentially, when you go after the supply,
you can potentially help stop some of the tragic stories we
heard earlier this morning from the families who have lost a
loved one.
Sheriff Ivey. Yes, sir, absolutely. In fact, one of our
families this morning talked about law enforcement did not go
after the dealer. I am a strong, strong advocate of we need to
go after these dealers with every ounce of passion we have to
lock them up. They are preying on the addictions of others.
Mr. Jordan. Question that is related, not maybe directly to
this, but what is your position on liberalizing marijuana laws?
Sheriff Ivey. I am absolutely 1,000 percent against it.
Mr. Jordan. In your experience, 40-some years in law
enforcement, sheriff of a county of over 600,000 people, do you
think liberalized marijuana laws can lead to, then, this
addiction problem in the opioid area?
Sheriff Ivey. Yes, sir. Actually, the greatest education I
ever got in why we should not legalize marijuana came from our
chain gang who we use often to talk to parents who are trying
to help their kids stay out of trouble. They absolutely said
that marijuana, the dealers of marijuana turned them on to the
other dealers who then sold them coke and heroin and the other
things. So, ironically, out of the mouths of what you would
probably call criminal experts because they are sitting in our
jail, they say it is a bad move as well.
Mr. Jordan. Yes. Mr. Sheriff, we appreciate your service,
and all of you, for your testimony today.
Director Carroll, what are your thoughts on liberalizing
marijuana?
Director Carroll. What we have seen is that the marijuana
we have today is nothing like what it was when I was a kid,
when I was in high school. Back then, the THC, the ingredient
in marijuana that makes you high, was in the teens in terms of
the percentage. Now what we are seeing is twice that, three
times that in the plant. But then in the edibles, 80 percent,
90 percent THC. We just do not understand yet. We are doing
more research. DEA is working hard. HHS is working hard to make
sure that we understand the impact of legalization of marijuana
on the body. We know already the impact it has on----
Mr. Jordan. One of the things that passed out of the
Judiciary Committee last Congress was this idea that--and I
think this is where you were going, Director--we need the
research and the studies done before we allow this to happen,
we liberalize these laws, as some states have already done. It
seems to me at least figure out what the research shows, and I
see Dr. Rattay shaking her head as well. Would you agree with
that?
Dr. Rattay. Yes, I would.
Mr. Jordan. All right. I appreciate that. Thank you all.
And with that, Chairman, I yield back.
Ms. Hill. Thank you.
I recognize Congresswoman Speier for five minutes.
Ms. Speier. Thank you, Madam Chair.
And thank you all for the good work that you are doing.
Director Carroll, when you last were with us, I submitted a
question for the record, asking you to provide the status of
each of the 56 recommendations from the Christie Commission,
including whether ONDCP or other Federal agencies had adopted
the recommendations, the reason why the recommendation was or
was not adopted, and all actions taken or planned to be taken
by ONDCP or a Federal agency in furtherance of the
recommendation. So, it is important once we create these
commissions, they come up with these far-reaching
recommendations, that we actually act upon them.
So, your response to me was a one-pager, as well as a one-
year report update on the Commission. Neither of these
documents provides specific information I requested on each of
the 56 Commission recommendations.
So, I am going to ask you one more time. Can we as a
committee receive from you a complete response to each of the
56 recommendations whether or not you have taken action, and if
not, why not, so that we can have a full understanding of
whether or not you have implemented those recommendations?
Director Carroll. We have given you a full answer in terms
of how the Commission--we grouped it into headings of nine,
because that is the way, when you look at the report, how they
fell. In terms of if there is a specific question, I am happy
to work with your staff to explain as to specific questions.
Ms. Speier. All right. Maybe--you know what? All we are
doing is asking for information that you should be able to
provide us.
Director Carroll. I am able to--ma'am, I just said I will
provide it.
Ms. Speier. Okay. Then that is what we will do.
Director Carroll. I am happy to come up and talk to you
about it.
Ms. Speier. Then that is what we will do. We will have you
come up, and you can make a presentation to me and anyone else
on this committee who would like to go over recommendation
after recommendation, and we will go over all 56, if that is
easier for you to do.
