    [Senate Hearing 114-722]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-722

                     AMERICA'S INSATIABLE DEMAND FOR DRUGS

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

                                     HEARING

                                   BEFORE THE

                                  COMMITTEE ON
                   HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 SECOND SESSION

                                   ----------

             AMERICA'S INSATIABLE DEMAND FOR DRUGS, APRIL 13, 2016

                  ASSESSING THE FEDERAL RESPONSE, MAY 17, 2016

                EXAMINING ALTERNATIVE APPROACHES, JUNE 15, 2016

                                   ----------

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            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                        RON JOHNSON, Wisconsin Chairman
    JOHN McCAIN, Arizona                 THOMAS R. CARPER, Delaware
    ROB PORTMAN, Ohio                    CLAIRE McCASKILL, Missouri
    RAND PAUL, Kentucky                  JON TESTER, Montana
    JAMES LANKFORD, Oklahoma             TAMMY BALDWIN, Wisconsin
    MICHAEL B. ENZI, Wyoming             HEIDI HEITKAMP, North Dakota
    KELLY AYOTTE, New Hampshire          CORY A. BOOKER, New Jersey
    JONI ERNST, Iowa                     GARY C. PETERS, Michigan
    BEN SASSE, Nebraska

                      Christopher R. Hixon, Staff Director
             Brooke N. Ericson, Chief Counsel for Homeland Security
                  Jose J. Bautista, Professional Staff Member
       Servando H. Gonzales, U.S. Customs and Border Protection Detailee
                  Gabrielle A. Batkin, Minority Staff Director
               John P. Kilvington, Minority Deputy Staff Director
                   Holly A. Idelson, Minority Senior Counsel
         Stephen R. Vina, Minority Chief Counsel for Homeland Security
             Brian F. Papp, Jr., Minority Professional Staff Member
            Ellen W. Harrington, Minority Professional Staff Member
                         Laura W. Kilbride, Chief Clerk
                       Benjamin C. Grazda, Hearing Clerk

                                C O N T E N T S

                                     ------
                                                                       Page

                           WEDNESDAY, APRIL 13, 2016

    Opening statements:
        Senator Johnson..............................................     1
        Senator Carper...............................................     2
        Senator Ayotte...............................................    21
        Senator Booker...............................................    24
        Senator McCaskill............................................    27
        Senator Portman..............................................    30
        Senator McCain...............................................    33
    Prepared statements:
        Senator Johnson..............................................    47
        Senator Carper...............................................    48

                                    WITNESS

    General John F. Kelly, USMC (Retired), Former Commander of the
      United States Southern Command (2012-2016).....................     5
    Jonathan P. Caulkins, H. Guyford Stever Professor of Operations
      Research and Public Policy, Heinz College, Carnegie Mellon
      University.....................................................     7
    Cheryl G. Healton, Dean, College of Global Public Health, New
      York University................................................     9
    Tony Sgro, Chief Executive Officer, EdVenture Partners...........    12
    Robert J. Budsock, President and Chief Executive Officer,
      Integrity House, Inc...........................................    14

                         Alphabetical List of Witnesses

    Budsock, Robert J:
        Testimony....................................................    14
        Prepared statement...........................................   121
    Caulkins, Jonathan P.:
        Testimony....................................................     7
        Prepared statement...........................................    70
    Healton, Cheryl G.:
        Testimony....................................................     9
        Prepared statement...........................................    93
    Kelly, General John F.:
        Testimony....................................................     5
        Prepared statement...........................................    50
    Sgro, Tony:
        Testimony....................................................    12
        Prepared statement with attachment...........................   105

                                    APPENDIX

    Response to post-hearing questions for the Record:
        Mr. Kelly....................................................   126
        Mr. Caulkins.................................................   138
        Ms. Healton..................................................   146
        Mr. Sgro.....................................................   155
        Mr. Budsock..................................................   159

                             TUESDAY, MAY 17, 2016

    Opening statements:
        Senator Johnson..............................................   253
        Senator Carper...............................................   253
        Senator Ayotte...............................................   267
        Senator Tester...............................................   272
    Prepared statements:
        Senator Johnson..............................................   285
        Senator Carper...............................................   286

                                    WITNESS

    Hon. Michael P. Botticelli, Director, Office of National Drug
      Control Policy.................................................   255
    Kana Enomoto, Principal Deputy Administrator, Substance Abuse and
      Mental Health Services Administration, U.S. Department of
      Health and Human Services......................................   257
    Diana C. Maurer, Director, Homeland Security and Justice, U.S.
      Government Accountability Office...............................   259

                         Alphabetical List of Witnesses

    Botticelli, Hon. Michael P.:
        Testimony....................................................   255
        Prepared statement...........................................   288
    Enomoto, Kana:
        Testimony....................................................   257
        Prepared statement...........................................   298
    Maurer, Diana C.:
        Testimony....................................................   259
        Prepared statement...........................................   308

                                    APPENDIX

    Information submitted by Mr. Botticelli..........................   329
    Information submitted by Mr. Botticelli..........................   330
    Information submitted by Mr. Botticelli..........................   332
    Responses to post-hearing questions for the Record
        Mr. Botticelli...............................................   333
        Ms. Enomoto..................................................   339
        Ms. Maurer...................................................   350

                            WEDNESDAY, JUNE 15, 2016

    Opening statements:
        Senator Johnson..............................................   355
        Senator Carper...............................................   356
        Senator Portman..............................................   371
        Senator Lankford.............................................   375

                                    WITNESS

    D. Scott MacDonald, M.D., Physician Lead, Providence Crosstown
      Clinic.........................................................   358
    Ethan Nadelmann, Ph.D., Executuve Director, Drug Policy Alliance.   360
    David W. Murray, Senior Fellow, Hudson Institute.................   363
    Frederick Ryan, Chief of Police, Arlington, Massachusetts........   367

                         Alphabetical List of Witnesses

    MacDonald, D. Scott, M.D.:
        Testimony....................................................   358
        Prepared statement...........................................   403
    Murray, David W.:
        Testimony....................................................   363
        Prepared statement...........................................   433
    Nadelmann Ph.D., Ethan:
        Testimony....................................................   360
        Prepared statement with attachment...........................   410
    Ryan, Frederick:
        Testimony....................................................   367
        Prepared statement...........................................   470

                     AMERICA'S INSATIABLE DEMAND FOR DRUGS

                                  ----------

                           WEDNESDAY, APRIL 13, 2016

                                         U.S. Senate,
                               Committee on Homeland Security
                                      and Governmental Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 9:33 a.m., in
    room 342, Dirksen Senate Office Building, Hon. Ron Johnson,
    Chairman of the Committee, presiding.
        Present: Senators Johnson, McCain, Portman, Ayotte, Ernst,
    Carper, McCaskill, Tester, Heitkamp, Booker, and Peters.

                 OPENING STATEMENT OF CHAIRMAN JOHNSON

        Chairman Johnson. Good morning. This hearing will come to
    order.
        I want to thank all of the witnesses for taking the time,
    not only to appear here today, but for taking the time to
    submit what I think are just extremely thoughtful testimonies.
        I hate to say this, but I am looking forward to this
    hearing. It is such a terrible subject. It is such an enormous
    problem facing this Nation.
        I took a swing through Wisconsin in January. We called it a
    ``national security tour.'' And, I asked every public--local,
    State, and Federal--public safety official that we talked to,
    in probably about six different stops, what is the primary
    problem you are dealing with in your job. And, without
    exception, it was drugs--drug abuse and drug addiction--not
    only because of the crime it creates, but also because of the
    broken lives and the broken families.
        Senator Ayotte has been, certainly, a big leader, in terms
    of highlighting the heroin overdoses, which are prevalent in
    New Hampshire--but also in Wisconsin. We had a 24-hour period
    in Milwaukee, Wisconsin, where there were six overdoses. Just
    in the last couple of years, the overdoses have increased
    almost fourfold.
        I know, Senator McCain--we did a hearing down in Arizona
    with his Governor--it is an enormous problem as it relates to
    the border. And, that is kind of the second point of my opening
    statement here, which, by the way--I have a written statement
    which, with consent, can be entered for the record.\1\
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Senator Johnson appears in the
    Appendix on page 47.
    ---------------------------------------------------------------------------
        Senator Carper. Without objection.
        Chairman Johnson. This Committee has a mission statement.
    It is pretty simple: to enhance the economic and national
    security of America. We established four basic priorities for
    the issues we are going to look at: border security,
    cybersecurity, protecting our critical infrastructure, and
    combating Islamic terrorism.
        On border security, alone, we have now held 15 hearings to
    look at the different aspects of it and have published a more
    than 100-page report on our findings. Among many causes,
    certainly my conclusion, I think--and a number of Members on
    this Committee would agree with me--the primary root cause of
    our unsecure border is America's insatiable demand for drugs,
    because it has given rise to the drug cartels, who, by and
    large, control whatever section of the Mexican side of the
    border they want to control--as General Kelly certainly showed
    us, in Guatemala, when we were with him--destroying public
    institutions throughout Central America and in some South
    American countries.
        This is an enormous problem and there are no easy
    solutions. We have been fighting a war on drugs for many
    decades, spending more than $25 billion a year. In testimony,
    General Barry McCaffrey, in front of this Committee, said that
    we are only interdicting between 5 and 10 percent of the
    illegal drugs coming into this country. We are not winning this
    war.
        So, the good folks, like General Kelly, have been fighting,
    heroically, the supply side of this equation. But, it is our
    insatiable demand that also has to be fought. I know Nancy
    Reagan had her ``Just Say No'' program--and I know there were
    mixed results with that. But, the fact of the matter is, we
    have been extremely effective as the world's leading
    advertising country. We know how to market. We have reduced
    tobacco use. We need to put that same type of committed, long-
    term effort into doing everything we can to reduce our
    insatiable demand for drugs, because it creates so many
    problems--so much heartache.
        So, again, I just really want to thank the witnesses. I
    really am looking forward to a really thorough discussion and
    to laying out the reality. We are going to be talking about
    different solutions. We are going to be talking about things
    that are controversial, probably. This is not black and white.
    We have to have a thorough and honest discussion about this,
    because we all agree on the end goal. We have to reduce that
    insatiable demand for drugs.
        So, with that, I will turn it over to Senator Carper.

                 OPENING STATEMENT OF SENATOR CARPER\1\

        Senator Carper. Thank you, Mr. Chairman. Thank you so much
    for bringing this together.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Senator Carper appears in the
    Appendix on page 48.
    ---------------------------------------------------------------------------
        I want to preface my remarks by just saying that General
    Kelly is out of uniform for the first time in a long time. We
    appreciate your service so much. How many years did you serve
    in all?
        General Kelly. Forty-five years and 5 months.
        Senator Carper. Wow. What? Did you start at about 9 years
    old? [Laughter.]
        Thank you for every one of those years.
        And, Cheryl, it is just great to see you. Cheryl and I
    worked together standing up an outfit called the American
    Legacy Foundation at the--it came out of the State Attorneys
    Generals' (AGs') efforts--50-State tobacco settlement--and just
    did great work in deterring young people from smoking. And, we
    are very grateful for your efforts there and for all you
    continue to do. Thank you so much for joining us.
        And, all of the rest of the panel as well. Tony, it is very
    nice to see you again. You can teach us all how to pronounce
    your last name it is and we will do just fine here. Thank you
    for joining us.
        But, as the Chairman has said, this is a serious matter and
    we are going to focus on America's devastating addiction to
    illegal drugs.
        I just came back from--last week, in our 2-week recess, I
    went to China. I had not been there before. I had been to Hong
    Kong a couple of times, but had never been to China. I learned
    a lot. They have their problems. They have their share of
    problems over there, as you know. But, they also do some things
    pretty well that, maybe, we can learn from. They have, pretty
    much, intact two-parent families. Drug addiction is not a
    problem there. Gambling is illegal. They do some things very
    well and, maybe, there is something that we can learn from what
    they are doing in this regard. I like to say, ``Find out what
    works, do more of that.'' Now, I am saying that we should find
    out what does not work and, maybe, learn from that as well.
        But, we look forward to hearing from all of you. This is a
    difficult issue. It is not only a health emergency in our
    country and our States, but it is also a--it contributes to the
    security challenges that a number of our Latin American
    neighbors continue to face each day. And, those of us who have
    been down there know exactly what I am talking about. General
    Kelly has been there with us on several occasions and we are
    grateful for that.
        But, drug abuse--particularly, prescription drug and heroin
    abuse--has been a growing problem across our country for a
    number of years now. It has led to tragic consequences, not
    just for those who are suffering from addiction, but also for
    their families and for the communities in which they live.
        The Centers for Disease Control and Prevention (CDC) notes
    that, between 2002 and 2012, the rate of heroin-related
    overdose deaths, nationally, nearly quadrupled. In my home
    State of Delaware, there were 189 suspected overdose deaths in
    2014 alone. That is a little State--189 people. And, around
    3,000 adults sought treatment for heroin in our State's primary
    treatment facilities.
        American demand for heroin and other drugs also fuels the
    violent tactics of the traffickers who move drugs, goods, and
    people across our borders. American drug demand is also having
    a dramatic effect on--and a deadly effect in South and Central
    America. As our Committee has found, much of the corruption and
    violence in the Northern Triangle--in Guatemala, Honduras, El
    Salvador, and other parts of Central and South America--are
    fueled largely by our appetite for illegal drugs. This
    corruption and violence are major causes of the surge of
    migration from the Northern Triangle to the United States in
    recent years, as well as a source of misery to those who do not
    flee.
        I know that General Kelly will speak to the extremely
    damaging impact our drug use has on our security and the
    security of our neighbors in the Northern Triangle--not to
    mention the lives of the users themselves.
        Today, we are going to have the opportunity to discuss ways
    to best address the root causes of our demand for drugs. We
    will also explore the merits of media campaigns, peer-to-peer
    (P2P) outreach, and other educational initiatives that are
    aimed at reducing this demand. I am especially pleased, again,
    to welcome Cheryl Healton, who has been an instrumental force
    behind the successful public health initiatives that I
    mentioned earlier aimed at reducing the use of tobacco--
    particularly, among young people--and who stood up this
    foundation, colleagues, in 2001 and went to work on it. If you
    look at the use of tobacco, among young people, between 2001
    and 2010, it is really remarkable what happened--and Cheryl and
    her team deserve a lot of credit for that. We are going to find
    out, today, how some of those lessons might be imparted and
    shared with us, as we face addictions to other kinds of
    substances.
        And, because addiction and substance abuse are medical
    conditions that can often be treated effectively, we will also
    discuss the role of prevention and treatment--how they can play
    an important role in reducing demand.
        In sum, these problems that we are facing are complex and
    the potential solutions are not easy or quick. We know that.
    Getting a handle on drug abuse and the tragic problems that
    stem from it will require an ``all hands on deck'' effort, if
    we are to be successful in addressing what drives people to use
    these harmful substances and to help them overcome their
    addictions.
        Again, my thanks to my Chairman. My thanks to our
    colleagues, particularly, to all of you. And, thank you to our
    staffs for bringing us together for this moment. Thank you.
    Welcome.
        Chairman Johnson. Thank you, Senator Carper.
        It is the tradition of this Committee to swear in
    witnesses. So, if you will all rise and raise your right hand.
        Do you swear the testimony you will give before this
    Committee will be the truth, the whole truth, and nothing but
    the truth, so help you, God?
        General Kelly. I do.
        Mr. Caulkins. I do.
        Ms. Healton. I do.
        Mr. Sgro. I do.
        Mr. Budsock. I do.
        Chairman Johnson. Thank you. Please be seated.
        Our first witness is General John F. Kelly. General Kelly
    served as Commander, United States Southern Command (SOUTHCOM),
    in Miami, Florida from November 2012 until January 2016. He
    retired from active duty after 45 years of service to the
    Nation in the United States Marine Corps (USMC), both as an
    enlisted infantryman and an infantry officer on February 1,
    2016.
        General Kelly, again, thank you for your service to this
    Nation and thank you for being here.

     TESTIMONY OF GENERAL JOHN F. KELLY, USMC (RETIRED),\1\ FORMER
      COMMANDER OF THE UNITED STATES SOUTHERN COMMAND (2012-2016)

        General Kelly. Thank you, Mr. Chairman. I would like to
    start by saying it is a tremendous honor and privilege to be
    here this morning and to appear before this Committee to talk
    about this very vital topic.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of General Kelly appears in the Appendix
    on page 50.
    ---------------------------------------------------------------------------
        I have submitted what I know is a lengthy written
    statement, but I also know how useful that is to the staff--
    particularly, to get these kind of insights. And, I will just
    be brief and sit, because I think the real, probably, nub of
    this whole thing is the queston and answer (Q and A) segment.
        But, I would just start by saying that, when I first
    assumed
    duties in SOUTHCOM, the thing that struck me was the
    visibility--the very accurate visibility that that organization
    had then, and has now, on the movement of drugs--cocaine,
    heroin, methamphetamine (meth) and pharmaceuticals--from along
    this incredibly complex network through my zone, through the
    Western Hemisphere, up to the Southwest border, and into the
    United States. It was very frustrating, because we had such
    clarity of the movement and we had such good partners working
    with us--particularly, in Colombia--and I cannot underline that
    enough. They are heroic in what they do--as are some of the
    other countries. But, the Colombians have really dedicated
    themselves to getting at this problem and to helping us--as
    well as helping themselves.
        But, the point is, my Title 10 responsibilities in that
    role were the detection--we did that, very well--and the
    monitoring of the movement--we did that extremely well--not
    interdiction. Interdiction, of course--I was part of the
    interdiction team, but, technically, it is a law enforcement
    event.
        But, that said, very early on, I became very frustrated at,
    really, the lack of assets available to interdict drugs in vast
    amounts--tons at a time. And, to watch those drugs make it into
    Central America. Once they get into Mexico, they enter a whole
    other kind of network that makes it, essentially, a given that
    these drugs will appear in Boston, Wisconsin, and Idaho--places
    like that. It is really unstoppable once it gets ashore. All of
    the drugs that I think you are most concerned with are either
    trafficked--they are all produced in Latin America--in Central
    America, and then, of course, they are all trafficked up
    through to the border.
        That same network, though, will carry anything. As I say in
    my written statement, the people that manage this network do
    not check the reasons for coming to the United States, do not
    check bags, and do not test for explosive residue on hands. If
    you pay the fare, you are in the United States. And, I do not
    mean the people that kind of rush the border--the Mexicans, as
    an example--that just come--or the unaccompanied minors that
    are coming here for economic reasons. These people are coming
    here for a reason. They are paying a lot of money to get here
    and they are getting in.
        So, from a national security standpoint, as I have said,
    certainly, in the Senate Armed Services Committee (SASC) and in
    the House Armed Services Committee (HASC) the 3-years I was in
    the job in SOUTHCOM, I would say that, when there is a major
    event in the United States--whether it is a biological attack,
    a dirty bomb, or something like that--when we do the forensics,
    we will find that those people came here through the network
    that comes up through the Southwest border.
        But, I will just simply end with the fact that, as I got
    more and more frustrated not being able to do more and more, I
    realized that the real problem--and all of the problems in the
    South--would go away--the network would fall apart, Colombia
    would not have to fight this fight, and the Hondurans would not
    be on the edge of the abyss, if we would get our arms around
    the drug demand.
        And, what I would leave you with--and I give you this
    example in my written statement--when I was a kid, 70 percent
    of Americans--according to CDC figures, 70 percent of Americans
    smoked. As a 9-year-old, I was sent down to the corner store to
    buy a pack of cigarettes for my mother and my father. Today,
    you cannot do any of that. Today, less than 20 percent--
    according to CDC numbers--smoke. So, we know how to do behavior
    modification, but we just have not done it. With all of the
    good things that people have tried to do to combat drugs, there
    is no comprehensive plan.
        And, I do highlight, in my written statement, what the Drug
    Enforcement Administration (DEA) and the Federal Bureau of
    Investigation (FBI) have done by producing a very powerful
    anti-demand program that they are focusing on grammar school
    kids, middle school kids, and high school--teachers, actually,
    to try to get them in the fight. And, I have been told many
    times, ``Kelly, this is not your concern. This is a law
    enforcement concern.'' OK. But, as I say so frequently, people
    are not doing it, And, since they are not doing it, the FBI and
    the DEA--people like that are, in fact, taking this task on.
        We know how to do this. I do not know why we do not do it.
    And, it is just killing Americans at kind of a remarkable rate.
        So, I will leave it at that, Mr. Chairman. Thank you very
    much.
        Chairman Johnson. Well, again, thank you, General Kelly.
    And, yes, I appreciate--I think most of the witnesses provided
    pretty robust statements. They will all be entered into the
    record and I appreciate you keeping it short.
        Since you left a minute, I just want to give you the kudos.
    This hearing is because of you. It was on our helicopter flight
    to the border between Guatemala and Mexico that you asked me
    the question, because, again, you are battling the supply. And,
    you asked me, ``Senator, when is the last time America had a
    concerted, national public relations advertising campaign
    against the use of drugs?'' And, I said, ``Well, boy, I
    remember Nancy Reagan's `Just Say No' campaign and then a
    number of years later, I remember that famous egg commercial:
    `Here is your brain. Here is your brain on drugs.' '' And, you
    said, ``No, that was all part of the same effort. That was back
    in 1985. That was 30 years ago.''
        And so, I mean, really, the reason we are doing this is
    because of that conversation in that helicopter--it was kind of
    hard to hear some of it, but I really credit you with bringing
    this, certainly, this dimension of the problem to the
    forefront. So, thank you.
        Our next witness is Jonathan Caulkins. Mr. Caulkins is the
    H. Guyford Stever Professor of Operations Research and Public
    Policy at Carnegie Mellon University's Heinz College and is a
    member of the National Academy of Engineering. Dr. Caulkins
    specializes in systems analysis of problems pertaining to
    drugs, crime, terror, violence, and prevention--work that has
    won him several awards. Issues surrounding marijuana
    legalization have been a particular focus of his in recent
    years. Dr. Caulkins.

       TESTIMONY OF JONATHAN P. CAULKINS,\1\ STEVER PROFESSOR OF
    OPERATIONS RESEARCH AND PUBLIC POLICY, HEINZ COLLEGE, CARNEGIE
                           MELLON UNIVERSITY

        Mr. Caulkins. Thank you. It is a privilege to have the
    chance to speak.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Caulkins appears in the Appendix
    on page 70.
    ---------------------------------------------------------------------------
        You mentioned that, when you were back in your home State,
    people were listing this as the largest problem. When I was a
    Doctor of Philosophy (Ph.D.) student in engineering at the
    Massachusetts Institute of Technology (MIT), in the late 1980s,
    the reason I chose to dedicate my life to building quantitative
    models of drug traffickers, markets, and policy is exactly
    because it was listed, by the public, as the Nation's biggest
    problem.
        In my written testimony, I tried to, basically, say three
    things. The first is to agree--yes, the flows are large--and to
    try to put some numbers to them. There are hundreds of metric
    tons, per year, of the hard drugs and thousands of metric tons,
    per year, of marijuana. And, the value, as it crosses the
    border, is probably over $10 billion a year. You may have heard
    that $100 billion is the dollar value of the U.S. drug market.
    That is at retail. Most of the price increase happens inside of
    the country, so the value at the border is lower--but $10
    billion is still a lot of money.
        In terms of root causes, I will note that the root cause,
    at some level, is just because Americans are people. We do
    consume more illegal drugs than most of our peer countries, but
    we do not actually consume more intoxicants, in total, in the
    sense that we consume less alcohol than many of our peer
    countries do. This use of intoxicants is sort of part and
    parcel of the human condition.
        The main part of the testimony was about the fact that,
    even if we did everything in the best possible way, in terms of
    our drug policies and their conventional programmatic levers,
    that would not eliminate the security hole. The hokey metaphor
    I used is that it is like we have a two-car garage. Both doors
    are open right now, so burglars can enter. If we did everything
    right, we might, at the outside, be able to reduce the flow by
    half, but that would still leave one door wide open.
        I was asked about a couple of particular tactics. Media
    campaigns to control illegal drugs have not fared well in
    scientific evaluations. It seems like they ought to work. The
    people who do them are sincere. But, when evaluated, they do
    not evaluate well--and not only here, but also in the
    international literature.
        I was asked about treatment. The academic consensus is
    absolutely in favor of expanding drug treatment, but, mostly,
    because of the potential to alleviate the suffering of the
    people who have dependence problems--not because that would
    quickly reduce the quantity consumed.
        It is always important to differentiate between the opioids
    and everything else. For opioids, there are pharmacotherapies
    that allow us to substitute a legal opioid for the illegal
    opioid--and that does help reduce purchases on the illegal
    market. But, we do not have any such technologies for the
    stimulants, like crack cocaine and methamphetamine.
        I was asked about legalization. It is absolutely true that,
    if we did legalize, that would essentially solve the border
    security problem. This is because legal businesses can out-
    compete illegal businesses when it comes to delivering a legal
    product. But, we are unlikely to do that for the hard drugs--
    and for good reason.
        Cannabis legalization seems to be the way the country is
    going. If we eliminated that part of the overall flow of
    illegal drugs, that would eliminate the majority of the weight,
    but only the minority of the value--maybe a quarter of the
    dollar value of the smuggled drugs. The marijuana
    liberalization we have seen to date is well short of national
    legalization--although very substantial--and, I think, it is
    better to understand it as part of a large body of
    liberalizations that include the medical laws--not just the
    State legal recreational regimes that started in 2012.
        There is no question that the market share of imports in
    the cannabis market has gone down, but the quantity of cannabis
    consumed in the United States has doubled. So, the impact of
    policy liberalization on the flow across the border is a lot
    smaller than you would think if you look only at the market
    share. It is a smaller market share of a bigger market. In the
    long run, if we do proceed with national legalization, that
    would, presumably, largely eliminate the marijuana part of the
    overall drug flow.
        The one exception to this fairly pessimistic view of how
    much the conventional drug policy levers can do is, a very
    innovative approach called ``Swift, Certain, and Fair (SCF),''
    which uses extremely frequent testing of people under criminal
    justice supervision, while they are on community release,
    coupled with certain, but very modest, sanctions. South
    Dakota's ``24/7 Sobriety'' program is the classic example. Drug
    tests are administered literally twice a day. If somebody tests
    positive, they are instantly placed in jail--but for only 24
    hours.
        These programs have had stunning success at reducing drug
    use, but there are real barriers to expanding them. They are a
    challenge to the conventional approach to treatment because
    they are not really treatment. They may be hard, perhaps, to do
    in larger jurisdictions. But, if anything is going to
    dramatically reduce the use of hard drugs, I think it would be
    some version of ``Swift, Certain, and Fair.''
        Then, the last point that I try to make is----
        Senator McCain. Some version of----
        Mr. Caulkins. ``Swift, Certain, and Fair''--is that, in
    some other respects, there has been the potential to shrink the
    amount of collateral damage caused by drug markets, even if the
    volume of drugs in the markets does not go down as much. So,
    for instance, we can try to reduce the number of drug-related
    homicides committed in the United States per metric ton of
    drugs distributed and consumed. I do not know whether or not
    that principle could be applied to border security problems,
    but that possibly seems, to me, to be worth investigating.
        Thank you.
        Chairman Johnson. Thank you, Dr. Caulkins.
        Our next witness is Cheryl Healton. Ms. Healton is Dean of
    the College of Global Public Health (GPH) at New York
    University (NYU) and Director of the Global Institute of Public
    Health. Prior to this appointment, Dr. Healton served as
    President and Chief Executive Officer (CEO) of Legacy, the
    leading foundation dedicated to tobacco control. During her
    tenure with the foundation, she guided the highly acclaimed
    national youth tobacco prevention counter-marketing campaign,
    ``Truth,'' which has been credited, in part, with reducing the
    prevalence of youth smoking to near record lows. Ms. Healton.

    TESTIMONY OF CHERYL HEALTON,\1\ DEAN, COLLEGE OF GLOBAL PUBLIC
                      HEALTH, NEW YORK UNIVERSITY

        Ms. Healton. Mr. Chairman and Members of the Committee, I
    am privileged to appear before you this morning to testify
    about unmarketing illicit drugs to youth before they start
    using them as well as how we can work to curb the adult demand
    for drugs.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Healton appears in the Appendix
    on page 93.
    ---------------------------------------------------------------------------
        My name is Dr. Cheryl Healton and I am Dean of the College
    of Global Public Health at New York University. Prior to my
    appointment at NYU, I worked for 14 years at American Legacy, a
    national 501(c)(3) nonprofit charity with a well-respected
    history of producing game changing public health initiatives
    proven to reduce tobacco use. Best known for its bold counter-
    marketing campaign for youth, ``Truth''--now in its 16th year--
    the campaign has been a major part of a comprehensive,
    national, State, and local tobacco control strategy. Together,
    these measures have resulted in remarkable declines in youth
    tobacco use prevalence rates, from 23 percent in 2000 to below
    7 percent today.
        I have also served on the Board of Directors of the Betty
    Ford Institute (BFI) and Phoenix House, a large nonprofit drug
    and alcohol rehabilitation organization.
        Using tobacco as a case study today, it is important to
    understand what it took to prompt dramatic social norm change,
    which resulted in these shifts in knowledge, beliefs,
    attitudes, and behaviors. Public health experts know that four
    factors figure prominently in maintaining dramatic declines in
    tobacco consumption.
        The first factor is bold, highly targeted counter-marketing
    public education campaigns.
        The second factor is ever-increasing excise taxes on
    products at the State and Federal level to prompt cessation
    among price-sensitive consumers and to reduce initiation.
        The third factor is policy initiatives that restrict access
    to tobacco, safeguard the public from secondhand smoke, and
    provide access to cessation services for those addicted to
    tobacco products.
        Cumulatively, these measures combine to change social norms
    and save lives. Yet, the unspoken fourth leg of this stool is
    critically important: mustering the political will to enact
    what we know works--even though it ruffles feathers and annoys
    special interests. Public health too often loses out to
    corporate profit motives and the associated political
    influence, so we fail to do what we know must be done to
    achieve the life-extending results we all desire.
        While today's discussion focuses on those who peddle
    illicit drugs to our most vulnerable populations, the business
    models are not dissimilar. Those who profit from selling drugs
    to risk-seeking and troubled teens do so to make long-term
    customers of them. They care more about the lucrative sales
    than health. They attract young customers when their developing
    brains are the most vulnerable to risk-taking and addiction.
    Then, they reap the long-term profits, as users remain addicted
    and age.
        The United States cannot be safe from drug-related criminal
    activity without, first, reframing the relationship between
    drug use and crime and, second, sharply reducing the insatiable
    appetite for illicit drugs. This can be accomplished through
    the prevention of youth initiation, deglamorizing use by
    disruptive and innovative mass media campaigns as well as un-
    selling use, and inducing those who are addicted--or teetering
    on the verge of addiction--to seek very prompt treatment. It
    goes without saying that drug treatment needs to be broadly
    available and covered by insurance plans.
        I have provided the Committee with key studies which
    demonstrate that well-designed and well-executed, paid mass
    media campaigns improve health. In the case of the ``Truth''
    campaign, youth social norms and behavior shifted, first in
    response to a Statewide Florida campaign and, then, a larger,
    national campaign. In the national campaign, after the first 4
    years, 450,000 youths did not initiate--as a direct result of
    the campaign. In an analysis at 2 years, at least 22 percent of
    the decline in youth smoking was directly attributable to the
    campaign.
        Researchers at Johns Hopkins University (JHU) and Columbia
    University also concluded that, in 2 years, alone, the campaign
    averted $1.9 billion to $5.4 billion in future medical care
    costs.
        These are key lessons for the primary prevention of illicit
    drug use and should be applied as a basis for a new and
    improved program at the national level. The same impact on
    initiation may be achieved by powerfully hard-hitting, youth-
    focused communications--especially, those designed by and for
    youth at the highest risk of using drugs. Messages must be
    targeted to those most likely to initiate drug use and must
    provide compelling reasons to avoid initiation--including the
    fact that those profiting from their drug use are using them--
    even if that person is a low-level dealer they see as their
    friend or their boyfriend or girlfriend.
        The Office of National Drug Control Policy (ONDCP)
    supported the Partnership for a Drug-Free America's--now called
    the Partnership for Drug-Free Kids'--paid advertising campaign,
    which was sharply curtailed after a decade of persistent budget
    cuts. It is critical to bring it back--but to restructure it,
    so that it is truly independent of the kinds of oversight that
    can undermine a public education campaign's ability to succeed.
        This, specifically, means that the creative development
    must come from paid advertising developed and placed at market
    rates to ensure that the work is done by the hardest hitting
    and best paid agency possible--and to ensure it gets the right
    media placements. Youth market research has to be undertaken to
    appropriately target the design to subsets of high-risk youth,
    which will likely result in bold advertisements that are
    exceptionally unpalatable to adults and government Agency
    staff. I believe that point is the key reason that the former
    campaign failed--and it did fail.
        We need vigorous, real-time evaluation to decommission
    advertisements that are not resonating with the intended
    audiences and to quickly replace them with those that do. This
    is essential, as ads have possible boomerang effects and it is
    difficult to predict those in advance.
        To effectively reach adults, the approach is similar. But,
    if we persist in using a moralistic, criminal justice model for
    those addicted and at risk, we will miss the opportunity to
    turn the tide on an epidemic that the National Institutes of
    Health's (NIH's) data suggests we have been achieving some
    success with--and that must continue.
        In closing, there are proven ways to reach these young,
    impressionable audiences--and adults--with successful
    messaging. It requires the abandonment of previous, failed
    policies in favor of game-changing new ones.
        Thank you.
        Chairman Johnson. Thank you, Dr. Healton.
        I do want to quickly ask a question, because--as long as
    you raised it. What is an example of an unpalatable ad?
        Ms. Healton. Well, I mean, I will use the ``Truth''
    campaign as an example. Our first advertisement piled 1,200
    body bags around a tobacco company in New York City--downtown
    Manhattan. The first call I got was from the Department of
    Health, which had received a call from then--Mayor Rudy
    Giuliani's office asking to pull our ability to execute the
    advertisement. Luckily, Mayor Giuliani, ultimately, declined
    that invitation to pull our ability to shoot the advertisement.
        And then, we received lots of push-back about the
    advertisement--including from networks that would not play the
    advertisement and including networks that actually took our
    advertisements, before they aired, and sent them to
    PhilipMorris USA. If they did that for Coca-Cola and Pepsi,
    they would be in court over it.
        Chairman Johnson. OK. I did not want to have that moment
    pass without getting an example.
        Our next witness is Tony Sgro. Mr. Sgro is the Chief
    Executive Officer of EdVenture Partners (EVP). EVP builds
    industry-education partnerships with over 800 universities by
    connecting students, educators, and industry leaders for
    societal changes and brand building purposes. Mr. Sgro has more
    than 40 years of experience in marketing, advertising, and
    promotion. Mr. Sgro.

     TESTIMONY OF TONY SGRO,\1\ CHIEF EXECUTIVE OFFICER, EDVENTURE
                                PARTNERS

        Mr. Sgro. Chairman Johnson, Ranking Member Carper, and
    Members of the Senate Homeland Security and Government Affairs
    Committee (HSGAC), thank you for allowing me the honor of
    speaking with you today.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Sgro appears in the Appendix on
    page 105.
    ---------------------------------------------------------------------------
        I have been asked to do two things today. First, to
    introduce you to ``Peer-to-Peer: Challenging Extremism
    (P2P:CE),'' a countering violent extremism (CVE) university
    initiative and competition sponsored by the Department of
    Homeland Security (DHS), the National Counterterrorism Center
    (NCTC), the Department of State (DOS), and the technology
    giant, Facebook. ``Peer-to-Peer: CE'' is based upon a simple
    premise. Who better to develop alternative-narratives and
    counter-narratives to extremist messaging than the very same
    audience extremists want to recruit? Government has recognized
    it cannot do it, so it makes perfect sense to enlist tech-savvy
    youth to be part of the solution to push back on hate, terror,
    and extremism.
        The second thing I have been asked to do, after introducing
    you to ``Peer-to-Peer: Challenging Extremism'', is to
    demonstrate how this clay-like model can, similarly, be
    utilized to push back on drug demand by enlisting the help of
    street smart digital natives, who can play a role in the
    substance abuse solution--as they know the drug and social
    media culture of their communities better than anyone in this
    room.
        Briefly, this is how we make ``Peer-to-Peer: Challenging
    Extremism'' work on America's college campuses--and, please,
    substitute the word ``extremism'' for the words ``drug demand''
    when I speak, so you get a sense of the possibilities.
        ``Peer-to-Peer: Challenging Extremism'' challenges a class
    of university students, over the entire semester, while earning
    a grade, to develop a social or digital media initiative,
    product, or tool to counter extremism in their communities.
    They do robust research, brainstorm extremely creative ``Peer-
    to-Peer: Challenging Extremism'' campaigns, and, after they
    present their campaigns for review, we give the class real
    money to spend--a $2,000 budget--and say, ``Now, go bring your
    idea to life. Do not just give us a plan about challenging
    extremism, go do something.'' When you give students money to
    spend to actually do something, it changes the dynamics of
    learning. And, they absolutely love taking this class and doing
    something positive in their communities.
        The results we have seen, on 98 different universities in
    over 30 countries, thus far, with ``Peer-to-Peer: Challenging
    Extremism'' have been phenomenal. These campaigns are credible,
    authentic, and believable, because they were created by youth
    for youth.
        Here are two brief examples. At Missouri State University
    (MSU), the ``Peer-to-Peer: Challenging Extremism'' class
    created, amongst other activities, four different oversized,
    downloadable posters for seventh and eighth graders, educating
    them about social media safety. They also developed a middle
    school social media curriculum designed to cover extremist
    recruitment prevention, which the Governor has expressed
    interest in expanding to middle schools throughout the State.
        Or, at Curtin University in Australia, where students
    created a mobile application (app) for vulnerable, young
    Muslims called ``52 Jumaa,'' which means 52 Fridays. The
    ``Peer-to-Peer: Challenging Extremism'' program--and the app
    they created--was so successful, it changed the behaviors and
    lives of self-proclaimed, at-risk Somali youth in Perth. One
    student's brother went to Syria and was killed. Another Somali
    youth's brother was in jail for gang violence. Parents of these
    troubled, college-age young men thanked our faculty
    administration profusely for offering ``Peer-to-Peer:
    Challenging Extremism.'' These kids were on a similar path to
    destruction and, because of ``Peer-to-Peer: Challenging
    Extremism,'' they are now looked upon as role models in the
    Somali community in Perth.
        I could share many more stories, but given time
    limitations, I simply cannot. However, I believe you might
    recognize the transferability of this peer-to-peer model and
    can see it adapted to other social ills, such as tackling
    America's drug problem.
        This is how it could be done. It could use the same peer-
    to-peer model, where a class forms an agency to address program
    objectives that read something like this: ``You, class, are
    challenged to create and implement a social or digital media
    initiative, product, or tool to curb America's insatiable
    demand for drugs. Your campaign will promote drug awareness,
    abstinence, intervention, prevention, or whatever you identify,
    in your communities, that will be most effective in preventing
    drug demand and substance abuse.'' We can wordsmith the
    objectives, but I think you get the idea.
        From a how-to perspective, we would invite faculty that
    teach courses in marketing, advertising, and social media as
    well as those that teach about youth drug culture, addictive
    disorders, drugs in society, and narcoterrorism to see how
    these faculty and students attack the drug problem.
        Additionally, the top teams come to Washington to present
    and compete in a national face-off competition. The ``Peer-to-
    Peer Substance Abuse Challenge'' becomes a national campaign
    and movement, like it has with ``Peer-to-Peer: Challenging
    Extremism.'' And, Generation Y and Generation Z are owning this
    community-based, problem solving approach to push back on
    substance abuse in their cities and towns.
        Finally, let me close with these four short points. First,
    the peer-to-peer model is scalable. For example, with ``P2P:
    Challenging Extremism,'' our proof of performance pilot was 20
    universities. Today, ``Peer-to-Peer: Challenging Extremism''
    has 55 colleges participating--and, in the fall semester, 150
    universities in 50 countries will be unleashing a social media
    tsunami against the Islamic State of Iraq and Syria (ISIS).
        Two, peer-to-peer models can be targeted to reach youth in
    States where drug demand is growing or already crippling.
    EdVenture Partners has worked with over 800 rural, suburban,
    and urban campuses throughout the United States for the last 26
    years.
        Third, the peer-to-peer model becomes a ``Silicon Valley-
    like'' incubator of new, fresh ideas to tackle the drug
    problem, where the best ones can be grown, scaled, resourced,
    and pushed out--similar to what we are doing with ``P2P:
    Challenging Extremism.''
        And, lastly, the P2P model is cheap--dirt cheap in
    government dollars--according to the National Counterterrorism
    Center.
        However, I like the way the Committee says it best: ``the
    peer-to-peer model is high impact, low cost, and easy on U.S.
    taxpayer dollars.''
        With that said, I would like to thank you for allowing me
    to share my thoughts about, potentially, using a peer-to-peer
    strategy to confront America's insatiable demand for drugs.
        Chairman Johnson. Thank you, Mr. Sgro.
        I do kind of wonder what comes after Generation Z.
    [Laughter.]
        Mr. Sgro. We do not know yet.
        Chairman Johnson. OK.
        Our next witness is Robert Budsock. Mr. Budsock is
    President and CEO of Integrity House, a nonprofit organization
    that provides a full range of addiction treatment and recovery
    support for individuals diagnosed with substance use disorders.
    Mr. Budsock has been with Integrity House since 1984, having
    started his career in clinical services. Mr. Budsock.
        Senator Booker. Mr. Chairman, he prefers Bob, please.
        Chairman Johnson. OK. Bob.

