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




      LOCAL RESPONSES AND RESOURCES TO CURTAIL THE OPIOID EPIDEMIC

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

                                HEARING

                               BEFORE THE

                      SUBCOMMITTEE ON HEALTHCARE,
                   BENEFITS, AND ADMINISTRATIVE RULES

                                 OF THE

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 11, 2018

                               __________

                           Serial No. 115-76

                               __________

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




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                       http://oversight.house.gov
                                   ______
		 
                     U.S. GOVERNMENT PUBLISHING OFFICE 
		 
31-106 PDF                WASHINGTON : 2018                 
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
                       
              Committee on Oversight and Government Reform

                  Trey Gowdy, South Carolina, Chairman
John J. Duncan, Jr., Tennessee       Elijah E. Cummings, Maryland, 
Darrell E. Issa, California              Ranking Minority Member
Jim Jordan, Ohio                     Carolyn B. Maloney, New York
Mark Sanford, South Carolina         Eleanor Holmes Norton, District of 
Justin Amash, Michigan                   Columbia
Paul A. Gosar, Arizona               Wm. Lacy Clay, Missouri
Scott DesJarlais, Tennessee          Stephen F. Lynch, Massachusetts
Blake Farenthold, Texas              Jim Cooper, Tennessee
Virginia Foxx, North Carolina        Gerald E. Connolly, Virginia
Thomas Massie, Kentucky              Robin L. Kelly, Illinois
Mark Meadows, North Carolina         Brenda L. Lawrence, Michigan
Ron DeSantis, Florida                Bonnie Watson Coleman, New Jersey
Dennis A. Ross, Florida              Raja Krishnamoorthi, Illinois
Mark Walker, North Carolina          Jamie Raskin, Maryland
Rod Blum, Iowa                       Jimmy Gomez, Maryland
Jody B. Hice, Georgia                Peter Welch, Vermont
Steve Russell, Oklahoma              Matt Cartwright, Pennsylvania
Glenn Grothman, Wisconsin            Mark DeSaulnier, California
Will Hurd, Texas                     Stacey E. Plaskett, Virgin Islands
Gary J. Palmer, Alabama              John P. Sarbanes, Maryland
James Comer, Kentucky
Paul Mitchell, Michigan
Greg Gianforte, Montana

                     Sheria Clarke, Staff Director
                  Robert Borden, Deputy Staff Director
                    William McKenna, General Counsel
                        Betsy Ferguson, Counsel
                         Kiley Bidelman, Clerk
                 David Rapallo, Minority Staff Director
                                 ------                                

     Subcommittee on Healthcare, Benefits, and Administrative Rules

                       Jim Jordan, Ohio, Chairman
Mark Walker, North Carolina, Vice    Raja Krishnamoorthi, Illinois, 
    Chair                                Ranking Minority Member
Darrell E. Issa, California          Jim Cooper, Tennessee
Mark Sanford, South Carolina         Eleanor Holmes Norton, District of 
Scott DesJarlais, Tennessee              Columbia
Mark Meadows, North Carolina         Robin L. Kelly, Illinois
Glenn Grothman, Wisconsin            Bonnie Watson Coleman, New Jersey
Paul Mitchell, Michigan              Stacey E. Plaskett, Virgin Islands 
























                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on April 11, 2018...................................     1

                               WITNESSES

Ms. Amy Haskins, Project Director, Jackson County Anti-Drug 
  Coalition
    Oral Statement...............................................     4
    Written Statement............................................     6
Ms. Lisa Roberts, Coordinator, Scioto County Drug Action Team 
  Alliance
    Oral Statement...............................................    24
    Written Statement............................................    26
Mr. Derek Siegle, Executive Director, Ohio HIDTA
    Oral Statement...............................................    45
    Written Statement............................................    47
Ms. Karen Ayala, Lead Staff, DuPage HOPE (Heroin/Opioid 
  Prevention and Education) Task-Force
    Oral Statement...............................................    55
    Written Statement............................................    57

                                APPENDIX

Reprensentative Mark Walker Statement for the Record.............    92
DuPage County Statement for the Record, submitted by Ranking 
  Member Krishnamoorthi..........................................    93
Gateway Foundation Statement for the Record, submitted by Ranking 
  Member Krishnamoorthi..........................................    99
Robert Crown Center for Health Education Statement for the 
  Record, submitted by Ranking Member Krishnamoorthi.............   104