Director Carroll. Ma'am, I am trying to save lives on a
daily basis.
Ms. Speier. I understand that. So, are we.
Director Carroll. And so what I am trying to do is make
sure that I am focusing on the priority targets. I gave you a
response to the Commission and, as I said, I am happy to go--if
you have a specific one you want to go through, I am happy to
send my staff up to work with your staff or to work with you.
Ms. Speier. That is not what you just said. You said that
you would come up.
Director Carroll. I said I would--I am happy to come up
with my staff and sit down and answer any questions about a
specific one you want.
Ms. Speier. All right. Then I will get specific questions,
and they will be submitted to you, and then you will come up
with your staff, and we will invite other members of the
committee to join me to get the----
Director Carroll. I want to be sure I send the right staff
to answer your questions, ma'am.
Ms. Speier. I think you are being very belligerent, and I
do not think that is conducive to us working together.
Director Carroll. I think I am trying to answer this in the
most bipartisan fashion I can. And in terms of being
belligerent, I am trying to get you answers that you want.
Ms. Speier. All we did was ask you to respond to the fact
that Mr. Christie was in charge of this Commission, he came up
with 56 recommendations. We wanted to know where you were in
implementing the 56 recommendations, and instead you sent us a
one-page with another document that does not really answer
whether or not these 56 recommendations have been implemented.
It was a pretty simple request, and it should have been
something that you could have responded to in a very simple
manner, but you chose not to.
Director Carroll. I think I did respond in a very simple
manner that pretty much anyone can read and see exactly how we
went about trying to answer these questions.
Ms. Speier. Well, that was not sufficient, so you can come
back, then. Thank you.
Director Carroll. I will send the right staff to come back
and meet with you, ma'am. Do not worry.
Ms. Speier. Again, I object to the tone that you are
using----
Director Carroll. I object to the tone you are using.
Ms. Speier. Well, you do not have the right to object to my
tone, because we have two different roles here.
Director Carroll. Yes, ma'am. I am saving lives.
Ms. Speier. I have oversight role----
Director Carroll. And my job is to save lives, and that is
what I am trying to do every day.
Ms. Speier. Well, if you are trying to do that every day, I
would think you would want to work with the committees that
have the authority to provide you with the resources to do your
job so you can save more lives.
Director Carroll. I have a great relationship, I think,
with most members of the committee and their staff. We are
trying so hard. We have been working with GAO. They have been a
great partner in the last 60 days to be able to work with them
and show them exactly the direction we are going.
Ms. Speier. Well, if I remember correctly, GAO was not
happy with how the Office was operating and made
recommendations. I am glad to know that Ms. McNeil feels that
you are indeed responding to them.
Is that true, Ms. McNeil?
Ms. McNeil. Yes. We have had four meetings with ONDCP staff
since the last hearing, and then we had an additional briefing
where I brought some experts over and walked them through some
best practices related to collaboration and strategic planning.
But I do want to highlight there are two things we have
been asking for that we really need from ONDCP for us to
continue to make progress. One, the budget guidance that they
used before there was a Strategy. We need to understand what
that guidance entails. And two, the National Security Council's
Strategic Framework for Reducing the Availability of Illicit
Drugs. The staff told us that is what they used in lieu of a
Strategy in prior years. We would like access to that. We asked
for it in December and still have not received it.
Ms. Speier. Okay. So, you asked for it in December and have
not yet received it----
Director Carroll. Ma'am, if you listen to what she just
said----
Ms. Hill. The gentlewoman's time has expired.
Director Carroll.--by the National Security Council. We do
not own the document. I am not the National Security Council.
We have given them the information----
Ms. Hill. Director Carroll, I need you to stop. Thank you.
Next I would recognize Mr. Comer for five minutes.
Mr. Comer. Thank you, Madam Chair, and Director Carroll,
and Sheriff Ivey. I just want to thank you for doing everything
you can to try to save lives, and I believe that you all are
trying to save lives.