     TESTIMONY OF ROBERT BUDSOCK,\1\ PRESIDENT AND CHIEF EXECUTIVE
                     OFFICER, INTEGRITY HOUSE, INC.

        Mr. Budsock. Chairman Johnson, Ranking Member Carper, and
    Members of the Committee, it is an honor to be here today with
    you and the other leaders that are testifying.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Budsock appears in the Appendix
    on page 121.
    ---------------------------------------------------------------------------
        As Senator Johnson said, I am Robert Budsock. I am the
    President and CEO of Integrity House, and we are a nonprofit
    addiction treatment program providing services in the State of
    New Jersey. Integrity House was founded in 1968 and our mission
    is to provide comprehensive addiction and recovery support to
    help individuals reclaim their lives.
        Addressing the demand for illegal drugs is one of our
    Nation's greatest challenges. The consequences of drug use for
    individuals include: drug dependency and addiction, involvement
    with the criminal justice system, chronic health issues,
    overdose, and, in many cases, death.
        Many of the challenges faced by this Committee are linked
    to the demand for drugs. The consequences of the demand for
    drugs include: drug trafficking and violence, billions of
    dollars in costs in our criminal justice and public health
    systems, and compromises to our border security.
        Through science and research, we know that drug addiction
    is a brain disease that can be treated effectively.
        I would like to present some facts about the insatiable
    demand for illegal drugs that we are experiencing in America.
    Illicit drug use in the United States has been increasing at a
    frightening rate. The annual National Survey on Drug Use and
    Health (NSDUH), conducted by the Substance Abuse and Mental
    Health Services Administration (SAMHSA), estimated that 24.6
    million Americans age 12 and older had used an illicit drug in
    the past month. That is 9.4 percent of the entire population.
        One of the factors that has led us to categorize the
    current crisis, in the United States, as an epidemic is the
    huge increase in the number of overdose deaths. Accidental
    death from the use of drugs recently surpassed motor vehicle
    accidents as the number one cause of death for young people in
    our Nation.
        According to the CDC, in 2014, there were 47,055 overdose
    deaths and, approximately, 129 Americans, on average, died from
    an overdose every day. Tragically, overdose deaths are
    increasing in every State, in rural areas, cities, and suburbs
    alike--among all segments of our population.
        Drug addiction is a complex disorder that can involve,
    virtually, every aspect of an individual's ability to
    function--in the family, at work, and at school. Because of the
    complexity and pervasive consequences of addiction, treatment,
    typically, must involve many components. Some of those
    components focus directly on the individual's drug use. Others,
    like employment training, focus on restoring the addicted
    individual to productive membership in the family and in
    society, enabling him or her to experience the rewards
    associated with abstinence.
        Like other chronic diseases, addiction can be managed
    successfully. Treatment enables people to counteract
    addiction's powerful, disruptive effects on the brain and
    behavior as well as to regain control of their lives. But, the
    chronic nature of the disease means that relapsing back to drug
    use is not only possible, but also likely, with symptom
    reoccurrence rates similar to those for other well-
    characterized chronic medical diseases--such as diabetes,
    hypertension, and asthma--that also have psychological and
    behavioral components.
        Based on scientific research conducted by the National
    Institute on Drug Abuse (NIDA) over the past 40 years, I would
    like to highlight five key principles that form the basis of
    effective treatment. Addiction is a complex--but treatable--
    disease that affects brain function and behavior. No single
    treatment is right for everyone. People need to have quick and
    ready access to treatment. Effective treatment addresses all of
    the patient's needs--not just his or her drug use. There is a
    correlation between length of stay and the effectiveness of
    treatment. Staying in treatment long enough is critical. Short-
    term programs or interventions are just not effective for
    everyone.
        It has been known for many years that the treatment gap is
    massive. That means, despite the large and growing number of
    those who need substance abuse treatment, few receive it. I
    cannot name another disease or chronic health condition where
    this is tolerated or allowed to perpetuate.
        One barrier that I would like to discuss is that, if you
    get your health insurance through Medicaid--it is barred from
    paying for community-based residential treatment at a facility
    of 16 beds or more. This happens under something called the
    Medicaid Institutions of Mental Diseases (IMDs) exclusion,
    which originated in the 1960s as part of a national effort to
    deinstitutionalize large psychiatric hospitals. Though
    community-based residential treatment programs for substance
    use disorders did not exist when the IMD exclusion was
    established, addiction treatment programs are considered IMDs
    in the eyes of Medicare and Medicaid--thus disqualifying
    reimbursement for care at a program like Integrity House and
    hundreds of other similar programs around the country.
        Integrity House is a longtime and active member of
    Treatment Communities of America, a national association of
    nonprofit addiction treatment programs, who has advocated for
    years for expanding access to treatment by eliminating the IMD
    exclusion.
        Thank you.
        Chairman Johnson. Thank you, Bob.
        I realize this hearing is about the insatiable demand for
    drugs, but, General Kelly, I want to go to you because you have
    been on the front lines of the war against the supply of drugs.
    And, I just want to kind of get your input, in terms of where
    we are on that.
        When we were down in Guatemala and Honduras and we talked
    to, not only you, but also other people on the front lines--
    people just incredibly dedicated to try and do that work--one
    of the comments that really stuck in my mind was from somebody,
    who had been battling this a long time, about how we are really
    not looking at stopping the flow. We are just talking about
    redirecting it out of the country they are operating in. I
    mean, we had the drug flow from Colombia through the Caribbean
    Islands up into Miami. And, that got redirected through Central
    America.
        So, just kind of speak to that basic dynamic--what we are
    really dealing with--because, the fact of the matter is,
    heroin--the cost of heroin in 1981 was over $3,000 a gram. We
    are going to do a field hearing outside of Milwaukee on Friday
    and research for that shows that, in some places in Milwaukee,
    that is down to $100 per gram--about $10 a hit, which is why
    you are seeing heroin take the place of opiates, in terms of
    addiction.
        So, just talk about the fact that we are not--well, I do
    not want to put words in your mouth. Talk about how we are
    doing with interdicting the supply.
        General Kelly. Thank you, Mr. Chairman. I would just
    comment that the demand signal, from the United States, has
    many thousands of very bad people responding to that demand. At
    the higher levels of the cartels, these guys are international
    businessmen and they control the network. They control the
    price. They control the flow--not only up through the Western
    Hemisphere into our own country, but around the world,
    frankly--I am speaking right now about cocaine.
        Back in the 1980s, when the flow of cocaine and other drugs
    went up the Caribbean Islands into, primarily, Miami--the old
    ``Cocaine Cowboy'' days--the vast majority, as I understand it,
    of the heroin consumed in the United States--and it was a lot--
    not as much as today, but a lot--was coming from Asia and,
    essentially, Afghanistan. That no longer is the case, because,
    as the cartels saw the increase in demand for that particular
    drug, they just started to produce it--primarily, today, in
    Mexico, but also a little bit in Guatemala. They grow the
    poppies, they have the factories, and they make the heroin that
    comes in.
        For methamphetamines, a lot of legislation and a lot of
    very good law enforcement activity in the United States shut
    down the many thousands of small meth labs operating in the
    United States. And, again, these international businessmen--
    cartel leaders--saw the demand and, now, most of the
    methamphetamine consumed in the United States is produced in
    industrial quantities, in Mexico, using precursors that are now
    either illegal in the United States--because, again, of what
    Congress has done--or are very hard to get. They just import it
    in from China and other parts of Asia.
        So, no matter what we do to try to interdict it, it will
    come, so long as there is the demand.
        Chairman Johnson. Talk about the brutality of the cartels,
    because, when we were down in Central America, you were kind of
    describing how they are, basically, untouchable because they
    are so brutal. Central America is battling two things:
    corruption and impunity. That last one kind of surprised me--
    impunity. Well, impunity because the drug cartels operate with
    impunity and then that transfers over to the other parts of
    society, where you have the extortionists murdering people if
    they do not get bribes. Just speak to how our insatiable demand
    for drugs has destroyed--or is destroying--public institutions
    in Central America.
        General Kelly. Well, due to the immense profits that come
    out of our country and are available to the cartels, to the
    network of people, and to the criminals, they have an unlimited
    amount of money to bribe--or an unlimited amount of money to
    kill. In my opinion, no legislator, prosecutor, police officer,
    or police chief in his right mind would do anything to stop the
    flow of drugs----
        Chairman Johnson. Because what happens to those individuals
    who try?
        General Kelly. Because they are either--well, the example I
    would give you--in a Latin American country or a Central
    American country, when I was talking to a Minister of the
    Interior--kind of like our AG or FBI Director, he said, ``Look,
    I will not take their money.'' I think I have told you and
    Senator Carper this story. ``I will not take their money and
    they know it. And, I will continue to go after them.'' This was
    what he said when he first got in office.
        But then, he just received a computer disc (CD) in the mail
    and the first sequence of the CD had his two little girls
    leaving the house in the morning, bouncing down the street on
    their way to school. And, the next sequence had him, his wife,
    and the two little girls on Sunday morning, walking out of the
    house and going down to Sunday mass. And, there was a third and
    a fourth. And, as he said, ``No way. I will not take their
    money, but I am not going to go after them.'' And, that is the
    intimidation factor.
        And, their brutal tactics are as bad as anything ISIS and
    the rest of the extremists use. They have no laws. They have no
    regulations. They have no morals. They have no limits to what
    they will do. And, they hold many of these countries,
    particularly the Central American countries, in really a grip
    of fear.
        Chairman Johnson. I often hear--we often hear that taking
    drugs is a victimless crime. When we were in Guatemala, we did
    visit a shelter for sex trafficked little girls. And, again, it
    is the drug cartels that are run by business people and they
    expand their product lines into human trafficking--sex
    trafficking. By the way, those little girls were ages 11 to 16.
    There were also little cribs there, because they become
    pregnant. I think the average age was 14.
        Can you just speak to what these drug cartels--how do they
    expand their business and really cause the mayhem and the
    broken lives down in Central America?
        General Kelly. Again, think about businessmen. If there is
    a need and they detect a need, then they will provide the need.
    Again, when pharmaceuticals were getting more and more
    expensive--pills were getting more and more expensive in the
    United States--and, because of legislation and some other
    factors, pills became very expensive and less available--then
    the businessmen--the cartel members--went into business and
    started producing pharmaceuticals. It is the same thing with
    heroin--we have already talked about that--and
    methamphetamines. It was good news up here, but so it moved
    down to Mexico.
        But, in terms of other needs, Latin American and Caribbean
    citizens will tell you--and their law enforcement people--that
    the movement of guns is, primarily, from our country to the
    South. And, many of the guns used to commit crimes in Central
    America, Mexico, and the Caribbean are trafficked, by the same
    traffickers, into those places.
        Anything that we demand in this country, they will provide.
    I think the United Nations (U.N.) figures tell us that 18,000
    or so young women--mostly adolescents--young girls--are
    trafficked into our country every year as sex workers. I do not
    think they know they are coming here to become sex workers, but
    they come here every year--some little boys, as well, to
    provide the same services.
        So, they will respond to what the demand is. And so, we
    have to, in all of these cases--in my view--reduce the demand,
    significantly, and keep up the pressure on the networks.
        I am told that this network is really mostly about drugs--
    which it is--and mostly about profit--which it is--and that it
    is not in the interest of the traffickers to allow other
    things--like, say, a terrorist--to come into the country. But,
    I will go back to what I said in my written statement--and I
    say it all of the time. These people that control the networks
    do not check passports. They do not check bags. They do not
    care why you are coming, as long as you can pay the freight.
    And, you will get in. You will get in. Or, it will get in--
    depending on what you want to get here.
        Chairman Johnson. They are some of the most evil people on
    the planet.
        So, again, I am looking for kind of a one-word answer. As
    somebody who has been on the front lines for years and in
    command of others--of heroic efforts to try to win the war on
    drugs--the supply side--are we winning that war?
        General Kelly. I could give you a one-word answer, but I
    will give it to you at the end. I would just simply say that we
    think that an unlimited amount of drugs get into this country--
    in the hundreds of tons--not even counting marijuana--in the
    hundreds of tons of cocaine, heroin, and methamphetamines. It
    gets in, no problem. It gets all the way to Portland, Maine as
    fast as it gets to San Diego, California.
        We know that tens of thousands of people come into this
    country--I am not talking about people coming for economic
    reasons and people seeking a better life--I am talking about
    sex workers and other people. They get here, no problem.
        Millions and millions of items--of counterfeit, industrial-
    type items--like electronics--get in.
        This very question was posed to me in my last SASC hearing
    and I gave the same answer. If all of that is getting in, no
    problem, then I would argue that our border is not secure.
        Chairman Johnson. Thank you, General Kelly. Senator Carper.
        Senator Carper. We are glad you came. You have given us a
    lot to chew on and we thank you for that.
        I have a couple of aphorisms that these guys and gals, on
    our Committee, hear me use all of the time. I like to say,
    ``There are no silver bullets--a lot of `silver BBs.' '' Some
    of them are better than others and you have mentioned some of
    those ``silver BBs,'' today.
        Oftentimes, I say, ``find out what works and do more of
    that.'' Several of you have mentioned programs or initiatives
    that have worked very well.
        I also am a big advocate, as my colleagues know, of root
    causes--like, do not just address the symptoms of problems. Let
    us go after the root causes.
        And, I got hooked on this, with respect to going to the
    border. We have all of these tens of thousands of people trying
    to get into our country, mostly from Honduras, Guatemala, and
    El Salvador. The flow of people between our country--illegal
    aliens between our country and Mexico--there are more Mexicans
    going back into Mexico, these days, than coming the other way.
        So, the folks that are coming here, largely, from these
    three countries--we call it the Northern Triangle--so my focus
    has been on determining why their lives are so miserable. What
    is it about their lives that compels them to try to get here--
    to risk life and limb to make that 1,500-mile trip to the U.S.-
    Mexican border to get in. It is the violence, which we are
    complicit in by virtue of our addiction to these drugs that are
    trafficked through the Northern Triangle nations.
        What I want each of you to do is to, maybe, think out loud
    for us, maybe, for a minute apiece, about a comprehensive
    strategy in this country that might be funded to address this
    problem. And, while you think about it, I will just say that we
    spend a ton of money on law enforcement--arresting people,
    prosecuting them, and putting them in jail for drug-related
    crimes that are committed. We spend a ton of money, in my State
    and in every State that is represented here--State dollars,
    local dollars, and Federal dollars--to incarcerate people. And,
    we spend a ton of money for treatment.
        My gut tells me that there is money out there that, if we
    could just take a fraction--just come up with a fraction of
    what we are spending in the areas I just described--we could
    probably fund a pretty darn good comprehensive strategy.
        Let me just start with General Kelly. Just take a minute
    and tell us what could be some of the key elements of a
    national strategy.
        General Kelly. Well, I will start in the North and just
    simply say that it is all about demand. So, doing whatever it
    takes to reduce demand to the greatest degree that we can. And
    then, it is--coming South--then it is law enforcement and it is
    the rehabilitation to take care of these sick people--because
    they are sick people. As you get further South, down into the
    zone that I used to work in, it is doing better with our
    partners--because many of our partners are, in fact, willing to
    do more for us. They just are limited in certain ways. Then,
    you move a little bit further South into the production zones--
    same kind of things. Help them get at the poppies, coca, or
    whatever and work with the partners more and more and more.
    And, again, they are all good partners--some are better than
    others in their capabilities.
        But, it just came to me that, frankly--I will be a little
    bit cynical--it just does not seem to me that the country is
    all that interested in reducing the demand. It is, certainly,
    not that interested--for a lot of different reasons--in
    providing the kind of assets to the SOUTHCOM Commander that are
    needed to interdict. And, I cannot say, by the way, enough good
    things about the FBI, the DEA, and DHS. They are just the best
    of the best. They are superb men and women.
        But, it is about finances--the amazing amounts of money
    that have to be laundered out of our country--and the billions
    and billions and billions of dollars--we think maybe as much as
    $100 billion--has to be laundered. So, it has to go into some
    banking institution. And, we know--I think--where those banking
    institutions are. It would just be great, in my mind, to just
    go after those institutions and take that money away, because,
    if you go to sleep at night as a drug cartel leader with
    billions of dollars in the bank and you wake up the next
    morning and it is going--wherever it went, but it is gone--you
    are not a drug cartel leader anymore. You are a dead man.
        So, that is what I would say. It is very comprehensive.
        Senator Carper. Great. That is great. Thank you. Jonathan.
        Mr. Caulkins. It is important, whenever we are talking
    about drugs, to disaggregate marijuana from the hard drugs. Mr.
    Budsock said 24 or 25 million Americans will self-report having
    used an illegal drug within the last 30 days. The comparable
    number for marijuana, alone, is 22 million.
        Marijuana is a mass market drug. There are more than half
    as many Americans who use marijuana, on a daily or near daily
    basis, as there are Americans who drink alcohol on a daily or
    near daily basis. Marijuana use is within a factor of two of
    alcohol, in terms of daily or near daily use.
        That is a very different situation than for cocaine, crack,
    heroin, and meth, where the consumption is enormously
    concentrated in a very small number of people. Eighty percent
    of the consumption is accounted for by just 20 percent of the
    people who use. It is, maybe, three million people.
        The majority of the hard drugs are consumed in the United
    States. And so, the majority of that flow across the border
    comes from people who are, literally, under criminal justice
    supervision, in the sense that they are on probation, on
    parole, or on pretrial release. If you want to cut the flow of
    the hard drugs, you have to focus on that very small number of
    people who are living very chaotic lives and are interacting
    with the criminal justice system. If you want to affect
    marijuana--that is much more of a mass market public health
    target.
        Senator Carper. Good. Thank you so much. Cheryl.
        Ms. Healton. I have just a few points. One, I think we need
    to decriminalize--which does not mean legalize.
        We need to instill the availability for mass treatment,
    particularly, for the opioid epidemic that we now have, which
    you will see in my testimony, can be, partially, laid at the
    feet of the pharmaceutical industry, sadly, because the pricing
    of these drugs is driving people to street heroin.
        And, we need to unsell drug use to both users and non-
    users--and that, I think, can be done. And, some of the stories
    that General Kelly told us, I think, are great starting points
    for motivating people to change their behavior. We consume 40
    percent of the world's cocaine and 20 percent of the world's
    opioids. We are the number one problem in the world, in terms
    of drug consumption.
        And, I would just make one added point to the points that
    Jonathan Caulkins was making. And, that is that the opioid
    problem is much more complex, because--it is either 11 or 17
    percent--or somewhere in that range--of adolescents who report
    using pills. And, the modal pill that they are using are
    opioids--often left over from their last dental visit or the
    dental visit of a friend. And, that, in turn, leads to a young
    adult opiate addiction for a substantial proportion of those
    kids, which, as you can see in the tables that are out there,
    is producing a very large number of intentional and
    unintentional deaths. It has now surpassed traffic accidents in
    the United States, which is a startling statistic. As a 35-year
    public health professional, if you told me 25 years ago that
    drug-related deaths could exceed traffic accidents, I would
    look at you as if you were out of your mind.
        Senator Carper. My time has expired, but, when we have a
    second round, Mr. Sgro and Mr. Budsock, I am going to come back
    and ask the same questions of you. But, those are wonderful
    answers. Thank you so much for giving us those thoughts.
        Chairman Johnson. Senator Ayotte.

                  OPENING STATEMENT OF SENATOR AYOTTE

        Senator Ayotte. I want to thank you, Chairman. And, I want
    to thank all of you for being here.
        General Kelly, I wanted to follow up, because this is a
    topic that you and I have talked about, in the past, when you
    were SOUTHCOM Commander. And, one of the things that struck me
    is that I have been working on the demand side with people,
    like Senator Portman, and we have worked, for several years, on
    what is called the Comprehensive Addiction and Recovery Act
    (CARA) that was passed in the Senate in the last few weeks. And
    so, it has a prevention piece, a treatment piece, and some
    support, in terms of the relationship between prescription
    drugs and heroin.
        But, I want to get to this interdiction issue too, because
    these drug cartels have been particularly clever. They have
    flooded this market and driven down the price of heroin, going
    to rural areas in New Hampshire, Ohio, and other places in this
    country. And so, I actually think that, for the demand side, we
    have to do all we can to get at--but we also need to drive the
    price up on the supply side.
        And, when you were SOUTHCOM Commander, I remember you
    testifying about--and I think your written testimony today
    reflects that--we see a lot of these drugs coming over, but we
    are not putting as much teeth into the interdiction piece as we
    possibly could. In fact, what you said is that the effort to
    get at our drug demand begins--or should begin--on the cartel's
    end of the field, with much greater effort. And, the U.S.
    military is almost absent in the effort, due to an almost total
    lack of Naval forces.
        So, as someone who serves jointly on the Senate Armed
    Services Committee, I want to know what we can do to help on
    that end, working with our partners--obviously, Customs and
    Border Protection (CBP), the Coast Guard, and law enforcement--
    that could give more assets to what we need to do, while we are
    working on the demand side--because I think this is an
    important piece as well.
        General Kelly. We need a bigger Navy. That is the answer. I
    mean, last year in SOUTHCOM--joint effort--and again, law
    enforcement is as important to me down there--or was as
    important to me down there, as Naval forces and the Coast
    Guard.
        But, 70 percent of the 191 metric tons of cocaine that we
    took out of the flow--and this is in one-ton to two-ton--
    generally speaking--one-ton to two-ton loads--70 percent would
    not have been taken had it not been for the occasional Canadian
    ship that showed up down there--or the Dutch buoy tender, the
    Coast Guard, or the occasional French or British ship. Seventy
    percent.
        Our Navy is absent for a lot of different reasons. There
    are a lot of things going on around the world and the Coast
    Guard Commandant, when he first came in, decided to double the
    number of cutters----
        Senator Ayotte. Right.
        General Kelly [continuing]. That is good, but that is only
    three or four. And, the way to get at this cocaine problem is
    to get it when it is on the high seas, when it is still moving,
    and before it makes landfall.
        Methamphetamines and heroin produced in Mexico--that does
    not move through the transit zone, so to speak, so that really
    does become a question of how closely we can work with the
    Mexicans to get vast quantities of those drugs. Their best
    counter-drug organization down there is the Mexican Marines.
    They do very well. And, there are a lot of reasons for that.
    But, they do take a lot of drugs in movement.
        But, if you are not getting a lot of it to drive up the
    price--one of the things that I think I learned from the DEA,
    here on Capitol Hill, to buy an illegal Oxycontin or something
    like that--Percocet or something like that--a single pill will
    cost you about $90. The same amount of heroin to get you to the
    same place is $6.
        Senator Ayotte. Right.
        General Kelly. And, that is why they move to heroin. And,
    unless you can do something about inhibiting the flow--and I do
    not believe that is entirely a Southwest border issue. I think
    it is deep down in Mexico--Sinaloa--places like that. But,
    again, our drug demands have turned vast amounts of Mexico into
    insurgent-held--if you will--insurgent-held regions that are
    dominated by the Joaquin ``El Chapo'' Guzmans of the world--and
    not even their army will go in there.
        So, the problem is, again, the demand--and, frankly, in my
    mind--not to criticize countries like Mexico, Honduras, or
    others for not doing enough--because I spent the last 3 years
    of my life looking North--not South--and they would tell us,
    ``Look, we are doing the best we can down there. Why do you not
    get your arms around your demand.''
        Senator Ayotte. And, that gets me, Dr. Healton, knowing
    what has happened with the Legacy Foundation and having been an
    Attorney General, myself, before I served in the Senate--I have
    two young children. I have an 8-year-old and an 11-year-old. I
    have to tell you, their attitude toward smoking is totally
    different than attitudes when I was a kid. They, literally, see
    someone smoking on the other side of the road--and this is not
    something they do because their parents have said to do this--
    they will move to the other side of the road.
        And so, the notion that we cannot do an ad campaign that
    would really focus on this issue--and, especially, I think,
    focus on the opioid issue, because the national data shows four
    out of five people start with prescription drugs and then go to
    heroin. I believe we can do it.
        But, something you said is really interesting. And, I think
    we are trying to support efforts here to get resources toward
    the prevention piece--and that is this. How do we structure
    this in a way so that, if we give the Federal resources--along
    with combining them with State and local--we put it all
    together and we say, ``We are going to go after this and we are
    going to get this message out.'' How do we do it in a way so
    that it is a sufficient body that does not get the sort of
    bureaucracy stifling response of, ``Well, that message is too
    troubling'' or so that, when you have a talented advertising
    organization that has researched it, collected the data, and
    then come up with this--and that was what was so effective. I
    remember seeing the guy on the smoking campaign with the
    tracheotomy. I mean, you remember that.
        But, do you have any thoughts, for us, on how we could
    structure something that would give sufficient--the Legacy
    Foundation had its support and independence as a nonprofit that
    was formed. Obviously, there is an oversight board--many
    Attorneys General involved--but you had the sufficient
    authority and flexibility to be able to create a really hard
    hitting campaign--and that is what we need.
        We cannot sugarcoat this with our young people. We cannot
    sugarcoat this with adults. Otherwise, we are not going to get
    this message through. And, I have met too many families whose
    sons, daughters, sisters, brothers, and grandchildren have
    died--and it is about not sugarcoating what our families are
    experiencing.
        So, how do we do this?
        Ms. Healton. So, I have two models that I would recommend.
    One is driven by the Federal Government and one is a more
    private model driven by the States.
        In terms of the one driven by the Federal Government, I
    would create--I actually think NIDA or SAMHSA would not be a
    bad place to rest the bidding. But, I would open it up for a
    national bid and I would leave it alone once it is won.
        What hurt the ONDCP campaign--and I have pored over their
    results for years and have been very disheartened because they
    had a fabulous staff--still do--it is now drugfree.org--but
    they were not allowed to do what was needed to do the job. And,
    I believe the job can be done. I came to Legacy making the
    following statement, ``I do not think you can advertise your
    way out of an epidemic''--and I believed it at the time.
        And, in fact, I was almost going to stop the national
    campaign because we were pouring $100 million of money into it,
    in the first year, and we did not have any peer-reviewed
    literature. And, luckily, in February 2000, a paper came out,
    from Florida, that showed a 40-percent decline in middle school
    smoking and a 20-percent decline in high school smoking. And
    then, in good conscience, I could say, ``Go ahead. Let it go.''
    Within 6 months, we were in court. We were in court for 7 years
    and $17 million worth of litigation fees were was spent trying
    to shut us down.
        So, one thing you need to understand is, when you go after
    prescription opioids--which are saturating our young people,
    saturating adults, and producing the resurgent heroin
    epidemic--you will be going up against the pharmaceutical
    industry. So, one model is the model I just described.
        The second model may be preferable--or, maybe, it is a
    parallel model. You do something not unlike what Washington
    State did, in terms of Oxycodone and its effects. You do,
    basically, a metropolitan statistical area (MSA) focus on the
    ``unintended''--in
    quotes--consequences of pharmaceutical misadventures in pushing
    pain analgesics that, in turn, lead to heroin addiction and sow
    the seeds in our young kids, who just want to get a root canal,
    where the next thing you know--5 years later--they are a heroin
    addict. Not a good idea. There are fixes, but it will unleash a
    storm of unhappiness on the part of the pharmaceutical
    industry.
        Senator Ayotte. Well, I have to share with you--first of
    all, the storm of unhappiness that we are in right now, with
    people who are dying and lost--incredible people who had such
    potential--that is the storm of unhappiness. The other storm--
    as big as it could be--is minor compared to this storm.
        Chairman Johnson. Senator Booker.

                  OPENING STATEMENT OF SENATOR BOOKER

        Senator Booker. Thank you, Mr. Chairman. And, thank you
    both to the Chairman and Ranking Member for holding such an
    important hearing.
        So, really quickly, just, Bob, can you just hit that point,
    which is so important, one more time--that we have a law
    written that restricts funding for multi-bed facilities when,
    now we know--and I know this from being Mayor of Newark--that
    the best providers, in my city, who are creating transformative
    change, taking people from addiction to recovery and from
    criminality to productivity, are being denied funding. It is
    such a ridiculous bureaucratic block that is undermining
    grassroots efforts to meet this crisis. Could you just make it
    plain one more time, so we have it on the record, about the
    idiocy of this bureaucracy--and something that we need to
    change, in order to see more progress in communities?
        Mr. Budsock. Yes, Senator. So, the IMD exclusion was
    written into the Medicaid regulations back in the early 1960s.
    And, the IMD exclusion means that, in treatment facilities,
    such as Integrity House--and there are many other facilities
    like Integrity House all across the country--if an individual
    comes to us and they have Medicaid as their primary health care
    coverage, they are not eligible to access the full continuum of
    services that are necessary to treat their disorder. So, they
    are able to access certain parts of that continuum, but they
    are not able to access the residential services if the facility
    has more than 16 beds--and just about 99 percent of the
    agencies similar to Integrity House, throughout the United
    States, have facilities that are larger than 16 beds.
        Senator Booker. So, there are things we can do, right away,
    that can make a difference with this issue. And, this is one of
    them that is, to me, frustrating that we have not made an
    administrative change to fix.
        Just to give a larger perspective, having been--I live in
    the central ward of Newark, New Jersey. I would imagine that I
    am one of the Senators that returns to the poorer Census track
    to live. I live up the street from Integrity House and have
    been wrestling with the ravages of this reality for my entire
    professional career, seeing how we, as a society, would much--
    it seems to me, we are much more willing to pay exorbitant
    amounts to treat the symptoms of a problem. The law enforcement
    costs alone are outrageous, in terms of, again, local
    government, jails, police officers, courts, and prisons. But,
    that is just one massive cost.
        The other massive cost here is hospitals--and what I had to
    struggle with are the charity care costs for people being
    brought to the emergency room on a continuous basis. And, the
    depth--and this is why I appreciated Senator Ayotte's remarks--
    the depth of this crisis in our country is astonishing--
    especially when you realize how unique America is as a country.
        Not only due to the fact that, every day, 1 out of 10
    Americans is breaking U.S. drug law--not to mention the fact
    that, of the prescription drug consumption--opiate
    consumption--I thought it was 50 percent. My staff corrected
    me. It is about 80 percent of the globe's pills that are being
    consumed by people in this country. The overwhelming majority
    of that--of people who consume those pills--or people who get
    addicted to heroin--the gateway drug to them are these pills in
    which there are--again, we are the mass drivers of that
    consumption on the planet Earth--not to mention, Doctor, what
    you were talking about when it comes to heroin and the
    percentage of this country using it.
        But, then, let us even shift to just the antidepressants
    being consumed on the planet Earth. There is something going on
    here that we, as a Nation, are devouring drugs--prescription
    and illegal drugs at rates not seen in humanity--not seen
    anyplace else on the planet Earth.
        And so, it seems like we are paying for this problem, but
    we are not doing anything to get to the root cause. And, that
    is why I am so appreciative of this--is that what is causing
    us, as a Nation, to turn so dramatically to drugs--legal
    prescription and illegal drugs? And, that is what frustrates
    me, because I am tired of us spending billions and billions of
    dollars--trillions of dollars, as a country--not dealing with
    the real root cause of the problem, which is this insatiable
    demand for drugs.
        And so, I appreciate--we were just talking, when you were
    giving your testimony, Doctor, about the effectiveness of the
    tobacco campaign and how it really--as Senator Ayotte said--has
    changed the consumption patterns in this country. I go to
    Europe and you now see what America used to look like. So, we
    have done it there, but we are not even chipping away--it is
    getting worse in these other areas.
        So, I have a minute left. And, maybe, Doctor, I can go with
    you and then, Bob--just because you are my neighbor and I have
    to go home--and split that time. Doctor, what is going to get
    to the root cause of this? Is it just public relations (PR), or
    is it something even deeper within our society that we have to
    start having an honest conversation about?
        Ms. Healton. That is a very difficult question. Why do we
    use drugs? Humans have been using mind-altering substances
    for----
        Senator Booker. But, Doctor, I am sorry--just to interrupt
    you----
        Ms. Healton. Yes.
        Senator Booker. This is not a human problem. It is an
    American problem----
        Ms. Healton. Yes, it is----
        Senator Booker [continuing]. Because you do not see this
    going on--at this rate--in other countries.
        Ms. Healton. You are right. So, you could come up with lots
    of reasons, but the fact is, we have a very substantial profit
    motive in our country. Capitalism is our system, so people are
    very enterprising. And, people can create markets. Just like
    they create markets for the newest T-shirt and the nicest
    jeans, they can create markets for drugs. And, when you have
    kids who have time on their hands and are bored, they will turn
    to that. We do not have the kind of family structure we had in
    1950. It is a different world here--the modern world. So, I
    would say, it is a combination of drivers like boredom and
    poverty--I mean, if I were to pick two drivers.
        Senator Booker. Right. And so, Bob, you would say that one
    thing we need to do is to increase access to treatment. The
    majority of people we incarcerate--you see this, whether it is
    Newark--or pick your town--across the country--we are putting
    people in jail with addictions and we are not treating that. Is
    that what--so, the root cause that you think some of this is
    due to?
        Mr. Budsock. Yes. Statistics have shown that over 80
    percent of individuals that are involved in the criminal
    justice system have either a drug-related charge or a charge
    that, actually, was brought upon them as a result of their
    insatiable demand for illegal drugs.
        Do I have a minute to speak?
        Senator Booker. No.
        Mr. Budsock. No.
        Senator Booker. Unfortunately, because I am over my time.
    And, I just want to say, Chairman, really quickly, there is
    something missing here. In other words, it cannot just be
    capitalism, because there are other capitalist countries. We
    are different, somehow--and I would love to figure out a way to
    get to the root answer of that question, because I just do not
    think--I think that all of these people are doing admirable
    things to stop it, but there is something that is driving this
    that is different than in any other country--and we have
    similar economies, similar democracies, and similar free market
    systems, but America is unique, globally, in this problem.
        Chairman Johnson. Well, again, we are trying to get some of
    these answers. I come from a business standpoint. I could not
    addict my customers to plastic by giving them a free sample.
    You can addict a child to drugs--and that is what really drives
    a lot of these markets. Senator McCaskill.

                 OPENING STATEMENT OF SENATOR MCCASKILL

        Senator McCaskill. Thank you.
        In 2010, General Kelly, I chaired a hearing on the
    Oversight of Government Management Subcommittee, as part of
    this Committee, on our counter-narcotics efforts in Latin
    America. At that point in time--I mean, it was difficult for us
    to get information-- and we were, primarily, looking at the
    billions of dollars in contracts that had been given by the
    State Department for counter-narcotics efforts in Latin
    America.
        Six years ago, we had spent $7 billion in Latin America
    over the previous 10 years. And, the vast majority of that was
    being spent on contractors. Some of them were sole source
    contractors--Alaska Native corporations--where there did not
    appear to be a good rationale as to why. I mean, this was the
    hearing I will remember--never forget, because I discovered
    that contractors had prepared the people testifying at the
    hearing for the hearing about contractors--and it was one of
    those moments that made you think, ``Have we gone down the
    rabbit hole so far that we do not realize how silly this has
    gotten? ''
        So, I would like to ask you, as somebody who has been in
    command of SOUTHCOM, what are the metrics we are using for the
    massive investment the American taxpayer has made in counter-
    narcotics efforts in South America? And, is it still as
    dysfunctional as it was in 2010, in terms of the coordination
    between the State Department contractors, SOUTHCOM, the DEA,
    and all of the other players in the space?
        General Kelly. That is truly a great question. On the issue
    of money that is managed by the State Department, there is a
    lot of money managed by the State Department used to get at
    some of these problems. That money does not really touch me
    when I----
        Senator McCaskill. Should it?
        General Kelly. I would tell you, give me that money and I
    would be able to fix the problem. I think there is--the
    combination of the U.S. military--and I am not trying to
    militarize this thing, but there is a military aspect to it--
    the combination of the U.S. military down in the zone and our
    law enforcement people--to include the FBI, the DEA, and,
    frankly, the NSA--they are not law enforcement--but the CIA and
    all of the alphabet soup that is inside of DHS--phenomenal men
    and women--and we really do bring that together, regionally--we
    being SOUTHCOM--through a joint task force that is in Key West,
    Florida--a Joint Interagency Task Force (JIATF). It is the
    model for tactical--or for intelligence fusion around the
    world. In fact, it was replicated years ago in the fight in
    Iraq, Afghanistan, and now worldwide against terrorism. It is
    very effective.
        As I mentioned--I think you were gone--but I can see--we
    can see 10 percent--or 90 percent of the production and the
    flow, but we could only get at just a small percentage because
    we do not have end game authority. I did not have end game
    authority--that is, seizure authority. And, I did not,
    frankly--even if I had the authority, I did not have the
    assets.
        The countries that produce drugs in Latin America and the
    Caribbean--well, Latin America--are suffering from our drug
    demand in a way that is unimaginable in our country. The
    violence rates are just off of the page. In the United States,
    the U.N. figures go like this: roughly 5 per 100,000 of our
    citizens are killed every year. That is how they measure
    violence. In Latin America--places like Honduras--it is 91 out
    of 100,000. Colombia is down into the 30s now. They have done
    that, essentially, by themselves.
        But, in the countries that we--this group--this SOUTHCOM
    group of interagency actors--where they have spent time and
    effort--Colombia, as an example--things have gotten markedly
    better. The Colombians, again, have really done it themselves.
    We have provided encouragement and advice, but no boots on the
    ground.
        Senator McCaskill. Well, what is the State Department
    doing? I mean, you were there. You had vision. What is the
    State Department doing with these billions of dollars?
        General Kelly. They--as you have outlined--they invest it
    in ways that, perhaps, are acceptable to the State Department,
    but are not getting at----
        Senator McCaskill. Like, what are they doing?
        General Kelly. Well, I mean----
        Senator McCaskill. Like, give me an example of the
    activities they are paying for with the contractors.
        General Kelly. As you point out, they would fund--as an
    example--counter-drug or counter-gang violence--counter-gang
    participation by young kids in countries--pick a country--
    Honduras or somewhere like that.
        But, I can remember once sitting and talking to--I would
    always meet with the human rights groups when I would travel to
    these countries--which was frequently--and I was sitting there
    with a very senior person from our country team. And, we were
    talking about this kind of topic and I said, ``Well, how about
    preventing kids from getting into the gangs,'' which are really
    the point of the spear on drug trafficking and all of that--and
    drug marketing. And, very quickly, the State Department
    representative said, ``We have a very good program for that. In
    fact, we spend $10 million a year in this country.'' And, I
    said, ``Well, how long has this been going on in this country?
    I mean, how long have we been spending the money? '' I was
    told, ``Well, 10 years.''
        Well, even a Marine infantryman realizes that that is $100
    million. So, I asked a question, ``Is the problem of kids going
    into the gangs--and by extension into the drug trafficking--is
    it better than it was 10 years ago? ''
        Senator McCaskill. Or worse?
        General Kelly. That would, in my mind, make it a good
    investment. Is it the same? In my mind, that would be a bad
    investment. That is failure. Or, is it worse? And, he
    acknowledged, it is geometrically worse.
        So, I would just say that the way that we and the
    interagency--the military, certainly--the way we look at
    solving a problem is that you set up a program and start to pay
    for it. But, every 6 months or 3 months, whatever--we did this
    in Iraq and Afghanistan--we do this everywhere--I did it in
    SOUTHCOM with the monies that I held. Three months later, we
    look--is it getting worse, better, or is it the same? And then,
    we make an adjustment.
        Senator McCaskill. It is really frustrating. I wish--and I
    know that the Chairman is on the Senate Foreign Relations
    Committee (SFRC)--and it is frustrating to me, because I think
    the State Department means well. It is not that they are not
    trying to do things. But, these are legacy efforts without real
    metrics. And, as our Chairman likes to say, metrics matter in
    business. They ought to matter in government. Metrics matter.
    And, the idea that we are spending--just in that one example--
    $100 million in Honduras on an anti-gang problem and the
    problem has gotten exponentially worse as opposed to better.
    Why are we not figuring out a better way--even if it means
    moving some of that budget over to some of the players in the
    task force in Key West, Florida.
        And, I would like us to continue to follow up on this,
    because I was stunned at the lack of information that was
    available and the lack of metrics that were available for $7
    billion in investment--and that was 6 years ago. It has
    probably been another $7 billion since then, in terms of
    counter-narcotics in Latin America.
        And, before my time is up, I want to just briefly talk to
    Mr. Budsock. I was, I think, the second prosecutor in the
    country to aggressively go after a drug court model. And, I got
    a lot of blow-back, politically, from my police department
    (PD)--from a lot of people--that this was going to be something
    where we were going to bust down a drug house and then going to
    give them a bus pass, a job, and a pat on the head. Well, it
    was a little more complicated than that, but, as you well
    know--and as anybody who works in this field knows--that drug
    courts began on the bottom, exponentially grew, and have
    remained an incredibly effective way to get at the public
    health issue of drugs and crime.
        And, I would like--and maybe, Dr. Healton--one of you to
    speak to why have we stalled on expanding the drug court model
    into things like reentry courts. I mean, we take somebody who
    has been in the drug culture for all of their life, we put them
    in jail for 18 months, then we give them a bus pass and $20,
    and we are shocked that they are back in jail within 6 months.
    Why are we not making--since we know drug courts are cheap and
    they work--why are we so stubborn about not putting more
    resources into this model that has worked so well at turning
    folks around and reducing the recidivism rate?
        Mr. Budsock. Thank you, Senator. I think one of the major
    success factors for the drug courts, is that they are treating
    addiction as a chronic disease----
        Senator McCaskill. Right.
        Mr. Budsock [continuing]. Not as an acute illness. So, what
    happens is that, when an individual enters drug court, they
    receive a very rigorous schedule, that goes on for a period of
    anywhere from 3 to 5 years, where they are reporting to the
    drug court once a week on their progress. They are
    participating in a treatment program. And, also, their
    employment is being monitored and they have realistic and
    achievable goals that they must accomplish to progress
    throughout the drug court program. And, again, the key is that
    addiction is being treated as a chronic disorder.
        In New Jersey, we have seen an expansion of drug courts,
    specifically, the criminal justice model. However, there are
    other areas where drug courts would be effective when it comes
    to the family. There is one county in New Jersey that has a
    family drug court and we are hoping to see the expansion of
    that into other counties. And, anytime that an individual is
    involved with the criminal justice system, where there is a
    detection of drug use or drug dependency--the model has proven
    to be very effective.
        Senator McCaskill. Yes. I would just like to see us do it
    on the back end. So much of it has been focused on the front
    end--and the back end is where recidivism occurs so often.
        Chairman Johnson. Senator--let me--because we are 2 minutes
    over--but let me just give--there is one metric that we can
    use. You might have missed it when I first started questioning
    General Kelly.
        In 1980, in inflation adjusted dollars, the cost of heroin
    was $3,260 per gram. I do not know what it is in St. Louis,
    but, in Milwaukee, it is about $100 a gram.
        Senator McCaskill. Yes.
        Chairman Johnson. So, we are spending $25 billion a year to
    interdict the supply of drugs and you want an indication--you
    want a metric? Dropping from over $3,000 per gram to $100 per
    gram----
        Senator McCaskill. I would like a little more granular----
        Chairman Johnson. I understand, but that is a pretty
    effective macro----
        Senator McCaskill [continuing]. Have to tell me where----
        Chairman Johnson. Let us put it this way. We are not
    winning the war.
        Senator McCaskill. Yes.
        Chairman Johnson. Senator Portman.