 
      LOCAL RESPONSES AND RESOURCES TO CURTAIL THE OPIOID EPIDEMIC

                              ----------                              


                       Wednesday, April 11, 2018

                   House of Representatives
         Subcommittee on Healthcare, Benefits, and 
                               Administrative Rules
               Committee on Oversight and Government Reform
                                                   Washington, D.C.
    The subcommittee met, pursuant to call, at 10:05 a.m., in 
Room 2154, Rayburn Office Building, Hon. Jim Jordan, chairman 
of the subcommittee, presiding.
    Present: Representatives Jordan, DesJarlais, Massie, 
DeSantis, Walker, Grothman, Palmer, Comer, Krishnamoorthi, 
Norton, and Kelly.
    Mr. Jordan. The committee will come to order. I would ask 
unanimous consent that members not part of the subcommittee can 
participate in today's hearing.
    We want to thank you all for being here. Thank our 
witnesses. We will do a quick opening statement and we will 
introduce you. I will swear you in and get right to your 
important testimony. I am not even going to read my prepared 
remarks here. I am just going to say we all know how bad this 
crisis is.
    In 2016, 64,000 Americans died from overdose from an 
opioid, and it has hit certain areas of our country, as 
evidenced by the people we have here today, in a dramatic way. 
The ranking member came to me a few months ago and said we need 
to have a hearing where we at least continue this conversation 
about what we can do to help improve this situation, and I said 
that is a great idea, let us get folks together and do just do 
that. So, I want to thank our witnesses for being here today.
    I am going to turn it over to the ranking member for some 
opening comments. And then like I said, we will swear you in 
and hear your important testimony, and then get questions from 
members on the subcommittee and other members who have joined 
us for this important subject matter. So, with that I would 
recognize Mr. Krishnamoorthi for his opening remarks.
    Mr. Krishnamoorthi. Thank you very much, Chairman Jordan, 
for allowing us to have this hearing today on this very 
important topic. I really appreciate your cooperation and the 
cooperation of your staff. And thank you all for traveling from 
long distances to be here today, and thank you to people in the 
audience as well.
    I asked for this hearing today because opioid addiction is 
a public health crisis that has devastated neighborhoods across 
Illinois and communities in every State. Local communities are 
at the front line of this crisis, and Congress needs to listen 
to them.
    Today we will hear from local experts who are addressing 
the horrific impact of opioid addiction and other substance use 
disorders in Ohio, West Virginia, and in one part of my 
district, namely DuPage County, Illinois. In Illinois, there 
are an estimated 180,000 people with an opioid use disorder. 
Every single day I feel the impact this crisis has on so many 
of my constituents in DuPage, Cook, and King Counties. In 
DuPage County alone, 126 patients died of heroin overdoses, and 
another 108 from fentanyl just in the last 3 years alone.
    I applaud the $3.2 billion in new funding for opioid 
treatment that Congress passed this year, but Chairman Jordan 
and I need to know is the Federal government doing enough about 
this disease. Is Congress supporting you in the most effective 
ways possible to address the opioid crisis? We need to know if 
you have the flexibility to respond to opioids because what 
works in one area is not necessarily what works in another.
    We also need to know if you require more resources for 
prevention, treatment, and rehabilitation of those suffering 
from substance use disorders. We need to know if law 
enforcement is going after big drug cases and not just 
arresting addicts. We need to know if current law enforcement 
practices are preventing addicts from seeking treatment for 
fear of legal jeopardy.
    The public health crisis of opioid addiction demands that 
we are committing sufficient resources and that we are spending 
efficiently and effectively. It is critical to increase the 
supply and use of the highly-effective opioid overdose reversal 
drug, naloxone, so that we can save the lives of those who 
overdose. We must ensure that first responders and others have 
sufficient supply to prevent overdose deaths in their 
communities.
    I look forward to hearing today about evidence-based 
prevention efforts that have proven effective, including what 
we know about addressing the root causes of addiction, and that 
is something that is especially important to me. I want to know 
what is working in terms of preventing opioid addiction in the 
first instance.
    I look forward to hearing about effective harm reduction 
strategies for addicts with children in their household in 
order to lessen the burden addiction put on families. Once 
addicts do come forward, there must be effective evidence-based 
treatments available to them, and they need to know where and 
how to find treatment. We know that various forms of 
medication-assisted treatment, or MAT, can effectively treat 
addiction, but current access to such treatment is woefully 
inadequate. Let me repeat that. Resources for that type of 
treatment is woefully inadequate today.
    Recovering addicts should have the tools and support they 
need to both get clean and stay clean. I hear about this 
problem in Illinois nearly every day. Even when people can get 
treatment, can get into rehab, they and their families still 
have no support upon release. It is not enough for us to get 
them clean. We have to keep them clean. These people then 
struggle to maintain sobriety. I hope to hear today from our 
witnesses on ways to solve this problem.
    Finally, Federal spending has to be held accountable. One 
of this committee's core missions, and I know Chairman Jordan 
agrees, is to identify and root out government waste, make sure 
that we are not good money after bad. I look forward to hearing 
today how scientific evidence is being used to ensure that 
taxpayer dollars are being spent efficiently and effectively in 
local addiction response efforts.
    I hope today's hearing will provide a constructive 
conversation about what local communities are doing and what 
the Federal government should be doing to address the opioid 
crisis and the disease of addiction, and I look forward to 
working with my colleagues on both sides of the aisle to 
address this public health crisis. Thank you so much.
    Mr. Jordan. I thank the gentleman for his opening comments. 
We will introduce our witnesses. Why do we not start with the 
ranking member? I will let him introduce one of our witnesses 
who is from back in his district.
    Mr. Krishnamoorthi. Thank you again, Chairman. Yes, I would 
like to introduce our distinguished witness, Ms. Karen Ayala. 
She is the executive director with the DuPage County Health 
Department in Illinois, and she is the lead staff at the DuPage 
Hope Task Force, which she will be talking about today. This 
addresses opioid prevention and education in my district.
    Mr. Jordan. Thank you. I now recognize the gentleman from, 
even though he is from Kentucky and going to introduce someone 
from Ohio, there is a relationship there. So, the gentleman 
from Kentucky, Mr. Massie, is recognize.
    Mr. Massie. As the chairman well knows, there are some good 
people in Ohio.
    Mr. Jordan. Yeah.
    Mr. Massie. But we are always on the lookout for the 
Buckeye Navy coming across the Ohio River there.
    [Laughter.]
    Mr. Massie. It is my honor to introduce the next witness. 
Thank you for allowing me to participate in this subcommittee. 
The next witness, Lisa Roberts, is a registered nurse from 
Portsmouth, Ohio. She has been working at their health 
department since 1989, and the City of Portsmouth, as the 
chairman knows, is located in Scioto County, Ohio.
    Drug addiction does not recognize geographic boundaries, 
and the area of southern Ohio, eastern Kentucky, and western 
West Virginia, that tri-State area, has really been hit hard by 
opioid addiction. It has been the subject of some 
documentaries. But Lisa is at the forefront of fighting this. 
She helped form the Scioto County Drug Action Team Alliance, 
and she is currently administering the Drug Free Community 
Program in Scioto County, which is in its 6th year.
    She oversaw Scioto County's first public health overdose 
prevention pilot program, and that has been a model for other 
communities in Ohio as I understand it. But the most remarkable 
thing about Ms. Roberts is my mother was her nursing 
instructor, and she survived by mother's class, and I know she 
has been taught well. My mother taught me, and so it is an 
honor to have her testify here today.
    Mr. Jordan. Thank you, Mr. Massie. Good to have you with 
us, Ms. Roberts. Ms. Haskins is the Jackson County Anti-Drug 
Coalition representative from the great State of West Virginia. 
We are glad to have you here with us as well. And Mr. Siegle, 
who represents the Ohio HIDTA, High-Intensity Drug Trafficking 
Area Program, and we appreciate you being here also.
    If you all would please stand up. We have to swear you in, 
and then we will get right to your testimony. Raise your right 
hand.
    Do you solemnly swear or affirm the testimony you are about 
to give is the truth, the whole truth, and nothing but the 
truth, so help you God?
    [Chorus of ayes.]
    Mr. Jordan. Let the record show that each witness answered 
in the affirmative, and there is a clock in front of you that 
you can see it is 5 minutes. If you can keep your remarks 
within that 5-minute timeframe, that is great. If you are a 
couple of seconds over, we are not going to hurt you or 
anything, and then we will just move right down the list. And 
then, like I said, we will get to questions.
    Ms. Haskins, you can go first.

