[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]










               AMERICA'S HEROIN AND OPIOID ABUSE EPIDEMIC

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

                                HEARING

                               BEFORE THE

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 22, 2016

                               __________

                           Serial No. 114-155

                               __________

Printed for the use of the Committee on Oversight and Government Reform









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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                     JASON CHAFFETZ, Utah, Chairman
JOHN L. MICA, Florida                ELIJAH E. CUMMINGS, Maryland, 
MICHAEL R. TURNER, Ohio                  Ranking Minority Member
JOHN J. DUNCAN, Jr., Tennessee       CAROLYN B. MALONEY, New York
JIM JORDAN, Ohio                     ELEANOR HOLMES NORTON, District of 
TIM WALBERG, Michigan                    Columbia
JUSTIN AMASH, Michigan               WM. LACY CLAY, Missouri
PAUL A. GOSAR, Arizona               STEPHEN F. LYNCH, Massachusetts
SCOTT DesJARLAIS, Tennessee          JIM COOPER, Tennessee
TREY GOWDY, South Carolina           GERALD E. CONNOLLY, Virginia
BLAKE FARENTHOLD, Texas              MATT CARTWRIGHT, Pennsylvania
CYNTHIA M. LUMMIS, Wyoming           TAMMY DUCKWORTH, Illinois
THOMAS MASSIE, Kentucky              ROBIN L. KELLY, Illinois
MARK MEADOWS, North Carolina         BRENDA L. LAWRENCE, Michigan
RON DeSANTIS, Florida                TED LIEU, California
MICK MULVANEY, South Carolina        BONNIE WATSON COLEMAN, New Jersey
KEN BUCK, Colorado                   STACEY E. PLASKETT, Virgin Islands
MARK WALKER, North Carolina          MARK DeSAULNIER, California
ROD BLUM, Iowa                       BRENDAN F. BOYLE, Pennsylvania
JODY B. HICE, Georgia                PETER WELCH, Vermont
STEVE RUSSELL, Oklahoma              MICHELLE LUJAN GRISHAM, New Mexico
EARL L. ``BUDDY'' CARTER, Georgia
GLENN GROTHMAN, Wisconsin
WILL HURD, Texas
GARY J. PALMER, Alabama

                   Jennifer Hemingway, Staff Director
                    Andrew Dockham, General Counsel
 Michael R. Kiko, Transportation and Public Assets Subcommittee Staff 
                                Director
                  Ari Wisch, Professional Staff Member
                    Sharon Casey, Deputy Chief Clerk
                 David Rapallo, Minority Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on March 22, 2016...................................     1

                               WITNESSES

The Hon. Michael Botticelli, Director, Office of National Drug 
  Control Policy, The White House
    Oral Statement...............................................     6
    Written Statement............................................    10
Mr. Lou Milione, Deputy Assistant Administrator for Diversion 
  Control, Drug Enforcement Administration, U.S. Department of 
  Justice
    Oral Statement...............................................    22
    Written Statement............................................    24
Ms. Kana Enomoto, Principal Deputy Administrator, Substance Abuse 
  and Mental Health Services Administration, U.S. Department of 
  Health and Human Services
    Oral Statement...............................................    35
    Written Statement............................................    38
Leana S. Wen, M.D., MSC., FAAEM, Health Commissioner, Baltimore 
  City Health Department
    Oral Statement...............................................    48
    Written Statement............................................    50
The Hon. Teresa Jacobs, Mayor of Orange County, Florida
    Oral Statement...............................................   101
    Written Statement............................................   104

                                APPENDIX

March 19, 2016, Baltimore Sun ``The Effects of Opioid 
  Overprescription Are Evident in the Emergency Room'', submitted 
  by Mr. Mica....................................................   152
October 30, 2015,New York Times ``In Heroin Crisis'', submitted 
  by Mr. Lieu....................................................   154
October 29, 2010 Time ``Marijuana as a Gateway Drug The Myth That 
  Will Not Die'', submitted by Mr. Lieu..........................   158
Response from Mr. Milione, DEA, to Questions for the Record......   160
Response from Ms. Enomoto SAMHSA to Questions for the Record.....   170
Response from Dr. Wen, Baltimore City Health, to Questions for 
  the Record.....................................................   182

 
               AMERICA'S HEROIN AND OPIOID ABUSE EPIDEMIC

                              ----------                              


                        Tuesday, March 22, 2016

                   House of Representatives
               Committee on Oversight and Government Reform
                                                     Washington, DC
    The committee met, pursuant to call, at 10:01 a.m., in Room 
2154, Rayburn House Office Building, Hon. John Mica presiding.
    Present: Representatives Mica, Turner, Jordan, Walberg, 
Amash, Gowdy, Massie, Meadows, DeSantis, Buck, Walker, Blum, 
Hice, Carter, Grothman, Hurd, Palmer, Cummings, Maloney, 
Norton, Clay, Lynch, Connolly, Cartwright, Lawrence, Lieu, 
Watson Coleman, DeSaulnier, Boyle, and Lujan Grisham.
    Mr. Mica. Good morning. I would like to welcome everyone 
this morning to the Committee on Oversight and Government 
Reform, and to a hearing which is entitled ``America's Heroin 
and Opioid Abuse Epidemic.'' I would like to welcome our 
ranking member, Mr. Cummings, and all the members and our 
witnesses this morning to this hearing and call the hearing to 
order.
    Without objection, the Chair is authorized to declare 
recesses at any time.
    The order of business this morning will be as follows. We 
will begin the hearing with opening statements from myself and 
the ranking member. Other members are welcome to submit opening 
statements, and with Mr. Cummings' support we will leave the 
record open for 5 days, legislative days, for additional 
comments or statements.
    Without objection, so ordered.
    And when we complete the opening statements, we will turn 
to our panel of witnesses. We have five distinguished witnesses 
today, three at the Federal level, one at the state, and one at 
the local level for our hearing. We will swear those witnesses 
in, and then we will hear their testimony, and then we will 
proceed with questions. So that will be the order of business 
that will follow.
    So again, welcome, and I will start with my opening 
statement.
    Unfortunately, the United States is experiencing an 
historic epidemic of drug overdose deaths. Today, drug 
overdoses are the leading cause of accidental death in the 
United States. In 2014--I don't have the 2015 figures yet, but 
in 2014 there were--listen to this--47,055 deaths caused by 
drug overdose. That means if this hearing lasts for two hours, 
10 people will die in the next two hours in the United States 
from drug overdose deaths.
    This is a little chart showing you the increase since 1999. 
I remember I chaired Criminal Justice Drug Policy Oversight 
Subcommittee from 1998 to 1999, and we thought we had an 
epidemic back in 1999 with 16,000, and I can show you some of 
the headlines from my local newspapers where we had many people 
dying over a weekend. Unfortunately, that is what we are seeing 
again in my community and across the United States.
    Unfortunately, more Americans have died from drug-related 
overdoses in one year than all that were killed in the lengthy 
Korean War. If the current trend continues, the annual death 
rate could climb beyond those killed in Vietnam over that 
multi-year struggle in one year.
    The graph from the Washington Post illustrates the 
disturbing rise in drug overdoses between 1999 and 2014. Now, 
of the 47,000, more than 10,000 Americans died of heroin-
related overdoses. Heroin use is increasing at a faster rate. 
If you want to talk about a war on women and a war on our young 
people, the heroin deaths are killing our women at twice the 
rate of men and 109 percent more with our youth.
    Unfortunately, we have seen, according to the Centers for 
Disease Control and Prevention, that again with heroin deaths 
among our youth between 18 and 25 in the past decade have 
soared and again lead the statistics, the deadly statistics. 
Across all demographics, the rate of heroin-related overdose 
deaths has increased 286 percent.
    While the exact cause of this epidemic is up for debate, 
many experts believe the use of other drugs is also a driving 
factor. Addiction to other drugs such as prescription 
painkillers and marijuana potentially open the door to an 
epidemic now destroying families and communities.
    Those addicted to other drugs turn to heroin to get a 
similar high because it is cheaper and more readily available. 
Mexican drug cartels have established heroin trafficking routes 
here in the United States and coming across our borders. Now we 
see increased supplies in recent years.
    I had a chance to talk with my police chiefs and law 
enforcement folks in the district, our HIDTA folks, our DEA 
folks, and we are seeing an incredible supply, and we will have 
some questions about where that is specifically coming from. We 
know a lot of it is coming across the Mexican border.
    The impact, unfortunately, is felt in communities across 
the nation. Just a few weeks ago I met again with all of the 
local officials, and we have one of my local officials who we 
will hear from in a few minutes, Teresa Jacobs, our county 
mayor in Orange County, who has been forced to deal with the 
heroin epidemic in Central Florida in her county. In Orange 
County alone, and you will hear more about this, we had 475 
related heroin bookings in 2013. By the end of 2015, last year, 
we had 840. The majority of those arrested were between the age 
of 18 and 44.
    The Obama Administration, unfortunately, I believe, has 
been sending mixed signals about the use of substances such as 
marijuana, which is one of the gateway drugs. Talk to anyone 
who is in counseling, treatment, rehabilitation, and you will 
find out that marijuana is a gateway drug, and many of the 
heroin users start there and work their way up the chain of 
deadly drugs.
    According to the National Institute on Drug Abuse--now 
listen to this--more high school seniors are now using 
marijuana than cigarettes. A policy that has been adopted, 
unfortunately, has consequences. The ``Just Say No'' drug 
policy which was championed by the late First Lady, Nancy 
Reagan, has turned into a ``Just Say Okay'' policy, and now we 
are seeing the consequences.
    While improving treatment is a key, enforcement is and must 
remain an essential part of combatting the heroin epidemic. 
When I talked to the police chief and I saw the numbers in our 
locale, I said, well, it looks like you have been able to keep 
the lid on some of this, although it is now at epidemic 
proportions. And they told me, Mr. Mica, he said this is only 
because we now have antidotes that can bring these people back. 
The only reason we aren't seeing double or triple the deaths is 
because our law enforcement and our first responders can bring 
these people back if they can get to them in time.
    Not only illegal immigrants are flowing over the Mexican 
border but also illegal drugs. We know that is the main source 
of the supply of heroin, cocaine, marijuana, and a host of 
other deadly narcotics. Stopping deadly drugs from entering the 
United States is a Federal responsibility, and we will hear 
from some of those officials engaged in that war.
    New statistics show Federal drug prosecutions, 
unfortunately, are down 6 percent in the last year, 2015. This 
comes after a 14 percent drop since the beginning of the Obama 
Administration's so-called Smart On Crime initiative.
    Our frontline law enforcement officers, if we are going to 
save more of these kids and others who are overdosing, they 
should be equipped with the resources to prevent and save them 
from overdose deaths, not just our emergency medical officers. 
The EMS people get there usually after the first responders, 
and it may be too late. So this is something else we have 
learned from our local task force and law enforcement 
officials.
    One of the police chiefs in my district informed me that 
just within the last month or so, we had one student who had to 
be revived from overdosing three times in one week. That is 
astounding. What is astounding is he is still alive and we were 
able to catch that.
    Speaker Ryan announced addressing this current epidemic as 
a priority, and the Senate has acted on some legislation. I 
believe that this is absolutely critical, that this whole drug 
situation, including the heroin epidemic, become a priority for 
this Congress.
    I look forward to hearing from our witnesses today as we 
examine how to protect our communities from this fast-growing 
and skyrocketing national epidemic.
    I am now pleased to yield to our ranking member, Mr. 
Cummings. Mr. Cummings was my ranking member. We together led 
the effort from 1998 to 2000. I remember going into Baltimore 
with him and conducting hearings there when people were dying 
on the streets in huge numbers. But, Mr. Cummings, we are 
unfortunately backsliding, and here we are today. But he did a 
great job of trying to save people in his community, and he is 
now the ranking member of our full committee.
    Mr. Cummings?
    Mr. Cummings. Thank you very much, Mr. Chairman. I want to 
thank you for holding a hearing on America's heroin and opioid 
epidemic.
    I want to take a moment before I start to extend our 
prayers to the people of Brussels, Belgium.
    Mr. Mica. I would join you, and I would ask everyone for 
just a moment of silence, if we could.
    [Moment of silence observed.]
    Mr. Mica. Thank you, Mr. Cummings.
    Mr. Cummings. Thank you, Mr. Chairman.
    Today's hearing is about a national public health 
emergency, and we need to treat it like one. People are dying 
in Baltimore, Orlando, Salt Lake City, Manchester, and cities 
all across our nation. We can no longer ignore this public 
health emergency.
    The Congress needs to put its money where its mouth is and 
actually help, help our states fund treatment programs to stop 
this epidemic in its tracks. Drug treatment facilities without 
adequate funding are like firemen trying to put out a raging 
inferno without enough water. Last week, Leader Pelosi sent a 
letter urging Speaker Ryan to schedule a vote on $600 million 
in emergency funding to help states address this epidemic 
before this recess week.
    Our colleague from Connecticut, Representative Courtney, 
has already introduced this bill in the House, and Senator 
Shaheen has been pressing this legislation in the Senate. 
Congress should not leave town until we take emergency action 
to increase funding to help states combat this epidemic.
    We must also fully fund President Obama's budget request 
for $1.1 billion in 2017. This crisis will not end in a day. It 
will take our sustained commitment, and every one of us owes it 
to our constituents to make that a priority. They want us to 
take action, and they want us to take action now.
    Let me tell you why Federal funding is so important. In my 
home town of Baltimore, I witnessed with my own eyes, in my own 
neighborhood, the destruction drug addiction inflicts on our 
communities. The first time I ever heard of a drug overdose 
death was 55 years ago from heroin, 55 years ago. I didn't 
understand it then. It was a young man in our neighborhood who 
we looked up to who turned to heroin, named Bey-Bey, and I can 
remember being so confused as to what this was all about.
    So I have seen vibrant neighborhoods and hard-working 
families and communities destroyed. In Baltimore, where many of 
the victims were poor and black, this went on for decades. Our 
nation treated this issue like a war rather than a public 
health emergency. We incarcerated generations rather than 
giving them the treatment they needed.
    Now, things are changing. Between 2006 and 2013, the number 
of first-time heroin users nearly doubled. About 90 percent of 
these first-time users were white. This epidemic has become a 
runaway train barreling through every family and every 
community in its path. It has no respect for barriers. It is 
now responsible for the deaths of 78 Americans every single 
day, every single day.
    Why is this happening? In part, it is a result of doctors 
over-prescribing pain medication and drug companies urging them 
on so they can make massive profits. I would like to enter into 
the record an op-ed by Emily Narciso that appeared in the 
Baltimore Sun on March 19th.
    Mr. Mica. Without objection, so ordered.
    Mr. Cummings. I just want to read just a paragraph from 
this article. It says, ``Prescriptions of opioids have been 
traditionally limited to cancer pain and comfort measures. But 
in the mid-'90s, companies began marketing these pills as a 
solution to a new plethora of ailments. In their efforts to 
expand the market, producers understated and willfully ignored 
the powerfully addictive properties of their drugs. The 
promotion of OxyContin by Purdue Pharma was the most aggressive 
marketing of a Schedule II drug ever undertaken by a 
pharmaceutical company. The Sackler family, which owns 
Stanford, Connecticut-based Purdue Pharma, achieved a place on 
Forbes' 2015 List of America's Wealthiest Families. The 
Sacklers, the richest newcomers to the list, are worth an 
estimated $14 billion,'' $14 billion.
    Now, going on, as she explains, the United States has only 
5 percent of the world's population, but we consume 80 percent 
of the world's painkillers. Five percent, ladies and gentlemen, 
of the world's population, but 80 percent of the painkillers we 
consume.
    So, yes, I believe it was unconscionable that our nation 
ignored this issue for decades, but now Republicans and 
Democrats are starting to work together, and I thank God that 
this day has finally come and the stars are starting to align 
for meaningful change.
    We now have people like Orrin Hatch, Chris Christie, Rob 
Portman, Kelly Ayotte, and Mike Pence realizing the severity of 
this crisis and supporting more funding to help our cities and 
states. They are beginning to realize that this is not an urban 
issue, a rural issue, a black issue, an Hispanic issue, or a 
white issue. This is an American issue that affects your 
sisters, your brothers, your sons, and your daughters.
    There is something else we must do. We can no longer allow 
drug companies to keep ripping off taxpayers for life-saving 
medications. The Chairman mentioned just a moment ago the drug 
naloxone and its life-saving effects. Cities all around the 
country have recognized the need to equip their first 
responders, police officers and public health officials with 
naloxone, a drug that can reverse opioid overdoses in a matter 
of minutes. But their efforts have been directly undermined by 
corporate greed.
    As more first responders began using this drug, the company 
that makes it, Amphastar, began to increase its prices by 
staggering amounts. In May 2014, a 10-dose pack cost the 
Baltimore City Health Department roughly $190. Guess what? 
Today, it costs more than $400 for the life-saving drug. 
Despite repeated efforts by my home state of Maryland, this 
company continues to over-charge for this drug. The company 
also continues to obstruct congressional oversight by refusing 
to produce all of the documents I requested last May, last May, 
about their massive price increases.
    Mr. Chairman, today's hearing is rightly focused on the 
heroin and opioid epidemic, but I hope the committee will turn 
next to my request for documents, as well as my request for a 
hearing with executives from Amphastar.
    With that, let me welcome our esteemed panel of witnesses 
today, and I thank you for being here. In particular, I would 
like to welcome Dr. Leana Wen, the Baltimore City Health 
Commissioner, who has done an outstanding job. She is a true 
national leader in developing and carrying out effective 
solutions to the opioid crisis. We are very fortunate to have 
her heading our health efforts in Baltimore, and we are very 
pleased to have her here today.
    And with that, Mr. Chairman, I yield back.
    Mr. Mica. Thank you, Mr. Cummings.
    Again, we will leave the record open for members who came 
in late for 5 legislative days if you would like to submit them 
at this point in the record.
    Mr. Mica. We now want to again welcome our witnesses. Let 
me first introduce them, and then we will swear you in.
    I am pleased to welcome the Honorable Michael Botticelli, 
and he is the Director of Office of National Drug Control 
Policy at the White House.
    We have Mr. Lou Milione, and he is the Deputy Assistant 
Administrator for Diversion Control at DEA, the Federal Drug 
Enforcement Administration at the Department of Justice.
    And then we have Ms. Kana Enomoto, and she is the Principal 
Deputy Administrator of Substance Abuse and Mental Health 
Services Administration at the U.S. Department of Health and 
Human Services.
    And then we have Ms. Leana Wen, and she is the Health 
Commissioner for Baltimore City Health Department.
    And then I would like to also welcome my requested witness, 
the Honorable Teresa Jacobs, Mayor of Orange County, Florida.
    Some of you have been before us before, some of you 
haven't. We ask you that you limit your statements to 
approximately 5 minutes. You will see the little monitor. You 
can also request from the Chair additional statements or 
information be added to the record. So if you have a statement 
and you want to summarize it, you are welcome to do that.
    Since this is an oversight and investigations panel of 
Congress, I would like you to stand now and be sworn. Can you 
raise your right hand?
    Do you solemnly swear or affirm that the testimony you are 
about to give before this committee and Congress is the whole 
truth and nothing but the truth?
    [Witnesses sworn.]
    Mr. Mica. All of the witnesses have answered in the 
affirmative, and we will let the record reflect that.
    We will first turn to our ONDCP representative, the 
Director of the Office of National Drug Control Policy from the 
White House, Mr. Botticelli.
    Welcome, and you are recognized.