                  OPENING STATEMENT OF SENATOR PORTMAN

        Senator Portman. Thank you, Mr. Chairman. I really
    appreciate you and Senator Carper holding the hearing and your
    focus on this issue--not just with this hearing, but over the
    last couple of years--realizing that we do have an epidemic on
    our hands and getting this Committee engaged. In fact, you have
    allowed us to have a hearing in Ohio on April 22 to examine the
    impact of opioid addiction--and the epidemic we have in
    Northern Ohio--and I appreciate that. You guys are focused on
    the right thing, in my view.
        About 22 or 23 years ago, when I was first elected to the
    U.S. House of Representatives, a young mother came to see me
    and she wanted to talk about what we were doing on the drug
    war, as she called it. Her son had just died of heroin--I am
    sorry, of huffing gasoline, of all things, and smoking
    marijuana. He just dropped over dead. He was 16 years old. His
    name was Jeffrey Gardner. I still have his gold identification
    (ID) bracelet.
        She came to my office and she said, ``What are you doing?''
    And, I was ready for her. It was my first year in Congress. I
    said, ``We are spending $15 billion a year on interdicting
    drugs, on eradicating drugs in Colombia, and on prosecutions.''
    She said, ``How is that helping me?'' I called a meeting of my
    church. They were in denial. People said, ``It does not happen
    here.'' I called a meeting of the school. They said, ``We
    cannot get involved because it will hurt our ratings.'' I
    called a meeting of our neighbors. Nobody showed up.
        And, I was embarrassed not to have a better answer for
    her--and that is what got me involved in this. I was the author
    of that ``drug-free media'' campaign in 1998, which had its ups
    and downs--and we had some real difficulties with it--but the
    fact is, prevention--and General, you are the one that said
    it--it is demand.
        And, I agree the price of heroin is too low and I agree we
    should be doing more to deal with that, to stop the Fentanyl
    from coming in, and so on. But, folks, if we do not get at the
    demand side, it will be something else next. It was cocaine
    back in the 1990s. And, I was the author of the Drug-Free
    Communities Act of 1997, which has now helped spawn 2,000
    community coalitions. I started one back home. I chaired it for
    9 years. I am still very involved with it. And, we have seen
    our rates of use by youth going down, Mr. Caulkins--even among
    marijuana--which is, as you say, the single biggest drug
    abused.
        But, we now have this new epidemic and it has hit us hard.
    So, I guess my response to the really good question Senator
    Carper raised is that it has to be comprehensive, but it has to
    focus on demand also. If it does not, you cannot solve the
    problem. You cannot build a fence high enough. And, by the way,
    methamphetamine can be made in a basement and marijuana can be
    grown here--and it is. And, if it does not come from Mexico, it
    can come from Afghanistan through Canada--and it does. And,
    Fentanyl is coming from China, we are told.
        So, I mean, I do not have the answers, clearly, after being
    at this for more than two decades. But, I do think this CARA is
    a really good step in the right direction. It focuses on
    exactly what you all are talking about, today. I know a lot of
    you have helped us on it and I thank you for that. But, it does
    focus on prevention and education. It does fund these community
    coalitions and gets them more involved in the opiate issue,
    because that is the crisis we face. We almost have to focus on
    the crisis now, including the treatment and the recovery side
    of it, because we have so many people who are addicted.
        I meet with them almost every week in Ohio. I meet with
    recovering addicts and I ask the question, frankly, that was
    asked by Senator Booker--a really good question: why? And, a
    lot of these kids are suburban kids. So, this notion that it is
    all inner city--it is not anymore. In fact, in terms of our
    rate of use in Ohio, we think it is biggest per capita in the
    rural areas--of prescription drug abuse and heroin addiction.
        So, I really think it is the right question. I do not have
    the answer, but I do think that CARA is a step in the right
    direction, because it is comprehensive. It is broad. It is
    about $80 million. Is that enough? No, there should be more
    spent, but it is an additional $80 million, over time, if we
    can get this done. We passed it in the Senate with a 94 to 1
    vote. Do you know what that means? That means that every single
    Senator sees it back home now--all of them.
        And, it is the number one cause of accidental death--and it
    is destroying families and ripping communities apart. I mean, I
    talk to my prosecutors back home. They say 80 percent of the
    crime is now related to opioid addiction. So, it affects every
    emergency room and every firehouse.
        I have a couple of quick questions. One--and this is to Dr.
    Healton, again--in terms of a broader media campaign--you have
    studied this, I know--and, again, the ``drug-free media''
    campaign--we started it in the 1990s. We had the Partnership
    for a Drug-Free America as our partner--as a private sector
    partner. We tried to do something unique in government to bring
    the private sector in--the creative people from Madison
    Avenue--rather than doing it in-house. It did not work as well
    as we intended, in part because government did get involved and
    it was not the Madison Avenue, private sector, and hard-impact
    advertisements we tried to get. Plus, we lost the money. I
    mean, it was hard to keep the money coming.
        But, what do you think should be done, in terms of this
    broader prevention campaign, as an online or a broadcast media
    effort?
        Ms. Healton. Well, the ``Truth'' campaign at inception came
    at a time where 90 percent of young people were getting their
    media through television----
        Senator Portman. Yes.
        Ms. Healton [continuing]. As did the early days of the
    ONDCP. It was a little bit easier. It is more complex now, but
    it is doable. And so--I have made the comments before--I would
    hand it over with a hands-off approach, because it does get too
    complicated. When adults get into the approval process, the
    creativity becomes further and further distant from the target.
    And, in the case of substance abuse, you are picking the
    roughly 40 percent of young people who are open to using
    drugs--illicit or otherwise--and they are an interesting and
    different subset. You need to design your advertisements,
    specifically, for them--this is one of the reasons why the
    advertisements are often very hard-hitting.
        Also, you are to be commended for all of the work that you
    have done. I have been following your career on this issue for
    decades and thank you for everything you have done. People have
    to step up to this problem--even though the room is empty and
    you have been with the problem for a long time.
        It is my belief that it is easier to talk young people out
    of using tobacco than it is to talk young people out of using
    drugs. Drugs are highly mind altering. They are reinforcing in
    other ways. Kids have troubled lives. They turn to drugs to
    self-medicate. It is a very complex problem. It is not quite as
    simple as tobacco.
        But, I do think it can be fixed. I think, in the right
    hands, we can make a huge impact. And, I think we can know,
    quickly, whether we are making an impact and, if we are not,
    stop. It is the same reason I said that I almost stopped the
    ``Truth'' campaign, because $100 million is a lot of money to
    spend without any hard evidence that it is likely to work.
        Senator Portman. I really appreciate that answer. And, you
    are talking about, basically, a request for proposal (RFP),
    where you put it out and you have a merit-based process, but
    then, you are hands off and allow them to do what they do best.
        And, by the way, the good news is that we can target people
    more than before, because every company in the private sector
    is in marketing and has better--and more--data. In the
    political realm, we have more data. And, you can use that data
    to be able to target those kids who are the most vulnerable--
    who are most susceptible to falling into the grip of addiction.
    And, that is why I think it is worth doing.
        Again, to Senator Carper's question, we still spend a whole
    lot more on the demand side than on the supply side--I am
    sorry, on the supply side than on the demand side. And so, you
    are talking about $100 million. It is a lot of money. On the
    other hand, it is relatively small compared to the billions of
    dollars--probably close to 20 billion now--that you would
    ascribe to the supply side. Again, I am not saying the law
    enforcement--and the supply side--is not important. Of course,
    it is. But, ultimately, you are not going to solve it until we
    get at the demand side.
        My time has expired. Senator McCain is now here and we can
    have a chance--he has been a leader on this issue too. But, I
    just really appreciate the work you guys are doing in the
    trenches every day and we are very eager to get your
    perspective--which is more academic, where you can kind of look
    at what is really working and what is not working. It is like
    we have a fire, though, right now. We have to put out the
    fire--and that means better treatment and more treatment
    options, better recovery--evidence-based--and helping some of
    these people whose lives are just being destroyed by this grip
    of addiction--this really difficult grip of opioids--to get
    back on their feet.
        So, thank you all very much and thank you to the Chairman
    and Ranking Member for holding this hearing.
        Chairman Johnson. Senator McCain.

                  OPENING STATEMENT OF SENATOR MCCAIN

        Senator McCain. Both Professor Caulkins and Dean Healton
    talked about how the ``Just Say No'' efforts to reduce the use
    of tobacco have been very effective. Why do we not do that with
    drugs?
        Mr. Caulkins. It is really important to split drugs up into
    their different bins.
        Senator McCain. OK. Now we are talking about----
        Mr. Caulkins. Marijuana----
        Senator McCain. Well, wait a minute. Let us talk about the
    major problem right now all over the country, particularly in
    the Northeast and the Midwest--and that is manufactured heroin.
        Mr. Caulkins. If I might--so, marijuana is sort of similar
    to alcohol and tobacco in that it is consumed by a lot of
    people. The prescription opioid abuse crisis is absolutely
    driven by our policy of making painkillers much more widely
    available. For the other bin--the heroin, cocaine, and meth
    bin--it is, perhaps, one percent of the country's population
    that is completely dominating their consumption and, hence, the
    cross-border flows.
        Senator McCain. That is not----
        Mr. Caulkins. It is hard to reach the one percent with the
    media----
        Senator McCain. That is not the perception of the Governors
    of these States. In fact, Governors in the Northeast and the
    Midwest are saying that manufactured heroin has driven the drug
    overdose deaths up astronomically. Maybe they are using the
    wrong figures, but I do not think so. Go ahead.
        Mr. Caulkins. No, it is correct that that use has soared,
    but the consumption is still dominated by the small number of
    people who use with great frequency. It is only a subset of all
    people that have used within the last 12 months that are
    driving most of the use--and this is, actually, true not just
    of drugs. It would probably be true of plastics too. There are
    some high-volume consumers. That is a relatively small number
    of people.
        There is definitely an opportunity for a media campaign to
    change mores and norms around prescription drugs and their
    derivatives. I think it is a lot harder to do that for the
    three million or so daily and near daily users of cocaine,
    crack, meth, and, actually, heroin, who dominate the
    consumption that drives the cross-border flow of those drugs.
        So, I am trying to differentiate marijuana from the
    prescription drugs and to differentiate the prescription drugs
    from the classic hard drugs.
        Senator McCain. I am trying to address the issue of what is
    a, relatively, new threat. And, that is manufactured heroin--
    manufactured in Mexico, primarily--right, General Kelly?--that
    is now flooding in the view of every Governor--including the
    Governors of Wisconsin and Ohio--that is flooding the market--
    and people who have been using Oxycontin, which is six times
    more expensive--and other painkiller--are now turning to this
    manufactured heroin, which has driven up, dramatically, the
    deaths from manufactured heroin drug overdoses. Now, that may
    be only one percent. I do not know that. But, I do know that
    the number of deaths have skyrocketed, which has gotten the
    attention of every Governor in America.
        Go ahead.
        Mr. Caulkins. The question is just--is this the kind of
    thing that is best addressed with a broad-based media strategy
    or a different strategy? I absolutely agree it is an extremely
    important problem. I thought the premise of your question was
    why we are not addressing it with something more like a ``Just
    Say No'' strategy.
        Senator McCain. Why are we not addressing it at all?
        Go ahead, Dr. Healton.
        Ms. Healton. Well, first of all, I think a lot of the
    heroin problem that we are now seeing has its roots in moving
    from pills to cheaper heroin because of market forces.
        Senator McCain. And, supply.
        Ms. Healton. Yes, exactly, and supply, which, of course,
    helps to lower the price of heroin--as long as it is getting in
    as readily as it is.
        But, in France, after they made a drug that is a safe
    replacement for an opioid widely available, there was a 79
    percent reduction in deadly overdoses. So, there is a treatment
    arm that is urgently needed--and, frankly, it is time to get
    tough with the pharmaceutical industry. And, I think I did
    provide the Committee with some background information----
        Senator McCain. I agree with that. I agree about getting
    tough with the pharmaceutical industry. But, the fact is--and I
    will ask General Kelly--that most of the deaths can be
    attributed to manufactured heroin that is coming from Mexico. I
    am no friend of the pharmaceutical industry, but the
    pharmaceutical industry is not setting up heroin manufacturing
    in Mexico. General?
        General Kelly. Yes, Senator. As we have discussed--and I
    stated a couple of times, today--the heroin--virtually all of
    it--97 percent or more--comes from Mexico--and that is a
    reaction. It used to come from Afghanistan and the Golden
    Triangle--Burma. But, these cartels are run by unbelievably
    good businessmen and they see----
        Senator McCain. Are they getting into this country fairly
    easily? And, why?
        General Kelly. Yes. The estimation is that, to feed our
    demand, about 45 metric tons of heroin has to get into the
    market inside of the United States--about 45 metric tons. You
    would fill this room.
        So, why does it get in so easily? Because the cartels and
    the network--as we have discussed many times--are so
    efficient--so good at what they do. It gets in in a relatively
    small amount--5, 10, or 15 kilos at a time--and then, it gets
    distributed.
        A little earlier today, Senator, we were talking about
    whether the Southwest border is secure. I would just--as I said
    last year and the three previous years in your hearings--all of
    the drugs that the demand requires get in. Thousands and
    thousands of human beings get in--and all of the rest of it
    that comes in through the network. So, I would have to say that
    the border is--if not wide open, certainly, open enough to get
    inside of the country what the demand requires.
        Senator McCain. So, we are talking about a demand and we
    are also talking about a supply. And, could I have a quick
    recitation of how you can secure the border?
        General Kelly. I do not have a lot of experience on the
    border, but I would tell you, I think the men and women that
    are in law enforcement and at DHS and all, they would--and I
    have visited the border--and what they would argue for are
    policies--this is them talking--policies that they understand
    and can execute--whether it is about drugs or people--and just
    more of an effort--whether it is technology or other ways--to
    search more vehicles as they cross.
        But, really, at the end of the day--and that is a goal line
    stand, one day after another. I would argue, in the case of
    heroin--as you know, Senator, there are parts of Mexico that
    the Mexican authorities will not go. And, that is where this
    drug is produced--where the poppies are grown and all of that.
    And, I would just argue that we need to help the Mexicans help
    themselves and allow them the training and what not to go into
    those regions, because it is all--95 percent of it is grown in
    Mexico--the poppies--and then, turned into either manufactured
    heroin or real heroin--and then, trafficked into our country.
    But, it is the demand.
        Senator McCain. Mr. Chairman, could I ask your indulgence,
    maybe, just if there are any comments our other two witnesses
    would like to make?
        Chairman Johnson. Sure.
        Mr. Sgro. Thank you, Senator. And, I do not claim to have
    experience with drug demand. However, as a marketing
    communications professional and having taken on the tough
    challenge of preventing young people from being recruited by
    extremists--that is a tough problem as well. And, what we have
    seen with the ``Peer-to-Peer: Challenging Extremism'' program
    is that it is a communications issue. It is an awareness issue.
    It starts with awareness. And, from a marketing function--and
    Doctor, you will know this--you have awareness, interest,
    evaluation, trial, and adoption. That is ``marketing 101.''
        We need to have really strong education on top of
    awareness, because, ultimately, interested people who are
    curious are going to come down the funnel and we need
    touchpoints with youth all of the way down the funnel to
    prevent them from pursuing, trying, and getting addicted to
    drugs.
        Another point--television does not work with Millennials or
    Generation Z. It is social media driven. One of the key
    takeaways that we have learned with extremism is that it is who
    creates the message that delivers the credibility.
        Senator McCain. I can assure you that at least the three of
    us are aware of the habits of Millennials--and our attempts to
    communicate with them. [Laughter.]
        Mr. Sgro. It is almost useless. [Laughter.]
        Chairman Johnson. If you could stick around for just a
    couple of minutes, I want to kind of go down the same vein--
    and, maybe, it can--coming from a marketing background,
    myself--because I want to ask this question. Why has the
    advertising campaign against tobacco use been so effective and
    yet, why did it not work in the war on drugs--and it starts
    with the percent of the population that we are targeting?
        In 1996, youth smoking peaked at 38 percent of the
    population--38 percent as one percent of the population. Now,
    it is down to 7 percent. What Dr. Caulkins is talking about is
    how we are trying to target one percent--the real problem
    users, in terms of driving all of these problems. So, if you
    have a broad-based advertising campaign targeted at one
    percent, it is not going to be as effective as a broad-based
    advertising campaign targeted at 38 percent.
        Plus, the difference in the tobacco advertising campaign,
    compared to the campaign combatting drugs--tobacco is legal--
    and so, you can also increase taxes to reduce the demand. You
    can restrict access to restrict the demand.
        So, there are some key differences between the campaign
    that has been successful with tobacco and the campaign that--
    let us face it--has not been successful with drugs. And so, you
    have to recognize those differences--and as Mr. Sgro was
    talking about too--realize television advertising is not
    effective, particularly, when you try and do a broad-based,
    expensive broadcasting campaign that is trying to target one
    percent of the population--which is the problem.
        I mean--just kind of comment. Is that kind of an accurate
    evaluation? Dr. Healton.
        Ms. Healton. It is 90 percent accurate----
        Chairman Johnson. OK.
        Ms. Healton [continuing]. But, I want to focus on the 10
    percent that is not accurate, because I think it is a very
    important 10 percent. The one percent that Jonathan is
    describing, that is not the focus of a primary prevention
    public education campaign. A primary prevention public
    education campaign is targeting those who have never started.
        The ``Truth'' campaign was not targeting existing smokers.
    As a matter of fact, existing smokers intensely disliked the
    ``Truth'' campaign. They felt put down by it. They, actually,
    did respond positively to it, in the main, in terms of changing
    their behavior, but the bulk of the behavior change occurred by
    people never starting.
        And, the goal of a primary prevention education campaign is
    to stop kids from ever starting. And, you have to--you
    absolutely must include in this campaign the dangers of using
    opioid medication--period. The kids directly have to know it,
    because they are being handed it by doctors in sports medicine
    clinics, on their college campuses, at their dental offices,
    and from their friends for a price.
        Chairman Johnson. That is my next question, OK. And, by the
    way, you are exactly right. And, I appreciate you pointing that
    out.
        What is the gateway? We keep hearing that opiate drugs are
    the gateway for heroin, but what about the marijuana use? We
    are talking about 22 million Americans, in the last month,
    using marijuana, as opposed to two million or three million
    using the heavier drugs. What is the true gateway here?
        Mr. Budsock. I can speak to that.
        Chairman Johnson. Sure.
        Mr. Budsock. Well, the first thing I would like to cover is
    that I was recently participating in a roundtable discussion
    with some physicians in the State of New Jersey. They were
    talking about changing behaviors in emergency room medicine.
    And, one of the physicians asked if you would give heroin to
    your 13-year-old daughter. And then, what they did was start to
    explain that, chemically, a Percocet or an Oxycodone--
    chemically, they are very similar to heroin.
        I actually have my 13-year-old daughter with me here,
    today. She is a soccer player who has gotten some minor
    injuries before. But, I would be terrified if a doctor wanted
    to give my daughter a Percocet for an injury because of what I
    know--how chemically similar it is to heroin--and also because
    I know that different people--addiction is a brain disease--and
    everyone's brain is wired a little bit differently.
        And, you could go ahead and you could give that Percocet to
    10 different people and 10 people may just take it once or
    twice and be done with it. But, then the 11th person, maybe,
    their brain is a little different and what happens is that they
    quickly become addicted and they have that insatiable desire to
    just have more and more of that drug. Quickly, they cannot get
    the prescription medicine. So, once they find they get cut off
    by the doctors, it is very expensive to buy prescriptions on
    the street. They quickly go to the low-cost heroin.
        Chairman Johnson. Which, by the way, one of the pieces of
    legislation we have proposed would make sure the Centers for
    Medicare and Medicaid Services (CMS) does not penalize
    providers by asking those survey questions--``how did you think
    your pain was managed? ''--because that is driving some of
    that, along with the other points you are talking about.
        Dr. Healton, you had a comment about this.
        Ms. Healton. Well, I would just say that, for about 25
    years now, there has been a prevailing theory about nicotine
    being, actually, a very powerful gateway drug. And, the theory
    is--Denise Kandel, recently--I guess about 5 years ago--she,
    her husband, Eric Kandel, and Art Levine wrote a paper
    reporting on--I would not be a scientist if I did not talk
    about mice, but a mouse model in which, if you addict mice to
    nicotine and then challenge them with cocaine, they are much
    more likely to use the cocaine and to use it at higher levels.
    And, they proved it, literally, at the molecular level.
        It has not been replicated in humans yet, but there is sort
    of a growing body of evidence that nicotine and alcohol, which
    are, usually, the first drugs that young people use, are the
    most popular two drugs--prior to the big decline in tobacco.
    So, they kind of prime the pump for altered states.
        Chairman Johnson. I have two other lines of questioning I
    need to get at. So, we have begun the experimentation with
    marijuana legalization. I have talked to Chiefs of Police, in
    Wisconsin, that are involved in national associations and I
    just asked them, ``So, what are you hearing? '' And, again,
    this is just anecdotal, which you always have to be concerned
    about.
        The reaction, to me, has been a disaster from a public
    safety standpoint. I mean, does anybody want to chime in on--do
    you know anything about that? I mean, where are we, in terms of
    the experiment, on a State basis, with the legalization of
    marijuana? Dr. Healton.
        Ms. Healton. Well, I think the jury is out--and there are
    studies that are being done--because, really, in the final
    analysis, you have to weigh marijuana as a legal drug comapred
    to what the situation would be like with marijuana as an
    illegal drug. We have not seen an increase in marijuana use
    among the teens in the monitoring----
        Chairman Johnson. Did you say you have not or you have?
        Ms. Healton. Have not.
        Chairman Johnson. OK.
        Ms. Healton. It is flat. It is still high. I want to say it
    is, like, up there in the 30s----
        Mr. Caulkins. Use is up in adults.
        Ms. Healton. As I said, I am talking about youth. For
    youth, it is flat. I would not be surprised if it is up in
    adults. Sadly--and many people do not want to talk about this--
    but you could think of drug use as kind of a zero-sum game.
    People migrate from one to the other. The issue with marijuana
    is that it is well known--except for synthetic marijuana, which
    is a separate issue--to be, relatively, safer when compared to
    other drugs. I think it is socially toxic for young people
    because of what it does to motivation--a separate issue. But,
    in terms of whether it is going to kill you, it is hard to
    find----
        Chairman Johnson. What about the potency over the last few
    decades?
        Ms. Healton. Maybe you want to speak to it?
        Mr. Caulkins. Yes. I can----
        Ms. Healton. I mean, I could speak to it----
        Mr. Caulkins. To be a little bit self-promotional, my
    second book on marijuana legalization just came out this month.
    So, it is always risky to ask me about this because it is
    exactly where my deepest expertise lies.
        But, yes, potency has increased--that is the short answer.
    The market is bifurcated, including both commercial-grade and
    sinsemilla marijuana. The proportion that is the high potency
    sinsemilla has gone way up and there are also increases in
    potency within each of those bins. Furthermore, there is an
    increasing use of extract-based products, like vaping and
    dabbing, because, now that there is legal production, it is
    economical to extract tetrahydrocannabinol (THC) from parts of
    the plant that used to be destroyed.
        Chairman Johnson. So, does marijuana move into the
    very--again, you are bifurcating it, I am not--but does it move
    into more of a status of like heroin, cocaine, or
    methamphetamine----
        Mr. Caulkins. No. If anything, it is the opposite.
    Marijuana use is becoming normalized.
        Chairman Johnson. I am talking about, in terms of potency
    and the effect on the human brain and health----
        Mr. Caulkins. Oh, yes. So--really importantly--even very
    high potency marijuana does not stop your heart or your lungs.
    It is, behaviorally, a problem. About two to three times as
    many ``past month marijuana users'' will self-report that using
    it causes them problems at work, at school, and with family, as
    compared to the number of ``past-month alcohol users,'' who
    will self-report that the alcohol is causing problems in those
    areas. So, it interferes with life functioning, but it does not
    kill you the way that heroin and opiates do.
        Chairman Johnson. My last line of questioning is--we talk
    about treatment. First of all, what is the effectiveness of it?
    I mean, how effective is treating addiction and what is the
    cost? I will look to Bob.
        Mr. Budsock. Yes. So, what we have determined is that--or
    not we, basically, the field that studies addiction treatment
    has definitely determined that there is a correlation between
    the length of treatment and success. So, for individuals whose
    addiction is treated like an acute disorder, in other words,
    they go into a treatment facility for 14 days--for 21 days--and
    they just get spun out of that facility without any continuing
    care or aftercare--the rate of those individuals going back to
    active drug use is very high.
        Chairman Johnson. Which is what--90 percent? Ninety five
    percent?
        Mr. Budsock. You know what, it is very high. I would say--
    --
        Chairman Johnson. Does anybody have a----
        Mr. Budsock. I do not have the statistics in front of me,
    but it is at a very high rate. But, that also does not mean
    that it is a complete failure.
        Chairman Johnson. I understand. When you save one person,
    that is wonderful.
        What about longer-term treatment, then? What is the
    effectiveness?
        Mr. Budsock. So, what has been proven is that, with long-
    term treatment--when I say long-term treatment, addiction is
    treated like a chronic disorder--the same way that you would
    treat diabetes, hypertension, or asthma--what is found is that
    individuals that have that long-term continuing care have fewer
    returns to drug use, more stable employment, and more stable
    family situations----
        Chairman Johnson. OK. Well, give me--I want stats. I mean,
    are we talking--are we 80 percent effective or are we 20
    percent effective, even with long-term treatment? Again, I am
    trying to get to how----
        Mr. Budsock. It depends on, specifically, what you are
    measuring. I could tell you, recently, we had a study at
    Integrity House. For individuals that completed the residential
    component--and after they completed the residential component
    they continued in outpatient treatment and upon discharge from
    the outpatient treatment--and the outpatient treatment varied
    in length anywhere from 3 to 12 months--the day that they
    completed that outpatient treatment--which lasted between 3 and
    12 months--95 percent of those individuals were abstinent.
        Chairman Johnson. And, what does that----
        Mr. Budsock. That does not mean----
        Chairman Johnson. What does that long-term treatment cost,
    per person, per year--just a ballpark amount?
        Mr. Budsock. Yes. So, it depends on the intensity. The
    intensive, residential treatment, where individuals are
    supervised 24 hours a day, is about $100 a day for treatment.
    Once the individual completes that intensive residential stay,
    they move into a less intense level of care and that cost could
    be--if they come back for outpatient three times a week, it
    will be approximately $100 for each day that they come back for
    treatment.
        Chairman Johnson. So, on an annual basis, it would be
    $36,000, if it was a daily type of thing. Does that comport
    with what other people--again, I am just trying to get some
    sort of figure. Dr. Healton.
        Ms. Healton. Well, the figures are, generally, correct, but
    people are not in treatment, generally speaking, for a full
    year. They may be in for 30 days--and the insurers are pushing
    that back like crazy.
        There is a very well known paper--I can get it for you--
    that came out in the New England Journal of Medicine (NEJM)
    probably 15 years ago that unequivocally concluded that, for
    drug treatment, more is more. The more treatment that you get,
    the higher the probability that you will succeed for a longer
    period of time.
        Drug addiction is very similar to high blood pressure. It
    is not going to disappear. It is just--you are going to keep
    treating it. And, what you want to do is have the longest
    periods of sobriety and abstinence that you can get and have
    the safety net there for the person who slips off.
        So, if you have someone who is an addict--whatever they are
    addicted to--alcohol, pills, or heroin--if, out of 8 years,
    they can be drug-free for 6 years, that is a success story.
    And, that is how the field is now viewing success. Drug
    addiction is a chronic disease.
        This is another reason why primary prevention is so cost
    effective, because, once someone crosses over, they are at risk
    for drug addiction, in a cycle that simply is without end.
        Chairman Johnson. OK. I have gone way too long. Senator
    Carper.
        Senator Carper. Well, as we get close to the end of this
    hearing, I had high expectations that we were going to learn a
    lot--this was going to be valuable--more so than even I had
    hoped--so, we thank you very much for that.
        I had asked a question earlier and General Kelly, Mr.
    Caulkins, and Dr. Healton took a shot at it. And, that was
    about helping us put together some of the elements of a
    comprehensive strategy--and I am convinced that we could save a
    lot of money here--and treatment is expensive--so are some of
    the other things we talked about here--that comprehensive
    advertising campaign would be expensive, but, as I always like
    to say, ``compared to what? '' I have a friend. If you ask him
    how he is doing, he says, ``Well, compared to what? '' So,
    compared to what we are already spending, this would probably
    be--maybe, not a bargain, but, surely, a deep discount.
        Mr. Sgro, I want to come back to you and ask you to go back
    to the question that your three compadres there answered for me
    earlier. And, I would like for you, and then Mr. Budsock, to
    take a shot at the same question.
        Mr. Sgro. Yes. Thank you, Senator. I made some comments in
    your absence and I will just kind of stick by those. And, that
    is that the Millennial-mindset generation and the Generation Z-
    mindset are very suspicious of top-down, command messaging.
    And, the ability to have young people be a part of the
    solution--just given the sheer size of that demographic--is so
    important, because the ability to impact behavior exists
    between friends. And, not just----
        Senator Carper. Say that again. The ability to----
        Mr. Sgro. To impact behavior exists amongst friends. They
    are not going to be resentful--nor rebellious--with each
    other--compared to a top-down command--parents, law
    enforcement, or whatever it might be.
        Senator Carper. OK.
        Mr. Sgro. And, I think another really important issue, when
    it comes to the platform of messaging--there is a difference
    between what happens in different parts of Los Angeles. Is it
    Instagram, WhatsApp, or another social media platform that is
    being used? So, things are changing--we have seen--every 15
    weeks on social media--and that is how young people
    communicate. They may not talk to each other, but they will
    text each other. So, the platforms are equally as important as
    what, actually, the message is.
        Senator Carper. Thank you. Mr. Budsock.
        Mr. Budsock. Yes, Senator. So, the first thing I would like
    to talk about is cost--and it is important--we came up with a
    figure of $36,000 a year--and that would be somebody that is
    undergoing intensive services for 12 months. In most cases,
    those intensive services probably need to be only for the first
    6 months. So, it would probably be $18,000 to treat the
    individual for the first 6 months and then, that cost would
    decrease for the continuing care.
        The other thing that is important----
        Senator Carper. The thought comes to mind--I used to know
    these numbers better when I was Governor--but we used to say it
    cost $20,000 a year to keep an adult incarcerated in the State
    of Delaware--and, for youths, it was several times that. So, it
    is not far off of that--it is probably closer to $25,000,
    $30,000, or $35,000, today, for the incarceration of an adult
    for a year.
        Mr. Budsock. And, I believe the cost--that is a minimal
    cost. That is probably out in very rural areas, like Wyoming. I
    know, in New Jersey, it is as expensive as $60,000 to $70,000 a
    year to incarcerate someone--and I believe there is a study
    that actually has the exact figures for that.
        Senator Carper. The thought occurs to me--excuse me for
    interrupting. The thought occurs to me, if you have someone who
    is incarcerated for a drug-related crime, part of that $100 a
    day, if you will, is--if they are incarcerated--for actually
    doing a good job on treatment while they are incarcerated, you
    actually save some money.
        Mr. Budsock. Yes, absolutely.
        Senator Carper. Go ahead. I am sorry to keep interrupting.
        Mr. Budsock. Well, the other thing is that there are
    multiple studies that indicate that, for every dollar invested
    into treatment, there is a return to the economy anywhere from
    $4 to $7 in associated reduced costs related to crime, inactive
    workforce, etc. And, if you factor in the cost for health care
    savings, it could be as big of a return as a $12 return for
    every $1 invested.
        And, the other thing is--going back to your earlier
    question----
        Senator Carper. I am going to ask you to wrap it up really
    quickly, because I have one more question, but just go ahead.
        Mr. Budsock. OK.
        Senator Carper. Finish your thought.
        Mr. Budsock. I will wrap it up quickly. I am trying to put
    myself in your seat up there and saying, ``OK, what do I need
    to know to actually make sure that we are reducing demand? ''
        One piece is prevention--to make sure that we have
    effective prevention programs that are teaching kids refusal
    skills.
        The second is to make sure that treatment is available--
    that individuals who need it have quick and ready access to
    treatment--and that there is parity--that addiction treatment
    is covered in the same way that a physical illness is covered.
        And, the final piece is to repeal the IMD exclusion. I
    spoke about it earlier. It has been around since 1964 or 1965
    and for the current world that we are working in, it is
    absolutely an unfair barrier for many people.
        Senator Carper. OK. Thank you.
        Let me come back to Dr. Caulkins. I think you mentioned--I
    think it was a South Dakota program earlier, ``Swift, Certain,
    and Fair''--and, I guess, I want to know what possible role
    would a program like that, which has apparently been successful
    in one State--what possible role could that play on a broader
    scale?
        Mr. Caulkins. Sure. ``Swift, Certain, and Fair'' is the
    broad concept. ``24/7 Sobriety'' is the name of the particular
    program in South Dakota. It has now spread to Montana and North
    Dakota. Hawaii's Opportunity Probation with Enforcement (HOPE)
    is a parallel program.
        They have the potential to have a huge impact because of
    the fact that today's consumption of the hard drugs is
    concentrated in this, relatively, small number of people. And,
    these programs have been astonishingly successful at reducing
    use, even among that difficult population. So, treatment makes
    people better off and, in the long run, it may cut down on
    consumption.
        But, ``Swift, Certain, and Fair'' regimes are a very
    different paradigm. They just test very frequently--in South
    Dakota, literally, twice a day--originally, with driving under
    the influence (DUI) offenders. They are doing that, now, for
    alcohol and for other substances too. And, the remarkable thing
    is that an awful lot of people respond when you monitor that
    closely and there is an immediate sanction--not a severe
    sanction, but an immediate sanction--even if they are dependent
    and even if they are not in a traditional treatment program.
        One idea is that you can use ``Swift, Certain, and Fair''
    as a front end and, maybe, 70 percent of the use can be
    addressed by this testing with sanctions--which is a little bit
    like a drug court regime--and then, only the folks who fail
    ``Swift, Certain, and Fair'' would get to the conventional
    treatment. And, that would allow conventional treatment to
    focus on the smaller subset of people who do not respond to
    this incentives-based regime.
        Senator Carper. OK. Alright, Mr. Chairman. I have not used
    but 32 seconds of my extra time, but could I get another couple
    of minutes?
        Chairman Johnson. OK.
        Senator Carper. Thank you very much. That is what we call
    ``the Golden Rule.''
        Chairman Johnson. I do have to move, so----
        Senator Carper. Good. If you need to leave, I would be
    happy to stay. I promise not to get in trouble.
        Chairman Johnson. I have some questions myself.
        Senator Carper. OK. Fair enough.
        The other question I have relates to--somebody mentioned
    this in your comments--the use of other substances--for
    example, opioids. We are using opioids for pain and that kind
    of thing. But, there are substances--pharmaceuticals--that can
    be prescribed that are not addictive. I know we use other
    substances to treat people who are addicted to different types
    of drugs. What is the future of that? What is the promise of
    that particular approach for folks that might be addicted--
    whether it is to meth, cocaine, or heroin? What can be done? Is
    there any potential there for success, please?
        Mr. Budsock. I can speak, specifically, about opiate
    addiction. There is research proving that medication-assisted
    treatment (MAT), such as methadone, Suboxone (buprenorphine and
    naloxone), and Vivitrol (naltrexone), have all been very
    effective in helping the individual--giving the individual time
    for their brain to normalize and also to help them avoid the
    intense cravings that they are experiencing when they initially
    put down the heroin.
        What is important is that everyone realizes that it is
    medication-assisted treatment. There is no quick fix. If you
    just give someone one of these pharmaceuticals, which are
    approved by the Food and Drug Administration (FDA) and proven
    to be effective by research, the medication, alone, will not
    allow the person to actually transform their lives.
        Senator Carper. OK. Thank you.
        The last thing I would say--Cheryl, I do not know if you
    remember, but there was a campaign, in Montana, focused on meth
    that I think was very successful for a while. Would you mention
    that? And, why did it sort of fade away?
        Ms. Healton. Well, there was one evaluation of it that was
    done--that I am aware of--and that did show effectiveness. It
    was offered to every State in the Union and, in my opinion, the
    primary reason that there were only a handful of takers is
    because it fell into that category of being objectionable to
    adult viewers, in terms of the advertising.
        An example--one example was a young man on meth beating his
    mother up. Now, this, I am sure, came out of research with meth
    addicted kids----
        Senator Carper. Right.
        Ms. Healton [continuing]. Some in recovery and some not.
    They described how they became active in family violence and
    they thought that depicting that would turn young people away
    from it. That was more than a lot of States were prepared to
    air on their dime.
        Senator Carper. OK. Thank you all very much.
        Chairman Johnson. Thank you, Senator Carper.
        I did see that General Kelly wanted to get involved--make
    some comment on something, so----
        General Kelly. Yes. We talked a lot, obviously, about the
    very important topic of addiction and that kind of thing--which
    is, to say the least--usually important. I would just make a
    pitch. There is another aspect to this and that is--and I think
    it, probably, would lend itself to kind of advertising
    campaigns or whatever--and that is just the casual use--or the
    recreational use--of drugs, particularly, a drug like cocaine.
        People that use cocaine or other drugs, recreationally--
    that do not get strung out and that do not go down the road of
    addiction--they ought to know that their casual, fun use on a
    weekend really does end up resulting in the murder of police
    officers in Honduras or in the intimidation of families in
    Colombia.
        And, I think, just appealing to the right side of the
    American psyche--and that is understanding that it is not the
    same as having a couple of drinks after work because of the way
    that it is produced and trafficked into the United States. And,
    I have to think that that would--if we did educate--whether it
    is college students, young businessmen, Congressional staffers,
    or anyone else--that the casual use of these drugs really does
    result in terrible things down in the production zone and in
    the transit zone. Thank you.
        Senator Carper. That is a great point. Thank you.
        Chairman Johnson. And, it was the point that I made
    earlier. It is not a victimless crime.
        So, listen, the beauty of having five people on a panel is
    that we get a broad spectrum of views and we get some really
    good input. The unfortunate nature of it is that, for a lot of
    it, you are sitting there and not being able to answer all of
    the questions. So, view this hearing as really just one step in
    a series of hearings, because this is such an enormous problem.
    You have done a great job of raising our awareness, helping us
    to understand this a little better. But, it is incredibly
    complex.
        So, again, I just want to thank all of you for your time,
    your very thoughtful testimonies, and your very thoughtful
    answers to our questions. This will continue. We are, actually,
    continuing it, in Wisconsin, on Friday. And, we are going to
    continue the conversation, more specifically, in terms of the
    problems in Wisconsin, but every State in the Union is
    suffering under this.
        So, with that, the hearing record will remain open for 15
    days, until April 28, at 5 p.m., for the submission of
    statements and questions for the record.
        This hearing is adjourned.
        [Whereupon, at 11:48 a.m., the Committee was adjourned.]

                                A P P E N D I X

                                  ----------

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                         ASSESSING THE FEDERAL RESPONSE

                                  ----------

                             TUESDAY, MAY 17, 2016

                                         U.S. Senate,
                               Committee on Homeland Security
                                      and Governmental Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:33 p.m., in
    room SD-342, Dirksen Senate Office Building, Hon. Ron Johnson,
    Chairman of the Committee, presiding.
        Present: Senators Johnson, Portman, Ayotte, Carper,
    McCaskill, Tester, Booker, and Peters.