                       WITNESS STATEMENTS

                    STATEMENT OF AMY HASKINS

    Ms. Haskins. Good morning, Chairman Jordan, Ranking Member 
Krishnamoorthi, and esteemed members of the Subcommittee on 
Healthcare, Benefits, and Administrative Rules. My name is Amy 
Haskins, and I am the project director for the Jackson County 
Anti-Drug Coalition and also the administrator for the Jackson 
County Health Department located in West Virginia. It is on 
behalf of our coalition members and the Jackson County Board of 
Health that I want to thank you for the opportunity to testify 
today regarding the Drug Free Communities Program which is 
housed in the Office of National Drug Control Policy.
    The Drug Free Communities Program is the only Federal 
prevention program that goes directly to communities to tackle 
the local drug issues. DFC provides training through the 
institute to enable communities to implement substance abuse 
prevention strategies. In our community, DFC provided us with 
the tools needed to build capacity to achieve significant 
reduction in opioid use and misuse despite the State of West 
Virginia having one of the highest use and misuse rates in the 
country. Not only did we reduce our prescription drug abuse 
among youth, but we reduced population-level rates of youth 
substance abuse across the board, not just prescription drugs.
    Preventing or delaying substance abuse is the single most 
critical tool in stopping the pathway to addiction and 
overdose. Research shows that for each dollar invested in 
prevention, between $2 and $20 in treatment and other health 
costs can be saved. Substance abuse prevention has historically 
been under funded and underutilized in combating drug issues, 
including the current opioid epidemic.
    DFC has allowed our coalition to leverage other funds to 
provide prevention education within the school systems. It has 
also enabled us to respond and to address local trends as they 
arise. DFC has enabled our coalition to work on environmental 
strategies that create lasting population-level change and the 
ability to evaluate these changes through data collection. 
Specifically, we utilize the strategies of providing 
information, enhancing skills, providing support, enhancing 
access and reducing barriers, changes in physical design, and 
modifying or changing policies. Those environmental strategies 
are laid out in more detail in my written statement provided to 
you.
    With the training and technical assistance provided through 
the Drug Free Communities Program and ONDCP, our coalition has 
been able to change the environment not only in our community, 
but throughout West Virginia. The destruction of medication 
from static collection sites is a tremendous issue across the 
United States. Our community determined what worked best for us 
and successfully advocated for similar changes across the 
State.
    The individuality of each community is what makes ONDCP and 
DFC such a marvelous program. Our coalition has significant 
community-wide involvement from our school system to law 
enforcement, local business, media, youth-serving 
organizations, faith-based organizations, healthcare providers, 
civic organizations, parents, and more than a hundred youth to 
name just a few. We determine through data collection and 
assessment what the best plan is for our own communities. In 
fact, looking at the latest PRIDE survey data for Jackson 
County, 4.7 percent of our 12th graders report using 
prescription drugs in the last year, nearly 6 percent lower in 
use as compared to the national annual use as reported by the 
Monitoring the Future Survey. When looking at that same age 
group and the past 30-day use of prescription drugs, the 
national average is 4.9 percent as reported by the Monitoring 
the Future Survey, while only 1.8 percent of Jackson County 
12th graders report using prescription drugs in the last 30 
days.
    Since receiving DFC funding, our coalition has been 
successful in reducing 30-day use among our high school 
students across the board. In fact, we have seen a 15 percent 
reduction in alcohol use, 13 percent reduction in tobacco use, 
8 percent reduction in marijuana use, and nearly 6 percent in 
prescription drug abuse. The DFC Program is a great example of 
how a very small investment of $125,000 per year of Federal 
funds can inspire a great deal of coordinated and steadfast 
effort at the community level.
    Unfortunately, there is no one-size-fits-all solution to 
this opioid epidemic, but who best to determine what needs to 
be done to help a community than those who live, work, and 
raise their families there? I thank you for providing local 
communities like Jackson County, West Virginia the opportunity 
and the ability to do what is best to keep our children moving 
forward with positive change.
    Thank you for the opportunity to testify before you today, 
and I am happy to answer any questions you may have.
    [Prepared statement of Ms. Haskins follows:]

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    Mr. Jordan. Thank you, Ms. Haskins.
    Ms. Roberts, you are recognized for 5 minutes.

