[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]



 
                                                             
  AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND
                     MISUSE IN AMERICA

=======================================================================

                            VIRTUAL HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               ----------                              

                             APRIL 14, 2021

                               ----------                              

                           Serial No. 117-20
                           
                           
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                          
                           


     Published for the use of the Committee on Energy and Commerce
     
     

                        energycommerce.house.gov



 AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND MISUSE 
                               IN AMERICA
                               
                               
                               
                               

 
 AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND MISUSE 
                               IN AMERICA

=======================================================================

                            VIRTUAL HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 14, 2021

                               __________

                           Serial No. 117-20
                           
                           
                           
  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                         


     Published for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                        
                        
                           ______
 
              U.S. GOVERNMENT PUBLISHING OFFICE 
47-023 PDF              WASHINGTON : 2022                        
                        
                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California              Ranking Member
DIANA DeGETTE, Colorado              FRED UPTON, Michigan
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida                DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland           ADAM KINZINGER, Illinois
JERRY McNERNEY, California           H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
PAUL TONKO, New York                 BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York           BILLY LONG, Missouri
KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California                RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California          TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan             EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas                JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire         GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice       NEAL P. DUNN, Florida
    Chair                            JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California    DEBBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia         GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
DARREN SOTO, Florida                 JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona              KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                  NATE HODSON, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
G. K. BUTTERFIELD, North Carolina    BRETT GUTHRIE, Kentucky
DORIS O. MATSUI, California            Ranking Member
KATHY CASTOR, Florida                FRED UPTON, Michigan
JOHN P. SARBANES, Maryland, Vice     MICHAEL C. BURGESS, Texas
    Chair                            H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
TONY CARDENAS, California            LARRY BUCSHON, Indiana
RAUL RUIZ, California                MARKWAYNE MULLIN, Oklahoma
DEBBIE DINGELL, Michigan             RICHARD HUDSON, North Carolina
ANN M. KUSTER, New Hampshire         EARL L. ``BUDDY'' CARTER, Georgia
ROBIN L. KELLY, Illinois             NEAL P. DUNN, Florida
NANETTE DIAZ BARRAGAN, California    JOHN R. CURTIS, Utah
LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
ANGIE CRAIG, Minnesota               JOHN JOYCE, Pennsylvania
KIM SCHRIER, Washington              CATHY McMORRIS RODGERS, Washington 
LORI TRAHAN, Massachusetts               (ex officio)
LIZZIE FLETCHER, Texas
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
    
                             C O N T E N T S
                             

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     2
    Prepared statement...........................................     2
Hon. Ann M. Kuster, a Representative in Congress from the State 
  of New Hampshire, prepared statement...........................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     8
Hon. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................     9
    Prepared statement...........................................    10

                               Witnesses

Regina M. LaBelle, Acting Director, White House Office of 
  National Drug Control Policy...................................    12
    Prepared statement...........................................    14
    Answers to submitted questions...............................   308
Geoffrey Laredo, Principal, Santa Cruz Strategies, LLC...........    78
    Prepared statement...........................................    81
    Answers to submitted questions...............................   312
Patricia L. Richman, National Sentencing Resource Counsel, 
  Federal Public and Community Defenders.........................    88
    Prepared statement...........................................    90
Mark Vargo, Pennington County, S.D., State's Attorney, and Chair, 
  Legislative Committee, National District Attorneys Association.    96
    Prepared statement...........................................    98
Timothy Westlake, M.D., Emergency Department Medical Director, 
  ProHealth Care Oconomowoc Memorial Hospital....................   115
    Prepared statement...........................................   118
Deanna Wilson, M.D., Assistant Professor of Medicine and 
  Pediatrics, University of Pittsburgh School of Medicine........   132
    Prepared statement...........................................   134
    Answers to submitted questions...............................   315

                           Submitted Material

H.R. 654, the Drug-Free Communities Pandemic Relief Act, 
  submitted by Ms. Eshoo\1\
H.R. 955, the Medicaid Reentry Act of 2021, submitted by Ms. 
  Eshoo\1\
H.R. 1384, the Mainstreaming Addiction Treatment Act of 2021, 
  submitted by Ms. Esho\1\
H.R. 1910, the Federal Initiative to Guarantee Health by 
  Targeting Fentanyl Act, submitted by Ms. Eshoo\1\
H.R. 2051, the Methamphetamine Response Act, submitted by Ms. 
  Eshoo\1\
H.R. 2067, the Medication Access and Training Expansion Act, 
  submitted by Ms. Eshoo\1\
H.R. 2355, the Opioid Prescription Verification Act, submitted by 
  Ms. Eshoo\1\

----------

\1\ The proposed legislation has been retained in committee files and 
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=111439.
H.R. 2364, the Synthetic Opioid Danger Awareness Act, submitted 
  by Ms. Eshoo\1\
H.R. 2366, the Support, Treatment, and Overdose Prevention of 
  Fentanyl Act of 2021, submitted by Ms. Eshoo\1\
H.R. ___, the State Opioid Response Grant Reauthorization Act, 
  submitted by Ms. Eshoo\1\
H.R. ___, the Streamlining Research on Controlled Substances Act, 
  submitted by Ms. Eshoo\1\
Letter of April 13, 2021, from Ellen Glover, Drug Policy, Harm 
  Reduction and Criminal Justice Campaign Director, People's 
  Action, to Ms. Eshoo, submitted by Ms. Eshoo...................   171
Letter of April 13, 2021, from Senator Cory A. Booker, et al., to 
  President Biden, submitted by Ms. Eshoo........................   174
Statement of the American Property Casualty Insurance 
  Association, April 14, 2021, submitted by Ms. Eshoo............   177
Letter of March 2, 2021, from David Patton and Jon Sands, Co-
  Chairs, Federal Defenders Legislative Committee, to Alyssa M. 
  Hundrup, Acting Director, Health Care, Government 
  Accountability Office, submitted by Ms. Eshoo..................   178
Letter of April 14, 2021, from Dave Yost, Ohio Attorney General, 
  to Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo...........   186
Statement of the American Academy of PAs, April 14, 2021, 
  submitted by Ms. Eshoo.........................................   188
Letter of April 14, 2021, from Katherine McGuire, Chief Advocacy 
  Officer, American Psychological Associationm to Ms. Eshoo and 
  Mr. Guthrie, submitted by Ms. Eshoo............................   191
Statement of Bill Greer, President, SMART Recovery USA, April 14, 
  2021, submitted by Ms. Eshoo...................................   193
Letter from Brenda Siegel to Subcommittee on Health, submitted by 
  Ms. Eshoo......................................................   197
Letter of April 14, 2021, from Jeffrey A. Singer, Senior Fellow, 
  Department of Health Policy Studies, Cato Institute, to Ms. 
  Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..................   200
Letter of April 8, 2021, from A Little Piece of Light (NY), et 
  al., to Chairman Richard Durbin, Senate Judiciary Committee, et 
  al., submitted by Ms. Eshoo....................................   207
Statement of Sandra D. Comer, Professor of Neurobiology (in 
  Psychiatry), Columbia University Irving Medical Center, New 
  York State Psychiatric Institute, April 14, 2021, submitted by 
  Ms. Eshoo......................................................   216
Letter of April 14, 2021, from Grant Smith, Deputy Director, 
  National Affairs, Drug Policy Alliance, to Ms. Eshoo and Mr. 
  Guthrie, submitted by Ms. Eshoo................................   227
Statement of the American Nurses Association, April 14, 2021, 
  submitted by Ms. Eshoo.........................................   232
Report of the National Association of Assistant United States 
  Attorneys, ``Fentanyl Scheduling Charge and Response,'' 
  submitted by Ms. Eshoo.........................................   234
Letter of April 14, 2021, from Lawrence J. Leiser, President, 
  National Association of Assistant United States Attorneys, to 
  Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..............   238
Letter of April 14, 2021, from Elizabeth Connolly, Director, 
  Substance Use Prevention and Treatment Initiative, Pew 
  Charitable Trusts, to Ms. Eshoo and Mr. Guthrie, submitted by 
  Ms. Eshoo......................................................   240
Letter of December 11, 2019, from the National Association of 
  Attorneys General to Senators Lindsey Graham and Diane 
  Feinstein, submitted by Ms. Eshoo..............................   244
Letter of August 5, 2019, from the National Association of 
  Attorneys General to Rep. Nancy Pelosi, et al., submitted by 
  Ms. Eshoo......................................................   249
Letter of April 13, 2021, from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Ms. Eshoo and Mr. Guthrie, 
  submitted by Ms. Eshoo.........................................   255
Statement of Margaret Rizzo, Executive Director/Chief Executive 
  Officer, JSAS HealthCare, April 12, 2021, submitted by Ms. 
  Eshoo..........................................................   257

----------

\1\ The proposed legislation has been retained in committee files and 
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=111439.
Letter of April 13, 2021, from Erin Schanning, President, End 
  Substance Use Disorder, to Mr. Pallone and Mrs. Rodgers, 
  submitted by Ms. Eshoo.........................................   259
Letter of April 14, 2021, from Senator Telena Cruz Nelson to Mr. 
  Pallone re: H.R. 955, submitted by Ms. Eshoo...................   266
Letter of April 14, 2021, from Senator Telena Cruz Nelson to Mr. 
  Pallone re: H.R. 2355, et al., submitted by Ms. Eshoo..........   267
Letter of April 13, 2021, from Association for Behavioral Health 
  and Wellness, et al., to Xavier Becerra, Secretary, Department 
  of Health and Human Services, submitted by Ms. Eshoo...........   268
Letter of April 13, 2021, from Ryan Marino, Assistant Professor, 
  Departments of Emergency Medicine & Psychiatry, Case Western 
  Reserve University School of Medicine, to Congressional 
  Policymakers, submitted by Ms. Eshoo...........................   272
Statement of the Medication Assisted Treatment Leadership 
  Council, April 14, 2021, submitted by Ms. Eshoo................   274
Statement of the National Safety Council, April 14, 2021, 
  submitted by Ms. Eshoo.........................................   279
Letter of April 13, 2021, from Daniel Raymond, Director of 
  Policy, National Viral Hepatitis Roundtable, to the 
  Subcommittee on Health, submitted by Ms. Eshoo.................   285
Letter of April 13, 2021, from Marcia Lee Taylor, Chief External 
  and Government Relations Officer, Partnership to End Addiction, 
  to Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo...........   287
Statement of Shatterproof, April 14, 2021, submitted by Ms. Eshoo   290
Statement of Charles Ingoglia, President and Chief Executive 
  Officer, National Council for Behavioral Health, April 14, 
  2021, submitted by Ms. Eshoo...................................   292
Article of April 12, 2021, ``Biden Looks to Extend Trump's 
  Bolstered Mandatory Minimum Drug Sentencing,'' by Akela Lacy, 
  The Intercept, submitted by Ms. Eshoo..........................   293
Commentary of February 25, 2021, ``X the X-Waiver: How Congress 
  can facilitate treatment for opioid abuse,'' by Mike Hunter and 
  Josh Stein, The Hill, submitted by Ms. Eshoo...................   297
Statement of Timothy B. Conley and Dr. Debbie Akerman, Wurzweiler 
  School of Social Work, Yeshiva University, April 14, 2021, 
  submitted by Ms. Eshoo.........................................   300
Report of the Government Accounting Office, ``Synthetic Opioids: 
  Considerations for the Class-Wide Scheduling of Fentanyl-
  Related Substances,'' April 2021, submitted by Ms. Eshoo 1A\2\
Letter of February 9, 2021, from Lemrey ``Al'' Carter, Executive 
  Director/Secretary, National Association of Boards of Pharmacy, 
  to Mr.Tonko, submitted by Ms. Eshoo............................   306

----------

\2\ The report has been retained in committee files and is available at 
https://docs.house.gov/meetings/IF/IF14/20210414/111439/HHRG-117-IF14-
20210414-SD021.pdf.


 AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND MISUSE 
                               IN AMERICA

                              ----------                              


                       WEDNESDAY, APRIL 14, 2021

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:29 a.m., via 
Cisco Webex online video conferencing, Hon. Anna G. Eshoo 
(chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Butterfield, 
Matsui, Castor, Sarbanes, Welch, Schrader, Cardenas, Ruiz, 
Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Craig, 
Schrier, Trahan, Fletcher, Pallone (ex officio), Guthrie 
(subcommittee ranking member), Upton, Burgess, Griffith, 
Bilirakis, Long, Bucshon, Mullin, Hudson, Carter, Dunn, Curtis, 
Joyce, and Rodgers (ex officio).
    Also present: Representatives Tonko, O'Halleran, and Latta.
    Staff present: Joe Banez, Professional Staff Member; 
Jeffrey C. Carroll, Staff Director; Waverly Gordon, General 
Counsel; Tiffany Guarascio, Deputy Staff Director; Perry 
Hamilton, Clerk; Mackenzie Kuhl, Digital Assistant; Aisling 
McDonough, Policy Coordinator; Meghan Mullon, Policy Analyst; 
Kaitlyn Peel, Digital Director; Tim Robinson, Chief Counsel; 
Chloe Rodriguez, Clerk; Kimberlee Trzeciak, Chief Health 
Advisor; Caroline Wood, Staff Assistant; C.J. Young, Deputy 
Communications Director; Sarah Burke, Minority Deputy Staff 
Director; Theresa Gambo, Minority Financial and Office 
Administrator; Grace Graham, Minority Chief Counsel, Health; 
Caleb Graff, Minority Deputy Chief Counsel, Health; Nate 
Hodson, Minority Staff Director; Peter Kielty, Minority General 
Counsel; Emily King, Minority Member Services Director; Clare 
Paoletta, Minority Policy Analyst, Health; Kristin Seum, 
Minority Counsel, Health; Kristen Shatynski, Minority 
Professional Staff Member, Health; Olivia Shields, Minority 
Communications Director; Michael Taggart, Minority Policy 
Director; and Everett Winnick, Minority Director of Information 
Technology.
    Ms. Eshoo. The Subcommittee on Health will now come to 
order. And due to the COVID-19, today's hearing is being held 
remotely. All Members and witnesses will be participating via 
video conferencing.
    As part of our hearing, microphones will be set on mute to 
eliminate background noise. Members and witnesses need to 
remember to unmute your microphone each time you wish to speak. 
Documents for the record should be sent to Meghan Mullon at the 
email address that we provided to your staff, and all documents 
will be entered into the record at the conclusion of the 
hearing.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    According to recently reported data from the CDC, overdose 
deaths spiked after the start of the pandemic. From September 
2019 through August 2020, there were over 88,000 overdose 
deaths, with 2020 being the deadliest year for overdoses on 
record. These are really stunning numbers. So we are in an 
addiction crisis during a COVID crisis.
    In 2016 Congress passed the 21st Century Act and CARA, C-A-
R-A, and the SUPPORT Act in 2018 to stem the tide of addiction 
and the devastation that the opioid crisis has created. 
Congress also provided over $8 billion--with a B--to address 
opioid use and mental and behavioral healthcare through the 
American Rescue Plan in the fiscal year 2021 Appropriations 
Act.
    Yet despite our legislative efforts to increase access to 
evidence-based treatment, according to a National Academies of 
Science report, more than 80 percent of the 2 million people 
with opioid use disorder are not receiving medication-assisted 
treatment.
    Today we are going to hear from the Acting Director of the 
Office of National Drug Control Policy about where and why 
previous efforts have fallen short and what the Biden-Harris 
administration believes we need to do to save lives.
    We will also consider 11 bills, many bipartisan, to address 
the opioid crisis. According to the CDC, three in five people 
who died from overdose had an identified opportunity for care 
or other lifesaving actions.
    And we know that Representative Tonko and Trahan's 
bipartisan bills will ensure more doctors are trained and able 
to prescribe the medication-assisted treatment that we know 
saves lives.
    Those who are released from prisons and jails are 12 times 
more likely to die of an overdose than the general public, 
because they often have no access to treatment upon release. 
The bipartisan Medicaid Reentry Act addresses these inequities 
by extending Medicaid eligibility to incarcerated individuals 
30 days before release.
    And lastly, we are considering bills to address the 
upcoming expiration of the temporary placement of all fentanyl-
related substances in schedule I. Despite the temporary 
scheduling, deaths from fentanyl analogues rose by 10 percent. 
So clearly, scheduling is not the silver bullet and Congress 
has to consider alternatives to stop synthetic opioids.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    According to recently reported data from the CDC, overdose 
deaths spiked after the start of the pandemic. From September 
2019 through August 2020, there were over 88,000 overdose 
deaths, with 2020 being the deadliest year for overdoses on 
record. We're in an addiction crisis amid the COVID-19 crisis.
    In 2016 Congress passed the 21st Century Cures Act and 
CARA, and the SUPPORT Act in 2018 to stem the tide of addiction 
and devastation that the opioid crisis has created. Congress 
also provided over $8 billion to address opioid use and mental 
and behavioral healthcare through the American Rescue Plan and 
the FY 2021 Appropriations Act.
    Yet, despite our legislative efforts to increase access to 
evidence-based treatment, according to a National Academies of 
Science report, more than 80 percent of the 2 million people 
with opioid use disorder are not receiving medication-assisted 
treatment.
    Today we will hear from Acting Director of the Office of 
National Drug Control Policy (ONDCP) about where and why 
previous efforts have fallen short, and what the Biden-Harris 
administration believes we need to do to save lives.
    We'll also consider 11 bills, many bipartisan, to address 
the opioid crisis. According to the CDC, 3 in 5 people who died 
from overdose had an identified opportunity for care or other 
life-saving actions.
    Representative Tonko and Trahan's bipartisan bills will 
ensure more doctors are trained and able to prescribe the 
medication-assisted treatment that we know saves lives.
    Those who are released from prisons and jail are 12 times 
more likely to die of an overdose than the general public 
because they often have no access to treatment upon release. 
The bipartisan Medicaid Reentry Act addresses these inequities 
by extending Medicaid eligibility to incarcerated individuals 
30 days before release.
    And lastly, we're considering bills to address the upcoming 
expiration of the temporary placement of all fentanyl-related 
substances in schedule I. Despite the temporary scheduling, 
deaths from fentanyl analogues rose by 10%, so clearly 
scheduling is not the silver bullet and Congress has to 
consider alternatives to stop synthetic opioids.
    I yield the rest of my time to the sponsor of the STOP 
Fentanyl Act of 2021, Representative Annie Kuster.

    Ms. Eshoo. I now yield the rest of my time--I don't know 
how much is left--to the sponsor of the STOP Fentanyl Act of 
2021, Representative Annie Kuster.
    Ms. Kuster. Thank you so much, Chairwoman Eshoo. As we are 
all too well aware, the pandemic has exacerbated the already 
dire addiction and mental health crises in our country. From 
August 2019 to August 2020, 88,000 Americans died of an 
overdose, the highest number ever recorded over a 12-month 
period.
    But we also know the addiction and overdose crisis in this 
country did not occur overnight. It has devastated communities 
in my State of New Hampshire and across the U.S. for decades. 
What began as an opioid crisis has evolved to an epidemic that 
knows no bounds. It impacts every community, no matter the 
race. It is cross-regional and intergenerational.
    The complexity of this epidemic is urgent. Overdose deaths 
due to synthetic opioids such as fentanyl and fentanyl 
analogues have continued to rise. And what we have learned in 
New Hampshire is there is no silver bullet. It is an all-hands-
on-deck approach, and any serious solution must look at 
comprehensive reforms to both public health and our criminal 
justice system.
    And that is why I am so pleased to see my bill, the 
Support, Treatment, and Overdose Prevention of Fentanyl Act, 
included in today's hearing. I look forward to discussing it 
more, and thank you, Chairwoman Eshoo, for this time and I--
including my bill to support public health and public safety 
efforts into responding to fentanyl. It will be a real game 
changer.
    [The prepared statement of Ms. Kuster follows:]

                Prepared Statement of Hon. Ann M. Kuster

    Thank you, Chairwoman Eshoo.
    As we are all too well aware, the pandemic has exacerbated 
the already dire addiction and mental health crises in our 
country.
    From August 2019 to August 2020, 88,000 Americans died of 
an overdose. This is the highest number ever recorded over 12 
months.
    But we also know the addiction and overdose crisis in this 
country did not occur overnight: It has devastated communities 
in New Hampshire and across the US for over a decade.
    What began as an opioid crisis has evolved to an epidemic 
that knows no bounds: It impacts every community, no matter the 
race. It is cross-regional, and it is intergenerational.
    The complexity of this epidemic is urgent: overdose deaths 
due to synthetic opioids such as fentanyl and fentanyl 
analogues have continued to rise, and what we have learned in 
New Hampshire is that there is no silver bullet--it's an all 
hands on deck approach, and any serious solution must also look 
at comprehensive reforms to both our public health and criminal 
justice system.
    That is why I am pleased to see my bill, the Support, 
Treatment, and Overdose Prevention of Fentanyl Act, included in 
today's hearing.
    I look forward to discussing it more, and hope that all of 
my colleagues recognize the urgency of this crisis.
    Thank you, Chairwoman Eshoo, for the time, and including my 
bill to support both public health and public safety efforts in 
responding to fentanyl. This can be a real game changer, and I 
am grateful for the opportunity to discuss this legislation 
today.

    Ms. Kuster. And I yield back.
    Ms. Eshoo. Well, thank you, Annie. You have been and 
continue to be an important leader on the whole issue of 
opioids, and we are all very grateful to you.
    The Chair is now pleased to recognize Mr. Guthrie, the 
ranking member of the Subcommittee on Health, for 5 minutes for 
his opening statement.
    Good morning to you.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

    Mr. Guthrie. Good morning. Good morning, Chair Eshoo, and 
thank you for holding this important hearing today.
    It is devastating that we have lost more than 550,000 
Americans due to COVID-19. Sadly, we have another epidemic that 
has claimed around the same number of lives over the past two 
decades: the opioid crisis. We are hearing from public health 
providers that the COVID-19 pandemic has exacerbated this 
crisis. The CDC recently reported that--over 88,000 overdose 
deaths over the past year, ending in May of 2020, which is the 
highest number of overdose deaths in a 12-month time.
    In 2019 addiction and substance use disorders affected over 
20 million Americans, 10 million of which experienced opioid 
misuse. Last year we sadly saw that number increase even more. 
According to the CDC, we have had three waves of the opioid 
epidemic. First we saw the rise in prescription opioids. Then 
in 2010 we began to see the rise in heroin. And currently we 
are in the third wave, which includes the rise of synthetic 
opioids, which often includes deadly forms of fentanyl.
    My home State of Kentucky has seen some of the highest 
numbers of substance use disorder deaths. One Kentucky 
substance abuse provider group that my office spoke to shared 
that they have lost more patients to overdose during the 
pandemic than they had in the last 5 years. CDC compared the 
death by drug overdose rates over a 12-month period between 
August 2019 and August 2020. In August 2019, Kentucky and 1,307 
overdose deaths; one year later, that number was 1,874. 
Unfortunately, Kentucky is not alone with these increases.
    This committee has worked in a bipartisan way to authorize 
many programs to decrease overdose deaths. But more work needs 
to be done. Specifically, the Energy and Commerce Committee 
authorized the 21st Century Cures Act, the Comprehensive 
Addiction Recovery Act, and the SUPPORT Act for Patients and 
Communities--Communities Act to combat the opioid epidemic. 
Included in the final SUPPORT Act was my bill, the 
Comprehensive Opioid Recovery Act Centers of 2018, which 
authorized the creation of comprehensive opioid recovery 
centers throughout the Nation. This program is currently being 
implemented and provides evidence-based comprehensive care for 
those with substance use disorders.
    Overall, these laws continue to provide critical funding 
and authorizations to help address substance use disorder 
treatment, recovery, and prevention.
    I think it is important for us to look back and fully 
examine these laws and evaluate where we are and where we are 
headed. And while we have 11 new bills before us today, we must 
also examine current authorizations.
    One of these current authorizations is the extension of the 
temporary emergency scheduling of fentanyl analogues. Synthetic 
opioids, which includes fentanyl analogues, were involved in 
744 deaths in Kentucky in 2018. Fentanyl analogues are very 
dangerous, due to their potency, and often come across our 
borders illegally only to harm Americans. Just last month a 2-
year-old in Kentucky died from exposure to fentanyl. One 
healthcare provider group who treats patients with substance 
use disorders told my office that almost all of their patients 
have some sort of fentanyl in their system. Many of the 
patients are not aware of it themselves. I recently heard from 
another local healthcare provider in Kentucky who said it is 
almost rare to have an overdose that does not have some traces 
of synthetic opioids, such as fentanyl.
    This provider also shared that they have certain 
individuals using substances in their own parking lot in case 
they overdose or anything were to happen, because they know the 
provider is equipped with Narcan.
    We must protect Americans from these harmful drugs that 
ruin lives and families. I look forward to continuing the 
bipartisan work to combat the substance abuse disorder crisis 
in America. I appreciate this hearing, and the witnesses before 
us, and the Members present.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Chair Eshoo, thank you for holding this important hearing 
today.
    It is devastating that we have lost more than 550,000 
Americans due to COVID-19. Sadly, we have another epidemic that 
has claimed around the same number of American lives over the 
past two decades: the opioid crisis. We're hearing from public 
health providers that the COVID-19 pandemic has exacerbated 
this crisis. The CDC recently reported over 81,000 overdose 
deaths over the past year ending in May 2020, which is the 
highest number of overdose deaths in a 12-month time. In 2019, 
addiction and substance use disorders affected over 20 million 
Americans, 10 million of which experienced opioid misuse. Last 
year, we sadly saw that number increase even more. According to 
the CDC, we have had three waves of the opioid epidemic. First, 
we saw the rise in prescription opioids, then in 2010 we began 
to see a rise in heroin, and currently we are in the third 
wave, which includes the rise in synthetic opioids, which often 
includes deadly forms of fentanyl.
    My home State of Kentucky has seen some of the highest 
numbers of substance use disorder deaths. One Kentucky 
substance use provider group that my office spoke to shared 
that they have lost more patients to overdose during the 
pandemic than they have in the last 5 years. CDC compared the 
death by drug overdose rates over a 12-month period between 
August 2019 and August 2020. In August 2019, Kentucky had 1,307 
overdose deaths. One year later that number was up to 1,874. 
Unfortunately, Kentucky is not alone with these increases.
    This committee has worked in a bipartisan way to authorize 
many programs to decrease overdose deaths, but more work needs 
to be done. Specifically, the Energy and Commerce Committee 
authorized: the 21st Century Cures Act, the Comprehensive 
Addiction and Recovery Act, and the SUPPORT for Patients and 
Communities Act to combat the opioid epidemic. Included in the 
final SUPPORT Act was my bill, the Comprehensive Opioid 
Recovery Centers Act of 2018, which authorized the creation of 
comprehensive opioid recovery centers throughout the Nation. 
This program is currently being implemented and provides 
evidence-based comprehensive care for those with substance use 
disorders. Overall, these laws continue to provide critical 
funding and authorizations to help address substance use 
disorder treatment, recovery, and prevention. I think it is 
important for us to look back and fully examine these laws and 
evaluate where we are and where we are headed. And while we 
have 11 new bills before us today, we must also examine current 
authorizations.
    One of these current authorizations is the extension of the 
temporary emergency scheduling of fentanyl analogues. Synthetic 
opioids, which includes fentanyl analogues, were involved in 
744 deaths in Kentucky in 2018. Fentanyl analogues are very 
dangerous due to their potency and often come across our 
borders illegally only to harm Americans. Just last month, a 2-
year-old in Kentucky died from exposure of fentanyl. One 
healthcare provider group who treats patients with substance 
use disorders told my office that almost all their patients 
have some sort of fentanyl in their system; many of the 
patients are not aware themselves. I recently heard from 
another local healthcare provider in Kentucky who said it is 
almost rare to have an overdose case with a substance that is 
pure and does not also have traces of synthetic opioids such as 
fentanyl. This provider also shared that they have had certain 
individuals using substances in their own parking lot in case 
they overdose or anything were to happen, because they know the 
provider is equipped with Narcan. We must protect Americans 
from these harmful drugs that ruin lives and families.
    I look forward to continuing the bipartisan work to combat 
the substance use disorder crisis in America. I yield back.

    Mr. Guthrie. And, Madam Chair, I will yield back.
    Ms. Eshoo. The gentleman yields back, and I thank him for 
his opening statement.
    The Chair is now pleased to recognize Mr. Pallone, the 
chairman of the full committee, for his 5 minutes for an 
opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman, and thanks to the 
ranking member, as well.
    This committee has a long history of working on a 
bipartisan basis to combat the threat of opioids and substance 
use and misuse. And together we are making significant 
progress.
    But, unfortunately, the COVID-19 pandemic and the resulting 
economic downturn over the last year has weighed heavily on the 
American people and has only exacerbated substance use and 
misuse. And so today we are continuing our work to address the 
epidemic within the pandemic, essentially.
    The statistics are alarming. In 2019, prior to the 
pandemic, more than 20 million Americans experienced a 
substance use disorder, and half of those involved opioids. 
Tragically, there were nearly 71,000 drug overdose deaths. And 
recent data shows that the pandemic has accelerated overdose 
deaths. From August 2019 to August 2020, 88,000 overdose deaths 
were reported, the highest ever recorded in a 12-month period.
    The primary driver of these deaths was a dramatic increase 
in the availability of synthetic opioids derived from fentanyl. 
These low-cost substances can be 50 to 100 times more potent 
than morphine and are frequently mixed into other drugs like 
cocaine and methamphetamine.
    To combat the opioid epidemic the committee advanced major 
pieces of legislation that became law. These laws expanded 
critical substance use disorder services and supports for 
communities around the country. But our efforts have not ended 
there. And since the beginning of the pandemic we pushed for 
the inclusion of funding aimed at the dual public health 
threats of the virus and rising rates of overdose deaths, 
substance use and misuse, anxiety, and depression. And I look 
forward to hearing from our panelists about the implementation 
of these laws, how the pandemic is impacting people suffering 
from substance use, and what more can be done to help aid in 
response to these threats.
    Now, on our first panel we will hear from the Acting 
Director of the White House Office of National Drug Control 
Policy, or ONDCP, who recently released the Biden 
administration's first-year drug policy priorities. And I 
commend the administration for taking an evidence-based public 
health approach to the drug epidemic. I also applaud them for 
their plans to expand evidence-based treatment, reduce youth 
substance use, enhance recovery services, and advance racial 
equity. Their work falls squarely within the jurisdiction of 
this committee. I look forward to hearing more from ONDCP about 
how we can work together.
    And our second panel is composed of experienced providers, 
public health experts, advocates for justice, and Federal law 
enforcement professionals. This group is on the front lines of 
the epidemic, and their insight on the impact of Federal policy 
is invaluable. And I thank all the witnesses for their selfless 
dedication to this cause.
    Now, throughout our discussion it is important to remember 
that substance use disorder is complex but treatable. 
Regardless of a patient's personal history or healthcare 
coverage, they deserve compassion and help, just like any other 
patient with a diagnosable disease. And we have to approach 
this substance use epidemic as a public health crisis and take 
the lead on destigmatizing effective treatments.
    The 11 pieces of legislation we are considering today 
tackle the epidemic in multiple ways, and many of them take a 
public health approach. And we have considered some of these 
policies before, and they remain a critical component of a 
comprehensive response to the crisis. So we have to continue 
our work in a bipartisan fashion to combat the epidemic. 
Millions of lives depend on it.
    And I commend the sponsors of these bills for their 
leadership and look forward to our continued work to address 
this devastating epidemic in the months ahead.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    This committee has a long history of working on a 
bipartisan basis to combat the threat of opioids and substance 
use and misuse. Together, we were making significant progress, 
but unfortunately the COVID-19 pandemic and the resulting 
economic downturn over the last year has weighed heavily on the 
American people and has only exacerbated substance use and 
misuse. Today, we are continuing our work to address the 
epidemic within the pandemic.
    The statistics are alarming. In 2019--prior to the 
pandemic--more than 20 million Americans experienced a 
substance use disorder, and half of those involved opioids. 
Tragically, there were nearly 71,000 drug overdose deaths.
    Recent data shows that the pandemic has accelerated 
overdose deaths. From August 2019 to August 2020, 88,000 
overdose deaths were reported, the highest ever recorded in a 
12-month period. The primary driver of these deaths was a 
dramatic increase in the availability of synthetic opioids 
derived from fentanyl. These low-cost substances can be 50 to 
100 times more potent than morphine and are frequently mixed 
into other drugs like cocaine and methamphetamine.
    To combat the opioid epidemic, the committee advanced major 
pieces of legislation that became law, including the 
Comprehensive Addiction and Recovery Act, the 21st Century 
Cures Act, and the SUPPORT for Patients and Communities Act. 
These laws expanded critical substance use disorder services 
and supports for communities across the Nation. But our efforts 
have not ended there.
    And since the beginning of the pandemic, we pushed for the 
inclusion of funding aimed at the dual public health threats of 
the virus and rising rates of overdose deaths, substance use 
and misuse, anxiety, and depression. I look forward to hearing 
from our panelists about the implementation of these laws, how 
the pandemic is impacting people suffering from substance use 
and misuse, and what more can be done to help aid in response 
to these threats.
    On our first panel, we will hear from the Acting Director 
of the White House Office of National Drug Control Policy 
(ONDCP), who recently released the Biden administration's 
first-year drug policy priorities. I commend the administration 
for taking an evidence-based public health approach to the drug 
epidemic. I also applaud them for their plans to expand 
evidence-based treatment, reduce youth substance use, enhance 
recovery services, and advance racial equity. Their work falls 
squarely within the jurisdiction of this subcommittee. I look 
forward to hearing more from ONDCP about how we can work 
together to eradicate the threat of illicit fentanyl-derived 
substances.
    Our second panel is composed of experienced providers, 
public health experts, advocates for justice, and Federal law 
enforcement professionals. This group is on the frontlines of 
the opioid epidemic, and their insight on the impact of Federal 
policy is invaluable to our work here. I thank all the 
witnesses for their selfless dedication to this cause.
    Throughout our discussion, it is important to remember that 
substance use disorder is a complex, but treatable disease. 
Regardless of a patient's personal history or healthcare 
coverage, they deserve compassion and help just like any other 
patient with a diagnosable disease. We must approach the 
substance use epidemic as a public health crisis and take the 
lead on destigmatizing effective treatments.
    The 11 pieces of legislation we are considering today 
tackle the epidemic in multiple ways and many of them take a 
public health approach. This includes proposals to address the 
need for first responder training and prescriber education, to 
dismantle barriers to treatment, and to bolster public health 
and recovery programs in the States.
    We have considered some of these policies before and they 
remain a critical component of a comprehensive response to the 
crisis. Other policies are a result of the emerging data and 
rising threat of illicit fentanyl.
    We must continue to work in a bipartisan fashion to combat 
this epidemic as millions of lives depend on it. I commend the 
sponsors of these bills for their leadership and look forward 
to our continued work in addressing this devastating epidemic 
in the months ahead.
    Thank you, I yield the remainder of my time.