                 OPENING STATEMENT OF CHAIRMAN JOHNSON

        Chairman Johnson. This hearing will come to order. I do
    apologize to the witnesses for the delay. We had a couple of
    votes, so I appreciate your indulgence.
        Because we are short on time, I just have a written
    statement that I would ask consent to enter in the record.\1\
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Senator Johnson appears in the
    Appendix on page 285.
    ---------------------------------------------------------------------------
        And, I would also like to recognize the fact that it is
    National Police Week. There have been 123 law enforcement
    officers killed in the line of duty during calendar year 2015,
    including two in Wisconsin: Officer Ryan Copeland from
    McFarland, Wisconsin and Trooper Trevor John Caspar, who was
    killed in Fond du Lac, Wisconsin. So, I would just ask
    everybody to bow their heads and take a moment of silence.
        [Moment of silence.]
        Thank you. The sacrifice of our police officers is really
    too large to even express in words, so I appreciate everybody
    taking that moment of silence.
        With that, Senator Carper.

                  OPENING STATEMENT OF SENATOR CARPER

        Senator Carper. Thank you, Mr. Chairman. Thank you for
    pulling this together. To our witnesses, again, we apologize
    for the delay. Sometimes, our day jobs get in the way of our
    job here on the Committee--and that was voting--voting on the
    Senate floor.
        I have a statement and I would also like to ask, Mr.
    Chairman, unanimous consent that it be included in the
    record.\2\ I just want to mention one or two things, if I
    could, and then we will get going.
    ---------------------------------------------------------------------------
        \2\ The prepared statement of Senator Carper appears in the
    Appendix on page 286.
    ---------------------------------------------------------------------------
        The situation we are in, as a country--there is a large
    focus here on the three countries where the most illegal
    immigration is coming from in Central America--South America--
    and they are: Honduras, Guatemala, and El Salvador. And, the
    reason why people are coming up here is that, a lot of times,
    young kids--young families live hellacious lives. They live
    hellacious lives because we send them money and they send us
    drugs. We send money and guns to some of the people that are
    just making life miserable for the citizens of those countries.
        I am one who always wants to focus on root causes--to find
    out what is the root cause of a problem, not just look at the
    symptoms of a problem. You have all of these people trying to
    get into our country across the border. What is the root cause
    of that? The root cause of that is that their lives are
    miserable because of our addiction to drugs and the trafficking
    of those drugs through those countries.
        So, we are doing a couple of things to try to address it,
    including investing some money to help enable those countries
    to be a better place to live--less horrific--a place they would
    want to stay and raise their families. And, the root cause is
    our addiction--our addictions to opioids and heroin--that sort
    of thing. And, we cannot ignore that.
        The last thing I would say is this: We talk in this
    Committee, from time to time, about how, in order to be able to
    stop human trafficking--in order to be able to stop the
    bringing of things that are illegal--including drugs--into this
    country, we need to reduce the size of the ``haystack.'' The
    ``needle in the haystack''--we have to reduce the size of the
    ``haystack'' if we are going to find those ``needles.'' We have
    to be able to--and I am not talking about needles for
    addiction--but the key is reducing the size of the
    ``haystack.'' And, part of that is making sure that the people
    living in these countries have a life that is not miserable--
    not full of fear, but one for which they would be more inclined
    to stay if they could. And, I think they would like to. And,
    part of it is on us. Part of that is on us. And, that is why we
    are having this hearing today.
        We welcome you all. Thank you so much for coming.
        Chairman Johnson. Thank you, Senator Carper.
        I think this is our 18th hearing on some aspect of the lack
    of security on our border. And, certainly, my conclusion--and I
    think at least some of the Members here would probably, at
    least partially, agree with me--when I have looked at the root
    cause of our unsecured border--the primary root cause is our
    insatiable demand for drugs--which is why we are having this
    hearing. It has given rise to drug cartels who, let us face it,
    control whatever portion of the Mexican side of the border they
    choose to. It is destroying public institutions in Central
    America and parts of Mexico. So, this is an enormous problem
    and we just simply have not been winning the ``War on Drugs.''
        So, with that, it is the tradition of this Committee to
    swear in witnesses. So, if you will all rise and raise your
    right hand. Do you swear the testimony you will give before
    this Committee will be the truth, the whole truth, and nothing
    but the truth, so help you, God?
        Mr. Botticelli. I do.
        Ms. Enomoto. I do.
        Ms. Maurer. I do.
        Chairman Johnson. Thank you. Please be seated.
        Our first witness is Michael Botticelli. Mr. Botticelli is
    Director of the Office of National Drug Control Policy (ONDCP).
    Mr. Botticelli has more than two decades of experience
    supporting Americans who have been affected by substance abuse
    disorders. Prior to joining ONDCP, Mr. Botticelli served as
    Director of the Bureau of Substance Abuse Services (BSAS) at
    the Massachusetts Department of Public Health (DPH). He is also
    in long-term recovery from a substance use disorder,
    celebrating more than 25 years of sobriety. We certainly
    congratulate you on that. Thank you for your service and we
    look forward to your testimony.

    TESTIMONY OF HON. MICHAEL P. BOTTICELLI,\1\ DIRECTOR, OFFICE OF
                      NATIONAL DRUG CONTROL POLICY

        Mr. Botticelli. Thank you, Chairman Johnson, Ranking Member
    Carper, and Members of the Committee. I want to thank you for
    the opportunity to be here today to discuss ONDCP's authorities
    along with our collaborative efforts to carry out the
    Administration's drug control priorities, including our
    response to the opioid epidemic.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Botticelli appears in the
    Appendix on page 288.
    ---------------------------------------------------------------------------
        As a component of the Executive Office of the President
    (EOP), we establish policies and objectives for the Nation's
    drug control programs and ensure that adequate resources are
    provided to implement them. We also develop, evaluate,
    coordinate, and oversee the international and domestic anti-
    drug efforts of Executive Branch Agencies.
        We are charged with producing the annual National Drug
    Control Strategy, which is the Administration's blueprint for
    drug policy along with a national drug control budget.
        Let me first start off by saying that the National Drug
    Control Strategy has produced results. Particularly important
    to us, right now, is that, among youth aged 12 to 17, the
    number of current nonmedical users of opioid medication has
    declined 29 percent from 2009 to 2014--and 39 percent among
    young adults aged 18 to 29. Perhaps most importantly, the
    number of new nonmedical users of prescription pain medication
    went down 35 percent over this same time period--from 2.2
    million in 2009 to 1.4 million in 2014.
        Also, between 2009 and 2014, there were reductions in the
    use of illicit drugs--other than marijuana--dropping 21 percent
    among youth aged 12 to 17 and 20 percent among young adults
    aged 18 to 29.
        Substantial progress has also been achieved in reducing
    alcohol and tobacco use among youth, with a 28-percent decline
    in the rate of the lifetime use of alcohol among eighth-grade
    students--and 34 percent for cigarettes. These declines exceed
    the targets that we established for the 2010 National Drug
    Control Strategy.
        Despite these achievements, we know that much remains to be
    done. And, while we have seen the leveling off of deaths
    associated with prescription pain medication, we have seen a
    tremendously alarming increase in deaths involving heroin and
    illicit fentanyl. These correspond with recent increases in
    poppy cultivation and heroin production in Mexico.
        With the continued implementation of the Administration's
    plan for addressing this crisis, including our engagement with
    the government of Mexico, we are hopeful that the Nation will
    see renewed declines in the availability of heroin and in
    deaths involving opioids.
        ONDCP's oversight of the national drug control budget
    ensures that the government's efforts are well coordinated and
    support the objectives of the National Drug Control Strategy.
    ONDCP leads a broad range of interagency groups that support
    the National Drug Control Strategy's initiatives. Examples
    include interagency working groups on opioid treatment,
    prevention, and data as well as the National Heroin
    Coordination Group.
        ONDCP's funding authorities reflect a balanced demand
    reduction and supply reduction approach to drug control,
    including continued interdiction and enforcement actions
    against criminal drug-trafficking organizations. While the
    level of supply reduction funding has remained constant, demand
    reduction funding has increased. When the Administration took
    office, only 37 percent of Federal drug control resources were
    devoted to demand reduction efforts. For fiscal year (FY) 2017,
    51 percent has been requested for demand reduction and 49
    percent for supply reduction.
        The President's 2017 budget control matches the seriousness
    of the situation we face as a Nation. It includes $1.1 billion
    in new mandatory funding over 2 years to expand access to
    treatment and recovery support services for people with opioid
    use disorders. This funding will reduce barriers to treatment
    and will ensure that every American who wants treatment can
    access it and get the help that they need.
        Members of the Committee, ONDCP will seek to continue to
    find new and effective solutions to address drug use and its
    consequences. We remain committed to working with Federal,
    State, local, tribal, and private sector partners to develop an
    effective drug control strategy and use our budget authority to
    develop new programs and expand successful ones.
        We know that by working together, we will continue to
    reduce the prevalence and consequences of drug use and help
    individuals recover from the disease of addiction.
        Thank you.
        Chairman Johnson. Thank you, Mr. Botticelli.
        Our next witness is Kana Enomoto. Ms. Enomoto is Principal
    Deputy Administrator of the Substance Abuse and Mental Health
    Services Administration (SAMHSA) at the U.S. Department of
    Health and Human Services (HHS). SAMHSA is the agency, within
    HHS, that leads public health efforts to advance the behavioral
    health of the Nation with the mission of reducing the impact of
    substance abuse and mental illness on America's communities.
    Ms. Enomoto began her tenure at SAMHSA in 1998. Ms. Enomoto.

     TESTIMONY OF KANA ENOMOTO,\1\ PRINCIPAL DEPUTY ADMINISTRATOR,
    SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S.
                DEPARTMENT OF HEALTH AND HUMAN SERVICES

        Ms. Enomoto. Good afternoon, Chairman Johnson, Ranking
    Member Carper, and Members of the Committee. I thank all of you
    for your leadership to raise awareness and catalyze action to
    address addiction in America. It is truly a matter of life or
    death.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Enomoto appears in the Appendix
    on page 298.
    ---------------------------------------------------------------------------
        Unfortunately, in recent years, 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 one out of 10 people with a
    substance use disorder gets the treatment they need. It would
    not work for diabetes, it would not work for cancer, and it
    will not work for addiction. We must join together to ensure
    that every person with a substance use disorder, who seeks
    treatment, will find an open door.
        Toward this end, SAMHSA is proud to support the President's
    National Drug Control Strategy and HHS Secretary Sylvia Mathews
    Burwell's Opioid Initiative. The Fiscal Year 2017 President's
    budget, as Director Botticelli noted, makes a bold commitment
    to face this crisis head on: a $1.1 billion, 2-year investment
    in new mandatory funding to build the addiction workforce and
    bolster the continuum of services. Of the $1 billion, SAMHSA
    proposed $920 million, over 2 years, for State grants to close
    the treatment gap for opioid use disorder by making medication-
    assisted treatment (MAT), including needed psychosocial
    services and recovery supports, affordable and available to
    people who are seeking recovery. These funds would support
    community prevention, build the workforce, and use technology
    to expand the reach of treatment. The initiative also includes
    $30 million in new mandatory funding for SAMHSA to evaluate the
    effectiveness of MAT programs under real-world conditions.
        The fiscal year 2017 budget also includes $50 million of
    discretionary funding--an increase of $25 million--to support
    23 new State medication-assisted treatment prescription drug
    and opioid addiction (MAT-PDOA) grants. MAT-PDOA was created,
    in fiscal year 2015, to provide comprehensive care and
    evidence-based MAT, including all three medications approved by
    the Food and Drug Administration (FDA) to treat opioid use
    disorders. In fiscal year 2016, Congress grew this program and
    directed SAMHSA to allow medications and services to achieve
    and maintain abstinence from all opioids as well as to
    prioritize treatment regimens that are less susceptible to
    diversion.
        One example of MAT-PDOA's success is the Wisconsin Care
    Program. Their efforts to expand the availability of
    medication-assistant treatment. Originally, there were only two
    providers willing to prescribe long-acting injectable
    naltrexone in Sauk County, Wisconsin. But, by having a champion
    physician present on how effective MAT can be in combating
    addiction, that number has already expanded to 12 providers.
    That means that 10 more providers are willing to see patients
    with substance use disorders that may need life-saving
    medications to help them become and stay drug-free.
        We must ensure that the substance use workforce is
    sufficient to meet the growing demand. Another 2017 proposal to
    expand access to MAT is the $10 million Buprenorphine-
    Prescribing Authority Demonstration to test the safety and
    effectiveness of expanding buprenorphine prescribing to
    advanced practice providers, such as nurses and physician
    assistants (PAs).
        As part of its regulatory responsibility, SAMHSA certifies
    the Nation's opioid treatment programs, which provide
    monitored, controlled conditions for the safe and effective
    treatment of opioid addiction. Finally, SAMHSA is proposing a
    new regulation to increase the patient limit for physicians who
    have a waiver to prescribe buprenorphine.
        Another important program at SAMHSA is the Pregnant and
    Postpartum Women's (PPW) initiative. PPW grantees increase
    access to family centered residential treatment for pregnant
    and parenting women. The evaluation of this program shows great
    outcomes. On intake, about two-thirds of these pregnant women
    are using alcohol or drugs. At the 6-month follow-up point, 85
    percent are alcohol-and drug-free. Healthy babies are being
    born and progress is being made.
        But, there are still more lives to save. We know that
    naloxone can reverse a potentially fatal opioid overdose. But,
    it only works if you have it.
        In SAMHSA's overdose prevention course for prescribers and
    pharmacists, one of the targeted strategies we promote is the
    co-prescribing of naloxone with opioid analgesics,
    particularly, for patients at high risk of overdose. And, this
    month, SAMHSA is accepting applications for State grants to
    purchase naloxone and to equip and train first responders. We
    appreciate Congress' strong support of this effort.
        An underpinning of the Nation's Behavioral Health Safety
    Net is the Substance Abuse Prevention and Treatment Block Grant
    (SABG). Since 2013, the block grant has grown by $150 million
    to $1.9 billion. Further investments like these are crucial
    because this program is delivering an impact for the American
    people. At discharge, more than 70 percent of individuals who
    receive block grant-funded services report no drug use in the
    past month. Eighty-four percent report no alcohol use. And, 95
    percent report no involvement with the criminal justice system.
        Other important components of SAMHSA's treatment and
    recovery portfolio include: drug courts and offender reentry
    programs,
    efforts to combat homelessness, Human Immunodeficiency
    Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), peer
    services, and workforce training.
        Prevention is another important core element of the
    National Drug Control Strategy. SAMHSA's Center for Substance
    Abuse Prevention (CSAP) implements the Strategic Prevention
    Framework (SPF) grant program, where communities like New
    Castle County, Delaware work with their State to focus on using
    data and evidence-based strategies to reduce drug abuse and
    underage drinking.
        In 2016, Congress appropriated $10 million for a new
    program, SPF Rx, which will help States to use their
    Prescription Drug Monitoring Program (PDMP) data to identify
    communities at the highest risk for the diversion and misuse of
    prescription drugs.
        SAMHSA's prevention efforts also include the administration
    of ONDCP's Drug-Free Communities (DFC) Program, which supports
    anti-drug coalitions across the country, like Merrimack
    Safeguard in New Hampshire, who is implementing evidence-based
    programs to increase parental awareness, support parental
    responsibility, and reduce easy access to prescription
    medications by encouraging responsible and safe storage and
    disposal methods.
        SAMHSA also implements the Sober Truth on Preventing
    Underage Drinking (STOP) Program, so current and former drug-
    free communities can focus their efforts to reduce underage
    drinking. Thanks to these and other prevention strategies,
    national rates of underage drinking among 12-to 20-year-olds
    declined by 21 percent from 2004 to 2013.
        And, for our tribal communities, SAMHSA's Tribal Behavioral
    Health (Native Connections) Grant Program addresses the high
    incidence of substance use and suicide among American Indian
    and Alaska Native populations. And, we are pleased that, in
    fiscal year 2016, across all of its programs, SAMHSA will have
    its largest cohort of tribal grantees ever--of 160 grants.
        In the area of surveillance and evaluation, many of our
    efforts to inform policy and program decisionmaking are made
    possible through our Center for Behavioral Health Statistics
    and Quality (CBHSQ), which provides critical data to the field
    from evaluation and surveillance. CBHSQ's signature programs
    include the National Survey on Drug Use and Health (NSDUH), the
    Behavioral Health Barometer, and the National Registry of
    Evidence-based Programs and Practices (NREPP).
        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 a significant impact for the
    American people. I am happy to answer any questions.
        Chairman Johnson. Thank you, Ms. Enomoto.
        Our final witness is Diana Maurer. Ms. Maurer is the
    Director of Homeland Security and Justice (HSJ) at the U.S.
    Government Accountability Office (GAO). Ms. Maurer's recent
    work includes, among other issues, reports and testimonies on
    the Federal prison system, Department of Justice (DOJ) grant
    programs, nuclear smuggling, national drug control policy, and
    Department of Homeland Security (DHS) morale. Ms. Maurer.

     TESTIMONY OF DIANA C. MAURER,\1\ DIRECTOR, HOMELAND SECURITY
           AND JUSTICE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

        Ms. Maurer. Good afternoon, Chairman Johnson, Ranking
    Member Carper, other Members, and staff. I am pleased to be
    here today to discuss GAO's perspectives on Federal efforts to
    address illicit drug use.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Maurer appears in the Appendix on
    page 308.
    ---------------------------------------------------------------------------
        Drug trafficking, drug abuse, and the associated impacts on
    public health and safety have been longstanding issues.
    Combating these problems is costly. The Administration has
    requested more than $31 billion to prevent drug abuse, provide
    treatment for substance abuse disorders, support domestic
    enforcement of drug laws, interdict drug smuggling, and combat
    international drug trafficking.
        Now, consider that list of activities for just a second.
    Doing all of that involves dozens of very different Federal
    Agencies working in the fields of medicine, law enforcement,
    intelligence, corrections, and diplomacy. This truly is a
    multifaceted effort--and it needs to be, because the problems
    from drug abuse in the United States are complex and deep-
    seated.
        If there is one thing we have learned over the past several
    decades, it is that there are no quick or easy fixes. The
    Administration's 2017 request is noteworthy because, for the
    first time, it has proposed spending more on treatment and
    prevention--the so-called ``demand side'' of the problem--than
    on law enforcement, interdiction, and international programs--
    the so-called ``supply side.''
        Over the past several years, spending for supply side
    activities has remained roughly the same. Spending today is
    roughly comparable--allowing for inflation--to what we spent in
    2007. However, spending for the demand side has increased,
    especially in recent years. Specifically, since 2013, spending
    on treatment programs has increased 67 percent, from $7.9
    billion to over $13 billion today. This reflects a growing
    emphasis on the increasingly dire public health consequences of
    drug abuse, especially of controlled prescription drugs and
    heroin.
        In 2014, for example, the Center for Disease Control (CDC)
    reported nearly 50,000 drug-induced deaths in this country.
    That is about 136 Americans every day. To put it another way,
    it is also more per day than the total number of Americans
    killed, in this country, from terrorist attacks in the nearly
    15 years since the attacks on September 11, 2001 (9/11). Given
    that bleak fact, ensuring that this money is well spent, that
    we are making progress, and that the various agencies are well
    coordinated is vital.
        ONDCP, to its credit, has focused a great deal of time,
    attention, and resources on developing and using performance
    measures to assess the progress of Federal drug control
    efforts. The 2010 National Drug Control Strategy established a
    series of goals with specific outcomes ONDCP hoped to achieve
    by last year.
        In 2013, we reported that a related set of measures were
    generally consistent with effective performance management and
    useful for decisionmaking--so, unlike many other Federal
    programs, in this area, there is a dashboard with meaningful
    indicators of progress and clear targets. So, keep that in mind
    when the conversation turns to what these measures tell us.
    And, overall, there has been a lack of progress.
        According to a report ONDCP issued late last year, none of
    the seven goals were achieved. And, in some key areas, the
    trend lines moved in the opposite direction. For example, the
    percentage of eighth graders who have ever used illicit drugs
    increased rather than decreased. The number of drug-related
    deaths increased 27 percent rather than decreased 15 percent,
    as planned.
        We should also recognize some progress in key areas. For
    example, the 30-day prevalence of drug use by teenagers has
    dropped. There has also been recent progress in Federal drug
    abuse prevention and treatment programs. In 2013, we found that
    coordination across 76 Federal programs at 15 Agencies was all
    too often lacking. Forty percent of the programs at that time
    reported no coordination with other Federal agencies. We
    recommended that ONDCP take action to reduce the risk of
    duplication and improve coordination.
        Since our report, ONDCP has done just that. It has
    conducted an inventory of the various programs and updated its
    budget process and monitoring efforts to enhance coordination.
        Mr. Chairman, as Congress considers its options, it is
    worth reflecting on the deeply ingrained nature of illicit drug
    use in this country. It is an extremely complex problem that
    involves millions of people, billions of dollars, and thousands
    of communities. There are very real costs in lives and
    livelihoods across the United States. Helping reduce these
    costs and achieving national drug policy goals will require
    effective program implementation, demonstrated results, and
    enhanced coordination among the various Federal Agencies.
        GAO stands ready to help Congress assess the extent to
    which ONDCP and other Federal Agencies achieve these goals and
    reduce the impact of drug abuse in this country.
        Thank you for the opportunity to testify this afternoon. I
    look forward to your questions.
        Chairman Johnson. Thank you, Ms. Maurer.
        Our clocks are obviously not working here, so we have a
    timer, which I will ask staff to put it right there. So, when
    we see the little buttons go off, I will know I have run out of
    time.
        Mr. Botticelli, we have heard a lot of percentages--up and
    down. In previous testimony the Committee heard, about 24
    million Americans--I think that is correct, somewhere in that
    ballpark--use some sort of illegal drug on a monthly basis.
    About 3 million are using non-marijuana--in other words,
    cocaine, heroin, fentanyl, and those things. Is that pretty
    much the number we are talking about here?
        Mr. Botticelli. Correct.
        Chairman Johnson. How has that changed in the last 10 or 20
    years?
        Mr. Botticelli. As we have looked at measures--and I want
    to thank Ms. Maurer because we actually do have a dashboard of
    measures that we track. And, when we look across our measures,
    one of the reasons why we have not made progress in many of
    these areas, in terms of reducing illicit drug use, has to do
    with increasing rates of marijuana use among eighth graders
    and, particularly, young adults. And, if you take marijuana out
    of the equation, we actually have made significant results with
    12-year olds to 17-year-olds in many areas. And, there have
    been results among young adults, particularly, in cocaine,
    methamphetamine (meth), and prescription drug use issues.
        Chairman Johnson. So, rather than look at very narrow
    categories, I am just kind of looking at the macro level here.
    Three million hard drug users a month--that is about one
    percent of the population. Has that held pretty steady? Did it
    used to be 2 percent and now it is 1 percent? I mean, has it
    always been kind of in that 1-percent range?
        Mr. Botticelli. The overall prevalence of drug use has
    remained relatively stable over the years. And, we have seen
    some--I do think that one of the areas where we have seen a
    decrease in prevalence has largely been among youth in the
    United States. And, I think this speaks to our overall issues,
    because we know that drug use is an issue of early onset. So, I
    think as we have seen reductions in, particularly, underage use
    rates across the board--with the exception of marijuana--that
    it holds promise for seeing a significant decrease in
    prevalence overall.
        Chairman Johnson. But, in general, the percentage of
    Americans using hard drugs has held pretty steady?
        Mr. Botticelli. Generally.
        Chairman Johnson. So, not much--we have spent billions of
    dollars. I do not know what the history is, but we are spending
    $30 billion this year. And, prior to that we were spending $20
    billion to $25 billion. We spent a lot of money and we really
    have not made a dent in this.
        Mr. Botticelli. But, I do think, Chairman, if you would
    allow me--I think part of the intractability of the issue
    speaks to--the fact that, historically, our drug control budget
    has been out of balance. While supply reduction and law
    enforcement play a critical role, our historic funding around
    prevention and treatment efforts----
        Chairman Johnson. We will get to those issues.
        Mr. Botticelli. OK.
        Chairman Johnson. In testimony, General Kelly, former head
    of the Southern Command (SOUTHCOM), said that we have
    visibility for about 90 percent of the drug flow--and yet, we
    just lack the interdiction capability. Do you, basically, agree
    with that assessment?
        Mr. Botticelli. I do, to some extent. I get quarterly data
    on the amount of drugs that are interdicted in the United
    States. I have to say that, while we do have operational
    awareness, in terms of drugs, I think the U.S. Coast Guard
    (USCG) has, significantly, stepped up, in terms of their
    interdiction efforts--as well as some of our partner nations.
    So, actually, when you look at the amount of, particularly,
    cocaine that is interdicted, those numbers are at the highest
    level that they have ever been.
        Chairman Johnson. But, again, we are talking about narrow
    categories. Let us just take a look at another metric that has
    come out in testimony--certainly, in briefings. In the early
    1980s, the price of a gram of heroin would be, in today's
    terms, equivalent to about $3,200. There are reports in
    Milwaukee that you can get a gram of heroin for $100. At 10
    doses per gram, that is $10 a hit.
        Obviously, from the standpoint of interdicting supply, you
    would think that, if we were doing a better job, those prices
    would remain high. But, they have dropped significantly.
    Correct?
        Mr. Botticelli. I would say, particularly, in terms of
    heroin interdiction, we have a lot more work to do. Part of the
    reason that we are seeing such a dramatic increase in heroin
    has to do with the dramatic increase in availability and the
    lower price in many parts of the United States.
        Chairman Johnson. What I am just trying to elicit here is--
    we are not making progress on this. I think we are losing the
    war.
        Ms. Enomoto, all of us would love to believe that we could
    treat drug addiction effectively. What is the success rate, in
    terms
    of--Mr. Botticelli is obviously one of the examples of success.
    What is, basically, the success rate?
        Ms. Enomoto. I am incredibly optimistic in this space
    because we do have science that tells us people can and do
    recover. While substance use disorders are chronic neurological
    conditions that have the potential for recurrence, they also
    have amazing potential for recovery. So, within the SAMHSA
    portfolio, we are seeing about two-thirds of people coming out
    of our programs at the 6-month follow-up point not using drugs
    or alcohol. From our block grants, that number is a little bit
    higher. We are seeing that. And, there are other programs, like
    our drug court program, where people have a high degree of
    motivation. Or, our PPW programs, where we are seeing----
        Chairman Johnson. Those results are far higher than what I
    have heard in other testimony. For example, in Pewaukee,
    Wisconsin, we were being told 5, maybe--at most--10 percent. Do
    you dispute that then?
        Ms. Enomoto. I do not dispute that that is what those
    testimonies were, and----
        Chairman Johnson. I understand. Ms. Maurer, have you looked
    at any studies on these things?
        Ms. Maurer. GAO has not conducted any studies to assess the
    effectiveness of treatment or prevention programs. One of the
    issues here could be the difference between the number of
    people who successfully complete the program compared to the
    number of people who go into the program.
        I know that one of the indicators that ONDCP is tracking is
    trying to get to a 50-percent completion rate for some of the
    programs. And, they are close to that mark, but they have not
    been able to get to that 50-percent mark. What that says about
    people who have completed--as opposed to those who have not
    completed, we do not know, from a GAO perspective, but it is a
    part of the story.
        Chairman Johnson. OK. Mr. Botticelli, do you want to weigh
    in?
        Mr. Botticelli. So, one of the areas, particularly, with
    opioid use disorders, that we see problems with is the fact
    that we have three highly effective medications that should be
    the standard of care for people with opioid use disorders. Yet,
    too few people have access to those for a variety of reasons.
    And so, part of our----
        Chairman Johnson. Name those reasons.
        Mr. Botticelli. So, we have too few physicians who are
    prescribing these medications. We have parts of this country
    where we actually do not have a physician who is trained to do
    that. So, that workforce is important to make sure we do it--
    and SAMHSA's grants to promote that.
        We also know that we have too few treatment programs that
    have incorporated medication-assisted treatment into their
    treatment programs--and that has been a focus of both ONDCP and
    SAMHSA.
        And, we also know--and, again, Congress has taken action on
    this--that there was a cap on the number of patients that
    physicians treating people with addictions could serve. And,
    HHS has proposed increasing that number from 100 to 200 as a
    way to increase capacity for opioid use disorders.
        Chairman Johnson. OK. Thank you. I am out of time.
        I will pass it to you. It is scout's honor, by the way.
        Senator Carper. Alright, 6:56. No, I have 9 minutes. OK.
    This is good. We only get 7 minutes.
        Again, thank you all for joining us today. I started
    writing down, while you all were talking--testifying, rather--
    and I started writing down the elements of a comprehensive
    strategy to deal with these addiction-related problems. And, I
    wrote down treatment, I wrote down education--and not just the
    education of, particularly, young people--maybe, people not
    addicted to anything, but also education for health providers,
    particularly doctors, who I think are overprescribing. We have,
    in a lot of the Medicaid programs across the country, policies
    that are designed to make sure that someone who has a
    prescription for opioids can only go to one pharmacy. What do
    we call it? ``Lock-out'' or something like that.
        Certainly, the stuff that we are doing with drug
    interdiction--I used to be a naval flight officer (NFO) and we
    used my old Navy P-3 Orion airplanes in the Caribbean--and that
    part of the world--to try to interdict folks that are running
    drugs in by air. We do it by sea and by land. We do a lot of
    law enforcement and so forth.
        I want to ask each of you just to, if you could, craft for
    us just briefly--take about a minute and a half apiece--and
    just describe for us a comprehensive strategy that you think
    America would be smart to have. And, Ms. Maurer, if you would
    go first and
    then--is it ``Enomoto''? OK. And, is it ``Botticelli''? OK. Ms.
    Maurer.
        Ms. Maurer. Well, thank you. I think the elements of a key
    strategy would have to involve many different elements of
    national power and many of the elements that you already talked
    about. Certainly, there needs to be an approach to reduce the
    supply of illicit drugs--and that has to cover both fronts of
    that--drugs that are illegal everywhere all of the time--so
    heroin, cocaine, and so forth--as well as----
        Senator Carper. One of the things we tried to do, I think,
    in Afghanistan, was to convince the farmers there--and help the
    farmers there to learn how to plant stuff other than poppies
    and to make money doing that. Go ahead.
        Ms. Maurer. That is right. Exactly. And, that program ran
    into some problems as a result. But, that is certainly part of
    the overall effort.
        In addition to that, we also have to have efforts in place
    to put appropriate controls around the prescription medications
    that millions of Americans rely on for pain relief, but which
    can be misused and abused and----
        Senator Carper. Somebody told me--excuse me for
    interrupting. Somebody told me they had a daughter that had her
    wisdom teeth extracted and they got a month's prescription of
    opioids to help her deal with the pain.
        Ms. Maurer. That is right. I think, in the most recent
    data, there were 12 billion pills produced for U.S. domestic
    consumption. That is about 37 pills per American. So, that is a
    lot that you have to keep track of. That is on the supply side.
        Then, on the demand side, it is really important, like you
    said, to have education. It is vital to have treatment and
    prevention programs as well because you need to treat the
    medical disease of addiction. But, you need to couple that with
    programs to try to keep people from getting started and using
    drugs illegally and illicitly in the first place.
        Senator Carper. We have done that with tobacco quite
    successfully through the American Legacy Foundation's--which is
    now called the Truth Initiative's--``truth'' campaign.
        Ms. Maurer. Absolutely.
        Senator Carper. Also, Montana did some very good work years
    ago on methamphetamines--the same kind of approach as the
    ``truth'' campaign. Go ahead.
        Ms. Maurer. And, there may be things that we can learn from
    those efforts. One thing I would note about the campaigns to
    reduce the use of tobacco--as well as the campaign encouraging
    people to use seat belts--those are generational changes that
    require people to rethink the way they fundamentally approach
    things like smoking and driving. It took a while for that to
    take hold, but they were successful. There may be things we can
    learn from those efforts that we could apply to the drug
    problem in this country.
        Senator Carper. Alright. Thank you. I have only 8 minutes
    left, so, Ms. Enomoto?
        Ms. Enomoto. Thank you.
        Chairman Johnson. You were never a Boy Scout, were you?
        Senator Carper. No. [Laughter.]
        I aspired to be, but they would not let me in.
        Ms. Enomoto. Thank you very much. It is a great question. I
    will leave it to others to address the supply reduction or
    interdiction issues, but for us on the demand reduction side,
    we think that the President has put forward a very strong and
    meaningful strategy, which does encompass prevention,
    treatment, and recovery as well as data and public education
    initiatives around these issues. And, we are happy to be a part
    of that. For the opioid initiative, we are focusing on three
    opportunities for high impact, which are: changing prescriber
    behavior--as you noted, increasing access to naloxone to reduce
    those opioid overdoses, and increasing access to medication-
    assisted treatment. And, to do all three of those things, we
    need a strong emphasis on data collection, on surveillance, on
    evaluation, and on research. And, for all of those, we need to
    focus on engaging States and communities as well as expanding
    our behavioral health workforce, because, as it stands, when we
    only have 1 out of 10 people with an addiction getting
    treatment and only 2 out of 10 people with an opioid use
    disorder getting treatment--and we still have waitlists and we
    still cannot reach all of the people that we need to with our
    prevention messaging. We simply do not have the resources--we
    do not have the manpower, as it currently stands. And so, it
    will require additional investment. And, I think that is what
    the President has made clear in his proposals.
        Senator Carper. Alright. Thank you.
        Mr. Botticelli, you have about 2 minutes. Go ahead.
        Mr. Botticelli. First and foremost, if you look at the
    structure of our national drug----
        Senator Carper. What was the first thing you said? You do
    not agree with either of them? Is that what you said?
        Mr. Botticelli. Oh, no. I do agree with both of them.
        Senator Carper. Thank you.
        Mr. Botticelli. I agree that we should take this
    comprehensive, multifaceted approach that focuses on
    prevention, treatment, and criminal justice reform as well as
    looks at our supply reduction efforts, our international
    efforts, our interdiction efforts, and our domestic law
    enforcement efforts.
        I would agree that, particularly with the opioid piece, you
    are right on target in saying that reducing the prescribing of
    these medications becomes particularly important. So, just to
    underscore that, we are now prescribing enough pain medication
    to give every adult American their own bottle of pain pills.
    And, we know that, with the heroin situation, four out of five
    newer users to heroin started by misusing prescription pain
    medication.
        Senator Carper. Four out of five.
        Mr. Botticelli. Four out of five. Four out of five started
    misusing. So, this is not a heroin issue that is separate from
    our prescription drug issue.
        We have been calling for mandatory prescriber education,
    saying that we think it is not unreasonable to ask every
    prescriber in the United States to take a minimal amount of
    education on the topic of safe and effective opioid
    prescribing.
        Senator Carper. Alright. Thank you all for those responses.
        Chairman Johnson. Thank you, Senator Carper.
        While we are passing the timer down to Senator Ayotte, I
    had a couple seconds left. I just wanted to ask you--one of the
    pieces of legislation I have introduced is the Promoting
    Responsible Opioid Prescribing (PROP) Act, which is trying to
    get rid of the unintended consequences of the surveys being
    used, in terms of pain medication. Can you just quickly comment
    on that?
        Mr. Botticelli. Sure. So, one of the things we have heard--
    and, actually, the Department of Health and Human Services is
    doing a review. It is called the Hospital Consumer Assessment
    Healthcare Providers and Systems (HCAHPS) survey and it links
    financial incentives to patient satisfaction around pain. And,
    it has gotten reported to us that that could be, actually, a
    misaligned incentive and actually promote opioid prescribing.
    So, folks at HHS now are looking at that survey and seeing to
    what extent those questions have the unintended consequence of
    increased opioid prescribing--and if so, changing those
    questions to make them more about overall pain management and
    not necessarily about opioid prescribing.
        Chairman Johnson. Well, if you cannot do it internally--if
    you need that law, hopefully, you will support the PROP Act.
    Senator Ayotte.