                   STATEMENT OF LISA ROBERTS

    Ms. Roberts. Chairman Jordan, Ranking Member 
Krishnamoorthi, and esteemed members of the Subcommittee on 
Healthcare, Benefits, and Administrative Rules, my name is Lisa 
Roberts, and I am the coordinator for the Scioto County Drug 
Action Team in Scioto County, Ohio. I have been a public health 
nurse in Portsmouth, Ohio for 30 years. Portsmouth, located in 
Scioto County, is part of the Appalachian region that has been 
seriously impacted by prescription opioids since the mid-1990s.
    In 2010, Scioto County has the highest prescription opioid 
distribution rate in Ohio and the highest fatal overdose rate 
in the State at more than double the State average. We also had 
the highest rate of infants born with neonatal abstinence 
syndrome and numerous other community problems related to 
opioid addiction. And like so many parents, my own child 
developed and opioid use disorder at a young and has struggled 
mightily with this disease throughout adulthood. It has been a 
long and difficult struggle for my family.
    In 2010, the county health authorities declared a public 
health emergency, and we formed a coalition. I have been the 
coalition coordinator since that time. In 2012, Scioto County 
was awarded both a Drug Free Communities Support Program and a 
High Intensity Drug Trafficking Area Program. These two 
programs work collectively to provide comprehensive supply and 
demand reduction strategies across our community landscape.
    Thanks to the enhanced training, technical assistance, and 
programmatic support provided by the Office of National Drug 
Control Policy, I have been continuously professionally 
developed to guide this coalition's work. The combined efforts 
of these programs have resulted in numerous improved outcomes 
in our population.
    The DFC Program has allowed us to regularly collect and 
measure youth substance use and behavioral data for the first 
time in our county's history. This information allowed our 
coalition to plan and implement locally-tailored and evidence-
based strategies designed to reduce youth substance use. Since 
2013, these biannual data sets have documented significant and 
sustained reductions in youth substance use, not only for 
prescription drugs, but for all 12 measured substances, 
including tobacco and alcohol.
    I believe that these outcomes are a direct of the DFC 
Program and the training provided by the required year-long 
Community Anti-Drug Coalition Institute, which teaches 
coalition leaders like myself the essential processes to guide 
a highly-effective coalition capable of achieving these types 
of successful outcomes. The Institute taught us how to use 
local data and to implement a combination of evidence-based 
strategies. These strategies are further detailed in my written 
statement that you have.
    The opioid epidemic remains one of the biggest public 
health challenges of our time, but public health receives 
little funding to address it. The current structure of the DFC 
Program under the Office of National Drug Control Policy 
allowed my public health agency to be eligible for this Federal 
support and to comprehensively address our local public health 
crisis.
    In addition to improving youth substance use rates, we have 
also seen positive secondary outcomes. Our prescription opioid 
distribution rates are at the lowest point in a decade, and 
Scioto County no longer leads the State in fatal overdose. Less 
infants are being born opioid dependent, and our high school 
graduation rates are now above the State average. And because 
we have built a community interfere that supports treatment and 
recovery from addiction, more youth are living in stable homes 
and more adults are achieving recovery.
    The Federal investment of $125,000 annually provided by DFC 
has allowed our community to organize and work toward a better 
future for our residents and our children. It has also helped 
us to gain additional opioid fighting resources, and these will 
be sustained into the future through the institutionalization 
of programs and services. In short, this small Federal 
investment has seeded community recovery in Scioto County, 
Ohio.
    America's drug problems are extremely complex, dynamic, and 
ever-evolving. ONDCP is uniquely positioned to have a clear and 
broad understanding of these issues and how they can best be 
addressed through policy. These complexities require that we 
support an agency that has expertise and influence so as to 
provide national leadership and oversight to these issues. I 
believe it is critical the DFC Program remain in ONDCP and that 
this successful model is not disrupted.
    In closing, I want to thank the members of the committee 
for allowing me to testify on behalf of the critical importance 
of reauthorizing the Office of National Drug Control Policy and 
its vital programs. Because of them, we have been able to 
improve our community so that future generations of children 
and families can live safe, healthy, and drug free.
    Thank you for allowing me to speak on this important topic, 
and I am happy to answer any questions that you may have.
    [Prepared statement of Ms. Roberts follows:] 
    
    
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    Mr. Jordan. Thank you, Mr. Roberts.
    Mr. Siegle, you are now recognized.

                   STATEMENT OF DEREK SIEGLE

    Mr. Siegle. Chairman Jordan, Ranking Member Krishnamoorthi, 
and distinguished members of the subcommittee, I am honored to 
appear before you today to testify and highlight the Ohio High 
Intensity Drug Trafficking Area Program, or HIDTA, and how the 
program assists localities in addressing the opioid problem.
    Today fentanyl and fentanyl analogs account for 
approximately 58 percent of unintentional drug overdoses in 
Ohio. Opioids account for 86 percent of unintentional drug 
overdoses. Overdose deaths have risen 486 percent in the last 
13 years from 904 in 2004 to an expected 5,300 in 2017. We are 
seeing a rise in the seizure of crystal methamphetamine and 
cocaine being trafficked in large quantities by Mexican 
organizations. Recently, 140 pounds of methamphetamine was 
seized near Akron, Ohio.
    The foundation of the HIDTA strategy continues to be the 
co-location of law enforcement personnel in order to increase 
information and intelligence sharing, provide training, and 
incentivize participation in uniquely effective drug 
enforcement initiatives. These cooperative efforts support 
HIDTA's core mission of disrupting and dismantling drug 
trafficking organizations and money laundering organizations.
    The Ohio HIDTA supports traditional drug task forces along 
with highway interdiction, package interdiction, bulk cash 
smuggling units, and fugitive apprehension teams. De-
confliction services are a key contribution by the Ohio HIDTA 
for all our law enforcement partners. De-confliction prevents 
blue-on-blue incidents and duplication of efforts.
    In 2017, the Ohio HIDTA de-conflicted 4,200 law enforcement 
operational events and 7,200 subject elements for more than 300 
law enforcement agencies. The Ohio HIDTA participates in the 
ONDCP-sponsored Heroin Response Strategy, or HRS. The HRS is 
designed to enhance public health, public safety, and 
prevention collaboration supported by 10 HIDTAs across 22 
states with the goal of reducing drug overdose deaths.
    The Ohio HIDTA supports heroin-involved death investigation 
teams in our major metropolitan areas. These teams respond to 
overdose deaths and begin an investigation into the source of 
the drug. In July of 2016, the Ohio HIDTA began to train law 
enforcement officials throughout the State on an overdose 
incident form. Almost 10,000 overdose investigations have been 
entered from 42 of the 88 counties in Ohio, giving 
investigators the ability to instantly de-conflict information.
    The Investigative Support Center spearheaded efforts to 
form overdose initiative groups within each of these counties. 
The purpose is to more efficiently link overdose data and 
enable intelligence support that otherwise might not have been 
available to them.
    The Ohio HIDTA introduced the Overdose Detection Mapping 
Application Program, ODMAP, allowing first responders to report 
fatal and non-fatal overdoses and any administration of Narcan. 
The incidents were plotted on a map allowing participating 
agencies to visualize overdoses in near real time.
    The Ohio HIDTA participates in the Domestic Highway 
Enforcement Initiative promoting collaborative, intelligence-
based, unbiased policing on the Nation's highways. 
Investigating Support Centers provide analytical help to 
participating and non-participating agencies, many of which do 
not have analytical support or record analysis capabilities. 
During 2017, the Ohio HIDTA provided in excess of 15,000 hours 
of free training to more than 1,400 students, many who would 
not be able to attend training without the HIDTA.
    HIDTA has become more important as overdose deaths have 
doubled over the last decade while drug enforcement funding 
overall has declined. Because of the reputation that HIDTA has 
built for bringing individuals together and producing results, 
HIDTA components are often involved with prevention, treatment, 
and education initiatives. HIDTA executive boards are a key 
strength to the HIDTA program. Ohio HIDTA is managed locally by 
an executive board of 23 Federal, State, and local partners who 
each have an equal say in how their HIDTA prioritizes its 
efforts.
    As a program, not an agency, HIDTA is viewed as a neutral 
partner whose goal is to help all levels of law enforcement 
reduce drug trafficking organizations and their effect in our 
communities. HIDTA is best served under ONDCP, who provides 
leadership from a neutral, unbiased, non-competing point of 
view. ONDCP possesses the expertise and authority to look at 
the drug problem holistically and set direction across the 
board.
    Thank you for allowing me this opportunity to testify 
before you today. I look forward to answering your questions.
    [Prepared statement of Mr. Siegle follows:]