We have had committee hearings here and countless meetings
and discussions about the opioid issue and crisis for months
and years, and one of the things that has been mentioned today
by the Sheriff and others is that we have a drug problem in
America, and many of the drugs are coming illegally across the
border. We have a President and at least a majority of one
party that is serious about securing the border to try to stop
the illegal flow of drugs into the United States, and I think
that what we are seeing from a few members of this committee in
differing parties is that one party wants more money, more
money, more money, and at the end of the day, until we cutoff
the flow of illegal drugs crossing the border, we can spend all
the money in the world, we are still going to have a major drug
problem in the United States.
So, I think it is important to reiterate the fact that if
we are serious about stopping the flow of illegal drugs into
the United States, we are going to have to get serious in this
Congress about securing the border. So, I just wanted to
mention that.
And in my remaining time, I kind of wanted to shift gears
because I think that the biggest part of the opioid problem we
have had in America is the business model to treat pain has
been wrong. Doctors, at least in my Kentucky district, have,
for whatever reason, over-prescribed opioids for the treatment
of pain, and I think that we have come a long way in education,
in educating our medical providers on the perils of opioids.
But my question, Director Carroll, is as we move forward
and we talk about the opioid issue, again, I will say over and
over, I think the number-one thing that we can do is secure the
border. But as we move forward, there are a lot of people in
America that have legitimate pain, and there are people that
deserve and have the right to treat their pain.
One of the things that I have been doing a lot of research
on is alternative forms of pain treatment. In Kentucky, before
I came to Congress, I was Commissioner of Agriculture, and we
became the first state to legalize industrial hemp. The hemp
industry in Kentucky and in many states now is really booming.
It is an emerging industry. And one of the biggest products
that is coming from industrial hemp is CBD oil, cannabinoid
oil, non-THC, so we are not talking about marijuana, we are
talking about hemp, non-THC CBD oil for treatment of minor pain
like inflammation and other forms of minor pain. This seems to
be really making a difference.
We also, in my research, my staff, we have listened to
physical therapists, chiropractors, other alternative forms of
pain treatment.
Director Carroll, what are your thoughts on how we move
forward in trying to treat pain in America other than the old
business model that has failed so miserably in prescribing
severe pain medication?
Director Carroll. One of the things that I think is
important to do, and actually the Commission talked about this,
was removing the pain questions when there are surveys for
health care professionals. Working with HHS and working with
Members of Congress, one of the things that we have done is
removed the pain questions from the reimbursement side. So,
effective October 1, 2019, the questions on pain as they
determine reimbursement rates will no longer be asked.
So, the people understand that sometimes if you have--I
think we were talking earlier, one of the young men who lost
his life was because of an appendix, to be able to say to them
it is going to hurt, you just had surgery. So, by removing the
pain survey, that is one of the things that I appreciate
[about] the committee and Chairman Cummings, and I have talked
about too: making sure that we treat appropriate pain, but that
we also do not spend too much of an emphasis on it.
In terms of the CBD, that is something again that I think
HHS is going to regulate to make sure that we understand the
health impact of it. I do not know if Dr. Rattay feels
differently, but I think right now we are on the cutting edge
of research to show the----
Ms. Hill. The gentleman's time has expired.
Director Carroll. I am sorry.
Ms. Hill. I recognize Ms. Maloney for five minutes.
Mrs. Maloney. I thank the Chairwoman for yielding and all
of the panelists for your service.
One of the recommendations in the report really builds on
the question of Mr. Comer, and I applaud his questioning. It is
the same that I have heard from doctors in the city that I
represent, but they say they want to reduce opioid prescription
fills by 33 percent within three years. I think one of the
problems I have heard from doctors is the incentive is to give
pain medication, and I am pleased that that question has been
removed. It should be removed from everything.
Director Carroll. Thank you for your help on that.
Mrs. Maloney. They told me that they felt like they had to
give pain pills because they were being drilled on it, and I
think that removing it--my question is if you change the
incentive and instead of asking people to rate whether the
doctor took away all their pain, you could ask the question to
the doctor: ``Did you try every other alternative form of pain
relief before you moved to an opioid?'' Because what doctors
are telling me is that there is Tylenol, all types of different
pain relief that can help people. And I think if you changed
that incentive, I think it would be better.