    Mr. Pallone. Thank you again, Madam Chair. I think this is 
a very important hearing, and I yield back.
    Ms. Eshoo. Thank you, Mr. Chairman.
    The Chair now is pleased to recognize the ranking member of 
the full committee, Representative Cathy McMorris Rodgers, for 
her 5 minutes for an opening statement.

      OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A 
    REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

    Mrs. Rodgers. Good morning, everyone. Thank you, Chair 
Eshoo, and thank you to our witnesses.
    America remains in the midst of two national emergencies, 
COVID-19 and the substance use disorder crisis. Experts, 
including law enforcement, the DEA, and local leaders in my 
community, are raising the alarm.
    We are losing more people to the death of despair. The 
social isolation, economic shutdowns, stress, fear, loneliness 
has taken a severe toll. According to the CDC, 88,000 people 
died of overdose in the last 12 months leading up to August 
2020. That is a 26.8 percent increase. And that comes after the 
CDC released May data that we had the highest number of 
overdose deaths in the history of our country. This is how one 
mental health expert in eastern Washington put it to me: ``A 
situation such as 2020 that really stressed even the strongest-
willed among us, it can really impact how they are feeling, and 
it can increase their need for a substance use as a way to 
protect themselves, as a way to find the comfort they are used 
to having.''
    People need hope, hope to overcome fear, change their 
lives, provide for their families, and thrive, and that is what 
is on the line as we work to address this epidemic within the 
pandemic, head on.
    While I have some concerns with some of the bills, I am 
pleased that we are coming together to improve prevention, 
increase access to treatment, and offer support to those in 
recovery. All of this will build on our historic bipartisan 
work on the comprehensive Addiction and Recovery Act, CURES, 
and the Support for Patients and Communities Act.
    Energy and Commerce has a rich history of leading on the 
most significant efforts against addiction crisis, and today I 
am hopeful that we can move more of those solutions across the 
finish line. That includes stopping the scourge of fentanyl 
coming across our southern border from Mexico and also China. 
Nearly all States are seeing a spike in synthetic opioid 
deaths, with 10 western states reporting more than a 98 percent 
increase.
    In Washington State, it is even worse. The fentanyl 
positivity rate increased by 236 percent. Washington State is 
the highest in the Nation. Last fall we lost two teenagers in 
eastern Washington to potential fentanyl exposure. We have had 
close calls with police officers who barely came in contact 
with fentanyl, just a few milligrams. What can fit on Lincoln's 
ear on a penny is lethal. The analogues are oftentimes more 
potent. If it is reaching our streets in Washington State in 
deadly quantities from Mexico, I can assure you that the 
scourge is everywhere.
    That is why DEA created a temporary scheduling order for 
fentanyl analogues, placing these dangerous substances in the 
schedule I. Previously, drug traffickers could slightly change 
the chemical structure of fentanyl, so the novel formula was 
not considered prohibited. The DEA would then have to 
individually schedule each variant. Once one analogue was 
scheduled, a new one would emerge, creating this game of Whac-
a-mole for drug control efforts.
    With wide class scheduling, any dangerous variant of 
fentanyl is controlled under schedule I. This allows law 
enforcement to combat all fentanyl-related substances and 
protect the public. For example, one recently encountered 
substance was approximately 8 times more potent than fentanyl. 
A scheduling order is set to schedule in less than a month.
    Given the House schedule, Speaker Pelosi must make this a 
priority for this week or next. I fear that, like last year, 
the majority may wait until the last minute. We should work 
with DEA and other agencies to make this scheduling permanent, 
like with Mr. Latta's FIGHT Fentanyl Act.
    We should also look for reforms that encourage the 
scientific research. If the majority will not act on a 
permanent solution, then we must temporarily extend it. 
Judiciary Republican Leader Jordan and I are leading a one-year 
extension to buy us time. The clock is ticking. If this is 
allowed to expire, Customs and Border Protection will lose 
their authority to seize these substances at ports of entry, 
and drug traffickers regain the incentive to push deadlier and 
deadlier drugs on our streets.
    There is no excuse to let May 6th come and go without us 
doing our job to keep people safe, break the cycle of despair, 
and build a more prosperous future for America.
    [The prepared statement of Mrs. Rodgers follows:]

           Prepared Statement of Hon. Cathy McMorris Rodgers

INTRO
    Thank you, Chair Eshoo.
    And, thank you to the witnesses.
    America remains in the midst of two national emergencies--
COVID-19 and the substance use disorder crisis.
    Experts--including law enforcement, the DEA, and local 
leaders in my community--are raising the alarm.
    We are losing more people to the deaths of despair.
    The social isolation ... economic shutdowns ... stress ... 
fear ... loneliness have taken a severe toll.
    According to the CDC, 88,000 people died of an overdose in 
the 12 months leading up to August 2020.
    That's 26.8 precent increase ...
    ... and comes after the CDC released May data that we had 
the highest number of overdose deaths in our recorded history.
    This is how one mental health expert in Eastern Washington 
put it:
    ``A situation such as 2020--that really stressed even the 
strongest-willed of us--it can really impact how they're 
feeling, and it can increase their need for a substance use as 
a way to protect themselves, as a way to find that comfort 
they're used to having.''
    People need hope--hope to overcome fear ... change their 
lives ... provide for their families, and thrive.
    That's what is on the line as we work to address this 
epidemic within the pandemic head on.
SOLUTIONS
    While I have some concerns with some of these bills ...
    ... I'm pleased that we are coming together to improve 
prevention, increase access to treatment, and offer support to 
those in recovery.
    All of this will build on our historic bipartisan work on 
the Comprehensive Addiction and Recovery Act ... CURES ... and 
the SUPPORT for Patients and Communities Act.
    Energy and Commerce has a rich history on leading the most 
significant efforts against the addiction crisis.
    Today, I'm hopeful we can move more solutions across the 
finish line.
FENTANYL AND FENTANYL-RELATED SUBSTANCES
    That includes stopping the scourge of fentanyl coming 
across our southern border from Mexico and also from China.
    Nearly all States are seeing a spike in synthetic opioid 
deaths--with 10 western states reporting a more than 98 percent 
increase.
    In Washington State, it's even worse. The fentanyl 
positivity rate increased by 236 percent. That's the highest 
nationwide.
    Last fall, we lost two teenagers in Eastern Washington to 
potential fentanyl exposure.
    We've also had close calls with police officers who barely 
came in contact with fentanyl.
    Just a few milligrams--what can fit on Lincoln's ear on a 
penny--is lethal.
    The analogues are oftentimes more potent.
STOPPING ANALOGUES
    If it's reaching our streets in Washington State in deadly 
quantities from Mexico--I can assure you this scourge is 
everywhere.
    That's why the Drug Enforcement Agency created a temporary 
scheduling order for fentanyl analogues, placing these 
dangerous substances in schedule I.
    Previously, drug traffickers could slightly change the 
chemical structure of fentanyl, so the novel formula was not 
considered prohibited.
    The DEA would then have to individually schedule each 
variant.
    Once one analogue was scheduled, a new one would emerge, 
creating a game of ``Whac-a-mole'' for drug control efforts.
    With class-wide scheduling, any dangerous variant of 
fentanyl is controlled under schedule I.
    This allows law enforcement to combat all ``fentanyl-
related substances,'' and protect the public.
    For example, one recently encountered substance was 
approximately 8-times more potent than fentanyl.
    The scheduling order is set to expire in less than a month.
    Given the House schedule, Speaker Pelosi must make this a 
priority for this week or next.
    I fear that like last year, the majority is waiting until 
the last minute.
    We should work with the DEA and other agencies to make this 
scheduling permanent--like with Mr. Latta's FIGHT Fentanyl Act.
    We should also look for reforms that encourage scientific 
research.
    If the majority won't act on a permanent solution, then we 
must temporarily extend it immediately.
    Judiciary Republican Leader Jordan and I are leading for a 
one-year extension to buy us time.
    The clock is ticking.
    If Speaker Pelosi allows this to expire.
    Customs and Border Protection will lose the authority to 
seize these substances at Ports of Entry.
    ... and drug traffickers regain the incentive to push 
deadlier and deadlier drugs on our streets.
    There is no excuse to let May 6 come and go without us 
doing our jobs to keep people safe, break this cycle of 
despair, and build a more prosperous future for America.

    Mrs. Rodgers. With that, I yield back.
    Ms. Eshoo. The gentlewoman yields back. The Chair would 
like to remind Members that, pursuant to committee rules, all 
Members' written opening statements will be made part of the 
record.
    I would now like to introduce our witnesses for our first 
panel. Regina LaBelle is the Deputy Director of the White House 
Office of National Drug Control Policy and is currently the 
Acting Director of the agency, serving as the principal adviser 
to the Biden-Harris administration on drug policy matters 
ranging from substance use, prevention, treatment, and recovery 
to drug interdiction.
    Acting Director LaBelle previously served as the Chief of 
Staff of the ONDCP during the Obama administration, where she 
oversaw the Federal Government's initial efforts to address the 
opioid epidemic. And before returning to the agency, she served 
as a distinguished scholar and program director of the 
Addiction and Public Policy Initiative at Georgetown 
University's O'Neill Institute for National and Global Health 
Law, and was also a director of the graduate school's master of 
science program in addiction policy and practice.
    So we have a seasoned professional representing the agency.
    And Acting Director LaBelle, you are recognized for 5 
minutes. Please remember to unmute, and I recognize my--I will 
recognize myself for questions after your testimony.

 STATEMENT OF REGINA M. LaBELLE, ACTING DIRECTOR, WHITE HOUSE 
             OFFICE OF NATIONAL DRUG CONTROL POLICY

    Ms. LaBelle. Thank you, Chairwoman Eshoo, Ranking Member 
Guthrie, Chairman Pallone, Ranking Member McMorris Rodgers, 
members of the subcommittee. Thank you for inviting me to 
testify today. It is my pleasure to discuss the Biden-Harris 
administration's drug policy priorities for our first year and 
the activities of the Office of National Drug Control Policy. 
Thank you for holding this hearing so early in the 117th 
Congress. It reflects the urgency of addressing the overdose 
and addiction epidemic.
    ONDCP coordinates Federal drug policy by developing and 
overseeing the national drug control strategy and the national 
drug control budget. We develop, evaluate, coordinate, measure, 
and oversee the international and domestic drug-related efforts 
of executive branch agencies and work to ensure those efforts 
complement State, local, and Tribal drug policy activities.
    In this role I advocate for people with substance use 
disorder and their families, for a balanced approach to drug 
policy that includes public health and public safety, and for 
greater inclusion and equity in our efforts to tackle the 
addiction and overdose epidemic. These responsibilities are 
evident in the work ONDCP has undertaken since President Biden 
took office.
    On April 1st, ONDCP delivered the Biden-Harris 
administration's Statement of Drug Policy Priorities for the 
first year to Congress. These seven priorities have two 
overarching themes: first, immediately getting services to 
people most at risk for overdose; and second, building the 
addiction infrastructure necessary to meet the needs of the 
more than 20 million people in this country who have a 
substance use disorder.
    Our policy priorities include a focus on preventing 
substance use initiation, including through our Drug-Free 
Communities Support Program, and expanding access to quality 
treatment and recovery support services. It also includes 
supporting harm reduction services. This is especially 
important during this time when illicitly manufactured fentanyl 
is present in so many drugs. Harm reduction services include 
distributing the lock zone and fentanyl test strips, and 
expanding syringe services programs. These programs build 
connections, reduce people's chance of overdose, and give them 
the opportunity to receive services and engage them in 
healthcare, including treatment.
    As the epidemic continues, the shifting dynamics require us 
to adapt and meet people where they are. I have an example. I 
recently read about a 60-year-old woman in Miami who had 
untreated opioid use disorder. After many years she received 
services finally through a mobile service provider. She engaged 
in treatment, now has an apartment, and is able to spend time 
with her children and grandchildren.
    Also included in our policy priorities is racial equity in 
drug policy, both in criminal justice and healthcare. Our 
priorities include the entire continuum of care and seek to 
reduce the stigma of addiction.
    We also recognize the need to reduce the supply of illicit 
drugs in the United States. Illicitly manufactured fentanyl, 
fentanyl analogues, cocaine, methamphetamine, and other drugs 
enter our country through our ports of entry or through the 
mail, including express couriers. Our efforts to disrupt drug 
trafficking networks include working with domestic law 
enforcement through ONDCP's High Intensity Drug Trafficking 
Areas Program, and we appreciate Congress's strong support for 
this program.
    We are also working closely with countries such as 
Colombia, Mexico, and China to disrupt drug-trafficking 
networks and stem the flow of drugs coming into this country. 
On this issue Congress is facing a deadline of May 6 to extend 
the temporary fentanyl class scheduling bill. The 
administration is asking Congress to extend this law while we 
work with the Departments of Justice and Health and Human 
Services to address legitimate concerns regarding mandatory 
minimums and research provisions involved in class scheduling.
    Beyond extending temporary class scheduling, Congress has 
an important role to play in addressing the overdose and 
addiction epidemic. Already, Congress has provided needed 
resources through the American Rescue Plan, and the President's 
budget request calls for a substantial investment of $10 
billion. This funding will help build the type of 
infrastructure the Nation needs to reduce overdose deaths in 
the short term while laying the groundwork for a system of care 
that is long overdue. These funds will be guided by science and 
evidence, and we hope this budget request informs your work.
    Addressing the addiction and epidemic is an urgent issue, 
and the Biden-Harris administration's drug policy priorities 
are intended to bend the curve and save lives. And working with 
our Members--with Members of Congress, ONDCP will take quick 
action to implement them.
    Thank you for your time, and I look forward to your 
questions.
    [The prepared statement of Ms. LaBelle follows:]
    
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]   
    
