[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                      LIVES WORTH LIVING: ADDRESSING THE 
                  FENTANYL CRISIS, PROTECTING CRITICAL LIFE-
                      LINES, AND COMBATING DISCRIMINATION 
                      AGAINST THOSE WITH DISABILITIES

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            FEBRUARY 1, 2023

                               __________

                            Serial No. 118-2
                            
[GRAPHIC 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                    
51-563 PDF                 WASHINGTON : 2023                    
          
-----------------------------------------------------------------------------------                           
                       
                    COMMITTEE ON ENERGY AND COMMERCE

                   CATHY McMORRIS RODGERS, Washington
                                  Chair
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
ROBERT E. LATTA, Ohio                  Ranking Member
BRETT GUTHRIE, Kentucky              ANNA G. ESHOO, California
H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
GUS M. BILIRAKIS, Florida            JAN SCHAKOWSKY, Illinois
BILL JOHNSON, Ohio                   DORIS O. MATSUI, California
LARRY BUCSHON, Indiana               KATHY CASTOR, Florida
RICHARD HUDSON, North Carolina       JOHN P. SARBANES, Maryland
TIM WALBERG, Michigan                PAUL TONKO, New York
EARL L. ``BUDDY'' CARTER, Georgia    YVETTE D. CLARKE, New York
JEFF DUNCAN, South Carolina          TONY CARDENAS, California
GARY J. PALMER, Alabama              RAUL RUIZ, California
NEAL P. DUNN, Florida                SCOTT H. PETERS, California
JOHN R. CURTIS, Utah                 DEBBIE DINGELL, Michigan
DEBBBIE LESKO, Arizona               MARC A. VEASEY, Texas
GREG PENCE, Indiana                  ANN M. KUSTER, New Hampshire
DAN CRENSHAW, Texas                  ROBIN L. KELLY, Illinois
JOHN JOYCE, Pennsylvania             NANETTE DIAZ BARRAGAN, California
KELLY ARMSTRONG, North Dakota, Vice  LISA BLUNT ROCHESTER, Delaware
    Chair                            DARREN SOTO, Florida
RANDY K. WEBER, Sr., Texas           ANGIE CRAIG, Minnesota
RICK W. ALLEN, Georgia               KIM SCHRIER, Washington
TROY BALDERSON, Ohio                 LORI TRAHAN, Massachusetts
RUSS FULCHER, Idaho                  LIZZIE FLETCHER, Texas
AUGUST PFLUGER, Texas
DIANA HARSHBARGER, Tennessee
MARIANNETTE MILLER-MEEKS, Iowa
KAT CAMMACK, Florida
JAY OBERNOLTE, California
                                 ------                                

                           Professional Staff

                      NATE HODSON, Staff Director
                   SARAH BURKE, Deputy Staff Director
               TIFFANY GUARASCIO, Minority Staff Director
                         Subcommittee on Health

                        BRETT GUTHRIE, Kentucky
                                 Chairman
                                 
MICHAEL C. BURGESS, Texas            ANNA G. ESHOO, California
ROBERT E. LATTA, Ohio                  Ranking Member
H. MORGAN GRIFFITH, Virginia         JOHN P. SARBANES, Maryland
GUS M. BILIRAKIS, Florida            TONY CARDENAS, California
BILL JOHNSON, Ohio                   RAUL RUIZ, California
LARRY BUCSHON, Indiana, Vice Chair   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
GREG PENCE, Indiana                  LISA BLUNT ROCHESTER, Delaware
DAN CRENSHAW, Texas                  ANGIE CRAIG, Minnesota
JOHN JOYCE, Pennsylvania             KIM SCHRIER, Washington
DIANA HARSHBARGER, Tennessee         LORI TRAHAN, Massachusetts
MARIANNETTE MILLER-MEEKS, Iowa       FRANK PALLONE, Jr., New Jersey (ex 
JAY OBERNOLTE, California                officio)
CATHY McMORRIS RODGERS, Washington 
    (ex officio)
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     2
    Prepared statement...........................................     4
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     9
    Prepared statement...........................................    11
Hon. Cathy McMorris Rodgers, a Representative in Congress from 
  the State of Washington, opening statement.....................    13
    Prepared statement...........................................    15
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................    19
    Prepared statement...........................................    21
Hon. Robert E. Latta, a Representative in Congress from the State 
  of Ohio, prepared statement....................................   179
Hon. Richard Hudson, a Representative in Congress from the State 
  of North Carolina, prepared statement..........................   184

                               Witnesses

Kemp Chester, Senior Advisor, Office of National Drug Control 
  Policy.........................................................    23
    Prepared statement...........................................    26
    Submitted questions for the record \1\.......................   283
Neeraj Gandotra, M.D., Chief Medical Officer, Substance Abuse and 
  Mental Health Services Administration, Department of Health and 
  Human Services.................................................    37
    Prepared statement...........................................    39
    Answers to submitted questions...............................   287
John DeLena, Associate Administrator, Drug Enforcement 
  Administration, Department of Justice..........................    51
    Prepared statement...........................................    53
    Submitted questions for the record \1\.......................   299
Kandi Pickard, President and Chief Executive Officer, National 
  Down Syndrome Society..........................................   102
    Prepared statement...........................................   104
    Answers to submitted questions...............................   303
Frederick Isasi, Executive Director, Families USA................   110
    Prepared statement...........................................   112
    Additional material submitted for the record.................   120
    Answers to submitted questions...............................   307
Molly A. Cain, Parent Advocate...................................   128
    Prepared statement...........................................   130
Stephen Loyd, M.D., Chief Medical Officer, Cedar Recovery........   135
    Prepared statement...........................................   137
    Answers to submitted questions...............................   309
Timothy W. Westlake, M.D., Emergency Medicine Physician..........   141
    Prepared statement...........................................   143
    Answers to submitted questions...............................   313

----------

\1\ Mr. Chester and Mr. DeLena did not answer submitted questions for 
the record by the time of publication. Replies received after 
publication will be retained in committee files and made available at 
https://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=115361.

                              Legislation

H.R. ___, the Halt All Lethal Trafficking of Fentanyl Act........   186
H.R. ___, the Protecting Health Care for All Patients Act........   205
H.R. ___, the 9-8-8 Lifeline Cybersecurity Responsibility Act....   208
H.R. ___, the Block, Report, and Suspend Suspicious Shipments Act   212

                           Submitted Material

Inclusion of the following was approved by unanimous consent.
Letter of January 31, 2023, from Christopher Banks, President/
  Chief Executive Officer, Autism Society of America, to Mrs. 
  Rodgers and Mr. Pallone........................................   216
Letter of January 30, 2023, from Nicole Jorwic, Chief of Advocacy 
  and Campaigns, Caring Across Generations, to Mrs. Rodgers and 
  Mr. Pallone....................................................   218
Letter of January 31, 2023, from Silvia Yee, Senior Staff 
  Attorney, Disability Rights Education & Defense Fund, to Mrs. 
  Rodgers and Mr. Pallone........................................   220
Letter of January 27, 2023, from Allison Zetterquist, Acting 
  Chief Executive Officer, Epilepsy Foundation, to Mrs. Rodgers 
  and Mr. Pallone................................................   222
Letter of January 31, 2023, from Michael Lewis, Director, 
  Disability Policy, Muscular Dystrophy Association, to Mrs. 
  Rodgers, et al.................................................   224
Letter of January 31, 2023, from Paul C. Langley, Adjunct 
  Professor, College of Pharmacy, University of Minnesota, to Mr. 
  Guthrie, et al.................................................   226
Letter of October 3, 2022, from ACMCRN, et al., to Xavier 
  Becerra, Secretary, Department of Health and Human Services....   229
Letter of January 31, 2023, from Mary Sowers, Executive Director, 
  National Association of State Directors of Developmental 
  Disabilities Services, to Mrs. Rodgers and Mr. Pallone.........   240
Statement of the Partnership to Improve Patient Care, January 30, 
  2023...........................................................   242
Letter of February 1, 2023, from Terry Wilcox, Chief Executive 
  Officer and Founder, Patients Rising Now, to Mr. Guthrie, et 
  al.............................................................   243
Letter of January 31, 2023, from Julie Ward, Senior Executive 
  Officer, Public Policy, The Arc, to Mrs. Rodgers and Mr. 
  Pallone........................................................   248
Letter of January 31, 2023, from Kenneth Hobby, President, Cure 
  SMA, to Mrs. Rodgers...........................................   250
Letter of January 31, 2023, from Marlene Sallo, Executive 
  Director, National Disability Rights Network, to Mrs. Rodgers 
  and Mr. Pallone................................................   252
Report of the National Council on Disability, ``Quality-Adjusted 
  Life Years and the Devaluation of Life with Disability,'' 
  November 6, 2019 \2\
Letter of December 14, 2021, from Brian R. Marvel, President, 
  Peace Officers Research Association of California, to Senator 
  Bill Cassidy, et al............................................   255
Policy Brief of the National Council on Disability, 
  ``Alternatives to QALY-Based Cost-Effectiveness Analysis for 
  Determining the Value of Prescription Drugs and Other Health 
  Interventions,'' November 28, 2022 \2\
Article of January 31, 2009, ``Principles for allocation of 
  scarce medical interventions,'' by Govind Persad, Alan 
  Wertheimer, and Ezekiel J Emanuel, The Lancet..................   256
Article of March 27, 2020, ``People With Intellectual 
  Disabilities May Be Denied Lifesaving Care Under These Plans as 
  Coronavirus Spreads,'' by Amy Silverman, Arizona Daily Star....   265
Statement of Regina M. LaBelle, Director, Addiction and Public 
  Policy Initiative, O'Neill Institute for National and Global 
  Health Law, Georgetown University Law Center...................   270
Letter of March 8, 2017, from Sara Hart Weir, President, National 
  Down Syndrome Society, to Members of the Senate and House of 
  Representatives................................................   275
Fact sheet, ``Illicitly Manufactured Fentanyl as a Weapon of Mass 
  Destruction: Rhetoric and Reality,'' Addiction and Public 
  Policy Initiative, O'Neill Institute for National and Global 
  Health Law, November 2022......................................   279
Report of the National Institute on Drug Abuse, ``Medications to 
  Treat Opioid Use Disorder Research Report,'' December 2021\2\

----------

\2\ The information has been retained in committee files and is 
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=115361.

 
LIVES WORTH LIVING: ADDRESSING THE FENTANYL CRISIS, PROTECTING CRITICAL 
LIFELINES, AND COMBATING DISCRIMINATION AGAINST THOSE WITH DISABILITIES

                              ----------                              


                      WEDNESDAY, FEBRUARY 1, 2023

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:01 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Brett Guthrie (chairman of the subcommittee) presiding.
    Members present: Representatives Guthrie, Bucshon, Burgess, 
Latta, Griffith, Bilirakis, Johnson, Hudson, Carter, Dunn, 
Crenshaw, Joyce, Harshbarger, Miller-Meeks, Obernolte, Rodgers 
(ex officio), Eshoo (subcommittee ranking member), Sarbanes, 
Cardenas, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt 
Rochester, Craig, Schrier, Trahan, and Pallone (ex officio).
    Staff present: Alec Aramanda, Professional Staff Member, 
Health; Kate Arey, Content Manager and Digital Assistant; Jolie 
Brochin, Clerk, Health; Sarah Burke, Deputy Staff Director; 
Kristin Flukey, Professional Staff Member, Health; Theresa 
Gambo, Financial and Office Administrator; Seth Gold, 
Professional Staff Member, Health; Grace Graham, Chief Counsel, 
Health; Nate Hodson, Staff Director; Peter Kielty, General 
Counsel; Emily King, Member Services Director; Chris Krepich, 
Press Secretary; Clare Paoletta, Professional Staff Member, 
Health; Carla Rafael, Staff Assistant; Michael Taggart, Policy 
Director; Lydia Abma, Minority Policy Analyst; Jacquelyn Bolen, 
Minority Health Counsel; Waverly Gordon, Minority Deputy Staff 
Director and General Counsel; Tiffany Guarascio, Staff 
Director; Perry Hamilton, Minority Member Services and Outreach 
Manager; Saha Khaterzai, Minority Professional Staff Member; 
Una Lee, Minority Chief Health Counsel; Juan Negrete, Minority 
Professional Staff Member; Greg Pugh, Minority Staff Assistant; 
Andrew Rosario, Minority Health Fellow; Andrew Souvall, 
Minority Director of Communications, Outreach, and Member 
Services; Tristen Tellman, Minority Health Fellow; Rick Van 
Buren, Minority Senior Health Counsel; and C.J. Young, Minority 
Deputy Communications Director.
    Mr. Guthrie. The Subcommittee on Health will now come to 
order.
    The microphone is not on? It should be on. Yes, it is. Wow. 
I hit the button.
    Anyway, things you have to learn, right?
    Well, thanks a lot. I appreciate everybody being here 
today. And I appreciate working with Democrat Leader Eshoo. We 
enjoyed working together last Congress, and we will continue to 
do so. We have a lot of things before us.
    But the subcommittee will come to order. And the Chair now 
recognizes himself for 5 minutes for an opening statement.

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

    As we turn the page on both 2022 and the 117th Congress, 
thousands of Americans and their families are still reeling 
from failures by this administration and the last Congress to 
meaningfully address one of the greatest public health threats 
of our lifetimes, the fentanyl crisis.
    Over the past several years, the United States has seen a 
historic rise of drug overdoses, driven by an increased supply 
of synthetic opioids such as illicit fentanyl analogs. In 2021 
alone, there were over 107,000 drug overdoses reported, 
according to the Centers for Disease Control and Prevention, 
and over 60,000 of these were caused by synthetic opioids. My 
home State of Kentucky experienced a 14 percent jump in drug 
overdose deaths between 2020 and 2021, with over 70 percent of 
these deaths being caused by fentanyl alone.
    Sadly, you cannot go a week without reading or hearing 
about the stories of mothers, sons, sisters, brothers, and 
cherished friends and even babies losing their lives to 
fentanyl overdoses.
    How could this be possible? We don't have to look farther 
than the crisis right now at our southern border. Since last 
October, October of last year, our Border Patrol authorities 
have seized over 7,000 pounds of illicit fentanyl at our 
southwest border. This is on top of the over 14,000 pounds of 
illicit fentanyl seized the prior year. The dual crises, both 
the fentanyl and border crises, have effectively turned every 
community across the United States into a border community.
    Fortunately, this very subcommittee has the ability to take 
action and do what we know will work to help keep illicit 
fentanyl out of our communities and save lives.
    One of the bills before us today, H.R. 467, the Halt All 
Lethal Trafficking of Fentanyl Act, also known as the HALT 
Fentanyl Act, would take the critical step of permanently 
scheduling all fentanyl-related substances as Schedule I drugs 
under the Controlled Substances Act.
    Congress has enacted temporary extensions several times 
over the last few years. These continued temporary solutions 
are not sustainable. We need a permanent solution and must pass 
the HALT Fentanyl Act now. Doing so will be my top priority as 
long as I am chairman of this Health Subcommittee.
    I want to address the demand for illegal and dangerous 
drugs here in the United States while simultaneously focusing 
on support for recovery services for those who want help. We 
will have an opportunity later this year to reauthorize key 
parts of the SUPPORT Act, and we will be able to examine how to 
get people into recovery and keep them safe.
    But if we have learned anything over the past few years, it 
is that these illicit fentanyl analogs are an entirely 
different class of drugs than any other deadly substance that 
our country has faced thus far and has the ability to make 
other illegal drugs that much more lethal.
    Further, the Block, Report, and Suspend Suspicious 
Shipments Act, introduced by one of our newest subcommittee 
members, Representative Harshbarger, would also address the 
overdose crisis. This bill would require drug manufacturers and 
distributors to report all suspicious shipments of controlled 
substances to the Drug Enforcement Agency and require these 
entities to decline to fill such orders.
    Fighting the overdose epidemic necessitates a multipronged 
approach and a strong partnership between the public and 
private sectors, which this legislation accomplishes. I thank 
Representative Harshbarger for leading on this issue.
    The other important pieces of legislation before us today 
are equally as focused on protecting the sanctity of life. The 
988 Lifeline Cybersecurity Act would ensure that the lifesaving 
988 Suicide and Crisis Hotline is protected from cyber 
vulnerabilities.
    This comes after the lifeline suffered a cyber attack in 
early December which resulted in an hours-long outage of the 
lifeline. This cannot happen again, and I look forward to 
moving this bill through committee.
    Finally, we are examining legislation to permanently ban 
the use of quality-adjusted life years in all publicly funded 
healthcare programs like Medicare and Medicaid. It is long 
overdue for Congress to take the necessary step of banning 
QALYs. With the Protecting Health Care for All Patients Act 
before us today, this would be finally achieved.
    Such policies arbitrarily put a value on someone's life and 
are especially discriminatory towards those living with 
disabilities. A life worth living is always a life worth 
saving, regardless of someone's health status. I know this bill 
is personal and very important to our chair of the full 
committee, Chair McMorris Rodgers.
    I urge all of my colleagues on this subcommittee to support 
these four bills before us today.
    Thank you, and I yield back.
    [The prepared statement of Mr. Guthrie follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. The Chair now recognizes the subcommittee 
ranking member, Ms. Eshoo, for 5 minutes for an opening 
statement.

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

    Ms. Eshoo. Well, good morning, everyone.
    And thank you, Mr. Chairman. And, first of all, my warmest 
congratulations to you on becoming the chairman of this, what I 
think is an extraordinary Health Subcommittee.
    And welcome to the new members of this subcommittee. You 
are going to love serving here. And I know, from this side of 
the aisle, that we look forward to working with you for the 
benefit of the American people.
    Our first hearing today focuses on an issue this 
subcommittee has been struggling with for nearly 25 years, the 
opioid crisis.
    Over 900,000 Americans have died from opioids since 1999, 
including more than 107,000 deaths in just the last year. The 
country has had three waves of opioid deaths: prescription 
opioids, heroin opioids, and now fentanyl.
    Fentanyl is a synthetic opioid that is up to 50 times 
stronger than heroin and 100 times stronger than morphine. 
According to the CDC, over 66 percent of the overdose deaths in 
2021 were caused by fentanyl.
    Today, our subcommittee considers H.R. 467, the HALT 
Fentanyl Act, to address this epidemic.
    What is unfortunate is that the HALT Fentanyl Act does 
nothing to change the status quo. For the past 5 years, all 
fentanyl-related substances have been considered Schedule I 
drugs. The HALT Fentanyl Act would continue that scheduling.
    Scheduling doesn't stop deaths. Since 2018, when fentanyl-
related substances first became Schedule I, fentanyl deaths 
have risen by over 50 percent. So we have to do much more to 
save lives.
    First, I think we need to stop the supply of illicit 
fentanyl. We are making progress through record-breaking DEA 
seizures. For example, last year the DEA seized 10,000 pounds 
of illicit fentanyl powder--10,000 pounds. I mean, it is so 
difficult to get your head wrapped around these figures.
    There is another part of this, though, and it isn't really 
very often spoken about. I believe that we have broken gun 
laws. In this case, Mexican cartels are trading--they are 
trading illicit fentanyl for readily available American guns. 
We need to stop this so-called ``iron river'' of death between 
our two countries.
    Another major contributing factor to overdoses is the 
difficulty finding treatment. According to SAMHSA, only 11 
percent of people--only 11 percent, so 89 percent of people 
with opioid addiction do not receive medication-assisted 
treatment.
    Importantly, in December, Congressman Tonko's MAT Act 
became law. The new law eliminates bureaucratic guardrails that 
limit the availability of medication-assisted treatment. 
Medication-assisted treatment is proven to reduce overdose 
deaths and curb illicit drug use.
    Naloxone is another miracle medicine that saves lives. 
Anyone can use it to rapidly reverse opioid overdose. And I 
commend the FDA's recent work to make naloxone available over 
the counter. And I urge all the makers of this drug, including 
Emergent and Kaleo, to begin switching their product labels 
from prescription to over-the-counter.
    I look forward to hearing from ONDCP, SAMHSA, and the DEA 
today about what else Congress should do to change the status 
quo and save lives.
    We will also hear two other bills unrelated to fentanyl. 
H.R. 498, the 988 Lifeline Cybersecurity Responsibility Act, is 
a commonsense bill that requires the 988 network administrator 
to report potential cybersecurity threats to SAMHSA immediately 
upon discovery. I support that bill.
    H.R. 485 is focused on ending the Federal Government's use 
of quality-adjusted life years metrics, also known as QALYs. I 
support ending the use of discriminatory QALYs, because the 
metric devalues the lives of people with disabilities.
    So I look forward to learning more about the bill and its 
impact, Mr. Chairman, during today's hearing.
    So congratulations once again. It is your opening day. And, 
again, look forward to working with you.
    And I yield back.
    [The prepared statement of Ms. Eshoo follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. Thank you very--I thank the gentlelady for 
yielding back.
    And the Chair will now recognize the chair of the full 
committee, Mrs. McMorris Rodgers, for 5 minutes for an opening 
statement.

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

    Mrs. Rodgers. Thank you, Mr. Chair.
    Welcome, everyone, to the legislative hearing titled 
``Lives Worth Living: Addressing the Fentanyl Crisis, 
Protecting Critical Lifelines, and Combating Discrimination 
Against Those with Disabilities.'' We will hear from a diverse 
panel on how we can advance solutions that will help people in 
need of hope and healing in our communities.
    Last month, the Energy and Commerce Republicans held a 
roundtable on the fentanyl crisis, and we heard from Deb and 
Ray Cullen, who had lost their son, Zach. They told us they 
will never forget the moment that the police showed up at their 
door asking if they were Zach's parents. He was just 9 days 
past his 23rd birthday, and he was targeted and poisoned by a 
drug dealer.
    Today, we will hear from Molly Cain from my hometown of 
Spokane, Washington. She lost her son, Carson, to fentanyl 
poisoning when he was also 23 years old.
    Deb, Ray, and Molly have experienced immeasurable pain from 
losing their children, and they deserve justice. That is why 
Reps Griffith and Latta are working on the HALT Fentanyl Act. 
This bill would permanently place fentanyl-related substances 
into Schedule I of the Controlled Substances Act and make sure 
that our law enforcement can keep these weapons-grade poisons 
off the streets.
    Unfortunately, the administration is proposing to treat 
these deadly poisons differently from fentanyl and other 
currently scheduled fentanyl-related substances. The 
administration supports exempting the entire class from 
mandatory minimums that are typically imposed upon drug 
dealers, drug traffickers, preventing law enforcement from 
stopping those who would bring deadly substances into our 
communities.
    If the temporary legislation were to expire, it would mean 
the criminals who kill people like Zach and Carson could keep 
trafficking these lethal substances with little consequences. 
So let's make it permanent.
    And I am hopeful that we can work together, both sides of 
the aisle, to make sure that we take action that will punish 
those who make and import and distribute these poisons to our 
children.
    I also want to recognize Mrs. Harshbarger's bill in 
introducing the Block, Report, and Suspend Suspicious Shipments 
Act.
    The opioid epidemic is fueled in part by suspiciously large 
shipments of pain medication being delivered across the 
country, especially in places like Tennessee and West Virginia. 
This bill would stop this practice and save lives by requiring 
drug manufacturers and distributors that discover a suspicious 
order for controlled substances to halt the order and report 
the information to DEA.
    Additionally, just last month we learned about a cyber 
attack on the 988 Suicide and Crisis Lifeline. This lifeline is 
a network of local crisis centers that promotes emotional 
support to people in suicidal crisis or emotional distress. It 
is a critical tool that was established by the bipartisan work 
of this committee, and we must ensure that it is protected from 
future cyber threats.
    Representative Obernolte's 988 Lifeline Cybersecurity 
Responsibility Act would do just that. It requires coordination 
and reporting to improve cybersecurity protections for the 988 
Lifeline.
    Finally, we will discuss why it is important to take action 
to protect people with disabilities with the Protecting Health 
Care for All Patients Act. It would ban quality-adjusted life 
years, or QALYs, that discriminate against people with 
disabilities and patients with debilitating or life-threatening 
health conditions.
    QALYs undervalue treatments for patients who have shorter 
lifespans than others. In countries with QALYs, the most 
vulnerable get pushed to the back of the line for treatment. 
People like those with cystic fibrosis, ALS, or people like my 
son with Down syndrome, the government says that their lives 
don't matter as much. They are not valuable enough.
    In America, where we have led the world in amazing medical 
breakthroughs and innovation, we must ban QALYs and strongly 
affirm that every life is worth living. It is my sincere hope 
that we can move forward on this bill with bipartisan support.
    Families need hope. And there is inherent dignity in every 
human life. And that is why we are coming together today in our 
first legislative hearing this Congress, and I look forward to 
hearing more.
    I appreciate everyone being here to testify as we work 
together to promote life, liberty, and the pursuit of happiness 
for all.
    Thank you, and I yield back.
    [The prepared statement of Mrs. Rodgers follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. I thank the chair for yielding back.
    The Chair recognizes the ranking member of the full 
committee, Mr. Pallone, for 5 minutes.

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

    Mr. Pallone. Thank you, Chairman Guthrie.
    And I believe the top priority of this subcommittee is 
ensuring all Americans have access to quality and affordable 
health coverage so they can live long and healthy lives.
    And I am also proud of this subcommittee's work in the last 
Congress, which is a testament to the life-changing and 
lifesaving policies we can achieve if we work together.
    Last Congress, we passed landmark laws that make healthcare 
and prescription drugs more affordable; we expanded access to 
healthcare, including to children and mothers, through CHIP and 
Medicaid; we equipped the Food and Drug Administration and the 
Centers for Disease Control and Prevention with critical tools 
and resources to maintain and enhance our Nation's public 
health; and we made significant investments to address the 
mental health and substance use disorder crisis, including 
implementing historic policy reforms to address the overdose 
crisis. Specifically, we included the MAT Act, which will 
increase access to lifesaving treatments for those experiencing 
substance use disorders.
    We accomplished a tremendous amount, and I commend every 
member of the subcommittee for their dedication and hard work.
    Now, today, we will discuss the scourge that is illicit 
fentanyl and fentanyl-related substances, which have caused so 
much harm and death to our families, friends, and constituents.
    The policies passed in the fiscal year 2023 omnibus in 
December, some of which I just mentioned, are concrete examples 
of the work we are doing to save lives.
    I am disappointed that our first hearing in the Health 
Subcommittee does not build on the successes of last Congress 
but, rather, that my Republican colleagues have chosen to take 
a different route with the partisan HALT Fentanyl Act.
    We have learned time and time again that we cannot 
incarcerate our way out of a public health crisis and that a 
broader public health approach is needed to address what is at 
its root a health problem.
    Moreover, my Republican colleagues were unwilling to 
consider any Democratic bills to address the overdose crisis 
for inclusion in this hearing, and that is disappointing. If 
Republicans are serious about finding a long-term solution, 
then they should be willing to discuss bipartisan, evidence-
based policies to address the substance use and overdose 
crisis.
    One such bill is the bipartisan Save Americans from the 
Fentanyl Emergency Act, which was introduced by Representatives 
Pappas, Newhouse, and Gonzales. This legislation reflects the 
administration's comprehensive approach to address the fentanyl 
crisis. Our Nation's law enforcement and public health agencies 
both agreed to this approach.
    I am disappointed that this bill was not included in the 
hearing, as well as many other bipartisan bills that would help 
us address the overdose crisis. Representative Tonko's 
bipartisan Reentry Act would ensure that individuals 
transitioning out of the justice system and into our 
communities have access to treatment for substance use 
disorders.
    We are also considering a bill today to ban the use of 
quality-adjusted life years, often referred to as QALYs, in 
value measurements and price determinations set by Federal 
agencies and States.
    While I appreciate and respect the perspective of those in 
the disability community about any economic metrics that value 
certain lives differently, I fear this bill is a solution in 
search of a problem. Federal law already prohibits the use of 
QALYs in Medicare, and Medicaid is required to cover, with 
limited exceptions, every outpatient drug covered by the 
program if a manufacturer has a rebate agreement in place.
    As I mentioned earlier, Democrats delivered on our promise 
to lower drug prices last year with the enactment of the 
Inflation Reduction Act. That new landmark law provides the 
Secretary of Health and Human Services with the authority to 
negotiate lower drug prices for Medicare beneficiaries for the 
first time, while also explicitly prohibiting the use of QALYs 
in this process.
    I fear this bill would be a Trojan horse that goes far 
beyond just banning QALYs by potentially banning all other 
kinds of ways of measuring a drug's value. This would result in 
artificially keeping drug prices and healthcare costs high 
while also tying the hands of the Federal Government in 
determining the value of healthcare services and treatments.
    So, again, if my Republican colleagues want to discuss how 
to best protect the disability community, we should consider 
the impacts of proposed cuts that the Republican majority wants 
to make in exchange for a debt ceiling increase.
    The Republican Study Committee's budget for fiscal year 
2023 calls for cutting Medicaid and CHIP by $3.6 trillion and 
cutting Medicare by $2.8 trillion. These drastic cuts will be 
devastating for the millions of people with disabilities who 
rely on Medicaid for their health and well-being.
    The Republican plan to slash and burn Medicaid is an 
existential threat to a major source of health insurance for 
individuals with disabilities, and Democrats will aggressively 
oppose these cuts.
    As for today's hearing, I welcome the discussion on how we 
move forward to address the fentanyl crisis, and I hope that in 
the coming weeks the subcommittee can discuss bipartisan 
solutions that were unfortunately not included in this hearing 
today.
    And, with that, I yield back, Mr. Chairman.
    [The prepared statement of Mr. Pallone follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. The gentleman yields back. And I do look 
forward to working together as we move forward on reauthorizing 
the SUPPORT Act this year.
    We now conclude with Member opening statements. The Chair 
would like to remind Members that, pursuant to the committee 
rules, all Members' opening statements will be made part of the 
record.
    We will now move to our witnesses. We want to thank all of 
our witnesses for being here today and taking the time to 
testify before the subcommittee.
    Each witness will have the opportunity to give an opening 
statement, followed by a round of questions from Members.
    Our witnesses today are Mr. Kemp Chester, a senior advisor 
at the Office of National Drug Control Policy with expertise in 
international relations and supply reduction. Then we will have 
Dr. Neeraj Gandotra, the Chief Medical Officer for the 
Substance Abuse and Mental Health Services Administration. And, 
finally, we will be joined Mr. Jon DeLena, the Associate 
Administrator at the Drug Enforcement Administration.
    We appreciate you being here today. We will recognize each 
for 5 minutes. I think you have all testified before and know 
the lighting system. You will have a yellow light just to give 
you a warning, and then a red light means to wrap up.
    So we appreciate that, and we appreciate you being here.
    I will now recognize our first witness to give 5 minutes 
for an opening statement. Mr. Chester, you are recognized for 5 
minutes.

