[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]









              FENTANYL: THE NEXT WAVE OF THE OPIOID CRISIS

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 21, 2017

                               __________

                           Serial No. 115-16




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                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania             ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas            GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee          DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana             MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio                JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi            DORIS O. MATSUI, California
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
PETE OLSON, Texas                    JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
ADAM KINZINGER, Illinois             BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
GUS M. BILIRAKIS, Florida            YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio                   DAVID LOEBSACK, Iowa
BILLY LONG, Missouri                 KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana               JOSEPH P. KENNEDY, III, 
BILL FLORES, Texas                   Massachusetts
SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma           RAUL RUIZ, California
RICHARD HUDSON, North Carolina       SCOTT H. PETERS, California
CHRIS COLLINS, New York              DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia

                                 _____

              Subcommittee on Oversight and Investigations

                        TIM MURPHY, Pennsylvania
                                 Chairman
H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana             PAUL TONKO, New York
CHRIS COLLINS, New York              YVETTE D. CLARKE, New York
TIM WALBERG, Michigan                RAUL RUIZ, California
MIMI WALTERS, California             SCOTT H. PETERS, California
RYAN A. COSTELLO, Pennsylvania       FRANK PALLONE, Jr., New Jersey (ex 
EARL L. ``BUDDY'' CARTER, Georgia        officio)
GREG WALDEN, Oregon (ex officio)

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                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     3
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     4
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     6
    Prepared statement...........................................     7
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     8
    Prepared statement...........................................    10

                               Witnesses

Kemp L. Chester, Acting Director, Office of National Drug Control 
  Policy.........................................................    12
    Prepared statement...........................................    15
    Additional information for the record........................   127
    Answers to submitted questions...............................   163
Louis J. Milione, Assistant Administrator, Diversion Control 
  Division, Drug Enforcement Administration......................    26
    Prepared statement...........................................    28
    Answers to submitted questions...............................   172
Matthew C. Allen, Assistant Director, Homeland Security 
  Investigative Programs, Homeland Security Investigations, 
  Immigration and Customs Enforcement, Department of Homeland 
  Security.......................................................    38
    Prepared statement...........................................    40
    Answers to submitted questions...............................   188
William R. Brownfield, Assistant Secretary of State for 
  International Narcotics and Law Enforcement Affairs, Department 
  of State.......................................................    48
    Prepared statement...........................................    50
    Answers to submitted questions...............................   211
Debra Houry, M.D., Director, National Center for Injury 
  Prevention and Control, Centers for Disease Control and 
  Prevention.....................................................    57
    Prepared statement...........................................    59
    Answers to submitted questions...............................   219
Wilson M. Compton, M.D., Deputy Director, National Institute on 
  Drug Abuse, National Institutes of Health, Department of Health 
  and Human Services.............................................    72
    Prepared statement...........................................    74
    Answers to submitted questions...............................   227

                           Submitted Material

Subcommittee memorandum..........................................   129
Article of December 13, 2016, ``Where opiates killed the most 
  people in 2015,'' by Christopher Ingraham, Wonkblog, The 
  Washington Post, submitted by Mr. Murphy.......................   143
Letter of March 21, 2017, from Acadia Healthcare, et al., to Hon. 
  Paul Ryan and Hon. Nancy Pelosi, submitted by Mr. Tonko........   151
Letter of March 20, 2017, from Michael Seville, Executive 
  Director, Oregon AFSCME Council 75, to Mr. Murphy and Ms. 
  DeGette, submitted by Ms. DeGette..............................   161

 
              FENTANYL: THE NEXT WAVE OF THE OPIOID CRISIS

                              ----------                              


                        TUESDAY, MARCH 21, 2017

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:20 a.m., in 
Room 2123 Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Members present: Representatives Murphy, Griffith, Barton, 
Burgess, Brooks, Collins, Walberg, Walters, Costello, Carter, 
Bilirakis, Walden (ex officio), DeGette, Schakowsky, Castor, 
Tonko, Peters, and Pallone (ex officio).
    Staff present: Jennifer Barblan, Chief Counsel, Oversight 
and Investigations; Elena Brennan, Legislative Clerk, Oversight 
and Investigations; Adam Buckalew, Professional Staff Member, 
Health; Karen Christian, General Counsel; Zachary Dareshori, 
Staff Assistant; Jordan Davis, Director of Policy and External 
Affairs; Paige Decker, Executive Assistant and Committee Clerk; 
Scott Dziengelski, Policy Coordinator, Oversight and 
Investigations; Brittany Havens, Professional Staff, Oversight 
and Investigations; Alex Miller, Video Production Aide and 
Press Assistant; David Schaub, Detailee, Oversight and 
Investigations; Jennifer Sherman, Press Secretary; Alan 
Slobodin, Chief Investigative Counsel, Oversight and 
Investigations; Hamlin Wade, Special Advisor for External 
Affairs; Jeff Carroll, Minority Staff Director; Waverly Gordon, 
Minority Counsel, Health; Christopher Knauer, Minority 
Oversight Staff Director; Miles Lichtman, Minority Staff 
Assistant; Kevin McAloon, Minority Professional Staff Member; 
Jon Monger, Minority Counsel; Dino Papanastasiou, Minority GAO 
Detailee; and C.J. Young, Minority Press Secretary.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Good morning. Welcome to this hearing called 
``Fentanyl: The Next Wave of the Opioid Crisis.''
    America is in a full-on opioid crisis. About two decades 
ago, it started with the over prescribing of opioid drugs and 
then shifted more to heroin. Today, thesubcommittee examines 
the next wave of the opioid crisis, an even more dangerous 
threat on our streets--fentanyl.
    Fentanyl is made in the lab and for many years it has been 
a powerful pain medicine used by patients with cancer or for 
those with extreme pain.
    I might add to this, I remember when I was injured in Iraq 
a few years ago, battlefield medicine meant in recovery they 
gave me lots of fentanyl patches, and I know what it is like to 
have the reaction to that.
    It is 50 times more potent than heroin and 100 times more 
potent than morphine. Now illicit fentanyl has become a potent 
additive to heroin, cocaine, or even counterfeit prescription 
drugs.
    This is the way the drug dealers increase profits: Stretch 
out their supply and expand the number of addicts by juicing 
the potency of heroin or other street drugs, sort of what 
people have done with MSG in foods.
    Users often don't even know that fentanyl is in the heroin. 
The fentanyl crisis is exceptionally dangerous because of its 
high potency and the speed with which it reaches the brain. 
Just 2 milligrams of fentanyl can kill, whether swallowed, 
inhaled, or absorbed through skin.
    To appreciate how small an amount 2 milligrams is: A 
sweetener packet that you see at your restaurant table is about 
1,000 milligrams. Two milligrams of fentanyl can kill you.
    Those suffering from an overdose involving fentanyl may 
require both higher doses and multiple administrations of 
naloxone to reverse the overdose and to become stabilized. Even 
the police and first responders are at risk from inadvertently 
touching or inhaling fentanyl powder at a crime scene or 
helping an overdose victim.
    In March 2015, the Drug Enforcement Administration, or DEA, 
issued a nationwide alert on fentanyl as a threat to health and 
public safety.
    A year later, the DEA sent another alert, calling the spike 
in fentanyl seizures an unprecedented threat. Customs and 
Border Protection data shows an 83-fold increase in the amount 
of fentanyl seized in 3 years.
    An added challenge is that there are many chemical 
variations of fentanyl, commonly referred to as analogues. 
There are about 30 known analogues.
    However, only 19 of these analogues are controlled 
substances under Federal law. Since 2013, fentanyl overdoses 
and deaths have surged with no end in sight. Fentanyl and its 
analogues have contributed to at least 5,000 overdose deaths in 
the United States, including the death of music star Prince 
last year. In my district alone, fentanyl-related deaths have 
exploded since 2014.
    Last year, 86 people in Westmoreland County died from drug 
overdoses linked at least in part to fentanyl, and even these 
statistics seriously undercut the fentanyl threat nationally 
because most States and localities are not testing or tracking 
fentanyl in drug overdose cases. So we are flying blind.
    At this rate, the capacity of law enforcement and the 
healthcare system will be overwhelmed. China is the primary 
source of fentanyl, and there are thousands of labs making 
illicit pure fentanyl as well as the source of ingredients or 
precursors needed to manufacture fentanyl.
    Traffickers ship these ingredients to secret labs in Mexico 
run by drug cartels and then smuggle pounds of fentanyl over 
the Southwest border through our porous borders, launching it 
through catapults or drones and into the U.S.
    Chinese labs are also a primary source for fentanyl ordered 
on the open internet and on the dark web. Pure fentanyl is 
delivered through the mail or air express carriers.
    Finally, China is the main source of pill presses that can 
make thousands of pills an hour to support fentanyl press mill 
operations. I might add here I am pleased that China is saying 
that they are taking some action in helping to reduce this and 
we look forward to working with them because it is so deadly.
    The fentanyl problem is spreading and going to get worse 
because the money and profit is enormous. According to the data 
from the DEA, a kilogram of heroin can be purchased for roughly 
$6,000 and sold wholesale for $80,000.
    However, a kilogram of pure fentanyl can be purchased for 
less than $5,000 and is so potent that it can be stretched into 
16 to 24 kilograms of product when using cutting agents such as 
talcum powder or caffeine.
    Therefore, while each kilogram of fentanyl can be sold 
wholesale for $80,000, it can result in a total profit in the 
neighborhood of $1.6 million. That is about 20 times more 
profit.
    We need a Federal strategy dedicated to combating fentanyl 
as the clear and present danger it presents to our national 
security and public health.
    We welcome our panel of witnesses today. We salute you for 
your work, thank you for appearing today, and look forward to 
working together to stop the spread of this epidemic.
    [The prepared statement of Mr. Murphy follows:]

                 Prepared statement of Hon. Tim Murphy

    America is in a full-on opioid crisis. About two decades 
ago, it started with the overprescribing of opioid drugs and 
then shifted more to heroin. Today the subcommittee examines 
the next wave of the opioid crisis, an even more dangerous 
threat on our streets--fentanyl.
    The surge of fentanyl is having a dramatic and deadly 
effect on our communities. We all see the headlines-these are 
our neighbors, our families, our friends. We need an ``all 
hands on deck approach'' to fight this problem, which will 
involve not just the Federal Government, but States, 
localities, and even international partners.
    Fentanyl is made in a lab. For many years, it has been a 
powerful pain medicine used by patients with cancer or for 
those with extreme pain. It is about 50 times more potent than 
heroin and 100 times more potent than morphine.
    Now illicit fentanyl has become the MSG of narcotics, a 
potent additive to heroin, cocaine, or even counterfeit 
prescription drugs. This is the way the drug dealers increase 
profits, stretch out their supply, and expand the number of 
addicts by juicing the potency of heroin or other street drugs. 
Users often don't even know that fentanyl is in the drugs they 
are buying.
    The fentanyl crisis is exceptionally dangerous because of 
its high potency and the speed with which it reaches the brain. 
Just 2 milligrams of fentanyl can kill, whether swallowed, 
inhaled, or absorbed through skin. To appreciate how small an 
amount 2 milligrams is, a sweetener packet at a restaurant 
table contains 1,000 milligrams.
    Those suffering from an overdose involving fentanyl may 
require both higher doses and multiple administrations of 
naloxone to reverse the overdose and to become stabilized. Even 
the police and first responders are at risk from inadvertently 
touching or inhaling fentanyl powder at a crime scene or 
helping an overdose victim.
    An added challenge is that there are many chemical 
variations of fentanyl--commonly referred to as analogues. 
There are about 30 known analogues, however only 19 of these 
analogues are controlled substances under Federal law.
    Since 2013, fentanyl overdoses and deaths have surged with 
no end in sight. Fentanyl and its analogues have contributed to 
at least 5,000 overdose deaths in the United States, including 
the death of music star Prince last year. In my district alone, 
fentanyl-related deaths have exploded since 2014. Last year, 86 
people in Westmoreland County died from drug overdoses linked 
at least in part to fentanyl. Even these statistics seriously 
undercount the fentanyl threat nationally because most States 
and localities are not testing or tracking fentanyl in drug 
overdose cases. At this rate, the capacity of law enforcement 
and the healthcare system will be overwhelmed.
    China is the primary source of fentanyl. There are 
thousands of labs making illicit pure fentanyl as well as the 
source of ingredients or precursors needed to manufacture 
fentanyl. Traffickers ship these ingredients to secret labs in 
Mexico run by drug cartels and then smuggle pounds of fentanyl 
over the southwest border into the U.S. Chinese labs are also a 
primary source for pure fentanyl ordered on the open internet 
and on the dark web and delivered through the mail or air 
express carriers. Finally, China is the main source of pill 
presses that can make thousands of pills an hour to support 
fentanyl press mill operations.
    The fentanyl problem is spreading and going to get worse 
because the money and profit is enormous. According to data 
from the DEA, a kilogram of heroin can be purchased for roughly 
$6,000 and sold wholesale for $80,000. However, a kilogram of 
pure fentanyl can be purchased for less than $5,000 and is so 
potent that it can be stretched into 16 to 24 kilograms of 
product when using cutting agents such as talcum powder or 
caffeine. Each kilogram of cut fentanyl can besold wholesalefor 
$80,000, resulting in a total profit in the neighborhood of 
$1.6million. That is about20 times more profit than heroin.
    We need a Federal strategy dedicated to 
combattingfentanylas the clear andpresent danger it presents to 
our national security and publichealth.
    We welcome our panel of witnesses today. We salute you for 
your work, thank youforappearing today, and look forward to 
working together to stop the spread of thisepidemic.