                       WITNESS STATEMENTS

                STATEMENT OF MICHAEL BOTTICELLI

    Mr. Botticelli. Chairman Mica, Ranking Member Cummings, and 
members of the committee, thank you for the opportunity to 
appear here today to discuss the issues surrounding opioid 
drugs, including heroin and illicit fentanyl, in the United 
States, as well as our Federal response.
    During his State of the Union address, President Obama 
specifically mentioned addressing prescription drug and heroin 
use as a priority and an opportunity to work with Congress in a 
bipartisan manner on this issue that transcends party, income 
level, gender, race, and geography.
    The Office of National Drug Control Policy produces the 
National Drug Control Strategy, which is the Administration's 
blueprint for reducing drug use and its consequences. Using our 
role as the coordinator of Federal drug control agencies, in 
2011 the Administration released a plan to address the sharp 
rise in prescription opioid drug misuse that coincided with a 
surge in opioid drug prescribing at the beginning of this 
century. As this crisis has evolved with an increase in heroin 
and fentanyl use and overdose deaths, the Administration 
continues to put forward new initiatives to help deal with 
emerging issues.
    For example, in October the Administration announced a 
series of commitments it obtained from state, local, and 
private-sector partners, as well as Federal agencies, aimed at 
addressing this epidemic.
    Opioids are having an unimaginable impact on public health 
and safety in communities across the United States. Fifty-seven 
people died each day from opioids in 2010, and by 2014 that 
figure was up to 78 people. The number of drug overdose deaths 
involving synthetic opioids other than methadone, a category 
including fentanyl, has more than doubled since 2012.
    These overdose rates are harrowing. However, we are making 
some progress. Past-month non-medical use of opioids by 
Americans 12 and older was significantly lower in 2014 than 
during its peak in 2009, and the number of people initiating 
the non-medical use of prescription pain relievers in the past 
year also decreased significantly during that time.
    Unfortunately, this progress has been counteracted by an 
increase in the availability and use of heroin. Heroin purity 
has been rising while prices have remained low. The heroin 
crisis is compounded by the reemergence of illicit fentanyl, a 
powerful synthetic opioid that is sometimes added to heroin to 
increase its potency or used unsuspectingly on its own. Since 
fentanyl is far more potent than heroin, its use increases risk 
for overdose death.
    While prescription opioid misuse far surpasses heroin use, 
and the transition from non-medical prescription opioid use to 
heroin occurs at a very low rate, a recent review article 
concluded that this transition appears to be a part of the 
transition of addiction among those with frequent use or 
dependence rather than a response to the reduction and 
availability of prescription medications, as some have 
speculated.
    Graduate medical education programs do not provide a 
comprehensive focus on the identification or treatment of 
opioid use disorders. A startling evaluation of health care 
claims data found that a majority of non-fatal opioid overdose 
victims were receiving an opioid from a prescriber, and 91 
percent received an opioid prescription again from a prescriber 
following their overdose.
    In response last year, President Obama issued a 
Presidential Memorandum requiring all Federal agencies to 
provide training on the appropriate and effective prescribing 
of opioid medications to staff who prescribed controlled 
substances as part of their Federal duties.
    Just last week, the Centers for Disease Control issued 
recommendations for primary care clinicians on the prescribing 
of opioids to treat chronic pain. The Administration also 
obtained commitments by more than 40 provider groups that more 
than 500,000 health care providers will complete opioid 
prescriber training in the next two years. And the 
Administration continues to work with Congress to make 
mandatory prescriber education part of their controlled 
substance licensure.
    The Administration has also focused on several key areas to 
reduce and prevent opioid overdoses, including educating the 
public about overdose risks and interventions, increasing 
third-party and first responder access to the opioid overdose 
reversal medication naloxone, promoting Good Samaritan laws, 
and connecting overdose victims and persons with an opioid 
overdose to treatment.
    Yet, there remains in this country a considerable gap that 
inhibits many victims of this epidemic from accessing the 
treatment they so desperately need. Therefore, the President's 
Fiscal Year 2017 budget proposes $1 billion in new funding over 
two years to support cooperative agreements with states to 
expand access to medication-assisted treatment and to expand 
access to substance use treatment providers in areas across the 
country most in need of providers.
    And just a few days ago, HHS Secretary Burwell announced 
$94 million in Affordable Care Act funding to health centers to 
expand the delivery of substance use services, with a specific 
focus on medication-assisted treatment for opioid use disorders 
in underserved populations.
    While we appreciate Congress' support, the President's 
proposal underscores the need for additional funding to address 
this epidemic.
    To address the increase in heroin and illicit fentanyl use 
and availability, the National Drug Control Strategy focuses on 
identifying, disrupting, and dismantling criminal organizations 
trafficking opioid drugs, working with the international 
community to reduce the cultivation of poppy, and identifying 
labs creating synthetic opioids like fentanyl and its analogs.
    In addition, last year ONDCP created the National Heroin 
Coordination Group, which is a multi-disciplinary team of 
subject-matter experts to lead Federal efforts to reduce the 
supply of heroin and fentanyl in the United States, and we have 
also committed $2.5 million in high-intensity drug trafficking 
area programs to develop a heroin response strategy, providing 
law enforcement resources to address the heroin threat across 
15 states and the District of Columbia.
    We have also been actively engaged with the government of 
Mexico on efforts to reduce the flow of heroin and fentanyl 
into the United States. Earlier this month, I met with Mexican 
Attorney General Gomez and other interagency representatives. 
We agreed to further collaboration on efforts to disrupt the 
production of heroin and fentanyl. This bilateral cooperation 
will be mutually beneficial to both our countries.
    Members of the committee, we remain committed to working 
with our Federal, state, local, tribal, and private-sector 
partners to reduce and prevent the health and safety 
consequences of non-medical prescription opioid, heroin, and 
illicit fentanyl use. Thank you very much.
    [Prepared statement of Mr. Botticelli follows:]
    
    
  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    
    Mr. Mica. Thank you, and we will withhold questions until 
we have heard from everyone.
    Let me recognize Mr. Milione and welcome him, our DEA 
representative.

                    STATEMENT OF LOU MILIONE

    Mr. Milione. Thank you, Chairman Mica, Ranking Member 
Cummings, and distinguished members of the committee.
    DEA views the combined prescription opioid and heroin abuse 
epidemic as the number-one drug threat facing the country. I 
appreciate the opportunity to appear before you today and talk 
about what we at the DEA are doing to address that threat.
    Prescription opioids are walking users up to heroin's door, 
across that threshold, and into heroin's deadly embrace. 
Mexican cartels are entrenched in communities throughout our 
country, exploiting the prescription opioid abuse epidemic and 
flooding the country with high-purity, low-cost heroin. Those 
cartels are forming a toxic business relationship with the 
violent distribution cells that are slinging that dope in our 
communities.
    What is the end result? In one year, almost 30,000 of our 
fellow Americans died from a prescription opioid or heroin 
overdose. As everyone has acknowledged, this is an unimaginable 
tragedy.
    DEA understands that we need a balanced, holistic approach 
to this epidemic. We stand with our interagency partners, 
including those represented here today, and embrace prevention, 
treatment, and education as critical to our success. However, 
enforcement must be a key component of our overall strategy. We 
need to investigate and bring to justice not those suffering 
from opioid use disorder but those that are exploiting human 
frailty for profit.
    Our answer to dealing with this drug threat: attack supply, 
reduce demand, and power communities, DEA's 360 Strategy. There 
are three prongs to the strategy: law enforcement, diversion 
control, and community outreach. My comments today focus 
primarily on the Office of Diversion Control's role in that 
strategy, but we would be more than happy to follow up with 
details about Operation Rolling Thunder.
    Rolling Thunder is the heroin enforcement prong of the 360 
Strategy that is focused on the violent distribution cells that 
are pushing heroin in our communities and the Mexican cartels 
that are supplying the heroin that is killing so many 
Americans.
    With 1.6 million DEA registrants, DEA diversion is uniquely 
positioned to assist in this fight with enforcement, education, 
and engagement. The vast majority of those 1.6 million 
registrants are law-abiding citizens. These are our 
practitioners, pharmacists, manufacturers and distributors 
working in all our communities. We investigate the very small 
percentage of those that are operating outside the law but yet 
inflict considerable harm on our country: for example, 
practitioners not prescribing for a legitimate medical purpose 
outside the usual course of professional practice; pharmacists 
not performing their corresponding responsibility to ensure 
that the prescription is valid; manufacturers and distributors 
not upholding the regulatory obligations to prevent diversion.
    How do we do that? With our tactical diversion squads, our 
diversion groups, and our great Federal, state, and local 
counterparts. Our tactical diversion squads are specialized 
units made up of agents, diversion investigators, and intel 
analysts. We have 69 of them nationally. We are going to add 
eight, bringing our number up to 77 within the next six to nine 
months.
    We are creating two mobile tactical diversion squads that 
can deploy where the need is, giving us a fluid enforcement 
capability.
    We have almost 700 skilled diversion investigators spread 
across this country in our diversion groups. Both the tactical 
diversion squads and the diversion groups work with their 
respective U.S. Attorney's Office to bring criminal and/or 
civil charges against those registrants that are operating 
outside the law; and, where appropriate, they bring 
administrative actions, DEA's Orders to Show Cause or immediate 
suspension orders, potentially revoking a registrant's DEA 
registration.
    As I said earlier, enforcement will be a key part of the 
overall strategy, but engaging with that large registrant 
community and educating them are just as critical. In the last 
two years, DEA diversion has conducted more than 300 events, 
providing education and guidance to thousands of DEA 
registrants and industry leaders. Since 2011, with our great 
partners at the National Association of Boards of Pharmacy, we 
have conducted more than 64 pharmacy diversion awareness 
conferences in 29 states and have had the privilege of 
interacting with almost 10,000 pharmacy employees about the 
risks of diversion.
    Finally, we will continue engaging with our interagency 
partners on important initiatives, including expanding access 
to treatment, mandatory prescriber education, and the safe and 
responsible disposal of unwanted, unused prescription drugs. 
Early in February, a leading national chain pharmacy announced 
that they would place drug kiosks in 500 drugstores in 39 
states and Washington, D.C. We see that as a very positive step 
in the right direction. We look forward to the day when those 
secure kiosks are so commonplace throughout our communities 
that people can dispose of their unwanted and unused or expired 
prescriptions frequently, safely, and conveniently.
    DEA will also continue our national take-back initiative 
with national events every approximately six months. During our 
September 2015 take-back, from 5,202 collection sites we 
collected more than 370 tons of unwanted, unused prescription 
drugs. Our next national take-back event is April 30th, about 
five weeks from now.
    For almost 20 years, I have had the privilege of working 
with the brave men and women of the DEA, along with our 
Federal, state, local, and foreign counterparts, investigating 
some of the most entrenched domestic and foreign criminal 
organizations threatening our country. This current drug 
threat, the subject of this hearing, is unlike anything I have 
ever seen.
    We at the DEA will do whatever it takes to fight this 
epidemic. We will attack supply, we will work to reduce demand, 
we will do our best to empower communities.
    I thank you for the opportunity to appear before you and 
look forward to answering any questions you have.
    [Prepared statement of Mr. Milione follows:]
    
    
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    Mr. Mica. Thank you, and we will get to questions after all 
of our witnesses.
    Let me recognize Ms. Enomoto. She is the Deputy 
Administrator for the Substance Abuse and Mental Health 
Services Administration at the Department of Health and Human 
Services.
    Welcome, and you are recognized.

                   STATEMENT OF KANA ENOMOTO

    Ms. Enomoto. Thank you. Good morning, Acting Chairman Mica. 
Good morning, Ranking Member Cummings and members of the 
committee. My name is Kana Enomoto, and I am SAMHSA's Principal 
Deputy Administrator, and I am honored to have been delegated 
the duties and authorities of the SAMHSA Administrator by 
Secretary Burwell.
    Many thanks to all of you for your leadership to raise 
awareness and catalyze action on the nation's opioid crisis. As 
you have noted, this truly is a matter of life or death.
    I know prescription drugs, heroin, and illicit fentanyl 
have had devastating consequences in many of your districts. I 
know this because SAMHSA partners with leaders in your 
communities as they implement life-saving programs for 
individuals with or at risk for opioid use disorders.
    For example, the State of Maryland and the City of 
Baltimore are addressing high rates of opioid-related emergency 
room visits and utilizing peers to recruit patients into 
medication-assisted treatment. In Florida, SAMHSA's 
Prescription Drug Monitoring Program Interoperability Grant 
helped get critical data to the front lines of the fight to 
prevent prescription drug misuse. In Wyoming, we have seen 
fantastic progress as the state has implemented our Strategy 
Prevention Framework using data and science to focus their 
efforts. And at the Odyssey House in Utah, with SAMHSA's help, 
it is increasing access to family-based, family-centered 
residential treatment for pregnant and parenting women with 
substance use disorders. Healthy babies are being born, and 
progress is being made.
    And while treatment admissions are increasing, overdose 
deaths have reached record numbers, and not enough people are 
getting treatment. As a nation, we will not stem the rising 
tide of this public health crisis if only two out of ten people 
with an opioid use disorder have access to the treatment they 
need. It wouldn't work for diabetes, it wouldn't work for HIV, 
and it will not work for addiction. We must join together to 
ensure that every person with an opioid use disorder who seeks 
treatment finds an open door.
    Toward this end, SAMHSA is proud to support the President's 
National Drug Control Strategy and Secretary Burwell's Opioid 
Initiative. In HHS, the Secretary's initiative focuses on three 
high-impact areas: changing prescribing behavior, increasing 
access to naloxone, and expanding the use of medication-
assisted treatment and recovery.
    It is simple: to prevent prescription opioid misuse, we 
need to reduce the number of pills in people's medicine 
cabinets. SAMHSA will encourage the use of CDC's guidelines for 
prescribing opioids in order to chart a safer, more effective 
course to management of chronic pain.
    We know the vast majority of physicians and other 
prescribers are dedicated, well-trained professionals committed 
to their patients' good health. We must give them the tools 
they need to deliver high-quality, safe and effective care.
    Since 2007, SAMHSA has provided continuing education to 
over 72,000 primary care physicians, dentists, and other health 
care professionals. We also reach local communities through 
Drug-Free Community Grants we administer together with ONDCP. 
These coalitions do yeoman's work to create environments that 
promote health and prevent drug use, including the misuse of 
prescription drugs, heroin, and illicit fentanyl.
    The second aim of the Secretary's initiative is increasing 
access to naloxone. As you have noted, naloxone can reverse a 
potentially fatal opioid overdose, but it only works if it is 
there when you need it. In SAMHSA's Overdose Prevention Course 
for Prescribers and Pharmacists, one of the targeted strategies 
we promote is co-prescribing of naloxone with opioid 
analgesics, particularly for patients with high risk of 
overdose. We also let states know that they may use their 
SAMHSA block grant funds to purchase and disseminate naloxone, 
as well as for training and education on its use, and soon we 
will be issuing a funding announcement for states to purchase 
naloxone and equip and train first responders. We appreciate 
Congress' strong support in this area.
    The third area of the Secretary's opioid initiative is 
expanding the use of medication-assisted treatment. Research 
tells us that medications, along with behavioral therapies and 
recovery supports, are important components of an evidence-
based treatment plan. However, resources are limited, and MAT 
remains significantly underutilized.
    As Director Botticelli noted, the President's Fiscal Year 
2017 budget requests $1 billion in new mandatory funding which 
would focus on the continuum of prevention, treatment, and 
recovery services, expanding the use of MAT, expanding the use 
of telehealth, and building the substance abuse treatment 
workforce. The initiative also includes, importantly, $30 
million in new mandatory funding to evaluate the effectiveness 
of medication-assisted treatment programs under different real-
world situations.
    On the discretionary side, SAMHSA proposes to maintain and 
grow investments made by Congress in 2015 and 2016. We are 
providing funding for 23 more states to expand treatment 
capacity for MAT, and we are preserving the behavioral health 
safety net by maintaining increases to the Substance Abuse 
Prevention and Treatment Block Grant.
    We have also worked with ONDCP and DOJ to clarify and 
enhance the connection between MAT and the criminal justice 
system. Drug courts are the most successful criminal justice 
response to addiction in our nation's history. This year we 
will prioritize treatment that is less susceptible to abuse and 
diversion and expand our technical assistance to ensure that 
evidence-based practices are fully implemented.
    With all this new care, who is there to provide it? We must 
ensure that the substance use workforce is sufficient to meet 
growing demand. As such, we are requesting $10 million for a 
buprenorphine prescribing authority demonstration to test the 
safety and effectiveness of expanding buprenorphine prescribing 
to nurses and physician assistants, and the Administration has 
requested $20 million for our colleagues at the Health 
Resources and Services Administration to grow the addictions 
workforce via the National Health Service Corps.
    Finally, SAMHSA is proposing a new regulation to increase 
the patient limit for physicians who have a waiver to prescribe 
buprenorphine.
    Members of the committee, thank you for convening this 
important hearing. I look forward to working with you to ensure 
that we are using our investments strategically, responsibly, 
and effectively to deliver the greatest possible impact for the 
American people.
    [Prepared statement of Ms. Enomoto follows:]
    
    
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    Mr. Mica. Thank you.
    We will now recognize Dr. Wen, who is with the Baltimore 
Health Department, the City Health Department.
    Welcome, and you are recognized.