STATEMENTS OF KEMP CHESTER, SENIOR ADVISOR, OFFICE OF NATIONAL 
   DRUG CONTROL POLICY; NEERAJ GANDOTRA, M.D., CHIEF MEDICAL 
      OFFICER, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES 
 ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND 
     JON DeLENA, ASSOCIATE ADMINISTRATOR, DRUG ENFORCEMENT 
             ADMINISTRATION, DEPARTMENT OF JUSTICE

                   STATEMENT OF KEMP CHESTER

    Mr. Chester. Chairman Guthrie, Ranking Member Eshoo, 
members of the subcommittee, thank you for inviting me to 
testify today on the illicit drug environment we face in the 
United States and our efforts to address it.
    The administration is taking a number of tangible steps to 
reduce drug-related deaths, expand access to treatment for 
substance use disorder, and target the global production and 
trafficking of synthetic opioids like illicit fentanyl which 
currently kill more than 107,000 Americans every year.
    The administration's National Drug Control Strategy focuses 
on attacking the two drivers of the opioid epidemic: untreated 
addiction and the drug-trafficking profits that fuel this 
crisis.
    In terms of public health, we are expanding access to 
substance use prevention, harm reduction in addiction 
treatment, and recovery support services.
    And I want to thank the Congress for including key 
provisions of the MAT Act in the bipartisan omnibus government 
funding bill, which will allow prescribers across the country 
to treat their patients who have opioid use disorder with 
buprenorphine without additional Federal licensing.
    We are also working to remove barriers to naloxone, make 
permanent the COVID-19 flexibilities that expanded access to 
treatment, address emerging threats like xylazine being added 
into illicit fentanyl. And we look forward to working with the 
Congress to make permanent the 2-year extension of the 
scheduling of all fentanyl-related substances as a class.
    But while the opioid epidemic is a daunting public health 
issue, it presents a serious national security and economic 
prosperity challenge for the United States as well. The vast 
majority of the substances harming Americans are produced 
outside the United States and brought across our borders 
through a variety of means.
    To address this very real threat, we have taken a new and 
more comprehensive approach to this problem: to commercially 
disrupt the global business of illicit synthetic drug 
production and trafficking.
    We will target not only the finished drugs themselves and 
those who sell them but also the raw materials and machinery 
used to produce them, the commercial shipping that moves these 
items around the world, and the illicit financial structure 
that allows this global business to operate and allows drug 
traffickers to profit from the suffering of others.
    Using new authorities provided by Executive order, the 
Department of the Treasury has imposed sanctions against dozens 
of individuals and entities involved in the illicit drug trade, 
including illicitly manufactured fentanyl.
    In 2022 alone, Customs and Border Protection seized nearly 
262,000 pounds of illicit narcotics, including 15,000 pounds of 
fentanyl. And our HIDTA task forces seized more than 737,000 
pounds of drugs, including 26,000 pounds of illicit fentanyl in 
the United States.
    These are drugs permanently removed from the illicit supply 
chain, not killing our citizens. And domestic seizures alone 
denied $9 billion in profits and critical operating capital to 
drug traffickers.
    And the President has asked for increased funding for both 
Customs and Border Protection and the Drug Enforcement 
Administration to enable their vital work in keeping our Nation 
safe from these dangerous drugs.
    However, this problem does not begin or end at the United 
States border. This is a global problem that has negative 
effects not only in the United States but also the rest of the 
world. And American leadership at the global level is 
absolutely essential.
    These deadly drugs are manufactured using precursor 
chemicals made available by criminal elements, often in the 
People's Republic of China, that are shipped to Mexico, where 
they are used to produce illicit fentanyl or one of its analogs 
and often pressed into the counterfeit pills that have poisoned 
so many Americans.
    The administration is working bilaterally with our 
international partners, particularly Mexico, the People's 
Republic of China, India, and others, and multilaterally to 
address the global threat of illicit synthetic opioid 
production and trafficking.
    I am pleased to say that, as a result of our work in the 
public health and law enforcement domains, we are beginning to 
see some progress, with 5 straight months of decreased drug-
involved deaths.
    Together, the administration and the Congress are changing 
the trajectory of a complex national security, criminal 
justice, and public health challenge that has vexed the Nation 
for the better part of three decades. There are signs of hope, 
but we have a very long way to go.
    On behalf of Dr. Gupta and the men and women of the Office 
of National Drug Control Policy, thank you for your foresight 
and leadership on this difficult issue, and we look forward to 
continuing our work with you in the months and the years ahead.
    Thank you, and I look forward to your questions.
    [The prepared statement of Mr. Chester follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. Thank you.
    The gentleman yields back.
    And I will now recognize Dr. Gandotra for 5 minutes for 
your opening statement.

               STATEMENT OF NEERAJ GANDOTRA, M.D.

    Dr. Gandotra. Good morning. Thank you, Chair Guthrie, 
Ranking Member Eshoo, Chair McMorris Rodgers, Ranking Member 
Pallone, and members of the subcommittee, for inviting me to 
testify at this hearing covering fentanyl and the 988 Suicide 
and Crisis Lifeline, among other topics.
    My name is Dr. Neeraj Gandotra, and I am Chief Medical 
Officer for the Substance Abuse and Mental Health Services 
Administration, also known as SAMHSA. SAMHSA leads public 
health efforts to improve behavioral health of our Nation.
    I am pleased to be here along with my colleagues from the 
White House Office of National Drug Control Policy and the Drug 
Enforcement Administration.
    I look forward to discussing our work at SAMHSA, which aims 
to support all aspects of the care continuum, from prevention 
and harm reduction to treatment, crisis care, and sustained 
recovery services.
    Ultimately, SAMHSA envisions people with, affected by, or 
at risk for mental health and substance use conditions receive 
care, thrive, and achieve well-being.
    Over the past few years, we have seen the opioid overdose 
epidemic evolve. We are now faced with the reality that 
fentanyl and substances laced with fentanyl are far more deadly 
than other opioids or stimulants alone.
    That is why addressing addiction and the overdose epidemic 
are one of the four pillars of the Unity Agenda that the 
President outlined in last year's State of the Union Address.
    Additionally, at the beginning of the Biden-Harris 
administration, Secretary Becerra released the comprehensive 
HHS Overdose Prevention Strategy, which is designed to increase 
both access to primary substance use prevention activities and 
access to the full range of services for individuals at risk 
for overdose as well as services for their families. This 
strategy prioritizes four key areas: primary prevention, harm 
reduction, evidence-based treatment, and recovery support.
    SAMHSA's substance abuse prevention programs target at-risk 
populations and specific age groups to stop substance use 
before it starts. We work with State and local partners to 
reach people where they are and to reduce the impacts of 
substance misuse. For example, SAMHSA's First Responders-CARA 
program trains first responders on how to respond to overdose-
related incidents and provides training on naloxone 
administration.
    SAMHSA also provides funding and support for evidence-based 
harm-reduction services. Our harm-reduction grants support 
activities such as expanded distribution of overdose-reversal 
medications and fentanyl test strips. It also provides overdose 
education and counseling and works to stop the spread of 
infectious diseases.
    Fentanyl test strips are an important component of harm-
reduction programs, education and awareness-building toolkits, 
and low-threshold, on-demand treatment programs. All of these 
are efforts that help save lives.
    Because of Congress' commitment to treatment programs and 
thanks to December's omnibus, SAMHSA is actively working with 
Federal partners to implement the removal of the DATA 2000 
waiver and related policies so that more Americans can access 
this lifesaving medication.
    In addition to preventing and treating substance use, we 
also ensure that patients in mental health and substance use 
crisis are quickly directed to the appropriate level of care. 
This work includes helping States and localities coordinate 
crisis services through the 988 Suicide and Crisis Lifeline. 
The lifeline helps connect individuals with trained counselors 
and, if needed, crisis intervention and stabilization services. 
It may also include warm handoffs to treatment providers.
    Thanks to the support from Congress, the lifeline is 
serving more Americans in crisis. For example, when comparing 
December 2021 with December 2022, the 988 Lifeline answered 
434,000 contacts, which is 172,000 more calls, chats, and texts 
versus 2021, and it has also significantly improved how quickly 
these contacts were answered. Additionally, when comparing 
December 2022 to December 2021, calls, chats, and texts 
answered all increased--48 percent, 263 percent, and 1,443 
percent, respectively.
    In closing, on behalf of my colleagues at SAMHSA, thank you 
for supporting our programs and for working to improve our 
Nation's behavioral health. I would be pleased to answer any 
questions that you might have.
    [The prepared statement of Dr. Gandotra follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. I appreciate your testimony.
    The gentleman yields back.
    And I will recognize Mr. DeLena for 5 minutes for an 
opening statement.