    Mr. Murphy. Now I recognize my friend from Colorado, Ms. 
DeGette.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you so much, Mr. Chairman.
    Every day somewhere in this country there is a news account 
about how opiate addiction has wrecked a small town or family. 
Personal stories about Americans who have become addicted to 
pain pills and then they get hooked on heroin.
    These are heartbreaking stories about Americans dying and 
leaving loved ones, often their children, to pick up the 
pieces. The opioid epidemic is unprecedented and it is 
escalating, and I think we all agree that we need a 
comprehensive strategy to confront it.
    In 2015, more than 33,000 Americans died of an overdose 
involving a prescription or illicit opioid and more than 2 
million people had an opioid use disorder.
    Fentanyl is, of course, an even deadlier layer to this 
crisis. It can be up to 50 times more potent than heroin and a 
100 times more potent than morphine. It's lethal at even the 
tiniest amounts and anyone exposed to it can be--can have its 
detriments.
    You know, illicit fentanyl is not a new problem. What is 
new, though, is its growing prevalence. Since 2010, that number 
covered by American law enforcement nationwide has risen 
twentyfold, from 640 samples tested to 13,000 samples tested in 
2015, according to information from the DEA.
    U.S. law enforcement, as the chairman said, believes China 
is the primary source of illicit fentanyl and precursor 
chemicals. Chinese producers ship fentanyl or chemicals to make 
it directly into the United States.
    Precursor chemicals, or finished fentanyl, is shipped to 
Mexico and Canada where it is trafficked across our borders in 
pure form or is mixed with other illicit drugs like heroin.
    Today, we want to ask the panel some tough questions about 
law enforcement and diplomatic efforts to stem the tide of 
fentanyl flowing from China and whether they are sufficient.
    We are also going to ask which vectors drug traffickers use 
to ship this drug into our country, like express consignment 
carriers and international mail.
    I think this is another important step that this 
subcommittee had been taking to address the opioid epidemic, 
and for the record I want to continue this bipartisan work.
    That said, Mr. Chairman, I also think we need to find a way 
to address the treatment side of this epidemic and this is, 
sadly, where I have significant differences with my majority 
colleagues.
     Passage of the Affordable Care Act, as you know, has led 
to nearly 20 million Americans gaining healthcare coverage. In 
addition, the ACA has enabled Governors to expand the Medicaid 
services they offer, which was critical in States that were 
overwhelmed by the opioid epidemic.
    Studies estimate that, since 2014, 1.6 million uninsured 
Americans gained access to substance abuse treatment across the 
31 States like mine that expanded Medicaid coverage.
    This is particularly important for hard-hit States like 
Kentucky, where one study reports that residents saw a 700 
percent increase in Medicaid beneficiaries seeking treatment 
for substance use.
    Two weeks ago, the majority rushed through this committee a 
bill to repeal the ACA that many believe will threaten the 
progress that Medicaid expansion has made in getting people 
suffering from addiction into treatment.
    In its assessment of that bill last week, the Congressional 
Budget Office said that millions of Americans--24 million of 
them--will lose health coverage.
    Many of those will be people currently receiving Medicaid 
assistance which include people receiving treatment for opioid 
addiction.
    In January, healthcare experts from Harvard and NYU wrote 
and op-ed for the Hill about how repealing the ACA would 
reverse important public health gains. They focused primarily 
on my baby, the 21st Century Cures Act which I did with Fred 
Upton and all of this whole committee. We approved it 
unanimously.
    But it really--we can have a whole hearing just about how 
badly the GOP's ACA repeal bill will hamper the progress that 
we just passed in 21st Century Cures.
    I just want to draw attention to one part of this op-ed, 
though, where they authors wrote ``repealing the ACA and its 
behavioral health provisions would have stark effects on those 
with behavioral health illnesses. We estimate that 
approximately 1,253,000 people with serious mental disorders 
and about 2.8 million Americans with a substance abuse disorder 
of whom about 222,000 have an opioid disorder would lose some 
or all of their insurance coverage.''
    The end of the day, we don't know what kind of bill is 
going to reach the president's desk. But if we really want to 
address the opioid crisis, I suggest that we don't pass this 
very poorly thought out piece of legislation.
    I yield back.
    Mr. Murphy. Gentlelady yields back.
    I now recognize the chairman of the full committee, Mr. 
Walden, for 5 minutes.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. I thank the gentleman and I thank you for 
holding this very important hearing.
    The opioid crisis, as we know, has touched every corner of 
our Nation. Just like my colleagues, I have met with community 
leaders, physicians, first responders, law enforcement and 
families on this issue.
    Each have shared their heartbreaking stories on the effects 
of this crisis in our communities. You see, addiction doesn't 
understand politics. It doesn't understand income. It doesn't 
understand race or where someone's from. It is an equal 
opportunity destroyer. This crisis has hit close to home for 
all of us.
    Last Congress, this committee worked in a bipartisan way to 
advance sweeping legislation to fight the Nation's opioid 
epidemic. It was an effort that actually began in this 
subcommittee, which held a series of hearings that examined the 
growing problems of prescription drug and heroin abuse.
    We should be proud of those efforts but as we will discuss 
today there is a new threat emerging. Last year, there were 
encouraging reports that showed that the number of 
prescriptions for opioids in the United States had finally 
declined. That was good news. For the first time in 20 years 
that had happened. Yet, we saw the number of opioid-related 
overdoses and overdose-related deaths continuing to surge 
upward and we ask why.
    That is why we are having the hearing today. Emerging data 
strongly suggests the main driver is fentanyl and its chemical 
variations. Fentanyl essentially represents a third wave in the 
Nation's ongoing opioid crisis. It is why we are here.
    Fentanyl is a more challenging threat within the opioid 
crisis in comparison to threats of prescription opioids and 
heroin. The fentanyl threat is multifaceted. It's been produced 
as a legitimate pain medication by drug companies for decades 
but it is also produced illicitly in black market operations in 
China.
    Illicit fentanyl is hard to detect and, unlike prescription 
pain killers, it is not primarily diverted from the legitimate 
market nor is it strictly comparable to the black market of 
heroin. It can be purchased over the internet openly or on the 
dark web.
    Precursor chemicals used to make fentanyl are produced in 
China and shipped to clandestine labs in Mexico. Drug cartels 
are smuggling massive amounts of fentanyl with other narcotics 
from Mexico across the Southwest border.
    Drug traffickers in the United States not only are getting 
deliveries of fentanyl from China through the mail or express 
carriers but they are also getting direct or indirect shipments 
from China of pill presses that can make thousands of pills an 
hour to fuel their operations and distribution networks into 
our towns, our communities, and the lives of our citizens.
    Pure fentanyl is not considered a replacement drug for 
OxyContin or heroin. It is too potent. Just 2 to 3 milligrams 
can kill an individual, and has.
    More often than not, it is added in to heroin, cocaine, or 
counterfeit drugs to boost the potency and increase the 
likelihood of addiction. What's even scarier is people taking 
these drugs may not even know that they are taking fentanyl, 
let alone what it is.
    Fentanyl makes the deadly threat of opioid abuse even 
deadlier. In 2014 and 2015 in my home State of Oregon, a 
reported 49 people died from fentanyl. The number of deaths 
from fentanyl appears to be rising, and that is just what we 
know.
    As we work to combat this quickly evolving public health 
threat, there is an important question to be asked--how can we 
fight this threat when we don't even know how quickly it is 
spreading.
    Combating this growing multi-faceted fentanyl threat will 
require more than drug control strategies aimed at opioid 
overprescribing and heroin.
    Fentanyl is a global problem that requires an urgent 
response. I commend the efforts of our Government, ONDCP, DEA, 
and the State Department particularly for their success in 
gaining cooperation with China and the United Nations. We need 
to continue and support this international engagement to be 
successful.
    Like our work on the opioid epidemic last Congress, 
combating fentanyl truly requires an all-hands-on-deck effort. 
We need to think outside the box to find ways to stop the surge 
of the fentanyl crisis, and I look forward to your testimony 
and working with all of you to solve this problem.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    The opioid crisis has touched every corner of our Nation. 
Just like my colleagues, I have met with community leaders, 
physicians, first responders, law enforcement, and families on 
this issue. Each have shared heartbreaking stories on the 
effects of this crisis in our communities. You see, addiction 
doesn't understand politics. It doesn't understand income, 
race, or where someone is from. It is an equal opportunity 
destroyer. This crisis has hit close to home for each of us.
    Last Congress, this committee worked in a bipartisan way to 
advance sweeping legislation to fight the Nation's opioid 
epidemic. It was an effort that actually began in this 
subcommittee, which held a series of hearings that examined the 
growing problems of prescription drug and heroin abuse. We 
should be proud of those efforts. But as we will discuss today, 
there is a new threat emerging.
    Last year, there were encouraging reports that showed that 
the number of prescriptions for opioids in the United States 
finally declined--for the first time in 20 years. Yet, we saw 
the number of opioid-related overdoses and overdoserelated 
deaths continuing to surge upward. Why?
    Emerging data strongly suggest the main driver is fentanyl, 
and its chemical variations. Fentanyl essentially represents a 
third wave in the Nation's ongoing opioid crisis. It's why we 
are here today.
    Fentanyl is a more challenging threat within the opioid 
crisis, in comparison to the threats of prescription opioids 
and heroin. The fentanyl threat is multi-faceted. It has been 
produced as a legitimate pain medication by drug companies for 
decades. But it is also produced illicitly in black market 
operations in China. Illicit fentanyl is hard to detect, and 
unlike prescription painkillers it is not primarily diverted 
from the legitimate market. Nor is it strictly comparable to 
the black market of heroin. It can be purchased over the 
internet openly, or on the dark web. Precursor chemicals used 
to make fentanyl are produced in China, and shipped to 
clandestine labs in Mexico. Drug cartels are smuggling massive 
amounts of fentanyl with other narcotics from Mexico across the 
Southwest border. Drug traffickers in the U.S. not only are 
getting deliveries of fentanyl from China through the mail or 
air express carriers, but they are also getting direct or 
indirect shipments from China of pill presses that can make 
thousands of pills an hour to fuel their operations and 
distribution networks into our towns and communities.
    Pure fentanyl is not considered a replacement drug for 
OxyContin or heroin. It is too potent. Just 2 to 3 milligrams 
can kill an individual. More often than not, it is added into 
heroin, cocaine, or counterfeit drugs to boost the potency and 
increase the likelihood of addiction. What's even scarier is 
people taking these drugs may not even know that they are 
taking fentanyl, let alone what it is.
    Fentanyl makes the deadly threat of opioid abuse even 
deadlier. In 2014 and 2015 in my home State of Oregon, a 
reported 49 people died from fentanyl. The number of deaths 
from fentanyl appears to be rising, and that's just what we 
know. As we work to combat this quickly evolving public health 
threat, there's an important question to be asked. How can we 
fight this threat when we don't even know how quickly it is 
spreading?
    Combating this growing, multi-faceted fentanyl threat will 
require more than the drug-control strategies aimed at opioid 
overprescribing and heroin. Fentanyl is a global problem that 
requires an urgent response. I commend the efforts of our 
Government, ONDCP, DEA, and the State Department, particularly, 
for their success in gaining cooperation with China and the 
United Nations. We need to continue and support this 
international engagement to be successful. Like our work on the 
opioid epidemic last Congress, combating fentanyl truly 
requires an allhands- on-deck effort.
    We need to think outside the box to find ways to stop the 
surge of the fentanyl crisis. I look forward to your testimony, 
and working with all of you to solve thisproblem.

    Mr. Walden. And I yield the balance of my time to the 
gentleman, the chairman of the Health Subcommittee, Mr. 
Burgess.
    Mr. Burgess. Thank you, Mr. Chairman, and thank you, Mr. 
Chairman, for holding the hearing.
    I want to thank the DEA. Mr. Milione, I think you have been 
in to my office to talk about this issue in the past one on 
one. It is of concern to me.
    You know, I have been on the Health Subcommittee long 
enough that in 2005 we were having a hearing about why doctors 
weren't prescribing adequately for pain, and now the past two 
Congresses we have been concerned about the appearance of the 
opioid epidemic.
    Fentanyl is not a new product. It has been around for some 
time. But on the other hand, the analogues of fentanyl are 
relatively new, and it is the fueling of the illicit trade with 
the ability to get things over the internet which I think has 
probably been the crux of this problem.
    We do have problems with the overseas market with the way 
the supply comes in to our country.
    So I hope that we can hear some insight this morning on 
perhaps some additional things that might be done to stop that 
flow.
    Thank you, Mr. Chairman, and I will yield back to the 
gentleman from Oregon, who then yields back, correct?
    Mr. Murphy. Thank you. The gentleman's time has expired.
    I recognize the ranking member of the committee, Mr. 
Pallone, for 5 minutes.

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

    Mr. Pallone. Thank you, Mr. Chairman.
    The opioid epidemic in our country continues to grow at an 
alarming rate. In 2015, more than 33,000 Americans died of an 
opioid overdose and more than 2 million individuals have an 
opioid use disorder. According to the Center for Disease 
Control, 91 Americans die every day from an opioid overdose.
    Today we are focusing on fentanyl, a powerful synthetic 
opioid that is 50 times more potent than heroin and up to a 
hundred times more potent than morphine.
     Because of its potency, fentanyl is a dangerous substitute 
for heroin and it results in frequent overdoses that can cause 
respiratory depression and even death.
    The number of overdose deaths is rapidly increasing and the 
death rate from synthetic opioids other than methadone 
increased by 72 percent from 2014 to 2015.
    This substantial increase in the death rate from synthetic 
opioids is largely attributable to the increased availability 
of illicit fentanyl.
    I want to thank our witnesses today for their testimony and 
work on this very important issue. Fentanyl is dangerous not 
only to users but also to our law enforcement and public health 
officials on the front lines of this epidemic and I look 
forward to working together to explore ways that we can better 
confront the supply of the fentanyl now plaguing our 
communities.
    I also would like to talk today about the treatment side of 
the opioid epidemic. Just two weeks ago committee Republicans 
rushed Trumpcare through the committee, a bill which repeals 
the Affordable Care Act. The ACA has been instrumental in 
addressing the current opioid crisis and, inexcusably, 
Trumpcare would only exacerbate the crisis.
    Thanks to Medicaid expansion under the ACA, 1.6 million 
people with substance use disorders now can receive the 
treatment they need in the 31 States and Washington, DC, that 
expanded the program.
    But Trumpcare effectively ends Medicaid expansion in 2020. 
According to the CBO, Trumpcare also cuts $880 billion in 
Federal outlays for Medicaid over the next 10 years, which will 
severely undermine our efforts to fight the opioid crisis.
    These drastic cuts in Medicaid made possible by Republican 
plans to end Medicaid expansion in the CAPTA program will 
ration care for millions of Americans including the rationing 
of substance abuse treatment.
    Trumpcare also repeals the central health benefits for 
Medicaid expansion enrollees at the end of 2019. States would 
no longer have to offer benefits like substance abuse, mental 
health services or prescription drugs to millions of Americans 
who rely on such care.
    Repealing the essential benefits packages effectively 
repeals the mental and substance use disorder coverage 
provisions of the ACA and would remove approximately $5.5 
billion annually from the treatment of low-income people with 
mental and substance use disorders.
    Repeal will take away care from those who are actively 
seeking treatment and preventive services and we simply cannot 
afford to eliminate this care in what is oftentimes a life and 
death situation.
    Trumpcare threatens access to lifesaving treatment for more 
than 1 million people with opioid disorders.
    Our hearing today explores the fentanyl problem. However, I 
would argue that this issue is a part of a much wider opioid 
problem that we are battling.
     To address this properly, we must make sure Americans with 
substance abuse disorders can access effective treatment.
    And so, Mr. Chairman, I want to work with you to confront 
fentanyl and the larger opioid problem. However, in my opinion, 
repealing the ACA and cutting Medicaid by nearly a trillion 
dollars over the next 10 years will do nothing but undermine 
our efforts to treat Americans who are suffering from opioid 
addiction. We will not be able to arrest our way out of this 
problem.
    Without adequate treatment options for those suffering from 
an opioid addiction, this problem will only worsen and so will 
the deaths and destruction we have seen play out across the 
United States.
    I don't know if anybody wants my extra minute. If not, I 
will yield back.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Mr. Chairman, the opioid epidemic in our country continues 
to grow at an alarming rate. In 2015, more than 33,000 
Americans died of an opioid overdose, and more than 2 million 
individuals had an opioid use disorder. According to the Center 
for Disease Control, 91 Americans die every day from an opioid 
overdose.
    Today we are focusing on fentanyl, a powerful synthetic 
opioid that is 50 times more potent than heroin and up to 100 
times more potent than morphine.
    Because of its potency, fentanyl is a dangerous substitute 
for heroin and results in frequent overdoses that can cause 
respiratory depression and even death. The number of overdose 
deaths is rapidly increasing.
    The death rate from synthetic opioids, other than 
methadone, increased by 72 percent from 2014 to 2015. This 
substantial increase in the death rate from synthetic opioids 
is largely attributable to the increased availability of 
illicit fentanyl.
    I want to thank our witnesses today for their testimony and 
work on this very important issue. Fentanyl is dangerous not 
only to users, but also to our law enforcement and public 
health officials on the front lines of this epidemic.
    And I look forward to working together to explore ways that 
we can better confront the supply of the fentanyl now plaguing 
our communities.
    I would also like to talk today about the treatment side of 
the opioid epidemic.
    Just two weeks ago, committee Republicans rushed TrumpCare 
through the committee, a bill which repeals the Affordable Care 
Act. The ACA has been instrumental in addressing the current 
opioid crisis, and, inexcusably, TrumpCare would only 
exacerbate the crisis.
    Thanks to Medicaid Expansion under the ACA, 1.6 million 
people with substance use disorders now can receive the 
treatment they need in the 31 States and Washington, DC, that 
expanded the program. TrumpCare effectively ends Medicaid 
Expansion in 2020.
    According to the Congressional Budget Office, TrumpCare 
also cuts $880 billion in Federal outlays for Medicaid over the 
next 10 years, which will severely undermine our efforts to 
fight the opioid crisis. These drastic cuts in Medicaid, made 
possible by Republican plans to end Medicaid Expansion and to 
cap the program, will ration care for millions of Americans, 
including the rationing of substance abuse treatment.
    TrumpCare also repeals Essential Health Benefits for 
Medicaid expansion enrollees at the end of 2019. States would 
no longer have to offer benefits like substance abuse, mental 
health services or prescription drugs to millions of Americans 
who rely on such care.
    Repealing the mental and substance use disorder coverage 
provisions of the ACA would remove approximately $5.5 billion 
annually from the treatment of low income people with mental 
and substance use disorders.
    Repeal will take away care from those who are actively 
seeking treatment and preventive services. We simply cannot 
afford to eliminate this care in what is oftentimes a life and 
death situation. TrumpCare, threatens access to life-saving 
treatment for more than one million people with opioid 
disorders.
    Our hearing today explores the fentanyl problem. However, I 
would argue that this issue is a part of a much wider opioid 
problem we are battling. To address this problem, we must make 
sure Americans with substance abuse disorders can access 
effective treatment.
    Mr. Chairman, I want to work with you to confront fentanyl 
and the larger opioid problem. However, repealing the ACA and 
cutting Medicaid by nearly a trillion dollars over the next 10 
years, will do nothing but undermine our efforts to treat 
Americans who are suffering from an opioid addiction.
    We will not be able to arrest our way out of this problem. 
Without adequate treatment options for those suffering from an 
opioid addiction, this problem will only worsen, and so will 
the deaths and destruction we have seen play out across the 
U.S.
    Thank you, and I yield back.