          STATEMENT OF LEANA S. WEN, M.D., MSC., FAAEM

    Dr. Wen. Thank you very much, Chairman Mica and Ranking 
Member Cummings, and members of the committee. Thank you for 
calling this important hearing. I am here as an emergency 
physician who has treated hundreds of patients with opioid 
addiction. I am also here as the Health Commissioner in 
Baltimore, where I have declared the epidemic to be a public 
health emergency.
    Last year, Baltimore launched our three-pronged approach to 
fight this on the front lines. First, we have to save lives. 
That is why we are making the opioid antidote, naloxone, 
available to every single resident. In the ER, I have given 
naloxone to patients who are about to die and have watched them 
revive within seconds. Naloxone should be part of everyone's 
medicine cabinet. In 2015, we trained 8,000 people in the city 
on how to use it, including our police officers, who within six 
months have saved 21 citizens. In October, I issued a blanket 
prescription for naloxone to all 620,000 residents of 
Baltimore.
    But saving a life without connecting to treatment is just 
treading water. So our second approach is to increase on-demand 
addiction treatment. We believe that treating addiction as a 
crime is unscientific, inhumane, and ineffective. So our city's 
criminal justice and public health teams have partnered on drug 
treatment courts and on a pilot project where individuals 
caught with small amounts of drugs will be offered treatment 
instead of incarceration.
    The science is clear: addiction recovery requires 
medication-assisted treatment, psychosocial support, and 
wraparound services. Yet nationwide, only 11 percent of 
patients with addiction get the treatment that they need. 
Imagine if only one in ten cancer patients could get 
chemotherapy. Yet my patients come to the ER seeking addiction 
treatment, and I tell them that they must wait weeks or months. 
I have had patients overdose and die while they are waiting 
because we failed to get them help at the time that they asked.
    In Baltimore, we have started a 24/7 phone hotline that 
includes immediate access to an addiction counselor or social 
worker, and a direct connection to make an appointment. Our 
phone line was started less than six months ago and already 
receives about 1,000 calls per week, including from police 
officers and family members asking for resources.
    We have ample evidence to show what works for treating 
addiction, but we are nowhere near getting everyone treated, 
and we are still very limited, especially when it comes to 
wraparound services. Take housing. Every year we estimate that 
there are 18,000 turnaways for less than 100 recovery beds. 
Addiction treatment reduces crime and saves society money. We 
should invest in treating today rather than spending it on 
incarcerating tomorrow.
    Our third approach is to reduce addiction through educating 
the public and doctors. We launched a campaign to reduce stigma 
and encourage treatment at DontDie.org that also includes bus 
and billboard ads and targeted outreach at libraries, churches, 
and bars. Dontdie.org now has the first-of-its-kind naloxone 
training so that anyone who watches a short 10-minute video can 
print out my prescription to get naloxone.
    We are also targeting education to physicians. As the 
Administrator said, doctors want to do the right thing. We have 
to give them the tools to do so. So I have sent best practice 
letters to every doctor in Baltimore to set prescribing 
guidelines and require the co-prescribing of naloxone with 
opioids.
    We are also alerting doctors to emerging trends. 
Nationwide, one in three fatal overdoses from opioids involves 
benzodiazepines like Valium and Xanax, yet physicians routinely 
prescribe this dangerous combination together. Last month, I 
co-led a petition to the FDA with 40 other city and state 
health officials to call for a black-box warning, which is the 
FDA's strongest risk communication, on opioids and 
benzodiazepines.
    There is a lot that Baltimore has done to emerge as a model 
of overdose response and addiction recovery, but we need 
further support from Congress, including expanding funding for 
on-demand treatment and wraparound services like housing and 
peer recovery specialists; directly funding local 
jurisdictions, those of us on the front lines with highest 
need; removing regulatory barriers like the cap on 
buprenorphine and IND exclusion; regulating the escalating 
price of naloxone; and funding a national stigma reduction 
campaign.
    The epidemic of opioid addiction is a national public 
health emergency, and we know that addiction does not 
discriminate. We are all in this together. So I thank you for 
calling this hearing and look forward to answering your 
questions.
    [Prepared statement of Dr. Wen follows:]
    
    
    
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    Mr. Mica. Thank you.
    You are not allowed, unfortunately, in these committee 
hearings, to express your opinion or your approval or 
disapproval. I just have to let the public know that. Only your 
representatives can do that.
    Please now to welcome and recognize from my district, the 
Mayor of Orange County, Florida. Some of you have asked where 
that is. Of course, Orlando is the principal city, and we have 
our mayor who started a heroin task force when we were hit with 
this epidemic.
    She is also accompanied by our--but they are not going to 
testify. George Ralls, raise your hand, who is our Public 
Health Director. David Siegal, who lost a daughter to a drug 
overdose and has turned that tragedy into a concerted public 
effort. And Karen Diebold Sessions is the former City 
Commissioner from my fair city of Winter Park.
    So I welcome the guests accompanying our mayor and 
recognize Mayor Jacobs. Welcome.

                   STATEMENT OF TERESA JACOBS

    Ms. Jacobs. Thank you, Mr. Chairman. Chairman Mica, Ranking 
Member Cummings, members of the committee, thank you for 
calling this hearing, and thank you for this opportunity to 
discuss a serious threat facing our cities and counties across 
the country.
    As Mayor of Orange County, Florida, allow me to share a few 
statistics. But first, Mr. Chairman, I would like to ask that a 
statement from one of our constituents who you just introduced, 
Mr. David Siegal, be added to the record. Mr. Siegal is 
President of Victoria's Voice Foundation, and he is father of 
Victoria Siegal, who died last summer from a drug overdose at 
the young age of 18.
    Mr. Mica. Without objection, so ordered.
    Ms. Jacobs. Thank you.
    Many of you know Orange County as the home to Orlando and 
12 other municipalities. We have a population of 1.2 million 
people. Last year we broke a national record for tourism, 
entertaining more than 62 million visitors.
    But many of you probably don't know that last year we also 
lost 84 lives to heroin overdoses, and probably nobody will 
know that that was a 600 percent increase since 2011.
    Four years ago, like so many other counties across the 
country, we were fighting pill mills. We worked hard. We 
adopted tough regulations at a local and state level. We 
provided resources to break opiate addiction, and we were 
pretty successful.
    Today, the front line has moved but the battle is tougher 
than ever. Too many prescription drug abusers have found an 
inexpensive and often deadly alternative, heroin. Despite 
Central Florida's strong economy and our extraordinary quality 
of life, heroin has absolutely exploded. Last year, 
approximately 2,000 heroin users moved through our county jail. 
Many of these arrests, in fact most of them, were not heroin 
possession, but they were other related offenses resulting from 
the debilitating effect that heroin use has on its users.
    Tragically, in 2015 we housed 100 expectant mothers 
addicted to opioids and heroin.
    Quite frankly, our county jail has become the treatment 
center of last resort for so many people. Yet too many people 
still don't realize the severe threat that heroin poses not 
only to the lives of the addicts but to the fabric of our 
community.
    For the good of our citizens and our whole community, we 
are fighting, and we are fighting hard. Last summer I convened 
the Orange County Heroin Task Force, and I asked our Sheriff 
Demings to co-chair the effort. We have 22 high-ranking 
officials who served on the task force, from our chief judge to 
our state attorney, to medical professionals in all of our 
hospitals to our superintendent of public schools to 
representatives of our three colleges. I commend the effort of 
the Orange County Sheriff's Office and the Orlando Police 
Department, as well as our Metropolitan Bureau of 
Investigation, because since we formed this task force through 
collaboration and dedication, they have arrested more than 370 
heroin-related incidents just in six months, 370.
    Last week our task force concluded its efforts, and it made 
37 recommendations. Similar to the comments that you have heard 
from my colleagues here, we recommend bond increases for 
trafficking, and we recommend media and social media campaigns 
warning about the deadly nature of heroin.
    Heroin is a serial killer in our community, and so few 
people recognize it for that.
    Coordinated efforts to avoid fatal overdoses by demanding 
access to naloxone. I commend the work of my colleague here, 
Dr. Wen. Congratulations. Naloxone, as you have heard, is a 
life-saving drug that is used in severe overdose situations; 
and also to look for new opportunities to fight addiction by 
coupling detox at our jail with addiction treatment programs 
using the drug Vivitrol. Vivitrol is a long-acting opioid 
antidote.
    In addition to moving forward with the implementation of 
these recommendations, we are working with our partners at the 
National Association of Counties, which has teamed up 
nationally with the National League of Cities. We are working 
with HIDTA, and we are working with other organizations to 
implement the best practices.
    We know there is no single solution, but there are some 
universal effective approaches. Enforcement is absolutely 
critical to combatting heroin use. In keeping with what we 
learned with pill mills, we must be tireless in educating 
people that addiction is an illness. It is an illness that 
requires serious medical treatment.
    From law enforcement to families, the life-saving drug 
naloxone needs to be more accessible without a prescription and 
available at a reasonable cost.
    And one final point. I want you to know that in Orange 
County, through our collaborative effort, we are committed to 
doing everything we can with the resources that we have. Here 
is where we need your help.
    Help stop the influx of drugs across the border. We need 
you to continue to expand your efforts to stop these deadly 
drugs before they enter our communities. Local treatment and 
law enforcement will do their part, but the Federal Government 
must do everything possible to keep this plague from our shores 
and our communities.
    Help us treat more addicts. With a regional population of 
2.5 million, we have only 26 beds for the uninsured, 26 beds, 
and yet 62 percent of the overdoses in our community are among 
the uninsured.
    And help us raise awareness so that more people will choose 
not to try this deadly drug in the first place.
    To end this crisis and to save lives, we all need to be 
engaged.
    I thank you for your attention to this critical issue, I 
thank you for your leadership, and I thank you for your service 
to our country.
    [Prepared statement of Ms. Jacobs follows:]
    