                    STATEMENT OF JON DeLENA

    Mr. DeLena. Good morning, Subcommittee Chairman Guthrie, 
Ranking Member Eshoo, Committee Chair McMorris Rodgers, Ranking 
Member Pallone, and distinguished members of this subcommittee.
    On behalf of the Department of Justice and, in particular, 
the approximately 10,000 employees of the Drug Enforcement 
Administration, it is my honor to appear before you today. I 
thank the committee for bringing attention to this important 
topic.
    Today's hearing comes at a critical moment in our country's 
history. Our Nation is in the midst of a devastating drug 
poisoning epidemic that claimed the lives of over 107,000 
people this past year. An estimated 294 people die every day 
from drug poisoning, and countless more overdose and survive.
    I have had the privilege of being a DEA special agent for 
nearly 27 years. I have worked in Colorado, Florida, Virginia, 
and my home region, New England. The current drug poisoning 
epidemic is like nothing I have ever experienced in my career.
    In 2022, DEA seized more than 50 million fake pills and 
10,000 pounds of fentanyl powder. That is approximately 379 
million deadly doses of fentanyl taken off of American streets. 
That is enough fentanyl to supply a potentially lethal dose to 
every member of the U.S. population.
    As a country, we must do everything we can to stop this 
national crisis. For our part, the men and women of the DEA are 
relentlessly focused, day in and day out, on combating the 
deadly drug poisoning epidemic and on saving lives.
    DEA leads and coordinates the whole-of-government response 
to defeat the two Mexican drug cartels, the Sinaloa Cartel and 
the Jalisco Cartel, that are responsible for driving the drug 
poisoning epidemic in all of our communities.
    A unified response, with DEA in the lead, ensures that the 
whole of government is moving in one direction. Through this 
unified response, we can protect the safety and health of 
Americans.
    The Sinaloa and Jalisco cartels pose the greatest criminal 
drug threat the United States has ever faced. These ruthless, 
violent criminal organizations have associates, facilitators, 
and brokers in all 50 States as well as in more than 40 
countries around the world.
    The Sinaloa and Jalisco cartels control the supply chain 
for illicit fentanyl. They obtain precursors from China and use 
these precursor chemicals to manufacture fentanyl and other 
synthetic drugs in clandestine laboratories in Mexico. The 
cartels take that fentanyl and press it into fake prescription 
pills and other drugs. The cartels then transport fentanyl in 
pill and powder form, as well as other drugs like 
methamphetamine, heroin, and cocaine, into the United States.
    I have seen firsthand what the Mexican cartels have done to 
our great country. The cartels are destroying families and 
communities with callous indifference and greed.
    The DEA is working across its global operations to defeat 
these two cartels and protect our communities. I would like to 
briefly highlight three initiatives in particular.
    First are the counter-threat teams. DEA launched two cross-
agency counterthreat teams that focus exclusively on defeating 
the Sinaloa Cartel and Jalisco Cartel. The teams use a network-
focused approach. They are mapping, analyzing, and targeting 
the cartels' entire operations. The teams will use all of the 
resources at their disposal to defeat these two cartels.
    The second initiative is Operation Overdrive, which targets 
drug-trafficking organizations and gangs that are responsible 
for the greatest number of deaths and violence. Operation 
Overdrive is a data-driven approach that is currently in 57 
locations across the country, and we will expand.
    The final initiative I would like to highlight are DEA's 
family summits. In June and November of 2022, DEA brought 
together families from across the country who have lost loved 
ones to drug poisoning. The summits were incredibly impactful. 
They were an opportunity for DEA to explain what we are doing 
to combat the drug poisoning epidemic, but, more importantly, 
it was an opportunity for families to share their stories with 
one another and with us.
    Throughout my career, I have partnered with families, local 
groups, prevention specialists, and community outreach 
organizations for events big and small, and I appreciate the 
great work that they do and feel very strongly that the 
connections we have made with these people and these families 
will help educate, spread awareness, and save lives.
    Congress, of course, has an important role to play. I 
personally want to thank and extend my sincere thanks to the 
Members of Congress who have worked so hard to ensure the 
temporary classwide scheduling of fentanyl-related substances 
does not expire. Classwide scheduling is critical to DEA's 
ability to seize FRS when they are encountered and to 
investigate and prosecute those that manufacture and traffic in 
these deadly drugs. I urge Congress to make the temporary 
scheduling permanent. This is critical to the safety and health 
of Americans.
    Thank you for the opportunity to testify before your 
subcommittee on this important issue, and I look forward to 
your questions.
    [The prepared statement of Mr. DeLena follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Guthrie. Thank you.
    The gentleman yields back.
    I thank the witnesses for their testimony.
    And we will begin--we will now move into the Q&A portion of 
the hearing. I will begin the questioning and recognize myself 
for 5 minutes.
    So, Mr. Chester, first, we had Dr. Gupta in Bowling Green, 
Kentucky, my hometown, with Leader McConnell. And a lot of my 
law enforcement guys were real concerned. And it goes back to a 
comment that you made in a hearing in December 2021. And you 
were defending the context of--what they were upset about is 
that--and a lot of us are concerned about--is the 
administration's position to schedule fentanyl-related 
substances as a Schedule I but exempt it from the mandatory 
minimums.
    And in defending that policy before, you made this 
statement, and I will quote it to you. It says: The 
administration, quote, ``has gathered up an entire class of 
substances uncreated that, within the class of substance, there 
may be substances that either have medical merit or are not the 
least bit harmful. They are not any more harmful than water,'' 
unquote. That was a direct quote.
    I just can't imagine anywhere that a cartel would smuggle 
fentanyl analogs into our country that is not as harmful as 
water. Would you clarify that statement?
    Mr. Chester. Thank you for your question, Congressman. Yes. 
And I remember that. I remember that very clearly----
    Mr. Guthrie. I do, too.
    Mr. Chester [continuing]. When we were talking about two 
sides of the same coin, with gathering up an entire class of 
substances that have not been subjected to testing. And so it 
is chemically possible that there are alterations to the 
fentanyl molecule that have no effect on the body.
    The question is, we don't know that. And so, not until they 
are subjected to the three- and the eight-factor analysis that 
the FDA does that the effect on the body of these substances 
can be determined.
    Traffickers often create new substances based upon their 
chemical structure and then move them in and then ask for 
customer feedback afterwards. And this is something that we see 
quite often. They experiment with substances by sending them 
out and then hear what the users provide in terms of feedback.
    So there is a possibility that a trafficker creates a 
substance based upon the fentanyl molecule, maybe a deletion of 
the fentanyl molecule, sends it out, and it winds up having no 
effect on the body at all.
    Mr. Guthrie. That just seems--maybe that--I just can't 
imagine a cartel--maybe they do send some of this.
    But, anyway, you have illegal cartels smuggling drugs into 
our country. Say they have no effect, somebody takes them and 
complains, ``I took this pill. It has no effect.'' That is 
still an illegal cartel moving drugs into this country.
    The other one you said may have medical merit. You know, 
fentanyl in itself has medical merit, except it is illegal and 
is subject to mandatory minimums if you illegally traffic 
fentanyl.
    So I just--it is concerning the administration has that 
position and--it is concerning to me.
    So, Mr. DeLena, you are in the DEA. Do you believe that we 
should permanently--you said in your testimony that permanently 
scheduling illicit fentanyl analogs has an effect and you have 
the ability to--it gives you more authority. Would you care to 
just talk about how important it is for your administration to 
have this bill in place?
    Mr. DeLena. Thank you for the question, Congressman.
    It is the top legislative priority for DEA to permanently 
schedule fentanyl as a classwide substance. We have never seen 
a deadlier drug, and we have seen the impact throughout the 
entire United States.
    Mr. Guthrie. Have you ever seen a cartel smuggle a harmless 
drug into the country?
    Mr. DeLena. I can't speak to every single thing that has 
ever been smuggled, but what I can tell you----
    Mr. Guthrie. But have you ever seen a harmless drug 
smuggled into the country?
    Mr. DeLena [continuing]. The two cartels that we are laser 
focused on, the Sinaloa Cartel and the Jalisco Cartel, are 
producing fentanyl and methamphetamine at epic rates. And it is 
fentanyl and methamphetamine that is ending up in our 
communities and causing the devastation and harm that we have 
seen play out: 107,735 Americans died between August 2021 and 
August 2022. It has to stop.
    Mr. Guthrie. You do see drugs that have medical merit, that 
are prescription drugs that have been diverted, that are 
smuggled into our country. That should be a crime and subject 
to the same as well.
    I mean, the administration says, ``It could have medical 
merit. We need to test it first.'' But if a cartel is smuggling 
even prescription drugs that have been diverted, it still 
should be punished and subject to mandatory minimums. Do you 
agree?
    Mr. DeLena. Thank you for the question, Congressman.
    DEA is a law enforcement agency. We conduct investigations, 
and we bring these cases forward to prosecutors. It is the 
prosecutors and the judges who ultimately make those decisions.
    Mr. Guthrie. So, if we permanently schedule fentanyl 
analogs subject to Schedule I and some do come in that have 
medical merit, they will be treated just like any other drug 
that has medical merit? And if for some reason a cartel decides 
to send some that are harmless, you still want to have the 
ability to disrupt those cartels, correct?
    Mr. DeLena. Thank you for the question, Congressman.
    We are laser focused on disrupting and defeating the two 
cartels, Sinaloa and Jalisco, that are causing the damage and 
destruction throughout all of our communities.
    Mr. Guthrie. Thank you.
    My time has expired, and I recognize Ms. Eshoo from 
California for 5 minutes to ask questions.
    Ms. Eshoo. Thank you, Mr. Chairman.
    And thank you to the witnesses for your testimony.
    First, I want to go to Mr. DeLena.
    Thank you for being here. A lot of passion in your voice 
and in your testimony. A career that spans decades.
    I think you have answered my first question: Do Mexican 
cartels fuel the supply of illicit fentanyl in the United 
States? That is a definite ``yes.''
    So just ``yes'' or ``no'' to the following: Do the Mexican 
cartels benefit from the availability of American guns?
    Mr. DeLena. Thank you for the question, Congresswoman.
    As I stated, the two cartels, Sinaloa and Jalisco Cartel, 
are driven by greed. They are producing methamphetamine and 
fentanyl at catastrophic rates and bringing those drugs into 
all of our communities----
    Ms. Eshoo. So it is ``yes''?
    Mr. DeLena. They are fueled by any type of greed, and they 
are paid and repatriated in any way possible.
    Ms. Eshoo. Do they benefit from the guns, though, the 
trafficking of them?
    Mr. DeLena. Thank you for the question.
    These are ruthless, violent criminal organizations----
    Ms. Eshoo. But is it ``yes''----
    Mr. DeLena [continuing]. That are involved in----
    Ms. Eshoo. We know they are ruthless. I mean, my God. But 
is it ``yes'' or ``no''?
    Mr. DeLena. They use violence, guns of all----
    Ms. Eshoo. So it is ``yes''?
    Mr. DeLena. Yes.
    Ms. Eshoo. OK.
    If the cartels had less access to American guns, would that 
diminish their strength and their firepower?
    Mr. DeLena. Anything that we provide them----
    Ms. Eshoo. I think it is obvious, but I want to hear what 
you think.
    Mr. DeLena [continuing]. Less access to--exactly. Thank 
you.
    Ms. Eshoo. Uh-huh.
    If the cartels were weakened, would that reduce the amount 
of illicit fentanyl coming into the United States from Mexico?
    Mr. DeLena. Our focus is to defeat them, not just weaken 
them, but----
    Ms. Eshoo. But is it ``yes''----
    Mr. DeLena [continuing]. Defeat those two cartels.
    Ms. Eshoo [continuing]. Or ``no''?
    Mr. DeLena. Yes. Yes.
    Ms. Eshoo. OK.
    To Dr. Gandotra, as I said in my opening statement, only 11 
percent of people who need substance use treatment receive it. 
So that is a very small number of people in our country.
    Hopefully the number is going to grow soon, given the MAT 
Act that we passed that was signed into law. It is going to 
allow more doctors to prescribe medication-assisted treatment.
    As quickly as you can, what are both SAMHSA and ONDCP doing 
to educate the providers about the MAT Act so that we can 
expand the access to medication-assisted treatment?
    And if you can give us a specific, so that we have a 
clearer handle on what you are doing.
    Dr. Gandotra. Thank you for the question.
    Certainly SAMHSA, HHS, and our Federal partners at ONDCP 
and DEA are working together quickly to provide providers with 
education and direction.
    Ms. Eshoo. Yes, but what are you doing? Give us an example. 
When you say we are working to provide, what does that mean?
    Dr. Gandotra. Well, we are having regular meetings to 
coordinate frequently asked questions. There has been a letter 
that has been sent out to DEA registrants. Certainly we are 
working with the professional societies to perform a framework 
of educational priorities and competencies for providers.
    We have been reaching out to all of our stakeholders--
States, the State opioid treatment authorities, as well as 
providers themselves--so that they can have the education. 
There are updates on our web pages, both for ourselves as well 
as for our colleagues at the DEA.
    Mr. Chester. Ma'am, I think my colleague from SAMHSA has 
summed it up well in terms of implementation, but let me just 
add that it is critically important that the elimination of the 
X waiver created the opportunity for physicians to be able to 
do this. Through greater education through SAMHSA and others, 
they are creating the willingness of physicians to be able to 
prescribe this very necessary drug as well. And SAMHSA is doing 
great work in that regard.
    Ms. Eshoo. I think it is important to note here, as we talk 
about the need for medication-assisted treatment, how few in 
our country receive it today; what our goal is, certainly, with 
the new law; that Medicare currently covers an estimated 1.7 
million beneficiaries with substance use disorder. That is 
Medicare, which may be surprising to some people. You think of 
older people, there is addiction there that--it is a 
disappointment and a surprise. And Medicaid--Medicaid covers 
about 6 million people with substance use disorder.
    So I would say to my Republican friends that, as there is a 
nexus between debt ceiling and cutting Medicare, watch it. 
Because these are people that need, absolutely have to have 
this coverage.
    With that, I yield back, Mr. Chairman.
    Mr. Guthrie. The gentlelady yields back.
    Mr. Burgess from Texas is recognized for 5 minutes for 
questions.
    Mr. Burgess. Thank you, Mr. Chairman.
    I wasn't going to bring this up, but the ranking member and 
the ranking member of the full committee have provoked me on 
this.
    Look, cuts to Medicare over the past 2 years have been 
staggering. And you talk to any practicing physician out in the 
country and ask them, ``Have you felt the effect of Medicare 
cuts in the last 2 years?'' and the answer will be, 
``Absolutely, yes.''
    Now, the American Rescue Plan--actually, one of the pay-
fors of the American Rescue Plan was a sequester on Medicare. 
Yes, Congress has put a stay on that sequester, but that looms 
out there as a budget item in the future. The Inflation 
Reduction Act--$300 billion of Medicare cuts to pay for money 
to go to insurance companies.
    So, please, let's be careful about our language here, 
because it does matter.
    But we have a very important issue at hand.
    And, Mr. DeLena, thank you so much. Your testimony was very 
powerful. Your written testimony is some of the most disturbing 
that I have read since I have been on this committee, and that 
goes back to 2005.
    I am grateful that you are working with the State 
Department. You referenced the State Department's International 
Narcotics Control Strategy Report. So I am encouraged by that.
    What is concerning to me is the next paragraph. You say, 
``DEA has been willing to engage the People's Republic on 
fentanyl-related substances and precursors. However, due to 
diplomatic tensions between the United States, the People's 
Republic of China, the government''--I assume that is the PRC 
Government--``has suspended all counter-narcotics cooperation 
with the United States.''
    Is that an accurate statement?
    Mr. DeLena. Congressman, thank you for your question.
    DEA is working in China to stop the illicit flow of those 
precursor chemicals that are ending up in the hands of the two 
cartels, the Sinaloa Cartel and the Jalisco Cartel. We know 
that, every day, chemicals, precursor chemicals, are leaving 
China. China doesn't have a know-your-customer rule, or there 
is no oversight of any of that stuff that is ending up in 
Mexico.
    And we also know that in China and throughout China there 
has been a dramatic increase in money-laundering activities as 
another way to get back involved with those two cartels, 
essentially undercutting all the other traditional forms of 
money laundering that had occurred up until now.
    But the relationship right now, we know that China needs to 
do more to get more engaged.
    Mr. Burgess. Yes. There is the understatement of the year: 
``China needs to do more.''
    I mean, these are chemical weapons that are being 
dispatched into our country to kill our young people at a rate 
greater than 100,000 a year. Is that a fair statement that I 
have just made?
    Mr. DeLena. Thank you for the question.
    The chemicals, the precursor chemicals, that are 
essentially leaving China are ending up in Mexico, where those 
two cartels are mixing them in these clandestine laboratories 
into the synthetic drugs. And it has become a limitless supply 
now that we have, you know, switched to synthetics versus 
plant-based drugs.
    Mr. Burgess. So a terrorist organization producing weapons 
of mass destruction that are coming into our country, it seems 
like we would do everything within our power to disrupt them 
financially under tools that are already in existence probably 
dating back to the PATRIOT Act after 2001.
    So are we disrupting the financial instruments that are 
available to chemical precursors in China and the cartels in 
Mexico?
    Mr. DeLena. Thank you for the question.
    As a law enforcement agency, DEA has taken a network 
approach to try to fully map and analyze and identify where 
these cartels are operating. They are operating throughout the 
entire United States, obviously, and throughout Mexico but also 
in 40 countries around the world.
    It is our goal to absolutely infiltrate and defeat those 
cartels as they exist.
    Mr. Burgess. Well, let me give you a mission statement, 
then: Follow the money. Because I think, in this case, it is 
extremely important. And, further, disrupt the ability to 
continue to fund this operation.
    I mean, it is great we are doing harm reduction. And I 
would go back to Nancy Reagan's ``Just say no.'' I think that 
was the greatest harm reduction that was made available to the 
country, back in the 1980s. But if we do not disrupt the 
financial instruments that allow this warfare to continue, we 
can't win. You can't--you can't harm reduction your way out of 
this problem.
    And let me just ask you this as one last thing. We hear 
over and over again, ``Well, it is not--you know, people coming 
over the border is really not the problem. It is points of 
entry.'' But it is the removal of Customs and Border Protection 
and even some of your agents, having to handle these vast 
numbers of people that are coming across the border illegally, 
and deflecting them from other activities that might be used to 
interdict fentanyl and even agricultural products that 
shouldn't be coming into this country. Is that something that 
concerns you?
    Mr. DeLena. Thank you, Congressman.
    I think, specific to your question, it is probably best 
served for the Department of Homeland Security and their 
components who actually control the border and those points of 
entry.
    Mr. Burgess. They don't control the border is precisely the 
point.
    Thank you, Mr. Chairman. I will yield back.
    Mr. Guthrie. Thank you.
    The gentleman yields back.
    We are going to try to stick to 5 minutes. We have two 
panels today. So I know we had a couple run over. I want to try 
to get on to sticking to the 5 minutes.
    So next up is Mr. Sarbanes from Maryland. You are 
recognized for 5 minutes.
    Mr. Sarbanes. Thanks very much, Mr. Chairman. And 
congratulations on taking up the leadership of this 
subcommittee.
    I want to thank all of you for your testimony today. You 
have responsibility for a broad set of initiatives. And, in 
particular, I want to thank your agencies for their work to 
combat the mental health and behavioral health crises that we 
see. We know that there is an intersection of those crises with 
the addiction crisis across this country, so that is a very 
important part of our response.
    Last Congress, I was proud to work with colleagues on our 
committee to enact legislation that provided increased funding 
for mental health programs and reauthorize several key mental 
health and substance use disorder programs, including 
legislation I helped sponsor to bolster two programs that 
provide care for children and adolescents.
    Both of these programs--the first one, the Comprehensive 
Community Mental Health Services for Children with Serious 
Emotional Disturbances Program--and let me break that down, 
because that is a mouthful. Comprehensive community mental 
health services--so the idea that we have to take a holistic 
approach to this and make sure that it is a full community 
response--with children who have serious emotional 
disturbances, so that is the particular audience that it is 
being addressed to. The other program, the Youth and Family 
TREE Program. These are administered by SAMHSA, which has been 
working closely with the Biden administration to implement 
evidence-based policies and programs that save lives.
    Dr. Gandotra, in your testimony, you note that many of the 
recent actions taken by Congress and the Biden administration 
have had a measurable impact on mental and behavioral health 
outcomes.
    For example--and this is pretty remarkable--you note that 
the recent expansions in care through Certified Community 
Behavioral Health Clinics, which is an important part of the 
infrastructure in this area, have achieved a 74 percent 
reduction in hospitalizations and a 69 percent reduction in 
emergency department visits, not to mention a 31 percent 
increase in individuals' mental health functioning in everyday 
life.
    So there has definitely been a very positive response to 
these programs. It is remarkable progress. We have to keep 
building on the success.
    I do want to say that in Maryland we are working very hard 
to combat an acute crisis we face in pediatric mental health 
access, which has left far too many families struggling to find 
mental health care for their children, many of whom have been 
forced to remain in emergency departments or were turned away 
from care when they need it most.
    Governor Moore, recently inaugurated in Maryland, has 
deemed addressing health issues as a core priority of his 
administration and proposed an investment of almost $1.5 
billion in mental health care services in Maryland this year.
    Dr. Gandotra, can you further explain how the recent 
investments in mental health through the Bipartisan Safer 
Communities Act and the bipartisan mental health package that I 
referred to are making a real difference in communities and why 
it is so important that we continue to invest in these 
programs?
    Dr. Gandotra. Thank you, Congressman, for your question.
    And, certainly, investing in children's mental health pays 
dividends for the community, for services throughout not just 
Maryland but throughout the country. We have seen investments 
really pay dividends with regard to improved functioning in 
school, decreased criminal justice involvement, decreased 
hospitalizations, decreased emergency department use.
    As far as resources, SAMHSA's resources really do leverage 
a number of educational activities in terms of providing 
schools, counselors, teachers, as well as community 
organizations with the tools they need to help identify mental 
illness, prevent conditions before they worsen, and provide 
them with resources to link patients to treatment.
    Also, we like to enhance the services we already have, by 
providing culturally competent workforce educational products 
as well as an ensuring individuals who are identified early are 
not only linked to the right treatment but the appropriate 
level of care. That is also done with crisis management 
services as well.
    Mr. Sarbanes. Thanks very much.
    I am out of time. I was going to ask you about telehealth 
also being a means of expanding access. I know that is very 
important. We want to continue to explore the opportunities 
there.
    With that, Mr. Chairman, I yield back. Thank you.
    Mr. Guthrie. I thank the gentleman for yielding back.
    The Chair now recognizes Chair McMorris Rodgers for 5 
minutes.
    Mrs. Rodgers. Thank you, Mr. Chairman.
    In 2019, China permanently scheduled all fentanyl-related 
substances. They were the first country in the world to do so. 
So far, the United States has stopped short of doing the same. 
A permanent American solution, like passing the HALT Fentanyl 
Act, is necessary.
    Mr. Chester, can you discuss our working relationship with 
China to prevent the entry and sale of fentanyl and its 
analogs?
    Mr. Chester. Thank you for the question, Congresswoman. Our 
relationship with the PRC doesn't move in a straight line, but 
as you point out, we have, in the past, had success in dealing 
with the PRC, specifically the class scheduling of fentanyl 
that we asked them to do that they announced in 2019, and a 
couple of things happened when that occurred.
    The first one was, shipments of finished fentanyl directly 
from the PRC to the United States, principally through mail and 
express consignment, dropped to almost zero where they remain 
today.
    Traffickers moved from the business of finished fentanyl to 
the precursor chemicals that they supply to manufacturers 
within Mexico, and Mexico became the locus of illicit fentanyl 
production.
    We have worked with the PRC on a number of issues in terms 
of accountability and the prevention of the diversion of 
illicit chemicals, pill presses, better oversight over the 
shipping companies.
    And while it is true that within an environment of 
competition, there are some areas of cooperation and that the 
PRC stepped back last summer from many of them, we continue to 
have contact with the government of the PRC, and we continue to 
call upon them to partner with the United States on a global 
level because they share a large portion of the task in dealing 
with this issue.
    Mrs. Rodgers. Would you speak to how they are enforcing 
this ban on fentanyl and fentanyl-related substances in China, 
and what mechanisms do we have to hold China accountable to its 
commitment to ban the export of fentanyl in its analogs?
    Mr. Chester. Within the PRC, their Ministry of Public 
Security and their law enforcement organizations take the issue 
of fentanyl trafficking very, very seriously, and in fact, when 
they announced in May 2019 that they were scheduling all 
fentanyl-related substances as a class, that September they 
invited members of our embassy over to witness the sentencing 
of 10 fentanyl traffickers.
    And this was remarkable because, not just a year before, 
the government of the PRC had told me that no fentanyl was 
coming from the PRC. So what that tells us is, they take it 
very seriously.
    We do have the opportunity to have progress, and when the 
government of PRC takes this issue seriously, they can do very, 
very good things. What we are asking them to do now is exert 
more oversight over their shipping industries and their 
chemical industries----
    Mrs. Rodgers. Yes.
    Mr. Chester [continuing]. That divert these chemicals for 
production.
    Mrs. Rodgers. Right. It is frightening how many plants in 
China are producing the chemicals.
    Mr. Chester. Yes, ma'am. There are about, we are told about 
160,000 chemical plants, but the issue is that they are 
diverted on their way out of the country, destined for unknown 
and undeclared customers in Mexico who use them to produce the 
fentanyl-related substances.
    Mrs. Rodgers. Have any other countries permanently 
scheduled all fentanyl-related substances?
    Mr. Chester. I believe not, but I will get you that 
definite answer, ma'am.
    Mrs. Rodgers. OK. Mr. DeLena, offenses prosecuted under 
classwide scheduling can trigger a mandatory minimum of 5 years 
for 10 grams or 10 years for 100 grams of a drug mixture 
containing a detectable amount of fentanyl analogs.
    To put it into perspective, how many grams are fentanyl are 
lethal?
    Mr. DeLena. Congresswoman, thank you for the question. DEA 
estimates about 2 milligrams is a potentially lethal dose. That 
is about enough to fit on the tip of a pencil.
    Mrs. Rodgers. And then what is a lethal dose of 
carfentanil, which is a fentanyl analog?
    Mr. DeLena. Thank you, Congresswoman. I would have to defer 
to some of the scientists and lab folks at DEA, but I can get 
you that exact, specific answer.
    Mrs. Rodgers. Well, bottom line--bottom line--we know that 
there is enough fentanyl now in the United States to kill every 
person seven times over, and so it is a huge amount of fentanyl 
that has come into the United States.
    And it is lethal, and it is impacting those that are 
addicted, but it is also impacting people who don't know even 
what they are doing or what they are taking, some of these 
pills that are laced with fentanyl.
    And so I really just appreciate all you being here. We are 
committed to taking action to ensure that we are doing 
everything we can to keep fentanyl and fentanyl-related 
substances off our streets. It is destroying families, 
individuals, and communities all across this country, so thank 
you. I yield back.
    Mr. Guthrie. I thank--the Chair yields back. The ranking 
member, Mr. Pallone from New Jersey, is now recognized.
    Mr. Pallone. Thank you, Chairman.
    One bill that would have been a great addition to this 
hearing today is the Medicaid Reentry Act, and this bipartisan 
legislation would extend Medicaid eligibility to incarcerated 
individuals back to 30 days prior to their release. So let me 
start with Dr. Gandotra.
    It is my understanding that individuals newly released from 
incarceration are at a much higher risk of overdose than 
suicide. Can you describe some of the reasons for that?
    Dr. Gandotra. Thank you for the question. And as you 
accurately describe, individuals who are reentering society 
from incarceration are at higher risk for overdose, in 
particular, because during their incarceration, their tolerance 
levels have changed, and when they reenter society and they use 
again, they are much more likely to overdose if they 
previously--amounts that they had previously used that they 
were tolerant to.
    So it is vitally important that these individuals engage in 
treatment, both prevention and recovery services as well as 
evidence-based treatment, well before they are actually 
released.
    The most important aspect of that is the transition 
planning. There are certainly models that have been successful, 
such as the sequential intercept model, which not only 
encourages transitional planning by jail and end-reach 
providers but also can facilitate other resources that are 
necessary for success--social determinants of health, case 
management, resources that will be needed.
    Sometimes a warm handoff and actual conversations with the 
service providers in the communities can really go a long way 
towards reducing mortality for those reentering society.
    Mr. Pallone. And the problem now, Doctor, is that they are 
not eligible for Medicaid under the law now until they leave 
prison, and then oftentimes we can't even find them to tell 
them to sign up or whatever, correct?
    Dr. Gandotra. So certainly there are treatment gaps that 
need to be addressed, particular coverage gaps with regard to 
remuneration of services, but the prescriptions themselves, 
having those before they leave, having a contact, peer recovery 
support specialist in the community that can help connect them 
and keep them connected to treatment, because we know the 
treatment retention yields better outcomes.
    Mr. Pallone. All right. Now, I wanted to shift to Mr. 
Chester. In order to conduct quality research, investigators 
need access to fentanyl analogs as they might be useful in 
enhancing current treatments or developing new ones.
    A key component of the administration's proposal involves 
how FRS are classified, or subsequently reclassified if found 
to have a lower risk profile. Can you explain the importance of 
the provision for off ramping and FRS?
    Mr. Chester. Thank you, Congressman. That was a key 
component of the administration's proposal when it comes to 
fentanyl-related substances. So the first step is to scoop 
these substances up and make sure that Americans don't have 
access to them, that they can't be harmed.
    But the second one is what you say, to determine two 
things: if those substances may have some medical merit, and 
what their qualitative effect is on the body. And it is 
critically important for researchers to be able to, even though 
they are in Schedule I, to have access to them.
    And part of the proposal for FRS was not only FRS, but all 
Schedule I drugs, actually reworking the process by which 
researchers can have access to Schedule I drugs for the 
purposes of research.
    Mr. Pallone. All right. Now, I am just going to rush 
through this because there is only about a minute left. What is 
your understanding of how the current administration's proposal 
differs from the HALT Fentanyl approach, and is the 
administration's approach evidence based? Why is it important 
to use evidence-based approaches when it comes to scheduling of 
FRS?
    Mr. Chester. So on the first part, I apologize, I can't 
take a position on a specific piece of legislation, but what I 
can say is, the administration's proposal was comprehensive, 
and it was a consensus-based proposal that came across the 
interagency, and it is evidence based. It is based on what we 
know about access to research, what we know about criminal 
justice outcomes, and also what we know about the trafficking 
of these substances.
    Mr. Pallone. All right. I appreciate that. Thank you, Mr. 
Chester, for helping us understand some of the differences, if 
you will, from what the current administration is proposing.
    And I just want to say appropriately studying and 
categorizing substances is key to addressing the opioid and 
fentanyl crisis. So it is important that we understand the 
differences between these various approaches.
    And with that, I will yield back, Mr. Chairman.
    Mr. Guthrie. Thank you. The gentleman yields back. The 
Chair recognizes Mr. Latta for 5 minutes for the purpose of 
asking questions.
    Mr. Latta. Well, thank you, Mr. Chairman, and thanks to our 
witnesses for being here. First, I would just like to, once 
again, show people--well, this is from the DEA website that I 
have used back in our district.
    This is the amount of fentanyl that will kill you when you 
are looking at it next to a penny, and I think it is really 
important to see that because, again, what everyone is up 
against in this country and how we are going to have to stop 
this, because--and the testimony again being today that 107,477 
Americans that lost their lives last year.
    And, Mr. DeLena, I really appreciate something you are 
saying. You are saying ``poisoning'' now. We are not talking 
about overdose deaths, we are talking about poisoning.
    And that is something that came up in the roundtable that 
we had with family members and law enforcement. It is no longer 
overdose. This is poisoning.
    And when you think about the--you mentioned 294 people died 
from drug poisoning every day in this country, and that, you 
know, what was interdicted, that we know of, is 7.5 million 
tons of fentanyl that came into this country--7\1/2\ tons, not 
millions, excuse me--7\1/2\ tons of fentanyl that came into the 
country. So I think it is really important that we keep that in 
line.
    And something else I think is really important, I think, in 
your testimony. It is costing--it says in your testimony, you 
say, it costs the cartels as little as 10 cents to produce a 
fentanyl-laced fake prescription pill sold in the United 
States. That is what we are saying, then, is they can kill us 
for 10 cents--10 cents.
    So when we talk about do we got a crisis on our hands, we 
are past a crisis in this country, and I know my friend from 
Texas asked some of the questions especially dealing with the 
PRC, but--and the paragraph before because, again, it is where 
these chemicals be coming in, when you talk about 160,000 
chemical companies in the PRC and those that are distributing 
the precursor chemicals for use in fentanyl and meth.
    The question, you know, right now is that since they are 
faking these labels as they are going from China to Mexico, we 
are talking to our Mexican counterparts, is there anything that 
they are--being done within Mexico to try to find these fake 
labeled shipments as they come through?
    Mr. DeLena. Congressman, thank you for your question, and 
to address the first part of it with drug poisonings, DEA--and 
I have been a part of it--has met with family members that have 
lost loved ones. We had 22 family summits, where we met with 
families who have lost loved ones, and, you know, we hear from 
them every day, you know, the pain and suffering that is caused 
by this drug, fentanyl.
    And it truly is a poisoning, that is how we look at it now, 
that it is Americans that are being poisoned across the 
country.
    To talk about the chemicals that you ask about, these 
Chinese chemical supply companies, there is no oversight or 
know-your-customer rule, and as you said, they are shipping 
these precursor chemicals into Mexico all the time.
    We know, on one side, China needs to do a lot more, and we 
know the same has to happen in Mexico. The Mexican Government 
needs to do a lot more to enforce what is coming into that 
country and work with us to try to defeat these two cartels.
    Mr. Latta. Great. Let me follow up on, because, again, when 
you look at the, prior to 2018 with fentanyl, and what we want 
to do, my good friend from Virginia and I and our legislation 
on HALT Fentanyl, again, what will having it permanent because, 
again, you know, you always--you talk in your testimony about 
the temporary scheduling order 8 times. How will this bill help 
you on the crisis that we have with fentanyl?
    Mr. DeLena. Thank you again for the question. The permanent 
scheduling will allow DEA to arrest and seize when we encounter 
fentanyl-related substances wherever that happens.
    We also know that with classwide scheduling, there has been 
less production of different analogs. It is just not worth the 
chemical brokers and chemists in Mexico when they are making 
this substance, when they know it is a classwide, you know--it 
is illegal classwide, there is no benefit for them to try to 
create new substances.
    Mr. Latta. Well, again, I appreciate, you know, the work 
that you are doing because, again, we need to get this 
legislation across the finish line because we want to stop this 
horrendous rise in deaths across this country. And it has got 
to happen now.
    So, Mr. Chairman, I yield back the balance of my time.
    Mr. Guthrie. Thank you. The gentleman yields back.
    The Chair now recognizes Mr. Cardenas of California for 5 
minutes for asking questions.
    Mr. Cardenas. Thank you very much, and congratulations, 
Chairman Guthrie. I have always enjoyed working with you and 
looking forward to working with you as the chairman of this 
very important committee.
    And also to Ranking Member Eshoo, thank you so much for 
your diligent work, and I have enjoyed working with you, and 
this committee is going to hopefully do much, much good work 
over these next 2 years.
    Before I ask my questions, I just want to mention a few 
words--Purdue, the Sackler family, and crime pays. Still one of 
the richest families in the world. Where did all this start and 
who was a big part of where we are today.
    Dr. Gandotra, thank you for joining us today and for 
sharing your informative and valuable expertise on mental 
health policy.
    As you are aware, HHS recently implemented the 988 hotline, 
a potentially life-saving service for individuals experiencing 
mental health crises, spearheaded by my colleague here, 
Congressman Sarbanes.
    Thank you so much for everything you do in the space of 
mental health.
    While there is much work to be done, I believe that the 
promise of 988 and the momentum--excuse me--the continuum of 
crisis care built around it, offers some much-needed hope for 
those struggling with their mental health.
    However, in December the 988 hotline experienced a service 
interruption after a suspected cyber attack on Intrado, a large 
telecommunications company that provides services to Vibrant, 
the administrator of the 988 hotline.
    The bill before us today, which I am co-leading, aims to 
prevent this from happening again. In the wake of the December 
Intrado service outage, how is SAMHSA mitigating the risk of 
similar incidents and hoping to keep that from happening again? 
Can you put your microphone just a little closer? Thank you.
    Dr. Gandotra. Sure. Thank you, Congressman, for your 
question, and also for the ongoing support for the 988 program. 
And I would like to first state that our highest priorities are 
to develop additional redundancies in the event of any future 
outages.
    While minimizing the likelihood of such events, we want to 
continue to protect personal information and be sure that there 
is clear communication protocols among the partners and the 
public. We certainly owe the public trust when it comes to 
their personal information.
    We also want to be able to continue to expand services and 
understanding that when these problems arise, we want to 
quickly resolve them and provide clear guidance on where and 
how to seek help. Certainly, clear communication and protocols 
between the partners and public is going to be paramount.
    Mr. Cardenas. Are more resources needed, and do you 
appreciate Congress actually providing more resources in the 
future?
    Dr. Gandotra. Well, we thank Congress for the investment 
certainly as we recognize that mental health crisis services 
are always needed. As there has been a growing need recognized, 
not just in the past years, but throughout the past decade, we 
would appreciate all the support the Congress has given us.
    Mr. Cardenas. Thank you. I look forward to working with you 
and SAMHSA on improving 988 and getting it to where it should 
be in the future.
    I also want to take a moment to discuss our policy around 
fentanyl and fentanyl-related substances. Overdose deaths are 
skyrocketing in this country, and I share my colleagues' horror 
at the devastation we have seen at the hands of the fentanyl 
crisis.
    But among other things, this is a complex, multifaceted 
public health crisis that requires a robust public health 
response. And candidly, I am concerned that this class-wide 
scheduling approach sets a precedent of guilty until proven 
innocent.
    The proposal put forth by my Republican colleagues goes all 
in on applying harsh Federal penalties, but lays almost no 
groundwork to test for the potential harmlessness of these 