    Mr. Murphy. I thank the gentleman. Yields back.
    For a minute, I want to offer for the record, if unanimous 
consent, an article from the Washington Post called ``Where 
opiates killed the most people in 2015.'' It has interesting 
maps of where these occur throughout the country.
    [The information appears at the conclusion of the hearing.]
    Mr. Murphy. For example, synthetic opioid rates in Ohio, 
West Virginia, and Kentucky, and pockets in New Hampshire, 
Massachusetts, Rhode Island, and other aspects, which kind of 
tell us that there is not one opiate epidemic but several, and 
no silver bullet.
    We are going to have to make sure whatever this committee 
does and finds today from our esteemed witnesses, we are going 
to have to work in a way to give flexibility--maximum 
flexibility to States to work this out.
    I ask unanimous consent that the Members' written opening 
statements be introduced in the record, and without objection 
those documents will be entered in the record.
    Now I'd like to introduce our panel of Federal witnesses 
for today's hearing. We will start with Mr. Kemp Chester, 
Acting Deputy Director in the Office of National Drug Control 
Policy; Mr. Louis Milione, assistant administrator at the 
Diversion Control Division within the Drug Enforcement 
Administration, or DEA; Mr. Matthew Allen, Assistant Director 
of Homeland Security Investigative Programs at the U.S. 
Immigration and Customs Enforcement Division within the 
Department of Homeland Security, or DHS; the Honorable William 
Brownfield, Assistant Secretary of State, International 
Narcotics and Law Enforcement Affairs of the U.S. Department of 
State; Dr. Debra Houry, Director, National Center for Injury 
Prevention and Control at the Centers for Disease Control and 
Prevention; and Dr. Wilson Compton, Deputy Director at the 
National Institute on Drug Abuse within the National Institutes 
of Health.
    I want to thank all our witnesses today for being here and 
providing testimony. We look forward to a very productive 
hearing.
    Let me charge you with this, though, which I usually don't 
do. More people are dying of drug overdose deaths than of guns.
    We have reached the point where more people are dying of 
drug overdose deaths than deaths in the entire Vietnam War, 
almost in a per-year basis.
    What you are going to tell us today is falling on ears that 
are open to anything you can offer us. The families in 
America--and you have heard the stories, impassioned stories 
from Members here--stories of the deep concerns of the number 
of the deaths, the devastation in communities--what you're 
saying here is extremely important.
    So we look forward to hearing from you on this growing 
threat of fentanyl- and opioid-related deaths.
    So as you are aware, this committee is holding an 
investigative hearing, and when doing so it is our practice of 
taking testimony under oath.
    Do any of you have any objection to giving testimony under 
oath? Seeing no objections, the Chair then advises you are 
under the rules of the House and rules of the committee. You're 
entitled to be advised by counsel.
    Do any of you desire to be advised by counsel during your 
testimony today? Seeing none, in that case, will you all please 
rise and raise your right hand and I'll swear you in.
    [Witnesses sworn.]
    Thank you. You are all sworn in. You are now under oath and 
subject to the penalties set forth in Title 18 Section 1001, 
the United States Code.
    I will call upon you each to give a 5-minute summary of 
your written statement. Just watch the lights there and you'll 
have a sense of that.
    I'll begin with Mr. Chester. You are recognized for 5 
minutes.

   STATEMENTS OF KEMP L. CHESTER, ACTING DIRECTOR, OFFICE OF 
   NATIONAL DRUG CONTROL POLICY; LOUIS J. MILIONE, ASSISTANT 
  ADMINISTRATOR, DIVERSION CONTROL DIVISION, DRUG ENFORCEMENT 
ADMINISTRATION; MATTHEW C. ALLEN, ASSISTANT DIRECTOR, HOMELAND 
      SECURITY INVESTIGATIVE PROGRAMS, HOMELAND SECURITY 
INVESTIGATIONS, IMMIGRATION AND CUSTOMS ENFORCEMENT, DEPARTMENT 
    OF HOMELAND SECURITY; WILLIAM R. BROWNFIELD, ASSISTANT 
    SECRETARY OF STATE FOR INTERNATIONAL NARCOTICS AND LAW 
 ENFORCEMENT AFFAIRS, DEPARTMENT OF STATE; DEBRA HOURY, M.D., 
 DIRECTOR, NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL, 
CENTERS FOR DISEASE CONTROL AND PREVENTION; WILSON M. COMPTON, 
   M.D., DEPUTY DIRECTOR, NATIONAL INSTITUTE ON DRUG ABUSE, 
 NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

                  STATEMENT OF KEMP L. CHESTER

    Mr. Chester. Chairman Murphy, Ranking Member DeGette and 
members of the subcommittee, thank you for inviting me and my 
interagency colleagues to discuss the public health and public 
safety issues surrounding the opioid epidemic, particularly 
that of illicit fentanyl and what the Federal Government is 
doing to address this problem.
    I appreciate the committee's strong support of our work to 
reduce drug use and its consequences. I currently serve as the 
acting director of the Office of National Drug Control Policy, 
which crafts the president's drug control policy and oversees 
all Federal Government counter drug activities and related 
funding.
    This is a critical mission because, as you are aware, more 
than 52,000 Americans died from a drug overdose in 2015. That's 
an average of 144 per day with 91 of those deaths involving 
opioids such as prescription pain medications, heroin and 
illicit fentanyl.
    Overdoses involving opioids have nearly quadrupled since 
2000 and between 2013 and 2015 the number of deaths involving 
synthetic opioids other than methadone, a statistical category 
that includes fentanyl, has more than tripled, reaching nearly 
10,000 in 2015, and this number is likely low because not every 
overdose death investigation looks for fentanyl.
    The majority of the illicit fentanyl in the U.S. is 
smuggled in after being produced in Mexico or China. Both 
heroin and clandestinely produced fentanyl can be manufactured, 
packaged and smuggled by the same drug trafficking 
organization.
    The reemergence of illicit fentanyl represents a complex 
problem. It is considerably more powerful than heroin, its 
precursor chemicals are not fully controlled in other 
countries.
    It's being added into the heroin supply or pressed into 
counterfeit prescription opioid pain pills, meaning users are 
often unaware they are taking fentanyl, and because of its 
potency it can be shipped in small packages and transactions 
then involve relatively low dollar amounts, making it much 
harder to detect.
    First responders and police officers report that they need 
to use much more than the standard dose of naloxone to reverse 
an overdose caused by fentanyl, which strains resources.
    We also have a limited capacity to treat those who 
habitually use illicit opioids. Only one in nine people in the 
U.S. who need treatment are receiving it, and we have seen 
outbreaks in many States where fentanyl, carfentanil and other 
fentanyl analogues have played a role in the wave of overdose 
deaths that devastate communities.
    In short, illicit fentanyl is exacerbating an already 
challenging problem that the Federal Government is working 
extremely hard to address.
    The reality of this epidemic has led us to adopt new ways 
of addressing drug use and trafficking. That's why the heart of 
our effort is the partnership between public health and law 
enforcement, some of whom are represented here today, to help 
address the problem in communities across the country.
    We are also working with our State Department colleagues to 
engage foreign partners to prevent illicit drugs from being 
manufactured and trafficked into the United States.
    In terms of public health, we are working to prevent new 
initiates to drug use by encouraging prescriber and public 
education, encouraging prescribes to use the CDC's guidelines 
and their State prescription drug monitoring programs and 
emphasizing prevention efforts to deter drug use initiation, 
including ONDCP's Drug-Free Communities Program.We are also 
working to expand access to treatment including evidence-based 
medication assisted treatment for opioid use disorder and help 
people sustain long-term recovery.
    In this regard, we deeply appreciate Congress' support for 
treatment expansion through the funds authorized under the 21st 
Century Cures Act.
    Another critical innovation is that we are helping to build 
new partnerships between local law enforcement partners and the 
public health community to end this crisis and to establish 
routine cooperation between the Federal Government and the 
State, Tribal. and local levels.
    In terms of reducing the availability of these drugs in the 
United States, the Federal Government's efforts are centered on 
stopping illicit drugs before they cross our borders and 
dismantling the organization that traffic drugs into and 
through our communities.
    Within ONDCP, the National Heroin Coordination Group was 
created in October 2015 in partnership with the National 
Security Council to synchronize Federal Government efforts to 
reduce the availability of heroin and illicit fentanyl across 
the country and address gaps in redundancies in department and 
agency activities through its interagency-coordinated Heroin 
Availability Reduction Plan, which addresses heroin and 
fentanyl as a single problem set.
    ONDCP also funds the High-Intensity Drug Trafficking Areas 
program that coordinates anti-trafficking efforts and 
intelligence across State, local, Tribal, and Federal law 
enforcement communities, and in 2015, ONDCP developed the 
Heroin HIDTA Response Strategy, a coordinated effort across 20 
States and the District of Columbia in response to the heroin 
and fentanyl crisis.
    And internationally we are working with foreign partners 
like Mexico, China and Canada to reduce the supply of illicit 
fentanyl, its precursors and its analogues into and across 
North America.
    While we are working diligently to turn the tide on this 
epidemic, and perhaps are making some progress, we continue to 
work through numerous challenges such as detecting illicit 
fentanyl at our borders and in our mail and parcel system, 
working with our international partners to reduce the 
manufacturing and trafficking of heroin and fentanyl, and 
finding and disrupting the internet marketplaces where illicit 
fentanyl is purchased and delivered.
    Mr. Murphy. Could you finish up because we are----
    Mr. Chester. Yes, sir.
    As the Federal Government works to reduce the size of the 
opioid-using population through prevention and treatment and 
reduce the availability of these drugs in our communities, your 
support for these efforts is critical to our success.
    Thank you, and I look forward to answering your questions.
    [The prepared statement of Mr. Chester follows:]
    
    
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    Mr. Murphy. Thank you, Mr. Chester.
    Mr. Milione, you're recognized for 5 minutes.

                   STATEMENT OF LOUIS MILIONE

    Mr. Milione. Thank you, Committee Chair Murphy, Ranking 
Member DeGette, distinguished members of the subcommittee.
    I want to put these overdose death numbers in some context. 
So spring is here today and major league baseball will kick off 
their season next month.
    Picture the MLB stadium in any of your respective cities. 
The more than 52,000 Americans we lost in 2015 to drug 
overdoses would overflow any of those MLB stadiums, bar none.
    I'm sure we all agree that this is an unimaginable tragedy. 
To the DEA, the fentanyl threat and the broader opioid epidemic 
are the number-one drug threats facing our country.
    With illicitly produced fentanyl, you have substances many 
times more potent than heroin, sold as heroin, mixed with 
heroin and, increasingly, pressed into pill form before being 
sold by criminal networks on our streets as prescription pain 
killers.
    There are five pills that represent five counterfeit pain 
killers. Based on laboratory analysis of the thousands of 
seized counterfeit pills, one of every five will contain three 
times the lethal amount of fentanyl--lethal at 2 milligrams, as 
was mentioned earlier. To the unsuspecting user, death is 
lurking in just one of these pills.
    Sadly, but not unexpectedly, Mexican cartels are exploiting 
the opioid use epidemic and aggressively purchasing illicitly 
produced fentanyl from China, shipping it to Mexico, mixing it 
with heroin and other substances and shipping it back into the 
United States through established distribution networks where 
it is sold in our communities.
    Illicitly made fentanyl is also being shipped from China 
into Canada for distribution across our northern border. It's 
also being shipped directly from China into the United States 
for domestic distribution cells.
    Why are they doing this? Greed and a complete disregard for 
human life. There is a massive profit potential with fentanyl. 
One kilogram of pure fentanyl costs approximately in China 
about $3,500.
    If you project that kilogram of fentanyl all the way 
through the supply chain to the distribution level, that $3,500 
kilogram will potentially yield millions of dollars in revenue.
    For the DEA and broader U.S. Government to deal 
successfully with this threat we need a balanced holistic 
approach that attacks supply and reduces demand. Most 
importantly, we must be proactive.
    We need to use any and all available investigative 
techniques to identify, infiltrate, indict, capture and convict 
all members of these criminal organizations both domestic and 
foreign.
    With 221 domestic offices in 21 field divisions and 92 
foreign offices in 70 countries, DEA, working with our Federal, 
State, local, international partners is well positioned to 
engage in this fight.
    Throughout DEA's proud history, our greatest successes have 
come from our collaborative efforts with the U.S. interagency 
and our foreign counterparts. Our approach to this threat is no 
different.
    We have had success and we will continue to have successes 
against members of these fentanyl manufacturing and 
distribution networks. But here is the most frustrating part.
    Foreign-based fentanyl manufacturers and the domestic Pied 
Pipers of this poison often operate with impunity because they 
exploit loopholes in the analogue provisions of the Controlled 
Substances Act and capitalize on the lengthy resource-intensive 
reactive process required to temporarily or permanently 
schedule these dangerous substances.
    As we speak, criminal chemists in foreign countries are 
tweaking the molecular structure of different fentanyl 
analogues, keeping the same dangerous pharmacologic properties 
as the controlled substances but helping the manufacturers and 
distributors avoid criminal exposure because of an altered 
molecular structure.
    Since July of 2015, DEA has emergency scheduled five 
illicitly produced fentanyls. Four are currently in process. We 
are tracking 19 more.
    Scheduling actions are critically important, but they are 
reactive, resource-intensive processes. We will continue to do 
everything we can on the scheduling front, but in the short-
term, this esteemed body could provide DEA and our law 
enforcement partners immediate relief by placing the identified 
fentanyls and the other dangerous synthetic substances into 
Schedule I.
    This would allow us to keep these drugs out of country and 
bring to justice the egregious domestic and foreign traffickers 
preying on our youth and flooding our country with these 
dangerous drugs.
    I would like to end with two oppositive but interconnected 
images--sunlight and shadows. DEA will always operate in the 
sunlight. We will always follow the rule of law. We will work 
to reduce demand with our community outreach and prevention 
efforts throughout the country.
    But we have to also operate in the shadows. We need to 
infiltrate these secretive, dangerous transnational criminal 
organizations, whether they are here in the United States or in 
foreign countries.
    We need to develop and collect the necessary evidence to 
bring those that exploit human frailty for profit out from the 
shadows and into the sunlight of our transparent judicial 
system for prosecution in the U.S.
    The brave men and women of DEA will continue to do the 
necessarily difficult and dangerous work to address this 
threat.
    Thank you for the opportunity to appear before you and I 
look forward to answering any of your questions.
    [The prepared statement of Mr. Milione follows:]
    
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    
    Mr. Murphy. Thank you, Mr. Milione.
    Now, Mr. Allen, you're recognized for 5 minutes.

                 STATEMENT OF MATTHEW C. ALLEN

    Mr. Allen. Chairman Murphy, Ranking Member DeGette and 
distinguished members, thank you for the opportunity to appear 
before you today to discuss the heroin and fentanyl crisis in 
the United States and the efforts of U.S. Immigration and 
Customs Enforcement to target, investigate, disrupt, and 
dismantle and bring to justice the criminal elements 
responsible for manufacturing, smuggling, and distribution of 
dangerous opioid.
    As the largest investigative agency within DHS, ICE 
Homeland Security Investigations investigates and enforces more 
than 400 Federal criminal statutes.
    HSI special agents use their authority to investigate all 
types of cross-border criminal activity and work in close 
coordination with U.S. Customs and Border Protection and the 
Drug Enforcement Administration in a unified effort with both 
domestic and international law enforcement partners to target 
transnational criminal organizations that are supplying heroin 
and fentanyl to the United States.
    Today, I would like to highlight our efforts to reduce the 
supply of heroin and fentanyl to the U.S. and the operational 
challenges that we encounter.
    The United States, as you have heard already, is in the 
midst of a fentanyl crisis that is multifaceted and deadly. 
Fentanyl is a Schedule II synthetic opioid used medically for 
severe pain relief and it is 50 to 100 times more potent than 
morphine.
    United States law enforcement has identified two primary 
sources of the U.S. illicit fentanyl threat--China and Mexico. 
China is a global supplier of illicit fentanyl and Chinese 
laboratories openly sell fentanyl.
    In China, criminal chemists work around their government's 
control efforts by modifying chemical structures to create 
substances referred to as analogues not recognized as illicit 
in China but having the same deadly effects.
    Although there is ongoing collaboration with China, the 
lack of current Chinese laws that prohibit analogue 
manufacturing or export is one of the challenges we face in 
stemming the flow of illicit fentanyl from China.
    Mexican drug cartels also obtain illicit fentanyl and 
precursor materials required to manufacture fentanyl-related 
substances from China and primarily use fentanyl as an 
adulterant in heroin that is produced in Mexico.
    The cartels have discovered that manufacturing fentanyl is 
much more cost effective, efficient and draws less law 
enforcement attention than cultivating opium poppies to produce 
heroin.
    Fentanyl seized at our U.S. Southwest border is typically 5 
to 10 percent in purity. Once illicit fentanyl is distributed 
in local American drug markets, many people who use drugs, 
whether heroin or prescription pain pills, are unaware of the 
presence of more potent fentanyl in their narcotic.
    As fentanyl used in suspected heroin or counterfeit pills 
is more potent than the drugs they resemble, it readily leads 
to overdosing and this is often how law enforcement first 
learns that fentanyl or an analogue has been introduced into a 
local drug market.
    The addictive nature and demand for opioids paired with the 
low cost and high potency of fentanyl used in counterfeit 
opioid production has led TCOs to compete for a portion of the 
illicit U.S. drug market.
    Illicit fentanyl is not only dangerous for people who abuse 
drugs but also for law enforcement, public health workers and 
first responders who could unknowingly come into contact with 
it.
    Accidental skin contact or inhalation of the substance 
during law enforcement activity or during field testing of the 
substance is one of the biggest dangers and challenges we face 
in law enforcement.
    In response to the dramatic increase in the availability of 
opioids, the Office of National Drug Control Policy, in close 
coordination with other Federal departments and agencies, 
developed a Heroin Availability Reduction Plan to reduce the 
supply of heroin and illicit fentanyl in the United States.
    ICE has been supporting HARP since its inception. We are 
targeting supply chain networks, coordinating with domestic and 
international partners and providing field training to 
highlight officer safety and collaboration efforts.
    ICE is also fully engaged with the DEA Special Operations 
Division and the CBP National Targeting Center to identify 
shipment routes, targeting parcels that may contain heroin, 
illicit fentanyl and fentanyl-related substances and 
manufacturing materials that go into making pills in the United 
States, fully exploiting financial and other investigative 
analyses along the way.
    ICE is committed to battling the U.S. heroin and illicit 
fentanyl crisis that demands urgent and immediate action across 
law enforcement interagency lines in conjunction with experts 
in the scientific, medical and public health communities.
    Thank you for the opportunity to appear before you today 
and I look forward to your questions.
    [The prepared statement of Mr. Allen follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    
    Mr. Murphy. Thank you very much.
    Now, Mr. Brownfield, you are recognized for 5 minutes. Make 
sure your microphone is on, please.