                  OPENING STATEMENT OF SENATOR AYOTTE

        Senator Ayotte. Thank you, Chairman.
        Director Botticelli, I wanted to follow up on the issue of
    the cap for buprenorphine. I have certainly written--and I know
    others here in Congress have also--on this issue. But, do you
    know where the decisionmaking process is at for HHS? Right now
    the cap still exists, right? And so, as we think about trying
    to increase our capacity for medication assisted treatment, how
    quickly do you expect the Administration is going to look at
    lifting the cap, so that we can increase our capacity there?
        Mr. Botticelli. Sure. I believe that is still open for
    public comment from now until, I believe, the end of May. I can
    check, in terms of HHS' timeline on that. I would suspect,
    Senator, that we are going to have a significant number of
    comments that we are going to have to work through surrounding
    that. But, it is an important priority.
        But, we also want to look at other opportunities--through
    SAMHSA's grants and through increasing the number of physicians
    who can prescribe this. But, increasing capacity is
    particularly important.
        Senator Ayotte. Right. And, also, I would ask you, Director
    and Ms. Enomoto, about the issue of the bed cap. So we have--as
    I understand it--a cap of 16, in terms of the number of
    residential beds, not only for the treatment of substance use
    disorders, but also for mental illness. As we think about--I
    know efforts in my own State--and elsewhere--to try to increase
    capacity--sometimes it makes sense to increase the existing
    capacity of a facility that already has a good treatment
    program in place. So, what are your thoughts on that cap? And,
    what efforts should be taken to lift that cap as well?
        Ms. Enomoto. So, within the Department, the Centers for
    Medicare and Medicaid Services (CMS) has the leading role for
    the Institute for Mental Disease (IMD) exclusion. And, they
    have been working really closely, I think, with States to
    promote innovation in this area--and California is an example
    of a State with an 1115 waiver that is looking at providing
    support to residential treatment providers that have more than
    16 beds under their waiver. And so, I think there is a
    considerable effort to look at this, both on the mental health
    side and on the substance abuse side.
        Senator Ayotte. Also, a lot of this is sometimes co-
    occurring between these illnesses.
        Ms. Enomoto. Right. We also think it is important, though,
    to look at expanding options for community-based treatment
    because we know that that is important and is an avenue--that
    not everyone needs residential treatment and not everyone
    requires hospitalization if adequate community-level or
    intensive outpatient services and supports are readily
    available.
        Senator Ayotte. And, as a follow up to that, I have been
    one of the lead sponsors of the Improving Treatment for
    Pregnant and Postpartum Women Act of 2016. And, a component of
    that Act also involves looking at nonresidential treatment
    options for pregnant women. And, I wanted to get your thoughts
    on that as well.
        Ms. Enomoto. In the President's Fiscal Year 2017 budget
    proposal, we have proposed a pilot demonstration innovation
    program, which would request the ``notwithstanding'' language
    for the PPW program because the statute requires that it is,
    right now, exclusively for residential treatment. We would like
    to have the flexibility to use some of the funding for States
    looking at options for multiple pathways to care. So, for some
    of the women in those programs--who have other children at home
    or who have other job or family responsibilities--to be able to
    participate in treatment on an outpatient basis as well and to
    see whether or not they achieve similar, comparable outcomes.
        Senator Ayotte. Great. Thank you.
        Director Botticelli, a lot of the efforts--as I, certainly,
    heard in the testimony from Ms. Maurer as well--as we think
    about the supply side piece of this--you and I have talked
    about this in the past--the heroin and fentanyl are coming over
    the Southern border. And, an amendment that I offered to the
    National Defense Authorization Act (NDAA), is going to increase
    some resources there for the interdiction of heroin and
    fentanyl.
        But, one of the concerns we have heard before, on this
    Committee, is that the precursor chemicals needed to make
    fentanyl are actually shipped to Central America from China and
    then smuggled into Mexico--or sometimes actually shipped to the
    United States and then smuggled into Mexico--and then made into
    fentanyl.
        So, where do you see our efforts? And, certainly, Ms.
    Maurer, if you have any comments on that, in terms of what we
    are doing to look at our drug policy. What more can we do to
    address the fentanyl interdiction issue? I heard what you had
    to say on cocaine and I know that we have seen an increase.
    But, this is really the main driver of the drug deaths--as I
    see the huge increase in New Hampshire, obviously, with heroin
    and prescription drugs. But, when you combine the fentanyl,
    that is really the killer.
        Mr. Botticelli. Correct. And, actually, the vast majority
    of increases that we have seen, in overdose deaths in the
    United States, seem to be attributed to either straight
    fentanyl or heroin-laced fentanyl--not just in New Hampshire,
    but around the country. And, you are right. While we know some
    about the fentanyl supply chain, we need to actually amplify
    our intelligence around the fentanyl supply chain.
        So, we have been working with the intelligence community
    (IC) to look at--so, clearly, I think what you have
    articulated--of
    this being manufactured in China, either shipped directly to
    the United States--or through Mexico--and getting into the
    supply chain--particularly important areas, but we need to
    continue to study that.
        But, we have had--China has actually moved to schedule a
    number of new chemicals, including acetyl fentanyl, which is
    one of the precursors of that--and we continue to work with the
    Mexican Government. I was just down there in March meeting with
    the Attorney General (AG), focusing on both reducing poppy
    cultivation and on increasing their efforts to combat fentanyl
    and fentanyl labs.
        Senator Ayotte. Good.
        I did not know if you wanted to comment on this at all?
        Ms. Maurer. We do not have any specific work focused on
    fentanyl. We have done work more broadly on supply chain
    security and drug control policy.
        Senator Ayotte. OK.
        Ms. Maurer. But, nothing specific to fentanyl yet.
        Senator Ayotte. Well, I think we are going to, probably,
    have you engaged on that, too--just because this is a huge,
    growing issue.
        Ms. Maurer. Fantastic.
        Senator Ayotte. Thank you.
        I have one final question. We have been seeing these
    reports about the increased price of naloxone and having been
    working on this issue with you. Having been in my State doing
    ride-alongs with our police and fire departments--with Narcan,
    which is the brand name for naloxone, we are saving so many
    lives. Our numbers of drug deaths would be so much higher
    without access to the life-saving drug. And, that is a key
    component of CARA. But, the reports that I have been seeing--at
    least in the news--is an increase in this drug price. And, do
    you know what is happening with this? Anyone who would like to
    jump in and comment on this--the increases in naloxone prices--
    why these price increases are occurring--please do. And, should
    we be concerned that some manufacturers looking to profit off
    of this epidemic? I just think it is important that we
    highlight this and understand it.
        Mr. Botticelli. I wish I could give you the reasons why the
    manufacturer has decided to increase the price of this. My gut
    tells me the same thing that yours does--that there are some
    opportunistic issues----
        Senator Ayotte. I do not like what my gut is telling me.
    That is why I am raising this.
        Mr. Botticelli. No, I think you are absolutely right. I
    think what we have been trying to do by acknowledging the price
    increase around naloxone, is to look at, one--through CARA and
    other vehicles--how we can get increased access. There has been
    a purchasing collaborative set up through the National
    Governors Association (NGA) and the U.S. Conference of Mayors
    to harness their purchasing authority to do it--and SAMHSA is
    giving guidance to States, through their block grant, about
    using naloxone purchased. But, it is particularly disturbing
    that the cost has gone up, dramatically, at the time that we
    need it the most.
        Senator Ayotte. I just think, as we think about this
    issue--we are in this very public hearing--I hope that those
    who are hiking up these prices take notice that we notice. And,
    we are going to be focusing on this, because the last thing
    that we want as we increase access, is for the price to
    increase--so that we can actually save fewer people.
        Chairman Johnson. Senator Portman.
        Senator Portman. Thank you, Mr. Chairman. And, thank you
    for having this hearing on an incredibly important issue. We
    have an epidemic in our country right now. And, obviously, I am
    concerned by some of the testimony this morning, because, as we
    heard from Ms. Maurer, at a time when we have had a huge
    increase in opioid addictions, overdoses, and deaths, that, of
    the goals that were set out in the 2010 strategy, not a single
    one has been achieved. And, Mr. Botticelli said, ``Well, that
    is because we are not taking into account the increase in
    marijuana use--it is not other things.'' And, one of the things
    you talked about was overdose deaths going from--instead of a
    15-percent reduction--a 27-percent increase. That is not
    marijuana, is it?
        Mr. Botticelli. No. That is, typically, other drugs.
        Senator Portman. OK. So, I mean, I think I understand, from
    the Administration's point of view, why you want to put a good
    face on it and say things are going great. They are not going
    great. They are going terribly. And, we have had, since March
    10th, when CARA passed the U.S. Senate--we believe there are
    about 7,000 Americans who have died of an overdose. We spent a
    lot of time today talking about the Zika virus, which is a huge
    problem. I think one American has died so far--and I support
    more efforts on Zika. But, my gosh, we have a crisis and an
    epidemic going on right now--and it is right in front of our
    eyes.
        I was at another treatment center yesterday. I appreciate
    what both of you do every day. I do. And, I really appreciate
    your testimony to the Senate Judiciary Committee, where you
    talked about the need for CARA to provide a more comprehensive
    response. And, I would just say everything we have talked about
    today is touched on in CARA. The House bill, I think, improves
    CARA with regard to the limitation on the number of patients
    that a buprenorphine-prescribing doctor can handle. That is
    going to be part of the final conference report. On the
    increased number of beds, we kicked it to GAO because we did
    not have a consensus on that. But, you are going to be working
    on that issue, I hope, very soon.
        On naloxone--as you know, thanks to your help, we do a lot
    more on naloxone, in terms of funding the grants. But, also
    significantly, we put some more contours around it to target it
    more and to encourage people to provide folks with treatment
    options, which, when I went--as I did--to one of our major drug
    store pharmacy companies recently to talk about over-the-
    counter Narcan--I, of course, support that--and strongly--but I
    also support having a consultation, so that the people who are
    getting this naloxone--or Narcan--to be able to help a loved
    one or a friend can also know where the treatment centers are
    in the area and can get these people into treatment. The
    solution, alone, is not more Narcan--the treatment is Narcan to
    save lives--but also getting people into treatment.
        So, I appreciate both of you and what you do every day, but
    I think we have to have a little bit of a different attitude
    about this. It has to be a crisis mentality, in order for us to
    do what needs to be done. And, as you know, the House, on
    Friday, passed 18 different bills and put them into one bill--
    into the CARA legislation. We have our CARA legislation. The
    difference is, I have put down here--and I am happy to provide
    this to you today--we would love your help in getting us
    through this conference as quickly as possible, because we
    cannot wait. And, there are people now talking about adding new
    elements to it that have to do with other important issues. We
    have to focus on this issue--the opioid crisis that we face.
        So, I would ask you today, are you willing to work with us,
    as you did in the Senate Judiciary Committee? And, both of your
    testimonies were, actually, very helpful. And, as you know,
    there are many groups--130 groups at last count--around the
    country, who are with us on this to try to get through a
    process with the House and the Senate where we take the best of
    both and can be sure that we do not weaken the Senate bill.
        I know you care a lot about funding. So do I. But, let us
    be honest. We did increase the funding in the omnibus for this
    year. We have to do it again for next year. The $82 million
    that is authorized every year going forward, in the additional
    funding in CARA, has to be held and not taken from programs
    that may not have an authorization anymore, but that are
    appropriated every year. For instance, with the Drug Monitoring
    Program, I saw the House used that for some of their funding.
    That has to continue to be used for drug monitoring.
        So, anyway, any thoughts on that, Director Botticelli?
        Mr. Botticelli. So, first of all, I really appreciated your
    leadership on this important issue and on CARA. I think you
    know that many of the elements of CARA are very important to
    the Administration here.
        I think we also understand, though, that this issue needs
    to be resourced. As I travel the country, in Ohio and other
    places, the biggest issue that I hear is the number of people
    who want treatment who cannot get it. And, despite everything
    that we have done, I think, in previous--and with the support
    of Congress and by increasing capacity--we still have too many
    people who are not able to access treatment when they need it.
    And, I think we need to work with Congress on additional
    funding for this issue, because having long waiting lists of
    people who cannot get in is a tremendously important issue. We
    have parts of the country that do not have a treatment program
    that people can access.
        So, we know we need a comprehensive response to this, but
    it also really needs to include a robust increase in treatment
    funding in the United States.
        Senator Portman. Yes. Well, this is an authorization bill
    and it does authorize additional funding. And then, we need,
    every year, of course, to fight for that appropriation. And, it
    is not just for one year. It is an authorization going forward.
    And, the way these authorization bills work around here is
    that, once you get it authorized, it tends to continue. And so,
    it is $800 million--$820 million, over 10 years, of additional
    funding. And, most of it does go into treatment--not all of it.
    But, it is for prevention. One of the things I want to fight
    for, in the conference, is a prevention program, because I do
    think that is part of the answer, as Ms. Maurer talked about.
        So, we need your help on this because we can keep talking
    about how we want more of this and we want more of that, but
    nothing is going to happen. And then, in our communities we are
    going to continue to see families torn apart, communities
    devastated,
    people dying, and people not being able to fulfill their
    purpose in life--their God-given purpose. And, that is where we
    are now--and where we will continue to be if we continue to
    disagree.
        So, let us figure out how to come together. And, again, you
    all were very constructive and helpful in the Senate Judiciary
    Committee. I do not think we would have gotten a unanimous
    vote--or a 94-1 vote--on the floor of the Senate without your
    help--and I appreciate that. But, it has some--as I mentioned,
    those four items that we have talked about today, they are all
    addressed in here. And, of course, treatment is addressed.
        Finally, I just want to say--I cannot really figure this
    out. OK. I really appreciate the additional emphasis on the
    demand side. As you know, I am the author of the Drug-Free
    Communities Act of 1997, I started my own coalition back home,
    and I am still very involved with that. We just had our 20th
    anniversary, by the way. But, we have to make that shift--and
    continue to make it. So, I do not disagree with my colleagues
    who talk about the need for us to have better border
    enforcement. Of course. But, I will just, I guess, stipulate
    that, if it is not coming from Mexico, it is coming from your
    basement. And, if it is not coming across the border, it is
    coming across on a ship. And, as long as the demand is strong
    here, there will be ways that it will be filled--whether it is
    a return to methamphetamines, which we finally started to make
    progress on, or whether it is other drugs that can be produced
    by chemists--by the way, that is the case with regard to
    fentanyl. It is a form of synthetic heroin. It is produced by
    chemists. So, we have to continue to focus on the prevention
    side and the treatment and recovery side. And, if we do not, we
    will never be able to turn the tide.
        So, Ms. Enomoto, do you have any thoughts?
        Ms. Enomoto. I just want to express my absolute willingness
    to work with you on a package that moves forward. And, to
    emphasize your point about the prevention piece of CARA, we
    must make sure that we have robust prevention programming in
    this country with the resources to match it as well as the
    recovery support piece and the peer piece. These are both very
    important to helping people achieve and maintain their
    recovery.
        Senator Portman. Yes. Thank you.
        Thank you, Mr. Chairman.
        Chairman Johnson. Senator Tester.

                  OPENING STATEMENT OF SENATOR TESTER

        Senator Tester. Thank you, Mr. Chairman. I want to thank
    the panelists for being here today.
        We hear a lot about the health effects of drugs, about
    incarceration for minor drug offenses, and about the rates of
    drug abuse among minors. I want to talk a little bit about the
    effect of drugs on Federal hiring practices. Right now, four
    States and the District of Columbia have legalized marijuana
    and a number of States have passed medical marijuana laws that
    allow for limited use of cannabis. Mr. Botticelli, have you
    seen any evidence that marijuana laws in these States have
    affected the hiring decisions for Federal positions?
        Mr. Botticelli. I was actually just looking at workplace
    drug testing data this morning. The data shows significant
    increases in overall general workplace testing--and we have
    seen the rates of positive marijuana tests go up dramatically.
    I will go back and ask my staff to see if they have specific
    data, as it relates to Federal hiring practices.\1\
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        \1\ The information submitted by Mr. Botticelli appears in the
    Appendix on page 329.
    ---------------------------------------------------------------------------
        What we do know is that there was actually an interesting
    article in the New York Times this morning that said that many
    employers with available jobs are having difficulty hiring
    folks because they cannot pass a drug test.
        Senator Tester. I would also like to know if you have seen
    an increase within the four States that have legalized it--or
    if you have seen a problem in the hiring practices of the
    Federal Government. If you can pare those out, that would be
    good.
        Mr. Botticelli. Great. I am happy to do that.
        Senator Tester. You said that there has been a significant
    increase. Since when?
        Mr. Botticelli. I believe this goes back over the past 5
    years. Particularly, over the past 3 years, we have seen a
    significant increase in people who are testing positive for
    marijuana use as a part of their workplace testing.
        Senator Tester. Did you do any other testing for substances
    other than marijuana?
        Mr. Botticelli. This is actually an independent--yes, it
    did. So, we have seen actually--and here is where it is
    challenging, because some of the--we have seen increases in
    positive amphetamine results, but the tests do not show us
    whether a result is due to a misuse or because of a
    prescription. We have actually seen decreases in positive
    prescription pain medication test results as well as for
    methamphetamine and cocaine.
        Senator Tester. You have seen decreases in those?
        Mr. Botticelli. Correct.
        Senator Tester. OK. But, increases in amphetamine?
        Mr. Botticelli. Yes.
        Senator Tester. But, you do not know if it is because of
    prescription drugs or----
        Mr. Botticelli. Correct. So, for instance, we know that
    there are a lot of people who are on Attention Deficit
    Hyperactivity Disorder (ADHD) medications, which could be a
    part of it. The test does not differentiate between those who
    are testing positive because of misuse and those who have a
    legitimate prescription. Obviously, marijuana is not in that
    category.
        Senator Tester. OK. Do any of you have metrics, as far as
    that goes, or metrics on the connection to poverty and drug
    abuse?
        Mr. Botticelli. So, we have known for a long time that
    people's economic circumstances can significantly contribute to
    drug use rates. We have seen this in recent studies that looked
    at the dramatic increase in mortality rates among 44-year-old
    to 54-year-old men and women in some areas of particularly
    significant poverty in the United States. So, we have known
    that there is a correlation there. And, there have been a
    number of interesting studies that looked at the intersection
    of poverty and increased mortality, particularly around liver
    disease, which is associated with alcoholism, suicide, and drug
    overdoses.
        Senator Tester. OK, So, last weekend I did a little sweep
    around the western part of Montana and I was up near the
    Salish-Kootenai reservation. A hospital in a little town up
    there said that somewhere between 70 to 80 percent of the
    pregnancies they saw resulted in children born drug-addicted.
    Although it is not the economically worst-off reservation in
    the State of Montana, poverty is high. In fact, it is probably
    the economically best-off reservation, but poverty is still
    very high.
        Are these the kinds of rates you are seeing in poor urban
    areas, too?
        Mr. Botticelli. I do not know if it is that high, in terms
    of that. I mean, we have known for a long time that substance
    use, among Native Americans, is very high in many of our tribal
    communities. And, I know Ms. Enomoto can talk about this, but
    part of our efforts have been to increase our efforts--our
    prevention and treatment. We have seen a higher-than-normal
    overdose rate among Native Americans as a result of this
    epidemic.
        Senator Tester. You are going to increase your prevention
    and treatments efforts in Indian country? Is that what you
    meant?
        Mr. Botticelli. Correct.
        Senator Tester. So, how are you doing that? Are you working
    through the Bureau of Indian Affairs (BIA)? How are you doing
    it?
        Mr. Botticelli. So, one effort is through our Drug-Free
    Communities Program grants. We are actually reaching out to
    tribes.
        Senator Tester. And, is that being utilized by the tribes?
        Mr. Botticelli. It has been underutilized. And, we think,
    in terms of----
        Senator Tester. So, who are you reaching out to in the
    tribes?
        Mr. Botticelli. We can get you their information, because
    we have done a number of technical assistance visits to
    tribes.\1\
    ---------------------------------------------------------------------------
        \1\ The information submitted by Mr. Botticelli appears in the
    Appendix on page 330.
    ---------------------------------------------------------------------------
        Senator Tester. That would be really good because, who you
    reach out to is going to make a difference, in terms of what
    the take-up rate is.
        Mr. Botticelli. We also worked with the Bureau of Indian
    Affairs and the Indian Health Service (IHS) to actually start
    equipping tribal law enforcement with naloxone. We have seen a
    dramatic increase in overdoses among Native American tribes.
        Senator Tester. How about education in the schools? Are
    there any efforts being done by--and I do not care if it is in
    poverty-stricken areas or not. It would seem to me that
    poverty-stricken areas should be the focus, but is there any
    education being done in the schools?
        Ms. Enomoto. We are really excited that, this year, we are
    issuing $25 million--$30 million in grants under our Tribal
    Behavioral Health Grant Programs.
        Senator Tester. OK.
        Ms. Enomoto. We will have over 100 new tribal grantees
    focusing on substance abuse prevention, suicide prevention, and
    emotional wellness among tribal youth, including doing
    activities in the schools and to educate youth. And, also
    working----
        Senator Tester. Once again, is this money granted out or
    how----
        Ms. Enomoto. These are grants.
        Senator Tester. So, it is a competitive grant?
        Ms. Enomoto. It is a competitive grant, yes.
        Senator Tester. OK. Go ahead.
        Mr. Botticelli. Are there particular tribes, actually, that
    you would like to----
        Senator Tester. I mean, all that I am telling you is that I
    think you can look at the tribes who have high instances of
    poverty--most of which are non-gaming tribes--and you can see
    they have issues. They have issues with domestic violence. They
    have issues with drug use. They have issues with housing. They
    have issues--pick a topic, truthfully.
        The point is that you cannot do it from this level. You
    need to have partners on the local level to do it--whether it
    is education for kids, whether it is prevention for adults, or
    whatever it might be. If you do not have those partners, we are
    going to be throwing money out of the window. And, those
    partners have to be held accountable, too, by the way. So, it
    is a hell of a circle. But, when I am told that 70 to 80
    percent of the kids that are born on that reservation--and
    these figures could be wrong because I did not fact-check them.
    But, they came from somewhere. Those kids are born drug-
    addicted--holy mackerel. I mean, in the world we live in, I
    mean, talk about being put in the hole right out of the chute.
    Holy mackerel.
        So, go ahead. You were going to say something.
        Ms. Enomoto. I do not think those numbers are completely
    unexpected for some tribal communities. I think we have also
    seen five-time increases for the American Academy of
    Neurology's (AAN's) statistics on overdoses. So, while we talk
    about this--often people talk about this overdose as a white
    middle-class
    problem--it is striking Indian country very hard. And, on
    average, of American pregnant women, about 30 percent are
    getting prescriptions for opioids during pregnancy. So, that
    rate for women in Indian country is very high.
        I wanted to let you know that we are about to release a
    Tribal Behavioral Health Agenda (TBHA)--a National Tribal
    Behavioral Health Agenda. We have worked very closely across
    the country with the National Indian Health Board, which we
    have consulted, in many communities, to identify, across our
    Federal partners, local partners, and national organizations--
    we talked about what the priorities are for tribal behavioral
    health and how can we agree to move forward together. We are
    all rowing in the same direction, giving communities a
    blueprint for working toward better behavioral health for all
    of their young people, including--as well as the adult
    populations in their communities.
        Senator Tester. OK. My light is flashing, so you can cut me
    off here, Mr. Chairman. But, I do have one more question.
        Chairman Johnson. OK. Well, I am just a little concerned
    about that thing going off.
        Senator Tester. Will it buzz?
        Chairman Johnson. I am not sure.
        Senator Tester. I cannot wait.
        Chairman Johnson. Go ahead.
        Senator Tester. I will just hold it next to the microphone
    so that everybody can hear it. [Laughter.]
        This is the last one. Mr. Botticelli, you talked about a
    significant increase over the last 5 years--and, especially,
    the last 3 years. Has anybody asked why? Why are we seeing a
    significant increase in drug abuse over the last 3 years? Why
    now?
        Mr. Botticelli. I do not mean to sound overly simplistic,
    but I think----
        Senator Tester. The simpler, the better.
        Mr. Botticelli. The simpler, the better. It is the
    overprescribing of prescription pain medication in the United
    States. We have never had an epidemic like we are currently
    facing, in terms of addictions to prescription pain medication
    and the overdoses----
        Senator Tester. So, are we working with the American
    Medical Association (AMA)?
        Mr. Botticelli. I will tell you that the AMA has stepped
    forward, in terms of voluntary training. I know that they have,
    historically, opposed mandatory training. Also, the AMA has
    issued a policy statement urging physicians to check
    prescription drug monitoring programs. But, at this point, they
    see it as a totally voluntary issue. But, we think, at this
    time in the epidemic, asking these things to be mandatory is
    not unreasonable.
        Senator Tester. OK. I am going to give you just a really
    quick little story. I had some veterans' listening sessions a
    few years ago--I have had some since then, too. But, a few
    years ago, one of the people stood up and said--and these were
    back-to-back, honest to God. One stood up and said, ``I needed
    pain pills for my back and the Department of Veterans Affairs
    (VA) would not give me the pain medication.'' The very next
    person stood up and said, ``The VA killed my son because of
    overmedication.''
        There has to be some education done here on what the right
    line is, because this is insanity.
        Mr. Botticelli. Let me respond to that. As part of the
    Federal Government, the President felt it to be so important
    that we model this for the medical community, that every
    Federal prescriber--including the VA--has to go through
    mandatory training and education.
        Senator Tester. Yes. Thank you all very much.
        Chairman Johnson. The bottom line is, there are no easy
    solutions. You may want to take a look at the PROP Act. That,
    to a certain extent, addresses some of the unintended
    consequences in our law.
        I want to go back to treatment metrics. What percentage of
    those 3 million hard drug users ever seeks treatment in a given
    year? Mr. Botticelli, you were talking about how you hear
    consistently that there is no funding for treatment. What
    percentage actually seeks treatment?
        Mr. Botticelli. So, we know from the National Survey on
    Drug Use and Health, which SAMHSA administers, that only a very
    small percentage of people who actually meet diagnostic
    criteria for a substance use disorder get care and treatment--
    and that number is usually between 10 and 20 percent. And, if I
    can give you some--substance use disorders have roughly the
    prevalence of diabetes. Yet, the treatment rate for diabetes is
    about 80 to 85 percent. And, we know some of the reasons why
    people do not get care and treatment. One is that they either
    do not have insurance or that their insurance does not
    appropriately cover it. Stigma also still plays a huge role--
    that people are afraid to ask for help. So, part of our effort
    here has been to kind of destigmatize people with addiction.
    And, we have seen great efforts, I think, across this country,
    to encourage people in recovery to stand up.
        But, that is part of what fuels our demand--what fuels some
    of the negative consequences--this huge treatment gap that we
    have in the United States. And, that is why the President
    really kind of stepped forward and said that, despite all of
    the insurance and expansion that we have done, we still have
    too large of a treatment gap in the United States.
        Chairman Johnson. What percentage of alcoholics seek
    treatment in a given year?
        Mr. Botticelli. It depends. And, I can give you the exact
    number, depending on the diagnosis. I think that the number is
    slightly higher for people with alcohol use disorders--and,
    Kana, you may know these numbers better than I do. But, we can
    get you those. But, it is not much higher than 20 percent for
    alcohol use disorders.\1\
    ---------------------------------------------------------------------------
        \1\ The information submitted by Mr. Botticelli appears in the
    Appendix on page 332.
    ---------------------------------------------------------------------------
        Chairman Johnson. So, my point is that you have things,
    like Alcoholics Anonymous (AA) for alcohol--that type of thing.
    If you do not have a significantly higher percentage of people
    seeking treatment there, what would make us expect that there
    would be a higher percentage--even if there was more funding--
    for treatment? How many addicts just want to keep using drugs
    and really do not desire treatment?
        Mr. Botticelli. I think that there is a significant number
    of people who do. First of all, I have some experience with
    this and I think that most people who are addicted to drugs--
    particularly, to opioids--want to stop using. And, the hallmark
    of addiction is that people keep using.
        We have to do a better job with intervening. One of the
    reasons why we have done a great job with tobacco is that,
    every time you go to the doctor, if you are smoking, the doctor
    offers you an intervention. And, we need to do the same thing
    for people with substance use disorders. And, unfortunately, we
    often wait until they get to their most acute stage--and,
    often, that is an intersection with the criminal justice
    system, where we do then leverage people into treatment. Our
    drug courts--and other programs--do a fabulous job, but we wait
    far too long while people are developing these disorders and we
    need to do a better job at systemically intervening before
    people even reach that acute stage.
        We would have better treatment outcomes if we intervened
    earlier in people's disease progression as opposed to how we
    wait now until basic--you have heard the expression ``hitting
    bottom.'' It is crazy that we expect people to hit bottom
    before we give them care and treatment.
        Chairman Johnson. The best solution would be trying to
    convince people never to even try a drug, so they do not become
    addicted. We have been successful--we had a hearing on it. This
    strategy has been really very successful, in terms of reducing
    the use of tobacco through a very concerted, long-term effort--
    through education and a public relations campaign. Does anybody
    want to express an opinion as to why, for example, our
    education efforts with drugs have not worked? Ms. Maurer.
        Ms. Maurer. I think, in many respects, the challenge is
    much more difficult. We issued some reports early in the decade
    that looked at some of the education campaigns that were
    implemented in the late 1990s. We found that, for those
    particular programs, many did not have any discernible impact--
    and, in a few cases, it actually worked in the opposite
    direction. So, in other words, in some groups, when teenagers
    were exposed to the anti-drug message, they actually used drugs
    more frequently. That is an issue with the----
        Chairman Johnson. That is not very effective education.
        Ms. Maurer. It is not. And, it really goes back to the idea
    that you need to have good program design and implementation
    for these things to be successful.
        I think that, in many respects, the problem we are trying
    to address here--while there may be lessons learned from seat
    belts and smoking--it is a much more difficult problem, because
    it is associated with particular kinds of behaviors and
    particular kinds of medical conditions. It is intertwined with
    poverty and a bunch of other issues as well. It is tougher to
    crack, absolutely.
        Chairman Johnson. Ms. Enomoto, in your testimony--and now I
    want to try and name these drugs--naltrexone, methadone,
    and--what is it?--buprenorphine? Whatever. Can you describe the
    difference in those drugs--those treatment drugs--and how they
    really work? What are the differences? Or are they all the
    same?
        Ms. Enomoto. I am not a physician. So, I am happy to get
    you a more expert description of the pharmacology of those
    different medications. But, from my perspective, the two drugs
    methadone and buprenorphine are often referred to as ``agonist
    medications'' because they have some opioid qualities. But,
    they do not lead to the euphoric state that people get when
    they are using drugs, like heroin or oxycodone. And, they
    minimize the cravings that people will have for illicit drugs.
    And, people are able to initiate the use of those drugs while
    they are still in a state of active addiction, so that they can
    taper off of the drugs that they are using with the medication-
    assisted treatment and work toward their recovery without
    maintaining illicit drug use. Those go along with behavioral
    services and supports to get the best outcomes. Methadone is a
    dispensed drug. It is a prescribed drug for pain relief, but,
    for addiction treatment, it is a dispensed drug. Buprenorphine
    is available as a prescription in office-based treatment.
        Naltrexone is available in two formulations, both an oral
    form and an injectable, long-acting form. The oral form is a
    pill and the other one is an injection. Those can be prescribed
    by any physician, so they are not Schedule II drugs, like
    buprenorphine and methadone. And, to use the long-acting
    naltrexone--people need to be detoxed from their opioid.
    Naltrexone also works on alcohol as well, so that, once people
    are through detox and they can get the naltrexone--it is an
    antagonist medication, so it actually completely blocks the
    opioid receptors. So, if you are taking any other--if you take
    alcohol or if you take an opioid, then you will not feel the
    effects of those drugs. I think often people refer to it as a
    relapse prevention intervention. So, they have different
    actions--mechanisms of action--and, maybe, they are preferable
    by different--one patient may prefer one over the other. I
    think it is a decision between a patient and their physician
    about what is the best avenue for them and for their particular
    condition.
        Chairman Johnson. So, they reduce the craving. Is that kind
    of a simple way of putting it?
        Ms. Enomoto. Yes.
        Chairman Johnson. Can somebody describe for me the
    difference between heroin and the other opioids?
        Mr. Botticelli. The difference from the medication?
        Chairman Johnson. Yes, I mean like OxyContin, is that a
    synthetic opioid?
        Mr. Botticelli. Again, while I often pretend to be a
    doctor, I am not.
        Chairman Johnson. We will stipulate that.
        Mr. Botticelli. No, but they have very similar properties,
    in terms of how they interact on the brain. And so, that is why
    people often turn from opiate pain medication to heroin.
        Chairman Johnson. But, are those synthetic drugs or are
    those also grown from--where are they sourced from?
        Mr. Botticelli. So, the others are manufactured
    medications. Heroin, which is an illicit--it is a grown----
        Chairman Johnson. It is a plant.
        Mr. Botticelli. It is a plant.
        Chairman Johnson. Whereas the others are the result of some
    manufacturing process?
        Mr. Botticelli. They are manufactured.
        Chairman Johnson. Like fentanyl, for example?. Fentanyl is
    a synthetic compound?
        Mr. Botticelli. Yes.
        Chairman Johnson. OK. Interesting. Senator Carper.
        Senator Carper. Thank you, Mr. Chairman.
        A little more than a month ago, I was part of an Aspen
    Institute seminar in China. And, I had learned some things
    about China, but never really spent any time there to speak of.
    And, I learned a lot of things. One of the things I learned
    about China is that they now have a two-child policy--not a
    one-child policy, but a two-child policy that they are kind of
    moving toward. I learned that a lot of the kids that grow up
    there grow up in intact, two-parent families, which I was
    pleased to see. I learned that folks are not much into
    gambling, lotteries, or stuff like that. And, I learned that
    drug abuse is not really a problem to speak of in their
    society.
        And, yet, we hear that they ship us materials that are used
    for fentanyl and stuff like that--and we have had problems
    before with the Chinese using cyber theft to steal our
    intellectual property and to use that to create economic
    opportunity for themselves at our expense.
        I do not know that we have ever said to the Chinese--that
    our President said to President Xi Jinping, last September,
    with respect to cyber theft, to, basically, ``knock it off.''
    And, the Chinese always say, ``Well, we do not do that.'' And,
    he said, ``Knock it off,'' just not in so many words. And, they
    said, ``We do not really do that.'' And, our President,
    basically, said--just not in so many words, ``If you continue
    to use cyber theft to steal our intellectual property, you know
    what we did to Iran with economic sanctions? We are your
    biggest customer. We could do that to you.'' And, we have seen,
    since that time, literally, a significant reduction in the
    instances of cyber theft going on with intellectual property.
        Have you ever heard, in terms of whether it is China--or
    some other country--that is providing these kinds of
    substances--have you ever heard of how we can use direct
    contact, leader to leader and agency to agency, to get them to
    stop?
        Mr. Botticelli. I can talk about that a little bit. So, I
    do not know if President Obama has had a direct conversation,
    in terms of the fentanyl issue.
        Senator Carper. Not that I know of.
        Mr. Botticelli. I know he has with President Enrique Pena
    Nieto, in terms of the heroin and fentanyl issue--around that--
    and trying to get his commitment to work government to
    government.
        Senator Carper. Any luck on that?
        Mr. Botticelli. We have been having very productive
    conversations with the Mexican Government at the working level.
        Senator Carper. Good.
        Mr. Botticelli. I met with the Mexican Attorney General,
    who is spearheading their efforts around it. I think they have
    come up with a plan. I think what we would like to see, is for
    that to translate into actionable work that they are able to
    do, in terms of reducing poppy cultivation, going after labs,
    and looking at the fentanyl situation.
        Senator Carper. OK.
        Mr. Botticelli. I know, at the working level, both the
    State Department and I have had a number of conversations with
    our colleagues in the Chinese Government, particularly around
    the fentanyl issue. We are somewhat optimistic. They have moved
    to reschedule a number of the drugs that they are producing. I
    think what we would like to see next, is incredibly more robust
    enforcement action, on their part, to go after--I mean, they
    have a huge industry there, but we would like to see more
    oversight and see them going after some of these producers.
    This is where, I think, being able to have better intelligence,
    in terms of knowing directly where these substances might be
    coming from and how they are being shipped, becomes very
    important for us.
        Senator Carper. Thank you.
        Could I ask you another question, Mr. Botticelli? While I
    am asking this question, I want the other witnesses just to--I
    have been in and out of the hearing today. I apologize for
    that. We had to start late--not our fault--not the Chairman's
    fault, but it is because of the series of votes on the floor.
    So, I missed part of what you said--and, Ms. Maurer--and I am
    going to ask Ms. Enomoto to just share with me like one great
    takeaway from this hearing, as we think of this issue and how
    to deal with it--this challenge and how to deal with it,
    please.
        Here is my question, Mr. Botticelli, while they are
    thinking of that. I was pleased to see--we only have three
    counties in Delaware. The northernmost county is called New
    Castle County and it is right up along the Pennsylvania border,
    as you may know. And, I was pleased to see that New Castle
    County was added to the Philadelphia-Camden regional High
    Intensity Drug Trafficking Area (HIDTA) program last year.
        Could you just take a moment and share with us some
    insights on why the work of HIDTAs is so critical to the
    success of your office, overall, please?
        Mr. Botticelli. So, we were glad to be able to have the
    resources from Congress to be able to do that, first of all.
    But, I will say two things about why I think HIDTAs are very
    successful--or three reasons.
        One, I think they do a very accurate assessment of what the
    drug threat looks like in any given county in a community and
    they are able to target resources against that.
        I think, second, as we talked about, that coordination is
    key. They are able to really coordinate law enforcement efforts
    at the Federal, State, and local level. And, they involve local
    law enforcement, in terms of their work, to be able to do that.
        I think the third thing is that they understand that law
    enforcement is only part of the problem and they actually work
    with public health officials to really make sure that we are
    having that balanced strategy--that we are not just focusing on
    law enforcement, but we are also focusing on demand reduction,
    too.
        So, I think that is, from my perspective, why the HIDTAs do
    a very good job at the local level.
        Senator Carper. OK, good. Alright. Ms. Maurer.
        Ms. Maurer. I think the one key takeaway from today's
    hearing would be that, I think, we are in a unique time right
    now, where there is an appreciation that addressing this
    problem is going to involve many different aspects of the
    Federal Government and involve working with State and local
    authorities. We have not always----
        Senator Carper. And, the nonprofits.
        Ms. Maurer. And, nonprofits.
        Senator Carper. The health community, schools, etc.
        Ms. Maurer. Absolutely. So, we have not, for example,
    always seen this emphasis--or almost an equal emphasis--on the
    demand side and the supply side--because both are equally
    important for addressing the problem.
        I will put in a plug for GAO. There are a lot of programs
    at a lot of different Federal Agencies. We could play a role in
    helping to assist Congress with its oversight responsibilities
    to make sure these programs are being implemented effectively
    and efficiently.
        Senator Carper. OK. Thank you. Ms. Enomoto.
        Ms. Enomoto. So, I have a couple of points and some of them
    go back to questions that Senator Johnson asked.
        Senator Carper. OK.
        Ms. Enomoto. And, I did not get a chance to jump in, but I
    think they are relevant.
        One of the questions that had been asked is, ``Why are
    people saying that only a small fraction of people who go to
    treatment get better? ''
        Senator Carper. That is a very good question.
        Ms. Enomoto. And, what I would say, is that not all
    treatment is created equal. Director Botticelli referenced
    medication-assisted treatment, which we know is a standard of
    care for opioid use disorders. Not all treatment providers are
    equipped or adequately resourced to provide evidence-based
    services and the interventions and supports that we know yield
    the best outcomes. And, that is why, when you ask the question
    about why more resources would make a difference--how do we
    know that more resources are going to help--first of all, it is
    because we know that not all providers are able to really
    provide that wrap-around, science-based level of care that we
    know can create recovery for the majority of people.
        The other thing is that, in our surveys--and I am happy to
    get you this data--we actually do not ask people, ``Do you
    think you have a disorder?'' We ask people what their behaviors
    and their symptoms are--and then, we can generate that
    deduction. And then, we ask them: ``Did you seek treatment? Did
    you get treatment? If you did not get treatment, why did you
    not get treatment? Or, did you not seek treatment at all? If
    you did not seek treatment, why was that? ''
        For opioid use disorders, we know that there are about half
    a million people who wanted treatment, but had different
    reasons for not being able to get that treatment. Often it is
    because they did not know where to go, their insurance was not
    adequate, or they did not have the insurance to pay for it.
        So, it is not an insignificant number of people--half a
    million people--who need treatment and who are ready to get
    treatment, but who do not have a way to pay for it or to get
    there. So, I think that is a tremendous opportunity.
        And, in terms of public campaigns, I know that GAO had a
    look at campaigns and whether or not they were making a
    difference. This is something that Madison Avenue figured out a
    long time ago. There is a science to this. I think people who
    run campaigns also know that there is a science to how many
    impressions over a given period of time you need to have to
    raise awareness, how many impressions over a given period of
    time you need to change belief, and then, even further, how
    many you need to change behavior.
        Our campaigns are often significantly underresourced, so it
    is sort of like, ``Well, we gave you a $10 kit to build a
    potato clock, how come you did not get to the moon with that,
    when your neighbor, the National Aeronautics and Space
    Administration (NASA), was able to get to the moon? Well, we
    had a $10 potato clock kit, so that is why we did not get to
    the moon. But, with our $10 potato clock, we actually did some
    amazing work.''
        And so, for example, with our $1 million STOP Act campaign
    to combat underage drinking, we are generating $54 million of
    donated media. That is a lot. We are getting millions and
    millions of impressions.
        That being said, we may not be rising to the level that we
    know--that the science would tell us--that you need to get to
    in order to change knowledge, behavior, and action over time.
    And so, I think that is the conversation that needs to be had.
        Senator Carper. Great. Those are great answers. Thank you,
    Mr. Chairman. And, our thanks to all of you. I am sorry we were
    in and out this afternoon, but thank you for bearing with us
    and for your testimonies.
        Chairman Johnson. Thank you, Senator Carper.
        I want to thank the witnesses again for your time, your
    testimonies, your answers to our questions, and, really, for
    all of your work and efforts in this area. This is a crisis. It
    is an enormously difficult challenge--a very complex problem.
    So, again, thank you all.
        The hearing record will remain open for 15 days until June
    1, at 5 p.m., for the submission of statements and questions
    for the record.
        This hearing is adjourned.
        [Whereupon, at 4:56 p.m., the Committee was adjourned.]

                                A P P E N D I X

                                  ----------

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                  ROUNDTABLE: EXAMINING ALTERNATIVE APPROACHES

                                  ----------

                            WEDNESDAY, JUNE 15, 2016

                                         U.S. Senate,
                               Committee on Homeland Security
                                      and Governmental Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10:02 a.m., in
    room SD-342, Dirksen Senate Office Building, Hon. Ron Johnson,
    Chairman of the Committee, presiding.
        Present: Senators Johnson, Portman, Lankford, Ayotte,
    Sasse, Carper, Tester, and Peters.

                 OPENING STATEMENT OF CHAIRMAN JOHNSON

        Chairman Johnson. Good morning. This roundtable will begin.
        The reason we are having this roundtable, of course, is
    that the scourge of drug abuse is an incredibly serious, but
    also an incredibly difficult problem. There is a somewhat
    unusual path that really led to today. When I took over the
    Chairmanship, working with Ranking Member Carper, the first
    thing we did was develop a mission statement for the Committee:
    to enhance the economic and national security of America. And,
    then we laid out some priorities.
        On the homeland security side, the prorities are: border
    security, cybersecurity, protecting our critical
    infrastructure, and countering Islamic terror. We have really
    focused an awful lot on border security. We have held 18
    hearings on different aspects of it and published an
    approximately 100-page report.
        I think, Senator Carper, you are at least sympathetic to
    what I have come up with as the primary reason--the primary
    root cause--of our unsecured border: America's insatiable
    demand for drugs.
        Now, trust me, I did not go into those hearings thinking
    that would be my conclusion. Again, there are many causes, but
    this is a primary cause.
        I did a national security swing through Wisconsin in early
    January. Every public safety official I talked to--whether it
    was State, local, or Federal--I always asked them the question,
    ``What is the biggest problem you are dealing with here in your
    communities?'' Communities large and small--without exception--
    said that the biggest problem was drug abuse, because of the
    crime it creates, the broken families, the broken lives, and
    the overdoses that we are seeing.
        And so, if you take a look at the nexus of so many problems
    facing this Nation, our unsecured border--which is a problem,
    not only in terms of us being able to try and figure out how to
    solve the immigration problem, but also for public health and
    safety as well as for national security. And then, you take a
    look at how, in every city--certainly in Wisconsin's cities--I
    will say in America, it is true--and I think it is probably
    pretty universally true--that the number one issue that public
    safety officials are grappling with is drug abuse. That is a
    big problem.
        Now, we are going to have a pretty broad spectrum of ideas
    and different approaches as to how to address this unbelievably
    difficult problem. I will just finish with a little story here
    and then I will turn it over to Senator Carper.
        This never came up when I was running in 2010--what my
    thoughts are on the legalization of marijuana--or the
    decriminalization of marijuana. It never came up during the
    campaign. About 2 years into my term, I was in front of a group
    of a couple hundred seventh grade kids. And, one of these
    seventh graders stood up and said, ``Senator Johnson, would you
    support the legalization of marijuana?''
        We are holding this hearing because this is a very complex
    issue. And, like Prohibition, which fueled the gangs back then,
    what we are doing right now is fueling the drug cartels, which
    is the reason why we have an unsecured border.
        So, I am sympathetic to the broad spectrum of arguments
    here, but, at that moment, while I could have punted--I could
    have kicked the can down the road--I could have dodged the
    question, but I decided to make a decision in front of that
    audience. I said, ``No, because of the terrible signal it would
    send to kids your age.'' And, there is the dilemma.
        So, again, I am looking forward to a good discussion here
    to laying out the realities. I talked a little bit before I
    struck the gavel here. Let us talk about the significant
    problem. Let us talk about what the reality of the situation is
    and let us try and move forward with some approaches that make
    some sense.
        With that, I will turn it over to Senator Carper.