fentanyl-related substances, or even their potential 
therapeutic value.
    We could be overlooking the next naloxone, which has saved 
countless lives from opioid overdose because our focus is 
solely punitive, and I think that is a grave error with immense 
consequences. The responses are usually multifaceted, but not 
simple.
    Mr. DeLena, under the current classification system, what 
kind of resources have you allocated toward testing the effects 
of Schedule I compounds which may have medicinal purposes?
    Mr. DeLena. Congressman, thank you for the question. DEA is 
open to the testing of Schedule I substances. It is our 
partners at HHS that conduct those type of tests, and as I 
said, we are open to Schedule I testing and research for any 
scientific need, and for any medical evaluation that could come 
out of it.
    Mr. Cardenas. OK. Thank you so much. My time having 
expired, I yield back.
    Mr. Guthrie. Thank you. The gentleman yields back, and now 
Mr. Griffith is recognized for 5 minutes for the purpose of 
asking questions.
    Mr. Griffith. Thank you very much, Mr. Chairman.
    There is some confusion about the HALT Fentanyl Act that I 
am hearing in some of the questioning and in some of the 
statements that have been made. The Act does, in fact, include 
the ability to do research and makes it easier to get through 
the pathways to get research done.
    On some of those--and to our colleagues on the other side 
of the aisle, they held a great hearing earlier, last year, 
sometime last year. If memory serves me correct, there are 
approximately 48,000 potential analogs to fentanyl, of which, 
we have looked at somewhere between 30 and 40.
    But that is a--you know, if you want more research, this 
makes it easier, and we probably need to get the appropriators 
to appropriate money to go in that direction, if that is the 
intent.
    But we are--the bill does allow for more research. I have 
been a big advocate for researching substances and their 
potential medical use since I came to Congress.
    Also, Mr. Chairman, I would request unanimous consent for 
the introduction of a letter for the record from the Peace 
Officers Research Association of California, representing 
75,000 public safety members and 930 public safety associations 
which expressed their support for the HALT Fentanyl Act.
    Mr. Guthrie. Any objections?
    Seeing none, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Griffith. And from that letter, Mr. Chairman, they say, 
as the law enforcement community continues working to reverse 
these trends, the HALT Fentanyl Act would help to bolster the 
efforts by ensuring current Schedule I classification of 
fentanyl under the Controlled Substances Act does not expire. 
So there is that.
    Let me ask a couple other things that I thought was 
interesting. Mr. DeLena, you indicated that because of the 
temporary ban, it is not worth it to the cartels to work on the 
analogs. That implies, and I believe it was happening, is that 
when there wasn't--when the analogs were not illegal, they were 
looking for analogs that would be legal, that they could get 
around the laws and not face criminal punishment in the United 
States by importing these poisons into our country. And this 
has actually helped stop that.
    It may not have stopped the fentanyl deaths, and certainly 
this is only one part of a complex answer. But I am I correct 
that they were looking for other ways so they could avoid 
criminal punishment, yes or no?
    Mr. DeLena. Thank you for the question. We have actually 
seen that play out before where they can flip one molecule and 
keep moving it along. With the class-wide scheduling, it is 
just not beneficial for them to do that.
    Mr. Griffith. And I appreciate that. I am going to switch 
gears for a second, Doctor, and I hope I am saying it right, 
Gandota, Gandotta?
    Dr. Gandotra. Gandotra.
    Mr. Griffith. Gandotra. In a recent study published in the 
Journal of the American Medical Association, they said there 
was no evidence that telemedicine has actually expanded access 
to care for opioid use disorder.
    They also found that telemedicine opioid use disorder 
patients tended to be more concentrated in higher income metro 
areas. And I am a big believer in telemedicine, so what do you 
think we can do to expand access to more rural areas like mine?
    Dr. Gandotra. Thank you, Congressman, for the question. 
Certainly SAMHSA is committed to expanding treatment access for 
medications for opioid use disorder. We have heard from 
numerous stakeholders, in particular, from rural areas or from 
our State opioid treatment authorities.
    Mr. Griffith. So you are going to work with us on that?
    Dr. Gandotra. Yes, sir.
    Mr. Griffith. All right, I appreciate that.
    Buprenorphine. Now there is no limit on the number of 
doctors prescribing, but even before that--or the number of 
patients that a doctor can have to prescribe, but even before 
that, it was starting to become used as a street drug in a 
couple of my counties.
    Are we monitoring to see if this is going to be a national 
trend? Are you all looking at that as a possibility? Because 
apparently, it is happening, according to some of my law 
enforcement folks.
    Dr. Gandotra. Certainly expanding medications for opioid 
use disorder including buprenorphine is one of our goals for--
--
    Mr. Griffith. Well, I want to know if we are looking to 
make sure that we are not creating a new street drug.
    Dr. Gandotra. We are certainly--we are certainly educating 
providers----
    Mr. Griffith. Mr. DeLena, you too? You are all looking at 
this?
    Mr. DeLena. Thank you, Congressman. Absolutely. Any threat 
that is posed to the American public, DEA will continue to 
monitor.
    Mr. Griffith. And have you seen any uptick in buprenorphine 
being used as a street drug?
    Mr. DeLena. Again, thank you for the question. I can't 
speak to that. I have not seen that in the area that I came 
from. My last assignment in New England, we did not see that 
trend.
    Mr. Griffith. All right. And I am running out of time, so 
last question. Got all these cartels in Mexico. Is the Mexican 
Government capable of defeating those cartels on their side of 
the border?
    Mr. DeLena. Thank you for the question. Those two specific 
cartels, Jalisco and Sinaloa, that are causing all of this harm 
are operating virtually with impunity. We need the Mexican 
Government to lean in and do a lot more.
    Mr. Griffith. But right now, they can't do it, can they?
    I yield back.
    Mr. Guthrie. Thank you. The gentleman yields back.
    The Chair now recognizes Dr. Ruiz for 5 minutes for 
questions.
    Mr. Ruiz. Thank you. As an emergency physician, I have seen 
time and time again the devastating and often fatal effects of 
drug overdose. Fentanyl, in particular, continues to wreak 
havoc on our communities.
    The most recent data from CDC shows that 67 percent of all 
overdose deaths in the U.S. involve synthetic opioids like 
fentanyl, and DEA Administrator Ann Milgram called fentanyl, 
quote, ``the single deadliest drug threat our Nation has ever 
encountered,'' unquote.
    Over the past several years, this Congress adopted many 
policies to try to stem the tide of the substance use crisis 
and increase access to prevention, treatment, and recovery 
services.
    However, still more needs to be done. I think it is 
critical to remind everyone that substance use disorder is a 
disease, and it needs to be treated as such. This means we need 
to focus on greater access to harm reduction programs and 
increase efforts towards prevention.
    I approach this disease like I would any other, addressing 
how to get someone well after they are sick, but also how to 
prevent them from getting sick in the first place.
    Our healthcare system is good at healing the sick, but 
often too frequently ignores or undervalues prevention so that 
people don't get sick in the first place.
    So on that note, I would like to talk about the HHS 
overdose prevention strategy and what it is accomplishing in 
this regard. The strategy involves four priorities: primary 
prevention, evidence-based treatment, harm reduction, and 
recovery support.
    This is especially important among youth as recent data 
from the nonprofit group Families Against Fentanyl suggested 
children under 14 are dying a faster rate than any other age 
group.
    So we know you can't incarcerate a public health problem 
from ending, and you also got to think through how--that, you 
know, the focus is on the drug cartels moving drugs over, but 
how about those who have the disease of addiction who are also 
fueling that through the enormous demand on our side?
    So, Dr. Gandotra, what are the interventions and early 
prevention strategies used in the overdose prevention strategy 
to address opioid use, particularly among youth.
    Dr. Gandotra. Thank you, Congressman, for that question. 
Certainly the prevention pillar is important in terms of the 
overdose prevention strategy. Our strategic prevention 
framework is one of our major grant programs that allows for 
community organizations, States themselves, and local 
jurisdictions, to identify the problem, also identify then the 
resources they have in terms of capacity.
    Mr. Ruiz. Well, identifying a problem is not necessarily 
prevention because there is already a problem. So how do you 
prevent it from becoming a problem?
    Let's say a school wants to start a program. Where can they 
go to get information or resources and moneys to create 
education outreach to prevent this from happening?
    Dr. Gandotra. So SAMHSA's Block Grant Program--substance 
use Prevention Block Grant, has a 20 percent set-aside where 
the local jurisdictions can determine what is best suiting 
their needs. That 20 percent set-aside has been incredibly 
effective for schools and community organizations.
    Mr. Ruiz. Can you explain the concept of harm reduction and 
what that means in practice?
    Dr. Gandotra. Certainly. Harm reduction is a practice that 
utilizes the principle to meet the patient where they are, to 
reduce the morbidities, or negative aspects of use.
    This may mean that individuals who may not be necessarily 
ready to engage in full treatment can still mitigate some of 
the effects of their use. In particular, harm reduction can 
involve naloxone administration for preventing overdose, as 
well as fentanyl test strips for drug testing to allow for 
individuals to determine how safe the product is that they have 
in their hand.
    Those are just two examples, and there is a number of other 
harm reduction interventions that can be utilized.
    Mr. Ruiz. Thank you. And how does the strategy address 
helping people after they receive treatment for SUD? Or how 
important is it to facilitate a safe recovery environment?
    Dr. Gandotra. So thank you for that question, and for 
really highlighting the part that individuals who engage in 
harm reduction are much more likely to later engage in 
treatment, and be retained in treatment.
    You have to reach patients where they are, where they are 
willing to actually engage with you. That means that if they 
are able to stay alive, you can treat them later. If you can't 
keep them alive, then there is no way that they can be engaged 
in treatment. So, certainly, the naloxone administration is a 
big aspect to that.
    Mr. Ruiz. You know, I got to also mention that this illness 
of addiction is not just for the individual, but it is for 
their family, for their neighborhood as well, and treatment 
needs to go toward a family-based, home-based, community-based 
treatment programs for prevention and also harm reduction. 
Thank you. I yield back my time.
    Mr. Guthrie. Thank you. The gentleman yields back.
    The Chair now recognizes Mr. Johnson for 5 minutes.
    Mr. Johnson. Well, thank you, Mr. Chairman. First I want to 
say how excited I am to have been selected to serve on the 
Health Subcommittee. Healthcare is such an important issue in 
my rural Appalachian district, everything from cost to quality 
to availability, and I look forward to working on these 
important issues under your leadership, with all of our 
colleagues.
    For today, however, I want to read some excerpts of a 
letter I received from a constituent yesterday right near my 
home in Washington County, Ohio. The letter is from a grieving 
mother of a young man named Jason who tragically died exactly 2 
years ago yesterday, January 31st, 2021.
    Jason's mom wrote to me and said, Jason was prescribed 
Vicodin by our family doctor after a car accident. Why wouldn't 
we trust it? Our doctor prescribed it. Our son had a couple of 
relapses after a stint in the Marines and some college, but we 
had good insurance and a medication-assisted treatment helped 
him pick up the pieces.
    His relapse in September 2019 set the stage for a terrible, 
15-month battle to save our son's life. By the time we were in 
the throes of COVID in March 2020, our son was in the worst of 
his disease.
    She then went on to say, his drug of choice was heroin, and 
now that drug is laced with fentanyl. It was the first time I 
realized he was most likely going to die.
    Fentanyl is a game-changer, she said. She closed with this. 
Jason was so much more than simply addicted. He was loved by so 
many, especially his own son, who we are now raising.
    My friends and colleagues, this grieving mother is right--
fentanyl is a game-changer. We are in entirely new territory 
now compared to when we started confronting what we called at 
the time the opioid epidemic, particularly in rural areas, like 
where I live.
    So, Mr. Chester, let me start with you. Thank you for being 
here. The 2021 Drug Free Communities report highlights that 
close to 98 percent of Drug Free Communities coalitions address 
prescription opioids.
    But only just over half address fentanyl, fentanyl analogs, 
or other synthetic opioids. And as we know, an increasing 
number of overdose deaths are attributed to synthetic opioids 
like the situation I highlighted.
    The victim started with prescription opioids but moved on 
to heroin and then an accidental, extremely potent, and fatal 
fentanyl overdose.
    Why does this disparity exist within the Drug Free 
Communities program? Does ONDCP plan to revisit their efforts 
and strengthen its response to synthetic opioids?
    Mr. Chester. Thank you very much for the question, and we 
all are incredibly sorry for your constituent and the many 
others----
    Mr. Johnson. I got another question so if you could answer 
that one.
    Mr. Chester. Yes, sir. The Drug Free Communities program, 
the more than 700 grantees, their programs are locally designed 
based upon local conditions, and there is not a single Drug 
Free Communities overlay over all of them.
    Mr. Johnson. Yes, but the fentanyl crisis and synthetic 
opioids is a nationwide problem. How can only half of them be 
digging into that area?
    Mr. Chester. And the Drug Free Communities grantees decide 
based upon their local conditions what they want. Now, we do 
manage the program in cooperation with others, and we will 
absolutely be glad to address that. But the Drug Free 
Communities Program is centered at the community level.
    Mr. Johnson. OK. I have got one question for you, Mr. 
DeLena. Some say the problem with class wide bans is that 
potentially thousands of compounds are defined solely by their 
chemical structures without regard for their pharmacological 
activity.
    It is my understanding that the DEA looked at more than 
structural similarity when arriving at the definition of 
fentanyl-related substances. Can you explain to our committee 
what structure activity relationships are?
    Mr. DeLena. Congressman, thank you for the question. 
Unfortunately, I am focused on the enforcement side. That is my 
background and where I come from, but we do have scientists and 
experts that handle that. I would be happy to take that 
question back.
    Mr. Johnson. Are you happy--my time has run out, Mr. 
DeLena. Can you get back to your organization and those 
scientists and get us some information on that?
    Mr. DeLena. We would be happy to. Thank you.
    Mr. Johnson. OK. Thank you.
    Mr. Chairman, I yield back.
    Mr. Guthrie. The gentleman yields back.
    The Chair now recognizes Ms. Kuster from New Hampshire for 
5 minutes.
    Ms. Kuster. Thank you, Mr. Chairman, and thank you to the 
witnesses joining us today for your testimony. In particular, I 
want to thank Mr. DeLena who has been such a great resource for 
us in New England. I really appreciate our work together.
    I am cochair of the bipartisan Task Force on Mental Health 
and Substance Use Disorder with my Republican colleague, Brian 
Fitzpatrick, and David Trone of Maryland.
    And we are all grateful for the progress that this 
committee made in the 117th Congress, passing important mental 
health and substance use disorder legislation and, in 
particular, the Restoring Hope for Mental Health and Well-Being 
that I might add passed the House with 402 votes. I think it 
was probably the most bipartisan bill in the 117th Congress.
    But as we all know, there is much more to be done. I am 
working closely with my colleague from Delaware, Congresswoman 
Blunt Rochester, to reintroduce our legislation, the STOP 
Fentanyl Act, and I hope that the Chair will bring that up in a 
subcommittee on a future date.
    This bipartisan bill was introduced in the 117th to invest 
in fentanyl detection and data collection, stem the supply of 
fentanyl, and address demand for synthetics through overdose 
prevention and substance use disorder treatments.
    As Mr. Chester's testimony stated, fentanyl is a complex 
national security, criminal justice, and public health 
challenge that requires a multifaceted approach, and that is 
why the STOP Fentanyl Act devotes resources to enhance fentanyl 
surveillance, empowering officials at the State, local, and 
Federal level, to support detection and reporting.
    We must continue to aggressively pursue the sources of 
fentanyl that have been described here today, stopping the flow 
of materials for synthetic drugs into this country, and cutting 
off the paths that bring these harmful substance into our 
communities.
    This bill supports efforts to hold bad actors accountable 
both at the international governance level and with the social 
media companies that our families and friends use every day.
    As the experts in this room know, a public health approach 
much be complemented by a well-resourced, data-driven plan to 
stem the supply of fentanyl. STOP Fentanyl is the path forward 
to respond to the challenges before us.
    I look forward to hearing from my colleagues on this 
committee who are interested in a comprehensive approach to 
protect our companies from fentanyl--our communities. I ask for 
your partnership and support.
    In order to best craft solutions, it is essential to 
definitively understand the problems. Mr. DeLena, it is great 
to be with you, and I wanted to ask you--you have seen how 
these issues affect communities like my district in New 
Hampshire, and the DEA has worked to prevent shipment through 
the postal system and crack down on chemists overseas as you 
describe--what is the top way that fentanyl enters the country, 
and where should congressional efforts be focused to complement 
your agency's work?
    Mr. DeLena. Congresswoman, thank you for the question and 
for your work when it comes to fentanyl.
    A majority of the fentanyl that is coming into our 
communities crosses the southwest border, predominantly through 
the ports of entry, but they use any possible way to get it 
across.
    Ms. Kuster. And, Mr. Chester, what role can HIDTAs play in 
expanding our surveillance and data collection efforts moving 
forward?
    Mr. Chester. Our HIDTAs play a vital role because they are 
in all 50 States. They cover the vast majority of the 
population of the United States, and 99 of 100 major 
metropolitan areas. They are the one that can provide us the 
bottom's up information of what is actually happening in their 
communities, and they provide this information nationwide. They 
are an extremely valuable resource.
    Ms. Kuster. And is there coordination and sufficient 
resources for data collection and surveillance to know--I heard 
a reference to a new substance today that I wasn't even aware 
of, but to know when they are emerging threats?
    Mr. Chester. Yes, ma'am. In fact, the HIDTAs are very 
valuable, not only do they work effectively in their own right, 
but they are networked together very well, particularly through 
their drug intelligence officers, who are able to share that 
information, and be able to determine nationwide trends, based 
upon the local data that they are seeing from their particular 
HIDTAs.
    Ms. Kuster. I think that data collection and surveillance 
is going to be really important.
    Dr. Gandotra, I am going to probably have to leave this 
question for the record, but once fentanyl enters our borders, 
how does SAMHSA work with first responders to educate on 
interacting with fentanyl?
    Dr. Gandotra. Thank you for that question. I will point to 
our grant program, the First Responders--Comprehensive 
Addiction and Recovery Act that educates first responders, 
firemen, police officers, on how to administer fentanyl, how to 
recognize the signs for overdose, and how to link to care.
    Ms. Kuster. Great. Thank you. And with that, I yield back.
    Mr. Guthrie. Thank you. The gentlelady yields back.
    The Chair recognizes Mr. Bilirakis for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it. 
Thanks for convening this hearing today.
    I would like to start by briefly sharing a news story from 
my district in Florida, the Tampa Bay area, and also the nature 
coast.
    Just last week, the Citrus County Sheriff's Office 
apprehended a long-time drug dealer who, as he attempted to 
flee arrest in his vehicle, threw a bag of drugs from his 
vehicle.
    Having ruptured upon impact, the contents of this baggy 
were scattered throughout the grass shoulder. HAZMAT teams were 
deployed, and approximately 51 grams of fentanyl was collected, 
enough fentanyl to kill more than 25,000 people, believe it or 
not.
    This, once again, highlights that we are in a crisis 
situation that deserves the highest amount of attention and 
response at every level of government, starting with the Biden 
administration.
    It is clear they are not doing enough, and I am 
disheartened by the tragedies we are seeing on a daily basis. 
Headlines of toddlers, adolescents, young adults that have died 
already just 1 month into 2023.
    Mr. Chairman, thank you for making this a priority.
    Fentanyl coming into the country from Mexican cartels; 
fentanyl created with chemicals imported from China and India; 
enough fentanyl to kill every American in the country multiple 
times over.
    Now I know there is no silver bullet as we all know that 
will solve this crisis right away, but Republicans on this 
committee are taking this threat seriously, and there should be 
serious doubts--zero doubts though--zero doubts or opposition 
permanently scheduling fentanyl-related substances to the 
Schedule I, again permanently.
    And thank you for taking this on again, Mr. Chairman.
    My question is to Mr. DeLena. You talk about the way these 
cartels are aggressively lacing other fake pills and 
distributing via social media networks. Can you tell us what 
your coordination is with social media companies, if any? How 
can you better improve communication to quickly respond to drug 
sales on these platforms?
    Mr. DeLena. Congressman, thank you for the question. It is 
very clear that social media has become a superhighway for 
drugs. The role of these drug cartels and the drug trafficking 
organizations that work on behalf of them, they are 
advertising, actually completing sales and effectuating payment 
using these types of applications.
    And we know that the social media companies who control the 
algorithms, they control the content that is driven to the 
users, and they control all of the data therein, can do more 
and must do more.
    You asked about our interaction with them. We interact with 
these companies on a regular basis in terms of the 
investigations that we are conducting.
    Mr. Bilirakis. How much cooperation are you getting?
    Mr. DeLena. These social media companies, Congressman, need 
to do more. As I stated, they control all of that content, and 
there must be more transparency. There must be efforts for 
preservation of evidence.
    There is applications that have disappearing stories. 
Twenty-four hours, you know, later, all of that information can 
be gone. I can tell you firsthand that the men and women of DEA 
who are--and our friends in law enforcement who are responding 
to these drug poisoning deaths, you know, the first thing they 
want to do is take steps to prevent another death from 
happening in that community.
    And the way they do that is by identifying who that drug 
trafficker was that maybe sold those drugs to the decedent. If 
that information is gone, if there is no way that we can look 
at it, there is no steps that can be taken.
    Mr. Bilirakis. Well, we must hold them accountable. In the 
spirit of being proactive and keeping pace to address new 
concerns on the horizon, I am also interested in addressing the 
drug xylazine, a tranquilizer drug with no approved medical use 
in humans. It is used for horses. It is used as a sedative and 
veterinary medicine, I understand.
    Florida has led the way in addressing this by scheduling 
xylazine on the State level. It is time that we follow suit and 
do this federally since it is being discovered in fentanyl 
overdose deaths and has horrifying side effects on the human 
body and does not respond to naloxone.
    Mr. Chester, what can be done to properly trace and track 
the presence of xylazine in our drug supply? How important is 
it to accurately pinpoint the drugs that are contributing to 
overdose deaths throughout the U.S.?
    Mr. Guthrie. Thanks. Can we get that on the record so we 
can--can you give your answer on the record, do you mind?
    I am sorry, your time is expired, and we are trying to get 
two panels through. So the gentleman yields back. The Chair now 
recognizes Ms. Kelly from Illinois for 5 minutes.
    Ms. Kelly. Thank you so much, and I have one dilemma. 
Congratulations to you, Mr. Chair, and I want to thank Chairman 
Guthrie and Ranking Member Eshoo for holding a hearing on this 
very important topic.
    We need to eliminate the racial and ethnic disparities that 
plague the overdose epidemic and the broader healthcare system, 
and I do believe we all agree on that.
    Unfortunately, overdose deaths are beginning to rise even 
before the pandemic, and Black and Brown communities are 
experiencing the fastest increasing rates of overdose deaths 
involving synthetic opioids.
    In 2020, drug overdose death rates increased by 44 percent 
for Black people, 21 percent for Hispanic people, and 39 
percent for American Indian and Alaska Native people.
    Moreover, access to opioid and substance use disorder 
treatment is lower in Black, Latino, and Asian communities.
    We could go on forever in the remainder of this hearing, 
highlighting diseases and conditions for which people of color 
have higher incidences of illness and less access to 
healthcare.
    Dr. Gandotra, what is SAMHSA doing to reduce disparities in 
substance use and mental health in the United States?
    Dr. Gandotra. Thank you for that question, and certainly 
SAMHSA has recognized this issue as well. We require all new 
grant programs, recipients, to submit a data-driven disparity 
impact statement, outlining how they are going to address 
behavioral health disparities within their grants.
    We also have several programs themselves to address closing 
equity gaps. In particular, we have the Tribal Opioid Response 
Program, which addresses the public health crisis caused by 
escalating opioid and stimulant misuse in Tribal communities.
    We also have our Technology Transfer Centers, which 
disseminate information, specifically Technology Transfer 
Centers dedicated to American Indian and Alaska Native 
populations, and a separate one for Hispanic and Latino 
populations.
    We also have three Centers of Excellence for African 
American populations, LGBTQI-plus, as well as older adults.
    We also fund the Center of Excellence for historically 
black colleges and universities to help expand the workforce 
within behavioral health.
    We have the minority fellowship program which provides 
stipends to increase the number of culturally competent, 
behavioral health professionals.
    And finally, we fund the National Network to Eliminate 
Disparities in Behavioral Health Network, which really does 
exchange a lot of information between organizations and provide 
networking to advance best practices.
    Ms. Kelly. Thank you. I just want to make sure that 
Congress is taking a holistic approach by investigating 
significantly in prevention treatment and recovery.
    And also, as my colleague, Mr. Griffith, had brought 
forward, my district is urban, suburban, and rural, and it has 
become even more rural in the remapping. I have over 2,000 
farms in my district, so I want to make sure that we are paying 
attention to the rural areas also.
    How are you addressing the social determinants of health 
and their impact on human well-being?
    Dr. Gandotra. Certainly, social determinants of health can 
not only impact treatment outcomes, but they also impact 
treatment engagement. SAMHSA understands that not all services 
are clinical in nature, and they need to be covered.
    Through our Block Grant Program, there are set-asides for 
wrap-around services such as case management. We have 
partnerships with other entities such as HUD to establish 
housing opportunities for those within--who are suffering from 
HIV or AIDS.
    We have a number of other programs that address the social 
determinants of health as well.
    Ms. Kelly. And may I ask what other agencies you 
collaborate with to address health inequities?
    Dr. Gandotra. I would say within HHS, our operational 
divisions, we with coordinate with HRSA, the Bureau of Indian 
Health Services as well, as well as the Bureau of Prisons. We 
work with a number of Federal entities when it comes to 
establishing treatment and evidence-based care.
    Ms. Kelly. Thank you so much. We must intentionally address 
the root causes and the inequities, or else we will never get 
out of this situation. Thank you.
    Mr. Guthrie. Thank you. The gentlelady yields back.
    And I should have pointed out to my colleagues on the other 
side earlier, Dr. Larry Bucshon will be vice chair of this 
committee, and we look forward to working together with him. So 
you will see him in the chair quite often. Just want to make 
that aware and that announcement.
    But I will now recognize the vice chair of the committee, 
Dr. Bucshon, for 5 minutes for questions.
    Mr. Bucshon. Thank you, Mr. Chairman, and I apologize, I 
have another hearing at the same time, as many of us do, but I 
have read through your testimony.
    Thank you, Chairman Guthrie, for holding the hearing and 
drawing attention to this very important point we so often take 
for granted, that all life is precious and valuable.
    Each of these bills before us today serves as an important 
reminder of that fact. Two of them touch on the issue of 
illicit drug trafficking and use which affects each of our 
districts.
    As the medical community has attempted to deal with 
increasing rates of illegal drug use and addiction, we have 
developed medication-assisted treatment.
    And just so you know, I was a physician before I was in 
Congress.
    While this can be an important tool, and it is an important 
tool in the right circumstances, I have long voiced concerns 
about its potential to cause harm without the proper 
guardrails.
    Furthermore, buprenorphine, the primary medication being 
used in medication-assisted treatment for opioid use disorder, 
is itself an opioid and is extremely vulnerable for misuse and 
diversion.
    People who have been on the committee know that I have long 
been opposed to the broad expansion of prescribing authority 
under the umbrella of expanding the availability of treatment.
    In medicine, sometimes we are in these situations where 
medications are dangerous potentially, and even though we want 
more access, we still have to stick with science and make sure 
the proper individuals, who are properly trained, are the only 
ones that have the ability to prescribe these medications.
    Unfortunately, I haven't been able to convince all my 
colleagues of my view on this issue. So we have dramatically 
expanded it, and I hope that we don't see problems.
    Mr. Gandotra, you spoke to my colleague, Mr. Griffith, 
earlier about the potential for buprenorphine diversion and 
said that you were not aware of it being used as a street drug. 
Is that correct?
    Dr. Gandotra. Most cases are of buprenorphine have been 
utilized for treatment, or for withdrawal mitigation as far 
as----
    Mr. Bucshon. Well, just, I mean, as you probably know, 
there is multiple peer-reviewed articles and even some NIH and 
DOJ intelligence research suggesting that it is a significant 
risk, that buprenorphine, being a diverted drug.
    So even though it sounds like you think that that is a 
small issue--we can agree to disagree--what steps is SAMHSA 
taking to combat the possible diversion of buprenorphine?
    Dr. Gandotra. Thank you very much for that question. 
Certainly we know that education on substance use disorder is 
important as practitioners diagnose and treat these conditions.
    We are working with professional societies to ensure that 
there is appropriate and summative information provided to all 
members so that ongoing education and training becomes the 
standard. That is irrespective of the ex-waiver itself.
    And certainly as far as diversion goes, I could also turn 
to my DEA colleague for specific diversion actions.
    Mr. Bucshon. Yes, sure.
    Mr. DeLena. Congressman, thank you for your question. You 
asked about buprenorphine and you asked about potential abuse--
--
    Mr. Bucshon. Yes, potential diversion, and I mean, for many 
years it has been considered one of the highly vulnerable drugs 
to being diverted because it is an opioid itself, and as we 
increase access, and as I have previously stated, probably have 
people that aren't properly trained prescribing it. So what are 
you going to do when we start to see it on the street?
    Mr. DeLena. I think the word you used, Congressman, 
guardrails, puts it best. While we want to make sure that 
people get access to the treatment that they need, it has to be 
done in a way that does not contribute to overprescribing, 
misprescribing, or diversion of that substance.
    And we need to make sure that we educate and make aware our 
communities and our law enforcement partners as such.
    Mr. Bucshon. Yes, I would agree with that. And I mean, as 
probably anyone knows that works in this space--and that is not 
my area of expertise, but I was a physician--that ongoing 
counseling and therapy is extremely important. You know, 
showing up and getting medication-assisted treatment without 
proper counseling, follow-up, probably almost for the lifetime 
in many cases, doesn't give very good results.
    I will save this question for your written response. 
Naloxone, it is going to come over the counter. This is for Mr. 
Gandotra. Will that change any, or affect any existing work or 
grant programs at SAMHSA, and how do you plan to deal with 
those changes? If you could submit that for the record, I would 
appreciate it.
    Dr. Gandotra. Thank you.
    Mr. Bucshon. Thank you very much. I yield back.
    Mr. Guthrie. Thank you. I appreciate the vice chair for 
yielding and now recognize Ms. Barragan from California for 5 
minutes for questions.
    Ms. Barragan. Thank you, Mr. Chairman.
    Mr. DeLena, I am looking at your testimony, and under the 
Sinaloa Cartel, you mentioned drug trafficking activity in 
various regions in Mexico, particularly along the Pacific 
coast. Would that include trafficking through boats across 
waters, or is that not included in that?
    Mr. DeLena. Thank you for the question, Congresswoman. 
Those cartels, the Jalisco Cartel and Sinaloa Cartel, will use 
any method possible to get drugs into the United States and 
into all of our communities.
    Ms. Barragan. So do you work with the Coast Guard for 
operations on water?
    Mr. DeLena. Thank you. We work with all our Federal 
partners. We do work with the Coast Guard, and we work with 
State and local law enforcement throughout the country.
    Ms. Barragan. Thank you. I was stricken by your testimony. 
You, on several occasions, mentioned your top priority--your 
operational priority is to defeat these two Mexican cartels 
that are responsible for driving the drug poisoning epidemic in 
the United States.
    You say it once there, and then you go on later to say they 
are using cars and trucks and other routes to transport these 
drugs from Mexico to the United States. And then you continue 
to say it on the crossing points, and you even end with saying, 
again, that the cartels are driving drug poisoning and 
threatening the safety of our health communities.
    And I guess I was struck by the number of times you 
mentioned driving, just because there has been a lot of 
misinformation sometimes put out there.
    My understanding has been since, I think, 2020 about 97 
percent of fentanyl seizures have been ports of entry. You 
previously testified the majority have been at ports of entry. 
Does that 97 percent sound about accurate?
    Mr. DeLena. Congresswoman, thank you again for the 
question.
    I don't have the specifics related to the border and the 
points of entry. That is probably a better question for the 
Department of Homeland Security and the entities therein.
    Ms. Barragan. OK. Well, thank you.
    I think your testimony about the majority is important. It 
is also, I think, why Democrats have prioritized making sure 
there was more than $400 million in nonintrusive inspection 
systems at the southwest land border, because we know the 
majority of this is coming over through the ports of entry.
    Democrats also funded additional staffing for CBP points of 
entry in the fiscal 2023 omnibus because it historically has 
been understaffed. These are the officers that are doing the 
interdicting drug attempts to enter our communities. And so we 
are going to continue to work on that as one of the tools. I 
think in your testimony you mentioned there has to be an 
entire--a lot of tools that are necessary for that.
    So I just want to thank you for the efforts that you are 
doing, and we certainly want to be helpful in making sure that 
Congress is funding efforts to help in your fight, in the DEA's 
fight.
    Dr. Gandotra, I would like to now shift a little bit. In 
Los Angeles County and across the country, we are seeing the 
humanitarian crisis of people experiencing homelessness, and 
they are dying from fentanyl overdoses.
    Between 2017 and 2019, people experiencing homelessness in 
L.A. County were more than 36 times more likely to die of a 
drug overdose compared to the general population. Drug overdose 
deaths involving fentanyl tripled between 2018 and 2020, and 
drug overdoses remains the primary cause of death for people 
experiencing homelessness in L.A. County.
    I believe we need a drug policy aimed at reducing harm 
caused by fentanyl, and it must include a holistic public 
health approach.
    So my question to you is: You know, the last time this 
committee came together, it was on a bipartisan basis to pass 
the Restoring Help for Mental Health and Well-Being Act, which 
reauthorized billions of dollars in programs to address mental 
health and substance abuse.
    Can you discuss how the Substance Abuse and Mental Health 
Services Administration can use these programs to address 
social factors, like homelessness, that worsen fentanyl-related 
substance overdoses among the more than 500,000 people 
experiencing homelessness in our country?
    Dr. Gandotra. Thank you for the question.
    Certainly, when we try to address substance use disorder 
and mental illness, we have to address people where they are. 
Through our block grant funding, the Substance Abuse and Mental 
Health Services Administration does provide billions of dollars 
to each State, where they can identify the interventions that 
are best suited for their communities. This may involve 
wraparound services, prevention efforts, harm-reduction 
efforts, as well as things specifically such as naloxone 
administration.
    As far as homelessness goes, we also expanded our 
educational resources. We recently released our evidence-based 
resource guide, ``Expanding Access to and Use of Behavioral 
Health Services for People Experiencing Homelessness.'' This 
guide has strategies for engagement, retention, as well as 
involvement of recovery efforts. We also highlight key 
strategies to ensure success and measure that success in terms 
of recovery support for both the unsheltered and sheltered 
homeless.
    Ms. Barragan. Thank you.
    My time has expired. I yield back.
    Mr. Guthrie. Thank you.
    The gentlelady yields back.
    The Chair recognizes Dr. Joyce from Pennsylvania for 5 
minutes.
    Mr. Joyce. Thank you for yielding, Mr. Chairman.
    And I further would like to thank our full committee 
Chairwoman McMorris Rodgers for holding this hearing today and 
for your continued focus on stopping the scourge of the illicit 
fentanyl substances and the tragic impact that they have on our 
Nation, specifically in my community in Pennsylvania.
    Last month, we were able to hear powerful testimony here 
from two of my constituents, Ray and Deb Cullen, who tragically 
lost their son to fentanyl poisoning just months ago. Their 
loss and those who have felt this across the Nation over the 
past year underscores how critical it is that we act to 
permanently schedule fentanyl-related substances classwide.
    It is shocking to hear that in 2022 alone the DEA seized 
almost 379 million deadly doses of fentanyl, which is more than 
enough to kill every single man, woman, and child in the United 
States. And this is just what was seized.
    Lack of operational control over our southern border has 
allowed the cartels, the drug traffickers, to flood our streets 
with these deadly substances, literally placing every community 
in America at risk.
    Associate Administrator DeLena, the CDC estimates that 
illicit fentanyl or fentanyl-related substances are responsible 
for most overdose deaths in our country. I firmly believe that 
we must empower law enforcement with every tool that is 
necessary to stop those who traffic these deadly substances 
into our communities.
    For this reason, I am troubled by the Biden 
administration's insistence that we should exempt certain 
fentanyl-related substances scheduled by class from all 
quantity-based mandatory minimums.
    Associate Administrator DeLena, with this approach of less-
harsh sentencing guidelines for fentanyl-related substances 
under the Biden plan, if a drug trafficker would bring, let's 
say, this amount of a fentanyl-related substance into the 
United States and, in contrast, had this amount of cocaine, the 
mandatory minimum sentences would be greater for this in 
cocaine than the more deadly fentanyl-related substances, which 
potentially could kill everyone in my district.
    Wouldn't this incentivize the drug traffickers to bring 
fentanyl-related substances, more of them in, causing more 
tragedy, more deaths in the United States?
    Mr. DeLena. Congressman, thank you for the question.
    It is the top legislative priority of DEA for the permanent 
classwide scheduling of fentanyl-related substances.
    DEA is a law enforcement agency. We conduct investigations 
and make arrests. When it comes to the sentencing and 
everything that goes along with it, we defer that to the 
prosecutors that we work with and the judges.
    Mr. Joyce. So the Biden administration does not recommend 
decreased or absent mandatory minimum sentences for fentanyl-
related substances?
    Mr. DeLena. Congressman, again, thank you. I would have to 
defer to those prosecutors and the judges that make those 
decisions, is the best answer to that.
    As an investigative law enforcement agency, our goal is to 
target those cartels and the drug-trafficking organizations 
that are doing the most harm and to make those arrests. Then we 
move that forward for prosecution, and those decisions are made 
by prosecutors and judges.
    Mr. Joyce. Would you agree with me that mandatory minimum 
sentences for fentanyl-related substances should be equal to 
other narcotics that could be introduced into our country?
    Mr. DeLena. Thank you, Congressman, for the question.
    I would have to defer to the people that make those 
decisions. As a law enforcement agency, we are laser focused on 
defeating the two cartels and reducing harm in all of our 
communities.
    Mr. Joyce. And you talk about that harm in our communities. 