               STATEMENT OF WILLIAM R. BROWNFIELD

    Mr. Brownfield. Thank you, Chairman Murphy, Ranking Member 
DeGette, and members of the subcommittee. Thank you for the 
opportunity to appear before you today.
    The broad interagency panel here today demonstrates that 
this is a health issue, a law enforcement issue and an 
international issue.
    This opioid crisis is perhaps our worst drug crisis in 30 
years. It kills tens of thousands of our fellow citizens every 
year. Illicit fentanyl is responsible for many of those deaths 
and virtually all of that fentanyl is sourced from abroad 
through foreign drug trafficking organizations.
    To solve the problem, we must cut off international supply. 
That is where my INL bureau comes into play.
    Our strategy is three-part--work the neighbors, work China, 
work the United Nations. First, we realize that most illicit 
opioids reaching the United States enter through Mexico and 
Canada.
    Mexico produces more than 80 percent of the heroin consumed 
in the U.S. and Mexican heroin trafficking networks introduce 
fentanyl into the supply chain.
    Since the start of Merida Initiative cooperation in 2008, 
we have developed a close relationship with Mexican Federal law 
enforcement. We have delivered hundreds of millions of dollars 
in border inspection and law enforcement equipment, training 
and capacity building and intelligence exchange.
    Mexico invests $20 for every one of ours. Mexico has 
increased efforts to eradicate opium poppies and we recently 
agreed to expand those efforts further.
    Canada is suffering its own opioid crisis, although most of 
its heroin comes from Afghanistan. We coordinate closely with 
Canada to address a shared crisis, ensuring both governments 
have statutory authority to address the problem and sharing 
real-time law enforcement intelligence.
    And all three governments cooperate through the new North 
American Drug Dialogue where we share information on narcotics 
research, exchange best practices and develop actions to 
protect our citizens.
    Second, we have expanded cooperation with China, a major 
fentanyl source country. In 2015, China moved to regulate 116 
new synthetic drugs and on March 1st of this year it added four 
critical fentanyl analogues to its domestic control including 
carfentanil, sometimes described as fentanyl on steroids--100 
times more potent than fentanyl.
    We asked China to do more, but I acknowledge these steps by 
the Chinese Government. They improve our ability to track and 
control fentanyl and other synthetic drugs entering the United 
States.
    We are also using, targeting and sanctions programs like 
the narcotics reward and drug kingpin authorities to target 
fentanyl traffickers.
    For nearly 20 years, the U.S. and China have coordinated 
law enforcement policy through the U.S.-China Joint Liaison 
Group on Law Enforcement and that dialogue produces valuable 
cooperation.
    Third and finally, we are working through the U.N. system 
to regulate dangerous opioids and precursors throughout the 
world. I was in Vienna last week for the annual meeting on the 
Commission on Narcotic Drugs, the governing body for all U.N. 
drug policy.
    By a vote of 51 to 0, the CND approved our proposal to 
regulate two essential fentanyl precursors. The entire process 
took four months rather than the normal 2 years, and while the 
regulation will not stop illicit fentanyl production, it will 
be more difficult for criminals to obtain the chemicals needed 
to make it and easier for countries to prosecute them.
    We also support programs by the U.N.'s drug control 
organization, UNODC, to eliminate opium poppy cultivation and 
heroin production in Afghanistan, Mexico, Colombia and 
Guatemala.
    Mr. Chairman, members of the committee, we have an 
international strategy. We are committed to that strategy. We 
welcome ideas to improve that strategy.
    I have learned two lessons in 25 years engagement in 
international drug policy. First, it takes decades to get into 
a drug crisis and will take years of patient persistent effort 
to get out. Second, no strategy is so perfect it cannot be 
improved.
    Thank you, Mr. Chairman. I look forward to the committee's 
suggestions.
    [The prepared statement of Mr. Brownfield follows:]
    
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    Mr. Murphy. Thank you.
    Dr. Houry, you are recognized for 5 minutes.

                    STATEMENT OF DEBRA HOURY

    Dr. Houry. Chairman Murphy, Ranking Member DeGette, I would 
like to thank you for inviting me here today to discuss this 
very important issue.
    As the director of the National Center for Injury 
Prevention and Control at the CDC, I would also like to thank 
the committee for your continued interest in the prevention of 
opioid misuse and prevention and overdose.
    As an emergency physician, I have seen first hand this 
devastation all over the country. Drug overdose deaths in the 
United States have nearly tripled in the last 15 years. In 
2015, there were approximately 52,000 drug overdose deaths and 
of those 63 percent involved an opioid.
    The large increase in deaths seem to be primarily driven 
from heroin and synthetic opioids such as fentanyl. fentanyl is 
an opioid analgesic 80 times more potent than morphine and is 
almost administered in hospital settings for painful 
conditions.
    Illegally manufactured fentanyl can be mixed with or sold 
as heroin and is fast acting. Overdoses can occur in seconds 
after consumption and an overdose from fentanyl is much more 
difficult to reverse because it is so powerful.
    The rate of drug overdose deaths involving fentanyl more 
than doubled from 2013 to '14, and some States have seen the 
dramatic effect of this drug much more so than others.
    For example, Massachusetts experienced a surge of opioid-
related deaths from 698 in 2012 to 1,747 in 2015. To examine 
this increase, the Massachusetts Department of Public Health 
requested CDC's assistance in an epidemiological investigation, 
or Epi-Aid.
    CDC determined that over 74 percent of the recent drug 
overdose deaths involve fentanyl and recommended conducting 
outreach to high risk groups such as people with substance 
abuse problems recently released from incarceration.
    The rise in fentanyl, heroin and prescription drug 
overdoses are not unrelated. In Ohio, CDC found that 
approximately 62 percent of fentanyl and heroin overdose deaths 
were preceded by at least one opioid prescription during the 7 
years prior to death and one in five people who died from a 
fentanyl overdose had an opioid prescribed to them at the time 
of their death.
    CDC is committed to three strategies that comprehensively 
protect the public's health and prevents all opioid misuse and 
overdose deaths.
    The first approach is improving data quality and timeliness 
to better track trends, identify communities at risk and 
evaluate prevention strategies.
    CDC funds 12 States to improve tracking and reporting of 
illicit opioid overdoses including fentanyl. Improved 
surveillance is crucial for States to facilitate faster 
identification in response to spikes in overdoses, leading to 
quicker, more tailored interventions.
    The second approach is supporting States in their efforts 
to implement effective solutions and interventions. CDC has 
funded 44 states and Washington, DC, for prevention efforts and 
surveillance activities.
    For example, we have funded Ohio to use their prescription 
drug monitoring program to identify high-risk patients and they 
have achieved full data integration with Kroger Pharmacies as 
part of their integration with electronic health records.
    Our third approach is to equip health care providers with 
the data and tools needed to improve the safety of their 
patients. To aid primary care providers and evidence-based 
prescribing practices, CDC developed and published the CDC 
guideline for prescribing opioids for chronic pain.
    In addition to the critical partnership with States, CDC 
knows this epidemic requires partnerships across sectors and 
we've been working side by side with law enforcement. We are 
working with the Drug Enforcement Agency to implement 
prevention strategies and have initiated a personnel exchange.
    The heroin response strategy, which is funded by ONDCP and 
deployed in eight high-intensity drug trafficking areas, sets 
out to link public health and public safety. CDC is working to 
coordinate public health workers on the ground. Successfully 
addressing this problem requires focused efforts in prevention. 
All three components--law enforcement, treatment and 
prevention--must work together to reverse this dangerous 
threat. We each have a critical role to play. Without 
effectively preventing more Americans from developing opioid 
use disorder in the first place we will never get ahead of the 
problem. Without prevention, more Americans will require 
treatment, often for the rest of their lives, and more will 
overdose.
    Thank you again for the opportunity to be here with you 
today and for your continued support of CDC's work in 
protecting the public's health. I look forward to your 
questions.
    [The prepared statement of Dr. Houry follows:]
    
    
    
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    Mr. Murphy. Thank you, Doctor.
    Now, Dr. Compton, you're recognized for 5 minutes.

                 STATEMENT OF WILSON M. COMPTON

    Dr. Compton. Chairman Murphy, Ranking Member DeGette and 
members of the subcommittee. Thank you for inviting me to 
provide an overview of how science can help us address the rise 
in fentanyl use in overdose deaths.
    My name is Dr. Wilson Compton and I'm the deputy director 
of the National Institute on drug abuse. As a physician and 
researcher, I've seen first hand the devastating impact of the 
opioid crisis on families and communities and have conducted 
numerous studies to better understand trends in opioid use and 
ways to respond.
    What is fentanyl and its relationship to the opioid crisis? 
Fentanyl's high potency and fat solubility allow it to rapidly 
enter the brain, leading to a fast onset of effects which 
increases the risk for addiction and overdose.
    The emergence of fentanyl and other even higher potency 
synthetic opioids creates enormous challenges for controlling 
supply since very small amounts can cause large-scale damage to 
users as well as to law enforcement and first responders who 
may come into contact with the drugs.
    Fentanyl is one part of the ongoing opioid overdose 
epidemic which also includes prescription opioids and heroin. 
While recent Federal and State efforts have begun to help curb 
over prescribing of the prescription opioids, overdoses 
continue to rise mainly due to the rise in heroin in fentanyl-
related deaths.
    NIDA's efforts in this area are part of the broader 
initiatives of the Office of National Drug Control Policy and 
the Department of Health and Human Services.
    The population of people using fentanyl largely overlaps 
with those using heroin and so the strategies being implemented 
to address the ongoing opioid crisis are expected to help 
address fentanyl addiction and overdoses.
    NIDA, along with FDA, co-chairs the Opioid Subcommittee of 
the Department of Health and Human Services Behavioral Health 
Coordinating Council and in this role we help to coordinate 
interagency efforts.
    So how is research helping to address the opioid crisis? 
NIDA has supported the development of the three medications 
that have been FDA approved to treat opioid addiction. 
Methadone, buprenorphine and naltrexone all have strong 
evidence of effectiveness.
    Despite this effectiveness, only a fraction of people with 
opioid use disorders are being treated with these medications 
due to limited treatment capacity, stigma, lack of provider 
training and cost.
    Therefore, NIDA research is helping to develop strategies 
to promote wider adoption of these medications in variety of 
settings. For example, initiating buprenorphine treatment in 
emergency departments has been shown to help ensure that people 
who overdose are effectively engaged in ongoing treatment for 
their underlying opioid use disorder.
    Other studies have found that providing interim 
buprenorphine or methadone while awaiting admission to a 
treatment program reduces opioid use and increases the 
likelihood of engaging in treatment.
    How can research specifically inform our response to 
fentanyl? Through NIDA's national drug early warning system, we 
are supporting research to better understand fentanyl's use 
patterns and trends in hot spots such as Ohio and New 
Hampshire.
    In the first phase of the New Hampshire study, for example, 
researchers reported that about one-third of fentanyl users 
knowingly use the drug and may seek out a certain dealer or 
product when they hear about overdoses because they think it 
must be highly potent.
    What about overdose treatment? Although naloxone can 
rapidly reverse an opioid overdose, the current standard dose 
of naloxone is likely not adequate to reverse some overdoses 
from high-potency opioids like fentanyl.
    In response, we are supporting research to develop new 
longer lasting naloxone formulations and new administration 
protocols.
    NIDA also supports research on prevention and treatment. 
For instance, in partnership with the CDC, SAMHSA and the 
Appalachian Regional Commission, NIDA is testing interventions 
to address opioid misuse in rural America.
    In addition, we are planning a research initiative to study 
treatment expansion models resulting from the additional 
resources provided to states via the 21st Century Cures Act.
    Research is also underway to develop a vaccine for fentanyl 
to keep fentanyl from entering the brain, thereby protecting 
against addiction and overdose.
    In summary, over 33,000 deaths for opioid overdoses 
occurred in 2015 with nearly 10,000 involving synthetic opioids 
like fentanyl. Science-based solutions are available. The 
challenge is often in their implementation.
    NIDA will continue to work closely with the other Federal 
agencies, both those that are here today and many others, 
community organizations and private industry to address these 
complex challenges.
    Thank you. I look forward to your questions.
    [The statement of Dr. Compton follows:]
    