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    Mr. Jordan. Thank you, Mr. Siegle.
    Ms. Ayala, you are recognized now for 5 minutes.

                    STATEMENT OF KAREN AYALA

    Ms. Ayala. I am both grateful and humbled for the 
opportunity to speak before you today. My name is Karen Ayala, 
and I serve as the executive director of the DuPage County 
Health Department. DuPage County is the second-largest county 
in the State of Illinois. In this role, I have witnessed the 
heroin and prescription drug crisis unfold across our 
communities, and also instructed participation efforts to 
reduce the impact in our neighborhoods.
    I am, oh, so proud of our nationally-recognized healthcare 
systems as well as the most recent recognition of DuPage County 
as the healthiest county in Illinois. However, we are now in 
the 5th year of our response to this opioid crisis, and with 
the framework that has recently been developed through the HOPE 
Task Force, which is included in my written documents, I 
realize that we lack the resources needed to fully and 
successfully address this public health epidemic.
    I strongly believe as we are faced with responding to the 
complex needs of residents affected by this pervasive and 
impressive public health threat, we need additional resources. 
So, first, with the rise in direct consumer marketing of 
pharmaceutical companies, coupled with the efforts of the drug 
companies to market opioids as safe, effective treatments for 
chronic pain, our culture has developed an unprecedented 
reliance on these medications, while removing any perceived 
risk of harm or dependence.
    With that realization, the first opportunity for action by 
our Federal partners is to review and to restrict the methods 
that pharmaceutical companies continue to use in order to 
increase the number of users of opioid medications. Until we 
are able to reduce the number of new users, we are waging a 
losing battle against this epidemic in our communities and 
across our country.
    The next opportunity to support our local efforts is to 
expand the critical need for access to effective and evidence-
based treatment. Integrating behavioral healthcare with primary 
healthcare ensures the best outcomes for individuals with 
multiple healthcare needs. This integrated care, however, 
requires unrestricted sharing of information between all 
members of the healthcare team. Currently, Federal law, 
specifically 42 CFR Part 2, prohibits access to substance use 
disorder treatment, which represents a significant barrier. 
This regulation prohibits information related to substance use 
disorder treatment to be shared across all members of an 
individual's healthcare team.
    Earlier this year, the President's Opioid Commission 
identified this as an important component to address the crisis 
across our country. We and our DuPage County partners strongly 
support this recommendation and urge immediate action in this 
matter.
    Expanding treatment to all individuals in need represents a 
strategic focus of our local efforts. With an increasing number 
of individuals ensnared in this chronic and lifelong illness, 
treatment, in fact, represents hope and the opportunity to 
succeed. Currently, estimates indicate that only 11 percent of 
individuals experiencing substance use disorders are actually 
able to engage in treatment.
    Expanded publicly-funded treatment opportunities must be 
achieved in communities across our country. Although I 
recognize this is a bold goal, I believe the utilization of 
existing networks that Congress currently funds and established 
through the federally-qualified healthcare system, the 
community healthcare system, the rural health system, will 
assure this goal is achieved.
    Funding for this critical expansion of treatment must be 
allocated to achieve the additional treatment capacity we need 
in local communities today. Public health systems must be 
equipped to address this crisis and prevent others in the long 
term. DuPage County has been successful through the development 
of the HOPE Task Force multifaceted and comprehensive response 
plan. I am confident that our efforts to develop systems 
preventing substance use disorders, while engaging individuals 
in treatment and recovery, may serve as a model for other 
communities attempting to address this goal as well. These 
efforts, however, must be supported with Federal assistance 
focused on developing new policies that reduce new opioid users 
coming into the system, easing of restrictions preventing the 
unrestricted flow of information across healthcare provider 
teams, as well as building the capacity through the expansion 
of treatment services from Federal intervention.
    I look forward to continued partnership with you in these 
critical areas, and I wish to thank you once again for the 
opportunity to share.
    [Prepared statement of Ms. Ayala follows:]
   
   
   