        
    Ms. Eshoo. Thank you very much, Acting Director LaBelle, 
for being with us.
    So how many days have you been on the job?
    Ms. LaBelle. So I was sworn in the afternoon of 
Inauguration Day, so it is 85 days, I guess.
    Ms. Eshoo. Well, congratulations to you.
    Ms. LaBelle. Thanks.
    Ms. Eshoo. You have a weighty portfolio. Now, based on the 
early data, 2020 is the deadliest year for overdoses, with 
88,000 deaths counted so far, 88,000 in 2020.
    Now, as Members stated in their opening statements, our 
subcommittee and the full committee have done a lot of work. We 
have passed packages of bills. The first big effort, I think, 
was something like 53 bills. I think every single one of them 
was bipartisan. We have put money to this.
    Something isn't working. Something isn't working. We are 
not putting a dent in this. And I don't know--I know that you 
were part of doing a report before you came to head up the 
agency. What instructions do you have for the subcommittee 
about what we need to change, what we need to do more of, what 
is not working, and also the bills, the 11 bills that we have 
before us? Can you comment on this?
    It is very disturbing to me that we all think we have done 
very important work. And I still think that we have. But 88,000 
deaths? I mean, that--we just--it seems to me that we are not 
making--to put it mildly, I don't think we are making progress.
    Ms. LaBelle. Right. So thank you, Chairwoman.
    I think the issues are very complex, but I think that we 
can't see immediate results over a problem that has evolved for 
decades. You know, we have had overdose deaths increasing since 
the 1970s. They did go down in 2018, but fentanyl, illicit 
fentanyl that is getting into the drug stream, it is getting 
into coke, methamphetamine, heroin, that is really what is 
driving a lot of these overdose deaths.
    So there are things--I mean, there are bright spots. The 
money has not been wasted. We have seen an increase in the 
number of providers who are--provide buprenorphine, one of the 
three forms of medication treatment. We have made efforts. It 
is not enough yet. And that is why our policy priorities stress 
what it does--harm reduction, prevention, recovery supports--
because this is a chronic disease, and we need the full 
continuum of care.
    Ms. Eshoo. On the soon-to-expire temporary scheduling of 
the fentanyl-related substances, what is your agency's 
suggested policy on this?
    Ms. LaBelle. So we are going to--we have been having 
discussions with HHS and the Department of Justice and DEA. We 
just got the GAO report that had--that was required as part of 
the Federal scheduling extension from 2 years ago. We are going 
to be looking closely at what the results have been of that 
and, you know, come together to make sure we have a whole-of-
government approach to this issue.
    Ms. Eshoo. And what kind of timeframe are you thinking of 
here, to get the job done?
    Ms. LaBelle. So we are, you know, engaged in continuous 
conversations about this. We understand the urgency. It is not 
going to happen before May 6th, but we are going to work as 
quickly as possible after that.
    Ms. Eshoo. And what is your response to the criticisms that 
classwide scheduling leads to disproportionate incarceration of 
Black and brown people, many of whom--who don't receive the 
treatment they need while they are in jail or prison?
    But of course, we have an excellent bill that--before us 
that addresses that. But can you comment on that, please?
    Ms. LaBelle. Yes. So the mandatory minimum issues are much 
broader than this bill. But when we work with Department of 
Justice, we are going to look exactly at that. What are the 
effects of this legislation on the fentanyl scheduling on 
mandatory minimums?
    But the--you know, but the mandatory minimum issue is a 
much broader issue that involves all forms of drug as well as 
other sentencing.
    Ms. Eshoo. Well, thank you very much for agreeing to 
testify today, and we need to--you know, we need the agency to 
really operate in top gear, because this number of deaths says 
to me that we are not making progress, and we have to change 
that. We have to change that. So thank you very much to you.
    And now I will recognize Mr. Guthrie, the wonderful ranking 
member of our subcommittee, for his 5 minutes of questions.
    Mr. Guthrie. Thank you very much. And thank you, Director, 
for being here. I really appreciate it.
    One of my prepared questions, by not meeting the May 6 
deadline, we have to make, you know, some important decisions--
or not having information for us--and I know you have a lot of 
the experts. I think you said that fentanyl analogues are 
driving the overdose deaths. And I would--and I said in my 
opening statement that almost all of my providers are saying 
that everybody with an overdose death has some fentanyl 
analogue.
    And I would agree it is not just a criminal justice issue, 
but I think it is a criminal justice issue, but not just. And 
this committee has responded with the CARES Act, SUPPORT Act, 
and hopefully we will have a chance to look at all of that and 
see how it is making a difference. But I think it is both, we 
have to deal with both. And any disparities in the laws being 
enforced absolutely need to be dealt with as well. But I 
would--it would be nice to have information before May 6, or a 
position from the administration. But I appreciate it.
    I know you had--you put out your priorities for the year 
one report, and I really want to work with you to achieve your 
seven goals that you set. And specifically, I would like to 
focus on evidence-based treatment and how you plan to address 
holistic treatment for those with co-occurring substance use 
disorders. Are you willing to work with me and the committee on 
fully evaluating current programs that are authorized or funded 
for substance use disorders?
    Ms. LaBelle. I am sorry, can you repeat the last part of 
your question? I had a hard time hearing.
    Mr. Guthrie. OK. Are you willing to work with me and the 
committee on fully evaluating current programs that are 
authorized or funded for substance use disorders?
    Ms. LaBelle. Yes, absolutely, Congressman Guthrie, thanks 
for your question. That is--you know, we want to make sure that 
it is quality treatment that is evidence-based. And so we 
intend to work across, you know, all the HHS, SAMHSA to make 
sure that the programs that the Federal Government is funding 
are effective. And so we have to put those standards into 
place.
    Mr. Guthrie. OK, thank you for that.
    And then, additionally, I believe we need to ensure that 
the Office of National Drug Control Policy is addressing 
polysubstance abuse, not just opioids, but also stimulants and 
alcohol abuse. Can you please share how you plan to address 
this, and while also taking a wide lens on what programs we are 
already funding and how we can make sure they are best serving 
those with substance use disorders?
    Ms. LaBelle. Yes----
    Mr. Guthrie. So kind of more emphasis on your----
    Ms. LaBelle. Sure----
    Mr. Guthrie. You sort of answered a little bit, but just a 
little broader on what you just answered.
    Ms. LaBelle. Sure, thanks. So polysubstance use is, 
obviously, as you point out, a huge problem. People are not 
just using one substance, they are using multiple substances. 
And we can't kind of have blinders on that we are only going to 
deal with one drug at a time.
    So our policy priorities call for a holistic approach, 
starting with prevention of all substances--as you mentioned, 
youth alcohol use--and then treatment, making sure the quality 
treatment is available where people live, harm reduction, and 
recovery support services. Those don't have--there are 
certainly medications that work for certain drugs, but we need 
to make sure that we are responsive to all forms of substance 
use disorder.
    Mr. Guthrie. Great, thank you. And then I will just say 
again that, when we were looking at all the CARES Act, SUPPORT 
Act, and all the others that we worked on, I know--and I had to 
change some of my attitude. Mine was coming from a pure--not 
pure, but strong emphasis on the criminal justice side, that 
this is illegal, and people use it illegally. And as you really 
delve into this, some people commit crimes because of their 
drug habit. If you could deal with the substance abuse 
disorder, you could solve the criminal problem.
    But some people are criminal, and they are out to--and a 
lot of them aren't users. That is--if you read some of the 
books that you read about, that they avoid using because it 
takes away from their ability to do business. And so my--I 
would be really concerned if we start descheduling, or not 
allowing these types of drugs to go forward, particularly 
that--you have said, and I have witnessed or heard from people 
who practice in this, that fentanyl analogues are a big driver 
in the overdose and overdose deaths.
    We had a--I mentioned in my opening statement--a little--I 
have a couple of--few seconds--but a 2-year-old, we felt--they 
believe touched and handled his mother's fentanyl, and her 
opioid, which had fentanyl in it, and that is why the 2-year-
old passed away.
    And so this is just something that--we need to really look 
at this as we move forward, and try to work together. So I 
really appreciate your time, and I will yield back to the 
Chair.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. The gentleman yields back. The Chair now 
recognizes the ranking member of the full committee--pardon me?
    Voice. Mr. Pallone.
    Ms. Eshoo. Oh, I am sorry. The chairman of the full 
committee first.
    Mr. Pallone?
    Mr. Pallone. Thank you, thank you, Chairwoman. I wanted to 
ask the Director about this drug policy, first-year drug policy 
report that you just released.
    I know your jurisdiction puts you in a unique position, 
because you collaborate with public health and public safety 
agencies to drive the direction of drug policy, not only in the 
U.S. but around the world. And what we discussed today and what 
we do in the months to come is really an issue of life and 
death, so it is very serious.
    But your office recently released the Biden 
administration's first-year drug policy priorities. I want to 
applaud the bold approach in that to reducing overdose deaths 
and the urgency in which you intend to act. But I wanted to 
focus on the first priority, which is expanding access to 
evidence-based treatment.
    Acting Director LaBelle, the statement of drug policy 
priorities places expanded access to evidence-based treatment 
at the top of the list. So what actions are you going to take 
in year one to achieve that specific goal, if you would?
    Ms. LaBelle. Sure, thanks. So it is important that we look 
at the full continuum of care, but also that we look at the 
types of FDA-approved medications. So it is buprenorphine. We 
will be looking at how we can reduce barriers to buprenorphine 
access.
    We are also looking at how can we modernize our methadone 
treatment that is available to people. So there is--there are 
many steps that we have to take to look for how to update 
today's treatment approaches and not be stuck in approaches 
that we had 15 to 20 years ago.
    Mr. Pallone. Well, you know, only a fraction of the 
patients with substance use disorders have access to these 
evidence-based treatments. And as part of expanding access for 
evidence-based treatment, the statement noted that the Biden 
administration will ``remove unnecessary barriers to 
prescribing BUP, and identify opportunities to expand low-
barrier treatment services.''
    Just discuss a little further the barriers the 
administration sees currently to prescribe BUP, and the steps 
that the administration plans to take to address those 
barriers, if you will.
    Ms. LaBelle. Sure. So the research shows that some of the 
barriers to people--to prescribers prescribing buprenorphine 
include--so they don't necessarily feel comfortable treating 
patients with addiction, so there is stigma attached to that.
    There is also a lack of training in many medical schools. 
We don't do a good job of building out the addiction workforce. 
That is a second piece we will be working with medical schools 
to talk about that.
    And then lastly, we have an--interagency working groups 
going on that are looking at the X-waiver, specifically, which 
is the eight-hour training for doctors and a 24-hour training 
for nurse practitioners and physician's assistants. So we are 
looking specifically at that issue, as well, at how we can 
remove barriers to the X-waiver, what we can do 
administratively, what requires legislative action.
    Mr. Pallone. Well, that is great. That is very important, 
and I appreciate your answer.
    Last question: Any other steps that Congress or the Biden 
administration can take to ensure that providers are equipped 
with the tools that they need to diagnose or treat patients 
with substance use disorder?
    Ms. LaBelle. Sure. I think--so many of the authors of the 
appropriations have helped to expand our addiction workforce. 
We need to look where there have been things authorized and 
money has not yet been appropriated, because we really need to 
expand the number of physicians and nurse practitioners and 
healthcare providers who feel competent to not only treat 
addiction but to screen for it. Because the earlier we can 
identify someone who might have an emerging substance use 
disorder, the easier it will be to treat those people before 
their condition becomes chronic.
    So Congress can help us, you know, expand awareness about 
the importance of medical training and nurse--nursing training 
on addiction.
    Mr. Pallone. Well, thank you. You know, I heard Chairwoman 
Eshoo, you know, repeatedly point out how, you know, this 
scourge of overdose deaths, and the rising rates, particularly 
now during the pandemic--so we really look forward to working 
with ONDCP and the Biden administration to reduce this.
    I mean, it is just--I think the ranking member, Mrs. 
Rodgers, you know, talked about, you know, this essentially 
double dose of problems between the pandemic and the opioid 
abuse and misuse. And so we really want to get to the bottom of 
it. Thank you for being here.
    Thank you, Madam Chair.
    Ms. LaBelle. Thank you, Congressman.
    Ms. Eshoo. Thank you, Mr. Chairman.
    Now the Chair recognizes the ranking member of the full 
committee for her 5 minutes of questions.
    Mrs. Rodgers. Thank you. Thank you, Madam Chair and Mr. 
Chairman. And I too just want to join in saying that we on the 
Republican side of the aisle look forward to working with you, 
continuing to work with you. This is a huge issue all across 
the country. And I think, without a doubt, the last year has 
been a difficult year, with COVID and everything that it has 
meant as far as lockdowns, and isolation, and fear, and 
uncertainty.
    But there is this other crisis underway, and the depths of 
despair has really been on my heart, and I know it is on a lot 
of people's hearts, with the increased substance abuse, 
increased suicides. And I absolutely believe that this is an 
area that we must take action. We must continue to identify 
what is going to work, what is going to be most successful in 
ensuring that individuals and families get the support and the 
treatment that they need.
    But I also think there is more that Congress needs to be 
doing.
    And I just wanted to start by asking the Acting Director 
LaBelle--and I appreciate you being with us today--just--I 
would like to ask you, do you believe that Congress should 
extend this--the temporary scheduling order for fentanyl-
related substances before it expires on May 6th?
    Ms. LaBelle. We are asking Congress to give us more time 
to--I mean, it can be extended. We need more time to--before it 
is extended further. So we--as I said, I don't think we--there 
is any way we can come to you with new legislation before May 
6. So we need--we are asking Congress to extend the time so 
that we have time to come together and present you with another 
proposal.
    Mrs. Rodgers. So just so I understand, so would you support 
the temporary extension while we work on a more permanent 
solution?
    Ms. LaBelle. We are looking to Congress to extend this for 
a period of time. We don't have a period of time in mind yet, 
because we have to get our interagency together to talk about 
this. But we support and we are asking Congress to extend 
this--the fentanyl scheduling bill for a short period of time.
    Mrs. Rodgers. OK, great. I wanted just to highlight to the 
committee that, when ONDCP Assistant Director Kemp Chester 
testified before the Senate Judiciary Committee, he stated that 
codifying the scheduling emergency order and making it 
permanent is a ``critical, most important first step that we 
have to take.''
    And to the Acting Director LaBelle, is it still the 
position of ONDCP that the scheduling order be made permanent?
    And would you just speak if the position is changed?
    Ms. LaBelle. Sure. So I think we just got the GAO report. 
We are working with DEA to see what the results of this 
fentanyl scheduling act has been so far.
    One thing that we know about the drug environment is that 
it is ever changing. And sometimes legislation that we put in 
place 2 years ago doesn't address today's issue. But the 
biggest challenges we face are synthetic drugs, and those are 
morphing over time. We want to make sure that the solutions we 
put into place and that we ask Congress to put into place 
address today's problems, not yesterday's problems.
    Mrs. Rodgers. OK. The chairman of--the chair of the 
subcommittee highlighted the 88,000 deaths this last year. I 
would just like to reiterate to the committee that I believe 
Congress must act, either this week or next, to prevent the 
spread of deadly fentanyl variants by making it permanent and 
extending DEA's classwide scheduling order.
    You know, I would just highlight, when you compare the 
first quarter of 2021--so January to March, 2021, the seizure 
of fentanyl at the southwestern border by CBP has increased, 
just in this quarter, by 233 percent from last year, 2020 
quarter 1. And so I think what we are seeing is that we do have 
a crisis on our hands, and we are seeing a huge increase.
    If--so if you compare first quarter of 2020 to this 
quarter, January to March, 2021, seizure of fentanyl at the 
southwestern border has increased by 233 percent. So we need to 
make sure that we are providing the support necessary at the 
border and throughout the country so that people are protected 
and that we do not allow the continued negative impacts and 
destruction of lives and families due to fentanyl in America.
    With that, I will yield back. Thank you, Madam Chair.
    Ms. Eshoo. I thank the gentlewoman. Yes, there has been the 
increase coming in from Mexico, but thank God we--the reason we 
know the figures that you just stated is because it was seized. 
And--but we need, really, a refreshed plan on this, because we 
can't gather a year from now and have statistics saying this is 
what happened in 2021, and it is more lives lost.
    The Chair now recognizes the gentleman from North Carolina, 
Mr. Butterfield, for your 5 minutes of questions.
    Good to see you.
    Mr. Butterfield. Thank you so very much, Madam Chair, for 
convening this hearing----
    Ms. Eshoo. I think you are--I can't hear you.
    Can everyone else hear Mr. Butterfield?
    No, they are shaking their heads no. There is something 
wrong with your microphone. We can't hear you.
    Mr. Butterfield. Does that work?
    Ms. Eshoo. Yes, there you go.
    Mr. Butterfield. OK, I had my earpiece plugged in. That 
messed it up.
    Thank you. Thank you very much, Madam Chair, for convening 
this very, very important hearing this morning. And thank you 
for your leadership. It has been nothing less than stellar. 
Thank you so very much. And thank you for the direction that 
you are taking this subcommittee. And thank you to the 
witnesses, the one witness on this panel and the witnesses on 
the next panel. Thank you for taking the time to join us today.
    Director LaBelle, let me just start here. I am hoping that 
you can help us better understand the ways in which the Federal 
Government benefits from your office. This is simply a 
continuation of what Mr. Malone was--Pallone was talking about 
a few minutes ago.
    I understand that your office leads and it coordinates the 
Nation's drug policy with the goal of improving the health and 
lives of our constituents. So my question is, your priorities 
seem to intersect with both public health and public safety. I 
want to talk about that intersection, if I can. How does your 
office--what is your office's role, and how does it differ from 
that of HHS and DEA?
    Ms. LaBelle. Sure. Thanks, Congressman. So the Office of 
National Drug Control Policy is, obviously, a unique office 
situated in the Executive Office of the President. And the 
purpose--our purpose of our office is to bridge the gap that 
often occurs between public health and public safety.
    So we bring Drug Enforcement Administration in, the 
Department of Justice in, as well as with our colleagues from 
HHS, from all of the various components of HHS, to discuss 
issues like fentanyl scheduling, because there are different--
the X-waiver is a perfect example. Law enforcement has a 
different perspective and a different goal sometimes. I mean, 
all of our goals is to reduce overdose deaths. But our charges 
are different.
    So the Office of National Drug Control Policy, we have 
about 65 full-time staff, about 35 additional staff detailees, 
and they bring these sides together so we can find solutions 
that serve both needs. So that is really the unique role that 
ONDCP plays.
    Mr. Butterfield. Well, in that light, in what way do you 
coordinate and/or convene the other relevant agencies in your 
work?
    Ms. LaBelle. Sure----
    Mr. Butterfield. Do you coordinate with the other agencies?
    Ms. LaBelle. Yes. So we often have convenings. We have--I 
mean, I think someone gave me data about the number of meetings 
we have had across the interagency just since the end of 
January. It has been about 78 meetings, where we work with 
other White House components. We work with HHS, DOJ, and we 
talk about these issues that we--our goal is to make things 
move quicker, and--so that we don't have to--and build those 
bridges, so that we are not separately talking to Congress, for 
example, so that we can come together with one approach on an 
issue.
    Mr. Butterfield. You know, during the presidential 
campaign, Joe Biden announced a very robust and comprehensive 
drug policy agenda, and I hope that he will continue to pursue 
that agenda. How will the administration leverage your office 
--if you know, how will the administration leverage your office 
to carry out its drug policy agenda?
    Ms. LaBelle. Sure, thanks. So I think the one unique role, 
again, is that we have public health and public safety experts 
together in the same agency. That doesn't occur anywhere else.
    I am very engaged and aware of all the Biden-Harris 
campaign pledges that were made. Those are areas that--we are 
going to take them one by one and look at how we can implement 
those over the next couple of years and, again, by having our 
convening authority, which helps to have one voice on these 
issues.
    Mr. Butterfield. Thank you for those responses, and thank 
you for your incredible work. I realize that you were just 
installed the day after the inauguration, whatever date you 
announced, but it seems like you have hit the ground running. 
And just thank you so much for what you are doing and what you 
are going to do. I look forward to working with you as the 
administration advances its priorities in this space. So thank 
you, thank you, thank you.
    I yield back.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. The gentleman yields back, and I appreciate your 
very kind comments, Mr. Butterfield.
    It is a pleasure to recognize a former chairman of our full 
committee, the gentleman from Michigan, Mr. Upton, for your 5 
minutes of questions.
    Mr. Upton. Well, thank you, Madam Chair. And I just want to 
share, Ms. LaBelle, this is so personal to all of us. I mean, 
every one of us on both sides of the aisle have many personal 
stories on this. We have family members. It is indeed close to 
our heart, as we try to do our very best to resolve this major 
issue that continues to plague virtually every one of our 
communities, families across the country. So I appreciate your 
leadership.
    You and I, of course, both sit as members of the Commission 
on Preventing Synthetic Opioid Trafficking, as appointed by our 
respective leaders. And though we had our first meeting just a 
week or so ago on Zoom, certainly I just want to commit and 
definitely look forward to working with you and other members 
of the Commission on ideas to help curb this terrible scourge 
that plagues our Nation.
    Can you briefly share your thoughts on how the Commission 
could be most impactful on stopping this trafficking?
    Ms. LaBelle. Thank you, Congressman. And the Synthetics 
Commission, we--as you mentioned, we just had our first 
meeting. We are just organizing it. I think it is charged with 
a very--with very specific--it has a very specific charge. I 
think what it--the best part about the Commission is it has 
external experts, it has a bipartisan approach, including 
Congressman Trone, yourself, Senator Markey, and Senator 
Cotton.
    So what I think the Commission will be best able to do is 
to look at these issues, the international synthetics 
landscape, and come up with some--take the time to come up with 
some specific approaches that Congress can take up, that we can 
do by Executive order or administratively. So it is going to be 
a real focused effort that I think is going to help with this 
issue.
    Mr. Upton. So I want to--well, thank you. I want to echo 
our Republican leader, Cathy McMorris Rodgers, in terms of her 
question on why don't we make this permanent, the classwide 
scheduling for fentanyl, rather than an extension. I think that 
makes a lot of sense.
    You sensed, as we get--close in on this deadline, again, 
that perhaps the administration, if Congress fails to act, 
knowing that we are only in session this week and next, that 
they might pursue an Executive order to try and extend that?
    Ms. LaBelle. So, Congressman, I think I would have to check 
to see if we have the authority by Executive order. I am not 
sure that we can do it.
    What DEA can do is, you know, ask for--by--analogue by 
analogue, to schedule it. That they certainly could do. I am 
not sure the Executive order would--could make it--could extend 
it, however.
    Mr. Upton. So we know that much of the fentanyl issue is 
coming from China, right? Tell us what you are doing to try and 
close that door.
    Ms. LaBelle. Sure, thanks. So what we are seeing right now, 
as I said, these issues are very dynamic, and drug traffickers 
are, obviously, very crafty. And so what is happening--what 
Congress did over the last several years is pass several pieces 
of legislation that allowed our Customs and Border Patrol to 
identify this--the drugs that were coming through the mail.
    Now--and China acted to schedule fentanyl as a class. So 
now a lot of the drugs are going in through Mexico. We are 
working with Mexico to make sure that they are working on 
interdiction, so that it never even comes to the border, that 
they are working on identifying labs so they can seize these 
labs. And then lastly, working at their ports of entry to 
identify and seize these substances. So we have a good working 
relationship with Mexico on these types of issues, and our law 
enforcement partners can work together on it.
    Mr. Upton. I don't know--I don't have the clock on my 
screen. Do I have a lot of time left, Anna?
    Wait, I didn't hear you.
    Voice. You have 50 seconds.
    Ms. Eshoo. You have a minute.
    Mr. Upton. OK, one of the things that we discovered in the 
last Congress was that our postal inspectors, frankly, didn't 
have the resources.
    So, as you know, I am from Michigan. Much of our mail in 
west Michigan actually goes through the Grand Rapids postal 
facility. You know, we learned that, at the time, they had one 
postal inspector to really look through all of these different 
packages coming through. I know Dr. Burgess was up to New York 
and saw just a number of these facilities. There has been a lot 
of documentation on that on TV, in terms of the issues there.
    What are we doing on more resources to try and stop this 
from coming in using FedEx, UPS, as well as the Postal Service, 
things that would seem pretty routine to you and me?
    Ms. LaBelle. So I will quickly answer that. So, number one, 
we saw that there was a decided drop in mail coming from China 
that had fentanyl in it. So that was a success over the last 
year.
    However, Congress did provide additional resources to the 
U.S. Postal Service, Inspection Service, to identify these 
drugs. And there were other pieces of legislation passed to 
make it easier to identify something that might be coming from 
a chemical company that could have fentanyl in it.
    Mr. Upton. Thank you, I yield back.
    Ms. Eshoo. We thank the gentleman.
    It is a pleasure to recognize the gentlewoman from 
California--and she is a gentlewoman--Congresswoman Matsui.
    Ms. Matsui. Thank you very much, Madam Chair, and thank you 
for holding this very important hearing.
    And Ms. LaBelle, welcome to the committee and thank you for 
your testimony and the very important work that you are doing.
    Now, we know that the lack of access to timely, high-
quality behavioral health treatment continues to be a 
significant challenge. And that is why I have long supported 
the expansion of Certified Community Behavioral Health Clinics, 
CCBHCs, which provide a comprehensive range of mental health 
and substance use disorder services to vulnerable individuals, 
including 24/7 crisis response and care coordination.
    Addiction treatment is a core component of CCBHCs' required 
service offerings. And as a result, all 340 clinics across 40 
States, DC, and Guam have either launched new addiction 
treatment services or expanded the scope of their addiction 
care. And well over half of CCBHCs provide same-day access to 
medication-assisted treatment for patients with opioid use 
disorder. This model is really well placed to respond to the 
pandemic's expected long-term impact on behavioral health 
needs, and Congress has recognized its value by extending 
support to the program in recent COVID relief bills.
    Ms. LaBelle, how does the Biden administration plan to 
leverage existing treatment networks like CCBHCs expand access 
to recovery support services?
    Ms. LaBelle. Sure, thank you, Congresswoman. You raise a 
really important point about recovery services.
    As we recognize that addiction is a chronic condition, we 
need to have recovery support so that we can sustain people's 
recovery over a period of time. CCBHCs received about $420 
million in the American Rescue Plan, and that includes--they 
are required to have recovery support services within them.
    Peer support services are incredibly important, as you 
point out. They have to be provided throughout communities. As 
some Member of Congress mentioned, one of our highest rates of 
overdose death are among people--the reentry population, people 
leaving jails and prisons. It is important that recovery 
services reach them to help them sustain their recovery so that 
they don't overdose and that they can go on to live full lives.
    So we look forward to working with you further to determine 
how to integrate recovery services throughout all of our 
treatment programs.
    Ms. Matsui. Well, I look forward to that, thank you very 
much.
    You know, in 2018 Congress included in the SUPPORT Act a 
provision requiring DEA to issue regulations around a special 
registration process to expand remote prescribing of controlled 
substances. While in the past year the public health emergency 
has eased historic barriers to certain telehealth services, 
including allowing providers to initiate treatment for opioid 
use disorder over the phone and via video chat, the DEA has 
still not completed its statutory requirement to stand up the 
special registration process for remote prescribing.
    Ms. LaBelle, can you expand a bit on the framework ONDCP is 
using to evaluate whether to make permanent the emergency 
telehealth provisions related to MAT prescribing?
    Ms. LaBelle. Thanks for asking that. So we--you know, we 
have this included in our policy priorities. There are 
researchers at NIDA who are funded by the National Institute on 
Drug Abuse who are looking at exactly how effective the 
regulatory changes that were made during COVID have been. We 
are going to be looking at that and determining if it is 
administrative changes that need to be made, are there 
legislative changes, and how can we--what we have heard is a 
lot of anecdotal information that is really positive about how 
telehealth has helped people who are already in treatment be 
retained in treatment.
    So we want to be guided by science and evidence, and we are 
working with our colleagues at the National Institute on Drug 
Abuse to inform those policies.
    Ms. Matsui. Well, thank you very much, because I have been 
working with many providers in my community, and--whether it is 
at the hospital or the community health centers, they have had 
an increase in the telehealth with their patients and found 
very much that it was almost immediate, as far as the 
prescriptions and all of this and the sense of being able to, 
in fact, walk people through some of these crises as they have 
occurred.
    So I really do encourage that you really look at this, and 
I would be happy to work with you as we do this too. So thank 
you very much, very much for being here today.
    Ms. LaBelle. Thanks.
    Ms. Matsui. I yield back.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentleman from Texas, Dr. Burgess, for his 5 
minutes of questions.
    Mr. Burgess. I thank the Chair. I thank our witness for 
being here.
    Ms. LaBelle, it is great to make your acquaintance. I have 
worked with your predecessor, James Carroll, while we--in two 
Congresses ago, when we worked on the SUPPORT Act. So this 
ongoing work is critically important.
    Just to pick up on one of your answers to Ms. Matsui's 
question about telehealth, do you sort of foresee telehealth, 
you know--that was a big deal in getting people to continue 
doing their treatment, because they lost the in-person care 
that they were at one point receiving during the pandemic. So 
how do you see this working, as we come on the other side of 
the pandemic?
    Will telehealth continue to be complementary to the 
treatment available?
    Ms. LaBelle. Yes, thank you, Congressman. I think that 
telehealth will always be an essential piece going forward.
    I don't think it is going to replace in-person care, but it 
certainly makes it a lot easier for people who may be some 
distance from a treatment provider. What we want to do is 
increase interventions at every single point. And so, if we can 
remove the barrier that people face--it might be 
transportation, it might be child care--telehealth can help 
remove those types of barriers to get people to be retained in 
treatment.
    Mr. Burgess. Yes, and I was interested in your testimony, 
because it actually talked a little bit about the methadone 
treatment programs. Obviously, that is--by definition, that is 
in person, because the methadone is administered and has to be 
taken on site, literally.
    I actually worked in a methadone clinic when I was a senior 
medical student on an elective, but this was back in 1975, so 
it has been some time. But methadone--you are right, I don't 
think the methadone availability or methadone clinics have 
quite kept pace with what is available technologically. And I 
do think that is an important part that we need to include.
    Ms. LaBelle. Yes, sure. And that is--I think that is one 
thing we found, again, anecdotally--the research will follow 
soon, hopefully--is that, particularly for patients early in 
their methadone treatment, I mean, that is a long haul for many 
people to get to a methadone clinic, as you know. And so 
allowing them to have take-home doses and be able to have 
telehealth is a really--a great way to remove a barrier for 
someone who might otherwise not be able to continue in 
treatment and might be subject to overdose.
    Mr. Burgess. Right. But the risk for diversion is 
significant with methadone, and that has to be borne in mind.
    Let me just ask you--and I appreciate you providing the 
Biden-Harris administration policy priorities. One of those 
listed is reducing the supply of illicit substances. And 
clearly, that is absolutely critical. And many of us have spent 
some recent time down on the--I represent a district in Texas. 
I am not on the Texas border with Mexico, but there is a lot of 
activity, and a lot of illicit activity, a lot of contraband, 
of course, as well as people that are coming across the border.
    So how do you see what your task in preventing that is, in 
disrupting the supply of illicit substances? How do you see 
that working?
    Ms. LaBelle. Sure. So we have ongoing conversations with 
the Government of Mexico, and with our law enforcement partners 
through something called North American Drug Dialogue. We are 
working with Mexico on interdiction in their own country to 
prevent those drugs from even getting to the border, 
identifying and disrupting their labs, lab production, which is 
how the fentanyl is produced, or heroin, and then also their 
ports, which is where the precursor chemicals come. So that is 
kind of what--you know, some of the steps we are taking to make 
sure that it never even gets to the border. And that is a 
partnership that we have had, a long partnership with Mexico.
    Mr. Burgess. Well, good luck. But, I mean, if you have ever 
been down to the Texas-Mexico border, particularly that sector 
in the lower Rio Grande Valley, it is very, very difficult to 
provide those--that interdiction. And, of course, you couple 
that with the human toll that is coming across the border, and 
our Customs and Border Protection are tied up having to 
administer to them, it creates a diversion where additional 
supply can pretty much come across uninterrupted. So please 
don't take your eye off of that. That is absolutely critical, 
that we bring that under control. And that is certainly part of 
the Biden-Harris agenda that I would support, is interdicting 
that illicit supply coming into the country.
    Ms. LaBelle. Right----
    Mr. Burgess. Thank you, Madam Chair, I will yield back.
    Ms. Eshoo. The gentleman yields back. Those are excellent 
points.
    And now it is a pleasure to yield to the gentleman from 
Maryland, Mr. Sarbanes.
    [Pause.]
    Ms. Eshoo. I saw Mr. Sarbanes.
    There you are. Are you--Mr. Sarbanes? Can you hear us?
    Mr. Sarbanes, you need to unmute.
    Mr. Sarbanes. Sorry, Madam Chair.
    Ms. Eshoo. You looked like you were studying something very 
hard there.
    Mr. Sarbanes. Yes, I appreciate----
    Ms. Eshoo. You are recognized.
    Mr. Sarbanes. Yes, thank you very much for the hearing.
    Many of us, it is clear from our comments already, are 
focused on the impact of this opioid crisis on our particular 
States, the districts that we represent. I am no different from 
my colleagues in that respect.
    In Maryland, since 2017 we have seen over 2,000 opioid-
related deaths each year, and the numbers have gotten worse, as 
we have been discussing today, during the coronavirus pandemic. 
In the first three quarters of 2020 there were more opioid-
related deaths in Maryland than in the same time period in 
prior years. So we are seeing that acceleration. I think that 
goes to the heart of your opening comments about what do we 
need to do to really get our arms around this.
    I had the opportunity to serve on Energy and Commerce back 
in 2018, when we were crafting a legislative package to address 
the crisis that resulted, as you will recall, in H.R. 6, the 
SUPPORT for Patients and Communities Act, which included bills 
addressing a wide range of substance use disorder issues.
    Workforce issues are a very important part of the 
conversation, in terms of reversing this opioid epidemic. And 
the package back in 2018 included a bill which I had worked on, 
the Substance Use Disorder Workforce Loan Repayment Act, which 
would help increase the number of healthcare professionals 
working in addiction treatment and substance use disorder 
programs. It would provide loan repayment for individuals who 
provide direct patient care at opioid treatment programs in 
high-need areas.
    Director LaBelle, in your testimony you discuss staffing 
shortages in the behavioral health occupations. Could you 
describe some of the challenges that you are seeing in this 
area in particular and how it relates to our ability to address 
this crisis?
    Ms. LaBelle. Sure. Thank you, Congressman. And the loan 
repayment program is a good example of a solution.
    You know, we know how much colleges--medical school costs 
for people. And it might be--there are many communities around 
this country where they don't have access to any type of 
addiction treatment. Buprenorphine-waived doctors are not 
available. Methadone clinics are not available. Doctors don't 
know how to treat addiction or screen for it.
    So the workforce piece is something we are looking at very 
closely, and actually have had conversations with Johns Hopkins 
about how we work to encourage more medical schools, more 
healthcare providers, healthcare professional schools to 
include addiction in their curriculum, so that when people come 
out they are prepared to screen and identify folks for 
substance use disorder. The workforce issue is so important 
because, as we--Congress has been very generous in giving a lot 
of money to the States, but unless we address those workforce 
shortages, we are not going to be able to put that money to 
good use across the country.
    Mr. Sarbanes. Can you be a little more specific about some 
of the actions you plan to take in this space in the coming 
months?
    I mean, do you have a kind of prioritized list when it 
comes to boosting the workforce?
    And then, how can we help? I mean, how can Congress help 
support those efforts in concrete ways?
    Ms. LaBelle. Sure, thanks. So a couple of things.
    One is that there are fellowships that are available that 
have been funded by--in HRSA by HHS that are not filled yet. So 
we are going--we plan first to just make sure that people know 
that these fellowships, addiction fellowships, are available 
that can help build the addiction treatment workforce.
    Secondly, we plan to talk once again with our colleagues in 
medical school--medical schools, nursing schools--about what 
they can do to make sure that, for example, all of their 
residents are DATA-waived. That is one step they can take.
    So those are two things that we plan to take on right away. 
And again, we are going to work closely with Johns Hopkins on 
several of these issues.
    Mr. Sarbanes. Thank you very much.
    Madam Chair, I yield back my time.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentleman from Virginia, Mr. Griffith, for your 5 
minutes of questions.
    Mr. Griffith. Thank you very much, Madam Chair.
    Director LaBelle, I first want to say that I greatly 
appreciate the work that the Office of National Drug Control 
Policy does and the role it plays in combating abuse of 
controlled substances.
    In fact, you mentioned one of the programs that was very 
helpful in my district--in fact, they would like it expanded--
and that is the HIDA program.
    Former Director Jim Carroll traveled to the district a 
little over a year ago, and we visited with the folks in a far 
southwest corner of Virginia where the opioid epidemic has hit 
particularly hard, although it is spread across the district. 
And prescription opioid abuse has been a major problem, as it 
has been in many districts. But for many years, the Nation's 
highest per-capita prescribing rates for opioid pain pills 
occurred in two of the localities in my district. One, it was 
306 pills per person, and in another it was 242. So obviously, 
we can do better, and we are doing better, and I appreciate 
your work on this as well.
    And we have more than our share of illegal drugs trafficked 
in from China and Mexico.
    But the question is, how does the ONDCP approach to data 
collection and recommendations differ between schedule I and 
schedule II substances?
    Ms. LaBelle. So I think--I am sorry, can you repeat the 
last part of the question?
    Mr. Griffith. Sure. What is--what are the differences 
between schedule I and schedule II when it comes to your data 
collection and then the recommendations you make?
    Ms. LaBelle. So the National Survey on Drug Use and Health 
is one of our tools that the Health and Human Services 
Department uses to collect data on drug use. And it has--it 
asks questions about lifetime drug use, substance use. It 
includes alcohol, it includes schedule I and schedule II drugs. 
And they added a lot about schedule II--I am sorry?
    They added quite a few questions about schedule II drugs in 
the last couple of years because, as you said, we can't keep 
our eye off the ball of other types of substance misuse.
    What we are trying to do in our strategy, in our policy 
priorities, is look at this from a holistic standpoint, that it 
is not just about one drug, it is about all drugs. It is about 
polysubstance use. And that can include alcohol use, as well, 
because we know that that is a substance that young people 
first start with, including alcohol and marijuana.
    So those are our issues. We work closely with HHS through 
their National Survey on Drug Use and Health to inform our 
policies.
    Mr. Griffith. And I appreciate that. And I appreciate 
recognizing that all substances may have a problem. I come from 
a family with some history of substance abuse, and so I have 
chosen throughout my life not to use any of the substances, 
including alcohol and marijuana.
    All right, new subject, Director LaBelle. In 2019 a Federal 
interagency work group led by ONDCP recommended the use of 
permanent classified scheduling for fentanyl-related 
substances, along with legislative modifications to allow for 
easier rescheduling of any fentanyl-related substances with low 
or no abuse potential. This would allow rescheduling to happen 
in a more timely manner, and it would make it easier to conduct 
research on schedule I substances. And I am big on research.
    I understand that ONDCP is reevaluating permanent 
scheduling, but does ONDCP still stand by these recommendations 
to make conducting research for medical purposes easier?
    Ms. LaBelle. So we are talking to HHS about exactly what 
the barriers are to research with the fentanyl scheduling 
legislation as it currently stands. We will be engaging with 
them in the future. We can build off of what was done and have 
that inform our work, but we need to make sure we are talking 
to them about the issues they are facing today.
    Mr. Griffith. Because, I mean, I think this is an important 
issue, and I think we need to do research because, while some 
of this stuff is the nastiest stuff out there and has no 
benefit whatsoever, sometimes things have medical capabilities 
that we are just not aware of. And if we don't allow our 
research facilities and our medical teams to experiment and try 
to figure out how to--how do you solve these problems, then we 
will still be in the dark 20 years from now.
    Ms. LaBelle. Right.
    Mr. Griffith. So I would hope that you all would allow more 
research, even on schedule I, and figure out ways to make it so 
that it is practical and effective and efficient.
    And I have got a little bill that will help you do that, 
but--that Dan Crenshaw and I are carrying. But I am encouraged 
by your comments, and I yield back.
    Thank you, Madam Chair.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. I thank the gentleman, and especially for being 
willing to express what your family and extended family have 
dealt with. That is to your credit. And I think it is important 
for not only Members but the American people hear you express 
that, Mr. Griffith.
    Now I would like to recognize the gentleman from Oregon, 
Mr. Schrader, for your 5 minutes of questions.
    Mr. Schrader. Thank you very much, Madam Chair.
    And Director LaBelle, thanks for being here. I appreciate 
it very, very much. I am encouraged by the interest shown by 
ONDCP in pursuing mental health parity. We try and do that in 
Oregon. It is a huge benefit at minimal cost, and I would argue 
it saves millions of lives and a lot of money in the long run.
    Just like we have been talking about here, access to 
treatment is a huge issue. And while payers can't create more 
providers, ensuring that, you know, they cover the ones that 
exist is one piece of the puzzle.
    And so, in that regard, what policies is ONDCP considering 
to encourage the growth of substance use disorder providers?
    Ms. LaBelle. So what we are doing is making sure, 
obviously, that there is quality treatment. As you mentioned, 
the parity work, we did quite a bit of that when I was here at 
ONDCP last. We need to catch up to see where the barriers still 
exist to parity. We need to work with Department of Labor as 
the agency that administers and enforces the Parity Act. So we 
will be working with them to determine what the gaps--where the 
gaps continue to be.
    Mr. Schrader. Very good, very good, excellent.
    And others have spoken about this too, but, you know, the--
last March, millions of Americans that were getting treatment 
for alcohol, cocaine, methamphetamine, marijuana, fentanyl, 
heroin addictions basically lost access. There have been some 
creative opportunities through telehealth to help in that 
regard.
    And so, given the constraints that we have encountered with 
the in-person care, has ONDCP given any consideration--the 
field--the FDA cleared and regulated products called 
Prescription Digital Therapeutics that use software to treat 