    
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    Mr. Murphy. Thank you, Doctor.
    We will now begin with questions. I will recognize myself 
for 5 minutes.
    Mr. Chester, does the ONDCP believe that fentanyl is 
another wave of the opioid epidemic?
    Mr. Chester. Yes, sir. It really is two things. I think it 
is an outgrowth of the heroin crisis, and then once fentanyl 
has found its way into the supply chain it represents a unique 
aspect of that particular problem.
    Mr. Murphy. So do we have a strategic plan? Does the 
Federal Government have a strategic plan to address that unique 
issue?
    Mr. Chester. We do. As I mentioned, the Heroin Availability 
Reduction Plan included both heroin and fentanyl as part of its 
problem set and that particular plan guides and synchronizes 
Federal Government activities against the opioid problem set, 
specifically heroin and fentanyl. Yes, sir.
    Mr. Murphy. Mr. Milione, do you believe that with this 
unprecedented threat of fentanyl that we have a Federal plan 
solidly in place as broad as it needs to be?
    Mr. Milione. I always think there is more to do, based on 
the level of the threat. Certainly, at DEA it is a priority. We 
have programs in place to deal with it. But as Ambassador 
Brownfield said, there is always room for improvement based on 
the need of the threat.
    Mr. Murphy. Mr. Allen, based on the data that our law 
enforcement places at international mail facilities at nine 
different airports in 2015 and 2017, I find it amazing that not 
one package of fentanyl was detected out of 8,473 that were 
examined.
    Is there more difficulty in coming up with a targeting 
profile for fentanyl shipments than we know about and what can 
be done to prove this?
    Mr. Allen. Detection of fentanyl in--you know, at the land 
border and in consignment packages and mail is a challenge that 
we continue to deal with. I think we have better success in 
certain channels than we do in others. Because Customs and 
Border Protection gets advanced information from the express 
consignment companies, their ability to target packages that 
are inbound to the United States is much better than our 
ability to target mail that is coming to the United States 
because the universal postal union that we operate under does 
not mandate that international shippers including China and 
others provide advanced information about packages and mail 
that is coming to the United States.
    Mr. Murphy. So requiring that would help? Would requiring 
that information help with the postal service?
    Mr. Allen. Yes, it would.
    Mr. Murphy. Can I also ask where is--who can answer this 
question? Where is it coming over the border with Mexico? I 
understand it is places in California and Arizona, am I 
correct? Do we know specifically?
    Mr. Allen. The two areas where we've seen it most prevalent 
is in southern California and southern Arizona. The vast 
majority has been detected.
    Mr. Murphy. And how do they bring it across the border?
    Mr. Allen. In personally owned vehicles or on bodies 
coming--people that are coming as pedestrians across the land 
border detected at ports of entry.
    Mr. Murphy. People--so people walk across or people who 
come through--legally through ports of entry and it is either 
way? Illegal or legal, they're both coming through?
    Mr. Allen. Legal. Where we are not detecting it is between 
the ports of entry. We are seeing it come in at designated 
points of entry and it is being detected and seized and arrests 
are being made by Customs and Border Protection at ports of 
entry.
    Mr. Murphy. But in other parts we are not seeing it? 
They're coming across the border in other places and they're 
not picked up there?
    Mr. Allen. On the land border we are not seeing it come 
between the ports of entry. The other method of it coming into 
the United States is through express consignment packages and 
mail, which generally is detected in the interior at express 
consignment hubs where all consignment packages are cleared by 
CBP or at international mail facilities that are designated 
around the United States.
    Mr. Murphy. Thank you.
    Dr. Houry, the most recent available data of fentanyl-
related overdose deaths come from 2015. Am I correct or do you 
have more recent data for 2016?
    Dr. Houry. So we have data through 2015 but we've also 
released a quarterly report for 2016 through the National 
Center for Health Statistics and that is death data.
    I think what is really helpful is, with the funding that we 
received this past year, we've stood up a surveillance system 
in 12 States that looks at nonfatal data also. That has been in 
place for six months.
    That allows us to have some DROMIC data from emergency 
departments to capture more quickly emerging trends.
    Mr. Murphy. With all that, is it--do you think it is still 
underreported significantly?
    Dr. Houry. I do think it is significantly under reported 
because many medical examiners and coroners aren't testing for 
fentanyl analogues. Up to 20 percent of times, you know, the 
type of drug is not reported. We are working with AFSO and with 
the National Association of Medical Examiners to improve death 
certificate reporting.
    Mr. Murphy. Dr. Compton, in just a few seconds--it is a 
scientific challenge. Can you explain how it is that fentanyl 
is more dangerous than other opioids medically?
    Dr. Compton. Well, the key is through both its strength as 
well as its fat solubility. So not only is it inherently more 
potent but it can more rapidly enter the brain where it exerts 
its respiratory depression, which is what kills people.
    Mr. Murphy. And all right. We will get to more of these but 
I will go to Ms. DeGette now for 5 minutes. Thank you.
    Ms. DeGette. Thank you very much, Mr. Chairman.
    Mr. Milione, as I mentioned in my opening statement, I 
think we all agree the amount of fentanyl recovered by American 
law enforcement has risen from 640 samples tested to 13,000 
samples tested in 2015. Would you agree with that statistic?
    Mr. Milione. I would, not having them in front of me. But 
that sounds right.
    Ms. DeGette. Yes. I mean, it is really raised--going up in 
crisis proportions, right?
    Mr. Milione. That's correct.
     Ms. DeGette. And have arrests for counterfeit pills or 
sources increased as well?
    Mr. Milione. I would have to get back to you as far as if 
there has been an increase. We have been studying--we have been 
very aggressively investigating these networks.
    Ms. DeGette. But I think you would agree that the amount of 
fentanyl recovered has been growing exponentially, right?
    Mr. Milione. It has.
     Ms. DeGette. Now, Dr. Compton, I want to ask you, because 
other opioids sometimes--often lead to fentanyl use some have 
suggested that to stem the demand for fentanyl we also need to 
treat opioid addiction because addiction drives the users to 
seek those other drugs that contain fentanyl. Would you agree?
    Dr. Compton. Yes. I think the fentanyl issue is most 
closely related to heroin addiction. So it is the very same 
people using heroin that seem to have the most trouble with 
fentanyl.
    Ms. DeGette. And treatment, as we've learned in many, many 
hearings in this subcommittee, is an important component in the 
addiction fight. Is that right?
     Dr. Compton. Absolutely. We think expanding treatment 
access is a key component of our--of our attempts to address 
this.
    Ms. DeGette. Now, based on--I assume you have had 
experience with opioids and with heroin. You just can't stop 
this by arresting people. Would that be fair to say? You have 
got to also have treatment.
    Dr. Compton. I think it is either--to point out that it is 
the combined public health and public safety approaches that 
look most promising.
    So we look at models that include criminal justice systems 
as well as public health as showing reductions in crime as well 
as important health outcomes.
    Ms. DeGette. OK. But health outcomes are a key part of 
that, right?
    Dr. Compton. Of course.
    Ms. DeGette. And so this what I am concerned about. When 
you're trying to treat opioid addiction, as we have also 
learned in our many hearings in this subcommittee it is a 
comprehensive treatment that is very extensive. Wouldn't you 
agree with that?
    Dr. Compton. Yes. We have certainly learned that the 
treatment needs to last quite a long time. It takes people a 
long time to turn their lives around and recovery is not an 
instantaneous process.
    Ms. DeGette. And these drugs, they sometimes change the 
chemistry of the brain so that you have to have to medication-
assisted treatment and other types of tools to be able to treat 
this. Is that right?
    Dr. Compton. Yes. NIDA research has certainly demonstrated 
that.
    Ms. DeGette. And so in some of these States that have been 
hit hard with the opioid and fentanyl epidemic, the Medicaid 
expansion that they have been able to get has been able to help 
them really target populations for addiction treatment and 
prevention. Would that be fair to say?
    Dr. Compton. Certainly treatment expansion is a shared goal 
for all of us and making sure that the research we support is 
embedded within the health care system is essential.
    Ms. DeGette. Now, in the past few years after the passage 
of the Affordable Care Act Medicaid was now able to pay up to 
50 percent of medication treatment in some of these hardest-hit 
States. Is that right?
    Dr. Compton. Well, I would really want to refer the 
specific questions about how Medicaid is funded to the State 
officials that implement those programs or the CMSes.
    Ms. DeGette. So you are not familiar about how some States 
in the last years have been able to increase their treatment?
    Dr. Compton. I'm certainly familiar with the States' 
efforts to expand treatment in the last few years.
    Ms. DeGette. Well, let us talk about Ohio, for example. In 
Ohio, Republican Governor John Kasich recently said, ``Thank 
God we expanded Medicaid because that Medicaid money is helping 
to rehab people,'' and in fact a February 6th, 2017, Pew Report 
noted that Ohio added 700,000 new Medicaid recipients under its 
expanded program, and roughly a third were diagnosed with a 
substance abuse disorder.
    According to the CBO, the Republican ACA repeal's proposal 
would cut $880 billion in Federal outlays for Medicaid over the 
next 10 years. Would you disagree with any of those figures?
    Dr. Compton. Well, certainly, we are interested in research 
that can look at changes in the health care system. We are 
partnering with SAMHSA to study the implementation of the 21st 
Century Cures Act.
    Ms. DeGette. Right. But would you--would you disagree, for 
example, that Ohio added 700 [sic] new Medicaid recipients 
under its expanded program and a third were diagnosed with 
substance abuse disorders?
    Dr. Compton. Those figures sound reasonable.
    Ms. DeGette. OK. So what I'm worried about is probably 
pretty clear. If you reduce the Medicaid expansion that in 
States like Ohio, Kentucky, West Virginia, other States that 
have been hard hit by fentanyl and opioid and heroin that that 
is also going to reduce the treatment programs we are able to 
give them.
    Thank you, Mr. Chairman.
    Mr. Murphy. You're right. We can't arrest our way out of 
this. We have to treat it. And just a follow-up to what you're 
saying: Do we even have enough providers? Does anybody know? We 
know that half the counties in America don't have 
psychiatrists, psychologists, social workers. Do we have enough 
trained drug treatment providers in America?
    Dr. Compton. We do not have enough to fully meet the needs 
and they are not evenly spread across the country. So that is 
why we are engaging in the rural initiative to address the 
particularly severe shortages in rural areas.
    Mr. Murphy. Thank you very much.
    Dr. Houry. And I would just add to that treatment is 
important but preventing people from needing addiction services 
in the first place will also save the health care system a lot 
of money. So making sure we are using safe prescribing 
practices is a key component.
    Mr. Murphy. And we'll get to that as well.
    Ms. Walters of California is recognized for 5 minutes.
    Ms. Walters. Thank you, Mr. Chairman.
    We have seen the opioid and heroin epidemic ravage every 
part of our country. Even affluent areas like my home of Orange 
County, California, are struggling with over 200 deaths per 
year.
    Now we are witnessing a far deadlier iteration, fentanyl-
laced drugs. This incredibly powerful pain killer reserved for 
the most severe and acute pain are being added to heroin, 
cocaine and counterfeit drugs.
    As a mother of four young adults, it breaks my heart every 
time I see or hear of another life lost. Just last year, a 19-
year-old from Orange County overdosed after taking fentanyl-
laced cocaine.
    This epidemic again hit home when a DEA investigation 
resulted in four arrests for an alleged fentanyl importation 
and distribution conspiracy in Long Beach.
    The DEA reported that the men had over 30,000 acetyl 
fentanyl tablets and 13 kilograms of the narcotic.
    Mr. Milione, I want to commend your agency for this 
investigation and keeping this deadly drug off the streets of 
Orange County.
    Mr. Milione, the making and distributing of pills 
containing fentanyl has been disguised by molding the pills in 
a wide variety of counterfeit brands and colors. What are the 
most prevalent pill types being discovered?
    Mr. Milione. Thank you for the question. It's a pretty 
broad range but oxycodone--they are going to mimic whatever is 
popular on the street depending on the market, depending on the 
area.
    So if there is a real market for oxycodone 30s, they'll 
replicate those. If it is more a powdered substance that they 
want in a capsule because they'd rather snort the substance, 
that market will influence how they package it.
    Ms. Walters. What types of pill making machinery are most 
commonly associated with these counterfeit drug operations?
    Mr. Milione. There is a broad range. I mean, anywhere from 
an inexpensive pill machine to ones that cost $10,000, $15,000, 
$20,000 that can produce 250,000 pills an hour.
    Some of them are handheld that can be very easily used. So 
it is a broad spectrum there.
    Ms. Walters. OK. And what are the most likely sources of 
these counterfeit drugs?
    Mr. Milione. China is the primary source for the fentanyl. 
But then, as I said before, going into Mexico and then the 
networks are shipping the merchandise up into the United 
States, and what we are seeing more and more is that actually 
the pills--the counterfeit pills--are being made in the United 
States at different domestic transportation cells around the 
country.
    Ms. Walters. OK. Thank you. And Dr. Houry, we understand 
that the typical victim of a fentanyl overdose can be extremely 
hard to define since it does not follow economic structure or 
community locales.
    What can you tell us about current trends and tendencies?
    Dr. Houry. So you are right, we are seeing this epidemic 
really increase in all demographics. It's most hardest hit in 
those 20 to 44 and really that--or 25 to 44 and we are seeing 
it more in men.
    What I think is important, though, is people--like in Rhode 
Island we saw that a third of the decedents had had a 
prescription within the past 90 days for an opioid and a third 
of those had had a high dose of morphine milliequivalent 
prescription.
    So what we had said in the guideline to really be cautious 
was that people are getting exposed to opioids and then going 
on to fuel their addiction through heroin and fentanyl.
    Ms. Walters. OK. Thank you.
    And Mr. Chester, in recent months fentanyl was first 
identified as a major problem in the Northeast, parts of the 
Midwest and certain States like Florida and Maryland. What do 
you see as trends or directions of its spread?
    Mr. Chester. We have begun to see some indications that it 
has moved west. Obviously, Sacramento, California was the first 
one. That was about a year ago that we had begun to see it move 
a little bit farther west.
    I think fentanyl found its way into the Northeast simply 
because it was easier to mix into the powdered white heroin 
that was popular in the northeast United States.
    And so in the western part of the United States we are 
beginning to see more of the pill form that Mr. Milione was 
discussing as well.
    But fentanyl, even though it began being geographically 
concentrated in the Northeast, we've seen indicators of areas 
throughout the United States.
    Ms. Walters. OK. Thank you. And I yield back the balance of 
my time.
    Mr. Murphy. Ms. Castor is recognized for 5 minutes.
    Ms. Castor. Well, thank you, Mr. Chairman, for calling this 
hearing and thank you to all of our expert witnesses for 
shining a light on this.
    It does feel like we are in the Twilight Zone though 
because as we are talking about the seriousness of the opioid 
epidemic we are faced in two days with a vote on a health bill 
that will recede in this country's responsibility in health 
services to families who are addicted, who need substance abuse 
treatment, mental health treatment.
    Mr. Chester, you said that only one in nine are receiving 
treatment who need it. Mr. Milione, you say we have to reduce 
demand as part of a balanced strategy.
    And yet, this GOP health care bill that is coming to the 
floor will take a hatchet to coverage for millions of Americans 
plus it will end Medicaid health services as we know it that 
provide in Florida, in most States, the most important mental 
health and substance abuse health services.
    So this is very important. But, boy, this bill that is 
coming up for a vote would really take us backwards when we are 
talking about opioids.
    In fact, my--one of my local sheriffs in Pinellas County, 
which is St. Petersburg and Clearwater, says we cannot and we 
never will solve this problem at the law enforcement level.
    This needs to be treated as an addiction problem--a mental 
health problem. We may have had great success in beating back 
the pill mills but all that meant is we are going to see a 
switch to different drugs and different dealers.
    And I wanted to highlight what's happening in West Virginia 
because it is startling and there is a good investigative 
reporter that is shining a light on it.
    Mr. Milione, according to a December 2016 article in the 
Charleston Gazette Mail, opioid wholesalers ship mass 
quantities of opioid medicines that appear to be foreign excess 
of what certain communities in West Virginia should receive 
based on sound medical needs.
    The article says, ``In six years, drug wholesalers showered 
the State with 780 million hydrocodone and oxycodone pills 
while 1,728 West Virginians fatally overdosed on those two 
painkillers. The unfettered shipments amount to 433 pain pills 
for every man, woman and child in West Virginia.''
    This reporting strongly suggests that West Virginia appears 
to have been receiving quantities of hydrocodone and oxycodone 
pills that would clearly be more than what would be medically 
necessary.
    Mr. Milione, are you familiar with some of the reporting 
which suggests West Virginia may have been grossly oversupplied 
with dangerous prescription opiates?
    Mr. Milione. I am.
    Ms. Castor. I mean, this is really shocking. It would 
appear that addiction to pain pills can, according to all of 
the reporting and what you all have testified here today that 
once you have oxy and hydrocodone that takes over someone's 
life that that will quickly lead to the user seeking more 
powerful opiates such as heroine or counterfeit pills, both of 
which may be adulterated with fentanyl.
    Dr. Houry, in your testimony you say reversing epidemic--
the epidemic requires changing the way opioids are prescribed. 
Is it therefore reasonable to assume that addiction to 
prescription pain medicines have a connection ultimately to the 
fentanyl problem and the larger opioid epidemic?
    Dr. Houry. Yes. Many of the people who have overdosed on 
fentanyl have had a opioid prescription at the time of their 
death. So I believe all of these fentanyl, heroin and 
prescription opioid overdose deaths are linked.
    Ms. Castor. And Mr. Milione, MSNBC also ran a story about 
the substantial influx of opioids into West Virginia. It 
reported on a small town called Kermit, which I understand only 
has 392 people.
    They reported that Kermit received 9 million hydrocodone 
pills in 2 years. If this reporting is true, it is hard to 
believe that we have sufficient systems in place to spot 
dangerous trends.
    Is the DEA familiar with the reports regarding what 
happened in this small town with the oversupply of addictive 
pills and what can you tell us about it?
    Mr. Milione. I am familiar with that report, but we are 
all--we are familiar that that has happened in many, many 
locations across the country. So we have an obligation, 
obviously, across the whole supply chain from the manufacturers 
to the distributors.
    Ms. Castor. What is happening with the wholesalers?
    Mr. Milione. Well, the wholesalers have to uphold their 
regulatory obligations and we have taken action recently 
against the big--two of the big three, McKesson and Cardinal.
    Our hope is that their compliance programs, like any good 
corporate citizens, would work to prevent diversion and they 
would uphold those obligations. But it is not just the 
wholesalers. We have to go all the way down the supply chain in 
order to kind of try to maintain this closed system of 
distribution.
    So it is certainly complex and it is a challenge. But we 
are well aware of all the issues across the country.
    Ms. Castor. Thank you. My time has run out.
    Mr. Murphy. Thank you.
    Dr. Burgess, you're recognized for 5 minutes.
    Mr. Burgess. Thank you, Mr. Chairman.
    Mr. Milione, let me stay with you if I can, and I don't 
know if we can get this map of the opiate deaths in 2015 up on 
the screen. But the map is almost counterintuitive to me. We 
talk about--that is not the one. It is the total opiate deaths 
in 2015, just for the purposes of illustration. Thank you.
    Almost counterintuitive--six of the States with the lowest 
numbers--go back one slide, please--six of the States with the 
lowest numbers, of those six, four are border States--Texas, 
California, North Dakota, and Montana--which would be 
counterintuitive if we talk about things that are coming in 
across the border.
    But also if you look at the map, boy, it seems like there 
is a bullseye on the Midwest, and what are you doing to sort of 
interrupt those supply chains that seem to have targeted a 
portion of the country?
    Mr. Milione. A great question. So you're right, it is 
transiting in and it is going to--it is not staying at the 
border where it crosses. It is going to locations around the 
country.
    The Northeast is getting hit. The Midwest is, 
unfortunately, increasingly getting hit. But now the West is 
also getting hit.
    So what are we doing? Applying law enforcement techniques. 
We are working with our Federal partners, infiltrating the 
supply chain but also looking at the distributors and trying to 
disrupt them with the judicial process.
    Mr. Burgess. Ambassador Brownfield, let me ask you a 
question and anytime we have a Texan on the panel that is a 
good thing. So I thank you for being here today.
    And just for the record, you are career at the State 
Department. Is that correct?
    Mr. Brownfield. I am, Congressman.
    Mr. Burgess. Well, and thank you for your service to the 
State Department.
    Now, of course, the secretary is in China or has been in 
China recently. Your testimony today--your written testimony 
that you provided and your--and your verbal testimony kind of 
indicated that perhaps things were looking up. Things were--
there were positive developments, and I guess I am just not 
feeling that there are positive developments.
    And in fact, Mr. Milione, please don't arrest me but I went 
online and looked at how to order fentanyl online just while we 
are sitting here and there are a lot of opportunities and I 
suspect those opportunities many of them come from Asia or come 
through China.
    Mr. Brownfield, do you--Ambassador Brownfield, do you think 
we are doing enough to interrupt those?
    Mr. Brownfield. Congressman, I will say we are starting 
very close to point zero in terms of our cooperation with 
China. We have moved in a positive direction.
    We are dealing with a country that has somewhere between 
170,000 and 400,000 companies that produce pharmaceuticals 
somewhere in the People's Republic of China.
    As recently as 2 or 3 years ago, there was largely no 
control over their production whatsoever. Since then, 116 
synthetic drugs are now controlled by the Chinese Government 
and within the last month and a half--literally, within the 
last month, 4 new ones, including important fentanyl analogies, 
are now controlled by the Chinese Government.
    We have a dialogue. We are talking to one another. Three 
years ago, their answer was--by the way, is not unusual--around 
the world was we do not have a fentanyl problem and therefore 
we are not particularly interested in cooperating with you 
because it is not being abused in China.
    We have gotten beyond that. Are we where we want to be? No, 
of course not. What you have just proven is we have not yet 
solved the problem. But are we in fact ahead of where we were 2 
or 3 years ago? On that, I say yes.
    Mr. Burgess. Well, and that--I thank you for that effort. I 
agree with you that is a positive development. But given the 
distributional aspects on our United States map, is it 
possible--and, really, it is for anyone on the panel--is it 
possible to identify from which laboratories or manufacturing 
houses overseas, which are causing us the greatest problems in 
these areas that we are seeing on our United States map. Does 
anyone have an answer for that?
    Mr. Milione. Congressman, it is a great question, and to 
build on what Ambassador Brownfield was saying, we have had, on 
the law enforcement side in China in our Beijing country office 
tremendous success getting leads from the Chinese of U.S.-based 
recipients of their fentanyl. That's a huge step forward and 
allows us now to kind of uncover that network in the United 
States.
    Yes, we have had successes uncovering what those labs are 
in China and we've been working cooperatively with our law 
enforcement counterparts over there and we are very pleased 
with the direction that it is going.
    Mr. Burgess. Well, and just in the limited time I have 
remaining, Dr. Houry and Dr. Compton, I mean, both of you 
talked about fentanyl use patterns and I'm a big believer in 
prescription drug monitoring programs.
    Look, I was a physician. It's important to have drugs like 
fentanyl available. We are grateful for their utility in 
clinical settings. Clearly, they have to be used appropriately.
    But do you have a sense of what I was talking to the DEA 
and the State Department about--do you have a sense of where 
the use patterns are occurring?
    Is--are you able then to target limited resources so that 
perhaps an ER can have one of these early intervention 
programs?
    If you're in a hot spot I think that is a good idea. If 
you're in--out in Lubbock, Texas that might not be as 
important.
    Dr. Houry. In Ohio we were able to do that. We did an Epi-