I think every Member, both sides of the aisle, has witnessed 
those harms and has heard those stories in our communities, in 
our families, in our neighborhoods.
    I think protecting our southern border is utmost important. 
And I think those mandatory minimum sentences should not allow 
the exemption of fentanyl-related substances.
    I think we have to agree that the impact of fentanyl-
related substances and the ability to carry the similar 
mandatory sentencing has to stop the cartels from looking at it 
as a business decision, which would carry a great amount of 
harm throughout the United States.
    I thank you for participating.
    And I yield the remainder of my time.
    Mr. Guthrie. The gentleman yields back.
    The Chair now recognizes Ms. Craig from Minnesota for 5 
minutes for questions.
    Ms. Craig. Thank you so much, Mr. Chairman.
    And especially to our witnesses, thank you for being before 
us today to address this absolute crisis here across our 
country and in Minnesota's Second Congressional District that I 
represent.
    You know, families across America are suffering unthinkable 
losses as a result of these drugs. I know firsthand that our 
Nation's public safety and healthcare professionals are on the 
front lines of this battle. In November of last year, I was on 
a ride-along with the Shakopee Police Department in my 
congressional district. Our first call of the night led us to 
the scene of a public drug overdose, where I watched Officer 
Soto and two of her colleagues literally bring a young man back 
to life from the bathroom floor of a family restaurant.
    I know that is just another night in the line of work that 
they are in, but addiction, mental health, and other challenges 
have stretched them thin. We in Congress owe them both the 
utmost respect and the conviction to address and fight these 
issues, or we face the possibility of losing countless more 
lives to this opioid crisis.
    We owe the parents, the grandparents, the friends, and 
family of all that were not saved the responsibility to address 
these issues in a comprehensive way and not use these tragedies 
as another political wedge issue.
    Look, I know this is complex. Congress doesn't do complex 
very well. I have learned that in my first 4 years in Congress. 
And I am disappointed this morning that my Republican 
colleagues, some of them, have decided to use this hearing as a 
partisan pulpit rather than address this as a forum to talk 
about bipartisan solutions to this deadly epidemic.
    Yes, we have to disrupt the flow of these drugs and their 
raw materials into our Nation. Yes, we have to ensure that 
Customs and Border Patrol have what they need in order to 
detect and seize these drugs at our border. Yes, we must 
permanently schedule these drugs as Class I.
    And yes, we have to figure out what to do about social 
media companies across our Nation that are promoting on 
Snapchat and other platforms these drugs to our young people. 
And yes, we have to treat addiction across our Nation.
    You know, we sit up here this morning and we ask you single 
questions in 5 minutes, and none of those individual questions 
encapsulates the enormity and complexity of these issues.
    So I am just going to start with this, and I only have 
about 1 minute for each answer. But, first of all, the legal 
ports of entry, what else do you need to keep them from getting 
to our Nation in the first place? What do you need from 
Congress?
    Mr. DeLena or Mr. Chester?
    Mr. DeLena. Thank you, Congresswoman, for your question and 
for sharing that story of your ride-along and the heroic 
actions of the men and women in law enforcement that day. That 
is a scene that I have seen play out personally in all of the 
communities that I have served. I know that first responders 
are doing that same exact duty all day every day, and we are 
seeing it in communities throughout the entire United States.
    What we need is the permanent classwide scheduling of 
fentanyl-related substances. That is a critical step for us as 
we move forward.
    I would like to thank Congress for the enhancements that 
came to our budget last year. That is very important to us. 
DEA's operations that I mentioned, Operation Overdrive and One 
Pill Can Kill--One Pill Can Kill, not just an enforcement 
operation but an actual outreach and awareness program that is 
having such impact in all of our communities--and the counter-
threat teams that I talked about.
    We need the support of Congress to be able to continue to 
move forward. We want to stay ahead of these cartels when it 
comes to our infrastructure, our digital and data. We need that 
support to be able to stay ahead of those violent, ruthless 
drug cartels.
    Ms. Craig. Thank you so much.
    And just one more time, why do we need to treat this as a 
public health topic? Why do we need a public health solution?
    Dr. Gandotra. Thank you for that question.
    Certainly, it affects all aspects of public health--
communities and schools, as well as employment, the GDP, as 
well as crisis services. We would like to address this on 
several fronts, as it affects all aspects of our lives.
    Ms. Craig. Thank you so much.
    And, with that, Mr. Chairman, unfortunately, my time has 
expired. I yield back.
    Mr. Bucshon [presiding]. The gentlelady yields back.
    I now recognize the gentlelady from Tennessee, Mrs. 
Harshbarger.
    Mrs. Harshbarger. Thank you, Mr. Chairman.
    Thank you to the witnesses today.
    Mr. Chester, some Members of Congress and a number of State 
attorney generals, both Democrat and Republican, support 
designating illicit fentanyl analogs and all precursor 
chemicals as weapons of mass destruction, whether through 
executive branch action or congressional legislation, either 
way.
    This would increase interagency coordination to stop 
fentanyl and would increase resources for technical development 
and deployment of sensors to detect fentanyl and analytical, 
data-based decisionmaking.
    What are your thoughts on the merits of such a policy?
    Mr. Chester. Thank you very much for that question.
    That issue and the related issue of a foreign terrorist 
designation are something that the administration has looked 
very, very closely at across the interagency, and we have 
examined it from top to bottom.
    The fundamental question is, would doing so provide us any 
capabilities, authorities, or procedures that we don't already 
have and are not already applying to this problem? And the 
answer is ``no.''
    All of the architecture, the structure, the capability, and 
the authorities that we need to be able to deal with this 
problem in a comprehensive way we have available and we are 
already applying to this particular problem.
    Mrs. Harshbarger. OK.
    I have another question for you, sir.
    The High Intensity Drug Trafficking Areas, the HIDTA, 
program that was created back in 1988 is administered by ONDCP 
and provides assistance to law enforcement agencies at the 
Federal, State, local, and Tribal levels. They are operating in 
regions of the United States that have been deemed as critical 
drug-trafficking regions.
    My district is east Tennessee, and we are part of the 
Appalachian HIDTA. And that plays an important role in pursuing 
the disruption and dismantlement of drug-trafficking 
organizations and drug threats in the Appalachian region. And 
we have been inundated, along with southwest Virginia and 
eastern Kentucky, with that.
    Its activities include multiagency intelligence-sharing and 
enforcement initiatives involving investigation, interdiction, 
and prosecution, and also drug use prevention and treatment 
initiatives.
    Over the past several years, Congress has steadily 
increased appropriations for this program, funding it at $280 
million in fiscal year 2019 to a point most recently for fiscal 
year 2023 at $302 million.
    My question is, do you believe it is sufficient funding for 
HIDTA? And explain your answer as to why or why not.
    Mr. Chester. First off, I agree with your characterization 
of the HIDTA program. And, particularly, the Appalachia HIDTA 
and Vic Brown do an enormous job in that part of the country. 
And we appreciate very much the Congress' continued support for 
the HIDTA program, and we appreciate the funding that we have 
received.
    What I can tell you is that every single penny that the 
Congress provides the HIDTA program is put in the right place 
to do the right work that they need to do to protect our 
communities and protect our country. And we thank you for that.
    Mrs. Harshbarger. Well, do you think it is sufficient?
    Mr. Chester. Yes, ma'am. We appreciate all of the funding 
that we have gotten. Thank you.
    Mrs. Harshbarger. OK. Very good.
    Mr. DeLena, the DEA--I am very familiar with the DEA and a 
bunch of other three- and four-letter agencies in my 
profession, as a matter of fact.
    My question to you is, can you provide us an update on the 
status of DEA's two proposed rules addressing controlled-
substance prescribing via telemedicine? And when will they be 
released to the public for review and comment?
    Mr. DeLena. Thank you, Congresswoman, for your question.
    DEA takes telehealth very seriously, and it is something 
that we are moving forward towards. My understanding is that we 
are very close to making that. Anything beyond that, I could 
take it back and try to get back to you with a more accurate 
update.
    Mrs. Harshbarger. OK. So it is not open for public comment 
yet, but you are close.
    Does that mean you have put rules on the books to where we 
can look at some of the--I mean, I can't give you information 
if I don't know what you have talked about.
    Mr. DeLena. Thank you. I don't have that exact answer, but 
I will get it back to you.
    What I can say is, you know, we want to ensure that 
Americans have access to telehealth, and it has to be done in a 
way that is safe and, you know, has guardrails that prevent 
from overprescribing and misprescribing and diversion.
    Mrs. Harshbarger. Yes. Absolutely.
    With such a short timeframe before the end of COVID, what 
is DEA's plan to ensure patients don't lose access to those 
controlled substances that they need? And I guess that would 
include buprenorphine as medication for opioid use disorder.
    And, you know, I look at that in different ways. I have 
seen it misused. There are people who take those strips, you 
know, heat them up, use them as injectables. There is a lot of 
diversion that goes on with that. But you can't just stop 
somebody. But you don't try to drag forward a drug either. You 
know, there is a lot that goes into that.
    I just wondered what your thoughts are on that.
    Mr. DeLena. Thank you, Congresswoman.
    We are committed--DEA is committed to continued access to 
medications for opioid use disorders. When the COVID-19 public 
health emergency has ended, we will address that when it 
happens, and we will take steps to make sure that everybody 
that is seeking medication has access to it.
    Mrs. Harshbarger. OK. All right. Thank you, sir.
    And, with that, I yield back.
    Mr. Bucshon. The gentlelady yields back.
    I now recognize Ms. Blunt Rochester from Delaware for her 5 
minutes.
    Ms. Blunt Rochester. Thank you, Mr. Chairman, for the 
recognition, and congratulations.
    I also want to thank the Biden administration officials 
testifying today for their tireless efforts to disrupt the 
global illicit drug-trafficking enterprise as well as your 
efforts to address the public health and national security 
challenges that this crisis presents.
    Fentanyl remains the deadliest drug threat facing the 
people of Delaware and America. In 2021, Delaware had the 
fourth-highest rate of drug overdose deaths in the country, and 
over 80 percent of these deaths involved fentanyl.
    That is why addressing the opioid crisis, now driven by 
fentanyl, is one of my top priorities in Congress. I am pleased 
my colleagues on the other side of the aisle have also 
prioritized addressing the fentanyl crisis, because, at over 
100,000 overdose deaths per year, this crisis is sparing no 
one.
    Unfortunately, the legislation we are considering today 
misses the mark. The approach we are considering today focuses 
almost exclusively on law enforcement solutions, and, as I have 
said many times before in this committee, we cannot incarcerate 
ourselves out of this public health problem.
    I have been working on legislation with Congresswoman 
Kuster called the STOP Fentanyl Act to comprehensively address 
both supply-side and demand-side drivers of the fentanyl 
crisis. I want to run through a few important provisions of 
this legislation.
    Our bill will help States improve their fentanyl 
surveillance and forensic laboratories so that States can 
distinguish between fentanyl, fentanyl analogs, and fentanyl-
related substances.
    It will improve access to all forms of medication-assisted 
treatment, including methadone, which, along with psycho-social 
therapies and community-based recovery supports, is the gold 
standard for treating those with opioid use disorder.
    It will extend the reach of harm-reduction programs so that 
they can help keep more people alive long enough to seek 
treatment.
    And it will support law enforcement agencies in detecting 
and handling fentanyl.
    And my first question: Dr. Gandotra--make sure I say that 
correctly. Is that correct?
    Dr. Gandotra. Thank you. That is correct.
    Ms. Blunt Rochester. Can you describe SAMHSA's approach to 
expanding harm-reduction strategies and evidence-based 
treatment? And explain why focusing on those suffering from 
substance use disorder is important, why it is important, 
focusing there.
    Dr. Gandotra. Thank you, Congresswoman, for this question.
    This is part of SAMHSA's mission, to not only address 
substance use disorder but reduce the harms that are associated 
with its use. Harm reduction is an important pathway to ensure 
that patients who may not be ready to engage in full treatment 
are at least able to mitigate the harms associated with use.
    Harm-reduction principles such as overdose mitigation with 
naloxone has been shown to be very beneficial, not just in 
training providers but also making them sensitive to asking the 
right questions. In addition to that, if we don't identify 
patients, we are not actually able to get them into treatment.
    Of course, medications for opioid use disorder are the gold 
standard for preventing overdose mortality. So certainly we 
expand that with our substance use block grants as well as our 
State opioid response grants, as well, which dedicates billions 
of dollars to the States.
    Ms. Blunt Rochester. Thank you.
    Our legislation focuses heavily on public health 
surveillance and data collection, because data is a powerful 
tool that can help us target resources to those most in need.
    For example, through robust data collection on overdoses in 
Delaware, public health officials identified that 23 percent of 
overdose deaths in recent years occurred among those working in 
the construction industry.
    Through this information grew a partnership between public 
health officials and the State's construction industry to 
directly distribute Narcan into the hands of workers at risk, 
train supervisors on overdoses, and train workers on the stigma 
associated with addiction.
    Mr. Chester, can you share how Biden administration 
agencies currently track fatal and nonfatal overdoses? And do 
you have suggestions on how the many different data sources can 
be integrated in a way that is more helpful to policymakers?
    Mr. Chester. Thank you, Congresswoman. I will be as quick 
as I can.
    The tracking of fatal overdoses is done by the Centers for 
Disease Control and Prevention through the National Center for 
Health Statistics. What we were lacking was nonfatal overdose 
data, which is a prime indicator for the eventuality of a fatal 
overdose.
    Just recently, within the last 2 months, ONDCP has launched 
a dashboard that works with other agencies to track nonfatal 
overdose data, which is incredibly important. And we work 
across the interagency in order to track that.
    The most important thing that we can do--and I think you 
brought this up in your statement--is to use that data and 
bring it together to figure out those areas that have the 
greatest need, where we can surge resources and make the 
greatest effect. And that is principally how we use that data.
    Ms. Blunt Rochester. Thank you so much.
    I am over time. I will be reaching out to you with a 
question about data and DEA.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Bucshon. The gentlelady yields back.
    I now recognize the gentleman from Georgia, Mr. Carter, for 
his 5 minutes.
    Mr. Carter. Thank you, Mr. Chairman.
    And thank all of you for being here.
    I think that we would all agree--members of the committee, 
witnesses, everyone in America--this is an epidemic. This is 
something that has got to be addressed. We all know what is 
going on here.
    And there are a number of reasons, none that are more 
important than the fact that we have to secure our southern 
border. I mean, we all know that this is where the vast 
majority, if not all, of the fentanyl is coming across, and it 
is causing problems. A lot of people look at the border 
situation, the crisis that exists down there as being just 
illegal immigrants coming across, but we know that it is much 
more than that.
    And we know that it is infesting all of our communities. In 
my district, we--and I represent south Georgia. I represent the 
entire coast of Georgia, but I have a lot of rural areas in 
south Georgia. We had an incident just last week where we had a 
number of people who overdosed in a small community, a small 
rural community in south Georgia, and overdosed on fentanyl. 
And if it weren't for the heroics of the public safety 
personnel in administering Narcan and naloxone, they would have 
perished.
    And we know what is happening here, and I won't take up my 
valuable time with repeating all the numbers. You know, 7 
billion--enough fentanyl in this country to kill 7 billion 
people, almost 21 times our population. Unbelievable.
    You know, I want to share to you a quick story that 
happened to me. And, you know, I am a pharmacist, and it 
happened to me. I was at a townhall meeting this past August, 
and I made a comment about fentanyl addiction, and a mother 
rightfully corrected me. She said, ``No, sir. You are wrong.'' 
She said, ``It is not fentanyl addiction. It is fentanyl 
poisoning.'' She said, ``My son took one pill, and he is 
dead.''
    She was right, and I was wrong. It is fentanyl poisoning. 
And we have to do something about it, and we have to address 
it. The number-one killer, according to the CDC. It is the 
leading cause of death in the U.S. for adults age 18 to 45.
    So, enough of that. Mr. Chester, I will start with you and 
ask you: In a White House press release dated September the 2nd 
of 2021, DEA Administrator Anne Milgram stated, ``The permanent 
scheduling of all fentanyl-related substances is critical to 
the safety and health of our communities. Class-wide scheduling 
provides a vital tool to combat overdose deaths in the United 
States.''
    Is support for permanent scheduling the official position 
of the Biden administration?
    Mr. Chester. Yes, Congressman, it is. We support the 
scheduling of fentanyl-related substances as a class. We do.
    Mr. Carter. I want to remind members of this committee and 
everyone here that we are considering the HALT Fentanyl Act, 
and that would permanently schedule fentanyl-related substances 
and keep them out of our communities, hopefully.
    You know, I dealt with this when I was in the Georgia State 
legislature and a member of the pharmacy caucus there. We dealt 
with this every year when trying to identify the analogs and 
trying to--and every time we would identify them one year, they 
would come up with different ones the next year. It was just a 
vicious cycle.
    This is something that has to be done. And I hope that we 
will have the administration's support with this, and I hope we 
will have everyone on this committee's support.
    Mr. DeLena, I want to ask you--and I can't help but bring 
up this report that was in The Washington Post recently about 
some of the problems that we have had with the DEA agents down 
in Mexico. In fact, we had a 6-month time when we were without 
personnel down there that we should have had.
    And I just need--I need reassurance from you that the 
personnel problems that we have had down in Mexico, 
particularly with the DEA agents, have been straightened out.
    And I think you know what I am talking about. I am talking 
about, specifically, the DEA's Mexico office was in turmoil for 
more than 6 months, with the Director recalled to Washington 
while investigators probed his conduct.
    Mr. DeLena. Congressman, thank you for your question.
    While I can't comment directly on a personnel matter, what 
I can tell you is that DEA's top operational priority is 
defeating these Mexican cartels. And the----
    Mr. Carter. That is not what I asked you. Come on, now.
    Mr. DeLena. The administration----
    Mr. Carter. You need to give me confidence that you all got 
this straightened out. This is too important. Two hundred 
people are dying every day.
    Mr. DeLena. Thank you, Congressman.
    The Administrator in summer of 2021 ordered a review of all 
of our foreign operations to make sure that we have the right 
people and that we are most effective in all of the places 
where we are situated----
    Mr. Carter. This article also indicates that the Mexican 
Government is not working with us on this. Can you shine any 
light on that with us?
    Mr. DeLena. Congressman, thank you.
    The Mexican Government needs to do more. We are there in 
Mexico laser focused on the cartels and the fentanyl and 
methamphetamine that they are producing, but we know that they 
need to do more when it comes to collaboration. And----
    Mr. Carter. I trust that you all are getting your staff 
worked out, straightened out, your situation straightened out. 
Two hundred people every day. We don't have time. We don't have 
time for this. We have to do something about this right now.
    Thank you, Mr. Chairman, and I will yield back.
    Mr. Bucshon. The gentleman yields back.
    I now recognize the gentlelady from Washington, Ms. 
Schrier, for her 5 minutes.
    Ms. Schrier. Thank you, Dr. Vice Chair.
    And thank you to these excellent witnesses for being here 
today. I have learned a lot from this conversation.
    In my State of Washington, like every other State, fentanyl 
has had profound and devastating impacts. Just months ago, in 
my hometown of Sammamish, a Seattle suburb, two parents of a 
toddler were buying, using, and dealing fentanyl. They left 
pills on their nightstand. Their toddler found them, and the 
toddler died from the overdose.
    On the other side of my district, in Chelan County, a rural 
county in the eastern part of my district, the coroner recently 
reported that deaths from fentanyl overdose rose from 6 in 2021 
to 20 in 2022.
    And, in recent years, local high schoolers have died from 
fentanyl overdoses because they did not know that a pill that a 
friend gave them or that they got elsewhere or online was laced 
with fentanyl.
    And I know that every one of us--and we have heard them 
today--every one of us has stories just like this from our own 
districts.
    Mr. DeLena, you noted in your testimony that the Drug 
Enforcement Agency investigated more than 129 cases directly 
linking the sale of fake pills containing fentanyl to social 
media sites, and then alluded to Snapchat just earlier with 
links that disappear. And this is where teens are getting these 
pills.
    So, as a pediatrician, I need to ask, can you talk a little 
bit more about what the DEA is doing on this issue to make sure 
we don't keep losing our kids? Because they are all on social 
media.
    Mr. DeLena. Congresswoman, thank you for the question.
    And your references to the tragedies that occurred in your 
district--at DEA, we have over 4,800 photos of those that have 
been lost to fentanyl poisoning in our lobby. The youngest is 
17 months, and the oldest is 70 years. So, you know, this drug 
does not distinguish.
    We are laser focused on the cartels that are pushing this 
drug into our country, and we know that those drug cartels and 
their entire drug-trafficking organizations are using social 
media platforms to try to reach hundreds of millions of 
potentially new customers. Because that is truly where 
Americans are spending time, is on those social media sites, 
particularly young people, which is something that, you know, 
is gravely concerning to all of us.
    We need to continue with programs like One Pill Can Kill, 
where not only are we conducting enforcement and seizing these 
pills--50 million pills DEA seized last year--but we are 
educating and getting the word out there. We----
    Ms. Schrier. In addition to educating parents and students, 
what is your interaction with social media sites on this? Do 
you get cooperation? And what do you need from Congress to get 
those tools?
    Mr. DeLena. Thank you, Congresswoman.
    We do interact with the social media companies. We do so on 
a regular basis, specific to each investigation that we are 
conducting. But we know that these social media companies can 
and must do more.
    They control all of the algorithms. They know how content 
is being pushed to all of their hundreds of millions of users. 
They control all of the data. And unless we can get a look 
inside there, as DEA or, as you said, for Congress to be able 
to do something, we can't make those type of recommendations.
    So there needs to be more transparency. If they want to fix 
this problem, they can fix this problem.
    Ms. Schrier. Thank you. This is an area that I look forward 
to working with my colleagues on both sides of the aisle to 
figure out for a variety of reasons.
    I have another question for you. As you may know, 
Washington State has many ports. And I have supported 
legislation to build up law enforcement capacity to detect 
synthetic drugs.
    And I appreciate that your testimony also focuses on the 
southern border. Can you tell me a little bit about what DEA is 
doing to monitor at our seaports?
    Mr. DeLena. Thank you, Congresswoman.
    First of all, DEA is focused on wherever the threat takes 
us and wherever these investigations shall lead. We do work in 
all of our communities not only with our other Federal partners 
but with our State and local partners as well. I have 
personally been involved, in my tenure, particularly in my time 
in Florida, with investigations that lead us, you know, to the 
sea. And we work hand-in-hand with those that are conducting 
those investigations.
    And each of it is threat based. If we know that there is a 
threat, you know, in your specific area coming in through the 
seaport, we are going to be focused on that.
    Ms. Schrier. Thank you.
    I don't have time to get an answer to this, but, Dr. 
Gandotra, I would love it if you could, afterwards, submit 
perhaps a list of places that parents can consult so that they 
can have conversations with their children about how to not 
fall prey to fentanyl poisoning online.
    Thank you. I yield back.
    Mr. Guthrie [presiding]. Thank you.
    The gentlelady yields back.
    The Chair recognizes Dr. Miller-Meeks for 5 minutes for the 
purpose of asking questions.
    Mrs. Miller-Meeks. Thank you very much. And I thank the 
Chair and all the witnesses that are here for this 
extraordinarily important topic.
    And just as an introduction to you, I am a physician, as is 
Dr. Schrier. I am the former director of the Iowa Department of 
Public Health, under which behavioral health, substance use 
disorder was a part. And I also was a State senator and, as a 
State senator, passed no preauthorizations for medicated-
assisted treatment, or MAT, for substance use disorder in one 
session; also schools as a site of service for behavioral 
health, which I think was very forward thinking at the time.
    And so my question, Dr. Gandotra: SAMHSA's 2022 report 
titled ``National Guidelines for Child and Youth Behavioral 
Health Crisis Care'' outlines best practices for implementing 
mobile crisis response teams. And we have set these up in Iowa, 
when we have set up our child and mental health--or like I 
would prefer to call it, brain health--systems. These mobile 
crisis teams are typically made up of mental health 
professionals, nurses, and peer support providers.
    The report recommends that these teams respond to crises 
without law enforcement accompaniment unless special 
circumstances warrant their inclusion.
    And let me also say that in SAMHSA's September 2021 ``Ready 
to Respond,'' also on mental health, on page 20, it also notes 
shifts away from traditional law enforcement responses in many 
cases.
    So my question: Is it SAMHSA's position that mobile crisis 
teams should respond to calls in lieu of law enforcement?
    Dr. Gandotra. Thank you for that question.
    Certainly, we understand that, when it comes to crisis 
management, providers who are going to deliver the service have 
to maintain their safety but also approach this from a trauma-
informed perspective, understanding that sometimes individuals 
who have experienced past trauma may be more vulnerable and 
more sensitive to the application of law enforcement entities. 
Certainly, that has to be balanced with public safety as well 
as the information that is given.
    And that is really the key, is having the most information, 
most up-to-date information, so that the approach can be 
tailored and individualized for those purposes, would be my 
first and ideal situation. Certainly----
    Mrs. Miller-Meeks. So, just to make sure I am 
understanding, you are saying it is not in lieu of law 
enforcement.
    Dr. Gandotra. I am saying it should fit, from the 
information, from the clinical perspective, what is best 
required for the safety of the patient as well as for the 
community provider that is delivering that service, certainly.
    Mrs. Miller-Meeks. So, as in an episode we saw--and this 
was not a child, but--in subways in New York City where someone 
was pushing somebody else off a train track but they are in a 
mental health crisis, how do you respond to that then? Because 
you may not have that information when a 911 call is made to 
know clinically what is the best approach. So, again, is it in 
lieu of law enforcement?
    And, then, what are the criteria for determining special 
circumstances that warrant the involvement of law enforcement? 
That perhaps will better answer this question.
    Dr. Gandotra. So the strategy that should be employed would 
be an evidence-based strategy that would still incorporate 
trauma-informed approaches but still maintain safety for the 
individual delivering the care as well as the individual 
needing the care. We would try to encompass all aspects of the 
needs of the provider as well as for the patient.
    Mrs. Miller-Meeks. Well, I can certainly see that, perhaps, 
if someone is calling a crisis line before there is a crisis. 
But when there is an actual incident, as you may see in public, 
it could be very difficult to do that.
    So thank you so much for the answer, and perhaps you could 
elucidate that further in writing.
    And I yield back my time.
    Mr. Guthrie. The gentlelady yields back.
    The Chair now recognizes Mr. Crenshaw from Texas for 5 
minutes for asking questions.
    Mr. Crenshaw. Thank you, Mr. Chairman.
    Thank you all for being here.
    I would like to direct most of my questions towards you, 
Mr. DeLena. I do have an interest in battling what seems to be 
a war with the cartels south of our border.
    One of my first questions to you is, you know, you laid out 
three strategies the DEA is currently engaged in, but do you 
really have enough resources? And do you need more engagement 
from other entities, such as the intelligence community and 
perhaps the Department of Defense? What else do you need that 
would help battle this problem?
    Mr. DeLena. Thank you for the question and for your 
commitment to this issue, Congressman.
    DEA is equipped right now with the resources that have been 
allocated to us to focus on these two cartels. Any additional 
resources is something, obviously, that, you know, we would be 
open to and to discuss, but it would have to be sort of 
specific to, you know, maybe what you are talking about.
    Mr. Crenshaw. Well, yes, you have certainly been allocated 
the resources, and that is what you are working with. I 
understand that to be the case. But the question is not that. 
It is, is it enough? Are you making an impact against these 
cartels?
    And if not--clearly not, because they are able to wage a 
war against the Mexican Government at will in the state of 
Sinaloa just recently, a couple weeks ago. So, obviously, we 
are not doing enough. What more is needed?
    Mr. DeLena. Congressman, thank you.
    I think, you know, with the successes that we talked about, 
that DEA seized over 50 million pills last year and 10,000 
pounds just of fentanyl and, you know, an exorbitant amount of 
methamphetamine as well, you know, our focus right now is to 
defeat those two cartels and----
    Mr. Crenshaw. OK. OK. What about authorities?
    So I have a bill that I am reintroducing today called 
Declaring War on the Cartels Act. And what this does is deliver 
the same authorities that you would have to go after ISIS 
without necessarily labeling them as a terrorist organization.
    Would that be helpful? Because that would allow you to go 
after their financing. It would allow the U.S. Government to 
sanction officials in Mexico that operate with the cartels. 
Would that be helpful?
    Mr. DeLena. Congressman, thank you.
    I can't comment on pending litigation like that. We would 
work the interagency process as those things came in.
    Mr. Crenshaw. Sure. I imagine it would be helpful if you 
had more authority. That is not a trick question. Yes.
    All right. What is your cooperation like with the Mexican 
Government? Is it good? Is it bad? Has it been better? Does it 
mirror at all the longstanding cooperation we have had with, 
say, the Government of Colombia during Plan Colombia and the 
successes we have had there?
    Mr. DeLena. Thank you, Congressman.
    This is obviously a fluid and rapidly evolving situation. 
We see these cartels in their switch from plant-based drugs to 
synthetic-based drugs. This thing continues to evolve every 
single day.
    We know that the Mexican Government needs to do more. They 
need to take steps in their own country, and they need to 
assist us additionally than how they are already doing that 
right now.
    Mr. Crenshaw. OK. So, no, they are not doing enough. They 
don't cooperate with you to the extent that you would like.
    Do you trust them? If you give them intelligence--like, for 
instance, I am assuming that you know where some of these 
clandestine labs are that they are making fentanyl that is 
killings tens of thousand of Americans a year. I am assuming 
you know that. You currently do not have the authority to go 
raid that facility in Mexico. The Mexican Government does. If 
you tell them about it, will they go take care of it?
    Mr. DeLena. Congressman, thank you.
    I don't want to get into specifics of investigations, and 
that is essentially----
    Mr. Crenshaw. I am not asking you to get into specifics. I 
am asking you in generalities. You know where a bad guy is. You 
tell the Mexican Government to go get them. Will they do it? Do 
you even trust them with that information, or do you think they 
will tip them off?
    Mr. DeLena. Thank you, Congressman.
    The Mexican Government needs to do more. They need to seize 
those drug labs. They need to disrupt those drug labs. They 
need to assist with extradition on the investigations that we 
build.
    Mr. Crenshaw. All right. You are being very diplomatic, and 
that is fine.
    Earlier, you mentioned specifically the Jalisco Cartel and 
the Sinaloa Cartel. It is worth also naming the leaders of 
those cartels and how dangerous these two particular people are 
to tens of thousands of Americans. The leader of the Jalisco 
Cartel is Nemesio Oseguera Cervantes. They know him as El 
Mencho. The leader of the Sinaloa Cartel is Ismael Zambada 
Garcia, known as El Mayo.
    Everyone should know who these two guys are, because they 
are killing tens of thousands of Americans. We all know who 
Osama bin Laden is. We started a war just to go after him. And 
we should start a war with these cartels, because they are at 
war with us. And I would encourage all of my colleagues, across 
the aisle, all Republicans, all Democrats, to join with us on 
this issue.
    I have currently introduced an Authorized Use of Military 
Force to go after the cartels specifically with every aspect of 
our government's power. I think this needs to be a whole-of-
government approach. And I think we need to be unified, as 
Democrats and Republicans, in dealing with this problem.
    Thank you.
    Mr. Guthrie. Thank you.
    The gentleman yields back.
    The Chair now recognizes Mrs. Trahan from Massachusetts for 
5 minutes to ask questions.
    Mrs. Trahan. Thank you, Chairman Guthrie--and I am sorry 
the elevator closed on us earlier--Ranking Member Eshoo.
    Thank you to the administration witnesses for being here 
today.
    Based on today's hearing, it is clear that passing policy 
solutions to address the fentanyl crisis is top of mind for 
Democrats and Republicans alike. And I hope this will be one of 
many hearings this subcommittee holds to build on the 
bipartisan addiction prevention and treatment policies like the 
MAT Act that we passed at the end of last Congress.
    The Biden administration's proposal to permanently schedule 
FRS within Schedule I includes an important off-ramp to 
reschedule an FRS found to have medicinal value, as well as 
research provisions which have been adopted by my Republican 
colleagues in their HALT Fentanyl bill.
    It is important because fentanyl itself has an approved 
medical use, and it is possible there are unknown 
pharmacological effects and therapeutic potential for the 
entire class of substances if studied and regulated properly. 
For example, studying FRS may be key to discovering the next 
generation of naloxone, commonly known as Narcan, which will 
help to save lines.
    Our recent trends in overdose deaths show the emergence of 
fentanyl adulterated with a powerful animal sedative called 
xylazine, which has been talked a lot about today, more 
commonly known as ``tranq dope.''
    According to the Lowell Sun, the paper in my district, 
first responders have already seen this deadly drug make its 
way into Lowell, the gateway city where I grew up and I 
represent. In fact, the Lowell Police Department has sent out 
alerts to residents to inform them of the dangers of this drug. 
The city worries that Narcan does not counteract xylazine like 
it does with fentanyl. And the FDA issued a similar alert back 
in November.
    So, Dr. Gandotra, can you please shed light on how naloxone 
was discovered and how research into FRS may lead into similar 
opioid antagonists?
    Dr. Gandotra. Thank you, Congresswoman, for the question.
    Certainly, we know naloxone is an important tool for 
reversing opioid overdose. It was discovered in the 1960s by a 
researcher who was trying to alleviate symptoms of constipation 
from chronic opioid use, and it is derived from oxymorphone.
    I will also state that it is this property as an opioid 
antagonist that makes it incredibly useful as a mono product 
for reversing overdoses but also as a combination product with 
buprenorphine for Suboxone for opioid treatment and has quite a 
different risk profile and diversion profile, making that a 
wonderful, evidence-based practice for treating opioid use 
disorder.
    Mrs. Trahan. Thank you, Doctor. It seems that we do agree 
that reforming the research landscape is key to finding new 
therapeutic treatments and those lifesaving antidotes.
    I am going to attempt to switch gears a bit, because I 
would like to focus on access to treatment for opioid disorder.
    Since March 2020, the DEA, under authorities associated 
with the public health emergency, has allowed registered 
clinicians to prescribe some controlled medications after a 
telehealth examination for patients suffering from mental 
health issues.
    The expansion of telehealth services has been vital to 
patients across the country who rely on controlled-medication 
prescriptions to support their mental health care and aid in 
their recovery. And there is broad support across the medical 
community for maintaining access to controlled-medication 
prescribing through telehealth to ensure patient access to 
treatments even if they can't make it into the doctor's office.
    I was pleased to see that a very recent study published in 
GEMMA Network found that rules permitting doctors to prescribe 
buprenorphine via telehealth to treat OUD did not increase 
overdose deaths involving the drug.
    Congress has directed the DEA to establish a special 
registration for providers to prescribe controlled medications 
through telehealth. Congresswoman Kuster and I have urged DEA 
to release this special registration and maintain access to OUD 
treatment via telehealth.
    With the public health emergency ending on May 11th of this 
year, it is unlikely that the special registration process will 
be in place, and patients may lose access to a critical pathway 
of treatment.
    So, Mr. DeLena, what is the timeline for this special 
registration proposed rulemaking? And to avoid a gap in access 
to treatment and care, does DEA intend to extend that waiver 
allowing clinicians to prescribe controlled medications through 
telehealth until the special registration process is in place?
    Mr. DeLena. Congresswoman, thank you for the question.
    DEA strongly believes that Americans should have access to 
telehealth, but it has to be done so in the appropriate way to 
avoid overprescribing and misprescribing.
    I can't speak to the specific dates and what you are asking 
for, but I can certainly take that back and try to get you some 
of that information.
    Mrs. Trahan. Terrific. Thank you so much.
    I have run out of time. I yield back.
    Mr. Guthrie. Thank you.
    The gentlelady yields back. And that does conclude our 
first witness panel.
    And I will just say to all three of you: A couple of things 
we might have had a difference of opinion on, but I know we are 
going to have to all work together. And I respect all of you, 
and we look forward to going forward, because this is a crisis.
    There are other bills on the agenda as well, but certainly 
the fentanyl crisis is first and foremost in everyone's mind. 
So hopefully we can find opportunities to move this legislation 
forward in a way that we all can support in the end but also be 
effective. So we have to have both moving forward.
    So thank you very much. Thanks for your patience. Thanks 
for being here, and thanks for your answers. And there was a 
couple of ``ran out of time, you are going to have to answer on 
paper.'' I know we have a record of that, and we look forward 
to your timely responses for that.
    So the first panel is dismissed, and we will set up for the 
second panel.
    [Recess.]
    Mr. Guthrie. Well, thank you. The subcommittee will come 
back to order.
    We appreciate all of our witnesses being here today.
    This is the beginning of our second panel. And I will 
introduce our witnesses, and then we will begin our witness 
testimony.
    First we have Ms. Kandi Pickard, the president and CEO of 
the National Down Syndrome Society.
    Then we will hear from Frederick--I-sah-si, is that 
correct, because we all want to know how to say your names 
correctly--Isasi, the executive director of Families USA.
    And then from Molly Cain, a parent advocate who has been 
directly impacted by the fentanyl crisis.
    And then Dr. Stephen Loyd, the chief medical officer of 
Cedar Recovery.
    And, finally, we will hear from Dr. Timothy Westlake, an 
emergency room physician and former chairman of the Wisconsin 
Medical Examining Board as well as former member of the Badger 
State's Controlled Substance Board.
    So we thank you all for being here and thank you for your 
testimony. It is all important to know. Some of you bring in 
personal stories.
    And some of you haven't testified here before, so I am just 
going to explain. You will see the lights in front of you. You 
have 5 minutes to do your opening statement. After 4 minutes, 
you will see a yellow light to kind of let you know when moving 
forward.
    But I know you have some stories to tell, so we are not 
going to gavel you down too hard. We want to hear your stories. 
And so, just relax. And if you are not--people that haven't 
testified before, sometimes that can be daunting, but we are 
glad to have you here.
    And we will begin with Ms. Pickard. You have 5 minutes--you 
are recognized for 5 minutes for your opening statement.