serious unmet medical health needs? And if so, how so?
    Ms. LaBelle. Sure. Thank you for asking that. So clearly, 
there are lots of innovations that have come out across the 
country to address this need.
    I mean, there are--technological innovations kind of 
abound, which is great because, as I said before, our policy 
priority is about increasing interventions at every single 
point and removing barriers. And technological advances such as 
the one you identified, that is something I need to look into a 
little bit further, and I would be happy to talk to you about 
that more.
    Mr. Schrader. Well, that would be great. I would like to 
have you work with the committee on the opportunities that are 
there.
    My understanding is that the products actually have 
accountability and support features built into them, which are 
both very, very important in terms of followthrough. So I want 
to make sure that, while these apps and opportunities are 
there, they are actually doing what we want them to do and can 
register improvement from our patients. So if you will work 
with us, I would appreciate it.
    Ms. LaBelle. Sure, thank you.
    Mr. Schrader. Thank you.
    And Madam Chair, I yield back.
    Ms. Eshoo. Thank you. The gentleman yields back.
    It is a pleasure to recognize the wonderful Mr. Bilirakis--
--
    Mr. Bilirakis. Thank you very much. I appreciate it, Madam 
Chair----
    Ms. Eshoo [continuing]. Members on our committee.
    Mr. Bilirakis. Thank you so much, it is appreciated.
    Madam Chair, the United States remains in an overdose 
epidemic. I know you know that. Sadly, according to the CDC, 
drug overdose deaths rose from 2018 to 2019; 70,630 lives lost 
in 2019, sadly. And with deaths involving synthetic opioids, 
primarily fentanyl, there was a continued increase with more 
than 36,359 lives lost in 2019. It is just terrible.
    DEA temporarily scheduled fentanyl analogues as controlled 
substances 3 years ago. Last year Congress passed a temporary 
extension that continued to criminalize fentanyl analogues 
until May 6, 2021. Locally, we have seen that fentanyl has been 
a major problem even with the schedule being in place. Madam 
Chair.
    For example, Pasco County in my district has already had 48 
people die from overdoses since January of this year. And Pasco 
is not alone, as you know. Many communities throughout the 
country are experiencing the same overdose increases as the 
pandemic has only exacerbated the mental health and addiction 
crisis in our country. If this scheduling ban expires, we 
expect far more fentanyl to flood our streets and many more 
lives to be tragically lost. We cannot allow that to happen.
    While we have made meaningful bipartisan strides to address 
this scourge, we are certainly far from being out of the woods. 
It is critical that we remain engaged in the fight to save the 
communities we are charged to represent, and the lives of our 
neighbors too often cut short.
    Director LaBelle, thank you for being here. Thank you for 
your testimony. Can you discuss our working relationship with 
China to prevent the entry and sale of fentanyl and its 
analogues?
    And then, given the dynamics of the current U.S.-China 
relationship, what is the level of transparency and information 
sharing with law enforcement agencies, please? Thank you.
    Ms. LaBelle. Sure, thank you, Congressman. I will start 
with your first question first.
    So our office, the Office of National Drug Control Policy, 
has a regular conversation with our embassy in Beijing, where 
we discuss these very issues that you raised. China has a very 
large chemical industry, much of it which is unregulated. So we 
are discussing with them on a regular basis about just the 
issues that we have discussed, how to control the chemical 
industry so the precursor chemicals that are used in the 
manufacturing of fentanyl and fentanyl analogue are more 
controlled.
    And then the second--your second question concerned, you 
know, what--going forward, what we can do. Again, you know, it 
is making sure that--there were several pieces of legislation 
put into place that--so we could have our Customs and Border 
Protection and the U.S. Postal Service make sure they are 
getting the chemicals that are coming in, the fentanyl 
analogues that are coming in through the mail or express 
couriers, so they can seize those.
    And then also, I think it was good in--a couple of years 
ago when China--working with China to make sure they were--they 
scheduled all of their fentanyl. So that did reduce the amount 
of fentanyl coming in directly to the United States from China.
    Unfortunately, a lot of that--the chemicals are now going 
to Mexico, where we are working with Mexico on the problem.
    Mr. Bilirakis. Thank you.
    You know, Madam Chair, while China's step to designate 
fentanyl and all its related analogues as controlled substances 
is certainly helpful, if COVID-19 has taught us anything, it is 
that we ought to remain skeptical and not rely on the goodwill 
of the Chinese Communist Party.
    A permanent American solution is necessary, as you know, 
and I encourage my colleagues to review and consider a 
permanent ban for these deadly analogues under H.R. 1910, the 
FIGHT Fentanyl Act, or continuing the temporary ban under H.R. 
2430, the Temporary Reauthorization of the Emergency Scheduling 
Fentanyl Analogues Act.
    Thank you very much for holding this very important 
hearing, Madam Chair, and I will yield back. Thank you.
    Ms. Eshoo. I thank the gentleman, and he yields back.
    I don't see Dr. Ruiz, so I am going to go to the 
gentlewoman from Michigan, Mrs. Dingell.
    You are recognized.
    [Pause.]
    Ms. Eshoo. Unmute.
    Mrs. Dingell. I know----
    Ms. Eshoo. Now we can hear your voice.
    Mrs. Dingell. I am sorry. Thank you, Chairwoman Eshoo and 
Ranking Member Guthrie, for convening this important hearing on 
the opioid crisis, which, as we have all talked about this 
morning, remains one of the defining public health challenges 
of our time. And thank you, Acting Director LaBelle, for the 
leadership you and your team have already put forward at the 
Office of National Drug Control Policy.
    As we know, substance abuse disorders are complex, but they 
are treatable diseases. And it is good to be part of a 
committee that has recognized that and sees this as a public 
health problem.
    Despite all of our work over the years, the Nation is still 
experiencing a significant treatment gap, and I would like to 
ask you to expand on how we can work together to reduce 
barriers to treatment, particularly for patients who receive 
methadone. By law, only certain treatment programs can dispense 
methadone for the treatment of opioid use disorder. Patients 
who receive methadone as part of their treatment must also 
receive the medication under the supervision of a practitioner.
    Could you--Director LaBelle, could you--the 
administration's drug policy priority states that you plan to 
review policies relating to the methadone treatment and develop 
recommendations to modernize them. When will this review begin, 
and when do you expect to develop recommendations?
    Ms. LaBelle. Thank you for your question. And methadone is, 
obviously, a proven medication for opioid use disorder, as you 
have recognized. We are--we have not yet begun that review. I 
can't give you a timeline. We do know how urgent it is.
    Methadone regulations and rules haven't been reviewed in 
some--for some time. So we need to--you know, our policy 
priorities were issued on April 1st. We are now looking for 
what the best venue is to review that. So as soon as we know 
that, I will make sure our office stays in touch with your 
staff about it.
    Mrs. Dingell. Thank you. During the pandemic SAMHSA and 
other agencies have made exceptions to rules around treatment 
for opioid use disorder. But some restrictions around methadone 
remain in place, such as requiring new patients that are 
treated with methadone to complete an in-person medical exam. 
Does that in-person requirement exist for other forms of opioid 
use disorder treatment?
    Can this requirement be a barrier for patients seeking 
treatment?
    Ms. LaBelle. So the methadone--the way--and again, I am a 
lawyer, not a doctor, so I don't want to step into clinical 
recommendations. But as I understand it, one of the issues with 
methadone is making sure you get the right dose, which is why 
it is so important to have the in-person piece.
    Those are issues that we need to make sure are reviewed and 
that we have clinicians who can discuss that very issue, 
because we know methadone works and we want to remove those 
barriers.
    Mrs. Dingell. One way to--thank you for that. One way to 
reduce barriers to treatment is to find ways to meet patients 
where they are. Your priorities include finalizing a rule 
related to methadone treatment vans. Can you talk to--talk us 
through how these would work and why they might be important 
for both rural and urban communities?
    Ms. LaBelle. Great, thank you. So methadone treatment vans 
have been--we haven't had new ones for almost a decade now, and 
so that is why it is so important to get these methadone rules 
out. The mobile methadone vans can be useful. I feel very 
strongly they can be useful in--across the country in jails 
that may not have their own opioid treatment program. A 
methadone van could provide those services to those 
individuals.
    I also think that it is important--and I talked about the, 
you know, the mobile treatment availability. It is--that is 
important for rural areas, but it is also important in urban 
areas as well, where you might have the same type of--or 
similar issues with transportation. So I am a strong proponent 
of mobile methadone vans, and we are working diligently to make 
sure that those get out as soon as possible.
    Mrs. Dingell. Thank you, Director LaBelle. As we have heard 
today, the trend in drug overdose death statistics is really 
alarming, and we know that increasing the availability of 
treatment will ultimately save lives.
    I lost my sister to this, so it is an issue that remains 
very personal. My father was an addict too. So thank you for 
all the work you are doing, and we also have to remove this 
stigma attached to it so we can get out there and really treat 
the problems. Thank you.
    I yield back, Madam Chair.
    Ms. Eshoo. The gentlewoman yields back. And I would also 
add to Mr. Griffith's personal testimony, I think that it is 
really rather courageous of Members coming forward, as Mrs. 
Dingell has, to let the American people know that we are all 
just as human as the rest of the people in our country and that 
these terrible, terrible drugs have impacted so many Members 
in--obviously, in a very personal way. So thank you to you.
    The Chair now recognizes the gentleman from Missouri, the 
one, the only Congressman Long.
    Mr. Long. Thank you, Madam Chair, and I appreciate it very 
much. And I remember being on a trip to Turkey with you a few 
years ago, right around the start of the Syrian War. And we had 
some refugees from Syria in our roundtable discussion, so we 
were there a week and really trying to drill down. And at one 
point you leaned back and you said, ``What a mess.'' And that, 
I think, is what we are faced with here again today. What a 
mess.
    I never came home growing up and had my parents tell me 
that one of their friend's children had deceased from drugs. 
And just within the last month I have had the fourth child that 
is the same age as my children and grew up with them, that 
deceased from opioid abuse, I guess you would call it. And all 
four of those cases, all four, are personal friends of mine 
that have lost children. They had had them--they were all 
middle--upper- or middle-class and above. They had all done 
everything humanly possible for their children, had them in 
rehab facility, rehab facility, after rehab facility. One died, 
they found him in the bushes of the rehab facility with a 
needle still stuck in his arm.
    So thank you very much, Madam Chair, for holding this very 
important hearing today. It is titled, ``An Epidemic Within a 
Pandemic: Understanding Substance Use and Misuse in America.'' 
And I hope we can understand how to break the addiction for 
these kids, because in all four cases in our--you knew what was 
going to happen, you knew how the book was going to end, how 
the story was going to end. And it did. And I don't know what 
the breakthrough will be, with a drug company or with someone 
to come up with something to break this horrendous addiction, 
and--that brings so much death to families across America.
    I was in Kansas City a couple of years ago visiting a drug 
facility where, when the cops pick you up, instead of taking 
you to jail, they take you to this facility. And the first 
thing that they do is they test you for drugs. And they have 
got this guy in there, the cops brought him in, and instead of 
taking him to jail, bringing him to the rehab facility, brought 
him in, and they said, ``What are you on?''
    And he said that he was on opioids, and they tested him and 
they said, ``You don't have one opioid in your system. You have 
fentanyl.''
    He said, ``What is fentanyl?''
    So, again, I, you know, just want to thank you for holding 
the hearing.
    And Ms. LaBelle, for years Missouri had one of the worst 
problems in the country with meth labs. And that trend has, 
thankfully, gone down. But, unfortunately, these bigger 
manufacturing operations are filling the void.
    We tend to think of meth as the small lab's business. And 
when I was an auctioneer, I would go out to book a farm, a real 
estate auction, and there would be a black trash bag on the 
ground with, like, smoke coming up. It wasn't smoke. I don't 
know exactly what it was, but somehow I guess you can put meth 
in a black plastic trash bag. But--so we tend to think of it as 
small labs in basements or out in the fields, I guess. But it 
is clear that the meth production has turned into a highly 
industrialized operation.
    And last week a Missouri State Highway Patrol trooper found 
88 pounds of meth in a car during a traffic stop. And this was 
following a similar traffic stop in Missouri the week before, 
where they discovered 75 pounds in a cooler in the back of a 
car.
    Last year, in March, we had a hearing on substance use 
disorder, and I asked Admiral Brett Giroir, the Assistant 
Secretary of HHS at the time, about methamphetamine. He noted 
the cartels were manufacturing and then distributing hundreds 
of thousand pounds of pure methamphetamine. And he 
characterized methamphetamine as the fourth wave of substance 
abuse.
    Director LaBelle, last year's hearing was right before the 
COVID pandemic and everything that came with it. Fast forward a 
year. What are you now seeing, in terms of availability, 
manufacture, and distribution, and use of methamphetamine?
    Ms. LaBelle. Thank you, Congressman. So I think, as you 
said, it is not yesterday's meth. Meth that is being--now it is 
manufactured in Mexico, and it is coming in to the United 
States across the border. So--and we are seeing it where--I 
grew up in New England, but lived in Washington State for a 
long time. Never heard of it in New England. Washington State 
had a lot of meth labs. Now we are seeing more meth 
availability in the Northeast and across the country.
    And so I think that that is getting much more attention. We 
know there are treatment programs that work, and will be 
working with HHS on making sure that, again, the barrier to 
effective treatment for meth use disorder is something that we 
take up.
    Mr. Long. OK, I only have 47 more questions, but I am out 
of time. So, Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back. I think that it is 
worth noting that when--with a sweeping schedule I designation, 
it is very difficult for there to be the development of new 
drugs to be administered to people that would benefit from 
them, because in that sweeping schedule I it eliminates the 
possibility of some of these substances to be used to the--for 
the benefit of individuals. So I think we need to keep that in 
mind.
    Let me recognize the gentleman from California, Dr. Ruiz, 
for his 5 minutes of questions.
    Mr. Ruiz. Thank you, Madam Chair, and thank you, Acting 
Director LaBelle, for providing an update on the 
administration's drug policy priorities.
    One issue I would like to address today is access to 
treatment, and how that is directly related to the amount of 
education and training of providers. In other words, also the 
physician shortage that we see, not only in all aspects and all 
specialties, but specifically with addiction medicine.
    As an emergency physician myself, I have cared for 
countless individuals in the emergency department who were 
actively overdosing and have resuscitated many and intubated 
them, et cetera, given them the appropriate medications when 
appropriate, and saved their lives. And there is an obvious 
opportunity in the emergency department to help an individual 
get help by seeking long-term treatment.
    However, many patients with substance use disorders also 
come to the emergency department for completely different 
reasons. And being able to identify the more subtle signs of 
substance use disorders can be a critical tool to help more 
individuals get access to the treatment they need. In other 
words, identify those at risk, give them the treatment before 
they come in blue and not breathing.
    And this is not just for emergency physicians. The more 
providers in all specialties that can help identify the signs, 
the more opportunity we have to open doors for our patients to 
seek care and improve their lives. A National Academies paper 
issued last April found that, ``despite the impact and 
pervasiveness of the opioid epidemic, most clinicians cannot 
confidently diagnose and treat patients with substance use 
disorder.''
    So Acting Director LaBelle, just talk to me about whether 
or not additional education and training around substance use 
disorders improve provider confidence in diagnosing and 
treating substance use disorders and, therefore, increase 
access to treatments for individuals with substance use 
disorders.
    Ms. LaBelle. Thank you, Doctor. I couldn't agree more about 
the importance of all providers, all healthcare providers, 
being able to identify early stages of a substance use disorder 
before it becomes chronic, when it is much harder to treat, as 
you know.
    So we are working with the National Academies. We will 
continue to work with the National Academies, the American 
Medical Association, pediatricians. These are all important 
parts of the answer to this, is to make sure that they get the 
training that they need in medical school but also, you know, 
during residency, so that they understand how to identify and 
refer people to treatment. That is a key element of our 
strategy.
    Mr. Ruiz. Thank you. And you also note in your testimony 
that the Nation's addiction workforce is experiencing staffing 
shortages. In what way does the Biden-Harris administration 
plan to support, diversify, and expand the addiction workforce?
    Ms. LaBelle. Thank you, an important point about 
diversifying the addiction workforce.
    There are fellowship programs, minority fellowship programs 
in particular, that would help diversify the workforce. I don't 
think we are there yet. And I want to work with your office to 
identify how better to address those issues, because I think 
there have been workforce approaches that have been authorized 
but not appropriated. We need to work with HHS to identify what 
those are and expand them, and particularly in areas where 
there is a high need.
    Mr. Ruiz. Director LaBelle, I helped start a medical school 
in one of the--California's most underresourced areas that 
faced high health disparities, our senior--founding senior 
associate dean at the UC Riverside School of Medicine. And one 
of our missions was to develop a workforce that comes from the 
underserved communities. In other words, it is--diversity was 
very important.
    The best way to do so is to create pipelines from those 
communities into those specific targeted specialties that you 
need for that region. And so I am more--and I developed 
pipelines, not only through my pre-med mentorship programs from 
those underserved communities but also developing residency, 
because the best predictors of where a person will practice is 
where they are from and where they last train. So you need to 
develop pipelines and create residencies in addiction medicine 
in those under-served communities.
    And so with that, I want to thank you. I want to make 
myself available to you as we address this pandemic the right 
way.
    And I yield back my time.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. The gentleman yields back. It is a pleasure 
now----
    Mr. Guthrie. Excuse me, Madam Chair?
    Ms. Eshoo. Yes?
    Mr. Guthrie. Hey, it is Brett Guthrie. Hey, you made a 
comment between the last two questioners about research and 
fentanyl. And I am not speaking for every single Republican, I 
think, but for our side is that we just want to say we want to 
do research, but we don't think they are mutually exclusive, 
that you can have scheduling--and there is a bill that I think 
Mr. Griffith and Mr. Crenshaw have allows for research to go 
forward too.
    So I just wanted to--I know we don't have a chance to 
respond to that comment, I just wanted to respond to what you 
said between the last two.
    Ms. Eshoo. Yes, it is not a hit on anyone. I think there is 
bipartisanship on the--always on the development of new drugs 
to----
    Mr. Guthrie. Absolutely.
    Ms. Eshoo [continuing]. Suppress whatever it is that is 
serious out there.
    Mr. Guthrie. Right.
    Ms. Eshoo. I thought it was, you know, important just to 
mention, and thank you for raising it.
    Mr. Guthrie. Thank you, I appreciate that.
    Ms. Eshoo. We can be for--we can certainly be for both, and 
I believe that we are, and bills address it.
    I now would like to recognize the gentleman from Indiana, 
Dr. Bucshon, for his 5 minutes of questions.
    Great to see you. Look at that big smile. You make me 
happy, just looking at my screen.
    Mr. Bucshon. Yes, well, thank you, Madam Chairwoman. I very 
much appreciate it. And thank you to the panel.
    I was a cardiovascular and thoracic surgeon before, so I 
have been in healthcare for over 30 years, and this is really a 
critical subject.
    But before I get to my questions, I would like to share my 
concerns regarding one of the bills being considered today. 
Buprenorphine can be effectively administered by properly 
educated and trained providers who counsel and educate 
patients. However, the vast majority of individuals currently 
receive little or no counseling.
    I have been working in Congress to implement prescribing 
limits and increased prescriber education for buprenorphine and 
other medication-assisted treatment to mitigate the practice of 
only treating people with medication-assisted treatment but not 
continuing on with a more comprehensive treatment plan.
    However, not everyone agrees with this, and some of my 
friends continue to work on expanding the scope of practice to 
allow almost anyone, regardless of their qualifications and/or 
training, to prescribe buprenorphine. In my opinion, that is 
exactly what H.R. 1384, the Mainstreaming Addiction Treatment 
Act, does. It removes education requirements and limits, making 
it easier to prescribe the medication known to be one of the 
most highly diverted drugs in the country.
    This bill will only expand access to medication, not real 
and effective treatment for individuals with substance use 
disorder. Everyone who is legitimately involved in the 
medication-assisted treatment space to treat people who are 
addicted recognize the importance of a comprehensive treatment 
plan. The last thing Congress should do is relax the 
requirements for prescribing and dispensing narcotic drugs such 
as buprenorphine because, as I mentioned before, expanding the 
use of medication-assisted treatment is not going to be 
effective unless we have a comprehensive treatment plan in 
place. So I would like to voice my opposition to this 
legislation.
    Pivoting now to another topic, pain management is real, and 
people have chronic pain, and we must look--all of us--to 
finding non-opioid alternatives to use to help individuals that 
suffer from pain daily. Director LaBelle, recently eight States 
have passed non-opioid directives that ensure non-opioid 
options are considered for the treatment of pain management. 
These directives are voluntary and are intended to spur 
discussions between patients and providers around alternative 
ways to alleviate pain.
    Does the White House support establishing a Federal--my 
question is, does the White House support establishing a 
Federal non-opioid directive to further empower patients and 
providers across the country to engage in important 
conversations around the need for non-opioid alternatives?
    And are we--also I would request that the White House 
consider reimbursement as an issue, as opioids are cheap and 
new medicines are expensive. And what advice might you have to 
Congress in addressing that particular issue?
    Ms. LaBelle. Thank you, Congressman. So, on the first one, 
I think we could--we would be happy to work with your office to 
get more information on that issue, on the directives.
    On the second issue, the reimbursement rates certainly, you 
know, are something that we would have to speak with CMS about. 
And as we go forward in our national drug control strategy, 
which we will issue next year, we can certainly take a look at 
that.
    Mr. Bucshon. Yes, because that is one of the most important 
barriers for hospital systems or clinics, is, again, opioids 
are very cheap, potentially new non-opioid alternatives are 
expensive. And when you look at, you know, bundled payments 
that--based on diagnostic-related groups and other ways 
providers are reimbursed, it doesn't make a lot of economic 
sense, in many cases, to use non-opioid alternatives, and we 
need to fix that, because, whether we like it or not, in 
healthcare financial incentives drive the ship many times.
    Ms. LaBelle. Right, right.
    Mr. Bucshon. And so we need to address that. So I 
appreciate that.
    You can also not properly combat the opioid misuse epidemic 
without addressing one of its root causes: again, as I just 
mentioned, inadequate pain management. HHS has included 
improving pain management as one of their pillars of the opioid 
strategy. What is ONDCP's position on improving pain 
management, provider education, and patient access to non-
opioid therapies?
    And that is just an extension of what I just mentioned.
    Ms. LaBelle. Sure. I think it is really important that we 
make sure that people who are--have pain are treated properly, 
whether that is--and what the alternatives are, that is an 
important issue that I know that the National Institutes on 
Drug Abuse have looked at, as well as the rest of HHS and CDC. 
So it is a very important issue that we will look at, going 
forward.
    Mr. Bucshon. Thank you. I can--I had a personal experience 
with my father, who has now passed away, had substantial back 
issues that, really, there was nothing they could do for him--
he was in his late 70s, early 80s--other than opioids, 
unfortunately. And all of us are fighting the opioid epidemic. 
But what happened to him is--in his home State--is it became 
more and more difficult to acquire his medication, even through 
his primary care provider, because of things put in place at 
the State level.
    So I just want to mention the pain--chronic pain management 
is an issue. We need good opioid alternatives.
    With that, Madam Chairwoman, I yield back. Thank you.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentlewoman from New Hampshire, certainly not a 
newcomer to this issue, offered really important insights and 
leadership on the whole issue of opioids, Ms. Kuster.
    You are recognized.
    Ms. Kuster. Thank you so much, Chairwoman Eshoo, and thank 
you to Director LaBelle for joining us today. I am pleased to 
see that this administration's priorities focus on evidence-
based approaches that holistically address prevention, support, 
and treatment for those battling with substance use disorder. 
And I think you can appreciate today, for many of us, this is a 
personal issue in our families as well.
    My legislation, the Emergency Support for Substance Use 
Disorder, was included in the American Rescue Plan to ensure 
smaller organizations on the front lines of the addiction 
crisis would receive support for their harm reduction services 
during COVID-19. I look forward to working with you.
    I want to commend Representative Tonko's bill today about 
treatment at the end of incarceration, and I would like to meet 
with you about treatment during incarceration so that we can 
break this terrible recidivism cycle that we are engaged in.
    This is deeply personal. And New Hampshire has consistently 
had one of the highest rates of overdose deaths in the country. 
In 2019 my State ranked third for the most overdose deaths per 
100,000 people. And we had the highest rate of fentanyl 
overdose deaths per capita in the United States for many years. 
In 2020 about 65 percent of the overdoses in New Hampshire were 
caused by fentanyl, or a combination of fentanyl and other 
drugs, as we have heard today.
    But we know this is not just happening in my State. My 
colleagues all have similar stories about how the opioid crisis 
has evolved into an overdose crisis at the hands of synthetic 
opioids.
    Now, at the same time, the Drug Enforcement Agency has had 
the ability to go after the proliferation of fentanyl-related 
substances through emergency classwide scheduling. Despite this 
tool, we have seen the continued upward trend of overdose 
deaths related to fentanyl and its analogues. And that is why I 
have introduced, with my good friend and colleague 
Congresswoman Blunt Rochester, the STOP Fentanyl Act to provide 
a comprehensive, balanced public health approach.
    Director LaBelle. You have said the administration is 
supportive of this short-term extension, but could you explain, 
as specifically as you can, how another temporary extension is 
necessary to explore a more comprehensive and effective 
approach to fentanyl-related substances?
    Ms. LaBelle. Sure. Thank you, Congresswoman, and thank you 
for your work on this issue.
    I think that we need the extension because we need a little 
bit more time to--you know, we have only been in this position 
for about 85 days. There are many people who aren't even in 
place yet. This is a critically important issue, and we want to 
do it right. So we need the time to look at the mandatory 
minimum implications of this legislation as well as the 
research implications that have come up several times on both 
sides of the aisle. So that is why we need the extension of 
time.
    Ms. Kuster. And if I could press you a bit further, what is 
the plan to use that time effectively, so we won't be back in 
this same situation if we grant a seven-month extension?
    Ms. LaBelle. Sure. I mean, so the plan is that, you know, 
it is a process plan, which is we get our colleagues together 
from the Department of Justice, we get our colleagues together 
from HHS, and we hash this out. We have had a couple of 
meetings already. We are going to have more, and we are going 
to come together and have a resolution of the issues.
    Ms. Kuster. And how can we work with you to make sure that 
we address the issue of racial equality?
    I am very concerned, as many of us are on both sides of the 
aisle, about the disparate impact on race with these mandatory 
minimums. How can we do a better job with a public health 
approach, rather than being so focused on mandatory minimums, 
when we know we are not getting the treatment into the jails 
and prisons across this country?
    Ms. LaBelle. Yes, so we know that incarceration rates are 
higher for poor Black Americans, and the work that has to be 
done in jails across the country, we are getting there. 
Certainly, New Hampshire has medication, most of the New 
England States do. There is a lot more work that needs to be 
done.
    I am encouraged by the Congress's help, though, to provide 
funds through the Department of Justice to expand access to 
treatment in jails.
    Ms. Kuster. Well, we would love to meet with you. I will 
set that up. We have game-changer legislation that would 
eliminate the exclusion of Medicaid during incarceration. And I 
think it would really change the scope. We would be talking 
about treatment, we would be talking about support services, 
and we would help people get back on their feet and lead much 
more productive lives.
    So with that, I yield back, and thank you.
    Ms. Eshoo. The gentlewoman yields back. I would like to 
recognize the gentleman from Georgia, Mr. Carter, our favorite 
pharmacist.
    Mr. Carter. Thank you, Madam Chair. I appreciate that very 
much. And thank you for being here. We appreciate this very 
much, this is extremely important.
    I wanted to mention, first of all, that I understand we 
don't have jurisdiction over the border in this committee. But 
I do want to bring up the border crisis, as it is impacting 
this epidemic. And I know that because I was there last week. I 
was there last Friday.
    The GAO has reported that Customs and Border Patrol data at 
U.S. ports of entry at the southern border show seizures of 
fentanyl and its analogues have gone up more than 200 percent 
in the last couple of years.
    Ms. LaBelle, is it correct the majority of fentanyl and its 
analogues come through the southern border from Mexico?
    Ms. LaBelle. Most--well, much of fentanyl certainly is 
seized at the border. We are getting some that comes through 
couriers. So mail systems, that is much reduced, but much of it 
comes--is seized at the southern border.
    Mr. Carter. Well, from my investigation of it, my studies 
of it, what I have seen is there is enough fentanyl coming 
across the southern border to kill every American several times 
over. So I think it is really a stunning problem.
    Again, I want to allude back to my visit this past Friday 
to the border, and what I witnessed there, because, listen, 
these cartels, they are not dumb. In fact, they are very smart. 
And what they are doing is flooding the border in one area so 
that it takes the attention of Customs and Border Patrol 
agents, and then they are just bringing drugs across at another 
point. It is causing us to have even more of a problem.
    Obviously, we have got a humanitarian crisis down at the 
border with what is going on with the illegal immigrants. But 
we have also got another problem, and that is a national 
security problem with our--with all of these drugs that are 
coming across this border. We have got to get this under 
control.
    You know, it would be easy for all of us just to sit back 
and think, oh, what is happening down there is just a problem 
at the border, and those poor people down there. But it is much 
more than that, because when we talk about fentanyl, when we 
talk about illegal drugs, those drugs that are coming across 
that border, they are going to be in your community next. 
Whether you are in Georgia, whether you are in the northern 
United States, or the northeast, or the northwest, it is going 
to be impacting you.
    And that is why it is such a big problem. It is killing 
people in our communities. Just this past week in Georgia we 
had two incidents of fentanyl overdoses, one in Richmond County 
near Augusta, one in Chatham County near Savannah, where my 
district is. And that is a problem that we have got to deal 
with, and it is a problem that is being exacerbated by the 
fentanyl that is coming across the southern border and coming 
across from Mexico.
    I wanted to ask you, Ms. LaBelle, would you agree that you 
have an obligation to advise the President, as he must get the 
border under control, because the epidemic that we are 
discussing today has gotten much, much worse--have you 
discussed with the Vice President or the President the harm an 
open border is having on the opioid epidemic, specifically the 
trafficking of fentanyl?
    Ms. LaBelle. So we are working very closely with all of our 
White House colleagues on this issue. We are separating the 
migrant issue from the drug issue. And that is where we have 
ongoing conversations on a monthly basis with the Government of 
Mexico and with our law enforcement partners, to make sure that 
they are doing everything they can to interdict the synthetic 
drugs that are coming from China into Mexico. So certainly 
these are ongoing conversations, and particularly with the 
National Security Council.
    Mr. Carter. So I want to make sure I heard you right. You 
said these are monthly conversations, that you only discuss 
them once a month?
    Ms. LaBelle. With Mexico.
    Mr. Carter. With Mexico. But in the administration, with 
the Vice President----
    Ms. LaBelle. Oh, no, we have----
    Mr. Carter. That was----
    Ms. LaBelle. I am sorry, sir. We have ongoing conversations 
with our colleagues throughout the White House on this issue on 
a daily basis.
    Mr. Carter. We were told last week when we were down there 
that over $400 million of illegal drugs crossed that border 
last month, that we know of. That, to me, is substantial. And I 
think to everyone in America it would be substantial. Don't you 
feel like this deserves more immediate attention than what it 
is getting at the White House right now?
    Ms. LaBelle. I think that everyone is paying very close 
attention to the issue. Certainly, the issue of how many drugs 
are coming through can be a matter of enforcement, because that 
is what we are seizing. That is not necessarily--it is hard to 
tell what it is when----
    Mr. Carter. And that is why I mentioned $400 million of 
what we know of, because what is happening is the Customs and 
Border Patrol agents, as you know, are having to be in the 
processing facility, and they are not able to monitor the 
borders. Therefore, we are not catching as much as what is 
coming across. So we don't really know the true number, but we 
know it is more than 400 million.
    OK, well, listen, this deserves immediate attention, Ms. 
LaBelle.
    Ms. LaBelle. Yes, sir.
    Mr. Carter. I hope you will go back to the White House 
immediately. And listen, we have got to get this stopped.
    Thank you, Madam Chair, and I yield back.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentlewoman from Illinois, Ms. Kelly.
    Ms. Kelly. Thank you, Madam Chair. The Biden-Harris 
administration's statement of drug policy priorities for year 
one published by the Office of National Drug Control Policy 
stated, and I quote, ``Black individuals generally entered 
addiction treatment 4 to 5 years later than White individuals. 
And this effect remains when controlling for socioeconomic 
status.''
    Have plans been identified on how to ensure that Black 
people have more timely access to evidence-based care that 
includes prevention, harm reduction, treatment, and recovery 
services?
    Ms. LaBelle. Thank you, Congresswoman. So we included that 
in there in order to make sure that we can work with HHS to 
look at the data, to look at the research, just what we 
identified in our policy priorities, and then put in place 
specific programs that can handle--that can tackle those 
issues.
    We want to do more than just a program that sounds good or 
looks nice. We want to put in programs and policies that are 
really going to make a difference once and for all on this 
issue. And it is not going to happen overnight.
    I mean, one of the first steps is making sure that we 
acknowledge this is an issue, and then we are going to work 
with HHS to put plans in place that are going to make a 
difference on it.
    Ms. Kelly. Thank you. In the HHS OIG report titled 
``Geographic Disparities Affect Access to Buprenorphine 
Services for Opioid Use Disorder,'' 40 percent of counties in 
the United States did not have a single waivered provider, and 
waivered providers were not necessarily found in areas where 
the need for the treatment is most critical.
    How can we ensure equity of access for geographic 
locations, and is telehealth a tool that we can use to ensure 
provider equity?
    Ms. LaBelle. Thank you. So this raises the issue that we 
talked about before with methadone clinics, that--you know, so 
you can go to an office and get your buprenorphine, a doctor's 
office. If you are going to a methadone clinic, you are 
probably standing out in the street corner, waiting to get in. 
So much less private, much less personal care.
    Certainly, there are a lot of great opioid treatment 
programs around the country that provide methadone, but it is a 
different form of care.
    So how we tackle this is, number one, removing barriers to 
buprenorphine treatment to expand the number of providers--not 
just physicians, but nurse practitioners and physicians' 
assistants--so that we can reduce those barriers to care that 
occur around the country.
    Ms. Kelly. And can you give more insight on why providers 
must receive a waiver to provide medication to treat opioid use 
disorders but not to prescribe the medications that have gotten 
us to where we are today? This seems counterproductive.
    Ms. LaBelle. Sure, thank you. So I think the issue is that 
we have--as we have spoken about, we really have minimal 
training and education in addiction in the healthcare services. 
And so, in order--and so, you know, people who are prescribing 
buprenorphine are required to go through that training, the 
eight-hour training, because they may not have ever really 
encountered or have a lot of knowledge about the treatment of 
addiction.
    So I think what we really need to do is expand the number 
of people in our healthcare system who understand how to screen 
and treat and help people recover from addiction, as opposed to 
hinging it all on this one medication.
    Ms. Kelly. OK, thank you so much. And Madam Chair, believe 
it or not, I will yield back.
    Ms. Eshoo. The gentlewoman yields back, and now I have the 
pleasure of recognizing the gentleman from Florida, Mr. Dunn, 
for your 5 minutes of questions.
    Mr. Dunn. Thank you very much, Madam Chair. You know, the 
increase in fentanyl throughout the United States, including 
Florida, is deeply troubling. Sadly, this has been a growing 
problem in my district too.
    Just last month the Panama City Police Department arrested 
a man with 90 grams of fentanyl. That is more than 43,000 
lethal doses of this drug. And for perspective, that is enough 
to kill over half of the population of Panama City.
    On the other end of my district, the Ocala Police 
Department seized 177 grams of fentanyl in a single bust just 
last fall, and the police chief there said that that was enough 
fentanyl to kill, with overdose, every person in Polk County, 
man, woman, or child.
    When using fentanyl for medical purposes, a typical dose 
would be 25 micrograms. That is 25 millionths of a gram. 
Doctors always use this drug very, very cautiously, with 
extreme care, because even the medical formulation of fentanyl 
is extremely potent and potentially hazardous.
    Florida law enforcement is doing a heroic job getting it 
off the streets, putting traffickers behind bars. However, they 
need help. Fighting fentanyl requires a team effort among the 
trade and shipping industries, law enforcement, healthcare 
professionals, community leaders, and lawmakers.
    And I want to associate myself with the comments made by my 
colleague Dr. Bucshon regarding the dangers of making access to 
buprenorphine and Suboxone too easy. Because honestly, these 
are drugs that are used--buprenorphine is the single most 
common cause of opioid overdose in northern Europe. So we have 
to be careful. We have to get this in the hands of skilled 
people who know how to use it safely.
    And I do have some questions, but I will be submitting 
those to the second panel of witnesses. So with that, Madam 
Chair, I yield back. Thanks so very much.
    Ms. Eshoo. The gentleman yields back, and I thank him for 
his questioning, and it is a pleasure to recognize the 
gentlewoman from Delaware, Ms. Rochester Blunt--Blunt 
Rochester, I am sorry. You need to unmute.
    [Pause.]
    Ms. Eshoo. You need to unmute. Lisa?
    [Pause.]
    Ms. Eshoo. We will get this one of these days, right?
    Voice. I don't think she can hear you.
    Ms. Eshoo. I don't think she hears us, so I think I will go 
to--Angie Craig?
    Voice. Angie Craig.
    Ms. Eshoo. We will go to the gentlewoman from Minnesota, 
Angie Craig, for her 5 minutes of questions, and then circle 
back with--I hope Ms. Blunt Rochester's staff is listening, but 
we will--Ms. Craig is--Representative Craig is recognized for 
her 5 minutes of questions.
    Are you with us?
    No?
    Voice. Schrier.
    Ms. Eshoo. All right, then we are going to go to another 
doctor, the gentlewoman from Washington, Dr. Schrier.
    It is great to see you.
    Ms. Schrier. Well, great to see you, and I am now unmuted. 
I was just texting Lisa to see if I could let her know. Thank 
you, Madam Chair, and thank you to Ms. LaBelle for sharing how 
the White House is going to be focusing on these issues.
    You have already heard that Washington State has been hit 
hard by this opioid epidemic. For over a decade, our State has 
lost about 700 people per year from overdoses, mostly from 
opioids. And sadly, we saw a 40 percent increase in mortality 
due to opioid use in 2020.
    So we know fentanyl in particular has become an 
increasingly dangerous threat in my State and, as we have 
heard, across the country. In 2019, three students in my 
district died because the oxycodone that they thought they were 
taking, which is bad enough already, was laced with fentanyl. 
And two were students in the high school just down the street 
from my house.
    Then, 2 days ago, in a conversation with another parent, I 
heard about a bring-your-own-pill party, where a group of high 
school seniors in my town all brought whatever pills they had 
to a party: Ritalin, Adderall, oxycodone, Vicodin, whatever. 
They dumped it in a bowl like M&Ms and then helped themselves 
without even knowing what they were taking. And this is barely 
1 year after the two deaths that I just mentioned.
    So, Ms. LaBelle, you mentioned in your testimony that one 
of your strategies to mitigate drug abuse and death is support 
evidence-based prevention efforts to reduce youth substance 
abuse. And as a pediatrician I know how important it is for 
pediatricians to talk with their patients, and parents to talk 
with their children. I wonder if you could just talk briefly 
about the most effective ways to prevent these risky behaviors 
from starting, and then these tragedies.
    Ms. LaBelle. Thank you very much, Congresswoman, for asking 
that important question. I want to raise one issue about the 
pressed pill issue that you raised. I think all of us need to 
be aware that this is a trend. CDC has sent alerts about these 
pressed pills. That is a lot of what we are seeing. This is 
pure fentanyl, and people have no idea what they are getting. 
And this is why the administration has put out the fentanyl 
test strips, so people who--can test what it is that they are 
getting. I am not talking about that for youth use, but that is 
important for--to prevent overdose deaths.
    So for youth use, the National Institute on Drug Abuse has 
some great tools. SAMHSA--I am a parent myself. I probably 
drive my son crazy by talking to him about these issues so 
much, because he has a genetic predisposition to this. So I--
you know, you have to--there is a--SAMHSA has a ``you talk, 
they listen,'' which is a great tool. And actually, the 
University of Washington has some great prevention programs, 
and one of the preeminent prevention researchers in the country 
is there.
    So there--we can't--we think that kids won't listen. 
Certainly, they are going to roll their eyes, but they will 
listen to you when you talk to them.
    The other piece that we want to do on prevention is 
preventing adverse childhood experiences that lead to risky 
behavior, and that includes substance use. So that is an area 
that we will be working more with the Centers for Disease 
Control and Prevention on, particularly with our drug-free 
community coalitions.
    Ms. Schrier. I really appreciate you bringing all those 
things up. Can I ask just a quick followup question on the 
fentanyl test strips?
    Are those--are the pills--do they contain fentanyl only on 
the outside, or throughout?
    I mean, is this something we have to crush a pill to test 
strip it, or can you just rub it on the outside of a pill?
    Ms. LaBelle. You could--you wet the test strip, and you can 
rub it on the outside of the pill.
    Again, these are--you know, these are--there are various 
forms of this, but in many cases it is pure fentanyl.
    Ms. Schrier. OK. It is devastating. Thank you.
    Also, with the limited time I have left, you know, one of 
the barriers to care that we have all talked about is simply 
not having enough access to providers who are trained and 
confident in treating substance abuse disorder. In particular, 
most pediatricians have no experience with medically assisted 
treatment. And I was wondering what ONDCP's role is in ensuring 
that there is a broad provider network that is adequately 
trained, and where pediatricians might fall in that plan.
    Ms. LaBelle. So the pediatrician association actually 
encourages, as you are probably aware, screening for all of 
their patients. So we want to work with them again on expanding 
that work.
    Ms. Schrier. And screening is standard. Treatment, not so 
much----
    Ms. LaBelle. Right----
    Ms. Schrier [continuing]. Pretty intensive appointments. Do 
pediatricians generally get the special training?
    Ms. LaBelle. No, they don't. So we need to--we will be 
happy to work with you on that issue.
    Ms. Schrier. Thank you, I yield back.
    Ms. Eshoo. The gentle doctor yields back, and it is a 
pleasure to recognize the gentleman from Pennsylvania, Mr. 
Joyce, for your 5 minutes of questions.
    Mr. Joyce. Thank you, Chairman Eshoo, and thank you, 