Personally, I think we should take opioids totally off the
market unless you are in hospice, because it is harmful to
people. From the stories that we read, most people are addicted
by their doctors giving them these pills.
I want to tell a story of a constituent who became addicted
in five days on opioids. She was in one of the finest hospitals
in my district, and they asked her all the time to fill out
forms on whether or not she was in pain. Of course she was in
pain. She had a minor operation. They cut on you, you are in
pain. She did not want all these pain pills. They kept giving
them to her. When she left they gave her three different
painkillers, big bottles of opioids to take home with her and
fill out her form that she did not have any pain, because the
doctors did not want to be rated badly.
So, I think removing that rating completely--it should not
be anywhere--it should be removed, and I think the incentive
should be changed to what are you doing to prevent having to go
on opioids.
And my question is why do we continue to allow this to be
legally dispensed when we know it is killing people? We know it
is killing. The numbers are astronomical of people becoming
addicted. This woman became addicted in five days.
Now, people are different. Some people will never become
addicted for whatever reason, the chemistry in the body. She
became addicted and had a difficult, difficult time getting off
of it. But she did not want all these pain pills. They just
kept giving them to her because the incentive was do you have
any pain, you cannot have any pain, do not rate me for giving
you pain.
But I would just like to ask the panel, what about changing
the incentive and saying instead of do you have any pain, ask
the doctor have you tried every other way to relieve the pain
and give the incentive to the doctor to talk to the person that
you may be uncomfortable for one day but you are much better
off not taking these killer opioids.
If anybody wants to comment, I would like to hear your
response.
Director Carroll. I will just take 10 seconds at the end.
Dr. Rattay. This is a tough-to-crack. Changing prescribing
practices is much more stubborn than we realized. The Centers
for Disease Control and Prevention has done a nice job
reviewing the evidence. I think we all know now opioids really
are not very effective for pain management, and the risks are
much, much higher. But access to alternative and more effective
approaches to pain management has been limited.
So, one of the things we have done in our state is not only
educating the public and providers but changing insurance----
Mrs. Maloney. May I ask a question, with all respect? Why
is it difficult? Why is it difficult for your states to have
alternatives that could save a life if you kept them off of
opioids? Why is it difficult? There is Tylenol. I mean, I am
not a doctor, I do not know these terms, but there are lots of
little drugs that can help you. Why is it difficult to get an
alternative?
Dr. Rattay. There is a lot of resistance overall. The
public still has--there is a lot of demand for opioids for pain
management. Physicians, many do not particularly want to be
told to decrease their prescribing. But you mentioned, and I
think it is very much the case, insurance is much better at
reimbursing for pharmaceuticals, including opioids, and we are
really pushing change to get chiropractic care, physical
therapy. We have removed the caps for those in our state. We
are now working on massage and acupuncture, requiring
reimbursement for those, as examples.
But right now, a lot of people do not have access through
their insurance to alternative approaches.
Ms. Hill. The gentlewoman's time has expired.
Mrs. Maloney. Thank you.
Ms. Hill. With that, I recognize Ms. Ocasio-Cortez for five
minutes.
Ms. Ocasio-Cortez. Thank you so much. I would like to thank
the Chair and the committee for convening today's hearing, as
well as all of our witnesses for joining us today.
While I am pleased to hear that the Administration is
supporting efforts to combat the opioid crisis, and that the
President's budget requests some discretionary funds for this
purpose, it seems that upon closer inspection he is actually
gutting the very programs that are critical to combating the
opioid epidemic.
The Medicaid program is the Nation's single largest payer
for behavioral health services, and it covers nearly four in 10
non-elderly adults struggling with opioid addiction, and adults
with Medicaid are more likely than even the privately insured
and the uninsured to receive substance use disorder treatment.
So, at the same time we should be dedicating greater
resources to this critical program, the President's budget is
proposing $1.5 trillion in cuts to the Medicaid program over
the next 10 years, the very program that is the largest payer
and the larger assistant in behavioral health services.
So, I have a question, Dr. Rattay. In your written
testimony you speak about the importance of Delaware's Medicaid
expansion. What would it mean for your state, and how would
this impact your ability to respond to the opioid epidemic, if
the ACA were repealed?