                  OPENING STATEMENT OF SENATOR CARPER

        Senator Carper. Thank you, Mr. Chairman. We are delighted
    to see you all. Thank you so much for coming. Thank you for
    what you do with your lives.
        I come at this issue with a variety of hats on. I am a
    retired Navy captain and I spent a long time in the military.
    And, we focused a good deal, in those years, on drugs and
    trying to make sure that the folks that are serving us--in my
    case, in airplanes--were not using drugs that are illegal. And,
    if they were, we had a policy that basically said that, if you
    are doing drugs, you are out of here. So, I come at this as a
    recovering Governor, who focused a fair amount on trying to
    make sure that kids were born to parents who were ready to
    raise them and to be good parents with high expectations
    involved in the education of their children--and that kids had
    good role models, mentors and stuff like that. So, I think one
    of the reasons why people end up using drugs--and I spent
    plenty of time in prison--just as a visitor--but I have been to
    every prison in Delaware and talked to inmates. And, I asked
    every one of them, ``How did you end up here?'' For the most
    part, their stories are similar: ``I was born and I never knew
    my dad. My mom was young when I was born. I started school
    behind. I started kindergarten behind everybody else who could
    read. They knew letters, I did not. And, I just fell further
    and further behind and ended up dropping out of school. And, I
    cannot support''--they would say, ``I want to be happy. I want
    to feel good about myself. How do I do that? I got involved
    with drugs. I got caught and I went to prison.'' Again and
    again and again, that is the way it happens in my State.
        People serve their time, they get out, and they go through,
    maybe, work release. Eventually, they are back in their
    communities and back in their neighborhoods, with the same
    influences, and then, the same problems. So, it is a familiar
    story. And, it is not just in Delaware. It is across the
    country.
        I have taken a special interest in three countries in
    Central America: Honduras, Guatemala, and El Salvador. Some of
    us have been down there together. The Chairman and I have been
    to at least a couple of those countries together. And, I
    started focusing on them when I would go to the border to see
    what was going on, with respect to all of these tens of
    thousands of folks coming into our country illegally. And, what
    do we need to do to keep them out? And, we have built walls and
    we have built fences. We have over 20,000 U.S. Customs and
    Border Patrol (CBP) agents arrayed along the border. We have
    drones in the air. We have aerostats--tethered aerostats. We
    have P-3 airplanes, we have helicopters, and we have boats. You
    name it. We have spent a quarter of $1 trillion to keep people
    out over the last 10 years--to keep them from coming, mostly,
    from those three countries into the United States. A quarter of
    $1 trillion. We spent less than 1 percent of that in order to
    address the root causes of their misery, which we are complicit
    in creating.
        So, for me, a root cause was really addressing the lack of
    rule of law in these countries, the lack of opportunity, the
    lack of entrepreneurial spirit, and the lack of a workforce. So
    my focus was: How do we address those countries, kind of like a
    Plan Colombia, if you will, for those three countries? And,
    they created something for themselves called the ``Alliance for
    Prosperity.'' It is being funded, rather significantly, with
    our support and the support of the President and the Vice
    President.
        But, as the Chairman suggests, that is not really the root
    cause. The root cause is our insatiable appetite for drugs. So,
    we are complicit in their misery. How do we reduce that
    complicity? We do that by reducing our demand for the drugs
    that travel through those countries.
        So, this is something we all have--everybody on this
    Committee has thought a lot about it and we are interested in
    finding out what works and doing more of that--and what does
    not work, doing less of that.
        Thank you so much for being here today and for being an
    important part of this conversation.
        Chairman Johnson. Thank you, Senator Carper.
        One thing I missed in my opening statement--I just wanted
    to lay out a couple of facts. The United States has spent an
    estimated $1 trillion on the War on Drugs over the last 40
    years. There are, roughly, 27 million illegal drug users in the
    United States. In 2014, there were 47,000 drug overdoses--an
    average of 129 people per day. So, that gives you kind of a
    sense of the magnitude of the problem. On an annual basis, we
    probably spend about $31 trillion on the War on Drugs. And,
    certainly, my conclusion would be that we are not winning that
    war. So, this is really about looking at different approaches.
    I had a nephew die of a fentanyl overdose in January. So, this
    affects every community in America.
        With that, again, I want to thank the witnesses. I know
    this has been kind of an on-again, off-again process. I know,
    Dr. MacDonald, you probably had a pretty fun flight. I love
    those red-eye flights myself. I truly appreciate you doing
    that. We will start off with Dr. MacDonald. We would like to
    give you guys about 5 minutes to do an opening statement, then
    we will kind of get into a free-flowing discussion.
        Our first witness is Dr. Scott MacDonald. He is a lead
    physician at the Providence Crosstown Clinic in downtown
    Vancouver, British Columbia. Crosstown is the only clinic in
    North America that provides opiate-assisted treatment for
    people with severe opiate use disorders. Dr. MacDonald.
        Senator Carper. Did you fly in this morning?

       TESTIMONY OF D. SCOTT MACDONALD, M.D.,\1\ PHYSICIAN LEAD,
                      PROVIDENCE CROSSTOWN CLINIC

        Dr. MacDonald. Yes, I flew in this morning.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. MacDonald appears in the Appendix
    on page 403.
    ---------------------------------------------------------------------------
        At Providence Crosstown Clinic, 140 people are receiving
    daily treatment with injectable opioids, an intensified form of
    medication-assisted treatment (MAT). And, I want to thank the
    Government of British Columbia for supporting our clinic and
    making the delivery of this treatment possible in Vancouver.
    About half of the patients are receiving treatment with
    hydromorphone, a widely available licensed pain medication. The
    remainder receive diacetylmorphine.
        Our patients can come up to three times a day for
    treatment. Half come twice per day and the other half come
    three times a day. About a third take a small dose of methadone
    with their last session at night. All of these patients have a
    chronic disease--a medical condition for life that can be
    successfully managed. Treatment prevents withdrawal and
    stabilizes their lives. Here, they have an opportunity to deal
    with underlying psychological and mental health issues. In
    time, some will step down to less intensive treatments or
    gradually wean themselves off.
        These patients were all participants in the Study to Assess
    Long-term Opioid Medication Effectiveness (SALOME). SALOME was
    a follow-up to the North American Opioid Medication Initiative
    (NAOMI), which showed that diacetylmorphine, or prescription
    heroin, is superior to methadone in that group of patients that
    continue to use illicit heroin despite attempts at the standard
    treatments. A small group of NAOMI folks received hydromorphone
    and, in a surprise finding, these experienced drug users could
    not distinguish which treatment they received--and the
    beneficial treatment effect was preserved in the hydromorphone
    arm.
        Some people suffering from severe opioid use disorder need
    an intensified treatment like this. While methadone and
    buprenorphine are effective treatments for many people and
    should remain the first-line responses, no single treatment is
    effective for all individuals. Every person left untreated is
    at high risk for serious illness and premature death.
        Despite the positive results for diacetylmorphine, as
    published in the New England Journal of Medicine (NEJM), only
    Denmark acted on these results and incorporated prescription
    heroin into their health system.
        But, it did lead to our follow-up study and testing of
    hydromorphone, or Dilaudid, as a potential treatment. And,
    hydromorphone has the advantage, over diacetylmorphine, of
    already being a licensed pharmaceutical.
        The SALOME group underwent stringent testing and controls
    to show the need for treatment. For them, the standard
    treatments, Suboxone and methadone, had not worked and most had
    multiple prior attempts at treatment. They had used injectable
    opioids for at least 5 years and, on average, for 15 years.
    They had medical and psychological health problems. They had
    nearly universal involvement in the criminal justice system. In
    short, we were able to recruit the appropriate patients for an
    intensified treatment like this.
        At the start of the study, they were using illicit opioids
    every day. By 6 months, their use was down to just 3 to 5 days
    per month. Nearly 80 percent were retained in care and that
    high rate continues to this day. At the outset, they were
    engaged in illegal activities, on average, 14 days per month.
    With treatment that reduced to less than 4 days. This study was
    published this past April in the Journal of the American
    Medical Association (JAMA) Psychiatry and I would like to
    acknowledge Health Canada for allowing us to investigate this
    important scientific question and for allowing a number of our
    patients to continue on diacetylmorphine, those who need it, on
    a compassionate0use basis.
        Supervised use of injectable hydromorphone is indicated for
    the treatment of severe opioid use disorder. And, we are using
    injectable hydromorphone as a medication-assisted treatment, an
    intensified medical intervention as a part of the treatment
    continuum. Severe opioid use disorder is a chronic disease that
    needs to be managed long term, just like Type 2 diabetes or
    hypertension. Without our treatment, this group's only option
    would be illicit opioids through the narco-capitalist networks.
        We still have people who use drugs on the street in
    Vancouver, but we have another option, in addition to needle
    exchanges: supervised consumption rooms or injection sites.
    These are legally protected places where drug users consume
    pre-obtained illicit drugs in a safe, nonjudgmental
    environment. Vancouver has two such sites. These sites provide
    an important entry point for people into medical care and
    substance use treatment. They also provide value over needle
    exchanges, alone, as needles and equipment are all contained
    onsite and needles will not end up in playgrounds or
    schoolyards, where they could cause injury.
        To contrast with these harm-reduction interventions, at our
    clinic, Crosstown, we are providing a medical treatment.
    Providing injectable medication in a specialized opioid clinic,
    under the supervision of medical professionals who are not only
    ensuring the safety of the patients and the community, but are
    also providing comprehensive care.
        We are able to use hydromorphone ``off-label'' in Canada
    for the treatment of substance use disorders, but some
    jurisdictions restrict its use to pain. I have seen remarkable
    transformations in our patients. Some of our patients have
    already returned to work or school.
        Supervised injectable hydromorphone is safe, effective, and
    cost-effective. It is a useful tool when the standard
    treatments are not effective. Treatments are dispensed within
    our opioid treatment clinic and prescribed on a ``dispensing
    basis'' onsite. In this setting, hydromorphone is not
    susceptible to diversion and an exemption for its use could be
    considered in jurisdictions where its use to treat substance
    use disorders is prohibited by law.
        In British Columbia, we need every tool in the toolkit to
    rise to the challenge of the opioid epidemic. Injectable
    opioid-assisted treatment in supervised clinics is one
    effective approach. Supervised consumption rooms, like Insite,
    in Vancouver, are valuable for public health. Of course, we
    would like to see an end to people's dependence on heroin but,
    for those already suffering, it is essential to provide care--
    and care based on evidence.
        Chairman Johnson. Thank you, Dr. MacDonald.
        Our next witness is Dr. Ethan Nadelmann. Dr. Nadelmann is
    the founder and executive director of the Drug Policy Alliance
    (DPA), the leading organization in the United States promoting
    alternatives to the War on Drugs. Dr. Nadelmann.

      TESTIMONY OF ETHAN NADELMANN, PH.D.,\1\ EXECUTIVE DIRECTOR,
                          DRUG POLICY ALLIANCE

        Mr. Nadelmann. Thank you, Senator Johnson, for initiating
    this roundtable and for inviting me. I have been waiting a long
    time for the opportunity to share some of my thoughts with
    members of the U.S. Senate.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Nadelmann appears in the Appendix
    on page 410.
    ---------------------------------------------------------------------------
        Let me just be frank. I fundamentally believe that the War
    on Drugs, in this country and around the world, has been a
    monumental disaster. It has been a disaster in public health
    terms. It has been a disaster in public safety terms. It has
    been a disaster in fiscal terms. And, it has been a disaster in
    human rights terms.
        I appreciate you bringing up the analogy to alcohol
    prohibition before because, if you look back at alcohol
    prohibition, some of what led the Nation to embrace the 18th
    Amendment, back then, was the notion that alcohol was a
    horrific drug that was causing immense devastation in this
    country and what have you. And, people embarked upon the
    experiment of national Prohibition. What happened? We saw Al
    Capone and rising levels of organized crime. We saw all sorts
    of violence and bootleggers at the borders with Canada and
    Mexico--and all around the country. We saw overflowing jail
    cells and courthouses. We saw hundreds of thousands of
    Americans being blinded, poisoned, and killed by bad bootleg
    liquor--liquor that was more dangerous because it was illegal.
    We saw people talking about nullifying elements of the Bill of
    Rights to the U.S. Constitution. We saw levels of corruption
    that were unparalleled, in many parts of the country. We saw
    Chicago and other towns essentially taken over by the narco-
    traffickers of the day--the alcohol bootleggers. And, we saw a
    rising level of cynicism and disregard for the law.
        Do you know what else we saw? We did not see any reduction
    in alcohol consumption. At the beginning, it looked like it was
    going to drive down alcohol use, but, by the end of alcohol
    prohibition, alcohol use was as high as it had been at the
    beginning. And, the major switch was that people had shifted
    from beer and wine to hard liquor--oftentimes underground hard
    liquor that was more dangerous. That is when the country came
    to its senses and said, ``Enough of this. We are repealing
    alcohol Prohibition.''
        At the same time, many countries in Europe that were
    flirting with Prohibition, they looked at us--they saw Al
    Capone, they saw all of the money going down the drain, they
    saw all of the failures, and they saw all of the hypocrisy.
    They said, ``We are not going to do that. We are going to crack
    down on booze with higher taxes, tougher licensing
    restrictions, and public education campaigns.'' Do you know
    what happened in Europe with that? Without prohibiting alcohol,
    they drove alcohol use and alcohol abuse down further than we
    did at the beginning of alcohol Prohibition in the United
    States. And, rather than putting billions of pounds or
    guilders--or whatever it might be--into the hands of
    traffickers and gangsters, they put it into government
    treasuries. It seems to me, that was the better approach then.
    There is a lot to be learned.
        Fast forward to right now. Drug prohibition has been a
    monumental disaster. You mentioned what is going on in Mexico
    and places like that--in Afghanistan--what is going down in
    Colombia and parts of Central America. They are like Al Capone
    and Chicago times 50. It is the result of a failed
    Prohibitionist policy.
        Then, you look at what is happening in American prisons.
    What are we, less than 5 percent of the world's population?
    But, we are almost 25 percent of the world's incarcerated
    populations--the highest rate of incarceration in the history
    of a democratic society--a rate of incarcerating black people,
    in this country, that puts South Africa--during apartheid--or
    the Soviet gulags to shame. It is nothing to be proud of and it
    turned out to be remarkably ineffective in dealing with the
    problems of drug abuse.
        Then, you look at the public health side. When human
    immunodeficiency virus (HIV) started to spread among injecting
    drug users back in the 1980s, those countries--not just
    Australia and the Netherlands, but Prime Minister Margaret
    Thatcher's Britain--decided that needle exchange programs were
    the right thing to do. They succeeded in keeping their HIV
    rates among injecting drug users to under 5 percent. In
    America, we said, ``No way, no way, no way.'' And, we ended up
    killing 100,000 to 200,000 people in this country--not just
    injecting drug users but their lovers and their kids as well.
    That was a disaster as well.
        So, I think that this ``War on Drugs'' has just served this
    country so poorly. I think what happened is that we developed
    an addiction. It was an addiction to ``drug-war'' thinking,
    ``drug-war'' ideology, and ``drug-war'' policies. And, right
    now, finally, thankfully--the country is finally in recovery
    from the ``drug-war'' addiction of our past.
        Now, that said, in making the analogy to alcohol
    prohibition, I think it applies mightily to the issue of
    marijuana prohibition. And, if I had been coaching that student
    who asked you that question the day that you spoke in that
    school, I would have said, ``Senator, let me tell you
    something. Marijuana--I do not see any evidence that the
    marijuana laws are preventing young people from getting it or
    any evidence that they are preventing older people from getting
    it. All that I see is evidence that it is putting a lot of
    people in jail and costing the government a lot of money. Do
    you still support a marijuana prohibition policy, knowing that
    it has been totally ineffective?''
        But, with the other drugs, I think this is the way to think
    about it--and I am going to conclude my comments with this: I
    think what the best drug policy tries to do is it starts with
    the understanding that there has never been a drug-free
    society, more or less, in human history--and there is never
    going to be a drug-free society. If anything, we are going to
    see more drugs--legal, illegal, in between, and gray market--in
    the future--from pharmaceutical companies and underground
    manufacturers--you name it. Therefore, our challenge is not to
    try to keep drugs at bay or to build a wall or a moat between
    this country and others--between our schools and what have you.
    That has failed. The evidence is in.
        What we have to do is to accept the fact, sadly, that drugs
    are here to stay and that our great challenge is to learn how
    to live with this so that they cause the least amount of harm
    possible--and, in some cases, the greatest possible good.
    Therefore, we need to think about drug policy in the following
    two ways:
        First, the optimal drug policy should try to do two things:
    It should seek to reduce the negative consequences of drug
    use--the death, the disease, the crime, the suffering, and the
    devastation of families, individuals, and communities. It
    should seek to reduce the harms of drugs. And, second, it must
    seek to reduce the harms of government policies, reduce the
    mass incarceration, reduce the drug gangs abroad, reduce all of
    the negative health consequences, and reduce violations of
    civil and human rights. The optimal drug policy is the one that
    most successfully reduces both the harms of drugs and the harms
    of government policies.
        And, the second frame--and I will finish with this--I think
    it is helpful, because all change, essentially, is incremental
    in these areas--and most others--to think about our options as
    arrayed along the spectrum, from the most punitive drug
    policies, on the one hand, as in Saudi Arabia, Singapore, and
    Malaysia--cut off your hands, execute you, lock you up, drug
    test you without cause, and throw you into what are called
    ``treatment camps'' that are really prisons--all of the way
    down to the most free-market, ``Milton Friedman-esque,''
    policies with no restrictions, except to keep kids away.
        The way that we need to think about drug policy is by
    moving down this spectrum, from the highly punitive
    overreliance on criminal law and criminal justice institutions,
    moving incrementally, step-by-step, down this spectrum, but
    stopping short at the point at which going any further would
    actually entail real risks to public health or public safety.
    And, it means being driven by the type of evidence that Dr.
    MacDonald just made reference to.
        When the evidence shows that mandatory minimum sentences
    are not having an effective deterrent impact, then it is time
    to reform and repeal those.
        When the evidence shows that marijuana has useful medical
    purposes, it is time to acknowledge that.
        When the evidence shows that providing sterile syringes to
    injecting drug users, through pharmacies and needle exchange
    programs, reduces the spread of Human Immunodeficiency Virus/
    Acquired Immunodeficiency Syndrome (HIV/AIDS) as well as
    hepatitis C--without increasing drug use, it is time to do
    that.
        When the evidence shows that methadone maintenance and
    buprenorphine maintenance are successful in reducing the harms
    of addiction and in helping people get their lives together, it
    is time to do that.
        When the evidence shows that heroin maintenance and safe
    injection sites reduce all sorts of harms and produce a net
    benefit, it is time to do that.
        With marijuana legalization, we will see. My judgment is
    that the net benefits of moving in the direction of the
    sensible regulation of marijuana exceed the risks. That is a
    judgment and we will see how that works out. But, I think that
    the evidence, overwhelmingly, suggests it is the right way to
    go. With the other drugs, we need to move toward the
    decriminalization and public health approach, focusing--and
    this is what I will do in my comments later--on reducing the
    demand and the magnitude for the demand of these drugs. So long
    as there is a demand, there will be a supply. Pouring money
    into supply just pushes it from one place to another--like
    trying to bang down on mercury or step down on a balloon. It is
    about reducing demand in ways that are driven by the evidence
    and a respect for basic human decency.
        Thank you.
        Chairman Johnson. Thank you, Dr. Nadelmann.
        Now for a slightly different perspective, Dr. David Murray
    served for nearly 13 years in President Bush's and President
    Obama's Administrations as Chief Scientist and Associate
    Director of Supply Reduction in the White House Office of
    National Drug Control Policy (ONDCP). He is currently Senior
    Fellow at the Hudson Institute. Dr. Murray.

        TESTIMONY OF DAVID W. MURRAY,\1\ SENIOR FELLOW, HUDSON
                               INSTITUTE

        Mr. Murray. Thank you, Senator. I, certainly, want to take
    a moment to give my appreciation for each of you that is
    persisting in this issue and this problem. It is an urgent
    issue and it does not get the attention it deserves. And, I
    want to commend you Senators, who have persisted in careful
    attention to this issue and are probing for answers for what
    is, as you identified, the cause of 47,000 deaths of Americans
    a year--and overwhelming morbidity that is an additional toll.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Murray appears in the Appendix on
    page 433.
    ---------------------------------------------------------------------------
        My perspective, from having worked inside of the government
    and having looked at the biomedical literature, is that we need
    to approach drug policy somewhat differently than we have most
    recently--but, that it can work--that we can save lives and
    that we can, effectively, transition people into more secure
    and better lives. The underlying role of substance abuse--of
    drug use--in driving American pathologies is extraordinary.
    From homelessness to domestic violence to law enforcement
    difficulties to national security risks to education failure to
    the death of our beloved fellow citizens and family members,
    this is an extraordinary cancer that has been eating at us for
    a long time.
        You will hear arguments--and have heard some of them
    already--I will probably be an outlier--a resister with regard
    to certain claims. It is not so much that I do not share the
    goals of lower amounts of drug use or of a safer, healthier
    society. It is that I am not convinced that the evidence is as
    strong as it is sometimes portrayed as, for these methodologies
    that are sometimes referred to as ``harm reduction.''
        There are claims made about impact that, when you look more
    carefully, the evidence is actually very weak and relies on
    self-report and on methodological studies that are very
    difficult to validate--very difficult to see the actual
    replicability of them. The evidence is much weaker than you
    might anticipate, with regard to moving in the direction that
    has been counseled.
        I would point out that we have moved in this direction, in
    the last 7\1/2\ years, under this Administration. It is a
    direction that has not strongly applied the strategic lessons
    of a balanced drug strategy approach and that has weakened and
    undermined the very office responsible for setting that
    strategy--and that has moved us down a pathway that approaches
    harm reduction mentalities. It has led to the enabling of legal
    marijuana. It has led to discussions about the distribution of
    harm reduction activities, including supervised injection
    facilities (SIFs). And, I think we can say that the results
    that we are seeing are before us and are really quite
    appalling. The results are disaster, epidemic, and tragedy.
        Does the ``War on Drugs'' work? Well, I would say that that
    is contingent on two things.
        First, you have to define what is success. And, when you
    have roughly between a tenth and a sixth of the prevalence
    rates of illicit substances, such as marijuana--the most widely
    used--compared to alcohol or tobacco--that is a form of
    success. You are reducing the disease and its morbidity as well
    as its impact. When you have one-sixth to one-tenth the
    prevalence rate, among young people and adults, of the use of a
    substance, part of that is attributable to the fact that there
    are social norms against its use and law enforcement sanctions
    against its use--and that law enforcement can be a powerful
    partner in referring people into treatment and recovery. And,
    when we decriminalize or move toward a model of deregulation
    and so forth, this really does not suffice. It does not answer
    our needs. It undermines the most effective partner for
    referring people to treatment. It undermines our hold on
    prevention, on the norms of non-using of drugs, and,
    ultimately, it weakens our approach, I believe.
        The second contingency is this: drug policy, where it has
    been effective--and there are models of where it has been
    highly effective. Reducing the youth use rates of marijuana 25
    percent, in the period from 2001 to 2008--that was an
    achievement. Reducing the use of major drugs, including
    methamphetamine (meth) and heroin, during that same time
    period, were major achievements. And, they are almost always
    attributable to having a bipartisan approach that crosses the
    aisle, so that it is a unified American understanding of
    American lives and American risk. At the same time, you cannot
    be--and my famous story of this, which strikes me as so
    compelling, is Penelope of Ithaca, the wife of Ulysses. He is
    sailing for 20 years and she must marry a suitor when she
    finally finishes a tapestry in front of her. And, when that
    figure in the tapestry is done, she will be forced to make a
    decision. But, what does she do every night as she waits for
    Ulysses? She unravels it, because she does not want it to come
    to an end.
        That is a positive model. But, unfortunately, we have taken
    the worst of that. We unravel our drug policy almost every 4 or
    8 years. We make gains and we have effective strategies. And
    then, we spend the next period of time reversing ourselves.
    Under that model, you cannot achieve long-range, sustained
    goals. We need to get back to that model of a sustained,
    bipartisan approach.
        So, what am I recommending? We have to acknowledge a couple
    of things. The urgency before us, at the moment, is opioid
    overdose deaths. But, we cannot let that drive all of our
    understanding. It is a, relatively, unique situation because we
    have, for opioids, methadone-assisted or medication-assisted
    treatment of various types. We have naloxone, an overdose
    reversal drug. We have the capacity to do things, like
    injection facilities, if we move in that direction. I would
    counsel against it.
        These are not available tools for drugs like
    methamphetamine, cocaine, or cannabis. We do not have the
    medications. We do not have the methodologies of approach. A
    comprehensive drug strategy cannot simply focus on the one
    urgent thing before us.
        The second issue is that we have overwhelmingly focused, in
    the last little while in this discussion today and in the
    Administration's perspective on the consequences of the opioid
    epidemic, on those who have the disease--those who need
    treatment. Those who are suffering already--how are we going to
    help them? Compassion requires that we do so, but we have to
    address the principal urgency, if you are thinking medically,
    thinking epidemiologically, or thinking in terms of sound
    public policy. You have to shut off the entry into that state
    by protection--prevention. You have to find the mechanisms of
    preventing people from falling into the state of addiction and
    dependency, where we then need to try to rescue them from
    overdose constantly with naloxone and within treatment
    facilities. This is too late. We can do things for them.
    Recovery is possible. But, if we are not urgently addressing
    the underlying mechanisms that are driving people into this, we
    are missing our policy opportunity and we are committing a
    tragedy.
        What must we do? Well, one thing would be to not enable the
    legalization, the normative acceptance, and the reduction in
    perception of risk regarding drugs. And, that is what
    legalization precisely does. It undermines the fabric of
    resistance and the capacity to prevent. And, I would offer--and
    we will have time to discuss, so I will not put all of the
    cards on the table at this point. But, I would say that there
    is a superior means of approaching this and it is the one piece
    of public policy that was, actually, eliminated--or neglected--
    in the last 7 years. We have to focus on the drug supply--the
    availability of the drugs, themselves. The Administration
    recognizes this, with regard to prescription opiates, which are
    the number two drug problem in America, in terms of prevalence
    rates--behind marijuana--which should tell you, by the way,
    that regulation, legalization, and medical practice are not
    sufficient to make the problem go away, because we have an
    enormous problem with regulated, formerly acceptable medical
    practice prescription opiates. They are killing 18,000 people a
    year, according to the last count. So, that is not sufficient,
    somehow.
        At the same time, we have seen the supply, as it is being
    reduced from medical practice, showing up, as this rate is
    starting to slow. What about cocaine? Cocaine from South
    America--from Colombia--was reduced 76 percent between around
    2003 through around 2010 2011. The consequences were major in
    the United States. People got better. People got into recovery.
    Overdose deaths from cocaine dropped significantly.
        Well, guess what has happened in the last 2 years in
    Colombia? Cocaine is taking off again and it is coming right
    back at us. And, it will soon be right back at our throats. As
    the supply increased, overdose deaths are starting to climb
    once again.
        And, the third example--and the one I think that we are not
    sufficiently paying attention to--is heroin--the illicit
    opiate. Twenty-six metric tons were produced out of Mexico--our
    primary source--back in 2013. The assumed need for the use of
    heroin in the United States was never more than 18 metric tons.
    What were they doing with this abundance? A year later, it rose
    to 40 metric tons. That is an extraordinary amount of a deadly
    substance that is being manufactured and sent across the
    border. And, as of 2015, it has now skyrocketed up to 70 metric
    tons. Where is it going? Who is it infecting? Why are we not
    doing more with international partnerships, interdiction, and
    border protection? If you are thinking epidemiologically--and
    this is a disease--you have to drive down the presence of the
    pathogen--the thing that infects people. It is a behavioral
    disease and the pathogen, in this instance, is the illicit
    market of heroin that killed 10,500 people in 2014.
        And, now, I hate to make a worse statement, but there is
    worse. We are not done yet. The deaths that we have seen, which
    have driven the news coverage and have driven our urgencies and
    concerns are based on 2013 and 2014 production. It has already
    surpassed that. It is already coming now at a 170 percent
    increase and it is being added to by synthetic opioids. Look
    out. Hang on to your hat. They are going to kill many more.
        The fentanyl seizures at the border--fentanyl is measured
    in micrograms for a dose. When first responders open a package,
    they are at risk for dying. It is that potent--that lethal.
    And, it is growing in the tens to hundreds of pounds, which are
    now showing up at our border as illicitly manufactured and it
    is being laced into heroin. I am sorry to say this, but next
    year's death toll will probably be worse--and the year after,
    because we have not sufficiently applied the measures that are
    absolutely requisite to shut off this pathogen that is killing
    many Americans. We need a balanced strategy. We need to have
    treatment and recovery. We need to have prevention in our
    schools for young people. But, we have to address the sheer
    magnitude of the deadly supply that
    is driving this engine. And, I would argue--and I will end with
    this--when we do approach supply and reduce its capacity to
    entangle us, we thereby give power to treatment and recovery as
    well as to prevention. We make them more possible and
    stronger--and in the presence of law enforcement and drug
    courts and referrals to treatment, we have a powerful
    partnership that we unfortunately let slip through our grasp--
    and we are now paying the price.
        Chairman Johnson. Thank you, Dr. Murray.
        Our final witness is Chief Frederick Ryan. Chief Ryan has
    been a police officer since 1984 and has served as Chief of
    Police in Arlington, Massachusetts since 1999. Thank you for
    your service and thank you for coming here.

      TESTIMONY OF FREDERICK RYAN,\1\ CHIEF OF POLICE, ARLINGTON,
                             MASSACHUSETTS

        Chief Ryan. Good morning, Senator and honorable Members of
    the Committee. Thank you for having me. Again, my name is
    Frederick Ryan. I am Chief of Police in Arlington,
    Massachusetts. I also serve as the vice president of the
    Massachusetts Major City Chiefs of Police Association (MMCC),
    and I am on the board of the Police Assisted Addiction Recovery
    Initiative (PAARI), which was founded out of Gloucester,
    Massachusetts.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Ryan appears in the Appendix on
    page 470.
    ---------------------------------------------------------------------------
        I am here to talk about the opiate epidemic that has swept
    across America. But, before I get into my prepared comments, I
    wanted to share with the Committee a text message that I got
    this morning, while I was in the other room changing into this
    lovely uniform that I am wearing. That message was from a young
    man, who our officers had arrested many times for crimes
    associated with his drug addiction. After affiliating with the
    Police Assisted Addiction Recovery Initiative, we referred this
    young man into treatment, rather than to the criminal justice
    system. He is now coming up on a year of sobriety. And, he
    texted me to thank me for helping him and for coming here today
    to speak before this Committee. I think that really illustrates
    what I am going to talk about, in terms of police referral to
    recovery.
        My views are shaped by what I have seen and done as a
    police officer on the streets of the Commonwealth of
    Massachusetts for more than 30 years and by what I have learned
    from individuals suffering from the disease of addiction. I
    will summarize my points as follows:
        We, as law enforcement, cannot solve this problem alone--
    and we must stop telling America that, with just some more
    resources, we can do so. In fact, a strategy that relies
    largely on law enforcement and arrest, especially aimed at low-
    end users, only fuels the epidemic and complicates the chances
    for long-term recovery.
        Every dealer we arrest and take off of the streets is
    quickly replaced by one or more rivals who sometimes compete
    for that territory by cutting their prices, increasing the
    supply, and marketing new and even more dangerous products,
    such as fentanyl-laced heroin. This often makes the situation
    worse than it was before the arrest.
        Every person with a substance abuse problem that I have
    talked to has said that arrest and prosecution has never been a
    deterrent. The physical and psychological need for the
    substance was far stronger than any seemingly rational
    deterrent that the police and the criminal justice system
    posed.
        Those suffering from substance use disorders are not our
    enemies. They are our sons, our daughters, our neighbors, and
    our nephews. And, this notion that we are at war with them must
    be abandoned.
        The solution to the epidemic relies on reducing the demand
    for opiates and other substances. This epidemic was built one
    drug-dependent victim at a time. And, the solution, while
    complex and multidisciplinary, needs to be heavily based on
    modern evidence-based treatment options. There are really only
    two choices here: long term treatment or death.
        Police officers and Chiefs of Police, throughout our
    country, are stepping forward to call for change. Through the
    leadership of my dear friend and colleague, Chief Campanello up
    in Gloucester, Massachusetts and businessman John Rosenthal,
    from Boston, the Police Assisted Addiction Recovery Initiative
    was founded as a private nonprofit.
        And, by the way, as an aside, after it was founded by
    businessman John Rosenthal, he lost a nephew to the epidemic as
    well.
        To date, we have more than 120 police departments that have
    affiliated with PAARI. And, we have treatment providers, in 28
    States, that are offering scholarships to those suffering from
    substance use disorders. These police departments, and many
    others, are joining PAARI every day and have stopped arresting
    and criminalizing addiction and incarcerating people merely
    because they suffer from a substance use disorder.
        I want to tell you how and why I came to these conclusions.
    You probably expect that a 30-year cop might have a different
    perspective on these matters. Simply stated, we are not at war
    with our communities--nor should we be.
        The epiphany, for me, that we had to have a philosophical
    change, came when I was being briefed by our crime analyst on
    trending overdose fatalities in our jurisdiction. She displayed
    it on a spreadsheet for us. One very young lady, who, by all
    standards of measure, was an American success story--college
    educated--her mom a school teacher and her dad a firefighter--
    overdosed on heroin. Police and emergency medical services
    (EMS) responded, reversed the overdose with nasal naloxone, and
    she was transported to a Boston hospital. One week later, the
    same young lady overdosed--a 911 call, police and EMS response,
    naloxone reversal and transportation to a Boston area hospital.
    Seven hours later, she overdosed. Fatality. If that does not
    illustrate that these deaths are not only predictable, but also
    preventable, nothing does. This overdose death was predictable
    and, therefore, preventable. And, it highlighted the fact that
    we, the police department, possess the identities of those at
    the highest risk of a fatal overdose--those who have previously
    overdosed--and that, with every non-fatal overdose, there is an
    opportunity to do an inventory, to get individuals into
    recovery, and to get the family and their loved ones the
    resources they need to ensure survival.
        Further, this death depicted the real fact that many
    emergency rooms (ERs) in America do not have the desire or the
    capacity to treat overdose victims in any meaningful way.
    Medical and substance use disorder treatment programs cannot be
    allowed to continue discharging, to the street, sick people at
    risk of immediate death. We would not tolerate this for any
    other chronic disease, such as cancer, heart disease, or
    diabetes.
        This experience led the Arlington Police Department to be
    the first in the Nation to affiliate with PAARI. What was a
    desperate response to an epidemic threat in two distinct
    communities in Massachusetts--Gloucester way up on the north
    shore and Arlington in the metropolitan Boston area--resonated
    swiftly and broadly across the region and, indeed, the Nation.
    And, legislation is moving rapidly through many State
    legislatures, empowering police-assisted recovery initiatives
    and focusing on reducing the demand for opiates by increasing
    access to treatment and prevention.
        Essentially, there are two models: the Gloucester and the
    Arlington model. The Gloucester model invites those suffering
    into the police department. And, they connect them with a
    volunteer ``angel'' that helps them navigate the system in
    recovery. The Arlington model--we have a social worker who does
    outreach to the known population of people suffering from
    substance use disorders and works with them and their loved
    ones to put in place an intervention plan to plan for the next
    overdose, so that we can prevent it from being a fatality. And,
    I will talk, in a minute, about the early data trending.
        In 2014 and early 2015, in our jurisdiction, we were
    averaging one fatality per month on heroin overdoses--many more
    non-fatal overdoses and reversals. Following the implementation
    of our program, on July 1, 2015, we went 8 months with only one
    fatal overdose. Sadly, while I was preparing the testimony that
    I am speaking about today, in my office on Sunday morning, the
    radio call went out and our officers responded to an overdose,
    while I was typing this testimony. And, I listened to the radio
    carefully and, at that scene, a family member had dispensed
    nasal naloxone and saved their family member. Likely, the
    naloxone was dispensed by the Arlington Police Department.
        Through the Boston University (BU) School of Public Health,
    we are tracking all of our program participants. And, although
    it is early, we are seeing significantly lower relapse rates
    among the participants in our pre-arrest diversion programs,
    both in Gloucester and Arlington.
        The Arlington and the other police-assisted recovery
    initiatives are only a year old--and it is far too early to
    draw conclusions. After all, the disease of addiction is a
    chronic condition that often involves relapsing. I think,
    maybe, we will talk later about what success looks like, but we
    have to prepare for relapse. Nevertheless, there are important
    markers that demonstrate we are on the right course:
        We are saving lives and we are reducing crime--crimes that
    are often associated with drug addiction--burglary,
    shoplifting, and other quality-of-life crimes. Some
    jurisdictions are reporting as much as a 25-percent reduction
    for those crimes.
        Our new approach is restoring and building the community's
    trust in police--and this is of critical importance to your
    Committee. In this very challenging time in the history of
    policing in America, where the trust has been lost in many
    jurisdictions, programs, such as the one I am speaking of, have
    been incredibly valuable at rebuilding the trust in the
    community and its police department--and many residents are
    shaking their head, saying, ``Finally, the cops got it.'' We
    have to stop arresting people because they have an addiction.
        Stigma and shame inhibit patients and their families from
    seeking treatment and support. The fact that law enforcement is
    recognizing this as a disease that needs to be treated into
    remission, rather than a crime that requires arrest and
    incarceration, has had a positive impact in communities
    throughout America.
        To that end, I do not, personally, respond to fatal
    overdoses. We had the brother of one of our police officers
    fatally overdose. I went out to the scene to offer my
    condolences to his mom and the family. The young man was,
    literally, dead on the other side of the wall and his mom
    looked at me and told me, ``Thank you for what you are doing
    around addiction in the community. We were just too ashamed to
    reach out for help.'' And, it is that shame and that stigma,
    which is killing people, that we have to set aside.
        You will notice that, in my testimony, I never labeled
    those suffering from substance use disorders as ``junkies'' or
    ``addicts.'' And, I otherwise refrained from labeling these
    people--these members of our community. The very real stigma
    associated with addiction is among the greatest barriers to
    success and it has inhibited the power and the might of the
    U.S. Government from bringing a real sense of urgency to the
    opioid addiction epidemic and from adopting meaningful and
    effective policy changes to address the demand side of this
    public health crisis.
        Today, in Massachusetts, we lose an average of four people
    a day to opiate overdoses--and it is projected that more people
    will die this year from overdoses than from automobile
    accidents. It is time that we bring a true sense of urgency to
    this public health epidemic and that we unleash the might of
    our government to address the demand side of the opiate crisis.
    And, municipal police departments and PAARI partners across
    this country are willing partners in that solution. As I stated
    earlier, there are only two choices: long-term treatment or
    death. Clearly, we all know the answer that we want. I look
    forward to getting started on this work with the Committee,
    today. And, I thank you for the invitation to speak here,
    today.
        Thank you, Senator.
        Chairman Johnson. Thank you, Chief Ryan.
        Obviously, we have some effective advocates for the various
    positions here. And, I truly appreciate the excellent testimony
    here.
        I am going to be here for the entire roundtable, so I guess
    what I would like to do is to turn it over to my colleagues.
    And, we can do it--again, I want this to be a free-flowing
    discussion. I do want to keep answers relatively short. It
    looks like all of us--our witnesses can, certainly, again, be
    effective advocates, but let us keep the conversation and
    discussion relatively short. Let us keep the answers clipped--
    and the questions as well.
        We will start with Senator Portman.