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    Mr. Mica. I thank you, Mayor Jacobs, for participating 
today, and all of our witnesses.
    Now we will turn to questions, and I will lead off.
    The scope of the problem that we are facing, I don't think 
people are comprehending this. From 16,000, when we chaired the 
Criminal Justice Policy Subcommittee, 16,000 to 47,000. We are 
approaching 50,000 in one year. Heroin is only 20 percent of 
that, 10,000 deaths. When are the 2015 figures coming out?
    Mr. Botticelli. We hope to have the 2015 figures by the end 
of the year. But part of what ----
    Mr. Mica. By the end of the year. We can't get them until 
the end of the year?
    Mr. Botticelli. Well, unfortunately, a part of the issue is 
that these data get reported from county ----
    Mr. Mica. And 47,000 from 2014, and I am afraid it is going 
to be off the charts. That does not count, folks, that does not 
count--there are 35,000 automobile deaths in the United States. 
Half of those, people have some kind of substance in their 
system when they are killing themselves. It used to be that 
teens, the biggest killer of teens was automobile accidents. 
Now it is drugs. Isn't that right?
    Mr. Botticelli. That is correct.
    Mr. Mica. Yes. It is killing our youth. We haven't even 
gotten into firearms. Firearms are the tool of the drug trade, 
and they have illegal weapons that they are using to commit 
robberies, mayhem. Again, it is an astounding number. We 
haven't killed this many in multiple-year wars as we are 
killing in one year.
    We will lose, guys, a half-a-million people in a decade at 
the rate we are going, or more. Every family has been affected 
by it, and now it is just a slaughter out of control.
    Now, we have lots of responsibility, and I am all for 
treatment. Treatment is at the end of the process. They have 
already been addicted. We have got to stop this stuff at our 
borders.
    I sat with our police chief. I sat with our HIDTA people. 
We put in place the HIDTA. I had to do that by legislation a 
number of years ago because they play political games with even 
the creation of high-intensity drug traffic areas, but we did 
it years ago. And here we are back where we--we are far beyond 
where we ever were then.
    This is out of our newspaper from just a few days ago, six 
pounds of heroin at OIA. They are bringing this deadly, these 
deadly substances, and it is not just heroin.
    Mexico, you talked about Mexico, and I said it is not just 
illegals coming across the border, but they are coming across 
with drugs. Isn't that right, Mr. Milione?
    Mr. Milione. Yes, that is correct.
    Mr. Mica. I sat with the HIDTA folks and saw the pattern. 
These are cartels. They are organized.
    What I just heard--did you all see what's his name, El 
Chapo? He said he came across the border, it was like a sieve. 
That was the major drug dealer, the most sought-after drug 
dealer, and he transits the border like it is some kind of a 
holiday visit to the United States. So somehow we have to get a 
handle on this.
    I just looked up the prosecutions. The prosecutions, when 
we looked at trafficking with illegal weapons, is down, and 
prosecution--I talked to some of my DEA folks; they won't tell 
you this on the record. They are not going to say this, but it 
is very hard to make cases on these guys. A lot of cases are 
dropped on the traffickers. These are dealers in death.
    You are aware, sir, that we have prosecutions. You build 
the case, you give them to the district, and I am going to 
demand a meeting with my U.S. Attorney in the central district 
and see why the prosecutions are down, but they are down. Did 
you know that?
    Mr. Milione. I have seen that they are down. However, I 
have also seen that sentences have gone up, and I have seen 
that we are focused on the ----
    Mr. Mica. But they are telling me it is hard sometimes to 
make a case. These are murderers, and we can't stop them. They 
are bringing deadly substances in, and the trafficking pattern, 
too, trying to find out--some is coming through the U.S. mail. 
I will say they told me the mail is starting to crack down. It 
gets across the border, and then they transit it in the United 
States like they are sending some kind of a gift package. Is 
that correct, sir?
    Mr. Milione. There are many ways that it comes across into 
----
    Mr. Mica. Through packaging services? Who are also intent 
on getting the package there on time, have to get the deadly 
drugs there on time.
    So we have to look at every avenue. These guys are using 
the border. I was in Mexico years ago. I don't know if you came 
with me on that trip, Mr. Cummings, but we warned them.
    Now, you can do a DEA signature of heroin and cocaine, 
can't you?
    Mr. Milione. Yes.
    Mr. Mica. And you have looked at the stuff coming across. 
Where is it coming from?
    Mr. Milione. Mexico.
    Mr. Mica. And 15 years ago it was all Colombia, wasn't it?
    Mr. Milione. It still comes from Colombia ----
    Mr. Mica. But there was very little. I forget, it was black 
heroin or something, coming out of Mexico. But Mexico was like 
the amateur hour in this game. Now they have become the pros, 
and they are dumping this stuff in our communities. By the time 
we get to treatment, it is way too late, and it is kind of sad. 
I mean, I am all for the naloxone and having that with our 
first responders, where it should be. But I told you the story 
one police chief told me, three times in one week a student, 
they had to revive him.
    We have to change our prescription drugs in the cabinet to 
naloxone so people are reviving their surviving kids and 
family.
    Where is the chart? Now, we have done a good job. Put the 
chart up on heroin versus--okay. Look at the opioid drugs at 
the top, and heroin. We have actually brought that down a 
little bit when it went up. So we have been somewhat effective 
on cracking down on prescription drugs. But look at what is 
happening with heroin; it is off the charts. It is being 
replaced by a cheaper and more available drug.
    They told me, sir, and you verify this from DEA, they said 
the price is down.
    Mr. Milione. That is correct.
    Mr. Mica. Yes, it is down. When is the price down when the 
supply is all over the place?
    So it is not just Baltimore. It is not Washington, D.C. It 
is not Orange County. It is New Hampshire, Kentucky, every 
state in the United States we are seeing this. Aren't we, sir?
    Mr. Milione. That is correct.
    Mr. Mica. Yes. So again, I get a little hot to trot over 
this, but our job is protecting the citizens of the United 
States, primarily national defense. We saw what happened with a 
terrorist attack in Brussels. We are being attacked in our 
streets, in our schools, in our families.
    I mean, again, they killed today 40 people. They killed 
50,000 people in the latest statistics we have, which are more 
than a year old. I know tough enforcement works. It worked with 
Mayor Giuliani in New York. They stopped a lot of the crime, 
the drugs, with zero tolerance. Now we have Just Say Maybe, and 
I just announced the new Federal policy, Just Say Okay instead 
of Just Say No.
    Doesn't it have to start, ONDCP Director, with families and 
communities?
    Mr. Botticelli. I would agree that part of our strategy is 
to focus on primary prevention, that we know that by delaying 
when people use, particularly kids use alcohol, marijuana or 
tobacco, we substantially increase the fact that they are going 
to have a life free of drug ----
    Mr. Mica. And were you aware that high school seniors now 
abuse marijuana more than cigarettes?
    Mr. Botticelli. Yes, I have ----
    Mr. Mica. That is great commentary on our success in 
combatting this with our youth.
    I would like to yield now to Mr. Clay.
    Mr. Clay. Thank you, Mr. Chair. And thank you and the 
ranking member for your comments on the heroin and opioid 
epidemic.
    Let me start with Dr. Wen, and I want to commend you for 
the groundbreaking work that you are doing in Baltimore. You 
are not just talking the talk when it comes to speaking out 
about ending the stigma related to addiction, you are walking 
the walk when it comes to expanding access to treatment for 
your residents.
    In your testimony, you discuss your efforts to provide 
treatment on-demand on a 24/7 basis for Baltimore residents. I 
would imagine that ensuring someone can access treatment as 
soon as they present themselves as willing to do so is a 
powerful tool for making sure that they actually begin 
treatment, and that your approach will save hundreds or 
thousands of lives as a result.
    Today, one of the barriers to treatment is the Medicaid IMD 
exclusion which prohibits Medicaid from paying for community-
based, non-hospital inpatient residential treatment in a 
facility of 60 or more beds. Unfortunately, the IMD exclusion 
means that if you are on Medicaid, you are treated like a 
second-class citizen, unable to access what may be the 
appropriate care for your substance use disorder.
    For the residents you are responsible for in Baltimore, do 
you agree that they should have access to the medically 
appropriate care they need whether or not they are on Medicaid?
    Dr. Wen. Thank you, Congressman Clay. I absolutely agree, 
and I thank you for acknowledging that addiction is a disease. 
If a patient came to the hospital with a heart attack, we would 
never say wait three weeks and maybe if there is a bed 
available we will get you in then. The same thing should apply, 
and the IMD exclusion is not based on evidence. We desperately 
need residential substance use disorder treatments, and 
removing the waiver on the Federal level will allow us to 
increase the ability to treat all of our patients regardless of 
their insurance status.
    Mr. Clay. And that would put those patients on equal 
footing with everyone else so that we don't seem to be 
discriminating based on level of care.
    Dr. Wen. Yes, and it would also increase more providers 
whom we desperately need at the time, when our treatment 
capacity is just 1 in 10 nationwide.
    Mr. Clay. Yes, and let me thank you for appearing here 
today.
    Every city and county, Mayor Jacobs, should have a health 
commissioner raising the alarm as forcefully and as effectively 
as Dr. Wen is, and hopefully Orange County has that, and 
Congress will finally heed the call and do something 
significant about the opioid epidemic because it seems as 
though we as a country have come together and have decided this 
is a national emergency. We should sit up and pay attention. So 
let me thank you, too, Mayor Jacobs, for being here and for 
what you have done to raise the level of awareness in your 
community.
    Let me go to Ms. Enomoto. You testified about the work that 
SAMHSA does. Can you describe that work in additional detail? 
You testified that of the $1 billion in mandatory funding, 
SAMHSA proposes $920 million over two years to support 
cooperative agreements with states to expand access to 
treatment for opioid use disorders. Why is it important that 
SAMHSA receive these funds?
    Ms. Enomoto. As you have so articulately stated, the need 
far exceeds the capacity of our treatment system today, and we 
believe that every person who has an opioid use disorder who 
seeks treatment, just as Dr. Wen has done, 24-hour access to 
treatment, that should be the standard of care for everyone. 
With this President's proposal for $920 million to be infused 
across two years, we think that would super-charge the capacity 
of our states, of our communities with the greatest need so 
that individuals who are seeking treatment would have an open 
door window when they are ready to get that treatment, because, 
as we know, the window can be small for some people, and we 
need to take advantage of that opportunity when they come 
knocking.
    Mr. Clay. Thank you so much for your response.
    Mr. Chairman, I yield back.
    Mr. Mica. I thank the gentleman.
    Let me recognize Mr. Turner from Ohio.
    Mr. Turner. Mr. Chairman, thank you for holding this 
hearing. Mr. Cummings, thank you for your comments. This is 
certainly a scourge that is affecting everyone.
    In my community, I was touring a brand-new hospital, 
Medical Hospital, and was taken back to a conference room to 
meet with the leadership of the brand-new hospital and asked 
them what is their most significant challenge, and they told me 
babies being born addicted to opiates. A brand-new hospital. 
Out of all the Federal regulations, of all the funding issues 
that they would have, you would not have thought that the 
biggest challenge a brand-new hospital was having was babies 
addicted to opiates.
    Mr. Botticelli, thank you for all of your efforts. I 
appreciate your leadership. I think you are doing a great job 
and appreciate your advice to Congress as to how we might be 
able to formulate our to-do list.
    Mayor, I am a former mayor. Thank you. You live in your to-
do list, so thank you for your representation of the community.
    Ms. Enomoto, I would like to put up a few slides that come 
from your Fiscal Year 2017 congressional budget justification, 
the first one being a quote that says that approximately 1 
million Americans need but do not access treatment for an 
opioid abuse disorder. Again, these slides come from your 
Fiscal Year 2017 congressional budget justification.
    Ms. Enomoto, when we hold these hearings, we don't do them 
just merely for increased community awareness. We do them for a 
congressional to-do list, but also for an agency to-do list. So 
that is why I am turning to your budget justification. We know 
1 million Americans need but do not access treatment.
    The next slide.
    For example, more than 80 percent of state prisoners, 72 
percent of Federal prisoners, and 82 percent of jail inmates 
meet the criteria for having either a mental health or 
substance abuse issue. Those are staggering numbers, 80 percent 
of state prisoners, 72 percent of Federal, 82 percent of jail 
inmates, a mental or substance use issue.
    The next slide.
    Studies show--again, your budget justification, Ms. 
Enomoto. Studies show that only 8.3 percent of individuals 
involved with the criminal justice system who are in need of 
substance use disorder treatment receive it as part of their 
justice system supervision.
    Ms. Enomoto, after I left that hospital, I then began the 
quest of trying to find out in my community where are the 
resources, how can we find resources to provide treatment. In 
our criminal justice system, in our community, I was introduced 
to people who were struggling to try to provide treatment to 
those who are incarcerated, and then I was introduced to a 
prohibition in your agency's funding that prevents it from 
being utilized for those people who are incarcerated.
    So in your very agency's documents, it indicates that the 
problem--we have a self-sorting, right? We have people who 
present themselves in the criminal justice system with this 
problem. We have an understanding that without treatment, they 
will not be able to transition and we will, as our chairman has 
said, once again be providing assistance to them in either an 
overdose situation or see them again in the criminal justice 
system. And yet in your funding, there is an exclusion that 
prevents communities from using dollars that they receive from 
you to actually address that for people who are incarcerated.
    To Mr. Clay's comments, in Medicare and Medicaid, there are 
also similar exclusions that prevent people who are entitled to 
receive their treatment from receiving that treatment.
    I have a bill, H.R. 4076, that would eliminate those 
restrictions, that would say this is funding that is already 
there, it is not an increase in funding, although I am for 
increasing the funding, but these are funds that are already 
there that would just allow those people to receive it.
    Now, Ms. Enomoto, your agency, by rule, could eliminate 
that restriction. Why don't you?
    Ms. Enomoto. You know, I think the issue that you have 
pointed out is clearly so important to communities all across 
the country. We know that people in our jails, in our prisons 
are over-represented with mental illnesses and substance use 
disorders, and getting them adequate care is absolutely 
important for this nation.
    At the same time, we strongly support approaches such as 
drug courts, diversion, early diversion, as well as reentry 
programs, and we have made significant investments to ensure 
that evidence-based ----
    Mr. Turner. Ms. Enomoto, I appreciate all that. But before 
I completely lose my time, could you please tell me why your 
agency won't waive the requirement and allow your funding to be 
able to be utilized for those who are incarcerated who need it 
most?
    Ms. Enomoto. You know, I want to make sure that I get you 
an accurate answer to that, so I am happy to follow up further 
either for the record or in person.
    Mr. Turner. Excellent, and I do appreciate your hard work. 
I know you are trying to assist us also, and I would encourage 
members to please co-sponsor 4076, because it would help the 
agency have the momentum to waive the prohibition themselves. 
Thank you.
    Mr. Mica. Thank you, Mr. Turner.
    I now recognize our ranking member, Mr. Cummings.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    Dr. Wen, again, I want to thank you for being here. At the 
beginning of today's hearing we put into the record an op-ed 
from the Baltimore Sun. ``The Effects of Opioid Over-
Prescription Are Evident in the Emergency Room'' it is 
entitled. The author explains that one reason we are now seeing 
such a huge increase in heroin overdoses is because legal 
prescription painkillers are being over-prescribed. She says, 
and I quote, ``Once a patient is hooked, he or she often turns 
to street drugs, which can be easier and less expensive to 
acquire.'' I think you and just about everybody else has said 
that this morning.
    I want to be clear: I am not trying to blame the doctors. 
They have a very difficult job. But, Dr. Wen, do you agree that 
one reason we are seeing an uptick in heroin overdoses is 
because of the abuse of prescription opioids? Yes or no?
    Dr. Wen. Yes.
    Mr. Cummings. The op-ed has a startling stat. It says, and 
I quote, ``With only 5 percent of the world's population, we 
are consuming over 80 percent of the world's painkillers.'' The 
op-ed explains that drug companies are actively promoting this 
problem. It says, and I quote, ``Prescriptions for opioids have 
been traditionally limited to cancer pain and comfort measures, 
but in the mid-'90s drug companies began marketing these pills 
as the solution to a new plethora of ailments. In their efforts 
to expand the market, producers understated and willfully 
ignored the powerful addictive properties of their drugs.''
    Now, that sounds like drug companies are almost like drug 
pushers. The op-ed cites several examples. For instance, it 
says this, and I quote, ``The promotion of OxyContin by Purdue 
Pharma was the most aggressive marketing of a Schedule II drug 
ever undertaken by a pharmaceutical company.''
    Dr. Wen, this is big business. How in the world do we 
combat this massive and aggressive effort by drug companies 
when they are making billions? Go ahead, I am listening.
    Dr. Wen. Congressman Cummings, thank you for asking that 
question. I appreciate your saying that doctors want to do the 
right thing. We want to do the right thing. And actually, when 
we talk to our communities, our youth also recognize--if you 
ask our youth in schools is heroin good or bad, they are going 
to say that heroin is bad. But we have a culture of excess. We 
have, because of the aggressive marketing of drug companies, we 
have this expectation that there should be a pill prescribed 
for every pain. This is what we have to change.
    So we have to make sure that doctors get the resources, the 
tools that they need, including prescription drug monitoring 
programs, including guidelines that can help with safe 
prescribing. But also we need the resources when we are in the 
ER. We need the resources to connect our patients to treatment, 
because otherwise we also feel frustrated knowing that our 
patients need care but we can't deliver it to them.
    Mr. Cummings. Now, you talked about some guidance you sent 
out. Does that guidance also include using painkillers that are 
not so addictive or not addictive at all?
    Dr. Wen. Yes. Our guidelines include three things. The 
first is the necessity of co-prescribing naloxone with any 
opioids, because somebody could die from this, so they should 
get that as well. The second is to be careful about the opioid 
medications knowing that they are not first-line medications. 
They should only be prescribed for severe pain. And the third 
is for the danger of benzodiazepines, which are also killing 
our residents.
    Mr. Cummings. So the op-ed goes on to explain why drug 
companies are doing this, and that is no surprise. It is about 
profit. It says, ``The Sackler family, which owns Purdue 
Pharma, achieved a place on the Forbes 2015 list of America's 
Wealthiest Families. The Sacklers, the richest newcomers to the 
list, are worth an estimated $14 billion.'' That is appalling. 
I call that blood money, because people are dying big-time.
    I want to go back to something, Ms. Enomoto, and maybe some 
of you others can answer this. Yesterday I was talking to a 
reporter and he was saying that, Cummings, aren't you concerned 
that with even more money being requested for treatment and to 
deal with this problem, because there are so many more people 
getting into opioids and heroin, that money will be spread so 
thin that it will not have the kind of impact that you are 
hoping for?
    Mr. Botticelli?
    Mr. Botticelli. To your point, I think we have to have a 
comprehensive response to this. First and foremost, we need to 
rein in prescribing behavior in the United States. The Centers 
for Disease Control just put out recommendations last week that 
closely follow the guidance that Dr. Wen put out, because that 
is where we know the significant driver is to the problem.
    But we also know that despite all of our efforts, we still 
have too many people overdosing and dying, largely because they 
can't access treatment programs when they need treatment 
programs, and this is why the President has put forward a 
significant proposal to expand treatment capacity in the United 
States.
    I hear this wherever I go. I just did a town hall forum in 
Toledo, Ohio where the sheriff--I asked the sheriff what one 
single thing the Federal Government should be doing to address 
this opioid epidemic, and he didn't say we need more police 
officers. He said we need more treatment capacity because we 
are arresting too many people who haven't been able to access 
treatment.
    So we took a careful look at how many people need treatment 
and tried to adjust the proposal to really focus on making sure 
that as many people as possible had access to treatment when 
they needed it.
    Mr. Cummings. Just one more question. Dr. Wen, what 
happened? In other words, this was not a problem before, not as 
much of a problem, but then something happened. Can you tell me 
what happened? I mean, the numbers that the Chairman cited--and 
I realize that people are moving from the opioids to the 
heroin, but what happened with regard to the opioids to get so 
many people on them, and then for them to move to the heroin? 
Do you know?
    Dr. Wen. My understanding is that there was aggressive 
marketing by drug companies, so that the pain scale is 
something that is asked of every patient all the time in the 
course of their hospital stay, but the goal should not be 
getting to pain free. The goal should be appropriate treatment, 
yet this is the expectation that is placed on patients and on 
doctors. So doctors are put in a hard place, too, of satisfying 
those requirements when all of that was done for drug 
companies' benefit.
    Mr. Cummings. So doctors have a tough time. In other words, 
the patient keeps coming in, and the pain could be at a 2, 
being the mildest. The patient has a 2, and then he or she 
comes in and doesn't tell the truth and says I am at a 9. Is 
that the kind of thing that happens?
    Dr. Wen. That definitely happens, and then doctors feel 
that they have to get the patient's pain to zero, which 
includes over-prescribing of narcotic painkillers in order to 
do so.
    Mr. Cummings. Wow.
    Mr. Botticelli, it seems like you wanted to say something.
    Mr. Botticelli. Yes. It seems like we set up an expectation 
whereby opioids are the first-line defense around pain 
therapies, and I think what we are trying to do through the 
guidance and through Dr. Wen is, particularly for people with 
chronic pain, that opioids are not the first-line defense to 
really substantially reduce pain and we have to focus on 
other--and the evidence seems to be pretty strong that people 
who are in chronic pain don't have significantly better 
functioning when they are on opioids, that we need to be 
thinking about things like exercise and diet and cognitive 
behavioral therapy and non-opioid-based therapies, particularly 
for people with chronic pain.
    Mr. Cummings. My last question. Mr. Turner asked a critical 
question, Ms. Enomoto. I guess he was talking about treatment 
in prison--is that right?--and what stops you from providing 
treatment in prison. Is that what he was asking you?
    Ms. Enomoto. Yes.
    Mr. Cummings. There is a regulation that says you can't do 
that?
    Ms. Enomoto. Yes, and I guess I want to check into that so 
I make sure I get you a complete and accurate answer.
    Mr. Cummings. Yes, please do, please do, because I am 
wondering whether it is something that Congress should be 
dealing with. I don't know whether that should be in your 
control or our control. You follow me?