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    Mr. Jordan. Thank you, Ms. Ayala. I will now go to Dr. 
DesJarlais from Tennessee for the first round of questions.
    Mr. DesJarlais. Thank you, Mr. Chairman. Thank you for 
being here to discuss this very important and relevant topic.
    Mr. Siegle--I have a lot of questions for all of you, so if 
you can keep your answers short, that would be helpful--you 
testified that ONDCP's neutrality is an asset to the HIDTA 
Program. Can you elaborate on that for me?
    Mr. Siegle. Yes, the participation and oversight and 
guidance given by the ONDCP versus a traditional law 
enforcement agency is actually a very good benefit. It is 
neutral. It does not make the State and locals feel alienated. 
It empowers the regional and local executive boards to make 
decisions in their area. And it, I think, has increased and 
continues the increase of the program because of the belief 
that they have a say in the program because it is not 
controlled by one agency. It is controlled and directed by the 
executive board.
    Mr. DesJarlais. Okay. And how does the reauthorization of 
the ONDCP ensure the continued success of the HIDTA Program?
    Mr. Siegle. It places the HIDTA Program under ONDCP and 
continue our operation under their coordination, and guidance, 
and funding.
    Mr. DesJarlais. How important is ONDCP's national drug 
control strategy in shaping the focus of the HIDTA Program?
    Mr. Siegle. It is very important, and it kind of goes both 
ways in that the drug problem started at the local or regional 
level, and all those combined feed in to the National Drug 
Strategy, which ONDCP puts together. And by having HIDTA and 
ONDCP together, they can reach out to the HIDTAs across the 
country and have instant access to all the different drug 
information at the various, you know, regional areas and cities 
and levels of law enforcement across the country.
    Mr. DesJarlais. Okay. Thank you. Ms. Haskins, the Drug-Free 
Communities Program provides Federal funding straight to the 
local level. How effective is ONDCP, a Federal policy shop, in 
administering a program geared towards local communities?
    Ms. Haskins. They are extremely effective. Something that 
is helpful with ONDCP being over the Drug-Free Communities 
Program is that ONDCP, their focus is substance use and abuse. 
So, there is nothing else that is kind of clouding their focus 
area. They provide us technical assistance whenever it is 
needed. They help us out if we have difficulty with our program 
officers or project officers through SAMHSA. They are there to 
help kind of connect us and help move that process forward.
    Mr. DesJarlais. Okay. The DFC Program is required to 
collect and submit data about its coalitions every 2 years. How 
does this data collection share the effectiveness of your 
coalition?
    Ms. Haskins. We have to be able to prove that, the $125,000 
annually that we receive that we are seeing reduction in use. 
Without that data collection, we are unable to do that.
    Mr. DesJarlais. Would it be helpful to collect the 
information on an annual basis?
    Ms. Haskins. There are some drug-free communities locations 
that do that. I think that in order to see long-term change, 
though, it is not going to be as effective to do it on an 
annual basis.
    Mr. DesJarlais. What does ONDCP need to improve its data 
collection, or does it need to improve it in any way?
    Ms. Haskins. The reports that we have to provide, it is 
once every 6 months. They provide a submission of what we have 
turned into them so that we have an overarching idea of where 
we are moving from and where we are going to. At this point, I 
would not say that there would be anything that would need to 
be changed.
    Mr. DesJarlais. Does your coalition work with the HIDTA 
Program?
    Ms. Haskins. We work with some of their officers in West 
Virginia. We particularly are not a HIDTA county, but all of 
the counties surrounding us are HIDTA counties.
    Mr. DesJarlais. Okay. Ms. Roberts, as Congress appropriates 
increased funding to tackle the opioid crisis, the need for 
Federal-level coordination is imperative. How does ONDCP assist 
your local initiatives in preventing and reducing illicit drug 
use?
    Ms. Roberts. ONDCP has helped us tremendously to address 
supply and demand at the local level. Sometimes evidence-based 
practices and best science does not get transmitted to the 
local-level area people so much. And so, by allowing us to be 
exposed to forums, conferences, the leadership, the reporting 
systems, we are able to find out what is kind of the cutting-
edge types of things, science that is being researched at the 
Federal level. And we are able to take that to our local 
communities then and translate that into action at the local 
level.
    Mr. DesJarlais. How does the reauthorization of ONDCP 
affect the HIDTA and DFC grant programs?
    Ms. Roberts. Because they are both under the Office of 
National Drug Control Policy, these are their two main 
programs. Like Mr. Siegle said, it is very important that they 
be led by an agency that has very broad understanding. This is 
an extremely, extremely complex and evolving issue. And so, it 
is very important for an office to be able to look at law 
enforcement's concerns, public health's concerns, treatment 
concerns, and be able to kind of lead and develop policies that 
do not necessarily hurt another branch or another entity while 
developing a policy that helps another entity. So, it is just 
very important for them to be able to have a very broad 
picture, and to be able to translate that into information that 
communities like mine can use at the local level.
    Mr. DesJarlais. Okay, thank you all for your responses. I 
yield back.
    Mr. Jordan. Thank you, Doctor. The gentleman from Illinois 
is recognized for 5 minutes.
    Mr. Krishnamoorthi. Thank you, Chairman, and thank you all 
for your really enlightening testimony. I wanted to first start 
out by saying representatives from three organizations, namely 
the Robert Crown Center for Health Education, the DuPage County 
Board, and the Gateway Foundation, have provided additional 
testimony for the record about local efforts to combat the 
opioid epidemic in Illinois. Mr. Chairman, I request unanimous 
consent that this testimony be made part of the official record 
for today's hearing.
    Mr. Jordan. Without objection, so ordered.
    Mr. Krishnamoorthi. Thank you.
    [The information follows:]
    Mr. Krishnamoorthi. I would like to start, I have several 
questions, so I ask everyone to please be brief. But, first, I 
would like to start with Ms. Ayala. Thank you again. We are 
honored to have you here today.
    Ms. Ayala, how has the Federal grant landscape shaped the 
work you are able to do with the HOPE Task Force?
    Ms. Ayala: So, it was not part of my comments provided 
earlier, but we have been a recipient of the Drug-Free 
Communities grant for the past 5 years. That, as other members 
providing testimony, has provided us with an opportunity to 
coalesce a group and really provide the framework in which we 