                  OPENING STATEMENT OF SENATOR PORTMAN

        Senator Portman. Thank you. And, first, thank you for
    having the roundtable. And, to all four of you, thank you for
    your important work in this field. As you know, the Senate has
    been grappling with this. We spent 2\1/2\ weeks on the floor
    with this legislation, called the Comprehensive Addiction and
    Recovery Act (CARA). We spent 3 years putting it together. We
    had five conferences here, in Washington. Some of you
    participated in those. We brought in experts, in various areas,
    to try to figure out how to get at the very issues you are
    talking about--dealing with this, not as a drug problem, but as
    a public health problem, acknowledging that this is an illness,
    this is to be treated as a disease--trying to take away the
    stigma, which, Chief Ryan, you have talked about--which I agree
    with you is part of the reason people are not seeking
    treatment. There are other reasons as well.
        I am someone who is frustrated, because I have been at this
    a long time. Twenty-two years ago, a constituent came to me,
    when I was in the House of Represenatives, and said, ``My son
    just died. What are you going to do about it?'' And, I was
    fully armed with all of the statistics--$15 billion a year on
    interdiction and eradication of drugs as well as on
    prosecutions and incarceration. And, she said, ``What are you
    doing for me in my neighborhood?'' And, that led to a whole
    series of thinking and, frankly, to a different position on my
    part, in terms of focusing more on the demand side. And, we did
    pass a number of bills, the Drug-Free Workplace Act of 1988,
    the Drug-Free Media Campaign which I was proud to be the author
    of--but also the Drug-Free Communities Act of 1997. We sent out
    $1.3 billion, supplying 2,000 community coalitions around our
    country, including one I chaired in my hometown for 9 years--
    and, which I was on the board of before I ran for this job. I
    am still very involved with it.
        I think CARA addresses much of what you are talking about.
    It will not solve the problem. Washington is not going to solve
    this problem. But, it does focus on, primarily, four things.
    One is the notion of placing much more emphasis on prevention
    and education. And, David, you talked a little about that--the
    importance of not taking your eye off of the ball--and, I
    think, that is one of the problems we have had. When we solve a
    problem--we had cocaine solved, you will recall, back in the
    1980s. And, thanks to a basketball player at the University of
    Maryland (UMD), everybody thought, ``Cocaine is the issue, we
    are going to focus on this.'' When Len Bias died, there was a
    lot of emphasis and focus. As soon as you take your eye off of
    the ball, it is something else.
        You mentioned methamphetamines here today. You mentioned
    cocaine coming back. I would tell you that overdoses in my home
    State of Ohio, we are starting to see more cocaine, we are
    starting to see more meth coming back. And, we thought we had
    sort of turned the corner there. So, every time you take your
    eye off the ball--I agree with what was said here today--
    something will crop back up again.
        So, I think there is a growing consensus around this issue
    of treating addiction like a disease--removing the stigma, so
    people get treatment--and focusing more on demand, rather than
    just focusing on the supply side. And, by the way, look at
    where the money has gone. The Drug-Free Communities Act of 1997
    is part of this, but there has been more money placed on the
    demand side. I would say that it is still not enough, because I
    think this will--unfortunately, it is not going to be solved at
    the border. If it is not, in my view--and I am not,
    necessarily, speaking for my colleagues here, on either side of
    the aisle, but we are not going to be able to solve this
    problem by building a bigger wall or by stopping it at the
    border--because methamphetamines can be made in the basement--
    by the way, so can fentanyl. Fentanyl is a synthetic form of
    heroin that can be made by a chemist--and is.
        So, I have three questions for you. One is with regard to
    medication-assisted treatment. It sounds like, Dr. MacDonald,
    you have had some success in, essentially, using synthetic
    heroin to keep people stabilized--and they have gone back to
    work. You did not mention what your percentage is. I would love
    to hear that. You did say that, by dealing with the underlying
    psychological and mental health issues, some will step down to
    less intensive treatments and gradually wean themselves off.
    And, some are back at work and back with their families--and, I
    assume, into a life where the drugs are not everything. Can you
    give us some sense of what the percentage is there? And then,
    also my question to you all is: What are some other potential
    medical breakthroughs, here? The one that we are using a lot in
    Ohio--we have 12 pilots right now--is Vivitrol. And, the notion
    is that you have this blocking of the craving, rather than a
    synthetic form of an opioid--or an opioid, in the case of
    methadone or Suboxone. What else do you see out there? And,
    what do you think about Vivitrol or the other drugs coming on?
        And then, finally, how about pain medications? Four out of
    the five heroin addicts, in Ohio, started on prescription
    drugs. And, prescription drugs, as was said by all of you, are
    legal, prescribed drugs. I could not agree more with what David
    Murray said about the perception of harm. All of the evidence
    shows this. If you show there is a perception of harm, you will
    have fewer, particularly young people, getting into this. But,
    what is the perception of harm when a doctor gives you 80
    Percocets after you get your wisdom teeth taken out? And, I
    know two parents back home--two parents who lost their child,
    because a child went in, as a teenager, to get their wisdom
    teeth taken out and ended up getting addicted to prescription
    drugs--and they moved to heroin and overdosed.
        So, how about pain medication? When was the last time there
    was a new pain medication to come on the market? Why are we
    using prescription narcotic drugs to deal with things like the
    extraction of a wisdom tooth or even a sports injury, when
    there has to be much more targeted ways in which to deal with
    that pain--and pain management in general?
        So, those are the questions I have. And, I would open it up
    to everybody.
        Dr. MacDonald. We have only had a treatment program, in
    Vancouver, for about 2 years. So, it is in the early days. We
    are still learning and still studying our patients. Our
    patients that are working or that have found work are a small
    number. It is, probably, about 5 percent. That is still
    significant and, hopefully, it will grow.
        The other side of that equation is, our patients have been
    using illicit heroin for 15 years, on average--or longer.
    Ideally, I would like to engage those folks earlier--not wait
    15 years before we intensify their treatment.
        With regard to pain medications, I think there is overuse
    of opioids for pain medication. And that needs to be reduced.
    But, when it comes to people with severe opioid use disorders,
    that need to access care, we need to increase access to opioids
    and to treatment for them. So, there are two sides to that
    solution.
        Mr. Nadelmann. If I could just add to that, Senator
    Portman--and I also want to thank you for your leadership on
    CARA. I think that there are many elements in there, especially
    expanding access to methadone and buprenorphine, making
    naloxone easier to get, and opening up the possibility for
    funding more diversion programs by law enforcement. They are
    really wonderful elements and really an important part of the
    solution to this.
        Let me just say, with respect to what Dr. MacDonald talked
    about--about heroin maintenance--it did not start in Vancouver.
    It started in Switzerland, back in the early 1990s. First, it
    was on an experimental basis. And, once the results were found
    to be successful, it was then implemented, first city by city,
    and then, on a national basis. It is now a part of Swiss
    national drug policy.
        Then, the Dutch did the same, and then the Germans did the
    same, and then the British did the same, and then Montreal and
    Vancouver proceeded. And then, Denmark was considering doing
    experiments--trials, with respect to heroin maintenance--and
    they looked at the extensive research that had already been
    published. They realized that most of the people in Denmark,
    who were addicted to heroin, were no different from people
    elsewhere in Europe. And, they just proceeded right to go ahead
    and start implementing these programs as well.
        So, I think you should be aware there is now 20 years of
    research, including research published in the New England
    Journal of Medicine, and all of the top European journals,
    showing that prescribing heroin to those people, who have tried
    every other form of treatment--drug-free, in jail, methadone,
    and buprenorphine--that it, actually, reduces their illicit
    heroin use. It pulls them out of the illicit drug markets and
    thereby reduces their other illicit drug use. It reduces their
    risk of contracting HIV and hepatitis C. It results in fewer
    arrests, less crime, and more people reuniting with family,
    because, keep in mind, when you have been using heroin for 10
    years or 15 years, you are not getting so high anymore when you
    use it. You are, basically, using it to keep from getting sick,
    right? And, the fact of the matter is, heroin addicts--unlike
    being an alcoholic, where you are still getting drunk or
    cocaine users, where it is still messing you up in different
    ways--when you have stabilized, whether it is on methadone,
    buprenorphine, or--Germany used to have codeine maintenance--
    or, for that matter, heroin maintenance, you actually can hold
    a job. You can operate as a normal human being. It is hard for
    people to believe that, but that is what the evidence shows.
        I think your other question about the pain medicine--it is
    a great question. Let me say a few things about that.
        There are a few things that I think are really seriously
    missing here. The first one is more of an understanding of what
    is going on with all of these people getting in trouble with
    pain medicine and heroin and overdosing and all of this sort of
    stuff. What I would recommend is, if you are looking at the
    budget of the National Institute on Drug Abuse (NIDA), it is
    all well and good that they are doing all of this brain disease
    stuff--and I am sure something will come of it--but I would
    encourage you to do a more rigorous analysis of what has really
    come of the multi-billion-dollar investment in that. But, I
    would hire an army--an army of ethnographers and other
    researchers to hit the ground and find out what is going on.
    Whether it is the kid who got addicted to it from a football
    injury going in, or whether it is somebody struggling with
    mental illness or with depression, what is going on with each
    one of these things? Why are people using these drugs? How are
    they using them? What do they know and what do they not know?
        When the word hits the streets that there is some dope that
    is laced with fentanyl, does that make people want to search it
    out or run away? And, if so, why?
        With respect to the people dealing, as responders to this
    thing, what do they know? Do they know that, for example, a
    fentanyl overdose may require a higher level of naloxone? Do
    they know how to administer it?
        One of my greatest frustrations is that, if you look at the
    majority of overdose fatalities in this country, you know what
    you find. The majority of them did not solely involve the use
    of heroin or a pharmaceutical opiate. Right? The majority
    involved the use of opiates with alcohol or sometimes
    tranquilizer drugs--benzodiazepines. The fact that using
    opiates and alcohol is, oftentimes are most of what--called
    overdoses are, in fact, fatal drug combinations. And, I think
    that information is not known--not known by young people, not
    known by active drug users, and not known by all sorts of
    people.
        The other thing I would say is that what we are really
    dealing with here is an epidemic of pain in this country. It is
    physical pain, it is psychological pain, it is emotional pain,
    and it is existential pain. And, we then try to deal with all
    of this, with opiates, in a way that is incredibly
    inappropriate.
        The ``New York Times'' had an amazing story, a few days
    ago, on the front page. It was about a hospital--an emergency
    room at St. Joseph's Hospital, in Paterson, New Jersey, that
    has reduced its use of prescriptions and use of opioids in the
    emergency room by almost 40 percent since last year. Now, what
    are they doing? They are trying whatever works--from new-agey
    alternative stuff to feedback to using ketamine for a pain
    issue--whatever it might be. You have to be innovative on this
    stuff. But, I think finding out the research really truly
    committing to the research--do not act and do not put on new
    criminal penalties before we really know what is going on.
        I will conclude with this: I actually think that, when Len
    Bias died 30 years ago, if, somehow, there had been a
    prohibition on Congress and State legislatures adding in any
    new criminal laws and any new criminal penalties as well as a
    simple requirement that every dollar that you wanted to spend
    on law enforcement had to be spent on treating drug addiction
    and drug use as a health issue--if we had been obliged to spend
    those hundreds of billions of dollars, in recent years--or the
    $1 trillion on public health, instead of on law enforcement--I
    think the evidence, overwhelmingly, indicates that our drug
    problems in America would be dramatically less than they are
    today--that the number of people alive would be far greater.
        Chairman Johnson. OK. Again, I would like to kind of----
        Mr. Nadelmann. I apologize.
        Chairman Johnson. That is fine. I want a free-flowing
    discussion. And, by the way, when we are on a particular topic,
    you
    do not have to sit and wait for your turn. OK? But, let us go
    on to--Senator Lankford came in next, but, again, I want this
    to be a discussion and to have a little bit shorter answers--a
    little bit shorter questions.