    Ms. Enomoto. Yes.
    Mr. Cummings. But I would appreciate an answer as soon as 
possible.
    Do you know, Mr. Botticelli?
    Mr. Botticelli. I do not.
    Mr. Cummings. Okay. Thank you.
    Mr. Mica. I think Mr. Turner said it is in their control, 
and he has a bill to remedy that.
    Let me recognize Mr. Walker now. You are recognized, sir.
    Mr. Walker. Thank you, Mr. Chairman. I appreciate this 
hearing. I appreciate the panel of witnesses being here today.
    Mr. Botticelli, you just talked a few minutes earlier about 
treatment. I think you mentioned that that is the one thing the 
Federal Government could do. Treatment is good, and we need 
more of it, but that is reactive after the problem already 
exists. Is that fair to say?
    So let's start from the very basis. I married into the 
medical community. My wife can write prescriptions as a family 
nurse practitioner. She works in a Level I trauma center. One 
of the things that I have seen as a minister for two decades is 
the introduction of marijuana. We heard the statistic today 
already that more high school seniors now do weed instead of 
cigarettes.
    You recently discussed, I believe, the legalization of 
marijuana during a 60 Minutes profile, if I remember correctly. 
Do you believe that this could potentially lead to future drug 
use among the youth?
    Mr. Botticelli. I do, and I think the evidence is pretty 
clear, that when you are talking particularly about early drug 
use by youth, particularly alcohol, tobacco and marijuana, that 
that significantly increases the probability that people are 
going to have more significant problems later in life. In that 
episode I talked about the fact that I and the Federal 
Government do not support legalization of marijuana because I 
do believe that when you look at the data in terms of the high 
levels of marijuana use that we have among youth in the 
country, and particularly when we have an industry that is, 
quite honestly, targeting our youth with things like funny 
cartoon characters and edibles, that we are in for more 
significant problems in the United States.
    Mr. Walker. Part of our pop culture now, you could say.
    Mr. Botticelli. I hear that we are replicating kind of what 
has happened in the past.
    Mr. Walker. Do we have to worry that legalizing marijuana 
could lead to more drug use in the future for not just youth 
but for people in general?
    Mr. Botticelli. We have been tracking data for the past 40 
years, and what it has shown is that when youth perceive using 
drugs, and particularly marijuana, as less risky, we often see 
an increase in drug use, and not only have we had very high and 
historically high levels of marijuana use among youth, we are 
also seeing historically low levels of perception of risk of 
marijuana use among the youth in our country.
    Mr. Walker. And just a question, and then I will let you 
go, really quick. I don't want to use all my time here. Does 
anybody disagree with the findings of Mr. Botticelli? Just for 
the record, does everybody agree that this marijuana usage is 
the beginning of what potentially could be a greater problem? 
So just for the record, I am seeing everybody say yes, except 
for Dr. Wen.
    Dr. Wen, you have a different opinion?
    Dr. Wen. It is one contributor. Another contributor is our 
prescription drug crisis. Eighty percent of people who start 
using heroin first start using prescription painkillers.
    Mr. Walker. True, but most high school students are not 
going to the doctor and getting prescribed major types of pain 
relievers. Sometimes their first introduction is through 
purchasing marijuana. Is that fair to say?
    Dr. Wen. Yes, and also through misusing other prescription 
drugs.
    Mr. Walker. A nice transition. I do want to come to that. I 
want to make sure that we are not painting the doctors as the 
bad guys here today. In counseling some of the people who have 
gone through some of this, as good people as they are, they 
have learned to become master manipulators as far as going into 
the various doctors' offices and the emergency rooms. Mr. 
Cummings talked about the different pain levels, sometimes the 
threshold. Obviously, there are also scoring systems by 
customer satisfaction indexes that hospitals have to worry 
about.
    Dr. Wen, would you speak to that? Is that something that is 
fair to say?
    Dr. Wen. Most doctors are--by far, the majority of doctors 
are trying to do the right thing. And similarly, most patients 
are just trying to get the care that they want. Unfortunately, 
patients have the expectation that they have to be pain free. 
But if I fall down and bruise my knee, I will have some pain. 
Getting opioids is not the right answer.
    Mr. Walker. I agree, and I love what you said, a pill for 
every pain. We have to get away from that culture, as you 
mentioned a little earlier.
    We have seen kind of a plateau even though it is a large 
number of prescriptions. We have to continue to do better, and 
I think people in the community--I think of Richard and 
Jennifer Kaffenberger in Central North Carolina. They had a son 
who had no drugs in his system except one thing. He had played 
a football game the night before. He had taken one prescription 
pain pill methadone from his grandmother's medicine cabinet, 
and it killed him. Sad story, but they have taken that message 
throughout all--they are two educators, two teachers in a 
middle school in Burlington, North Carolina, and they have 
traveled different parts of the state to bring more awareness 
of what that can do.
    So I am glad to see that that has plateaued, and we need to 
continue to stay on top of that, but I am overwhelmingly 
alarmed at the spike, and I would like to see those 2015 
numbers as soon as those are available of where we are going 
with this heroin epidemic. It is something--it is a problem for 
all of us, and we have to continue to do more.
    With that, I yield back the balance of my time. Thank you, 
Mr. Chairman.
    Mr. Mica. I thank the gentleman.
    Let me recognize now the gentle lady from New York, Mrs. 
Maloney.
    Mrs. Maloney. I thank the chairman and ranking member and 
all of the panelists for focusing on this real crisis in health 
care in our country, and it is encouraging to hear your 
testimony and the efforts that are taking place in the city, 
state, and Federal governments across our country.
    But we in Congress need to put money where our mouth is. In 
the short term, I urge my colleagues to approve the $600 
million in emergency funding which the professionals are asking 
for to combat this epidemic. From what I am hearing from Dr. 
Wen and others is if we hit the treatment level when they are 
becoming addicted to the painkillers, if you hit it then, then 
it doesn't get to another level of the opioid. So I think if we 
could fund it, that would be important.
    Now, the Senate recently acted on this crisis. They passed 
the Comprehensive Addiction and Recovery Act of 2016 to help 
prevent and treat the opioid addiction, but it does not provide 
any funding. So what good is a program, Mayor Jacobs, that 
doesn't provide any funding? Does this program help people 
suffering in your city or your area?
    Ms. Jacobs. Obviously, Congresswoman, funding is a 
necessary component of any program that we offer. If I could 
add just one thing, because we talked a lot about treatment, 
and we have mentioned that that is on the tail end, that is 
reactive.
    This country came together, it galvanized around tobacco 
use, and it profoundly changed the way our youth looked at 
that. If this country would come together, if the Congress, if 
the state and local level, if we would come together around a 
campaign of awareness about how very serious heroin use is, 
opioid addiction, painkillers, all of those things, I think we 
could make a bigger impact at that level and stem the tide of 
this. But it ----
    Mrs. Maloney. I think that is a very important point, but 
that whole tobacco effort, a lot of it stemmed access. It 
stemmed access to tobacco, and they made it more difficult to 
have access to tobacco. I know the CDC just came out with some 
guidelines that basically say don't prescribe this so easily, 
you should have a higher threshold for it, as Dr. Wen said. 
When you fall down, you hurt yourself, you bruise yourself, you 
are not always completely--you are going to have pain 
sometimes. We have to lower the expectation that no one can 
have any pain. If you have an operation, you are going to have 
pain. It is certainly better to have pain than to become 
addicted to heroin or something worse.
    But maybe some concrete guidelines on access to it, that 
maybe the scientific community should define what pain level 
should have access to opioids and that it should not be 
something that everyone should expect to be pain free the whole 
time they are in a hospital.
    How would you react to that, Dr. Wen, to having guidelines 
that really stemmed access to very severe pain levels? Because 
what we are doing is, for someone to be comfortable for a week, 
we are turning them into addicts. I mean, this is a national 
health crisis. This has got to stop, and I would say to my 
colleagues on the other side of the aisle and on my side of the 
aisle, we shouldn't leave here until we vote that $600 million 
that is needed for the program. What good is a program if you 
don't fund it? It makes it sound like we are doing something 
when we are not really doing something. What they need is the 
treatment in the field.
    But I would like to ask Dr. Wen, what do you think about 
reversing it, not just education but giving doctors help in 
knowing what threshold of pain would be necessary before this 
dangerous addictive drug is allowed?
    Dr. Wen. Congresswoman Maloney, thank you for the excellent 
point. I agree with you that doctors need further guidance and 
tools in order to make the best decisions possible for their 
patients, and having guidance would also be useful because we 
don't want to punish doctors who are doing the right thing. 
Currently, when reimbursement is tied to getting the doctor or 
getting the patient to become pain free, that becomes very 
difficult for the doctor to practice appropriately.
    But I also want to caution that there are appropriate uses 
for opioid medications for cancer pain, for surgery, so we 
don't want to eliminate that altogether.
    Mrs. Maloney. Absolutely. But direct guidelines--now, who 
would be the one to do that? The CDC? Have you looked at the 
guidelines that they just came forward with?
    Dr. Wen. I have, and the CDC guidelines we agree with and 
actually hope that they would go further in requiring the co-
prescribing of naloxone, and also in helping us to put further 
warnings, including black-box warnings, on benzodiazepines and 
opioids, which are the FDA's highest risk recommendation, to 
alert both patients and doctors.
    Mrs. Maloney. Well, my time is up. Thank you.
    Mr. Mica. Let me see. We have Mr. Buck of Colorado. You are 
recognized.
    Mr. Buck. Thank you, Mr. Chairman.
    Mr. Milione, I have a few questions for you. In 1970, 
Congress enacted the Poison Prevention Packaging Act to address 
aspirin overdose cases with children, and as part of that a 
tamper-resistant container was developed for that purpose. We 
are now dealing with a situation where there are a huge number 
of young people who get these opioids from their parents' 
medicine cabinet, and I have been made aware of a product that 
I am holding right there that costs less than $1. It would 
increase the cost of the prescription less than $1, and it has 
a combination on it. It would require the parents to open that. 
If a child that didn't have the combination tried to get into 
something like this, it would be evident to the parent that 
this was opened by someone that didn't have the combination. 
Has DEA looked into packaging like this?
    Mr. Milione. Congressman, obviously as a father of three, 
we support anything that would serve that purpose, and we are 
aware of that company and that device.
    Mr. Buck. You are probably aware that the company comes 
from the great state of Colorado also.
    Mr. Milione. I almost said that.
    Mr. Buck. Thank you.
    [Laughter.]
    Mr. Milione. So we are aware of it, and we were happy to 
listen to them about that technology. We would support that. We 
would support, obviously, the take-back kiosks to get drugs out 
of the medicine cabinet. That is a critical part of our overall 
strategy. But certainly any technology that would prevent those 
dangerous drugs getting in the hands of children or anyone we 
would support.
    Mr. Buck. And what needs to be done? Do we need a law for 
that? And I am not a big proponent of administrative 
regulations, believe me; but can you, by regulation, require 
that dangerous drugs be dispensed in packaging like this?
    Mr. Milione. We can require that they are disposed of. The 
regulations cover that, cover the disposal. As far as requiring 
how it is dispensed, I don't believe we can. I can certainly 
take that back and look at it. We have to navigate somewhat 
carefully because if this technology were made widely 
available, that would be great, but that would have to come 
from a private entity. It wouldn't be something that we would 
be able to mandate necessarily.
    Mr. Buck. So would you need an act of Congress to require--
obviously we are not going to name a company or a particular 
technology, but we would certainly require opioids to be 
dispensed in some kind of safe container. Would that be 
something that would help you in furthering this goal?
    Mr. Milione. It would certainly help prevent it from 
getting in the hands of, like you say, children. It is 
something we would be happy to talk to you about or follow up 
if there was some pending legislation.
    Mr. Buck. I would appreciate that very much.
    I want to make sure I pronounce this correctly--Mr. 
Botticelli?
    Mr. Botticelli. Yes.
    Mr. Buck. Great. Wow. The Federal Government dispenses 
drugs through the VA and other agencies. Again, would it 
require an act of Congress, or could the Federal Government, 
for purposes of its dispensing drugs to Federal employees or 
veterans, use packaging like this without a Federal law from 
Congress?
    Mr. Botticelli. I don't know that, and similarly, I think 
we would have to go back and look at what kind of authority we 
would have or if the Federal Government needs additional 
authority to do that.
    You know, I will say that part of what we have been trying 
to do at the Federal level is ensure that every Federal 
prescriber at least has some level of mandatory education as it 
relates to those. But as far as mandating a package, I don't 
know if we either have the authority or we need additional 
authority to be able to do that. I could look into it.
    Mr. Buck. If you could work with my office on that, I would 
very much appreciate that and look forward to working with you 
to try to develop this in this area.
    I thank the chairman and I yield back.
    Mr. Mica. I thank the gentleman.
    We will recognize now Mr. Lynch, the gentleman from 
Massachusetts.
    Mr. Lynch. Thank you, Mr. Chairman.
    I do want to associate myself with the words of the 
chairman and the ranking member earlier on on this issue. I 
think there is much we can do on the treatment side, but up 
front, there is also the opportunity to reduce the number of 
people who require treatment, and I think we really have to 
double our efforts in that regard.
    Mike Botticelli, good to see you again.
    Mike, for those who don't know, headed up our efforts in 
Massachusetts for quite a few years, did great work, and I want 
to thank Mr. Milione for the DEA's help. My district has been 
overrun, so you have actually been kind enough to assign DEA 
officers and agents up in my area, working with our local 
police. So we really appreciate the help there.
    Obviously, any individual state doesn't have impact on the 
border, but you do, so that has been an enormous help for us in 
trying to interdict some of the heroin pipeline that has been 
coming up into the Boston area.
    I had the honor of co-founding the Cushing House in Boston 
for Boys and Girls. It is actually an adolescent treatment 
facility because our kids are coming in so young with 
addictions to both opioids and heroin. We have basically 24 
beds for boys, 20 for girls, but the problem is I have a line 
out the door, and it is happening over and over and over again.
    I do want to say, just as a sidelight here, as I talk to 
our young people--and we have put thousands of kids through our 
home, and it is a long-term rehab facility. While I don't know 
if marijuana is a gateway drug to heroin, every single kid that 
I am dealing with who is on opioids and on heroin started with 
marijuana. So there is a perfect match, 100 percent. Every kid 
I am dealing with for heroin and for opioids, when I ask them 
what did you start out with, they all say marijuana. So maybe 
there is a susceptibility there or something, I am not sure. It 
is not anecdotal; it is more than that. It is empirical, over 
thousands of kids, but it certainly points in that direction. 
So I think it deserves a cautionary note in terms of some of 
this marijuana legalization. I think we are buying ourselves a 
huge problem.
    One thing I want to talk about and get your opinion, we 
haven't talked about the power of these opioids, and I will 
give you a couple of examples. A young woman in my district had 
a tooth problem. She had an extraction. They gave her a very 
large prescription of OxyContin. She consumed that, went back 
and complained, falsely she tells me now, of continued tooth 
pain, got another prescription, and actually went back in and 
complained that another tooth was hurting, which was not. So 
she is yanking teeth out of her head just so she could get 
prescriptions of OxyContin. That is unbelievable.
    I talked to some of my docs in the Boston area, and they 
tell me that the chemical changes in the brain, it overrides--
the OxyContin and hydrocodone actually overrides the endorphin 
creation in the brain. So it is more powerful than the 
endorphins that the brain can produce on its own. So when they 
come off that, when they need that, that is why they are going 
for more OxyContin or heroin, because that is the only thing 
that can scratch that itch.
    So we have to think about this. These drug companies are 
creating customers for life, customers for life.
    Another young father in my district, shoulder pain. Same 
deal, gave him too much OxyContin prescription. Two or three 
prescriptions later, bam, now he is buying it on the street. A 
good dad, good family, just totally fell into that trap.
    So we have to figure out--I think it is a huge commercial 
advantage for some of these companies to produce a product that 
creates a customer for life. We have to think about what we are 
doing in that regard. That is a huge commercial advantage.
    I think that Governor Baker in the Massachusetts 
legislature just came out and said if you are going to 
prescribe this stuff, you can only give so many pills, and we 
are not going to let you refill them. It is also part of our 
drug monitoring piece that we are doing along those lines as 
well.
    But is there anything on the front end, Mike, that we could 
be doing to stop the number of people? Because once they get in 
there, we are having a terrible, terrible, terrible problem. We 
have a lot of recidivism, a lot of relapse, a lot of money we 
are spending for rehab, and we need to do that, I am not 
discounting that. But on the front end, to stop these kids from 
being trapped, and other unsuspecting patients from being 
trapped into this cycle, is there anything else we can do up 
front to stop that from happening?
    Mr. Botticelli. Sure, and I thank you for that question 
because I think it is really important. Again, the CDC just 
released guidelines, but they are only guidelines. I agree that 
I think the vast majority of physicians and dentists are well 
meaning, and part of what Massachusetts has done, 16 other 
states, there is legislation in Congress now. We would love to 
work with you on mandatory prescriber education because we 
feel, again, this is not about bad docs, but they have gotten a 
lot of misinformation, largely from drug companies, that these 
are not addictive medications, and that we can continue to hand 
them out.
    I don't think, quite honestly, in the middle of an 
epidemic, it is unreasonable to ask a prescriber to take a 
minimal amount of education as it relates to safe and effective 
opioid prescribing. If you look at the overdoses that we have 
seen here, there is a direct correlation between the amount of 
prescriptions that we are giving out and overdose deaths, and 
this has been going on for 10 years, and I think the medical 
community has a role to play, and that is a good starting 
point.
    Mr. Lynch. What about liability? What about having joint 
and several liability for drug companies and the docs that push 
this stuff out there? Because these people are unsuspecting and 
they are getting addicted like that.
    Mr. Botticelli. I agree, and there has been legal action 
against Purdue Pharmaceutical for precisely that reason. They 
have a role to play not only in terms of making sure they are 
meeting the letter of the law about marketing, but also 
encouraging abuse-deterrent formulations, another particularly 
important area.
    We do need to work with the DEA and others to go after 
outlying prescribers who are wantonly ignoring the law on this. 
But you are right, we need prescriber education, good 
prescription drug monitoring programs so physicians can 
identify people who might be going from doctor to doctor to do 
that.
    But to your point, if we are really going to reduce the 
magnitude of the problem, we have got to scale back on the 
prescribing and identify people who are starting to develop 
problems.
    Mr. Lynch. Thank you, and I yield back.
    Mr. Mica. I thank the gentleman.
    Also, Mr. Lynch, I went into one of the drug programs in my 
community, talked to every kid I could in the treatment 
program. Every kid told me the same thing, he started with 
marijuana, then they go on to all the rest of it. So we have a 
very serious situation in this country.
    Let me recognize--Mr. Walberg is next, the gentleman from 
Michigan.
    Mr. Walberg. Thank you, Mr. Chairman. I apologize for being 
out but Rosie the Riveter showed up at the Capitol and I wanted 
to say hi to four of them from my district.
    An interesting issue because it does affect all of us. My 
district in Southeast, South Central Michigan has tremendous 
challenges there, and I appreciate the efforts that all of you 
have shown toward this issue.
    Mr. Milione, how long has the DEA been aware of the 
increased prevalence of fentanyl-laced drugs, and how are you 
responding to this problem specifically?
    Mr. Milione. Thank you for the question. We have been aware 
of fentanyl going back a number of years, and we have seen its 
increasing use and have seen it flood the country.
    What are we doing? We are doing basically what we do with 
all our criminal investigations. We look to target the worst of 
the worst, criminal trafficking organizations, identify them, 
infiltrate them, indict them, capture, convict them. We are 
trying to educate, certainly, our state and locals about the 
risks associated with fentanyl. It is a multi-pronged approach, 
and it is definitely something we are concerned about.
    We certainly are concerned about the unsuspecting users 
that are being exposed to it when it is combined with heroin or 
when it is put into an exact replica of an opioid pill.
    Mr. Walberg. Are those the special enforcement challenges 
that you have, or are there others beyond that?
    Mr. Milione. There is a whole panoply of different 
challenges, and that is certainly one of them. It also poses a 
risk to my law enforcement brothers and sisters that encounter 
increasingly fentanyl in an enforcement operation. As you know, 
it can be inhaled, it can be absorbed through your skin, with 
tragic consequences. So it certainly is a major problem for us, 
for users, for the country, and then also for law enforcement.
    Mr. Walberg. What has the DEA learned about the source of 
fentanyl when it appears in heroin?
    Mr. Milione. Two primary sources. The majority of it is 
coming up from Mexico, with precursors and actual fentanyl 
shipped from China, from Asia, into Mexico for production, and 
then across the Southwest border, all over the country, 
particularly up in the Northeast, but also directly from China. 
So those are the two primary threats.
    Mr. Walberg. It is my understanding that Mexico has been a 
primary source. Is that true?
    Mr. Milione. That is true.
    Mr. Walberg. How are you working to decrease this 
trafficking? Any additional efforts that you can talk about in 
regards to what is coming across the border?
    Mr. Milione. We have a great relationship with one of our 
largest, if not our largest, office in Mexico. We have a great 
relationship with our counterparts. We continue to work with 
them on those trafficking organizations. The Sinaloa Cartel is 
probably the most powerful cartel down there. It has a 
tremendous distribution network spread across the country. They 
are capitalizing on the prescription opioid abuse epidemic. 
They are flooding the country with heroin, but they are also 
now flooding it with fentanyl.
    So we are just going to continue an aggressive approach 
from the law enforcement side and do what we do with our state 
and local counterparts every day.
    Mr. Walberg. Okay. Mr. Botticelli, what efforts is the U.S. 
engaging in to work with governments where heroin is produced 
to cut off the supply? And then secondly, does this involve 