can develop a more expanded approach based in the local 
communities to meet our needs.
    Primarily the efforts and the funding that we have received 
from the Federal level so far have been around the use 
naloxone, which we greatly appreciate, and it is very much 
needed within our community. However, one of the opportunities 
I think that grants such as the Drug-Free Communities and the 
HIDTA model provide is an opportunity for local communities to 
better define where their needs lie versus the categorical 
funding that has been historically provided to us.
    Mr. Krishnamoorthi. Got it. Thank you, Ms. Ayala. Ms. 
Haskins and Ms. Roberts, with the Drug-Free Communities grants 
that you have received, could you each just talk about a couple 
like tangible examples of how you use that money to reduce, you 
know, the addiction rates in each of your counties. I was 
especially interested in Ms. Haskins' testimony about the 
reductions pretty much across the board. Could you talk about 
this, the tangible application of the money?
    Ms. Haskins. Absolutely. The very first year that we began 
our coalition back in 2009, we had had 16 youth die in a matter 
of 2 years all pretty much from the same graduating class. So, 
that is pretty difficult for a community to put aside and not 
recognize that we have a prescription drug issue.
    We were able to do a comprehensive public awareness 
campaign to help bring that forward and help kick off some 
conversation that otherwise was not being had in our community. 
We educated anybody from preschool all the way up to the 
elderly who participate in our senior centers, you know. We had 
pharmacy students that would come in and volunteer their time 
to go over medications with the elderly and let them know what 
were some of the medications that were being taken out of the 
home, you know, people watching mailboxes to take that 
medication out of mailboxes that had been sent through the 
Postal Service. So, our comprehensive public education strategy 
was probably the biggest thing that we have done.
    That money has also helped us utilize, like I said, the 
destruction of prescription pills. We have three static 
takeback locations that we advertise constantly. We are a 
county of 29,000, and we usually get about 99 pounds of 
medication back per quarter. It is fiscally difficult to 
destroy that medication properly, so one of the things that we 
were able to utilize, only $2,000 of our Federal money was to 
build and purchase an incinerator for our community so that we 
can destroy these pills and it will not be a financial burden 
on our community. We then took that idea and we advocated that 
that needs to take place throughout the State of West Virginia, 
so, therefore, we now have regional incinerators throughout the 
State of West Virginia to help other small communities like our 
own.
    You know, when you do public education, and you are going 
into the classroom, and you are teaching kids, you are teaching 
parents what to watch for for substance abuse, you are teaching 
teachers what substance abuse looks like so that they can 
understand, you know, when kids are high in the classroom. We 
have done law enforcement training to train them on diversion 
because when we started seeing pill issues in our county, law 
enforcement did not have a clue. They do not know if it is a 
blood pressure medication or an oxycodone, you know.
    So, those types of trainings were very important, and our 
DFC funding enabled us to do all those of skill building 
opportunities. And that is how we ended up with a reduction 
across the board was all of our educational opportunities that 
we are able to provide.
    Mr. Krishnamoorthi. Thank you. Can Ms. Roberts answer 
briefly?
    Mr. Jordan. Sure.
    Mr. Krishnamoorthi. Ms. Roberts, can you please address the 
question?
    Ms. Roberts. Yes, our DFC funding enabled us to do 
comprehensive strategies across the entire community. And one 
of the requirements of drug-free communities is that you have 
very broad sector representation. There are 12 sector members 
that are required to be part of the coalition.
    When we first started our coalition in 2010, we were 
actually in incident command mode, which is a public health 
military type of strategy that is used for an emergency, which 
we had declared an emergency. But we needed to learn to be more 
strategic and long term and have outcomes that were going to 
last over a period of time after the urgency subsided.
    So, sector leaders ended up being very important. One 
sector in particular is a healthcare provider. Our healthcare 
provider at the moment is our health commissioner who is also a 
Data 2000 waivered physician, and just the coalition inspired 
him to become a Board-certified addictionologist.
    And so, those strategies allowed us to have access to 
prescribers, the people that are actually writing 
prescriptions. And so, we were able to get into hospitals, and 
medical societies, and dental societies, and things like that, 
and tell them about the opioid crisis, which they were not 
aware of at the time in 2010. But also to change their 
prescribing habits, prescribing guidelines, to increase their 
access or utilization of the Prescription Monitoring Program.
    And so, in my written testimony you can see that we are the 
lowest point since the Prescription Monitoring Program began in 
terms of opioid prescription being written. Thank you.
    Mr. Krishnamoorthi. Thank you.
    Mr. Jordan. If you could do just one thing and only one 
thing, what would it be? The single one thing you would do to 
deal with the problem? Ms. Haskins. I am just going to go down 
the line.
    Ms. Haskins. I would ----
    Mr. Jordan. Single most important thing to address the 
problem in your community or communities across the country. 
What would it be? Only one thing.
    Ms. Haskins. I would have to put in place some type of 
parameters for the MATs that are in our area, for the 
Medication-Assisted Treatment programs that are in our area, 
for the adults. For youth, it would absolutely prevention, 
prevention, prevention.
    Mr. Jordan. Okay. That sounded like two things.
    [Laughter.]
    Mr. Jordan. Ms. Roberts.
    Ms. Roberts. Well, in terms of the overall, drugs are 
always a symptom of a bigger thing. And so, you know, 
Appalachia has been an area that has kind of been impoverished. 
And so, I think that overall anything that can improve the 
economy is going to be helpful in the long term.
    But I would have to say at the moment that this is not 
necessarily being treated like a public health emergency even 
though it has been declared. Whenever there is a public health 
emergency, there is typically a stabilization period where the 
crisis kind of gets contained. And having been through multiple 
addiction treatment facilities with my own child and 
experienced a gamut of things that did not work, my daughter 
thrives on medication-assisted treatment. But I cannot tell you 
how difficult that was for me to access for her.
    So, I think that I would have to say I would like to see 