Ranking Member Guthrie. This is an important discussion that we 
have, specifically discussing the epidemic that we face within 
the pandemic.
    In Pennsylvania, where I represent, the availability of 
illicit drugs, and specifically fentanyl, is a crushing blow to 
our local communities. In joining this COVID-19 pandemic, this 
epidemic has spiraled further out of control. In 2020, Blair 
County, my home county, we have seen an 80 percent increase in 
overdose deaths. Eighty percent.
    Coroner Patty Ross, she can rattle off these statistics in 
a breath, and she will tell you that fentanyl can be 100 times 
more potent than morphine. Coroner Patty Ross knows how many 
families have been torn apart, how many children have suffered 
from drug-related circumstances. She has witnesses--she has 
been a witness to tragedies firsthand. She talks about 
addressing families, talking to them as she relays the tragedy 
of the death of a loved one, talking to them about these loved 
ones who have just come out of rehab.
    In Pennsylvania and around the country, Coroner Ross and 
other local leaders, they are desperate for Congress to get 
serious about combating fentanyl and illicit drugs, providing 
support to the brave Americans in recovery, and advocating for 
communities with the widespread ramifications of substance 
abuse and addiction, and addressing what we need to address: 
the stigma of drug abuse. We need to be taking action right now 
to keep our communities safe. But also we need to expand 
lifesaving treatments for those who have substance abuse 
disorders.
    Director LaBelle, shortly before leaving office, the 
previous Director of ONDCP, James Carroll, announced new 
practice guidelines for the administration of buprenorphine for 
treating opioid use disorder. And these guidelines were 
intended to make it easier for practitioners to prescribe 
buprenorphine. As I understand it, on January 14th the Biden 
administration made a statement saying that those guidelines 
were issued prematurely and could not be sustained.
    Director, could you please tell us why these guidelines 
were pulled?
    Ms. LaBelle. Sure, thank you, Dr. Joyce. These are 
important issues that you just raised. We all want to expand 
access to evidence-based care. The practice guideline that was 
rescinded by the administration, or that is being reconsidered, 
and making sure--what we don't want to do is to issue a 
practice guideline that would not be upheld, or would not 
withstand legal scrutiny.
    So we are taking a look at it to make sure that anything 
else that is issued can withstand any kind of legal challenge 
to it. So that is where we are at right now.
    Mr. Joyce. And what is the current status of your 
evaluation for renewing these guidelines?
    Ms. LaBelle. We are taking a look with our lawyers on it to 
make sure that it gets issued. So we are working on it. I can't 
give you a precise timeline right now.
    Mr. Joyce. The previous administration came up with rural 
guidelines addressing substance abuse. In the rural communities 
throughout America, as you pointed out, as well as in the 
metropolitan areas, these substance abuses still exist. And we 
are looking forward to having the answers to when these 
guidelines will be reissued.
    Can you assure us, so I can take back to the coroners, to 
the leaders who are facing these issues, that this is of utmost 
concern to you, as the acting director of the ONDCP, as it was 
to your predecessor?
    Ms. LaBelle. Absolutely, sir.
    Mr. Joyce. Can you provide for us additional guidance of 
what we should be doing from a legislative point of view to aid 
you in making this decision?
    Ms. LaBelle. So I think that what we want to make sure is 
that, when it is released, that it is lifted up.
    But we can't stop there. We have a lot more work to do. Our 
policy priorities lay out our expansive approach to this, 
because it can't--we can't just look at one tool. We have to 
look at all the tools available to address every form of 
addiction, not just opioid use disorder. So we are looking 
forward to working with you on the totality of the addiction 
epidemic.
    Mr. Joyce. I thank you for your hard work, and I look 
forward to seeing the guidelines on the administration of 
buprenorphine for treating opioid disorders. Thank you for 
being here today.
    And again, thank you, Chair Eshoo and Ranking Member 
Guthrie.
    Ms. Eshoo. The gentleman yields back.
    And I apologize to you, Dr. Joyce. I think it is very 
important, when recognizing our physician Members, that it--
that that always be stated. So apologies to you.
    Mr. Joyce. Not necessary, Chair. Thank you, though. I 
appreciate that.
    Ms. Eshoo. We are very happy to have you as a member of our 
subcommittee.
    Mr. Joyce. It is an honor, thank you.
    Ms. Eshoo. Oh, you are very nice. You are such a gentleman.
    And now I recognize with pleasure, from Delaware, 
Congresswoman Lisa Blunt Rochester.
    I am sorry that you didn't hear us earlier.
    Ms. Blunt Rochester. Thank you so much, Madam Chairwoman. 
And forgive me, I am on two screens at the same time, so 
please----
    Ms. Eshoo. Not to worry, not to worry. We see you and hear 
you now.
    Ms. Blunt Rochester. Thank you so much. And I want to thank 
you, Ms. LaBelle, for joining us as well, and for your work and 
dedication.
    Under the previous administration, the approach towards 
fentanyl-related substances was handled through policies that 
more promoted decriminalization and not public health. And 
evidence shows us that that isn't the most effective approach.
    The U.S. Sentencing Commission's January 2021 report on 
fentanyl and fentanyl analogues found that in fiscal year 2019 
a greater proportion of fentanyl and fentanyl analogue 
offenders were Black, and over half of the total offenders were 
convicted of an offense with a mandatory minimum penalty. But 
less than 10 percent of offenders knowingly sold fentanyl and 
fentanyl analogues as another substance.
    I am seriously concerned that our efforts are targeting 
minimally involved individuals instead of the higher-up 
traffickers and cartels. What is the administration's plan to 
stop illicit fentanyl from coming into the country, so we are 
targeting the drug traffickers that are manufacturing fentanyl 
and placing it into the drug supply?
    Ms. LaBelle. Thank you, Congresswoman, for that important 
question.
    So, you know, when--the Office of National Drug Control 
Policy works a lot on international issues. I would say it is 
probably half of the time in our office. And so we are working 
with China to look at their regulatory controls over their vast 
chemical industry. We are also working closely with Mexico on 
their interdiction efforts inside Mexico, as well as destroying 
and using evidence from their labs, their lab takedowns, and 
then--as well as working with them on how to identify some of 
the precursor chemicals that are coming from China into their 
ports.
    So those are numerous--a number of issues that we are 
dealing with with China and Mexico right now to stop it from 
ever coming into the country.
    Ms. Blunt Rochester. And can you be more specific about the 
length of time that you would need to come up with the 
permanent solution of--because I know a couple of people have 
asked this, and because time is of the essence, it would be 
really good if we could get a clearer picture of the specific 
length of time that you would need.
    Ms. LaBelle. Yes, thank you for asking that. It is urgent. 
We know it is urgent. I can't give a timeline. As I said, you 
know, we have been here about 85 days, and there are plenty of 
people at DOJ who aren't in place yet. So I can't give a 
timeline, but know that we are working diligently on this 
issue.
    Ms. Blunt Rochester. And thank you. I know that you are 
aware that overdose deaths involving synthetic opioids like 
fentanyl continue to rise, and from 2017 to 2018 rose as high 
as 10 percent. If we don't pursue a public health approach as 
part of the solution for addressing fentanyl-related 
substances, as Representative Kuster and I are suggesting, what 
would be the impact on people with substance use disorder, and 
how will their access to evidence-based treatment change?
    Ms. LaBelle. So the public health approach that we have 
laid out in our policy priorities identifies the specific 
actions we can take, as--such as harm reduction programs that 
can prevent people from overdosing.
    I am very concerned that, if we don't expand access to 
evidence-based treatment throughout the country, especially in 
areas of high risk for overdose, that these rates are just 
going to continue to climb. And I have been working on this 
issue since 2009, when it first started. And it is--and the 
steps that we are taking are--every day counts at this point.
    Ms. Blunt Rochester. Yes. Will ONDCP commit to working with 
Congresswoman Kuster and I on a comprehensive public health 
approach to addressing the overdose epidemic?
    Ms. LaBelle. Yes, we look forward to working with you, 
absolutely.
    Ms. Blunt Rochester. Thank you so much, and I yield back my 
time.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentleman from Utah, Mr. Curtis, for your 5 
minutes of questions.
    Mr. Curtis. Thank you, Madam Chair. I enjoyed the 
interchange between you and Dr. Joyce. I am wondering if there 
is a title that we should use for those of us that have put 
children through medical school. Maybe we could work on that. 
And you are on mute, so I am just going to keep going, Madam 
Chair.
    Director, 4 in 10 adults--and this is as reported by the 
Huntsman Institute of Mental Health--have reported new symptoms 
of anxiety and depression disorder, which is a fourfold 
increase since last year. And so, to state the obvious, this 
hearing couldn't be more important, couldn't be more timely, 
and the work that you do.
    I am grateful for Representative Scott Peters of San Diego. 
He and I recently reintroduced a bill, H.R. 2051, which would 
declare meth an emerging drug threat. And I want to thank 
Congressman Peters for his leadership on this issue. It is an 
important issue to both of us in our districts, and we view it 
as the first of many steps in continuing to fight substance 
abuse.
    The legislation would require the Office of National Drug 
Control Policy--you--to develop a strategy to prevent the sale 
and use of this drug. We have touched on meth a little bit in 
this hearing. Can you just share, from your perspective, where 
this fits in with the larger picture of what you are seeing 
across--with meth across the United States?
    And specifically what can Congress be doing to help you?
    Ms. LaBelle. Sure. Thank you. So our policy priorities 
include contingency management and looking at the barriers to 
expanding access to contingency management therapy, which is an 
effective tool to use for people with meth use disorder.
    Our policy priorities also include an emphasis on 
prevention. So that is another tool that we need to use to 
reduce meth use.
    And then also our policy priorities include disrupting the 
drug supply coming in from Mexico, which is where much of our 
methamphetamine is sourced. So all of that is part of our 
priorities for us that we will be looking at in the first year.
    As far as what Congress can do, I think that we may be 
coming back to on contingency management, to see if there are 
legislative barriers to expanding that. I think the most 
important thing that Congress can do is making sure that we 
have sustainable funding for a lot of these programs, 
particularly for prevention and treatment, so that the States 
are not reliant and local communities are not reliant on one-
time grants that may not help them address the totality of the 
issue.
    Mr. Curtis. Thank you, a very good answer.
    I have listened as my colleagues have all expressed--many 
have expressed close loved ones and people they know who have 
been impacted by this tragic problem. It came home to me and my 
wife with not only some of our loved ones, but this summer, 
when we purchased a home, we kind of randomly did a meth test 
that--we were purchasing a home from a couple that had passed 
away in old age, and we were surprised to find out the home had 
been used as a meth lab. And I think that is just a small 
indication of what is going on across the United States.
    Quickly, I represent a very rural community with very 
limited resources, particularly for law enforcement, a vast 
geography, very, very difficult for law enforcement to cover 
it, which poses a challenge to crack down on this. Are there 
ways that we can leverage machine learning?
    Have you spent any time on this, by using data collected by 
law enforcement agencies and public health agencies on drug 
overdose in certain communities to help augment the local 
authorities in rural areas?
    Ms. LaBelle. So ONDCP funds ODMAP, which gets information 
from local law enforcement that helps kind of identify trends. 
That is in all 50 States, but it is not universal. That is one 
tool.
    We also should be working with our partners at the Bureau 
of Justice Assistance and the COPS program to look at exactly 
those issues that you just raised, because we know law 
enforcement in rural areas is stretched thin.
    Our High Intensity Drug Trafficking Areas Program works 
with a lot of law enforcement in rural areas, and that is a 
force multiplier for a lot of rural efforts.
    Mr. Curtis. Yes, thank you for appreciating the special 
needs in rural.
    It has been touched on a lot today, so I am only just going 
to mention--not ask the question, but just--I want to 
reemphasize the conversations we have had today about 
telehealth, how important it is in these rural parts of my 
district.
    And with that, Madam Chair, I yield my time.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. I agree with you on telehealth. I think that--
and I think other Members believe that it should be made 
permanent. So we have our work to do on that.
    I don't think there are any other Republicans that need to 
be recognized. I see Mr. Latta, but I know that you are 
interested in panel two, is that correct?
    OK, so we have two Democrats, and then we are going to go 
to--or we might have another one, I don't know, but I have two 
lined up right now.
    And then, Members, we do have a second panel with five 
witnesses that are waiting in the wings for us. So I will 
recognize the gentlewoman from Minnesota, Ms. Craig, for her 5 
minutes.
    Ms. Craig. Well, thank you so much, Madam Chair.
    Acting Director LaBelle, thank you very much for your 
testimony today. Your experience and your expertise is greatly 
appreciated.
    As many of you are aware, over 20 million Americans 
struggle with substance use disorder. A significant portion of 
them have an opioid use disorder. Moreover, many overdose 
deaths involve opioids such as illicit fentanyl and fentanyl-
mixed substances. The DEA recently cited fentanyl-mixed cocaine 
and meth as an accelerant of overdose deaths, due to its 
widespread availability. This trend is reflected in my home 
State of Minnesota, where an overwhelming majority of opioid 
overdose deaths involve synthetic opioids. Unfortunately, it is 
likely we are going to see a record increase in those deaths 
from 2020.
    I recently hosted a roundtable in my district that 
addressed veterans' access to mental health services and the 
disproportionate rate of substance use disorder among veterans. 
One of the barriers to care raised by stakeholders is the 
stigma that often surrounds substance use disorders, an issue I 
know is not limited just to this Nation's veterans.
    It is critical to remember that substance use disorder is a 
treatable disease. People with substance use disorder deserve 
compassion and adequate access to affordable, quality care. The 
problem won't be solved in jails and emergency rooms. It will 
take a shift in attitudes by many of the stakeholders involved.
    So Acting Director LaBelle, how does ONDCP hope to reduce 
stigma associated with substance use disorders through its drug 
policy priorities in year one?
    Ms. LaBelle. Thank you for asking that important question, 
Congresswoman.
    So the first step we took, and that happened during the 
transition, was hiring people, bringing people on who are in 
recovery. Our chief policy adviser is a person in long-term 
recovery. Our outreach director is a person in long-term 
recovery.
    And we are expanding a lot of our work on talking about 
recovery and making--because really, when you look at our 
policy priorities, all of these barriers really go back to 
stigma, the stigma that is attached to addiction. Why don't 
people want to treat addiction? There is stigma attached to it. 
Why don't people want to seek out help? Because there is stigma 
attached to it.
    So the first step we can take, as ONDCP, is setting an 
example and involving people who are in recovery in the 
policymaking process.
    Ms. Craig. Thank you so much. And I know stigma is one part 
of this that you are focused on, but also folks face barriers 
due to lack of access to coverage. So what levers is your 
office using, can you use, to address the access to care in the 
long term?
    Ms. LaBelle. So there are lots of pieces to this. One is we 
are going to focus on parity to make sure that coverage, 
insurance coverage, is--that people are complying with parity.
    The other access-to-care pieces are--involve workforce. How 
do we improve the workforce access throughout this country, and 
then also identifying, you know, the barriers to treatment with 
buprenorphine, methadone treatment, and contingency management 
services.
    Ms. Craig. Let me ask you what you think Congress can do to 
build on the previous legislation that we put forward, 
particularly around reduction of stigma. What are the most 
important couple of things that we could be focused on that 
helps you reduce stigma when it comes to this particular 
disease?
    Ms. LaBelle. Thanks. So I think one thing we can do is to 
make sure that Congress, by looking at this as an ongoing 
issue--this is not a--these are chronic conditions, not acute 
conditions, that require sustainable funding over the long 
term. So if we--by having Congress make sure that we are 
recognizing that these are not acute conditions, that people 
don't go into treatment and then 20 days later they are cured, 
that recovery services are part of the continuum of care, and 
continuing to emphasize recovery services is important.
    Ms. Craig. Well, thank you so much, Director LaBelle, and I 
look forward to working with you and the Biden-Harris 
administration.
    Madam Chair, with that I will yield back.
    Ms. Eshoo. The gentlewoman yields back, and we thank her, 
and we now will go to the gentlewoman from Massachusetts, Mrs. 
Trahan, for your 5 minutes.
    And thank you for your patience. You have been with us from 
the very--as most Members--from the very beginning of today's 
hearing.
    Mrs. Trahan. Well, thank you----
    Ms. Eshoo. And it is now afternoon.
    Mrs. Trahan. Yes. But it is such a critically important 
hearing, and I thank you for convening us on this topic. 
Certainly my thanks to Director LaBelle for being here today. 
And we all look forward to working closely with you and ONDCP 
in the months and years ahead to push policies that take a 
multipronged approach to curb overdoses.
    You know, the substance use disorder epidemic has claimed 
too many lives in all of our districts, red and blue alike. And 
over the last 20 years our Nation has lost more than 750,000 
lives due to drug overdoses. The latest CDC data suggests that 
the coronavirus pandemic has triggered an acceleration in lives 
lost to overdoses.
    Now, anyone with a loved one who has suffered from this 
terrible disease knows how powerful addiction can be. It can 
appear to have an unbreakable hold on those in its grip. My 
heart certainly goes out to those suffering from substance use 
disorder. You know, I have met with too many moms who have lost 
a child--the worst thing a parent can even imagine--and they 
and their families deserve our compassion and acceptance, free 
from judgment.
    But we also owe it to all of our constituents, particularly 
our young people, to do more to defeat SUD through greater 
attention to preventative measures and safer, effective 
treatment options. The Medication Access and Training Extension 
Act, legislation I have introduced with Representatives Kuster, 
Carter, Trone, and McKinley, would ensure that most DEA-
licensed prescribers, at a minimum, have the baseline knowledge 
to treat and manage their patients with substance use disorder.
    So Director LaBelle, in your written testimony you say that 
the origins of the overdose epidemic began with prescription 
opioids. Current CDC data shows that overdose deaths involving 
prescription opioids more than quadrupled from 1999 to 2019. 
How does prescription drug misuse continue to contribute to the 
overdose and overdose death epidemic in our Nation today?
    Ms. LaBelle. Thank you, Congresswoman, for asking that. So 
it continues to be part of the issue. As I said, our policy 
priorities focus on the addiction epidemic. And so there are 
certainly specific prevention tools that we can use for each 
substance. So in that regard, prescription opioids as a driver 
is--of later substance use disorders is important.
    But we are really taking the entirety of the addiction 
epidemic and looking at it from how do we prevent, treat--have 
quality treatment, provide harm reduction services, and help 
people recover. So that is really our--the extent of our 
continuum of care that we are looking at implementing.
    Mrs. Trahan. So many prescribers must take some sort of, 
say, prescribing education, but few take substantial education 
on how to identify, treat, and manage their patients with 
opioid and substance use disorder. You know, Dr. Ruiz said it 
himself, that many patients with SUD enter medical offices and 
emergency rooms for separate medical reasons. And so the 
ability of physicians to identify the more subtle signs of SUD 
is critically important.
    Does the Biden-Harris administration believe that it is the 
responsibility of all prescribers with a DEA license to know 
how to identify, treat, and manage their patients with opioid 
and substance use disorder?
    And would this education increase access to care?
    Ms. LaBelle. Yes, if we recognize that addiction is a 
chronic disease, then it is up to the healthcare community 
providers, healthcare providers, to be able to recognize it, 
screen for it, and treat it, or at least refer people to 
treatment. But if they can't identify it, they are not going to 
screen it or treat it.
    So I think that that is something that we have long 
emphasized, is the importance of addiction training in medical 
schools for DEA-licensed providers. And I think it is something 
we need to look at.
    Mrs. Trahan. And certainly one of the best things that we 
could do to, as Congresswoman Craig said, accelerate the end of 
stigma associated with addiction.
    Thank you, I yield back the remainder of my time.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentlewoman from Florida, Ms. Castor, for your 5 
minutes of questions.
    Ms. Castor. Well, thank you, Madam Chair, and thank you so 
much for your leadership on this very important issue. I know 
you have seen today that all of the Members, we are really 
interested and concerned about substance use and misuse.
    And thank you, Acting Director LaBelle, for spending some 
very--a lot of quality time with the committee today. And thank 
you for your leadership. I want to--I have two real quick 
questions. One is going back to Dr. Schrier's attention to 
prevention, especially among young people.
    And one of the bills that is on our list today is the Drug-
Free Communities Pandemic Relief Act. You identified in the--in 
your--the national drug control strategy that this is an 
essential element to prevent and reduce drug addiction misuse 
among young people. That bill would waive the local matching 
requirement during the pandemic, because many of these local 
community groups simply haven't been able to make that local 
match.
    Can you share with me why that is important at this time, 
and what you are hearing from drug-free communities across the 
country?
    Ms. LaBelle. Sure. Thank you, Congresswoman. So the Drug-
Free Community Coalition is--one of the great things about them 
is that they are community-based, and--but they rely upon in-
kind contributions. In-kind contributions that we found in the 
last year during COVID have been--there have been shortfalls in 
that. And so helping Drug-Free Community Coalitions in that 
regard is very important. They--we know that Drug-Free 
Community Coalitions reduce youth substance use, and that is an 
important tool that we can use to reduce addiction overall.
    Ms. Castor. Thank you very much. And that is what I hear 
from folks back home, as well. The issues that are so complex 
these days--but there has been a dropoff on community support, 
and I think this would go a long way to helping keep all of 
those coalitions moving forward and focused on youth drug use 
prevention.
    So my second question is a much broader one on the American 
Rescue Plan. We are so proud of the depth and breadth of the 
American Rescue Plan recently signed into law by President 
Biden. It provides, just in this area, $4 billion to SAMHSA and 
HRSA for a lot of the issues that your office will oversee.
    Give us a good thumbnail sketch on what you are working on 
right now, in coordination with those agencies and our local 
partners, to ensure that those dollars get to communities and 
families that need them. Will--we--are you coordinating the 
guidance that will be issued from the agencies, and what can we 
expect?
    Ms. LaBelle. Thank you. So the--HHS, SAMHSA, the Substance 
Abuse Mental Health Services Administration, we are working 
closely with them on what this is going to look like, because, 
I mean, the good thing is that this funding can be spent over a 
period of time so that States aren't going to get this huge 
influx of money that they have to spend in a year. So there 
will be a more sustainable funding source for them.
    So we are talking to SAMHSA about, you know, what are the 
gaps, what is missing, who are the vulnerable groups. That is--
so because this money is going through the block grant, it will 
be easier to facilitate that funding. So it is a great 
opportunity to really make a difference on this issue.
    Ms. LaBelle. I agree. We are all so proud of what we have 
been able to do in the American Rescue Plan. And a lot of folks 
are focused, of course, on vaccinations and the stimulus 
payments, and kids in school safely. But there are very 
significant dollars for our local communities when it comes to 
behavioral health. So thank you so much, and we will look 
forward to working with you in future months.
    Mrs. Trahan. I yield back.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize a fellow Californian, Mr. Cardenas, for his 5 minutes 
of questions.
    Mr. Cardenas. Hello, can you hear me?
    Ms. Eshoo. Yes, very well.
    Mr. Cardenas. OK, can you see me?
    Ms. Eshoo. I can see you, and you look very well too.
    Mr. Cardenas. OK, thank you so much, because earlier today 
during gavel I was not recognized as being seen, so I had to 
wait and----
    Ms. Eshoo. Oh, I am sorry.
    Mr. Cardenas [continuing]. My questions, so----
    Ms. Eshoo. Sorry. How does that happen?
    Mr. Cardenas. Sorry about that.
    Ms. Eshoo. Oh, my.
    Mr. Cardenas. We will hopefully get a better system within 
the committee to make sure that that doesn't happen again to 
any of us as we all try to be here at gavel----
    Ms. Eshoo. Is that the technological difficulty with the 
committee's technology, Tony?
    Mr. Cardenas. Well----
    Ms. Eshoo. No?
    Mr. Cardenas. I don't know what happened, because I saw 
myself on the screen, I heard you clearly, I saw you, I saw a 
bunch of my colleagues and the witnesses, or what have you. But 
anyway, that is housekeeping. We can take care of that later.
    Ms. Eshoo. OK, good.
    Mr. Cardenas. But thank you so much----
    Ms. Eshoo. I apologize.
    Mr. Cardenas [continuing]. Madam Chair. No, that is OK.
    Ms. Eshoo. What happened?
    Mr. Cardenas. I want to talk a bit about health 
disparities. And when it comes to pandemics, when it comes to 
addiction, when it comes to incarceration, all of these kinds 
of things are issues. So I would like to know, how does that 
fit into what the dynamic of the administration's efforts are 
on the topic we are talking about today when it comes to 
opioid--the opioid pandemic and--epidemic, excuse me, it is a 
pandemic, sort of--and when it comes to assisting with making 
sure that we treat it more as an illness, not as something that 
is just--we treat it as a punitive matter.
    Ms. LaBelle. Right. Thank you, Congressman. So the 
disparities in treatment, we have identified some of them in 
our policy priorities. They include kind of a two-track system 
that we have seen. Certainly, some people get healthcare, 
treated through the healthcare system, and others are 
incarcerated. And what the President has committed to is 
reducing rates of incarceration, and having--not having it so 
that people are incarcerated for drug possession alone, because 
we know that often people who have low amounts of drugs in 
their possession are--often have a substance use disorder 
themselves. So there is a couple of things that we want to do.
    Number one, we need to make sure that we have better data 
sources on this. And I know that sounds like it is not an 
immediate issue, but it is not something that we have a great 
deal of granularity on, you know, where the disparities exist 
and how exactly are we going to address those disparities. So 
that is one step that we have to take.
    The second thing that we need to do, we talked a little bit 
about before, is make sure that our workforce reflects the 
people that are served. And that is something we will work 
closely with HHS on.
    And then also--so we also will be looking at, you know, 
criminal justice reform, writ large. The drug piece is a part 
of that, so we will be looking at that, as well.
    Mr. Cardenas. Thank you. And you mentioned something that--
my question is how are the departments going to work together?
    Because when there is this presumption that in poor 
communities--White communities, as well, poor White 
communities, poor Black and brown communities, Native American 
reservations, et cetera, where all of a sudden policing seems 
to be the fortified method of trying to address the issue of 
drug addiction and drug abuse in those communities. I think it 
is important that the departments understand that the amount of 
resources that we allocate at the Federal level, local level, 
et cetera, needs to be proportional to how we are going to--be 
honest with ourselves about how it should be addressed.
    Are you working with other departments to make sure that we 
are all on the same page?
    Ms. LaBelle. Yes, we work closely with our law enforcement 
partners as well as our health department partners.
    And I think what you raised is an important piece. I think 
that some of this is because--that is why we talked about harm 
reduction programs in our policy priorities, because that is--
provides an alternative intervention point for people who may 
not otherwise be able to get treatment and may end up in law 
enforcement's hands in the criminal justice system. So that 
provides an alternative intervention point.
    Mr. Cardenas. Yes, because I would venture to say--I am in 
Los Angeles, and in my community where I grew up in Pacoima, 
law enforcement seemed to be the answer to treating people with 
addictions or addressing the issue of people with the 
addictions.
    But yet, just a few miles away in Beverly Hills, I would 
contend that there is just as much drug use going on with 
teenagers and adults and seniors in those households as it is 
in households in Pacoima, in a different ZIP code, only the 
difference is, in those other communities like Beverly Hills, 
``Oh, my gosh,'' you know, ``little Johnny is addicted. We got 
to get Johnny some help. We got to put him in a program,'' et 
cetera, which I believe is the proper, humane way to deal with 
these issues.
    But yet, just a few miles away on the other side of town, 
book him and book him, send the cops in, get the DEA to do a 
crash unit or something, and all of a sudden you have people on 
one side of town who are behind bars, not addressing the issue 
of addiction. But on the other side of town, the other person 
is actually getting support.
    Do you believe that that has been going on in America far 
too much?
    Ms. LaBelle. I think we have two bifurcated systems of how 
we treat addiction. And I think that has been with us for a 
very long time, and we are going to work on that.
    Mr. Cardenas. OK. Well, I look forward to speaking to you 
in the future, and----
    Ms. LaBelle. Yes.
    Mr. Cardenas [continuing]. And also working with you----
    Ms. LaBelle. Yes.
    Mr. Cardenas [continuing]. Both as a legislator and as two 
Americans, to make sure that we get a system that is much more 
appropriate for addressing issues for all of us.
    Thank you so much, I yield back.
    Ms. LaBelle. Thank you, sir.
    Ms. Eshoo. The gentleman yields back. We now have two 
Members that have waived on to our subcommittee, and we welcome 
you. It is always a pleasure to have our colleagues from the 
full committee be a part of our subcommittee.
    So the Chair will recognize the gentleman--and he is a 
gentleman--from New York, Mr. Tonko, for his 5 minutes of 
questions. And he has been very active on the issue of opioids, 
especially, as I recall, fighting for more beds so that 
patients would really get the care that they need.
    You are recognized.
    Mr. Tonko. Thank you, Madam Chair. Can you hear me?
    Ms. Eshoo. I can. Talk a little louder, though.
    Mr. Tonko. OK, thank you, Madam Chair, and thank you for 
allowing me to waive on.
    I am indeed thankful to hear about the leadership already 
put forward by the Biden-Harris administration and want to 
express gratitude to you, Acting Director LaBelle, for agreeing 
to testify today, and thank you for your leadership.
    I am a proud sponsor of two pieces of legislation being 
considered today, including the Medicaid Reentry Act and the 
Mainstreaming Addiction Treatment, or MAT, Act. These two 
bipartisan bills are considered some of the most effective 
policy actions that we can take at reducing opioid overdoses.
    The Medicaid Reentry Act would empower States to restore 
Medicaid eligibility for incarcerated individuals up to 30 days 
before their release to ensure those transitioning will have 
immediate access to critical services, including mental health 
support, addiction treatment, and COVID testing. Granting 
States the ability to jumpstart Medicaid coverage for these 
individuals will mean they are not only able to receive 
lifesaving treatment for mental health, substance use 
disorders, and other conditions; it will also help them stay 
out of our already-overburdened hospitals and on the path to 
recovery and rebuilding their lives.
    As ONDCP identifies ways to reduce the increasing number of 
overdose deaths and to strengthen access to evidence-based 
substance use disorder treatment services and medications, 
would passage into law of the Medicaid Reentry Act help to 
achieve these important goals?
    Ms. LaBelle. Thank you, Congressman, for your leadership on 
these important issues.
    So I am a strong believer that we need to make sure that 
people, regardless of their circumstances, have access to 
evidence-based treatment. And providing incarcerated 
populations access to treatment before they leave is one way to 
do that.
    We also need to make sure that we follow up, that there are 
re-entry tools available to help people with their recovery. 
And actually, upstate New York has a lot of great examples. 
Buffalo MATTERS is one good example.
    So this is a high-risk population that we need to get 
services to.
    Mr. Tonko. Thank you so much. And I heard your earlier 
comments about giving your undivided attention to some of the 
issues concerning the X-waiver. So I also ask for your 
commitment to prioritize the elimination of the X-waiver in 
order to deliver on President Biden's promise to expand access 
to medication-assisted treatment. I ask that you examine all 
actions you can to take on this--support passage of our 
Mainstreaming Addiction Treatment Act, the MAT Act, in order to 
accomplish this goal.
    So a couple of questions. Are you aware that, after France 
took similar action to make buprenorphine available without a 
specialized waiver, opioid overdose deaths declined by some 79 
percent over, I believe it was, a 4-year period?
    Ms. LaBelle. Yes, I am familiar with the research, thanks. 
Yes.
    Mr. Tonko. Yes. And again, I thank you for your attention 
to this matter.
    Are you aware that in 2020 the number of waivered 
physicians accounted for only 5.9 percent of the total active 
physicians?
    Ms. LaBelle. Yes, sir.
    Mr. Tonko. And are you aware that, in 2018, 40 percent of 
counties in the U.S. did not have a single waivered provider?
    Ms. LaBelle. Yes.
    Mr. Tonko. And are you aware that providers can already 
prescribe buprenorphine without additional training, but only 
when treating pain?
    The X-waiver training to prescribe buprenorphine only 
applies to providers treating patients with opioid use 
disorder.
    Ms. LaBelle. Yes.
    Mr. Tonko. OK, so today I would like to submit a letter for 
the record signed by a number of groups, including the 
Association for Behavioral Health and Wellness of the Kennedy 
Forum, Shatterproof, Mental Health America, National 
Association of Attorneys General, the National Alliance on 
Mental Illness, the National Council for Behavioral Health, and 
many other groups.
    And I would indicate that they write--and I quote--``The 
existence of the X-waiver sends a terrible message to 
practitioners and the public alike, that treating OUD with 
buprenorphine requires separate, stigmatizing rules, and that 
buprenorphine is inherently more dangerous than the powerful 
opioids that have fueled this crisis.''
    So I fully agree that the X-waiver reflects a longstanding 
stigma around substance use treatment and sends a message to 
the medical community that they lack the knowledge or ability 
to effectively treat individuals with substance use disorder. 
So do you agree that the X-waiver sends a terrible message to 
practitioners and the public alike, and increases stigma?
    Ms. LaBelle. I think there is a great deal of stigma in 
every aspect of our addiction system, and this--you know, the 
buprenorphine waiver is just one element.
    Mr. Tonko. OK. Well, again, I thank you for your devotion 
to this issue and, again, for your open-mindedness as you 
approach it.
    Ms. LaBelle. Certainly, thank----
    Mr. Tonko. With that, Madam Chair, I yield back, and thank 
you again.
    Ms. Eshoo. The Chair thanks the gentleman, and the letters 
will be placed in the record at the end of the hearing.
    [The information appears at the conclusion of the hearing.]
    Mr. Tonko. Thank you.
    Ms. Eshoo. So thank you for joining us.
    And now we are going to switch back to a member of the 
subcommittee before we go to Mr. O'Halleran, who is waiving on.
    To Mrs. Fletcher from Texas, you are recognized for your 5 
minutes of questions. Great to see you.
    Mrs. Fletcher. Thank you so much, Madam Chairwoman. It is 
great to see you, and I am so grateful that you are holding 
this important hearing today.
    It is clear from the data and the testimony today that 
substance abuse disorders are an epidemic in this country. And 
my hometown of Houston is not immune. The pandemic has also 
exacerbated this crisis. Tragically, first responders in 
Houston reported a 17 percent increase in overdoses in the 
second quarter of 2020 compared to that same time period in 
2019. So I really appreciate that the committee is holding this 
hearing today.
    The alarming drug use overdose statistics are staggering. 
They are deeply concerning. However, I want to acknowledge that 
substance use disorder is a diagnosable and treatable disease. 
We have FDA-approved medications and evidence-based treatment 
that work. Patients with substance use disorder can and do 
recover, and they go on to lead meaningful lives in our 
society.
    In fact, the Biden-Harris Cabinet includes department heads 
like Secretaries Marty Walsh and Deb Haaland, who are both open 
about their long-term recovery from substance use disorders. 
They exemplify the fact that recovery is possible.
    My first question for you, Acting Director LaBelle: In your 
experience talking to communities across the country, what 
benefits do you hear about when it comes to efforts like 
recovery housing, college and high school recovery programs, 
and other peer support services?
    Ms. LaBelle. Thank you, Congresswoman, for asking that 
question. Recovery is something that is a relatively new area 
of research. But we know--I mean, I think all of us know people 
who have benefited from recovery facilities. Recovery high 
schools, I mean, literally, save lives. And so I think recovery 
supports--having people, peer support workers, working with 
folks in early recovery is a really important part. It is in 
our--included in our policy priorities, and something that we 
look forward to working----
    Mrs. Fletcher. Thank you so much. And I just want to follow 
up with that. Can you talk a little bit about the ways the 
Federal Government supports Americans in long-term recovery and 
how your office plans to build on or improve upon those 
efforts?
    Ms. LaBelle. Sure. So in a couple of ways. One is, as I 
mentioned, we have hired people who are in long-term recovery 
in our office. We engage people in recovery in all of our work. 
We will continue to engage people in recovery, and not just to 
tell their stories but to engage them in the policy development 
process and implementation process. Those are two ways.
    Also, we intend to work with the--with HHS on expanding 
recovery support services and--as well as research on what 
works best with different communities, and making sure we have 
culturally competent recovery services across the country.
    Mrs. Fletcher. Well, thank you for that explanation and 
thank you for all the recovery-related efforts that you and the 
administration are working on and plan to put forward. I 
appreciate your testimony here today.
    And again, I appreciate you, Madam Chairwoman, holding this 
hearing. And with that I will yield back the balance of my 
time.
    Ms. Eshoo. The gentlewoman yields back, and now it is a 
pleasure to welcome back to our subcommittee the gentleman from 
Arizona who is waiving on, Mr. O'Halleran.
    You have 5 minutes for your questions, and thank you for--
--
    Mr. O'Halleran. Thank you, Madam Chair--I appreciate it--
and Ranking Member, for putting on this meeting in a group that 
historically has been very bipartisan in addressing these types 
of issues. And I am looking forward to that occurring 
throughout this process and these bills.
    You know, I have--this is a different time, different 
place, different drugs, but here we are--all are again, sitting 
here. I was addressing it as a police officer back in the 
1970s: drug overdoses, drug crime. As far as how it was dealt 
with then, a lot of things have changed, but we still have a 
problem that is a continuing problem, day in and day out. And 
our families are being devastated by this, and we need to 
address it. And I know this group feels that way.
    But it is a comprehensive approach. It is not just one 
piece or another piece. It has to be comprehensive, taking into 
account the disparities within our society, taking into account 
the real elements of what causes this, and how do we get the 
therapists necessary to address this issue.
    And that is especially true in areas like rural America. We 
are short of doctors, anyway. We are short of therapists to a 
high degree. We have distances for patients to travel that are 
unreasonable. I know telemedicine is going to be coming around 
at a higher level later on, but not immediately, and we have to 
do something now. Two people die in Arizona every day.
    In August of this year--last year, I should say--507 people 
died from overdoses. And anybody that hasn't been around 
somebody that has died from an overdose, and watched them die, 
I can guarantee you--I am glad the families don't have to see 
it as much as the rest of society sees it when it happens in 
the public arena. But everybody should know that this is a 
tragic example of how America treats people with this type of 
health problem.
    And so, Ms. LaBelle, thank you for being here, obviously, 
but how is the administration planning on addressing the 
opioid--in rural America?
    Now, I want to--I don't see a healthcare issue, whether it 
is the VA or anything else dealing with healthcare, where there 
are specialists, where there are therapists, and our patients 
sometimes have to drive 10 hours round trip to get there. If 
you are calling from--for an overdose, you have to have people 
that--it might take an hour for people to get--even get to the 
house. And that is just something that has to be addressed 
immediately. So I am interested in how to address that.
    And by the way, hospitals are declining in rural America, 
they are not increasing.
    Ms. LaBelle. Thank you, Congressman. So I think in a couple 
of ways. One is you mentioned how long it takes for--it might 
take a first responder to get to a rural area to resuscitate 
someone who has experienced an overdose. So the first thing we 
want to do is make sure that we expand naloxone availability 
across the country, particularly in rural areas, to people who 
are at risk.
    The second piece of what you talk about--and this is going 
to take a little longer--is the workforce issue. As identified 
before, we have shortages. You just said, you know, you have 
healthcare shortages that are already predominant in rural 
areas. So we need to get--and specifically in targeted areas, 
with high rates of overdose, or high rates of substance use 
disorder generally--get the addiction workforce, the trained 
addiction workforce available and encourage them to stay there 
through loan repayment programs. So we will be working with our 
colleagues at HHS on those workforce issues that are important 
in rural America.
    Mr. O'Halleran. And I know that you have just started on 
this, so I appreciate the need for some time to get this going. 
But I think the people of America, and the people of rural 
America especially, would appreciate the ability to see a plan 
of action, not a plan that is going to take 2 years, 3 years to 
get it----
    Ms. LaBelle. Right.
    Mr. O'Halleran [continuing]. Addressed, and then the 
workforce issue is imperative. It is just imperative.
    And the realization, again, that this is not just one 
piece, it is not waking up in the morning and saying, ``I have 
an addiction to opioids.'' It is a process of lifestyle, it is 
a process of being--not being able to get jobs, or--alcoholism 
is part of it. It is a vast issue for this huge country of 
ours, and it hasn't been addressed in the appropriate way for 
decades.
    And I thank you, and I yield back.
    Ms. LaBelle. Thank you.
    Ms. Eshoo. All right. Well, the gentleman yields back.
    And I want to thank you, Doctor. I don't know when you--you 
probably didn't realize, when you signed on and said yes to us 
that you were going--would be willing to come and testify 
today, that you would be with us for, let's see, 10:30, 1:30--3 
hours and 10 minutes.
    What it demonstrates is what a deep and broad interest and 
concern every single member of the subcommittee has. And you 
heard firsthand what they see and have experienced in their 
districts, in their own families and extended families, and 
their knowledge of the various policies that have been 
proposed, legislation that we have put on the books, more--you 
know, bipartisan bills that are being voted on in the House 
today.
    So we look forward to working with you to put more than a 
dent in this. We have a lot of work to do. But you have a 
subcommittee that wants to work hand-in-hand with you.
    Ms. LaBelle. Right.
    Ms. Eshoo. And to the extent that your agency succeeds, 
then the--it will be the betterment of our country from this 
scourge that is taking place in people's lives. So we thank 
you. We thank you for being with us and the time that you gave 
to us. And we will keep working together.
    Now it is a pleasure for me to welcome our second panel of 
witnesses. Let me introduce them to you:
    Mr. Geoffrey Laredo, a principal at Santa Cruz Strategies, 
LLC.
    Ms. Patricia Richman, National Sentencing and Resource 
Counsel for the Federal Public and Community Defenders.
    Mr. Mark Vargo is the Pennington County State's Attorney 
and the legislative committee chairman for the National 
District Attorneys Association.
    Dr. Timothy Westlake is the emergency department medical 
director at the ProHealth Care Oconomowoc--let me do this 
again, Oconomowoc Memorial Hospital. I got it done, I did it.
    And last but not least, Dr. Deanna Wilson, who is the 
assistant professor of medicine and pediatrics at the 
University of Pittsburgh School of Medicine.
    Welcome to each one of you, and thank you for your 
patience, for waiting in the wings. I am sure that you found it 
highly instructive, whenever you joined us in the testimony of 
the new acting director and, very importantly, the excellent 
questions of members of the subcommittee.
    So I am going to go to you, Mr. Laredo, for your 5 minutes 
of testimony.
    And thank you again to each one of you, a panel of just 
superb experts who--you should each know will be highly 
instructive to each one of us.
    So, Mr. Laredo, you are recognized for your 5 minutes of 
testimony. Remember to unmute, please.
    Mr. Laredo. Thank you so much, and I hope that you can see 
and hear me OK this afternoon.
    Ms. Eshoo. I can, thank you.