Aid there and found eight counties that had highest rates. We 
were able to then, you know, help guide Ohio to where to focus 
their efforts. And then in Massachusetts we also saw that there 
was a high rate of overdose deaths in those that were recently 
incarcerated--about 50 times what we saw in other populations.
    So we were able to use the data for that. With prescription 
drug monitoring programs you can very much see people at risk 
for opioid use disorder and use that to help link to further--
--
    Mr. Burgess. Are you?
    Dr. Houry. What we are doing right now is the program has 
been in place for 2 years and we are in 44 States and getting 
data that is quicker and better able to be used by States and 
letting States really focus on evidence-based interventions.
    Mr. Burgess. I am way over time but, honestly, we 
authorized NASPR back in 2005. It shouldn't be just recently. 
This should have been an ongoing exercise over the last decade, 
in my opinion.
    Thank you, Mr. Chairman. I will yield back.
    Mr. Murphy. The gentleman yields back.
    Before I recognize the next one, I want to put together a 
couple pieces here we just had. So the gentlelady from Florida 
and Dr. Burgess from Texas talked about these issues.
    Kermit, West Virginia--I think that is where you mentioned 
this tremendous prescription rate--massive amount. I pulled up 
another chart here of disability rates in the United States and 
don't you know, Mingo County and those areas in West Virginia 
are among the highest in the Nation, where Dr. Burgess just 
pointed out the deaths that are occurring there.
    It makes me wonder as you're talking about collecting more 
data, Dr. Houry, how much more data do you have to have? You're 
seeing these targeted areas where the amount of prescriptions 
is way, way out of control.
    You can see on that map. This is way out of control and 
yet--and these deaths are occurring.
    So are there any kind of teams, like, going into these 
places and identifying who's writing these prescriptions and 
then the deaths that come from this?
    Dr. Houry. Absolutely. We've been sending teams into Ohio, 
to Massachusetts, to Rhode Island. We've given specific 
information to the States on how to combat----
    Mr. Murphy. West Virginia?
    Dr. Houry. West Virginia, we've been funding the program. I 
did the site visit myself out there to West Virginia.
    We've been working with each State to look at the 
prescription drug monitoring programs, and if you look at the 
guideline, 18 States have now adopted or have implemented 
aspects of the guideline to help with safer prescribing in 
their States and we are starting to see significant 
improvements and you see things like Kentucky through our CDC 
funding.
    Now on our prescription drug-monitoring program it has an 
alert for if there is high morphine-related equivalence to, 
again, make sure that people are getting safer prescriptions.
    Mr. Murphy. Thank you.
     Ms. Schakowsky, you're recognized for 5 minutes.
    Ms. Schakowsky. Thank you, Mr. Chairman, and I want to 
thank all of our witnesses. This has been a very important 
issue because it is an important fight for our communities.
    Obviously, the law enforcement piece and figuring out how 
we can stop the entry into our country of the components of 
fentanyl--very important.
    But I want to say, again, and it is been said many times 
before, this is also a very serious health issue. And to my 
Republican colleagues, as we face this vote that is coming up 
on Thursday we have to recognize the importance of the Medicaid 
program.
    It's the second biggest payer for drug abuse treatment in 
the United States. It funded, roughly, 25 percent of public and 
private spending on drug abuse treatment in 2014. We talk about 
West Virginia.
    We are talking about a lot of low-income people and 
Medicaid is really the source of help for them.
    For my home State of Illinois, Medicaid has been absolutely 
vital to address substance abuse and providing access to 
treatment.
    Medicaid expansion has provided coverage to 650,000 low-
income adults in Illinois, nearly one-third of whom have mental 
health or substance abuse disorders.
    That's just the typical percentage all over the country. 
Without Medicaid, these individuals would be more likely to end 
up in emergency rooms or jails, which would drive up costs for 
State and local budgets.
    It's also clear that in Illinois we need to be further 
expanding access to substance abuse treatment and I'm sure that 
is the case in many other States around the country.
    From 2014 to 2015, Illinois saw 120 percent increase in the 
number of deaths from drug overdoses. And so, you know, yet the 
Republican Trumpcare proposal would decimate the Medicare 
program that serves one in four people in Illinois--one in four 
people in Illinois.
    The Republican bill would end Medicaid expansion and pose a 
drastic per capita cap on funding. I don't want to go more--on 
more about that because it is been certainly addressed.
    Dr. Compton, wouldn't you agree that solving the fentanyl 
and opioid addiction problem requires that we also ensure that 
people have access to appropriate substance abuse treatment?
    Dr. Compton. Certainly given that the underlying issue is 
an opioid use disorder, treatment is a key component of solving 
this problem.
    Ms. Schakowsky. Thank you.
    And Dr. Houry, in your testimony you stated that ``a rise 
in fentanyl, heroin and prescription drugs involve overseas are 
not unrelated.'' I'm sorry--overdoses, not overseas. I'm going 
to say that again. ``The rise in fentanyl, heroin and 
prescription drug-involved overdoses are not unrelated.'' Would 
you agree that in order to solve the fentanyl crisis we must 
also address the larger opioid prescription drug epidemic?
    Dr. Houry. Yes. I think a very comprehensive approach is 
needed and I think prevention is a key aspect of that.
    Ms. Schakowsky. I wanted to also ask Dr. Compton how 
harmful would it be for a patient with an opioid disorder to 
have to discontinue his or her substance abuse treatment?
    Dr. Compton. One of the key predictors of relapse and of 
recidivism is stopping treatment. So when people stop 
treatment, particularly abruptly, they're extraordinarily high 
risk of relapse to their underlying addiction problems as well 
as criminal behavior and other serious problems.
    Ms. Schakowsky. Thank you.
    I'm very concerned. I'm also on the Budget Committee. We 
know that there has been proposed an 18 percent cut in HHS, 
$5.8 billion cut in the National Institutes of Health, which 
I--my understanding is that you're actually doing some research 
on--I don't know if the right word is vaccine, but some sort of 
prevention, something that would--against opioid addiction. Is 
that true?
    Dr. Compton. Well, we even have research specifically 
targeting fentanyl where the development of a vaccine might 
lead to an approach that could keep the--keep the fentanyl from 
getting into the brain.
    The goal is to keep it in the circulatory system so you get 
antibodies developed that attach to the fentanyl and keep it 
out of the brain where it exerts its dangerous effects.
    Ms. Schakowsky. Thank you.
    Again, I want to thank all of the people who are here today 
testifying how you're trying to stop it before it starts and 
understand all the sources. But I also am interested in the 
health services.
    Thank you. I yield back.
    Mr. Murphy. Gentlelady yields back.
    I now recognize the chairman of the committee, Mr. Walden.
    Mr. Walden. Thank you very much, Mr. Chairman. I want to 
thank the witnesses again for your learned testimony and your 
answers to our questions.
    The fentanyl threat, Mr. Chester, has been described to us 
as the third wave of the opioid epidemic. It seems to me that 
individual States--I've looked at some maps--are seeing 
different effects, different aspects of the overall epidemic. 
Some are facing fentanyl head on right now.
    Looks like in other areas it hasn't hit or at least not as 
with the deadly effect. Others are fighting against 
prescription drug or heroin overdoses.
    So I guess my question is, Are we better off to look at 
this as sort of a State-by-State basis? I realize there are 
national implications, but it seems like there are some real 
hot spots in the States.
    And so when we think about a strategy here to combat it, 
should it be multi-headed and look at this opioid epidemic in 
that way or and look at kind of all-of-the-above or sort of a 
one-size-fits-all? What, from your experience, would work best?
    Mr. Chester. Yes, Congressman. So we look at it as a 
complex national security law enforcement and public health 
issue at the national level, and then at the State level, there 
are unique environmental factors that cause different 
manifestations of the opioid problem and as you correctly point 
out there is fentanyl in some States more than it is in others, 
there are prescription opioids in others, and in others there 
is heroin. And in fact we've seen evidence in some places that 
heroin deaths are the preponderant cause of death, and in other 
cases fentanyl has surpassed heroin as being the preponderant 
cause of death.
    So in the implementation of our plans we do two things. 
Number one, we try and respond to unique aspects of that 
State's environment but also develop a framework to share 
lessons learned from one State to another.
    So things that certain States have found to be successful 
in dealing with their particular aspect of the problem can be 
shared with other States who may not be facing that particular 
problem but may see it in the future.
    Mr. Walden. All right. Thank you.
    And Ambassador Brownfield, first of all, I want to commend 
the State Department and the good work that you all have done 
and commend the DEA for your work in helping getting the 
recommendation of the March 16th effort by the U.N. Commission 
on Narcotic Drugs in favor of controlling two primary fentanyl 
precursors.
    And I want to thank the Chinese, too. I've met with the 
ambassador. We've sent them a letter thanking them for their 
work to shut down some of the facilities.
    What do you hope will be the impact from the U.N. 
recommendation on the fentanyl problem in the U.S.? What can we 
expect out of that?
    Mr. Brownfield. First, at the risk of shameless pandering 
to you, Congressman, may I thank you for your letter to the 
ambassador. It makes my job enormously easier when they hear 
directly from you.
    What do we respect from--expect from the CND decision to 
control the two precursors? First, we have to wait another, 
roughly, 170 or 168 days before it is fully implemented.
    This is a period of time during which the, roughly, 185 
member states of the U.N. who are also part of the CND have 
endorsed or ratified the treaties--have the right to seek an 
exception.
    I do not expect anyone to seek an exception to the ruling, 
because the vote was unanimous. It was 51 to 0.
    When it comes into effect, the countries that produce these 
two precursors, the two most prevalent precursors in the 
production of fentanyl in the entire world will be required to 
control, register, license and verify production of these 
precursors there. They will----
    Mr. Walden. And, again, which two countries are those?
    Mr. Brownfield. I mean, the two precursors. The most 
important country is China which, in fact, did support--not 
only vote for but did support and assist us to some extent in 
lobbying for the passage.
    So what will happen at that point in time is whenever a 
company, any company in the world, is going to export either of 
these two precursors, the government of the country where it is 
produced will be required to notify the national authorities of 
the country to which it is being exported and it will have to 
provide the basic data and information--how much, when, who is 
the receiving party, route by which it will be shipped.
    That then allows the national authority--in this case it 
might be HSI or ICE or DEA--to determine what is coming in and 
doing the due diligence to verify this is a legitimate and 
legal shipment.
    This is why I said in my oral statement this is a way to 
shut down the diversion of legal and illicitly produced 
fentanyl.
    Mr. Walden. You know, the State of Oregon and elsewhere 
tried this with methamphetamine to get at the precursor 
ingredients and it made a big difference when you put 
pseudoephedrine behind the counter and required a prescription.
    Boy, that just changed the whole dynamic in terms of the 
individual cooking operations that were polluting homes and 
killing people.
    And so I commend you and the State Department and the 
governments that were involved for taking this step. We look 
forward to being partners with you, going forward.
    And I yield back the balance of my time.
    Mr. Murphy. Mr. Tonko, you are recognized for 5 minutes.
    Mr. Tonko. Sorry about that. Problem with the mic.
    Thank you, Mr Chair. I am quite satisfied we are holding 
this hearing today because it is literally a life-or-death 
issue for my constituents.
    In my hometown of Amsterdam, New York, a small community of 
about 18,000 people, we had four overdose deaths and another 
dozen treated overdoses in the month of December alone.
    If that rate of carnage were maintained for an entire year, 
one in every 375 individuals in my hometown would perish. These 
overdoses were all attributed to fentanyl--one in 375.
    When you drive down the interstate in my district, instead 
of billboards advertising for McDonald's or Taco Bell, you see 
billboards advising you to call 911 in case of an opioid 
overdose.
    Last year, I had the opportunity to visit a clinic where I 
witnessed people taking their first steps to recovery aided by 
a law I helped to pass last year that raised the arbitrary 
limits on the number of patients a doctor can treat for opioid 
use disorder.
    Bearing witness to these success stories from the recovery 
community fuels my drive to push for policies that will expand 
the recovery opportunity for everyone.
    That is why I found it astounding that in all of the 
witnesses' testimony today the word Medicaid was mentioned just 
twice and both times in the context of prescription drug 
monitoring programs.
    We can talk supply reduction all we want. But you simply 
cannot talk about a Federal response to the opioid epidemic 
without talking about Medicaid, which is the largest payer for 
behavioral health care services in our country.
    In New York, Medicaid pays for 38 percent of all 
medication-assisted treatment for opioid use disorder. In New 
Jersey, it is 22 percent. Pennsylvania, 29. Indiana, 17. I 
could go down the list but you get the point.
    And as my colleagues have ably pointed out, there is a huge 
elephant in the room here. The Trumpcare bill this House is 
being asked to vote on later this week would be the single most 
devastating piece of legislation to individuals struggling with 
addiction in our Nation's history.
    Trumpcare would eviscerate treatment for individuals who 
are struggling with opioid addiction by ending the Medicaid 
expansion, repealing guarantees of mental health and substance 
use benefits and gutting Medicaid to the tune of $880 billion 
over the next 10 years alone.
    You don't have to take my word for it. The American Society 
of Addiction Medicine, a professional society representing over 
4,300 professionals in the field of addiction medicine wrote to 
Congress saying we are concerned that rolling back the Medicaid 
expansion, certainly sun setting the EHB requirements for 
Medicaid expansion plans and capping Federal support for 
Medicaid beneficiaries will reduce coverage for access to 
addiction treatment services, changes that will be particularly 
painful in the midst of the ongoing opioid epidemic.
    Rolling back the Medicaid expansion and fundamentally 
changing Medicaid's financing structure to cap spending on 
health care services will certainly reduce access to evidence-
based addiction treatment and reverse much or all progress made 
on the opioid crisis last year.
    The mental health liaison group, an umbrella organizations 
for groups involved in mental health and substance abuse 
service wrote, and I quote, ``The AHCA would leave without 
coverage the 1.3 million childless nonpregnant adults with 
serious mental illness who were able for the first time to gain 
coverage under Medicaid expansion. It would also leave 
uncovered the 2.8 million childless nonpregnant adults with 
substance abuse disorders who gained coverage under expansion 
for the first time.''
    Current Ohio Governor, Governor Kasich, ``Thank God we 
expanded Medicaid because that Medicaid money is helping to 
rehab people.''
    Former Arizona Governor Jan Brewer, no one's idea of a 
bleeding heart liberal, wrote, and I quote, ``It just really 
affects our most vulnerable, our elderly, our disabled, our 
childless adults, our chronically mentally ill, our drug 
addicted. It will simply devastate their lives and the lives 
that surround them because they're dealing with an issue which 
is very expensive to take care of as family with no money.''
    I could go on but you get the point. I would, Mr. Chair, 
like to enter into the record this letter from 415 addiction 
groups nationwide opposing Trumpcare for the devastating impact 
that Trumpcare would have on treatment for the opioid epidemic.
    Mr. Murphy. Without objection.
    [The information appears at the conclusion of the hearing.]
    Mr. Tonko. Thank you, Mr. Chair.
    From my vantage point, there is no one outside of a three-
block radius of this Capitol Building that thinks that 
Trumpcare is anything better than a raging dumpster fire.
    Certainly, no one thinks this back room bill will improve 
the lives of those struggling with the disease of addiction.
    And with that, Mr. Chair, I yield back.
    Mr. Murphy. Gentleman yields back. I do want to note for 
the gentleman that the article referenced before--I don't know 
if you've seen it--from the Washington Post.
    There's an important statement that says, the important 
takeaway is that there is not one opioid epidemic but several.
    To policymakers this may mean that solving the problem will 
similarly require more nuanced vascular solutions than a 
blanket war on drugs. A strategy to reduce pill overdose in 
Utah may not have any effect on fentanyl deaths in 
Massachusetts.
    I'm sure we'll go on and--I want to make sure we work 
together to make sure States have that kind of flexibility to 
do what they do. So I will continue to work with you on that. 
Thank you.
    I will now recognize Mr. Carter of Georgia, who is himself 
a pharmacist. Thank you.
    Mr. Carter. Thank you, Mr. Chairman. Thank you all for 
being here on this--what is obviously a very serious subject. I 
want to start by talking about the legal, if you will, 
marketing of fentanyl.
    We talked about it some during this hearing. One of the--
one of the questions I have, I know--I can't remember who it 
was that mentioned that you're working with the wholesalers, 
with Cardinal and McKesson in trying to make sure that they're 
doing their part and accurately pointed out that you need to 
follow it all the way through the supply chain.
    I can tell you as a practising pharmacist for over 30 years 
that is very important. We need to make sure that happens.
    Have you been in contact with any of the manufacturers--
Janssen making Duragesic or Mylan makes a generic--about how 
much they are able to manufacture and put on the market?
    Mr. Milione. What we are not seeing is a large-scale 
widespread diversion of legal fentanyl.
    Mr. Carter. Right.
    Mr. Milione. It's diverted for personal use mostly. What we 
are dealing with is clandestinely produced fentanyls. We do 
have engagement with the manufacturers, obviously, for issues 
that come up and we are happy to work with them.
    Mr. Carter. That's good, and, you know, that is important 
for a couple of reasons and I would be remiss if I did not 
point out that one of the problems we had at the dispensing 
level is not being able to get enough of the product so that 
the people who truly needed it--cancer patients and those who 
were truly in need of it--we would run short on them because 
they'd put monthly limits on us or something of that sort and 
we weren't able to get it and that was really a tragedy as 
well. So I hope we keep that in mind as we go along.
    One of the things that I was very involved with as a member 
of the Georgia State legislature was our yearly update of our 
dangerous drugs and one of the problems we always had was 
trying to identify the analogues, and I know that has to be a 
challenge.
    Dr. Houry, that is got to be a challenge here, and one of 
my other colleagues mentioned about the precursors to it and 
how we control that. One of the--one of the abused substances 
that I was always chasing was synthetic marijuana and, you 
know, and identify it and add it into the--each year into the 
dangerous drug list and then the next year they'd come out with 
something else.
    I even went as far as to try to identify the molecular 
structure and say anything with this and still it is just so 
difficult. Can you--can you address that, sir?
    Mr. Milione. Sure. I mean, that is--the synthetic threat, 
outside the fentanyl threat, which is significant, is massive. 
We have identified about 400 different substances.
    It's kind of a misnomer to call it synthetic marijuana. 
It's a synthetic cannabinoid and then you have the cathinones 
and then a whole other series of these synthetics.
    This is a major problem for us, and the same criminal 
chemists that are tweaking the molecular structures of fentanyl 
are doing the same when we schedule those cannabinoids.
    Very dangerous--one hit can send someone into a coma or 
have some kind of violent reaction. It's a big problem for 
first responders but it is a devastating problem because it is 
sold legally----
    Mr. Carter. Absolutely, and that is one of the problems we 
had. We had deaths in my district. We had five deaths in Glyn 
County because of that. They were buying it at the convenience 
store.
    Mr. Milione. We cannot keep up--we cannot keep up pace with 
the emergency scheduling on the cannabinoid cathinone.
    Mr. Carter. Absolutely. We are just chasing our shadows 
there.
    Mr. Milione. Right.
    Mr. Carter. And a couple other things, real quickly.
    First of all, from what I'm being told by some of the drug 
agents, particular in Georgia, part of the problem too is just 
with marijuana coming over. Some of it is laced with fentanyl. 
Now, that is a big problem.
    Now, full disclosure--I am a big, big opponent to the 
legalization of marijuana. I think it is just a gateway drug. 
But nevertheless, that seemed to be a problem, too.
    Now, before I run out of time, I want to get to a subject 
that is very important to me and that is mail order drugs and 
mail order prescriptions coming through the mail, being 
delivered to patients' houses. That's where we find out so 
much.
    And listen, Mr. Chairman, one of the biggest culprits--the 
VA. I am telling you, in Georgia, three out of the five 
facilities that deliver drugs through the mail are the VA 
clinics and that is a concern and something we need to address.
    We have--we have opioids coming through the mail, being 
delivered, left on the--on the front porch of someone's home. 
Not even having it signed for, just leaving a box there.
    How much of a problem have you found with what the drugs 
that are coming through our--through our mail system?
    Mr. Allen. Well, I don't want to imagine what they--on the 
VA issue we have a number of open investigations and we are 
trying to work cooperatively with the compliance departments at 
the VA nationally, at their headquarters also.
    But those are definitely areas of significant concern and I 
think, you know, that is distinguished from the trafficking of 
counterfeit drugs that are often moved through the mail.
    When Representative Burgess talked about going online, 
there is just a plethora of online pharmacies that are, you 
know, appearing to sell legitimate pills when in fact they are 
counterfeit.
    Mr. Carter. Absolutely.
    Mr. Allen. Those are moved through the mail system on a 
daily basis.
    Mr. Carter. And I see I'm out of time. But I do want to say 
that that is a problem we need to be looking at, Mr. Chairman. 
This committee and this Congress needs to be looking at mail 
order prescriptions and what's going through our mail now, and 
I yield back.
    Mr. Murphy. So let me ask the gentleman, who's a 
pharmacist, along those lines then. As a pharmacist who will 
see that perhaps you would be picking up patterns of 
prescribing it in the community as a pharmacist and you would 
notice perhaps a massive amount coming through but you would 
not see that on a mail order system at all? You would be 
completely blind to that? Am I correct?
    Mr. Carter. You--on a mail order system. In other words, 
pharmacies that are mailing through, if they're legitimate, 
they should be keeping records of what's going out, yes.
    Mr. Murphy. Well, I used the example before--the gentlelady 
from Florida was offering West Virginia, which is ground zero 
for this.
    Mr. Carter. Absolutely.
    Mr. Murphy. That pharmacy may not necessarily see that 
people are getting it mailed in from out of the area.
    Mr. Carter. Absolutely, especially if it is more than one. 
Now, you know, the PBM--excuse me, the PDMPs--sorry--that helps 
tremendously, especially if we can do it over State lines. That 
is a tremendous help. We've just recently started that in 
Georgia.
    But Florida is one of the States that is still not doing 
it, and that is a problem because it is a big problem down 
there.
    Mr. Murphy. Thank you. Appreciate that.
    Mr. Carter. Thank you, Mr. Chair.
    Mr. Murphy. I recognize the vice chairman of the committee, 
Mr. Griffith, for 5 minutes.
    Mr. Griffith. Thank you very much, Mr. Chairman, and I want 
to thank all of the witnesses for being here today. This is a 
very serious subject. But I've got to refute some things that I 
have heard today or at least one in particular.
    I think we are comparing apples and oranges when we try to 
bring in fentanyl and opioid abuse into the debate over whether 
you want Obamacare, Medicaid expansion or the American Health 
Care Act, and in fact what I've heard repeatedly is is that 
somehow Medicaid expansion has helped to solve this problem.
    But the map of deaths of opioid use that we saw earlier 
that Dr. Burgess put up--and I've got a paper copy here--shows 
us that is not the case and I think it is apples and oranges.
    I don't think Obamacare caused opioid abuse. I don't think 
that Obamacare is going to solve it on its own. We are trying 
to find those answers here today.
    I don't think the American Health Care Act is going to be 
able to solve it in and of itself on its own. But when you look 
at the States where the deaths are--you know, if you're just 
going to play games with numbers, the expansion States seem to 
have more deaths than the nonexpansion States.
    Now, do I think that is fair? No, I don't. I think that is 
horse hockey. But I think that what my colleagues on the other 
side of the aisle have said about us causing problems by voting 
for the American Health Care Act is irrelevant to our 
discussion today.