identifying labs in countries like Mexico which may be a 
trafficking bonanza of heroin and fentanyl in the United 
States, and what are the biggest barriers to stopping that?
    Mr. Botticelli. As we have looked at this issue, 
particularly heroin and fentanyl, having an aggressive approach 
that reduces the supply is particularly important. I actually 
was just in Mexico a few weeks ago meeting with the Attorney 
General and high-level folks in the government, calling for 
enhanced action particularly as it relates to heroin, looking 
at enhanced eradication efforts, looking at how we go after 
both heroin and fentanyl labs, and how we continue to support 
mutual collaboration in going after the organizations that deal 
with it.
    We have also been working with the DEA and our high-
intensity drug trafficking areas domestically to look at 
reducing and going after those organizations that are 
trafficking heroin and fentanyl domestically. I think it is 
really important for us to have this holistic approach and to 
really focus on a robust law enforcement response to reduce the 
availability of heroin and fentanyl.
    We have to really look at how we work with our Customs and 
Border Protection folks to increase the detection of both 
heroin and fentanyl. And I think, to Mr. Milione's point, we 
have to look at our international work with China that often 
produces these precursor chemicals as it relates to 
particularly fentanyl production.
    We were actually pleased that China just moved to schedule 
over 130 new substances, including one of the precursors, 
acetyl fentanyl. So it really is important for us to work with 
our international partners, particularly China, Mexico, and 
working with our domestic law enforcement folks.
    Mr. Walberg. Thank you. I yield back.
    Mr. Mica. I thank the gentleman.
    The gentleman from Pennsylvania, Mr. Cartwright.
    Mr. Cartwright. Thank you, Acting Chair Mica, and thank you 
to all the witnesses for coming today. I have listened to all 
of your testimony, and it is well taken.
    I come from Pennsylvania. In Pennsylvania, hospitalizations 
for overdoses due to pain medication increased 225 percent from 
2000 to 2014. Drug overdose deaths in Pennsylvania increased by 
12.9 percent between 2013 and 2014, compared to a 6.5 percent 
increase nationally in the same time period. It is a huge 
problem in Pennsylvania.
    Director Botticelli, you mentioned attending a town hall. 
Earlier this year I did a town hall in my district in Coaldale, 
in Schuylkill County, Pennsylvania. It is a rural place. 
Typically we get between 30 and 40 people out for routine town 
halls. At this one, we had over 100 people come out, and nobody 
was smiling. Every family is touched by this crisis, by this 
epidemic.
    The question is, what can be done to combat it? In 
Pennsylvania, there is a company, Iroko Pharmaceuticals, that 
is right now using nanotechnology and is following the FDA 
directive to use the lowest effective dose of NSAIDs for 
chronic pain. Iroko is an African American-owned company which 
is growing by the month, providing not only jobs in 
Pennsylvania but also a logical solution to our national opioid 
epidemic.
    I also believe there are legislative solutions to help 
address the issue, like H.R. 953, the Comprehensive Addiction 
and Recovery Act. This was introduced in the House by 
Representative Sensenbrenner of Wisconsin. In the Senate, the 
same bill was introduced by Senator Whitehouse of Rhode Island. 
That bill passed the Senate, and in the House I am a co-sponsor 
of 953. It is a bill that would adjust existing authorizations 
and programs to provide a series of resources and incentives to 
help health care providers, law enforcement officials, states 
and local governments expand drug treatment prevention and 
recovery efforts, and throw funding toward those efforts. I 
wish to urge Republican leadership to move H.R. 953 to the 
House floor for a vote. It is a concrete step we can take in 
the right direction.
    Now, my colleague, Mr. Lynch, talked about New England, and 
the New England area has been referred to as ``the cradle of 
the heroin epidemic'' by the New York Times, and I see you 
nodding your head, Mr. Milione. You are aware of that, I take 
it.
    Mr. Milione. Yes, sir, I am.
    Mr. Cartwright. According to the DEA's 2015 National Heroin 
Threat Assessment Summary, 63.4 percent of New England law 
enforcement agencies reported heroin as their greatest drug 
threat. And just last week, Governor Charlie Baker signed 
legislation making Massachusetts the first state to pass a 
statewide cap on first-time opioid prescriptions.
    My question is, with the rising number of opioid deaths, 
what steps has DEA taken to collaborate with the state and 
local law enforcement agencies to reduce opioid overdoses and 
deaths?
    Mr. Milione. Congressman, thank you for the question. Under 
the leadership of our Special Agent in Charge up there, Mike 
Ferguson, they have a great relationship with the U.S. 
Attorney's Office, and they have brought together all the 
different elements--state, Federal, local, working with the 
health community--to identify where the hot spots are, and then 
to do the community outreach piece, but then also to do the 
enforcement on the groups that are trafficking in those 
substances.
    Mr. Cartwright. Okay. And, Director Botticelli, how is the 
Federal Government working to encourage and support innovative 
ideas by the states to combat the opioid epidemic?
    Mr. Botticelli. I think there are a number of ways that we 
are doing that. One, looking at funding opportunities to 
provide states with the opportunities to really create 
innovative strategies. One of the things that our office does 
is really look at how do we promote some of these innovative 
things that are happening at the state level. So whether that 
is law enforcement that are working to get people into 
treatment, or things like the 24/7 triage programs.
    So part of what the Federal Government's response is is 
ensuring that states and locals have the resources they need to 
continue to implement programs that address these issues. 
Secretary Tennis in Pennsylvania I think has really 
demonstrated some really strong leadership in terms of the work 
that is happening here. I talk with the Secretary just about 
every day in terms of looking at what more the Federal 
Government can continue to do.
    But I think the largest function that we have is making 
sure that states and locals get the resources they need to 
continue to develop and show leadership on this issue.
    Mr. Cartwright. Well, amen to that, and I yield back, Mr. 
Chair.
    Mr. Mica. I recognize Mr. Hice from Georgia.
    Mr. Hice. Thank you, Mr. Chairman.
    The CDC in Georgia has a report that Georgia alone has seen 
a 10 percent increase in overdose deaths. I am sure you have 
seen that in the last couple of years. To me, this is 
especially alarming just for the fact that high school students 
are using painkiller medication at alarming rates which makes 
them 40 times more vulnerable to use heroin.
    The DEA said that heroin is currently available in larger 
quantities, that it is used by a larger number of people, and 
that it is causing an increasing number of overdose deaths. Is 
that correct?
    Mr. Milione. Yes, sir.
    Mr. Hice. I want to focus on where this stuff is coming 
from. So, Mr. Milione, let me start with you. From your 
testimony regarding the DEA's new 360 Strategy, which you 
referred to a little while ago, it sounds to me like the DEA is 
going to focus less on the Mexico-based organizations that are 
trafficking heroin and focus more on the street gangs that are 
distributing heroin. Is that a correct assessment?
    Mr. Milione. Congressman, it actually is not. We are more 
nuanced than that. We are never going to go away from our core 
mission of working up the chain to the cartel leaders in 
Mexico. So the 360 focuses on the link point, the link point 
that bridges the violent distribution cells domestically that 
are affecting the communities, and also the cartels that are 
flooding the country with the heroin. So it absolutely is not 
one or the other. It is a comprehensive approach.
    Mr. Hice. So is there a greater emphasis, though, on the 
distribution side of things now?
    Mr. Milione. I wouldn't say there was necessarily a greater 
emphasis. It is a shift of focus so that we can do everything 
we can to get the violent distribution cells under control and 
give the communities back their communities.
    Mr. Hice. Is it fair to say from your assessment that our 
interdiction efforts with the cartels have failed, or at least 
not been as successful as we had hoped?
    Mr. Milione. Congressman, I wouldn't characterize it as a 
failure. Interdiction is one part of it, but what we are 
focused on at the DEA is going after the actual individuals 
that are selling the powder, that are pushing it, the 
infrastructure, the corrupting influence, the money. Those are 
the things we are focused on. Interdiction is one piece of 
that.
    Mr. Hice. All right. Sounds to me like you were just then 
saying that the emphasis is going to be on the distribution 
side of things.
    Mr. Milione. No, I don't believe I said that it was just 
going to be on the distribution. It was going to be on ----
    Mr. Hice. I didn't say ``just,'' but the emphasis.
    Mr. Milione. There is going to be an emphasis on the 
distribution, and also on the supply side.
    Mr. Hice. Okay. You mentioned a while ago--and I will just 
shake my head with all of this, because we have been into this 
war on drugs forever, and it is getting worse. We are not 
making any headway on this. You mentioned just a while ago that 
we have a great relationship with the Mexican government and 
that that relationship--the reality is that heroin is coming 
across the border more now than it ever has. What good is a 
great relationship if we are not addressing the problem? At 
some point, this thing is getting worse and worse and worse, 
and we are throwing more and more money to it all the time. It 
frankly doesn't appear to me as though anything is happening to 
stop the problem that would go to the point of what you said a 
while ago, that we are addressing this aggressively.
    Mr. Milione. Congressman, as somebody who has served for 20 
years and has seen the sacrifices that the brave men and women 
of the DEA do every day, and dangerous situations in the 
country, and also in the foreign arena, we are doing everything 
we can to deal with this very, very difficult and complicated 
problem. We are working to reduce demand, but we also have to 
go after the organizations that are flooding our country.
    So the war on drugs is not necessarily a phrase that we 
would use. We do criminal investigations in highly dangerous, 
sophisticated cartels operating ----
    Mr. Hice. Well, I take my hat off to those agents who are 
out there in the field, and I am not in any way belittling 
them. But for us to come in here and somehow try to give a 
picture that we are aggressively dealing with the problem when 
in reality it is getting worse and worse is putting forth a 
false image.
    Mr. Milione. I would have to disagree with the false image.
    Mr. Hice. Well, you can disagree all you want. The fact is 
the problem is getting worse. You yourself have admitted that.
    Mr. Milione. Congressman, I don't disagree that it is a 
difficult problem and that there are parts of it that are 
getting worse, but I am not painting a picture that is 
inaccurate when I say that we are aggressively doing everything 
that we can, at tremendous sacrifice.
    Mr. Hice. So how many criminals have been arrested and 
prosecuted under DEA's Rolling Thunder program?
    Mr. Milione. I can't give you the number of arrests. I can 
tell you that there are 448 investigations in 125 cities around 
the country.
    Mr. Hice. But you don't know how many arrests?
    Mr. Milione. I would have to get back to you with any 
specific statistics.
    Mr. Hice. Please get back to me.
    Mr. Chairman, I see my time has expired.
    Mr. Mica. I thank the gentleman.
    The gentleman from California, Mr. DeSaulnier, you are 
recognized.
    Mr. DeSaulnier. Thank you, Mr. Chairman.
    First of all, I appreciate the panel. I think all of us 
have stories about constituents who have been affected by this, 
and the frustration I think of some of my colleagues at our 
inability as a country to deal with the drug problem, no matter 
what we have tried.
    I would like to ask a couple of questions on the opiate 
side. I have one constituent who came to me and made me aware 
of her personal situation where her son was going to school at 
the University of Arizona and drove to Los Angeles with some 
other students to actually go to a doctor in Los Angeles and 
then overdosed. This doctor was just recently convicted, 
multiple convictions in Los Angeles.
    I have another constituent who went out to walk to a Baskin 
and Robbins on a Sunday afternoon, and one of his two kids was 
killed right in front of him when a woman who had been abusing 
opioids and drinking came across. So all of us have those 
stories, unfortunately.
    One of the things we were able to do in California--and Mr. 
Lieu and I were part of this in the legislature--was update our 
prescription monitoring system. So my question is really around 
electronic health records. I would talk to doctors and they 
would say, well, electronic health records are right around the 
corner. Doctor shopping will be a thing of the past. We worked 
with the Attorney General in California, and that process is in 
effect now, but we are just waiting to see how effective that 
is.
    So, Mr. Botticelli, maybe you could tell us--and one of the 
frustrating things, of course, is when you have this patchwork 
of different states doing different things, it seems to me that 
it would be fairly efficient for the Federal Government to 
provide the infrastructure for a nationwide electronic 
monitoring system so that the Department of Justice in all 50 
states and the Federal Department of Justice would have red 
flags so that they would see if a doctor, like the doctor in 
Los Angeles, is abusing his or her privileges, or if a client 
is doctor shopping.
    Mr. Botticelli?
    Mr. Botticelli. Prescription drug monitoring programs have 
been part of our main emphasis since the beginning of this 
epidemic, and I think to your point, we are seeing a tremendous 
amount of success. When we started we had only 20 states that 
had effective prescription drug monitoring programs, and now we 
have 49 states that do that. We actually thought it was more 
prudent, because we had so many states that already had an 
existing program, to really look at the state level.
    But to your point, I think what we are trying to focus on 
next is interstate data sharing so that states can talk to one 
another, and interoperability with electronic health records, 
because that is the next phase of--we want to be responsive to 
physicians in terms of the burden of workload and look at how 
do we get timely information to them by supporting that. So we 
have been working with HHS and others. This is an important 
priority for governors as well, so we have been talking to the 
National Governors Association in terms of what states can do.
    But this has really been one of the more effective tools 
that we have seen, but we also need physicians to use them. So 
part of this is, again, I think we are very interested in 
states that have passed not only mandatory education but, like 
Massachusetts just did, checking the prescription drug 
monitoring program not only at first dispensing but at every 
dispensing ----
    Mr. DeSaulnier. So it is mandatory.
    Mr. Botticelli. So they are only as good as when people use 
them.
    Mr. DeSaulnier. And, Ms. Enomoto, maybe you could talk to 
this. In Northern California we have a lot of Kaiser clients. 
So there you have a closed system where there is still a 
problem, so there is a financial aspect to this. For them, if 
they were able to use electronic records both for the cost and 
efficient use of the system, but also to protect the clients 
from being either over-prescribed or clients taking advantage 
of the system, how far away are we from having a real strong 
electronic monitoring system that can do both?
    Ms. Enomoto. You know, I think we are seeing in some states 
already great progress. So in 2012, SAMHSA had the opportunity 
to issue grants for the enhancement of prescription drug 
monitoring programs that focused on both the interoperability 
with EHR as well as interstate interoperability. In those 
grants, during the period of the grant, we got six out of the 
nine states that were able to achieve that level of 
interoperability, and then post-grant we have two more states 
who are now online with their MOUs so that they should be able 
to start exchanging information with their EHRs very soon. So 
out of a relatively small investment, partnering with CDC, 
partnering with the Office of the National Coordinator and 
ONDCP, we were able to get eight out of nine states to achieve 
that level of interoperability.
    Mr. DeSaulnier. And lastly, the statistics always come to 
mind. The U.S. has about 5 percent of the world's population, 
but we use over 80 percent of the opiates. How much of this is 
the criminal aspect of it, Mr. Botticelli?
    Mr. Botticelli. I would actually say very little. Again, I 
think this has been a concerted effort by the pharmaceutical 
companies to falsely promote those medications. In 2013, we 
prescribed enough prescription pain medication to give every 
adult American a bottle of pain pills, and I think that is why 
the CDC guidelines become so important, looking at not having 
opioid therapy as a first-line defense for chronic pain, really 
supporting when you do start with opioids for some people who 
do need them, starting with the smallest, the lowest dosage and 
the smallest possible amount, because I really do believe that 
we have made progress in many areas, and I don't believe that 
we have made enough progress in really implementing safe opioid 
prescribing behavior.
    Mr. DeSaulnier. Thank you.
    Thank you, Mr. Chairman.
    Mr. Mica. Thank you.
    Let me recognize now Mr. Carter from Georgia.
    Mr. Carter. Thank you, Mr. Chairman. And thank all of you 
for being here.
    I have been kind of in and out. I apologize. I had three 
committee meetings at one time, at the same time. But I want to 
associate myself, first of all, with all the comments that have 
been made about marijuana being a gateway drug and leading to 
drug abuse. I could not feel more adamantly about that, so I 
just want to make sure everyone understands that.
    For those of you who don't know, I am a pharmacist, not 
practicing anymore. The only pharmacist in Congress. I have 
over 35 years of experience, and a lot of experience with 
opioids as a dispenser. I am very blessed that I have never 
taken any drugs, never had that. I am human and I have 
weaknesses, but that is not one of them, and I feel very 
strongly about that.
    I want to start with you, Mr. Milione. This is very 
uncomfortable, but I will tell you that almost a year ago, a 
little over a year ago, in fact, in Tampa, a judge ruled 
against the actions of the DEA when you raided a compounding 
pharmacy. You destroyed the medication and completely shut down 
the pharmacy without any real cause. This was Westchase 
Pharmacy in Florida. Are you familiar with that situation?
    Mr. Milione. I am not.
    Mr. Carter. You are not? Well, you need to be because, let 
me tell you, this is not a shining example that you want to 
point toward. This is an example where one of the supervisors 
that you oversee conducted a raid and at the time had no 
experience in diversion investigation, hadn't read the DEA 
handbook, yet raided a compounding pharmacy with tactical gear 
and guns, shut down the business, seized hundreds of thousands 
of dollars of medicine, and improperly stored them, therefore 
rendering them useless, all because the DEA misinterpreted and 
failed to follow their own laws. This is, as the judge said, 
preposterous, and this is not going to be accepted.
    Now, look, I support the DEA. I don't like anybody in 
health care who is not practicing by the best of standards. We 
have bad pharmacies out there, we have bad pharmacists, we have 
bad doctors. Dr. Wen, there are bad doctors out there. You 
can't paint with a broad brush. There are bad actors in every 
profession. But this kind of action, this kind is totally 
unacceptable, Mr. Milione, especially when we have someone 
coming to your pharmacy bearing guns. That is unacceptable. So 
I hope you will look at that. It is Westchase Pharmacy. I hope 
you will research that and understand that.
    I want to ask you, Dr. Wen especially, we have talked about 
opioids being used as the entry-level drug for pain control. 
One of the problems that I see here--and, Mr. Botticelli, you 
and I have worked together before. You know I sponsored the 
legislation in the Georgia State Senate to set up the PDMP for 
Georgia. But one of the problems I see is with the FDA taking a 
lot of the products off of the market.
    Now, specifically I want to talk about propoxyphene. You 
know, propoxyphene was on the market for years and years. I 
can't imagine how much I dispensed in my career. But I will 
tell you, when they took it off, what did it do? It led people 
to opioids. That is the only choice the doctors had. What do 
you do now? You have ibuprofen and acetaminophen. That is where 
you want to start.
    Well, let me tell you, as a practicing pharmacist I can 
tell you, you try to get a patient to take something that is 
available without a prescription, you are not going to be able 
to convince them that it is going to work. You have to have a 
prescription for it. That is just the way it is. No, it is not 
right, but I will try as hard as I can, and I can't convince 
them of that.
    And just like the propoxyphene, don't give me that white 
one, only the pink one works, that is the only one that works. 
That is what you are dealing with.
    But one of the problems, I think, has been the FDA taking--
and I know that propoxyphene had its problems. I am not trying 
to question that. But what I am trying to point out is that we 
need more entry-level drugs, something in-between the opioids 
and ibuprofen and acetaminophen. That would be better. The CDC 
guidelines that have come out, the prescribing guidelines for 
doctors, I think that is very, very helpful. It needs to be 
enforced more. It needs to have some kind of teeth in it.
    I am running out of time here because I want to get into so 
many things.
    Another problem is mail-order pharmacies sending these 
gigantic containers of opioids to the doorsteps of people, 
leaving them on the doorsteps for them to be--who knows what is 
going to happen to them. You get a 90-day supply. I have people 
bringing them now to the drugstore my wife now owns. They bring 
into those drugstores all the time giant containers of opioids. 
That needs to be suppressed, Mr. Milione. The DEA needs to do 
something about that. That is ridiculous and something that we 
need to address as well.
    The last thing I want to talk about is 21st Century Cures 
and the locking provision. Listen, I am a big proponent of 21st 
Century Cures. I think it is some of the best legislation we 
have passed here since I have been in Congress, and I support 
it, and I voted for it. However, that locking provision is very 
dangerous and I think it needs to be looked at. You have a 
relationship between pharmacies and patients, between doctors 
and patients. When you get into a locking provision, it is 
going to be very, very difficult, because you need pharmacists. 
You need pharmacists to participate in this and help us to curb 
this problem because it is--let me tell you, I have seen it 
ruin families, I have seen it ruin lives, I have seen it ruin 
careers, and it is worse than can even be imagined at this 
point.
    Mr. Chairman, I know I have gone over, and I apologize. 
Thank you.
    Mr. Mica. Thank you.
    The gentleman from Virginia, Mr. Connolly.
    Mr. Connolly. Thank you, Mr. Chairman.
    I will say, Mr. Mica and I had a series of hearings in the 
previous Congress on U.S. drug policy that included marijuana, 
and it forced me to reexamine some things I thought I knew or 
believed about our drug policy with respect to marijuana. But 
what is disturbing to me, if there is a gateway drug to heroin, 
it is opioid prescription drug addiction far more than 
marijuana, and that is why this hearing is so timely. It is 
affecting every community we represent here in this body. It is 
not a rural phenomenon or an urban phenomenon or a suburban 
phenomenon.
    Well, let me ask you, Mr. Botticelli, how did we get to 
this point? I mean, I don't want any doctor to leave a patient 
in pain. Serious pain is a terrible affliction, and first you 
do no harm. But how do we draw that line between pain 
management and just an unbelievable avalanche of prescriptions 
for opioids that has now led to an epidemic of addiction in 
America? With, presumably, the best of intentions originally.
    Mr. Botticelli. I agree, and I think when you look at the 
roots of this epidemic and what are the significant drivers, 
yes, there are other issues going on. It is really about the 
over-prescribing of these very addictive pain medications that 
we have.
    Mr. Connolly. But why? How did we get there? Doctors aren't 
stupid people.
    Mr. Botticelli. Well, I think that doctors were given a 
significant amount of misinformation from pharmaceutical 
companies, and even from the medical professions themselves, 
that these were not addictive medications. So that was really 
the start of this, that despite scant scientific evidence, 
there was this full court press to basically educate 