     STATEMENTS OF GEOFFREY LAREDO, PRINCIPAL, SANTA CRUZ 
   STRATEGIES, LLC; PATRICIA L. RICHMAN, NATIONAL SENTENCING 
RESOURCE COUNSEL, FEDERAL PUBLIC AND COMMUNITY DEFENDERS; MARK 
 VARGO, PENNINGTON COUNTY, S.D., STATE'S ATTORNEY, AND CHAIR, 
LEGISLATIVE COMMITTEE, NATIONAL DISTRICT ATTORNEYS ASSOCIATION; 
TIMOTHY WESTLAKE, M.D., EMERGENCY DEPARTMENT MEDICAL DIRECTOR, 
PROHEALTH CARE OCONOMOWOC MEMORIAL HOSPITAL; AND DEANNA WILSON, 
     M.D., ASSISTANT PROFESSOR OF MEDICINE AND PEDIATRICS, 
          UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE

                  STATEMENT OF GEOFFREY LAREDO

    Mr. Laredo. Chairwoman Eshoo, Ranking Member Guthrie, 
members of the subcommittee, thank you so much for inviting me 
here today. My name is Geoffrey Laredo. I am a substance use 
and addiction policy expert who retired from the Federal civil 
service in 2018 after serving for 30 years in a variety of 
policy positions, mostly within the U.S. Department of Health 
and Human Services. Twenty-two of those years were at the 
National Institutes of Health, where I advocated, as 
appropriate, for science and scientists, research and 
researchers. I continue that work now as a consultant.
    Voice. See, I have never had to do that before.
    Mr. Laredo. Thanks also for continuing your focus on the 
addiction crisis in the United States.
    This committee has for several years written in advance 
legislation aimed at a broad array of addiction research, 
prevention, treatment, and recovery issues. And it was my honor 
to work with you and your staffs on those bills.
    You are considering a range of legislative proposals 
addressing the addiction crisis. One of those is the potential 
classwide scheduling of fentanyl-like compounds. And because of 
that issue's timeliness and my experience working on it as a 
legislative and policy staff at the National Institute on Drug 
Abuse, that is where I have focused my testimony.
    It is absolutely crucial to define what we care about. As a 
public policy professional especially focused on public health, 
what I care about is morbidity and mortality. Every aspect of 
our Nation's drug policy must be laser-focused on decreasing 
disease and death.
    How do we decrease both, and how do we advance evidence-
based practices to achieve both?
    Classwide scheduling is not the road to success. Despite 
alternative claims, to my knowledge there just isn't any 
credible evidence to show where the classwide scheduling of any 
compound actually reduces morbidity and mortality. Conversely, 
there is ample evidence that properly funded and scaled 
research programs and evidence-based services can dramatically 
reduce morbidity and mortality.
    Further, proposals to increase the use of classwide 
scheduling minimize or eliminate the role of health agencies in 
this process. This is just unacceptable. Health agencies should 
have the primary, if not the sole, responsibility for deciding 
how or whether to schedule compounds. I don't support including 
the Drug Enforcement Administration in this decision process, 
and I would strongly support removing the agency from the 
process as it currently stands. Let health and medical 
authorities do the work of health and medicine, and let's 
provide them appropriate resources to do that work.
    I think you are familiar with the arguments around the 
difficulties of conducting schedule I research. You have talked 
about that a bit today. Since our time here is limited right 
now, I won't delve into those details. We tried hard when I was 
at NIDA to work with the DEA and the FDA to streamline that 
process. We reached some agreement, but it was unclear to me, 
frankly, whether any of those steps have actually really been 
taken. And I have to say this was not a pleasant process, and I 
will come back to that in a moment.
    Researchers have clearly shown that similarities in the 
chemistry of certain compounds do not necessarily equate to 
similar abuse liability. This is really important when 
discussing requirements for a schedule I designation, and I 
refer you to Dr. Sandra Comer and colleagues' work, as I 
mentioned in my written statement.
    So we find ourselves in a situation where placing an entire 
class of compounds into schedule I would clearly delay and 
deter research on exactly what you have been begging for: 
additional and improved solutions for opioid addiction, 
overdose reversal medications, and other medications' 
development results that we perhaps haven't even thought about. 
Why would we take a classwide scheduling action at exactly the 
time that we need to be increasing and accelerating potentially 
lifesaving work?
    In my written statement, I also describe steps we took in 
an effort to improve the overall situation. I hope you will 
read those details. They are pretty unpleasant. Not only did we 
not succeed, but senior DEA staff actually told me that I 
personally--and NIDA as an agency--were ``aiding and abetting 
drug dealers.'' That is pretty outrageous.
    That said, I am not naive, and I do understand the 
difficult position that the subcommittee and the full committee 
is in. I understand the politics. I understand the optics and 
the possible need for compromise. I also understand that you 
might choose to implement classwide scheduling. Such 
implementation without addressing crucial research issues would 
be a setback for our field. If you move in that direction, I 
strongly recommend that you include in your decision provisions 
that, for research purposes, treat all schedule I compounds as 
if they were in schedule II, truly streamline the process for 
obtaining a schedule I license, don't create separate licensing 
and process requirements for different classes of compounds, 
and finally, facilitate the de- or rescheduling of compounds 
when scientists verify that that would be justified.
    Members of the subcommittee, you focused a lot of time and 
effort on these issues over the past several years. So have 
other committees. If we are all really serious about this 
health issue, then I think you deserve to take and have the 
lead on legislation guiding those efforts.
    We should listen to science and scientists, and help them 
do their jobs. We should be thoughtful, especially in the face 
of significant disease and death. We should make the wise 
choice and avoid the knee-jerk reaction of just trying to 
``ban'' substances that might or might not be helpful.
    And they might or might not--excuse me, they might or might 
not be harmful, and they might or might not be helpful. By 
doing so, we will help find answers that will improve 
conditions in the field.
    Ms. Eshoo. Thank you, Mr.----
    Mr. Laredo. Thank you so much for the honor of sharing my 
views with you, and I will be glad to discuss these issues 
further.
    [The prepared statement of Mr. Laredo follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    

      
    Ms. Eshoo. Thank you very much, Mr. Laredo. We appreciate 
your being with us, your willingness to testify, and the 
content of your testimony.
    Next the Chair would like to recognize Ms. Richman for 5 
minutes for your testimony.
    And thank you for being a witness, and for your patience, 
and for your willingness to be instructive to us. We are all 
ears, so you may proceed.

                STATEMENT OF PATRICIA L. RICHMAN

    Ms. Richman. Thank you, Chairwoman Eshoo, Ranking Member 
Guthrie, members of the subcommittee for inviting me to this 
hearing today and the opportunity to share my perspective. I, 
too, will focus my remarks today on why this committee should 
reject the permanent or continued classwide scheduling of 
fentanyl analogues.
    Yesterday Senators Booker, Markey, Hirono, Warren, and 
Whitehouse wrote President Biden to caution against ``adopting 
a policy explicitly designed to expedite drug prosecutions and 
increase penalties.'' I urge you to follow their advice.
    We are in the midst of a national reckoning over police 
officers' use of force against communities of color. Last 
Sunday, Dante Wright was killed just 10 miles from where a 
police officer is on trial for the killing of George Floyd. 
Incidents like these are, in part, the product of a tough-on-
crime culture focused on punishment instead of preventative 
community and health solutions.
    As a former Federal public defender in Baltimore, Maryland, 
I witnessed the impact of these punitive practices. My clients 
faced harsh sentences for drug offenses. In recent years, 
nearly 80 percent--80 percent--of people who received drug 
mandatory minimums in Maryland's Federal courts are Black, even 
though they make up only 42 percent of the State's population.
    And there is no bright line between user and seller. The 
vast majority of my clients grappled with substance use 
disorder, and many had lost friends and family members to the 
overdose crisis. This crisis is a complicated problem.
    Today I ask this committee not to repeat past mistakes. 
Over the past decade, bipartisan efforts such as the Fair 
Sentencing Act of 2010 and the First Step Act moved in the 
right direction. And President Biden has pledged to end 
mandatory minimums, reduce racial disparities in the criminal 
legal system, and shift drug policy towards public health 
solutions.
    Today fear and misinformation are being used to support 
classwide scheduling of fentanyl analogues, and I ask you to 
look to the evidence. To be clear, harmful fentanyl analogues 
are illegal with or without classwide scheduling. If the 
classwide expires on May 6, no harmful fentanyl analogue will 
become legal.
    During the 3 years that the ban has been in place, many 
experts have examined whether the classwide approach works. 
They have asked two core questions: first, does classwide 
scheduling actually reduce overdose deaths; second, does 
classwide scheduling reduce the supply of harmful substances in 
our country? The answer to both questions is no.
    These are the facts, according to the CDC and the GAO. The 
CDC has reported that, during the 3 years the ban has been in 
place, the number of overdose deaths attributed to fentanyl and 
fentanyl analogues has continued to rise, and fentanyl and 
fentanyl analogues have continued to enter the country in large 
quantities. The recent GAO study found that ``seizures of 
fentanyl and its analogues entering the U.S. ports increased 
substantially from 2017 to 2020.''
    And a chorus of voices, public health experts, scientists, 
and impacted people in the criminal justice community, have 
also identified ways that classwide scheduling is 
counterproductive and unnecessary.
    Public health experts warn that, even if there is a shift 
away from novel fentanyl analogues, it will be to something 
even more potent and harmful.
    Scientists warn that blanket bans of substances impede 
scientific research and may delay or eliminate the discovery of 
badly needed antidotes and treatments. They have identified 
specific substances that have been improperly scheduled by the 
ban and have therapeutic promise.
    And the criminal justice community cautions that classwide 
scheduling would expand mandatory minimums, exacerbate racial 
disparities, and eliminate crucial checks against DEA 
overreach.
    Federal sentences for fentanyl analogues increased nearly 
6,000 percent between 2015 and 2019, and people of color made 
up 68 percent of those cases in 2019. That year, mandatory 
minimums were imposed in more than half of those cases. 
Meanwhile, classwide scheduling has not been used to prosecute 
kingpins but to continue the failed practice of prosecuting 
low-level players. This practice does not disrupt supply or the 
real driver here, demand.
    Classwide scheduling is not regulatory. It is punitive. We 
cannot incarcerate our way out of this problem. It is time to 
do the work to heal our communities and country by finding and 
building evidence-based, science-first solutions that are 
proven to reduce demand and harm associated with these 
substances.
    And in addition to this work, the most important step 
Congress can take to fix America's broken drug policy is to end 
mandatory minimums and to apply those changes retroactively.
    Thank you so much for the opportunity to testify today.
    [The prepared statement of Ms. Richman follows:]
    
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Ms. Eshoo. Thank you so much for your testimony. We will 
now go to Mr. Vargo.
    The Chair recognizes you for your 5 minutes of testimony, 
and thank you again for your willingness to be with us and the 
work that you do. You are now--make sure you unmute, please.

                    STATEMENT OF MARK VARGO

    Mr. Vargo. Thank you, Chairwoman Eshoo, Ranking Member 
Guthrie, and to the rest of the committee. I am proud to be 
here to represent the National District Attorneys Association 
and very grateful that you invited us to participate in this 
very important set of hearings on this topic, which we all know 
is extremely dire at this moment.
    I was struck as I prepared to address you today by Director 
LaBelle's characterization in an article she wrote a few years 
ago that addiction is the only disease where we expect people 
to diagnose themselves by hitting rock bottom. But then, you 
know, it dawned on me that perhaps we don't rely on them but 
rather that all of you have been relying on me, because it 
feels like we define rock bottom as arrest, incarceration, and 
criminal prosecution. And it is at that moment that we want to 
mobilize the forces of addiction recovery.
    It is my hope that today we can discuss about ending that 
mentality. And so everything that I tell you I want to put 
through the lens of moving the point of the intercept. Because 
the costs of waiting to intercept drug addiction are 
disastrous, they are disastrous for the addict. And 
Representative Kelly and Representative Cardenas, along with 
Dr. Wilson, in her written testimony, have talked about how 
early treatment is necessary and how our communities of color 
are being deprived that early treatment.
    It is also disastrous for our communities and our families. 
Fentanyl and all other drugs lead to abuse, neglect, and 
poverty. And methamphetamine, which remains a scourge in 
western South Dakota, adds to the problem. It is paranoia, 
hypervigilance, and aggression. People on methamphetamine are 
10 times more likely to be violent if they use every other day 
than a--even a meth addict who is presently in remission. And 
it is the only drug for which the most recent NIDA figures show 
an increase in drug overdose deaths, not just in combination 
with fentanyl or other synthetic opioids but on its own.
    As prosecutors, we do what we can from where we are with 
what we have, and I am very proud of what we are doing from the 
point of intercept that has been assigned to us onward. Our 
diversion programs, which I went into extensively in my written 
testimony, are just one example of how we are trying to change 
the way that we engage with people who have addictions to 
ensure that they have the best chance possible to become 
productive, functioning members of our community. I am very 
proud of my staff, who with very little budget have put 
together a tremendous array of programming to give diversion 
candidates a chance of success.
    Because we have very little funding and because we never 
ask our offenders to pay, we rely on a wide variety of 
community resources, including governments like the Oglala 
Sioux Tribe and cultural and community programs like the Wambli 
Ska Pow-Wow, an indigenous American legacy.
    We tried to change behavior without the criminogenic 
consequences of a conviction. I would like to mention to you 
that NDAA has specifically supported Representative Tonko's MAT 
Act, Representative Curtis and Peters' Methamphetamine Response 
Act, and we support the extension of classwide fentanyl 
analogue scheduling, and we support the EQUAL Act, which would 
reform sentencing.
    But I want to take the little time that I have left to ask 
you three things.
    I am asking you to move the intercept point. The 
descriptions of the needs of our communities, our at-risk 
communities and our communities of color, are very stark. We 
need from Congress money in both the criminal justice system 
and before the criminal justice system. In other words, we need 
you to lead.
    Secondly, we need you to use us in State and Tribal 
government as the laboratories of innovation. Representative 
Tonko, who in the last session talked about Buffalo MATTERS, an 
outstanding program that has been spearheaded by my friend and 
colleague John Flynn in Erie County--programs like that within 
the criminal justice system, and programs like treatment 
programs that are being dealt with by programs like Native 
Healing and Native Women's Health Care, here in South Dakota, 
are very important. In other words, we need you to follow.
    And then finally, I ask you to reduce the Federal 
collateral consequences of State court drug convictions. The 
origins of our diversion were that we recognized that people 
with minor drug convictions had major problems, largely based 
on Federal law. In other words, we need you to get out of the 
way.
    And so, with apologies to both Mr. Paine and to General 
Patton, we need you to lead, we need you to follow, and we need 
you to get out of the way.
    [The prepared statement of Mr. Vargo follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
        
    Ms. Eshoo. Mr. Vargo, thank you for your excellent 
testimony, really grabbing the attention of every single 
Member. Thank you, and thank you for the superb work you and 
your organization do.
    Now the Chair would like to recognize Dr. Westlake. Welcome 
to the committee. Thank you for being willing to be a witness 
and give testimony today, and for your patience in waiting for 
panel two to begin.
    So please unmute so that everyone can hear you. And 
welcome, again.

              STATEMENT OF TIMOTHY WESTLAKE, M.D.

    Dr. Westlake. Great, thank you. Thank you, Chair Eshoo, 
Ranking Member Guthrie, and members of the subcommittee. Thank 
you for the opportunity to talk with you and for your 
leadership. My name is Tim Westlake. I am a full-time emergency 
physician and the immediate past chair of the Wisconsin Medical 
Examining Board. I am a licensed provider and prescriber of 
buprenorphine and provide the medical control for the statewide 
peer-to-peer recovery network that provides free Narcan 
education and access. I was also the physician architect of the 
Wisconsin Prescription Opioid Reform Strategy starting in 2014.
    I originated the idea of targeted fentanyl class scheduling 
while serving on the Wisconsin Controlled Substance Board and 
got it enacted first in Wisconsin in 2017. The DEA then 
temporarily put in place the same language federally in 2018. 
Before that point, scheduling of fentanyls was like a lethal 
game of Whac-a-mole, as you have heard before, except for me it 
was literally waiting for kids to die before we could control 
and stop the spread.
    As an emergency physician, I was beyond weary and 
heartbroken having to tell parents, sometimes even friends of 
mine, that their kids were never coming home again after 
overdosing.
    The inspiration for the fentanyl class scheduling reform 
arose out of the tragedy of my friend's son, Archie Badura. 
Archie was an altar server alongside my daughters in church. 
Archie first got hooked on prescription pills and then IV 
opioids. I resuscitated him on his second-to-last overdose. We 
pulled out a body bag and laid it out for him, warning him that 
he would end up in it if he didn't reach out for help. He was 
able to stay clean for 6 months after that, but then fentanyl 
caught up with him and ended his life like it has for hundreds 
of thousands of other kids in our country. His mom, my good 
friend Lauri, remembers seeing me showing him the body bag in 
the emergency department. And the next time she saw that bag, 
Archie was being zipped up into it and taken away to the 
morgue.
    In 2020 Congress enacted a temporary extension of what I 
like to refer to as the ``Archie Badura Memorial Fentanyl Class 
Scheduling Language,'' closing a loophole in Federal drug law 
which cartels have been exploiting for years to create and then 
legally distribute these deadly substances. Now is not the time 
to eliminate a proven harm reduction and overdose prevention 
strategy.
    When looking for policy and legislative solutions to the 
fentanyl devastation that is wreaking havoc in our country, it 
is critical to look at this situation from the proper 
perspective. Unlike marijuana, hallucinogenics, cocaine, or 
even heroin, fentanyls are so toxic and lethal that they can be 
classified and actually can be used as chemical weapons. A 
lethal dose is 2 milligrams, meaning that one teaspoon--which 
is what is in this packet of sugar--can kill 2,000 people. 
Twenty-four pounds is more than enough to kill all 5.4 million 
residents of metropolitan Washington, DC.
    The effects of the 3 years of fentanyl class scheduling are 
clear: the creation and distribution of finished fentanyl and 
fentanyl-related substances from China has ground to a halt. 
Most importantly, according to the National Forensic Laboratory 
Information System, overdose deaths related to fentanyl-related 
substances--newly created fentanyl-related substances--have 
effectively ceased. In Florida, in comparison, between 2016 and 
2017 there were 2,500 deaths attributed to fentanyl-related 
substances themselves. During that same time in New York City, 
there were 900 deaths in the city alone.
    Concerns about potential negative consequences on research 
and increased incarceration simply really have not 
materialized. Most research concerns raised in opposition are 
theoretical and seem to be focused on schedule I research writ 
large and are not specific to fentanyl-class research itself. 
In clarification, there are an exceedingly small number of 
researchers who have studied and--registering to study the 
fentanyls, approximately 30 in total, with many of these being 
DEA and Department of Defense subcontractors focused 
exclusively on the analysis, detection, and attempt to 
understand the harm of these substances. The only dampening or 
restricting of research has been purely theoretical.
    Fentanyl and its derivatives have been extensively 
researched since discovery in 1960, and in that time not one 
fentanyl-based reversal agent or medication-assisted treatment 
has ever been found in the 60 years since.
    Naloxone and Narcan work exceedingly well at reversing 
overdoses from all opioids, including fentanyl and fentanyl-
related substances. This is something I, unfortunately, see 
sometimes on a daily basis. If it wears off, then more can 
easily be administered. Kids die because they ingest a lethal 
dose of toxic opioids, not because Narcan isn't effective.
    Opposition posits that the Analogue Act is sufficient to 
control any new fentanyl-related substances. But if that were 
the case, all 50 attorney generals, including then-California 
AG Xavier Becerra, wouldn't have crossed the aisle, coming 
together 2 years ago to ask Congress to enact this language, 
and we wouldn't be discussing it here in this hearing right 
now.
    It is important to understand using the Analogue Act is a 
reactive strategy. It often reacts to the deaths of hundreds or 
thousands of our kids. Overincarceration has simply not been 
seen. In fact, in the 3 years since the class scheduling has 
been in place, there have been a total of eight Federal 
prosecutions, half of whom already have known ties to drug 
cartels. It is because this is not a law enforcement bill, this 
is a prevention bill.
    Regarding the mandatory minimums, the amount that triggered 
the minimums are 10 and 100 grams, which at first glance seems 
harsh. But it is critical to remember that that is enough to 
kill 5,000 and 50,000 people, respectively.
    Also setting the record straight, there have been zero 
prosecutions for nonbioactive fentanyl-related substances. This 
is due to the fact that all fentanyl-related substances 
encountered and researched to date have been found to be strong 
and potent opioids. Benzyl fentanyl is not classifiable as a 
fentanyl-related substance.
    I would suggest that so little incarceration is occurring 
as a result of the fentanyl class scheduling because it is, 
first and foremost, an overdose prevention and harm reduction 
tool and strategy originated by me, an emergency physician, who 
was beyond weary having to tell more parents that their 
children would never be coming home.
    Ms. Eshoo. Dr. Westlake, can you just summarize in a 
sentence or two, because your time has expired?
    Dr. Westlake. I am sorry, yes. The solution is not to allow 
the expiration of the fentanyl class scheduling. Congress 
should enact the Archie Badura Memorial Fentanyl Class 
Scheduling language seen in the bipartisan FIGHT Fentanyl Act.
    We need to deploy every----
    Ms. Eshoo. Thank you very much. Thank you, Doctor, we 
appreciate you being with us and for your testimony.
    [The prepared statement of Dr. Westlake follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
       
    Ms. Eshoo. Last but not least, the Chair recognizes Dr. 
Wilson for 5 minutes for his testimony, and--your testimony.
    And thank you again for your patience in waiting for panel 
two to begin, and we are ready to hear from you. So thank you 
very much. Lovely to see you, and thank you for joining us.
    Dr. Wilson. Chairwoman----
    Ms. Eshoo. And please unmute.

                STATEMENT OF DEANNA WILSON, M.D.