    So with that being said, Dr. Compton, you mentioned the 
Appalachian Regional Commission--that you're all working on a 
project with them. What exactly are you doing? That's my turf, 
in part.
    I represent southwest Virginia, the Appalachian regions of 
southwest Virginia, which of course border hot spot areas for 
opioid abuse in Kentucky and West Virginia and it spills over 
into my district as well.
    Dr. Compton. Well, I certainly remember a terrific meeting 
in Wise, Virginia. It's a lovely town. They convened a group 
from all across the Appalachian region to look at this issue 
several months ago.
    Our initiative with the Appalachian Regional Commission is 
a grant program to look at demonstration projects to improve 
the public health infrastructure and determine how good a job 
that'll do to address the opioid crisis in rural parts of the 
country, and the Appalachian Regional Commission will be co-
funding this along with SAMHSA, the CDC and, of course, NIDA 
taking the lead on it.
    Mr. Griffith. Well, we appreciate it because it is a 
significant problem and one of the issues there that we have to 
look at is is that whether or not the folks started off because 
of the--it is a high area for disabilities as well. People have 
done for years a lot of hard manual work and that they get a 
prescription and then they get hooked.
    Dr. Houry, you indicated in Ohio at least that 62 percent 
of the people who died from opioid, from heroin or fentanyl 
had--in the last 7 years had a prescription drug for an opioid. 
Can you talk more about that?
    Dr. Houry. Sure. We've been seeing this in many States. 
Like in Rhode Island, a third of the people who had overdosed 
on fentanyl had had an opioid prescription within three months 
and a third of those had had a high dose opioid prescription, 
showing that, you know, people that are on prescription opioids 
get addicted to opioids and can then go on to overdose from 
heroin or fentanyl.
    Mr. Griffith. And sometimes their prescription runs out but 
they're hooked and is there some way we can connect the doctors 
recognizing that maybe their patient has gotten hooked to get 
them the help?
    Because if the prescription just ends and nobody's alerting 
anybody, aren't those a lot of the folks who are going out and 
buying it then illegally on the streets somewhere?
    Dr. Houry. Well, and I think that is why we've got our CDC 
prescribing guideline where we did talk in there about if you 
have a patient that you suspect opioid use disorder on of the 
importance of linking them to treatment.
    And I think one of the things that I've been really proud 
about the work CDC is doing is although we are funding the 
States to do what's most important for the States, each month 
we do technical assistance calls that help then with their data 
and provide scientific expertise and where to really focus 
resources and what are the best evidence-based treatments and 
then have a convening of all the States to share these best 
practices that way. As we are seeing different things emerge in 
different States we can share those.
    I think, you know, data does drive action and I heard us 
talk about should this be a national or a State approach. New 
Hampshire was number 20 one year for overdoses. The following 
year, it was number 5.
    So I think we need to give States the flexibility to deal 
with what's going on in their State, but we need to have that 
overall approach.
    Mr. Griffith. Thank you very much.
    Mr. Milione--if I said that right, and I apologize if I 
messed it up--but I would be remiss--while I think that 
marijuana is a dangerous drug I think your testimony here today 
indicated that fentanyl was your number-one concern and it is--
and it is not your jurisdiction so it is a rhetorical question.
    I ask you just to take back why don't we let there be more 
research on marijuana and its ability to help patients whether 
it be epilepsy or, in this case, pain? Because while I think it 
is a dangerous drug, I don't think it is as dangerous as 
fentanyl and other opioids.
    With that, Mr. Chairman, I yield back.
    Mr. Milione. If I could--if I could say in response to 
that, we support any approved research along those lines. So we 
will continue to work with the researchers on those things and 
we support that.
    Mr. Griffith. Well, if I might, Mr. Chairman, it is just 
the problem is as a Schedule I drug it makes it tougher than it 
would be if it were Schedule II like fentanyl and other 
opioids.
    Mr. Murphy. Gentleman yields back.
    Now, Mr. Pallone for 5 minutes.
    Mr. Pallone. Thank you, Mr. Chairman.
    The Affordable Care Act, through the expansion of Medicaid, 
extended health insurance coverage to hundreds of thousands of 
Americans in urgent need of treatment for opioid use disorders 
and I'm concerned that if the money is cut from Medicaid, which 
is what the CBO says would happen with the Republican bill, 
patients could lose access to care and this could make the 
fentanyl problem even worse.
    So Dr. Compton, in your testimony you state that, and I 
quote, ``opioid addiction is a chronic condition, and many 
patients will need ongoing treatment for many years.''
    What could happen to a patient if their treatment for an 
opioid addiction was interrupted, for example, because the 
patient no longer had health care coverage for substance use 
disorders?
    Dr. Compton. Well, we do know that when treatment is 
interrupted or stopped, whether that is intentional or 
unintentional, the risk of relapse is extraordinary.
    Mr. Pallone. Well, thank you.
    Now, some health experts estimate that nearly 1.3 million 
people are receiving treatment for mental health and substance 
abuse disorders thanks to Medicaid's expansion. Our efforts to 
curb the opiate epidemic, I believe, could be severely impacted 
if those now receiving treatment lose their health insurance.
    Should the ACA be repealed, we clearly would expect the 
opioid crisis, and by extension the fentanyl crisis, to worsen.
    So Dr. Compton, again, if people who are currently being 
treated for an opioid use disorder were to lose coverage, would 
we expect the numbers of overdoses from opioids including 
opioid containing fentanyl many increase?
     Dr. Compton. Well, I hesitate to make a prediction when 
there are so many factors that can play a role here in terms of 
how States will respond, how the Medicaid system in general 
will be organized.
    Our goal, of course, at NIH and NIDA is to make sure that 
the research we support is implemented no matter what the 
health care system is.
    Mr. Pallone. OK. I just use this State of West Virginia as 
an example because it was very hard hit by or is very hard hit 
by the opioid epidemic.
    A February 6th article by the Pew Charitable Trust reports 
that West Virginia in fact has the highest opiate overdose 
death rate in the Nation.
    Let me ask Dr. Houry--I don't know if I'm pronouncing it 
right there--are you aware that West Virginia has one of the 
highest death rates from opiate overdoses in the U.S.?
    Dr. Houry. Yes.
    Mr. Pallone. And Dr. Compton, that same Pew article reports 
that the Medicaid expansion has added 173,000 adults to West 
Virginia's Medicaid program. West Virginia's Medicaid 
enrollment is now at 573,000 people, which is about a third of 
the entire State's population, according to the Pew article.
    Dr. Compton, Pew also reported that in 2015, the first year 
that West Virginia expanded Medicaid, the number of people in 
treatment for substance abuse jumped from 16,000 to 27,000.
    The increased use of Medicaid services for substance abuse 
would suggest that thousands of West Virginians went without 
needed treatment service prior to Medicaid's expansion. Would 
that be a fair assumption, Dr. Compton?
    Dr. Compton. Well, certainly, when we think about States 
like West Virginia I would point out that the rural aspects 
make it very complicated to deliver services.
    So I am very proud that we are able to implement this new 
research program in rural areas.
    Mr. Pallone. And it would appear to me that Medicaid is 
essential in West Virginia's fight against opioid addiction, 
which would include the growing problem of fentanyl. I guess my 
last question, again, Dr. Compton, is if West Virginia were to 
lose these services would we expect that the opioid and 
fentanyl problems to worsen, assuming that they were--you know, 
lost Medicaid coverage--those people?
    Dr. Compton. Well, I can't speak to the implications of the 
coverage issues but, certainly, for individuals who are being 
treated, if you stop their treatment abruptly that could be 
very deleterious.
    Mr. Pallone. I mean, the problem that I see is that the 
Republican bill with regard to the expansion eliminates the 
essential services guarantee and what we have found in the past 
is a lot of times when you don't have that kind of guarantee 
the first thing to go is behavioral services, drug treatment, 
mental health services, things that are expensive and that many 
States didn't provide until we said in the Medicaid expansion 
that they would have to. And I just think that between the 
cutbacks that would occur, because States would be getting less 
money, they're going to get less money, they don't necessarily 
have to cover people depending upon their income, you know, as 
the--as they reduce the Medicaid expansion population, and then 
even with the traditional Medicaid or any kind of population if 
there is no guarantee of essential services then, you know, the 
first thing that often is cut back is treatment for drugs.
    So that is my fear and that is why I think that this is 
devastating if we are trying to deal with fentanyl and some of 
these other opiate problems that we have.
    So thank you all. Thank you, Mr. Chairman.
    Mr. Murphy. Thank you. The gentleman yields back.
    I recognize Mrs. Brooks for 5 minutes.
    Mrs. Brooks. Thank you, Mr. Chairman, and thanks to 
everybody on the panel for your incredibly important work.
    I must say that fentanyl is not a new problem. I was U.S. 
Attorney in Southern District of Indiana from '01 to '07. I 
learned about fentanyl then.
    But, yet, we didn't talk about it much the way we focused 
on methamphetamine and the dangers, for instance, to children, 
to the environment.
    What we are not talking about in the country is the danger. 
We talk about the overdoses and now seeing the incredible 
increase in overdoses.
    But can we talk a little bit about truly how just dangerous 
fentanyl is as a product? And I realize that this gets a little 
dicey because we use it in medical procedures. But I think, 
having just been with law enforcement and firefighters this 
past weekend, there are dangers, are there not, Mr. Allen, and 
that is part of why you're doing training?
    And I want to ask you, Mr. Milione, can you talk to us 
about the dangers of fentanyl and why haven't we, for a long 
time now, talked about the incredible danger?
    Because I don't think addicts and I don't think their 
families really have understood how incredibly dangerous it is.
    Mr. Allen. I would say that in the law enforcement 
community we have been. I would say since the recent surge in 
fentanyl one of the key things that we have gotten out to the 
law enforcement community, largely following the lead of DEA, 
is making awareness to our personnel, to public safety 
personnel generally, what they could be encountering.
    For us operationally it has changed how we do some of our 
work. One of the investigative techniques that we have done 
historically is to purchase drugs, whether it is online or 
domestically and online.
    We stopped doing that because of the officer safety 
concerns that we have that could be inherent to an undercover 
agent buying drugs or a State and local officer buying drugs 
and not necessarily knowing what they're purchasing.
    There's also a challenge for us from the perspective of 
field testing. You know, gone are the days, glorified in a lot 
of television shows, of agents, you know, pulling out a pocket 
knife and probing a package of suspected drugs and putting that 
into a test kit.
    We, particularly at DHS and within DHS Customs and Border 
Protection, have taken the lead on trying to examine and 
explore and field non-intrusive testing that would allow us to 
go to a place where agents don't have to physically open a 
package in order to determine what the substance is inside.
    Mrs. Brooks. Mr. Milione, why is there a surge in fentanyl? 
What is your DEA--and I know you've been at this for a long 
time--but what would you say is the cause behind the surge that 
we have been seeing?
    Mr. Milione. It's free-market principles applied to the 
convergence of the opioid epidemic with massive profits that 
can be made, and cartels and criminal groups that are 
exploiting that, they see the opportunity.
    They aggressively market the small amount of fentanyl. They 
can--they don't have to deal with the massive bulk of heroin 
and they can get so much more profit out of that. So that is 
one of the things.
    Mrs. Brooks. But they don't care that it is killing their 
customers because there are more that just--pipeline?
    Mr. Milione. In a perverse--in a--I mean, and it is very 
callous but it is the cost of doing business and I think some 
of the medical professionals on the panel would say 
unfortunately there is a perverse, sometimes, reaction when 
people overdose from high-potency fentanyl. It sometimes 
attracts more attention to that product.
    Mrs. Brooks. Any idea what the stats are of how many cases 
we've been charging in the last year or two causing death? 
Federal cases where we are actually prosecuting drug 
traffickers for causing death?
    Mr. Milione. I would have to get back to you with specific 
statistics. But we are doing more and more of those around the 
country--death resulting cases, working with the U.S. 
Attorneys' offices, engaging with the U.S. Attorneys, trying to 
get them to lean forward and work cooperatively on that. It is 
definitely what we are focused on.
    Mrs. Brooks. And I guess going to Dr. Houry's comment, is 
part of the challenge, maybe for a U.S. Attorney, is that 
coroners are not keeping track of and going into that much 
detail on the cause of death, which could be a problem, I could 
see, for a U.S. Attorney, but should we be--should we be asking 
or requiring coroners to do a better job on that aspect?
    Dr. Houry. I think it is a resource issue for coroners and 
medical examiners. When you look at the opioid epidemic and the 
number of deaths that they are now doing cases on, oftentimes 
they don't have the resources in their community to do that 
testing for fentanyl or they don't have the labs. They have to 
send it out, which is additional funding that they need.
    Mrs. Brooks. Besides the labs, what kind of resources would 
they need to do the testing aside a heroin death or a fentanyl 
death?
    Dr. Houry. So they would need the lab to distinguish the 
type of analogue. I think also it is helpful to have the 
medical examiner through the family history and so forth to 
determine if this was an unintentional overdose, was this a 
legal fentanyl where you can see the injection or other 
paraphernalia associated with it. But I would say it is really 
the testing for the laboratory and the training as well.
    Mrs. Brooks. Thank you. I yield back.
    Mr. Murphy. Mr. Walberg, you're recognized for 5 minutes.
    Mr. Walberg. Thank you, Mr. Chairman, and also thank you to 
the panel. It is clear from your testimony and the questions 
that you live in a world that is difficult, frustrating, 
challenging, ugly. But you're doing a great job for us and we 
appreciate that.
    My home State of Michigan shares over 700 miles of land and 
water border with Canada as part of the longest border in the 
world.
    Mr. Milione, does DEA have precise data on how much 
fentanyl is coming in directly from Canada?
    Mr. Milione. We can--we have the data as to what's been 
seized but that is--there is a certain flaw in that. We don't 
know exactly what is coming in but we know what we have seized 
and we can get those statistics to you.
    It is imperfect, though, because there are networks that 
are finding any porous entry to be able to get it in. So----
    Mr. Walberg. Having flown over the entry from Detroit River 
into Lake Erie and seeing the creative and amazing ways that 
people will find to cross that water border and seeing the 
efforts by Customs and Border Patrol as well as ICE and others 
to interdict that, I would agree with you. It is probably very 
difficult.
    But significant amount coming across?
    Mr. Milione. Significant in the sense that that is one of 
our--the main threat streams--China to Canada, Canada across 
our northern border.
    Mr. Walberg. Mr. Allen, do you have numbers on how much 
fentanyl ICE has interdicted from Canada and are there hot 
spots along the northern border?
    Mr. Allen. What we--what the DHS components, both ICE and 
CBP, have seized coming from Canada is primarily coming in 
through consignment and mail, not necessarily along the 
physical land border with Canada.
    Mr. Walberg. Consignment and mail?
    Mr. Allen. And mail.
    Mr. Walberg. OK. Mr. Allen, in your written testimony you 
mention that ISIS met with Canadian officials to share trends 
and targeting strategies in fentanyl-related investigations.
    Can you talk a little bit more about this effort and does 
your agency intend to expand the coordination with Canada?
    Mr. Allen. Well, we work along with the Department of State 
and DEA in that effort. We are meeting with Canadian 
counterparts, Mexican counterparts and Chinese counterparts, as 
you have heard today, and I do think that expanding the 
exchange of information with both source and transit countries 
is going to be part of how we improve what we do and 
recognizing that some of the fentanyl that makes its way to the 
United States either directly from China or via other places is 
also in the same stream that makes its way to Canada and Mexico 
as well.
    Mr. Walberg. I mean, it is great to have a border neighbor 
that generally we can work pretty well with.
    Mr. Allen. I would add, you know, one of the things that 
distinguishes the relationship between the U.S. and Canada and 
China and Mexico is that the Canadians have come to us and 
talked about them having a very similar and significant problem 
that we are.
    Mr. Walberg. I have supported legislation in the last two 
Congresses introduced by my colleague, Pat Tiberi, called the 
STOP Act, which, as you know, aims to stop the shipment of 
synthetic drugs like fentanyl and carfentanil into the U.S.
    The bill would require shipments from foreign countries 
through our postal system to provide electronic advanced data 
like where it is coming from, who it is going to and what is in 
it before crossing our borders into the U.S.
    Mr. Allen, how would this information help better target 
illegal drug shipments and keep these dangerous elements out of 
our communities?
    Mr. Allen. That would assist primarily Customs and Border 
Protection, which takes the lead on interdiction, by giving 
them advanced information that they could use at places like 
the National Targeting Center to be more effective and more 
efficient in targeting mail that is coming to the United 
States.
    As we have heard earlier, one of the things that constrains 
the ability of the--what information the postal--U.S. Postal 
Service has in advance is the Universal Postal Union and my 
understanding of the STOP Act is that it would require us to 
update the UPU through negotiations led by the State Department 
to provide more and more timely information that would assist 
CBP in targeting.
    Mr. Walberg. Are there additional steps Congress should 
consider along with that taking to assist your efforts to 
identify and stop these shipments?
    Mr. Allen. None that come to mind.
    Mr. Walberg. Anyone? Thank you, Mr. Chairman. I yield back.
    Mr. Murphy. Now I will recognize another member of the full 
committee, Mr. Bilirakis, for 5 minutes.
    Mr. Bilirakis. Thank you so much, Mr. Chairman. I 
appreciate it. Thanks for allowing me to ask the questions and 
I really appreciate the panel being here. This is such a very 
important issue. It affects all our districts.
    Mr. Chester, a lot of people are aware of opioid abuse like 
OxyContin or heroin but not fentanyl. Is that the case?
    And then what are the educational outreach programs 
currently underway and what resources are available for 
communities who want to get the message out? I think that is 
important. If you could answer that question I would appreciate 
it.
    Mr. Chester. Yes, Congressman. As I stated earlier, kind of 
the components of how we are dealing with this comprehensively 
is to prevent an issue as to drug use, provide treatment for 
those who are addicted to these drugs and then stop the flow of 
the drugs coming in to the United States.
    In terms of prevention, one of the primary mechanisms that 
we use in ONDCP is the Drug-Free Communities program. The Drug-
Free Communities program, which is funded by ONDCP and is 
managed by the Substance Abuse and Mental Health Services 
Administration, is in thousands of communities around the 
country as a prevention program that is focused on individual 
needs of individual communities.
    Local communities require local solutions and it is a 
coalition of 12 community members that are focused on the needs 
of that particular community not only to raise awareness of 
drug issues but prevent primary drug use or initiation of 
primary drug use focused on the demographic of about 13 to 17 
years old, which is the target demographic for that program. 
Very effective program.
    Mr. Bilirakis. It has been effective? OK. Very good.
    Mr. Milione and Mr. Allen, as you mentioned earlier, China 
announced its intention to ban the manufacture and sale of four 
additional types of fentanyl.
    Can you discuss our working relationship with China to 
prevent entry and sale and are there mechanisms to hold China 
accountable to its commitment to ban fentanyl?
    Mr. Milione. Our relationship on the law enforcement 
working level has been tremendous. Our administrator, Acting 
Administrator Chuck Rosenberg, was recently in China and met 
with our counterparts.
    As a result of those meetings and shortly thereafter and 
working with the State Department they agreed to schedule these 
four--one of them carfentanil, which is 10,000 times more 
potent than morphine.
    These are significant steps. The other positive thing has 
been, when they initiated investigations in China, there has 
been real bilateral sharing.
    They provided us leads of domestic-based distributors that 
are--that are ordering fentanyl and that is really helped flush 
out these networks and now these investigations are ongoing.
    So we've been very pleased with the cooperation. We hope it 
continues and, certainly, it can expand.
    Mr. Bilirakis. Very good.
    Mr. Allen. And I would only echo that. The Chinese 
Government has provided DHS with seizure--information about 
seizures made in China on their way to the United States and we 
have been able to use that information to, as Mr. Milione said, 
identify other individuals and organizations that have received 
shipments from the same points of origin in China that has 
allowed us to begin investigation.
    Mr. Bilirakis. Thank you.
    Mr. Brownfield. Finally, Congressman, if I could add one 
more point from the State Department's side.
    Mr. Bilirakis. Please go ahead. Please. Please.
    Mr. Brownfield. Beginning a little over a year ago, we 
reached a bilateral understanding with the Chinese Government 
that they would control the delivery of products from China to 
the U.S., even if they were not controlled in China if they 
were controlled in the U.S., in exchange for which we made the 
same commitment to them.
    Now, it is not enforceable in any sort of international 
organization. But it is an agreement that we reached between 
ourselves as two governments.
    Mr. Bilirakis. Thank you.
    Dr. Houry, in your testimony you mentioned that CDC is 
committed to giving providers and health systems the tools they 
need to improve how opioids are used and prescribed.
    Can you discuss these tools and how communities can take 
advantage of these tools?
    Dr. Houry. Absolutely. We have really had a multi-pronged 
approach. One is just through education. We have been working 
with--directly with medical schools and nursing schools on 
preclinical training on effective pain management and safe 
prescribing practices.
    We have also developed seven continuing education webinars 
that are available for free for providers on our Web site 
around safe prescribing of opioids, and with the guideline 
itself--I am a practising physician. I know you have to have 
something that you can use.
    So we have a checklist that is been downloaded more than 
25,000 times by providers to use and we also now have a mobile 
app on our phone around the guideline that has things on 
motivational interviewing and how do you talk with a patient 
about these difficult decisions on whether or not to give an 
opioid, a calculator to help you calculate what's the 
appropriate and safe dose of an opioid to give.
    And we are also--we have piloted a community education 
program and awareness around the risks of opioids in 10 cities 
that were hardest hit.
    Mr. Bilirakis. Very good. I would like to talk to you about 
possibly coming to my area in Florida, the Tampa Bay area, if 
you haven't already.
    Dr. Houry. I would welcome that.
    Mr. Bilirakis. Thank you very much. I yield back, Mr. 
Chairman.
    Mr. Murphy. Gentleman yields back.
    Now, just some closing comments. Ms. DeGette, 5 minutes.
    Ms. DeGette. Thank you, Mr. Chairman.
    I just wanted to respond to what our colleague, Mr. 
Griffith, said about the ACA. Certainly, nobody thinks that the 
shocking increase in opioid and heroin use is in any way 
related to the ACA, and we recognize that some of those areas 
where we do have the Medicaid expansion are the areas which are 
the red on the map, and that is quite disturbing.
    Our point, though, is that, if we hope to treat these folks 
who are getting addicted to opioids, it is important that they 
have access to medical treatment, and that is why we are 
concerned if the Medicaid expansion is retracted, because in 
those States the Medicaid expansion has helped many people who 
have--who need to have addiction treatment, which is extensive.
    And to that end, I have a letter dated March 20th, 2017, 
from the Oregon AFSCME which talks about the Medicaid expansion 
in Oregon and how many people would lose their Medicaid 
expansion and their treatment for opioid addiction if the 
Republican alternative passed this week.
    And I would like to ask unanimous consent to put a copy of 
that letter into the record, Mr. Chairman.
    Mr. Murphy. Without objection.
    [The information appears at the conclusion of the hearing.]
    Ms. DeGette. Thank you. I yield back.
    Mr. Murphy. Gentlelady yields back.
    Just a couple of questions that I have. Mr. Chester, do you 
have any idea how many Federal agencies are there that deal 
with substance abuse across all spectrums and all departments?
    Mr. Chester. I do not have that answer off the top of my 
head, but I would like to follow up with you, if I can, on 
that.
    [The information follows:]