  STATEMENTS OF KANDI PICKARD, PRESIDENT AND CHIEF EXECUTIVE 
   OFFICER, NATIONAL DOWN SYNDROME SOCIETY; FREDERICK ISASI, 
    EXECUTIVE DIRECTOR, FAMILIES USA; MOLLY A. CAIN, PARENT 
  ADVOCATE; STEPHEN LOYD, M.D., CHIEF MEDICAL OFFICER, CEDAR 
  RECOVERY; AND TIMOTHY W. WESTLAKE, M.D., EMERGENCY MEDICINE 
                           PHYSICIAN

                   STATEMENT OF KANDI PICKARD

    Ms. Pickard. Thank you.
    Chairwoman Rodgers, Chair Guthrie, Ranking Member Eshoo, 
and members of the committee, thank you for inviting me here 
today to testify on quality-adjusted life year measures, or 
QALYs, in combating discrimination against people with 
disabilities.
    My name is Kandi Pickard, and I proudly serve as the 
president and CEO of the National Down Syndrome Society. I am 
also the proud parent of four children, including my 10-year-
old son, Mason, who has Down syndrome.
    As the leading human rights organization for all 
individuals with Down syndrome, NDSS stands in strong support 
of a nationwide ban of the use of QALYs and similar measures in 
coverage determinations under Federal healthcare programs, like 
the one proposed in the Protecting Health Care for All Patients 
Act of 2023.
    As you know, QALYs place numerical value on the quality of 
one's life before and after healthcare treatments and 
interventions, and these calculations are then used by Federal 
health programs to determine the cost-effectiveness of 
treatments and services and, thus, coverage for patients.
    Since a substantial number of individuals with disabilities 
receive their healthcare through Medicaid, this flawed and 
discriminatory metric directly impacts access to necessary 
healthcare treatments when they are not deemed cost-effective 
enough to administer to individuals with disabilities.
    At NDSS, we are very concerned about the use of QALYs and 
other value assessments in all instances. And I would like to 
share two examples of how these discriminatory practices are 
affecting the Down syndrome community.
    People with Down syndrome are uniquely situated in the 
Alzheimer's landscape because of their extra copy of chromosome 
21, which carries the amyloid precursor protein gene that is 
strongly associated with Alzheimer's disease.
    As a result, individuals with Down syndrome have a higher 
than 90 percent lifetime risk for developing Alzheimer's 
disease, with the onset of symptoms coming earlier and 
progressing faster than the general population. In fact, 
Alzheimer's disease is the number-one cause of death for 
individuals with Down syndrome.
    CMS recently cited several studies that relied on QALYs in 
their national coverage decision for Aduhelm, a first-of-its-
kind Alzheimer's treatment.
    Access to treatments for this life-altering disease is 
paramount for our community, yet value assessments such as 
QALYs and other similar one-size-fits-all approaches are 
heavily relied upon in coverage decisions. Medicaid coverage 
decisions cannot be made based on flawed assessments that 
devalue the lives of people with disabilities, especially when 
those lives are uniquely at risk, as is the case for our loved 
ones with Down syndrome.
    Discriminatory metrics and value assessments are also 
experienced by individuals with disabilities in the organ 
transplant system. A 2019 report from the National Council on 
Disability, an independent Federal agency, found that 
discrimination against people with disabilities persists in the 
organ transplant system, rooted in biased attitudes about the 
value of the life of an individual with a disability.
    NDSS is proud to champion the bipartisan Charlotte Woodward 
Organ Transplant Discrimination Prevention Act, named after 
NDSS staff member Charlotte Woodward, who is here with us 
today, which prohibits discrimination based solely on 
disability in the organ transplant system.
    While advocating for the passage of this bill, we remain 
vigilant in our responses to other forms of value assessments, 
such as QALYs, that persist in many aspects of our healthcare 
system and threaten to access nondiscriminatory healthcare for 
people with Down syndrome and other disabilities.
    Today, alongside a diverse and nonpartisan group of 
stakeholders, including the National Council on Disability, the 
Consortium for Constituents with Disabilities, and 100 other 
disability advocacy groups, I urge you to ban the use of QALYs 
in Federal programs.
    A person's value is more than what can be determined by a 
metric. My son Mason is no less valuable than my other three 
children who don't have a disability just because he has Down 
syndrome. I see the value in how hard he works at school, the 
love of his siblings, and the joy he brings our friends and 
family.
    It is outright discrimination to deny individuals with 
disabilities access to treatment and the care they deserve and 
they need because a calculation determines their value.
    Congress deals with many challenging and controversial 
issues. This should not be one of them. No party condones 
discrimination against people with disabilities, and both 
Democrats and Republicans are on the record against the use of 
QALYs.
    I implore you to support this legislation and take the 
important step of protecting people like my son from healthcare 
discrimination.
    Thank you all for inviting me here to speak today. I look 
forward to working with the committee on commonsense health 
reforms that value patients and people with disabilities.
    [The prepared statement of Ms. Pickard follows:]
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    Mr. Guthrie. Thank you for your testimony. Let us welcome 
Charlotte. Charlotte Woods, did you say? What was her last 
name?
    Ms. Pickard. Charlotte Woodward.
    Mr. Guthrie. Woodward, stand up, and welcome to our 
committee. Yes, thank you. Thank you very much. Appreciate you 
being here.
    So now, Mr. Isasi, you are recognized for 5 minutes for an 
opening statement.

                  STATEMENT OF FREDERICK ISASI

    Mr. Isasi. Thank you very much, Chairman Guthrie, Ranking 
Member Eshoo, members of the subcommittee. Thank you for the 
opportunity to testify today.
    I also want to say thank you to Ms. Pickard for the 
beautiful testimony you just gave.
    For more than 40 years, Families USA has been working to 
achieve our mission of a Nation where the best health and 
healthcare are equally accessible and affordable to all. We are 
very proud to have always been, and will always be, a very 
strong partner with the disability community in support of 
their healthcare needs.
    I know the topic of this hearing is personally very 
important to many of us, especially full committee Chair 
McMorris Rodgers.
    No matter what our ideology, we are all much more alike 
than we are different. Everyone struggles with how to care for 
a loved one, and so many live with the financial stress of 
high-cost medical bills and the unaffordablity of our 
healthcare system.
    We at Families USA believe that every person in the United 
States should have high-quality, affordable healthcare that 
prevents illness, allows them to see a doctor, and helps to 
keep their family healthy.
    Yet almost half of all Americans report having to forego 
medical care due to unaffordable costs, and almost the same 
number live under the stress and burden of healthcare debt.
    For people with disabilities, the situation is considerably 
worse. Disabled people are 2\1/2\ more times likely to delay or 
to skip or delay healthcare because of cost, and they are 
significantly more likely to have unmet medical, dental, and 
prescription drug needs.
    It is because of our dedication to the needs of all 
families, including people with disabilities, that I urge the 
subcommittee to oppose the antivalue legislation that is under 
consideration.
    First, the proposed legislation's prohibition on the use of 
quality adjusted years, or such similar measures, is a solution 
in search of a problem. The Inflation Reduction Act drug 
negotiation provisions already have very specific guardrails 
against discrimination from many groups, including people with 
disabilities.
    Quoting directly from the text of the drug price 
negotiation law, it explicitly and unambiguously bars measures 
that treat ``extending the life of an elderly, disabled, or 
terminally ill individual as of lower value.''
    Moreover, similar guardrails exist in other elements of 
Federal law, like the Affordable Care Act. In fact, Families 
USA, working with our disabled partners, supported inclusion of 
these very guardrails in the drug price negotiation law.
    So given the explicit Federal protections that already 
exist, what is the real effect of the legislation being 
considered by the subcommittee today?
    This legislation is a giant loophole to allow the greed of 
drug companies to continue and would let other elements of our 
corporate healthcare sector to continue to price gouge 
unchecked, hurting millions of families, employers, taxpayers, 
and healthcare costs will continue to soar.
    The proposed legislation uses very broad language that drug 
company lawyers will argue bans any attempt to develop an 
understanding of whether a drug is worth the astronomical price 
being charged across pretty much all Federal programs.
    We know that terrible pricing abuses and waste are rampant 
in our healthcare system, totaling almost a trillion dollars a 
year. That is right, almost $1 trillion in healthcare spending 
each year is flat-out waste, hurting both the economic security 
of families and the U.S. taxpayer.
    But we also know that many American families are being hurt 
because of low-quality care. Over a quarter of a million people 
die each year not from their illness but from the medical 
system itself.
    Let me say that again. A quarter of a million souls in our 
Nation die each year because our healthcare sector is killing 
them through low value, poor care, all while we continue to 
spend 2 or even 3 times more on healthcare than other Nations.
    It is time for this to end, period. It is time for our 
Nation to hold our corporate healthcare sector responsible for 
providing high-quality care that is affordable.
    If Federal policymakers want to live up to our collective 
ideals of supporting people with disabilities, we should 
refocus our efforts, end the Medicare disability waiting 
period, extend Medicaid program in every State, fully fund and 
staff Medicaid home and community-based services, and train a 
healthcare workforce that will provide high-quality care to 
people with disabilities with dignity and without 
discrimination.
    I urge members of the subcommittee to oppose this ill-
conceived legislation that is simply playing into the hands of 
drug companies' greed. Thank you very much.
    [The prepared statement of Mr. Isasi follows:]
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    Mr. Guthrie. Thank you for your testimony. I appreciate 
that.
    Ms. Cain, you are now recognized for 5 minutes for your 
opening statement.

                   STATEMENT OF MOLLY A. CAIN

    Ms. Cain. Thank you, Chairs Guthrie and Rodgers and Ranking 
Members Eshoo and Pallone and members of the committee for 
inviting me to come and speak out about fentanyl, how it has 
invaded our communities, devastated families, and how it has 
become a public health crisis.
    My name is Molly Cain, and I lost my beloved 22-year-old 
son Carson to fentanyl poisoning on November 27th, 2020. Thank 
you for allowing me to share his story.
    I would like to begin by painting a story of who Carson 
was. Carson had a beautiful soul. He loved deeply and was wise 
beyond his years, and his heart was true.
    Carson persevered in the face of adversity. When Carson was 
6, he was diagnosed with dyslexia; at 7, he was diagnosed with 
a familial tremor that progressively worsened, and at 10 years 
old, he watched his healthy father be ravaged by and ultimately 
succumb to brain cancer.
    Carson and his brother took on more responsibility within 
our family without being prompted or asked. Carson graduated 
high school with both his high school diploma and his AA degree 
and went on to Gonzaga University to further his education.
    During his college years, Carson was prescribed Xanax for 
anxiety. Carson was a genuine and empathetic person who wanted 
to better the world around him. He would lend a hand or an 
understanding ear to those in need and did not expect anything 
in return.
    He was the shoulder of strength others leaned on, 
especially those friends who had lost a parent. Carson helped 
to guide them out of the dark abyss they now faced.
    During his college years, Carson would plow snow in the 
early-morning hours without request or compensation, would stop 
at the parking lot of a local cancer center to clear the lot. 
When asked why he made the stop, he replied, ``The patients 
going for treatment have enough challenges. They don't need one 
more to navigate.'' These actions embodied his compassionate 
and devoted spirit.
    At 22, Carson was diagnosed with appendix cancer. After a 
battery of scans and procedures, it was determined the cancer 
had not spread, but a spot found on his lung needed to be 
monitored. The anxiety my son had became elevated, and suddenly 
COVID hit.
    Carson, feeling immense pressure, went to counseling and 
was given Xanax again. He told me he felt counseling online was 
impersonal, and he was only offered appointments during his 
working hours. He stopped going.
    On November 26, 2020, Carson came home for Thanksgiving. He 
was exhausted. He said he was not sleeping. He had been working 
long hours and wasn't able to get the rest he needed. He hugged 
me goodbye and thanked me for a wonderful dinner and told me he 
loved me.
    The next day, after not hearing from him as I usually 
would, I called him with no answer. I went to his home, and I 
found my beautiful, loving son on his living room floor, 
deceased. I cannot put into words the guttural pain of finding 
Carson dead and knowing I couldn't save him.
    We had to wait almost 3 months for the toxicology report to 
find out that fentanyl had killed him. During this waiting 
period, we had Carson's phone, and he began to receive 
Snapchats with pictures of drugs and emojis from an individual.
    We dug into Carson's Cash App account and discovered a 
payment to the same individual the night he passed away. For 
months, the individual continued to Snapchat pictures of drugs 
and emojis.
    The DEA did a sting. The individual served less than 24 
hours in jail.
    I was the one who brought the drug dealer's account to the 
attention of Snapchat. Snapchat claims they have filters in 
place to monitor for such illicit activity. Then why for 5 
months did this individual continue to Snapchat such things if 
Snapchat's filters were operational?
    In my opinion, Snapchat is the courier, and they provide 
the getaway for the traffickers of this poison.
    In the months and now years that have ensued, I have 
grieved immeasurably. I knew what devastation was after losing 
my husband, but losing my child has left a gaping hole within 
my being.
    The heartache and pain is gripping. My son bought 
something, thinking it would ease anxiety, a mistake that cost 
him his life. It was not his intent to die. These individuals 
who are dying are not overdosing. They are being poisoned.
    In the 2 years since Carson's death, tens of thousands of 
people have lost their lives to this weapon of mass 
destruction. Many victims were unknowing.
    We need to be educating our children and families alike 
about fentanyl and its lethal effects. It has been published 
that in Seattle the fentanyl crisis is so bad the medical 
examiner is running low on storage for the dead bodies.
    I was told by a DEA agent that we will not see an end to 
fentanyl in my lifetime. I find these words exceptionally 
chilling. I never thought my son's photo would be hanging on 
the DEA's wall as one of the victims of fentanyl. 
Heartbreakingly, he is a statistic.
    How many lives must be lost before we hold the players in 
this hellish nightmare accountable? We must do more to prevent 
fentanyl from coming into our country, so one more mother, one 
more family, will not have to be brought to their knees in 
sorrow. I plead with you to take action.
    Thank you for allowing me the opportunity to speak.
    [The prepared statement of Ms. Cain follows:]
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    Mr. Guthrie. Thank you for your very moving testimony. 
Thank you.
    Dr. Loyd, you are recognized for 5 minutes for an opening 
statement.

                STATEMENT OF STEPHEN LOYD, M.D.

    Dr. Loyd. I am so sorry, Ms. Cain.
    Good afternoon, Chairman Guthrie, Chairwoman Rodgers, 
Ranking Members Eshoo and Pallone, and members of the 
committee. I am Stephen Loyd. I am an addiction medicine 
physician, and I am in recovery from opioid and benzodiazepine 
addiction myself.
    Through my work as a physician in Tennessee, I see at least 
5,000 patients a year in opioid treatment and recovery, and I 
serve as the chief medical officer at Cedar Recovery, which is 
an outpatient addiction medicine practice in middle and east 
Tennessee.
    Also, I am the medical director for an opioid treatment 
program in Cocke County, Tennessee, which serves an inmate 
population, as well as the medical director at Renewal House, a 
Nashville organization, which serves marginalized women with 
underlying substance use disorder.
    Thank you for the opportunity to appear here today as you 
consider these important bills and continue to discuss how to 
best address the fentanyl crisis in the United States.
    This is something I deal with every day, and I hear stories 
like this every day in my work in Tennessee, Kentucky, and 
Virginia, in both the patients I treat but also in my role as 
Tennessee's opioid czar that has been tasked with figuring out 
how to best abate the crisis in our State.
    This includes working with our citizens in jails and 
prisons as we consider best how to serve their needs along the 
needs of other Tennesseans who have been impacted by the opioid 
crisis.
    Under the Americans with Disabilities Act, those with 
substance use disorder are considered to have a disability. 
This protects individuals who are in recovery or who have used 
drugs in the past, a category that would apply to many 
individuals who are incarcerated in the United States.
    Under the ADA, as interpreted by the U.S. Department of 
Justice, people in recovery but who would be limited in a major 
life activity, including activities like communicating, caring 
for oneself, and thinking, in absence of treatment of recovery 
services are protected.
    This extends to inmates within the correctional system who 
are prescribed medications for opioid use disorder. In my own 
experience, both as someone who has been previously addicted to 
opioids and benzodiazepines and was given a second chance, as 
well as an addiction treatment doctor, a pathway to recovery is 
essential for all individuals, including those who may be 
incarcerated on drug-related charges.
    I have seen that many, not all, of the individuals who are 
incarcerated on drug-related crimes are dealing drugs as a 
means to get their own drugs in the midst of their own 
substance use disorder.
    In those cases, minimum sentencing won't work. If you want 
these individuals to stop dealing drugs and reenter society, 
you must safely stop their use. This includes not only 
medication if needed, but other things like safe housing and 
education.
    For the past few years, I have been fortunate enough to 
work with Judge Duane Slone who runs a drug recovery court in 
Tennessee's Fourth Judicial District, which covers four rural 
counties. This includes a TN ROCS docket, a program that serves 
offenders who have an urgent need for treatment but do not 
qualify for drug recovery court.
    Judge Slone and myself agree that addressing the social 
determinants of health are key to helping offenders with 
persistent substance abuse problems break the cycle of their 
addiction. This includes access to medical care, as well as 
food, steady income, housing, access to transportation and 
education opportunities.
    While I believe that violent drug offenders should be 
appropriately punished under the law, I would argue that those 
who were merely engaging in a system that are actively addicted 
to the drugs they sell should be afforded the same opportunity 
that I was given two decades ago.
    I appreciate the opportunity to appear before this 
committee, and I look forward to answering any questions you 
might have.
    [The prepared statement of Dr. Loyd follows:]
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    Mr. Guthrie. Thank you for your testimony, Dr. Loyd, and 
the Chair now recognizes Dr. Westlake for 5 minutes for your 
opening statement.

             STATEMENT OF TIMOTHY W. WESTLAKE, M.D.