                 OPENING STATEMENT OF SENATOR LANKFORD

        Senator Lankford. There has been a lot of conversation
    about the demand side of this--and the supply side as well. You
    need me to get a little closer?
        Chairman Johnson. Yes.
        Senator Lankford. OK. The supply side and the demand side.
    Mr. Murray, your conversation as well--about the normalization,
    somewhat--the more that we talk about decriminalizing and the
    more that we try to make sure people do not feel the stigma,
    does it create an environment where people actually feel like,
    ``OK, there is not a real problem and there is not a real
    threat.'' I would like to talk about that a little bit more.
    And, in the interdiction of drugs, actually, coming into the
    country, when you deal with heroin and the amount of heroin
    that is coming in, from Mexico, in particular--and the dramatic
    increase there. Poppy fields are not something you hide in the
    jungle, like marijuana. They are obvious from the air. They are
    obvious from a satellite. They can be known. So, some of the
    interdiction conversations.
        Finally, I would say that--just as a statement to be able
    to throw this out as well--I am concerned that we spend a
    tremendous amount of time talking about decriminalizing
    marijuana. And, it sends the wrong message, to people around
    the country, that drugs are no longer an issue. And, people
    just transition that from one drug to another and say, ``Well,
    drugs are not the problem if marijuana is not the problem.''
    And so, any comments on that? And, Mr. Murray, I would be
    interested in your comments.
        Mr. Murray. Thank you, Senator. And, again, it is
    impressive that you are attending and working on this issue. It
    is deeply appreciated. This has needed leadership for a long
    time.
        Quickly--it is good news that prescription use--opiate
    misuse--started going down in 2006. It is gradual, but it is
    going down. Effective interventions,the medical practice
    changing, and prescriber education--they are taking hold here.
    And, more responsibility is being shown. The rising ones are
    heroin and fentanyl now. And, fentanyl presents the new threat
    of the synthetics--the poppy fields. We used to image, by
    national technical means, the estimates we would make for
    production. That is over. Fentanyl and synthetics that are
    coming along--including new versions that are even more potent
    than fentanyl--are being made in labs--in urban settings very
    often. Chemicals coming from China and manufactured,
    distributed, and arranged in Mexico, are put into the United
    States as an adulterant to heroin. They have to be--they cannot
    be perceived, in terms of overhead technology. They cannot be
    estimated production-wise. It is the methamphetamine model. We
    have to go after the precursor chemicals. And, it is not just
    border control. You cannot sit here, without defense in-depth,
    and think we are going to intercept this, as it comes through
    the tunnels. What you must do is be forward-leaning into
    source-country partnerships. You have to work effectively, with
    leverage, with Mexico and with China. You have to have
    effective international programs. Budget data shows that this
    Administration has reduced funding for international drug
    control programs by the amount of $952 million, since 2009.
    That is the wrong direction--the wrong answer. We need to be,
    effectively, more engaged with reducing the production
    capacity--the chemicals, in the case of the synthetics, the
    opiates, in terms of the cultigens, cocaine, and the rest--they
    have to be done in international partnerships. We have lost our
    moral leadership in international partnerships. Every
    international body tells this to us when we allow--enabled
    highly potent marijuana--and highly potent marijuana, now legal
    and recreationally available--is, itself, linked to the opiate
    epidemic. There is a priming gateway dimension to this. An
    opiate or heroin user is very commonly--the great majority of
    them use at least three drugs at the same time--the polydrug
    use. Epidemiologically, it starts with a gateway access--
    alcohol, tobacco, or marijuana. These lead into the
    accessibility and the vulnerability for subsequent--being
    captured in more intense drug use as they grow. That is always
    a concern.
        Fentanyl divert--OK. The data that we can see, at the
    moment, overdose deaths from prescription opiates were
    dropping, and then, suddenly, in this last year--2014--
    unfortunately, we do not have good data--up to date--spiked
    again. That was fentanyl. It was attributed to prescription
    overdose problems. It was, probably, rogue illicit production.
    It caused 5,500 deaths, on top of what had been a declining----
        There are now indications that fentanyl is also being
    insinuated into counterfeit pills, so that people are
    purchasing what they think to be a medication. It has gotten
    micrograms--and the analogy that has been used is, if you are
    making chocolate chip cookies and you are putting chocolate
    chips in, one cookie has four chips and one cookie has three.
    That is the difference between life and death--when it is
    micrograms of fentanyl. It is that small. And, the people
    making this--the rogue pharmacists and the rogue chemists--do
    not have that degree of concern. And, therefore, the
    vulnerability, from these new synthetics, is extraordinary.
    Naloxone is a terrific response. It does revive people.
    Naloxone is not enough, if you are not reducing the supply of
    this pathogen. It gives you a 20-minute bridge to get people
    into an emergency room. The power of the new synthetics is so
    great--it occupies the receptors so strongly--that naloxone is
    losing its effectiveness, in terms of the capacity to overcome
    these. And, the condition will return.
        Media campaigns, Senator Portman--we missed that. My
    impression was that--sure, prevention happens in the home, in
    the church, in the synagogue, in the school, and in the
    community. That has to be done at the local level. But, the
    government could help with the incredible media outpouring of
    support for drug use and the pathology, thereof, if there is no
    counter. We have lost that counter--and my impression is, we
    really are missing that role.
        Chairman Johnson. Let me interject here. One of the
    reasons--and, again, I want to drive this process, because I
    want to come out with areas of agreement. The only way we are
    going to kind of come together and find out where we agree is
    if we kind of stick to specific issues--specific questions--
    without broadening--I am being serious about this. The way you
    solve problems is to find areas of agreement. So, again, I just
    want to have everybody involved in this discussion. Let us
    address specific issues and give, relatively, short answers.
    And, again, I kind of like the nodding of the heads, going,
    ``We all agree on that.'' And then, where we disagree, I think
    it will just be a little bit more helpful, in terms of the
    discussion. Does it make sense? Yes, that is--and, again, I
    would like to--as long as we are on a particular subject, let
    us stay on it, until we kind of fully discuss it, figure out
    where we agree, and figure out where we disagree. And then, we
    can move on to the next one.
        Senator Ayotte. Well, I have been really proud to work with
    Rob on CARA, so I am hoping that we get to this conference and
    get this legislation passed.
        I wanted to follow up on the prevention idea. We have had a
    lot of discussion, in this Committee, about what we have done
    on smoking. So, I get that, whether it is Drug-Free Community
    grants, like we have in CARA or local prevention efforts, which
    are a piece of it. We also have a national campaign. And, it
    seems to me that we have an opportunity also, in combination
    with local education efforts--whether it is in schools,
    churches, or local community organizations that are engaged in
    this to do that on a very personal level. But, I think we are
    pretty understanding that, if we were to put our might behind
    it, on the national level, too, we could change this dialogue
    on stigma. We could change the dialogue on exactly whether it
    is connection--the understanding of prescription drugs and
    heroin--and the devastating impact that this has on people.
        So, I would like to get your take on the prevention side--
    not only local efforts, but could there be something
    nationally? If we did it, it has to be, obviously, tested and
    done right. But, we have seen it work in other contexts.
        Mr. Nadelmann. Well, if I could just say that the Centers
    for Disease Control (CDC) just came out, last month, with its
    report on trends and the prevalence of drug use--and it was an
    analysis of the National Youth Risk Behavior Survey (YRBS),
    from 1991 to 2015. What they found--this is U.S. Government
    data--was that the prevalence of marijuana use, by high school
    students, decreased between 1999 and 2015. And, there was no
    change in prevalence between 2013 and 2015. OK? This is the
    period, by the way, during which we went from having half a
    dozen States with legal medical marijuana to now, with half of
    the States having legal medical marijuana.
        Senator Ayotte. How does this get, though, to my question
    of----
        Mr. Nadelmann. Well, the point I am making is that, at this
    point----
        Chairman Johnson. Let me just quickly stop you, because you
    are quoting a statistic and I am seeing David shake his head.
    Is that disputed, what he is saying?
        Mr. Murray. Yes, it is highly misleading to characterize it
    that way. You have a timeframe and you can ``data slice'' it in
    terms of what is up and what is down from the 1990s. What
    happened was, we had a steep decline in youth use and in
    overall drug use between 2001 and 2008. And then, we had a
    reversal beginning in 2009, that took it back up again. So, if
    you draw a straight line from the 1990s across, yes, it is down
    just a little bit. But, that trajectory is made up of two
    movements----
        Mr. Nadelmann. But, then again----
        Mr. Murray [continuing]. One down and one back up--the
    policies were reversed.
        Mr. Nadelmann. David, the same period you are picking up on
    was a period of massive increase in methamphetamine addiction
    and things----
        Senator Ayotte. I do not want to interrupt, but I want to
    ask a question----
        What can we do? We are supporting the CARA efforts, which I
    think we need to expand treatment--and the demand side. But,
    Chief, I do not know what your thoughts----
        Chief Ryan. Yes, in Massachusetts, under Governor Charlie
    Baker's leadership, we have the ``State Without StigMA''
    campaign, which has been incredibly effective. One of our
    treatment providers is the face of the ``State Without StigMA''
    campaign, coming from the Governor's office. That messaging was
    huge, in terms of us going out and having a dialogue at
    community meetings--and people saying, ``Hey, this is coming
    from the Governor's office. This is important stuff.'' And, it
    further----
        Senator Ayotte. Let me say that I admire Governor Baker's
    leadership on this.
        Chief Ryan. I do, too. He has been incredibly effective.
    And, he invited Chief Campanello and me when he signed the
    legislation. But, we cannot keep drugs out of our prisons. If
    we think we are going to keep it off of the streets of America
    through heavily-weighted enforcement priorities, we have simply
    got it wrong. And so, it speaks to the need for treatment and
    prevention. And, I have learned a lot during this process.
        And, the other notion--that we need to have a bed for
    everybody--that goes with the stigma, too: ``I need to be in
    some bed, somewhere, in some institution, because I have this
    substance use disorder.''
        Senator Ayotte. Do you have a lot of medication-assisted
    treatment?
        Chief Ryan. And, that is where I was going with this. And,
    the physicians can speak to this better than I can. But, as I
    understand it, the one addiction that is the most likely to
    respond to medication-assisted treatment is an opiate
    addiction. And, we have seen, with Vivitrol--like the Senator
    mentioned-incredible effectiveness--and we have partnered with
    a Vivitrol clinic. One of the challenges there and one of the
    things your Committee might be able to look at is, it is
    incredibly expensive.
        And so, we have patients that we have gotten into a
    Vivitrol clinic, and they go for many months and they are over
    the physical addiction. Now, it has become sort of a bit of a
    crutch. And, weaning them back off of Vivitrol is becoming
    challenging as well.
        Senator Ayotte. We also have caps on certain forms of
    treatment.
        Chief Ryan. Right.
        Senator Ayotte. I just want to make sure that, as I look to
    your point, Dr. Murray--1 gram of fentanyl is the equivalent,
    according to the CDC, of 7,000 street doses of heroin. So,
    this, obviously, is a very powerful synthetic drug. The drug
    deaths, in my State, are being driven by fentanyl. I mean, that
    is where we have seen a market--losing a person a day by
    fentanyl. And, as we talk about increasing the efforts on
    treatment--and, obviously, I would not have led the effort on
    CARA with great people like Rob--and prevention, which I think
    is key--and we have not invested enough in that. We need to
    invest more.
        Chief, I know you want that to be your emphasis--and I am
    with you. And, I have my local Chief, Nick Willard, who is the
    Chief in our largest city, Manchester, who is a great guy--and
    he will say the same thing to me.
        But, also, he would say to me, ``I do not want you to
    totally give up on the demand.'' And so, whether it is the
    fentanyl piece or--so I hope we are not saying that we are not
    going to totally abandon our demand efforts--but we need to
    focus more on the treatment. I just want to make sure we
    clarify that.
        Chief Ryan. Yes, thank you, Senator. And, thank you for
    putting me in the hot seat on that issue. Absolutely, it is
    about proportion, right?
        Senator Ayotte. Right.
        Chief Ryan. And so, we have drug control officers, but we
    can be smarter about our enforcement as well.
        Senator Ayotte. And, who we are going after, right? The
    high-level folks.
        Chief Ryan. Right. I will give you an example. We had two
    fatalities and we, quickly put together a case. The drug agents
    and drug cops do great, courageous work out there and we need
    to recognize that. And, in this instance, they put together a
    very good Federal case in a short period of time. And, when I
    was briefed on the search warrant, the arrest warrant, the
    tactical briefing, and outstanding law enforcement work--but, I
    asked two very simple questions after the briefing: ``Tomorrow,
    when we take this major supplier out of the loop----
        Senator Ayotte. Who comes next?
        Chief Ryan [continuing]. ``Do we know who his customers
    are?'' The answer was yes.
        Then, my follow-up question: ``What are we doing
    tomorrow''----
        Senator Ayotte. To get them into treatment.
        Chief Ryan [continuing]. ``To get them into treatment and
    to deal with the public health crisis that we are unwittingly
    creating in our own community?'' We can be smarter about our
    enforcement. And so, now, any tactical plan, in my
    jurisdiction, comes with a parallel social service----
        Senator Ayotte. And, you also like drug courts? That is a
    piece of ours--alternative sentence----
        Chief Ryan. The challenge there, Senator, is when you push
    the button for the criminal justice system, it is incredibly
    complex and difficult to reverse. And, when you take somebody
    suffering from a substance use disorder and put them into a
    complex criminal justice system, we are finding it creates even
    more challenges.
        Mr. Nadelmann. Senator, can I just also say that I agree
    with everything the chief just said there. Canada is dealing
    with a fentanyl crisis right now as well. Mostly, it is stuff
    being imported illegally from China and then pressed into
    pills. And, it is across the country--Ontario, Alberta, British
    Columbia. And, I was just looking at this last night. I saw
    that just recently the Chief Medical Officer (CMO) of British
    Columbia, Perry Kendall, issued a public health emergency--it
    is very rare for somebody to do that. But, it is what you do if
    there is a huge epidemic of a new disease.
        Senator Ayotte. Right.
        Mr. Nadelmann. And, what he said is that the number one
    thing this means for British Columbia is, we are going to treat
    this as we would have with what happened with Ebola--or
    something else. We are going to find out every single thing we
    can find about what is going on in this. Where are people
    getting this thing? Why are they using it? What is the drug?
    His emphasis was, first and foremost, on research--on finding
    out what is going on, what is going on, what is going on.
        My fear here is that we are engaging in interventions
    without knowing what is really going on. If somehow CARA, or
    something else, could allocate money for an army of researchers
    to hit the streets to find out what is really going on, I think
    policy would be so much better informed.
        Senator Portman. I am going to go to the floor to speak on
    this very issue and to talk about what Senator Ayotte was just
    talking about--how do we get this [inaudible]. But, one thing
    about CARA is, there is money in there for research,
    specifically [inaudible]--look at some of these issues that you
    are addressing. And, I think you are right. We need to have
    better information, including on the newest threat of fentanyl
    and how we deal with that. And, David, I was asking you about
    whether it is produced in America, because it can be and will
    be----
        Mr. Murray. Pharmaceutically, yes.
        Senator Ayotte. We saw it with methamphetamine.
        Mr. Murray. Right.
        Senator Portman. This is not going to go away. And, Chief,
    God bless you. Thank you for what you are doing.
        Chief Ryan. Thank you, Senator.
        Senator Portman. You are a leader on this. And, by the way,
    your Governor came to testify on CARA and helped us put
    together the legislation. Charlie Baker did a great job.
        Chief Ryan. Thank you, Senator.
        Mr. Nadelmann. And, Senator, thank you for your leadership
    on CARA.
        Mr. Murray. Senator, could I just make one comment about
    something you put on the table a minute ago, which we never
    quite followed up on? Tobacco is an analogy, because it has
    been successful. The youth-use rates have gone down fairly
    dramatically. There are different profiles--not a drug cartel--
    but, notice what we----
        Senator Ayotte. Different physical impact, too, obviously.
        Mr. Murray. It is, but the rates dropped. I do not want to
    be the guy making a case for stigma. Stigma stands in the way
    of our capacity to get people into treatment and recovery.
        Senator Portman. The perception of risk.
        Mr. Murray. Recovery is----
        Senator Ayotte. It is the perception of risk, exactly.
        Mr. Murray [continuing]. Rescue.
        Senator Ayotte. Stigma.
        Mr. Murray. The Titanic is sinking. OK. Stigma can be
    used--perception of risk--medical risk--was a major factor in
    driving down tobacco use and norms of social disapproval:
    ``Losers do this. What are you doing this for?'' And, making it
    stigmatize people, on the loading dock, out in the rain. But,
    they also--it was not regulation and taxation that did it.
    Those were high and present when tobacco use was high. It did
    not change.
        Senator Ayotte. Well, I also think----
        Mr. Murray. The perception of risk, the stigma, and the
    driving down its acceptability were useful. Can we borrow some
    of those tools with regard to drugs?
        Senator Ayotte. Well, I think that what we decide to focus
    on, nationally, sets the tone, right? So, to the research
    point, whatever our national campaign is, let us make sure that
    we are thoughtful about it--that we research and figure out
    what are the most effective ways to get this message to,
    obviously, reduce consumption and the number of people who
    start, in the first instance. I am not an expert on this. I do
    not know the answer. But, I know we are pretty smart people.
    And, we are also a very media-centric society--whether we like
    it or not.
        So, it seems to me that there is a role in this. CARA,
    basically, puts in place the opportunity to do this. It does
    not say how to do it. It says it has to be evidence-based
    research--and to the point of what your Governor did. Here is
    where we are, at a national level, in terms of what tone we are
    going to set here.
        Chairman Johnson. We held a hearing--and we actually
    addressed the difference between the success we had in tobacco
    and why the media campaign has not been particularly
    successful, in terms of drug demand. One of the conclusions--
    one of the statements was that we have not been graphic enough,
    in terms of communicating that this is squalor. There is
    nothing glamorous about it.
        Senator Ayotte. But, also, the other conclusion that came
    out of that is that the tobacco campaign was not a totally
    government-centric model. You actually engaged--because, if you
    look at the tobacco settlement, it was really done from a
    separate organization. Sometimes, the government-driven model
    is going to put you in a box. What we want to do is have the
    right media campaign that is actually evidence-based--what
    needs to be done--but is not having all of these--it gets
    complicated, as you know, with bureaucracy.
        Mr. Nadelmann. Yes, I think you are right about the public-
    private partnership. Also, just a few other things about the
    tobacco thing.
        First of all, unfortunately, the evidence actually shows
    that the single most effective way of decreasing adolescent
    tobacco use is through higher taxation. The other factors that
    David mentioned are also variable.
        But, I want to just make two other points here. The other
    thing we can say about tobacco--nicotine in the cigarettes--
    smokable particle matter--is, essentially, there is no other
    substance on Earth which is simultaneously so addictive and so
    deadly. Right? We know that if you smoke cigarettes for a month
    or so, you have a very good chance of becoming addicted to it.
    And, if you smoke cigarettes for years, you have what?--a 30-
    percent chance of dying prematurely, by 7 to 10 years. It is
    serious. And, we know that the harms associated with
    cigarettes--not nicotine, in the form of vaping. That is a very
    different situation that dramatically reduces the risk. Butm
    cigarettes are incredibly [inaudible].
        The second thing we know about cigarettes is also very
    interesting. All of the studies--when you interview heroin
    addicts and you ask them, ``What is the toughest drug to
    quit?'', do you know what the majority of heroin addicts say?
        Senator Carper. Cigarettes.
        Mr. Nadelmann. Cigarettes. Exactly.
        Now, it is also worth noting that we have actually cut
    cigarette addiction--cigarette use in America by over 50
    percent. It has been one of the greatest drug abuse prevention
    successes in American history. And, you know what? We did it
    entirely without threatening anybody with jail, incarceration,
    tobacco courts, or anything like that. We did it through
    education, through prevention, and through the provision of
    real information to young people and adults. Stigmatization did
    play a role. Higher taxation played a role. But, understand,
    our single greatest success in America, in reducing addiction
    to a deadly drug, was done entirely without reliance on the
    criminal justice system.
        Chairman Johnson. Yes.
        Mr. Murray. Which makes it perverse that we are enabling
    more marijuana----
        Senator Carper. Let me just----
        Mr. Murray [continuing]. More widely available, the
    pathogen.
        Senator Carper. Let me just jump in, if I can.
        Chairman Johnson. Sure.
        Senator Carper. I apologize for being in and out. One of
    our former colleagues, George Voinovich, a great Governor and a
    great Senator, has passed away. I am trying to figure out how
    to get my wife and I to the funeral Friday morning, so I
    apologize for being in and out.
        When George Voinovich and I were Governors together, I was
    asked to be the founding Vice Chairman of something called the
    ``American Legacy Foundation,'' which focused on how we
    convince young people who are smoking to stop and how to
    convince young people who are not smoking not to start. And, we
    used a multilayered approach, but a big part of it was working
    with young people, throughout the country, to develop a message
    to take to folks who were smoking already--young people who
    were already smoking or were thinking about it, and some of the
    success you talked about, I think, is directly attributable to
    the ``American Legacy Foundation.'' We got 41 billion out of
    the tobacco settlement money, between the States--50 States--
    and the tobacco industry--and with the help of some great
    advertising agencies, a lot of kids, and the States, we
    developed a multilayered media campaign called ``The Truth
    Campaign.'' Hard-hitting. Very hard-hitting. If you have ever
    seen these commercials, you remember them: a woman talking
    through a hole in her throat; huge trucks--tractor-trailers
    pulling up in front of tobacco headquarters, and people are
    pulling out hundreds of body bags and laying them out; and
    bullhorns talking to the tobacco industry people inside of the
    building. Very hard-hitting and very effective.
        The woman who helped us put that together, Cheryl Healton,
    who is now a dean, I think, at New York University (NYU) and
    doing good work again--we have involved them, and her folks, to
    help us on another truth campaign--and this is with regards to
    potential immigrants coming in from Honduras, Guatemala, and El
    Salvador--as they look, it is not everything it is painted to
    be--getting here, the United States, is not going to be easy.
    So, we are using that variation as well. We are creating,
    through the Department of Homeland Security (DHS), a somewhat
    similar campaign to counter violent extremism (CVE), by
    creating a partnership with the Muslim community across the
    country, and asking young Muslims to help us develop the same
    kind of truth campaign.
        If you look at the meth campaign, in Montana, which had
    success for a while--I think, maybe, it stopped, and that is
    why it did not continue. But, talk to us about this kind of
    approach, particularly, for young people who are thinking of
    trying heroin or are thinking of trying opioids--to have that
    countermessage. What role is there for this approach in this
    multilayered approach, which includes prevention and a whole
    lot of other things?
        Mr. Nadelmann. Senator, I do not want to--I am skeptical. I
    think that a basic message for young people about the risks of
    these drugs--and remember the old days--the Partnership for a
    Drug-Free America, they were sort of obsessed with the
    marijuana issue--and that was not the real problem. Alcohol was
    a major problem--and tobacco. Alcohol and tobacco--the much
    bigger problems. Now, we have the problem of diverted
    pharmaceutical drugs--huge numbers of young boys are being
    prescribed Ritalin and are sharing it with one another. In many
    communities in America, more young people are going to use
    Ritalin--either prescribed or diverted--than are actually going
    to be using marijuana.
        The other thing we found is that even as marijuana use went
    up and down and up and down over the last 30 years among
    adolescents, when the question was asked, ``Is marijuana easy
    to get,'' 80 percent, consistently, throughout the last 30
    years, said that it is easy to get.
        So, I think that, on the drug prevention education thing,
    we need to focus on the bottom line of keeping kids safe. The
    message ``Do not use, do not use, do not use--abstinence
    only,'' that is a good starting spot. My message to teenagers
    is, first, ``Do not do drugs.'' My second message is, ``Do not
    do drugs.'' My third message is: ``But, if you do do drugs,
    there are some things I want you to know, because my bottom
    line, as your parent, who loves you to death, ultimately, is
    not did you or did you not. My bottom line is: Are you going to
    come home safely at the end of the night, grow up and make me
    healthy grandkids. That is my bottom line.''
        So, I am focusing on safety. One of the things about
    marijuana--none of us want our kids----
        Senator Carper. I am going to ask you to stop. I appreciate
    everything you are saying, but I want to make sure I hear
    from----
        Mr. Nadelmann. I am sorry. OK.
        Senator Carper. Thank you. I appreciate your passion.
        Chief Ryan. Senator, if I may--and I wish I had the
    Wheaties he had this morning.
        I agree, but, we have to fold the medical profession into
    this conversation in a meaningful way. We are looking at people
    in our PAARI program. About 80 percent started with a
    prescribed opiate, following a traumatic injury. And, here is
    the pathway that we are seeing in metropolitan Boston.
    Opiates--a 30 milligram (mg), or 80 mg tablet, with a 90-day
    prescription. After 90 days, they are buying them on the
    street. A 30 mg tablet goes for $30, and an 80 mg tablet goes
    for $80. Quickly, they have a $400-, $500-, or $600-a-day
    habit. For somebody, who, before, would never have put an
    injectable narcotic into their arm, now it becomes a matter of
    economics. A $15 bag of heroin, or $500 worth of pills. They go
    to heroin.
        Chairman Johnson. Let me just interrupt quickly. Is that an
    agreement that this is really 80 percent started by----
        Mr. Nadelmann. I do not know. I do not know if it is 80
    percent. I know that is a growing issue and that people are
    trying to manage pain with other forms of it, but I do not----
        Chief Ryan. In the population we are serving, that is
    what--and there is self--I would agree. You mentioned this
    earlier, Dave. This is self-reported.
        Mr. Murray. The CDC's most recent----
        Chairman Johnson. Again, I really want to get to him, but
    just very quickly.
        Mr. Murray. Certainly. I am sorry. The issue is about who
    initiated with either heroin or prescription opiates. And,
    historically, people who are heroin users, initiated with
    heroin, but are poly-drug users and are at 15-times greater
    risk if they were adolescent marijuana users. But, today, the
    most recent initiation numbers--not all of those are heroin
    users--those who are starting are inclined to start with
    prescription opiates. That is the three out of four. The last
    few years, those who have initiated have a tendency to start
    with prescription opiates first.
        Chairman Johnson. That is the new phenomenon. OK.
        Chief Ryan. So, the point is--and we are starting to see--
    the University of Massachusetts Medical School invited me to
    speak at their in-service training for their physicians--a cop
    talking to physicians in their in-service training. So, I think
    it is some of those things. And, we are starting to fold in the
    medical profession, in a meaningful way, around prescribing of
    opiate painkillers.
        Dr. MacDonald. Looking at the demographics at our clinic,
    we have selected a population that has developed an entrenched,
    long-term street heroin dependency. It is the separation from
    family at a young age that is appallingly common. So, I am not
    sure how you are going to prevent----
        Chairman Johnson. I actually want to start asking
    questions. I have not done so. I am going to ask questions, OK?
    No statements. Questions.
        I remember watching a documentary on heroin addicts and,
    although the words were different, when they asked the
    question, ``Do you remember the first time you ever took
    heroin?''--the expression on their faces were almost identical.
    It was just kind of, ``Oh, yes. It was like I finally belonged
    or I was finally loved.'' According to testimony, there are
    about 3 million Americans--about 1 percent of our population--
    doing the hard drugs in some shape or form. There are 27
    million people doing illegal drugs--that is a little less than
    10 percent of our population. Has that changed one iota in 30
    years, 40 years, or 50 years--I mean, significantly? Or has
    that just been pretty constant? Just respond really quickly.
        Mr. Nadelmann. Yes, I mean, it appears to be fairly
    constant. It varies, somewhat, by drug. I will just say this:
    With alcohol--right?--roughly 10 percent of alcohol consumers
    consume over half of the alcohol----
        Chairman Johnson. Again, I am talking about drugs, right
    now.
        Mr. Nadelmann. No, I am making an analogy, here. The same
    thing is, probably, true of most other drugs as well--that it
    is the minority of each of the drug users who consume the
    majority of the drugs.
        Chairman Johnson. Again, 1 percent of the population is
    doing hard stuff and a little under 10 percent is doing
    marijuana and--is that----
        Mr. Murray. Taking a historical look, one of the problems
    is that the data sets do not go back far enough to tell us
    about continuity. We can go back to the mid-1970s--and that was
    the highest point of drug use in America--in 1979 through 1985.
    Compared to that period, we are down at least 35 percent, so
    there has been a major gain, over time, with respect to youth
    use that then was carried as a lifetime pattern. We have made a
    difference. It proceeds by sharp decreases and then, gradually,
    starts picking back up. We forget that it is intergenerational.
    We turn off the switch, and a new generation comes in, and it
    comes back at us. We have to continue--it is like using an
    antibiotic. You have to continue in a sustained fashion.
        We have made major gains. We have seen periods when it has
    been sharply reduced, and we look for the mechanisms that we
    had--the tools. Media campaigns were part of it. Supply
    reduction was part of it. Normative participation by American
    communities was part of it--and we made a difference.
        Chairman Johnson. So, again, let me ask----
        Mr. Murray. The answer is yes, we can do it.
        Chairman Johnson. Do you agree that we have gone up and
    down and that there have been gains made, for whatever reason--
    and then, it has kind of come back?
        Mr. Nadelmann. Yes, Senator--it depends what you are
    measuring, right? I mean, 1980 was the high point of the number
    of Americans who said they had used an illegal drug. Then
    again, by 1990, the total number of Americans saying that they
    had used an illegal drug had dropped by half--so you would say
    that was a success.
        On the other hand, in 1980, nobody had ever heard of crack
    cocaine. By 1990, it was a national epidemic. In 1980, there
    were no cases of drug-related AIDS. By 1990, hundreds of
    thousands were infected. In 1980, we had 50,000 people behind
    bars. In 1990, a quarter of a million people--or close to
    that--were behind bars. So, it really depends on what you are
    measuring. And, I think that focusing on the number of
    Americans who say yes to a pollster--saying ``I used an illegal
    drug last year,'' is far less important than looking at the
    cumulative harms associated with that drug.
        Chairman Johnson. Again, my point is--again, as----
        Mr. Nadelmann. You are going somewhere----
        Chairman Johnson. No, as a business guy, in manufacturing,
    you have to solve a lot of problems. So, you have to, first,
    understand what is the truth, what is the reality, and what are
    the numbers. Because I have a sense that we have spent $1
    trillion on the ``War on Drugs,'' and we are just not winning
    it.
        Mr. Murray. Right.
        Chairman Johnson. And, we are funneling tens of billions of
    dollars to some of the most evil people on the planet, in these
    drug cartels--and I am not sure that is, necessarily, a good
    thing.
        I think it is interesting--the way you are saying we need
    research. My point of that little story about the heroin
    addicts--those 3 million Americans--are they treating their own
    depression in some way, shape, or form? I mean, do we have any
    sense of--yes, once you are addicted, you are addicted and you
    are going back to the heroin, or whatever, to feed that
    addiction. Why are they first starting it? Do we have some
    sense of that? Is it, literally, treating depression? You
    talked about alienation from family. Well, that leads to
    depression as well. Do we have any kind of research--any kind
    of sense of why people first take it when--let us face it:
    people do realize drugs are dangerous, right? Although, in the
    media, sometimes, it is viewed as pretty glamorous.
        Mr. Nadelmann. Well, Senator, you realize that, for many
    people, the first time they take heroin, it is, ``Yuck.'' They
    throw up and they do not like it--whatever. There is a
    percentage----
        Chairman Johnson. Which was different than that
    documentary.
        Mr. Nadelmann. No, but for people who end up getting
    addicted to heroin, those are, oftentimes, the ones who liked
    it that first time. Then the question is: Why? Right? We have a
    sort of myth underlying the notion of a drug-free society,
    which is that all of us emerge as perfectly balanced chemical
    creatures from our mothers' wombs. That is not true. Some of us
    may emerge with an undersupply of endorphins--our own
    biological natural opioids--and that may incline us to drug
    addiction later on.
        Chairman Johnson. I had a spinal tap--and, I think, it was
    Vicodin. I took one and, literally, woke up kind of gasping for
    air. I never took another one. But, other people, then--what
    you are saying is, other people take--what is Vicodin, anyway?
    Is that an opiate?
        Mr. Murray. It is hydrocodone.
        Chairman Johnson. So, that is an opiate.
        Mr. Murray. Hydrocodone is a Schedule II opiate----
        Chairman Johnson. So, the fact of the matter is, different
    people react differently.
        Mr. Nadelmann. Exactly--to all drugs--to marijuana, to
    alcohol, to opiates, and what have you.
        Mr. Murray. There is a body of literature on the risk
    predisposing factors for drug use--and it is not a magic
    bullet. You cannot say that it is just those people and not
    others. Genetic predisposition--yes, it is a big one. And, the
    reaction is strikingly more vulnerable if they are presented
    with a challenge from the drug itself.
        Early childhood experience, including prenatal behavior--
    low birth weight children, and children from lower
    socioeconomic perspectives--where the mother was a substance
    user--they are born at risk--low birth weight, with
    extraordinary risk. As they grow up in contexts where they are
    challenged by drugs early in life, then the risk skyrockets. If
    they can hold off until they are age 20, 22, 23, or 24, they
    can be protected for life. There is a study of risk
    availability and comorbidity.
        Chairman Johnson. In the hearing in Pewaukee, we had some
    powerful testimonies. I think one of the most--again, I am not
    saying this is fact, but, one of the witnesses said that, on
    average, first-drug use, in whatever form, starts somewhere
    around the age of 11 or 12?
        Mr. Murray. In some communities.
        Chief Ryan. And, David, is it not true that, if you can
    delay that experimentation----
        Mr. Murray. Yes.
        Chief Ryan [continuing]. The risk of addiction goes down--
    --
        Mr. Murray. As the brain matures, if you can hold them
    through that window of vulnerability, from, basically, age 11
    until age 22, you have a huge capacity to protect them for
    life.
        Chairman Johnson. In testimony before this Committee, we
    had General John Kelly, former head of the U.S. Southern
    Command (SOUTHCOM), testify that we have visibility for about
    90 percent of drug traffic. We just do not have the
    interdiction capability. I think one of you said that, where
    there is demand--I agree with this--where there is demand, the
    supply is going to meet it.
        Further in testimony we heard that in inflated dollars--in
    1980, a gram of heroin cost $3,200. In the streets of
    Milwaukee, we are hearing reports of $100 a gram or $10 a dose.
    And, you talked about that--the difference between the cost of
    an OxyContin pill and a heroin addiction.
        Mr. Nadelmann. Senator, I think you can find other former
    directors of SOUTHCOM who would say that no amount of money we
    spend on interdiction is going to keep this stuff from really
    coming in. Right? That, whatever we spot, they will find
    another way to do it.
        Chairman Johnson. When we were down in Central America,
    they were talking about--these are the Drug Enforcement
    Administration (DEA) guys down there, saying, ``Yes, we
    redirected the flow from Colombia, through the Caribbean, up to
    Miami, and just, basically, redirected it into Central America.
    And, truthfully, I mean, the folks there were also saying that
    their goal was to redirect it someplace else.
        Mr. Nadelmann. Back to the Caribbean. Assistant Secretary
    William Brownfield----
        Chairman Johnson. Again, not stopping it, but redirecting
    it.
        Mr. Nadelmann. Assistant Secretary Brownfield just said,
    recently, he said, ``Caribbean, you better watch out,''
    because, the more successful we are in pushing it out of
    Central America, it is going to push it over there. It is not
    going to make any difference for the U.S. addict, who is
    suffering, which route it is coming by.
        Mr. Murray. Senator, I think that having worked on this,
    specifically, for 13 years with the ONDCP's Office of Supply
    Reduction, with SOUTHCOM, and with the Joint Interagency Task
    Force (JIATF's), there is a narrative of futility: ``Nothing
    has ever worked. It is cheaper than ever. And, it just comes
    another route--trains, boats, or planes. It gets in here. What
    are you going to do?''
        Well, there is something you can do. And, you have to have
    a chain of interventions that are staged and that work with
    each other. And, you begin in the source country, by
    eliminating the production. You drive it down 75 percent. At
    the same time, you come in with alternative development
    strategies, establishing the rule of law, in Colombia----
        Chairman Johnson. But, look at what is happening--again,
    look at the reality. We do not control Colombia. Look at what
    is happening in Colombia. There is different leadership.
        Mr. Murray. We went to legalization. And, Colombia and
    Mexico both called and said, ``What are you guys doing?'' And,
    when people said, ``Well, we are leading out on this. We are
    making it recreational,'' they said, ``We have to save
    ourselves.''
        Mr. Nadelmann. Right. And, now, Canada is about to legalize
    marijuana. And, once California votes to legalize it this
    November, Mexico is going to open up a significant debate.
    President Enrique Pena Nieto was just at the United Nations
    (U.N.), talking about----
        Mr. Murray. But, interdiction is only part of the----
        Mr. Nadelmann. Senator, I have to just say that the
    evidence powerfully shows that the overwhelming investment in
    interdiction has been money down the drain. And, when you look
    at the alternative, which is a focus on the public health
    approach and on the demand approach--you look at what Europe
    and Australia and other countries have done--where the large
    majority of resources have gone into a public health approach--
    not into interdiction--and what you see is, they have been,
    dramatically, more successful in keeping drug-use rates lower
    than us--as well as keeping HIV, hepatitis C, addiction,
    overdose, and all of those low.
        Chairman Johnson. The fact of the matter is that, now, in
    your testimony, we are laying it out. For a couple of decades,
    now, different countries and different cities have taken
    different approaches. Let us face it: we have an experiment
    going on here, in America, with legalization--full legalization
    in Colorado, Oregon, and Washington. I was with a group of
    Chiefs of Police in Wisconsin, talking about a host of issues.
    But, I brought this one up, because they just attended a
    national association meeting of Chiefs of Police. I just asked
    them, ``Is anybody reporting on this?'' Again, this is just
    anecdotal, but the response was that this has been a disaster.
    I do not know. Again, that is just a completely anecdotal
    comment, but what are you hearing? Are you going to those same
    type of national meetings? What are you hearing, in terms of
    what is happening in Oregon, Washington, and Colorado, in terms
    of legalization and how it is affecting policing?
        Chief Ryan. Yes, I mean, there are a lot of anecdotes, out
    of Colorado, of people getting their doctor's letter for
    athlete's foot to get medical marijuana and these things. But,
    you make a valid point. Much of it is anecdotal. I think there
    is some research that Ethan talked about--because, what I worry
    about is, the quality of life around these marijuana
    dispensaries and how the presence of a dispensary will
    compromise the quality of life by bringing a demographic into a
    neighborhood that would not otherwise come to that
    neighborhood.
        Mr. Nadelmann. But, there is actually research on that,
    showing no increase in crime or any decline in quality of life,
    in places where medical marijuana--in this country----
        Chief Ryan. I do not know if that is true.
        Mr. Nadelmann. By the way, it is also similar with
    methadone maintenance clinics. There is a huge ``not in my back
    yard'' (NIMBY) fear about having a methadone maintenance
    clinic. But, there is extensive research showing, once again,
    no diminution in quality of life or any increased criminality.
    I would be happy to send the studies about the issues--the
    public safety issues around there. And, I think it is
    worthwhile mentioning that you have the director of the High
    Intensity Drug Trafficking Area (HIDTA) in Colorado, who is,
    basically, saying that it is a relatively small number of
    crimes--he is quoted as saying that. When you look at overall
    crime in Denver, there are so many reasons it rises, and falls.
    The ``2016 Colorado Department of Public Safety Report'' notes,
    ``The total number of industry-related crimes has remained
    stable and makes up a very small proportion of overall crime in
    Denver.'' The most common problem is burglary. Burglary. And,
    that is the issue that Governor John Hickenlooper and others
    have asked Congress to fix, because that is that the legal
    marijuana industry has to be cash-dependent, because the
    marijuana industry is not allowed to engage with federally-
    registered banks.
        Chairman Johnson. Tom, feel free to hop in.
        Senator Carper. Well, thank you.
        Chairman Johnson. I had not asked any questions.
        Senator Carper. You have not?
        Chairman Johnson. I had not.
        Senator Carper. I want to come back to the issue of
    tobacco. And, the Chairman has heard me say, many times, to
    ``find out what works, do more of that; find out what does not
    work, do less of that.'' But, before I do that, I want to
    mention CARA, the legislation that we have been talking about,
    here, in this room, in the Senate, and in the House for a good
    part of this year.
        We have, as you know, in terms of funding programs a two-
    step process. We authorize programs and we authorize spending
    levels, and then we come back in and we appropriate money. I
    have a friend, who is a pastor of a church in Wilmington,
    Delaware. And, he likes to say to his congregation, ``It is not
    how high we jump up in church on Sunday that matters. It is
    what we do when our feet hit the ground.''
        It is one thing for us to pass authorizing legislation that
    would authorize programs to address this situation--opioids and
    opioid addiction. It is another thing to make sure that we have
    the resources to fully benefit from the programs we are
    authorizing.
        One of the meetings I just went out to, in the anteroom,
    was with a major insurance company. And, they cover a multi-
    State region, here in the Midatlantic. And, I told them what
    our discussion was dealing with here. And, they mentioned--they
    do business in Pennsylvania. They mentioned that the Governor
    of Pennsylvania has called for creating, across the State, 40
    different centers for treatment. And, the question is: How do
    you pay for that? And, I do not think anybody has figured that
    out. But, that was their idea.
        In terms of the policies and the coverage that they offer,
    it is a lot different, today, with respect to opioids. They
    talked about the idea--one of them said, just anecdotally, that
    someone that they knew had oral surgery and got a 30-day
    prescription for opioids. How crazy can we be?
        So, my sense is that--and this conversation, today, sort of
    bears it out--there is not any one silver bullet. I like to say
    ``There are a lot of silver BBs. Some are bigger than others.''
    And, this is not just on the Federal Government. This is not
    just on State and local governments. This is not just on
    insurance companies or on individuals--this is a shared
    responsibility. And, part of what our challenge is, is to
    figure out what the Federal responsibility is and how we can
    use the Federal actions to, maybe, leverage more effective
    action on the part of States, local governments, nonprofit
    organizations, and the health care delivery system.
        I want to come back to tobacco. ``Find out what works, do
    more of that.'' And, Dr. Nadelmann, I think you mentioned that
    nicotine--tobacco--is among the most addictive substances that
    we deal with. Yet, we have had pretty remarkable success in
    slowing down the growth of tobacco addiction and, actually, I
    think, reducing it--particularly among young people. And, it
    has been sustained. It is not like a one-trick pony--one-night
    stand. It has been sustained for about 20 years.
        Mr. Nadelmann. Yes.
        Senator Carper. About 20 years. What can we learn?
        Mr. Nadelmann. I think what we learned is that the tobacco
    education was remarkably honest and truthful. It reported on
    real risks and real dangers, and kids got it. And, they also
    knew people who were dying of cancer--and they could see it. I
    think they got it.
        I think a similar sort of campaign could, potentially, work
    with opiates. The difference is that you sometimes need
    opiates. Right? So, you do not need tobacco. You just have to
    say, ``Do not do it. Do not do it. Do not do it. It can kill
    you,'' and what have you.
        With opiates, the message has to be more nuanced, which is
    sometimes ``this is a useful medication, but, understand: if
    you get this for oral surgery, you are going to use it for 3 or
    4 days, maybe, and then no longer after that. Understand the
    risks. Understand what is going''--so the education has to be
    more sophisticated in that respect.
        I think the issue with marijuana is that kids look around
    and they know 40 percent of their peers are doing it by the
    time they are 17-years-old to 18-years-old. They know that some
    have a problem. Some are clinical--waking and baking--getting
    up in the morning and smoking marijuana and not doing well.
    And, they see that those kids are foolish. It is like drinking
    and going to school.
        But then, they see other kids, who are graduating with
    honors--going to good schools. They see adults who are
    successful and they understand that the anti-marijuana
    fanatical message we had is not truthful. When the government
    gives that message----
        Senator Carper. Just hold it right there. I just want to
    make sure----
        Mr. Nadelmann [continuing]. They lose credibility.
        Senator Carper [continuing]. We hear from the other
    witnesses, please. What can we learn from tobacco?
        Mr. Murray. Thank you. I appreciate it. It is a good
    question. I would be remiss, if I let this hearing end without
    saying what I think is a really critical message. Then I will
    address directly the----
        Senator Carper. Just do it briefly, please.
        Mr. Murray [continuing]. The misinformation that marijuana
    is not dangerous and that we have not been confronted with an
    enormous onslaught of media support that has, actually, been
    totally counterproductive for what youth are experiencing--and
    that the risks are very great, which they are--for those
    genetically predisposed--catastrophic--and that is a phrase
    used by the World Health Organization (WHO) in an article by
    the National Institute on Drug Abuse (NIDA), in the New England
    Journal of Medicine. ``Catastrophic''--and that the onset in
    early adolescence of high-potency marijuana use has the
    prospect of triggering a psychic break, depression, and
    schizophrenia--prospects that are truly damaging. We are
    running an experiment, with our youth--and they are being hurt.
    They are being hurt, in Colorado. This is a qualitatively
    different drug. Anyone who denies that or who refuses to look
    at that evidence is misleading the Nation and misleading
    themselves----
        Senator Carper. OK. Thank you.
        Mr. Murray [continuing]. And, we are sorry. Now, here is
    the most critical thing I want to deliver. We have looked
    carefully at----
        Senator Carper. The most critical thing, for me, is for you
    to answer my question.
        Mr. Murray. Therefore--oh, I am sorry. Dr. Nadelmann had
    suggested that we had offered----
        Senator Carper. What can we learn from our success, with
    respect to tobacco? That is my question.
        Mr. Murray [continuing]. And, he suggested that we had not
    offered a calculated risk appreciation--that it was craziness
    and reefer madness. I was suggesting that, no, in fact, we
    need, precisely, to message the degree of risk and not have
    snarky, sarcastic headlines in the ``Washington Post'' about
    how using marijuana is like not flossing. No, it is not that.
    In fact, it is misleading and irresponsible to make those kinds
    of arguments.
        Here is the critical thing, though----
        Senator Carper. Just be very brief, because I want to hear
    from the other witnesses.
        Mr. Murray. Yes, Senator, I will. Sorry. The black market
    has not withered away. It has not disappeared. All of the
    things that we are doing, with regard to recreational, legal
    marijuana--and efforts to leverage media, and so forth, on how
    to--the black market has gotten stronger. There are people
    flooding this country with poisons that are killing Americans.
    And, they are stronger, more embedded, richer, more corrupt,
    and more penetrating in their reach and scope than any that I
    have ever experienced. And, they are getting stronger. They are
    running in parallel----
        Senator Carper. OK. Mr. Murray, please hold your comments.
    Thank you.
        Dr. MacDonald, the same question. What can we learn from
    our success, with respect to tobacco?
        Dr. MacDonald. We have excellent treatments. It works. At
    our clinic, 90 percent of the folks smoke. They are also heroin
    users. When they come to us, they are interested in having
    better health. They are sick because of the severity of their
    smoking. They have chronic disease, because of their smoking.
    And, in care, we are able to engage them and decrease their
    smoking use. Anybody can quit smoking.
        Senator Carper. Alright. Thank you. Chief.
        Chief Ryan. Just very briefly--David makes a valid point
    about using stigma as leverage to try to help address the
    opiate issue, as we did with tobacco. My concern there is, if
    we had a magic wand, today, and we stopped any new person from
    becoming addicted to opiates, we still have a whole generation
    of people that have to run the course. And, the stigma is what
    is preventing--well, there are a number of things preventing,
    but, in my opinion, one of the major factors preventing people
    from seeking treatment is the stigma associated with opiate
    addiction and heroin addiction.
        Senator Carper. Alright. Thank you.
        Chief Ryan. I would caution against using stigma as
    leverage in this epidemic.
        Mr. Nadelmann. I agree. I think stigma did play a positive
    role with cigarettes, but it is not just with heroin addiction.
    We even have stigma with methadone treatment. One of the
    problems you have is that it is so stigmatized that people do
    not want to send their kid, who is addicted to opiates, to get
    methadone or buprenorphine. I have met people who are on
    methadone maintenance, and they are on it for decades. It is
    like a diabetic being on insulin. And, they are running a
    business, having a family, paying taxes, and doing everything
    right. It is methadone. They are not addicted to it. It is just
    their daily medication. And, I say, ``Why do you not speak
    publicly about this? Be a role model.'' They will say, ``Ethan,
    I cannot.'' I say, ``Why not?'' They say, ``Let me tell you
    something. If I go to work one morning and I am exhausted,
    because my kid was up all last night, and I put my head down on
    the table to take a nap, people are going to say, `Oh, poor
    boss--poor Joe, he must have been exhausted. Something must
    have happened with his kid last night.' If they knew that I was
    a methadone maintenance patient, the first thing they would be
    thinking is, `He is nodding out.' ''
        So, I think we have to fight the stigma--not just with
    illicit drugs, but even with the treatments, themselves.
        Senator Carper. Alright. Thank you.
        Chief Ryan. Another good analogy, Senator, is seat belt
    usage.
        Senator Carper. Is what?
        Chief Ryan. Seat belt usage. Highway safety bureaus, for
    many years, were using billboards as well as taking young
    ladies and showing scarred faces: ``This is what will happen to
    you if you do not wear a seat belt.'' That worked.
        Senator Carper. You know what else worked? Convincing
    legislators--State legislators--to pass laws that mandated seat
    belt usage.
        Chief Ryan. Right. But, I would urge caution in this
    situation.
        Senator Carper. Alright. Thank you.
        Chairman Johnson. And then, that kind of gets back to that
    point, in our hearing, where we had the one witness talking
    about the effectiveness of tobacco and saying that the reason
    why it has not been effective with drugs is that we just have
    not shown the truth--the graphic nature of this is not good.
        I want to talk to the doctor, a little bit, about the
    difference in chemistry between these drugs. What is the
    difference between a synthetic opioid and heroin?
        Dr. MacDonald. They are all opioids. They all have
    similarities. And, trying to distinguish one opioid from
    another--they all have potential benefits and they all have
    ultimately, risk.
        Chairman Johnson. My point is, why has one been legal--or a
    class of them legal--and another one illegal?
        Dr. MacDonald. Well, I will take diacetylmorphine--
    prescription heroin--for example. It is used as a pain
    medication, in many jurisdictions, in Europe. It does not have
    the same stigma that it does in North America.
        Chairman Johnson. How close is it, chemically, to natural
    heroin?
        Dr. MacDonald. It is very close to morphine and
    hydromorphone--diacetylmorphine, there is just----
        Chairman Johnson. So, we have one form of heroin that is
    produced artificially that is, basically, identical to heroin.
    That one is legal, because it is medically controlled versus--
    --
        Mr. Nadelmann. Right. The way to think about this is, both
    in Vancouver and also other places, they did a couple of
    studies. They took long-term illegal heroin users, and they
    tried, in a controlled, double-blind study--this group got
    illegal heroin--I mean legal heroin and did not know it. The
    other group got morphine. They could tell the difference. This
    group got injectable methadone and the other got heroin--they
    could tell.
        You know what they did? Half of the group got
    pharmaceutical heroin. The other half of the group got
    pharmaceutical Dilaudid, which is what people get prescribed.
    It turns out, long-time heroin users could not tell the
    difference, in the effect--how it felt between heroin and
    Dilaudid.
        Now, what does that mean? It, potentially, means that, if
    all of the hundreds of thousands of Americans in hospitals each
    year, were being given heroin instead of Dilaudid without
    knowing it, it would have the same effects. Nobody would know
    the difference. It means, alternatively, that if you would snap
    your fingers and all of the people in the world consuming
    illegal heroin were suddenly consuming Dilaudid, nobody would
    know the difference.
        It means if you were to spell heroin D-I-L-A-U-D-I-D or
    spell Dilaudid H-E-R-O-I-N, it would, essentially, be the same.
    Right? And, I think we need to understand that, part of what
    makes heroin what it is that it is called ``heroin.'' The
    bottom line is, it is diamorphine. It becomes morphine when it
    enters the human body. It is a legitimate painkiller. So, part
    of it is the cultural perception of the thing and who is
    perceived to use it.
        Chairman Johnson. Let me ask about the potency of
    marijuana. What has been the trend, from the 1970s to today?
    And, can you address the problems associated with the far
    greater potency? Doctor, can you speak to that?
        Dr. MacDonald. It is certainly not the same drug it was 30
    years ago. It is more dangerous.
        Chairman Johnson. Which speaks to what Dr. Murray was
    talking about.
        Mr. Murray. I am still reeling from what we just heard
    about diacetylmorphine. I think that that----
        Mr. Nadelmann. And, Dilaudid?
        Mr. Murray. You asked, specifically, Senator--and I will
    try to add hue to this. The potency of marijuana--as best we
    can tell from the seizure data from the DEA, in the 1980s--was
    around 3 percent Tetrahydrocannabinol (THC), which is the
    intoxicating element. It rose, steadily, year after year, about
    1 percent a year, until about 2010, when it approached,
    nationwide, around 12 percent to 14 percent THC--sinsemilla--a
    more potent drug.
        Since Colorado--and recreational legalization--the
    concentrates and new products--the ``shatter,'' the ``butter,''
    and so forth--that are extracts of just THC approach 70 percent
    to 90 percent pure THC. And, THC is then embedded in gummy
    bears, drinks, and candies being consumed at far higher rates.
    The rate of change of that kind of bolus to the brain is so
    striking that the risk of dependency and addiction seems to be
    elevated. The impact on psychotic breaks seems to be greatly
    elevated. And, the exposure, at a relatively early age, to a
    drug that is now 70 percent to 90 percent potency--averaging,
    nationwide, around 14 percent to 15 percent, for all marijuana
    markets combined, together--as opposed to the marijuana that
    most people know from previous generations--and, unfortunately,
    it is the marijuana that is reflected in the literature that
    has taken a longitudinal look at use of those exposed in New
    Zealand, in Canada, or in the United States--they were
    consuming 3 percent to 4 percent THC at age 17. It is a more
    dangerous----
        Chairman Johnson. So, is there any dispute about what Dr.
    Murray was talking about there, in terms of the potency and the
    danger of that?
        Mr. Nadelmann. Yes. First, let me agree on two key points.
    The potency of marijuana has increased. And, second, when he
    refers to something called ``shatter,'' which is a sort of
    crack-like version of marijuana, I am also deeply concerned
    about consuming marijuana potency that is at 70 percent or 80
    percent. That said----
        Chairman Johnson. But, it is the truth that that is moving
    in that direction--and it is legal.
        Mr. Nadelmann. Yes. But, it is important to--well,
    ``shatter?'' I do not know what is going on with ``shatter.''
        Mr. Murray. You call it legal--sir, it is smuggled into
    every State in----
        Mr. Nadelmann. Yes, smuggled. So, therefore, prohibition
    has been a failure, in that case. I think it is important to
    understand that doubling or tripling the potency of the THC, in
    marijuana, does not double or triple the high. I think it is
    also--and let me just be frank here, Senator. I have been an
    occasional marijuana consumer, for the last 40 years--since I
    was age 18. Right? I remember when I was 18, there were things
    called ``Acapulco Gold,'' ``Panama Red,'' and ``Thai Stick,''
    where one hit would get you high. There was a lot more low-
    quality Mexican marijuana around, but there was high-potency
    marijuana back then.
        Today, there is other high-potency stuff. Do you know what
    you do? You smoke less of it. OK? And, I think that is
    important to understand about the relative dangers.
        Chairman Johnson. Doctor, can you speak to the medical
    reality of those higher potencies?
        Dr. MacDonald. I think there is some risk for some
    individuals. It is hard to predict--especially with the
    edibles. I think those can be a concern. But, I agree with Dr.
    Nadelmann that the biggest risk is a criminal record, for
    somebody who is using marijuana.
        Chairman Johnson. We talked a little bit about the
    difference in tobacco. And, you had mentioned that increasing
    taxes was effective. I guess, I would argue--I just kind of
    want to throw this on the table--because, there really is no
    black market, for cigarettes--I mean, there is some black
    market, where you have a high-tax State next to a low-tax
    State, and there are some cigarette runners, from that
    standpoint. But, I mean, the problem you have with marijuana is
    that there is a very robust black market. And so, if you try
    and approach this, in terms of reducing use, by higher
    taxation, I mean, you just fuel the black market.
        Mr. Nadelmann. Except, what we are trying to do is to move
    it from a world where marijuana was 99 percent or 100 percent
    illegal, into a world, like tobacco or alcohol, essentially,
    where it is 10 percent or 15 percent illegal--people evading
    taxes and smuggling from low tax States, like North Carolina,
    to high-tax States, like New York. Or, from New York to Canada,
    or something like that. There is a huge benefit in moving this
    from an underground, uncontrolled market into a legally
    regulated market.
        Chairman Johnson. Chief Ryan, you, obviously, are talking
    about the opiate and heroin overdoses, and what you are trying
    to do there. What are you seeing, in terms of marijuana and the
    effects, potentially, the higher potency?
        Chief Ryan. Yes, I mean----
        Chairman Johnson. And, the trafficking, from the legal
    States into States like Massachusetts.
        Chief Ryan. Right. And, I remain concerned that the
    perception that it is acceptable will have devastating
    consequences, in terms of kids experimenting--and then
    experimenting at younger ages. And then, that manifesting to
    experimentation with other drugs.
        Chairman Johnson. You are saying that is a high-level
    concern, on your part.
        Chief Ryan. It is indeed. And, just--a quick personal
    story. I am playing basketball with my daughter, at the end of
    my driveway, recently--a 12-year-old girl. It is a Friday
    evening. My wife is on the front porch having a glass of wine.
    I am having a lovely time with my daughter. A young man pulls
    up, and I witness a marijuana deal going down. I went over and
    I intervened, as a dad. I never identified myself as a police
    officer. I do not want drug deals going on in my neighborhood.
    I took action. The kid got flip. I tried to get him to call his
    parents. He refused to do so. I called the police.
        Where I am going with this, Senator, is, the next day, do
    you know what the talk of the neighborhood was? What I did and
    how I handled the kid. It was not about the kid's behavior and
    the fact that he was in the neighborhood delivering illegal
    marijuana.
        So, this perception--that marijuana is acceptable and not a
    social norm violation--is resulting in kids experimenting
    younger. And, what I am seeing on the street--early on--I am
    concerned about.
        Chairman Johnson. So, the bottom line, going back to my
    story about the seventh grade kid, that is a very legitimate
    concern in this whole debate: What are we communicating to our
    youth?
        Chief Ryan. And, how do we manage that? That is the
    challenge.
        Chairman Johnson. There is the conundrum. So, we have
    this----
        Chief Ryan. This bad dad stopping----
        Chairman Johnson [continuing]. Drug problem, and, because
    of the illegal nature of it, we are funneling billions of
    dollars to some of the most evil people on the planet. And yet,
    you move away from that, and, all of a sudden, you are
    communicating, unfortunately, potentially, that this is OK.
        Mr. Nadelmann. Senator, I think we communicated a lot of
    very good messages to young people about tobacco without making
    it illegal for adults and creating a vast black market. I think
    we are increasingly communicating effectively about alcohol--
    right?--without creating a huge black market.
        Chairman Johnson. I am not sure we are very effective about
    that.
        Mr. Nadelmann. But, actually, binge drinking is going down.
    Some of the worse outcomes are actually going down, now. And
    so, I think it is important to understand--let us focus on
    using good, smart messages to young people about safety and
    health, and not getting into drugs and all that. We do not need
    to criminalize an entire adult population, spend tens of
    billions of dollars on a ``war on marijuana,'' and get 750,000
    arrests a year in order to send a message to kids. That is a
    very expensive and destructive way of sending a message.
        Chairman Johnson. Again, the purpose of this is really to
    try and find the areas of agreement. I think that is where you
    move forward from, because there is not going to be an
    agreement, by Dr. Murray and Dr. Nadelmann, on so many issues.
    But, I think there can be complete agreement in what we can do
    to communicate--to make sure our young people realize this is
    not a good path, this is dangerous, and this is not good for
    you to do. I think there would be agreement about that, on this
    Committee, as well.
        So, it really is about how we, effectively, develop a
    national, concerted public relations (PR) and education
    campaign to dissuade all Americans from abusing drugs,
    particularly our young people--because, it is good to hear that
    there are some effective treatments for addiction, but it is a
    pretty difficult path. You are better off never having somebody
    get addicted.
        Mr. Nadelmann. If I could just make two points. First, in
    direct response to your question, I just want to caution
    against overinvestment on the youth piece. We have done a lot--
    we are, actually, doing not so bad. The real investment needs
    to be on dealing with people who are really beginning to get in
    trouble with opiates at older ages. That is where most of the
    death and addiction is. It does not mean you ignore young
    people, but understand the great investment needs to be on the
    serious addiction.
        And, let me just finish----
        Chairman Johnson. Let me just comment on that point,
    because, again, I just want to ferret out----
        Mr. Nadelmann. Senator, if I could just--let me just throw
    in one last point.
        Chairman Johnson. OK.
        Mr. Nadelmann. Because, it goes two ways, in which the
    marijuana issue and the opiate issue have overlapped, here--the
    opioid overdose issue--and there are three fascinating studies
    that have come out, in the last couple of years, that go to the
    issue of people dying of overdose. And, what they find is that,
    in the States that have the most robust medical marijuana
    programs--the ones with the easiest access to marijuana for
    medical purposes--in those States, you see lower levels of
    opioids being prescribed. And, you see dramatically lower rates
    of opioid overdoses. Those studies are published in JAMA's
    Internal Medicine, in the prestigious Journal of Pain, and by
    the National Bureau of Economic Research (NBER). It is
    suggesting that, when you are treating pain, opioids are not
    the only thing. Marijuana can also play a positive role. And,
    that, for certain types of pain, marijuana may be a more
    effective way of dealing with pain than opioids are and a far
    less dangerous way.
        Chairman Johnson. Dr. Murray.
        Mr. Murray. Again, I am just reeling from the amount of
    partial truth, misinformation, misdirection, and improper----
        Chairman Johnson. Here is your opportunity to----
        Mr. Nadelmann. Well, except three studies published in
    peer-reviewed journals--top of the line--and I have not heard
    the contrary studies quoted, here. So, I rest my case right
    there.
        Mr. Murray. Dr. Nadelmann----
        Chief Ryan. I have my handcuffs with me, gentlemen.
    [Laughter.]
        Mr. Murray. It would please me to no end to offer you
    evidence. I do not anticipate that it would dent you.
        That said, I think we are in a battle for the brains of a
    new generation--that it is a continuing struggle and it is an
    urgent one. ``A battle for the brain,'' that is the phrase a
    colleague of mine, at Harvard Medical School, uses--Bertha
    Madras, who is a brain researcher, said that the critical issue
    here is we are losing these kids and we are losing them,
    rapidly. And, we are losing them, first in Colorado, but it is
    spreading, nationwide. And, if we do not address that
    urgently--because we think it is a soft drug. It has been
    called a ``medicine,'' and it is offered as such. It is a joke,
    when you read the national media. It is something that we see
    on television routinely. There is damage coming. There is
    damage that has already been planted into this generation. We
    have not seen it yet. It will manifest. And, the damage will
    cause us, in shock to think, ``What have we done, experimenting
    on this generation, without knowing what price we were going to
    pay in broken lives, cognitive impairment, educational failure,
    psychotic breaks, schizophrenia, and depression? These are the
    sequelae. If you do not believe me, read the New England
    Journal of Medicine. Or, you can listen to the World Health
    Organization--and they are issuing urgent pleas.
        Let me tell you my last story.
        Chairman Johnson. Here--I will tell you what. We are going
    to give everybody a chance to wrap it up----
        Mr. Murray. I can tell my story then.
        Chairman Johnson. You can tell your story then. I would
    like to give Senator Carper a chance for any further thoughts
    or closing questions. And then, we will give you each a chance
    to close--and, again, I want to keep it to about a minute. So,
    Senator Carper?
        Senator Carper. I am going to come back to ``find out what
    works, do more of that.'' And, go back to tobacco--highly
    addictive. And, among the things that worked that, I think,
    were helpful was the ``Truth Campaign,'' particularly for young
    people. I think it is still working. Among the other things, it
    has worked, with respect to tobacco's--I remember when I was
    brand-new to Delaware--right out of the Navy--and I remember
    going to the State fair. And, when we walked into the State
    fair, they had people actually handing out little packets of
    cigarettes--five or six cigarettes in a little packet. That is
    how easy it was to get. For many years, if you were a kid--I do
    not care if you were 9 years old or 90 years old--you could get
    access to tobacco in a vending machine. And, a lot of kids got
    access to it--and we made it easy for people. People would go
    to drug stores and supermarkets. Kids going in and buying
    cigarettes for their parents or whatever--maybe using them for
    themselves--maybe taking them to their parents.
        We made it more expensive, and we raised taxes, and that
    sort of thing. We have a substance that other people can use,
    if they are addicted to nicotine, like patches--people can have
    gum to chew that reduces the craving for cigarettes.
        I think there are lessons there, for us. And, I just want
    us to, again, ``Find out what works, do more of that.'' And, I
    think there are a number of things that we have done, on the
    tobacco side, other than just scaring young people straight.
        The other thing that is helpful for me--and, again, thank
    you so much--each of you. Some of you have come a long way, and
    we are grateful for your being here and for your years of
    commitment--your passion for this. Part of what we need to do
    is figure out what is the appropriate role for the Federal
    Government. And, I said this earlier. What is the appropriate
    role for the Federal Government? How do we use limited Federal
    resources to leverage, from a whole wide range of
    stakeholders--to leverage their contributions and their
    participation in things--in approaches that will actually work?
        I would just close with that thought, and, again, thank you
    all.
        Chairman Johnson. Thank you, Senator Carper.
        Again, I truly appreciate the time you have spent on very
    thoughtful prepared testimonies, coming here, hopping on a red-
    eye flight. We will be issuing a report on this. And you can
    kind of understand, and by from my background as a
    manufacturer, I am pretty data-driven. So, you will all be
    given the opportunity to provide the studies--the statistics
    that form the basis--the documents behind that report. So, we
    will have questions for the record, but we will definitely
    afford you that opportunity.
        You have heard the discussion. You have seen the
    differences. But, I also would encourage you, in what you
    supply the Committee for our report, to concentrate on the
    areas of agreement. I truly believe we share the same goal.
    That is a good place to start. Then, try and find all of the
    areas of agreement. And, yes, it will start breaking down
    beyond that point, but, in your response to the Committee,
    really concentrate on the things we agree on. Hopefully, we can
    agree on data. Facts are facts. I realize, sometimes, they are
    kind of hard to come by. But, again, I really want you to
    continue to help this Committee. I think this has been an
    incredibly interesting discussion.
        I will turn it over to Dr. MacDonald to kind of start out,
    if you have kind of a closing 1-minute comment, here.
        Dr. MacDonald. Just to sum up, supervised injectable
    hydromorphone--a pharmaceutical agent--can be effective at
    engaging the most severely affected heroin users who have not
    responded to the standard treatment.
        Chairman Johnson. And, I do want to quickly ask you a
    question, because I missed it. Your injectable sites, have they
    been magnets for--because, there has been some controversy,
    ``Well, this is going to be a magnet for drug dealers and crime
    and that type of thing.''
        Dr. MacDonald. There has been no increase in social
    instability around the clinics. In fact, they have stabilized.
    And, there has been no honeypot effect. So, people have not
    come from other jurisdictions seeking the treatment.
        Chairman Johnson. Was there any resistance by the
    neighborhoods, in terms of establishing those sites?
        Dr. MacDonald. With our first study, NAOMI, yes, there was.
    But, with people having seen the success and the benefits, both
    to the individuals and to the community, I think those have
    fallen away now.
        Chairman Johnson. Thank you. Dr. Nadelmann.
        Mr. Nadelmann. Yes, I think it is almost embarrassing that
    the United States has not proceeded with some form of
    experiment or policy reform to allow these sorts of safe
    injection sites and heroin maintenance programs to happen in
    the United States, given the overwhelming evidence, from
    outside of the United States, of their efficacy, in all
    regards.
        But, let me finish with this point--and it is a different
    one, in a way. I talked, before, about how valuable it would be
    if thousands of ethnographers and other researchers were really
    trying to figure out what is going on.
        The other part of this is treating pain--and just a couple
    of things about that.
        First, I think the bravest doctors, in America, are
    doctors, who are trying to manage pain in patients, who have
    been addicted to opiates, illegally. That population of people,
    who have been the junkies--the addicts--whatever you want to
    call them--that are dealing with real pain--they are
    courageous.
        And, second, I tell you, a few months ago, I was talking to
    my brother, who is a cardiologist--and his daughters are both
    going to medical school. And, I was saying to his daughters,
    ``I think the single most interesting area of medicine to go
    into is pain management.'' Right? It is so interdisciplinary.
    It is psychological and it is physical--it is an amazing
    subject. And, my brother got angry at me. He said, ``Do not
    tell my daughters--your nieces--to do that. Let me tell you, it
    is the most''--``You are going to have the DEA looking over
    your shoulder. They are looking over your shoulder. You do not
    know what is going on. Do not do it.'' But, something to
    incentivize medical students and, for that matter, physicians
    to learn dramatically more about managing pain, I think, would
    be an extraordinarily valuable investment.
        Chairman Johnson. And, of course, that was Senator
    Portman's point. Dr. Murray.
        Mr. Murray. In short order, here, we have heard a great
    deal about safe injection, supervised injection facilities, and
    giving out heroin to heroin addicts. I will just, in summary
    fashion, say that the true test of any good public policy, it
    seems to me--it must meet two criteria:
        It must be effective. And, the case is not, when you look
    at the literature, that these things are effective, as
    advertised. They still have many gaps. They do not, actually,
    transform the high-risk behavior of the populations. We
    continue to lose them, in overdose and HIV transmission. They
    continue to inject outside of the facilities. This is not ready
    to be an answer to our policy problem, at this point.
        The second criterion is, it must be humane. And, I would
    say, Senator, that, for the government to step into the role of
    officially providing addictive heroin to its citizens, so
    transforms the relationship of the citizen to the government
    that we should fear it.
        And, I will end with my story. I am frustrated by marijuana
    legalization advocates, who target children--and they do--and
    very effectively. And, they appeal to us by putting suffering
    victims--a woman with lupus, where medical marijuana made her
    walk again. We have seen this too much.
        In particular, I have seen it, recently, regarding another
    population that I care a great deal about, because of my
    service in the White House. I had the privilege of serving with
    the men and women of America's armed services, who occupy our
    office and are extraordinary people. And, the issue of Post-
    traumatic Stress Disorder (PTSD), in the U.S. veteran
    population, is an exceptionally troubling, profound one--many
    of them are being treated through, I think, an inadequate
    Department of Veterans Affairs (VA) system. I will let others
    judge that. And, it has been proposed, here, in this Congress,
    and elsewhere, by marijuana advocates, that what veterans
    suffering from PTSD most need is high-potency marijuana to
    medicate themselves. And, the VA, itself, is not sure about
    this and issues equivocal statements about the impact.
        But, a recent publication, by a Yale University
    psychiatrist indicated that the psychiatrist has studied the
    population of veterans who suffer from PTSD. And, he has looked
    at those who were given marijuana and the results were totally
    counterproductive. It put them at a greater risk of
    experiencing psychotic breaks and reduced the effectiveness of
    the treatment that they were already having. Many of these
    people are being medicated with very powerful psychotropic
    medications, already. No one has any idea what the interaction
    is, when you add THC to that mix. No one knows about the
    outcomes for the young kids in school taking Ritalin at
    exorbitant rates--or other antidepressants--interacting with
    THC. The potency of the mixtures, the unknown dimension of it,
    and to try and enlist veterans as a sympathetic audience--as a
    sympathetic profile--to try and sway us toward marijuana, as a
    medicine, strikes me as being highly irresponsible.
        Chairman Johnson. Thank you, Dr. Murray. We had our own
    tragedies at the Tomah VA because of the overprescription of
    opiates and drug toxicity.
        Chief Ryan, again, you are on the frontline of this. You
    are dealing with it on the streets. So, again, we appreciate
    your service and appreciate your testimony. Your closing
    thought?
        Chief Ryan. Thank you, Senator. And, thank you for your
    work and the work of your Committee. I would just, briefly,
    leave you with a couple of thoughts.
        I will never argue that enforcement is not a component to
    the global piece of the pie, on this challenge. But, it has to
    be proportional. And, we cannot label it a ``war.'' As we try
    to roll out community policing and to build trust in our
    communities, the last word we want to use--or conduct behavior
    like a ``warrior,'' in our communities. We are guardians in our
    communities, as law enforcement.
        That said, to the extent that you and your Committee can
    bring a true sense of urgency to this issue--particularly the
    opiate epidemic--and facilitate meaningful dialogue with the
    medical profession, law enforcement, and the pharmaceutical
    industry--so that, a decade from now, we are in our rocking
    chairs, and we can look back and look at our work and our
    collaboration--although we may differ--and say that we have
    made a positive change in America. And, thank you, Senator.
        Chairman Johnson. Well, again, thank you. We all share the
    same goal. So, again, we are trying to facilitate a very
    honest, very frank discussion. I think that is what we have,
    certainly, had here. And, help us build the record, to write a
    report that will, hopefully, move that process forward.
        So, again, I just thank you all for coming here and for all
    of your time. The roundtable record will remain open for 15
    days, until June 30, at 5 p.m., for the submission of
    statements and questions for the record.
        This roundtable is adjourned. Thank you all.
        [Whereupon, at 12:18 p.m., the Committee was adjourned.]

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