physicians, saying that these medications were not very 
addictive, and at the same time we had what I think is a very 
noble and should be a noble goal, that we have to do a better 
job at pain treatment in the United States, that there are a 
lot of people who have significant pain and who need it.
    So I think you had this confluence in terms of really a 
full court press to treat pain--the VA even talked about pain 
as the fifth vital sign--and little education on the part of 
these prescribers about how addictive these substances were, 
about how to identify people. So physicians in the United 
States get very little training on appropriate pain 
prescribing. I think there was a GAO study that showed 
veterinarians actually get more training on pain prescribing, 
and physicians get little to no training on substance use 
issues.
    So I think it was this kind of mixture of a whole set of 
factors that really drove up addiction and overdose in the 
United States, and now we have that compounded by heroin and 
fentanyl availability.
    Mr. Connolly. Dr. Wen, what is effective treatment? I mean, 
what is the system for recognizing somebody has a problem and 
we need to get them treatment? What is efficacious treatment in 
trying to turn this around early before it moves on to, say, 
heroin or something worse?
    Dr. Wen. It is often said that medicine is an art and not 
completely a science because even something like pain is 
subjective. What is a pain for you is not the same for somebody 
else. So that is why doctors do need discretion about how to 
treat each individual patient based on their symptoms and who 
they are, also recognizing that it is not just about 
medications. We also have to do physical therapy and counseling 
and education that sometimes pain is okay. We don't have to 
treat everything with a pill.
    So we very much agree with the increase in the use of 
PDMPs, recognizing that some PDMPs are very cumbersome to use. 
If I am seeing 40 patients in eight hours, I can't be spending 
an hour of that time figuring out how to get into every 
patient's PDMP.
    Mr. Connolly. Got it, but we are running out of time. So 
what is efficacious treatment? What do you recommend in the 
Baltimore Health Department?
    Dr. Wen. We recommend, first of all, judicious use of pain 
medication so that we are not ----
    Mr. Connolly. I get that. I am talking about treatment. We 
have a problem; what is the treatment? What is efficacious? 
What have we learned? Because, look, we are policymakers up 
here. We want to solve a problem. We get that part. But if we 
have gotten to the point where we have an addictive problem but 
we are trying to prevent that person from going on to the 
heroin part, what works? What, in your experience, works by way 
of intervention?
    Dr. Wen. One thing, recognizing that addiction is a 
disease, and therefore we have to get people into addiction 
treatment, which is medication-assisted treatment, psychosocial 
counseling, and wraparound services. We know that the World 
Health Organization shows for $1 invested in treatment, that 
saves $12 for society, and that is something we should invest 
in.
    Mr. Connolly. Thank you very much.
    Thank you, Mr. Chairman, and thank you for the hearings you 
and I held. They were quite informative ----
    Mr. Mica. I believe the only ones in Congress, and we got 
criticized for them.
    Government Operations, he was my ranking member, and then 
years ago with the ranking member here.
    Mr. Connolly. Thank you again, and thank you to the panel.
    Mr. Mica. The gentleman from Wisconsin, Mr. Grothman.
    Mr. Grothman. I will yield my first minute to Mr. Carter.
    Mr. Carter. I thank the gentleman for yielding.
    I would be remiss if I did not mention next week in Atlanta 
we are having the National Prescription Drug Abuse and Heroin 
Summit. Representative Hal Rogers from Kentucky, who has been a 
champion for this, is a co-chair of that. I hope that you will 
be there. I hope that my colleagues will be there. This is an 
opportunity to learn more about prescription drug abuse. It is 
a great, great summit, and I encourage everyone to attend. 
Thank you.
    I thank the gentleman for yielding.
    Mr. Grothman. Anytime.
    Okay, now I have a question. One of the things that bothers 
me is the legal prescription of opiates. I had two minor health 
things in my life in the last two years that I had earlier in 
my life. Both times, the medical professionals were willing to 
give opiates, like a month's worth of opiates, for something 
that had no business under any circumstances prescribing 
opiates, and they wouldn't have five years ago.
    I guess I will start with Mr. Botticelli, but anybody else 
can chime in here. What can we do to stop, in these basic 
things--I would say what they were, but I don't want to 
embarrass the medical professionals. They were par for the 
course. I mean, one of the things is we are not going to 
reimburse for Medicaid, we are not going to reimburse for 
Medicare, we are not going to reimburse anything else the 
Federal Government is kicking in for these sorts of problems, 
no matter how much pain you claim you have, because people 
never used to have it. Or we could perhaps say even for CMS. We 
are just not going to reimburse across the board. And if we are 
going to reimburse, it is for three days, none of this month's 
prescription stuff.
    Is that something that could be done? I don't think we can 
give the medical professionals a lot of wiggle room here 
because they have shown in the past they abuse that wiggle 
room.
    Mr. Botticelli. I think there are a number of things that 
we can be doing. I think, one, you are right, there are 
opportunities to work with not only CMS but private insurance 
as well with that.
    Mr. Grothman. Why don't we do it?
    Mr. Botticelli. CMS actually sent out a letter to state 
Medicaid directors this summer to really look at putting in 
place prescribing protocols around that. I also think that we 
really need to continue to focus on mandatory prescriber 
education. I am not a big fan of government mandates around 
that, but I do think, again, that we really need to educate the 
medical profession about safe and effective opioid prescribing.
    Mr. Grothman. All you need--I don't mean to cut you off. 
All you need is a little common sense. I mean, if we have that 
many people in the medical field that lacking in common sense, 
we have a bigger problem than lack of education.
    Mr. Botticelli. I don't think it is a matter of common 
sense. I think it was a matter of the medical profession, very 
well meaning to the largest extent, who were given 
misinformation on the lack of addictive properties of these 
drugs, and it was really a full court press to more 
appropriately treat pain with a prescribing community that gets 
little to no training on appropriate pain prescribing.
    Mr. Grothman. Well, 90 percent of the people on average in 
Wisconsin know this is all screwed up. I can't believe that the 
medical professionals need training on this, but okay, if you 
say they need training.
    Now I want to come around to the penalty thing, Mr. 
Milione. I got here late, didn't hear your name. It seems to me 
that the penalties for people who sell heroin is not as high as 
it should be, or they are not going to prison as long as 
possible. One of the problems I have is a lot of this is local 
stuff, it is not a Federal issue. But I assume we do arrest 
people. The Federal Government arrests people who possess 
heroin, at least enough that you can assume that they are 
dealing in that drug.
    Do we arrest people for that? And if we do, what is the 
recommended sentence?
    Mr. Milione. Congressman, at the DEA at the Federal level 
and in our task forces, we are not focused at all on users or 
simple possession.
    Mr. Grothman. I am not saying possession. If you get 
somebody with enough heroin, which isn't very much, that you 
know it can't be for personal consumption, you know they are 
going to be selling for somebody, what do you do with that 
person?
    Mr. Milione. I can't really give you a quick answer like 
that. It depends on the investigation and obviously in 
conjunction with the Federal prosecutors we work with, the 
state prosecutors. They look at the conduct, and then 
ultimately a judge decides what that sentence is going to be 
based upon the guidance that the judge gets. That is the 
clearest answer I can give you. It is not a very clear answer.
    Mr. Grothman. It is a very muddy answer, yes.
    Mr. Milione. Yes, but it is the world we live in.
    Mr. Grothman. Okay. I will give you one more quick 
question, then I will hang around here to see whether the 
Chairman eventually can call on me again if I wait long enough.
    What do they do in other countries on this? I toured 
another country 10 years ago and I asked about a drug problem, 
and they told me the criminal penalty for these severe drugs 
was shockingly high. I won't say what it was because it might 
have been wrong, shockingly high.
    What do they do in other countries to make sure they don't 
have this big opiate abuse, say in Southeast Asia in some of 
these countries where they don't want to have a penalty, so 
they hand out?
    Mr. Botticelli. It is interesting that you say that. I 
actually just returned from--there is a U.N. group of my 
colleagues from around the world in terms of looking at the 
global approach to drug policy, and I think that there is an 
emerging consensus with the vast majority of the countries that 
we need to continue to focus on an enhanced public health 
response, that while law enforcement plays a key role for some 
of our major traffickers, that we need to look at and continue 
to explore alternatives to incarceration.
    So I think that there is a kind of consensus among 
countries ----
    Mr. Grothman. I don't mean to cut you off. I am well past 
my time, and because I am past my time, I would like it if you 
would answer my question, okay? I know that there are a lot of 
people out there who like this public health response, okay? I 
am under the impression that we put people in prison for a 
reason, okay? Other countries have very large penalties and 
much less of an opiate problem. Could you tell me what their 
penalties are?
    Mr. Botticelli. Well, I think they probably have less of an 
opiate problem because in many parts of the world most people 
actually don't have access to medications at all. So it is not 
a function that they have criminal penalties.
    Mr. Grothman. No, you are wrong. But just tell me what they 
are because these are countries that are fairly advanced, and 
they don't have an opiate problem, and part of it is the 
penalties are pretty dramatic. Do you know what these penalties 
are, say in places in Southeast Asia?
    Mr. Botticelli. I don't, but I can tell you that Southeast 
Asia considers labor camps part of their treatment regimen. So 
I wouldn't necessarily equate drug policy around there as it 
relates to their drug problem.
    Mr. Mica. Thank you. I think in Singapore they also execute 
them.
    Mr. Lieu from California, you are recognized.
    Mr. Lieu. Thank you, Mr. Chairman.
    Mr. Botticelli, thank you for your public service. I have a 
few questions for you. Let me begin by saying that the current 
heroin and opiate epidemic has some similarities to the crack 
epidemic of the 1980s. Unfortunately, our response back then 
was to increase prison sentences. I am pleased to see we are 
taking a different approach this time, and America is finally 
starting to realize that drug addiction is primarily a disease.
    One of the most noticeable differences between the crack 
epidemic and the opioid epidemic is that the crack epidemic 
mostly affected poor communities of color, but the face of the 
opioid epidemic is very different. According to a study 
published in Journal of the American Medical Association, 
nearly 90 percent of the people who tried heroin for the first 
time in the past decade are white. Does that statistic sound 
largely correct to you, sir?
    Mr. Botticelli. It does.
    Mr. Lieu. I have an article here in the New York Times 
titled, ``In Heroin Crisis, White Families Seek Gentler War on 
Drugs.'' In that article you are quoted as saying, ``Because of 
demographics, the people affected are more white, more middle 
class. These are parents who are empowered. They know how to 
call a legislator. They know how to get angry with their 
insurance company. They know how to advocate. They have been so 
instrumental in changing the conversation.'' You said that, 
correct?
    Mr. Botticelli. Correct.
    Mr. Lieu. So I believe that it is important that we need to 
address these issues among the white middle class, but I want 
to make sure also that our resources are directed across the 
country regardless of socioeconomic or race status. My question 
to you is how to ensure that Federal resources are applied 
fairly and match the unique issues facing individual 
communities.
    Mr. Botticelli. Thank you for your comment. It is a really 
important issue to me and to you and Congressman Cummings. I 
have been doing this work for the better part of my life, and I 
am glad that in this country we are finally at a point where we 
have acknowledged the disproportionate impact on people of 
color and poor folk in terms of this issue, and I am glad we 
are at a different place. I am glad that we have now a huge 
political movement that is happening with people around the 
country to call for a different response.
    I completely agree. I think that we have to make sure that 
the policies that were implemented, that the programs that were 
implemented are targeted at those communities that have the 
most pressing need, and that when we talk about things like 
criminal justice reform, we are talking about criminal justice 
reform for everybody, regardless of color, as it relates to 
this, that our human response to this epidemic needs to be a 
human response for everybody and not just for the 90 percent of 
white people who are affected by this issue.
    I am glad we have learned a lot over the past 40 years in 
response to failed drug policies in the past. I am glad we are 
at the place where we are finally acknowledging that this is a 
disease and that we can't make our jails and prisons our de 
facto treatment programs for anybody.
    So I feel a tremendous responsibility in terms of making 
sure that we use this moment in time where there is broad 
acknowledgement of the fact that this is a disease and that we 
can't arrest and incarcerate, that we implement those policies 
and programs for everybody.
    Mr. Lieu. Thank you for that answer.
    Mr. Chairman, I would like to enter for the record the New 
York Times article, ``In Heroin Crisis, White Families Seek 
Gentler War on Drugs.''
    Mr. Mica. Without objection, so ordered.
    Mr. Lieu. There have been anecdotal stories today that 
marijuana is a gateway drug. Are you familiar with an article 
in Time magazine that says, ``Marijuana as a Gateway Drug, the 
Myth That Will Not Die''? Have you read that article?
    Mr. Botticelli. I don't know if I read that.
    Mr. Lieu. So let me quote from it. It says, ``Scientists 
long ago abandoned the idea that marijuana causes users to try 
other drugs. As far back as 1999, in a report commissioned by 
Congress to look at the possible dangers of medical marijuana, 
the Institute of Medicine of the National Academy of Sciences 
wrote there is no conclusive evidence that the drug effects of 
marijuana are causally linked to subsequent abuse of other 
illicit drugs.''
    Now, it is true there is a correlation, and this article 
and the study explains that underage drinking of alcohol also 
has a correlation, that those that actually use typically 
precedes marijuana, and that marijuana is not the most common 
and is rarely the first gateway illicit drug use. And then this 
article goes on to say why there might be a correlation, and 
one simple reason is that people who are extremely interested 
in altering their consciousness are likely to want to try more 
than one way of doing it. So if you are a true music fan, you 
probably won't stick to listening to just one band. That 
doesn't make lullabies a gateway to the Grateful Dead. It means 
people who really like music probably like many different songs 
and groups.
    So isn't it correct that there is no scientific evidence 
that marijuana is a causal link to illicit drug use?
    Mr. Botticelli. I think the evidence is pretty clear that 
early use of alcohol, tobacco and marijuana, often used 
together, significantly increases the probability that someone 
will develop a more significant addictive disorder later in 
their life, and I think that the more younger people use, the 
more that those chances grow.
    I also think that the music analogy is kind of inaccurate 
in this situation because early substance use actually affects 
brain development, not just affects people's taste, and it 
actually affects people's brain development and predisposes 
people for more significant vulnerabilities later in their 
life.
    Mr. Lieu. Thank you. My time is up. I will send you the 
article on that issue also.
    Mr. Chairman, if I could enter into the record the Time 
magazine article that says ``Marijuana as a Gateway Drug, the 
Myth That Will Not Die.''
    Mr. Mica. Without objection, so ordered.
    Mr. Mica. The gentle lady from New Mexico, Ms. Lujan 
Grisham.
    Ms. Lujan Grisham. Thank you, Mr. Chairman.
    I have no doubt that we will continue in Congress, and 
localities and cities and states will continue the debate about 
gateway drugs. Certainly, I participated in many of those 
discussions about alcohol, which is really the foundation in 
terms of creating an environment where you put yourself more at 
risk, particularly adolescents and adolescent drinking. I come 
from a state, unfortunately, that has some of the highest drug 
abuse rates and the highest overdose rates in the country.
    Mr. Botticelli, I appreciate very much you raising the 
issue in your testimony and talking about there is now a very 
direct and specific correlation between the number of 
prescriptions that have gone up and the number of prescription 
drug issues, which we are trying to deal with today. And I 
would hope that Congress undertakes an effort, when we are 
combating the opioid problem, that we look at drug issues in 
general, drug policy in general, and certainly continue to 
debate and work on criminal justice reform so that we are 
focusing on both prevention and effective treatment, which is 
really the way to get at it.
    I also want to say I appreciate the panel and members' 
questions. I am in a state that just passed legislation that 
would make naloxone available to far more than just the medical 
providers and prescribers, that we want it to be in the jails, 
we want first responders, and first responders to include 
family members in close proximity so that we can prevent 
overdose deaths. In a state that has a Republican House and a 
Democratic Senate, there was great bipartisan effort to 
recognize if we can prevent an overdose death, let's do that, 
but now let's not minimize everything else.
    So finally, potentially a question, and maybe either 
Director or Dr. Wen. This is a very complex set of problems, 
and that doesn't mean that we should walk away from it, and I 
could probably get into a debate with you right here about 
good-faith dispensing and how that can be a benefit, and how it 
will also limit access. One of the realities about over-
prescribing isn't just that the sellers, the manufacturers of 
these drugs have done such a great job, now it is cheap, so 
insurance companies are more than happy to make sure that that 
is right there.
    But if you can't get back to your physician, you are in the 
hospital or in the ER and you waited 27 hours to be seen, they 
need to make sure that whatever prescription they are giving 
you is going to tide you over. The issue is that you have lots 
of these patients who have other family members who then have 
access to the excess medication, and I am struck by the number 
of now large pharmacies that are thinking about making sure 
that they have kiosks and opportunities for you to get rid of 
those drugs safely and get them out of the hands potentially of 
guests and kids and families and grandkids, which is clearly 
part of the epidemic here.
    Given all of these complexities, I really want to talk 
about the behavioral health correlation, too, where we aren't 
treating--there really isn't mental health parity. In my state, 
we now have no behavioral health infrastructure, and I should 
admit to you that I think that is partially the fault of this 
Administration through CMS and HHS. So there is zero treatment 
available. We have some of the highest heroin overdose rates. 
In Mora County, it has been the highest. One in 500 is going to 
die of a heroin overdose. It is huge, and it is not new. It is 
decades old.
    What are we doing to really create policy that recognizes 
that behavioral health, that dual diagnosis and self-medicating 
is really also part of this larger problem here?
    Mr. Botticelli. I will start, and then I am sure that other 
folks on the panel can do that. So, I think there are a number 
of things from a large policy perspective that have happened. 
One is the Affordable Care Act, and one of the dramatic things, 
why 2 in 10 people get ----
    Ms. Lujan Grisham. I am really going to just caution you. 
The Affordable Care Act is the reason this Administration has 
said that it was okay to cancel 100 percent of all the 
behavioral health providers in my state. So in that example it 
doesn't quite work, although I am a fan of general access, make 
no mistake. But you should know that about New Mexico.
    Mr. Botticelli. Well, I will just say that part of the 
reason that people are not able to access care is the fact that 
they don't have affordable coverage. We know that from data. 
The Affordable Care Act says a couple of things; one, that 
mental health and substance abuse disorder benefits have to be 
a part of any marketplace plan. That is huge, because there has 
always been a lack of coverage.
    The second thing that it does, to your point, is basically 
say to insurance companies you can't discriminate in the 
provision of ----
    Ms. Lujan Grisham. How are we enforcing that? Because I 
will tell you that access is still a giant issue in my state 
and so many others. So we recognize it in policy, but what are 
we doing--and there are only 10 seconds left--to actually make 
sure it is occurring? And given that now Medicaid is largely a 
managed care environment, we are going to debate fee-for-
service and managed care ad nauseam, I am sure, in further 
health care reform environments. But the reality is, if the 
insurance companies aren't really making it available, then you 
really don't have access in spite of coverage; correct?
    Mr. Botticelli. I agree, and I should say I hear that a lot 
in my travels around the country, and I think that the Federal 
Government can do more work around enforcing parity, but states 
can play a key role, and the state insurance commissioners can 
play a pivotal role in this. Providers play a key role in 
making sure that complaints get to state insurance 
commissioners about this. So we all have a role to play in 
terms of enforcing parity and ensuring that we are about to 
finalize Medicaid managed care rules as it relates to parity.
    So I would agree that we each have a role to play in terms 
of parity enforcement.
    Ms. Lujan Grisham. I am well above my time. Thank you, Mr. 
Chairman, for your flexibility and patience.
    Mr. Mica. Thank you for staying and participating.
    The gentleman from South Carolina, Mr. Gowdy.
    Mr. Gowdy. Thank you, Mr. Chairman.
    Agent Milione--am I pronouncing that correctly?
    Mr. Milione. Yes, that is correct.
    Mr. Gowdy. Agent, I want to talk to you in a second about 
drug court. But before we get to drug court, would you agree 
that there are some who traffic in narcotics who themselves are 
not users?
    Mr. Milione. I would agree.
    Mr. Gowdy. So drug court is not going to be much help for 
us or for them because they are not addicts, they don't use. So 
let's go with those who are using drugs. I think you would also 
agree with me that folks who use drugs commit robberies and 
burglaries and domestic violence and a host of crimes that we 
consider to have an element of violence. Would you agree with 
that?
    Mr. Milione. Certainly, that contributes to an element of 
violence, yes.
    Mr. Gowdy. All right. So you have drug dealers who don't 
use, and then you have drug addicts who are not engaged in 
Title 21 crimes.
    Mr. Milione. That is correct.
    Mr. Gowdy. All right. There are different models for drug 
courts. Some are diversion programs where you just divert out 
of the criminal justice system altogether. Some you plead 
guilty and your sentence is drug court. We had a dickens of a 
time in South Carolina in getting criminal defense attorneys to 
plead their clients to drug court even though in the eyes of 
everyone it is better for their client, who happened to be an 
addict. It is tougher than probation, so the criminal defense 
attorneys had no interest in that.
    So how do we devise a plan where you get drug court even if 
your criminal defense attorney doesn't want you to have it?
    Mr. Milione. Congressman, I don't know that I am actually 
the right person to answer that since at the Federal level we 
are working at a level where we are going to take in the 
Federal system, and drug courts aren't an option. That would be 
more the state and local level with some of our state task 
forces. So I really wouldn't be in the best position to answer 
that question.
    Mr. Gowdy. Well, before I go to Mr. Botticelli, I want to 