        Office of National Drug Control Policy (ONDCP): There are a 
        total of 13 Federal Departments and 40 independent Federal 
        agencies and department bureaus designated as Drug Control 
        Program agencies that report funding as part of the drug 
        control program. An overview of the support provided to the 
        drug control program by these Departments and agencies is 
        provided in the ONDCP FY 2017 Budget and Performance Summary. 
        In addition, ONDCP works with many other Federal departments 
        and agencies on issues that relate to the development and 
        implementation drug control policies and programs needed to 
        support the National Drug Control Strategy.

    Mr. Murphy. Good. And I know when we asked GAO to do the 
scenario of mental illness they said at least 112, but it is 
probably more. They just couldn't figure this out. I don't know 
how many there are.
    I know one of the things this committee did in our mental 
health bill was tasked the Assistant Secretary of Mental Health 
and Substance Abuse to coordinate these 112 Federal agencies on 
efforts in the area of mental illness. Goodness knows how many 
there are in substance abuse.
    And it is a question that I want you all to let us know--I 
need some answer to--as well as getting back to us that what 
would you suggest that this administration do in working with 
Congress to combat this deadly, deadly problem.
    I mean, we will have meetings--we will have intense 
hearings here on things like Ebola, which affects a couple 
American lives, or on flu, which is thousands of deaths every 
year.
    But we are far past that with fentanyl and opioids and we 
see towns devastated. And so we do need your suggestions. We 
want to work together. And I say to my colleague, too, you and 
I have a shared passion in this area.
    It is absolutely unquestionable and this is one we have to 
be working together. As I said before, there is no silver 
bullet. States have to handle this a different way.
    What was affecting things in West Virginia with perhaps 
some prescription practices that Ms. Castor pointed out and 
disability rates and unemployment rates may be very different 
from Massachusetts or Utah or anywhere else, and I want to make 
sure States have full flexibility.
    So I look forward to saying, let's stay committed to this. 
We'll get answers to this together.
    And I also would ask, Mr. Chester, there is a letter we 
sent February 23rd, a bipartisan letter with several questions. 
You may be aware of that.
    Any idea when we can expect some answers to that?
    Mr. Chester. Yes, Congressman. It is in final--the letter 
is complete. It is in final interagency clearance. We hoped to 
get it to you this morning, but we will get it to you as soon 
as possible.
    Mr. Murphy. Thank you. Appreciate that.
    Mr. Chester. Thank you for the letter.
    Mr. Murphy. Yes. Now, let me just say that in conclusion I 
want to thank all the witnesses and members that participated 
in today's hearing and remind members you have 10 business days 
to submit questions for the record so the witnesses have time 
to respond to those.
    And with that, I again thank the witnesses. This is a very 
important hearing on a critically important issue for our 
Nation. We look forward to working with you again until we have 
this issue addressed.
    And with that, this hearing is adjourned.
    [Whereupon, at 12:36 p.m., the hearing was adjourned.]
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