    Dr. Wilson. Chairwoman Eshoo and Chairman Pallone, Ranking 
Members Guthrie and Rodgers, and members of the committee, 
thank you for the opportunity to speak with you today. My name 
is Dr. Deanna Wilson. I am a pediatrician and internist with 
subspecialty training in addiction medicine. I am an assistant 
professor at the University of Pittsburgh, where I teach 
students and physician trainees about addiction, and I also 
conduct research focused on improving health equity and 
reducing disparities among vulnerable populations with 
substance use disorders.
    The worsening overdose crisis and the setting of the COVID-
19 pandemic has both unmasked significant health inequities but 
has also created opportunities for us to rethink how we deliver 
care in ways that, one, prioritize equity; two, increase 
treatment access; and three, increase our workforce's capacity 
to treat addiction.
    In cities like Philadelphia, while rates of overdose deaths 
fell by 31 percent among White Americans, there was a 
concurrent increase by more than 50 percent among Black 
Americans. The racial and ethnic disparities and overdose rates 
today reflect our failure to center the needs of Black and 
Latinx communities and address the underlying systemic 
inequities, social inequalities, and structural racism that 
drive differential access and disparate treatment outcomes.
    For example, we know that medications like buprenorphine 
and methadone substantially reduce the risk for both all-cause 
and overdose mortality, making them truly lifesaving. And yet 
your race determines how likely you are to receive them. Black 
patients have 77 percent lower odds of receiving a 
buprenorphine prescription during an office visit compared to 
White patients.
    We must re-imagine how we deliver addiction treatment, 
partnering with community organizations like faith-based groups 
to rebuild trust and reduce stigma, supporting low-threshold 
models of care that minimize barriers, preventing marginalized 
groups from being well-served by traditional health systems.
    We need greater investment in how to support these 
programs, to document their efficacy, and to scale up their 
use.
    Secondly, we need improved treatment access. In response to 
the COVID-19 emergency there has been greater flexibility and 
funding to support telemedicine for the induction and 
maintenance of buprenorphine. Our ability to engage patients 
who are unable to physically make it into clinic allows us to 
see patients who may never have linked to or may have fallen 
out of care. We need legislation that permanently supports our 
ability to use telehealth, but we also need initiatives making 
sure that telehealth is more equitable, such as supporting 
digital literacy and improving access to broadband coverage.
    Similarly, opiate treatment programs were granted 
flexibility to increase take-home doses of methadone. 
Preliminary studies show no increase in fatal overdose. This 
suggests the intense regulation of methadone distribution may 
be unnecessarily restrictive. We urgently need studies to 
further examine outcomes from this period so we can reform 
methadone regulations to become both more evidence based and 
patient centered.
    In light of rising use of stimulants like methamphetamines 
and cocaine, we need to invest in research on effective medical 
therapies. We also need to remove current coverage gaps, 
limiting our ability to offer evidence-based behavioral 
treatments like contingency management.
    Similarly, we need to reform policies that contribute to 
lags in addiction care for incarcerated individuals post-
release. Incarcerated individuals are 129 times more likely to 
die from an overdose within the first 2 weeks after release 
compared to the general population. Lengthy lag times in 
reactivating insurance post-release contributes to potentially 
fatal return to use.
    In addition, we must recognize that abstinence-only 
approaches to substance use treatment can further stigmatize 
and marginalize patients. Harm reduction services are not only 
effective at reducing harms associated with drug use, but by 
engaging patients who may be ambivalent over time. They provide 
critical access points to link patients to addiction treatment 
when they are ready. We must remove regulatory barriers and 
thoughtfully implement and study promising harm reduction 
interventions.
    Thirdly, we need to increase the capacity of our health 
provider workforce to treat and normalize the care of patients 
with addiction. The regulatory barriers associated with 
prescribing buprenorphine, the X-waiver, have unnecessarily 
restricted access to lifesaving therapies. Removing the X-
waiver is low-hanging fruit with the potential to drastically 
increase patient access. But at the same time we need to 
support training in addiction medicine for all providers.
    For example, requiring education in addiction, including 
logistics on buprenorphine prescribing as part of DEA 
registration, would empower all providers with a DEA license 
learn how to recognize and treat patients with addiction.
    If I may leave you with these three thoughts: one, we need 
to center equity in our policies and programming; two, we have 
to use evidence-based strategies to expand access to addiction 
treatment; and three, we must remove regulatory barriers and 
normalize the treatment of addiction by all providers.
    Thank you. I am happy to take any questions.
    [The prepared statement of Dr. Wilson follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    
    Ms. Eshoo. Thank you very much, Doctor. The Chair 
recognizes herself for 5 minutes of questioning.
    I would just note that, amongst you, the five witnesses, 
there seems to be a really sharp diversion on the issue of the 
expiration date and how that should be handled. So I am not 
going to go into it, but know that it is clearly noted that 
there are just really sharp differences.
    We have two lawyers, two doctors, a researcher. This is 
really a very fine panel.
    In listening to you, I cannot help but think of FEMA coming 
into New York and other communities, setting up beds, treatment 
being made available to those that were tested positive for 
COVID. Now, I don't want to underestimate what treatment for 
opioid addiction is, but it seems to me that we need to ramp up 
on the urgency of this.
    I mean, to hear the doctor talk about the young person and 
showing him a body bag and saying that if he didn't do such-
and-such a thing that he would end up being zipped into it, and 
he was. So would each one of you want to comment on this?
    Don't we need more beds, more treatment, that we need to 
ratchet this up so that it matches the urgency that we all know 
this is?
    I just don't think that when we say that it is urgent, that 
we have to stem the tide of the deaths--I think that we need 
strike teams. I think people in every community and every State 
around the country have to see that we are taking this 
seriously and that we are going to do something about it.
    I mean, the number--over 540,000 deaths due to COVID in 
this last year, 88,000 just for opioid. I mean, what, are we 
going to be satisfied with these numbers?
    So I invite any one of you to tell me that I am off track, 
that we need more treatment, we need more beds, we need help 
for people. I think our system is really fragmented.
    So I have used my time to really dump my thinking and my 
frustration and my emotions on you. But you are the experts, so 
I want to hear what you think. You can say yes or no to more 
beds, more treatment, more people trained, more money in the 
effort, if that is what it takes.
    But we need to--I think that we have the capacity in this 
great country to go to near elimination of this.
    And when the district attorneys describe what they are left 
with, because we are not doing everything that we need to do--
these people are sick. They don't belong in the criminal 
justice system. Then we have to find money to pay for the 
people that are in jail, and in prisons before they leave. I 
mean, what are we doing?
    So who would like to start?
    Dr. Wilson, would you like to take it?
    Dr. Westlake. Sure, I think----
    Dr. Wilson. Yes----
    Dr. Westlake. Oh, sorry.
    Ms. Eshoo. Dr. Wilson?
    Dr. Wilson. Yes. Thank you so much, Chairwoman Eshoo. I 
think that is a critical point. We absolutely need additional 
treatment. We need more access to evidence-based therapies, and 
we need to make sure that we have equitable access to evidence-
based----
    Ms. Eshoo. Are therapies not the right ones? I mean, have 
we not settled on what works?
    Dr. Wilson. We have wonderful evidence that medications to 
treat opioid use disorder, like buprenorphine and methadone, 
are highly effective at keeping people alive. So I think the 
evidence and science is clear to show that that is the case.
    The problem is we are not getting the medical therapies to 
the patients and communities that need them. And so that is the 
huge treatment gap that we need urgent attention and action to 
address. And that means----
    Ms. Eshoo. So like trying to get the vaccines, enough 
allotments, into the States and into the arms of people.
    Another one of the doctors want to comment? My time is just 
about gone, because I talk too much.
    Yes?
    Dr. Westlake. Yes, Chairwoman, I think you are spot on with 
that.
    In the emergency department I would estimate between 10 and 
30 percent of the patients that I see, there is something to do 
relating to substance use disorder. Usually it is untreated. 
And so this is--I think we are going to look back 30 years from 
now and say, you know, I can't believe that we were doing----
    Ms. Eshoo. You can't--you don't have the ability to refer 
them anywhere?
    Dr. Westlake. Well, it depends on where you are at. So I am 
in a resource-rich community, and so I can. But so much of the 
State, especially the rural parts--and that is where the 
telehealth expansion is really helpful. But there is so much 
that can be done, I think, moving forward.
    Ms. Eshoo. Well, I thank each one of you. My time has 
expired, and I think you clearly know where I am.
    So now I would like to recognize, really, a wonderful, 
important member of our subcommittee, the ranking member, Mr. 
Guthrie, for his 5 minutes of questions.
    Mr. Guthrie. Thanks, Madam Chair. And I want to say I think 
when--somebody said it, they understand the politics and 
optics, and I certainly don't say there is not politics and 
optics in Washington, DC, but I will tell you all of us are 
trying to figure this out, to get it right, because it is 
people's lives that we are dealing with.
    And one that really springs to me, I was touring a lot of 
opioid recovery centers when we were working on the SUPPORT and 
the CARES Act, and one guy--Kentucky has a law that you can 
get--if you are a minor user or so forth--expunged, but you 
can't get expunged if you sell. And that makes sense, when you 
think about it. But I met an individual who said about 
everybody who is addicted had some selling in their background, 
because ``I would buy 30 pills and sell three so I could afford 
the 30.'' But it was--``I was selling to support my habit.'' 
And so--but if you read the book ``Dreamland,'' there are 
completely pure criminal enterprises that prey on people like 
him.
    And so I don't think it is all one or the other. I think we 
have to figure out how we punish those who are truly criminal 
and those who are being--who are committing crimes--committing 
to support their habit, if you--and I said in my opening 
statement--if you can help them with their addiction, then you 
help them with--then the crime goes away with that.
    And so--but I am concerned about the truly criminal 
enterprises that we have to deal with. And Dr. Westlake, in 
your testimony you did say that the goal of the fentanyl class 
scheduling is not to--not locking up low-level drug users but 
to stop the development of deadly fentanyl poisons at their 
origin, namely in drug labs overseas. That is the quote. And 
could you explain--expand on this point, and further describe 
how the scheduling order is meant to prevent large-scale 
importation and distribution and not target individuals with 
substance use disorder?
    Mr. Vargo, after, if you would comment on how you use this, 
as well, to focus on the--more the large-scale criminal than 
the low-level user.
    So, Dr. Westlake?
    Dr. Westlake. Sure, thank you. Thank you. The--I think that 
the main point of the whole Act was to--or the whole set of 
languages--is to stop the creation of these substances, so 
that--these substances have been very well--there is very well-
researched structure activity, pathways that go back 60 years. 
And so it is simply--it is as simple as plugging in a different 
chemical in a formula structure, like a cookbook.
    And so what that--and those are very well laid out. And if 
you look at my testimony, my written testimony, I go through 
this in detail. I don't think I have the time to do that now.
    But the goal was to make those so that those would be 
illegal, so that the--and they wouldn't be created because, 
again, it was this Whac-a-mole game, where they are going 
around what is legal and waiting for the Analogue Act, or 
waiting for the CSA to catch up with it, which would be a year 
or so, or maybe a couple thousand deaths.
    So this--what this does, was this stops the--and it 
disincentivizes them from doing that. I mean, granted, they may 
have switched over to producing illicit fentanyl, you know, but 
what it has done is it shut down the new fentanyl-related 
substance creation machine, the mine of new fentanyl-related 
substances, by--again, by eliminating the incentives for that 
to happen.
    Mr. Guthrie. Mr. Vargo, instead of answering that, can I 
just focus on a specific part of that?
    So--and it was said earlier in testimony that if the 
descheduling goes away, that they still remain illegal. But you 
have to use the Federal Analogue Act for them if they are not 
scheduled. And so could you talk about how that could be 
inconsistent jury findings?
    You have to present to a jury for--that they fall under the 
Federal Analogue Act, and not--that they are not illegal by 
law, they are illegal if you can prove they are illegal to a 
jury. Could you talk about that process and why it would hamper 
your prosecutions of major criminals?
    Mr. Vargo. Certainly, Representative Guthrie, and I will 
tell you that, obviously, I as a State prosecutor don't do a 
great deal of that now. I was, for 15 years, a prosecutor in 
the Federal system, so I have some familiarity.
    I will tell you that it does appear that the--both the goal 
and the effect of the classwide scheduling have been effective. 
If we look at the--what was happening before, we have kind of a 
before-and-after control group, if you will. And, as Dr. 
Westlake pointed out in his written testimony, the number of 
analogues that we are seeing at the border fell significantly 
after the passage of that legislation. In other words, the 
legislation worked in changing the game of Whac-a-mole that we 
were playing with the Chinese laboratories that were creating 
new versions of fentanyl analogues.
    The--as far as prosecution goes, I think it is illustrative 
that the article by the Sentencing Guideline Commission 
recently identified only two cases since the passage of that 
legislation that were actually scheduled--or sentenced under 
the fentanyl analogue classwide scheduling. So it has not led 
to a large-scale incarceration or even large-scale prosecution, 
but it has been effective in reducing the number of new 
analogues that we see.
    The difficulty becomes, if we went under the Analogue Act, 
you have to prove individually that it is an analogue, and then 
you have to prove the person who was distributing it or 
possessed it knew that it was a controlled substance or had a 
controlled nature. Both of those would be very difficult under 
the Analogue Act with every new substance.
    Mr. Guthrie. Thank you. I would--I will yield back my time.
    Thank you for those answers, I appreciate it.
    Ms. Eshoo. The gentleman yields back. The Chair recognizes 
the gentlewoman from California, Ms. Matsui, for your 5 minutes 
of questions.
    Ms. Matsui. Thank you again, Madam Chair, and I do thank 
the witnesses for their testimony today, and I think you feel 
and see the frustration in our voices because all of us are 
troubled by the rise in overdose deaths, especially over the 
past year. And despite the enormity of the COVID-19 pandemic, 
which is, you know--and the overdose deaths and the substance 
uses have been exacerbated. So we can't lose focus on addiction 
crisis in this country.
    Now, over the past several years we have worked in a 
bipartisan way to support targeted efforts that have finally 
begun to reverse some of the overdose trends. But the pandemic 
has robbed us of that progress. So in a way we are talking 
today about what are we going to do moving forward.
    The bills presented today represent an opportunity to take 
a much-needed, broader and bolder approach to address the 
crosscutting facets of the addiction epidemic.
    You know, the task to combat the crisis continues to 
evolve. We know that. And as our witnesses have stated, we are 
now seeing fentanyl increasingly mixed into drugs like cocaine 
or meth, and that is presenting unique challenges to those on 
the front lines. And in some parts of States, including 
California, stimulants are the primary drugs of choice.
    Mr. Vargo, you brought attention to the issue of meth. Can 
you talk more about how Americans who use meth may differ from 
those who use opioids?
    Mr. Vargo. Thank you, Representative Matsui, I would be 
glad to.
    Methamphetamine is one of our most challenging substances 
because every drug that is illegal, every substance that is 
illegal, creates a criminogenic factor because you are dealing 
with it illegally. In the old words of Glenn Frey, you always 
carry weapons because you always carry cash. So we know that we 
create problems any time something is illegal.
    Methamphetamine, though, is, if not unique amongst drugs of 
abuse, certainly the most prominent [inaudible] drugs of abuse. 
It carries with it biological factors that render those people 
more dangerous: the hypervigilance, the paranoia, 
hallucinations, the aggression that comes with it. Even if meth 
were 100 percent legal at every level, it would create 
criminality because it creates violence. It is very much like 
PCP was back in the 1980s. I am that old that I remember that.
    So methamphetamine presents a particularly difficult 
circumstance and, more importantly, presents a very difficult 
treatment because it is one of the most difficult drugs to 
treat. Until recently we didn't believe there was medically 
assisted treatment available. There is some hope in that 
regard, but it is a very difficult drug, both in its use and in 
its treatment.
    Ms. Matsui. OK. Dr. Wilson, you also discussed in your 
testimony the growing number of patients that use stimulants 
either as a primary drug or mixed in with other opioids. How 
does this impact how you care for patients?
    And how are treatment recovery services for these patients 
different from those who--primary for opioid disorders?
    Dr. Wilson. Thank you so much for that question. You know, 
I think it is really important to recognize that, while we have 
really effective medications to help patients with opiate use 
disorder, we do not have effective medical therapies to support 
patients who have stimulant use disorder like methamphetamines 
or cocaine. There are some medications that have very modest 
effects, but the primary treatments that have been shown to be 
effective for patients with stimulant use like methamphetamines 
have been behavioral health treatments.
    The sort of greatest evidence base supports things like 
contingency management, where you reinforce patients who are 
having negative urines and remaining abstinent, for example. 
But it is really hard to operationalize those kind of therapies 
within sort of traditional kind of outpatient treatment 
programs. And so getting access to sort of efficacious 
behavioral therapies for patients with stimulant use disorders 
is more challenging.
    Many of the patients that I see who use stimulants are also 
using other substances. And so I think it becomes really sort 
of challenging to figure out sort of how can you link and 
engage patients in care and get them access to a full 
complement of results. So----
    Ms. Matsui. It seems to me that we don't have as many 
effective treatments for patients that use stimulants.
    Dr. Wilson. That is absolutely true.
    Ms. Matsui. Right, and so we need to have more research in 
order to find some way to deal with this, because meth has been 
around forever, in essence. And I know, in California, people 
don't hear about it as much as they hear about opioids, and yet 
meth is still growing, in essence.
    So I see I am running out of town. Thank you for--time. 
Thank you very much, and I yield back.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the ranking member of the full committee, Mrs. Cathy 
McMorris Rodgers.
    Mrs. Rodgers. Thank you, Madam Chair. I want to just thank 
you again for holding this important hearing today. I know it 
has been a long one, but it is really important. And a big 
thank you to all the witnesses for joining us today, sharing 
your perspective, your stories.
    To Dr. Westlake, just thank you for sharing your own 
heartbreaking story. It, unfortunately, is repeated too often 
right now in America. And my heart just breaks for you. I 
wanted to start with a question to you, Dr. Westlake, as well 
as Mr. Vargo.
    GAO's recent analysis found that a number of reports of 
unscheduled fentanyl analogues decreased by 90 percent after 
DEA issued the classwide scheduling order. So they found that 
after DEA issued this classwide scheduling order, the fentanyl 
analogues decreased, the number of reports of it decreased, by 
90 percent. So specifically, in 2016 and 2017 there were over 
7,000 law enforcement reports, 7,058 law enforcement reports of 
encounters with these substances. So that was 2016, 2017. You 
look at 2018, 2019, the encounters were down to 787, so over--
yes, 7,000 to 787.
    Why did classwide scheduling so significantly reduce the 
encounters?
    And I will start with Dr. Westlake, and then Mr. Vargo.
    Dr. Westlake. Sure. Thank you for the question, 
Congresswoman.
    I have a--there is a phrase that I want to drive home, if 
there is, like, one point that I want to get brought out of 
this hearing. It is that you can't die from something that has 
never been created, and you can't be incarcerated for selling 
something that doesn't exist.
    And so that is what has happened, is, you know, in 
conjunction with our scheduling language--the Chinese actually 
knew about the language coming up. We have been, you know, 
partnering closely with them, trying to get them to control the 
fentanyls, and eventually that happened. And so that just 
stopped. So it is not just that there is no new fentanyl-
related substances that are being seen, or very few.
    The NFLIS, the National Forensic Lab Information System, 
shows that there is almost no deaths that are occurring from 
new fentanyl-related substances. So you are still seeing deaths 
from the older fentanyl-related substances that are now 
fentanyl analogues, but you are not seeing deaths from the new 
ones. And so that was the goal of this. The whole--this is not 
a law enforcement bill. The vehicle is a law enforcement 
vehicle for scheduling, but the bill is ultimately opioid, you 
know, harm reduction, and opioid reduction of overdoses, 
overdose prevention.
    Mrs. Rodgers. Thank you.
    Mr. Vargo?
    Mr. Vargo. Thank you, Madam Chair. I will tell you that it 
is hardly surprising that criminal enterprises go where the 
money is, and where the criminality is least likely to be 
punished. I think that the response that we have seen from 
these organizations--I wish I could tell you that I don't think 
they are dealing drugs anymore. I doubt that is the case. But 
it means that they haven't tried to go into the area of new 
fentanyl analogues, because that is no longer profitable and it 
is more likely to be punished.
    So I think that that, again, kind of speaks to the question 
of whether or not the original Analogue Act itself was 
sufficient. It was not. And it is the reason that I believe 
that an extension, at least until we get some other format in 
place, is absolutely essential.
    Mrs. Rodgers. Thank you. Thank you. I appreciate that.
    Mr. Vargo, in your testimony you mentioned the work with 
the Sioux Tribe, and the importance of cultural competency. I 
represent several Tribes in eastern Washington. I wanted to ask 
if you would just speak about what you are doing to meet the 
needs of the Tribal communities who have consistently 
experienced larger increases in drug overdose mortality. I know 
that the Colville Confederated Tribe in my district is building 
a new treatment facility, and just--would you speak briefly as 
to what role Congress can play in aiding these efforts?
    Mr. Vargo. Yes, absolutely. Thank you, Representative.
    The Oglala Sioux Tribe is the closest Tribe to us, but we 
also have the Cheyenne River Sioux Tribe and the Rosebud Sioux 
Tribe that are very much part of our geographic area. They face 
extreme poverty, 90 percent unemployment, and they have been 
hit hardest by methamphetamine probably of any group, certainly 
in South Dakota, possibly in the Nation. And they are fighting, 
literally, for their lives in a lot of instances.
    I think that Congress's role here can be to enhance and 
support what they are trying to do, both on the reservations 
and off.
    Native Women's Health Care is an organization that provides 
healthcare to, primarily, pregnant women. We are partnering 
with them as diversion partners. So we send pregnant women with 
criminal offenses to them. If they successfully complete their 
medical program, we dismiss the criminal cases.
    We have also not only partnered with but invested in an 
organization that involves a Tribe called Native Healing. That 
is a residential drug treatment facility. Unfortunately, 
because of COVID, they are not going to be open until June of 
this year. They were supposed to be open April of last year. 
But it is 25 beds. To give you a frame of reference, though, we 
had over 1,200 arrests last year for methamphetamine, so 25 
beds is a great beginning, I believe it gives people hope, but 
it is hardly enough. And I think Congress needs to take a close 
look at those communities to whom the United States has a very 
particular and special relationship.
    Mrs. Rodgers. Thank you. Thank you very much. My time has 
expired. I yield back, thank you.
    Ms. Eshoo. The gentlewoman yields back. The Chair now 
recognizes the gentleman from California, Mr. Cardenas, for 
your 5 minutes of questions, and thank you.
    Mr. Cardenas. Thank you very much, Madam Chairwoman and 
Ranking Member, for us having this incredibly important hearing 
that affects every single person in America. And I would hope 
and pray that we can be an example for the world of how to 
handle drug addiction and how to make sure that we curtail this 
method in the United States that--we have been trying to 
incarcerate our way out of this, which never works. It has 
never worked anywhere on the planet, and it is something that 
we can do better here in the United States.
    And I do appreciate the testimony of every single person on 
this panel. And it appears that you all are, in some fashion, 
in agreement that we need to look at this as treating addiction 
rather than incarcerating our way out of this. So thank you so 
much for all of that.
    And I want to thank all of my colleagues for all the 
legislation that you have done in the many various positions 
that we have all been in. For example, when I was in the State 
legislature we passed the Schiff-Cardenas Act, which is the 
Juvenile Justice Crime Prevention Act, which provided $120 
million per year to local communities to fund prevention and 
intervention programs.
    Also, today in Congress, my colleague Representative 
Griffith and I led the At-Risk Youth Medicaid Protection Act, 
which was signed into law in the SUPPORT Act. This bill allowed 
a young person who is otherwise eligible for Medicaid to 
continue their healthcare coverage immediately following 
release from the juvenile justice system.
    And also we are considering many great bills today. One 
bill I am incredibly supportive of is my colleague 
Representative Tonko's Medicaid Reentry Act. This bill would 
extend Medicaid eligibility to incarcerated individuals 30 days 
prior to their release. Passing this bill is critical to 
improve access to substance use disorder treatment. Ninety-five 
percent of adults who are incarcerated in America will 
transition back into our communities, and data shows that 
individuals released from incarceration are 129 times more 
likely--that is 129 more likely--to die of a drug overdose 
during their first 2 weeks after release.
    Dr. Wilson and Ms. Richman, can you each please share your 
thoughts on this bill, as well as the role Medicaid and access 
to healthcare plays in addressing substance use and misuse in 
America?
    Ms. Richman. Thank you so much for that question. I am 
happy to answer it, and I am very grateful for the work that is 
being done and proposed in both of those bills.
    As a Federal public defender, many of my clients who had 
grown up in Baltimore did not receive the opportunity for 
either mental health or substance use, or sometimes even just 
core healthcare, until they entered the incarceration system, 
whether it be when they were a juvenile or when they were an 
adult. And what I saw in a lot of those clients' lives was a 
cycling in and out and a discontinuity in their treatment 
because of their movements in and out of incarceration and 
because of the lack of resources in the community. So I am very 
glad to see work in this crucial area.
    Mr. Cardenas. Thank you.
    Dr. Wilson. Thank you. I think this is a critical point, 
and an important piece of legislation.
    So we know that access to substance use treatment within 
the correctional system is a critical public health and ethical 
issue. And research shows that, if we start medications like 
methadone or buprenorphine for the treatment of opiate use 
disorder while individuals are incarcerated, that improves the 
likelihood that they will enter treatment and it reduces their 
risk for dying post-release. And so reinstating Medicaid 
coverage before reentry to the community is an important and 
essential way to keep people alive and facilitate their entry 
into evidence-based treatment.
    Mr. Cardenas. Thank you, yes, evidence-based treatment is 
something that, unfortunately, in my opinion is a little too 
new in the United States. We were stuck on just tough on crime 
for far, far too long. And unfortunately, this has affected 
almost every family. We have actually had Members of Congress 
admit to the fact that some of their family members have been 
subjected to addictions, et cetera, and everybody wants to see 
their loved ones treated with respect and dignity, not be 
treated like criminals because they have fallen prey to being 
addicted to some kind of substance. So I really appreciate the 
opportunity for us to bring this to light.
    And also, I would like to point out that this issue of 
addiction has been going on for hundreds and hundreds of years 
across the planet, and certainly has been going on since the 
founding of our country. So, hopefully, during this Congress we 
can actually make substantive changes and have the kind of 
programs funded so that we can treat everybody with dignity and 
respect.
    So my time has expired, and I yield back. Thank you.
    Ms. Eshoo. The gentleman's time--the gentleman yields back. 
I now would like to recognize the gentleman from Virginia, Mr. 
Griffith, for your 5 minutes.
    You need to----
    Mr. Griffith. Thank you, Madam Chair. Yes, ma'am.
    Thank you, Madam Chair. My mask fell down there, so you all 
can hear me.
    Mr. Vargo, as we have discussed, last year Congress 
extended the order temporarily classifying fentanyl analogues 
as schedule I substances. If Congress does not further extend 
that order, what will be the status of fentanyl analogues come 
May 7, 2021?
    [Pause.]
    Mr. Griffith. Mr. Vargo, can you hear me?
    Mr. Vargo. I knew I was going to do it at some point. Sorry 
to do it on your time.
    Mr. Griffith. That is all right.
    Mr. Vargo. Thank you for the question, Representative. 
Those analogues are at least arguably legal. And certainly, if 
Ms. Richman were defending one of those defendants, she would 
say that those analogues had not been scheduled and were not 
illegal or that her client did not know that those analogues 
were illegal and therefore cannot be prosecuted.
    And so it is certainly something that is possible to argue, 
that under the old Analogue Act we can try to stop that 
importation and we can try to bring criminal prosecution, but 
it would be much less likely to be successful.
    And I believe that just the before-and-after has shown us 
that it emboldens folks when they are not specifically 
scheduled.
    Mr. Griffith. Well, and I appreciate that. And I can assure 
you, having been a criminal defense attorney myself for a big 
part of my career, that is exactly what Ms. Richman would 
argue, and properly so. She has got a duty to defend her 
clients. Our job is to make sure the law doesn't create 
loopholes that folks who are trying to do bad things can drive 
a Mack truck through--which, by the way, are made in my 
district, some of them.
    Mr. Laredo, some folks have said keeping fentanyl analogues 
in schedule I inhibits scientific research. Yet DEA has 
approved nearly 800 applications to research schedule I-
controlled substances, and half of those have been approved in 
just the last 5 years. Do you believe valuable research could 
continue if analogues remained in schedule I?
    Mr. Laredo. Thank you so much for the question. I do 
believe that research can continue. There would be much, much 
less of it if you folks don't provide some exemptions for 
researchers on the research field so that they can really do 
that work.
    There, you know----
    Mr. Griffith. So----
    Mr. Laredo [continuing]. For the time that I was at NIDA, 
it was almost a daily occurrence that I would get a phone call 
from a researcher in the field complaining about something 
about that.
    And even now, I would strongly recommend you reach out to 
the National Institute on Drug Abuse and the College on 
Problems of Drug Dependence, who have been compiling more 
information about this. I personally believe they should be 
compiling even more. But there are some documents that I think 
that they have now that should be shareable with the committee 
that would help you as you talk about this.
    Mr. Griffith. Well, and so, from listening to your 
comments, do you believe that my bill--and I think you do--but 
do you believe my bill, the Streamlining Research on Controlled 
Substances Act, would improve the landscape for conducting this 
research?
    Mr. Laredo. I thought you might be going in that direction.
    Mr. Griffith. Yes.
    Mr. Laredo. I do. I would like to study the bill just one 
more time to look at all the details, but overall I very much 
appreciate your approach.
    Mr. Griffith. Well, and as I have said before, I am a big 
believer in trying to do research. And sometimes we find--out 
of odd and strange things you find a cure or a treatment for 
something that you weren't even necessarily looking for. So I 
want to make sure we----
    Mr. Laredo. Exactly.
    Mr. Griffith [continuing]. The American medical science 
community, because they do amazing things, as we have seen this 
year with the coronavirus. And I want to make sure they have 
all the tools available. I want it to be done legally. I want 
it to be done in a way that--we are looking for a way to use 
these substances, if possible, for medicine. And I think that 
the bill does that.
    However, that being said, if you or any of your colleagues 
has a way that we might improve the bill, I am always happy to 
take a look at that as well.
    Mr. Laredo. Thank you. I would be glad to look at that 
again.
    Mr. Griffith. Thank you. And I invite anybody who wants to 
sponsor it, it is H.R. 2405. If they have concerns in this area 
like I do, please jump on the bill and cosponsor it on both 
sides of the aisle.
    And Director LaBelle said in her testimony, Mr. Vargo, that 
early data suggests a steep rise in overdose deaths during the 
pandemic. When do you expect that we will have a full picture 
on how the pandemic has affected illicit drug use?
    Mr. Vargo. Boy, that depends on when the pandemic ends, 
doesn't it, Representative?
    Part of that is going to be we have to basically get back 
to some kind of normal. We have to readjust for the fact that 
we probably spent a year to maybe 2 years not doing the things 
that we wanted to do. And then we have to guess what things 
might have been.
    I would say that your effect of the pandemic is going to be 
at least as long as the pandemic. So after it is over, it is 
going to take at least as long as that to determine what it 
meant.
    Mr. Griffith. All right. And then you don't think now is 
the time that we should be lightening up on the analogues, do 
you?
    Mr. Vargo. Absolutely not.
    Mr. Griffith. I thank you very much.
    And Madam Chair, I yield back.
    Ms. Eshoo. The gentleman yields back.
    Before I recognize Ms. Kuster, Ms. Richman, your name has 
come up several times. Do you want to just take 1 minute to--
for any kind of response? I think that it would only be fair to 
do that, but for a limited amount of time, though. You have, 
like, a minute, a minute and a half at the most.
    Ms. Richman. I thank you for the opportunity. A couple 
points I would like to respond to. I think it is tempting to 
draw simple causal connections, but the fact is that the GAO 
report could not analyze a connection between classwide 
scheduling and the decrease in novel substances because of 
multiple confounding factors.
    With respect to the Analogue Act, I do understand there 
have been many complaints about it. But the Department only 
relied on it five times between 2015 and 2019 to prosecute 
fentanyl analogues. In all other cases they have been able to 
make good use of individually scheduled substances, which still 
comprised most substances that are charged.
    In addition, most of these cases are polydrug cases, the 
overwhelming majority, meaning that the presence of the 
fentanyl analogue doesn't make the difference about whether 
something is interdicted or not. It acts, in essence, as a 
sentencing enhancement that triggers mandatory minimums for any 
trace of a fentanyl analogue in a substance weighing 10 
paperclips. It is 5 years. And so that is the source of many of 
our concerns.
    Thank you for the opportunity.
    Ms. Eshoo. Thank you. The Chair now recognizes the 
gentlewoman from New Hampshire, Ms. Kuster.
    You need to unmute, Annie. I have got to hear you.
    Voice. I am sorry, it is Dr. Ruiz.
    Ms. Eshoo. Oh, you know what? I made a mistake, Annie. The 
next one up is a fellow Californian, Dr. Ruiz.
    You are recognized for 5 minutes.
    Mr. Ruiz. Thank you.
    Ms. Eshoo. I am sorry.
    Mr. Ruiz. Thank you. No worries. Thank you to all the 
witnesses for taking the time to be here today. We have heard 
in today's testimony about the increasing rates of substance 
use and overdoses in the United States over the last year.
    However, disparities in prevention, treatment, and recovery 
strategies continue to plague communities of color. A 2020 
issue brief by the Substance Abuse and Mental Health Service 
Administration lists a number of barriers to care for Hispanic 
individuals, including a lack of culturally responsive 
prevention and treatment, less access to medically assisted 
therapy such as buprenorphine and Naltrexone than White 
individuals, and a higher likelihood of relying on detox alone.
    A stigma and misperception within the Hispanic community, 
with only 5 percent of Hispanics with a substance use disorder 
thinking they need treatment, is also an issue. And one of the 
most commonly cited issues regarding prevention, treatment, and 
recovery strategies in the opioid crisis: language barriers for 
substance use disorders, materials, and treatments, and 
culturally relevant treatment from providers who understand the 
communities. In other words, diversifying the workforce, the 
provider workforce.
    So it is clear that we need to examine the policies that we 
consider through a health equity lens and make sure that they 
address prevention and treatment services in high-risk 
communities.
    Dr. Wilson, can you speak more about barriers to prevention 
and treatment services that drive inequalities in outcomes for 
minority communities?
    And in your experience, what are the most common barriers?
    Dr. Wilson. Thank you so much. I think we know that stigma 
related to addiction, to opioid use disorder and other 
substance use disorders exist, and stigma related to that, as 
well as racial bias, really intersect to create overlapping and 
compounding systems of disadvantage. So this contributes to 
lower quality of care and worse treatment outcomes for racial 
and ethnic minorities.
    We have another--a number of physicians who often, due to 
racial bias or structural racism, have inequitable prescribing 
practices and treatment. So we see that, for example, when we 
look at well-known disparities in pain management, for example, 
with lower rates of opioid prescribing or increased oversight 
for Black patients, and we see similar things when we look at 
disparities in the prescription of medications to treat opiate 
use disorder, with much lower rates being prescribed to 
patients with opiate use disorder in communities of color.
    And so, you know, I think, when we think of barriers, it is 
essential that we train our workforce, and we train our 
workforce to provide care to communities of color, and we also 
increase the number of providers of color treating those 
communities.
    Mr. Ruiz. So, Dr. Wilson, I practice medicine, emergency 
medicine, and I do a lot of public health work in underserved, 
medically undeserved areas. And would you say that the driving 
force of the decrease in access to prevention and treatment is 
more the systemic barriers that exist, the lack of providers, 
the lack of clinics, the lack of language, the lack of 
knowledge to empower, the lack of services focused in these 
underserved areas, versus the stigma portion?
    Dr. Wilson. I mean, I think all of those things come 
together, right? I think that patients in these communities, 
families within these communities, are desperate for help. I 
think historically our solutions for those communities have 
been mass incarceration and failed policies.
    And so I think what we really need to do is invest in 
widespread treatment, and I think that means partnering with 
community organizations where patients have had positive 
experiences, increasing culturally competent care, and 
increasing a workforce that is able to provide competent and 
equitable services to those communities.
    Mr. Ruiz. You know, one of the risk factors that have been 
cited in the social studies literature is the lack of social 
capital within communities, or the lack of communities that 
are--so do you think the promotora community health worker 
models by individuals in the communities----
    Dr. Wilson. Yes.
    Mr. Ruiz [continuing]. To keep people together should be 
expounded on in our country?
    Dr. Wilson. Absolutely. I think--I learned a lot of what I 
learned from addiction from amazing peer recovery specialists 
with lived experience in addiction. And I think that there is 
nothing that you can do to sort of help prescribe hope to 
patients other than showing them somebody who has lived through 
addiction and has come out on the other side. And so I think 
supporting and investing in those models is essential to 
increase that sort of treatment access in communities of color.
    Mr. Ruiz. Great. So with your 15 seconds remaining, what 
other recommendations do you have that Congress can do to help 
relieve these disparities?
    Dr. Wilson. I think one essential thing is to support 
training in addiction medicine and to support sort of building 
a more diverse addiction medicine workforce. And so that means 
sort of supporting physicians of color and building and 
supporting the pipeline and incentivizing physicians of color 
to go into addiction medicine.
    Mr. Ruiz. Thank you. I agree. I yield back my time.
    Ms. Eshoo. The gentleman yields back, and it is a pleasure 
to recognize the gentleman, the very patient gentleman, from 
Ohio. He has been with us, I think, since we began at 10:30 
this morning. I kept asking my staff, ``What about Mr. Latta? 
What about Mr. Latta?'' So here he is, and the gentleman has 5 
minutes for his questions.
    And it is great to see you, thank you.
    Mr. Latta. Well, let me thank the Chair, the gentlelady 
from California, for allowing me to waive on today, and I 
really appreciate it. And again, this is such an important 
subcommittee hearing that you are holding today, so I really 
appreciate it. And I also want to thank our witnesses for 
today.
    But, you know, over a year ago the lives of every American 
changed due to the coronavirus. And every day we are getting 
closer to ending the COVID-19 pandemic and returning to 
normalcy. However, long before COVID-19 dominated the 
spotlight, we were dealing with another crisis in this country, 
and that epidemic is still ongoing, which is the opioid crisis 
that has been significantly heightened due to lockdowns and 
immense stress on those already struggling with addiction.
    And before COVID-19 we were beginning to see some light at 
the end of the tunnel, you might say, that--we saw that the 
number of deaths were going down for the first time in decades. 
And however, you know, we already talked about today--is that 
we have seen in the last year, from August of 2020, that over 
88,000 people died from drug overdoses in this country, which 
is the largest ever in a 12-month period.
    So substance use disorder, SUD, and mental health have been 
overshadowed through the pandemic. And those suffering from SUD 