Dr. Rattay. We have great concerns that if the ACA were
repealed and we went backward regarding expansion, that many
people would lose access to life-saving treatment services. So,
on the flip side, Medicaid expansion not only has been able to
enable us to increase access to services for individuals, but
it has also enabled us to use resources, other resources
differently; so, for example, whether it is wrap-around
services or peer recovery coaches.
Ms. Ocasio-Cortez. Have you seen any sort of relationship,
whether it is correlative or otherwise, between states that
have not expanded Medicaid and the depth of the opioid crisis
there, and the ability of people to seek treatment?
Dr. Rattay. I know that there has been a look at that, but
I have not studied that closely.
Ms. Ocasio-Cortez. Thank you.
In addition to the opioid crisis, I think one of the issues
that we have had here is that we do not see these crises hit
until they are crises, especially on the legislative side as
well. But we have to be able to identify emerging threats, and
what I have been seeing here is one of the lessons that we
learned from the opioid crisis and the rapid rise of fentanyl
and synthetic opioids is that we need to be prepared to react
quickly when new crises and new drugs emerge as threats.
Dr. Carroll, can you update us on the process of
identifying emerging threats when it comes to drugs and public
health? And when can we expect the Emerging Threats Committee
to be up and running?
Director Carroll. Thank you. If I may just spend 30 seconds
responding to Congresswoman Maloney, Congresswoman Maloney
referenced about reimbursement rates and tying it to pain. It
is an interesting idea. Maybe we should take a reverse approach
and for people----
Ms. Ocasio-Cortez. I would like to reclaim my time, Dr.
Carroll. I am so sorry. Her time has expired.
Director Carroll. I promise----
Ms. Hill. I will give you an extra 30 seconds.
Ms. Ocasio-Cortez. Great. Thank you.
Director Carroll. Maybe that is a great idea to say when
you cut down your prescriptions for--well, protecting chronic
pain people, the reimbursement rates will go higher the fewer
opioid prescriptions you write.
One of the things we are also doing is working with
medical----
Ms. Hill. I want to be sensitive to time. Can you please
answer the gentlewoman from New York?
Director Carroll. Thank you. I apologize, Congresswoman,
and I appreciate the committee, when you reauthorized us to
make that a centerpiece. So, we have sent invitations out to 14
members across the country from every disciple, every
discipline, and we will be hosting our first meeting with our
new Emerging Threats Coordinator on time.
Ms. Ocasio-Cortez. All right. Great. Thank you very much.
Director Carroll. I apologize for 30 seconds.
Ms. Ocasio-Cortez. No worries, no worries.
In fact, at our hearing in March, the Houston HIDTA
Director McDaniels testified that, quote, ``Our major threats
in Houston are methamphetamine, cocaine, and synthetic drugs.''
Our country, unfortunately, has a history of racial inequity
when it comes to how we pursue either enforcement or treatment,
depending on the type of drug.
I was wondering if you agree that one of our goals should
be to increase treatment for all drug addiction, including
addiction to methamphetamines, cocaine, and other drugs in
addition to opioids.
Director Carroll. Absolutely. I think we need to--people
say ``opioid crisis'' because that is what is killing so many
people, but at its core, you are right, this is an addiction
crisis, and we have to treat people as we find them.
Ms. Ocasio-Cortez. Thank you very much.
I will yield the rest of my time to the Chair.
Ms. Hill. Thank you.
With that, I will recognize myself for five minutes.
This question is to--well, first, I want to say thank you
so much to everyone for testifying, especially to those who
joined us earlier today.
But, Director Carroll, I am particularly glad to hear that
you are testifying about the importance of evidence-based
treatment. We actually see extensively in the GAO testimony
that highlights that medication-assisted treatment is
demonstrated that it reduces opioid use and increases treatment
retention compared to abstinence-based treatment.
One of the challenges identified in increasing access to
MAT is really about access to coverage, right? And the
availability and limits of insurance coverage for MAT. You
state that patients with no insurance coverage for MAT could
face prohibitive out-of-pocket costs that could limit their
access, and if coverage for MAT varied for those individuals
with insurance and coverage varied. Insurance plans, including
state Medicaid plans, did not always cover the medications, and
they sometimes imposed limits on the length of treatment.