    Dr. Westlake. Great. Thank you, Chairman Guthrie, Ranking 
Member Eshoo, and distinguished members of the subcommittee.
    Fentanyl-related substances, or FRSs, are highly active 
opioids almost identical to fentanyl except for a tiny 
difference in their chemical structure, created by tweaking the 
chemical scaffold of fentanyl during synthesis in Chinese and 
cartel labs. The result of this chemical tweak is a new potent 
opioid with the same deadly effect as fentanyl and which, 
before FRS class scheduling was put in place, would have been 
legal until causing numerous deaths, raising them on the radar 
to be scheduled reactively by DEA.
    As an emergency physician telling parents, unimaginably at 
times, even friends, that their kids will never come home is 
the worst part of my job.
    It was shortly after one such conversation with my good 
friend Lauri Badura that the idea for fentanyl class scheduling 
reform came to mind. Lauri's son Archie was an altar server 
with my daughters.
    It started with prescription opioids, then snorting heroin, 
and, unknowingly, fentanyl. I resuscitated Archie on his 
second-to-last overdose. At that time I pulled out a body bag, 
laid it down next to him, and warned him that that is where he 
would end if he didn't accept help.
    He stayed clean for 6 months until illicit fentanyl ended 
his life. One of the last things my friend Lauri saw of her son 
Archie was him being zipped up into a body bag.
    Motivated to act by hundreds of such deaths, FRS scheduling 
legislation, which is proactive and not reactive, as had 
previously been the case, came together quickly and was enacted 
with unanimous vote in the Wisconsin State legislature in 2017.
    Almost immediately, DEA adopted it as national policy, but 
only temporarily. Before that, scheduling new fentanyls was 
like a lethal game of Whac-a-mole. We literally had to wait for 
people to die before we could take action.
    So why isn't the Wisconsin law permanent Federal law yet? 
Some who of oppose FRS scheduling point to the recent spike in 
deaths from illicit fentanyl as the proof that it doesn't work. 
In reality, they are confabulating and misconstruing the facts.
    FRS scheduling does not address illicit fentanyl. Tt was 
never designed to do so. Rather, it removes the incentives for 
transnational criminal organizations to create new fentanyl-
related substances, thus stopping them from ever existing in 
the first place.
    It is truly the ultimate form of overdose prevention and 
harm reduction. At its core, it is not a law enforcement tool 
designed to put criminals in jail. In fact, in the years since 
FRS class scheduling has been in place, there have been a total 
of eight Federal prosecutions--I will repeat that: eight 
Federal prosecutions--in the entire United States under the FRS 
scheduling language, half of whom had already known ties to 
drug cartels.
    As well, there has never been a prosecution for a 
nonbioactive fentanyl-related substance because there are no 
nonbioactive fentanyl-related substances. All FRSs encountered 
in research to date have been found to have potent opioid 
activity.
    Concerns raised about the potential negative impacts of FRS 
scheduling on research are purely theoretical and have already 
been addressed by discussions with stakeholders.
    These proposed research accommodations that have been 
signed off on are supported by the very agencies and 
organizations representing academic scientific research in the 
U.S., including the National Institutes of Drug Abuse, the 
National Institutes of Health, the Department of Health and 
Human Services, and the FDA.
    These agreed-upon accommodations would significantly loosen 
research restrictions into studying all Schedule I substances, 
not just FRSs, and would open up wide, promising areas of 
research into substance abuse.
    Any dampening or restriction of research is purely 
theoretical. Fentanyl and its derivatives have been extensively 
researched since its discovery in 1960. And since then, not one 
fentanyl-based reversal agent or medication-assisted treatment 
agent has ever been found.
    It has been said that FRS class scheduling would impede 
research into life-saving opioid reversal agents, and that 
Narcan isn't a strong enough antidote. Take it from me, someone 
who sadly uses Narcan to resuscitate fentanyl poisonings far 
too often, Narcan works almost miraculously if given in time.
    Our kids are dying because they have ingested a lethal dose 
of toxic opioids, not because Narcan isn't potent enough.
    In conclusion, for 5 years now, FRS scheduling has been 
Federal policy, albeit temporary. I can't be more pleased about 
that and the big impact my small idea has had.
    According to NFLIS, the National Forensic Laboratory 
Information System, in a matter of a few short years, the 
creation and distribution of new FRSs from China has ground to 
a halt, as have the associated deaths.
    In the devastating battle we are in against the scourge of 
fentanyl, the elimination of related substances that had 
previously escaped our scheduling and made their way to 
devastate communities across the Nation is surely one bright 
spot.
    Fentanyls are so toxic and lethal that they can be 
classified and actually have been used as chemical weapons. The 
lethal dose is 2 milligrams, which is equivalent to 5 grains of 
sand. This means that one teaspoon can kill 2,000 people.
    That is the amount in this packet of sugar.
    Thank you for--I think I ran out of time. Thank you for the 
testimony.
    [The prepared statement of Dr. Westlake follows:]
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    Mr. Guthrie. Thank you. And after--I will give you a couple 
seconds since that was interrupted. But you are completed? All 
right. Thank you. So the gentleman yields back.
    That concludes testimony. This will begin the question-and-
answer portion of the hearing, and I will begin the questioning 
and recognize myself for 5 minutes for such.
    Thank you, Ms. Pickard, for being here. You know, if I 
would have come into this meeting--so you have already learned 
something today--from you, I would have thought the number one 
killer was probably heart disease or something such as that, 
but it is Alzheimer's. And I just didn't know that at all.
    So that gives us--and I was talking with the Democrat 
leader, and we said, well, that was a statistic we just didn't 
know. So thanks for coming, and sharing testimony is important 
when you come here and testify, put it on the record.
    I am going to kind of focus on the fentanyl side of it, 
but, Ms. Cain, thank you for coming. You are absolutely right, 
it is not necessarily people that are addicted or have 
addiction issues. There are people that may have prescription 
Xanax or Adderall.
    I have heard that for some reason they get one, they don't 
have their prescription filled, somebody, a friend, has one, 
and they use it, thinking they are using it medicinally and it 
is laced with fentanyl.
    And I tell everybody anywhere I go, if it doesn't come from 
a prescription bottle from a pharmacy, don't take it. But you 
just don't know that, and that is something that--you being 
here is important, and you being here continues--your child 
continues to live on that way, and we appreciate you being here 
for that.
    I just want to talk more with Dr. Westlake, though, on the 
bill before us, and, you know, the administration's position 
is, we should schedule illicit fentanyl, fentanyl-related 
substances, but not make them subject to the mandatory 
minimums. And they said because, as they appear, there may be 
some medicinal purposes, they may be as harmless as water, as 
we heard before, and that just doesn't ring true to me.
    One, I don't think there is anything going to be more 
harmless. Why would a cartel go to the effort to sell something 
as harmless as water? So it doesn't ring true.
    But if there is medicinal purposes, if it is trafficking 
illegally, like I said before, you know, other diverted 
narcotics that are prescription narcotics you can have that are 
diverted, are of medical merit, but if they are being diverted 
and trafficked illegally, they would still be subject to the 
same punishment.
    And so, what is your view of--I know you are kind of the 
founder of this idea--so what is your view of the 
administration's position? I mean, what effect would it have, 
if they say, ``OK, we are going schedule them, we are not going 
to make them subject to the mandatory minimums like other drugs 
are''?
    Dr. Westlake. Yes, great question. I think the whole--what 
you really have to remember about FRS scheduling is that it is 
not about locking people up. It is not a criminal justice bill. 
What it is about doing is purely preventing. So it prevents the 
existence and creation of these new fentanyl-related 
substances----
    Mr. Guthrie. Would you say it is not about locking people 
up, but if the risk of getting locked up is not there, then it 
changes people's behavior?
    Dr. Westlake. Absolutely. I mean, the effect is a 
preventative effect, but the law enforcement aspect is the key 
component to keeping it in place. And the reason that--that it 
is important to understand that the research behind structured 
activity relationships.
    So there is 60 years of research into fentanyl-related 
substances and fentanyl, and so there is a wide dearth of 
research--if you take a look at my written statement, it goes 
into detail about that--a wide--a mountain of literature of 
little tiny modifications that you can do to the fentanyl 
molecule to make it bioactive.
    And that is why the structural language that we used was 
targeted specifically for those modifications only. It is not 
this--you know, the opposition would say it is this broad-based 
thing, and, you know, like you said, it could be water or 
something.
    And of the 27 substances studied of the 36 that were found 
by DEA, all of them have been highly, highly active, bioactive 
opioids. One of them is 7,000 more potent than morphine, almost 
as potent as carfentanil is.
    Mr. Guthrie. So if we were to schedule fentanyl without 
subject to mandatory minimums--I am not saying--that is another 
debate whether we have a debate on, overall, the program. But 
if we were to schedule fentanyl and not subject it to the same 
penalties of other similar situation, then it would be a 
negative?
    Dr. Westlake. Yes. Because then it would take--what it 
would do, because right now, the cartels are producing illicit 
fentanyl because there is no reason to move to fentanyl-related 
substances because they are scheduled, you know, as a class. If 
that was removed, then there would be a lot of incentive to go 
back to making----
    Mr. Guthrie. Which can be more potent or probably more 
likely to be more potent and less harmless?
    Dr. Westlake. Exactly.
    Mr. Guthrie. So, Dr. Loyd, in your practice, what do you 
see as the number one thing that Congress needs to be doing? We 
are going to look at--I know it is not before--better look at 
the SUPPORT Act as we move forward.
    I only have about a half a minute left, but what do you 
think--because we need to do the enforcement side, but we also 
need to the recovery side.
    Dr. Loyd. Thank you, Chairman. The recovery side is 
extremely important. The number one thing is something we all 
have control over, and that is stigma, how we look at people 
with substance use disorder and allow them to step out and ask 
for treatment.
    But when that happens, the treatment has to be there, and 
it has to be evidence based, meeting people where they are.
    I heard the definition of ``harm reduction'' in the last 
panel, and I would argue that harm reduction is keeping people 
alive. I haven't figured out how to treat dead people, and so 
we got to keep them alive and then set up a system of recovery 
that allows them to succeed like the one I stepped into.
    Mr. Guthrie. Thank you. Well, my time is expired, so I will 
yield back the time and recognize the ranking Democrat leader 
of the subcommittee, Ms. Eshoo from California.
    Ms. Eshoo. Thank you, Mr. Chairman, and thank you to each 
one of the witnesses. Thank you for your patience in waiting to 
reach the witness table. To the two mothers at the witness 
table, thank you. I can't--I don't think that there can be a 
greater sorrow than burying one's own child.
    And, you know, our work here is--what you come and share 
with us is a source of inspiration to us, because this is 
really what all of the work is about. So thank you to each one 
of you.
    I want to say something about fentanyl. I know that it is 
going to be ongoing because we have legislation that is being 
proposed. You know what, I am struck by--and I am for the 
legislation, I think it should be scheduled, but I think that 
we are, in a way, deluding ourselves, because when I look at 
what has taken place over the last 5 years with fentanyl being 
scheduled, Schedule I, deaths have not been reduced in the 
country. They have gone up.
    I don't think it is a result of their being Schedule I that 
it has gone up. I just don't think scheduling--I think 
scheduling is a whole other issue when it comes to law 
enforcement, what tools they have, et cetera, et cetera.
    And I also think there is a 10-billion-pound gorilla in the 
middle of the room, and that is that sadly, tragically, the 
United States of America is the most extraordinary market for 
drugs. We have an insatiable appetite for drugs in our country.
    And then look at all the things that we are dealing with--
the grief, the sorrow, the wrecking of families, of human life, 
dealing with addiction, and all the things that we need to do 
to help people. So I just wanted to place those words on the 
table.
    On QALYs, for those that are tuned in and don't know, have 
never heard this word before, it stands for quality adjusted 
life years. And they may still not understand it, but that is 
what it stands for. And these are measures to determine the 
value of drugs or treatments.
    I think that QALY measures are discriminatory, period. They 
are discriminatory because they don't give equal weight to the 
lives of people with chronic disease or disabilities, as they 
do to the lives of healthy people.
    And as my beautiful mother used to say, God never created 
any junk. Each one is precious. Each one is precious.
    Now, maybe some legislators know this, others may not. It 
is why the Affordable Care Act banned their use in Medicare. 
That is very important. So this has not been lost on at least 
some of us.
    I welcome the legislation, but there is something in this 
that refers to the legislation we are considering, where it 
refers to similar measures. I don't know what ``similar 
measures'' are.
    Now, Mr. Isasi, I think that is what you were referencing 
in your testimony.
    Mr. Isasi. Yes.
    Ms. Eshoo. Is that term anywhere in the law today?
    Mr. Isasi. So that term is in aspects of the law, but very 
importantly, as you are pointing out, the legislation that is 
proposed is about one thing: It is about price. It is about 
similar measures being applied to price, and it applies----
    Ms. Eshoo. Well, that is what QALYs are, aren't they?
    Mr. Isasi. Right. So it is not just about----
    Ms. Eshoo. I mean, the end result is discriminatory?
    Mr. Isasi. That is right. But the problem here is, you 
know, as we know, in--so this is all about one thing. The 
pharmaceutical companies are trying to create a legal loophole 
so that we cannot actually negotiate fair prices with them.
    And in this case, they are trying to drive a huge hole 
through the drug negotiation law by saying any measures to try 
to measure value, any measures that are based on any 
assessments, would be barred from being used to set a price. So 
it is just a gaping hole.
    We are 100 percent with the disability community that they 
cannot be discriminatory. As I pointed out in my testimony, the 
law already says those prices cannot be set using metrics that 
are discriminatory against people with disabilities, against 
the elderly, against people who are terminally ill.
    So the law has the protections already in place. This is 
about giving lawyers for the pharmaceutical companies a giant 
loophole to fight against fair prices for American families.
    Ms. Eshoo. Well, I think that all of us, including the 
disabilities community, would rise up against what you just 
described.
    We are going to have to get this straight now, Mr. 
Chairman, because I think that there is full support on the 
issue of QALYs. We know it is discriminatory, but--and we need 
to get that done, but we are going to have to address this 
other language. Thank you, and I yield back.
    Mr. Guthrie. Thank you. I thank the gentlelady for yielding 
back. And the Chair now recognizes the chairman of the full 
committee, Mrs. McMorris Rodgers, for 5 minutes to ask 
questions.
    Mrs. Rodgers. Thank you, Mr. Chairman, and I think I will 
just start with a little follow-up to Mr. Isasi, because I saw 
in your testimony that you say, quote, ``IRA already includes 
explicit disability (and other) safeguards.'' So why shouldn't 
we apply similar prohibitions and protections to all Federal 
health payers? Why would that be a problem?
    Mr. Isasi. So, in this case, the proposed negotiation goes 
much, much further. It doesn't just ban discrimination, it bans 
in setting a price. And it is really important to say that.
    This is only about one thing in the legislation. It is 
about the price that is being set in drug negotiation, and it 
is saying clearly that any measure--and the language is so 
broad and so vague that a lawyer for the pharmaceutical 
industry will drive a truck through it and say you are trying 
to assess value----
    Mrs. Rodgers. OK. Thank you. We are going to work on this.
    Mr. Isasi. You bet.
    Mrs. Rodgers. And I do want to work with the ranking member 
to figure out how we can get this language where we need it to 
be, to make it clear.
    Mr. Isasi. And we are one----
    Mrs. Rodgers. OK. Thank you. I am sorry.
    Mr. Isasi. Sure.
    Mrs. Rodgers. OK. Ms. Cain, I understand you gave pretty 
compelling testimony, and we have had the chance to sit down 
before, and I greatly appreciate you making the trip to be 
here. Carson should be here. Carson should be here today.
    And, you know, we have been, especially on our side of the 
aisle, the Republicans have been sounding the alarm on fentanyl 
and the need for Congress to act. Just last week, we held a 
roundtable that was more focused on fentanyl and what is going 
on on social media platforms that are making it so available 
and platforms that are not taking their responsibility to 
moderate illegal activity on their platforms seriously enough.
    I just wanted to ask, from your perspective, how can 
lawmakers make the most impact, to spread awareness, and curb 
the buying and selling of illicit fentanyl? What do you think 
that we can do that would be most effective?
    Ms. Cain. I think that we need to begin by educating--
educating. Education is a huge thing. I think that I can only 
speak to Carson's case. The individual who sold him the pill 
served no time for my son's death because of these social media 
companies and Snapchat especially.
    Once that chat is open, the evidence is gone. And because 
they said that--I believe they said that they hold them for 90 
days in their server. It was already gone by the time we got 
the toxicology report.
    In my opinion, which I am sure many will disagree with, I 
do think that we need to hold these people accountable. We need 
to have tougher laws. In this day and age, when we know that it 
is a poison, they are being poisoned, and, again, not all of 
these individuals are--many of them are taking it unknowingly. 
And we shouldn't be holding them accountable. I think we need 
to be, as Dr. Loyd said, we need to be looking at this through 
a different lens.
    Mrs. Rodgers. Yes. Thank you, thank you for speaking out, 
thank you for being here. I will go back and listen to your 
testimony. I am sorry I had to step out.
    Ms. Cain. Thank you very much.
    Mrs. Rodgers. Ms. Pickard, I appreciate you being here 
also, and as you know, our son Cole was born with that extra 
21st chromosome that people know as Down syndrome. And I 
remember when he was born and just the doctors telling us, you 
know, what to expect. And in so many of the cases, they got it 
wrong. They got it wrong.
    He is a freshman in high school now, a 15-year-old, has big 
dreams. He wants to go to college. He wants to play football. 
You know, he is going to be in a band, he plays the drums. He 
is going to do it all.
    And, you know, he just reminds me every day as to the 
potential of every life. So, you know, I have heard some 
statements today about the QALY bill, and I am not sure that it 
is fair or conveys the full truth about QALYs.
    For example, it has been asserted that banning QALYs is not 
necessary in Medicaid, for example, because States are already 
required to cover all drugs. However, we know that States have 
limited drugs for muscular dystrophy to those who can walk 
rather than those who can't, because it is not necessarily seen 
as worth the cost of paying for it.
    So my question is, what would you like to say about QALYs 
in 6 seconds?
    Ms. Pickard. Myself?
    Mrs. Rodgers. Yes.
    Ms. Pickard. Thank you, thank you. So it sounds like Cole 
is just like every other 15-year-old young man. And I have to 
say, in the healthcare system, I can tell you that children and 
adults with Down syndrome regularly face deficiencies in care, 
including access.
    Doctors who specialize in care for patients in our 
community are scarce. There are only 16 adult clinics that 
specifically serve individuals with Down syndrome in the 
country, leaving patients in States such as Kentucky or New 
Jersey without access to specialized care.
    And in the moment of greatest need, discriminatory policies 
can even restrict individuals with Down syndrome from receiving 
those life-saving organ transplants.
    Banning QALYs is a step in the right direction, but so much 
more needs to be done, and I look forward to working with the 
committee to address these important issues. Thank you for 
being here.
    Mrs. Rodgers. I yield back.
    Mr. Guthrie. The gentlelady yields back.
    We are trying to--are we going to have time for one more, 
we think? Are we going to have time for one more?
    Mr. Cardenas. I am willing to risk it.
    Mr. Guthrie. Mr. Cardenas of California is recognized for 5 
minutes.
    Mr. Cardenas. Thank you so much, Mr. Chairman, and thank 
you for all your testimony and your important information that 
you are sharing with us as policymakers for our country. Thank 
you, Molly and Dr. Loyd. You inspired me to call my son.
    I want to apologize to my staff who wrote my questions, but 
I created my own after talking to my son.
    I am one of the lucky ones. My son is in AA. He goes every 
day. Thank God.
    So I asked him, what should I say? What should we talk 
about? What's the answers, et cetera? He doesn't have them all, 
but he did give me some advice.
    He says, you know, one of the things that I was taught when 
I go to this group, there is a boulevard in my district called 
Sepulveda. Two people end up in jail because they were buying 
drugs on Sepulveda. One has a drug problem. He wakes up in 
jail, ``Never going to do that again.'' Maybe he stops taking 
drugs.
    The person who has an addiction, they wake up in jail and 
go, ``Where am I, what is going on, I am never going to buy 
drugs on Sepulveda Boulevard.'' They are going to do it again.
    So my first question to you, Dr. Loyd, is this: On a per-
person basis, based on your testimony, what you provided for 
us, do you think that punitive incarceration answers is more or 
less expensive, in all aspects, than prevention, intervention, 
and support like you have been describing to us?
    Dr. Loyd. Thank you, Congressman Cardenas, and I am glad 
about your son. It is the best news. I am here to bring hope 
today. My son is in this audience today, watching me sit before 
my Congress and my country. It is because I got quality help.
    I am talking about people with addiction. I am not talking 
about cartels. I am talking about those suffering from the 
disease of addiction. Incarceration won't help them. It won't 
cure them, because they will do exactly what your son said they 
will do, and I would have done it too, and I am a practicing 
physician, and I was a practicing physician when I was 
addicted.
    Our money is much more better spent on prevention, 
education, and treatment. Carson didn't know he was getting 
fentanyl. He didn't know it. It shouldn't be a death sentence.
    And so I think we have to understand as a body and as human 
beings that the disease of addiction is not a moral failure. It 
is a chronic, treatable disease of the brain, and it is driven 
by cravings.
    And when you have somebody sitting in there--me, today, I 
would look at it and go, ``I am not going to do that again, 
period.'' But in the throes of addiction, the response that 
your son gave to his friend is exactly right, and it is exactly 
what will happen. And the case I always made: If that worked, 
nobody would go back to jail a second time.
    Mr. Cardenas. Yes. Doctor, you are blessed and fortunate 
you are still with us.
    Dr. Loyd. Yes.
    Mr. Cardenas. Molly, your son isn't. You are not one of the 
lucky ones. If we make good policy here, we are going to create 
more lucky ones, right, if we do it right.
    But if we do it wrong, people are going to continue to die 
in the United States of America in a way that no one should 
ever leave us.
    Is there any other advice you would like to give us, Molly?
    Ms. Cain. As I said, we--I can't speak to--I know that 
Carson's last year was a perfect storm. I can't speak to--I 
know that he was prescribed Xanax, and I know that he wasn't 
sleeping.
    I have heard from people on social media criticizing the 
parents and the people who have used, and that is so 
detrimental to the healing. We need to be addressing this 
problem.
    It is not a problem that just affects--fentanyl is 
indiscriminate. It affects all walks of life, every party.
    I am not a lawmaker. I came to share my son's story. I am 
asking of you to please make some sort of change so another 
mother can look across the dinner table, can celebrate her 
child's birthday with them.
    The only thing I can think of is, we have to educate and we 
have to educate young. I think about the Mothers Against Drunk 
Driving and how that started. And maybe this is something that 
we need to do.
    Mr. Cardenas. Thank you so much. My time having expired, I 
yield back.
    Ms. Cain. Thank you.
    Mr. Bucshon [presiding]. The gentleman yields back.
    I recognize the gentleman for Texas, Dr. Burgess, for his 5 
minutes.
    Mr. Burgess. Thank you, Mr. Chairman, and I want to thank 
our witnesses for being here today.
    Ms. Cain, I will just tell you, we have worked on this 
problem of opiate dependence and addiction up here for a long 
time, but until our chairwoman, Mrs. McMorris Rodgers, did a 
roundtable last week, I had no idea about the Snapchat focus.
    And clearly that has--when I talked to the previous panel, 
really concerned about fentanyl, because a lot of the work we 
have done has been more geared toward, oh, a dentist who 
prescribed too many Percodan after a wisdom tooth extraction 
and someone took it inappropriately.
    Fentanyl is a different disease. It is so much more deadly 
than anything that could be contained in a diverted 
prescription.
    And then Snapchat has added yet another dimension to this 
and, quite honestly, one that I had not appreciated, as I say, 
until we had done the roundtable up here.
    So, as painful as it is, I appreciate you coming and 
sharing your story, because we have to focus on these delivery 
modules that weren't even in existence when I started on this 
committee many, many years ago.
    I am up against a vote. I just want to ask, Ms. Pickard, 
briefly--thank you for your work that you have done for 
National Down Syndrome. We heard from our ranking member, Mr. 
Pallone, and I think we have seen in written testimony that 
this QALY legislation is a solution in search of a problem. 
Would you agree with that characterization?
    Ms. Pickard. I believe--thank you for the question. I 
believe that more research is needed. I think there is more 
research needed to really further develop and test those 
alternative methods and frameworks for determining the value of 
healthcare treatments.
    And we must ensure that individuals with disabilities, 
their voices, are included in this conversation.
    Mr. Burgess. Well, I wanted to ask unanimous consent to 
include two articles in the record. One is by three authors, 
one of whom is well known to this committee, Ezekiel Emanuel, 
and this is from The Lancet, ``Principles for allocation of 
scarce medical interventions.''
    And as frightened as I am about QALYs, he also talked about 
disability adjusted life years, and clearly that is a focus 
that I think will be exceedingly pernicious, and I do want us 
to focus on that.
    And then the other is from early in the pandemic from an 
article that was published in ProPublica that was from the 
Arizona Daily Star, dealing with the problem of scarce or 
limited resources when we thought we needed more ventilators 
than we turned out to need, and who gets to go on the 
ventilator and those questions that came up.
    ProPublica--I can't believe I am saying this--ProPublica 
actually did a very fair report on this, and, Mr. Chairman, I 
would just like to add these two articles for the record.
    Mr. Bucshon. Without objection.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. And then I have got to go vote. Thank you very 
much. I will yield back.
    Mr. Bucshon. At this time, we are going to take a brief 
recess, probably for about 15 minutes, so Members can vote, and 
we will come back right after that. The subcommittee stands in 
recess.
    [Recess.]
    Mr. Bucshon [presiding]. The subcommittee will come to 
order. We will restart with questioning, and I recognize the 
gentlewoman from Washington, Dr. Schrier, for her questions, 5 
minutes.
    Ms. Schrier. I should change this. I could take a new 
title.
    Thank you, Mr. Chairman, and I especially want to thank 
you, Ms. Cain, for coming out from Washington State today to 
share your son Carson's tragic story, and from one mom to 
another mom, I can only imagine your heartbreak. And I think 
about this frequently, as I have a 14-year-old boy. And your 
account makes so clear why we need to crack down on social 
media companies, the avenue by which so many teens get access 
to these deadly drugs, poisons.
    I am in the process of working on legislation to bring some 
of these issues to light and to make sure families have the 
tools to keep their children safe. And thank you for sharing 
your story, because it helps parents and the rest of this 
country and world understand how to keep others safe.
    Fentanyl has had profound, devastating impacts in my State 
of Washington. And parents want to engage with their children. 
Sometimes they don't know how. Just this morning, I met with 
the Enumclaw Youth Empowered coalition from my district, and 
their focus is on reaching families early to prevent drug use, 
experimentation, anything that gets their kids even close.
    Given the importance of educating kids and schools and 
prescribers and patients, I was wondering, Dr. Loyd, if you 
could highlight some of the ways that parents can find guidance 
on having these conversations.
    Dr. Loyd. Thank you for the question, and it is very 
difficult. You know, today is a different world than I grew up 
in with social media and what Molly shared with us. But it is 
also the world of ``take one pill and you die.'' And that is 
the message that is very, very hard.
    So when I talk with parents, it is always about being open 
and not thinking that you know everything. I see parents make 
mistakes all the time--``Oh, I know what is going on inside my 
house and I know''--and the truth is, Congresswoman, we don't 
have near as much control as we think we do.
    And so these opportunities to talk with our children and be 
open and honest, most of us have some kind of experience with 
things in our past that maybe we could have handled better, and 
we are not perfect, and our kids need to see that.
    And so my son, I told you, is in this room, and so he was 9 
when I got into recovery, and I started sharing my stuff with 
both him and my daughter at that time. So I think, for parents, 
it is important to realize that it is not the world that we 
grew up in, and now, not that anything is OK, but it is a one-
time thing and you can literally die this afternoon.
    And that is the part, if you don't know where it came from, 
you know, please don't take it, because it will look just like 
what comes out of somewhere.
    And the other thing I see, Congresswoman, is this. Just 
because it comes out of a bottle that a doctor wrote a 
prescription for, it is not OK. And I think a lot of times that 
kids will look at that, and, well, ``A doctor wrote this, this 
is OK''--I have seen it with numerous teenagers--and it is 
absolutely not. Those are the places I would start.
    Ms. Schrier. I think those are great points, and I will 
tell you, even as a pediatrician, it is challenging to have 
these conversations, but just last night I had the conversation 
again with my 14-year-old because he can't--I am just speaking 
to parents out there--you can't have this conversation enough, 
and reminding teenagers, who are, by their very nature, 
impulsive and experimental and trust their friends sometimes 
more than their parents, that anything anybody hands you--
whether they tell you it is an ibuprofen or somebody is trying 
to hand you an Adderall, telling you it can help you focus 
better--that that could be the pill that ends your life. And so 
thank you for bringing this to the forefront, and I will yield 
back my time.
    Mr. Bucshon. The gentlelady yields back. I now yield 5 
minutes to the gentleman from Florida, Dr. Dunn.
    Mr. Dunn. Thank you very much, Mr. Chair. So we have an 
important opportunity today to advance legislation that will 
protect all Americans, including the most vulnerable, the ones 
that Dr. Schrier mentioned, the children who are susceptible to 
accidental fentanyl exposure and experimentation with street 
drugs. So I am proud to support the bills before us today.
    Importantly, the HALT Fentanyl Act will permanently place 
all fentanyl-related substances into Schedule I. This bill 
addresses a failure of the administration and represents an 
important step towards getting these deadly fentanyl analogs 
off our streets.
    However, I believe that to wholly address the fentanyl 
crisis, we need to do some other things. We need to designate 
the entire class weapons of mass destruction.
    That is not a frivolous proposal. It empowers the DHS to 
help us with this effort. It also makes international policing 
substantially easier.
    We also have to better educate our youth again and again 
about the dangers of drug use. There is no street drug that is 
safe. There is no pusher who can be trusted. Everything could 
be laced with fentanyl.
    We also have to work to address recidivism in our 
communities and, frankly, fix the broken families. An example 
of that, one of the counties in my district that was hardest 
hit by fentanyl poisonings has 40,000 citizens. Of those 
40,000, 22,000 of them have spent time in the county jail. If 
we can address some of these root challenges that these 
communities face, we can decrease the demand for all street 
drugs.
    Another important bill we are going to discuss today is the 
use of QALYs, quality adjusted life years, by government 
insurance programs.
