[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.
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    \1\ The prepared statement of Ms. Enomoto appears in the Appendix 
on page 298.
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    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.
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    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.
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    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\
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    \1\ The information submitted by Mr. Botticelli appears in the 
Appendix on page 330.
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    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

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[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.
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    \1\ The prepared statement of Mr. Ryan appears in the Appendix on 
page 470.
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    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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