have shown that they are particularly susceptible for 
contracting COVID-19. So we must go back to work in defeating 
this deadly, ongoing crisis, and prepare to meet the needs in a 
post-pandemic world.
    And I have introduced several bills that would help curb 
the opioid pandemic, increase telehealth services, and assist 
those struggling with mental health. One bill that will 
immediately assist in stopping the illegal distribution of 
drugs is H.R. 1910, which is the Fight Fentanyl Act that I 
introduced with my colleague from Ohio, Mr. Chabot.
    In addition, my fellow Ohioan, Senator Rob Portman, and 
Senator Joe Manchin also introduced a Senate companion.
    In February of 2018 the DEA issued a temporary scheduling 
order to schedule fentanyl-related substances to allow our law 
enforcement to crack down on criminals flooding our 
neighborhoods and communities with this deadly drug. However, 
the order is set to expire on May the 6th, 2021. And so the 
Fight Fentanyl Act will simply codify the DEA's precedent to 
approve a schedule fentanyl-related--currently scheduled 
fentanyl-related substances as a schedule I drug.
    So, again, I want to thank our witnesses for being here 
today and, if I could, ask my first question to Dr. Westlake.
    In your written testimony you discussed how the goal of 
fentanyl class scheduling isn't to lock up low-level drug 
users, but to stop the development of deadly fentanyl poisons 
at their origin. Do you believe that the permanent scheduling 
of fentanyl as a schedule I substance, as my bill the Fight 
Fentanyl Act accomplishes, would--will help lower overdose 
death rates and help stop the influx of the illicit fentanyl 
into our communities?
    Dr. Westlake. Thank you, Congressman Latta. Yes, 
absolutely. So I think, to be clear, it will definitely 
decrease the existence and availability of newly created 
fentanyl-related substances. That has already happened. There 
has been a 90 percent decrease coming over from China that--the 
fentanyl-related substances that are new are not being seen in 
overdose deaths. And so that is definitely a part of it.
    So I think it is a huge piece, and I think that, you know, 
the language is very surgically targeted. If you look at my 
testimony, the written testimony, you can see that it is only 
very specific modifications to the molecule that have already 
been proven to have bioactive structure activity chemical 
relationships through the 60 years of research into the class. 
And so the language in your bill exactly, you know, is the 
perfect language to stop the creation of those likely bioactive 
substances.
    So, yes, I think it is a necessary--and from an emergency 
medicine perspective, you know, I am glad that I don't have to 
resuscitate people that are dead from a fentanyl-related 
substance. Unfortunately, we are seeing other, you know, 
illicit fentanyls coming through, and that is a whole 
different--there is only so much you can do at a time, and that 
is one thing we can do.
    Mr. Latta. Great. Well, let me ask--you know, as I 
mentioned, we have seen the largest overdose in our history in 
the last year, with 88,000 deaths. You know, what do you 
believe is the best way to address the crisis as we move 
forward, you know, while also addressing the needs of those who 
are suffering out there?
    Dr. Westlake. Yes, I think it is a huge--the issue for me--
so I looked at this, and I led the Prescription Opioid Reform 
Strategy in Wisconsin over the past 7 years, since we became 
aware of it.
    And so it is a really, really difficult issue. I mean, 
addiction goes back probably forever in human history. I don't 
think there is any time that we are ever going to get rid of 
addiction. I think that is, you know, like, you can't get rid 
of cancer, you are not--you know, it is a disease. What we have 
to do is, you know, we try to destigmatize it.
    I think the medication-assisted treatment part, and making 
it so that you can prescribe medication-assisted treatments--I 
am running out of--I think you are out of time--is really 
important and critical, because I can prescribe, as a 
physician, without any restrictions other than a DEA license, I 
can prescribe as much Oxycontin as I want, but I have to take 8 
hours to prescribe buprenorphine. And that makes--that has put 
a stigma on the prescribing of buprenorphine. And so that is 
something that is concrete that you guys can do that would make 
a big effect, just like it did in France, as was mentioned 
previously.
    Mr. Latta. Well, thank you very much. Yes, I appreciate the 
witnesses today.
    And Madam Chair, again, thank you very much for allowing me 
to waive on today. I appreciate it.
    Ms. Eshoo. Well, you are always, always welcome, Mr. Latta. 
You enhance our subcommittee any time you are with us.
    Mr. Latta. Thank you.
    Ms. Eshoo. We all feel that way about you.
    The Chair is pleased to recognize the gentlewoman from New 
Hampshire--I think I am correct this time--Ms. Kuster, for your 
5 minutes of questions.
    Ms. Kuster. Thank you so much, Madam Chairwoman. I 
apologize for my technical difficulties, but thanks to all the 
witnesses on the panel, and I appreciate your perspectives on 
the addiction epidemic in this country and your efforts to find 
solutions that will save lives and our communities.
    This is the reason that 7 years ago I founded the 
bipartisan Congressional Opioid Task Force and why this 
Congress we have now expanded it to the Addiction and Mental 
Health Task Force, to include this complex crisis that needs 
comprehensive solutions.
    It also is why I waited 6 years to join the Energy and 
Commerce Committee, and I am so delighted to be on the Health 
Subcommittee at this point. I want to commend you all for the 
incredible work that you do on substance use disorder and 
mental health, most recently working to include $4 billion in 
support for substance abuse and mental health services 
administration as part of our incredible American Rescue Plan.
    But that is not enough. We must do more to address the new 
realities of this epidemic defined by illicit synthetic opioids 
as well as ensure that our policies don't reinforce the 
mistakes of our past that disproportionately have impacted 
communities of color.
    So my legislation with Congresswoman Lisa Blunt Rochester, 
known as the STOP Fentanyl Act, is comprehensive in its public 
health approach to addressing fentanyl. And I want to take the 
time with all of you today to discuss some of those provisions.
    Ms. Richman, thank you for joining us. You stated the STOP 
Fentanyl Act takes a comprehensive health- and evidence-based 
response to fentanyl and fentanyl-related substances. Why do 
you think that this approach is necessary to addressing the 
addiction crisis in our country?
    Ms. Richman. Thank you so much for that question and the 
opportunity to comment on your legislation, Representative 
Kuster.
    I appreciate this putting sort of the work into finding 
what are the evidence-based science solutions that we can turn 
to. If you dive into the history of--the legislative history 
between--behind the draconian War on Drugs laws that were put 
on the books in the 1980s and 1990s, you will see that they 
were passed with the intent to incarcerate manufacturers, 
kingpins, to keep things from ever being brought into our 
country.
    And yet we are seeing substances that have been subject to 
harsh penalties for 30 years--methamphetamine is a case in 
point--proliferate new versions of it that are stronger. We are 
seeing new types of synthetic opioids, not fentanyl analogues, 
proliferate. U-47700 is beginning to see--beginning to be seen 
in more drugs.
    The truth is that most individuals who are incarcerated for 
drugs in our country are low-level dealers, are individuals who 
are minimally involved. And in the case of fentanyl analogues, 
many of them have not made a conscious choice to include that 
substance in whatever they are consuming or selling. So it is 
just acting as a way of bringing these harsh penalties onto 
communities of color that have been disparately impacted for 
far too long.
    Ms. Kuster. Well, thank you. And one provision of our STOP 
Fentanyl Act includes Good Samaritan protections to ensure that 
there are no impediments or fears and judiciary repercussions 
to assisting during an overdose, or reporting an overdose. Can 
you explain why these types of reforms are necessary to save 
lives?
    Ms. Richman. Gosh, I think that these are so very 
important, and I think that the stigmatization and punitive 
approach to drug use in our country really makes people afraid 
to reach out for help when people are in crisis.
    In particular, there is a 20-year mandatory minimum in the 
Federal system for giving or selling drugs to somebody that 
results in death. And we have heard of circumstances where 
people are in a sober house together, one user shares with the 
other one, that person begins to overdose. Their response to 
that may be inhibited by their fear of exposure to criminal 
penalty, and that harms public health.
    Ms. Kuster. Great.
    And Ms. Wilson, the STOP Fentanyl Act includes funding 
directed at community-based organizations that provide harm 
reduction services. Why are these services particularly 
critical for our fentanyl response policies?
    Dr. Wilson. Thank you so much. You know, I take care of a 
lot of patients who are at various points of interest in sort 
of stopping the use of substances, and it is important for us 
to offer sort of treatment and services to everyone, regardless 
of where they are. You know, it is--the harm reduction axiom is 
``Meet people where they are, but don't leave them there.'' 
These services help keep people alive, keep them engaged and 
linked to care, so that when they are ready they are able to 
actually access and get plugged into treatment.
    Ms. Kuster. Great. Well, my time is up. Thank you, Madam 
Chair, for including our bill, the STOP Fentanyl Act. Thank 
you. I yield back.
    Ms. Eshoo. The gentlewoman yields back. I want to--oh, we 
still have two Members, OK.
    The Chair recognizes the gentleman from Florida, Mr. 
Bilirakis, for your 5 minutes of questions.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it. 
This question is for Dr. Westlake.
    Higher-dosed pills from improperly mixed batches known as 
hot spots that led to overdose and death in a given area were 
often the way the medical community and law enforcement learned 
that fentanyl or an analogue had been introduced into a local 
drug market, which in turn would beget reactive scheduling in 
States or, as you put it in your testimony, a lethal game of 
Whac-a-mole. This led to work to remove the incentive that 
these international drug traffickers had in modifying the drug 
molecule by targeting likely bioactive fentanyls as a class.
    Can you discuss how fentanyl class scheduling is critical 
not only for law enforcement but for patient and community 
health as well?
    And should this scheduling ban expire, is it realistic to 
expect an increase or even sharp increase in overall deaths?
    Dr. Westlake. Yes. Thank you for the question, Congressman.
    I think, you know, when you look back at what was happening 
with fentanyl-related substances before the scheduling language 
was in place in your State, in Florida alone, in 2016 to 2017 
there were 2,500 deaths from two different fentanyl-related 
substances. We happen to have the similar deaths from similar 
substances in Wisconsin. So we scheduled them, we were the 
first State to schedule them. We are not seeing those any more. 
NFLIS is not reporting those, as I have said before.
    So I think it will definitely decrease the deaths and 
availability of those particular fentanyl-related substances. I 
think there are a lot of other things that need to fall into 
place to start to eliminate deaths, you know, writ large.
    I think also that, again, the important thing to remember 
about the scheduling is that it is surgically specific to only 
target the likely bioactive fentanyl molecules. It is not all 
potential fentanyl modifications. There is one fentanyl 
molecule, benzylfentanyl, a fentanyl analogue, that was found 
to be nonbioactive, and they did not include that in 
rescheduling for fentanyl-related substances. And so it--there 
has never been a nonbioactive fentanyl-related substance found.
    Mr. Bilirakis. Thank you. This question is for Mr. Vargo.
    While patients were not criminals, some career criminals do 
pose as patients or, in some cases, are even providers 
themselves, as recently observed in my district, unfortunately. 
As you alluded to throughout your testimony, prevention is 
worth a pound of cure, and treatment can be more successful 
than incarceration.
    From your conversations with district attorneys across the 
Nation, what law enforcement gaps, if any, exist within the 
current prescription drug monitoring program to detect and 
track?
    So again, yes, again, to detect and track patterns of 
abuse. Can you answer that question for me, please?
    Mr. Vargo. Yes, certainly, Representative, thank you for 
the question.
    Mr. Bilirakis. Of course.
    Mr. Vargo. I would say that we have done a fairly good job 
over recent years of making sure that our data has improved, 
but there is very much still room to take another step.
    Twenty years ago in South Dakota, if I wanted to prosecute 
somebody for doctor shopping, that was almost impossible. I 
would have to go to every doctor that they might have talked 
to, and we didn't have a central clearinghouse. And so our 
ability to say that you were doctor shopping and getting 
multiple prescriptions for the same reason was very, very 
limited. We took care of that clearinghouse now, and that has 
been very effective in making sure that people are only getting 
the prescriptions that they should, and that doctors have all 
the information that they need in making sure they are not 
double-prescribing.
    But I would guarantee you that there are circumstances 
where diversion still takes place. And so the monitoring and 
the tracking that--I believe could still very much be improved.
    Mr. Bilirakis. Thank you. Given the current opioid crisis 
in our Nation, the fact that all opioids are controlled 
substances, and our efforts to curb and eliminate doctor-
shopping, would you consider it to be a best practice for 
States to require patients to show ID when retrieving an opioid 
prescriptions, similar to purchasing alcohol, Sudafed, or even 
retrieving an MLB ticket from Will Call?
    What do you think about identification?
    Mr. Vargo. I would say that we want to make sure that the 
person receiving the prescription is the person for whom the 
prescription was made. And by whatever means that occurs, 
whether it is because it happens at the doctor's office, where 
the doctor would have direct knowledge, or whether it occurs at 
a linked pharmacy--again, where they would have direct 
knowledge, or whether there is an identification factor that 
guarantees it, that is very important.
    Mr. Bilirakis. Thank you so much.
    Madam Chair, my bill, H.R. 2355, the Opioid Prescription 
Verification Act, would encourage States to adopt systems that 
require pharmacists to check IDs to dispense opioids and 
require CDC to work collaboratively with other Federal agencies 
to provide guidance to pharmacists on ID verification while 
deferring to States on acceptable forms of identification, 
allowable immediate danger exemptions, of course, in addition 
to other State-specific needs that may need to be addressed. I 
encourage my colleagues to review this particular bill and 
consider joining my efforts by cosponsoring the bill.
    So I will yield back, Madam Chair. Thank you so very much.
    Mr. Bilirakis. You are very welcome for the extra 23 
seconds.
    The Chair now recognizes the gentlewoman from Delaware, Ms. 
Blunt Rochester, for your 5 minutes of questions.
    Ms. Blunt Rochester. Thank you, Madam Chair, and thank you 
to the witnesses for joining us for the second panel.
    It is clear our Nation's ongoing overdose crisis isn't 
limited to one community, one region, one race, or one 
socioeconomic class. Previous congressional efforts to reduce 
the number of fatal drug overdoses have helped us make 
progress. But as our chairwoman has said, it is far from 
enough. States like Delaware continue to be in the middle of a 
public health crisis due to the rise in synthetic opioids like 
fentanyl.
    We are anticipating a total of over 500 overdose deaths for 
2020, an all-time high for my State. That is why Congresswoman 
Kuster and I introduced the Support, Treatment, and Overdose 
Prevention of Fentanyl Act, STOP, a comprehensive package of 
public health policies to address the proliferation of 
synthetic opioids without the mainly punitive measures used in 
previous approaches to drug control.
    Dr. Wilson and Ms. Richman, how will a public health 
response to substance use disorder address some of the 
challenges you have seen throughout your careers? And we will 
start with Dr. Wilson.
    Dr. Wilson. Yes, thank you. I mean, I think it--as a 
physician, it is absolutely clear that addiction is a disease, 
and this is a huge public health crisis.
    We cannot schedule our way out of this epidemic, and we 
cannot incarcerate our way out of this epidemic. We absolutely 
need evidence-based and informed public health solutions. So 
expanding access to treatment, we need to get effective 
therapies to communities that need them. We need to partner 
with community organizations that are already embedded within 
communities to strengthen those communities and provide greater 
links from sort of our health care systems to sort of 
organizations already doing the work on the ground in local 
community settings.
    We need to keep people alive, which means we need to expand 
access to harm reduction services to prevent morbidity and 
mortality associated with opiate use, recognizing that not 
everybody is going to be ready to quit today but they may be 
tomorrow, and we have to keep them alive so that they can reach 
that point.
    Ms. Blunt Rochester. Thank you.
    Ms. Richman?
    Ms. Richman. Yes, thank you, Representative Blunt 
Rochester, I appreciate the opportunity to comment.
    I have also been very grateful for Mr. Vargo's response and 
remarks today about shifting the intervention point. And I 
think directing resources away from enforcement and towards 
public health gives the opportunity to bring those 
interventions earlier, and keep individuals from going down a 
path that will be very damaging.
    When I look at the lives of my clients, I see so many 
different intervention points that there could have been: with 
their mother, before she overdosed; when they were a child, to 
be placed in a setting where they would be given holistic, 
educational, medical substance abuse services; all the way into 
the criminal justice system.
    I will never forget working with my social workers and just 
spending hours on the phone for clients who came in suffering 
from substance use disorder to try to find them some sort of 
residential placement where they could go so that the court 
wouldn't send them to jail. A lot of my clients did not have a 
home to go to. They were struggling, and it would be incredibly 
difficult to find that place. And then you just cross your 
fingers and hope it worked.
    Ms. Blunt Rochester. Well, I thank you for sharing all of 
that.
    Included in our STOP Fentanyl Act is dedicated funding and 
support for overdose prevention and treatment programs, 
including grants for harm reduction providers and improving our 
understanding of evidence-based overdose interventions.
    Dr. Wilson, I think you also may have talked about harm 
reduction and the benefits of it. Can you tell us what 
scientific evidence there is that shows that there is a benefit 
for harm reduction efforts?
    Dr. Wilson. Absolutely, I think the evidence is really 
clear that programs, for example, that distribute naloxone 
are--there is a dose response, which is sort of one of the sort 
of strongest relationships in the medicine.
    So the more you integrate overdose prevention within 
communities, the greater the naloxone you distribute within 
communities, the lower the risk of having fatal overdoses, and 
your mortality rate will actually decrease. So there is great 
evidence showing that needle and syringe exchange programs, for 
example, reduce hepatitis C, reduce HIV, and infections related 
to injection drug use.
    And so, again, you know, I think we have to think broadly 
about this. Our goal is not just to reduce overdose, it is also 
to reduce sort of infectious complications, like infective 
endocarditis, associated with injection drug use. You know, we 
have to keep people alive so that we can get them access to 
treatment and harm reduction services. There is really a strong 
evidence base that these things are effective at doing that.
    Ms. Blunt Rochester. Thank you. The STOP Fentanyl Act is 
the long-term solution that our Nation needs to respond to the 
overdose epidemic. And I look forward to working with the 
committee to advance this critical legislation.
    Thank you, Madam Chairwoman, and I yield back.
    Ms. Eshoo. The gentlewoman yields back. The Chair now 
recognizes the gentlewoman from Minnesota, Ms. Craig, for your 
5 minutes of questions.
    Ms. Craig. Well, thank you so much, Madam Chair, and thank 
you to the panelists here today, the witnesses, for your 
incredible expert opinion that helps guide our policymaking.
    Mr. Vargo, you said something in your testimony that I 
would like to highlight. You wrote that, ``Just as we cannot 
incarcerate our way out of an epidemic, neither can we ignore 
it and expect it to go away.'' I completely agree with you, Mr. 
Vargo. And incarceration is not the answer to our current 
substance use epidemic. I would argue that we need additional 
public health support.
    I am proud to represent Minnesota's 2nd congressional 
district, where our county and local law enforcement partners 
have launched programs that focus on intervention, rather than 
incarceration for nonviolent offenders struggling with 
addiction.
    The Shakopee Police Department offers a scholarship program 
to cover the cost of drug or alcohol treatment funded by drug 
and alcohol forfeiture cases. Scott County's drug court 
provides supervision and treatment, an effective alternative to 
incarceration that saves taxpayer dollars and directs 
participants to long-term recovery.
    Mr. Vargo, starting with you, thank you again for your 
testimony here today. As you all know, one of our great 
colleagues, Representative Annie Kuster, put forward H.R. 2366, 
the Support, Treatment, and Overdose Prevention of Fentanyl 
Act. One provision requires HHS to report on how SAMHSA can 
provide and support health services to underserved individuals, 
taking into account drug courts.
    Can you talk a little bit more about how drug courts work, 
and the overall impact they may have in combating drug use and 
abuse, from your experience?
    Mr. Vargo. Thank you, Representative Craig, I would be 
happy to. Drug courts are near and dear to my heart.
    I am an old prosecutor, and I started in Miami in 1988, 
when Ms. Reno was the State attorney down there. And in the 
fall of 1988 into the spring of 1989 she began the Nation's 
first drug court. And so that has always been something that 
has--I have paid attention to. You could not find a county in 
America that doesn't have some access to one of these what we 
call specialty courts.
    The weakness of specialty courts, drug courts, DUI courts, 
even mental health courts, is that they tend to be aimed at 
those who are in the last steps before a penitentiary sentence. 
So they are wonderful. They do divert people from the 
penitentiary. They do not divert people from conviction, and 
they do not divert people at the beginning of their criminal 
justice involvement. That is why we believe that diversion, 
which we unabashedly stole from Manhattan and the Bronx, are 
answers that need to be more widely incorporated with 
prosecutors' offices from here on out.
    So I really am thrilled to hear about what is going on in 
Minnesota. I know some of your wonderful prosecutors--Mr. 
Freeman, Mr. Orput--are good friends of mine, and I am glad to 
hear what they are doing.
    I will tell you that I would love to see in the STOP 
legislation--the numbers are sometimes daunting. When you talk 
about HHS making reports on SAMHSA, we are in the process of 
looking for a grant or a diversion opportunity to test out the 
medical-assisted treatment model for methamphetamine. When 
working with our partners here who already provide opioid MAT 
treatment, they inform me that for half a million dollars a 
year I could probably treat 25 people. In a small county that 
is a daunting number, even on a grant funding.
    And so I am thrilled to hear that we are going to be 
documenting just what happens, because ultimately that 25 
people, that is still cheaper than putting them in the 
penitentiary. So in the end, if we can get that to work, that 
is great. But I do know that it is daunting and that the SAMHSA 
numbers are going to be stretched very thin. And so that is 
part of the hope that I would send to you, which is that you 
would treat this as even more important than the other 
infrastructure projects that you are presently considering. 
Human capital has to be our first goal of infrastructure.
    Ms. Craig. Thank you so much for that thoughtful answer.
    And with that, Madam Chair, I will yield back.
    Ms. Eshoo. The gentlewoman yields back. The Chair now 
recognizes the gentlewoman from Washington State, Dr. Schrier, 
for your 5 minutes of questions.
    Ms. Schrier. Thank you, Madam Chair, and thank you to all 
of our witnesses today for talking in such frank terms about 
how to take away stigma and address the real issues at hand, 
which are, you know, drug addiction and treatment and finding 
the right time, and mitigating mortality. I very much 
appreciate that focus on how to care for our families and our 
communities. I want to turn to Dr. Wilson for my question.
    Doctor, I very much appreciate your candor about how 
physicians in general do not receive sufficient education on 
how to recognize and treat substance abuse disorders. My State 
of Washington has been a leader in working to integrate 
behavioral health into primary care and utilize care 
coordination so people with complex conditions, whether that is 
diabetes and depression, or co-addiction to opioids and 
methamphetamines, can get the care that they need. And yet, 
personally, as a pediatrician, the extent to which I personally 
treated substance use disorder was screening for it and then, 
if I found it, ensuring immediate safety and then referring out 
to specialists.
    And so I was wondering, you know, from a pediatrician's 
perspective, could you just talk about what it looks like to 
treat a patient with substance abuse disorder in the primary 
care setting?
    Dr. Wilson. Absolutely.
    Ms. Schrier. Thanks.
    Dr. Wilson. You know, I often think of addiction as a 
pediatrics disease that we often fail to recognize and treat 
during childhood, which leads to worse outcomes later in life. 
The vast majority of adults who use substances have actually 
started using those substances during their adolescence. And so 
this is a huge missed opportunity to really shift the life 
trajectory of a generation of adolescents and young adults. So 
I think it is essential that we do a much better job, as a 
profession, of recognizing substance use in young people.
    As a pediatrician and adolescent medicine provider, I think 
I am the sort of perfect person to recognize substance use in 
my patients. You know, pediatricians have the ability to build 
deep relationships with patients and their families over time. 
We provide lots of anticipatory guidance and education about 
what to expect as they grow up about puberty, about all sorts 
of things that we know are going to impact the lives of our 
patients. And we know that substance use is a huge potential 
area that would have serious impact on their future. And so I 
think it is natural for us to be the ones to sort of have those 
kind of preventive conversations and start the conversations 
with patients.
    We also see patients regularly for well child visits, and 
that is a perfect opportunity to screen patients as we are 
doing a lot of preventive healthcare.
    And then to sort of offer treatment in the setting, it 
helps sort of remove some of the stigma that both patients and 
their families might have about the disease of addiction, 
right? So I don't say, ``You have an addiction, you have to go 
someplace else.'' I say, ``You have a disease, just like you 
have asthma. And as your doctor, I am going to treat you.'' And 
there is something that is so powerful about sort of flipping 
that narrative for parents. There is nothing shameful about 
dealing with addiction. It is a disease, and we have effective 
treatments, and our job as physicians and pediatricians are to 
get those effective therapies to children and their parents.
    Ms. Schrier. So I really appreciate that perspective. And I 
think it is really nice to destigmatize it like that. I guess--
here is my next question.
    I am in a generation that did not receive this kind of 
training in medical school or residency. And I understand that, 
you know, that the X-waiver may not be ideal. But then again, 
less than, I think, 1 percent of pediatricians have ever even 
applied for the X-waiver so aren't in a situation to do this 
testing.
    Can you talk about--if it is not--you know, what your 
thoughts are with the X-waiver and, if it is not that, how do 
you catch the more experienced doctors up to speed on treating 
substance use disorders?
    Dr. Wilson. I think----
    Ms. Eshoo. Excuse me, if you could, just summarize your 
answer, because the gentlewoman's time has expired.
    Ms. Schrier. Oh, I missed that.
    Ms. Eshoo. Oh, it hasn't. I am sorry, I am sorry. You have 
37 seconds. I am sorry.
    Dr. Wilson. I think we have to both integrate for sort of 
our learners into health professional education and medical 
residency programs, better education in addiction.
    And I think the X-waiver training is sort of an additional 
regulatory hurdle. I think we should eliminate the X-waiver 
training but integrate basic tenants of addiction medicine as 
sort of linked to, for example, DEA licensure. So as you sort 
of obtain your DEA license, you have to complete a certain 
amount of hours related to--basics related to addiction and 
buprenorphine prescribing, so all prescribers who are able to 
prescribe controlled substances are actually also able to 
recognize, treat, or refer to treat patients with addiction.
    Ms. Schrier. Great, thank you very much.
    Ms. Eshoo. The gentlewoman's time has expired, and excuse 
me for interrupting.
    The Chair now recognizes the gentlewoman from 
Massachusetts, who has been with us all day, and I think that 
is the quality of the hearing, right?
    Mrs. Trahan. Absolutely.
    Ms. Eshoo. Yes. Congresswoman Trahan, you are recognized 
for your 5 minutes, and thank you. You are a wonderful addition 
to our subcommittee.
    Mrs. Trahan. Well, I so appreciate that, Madam Chair, and I 
really do appreciate you convening us on this important issue 
and prioritizing it. Your leadership on substance use disorder 
is unparalleled. And I want to thank all the witnesses today. I 
know it has been a long day, but your contribution to our 
policymaking is so important.
    So in 2016 Max Baker was 23 years old when he died of an 
overdose after suffering from heroin addiction. Prior to his 
passing, Max's father, Dr. James Baker, a hospice care 
physician who works in my district, he sought help for his son 
through his own primary care doctor. But the answer Dr. Baker 
received was not at all encouraging: ``I hope he finds the help 
he needs.'' And this particular primary care doctor didn't have 
the working knowledge to treat Max's addiction or even the 
tools to refer him to someone who could.
    And that isn't a criticism. You know, it is a description 
of an all-too-common problem, as Dr. Schrier just mentioned. In 
fact, even over Dr. Baker's 35 years of practicing medicine, he 
hadn't learned how to treat opioid use disorder, not in his 
coursework at Johns Hopkins or Harvard, not in his medical 
school residency, and not in his public health education.
    So, Dr. Wilson, I am going to stay with you. Why should all 
medical professionals know how to identify and treat SUD?
    And what would you say to your medical colleagues across 
different medical specialties if they questioned why requiring 
education on treating patients with SUD is important to 
improving addiction treatment for all Americans?
    Dr. Wilson. Yes, thank you so much. You know, I think the 
sort of key takeaway point is there should be no wrong door for 
a patient who is seeking help, right?
    And so I think that we historically have had separation--
have separated addiction treatment from medical treatment. And 
so historically, providers, physicians have not learned about 
addiction medicine as part of routine sort of education or 
curriculum offered in medical school or as part of their 
residency training.
    And so, you know, I would call this out as a failure of our 
profession. And I think part of the treatment gap that we are 
seeing right now is because we haven't recognized that, you 
know, addiction and addiction medicine is part of the care that 
we need to offer all of our patients, right?
    And so you may not provide sort of really in-depth medical 
sort of addiction medicine when you see patients, but you 
should be able to screen, to diagnose, to recognize that a 
patient is struggling with addiction and to know how to refer 
them to treatment, and what treatments exist.
    You know, I take care of patients in the hospital who often 
are admitted with--for many things that have nothing to do with 
their addiction. And that is an opportunity for us to see them, 
offer treatment, and sort of really alter the course of their 
lives.
    Mrs. Trahan. Sure. So let's imagine that the X-waiver 
requirement were eliminated, and so a barrier to treating 
patients with buprenorphine, for example, was no longer an 
issue. That is a powerful drug which many prescribers may not 
be familiar with. And it strikes me that under that scenario it 
would be even more important for our prescribers to understand 
how to use buprenorphine to properly treat SUD.
    So would standardized education on treating addiction lead 
to better treatment for those suffering with SUD, especially if 
some treatment barriers are soon eliminated?
    Dr. Wilson. Yes, so I actually think that we often--and, in 
part, I think this is related to stigma around addiction--we 
prescribe many things which are far more dangerous for patients 
like morphine, like oxycodone, like the medications that 
started this crisis to begin with, that do not have the 
regulatory hurdles like prescribing buprenorphine. It should 
not be easier for us to prescribe pain medicine than it is for 
us to prescribe buprenorphine to treat someone with an opiate 
use disorder.
    So I think part of that is helping providers recognize it 
is actually not that challenging. This is something you can do, 
you are empowered to do it, and with sort of a short sort of 
kind of educational module, an hour or two focused on the 
medication of buprenorphine and how you start it, all providers 
will, I think, realize that they too can recognize and treat 
patients with opiate use disorders.
    Mrs. Trahan. And that is a huge part for us, eliminating 
the stigma.
    I mean, look, had standardized education been the protocol 
a few years ago, perhaps Max Baker would have received the 
early intervention and the support that he needed. And parents 
like--patients like him show up in medical offices across the 
country, and the medical community, frankly, needs to be ready 
to spot problems of this sort, whatever their specialty.
    I mean, this is, after all, a national crisis, and it is 
going to require all of us to do a bit more to keep patients 
healthy and safe, which is what the MATE Act aims to do.
    So I really appreciate your contribution to today's 
conversation, Dr. Wilson, and I yield back the remainder of my 
time.
    Ms. Eshoo. The gentlewoman yields back, and I think the 
final recognition of a wonderful Member is going to be our last 
one, and that is the gentlewoman from Texas, Mrs. Fletcher. Are 
you there?
    Mrs. Fletcher. Thank you----
    Ms. Eshoo. There you are.
    Mrs. Fletcher. Thank you so much, Chairwoman Eshoo. Yes, 
and thank you to all of our witnesses for testifying today 
about this critically important topic, and for being with us 
throughout the day. It really is important. And I want to touch 
on one thing that we haven't, to my knowledge, touched on in 
this panel and get insights from all of you.
    I have the privilege of representing a lot of medical 
professionals in my district in Houston, just outside the Texas 
Medical Center. And I have heard from a lot of the doctors and 
other medical professionals in my district that a lack of 
insurance coverage can significantly impact an individual's 
recovery.
    You know, for example, a person may be on medication-
assisted treatment and doing very well, but they are laid off 
or get dropped from their partner's coverage. There are a lot 
of scenarios, unfortunately, that we have seen over the last 
year where people have lost their coverage, and then they can 
no longer afford their treatment and they relapse.
    So Medicaid is the largest payer of mental health and 
substance use disorder treatment in the country. Unfortunately, 
in States like mine that have not expanded Medicaid, you know, 
many people who are struggling with substance use disorders are 
unable to get the coverage they need.
    So I want to start with Dr. Wilson. In your testimony you 
discuss the many barriers that can exist to accessing addiction 
treatment. In your opinion, would Medicaid expansion help 
reduce barriers and expand access to critical substance abuse 
disorder treatment?
    Dr. Wilson. Absolutely. It is really a no-brainer. You 
know, I think it is cost-prohibitive for people to pay out of 
pocket for addiction treatment. And I see patients all the time 
who have been doing great, are in sustained recovery, doing 
well, taking medications, engaged in recovery services, and 
they lose insurance coverage through no fault of their own and 
then have withdrawal from the medications that have been 
helping them stay sober and abstinent from illicit opioids and 
really lose access to all the recovery support services that 
have helped them stay in long-term recovery.
    And that can be--we know that any return to use could be a 
potentially fatal return to use. And so this is really a 
conversation about how we keep people alive and keep them 
getting access to medications and treatment that can help save 
lives.
    Mrs. Fletcher. Thank you, Dr. Wilson, and I would love to 
just open that question up to anyone, especially since I am the 
last--last couple of minutes of the hearing, just to see if 
anyone else wants to weigh in on that question about how we can 
keep getting people access to critical services, or--really, if 
somebody else has something to say that we didn't get to and 
you want to use this minute, I would be glad to hear your 
thoughts as we wrap up.
    Mr. Vargo. If I might, Representative?
    Mrs. Fletcher. Go ahead.
    Mr. Vargo. Well, thank you very much for giving me the 
opportunity. I will tell you that it is not just the existence 
of or the lapse of insurance. It is whether they have it in the 
very first place.
    As I said, we have got a 90 percent unemployment rate on 
the Pine Ridge Indian Reservation. So that means that the ACA 
makes no inroads as far as insurance goes.
    And I will also, though, point out one other difficulty, 
which is the ability of Medicaid and Medicare to reimburse for 
off-label uses of proven drugs that would be of assistance. It 
makes it prohibitively expensive for those people to seek 
treatment, and for us, as governments, to then pay for that 
treatment, because we are essentially out of pocket. So even 
before you get to Medicaid expansion, the capacity--I would 
rather that a doctor like Dr. Wilson, who knows what she is 
doing and she makes a decision that this drug is necessary for 
a patient's care, even if it is off label, it strikes me that 
that should be reimbursed by Medicaid.
    Mrs. Fletcher. Thank you, Mr. Vargo, I appreciate that.
    And I think that, Mr. Laredo, you had your hand up.
    Mr. Laredo. Thank you so much. Just following on what Mr. 
Vargo just said, you have a nationwide, systemwide problem of 
complete lack of services compared to the need. So, whether 
there is insurance or not, whether there is Medicaid expansion 
or not, it is another example of needing an all-of-the-above 
approach and, unfortunately, a truly dramatic increase in 
funding across the board to pay for these services.
    The public health system, as we have seen throughout the 
COVID pandemic, is in deep, deep trouble. And that translates 
through the substance use and addiction treatment system. It 
is--frankly, calling it a ``system'' is a little bit of an 
overstatement. So anything at all--you don't always want to 
throw money at a problem. This is a problem that has for 
decades required significantly more funding than it has ever 
received.
    Mrs. Fletcher. Well, thank you so much for that, and I am 
at the end of my time here.
    So, Chairwoman Eshoo, thank you again for holding this 
incredibly informative hearing, and thank you to all of our 
witnesses for your testimony here today. I yield back.
    Ms. Eshoo. The gentlewoman yields back. I don't see any 
other hands for Members, whether they were part of the 
subcommittee or waiving on.
    I want to thank each one of you. You have really given 
superb testimony. What always makes it very interesting in a 
hearing is, you know, the two sides of an issue from two 
professionals. And, you know, none of these issues are--well, I 
think the issue of, you know, the whole--the schedule I issue, 
and that we are going to have to sort out, it is an important 
one, but I can't give you an answer right now of where I am on 
it, because people have made excellent points about it. And 
that is the point of a hearing, is that we get the expert 
testimony. No one can say to any one of you that you don't know 
what you are talking about. You bring decades of professional 
experience to the Congress of the United States.
    And we are not only very deeply grateful to you, we are 
proud of you. When I listen to all the professionals I always 
think to myself, what a country we have, what a country we 
have, individuals that are so committed, so committed to the 
public health system, to research, to the criminal justice 
system. I could go on and on. So you have the collective 
gratitude of our entire committee, and you have been highly 
instructive to us. You have been highly patient for us to take 
up your panel, and we are lastingly grateful to you.
    So thank you, thank you, thank you, and know that we will 
circle back with you with the questions that Members submit. If 
they didn't have the opportunity, they will submit questions, 
and I trust that you will answer them in a timely way.
    So keep doing your extraordinary work. Our country and this 
issue really need you. And hopefully, we will shape policies 
that are going to really put a--really address what--as I said 
earlier, this scourge in our country.
    I mean, it just has wiped out--wrecked lives, wrecked 
families, taken tolls on communities across the country. And it 
doesn't matter what ZIP code people live in. Not a surprise, in 
poorer areas it is even worse. So thank you again.
    Now, I have a request of my wonderful--our wonderful 
ranking member. I have 37 documents to enter into the record. 
They are all wonderful and important, and organizations 
weighing in. And I would like to request a--make a unanimous 
consent request to enter into the record the 37 documents that 
have been submitted to our subcommittee.
    Mr. Guthrie. OK, thanks, and before--I don't object, so I 
won't object. But I just want to say again, to echo what you 
said, to have our witnesses here today, to spend an entire day 
of your time--I know you got to listen to the morning session 
and then spend your entire afternoon with us is--I know your 
time is valuable, but it is helpful. It really is helpful, 
because a lot of us are really trying to sort this out, and not 
coming with preconceived views or optics or anything like that. 
We really want to come up with the right answer. And we 
appreciate your time.
    And I do not object to your unanimous consent request.
    [The information appears at the conclusion of the 
hearing.\1\]
---------------------------------------------------------------------------
    \1\ The GAO report has been retained in committee files and is 
available at https://docs.house.gov/meetings/IF/IF14/20210414/111439/
HHRG-117-IF14-20210414-SD021.pdf.
---------------------------------------------------------------------------
    Ms. Eshoo. Well, thank you. Thank you very much. And I 
appreciate it. And yes, 5 hours and 10 minutes total.
    But I think it also--I think that, as you--before you turn 
off your laptops, I am very proud of our subcommittee and the 
Members on both sides of the aisle. You heard so many 
thoughtful, probing questions.
    So while, you know, Congress has always been kind of the--
at the--well, let's just put it that way, a lot of fingers 
pointed at us, we are made fun of or mocked in different ways. 
Sometimes it is earned. But I think most of the time, frankly, 
it isn't. You saw and heard firsthand the deep concern of 
Members, the knowledge that they have about the subject matter, 
and they are reaching out with deep respect to each one of you 
to probe further and seek your professional advice. So I am 
very grateful, and I am very proud of our subcommittee. It is a 
very important one. And I know that Mr. Guthrie shares that 
view, as well.
    So God bless each one of you. I know you are going to keep 
serving our country well. You have served us so well today.
    And with that, I adjourn the Health Subcommittee hearing of 
today, April 14th, the birthday of my son.
    [Whereupon, at 3:43 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]    
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]