    I am a doctor. I think the entire concept of QALYs is 
contrary to the American values that set our free society apart 
from socialist healthcare systems that restrict care and choose 
for you and your family what life is worth.
    It is disappointing to me that we have to legislate to 
prevent such tactics from driving our Federal healthcare 
policy. Our Nation supports some of the greatest biomedical 
research in the world. Regardless of one's ability or 
disability, all Americans should have the right to choose their 
care.
    Ms. Pickard, can you give us some examples of how QALYs are 
used internationally--where they are used, how they limit 
access to care--and how are they used in the United States?
    Ms. Pickard. Thank you, Congressman. Many countries, 
including our friends in the U.K. and Canada, heavily rely on 
QALYs. They help determine who is worth treating and who is too 
expensive, thus determining which medicines or treatments are 
available to patients.
    For example, from 2016 to 2019, the U.K. used QALYs to 
restrict access to the first-ever approved treatment for cystic 
fibrosis. Unfortunately, it is important to note that these 
metrics are not here, you know, used here in the United States 
as well.
    As you asked about examples about the U.S., most recently 
CMS relied on a report from ICER, the Institute for Clinical 
and Economic Review, that used QALYs and similar one-size-fits-
all metrics in its national coverage determination for Aduhelm, 
the first treatment approved for Alzheimer's disease.
    The initial coverage determination excluded individuals 
with disabilities. This was particularly concerning, as 
individuals with Down syndrome have that heightened lifetime 
risk, higher than 90 percent, of developing Alzheimer's 
disease.
    Access to treatments for this debilitating disease is 
paramount to our community, and we will continue to work with 
Members of Congress and this committee to ensure individuals 
with disabilities are not left out of this conversation.
    Mr. Dunn. You know, I think my professors from med school 
would be rolling over in their graves if they heard us having 
this conversation. It defies belief.
    Dr. Westlake, as a fellow physician, I agree with you 
regarding the importance of permanently scheduling the 
fentanyl-related substances into Schedule I. We all know this 
is a crisis. What the heck is the challenge here? We have been 
working on this for years. What is the head wind?
    Dr. Westlake. Yes, you and my wife have both the same 
question. I first testified at a hearing for House Judiciary 5 
years ago on this topic and brought this up. I don't know. I 
don't know if it is politics, if, you know, there is advantage 
in trying to, you know, access criminal justice reform.
    I think there is confusion between what this bill, you 
know, what the fentanyl-related scheduling does. You know, it 
is not going to stop all fentanyl deaths. It is going to stop 
fentanyl-related substance creation and fentanyl-related 
substance deaths, which it has.
    So I really don't--it is very simple to me, but I think it 
gets cloudy when you involve what happens in Washington.
    Mr. Dunn. I don't know, honestly, for the life of me, I 
have never come to one of these hearings and heard somebody 
say, ``Fentanyl is pretty good stuff. We ought to have more of 
it or push it out on the streets.'' Nobody says that. In China, 
it is Schedule I.
    Dr. Westlake. Yes. The last thing we need is another 
fentanyl.
    Mr. Dunn. This is crazy. Well, thank you. My time is 
elapsed, and I will yield back to the chairman.
    Mr. Bucshon. The gentleman yields back.
    I now yield to the gentlelady from Tennessee, Mrs. 
Harshbarger.
    Mrs. Harshbarger. Well, thank you, Mr. Chairman, and thank 
the witnesses. And, Ms. Cain, I am sorry about the loss of your 
son. I guarantee that there is not one person in this room who 
has not been touched by either the loss of a family member or 
friend to some type of drug overdose.
    You know, I have been a pharmacist 36 years, so I have 
dealt with a lot of this. And, Mr. Loyd, I have dealt with a 
lot of impaired physicians, a lot of impaired pharmacists, you 
know, employed some to give them a chance to get their hours so 
they can practice again. So it is not anything that is new to 
me.
    And I am telling you, I visited a lot of rehab clinics in 
the district, and I read that you have--you know, you are doing 
the incarcerated gentlemen at Cocke County in my district. And 
Judge Slone, I have met with Judge Slone, I have talked with 
him, and he walks the walk because, if I am not mistaken, he 
even adopted a child from a mom who was addicted to drugs.
    So, you know, these are the kind of judges we need on the 
bench in these drug courts, and I have talked to numerous drug 
court judges and heard the stories. And he has offered to come 
let me sit in with them as they go through that process, and I 
said, ``Absolutely, I will come. I want to hear that.''
    You know, when I visited some of those rehab clinics and 
talked to some of the physicians, you know, they have a 
multistep approach. It is not just giving them a drug to get 
off of a drug, because that is a problem. They can take those 
drugs--I have said this in the last session--they can heat 
those foils up. They can inject them. They can abuse that drug.
    But what they do, they have the counselors, they have the 
group sessions, you know, and there's limiting factors. And one 
of the pharmacists left Walgreen's to do a pharmacy there at 
one of the rehab centers because he said these guys don't have 
a place to go.
    A limiting factor is having a bed, having a home, and to 
get them back as contributing citizens to society, there's 
things that you have to address.
    So I guess with all that said, and as an ER physician, you 
see this. They come to me, years ago, we would have to come up 
with modalities as a compounding pharmacist. We would have to 
help them with different drugs. They used to use clonidine to 
get them off the drugs.
    There's so many things they do. Used to do things for 
patients with special needs or Down syndrome, you know, when 
you couldn't get specific products. We still do that. My son is 
a pharmacist now.
    But I guess my question is, you know, sometimes insurance 
won't cover them. I know Blue Cross Blue Shield dropped a lot 
of the clinics, and they would not cover that, you know, the 
drugs that they needed to rehab them.
    I guess my question is, what do you believe are the most 
important things Congress and/or the FDA or other Federal 
agencies can do this year to help us conquer this addiction?
    I am saying close the borders for one thing, hold those 
people who are selling these narcotics accountable, make those 
laws to where--if it were up to me, I would probably label the 
cartel as a terrorist organization, but, you know, they 
probably don't want me to talk about that. But go ahead, 
anybody can answer that.
    Dr. Loyd. Thank you, Representative Harshbarger. You are 
actually the Representative from my boyhood home district. I am 
from Jonesborough, Tennessee.
    Mrs. Harshbarger. Jonesborough?
    Dr. Loyd. Yes, ma'am.
    Mrs. Harshbarger. For heaven's sake, who knew.
    Dr. Loyd. So thank you, and I am very familiar with that 
area, it is my home, the foothills of the Appalachians. So the 
things that we can do as a society I have already talked about 
it, is decrease stigma.
    As a legislative body, the areas that move the needle the 
most in our country, in my opinion, is the criminal justice 
system and emergency departments, because these are the places 
that our patients are showing up being overdosed.
    And the system of care needs to be designed to, one, allow 
them to stay alive. And you are exactly right, medication will 
allow them to stay alive, but that is a pretty low bar.
    If I stop one of my young pregnant women from, you know, 
using a needle and putting drugs in her body, that is a good 
thing. But if I am sending her back to the environment where 
she is getting abused at night, that is a pretty low bar.
    So we have to have a system set up that allows us to 
reimburse for care, to help people with physical, sexual, and 
emotional abuse, which a lot of times are the underlying 
drivers of addiction.
    And until we can do that and support things like safe 
housing, I don't know how all of us would be here today if we 
slept on the street last night. Probably not in very good 
shape.
    And so our system needs to be designed as a comprehensive 
level of care to help people find what is right for them.
    And a lot of times we judge people on medication, and we 
have to stop doing that. Sometimes it is the only thing keeping 
them alive.
    And I really appreciate the plug for our drug court, and I 
invite everybody to come. It is good for your soul.
    Mrs. Harshbarger. Yes, it is.
    And, Ms. Cain, I just had a dear friend, she went up to 
wake her 17-year-old son up, and he was dead. It is the same 
thing, it only takes one pill. And people need to be aware of 
that. Two grains of sand is all it takes to kill you, and 
fentanyl is showing up in everything, and I have talked to a 
multitude of people about that.
    So we have a problem, we need to fix it, and you can't fix 
it if you don't understand it. So I appreciate you being here. 
And with that, I yield back.
    Mr. Bucshon. The gentlelady yields back.
    I now recognize the gentlelady from Iowa, Dr. Miller-Meeks, 
for 5 minutes.
    Mrs. Miller-Meeks. Thank you very much, Mr. Chair, and 
again, I thank our witnesses for their patience throughout this 
and then throughout the brief recess as we voted.
    I am a physician. I am the former director of the Iowa 
Department of Public Health, as I had mentioned earlier, and 
then also as a State senator. And it is a very timely topic.
    As a State senator, I successfully passed--I can't speak, 
but passed in one session no preauthorization for Medicaid-
assisted treatment through our programs, including Medicaid.
    I was also able to get behavioral health treatment as a 
side of service at schools, so for those individuals who either 
don't have transportation or can't get to their providers, so 
that we make sure there is a continuum of care.
    And, Dr. Westlake, as you referenced in your testimony, 
what can Congress do, and you mentioned the HALT Fentanyl Act. 
I am an original cosponsor of that, and I agree that there is a 
lot of misinformation about that.
    And I am also interested, so we are kind of sisters, I am 
Iowa, you are Wisconsin, and Wisconsin has a program, but in 
Iowa we have the Billion Pledge Program which is another one of 
Iowa's leading opioid prevention initiatives.
    Specifically, this program aims to remove 1 billion opioid 
bills from the medicine cabinets, using evidence-based 
protocols, peer-to-peer education, nurse support, and also 
preparation for surgery, because as we know, a lot of opioid 
addiction has started through postoperative care and pain 
management, pain relief.
    As part of this, they have a tool kit that has an ice-heat 
pack, a nurse responsive, or someone that they can call in 
addition to their regular provider. It has a nutritional water 
supplement, which gets to the NPO, or nothing by mouth, for, 
you know, hours before surgery, which leads to increased pain 
afterward. And then a regimen of alternating ibuprofen and 
Tylenol.
    So I think this program is a critical program that, you 
know, looking at their results and statistics, probably should 
be replicated. And I know that your experience is largely in 
the emergency room setting, but you were very instrumental in 
setting up Wisconsin's programs.
    So I would like to ask if you have knowledge or information 
about what can be done regarding post-op monitoring to reduce 
the number of Americans that come away from a surgery with an 
opioid addiction and whether you have experience with enhanced 
recovery after surgery guided care.
    Dr. Westlake. Yes. Thank you for the question.
    I think that education is key. You know, I led the 
prescription reform efforts in Wisconsin starting 8 or 9 years 
ago, 10 years ago, and educating the physicians about 
prescribing. But I think we also need to continue to educate 
the public.
    And, you know, one of the things is--there is a study out 
of Michigan that, you know, 1 out of 16 kids that gets exposed 
to Vicodin for wisdom tooth extraction becomes addicted to it.
    And so it is stopping the initial exposure. And I think as 
a society we have to understand that there are going to be 
things that are painful. I tell people when they have a broken 
wrist: It is going to hurt. You can take Tylenol, you can take 
ibuprofen, you do ice. You know, take this tramadol or 
hydrocodone only if you have to, at night, and realize that if 
you take it there is a potential you could be addicted to it.
    I think education is out there, though. I think we are 
moving forward significantly on that respect. I think 
prescription drugs are not nearly the problem they were 10 
years ago.
    Mrs. Miller-Meeks. Thank you for that.
    We also have increased access to harm-reduction tools, and 
we have mentioned that. And I remember going through these as 
director of the Public Health Department. And as beneficial as 
they are, I just want to also mention that, in my meetings with 
both public health and with law enforcement, that we now also 
have, you know, individuals who are abusing those very same 
tools that we are using to save lives. So, when I am speaking 
with individuals in recovery and in law enforcement, mentioning 
the use of Narcan--overdosing on medication, knowing that there 
is Narcan available. So I think it is an extremely important 
tool, but we also have to be cautious and be mindful of that.
    There have been significant efforts at the Federal and 
State levels to increase access to naloxone, but I want to ask 
you, Dr. Westlake, in the little time I have, what more can be 
done to ensure individuals, families, EMS, first responders, 
emergency departments have the tools they need to give 
individuals who have overdosed another chance at recovery?
    Dr. Westlake. Yes, I think that is key. I think, you know, 
making it over the counter would be ideal. There is no reason 
that you would need a prescription for it. There are no side 
effects to it, other than it stops opioids from, you know, 
affecting the nerve. And so there is really no downside to it.
    I think that would be a huge step, and then it could just 
be--you know, it could be widespread much more easily.
    Mrs. Miller-Meeks. Thank you.
    And, Dr. Loyd, my time has expired, but if you had 
comments, please feel free to submit those in writing to us 
afterwards.
    Thank you. I yield back.
    Mr. Bucshon. The gentlelady yields back.
    I now recognize the gentleman from Florida, Mr. Bilirakis, 
for 5 minutes.
    Mr. Bilirakis. Thank you, Doctor. I appreciate it very 
much.
    Ms. Pickard, thank you for sharing your story with regard 
to Mason. Your words provide insights into the joy he brings to 
you and your family.
    The topic of the quality-adjusted life year can get highly 
technical. Can you share with us the real-world implications 
for the use of QALYs in decisionmaking, particularly for people 
living with rare or chronic conditions, such as veterans?
    Ms. Pickard. Thank you for the question.
    Mr. Bilirakis. My pleasure.
    Ms. Pickard. Well, I cannot speak directly to the rare 
patient disease community. I can imagine that they encounter 
very similar problems as the disability does in regards to the 
utilization of QALYs in all of our Federal healthcare programs, 
specifically access to those necessary and at times lifesaving 
treatments.
    All lives have value, and no one should be discriminated 
against based on arbitrary, one-size-fits-all metrics.
    Mr. Bilirakis. I agree.
    Ms. Cain, I am sorry and saddened to hear about Carson's 
story, and I thank you for your bravery and your calls for 
action and need for accountability at every level, from Big 
Tech companies like Snapchat to the DEA itself.
    We are losing this battle. And I agree with your testimony 
calling this a weapon of mass destruction. It is completely 
appalling that the drug dealer only served in jail for less 
than 1 day. Unbelievable.
    Can you explain how we can better hold these bad actors and 
drug traffickers accountable and why both social media and the 
Federal agencies like the DEA need to coordinate better, 
please?
    Ms. Cain. That is a big question, and I don't know if I am 
qualified to answer that, to tell you the truth.
    I am a teacher. I believe in education. I believe we need 
to be educating, even as young as kindergarten--I am a 
kindergarten teacher this year--``Don't touch a pill. Don't--
touch nothing. Take nothing. Ask your parents.''
    We need to--as far as Snapchat, I think that they have been 
given a free pass, and there is no accountability on their 
part. And I think it is time we start holding them accountable.
    I would encourage you to go visit the DEA and see the faces 
of fentanyl, because it is eye-opening. There are 4,800 
pictures hanging in there. There is a family that lost three of 
their children. Three. There are children as young as 17 
months. You walk around and you look at those faces, and it 
hits home. It hits home.
    I would encourage you to go do that. They have a thousand 
more they haven't hung yet. They don't have the room to keep 
hanging them, and they are still coming in.
    Mr. Bilirakis. It is affecting all our communities. And, 
you know, this committee has made it a priority----
    Ms. Cain. I thank you.
    Mr. Bilirakis [continuing]. To go after fentanyl.
    Ms. Cain. Thank you so much.
    Mr. Bilirakis. But, Dr. Westlake--thank you again. I know 
it is very difficult, but thanks for your testimony, ma'am.
    But, Dr. Westlake, you say in your testimony that fentanyl-
related substance scheduling is preventive, not punitive.
    As we see other varieties of substances being laced and 
mixed in with fentanyl and other drugs like xylazine becoming 
more prevalent, can you explain how we can be more proactive--
we need to be ahead of the game--more proactive and preventive 
to stay ahead of the latest drug-trafficking trends?
    Dr. Westlake. Yes, I think the first thing that can be done 
is to pass the HALT Fentanyl Act. I think that--I mean, just--
the way I look at it, drug use and opioid poisonings are like a 
fire hydrant, and there are different nozzles on the fire 
hydrant. And you have got illicit fentanyl, which is this big, 
and you have got fentanyl-related substances, which is smaller. 
But right now it is closed off and it is closed. And to not 
permanently enact it is to let it reopen and to start that 
spewing again.
    It is a huge problem, you know, fentanyl and illicit 
fentanyl deaths and poisonings. And Congress--you know, I think 
there is always a push to have a legislative solution to do 
everything, and I don't know that for a lot of things there is 
a legislative solution. I think this is a cultural solution to 
the drives for drugs.
    But I think this is a legislative solution for FRSes, that 
you can stop that, and it doesn't impact, you know, other 
things. It is just going to stop the creation of these, and 
that is all it does.
    Mr. Bilirakis. Thank you very much.
    I yield back, Mr. Chairman.
    Mr. Bucshon. The gentleman yields back.
    I now recognize the gentleman from Pennsylvania, Dr. Joyce, 
for 5 minutes.
    Mr. Joyce. Thank you for yielding, Mr. Chairman.
    And thank you to our second panel for appearing here today, 
because you give us that critical insight into the bills that 
we are considering.
    Dr. Westlake, thank you for turning around and coming back 
in to talk to us again.
    And during the previous panel, we heard of numerous 
concerns regarding the permanent scheduling of fentanyl-related 
substances.
    First, on the issues of mandatory minimum requirements for 
fentanyl-related substances, do you feel these requirements are 
necessary to deter the trafficking, to deter the cartels, to 
deter the business model, as they continue to bring these 
deadly poisons into our communities?
    Dr. Westlake. Yes, I think absolutely, without question.
    I think that is what makes it prevention-based, is that it 
stops the incentive for creating them. If you remove mandatory 
minimums, just like you pointed out, you have something that 
has less--you know, there is less penalty with it, so that is 
where it is going to go, is they are going to start creating 
those fentanyl-related substances.
    Because if it is easy--there is a lot of literature on 
researching fentanyl-related substances and how to make them, 
and it is as easy as using just a different reagent. So, if you 
want to make methyl fentanyl, all you do is you use methyl 
instead of an ethyl group. And so it is literally just one 
tweak in a cookbook that is well-delineated in the literature.
    That is why the language for the structure is so surgically 
targeted, is because it just gets rid of those known pathways.
    Mr. Joyce. Dr. Westlake, do you feel that the cartels have 
those abilities to make those minor changes to the recipe, to 
cook the fentanyl-related products in just a different manner 
to allow them to come through and escape those sentencings?
    Dr. Westlake. Absolutely. If they can make fentanyl, they 
can make any fentanyl-related substance. All they have to do is 
look at--there is a Federal sentencing reform testimony that I 
put in my testimony that addresses that--Mike Van Linn of DEA, 
Ph.D. It is absolutely easy to find in the literature.
    Mr. Joyce. We have also heard substantial concerns raised 
over a classwide ban and how that could potentially criminalize 
harmless substances.
    In this case, have there been any fentanyl-related 
substances that have been found to be harmless?
    Dr. Westlake. No, there have been zero. So there----
    Mr. Joyce. Have there been any fentanyl-related products 
that have been found to be not addictive?
    Dr. Westlake. No, there have been zero.
    Mr. Joyce. Have there been any fentanyl-related products 
that do not bind to the opioid receptors in the brain?
    Dr. Westlake. Zero. All of the substances studied by DEA, 
all 27 of them that have been studied, have bioactivity. Again, 
one of them is 7,000 times more potent than morphine.
    Mr. Joyce. Dr. Westlake, do you feel that all of these 
fentanyl-related products are poisons?
    Dr. Westlake. Absolutely.
    Mr. Joyce. I think that your ability to take your clinical 
experience as an emergency room physician, to bring that to 
Congress, to take your personal ability to recognize that, as 
you put it, all of these fentanyl-related products are deadly 
poisons--they are having that impact throughout our country, 
making every State a border State, something you have heard us 
frequently say but something that you as a physician recognize.
    Would you relate personal experiences on what would make 
the fentanyl-related products more easily classified, more 
educated to those who potentially could see those?
    Dr. Westlake. So, again, I think the One Pill Can Kill 
idea, the education component of it, of just educating people 
that there is no--I have seen marijuana that people smoke that 
has fentanyl in it that they die from. I have seen all kinds--
you know, fake Xanax pills.
    I mean, I think just the education is key to the component 
of how dangerous the substances are.
    Mr. Joyce. Given the dangerous nature that we 
recognize,that just one pill can kill, if there could be only 
one Schedule I drug to have mandatory minimum sentences 
attached to it, what would that be?
    Dr. Westlake. Absolutely, without a doubt, fentanyl and 
fentanyl-related substances. I mean, it is literally--you know, 
it is literally a chemical-weapons-grade poison.
    You know, it is hard to die overdosing on cocaine. It can 
happen, but it does. It is hard to die from heroin, actually, 
compared to fentanyl. Fentanyl, I mean, literally 2,000--I 
don't have my packet of sugar--2,000 deaths from 1 teaspoon? I 
mean, that is insane.
    Mr. Joyce. Thank you for your concise presentation.
    I thank all of the members of the panel for being here 
today.
    And I yield the remainder of my time.
    Mr. Bucshon. The gentleman yields.
    I will now yield 5 minutes to myself for questions.
    Dr. Loyd, Cedar Recovery specializes in outpatient care. I 
think it is important that we get people care in the least 
restrictive setting and that we get them the care early that 
they need. This is for substance abuse, of course.
    However, we need access to all levels of care, including 
residential care and inpatient care, in my opinion. Do you 
agree that we should have all settings available to patients?
    Dr. Loyd. Thank you for the question, Vice Chairman 
Bucshon.
    And, yes, I do. I agreed with what you said earlier, and I 
am glad we are getting to talk right now, because I do agree 
with that. We need to help people find the level of treatment 
that is right for them, not the level of treatment that is 
right for the person who is providing the treatment. And I see 
that all the time.
    And there is a difference between access to care and access 
to quality care. The patients that we focus on in the 
outpatient setting are Medicaid and Medicare as well as State 
opioid response patients who don't have resources otherwise.
    So all levels of care need to be accessible, but we also 
need to look at what may hinder somebody from getting the 
necessary level of care. And the example I will give you is the 
single mom with two children. The level of care that she may 
need is inpatient care. And that is fine and dandy until they 
tell her she can't bring her kids with her, and she is the sole 
provider for her family.
    And so we have to be willing to be flexible and give 
patients the level of care that will keep them alive, first, 
and then help them find the path to recovery that is right for 
them.
    Mr. Bucshon. So you must think--there are some Federal 
barriers probably, particularly in the Medicare program, like 
the IMD exclusion, that maybe we should change or revisit?
    Dr. Loyd. Vice Chair, there are a lot of hindrances to 
people trying to get care for substance use disorder, and that 
would be one I would like to look at.
    Mr. Bucshon. Yes, I mean, I think we have talked about that 
quite a bit. And I think, personally, we need to just revisit 
some of the things we are doing and make sure we are not 
limiting access to care in all settings.
    Dr. Loyd. Yes, sir.
    Mr. Bucshon. Well, Dr. Westlake, I want to ask you again 
about naloxone. And you say you are in favor of it going over 
the counter.
    Dr. Westlake. I am.
    Mr. Bucshon. Before we do that--and I am not saying I am 
against it. But I was a practicing physician before, a 
cardiovascular and thoracic surgeon. So I had a lot of patients 
in the ICU that, you know, as you know, sometimes patients 
aren't waking up. And you are saying, ``Well, maybe they are 
narcotized, so let's try some Narcan and see if it works.'' And 
it does frequently.
    You know, chronic ICU patients sometimes are given pain 
medication even when they are not awake, just with the 
assumption that, you know, they are in pain. And that happens.
    But then, of course, you know naloxone in that setting and 
in other settings is not without some risk. I mean, there are 
cardiovascular--potential hypertension, tachycardia, 
cardiovascular ramifications. And sometimes people do awake 
suddenly and can be combative and have other issues.
    So, once we go to over the counter, what type of public 
education do you think we should put in place maybe a little 
bit before we take that step? Or do you think we--what do you 
think we should do?
    Dr. Westlake. I see it as--I mean, I think the people that 
are going to be using it are not going to be the ones that are 
at cardiovascular risk. I think you saw pretty skewed patients 
in the ICU that present to the ICU with advanced 
cardiovascular----
    Mr. Bucshon. I did. That is correct.
    Dr. Westlake. So what I am seeing in the E.D. is younger 
people, you know, mostly under the age of 40, and if they had 
access to it. Someone may have had it at home. Because when it 
is given, it works.
    And so----
    Mr. Bucshon. Absolutely.
    Dr. Westlake [continuing]. Definitely education is needed 
with it. But I think--and it is the same thing, I think, with 
buprenorphine.
    Buprenorphine is--I know that there is talk about it being 
abused, and I would much rather see buprenorphine abused than 
fentanyl or OxyContin or oxycodone. And the people that are 
abusing it with substance use disorder are going to be abusing 
something, and so that is--it kind of falls into the same 
thing, almost like a harm-reduction thing.
    Mr. Bucshon. I understand.
    Is there any evidence out there that the availability of 
naloxone facilitates ongoing illicit narcotics use?
    For example, I mean, I have had in some counties, rural 
counties, where they have gone to the same house three, four, 
five times. And the law enforcement, at least, tell me some of 
the suspicion is that the people know that this is available 
and, you know, the cavalry is going to show up.
    I don't personally believe that, but do you think there is 
any evidence of that, that the availability of naloxone could 
facilitate further use, or no?
    Dr. Westlake. No, I don't think there is.
    But do you want to----
    Mr. Bucshon. Whoever wants to comment on that.
    Dr. Loyd. Thank you, Dr. Westlake.
    I don't think there is any evidence to that either. But I 
would tell you this: that if it is my son, I hope the cavalry 
continues to show up.
    Mr. Bucshon. And they do. But they run out. That is the 
problem, right? I have counties that are literally--the county 
sheriffs, they run out every month before the end of the month. 
And then the cavalry may not come.
    So, with that, I yield back--oh, Mr. Johnson is here. I 
yield back. And I will now recognize the gentleman from Ohio, 
Mr. Johnson, for 5 minutes.
    Mr. Johnson. Thank you, Mr. Chairman.
    I appreciate the panel coming in.
    I do have another fentanyl question. Then I will move on. 
So let me go quickly to Dr. Westlake.
    Higher-dose pills from improperly mixed batches, known as 
hotspots, that lead to overdose and death in a given area are 
often the way the medical community and law enforcement learn 
that fentanyl or an analog has been introduced into a local 
drug market, which in turn would beget reactive scheduling in 
States.
    Dr. Westlake, this helped you--if I understood it right, 
this helped lead you to work to target bioactive fentanyls as a 
class, in order to remove the incentive that international drug 
traffickers had in modifying the drug molecule.
    Can you discuss how fentanyl class scheduling is critical 
not only for law enforcement but for patient and community 
health as well?
    Dr. Westlake. Yes. It is critical to leave that spigot 
closed so that--you know, again, right now, there are no more 
new fentanyl-related substances that are being created, so no 
one is dying from new fentanyl-related substances. They are 
dying, you know, a lot from illicit fentanyl but not from 
fentanyl-related substances.
    You know, what Congress can do is to pass a law that will 
stop the manufacture and creation of this and remove the 
incentive for it. If you take away the mandatory minimums, the 
incentive is going to creep back in, and I fear that that would 
come back into play.
    Mr. Johnson. OK. So, should this scheduling ban expire, is 
it realistic to expect that we would see an increase, perhaps 
even a sharp increase, in overdose deaths?
    Dr. Westlake. So that is a good question. So there is 
really not--the fentanyl-related substances are not being 
created or researched in America at all. It is all from Chinese 
chemical labs and, you know, potentially from Indian chemical 
companies if they were to choose to do that. And so the key 
thing is to make sure that the Chinese stop, you know, creating 
these fentanyl-related substances.
    So, yes, I mean, it is critical to get this passed.
    Mr. Johnson. OK. All right.
    And then I want to pivot to address another piece of 
legislation that we are considering today, this, quote, 
``quality-adjusted life years.''
    This concept is exactly what it sounds like. It is a 
calculation, not made by you or your loved ones, that decides 
how much, quote, ``quality'' remain in the remaining years of 
your life that you might have if you are diagnosed with an 
illness or a disability, and that then determines how much cost 
and coverage is going to be applied to that.
    I mean, another term for that is called rationing 
healthcare. That is not what we do in the United States. In 
some countries with nationalized healthcare, like the United 
Kingdom, the government gets a say in this, when it is time to 
consider healthcare treatment options.
    And some on the--not everybody, but some on the Democratic 
side want to emulate health systems like those in the United 
Kingdom. Well, I say, no, thanks, we don't want that here. This 
is a dystopian future that neither the people I represent nor I 
want any part of.
    So, Ms. Pickard, thank you for being here and for your 
advocacy on this issue, because the public needs to learn more 
about this.
    The legislation we are considering today prohibiting using 
quality-adjusted life years calculations in Federal programs, I 
fully support it. But, in addition, you mentioned other metrics 
and value assessments that also contribute to this type of 
discrimination or, as I refer to it, rationing.
    Can you outline, Ms. Pickard, any other metrics or 
assessments here in the United States or overseas that as 
policymakers we need to watch out for and work to mitigate the 
damage that they may cause?
    Ms. Pickard. Thank you for that question.
    Yes. I mentioned a little bit earlier that our friends in 
the U.K. and in Canada do heavily rely on these QALYs to 
determine who is worth treating and who is too expensive to 
treat.
    I think that, when we look at this, we really want to look 
at what is the best for people--in my case, the people with 
disabilities--and how do we make sure that we look at 
alternatives.
    And I think that there has been a number of alternatives 
and supplements proposed to replace or improve the QALY, but 
there is still more research that needs to be done to determine 
what is the best route.
    Mr. Johnson. OK. All right.
    Mr. Chairman, I see that my time has expired. I yield back.
    Mr. Bucshon. The gentleman yields back.
    I want to make a personal privilege here, that my wife is 
an anesthesiologist, and I have been using the term ``illicit 
fentanyl.'' Let me tell you why. Because every day in her job 
she uses fentanyl. And she is having patients--this message is 
getting out, which is good, that this is a problem in our 
country, but it is actually a very useful anesthetic agent that 
we use every day legally. So I have been using the term 
``illicit fentanyl'' rather than just saying ``fentanyl,'' just 
FYI.
    At this point, I ask unanimous consent to include in the 
record the following items on this list. It is my understanding 
these documents have been shared with the minority and approved 
by the minority.
    Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Bucshon. Seeing there are no further Members wishing to 
ask questions, I would like to thank all of our witnesses--it 
has been a long day--again for testifying here. Very strong 
testimony from all of you. Very much appreciate it.
    And, at this point, the committee stands adjourned.
    [Whereupon, at 3:01 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
    
                 HOUSE COMMITTEE ON ENERGY AND COMMERCE
                 
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