ask you something that might be in your wheelhouse, and that 
would be diversion. Do you have a background in diversion, 
Agent Milione?
    Mr. Milione. Yes, yes, yes.
    Mr. Gowdy. All right. Back in the old days, the standard 
was if physicians prescribe drugs outside the course of a 
medical practice, a professional medical practice, they 
actually could be prosecuted themselves.
    Mr. Milione. That is correct.
    Mr. Gowdy. There was a dip, it looked like to me, in the 
number of cases that DEA was pursuing from a diversion 
standpoint. Was that just an optical illusion, or at some point 
the DEA decided to interact more with the pharmaceutical 
companies and less with the physicians who were actually 
prescribing the medicine?
    Mr. Milione. I need to know if you are speaking about 
criminal cases. I am not aware of any dip on criminal or civil 
cases. But then there is also the administrative actions, 
potentially revoking the registrant's registration. I am not 
aware--if you are talking about criminal, I am not aware that 
there was a dip in any criminal numbers as far as the criminal 
prosecutions.
    Mr. Gowdy. Would you check that for me?
    Mr. Milione. Be happy to.
    Mr. Gowdy. All right, because ----
    Mr. Milione. What span were you speaking to?
    Mr. Gowdy. Well, I have been gone since 2010.
    Mr. Milione. Okay.
    Mr. Gowdy. I know that we did DEA diversion cases and we 
prosecuted doctors, and then it just seemed to me that the 
focus shifted over to pharmaceutical companies.
    Mr. Milione. I can tell you from a policy perspective, and 
also from what we are doing, it has never been a conscious 
shift. We have aggressively gone after, where appropriate, 
again a small percentage of the overall number of DEA 
registrants. But I will certainly look at those numbers and get 
back to you on that.
    Mr. Gowdy. All right. I know it is hard to prosecute 
doctors, but when you are prescribing medicine without even 
doing an examination, without even so much as checking blood 
pressure, you are just running a pill mill. I think, with all 
due respect to my friends on the other side, prison might be 
the right place for those doctors.
    Mr. Botticelli, what kind of drug court can you devise 
where criminal defense attorneys do not advise their clients 
against their overall better health to opt for probation 
instead of drug court?
    Mr. Botticelli. I am not familiar with that. I would be 
happy to work with you.
    Mr. Gowdy. Have you met any criminal defense attorneys? Are 
you familiar with them?
    Mr. Botticelli. No, I am. Actually, there has been huge 
support across the board as it relates to our drug courts.
    Mr. Gowdy. I am sure there is, if it is a diversion court. 
I am quite certain that there is huge support for that. I am 
not talking about diversion where you have no record and you 
actually don't face any consequences. I am talking about 
pleading guilty and your punishment is drug court as opposed to 
probation, with probation being much easier than drug court.
    Mr. Botticelli. There are many drug courts that operate 
under that model, right? So it is very interesting to me, and 
again, it has gotten wide support among many folks in the 
criminal justice world. So if there are particular folks you 
would like us to work with in terms of doing some more 
education around drug courts, what they can do with the various 
models, we work very closely with the National Association of 
Drug Court Professionals to do levels of training and outreach 
and I would be happy to work with you.
    Mr. Gowdy. I am out of time. Mr. Chairman, could I ask one 
more question?
    Mr. Mica. Yes.
    Mr. Gowdy. Let's assume that you plead guilty to armed 
robbery and your sentence is drug court. How many lapses do you 
think are appropriate before the actual sentence imposed is 
carried out?
    Mr. Botticelli. I would have to go back and see what the 
guidelines look like. I would assume that that probably gets 
interpreted different ways by different judges ----
    Mr. Gowdy. I was asking you.
    Mr. Botticelli. I actually don't know that in terms of if 
there is specific guidance around ----
    Mr. Gowdy. I am talking about best practices. I mean, 
obviously, for the first offense, the first relapse, it doesn't 
make any sense, but the hundredth doesn't make any sense 
either.
    Mr. Botticelli. No. I would have to look at the National 
Association of Drug Court Professionals. It does put out best 
practice guidance, and I don't know explicitly what that ----
    Mr. Gowdy. Would you do that for me so we can have an idea 
what is fair?
    Mr. Botticelli. Absolutely. But to your point, I think 
there is an acknowledgement that many people with substance use 
disorders do relapse, and we need to have a good response in 
terms of that. You are right, people need to be held 
accountable for their actions as well, so it is a real balance 
between recognizing relapse and still holding people 
accountable. But I would be happy to ----
    Mr. Gowdy. I will tell you what I will do, then. In honor 
of you, I will acknowledge that there are relapses. And in 
partial honor of me, the next time you have a chance to talk to 
criminal defense attorneys, you tell them that it is overall in 
their clients' best interest to get off drugs, not to get onto 
probation, which is much easier to navigate than drug court. In 
the short term it might inure to their clients' benefit. In the 
long run, it does not.
    Mr. Botticelli. Okay, happy to do that.
    Mr. Gowdy. Thank you.
    Mr. Mica. To conclude, we will do a quick round of summary 
questions.
    Mr. Cummings?
    Mr. Cummings. Dr. Wen, one of the things that is so 
disturbing to me is there are certain areas in Baltimore where 
people are getting methadone treatment, and when you see the 
number of people whose lives have been destroyed, and we see 
the masses of them--and I would say to the gentleman from South 
Carolina, would invite you, Mr. Gowdy, I would invite you at 
some point to come with me to Baltimore. When you see the 
masses of people who are using, it is painfully painful, I am 
telling you. I agree that there are those who are selling drugs 
who are not using. I agree with you that there are folks who 
are going out there and committing a lot of crime. As a matter 
of fact, probably most of the crime in Baltimore has something 
to do with drugs in one way or another.
    But there is also a group of people who are truly addicted, 
and they are dying at 78 a day. That is major stuff. So I would 
invite you. I think when you see it like that--because the 
Chairman came with me to Baltimore and saw what I am talking 
about. In some kind of way, we have to get to that, and I think 
there are a lot of different remedies to try to address these 
things, but I am definitely not one that wants to be soft on 
people who are going around and selling death, and I have said 
that many times. But at the same time, we have a lot of people 
who truly are addicted.
    Dr. Wen, where do you--and the gentleman from South 
Carolina made some good points--where do you draw the line and 
say, okay, I have these addicts, but these addicts, some of 
them are committing crimes. And what do you think of the 
methadone treatment? Because a lot of people question whether 
you are just keeping people continuing to be addicted to a 
substance. Do you follow me?
    Dr. Wen. Thank you very much, Congressman Cummings. So the 
first issue is that we know in Baltimore that there are 20,000 
people who use heroin, and many more who are addicted to other 
drugs, and most of the drug arrests that are happening--there 
are 73,000 arrests that happen in our city every year. The 
majority of the arrests that happen are for individuals for 
only selling drugs to feed their own habit.
    What they need is not incarceration. What they need is drug 
treatment, and that is what we have to provide, and we have to 
make sure they get treatment while they are incarcerated. If 
they are incarcerated, they have to get treatment in jail as 
well.
    Mr. Cummings. Can you pause there for one second? One thing 
a lot of people don't know about heroin is you can be addicted 
to heroin for 30 or 40 years. Am I right?
    Dr. Wen. Yes.
    Mr. Cummings. And still function. Is that right?
    Dr. Wen. Yes. There are some individuals who are very high 
functioning who are in all walks of life, all professions, 
while they are addicted to a variety of drugs, including 
alcohol as well.
    To your point about treatment, I am a doctor and a 
scientist and I have to use the evidence, and evidence shows 
that medication-assisted treatment, including methadone and 
buprenorphine, are the first line, they are the standard of 
care when it comes to opioid addiction. We also agree, though, 
that we need to have increased treatment, including with 
buprenorphine, which can be given in an office-based setting. 
That will also help us to reduce the stigma around addiction.
    And, Congressman Cummings, I want to thank you also for 
your leadership in Baltimore City. We hope that there will be 
additional funding directed to our cities of greatest need, 
areas of greatest need. We are the ones on the front lines, we 
are the ones who are innovating, and we are the ones who need 
the most resources, rather than have the peanut butter spread 
evenly across all areas.
    Mr. Cummings. You know, naloxone, the idea that we were 
getting a 10-pack for $190 back in 2014, and then they 
increased it to $400--is that right?--have you seen any 
movement? I know that various states and our attorney general 
has been trying to work out something where we can get that 
cost back down. Have you seen any movement in that area?
    Dr. Wen. We have not. We have not in Baltimore City. Last 
year we were fortunate to receive a generous donation from a 
pharmaceutical company to assist us for over 8,000 units of 
naloxone, but we can't depend forever on the generosity, on the 
donations from companies. We have to have this medication, 
which is a generic medication that is on the World Health 
Organization's list of essential medications, available to 
everyone so that we can save lives.
    Mr. Cummings. Again, I want to thank all of you for being 
here today. We do have a lot to do. It is a very serious 
problem, and we are going to have to try to hit it from a lot 
of angles. As Chairman Mica said, years ago he and I--you were 
the Chairman--the chairman and ranking member of a subcommittee 
called the Drug Subcommittee did a lot of work, and we are 
going to have to do even more. So, I thank all of you.
    Mr. Mica. Let's see. Mr. Grothman?
    Mr. Grothman. Sure. I will give you two quick questions.
    First of all, drunk driving is a big problem in our 
society, and when we arrest somebody for drunk driving, some 
people are alcoholics and have an addiction to alcohol, and a 
lot of people are just irresponsible people, social pressure, 
whatever, got a drunk driving ticket. I have only met two 
people in my life who have used heroin. They both were in the 
criminal justice system. Both felt they were not addicted.
    Percentage-wise, give me a stab at it. Of the people who 
are arrested with heroin possession or whatever, what 
percentage are addicts, and what percentage are just people who 
are social pressure or whatever, want to feel good for the day, 
are using heroin? What percentage do you think need treatment, 
and what percentage are people who are just like the person who 
gets a drunk driving ticket because they are just 
irresponsible? Could a couple of you give me your guess?
    Mr. Botticelli. I will take a stab at it and take a look at 
it. I would assume that the rates of non-addictive heroin use 
are incredibly low just because it is a very powerfully 
addictive drug.
    Mr. Grothman. Each one of you just give me a percentage. I 
don't have a lot of time. What percentage of people who are 
arrested for heroin are like the two people that I talked to 
who didn't crave it, didn't need it, one did it for social 
reasons and one was going through a depression at that time? 
What percentage are addicted and what percentage are just using 
it because my buddy is using it and it is cool?
    Mr. Botticelli. I would say probably 5 percent of people 
who are using marijuana have no addiction to it, but that would 
be ----
    Mr. Grothman. You mean heroin?
    Mr. Botticelli. Heroin. I am sorry.
    Mr. Grothman. Only 5 percent are addicted.
    The next gentleman?
    Mr. Milione. I can't give you a percentage. That is not how 
we encounter--we don't encounter individuals that way based on 
the work that we do at the DEA. So I can't give you a 
percentage.
    Mr. Grothman. Okay. Ms. Enomoto?
    Ms. Enomoto. What we can give you is data from our National 
Survey on Drug Use and Health, which just surveys people about 
how many people have used heroin the last month or in the last 
year, and then how many of those people actually meet criteria 
for disorder, and I would imagine you would find fairly 
parallel realities. We don't do screening on arrest. We don't 
have the time to do diagnostic evaluations on everyone who is 
arrested for possession, so we don't have those data available.
    Mr. Grothman. Do you have an opinion?
    Ms. Enomoto. No, but I am happy to get you those data, the 
data that we do have.
    Mr. Grothman. Anybody up there have an opinion? Anyone else 
have an opinion on the percentage that are addicted and the 
percentage that are just using?
    Dr. Wen. I can give you my perspective as a practicing 
physician, and also experience in Baltimore, which is that the 
vast majority--we are talking well over 90 percent--will be 
individuals who have an addiction. Heroin comes from opium, and 
it is one of the most addictive substances in the world.
    Mr. Grothman. Okay.
    Ms. Jacobs. I don't have the answer. I can tell you that 
out of the 2,000 people that come through our jail that 
acknowledge they are using heroin, all of them have an 
addiction. Now, the reality is that they are acknowledging it 
because they know they are going to go through withdrawal.
    But, you know, I think that there is some information that 
we could obtain through some databases dealing with people that 
have been prescribed opioids and how many of them have become 
addicted. I don't really think ----
    Mr. Grothman. I am out of time. I will cut you off because 
I want to ask one more question.
    Okay, so maybe the two people I have met who have actually 
used heroin and got caught, when they say they were not craving 
it at all, maybe they are an aberration.
    Okay, the next question I have, just one example. If I 
break my arm, just a simple break, do you think under any 
circumstances, given that they never prescribed it 15 years 
ago, under any circumstances--what percentage of the time do 
you think a doctor should prescribe opiates for a broken arm?
    Dr. Wen. A broken arm is extremely painful, and if somebody 
had come to the ER with a broken arm, I would give them even IV 
medications, including for opioids. So it does make sense that 
this is a reasonable use for opioids.
    Mr. Grothman. Does anybody else think in all cases for a 
broken arm you should be prescribing opiates? For how long? Say 
for over a week? What percent think if you have a broken arm 
you should prescribe opiates, give a prescription for at least 
a week?
    Mr. Botticelli. I can tell you what the CDC guidelines 
recommend in those kinds of situations. Obviously, that is a 
decision that needs to be made between the patient and the 
doctor. There should be a conversation to do it. But the CDC 
guidelines say the lowest possible dose and the shortest 
possible duration.
    Mr. Grothman. So would you, if you were the doctor, give a 
prescription for at least a week?
    You know, politicians are known for not giving straight 
answers, not you guys. But okay, go ahead.
    Anybody else have a stab at this? Is it responsible to give 
a prescription for opiates for at least a week if I crack my 
arm here?
    Ms. Jacobs. Sir, if I could take a stab at this?
    Mr. Grothman. Sure.
    Ms. Jacobs. I am not a doctor. I am a mother of four 
children. One of my children has had multiple broken bones in 
sports. One of them had three torn ACLs and meniscus tears, so 
they have all gone through a lot of surgery. Each time they 
have been given opioids, and each time I would say it was 
probably for about a week. In all cases they were warned--I was 
warned about what to look for in case of addiction. In every 
case, they were not on opioids for more than 48 hours. We took 
them off in 48 hours. So I can tell you that as severe as those 
injuries were, we weaned them off.
    I had a severely broken bone in both of my arms. I was off 
of painkillers in three days and never on opioids. So I hope 
that answers your question. I think anything more than that 
really needs to be carefully looked at.
    Mr. Grothman. Now, are you a mental health professional? 
I'm sorry, are you a health professional?
    Ms. Jacobs. Am I? No. I am a mom of four kids. I think I 
probably know a whole lot of things.
    Mr. Grothman. No wonder you have so much common sense.
    Ms. Jacobs. I could be a mental health professional by the 
time I raise four children.
    Mr. Grothman. Good. We got one commonsense answer out of 
the five, and it was the person who is not a mental health 
professional--not a health professional.
    Thank you very much.
    Mr. Mica. I thank the gentleman.
    Mr. Gowdy?
    Mr. Gowdy. Thank you, Mr. Chairman.
    I want to thank all of our panelists, and I want to thank 
my friend from Maryland for his gracious invitation, which I 
will take him up on. I would love to go see what is happening 
in Baltimore. I expect, Mr. Chairman, that it is, at least on a 
larger scale, similar to what was happening in my own home 
town, which is why I started a drug court in 2000, and in 
addition to that drug court we started a drug court for 
expectant mothers who were using controlled substances during 
the course of their pregnancy, because I do believe getting 
them off drugs is infinitely preferable to incarceration in 
non-violent cases.
    I would also say this, Mr. Chairman, and to my friend from 
Maryland, there is no joy like going to a graduation ceremony 
for those who have concluded drug court successfully. I have 
had folks that I prosecuted stop me in the grocery store to 
show me the certificate from their graduation, and they were 
prouder of that than anything you or I could have ever 
accomplished in our careers. I used to counsel folks who were 
still going to need prison, so I would be a little reluctant to 
close all the prisons as we open up drug courts.
    But the gentleman from Maryland is right. I would say about 
half the crime we saw for 16 years, drugs and/or alcohol were 
at the root of that. There was one addict in particular, Mr. 
Chairman, who took a hammer to the older couple that lived next 
to him and beat them. They were in bed, asleep, in the middle 
of the night, and he broke in to rob them, and he beat them 
with a hammer where they were unrecognizable as humans. That 
was the pathologist's description, not mine. And then he raped 
the female victim post-mortem. He was an addict.
    But we are going to need to hang onto those prisons, Mr. 
Chairman, in addition to the drug courts, and I would be happy 
to go to Maryland with my friend to see the work that they are 
doing there, and I would invite him down to Spartanburg.
    Drug courts can save people's lives and get them off. I 
just hope they get off before they do acts of violence against 
the innocent public, because the addicts sometimes leave a wake 
of violence and mayhem in the wake of their addiction.
    With that, I would yield back.
    Mr. Cummings. Would the gentleman yield, please, just for 
one second?
    Mr. Gowdy. Be happy to.
    Mr. Cummings. First of all, I want to thank you for 
agreeing to come to Baltimore. I agree to go to South Carolina, 
be happy to.
    Just one thing, Mr. Chairman. I agree with you, we have 
very effective drug courts in Maryland, and I know what you are 
talking about. One of my first cases was a death penalty case, 
early in my career, where a young man hammered his grandmother 
to death, and he was on drugs. So I get it, I get it.
    Like I said, I think there are different categories here of 
folks, and I swear, I just wish we could catch them early, like 
you said, because I have seen some really bad, bad stuff. So 
the thing is trying to figure out a balance here. And even when 
you figure out the balance, you are probably going to still 
find people falling through the cracks, but I guess we have to 
use our best science and best judgment.
    But I thank the gentleman for yielding.
    Mr. Gowdy. Yes, sir.
    Mr. Mica. I thank the members for participating, and our 
witnesses.
    I just have a couple of final things.
    It is now 1 o'clock. We started this some three hours ago. 
Fifteen people in the United States have died from drug 
overdoses, three of them from heroin. Before the day is over, 
120 Americans will die, 24 of them from heroin.
    We have heard different things touted here today. Some 
people have said we just need to put more money into treatment. 
Treatment is essential, but treatment is at the end of the 
line.
    You heard a couple of comments from the other side of the 
aisle today that we need to act before we go home at Easter and 
put more money into the heroin and drug overdose situation.
    This is the remarks of Senator Grassley on the floor. 
``According to the Office of National Drug Control Policy, the 
appropriations act passed in December provided more than $400 
million in funding specifically to address the opioid epidemic. 
This is an increase of $100 million over the previous year.'' 
That is a 25 percent increase, okay? None of that money, when 
he said that just a few months ago, has been spent yet. All of 
that money is available today. Is that right? Or most of it? 
Tell me. Most of that money is available today, and you would 
think we were going out of here not providing money--25 percent 
increase.
    I want this in the record, and then let's put in the record 
too the record of how much was asked for, how much was 
appropriated, how much money was taken from interdiction and 
law enforcement and put into treatment, okay? These are just 
the facts. We don't want to deal with the facts, but we are 
going to put this also in the record so you can see that, 
again, there is money there.
    And I want a report. I want a report, I am telling you, 
this week, of how much money is spent, and I want that in the 
record, okay Mr. Botticelli? And then I want something from 
you, too, Ms. Director of our Mental Health and Substance Abuse 
office. I want to see how much money is pending, and I want it 
in the record, and I want it in my office by Friday close of 
business, because I know the money is there. It hasn't even 
been distributed.
    So we are not going to play these games. I want the facts 
there, and we need to stop this stuff at our border. It is 
coming in, and I just showed--my mayor I think also cited it. 
It is coming in by the boatload across the borders.
    I have one question, too. I talked about El Chapo. The 
biggest drugs are coming across the border like it was some 
kind of a vacation holiday. I was told, speaking of weapons 
which are used in most drug offenses, most of the murders are--
in Baltimore, they are killing people in drugs. In Orlando, we 
are killing them--we kill them at the mall, we kill them in our 
streets, in our great communities, our poor communities. We are 
killing them. Most of them are gun deaths, and they are related 
to drug trafficking, aren't they, Mr. Milione?
    Mr. Milione. Yes ----
    Mr. Mica. Yes, and a lot of those are illegal weapons. Now 
I am told--I just got this this morning--El Chapo, who is 
coming back and forth, also one of the weapons he had was 
traced to the Fast and Furious. So it was a weapon that was 
supplied by the United States Government, and the principal 
drug trafficker who is trafficking across the border like a 
holiday visit, he had one of the Fast and Furious. Are you 
aware of that?
    Mr. Milione. I am aware from the press reports.
    Mr. Mica. Okay. Can you confirm that also for the 
committee?
    Mr. Milione. I wouldn't be in the best position to do that. 
It would be another agency. I will take it back to the 
Department.
    Mr. Mica. All right. Well, I want you to check on it for me 
and let me know, okay?
    And I am very pleased with the people out there, but I met 
with some of your people, and the prosecutions are not what 
they should be. You know, you go to Singapore and they do not 
have a treatment program. I want to put you out of business, 
Ms. Wen, all the treatment programs. I want to put them out of 
business because our kids and our adults should not have to go 
to treatment. But we are allowing this crap to come into the 
United States. It is offensive.
    We are killing tens of thousands, folks, and anything else, 
people would be outraged. Where are you? Just Say No, and 
saying Just Say Maybe, there are consequences, or Just Say Okay 
makes a difference to our young people and what is happening.
    You can tell I can get a little hot, the Italian comes out 
of me, but I have seen them. I have seen them dying in the 
streets of Baltimore, and I see them now dying again in my 
community, and we need to do something about it, and that 
supply has to be cut off. Then I can put Ms. Wen and others out 
of business. We won't have to be treating people. We won't have 
the scourge on our streets.
    There being no further business before this committee of 
the House, this hearing is adjourned.
    Thank you, witnesses.
    [Whereupon, at 1:10 p.m., the committee was adjourned.]


                                APPENDIX

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