That said--I have a lot of papers here, by the way. Sorry.
That said, we have the study that I earlier introduced from the
American Journal of Public Health that stated that the ACA
provides greater access to substance use disorder treatment
through major coverage expansions, regulatory changes,
requiring the coverage of substance use disorder treatment, and
existing insurance plans and requirements for treatment to be
offered on par with medical and surgery, as well as
opportunities to integrate substance use and to mainstream
health care. A Kaiser study, as mentioned previously, shows
that 4 in 10 adults with opioid addiction are covered by
Medicaid, and 21 million Americans have gained coverage through
the ACA, including 12 million through Medicaid.
So, Ms. McNeil, do you believe that if the ACA is
overturned, this issue of coverage would be better or worse?
Ms. McNeil. I will invite my colleague, Mary Denigan-
Macauley, to answer that.
Ms. Denigan-Macauley. I apologize. Can you repeat the
question, please?
Ms. Hill. The question was, given all of the information I
just shared and your belief that access to coverage and
provisions around coverage that makes it more difficult for
people to get MAT, is this something that you believe would be
made worse or better if the ACA was overturned?
Ms. Denigan-Macauley. Well, GAO would certainly encourage
any increased access to treatment, and Medicaid is one program
that does improve access to treatment. So, our concern would be
ensuring that that remains.
Ms. Hill. Do you have any estimates of how much was
provided by Medicaid or how much was spent by Medicaid on such
treatment?
Ms. Denigan-Macauley. We do not, but we do know that in
those states that had Medicaid expansion, that there were more
people who had the access, but we do not have a number.
Ms. Hill. Thank you.
And, Director Carroll, one of your goals listed in your
Performance Reporting Supplement is increasing the percentage
of specialty treatment facilities providing MAT for opioid use
by 100 percent within five years. I recently visited one such
facility in my district. It seems to be a great program, but
they spoke extensively about the challenges around coverage,
and the majority of their patients are covered by Medicaid, and
others are covered by health insurance that in many cases they
did not have prior to the ACA.
So, my question is, if the issue of coverage is
exponentially exacerbated by a successful overturn of the ACA,
how do you think you would be able to accomplish this
objective?
Director Carroll. Thank you. I am bipartisan on this issue.
We have to save lives regardless, and providing treatment to
everyone is critical to do this.
Ms. Hill. And to be clear, I am not making this about
partisanship. I am concerned about what the courts are going to
do, so I honestly want to know what is going to happen if the
ACA is overturned.
Director Carroll. In terms of first to talk about the
Medicaid and the reimbursement, as well as health insurance, we
have to make sure that it is sustainable going forward. So, to
be able to give states the authority to help more at that level
than at the Federal level to determine how they are going to
provide treatment for people I think is critical.
One of the things we are also seeing is making sure for
those people that do have insurance under the ACA--what we are
seeing are co-pays that are so high that it is really not
effective. There was a report this week that was talking about
co-pays for individuals under some of the ACA plans. I think it
is $6,000 or $8,000 per year, and $12,000 for families. At that
point, you really have to wonder whether it is working or not.
Ms. Hill. Right. Well, in large part that is because of the
increasing pressure we have seen from other attempts to
undermine the ACA that the costs have gone up and co-pays have
gone up exponentially.
But for me, I am wondering, and I do not know if this is
possible to request, but I would love to see some contingency
plans or other efforts from GAO and from your office on how
such an overturn of the ACA would affect treatment.
Director Carroll. I will see what we can get you as soon as
possible.
Ms. Hill. Thank you.
With that, I would like to thank our witnesses so much for
testifying today, and to you both who are still here, I was
incredibly moved by your testimony, and I am so sorry for your
loss, and thank you, really, for bringing this to life in the
halls of Congress.
Without objection, all members will have five legislative
days within which to submit additional written questions for
the witnesses to the Chair, which will be forwarded to the
witnesses for their response. I ask our witnesses to please
respond as promptly as you are able to.
And this hearing is adjourned.
[Whereupon, at 1:32 p.m., the committee was adjourned.]
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