our regulations surrounding medication-assisted treatment be 
lessened, similar to what some of the other countries in Europe 
are doing. People can actually dose on a methadone at a local 
pharmacy on their way to work. I do not have any access to 
methadone in my community. The closest clinic is, like, a 
hundred-and-some miles away. And so, that would be my answer. 
Thank you.
    Mr. Jordan. Thank you. Mr. Siegle?
    Mr. Siegle. Yes, if I could do one thing, it would be the 
continuance of HIDTA under ONDCP because, as I stated, it 
allows us to operate efficiently and effectively. And also 
interface and support the prevention and education and 
treatment sides more effectively. For instance, some of the 
items I mentioned, like ODMAPs, that is not just for law 
enforcement. We developed it for law enforcement, but it is 
open to hospitals, treatment people, other people, public 
health people to see where the overdoses are occurring.
    Mr. Jordan. Yep.
    Mr. Siegle. And some of the HIDTAs are starting to use that 
information to forward out to the treatment people to say, hey, 
we have responded to this individual 5 times or 3 times. They 
have been Narcan'd X number of times. You may want to get out 
and talk to these people because they are going to be your next 
overdose victim. But I think that totality of strategy that 
ONDCP encompasses allows us as an enforcement program to 
partner and have greater access to the areas and provide 
assistance in those areas.
    Mr. Jordan. Ms. Ayala?
    Ms. Ayala: My recommendation would be to integrate and 
expand access to substance use disorder treatment across the 
community with a particular focus on individuals who are 
uninsured or under insured using public funding for their care.
    Mr. Jordan. Do any of you believe that other social 
welfare, not other, but social welfare programs, government 
programs in our social welfare system I should say. There was a 
study by Senator Johnson's staff over on the Senate Oversight 
Committee, and there has been some research in this area, that 
the Medicaid expansion is actually in some ways maybe 
contributed to growing opioid use in certain communities. Do 
you think that is something that should be examined and may, in 
fact, be the case? Ms. Haskins?
    Ms. Haskins. I will not blame that for the reason that West 
Virginia has had an increase.
    Mr. Jordan. I am not saying cause and effect yet, but do 
you see a correlation and potentially cause and effect 
relationship between the Medicaid expansion and the opioid 
epidemic?
    Ms. Haskins. I believe it has made it easier for access, 
yes.
    Mr. Jordan. Yeah, that is what Senator Johnson's study 
indicates. Ms. Roberts?
    Ms. Roberts. Ohio is one of the States that did expand 
Medicaid, and so I can probably speak on that a little bit. 
However, Ohio had a prescription opioid problem before Medicaid 
expansion. What Medicaid expansion ----
    Mr. Jordan. If I could interrupt for a second. I am not 
saying it did not. I am asking do you as a professional in this 
area, do you think the Medicaid expansion exacerbated an 
already-existing problem?
    Ms. Roberts. I think Medicaid expansion helped tremendously 
in terms of the problem because it allowed access. What I see 
at the community level is that it allowed access to addiction 
treatment for a lot of population that was not able to access 
it.
    Mr. Jordan. Do you think welfare reform would be a 
necessary part of actually addressing this overall problem? 
Reforming our welfare policies, incentivizing work, doing 
different things. You mentioned in your comments earlier, Ms. 
Roberts, that economic concerns you think led to this. So, do 
you think reforming our welfare system would help with this 
problem as well?
    Ms. Roberts. I think that it would be worth taking a look 
at. But, you know, as far as where I am from, there really are 
not a lot of opportunities for people, and so, public 
assistance is necessary for those people. So, I was speaking 
more in terms of economic development and opportunities.
    Mr. Jordan. Ms. Haskins?
    Ms. Haskins. I would say, I mean, I would agree with that, 
yes. I think part of what would need to happen, though, is with 
the Medicaid expansion, they would need to be able to go across 
State lines to access treatment.
    Mr. Jordan. I am pushing my limit on time, so I am going to 
recognize Ms. Kelly for her 5 minutes of questioning.
    Ms. Kelly. Thank you, Mr. Chair, and thank you and the 
ranking member for having this hearing. And welcome to all the 
witnesses. I have another question that I had planned to ask, 
which I still will, but maybe I missed this.
    When you think about your places that you represent, or 
even if you think about nationally, how did this start? Like 
the majority of the people that have opioid addiction or died, 
how did it first begin?
    Ms. Ayala: If I could jump in. Within our community and 
within our research, we work closely with the National Safety 
Council, and what their evaluation demonstrates is that 75 to 
80 percent of the individuals who are currently addicted to 
heroin began their journey into this complex world through the 
use of opioids prescribed by their physicians.
    Ms. Kelly. Thank you.
    Ms. Ayala: Or doctors.
    Ms. Haskins. I would tend to agree with Ms. Ayala. I would 
also say that West Virginia had a very high heroin usage rate, 
and when that balloon started to get contracted on the heroin 
side, it is going to automatically flip over to the opioid 
side. You know, our particular issue in our community was 
fentanyl way before fentanyl was a household name. And that was 
coming from local prescribers.
    Ms. Kelly. Thank you. Anybody else?
    Ms. Roberts. I would like to chip in. I am from Portsmouth, 
Ohio, which we ended up with a lot of notoriety for being an 
area that saw the opioid crisis really early. We were making 
headlines back in 2002 in terms of OxyContin. And so, these 
products were marketed heavily in Appalachia, you know? That is 
why they ended up being called ``hillbilly heroin.'' And so, I 
would say the pharmaceutical company marketing played a role in 
that, but also what we saw was that it became a form of 
currency, currency in an impoverished area where people did not 
have access to other forms of making money. So, I think these 
things were interrelated.
    Ms. Kelly. I have to be careful. Both the ranking member 
and I are married to doctors, so I have to be careful.
    [Laughter.]
    Ms. Kelly. And my husband is an anesthesiologist. But that 
is what I thought, and when I went to a meeting with my 
hospital where I represent in Illinois, they actually started a 
program where they gave out the medicine to prevent the deaths. 
But that was something they talked about, more education for 
the prescribers, that that was needed, too. But anyway, again, 
I want to thank you.
    I wanted to talk to you about access to the lifesaving 
drug, naloxone. As you know, it is a drug that reverses opioid 
overdoses and prevents death, and last week the Surgeon General 
issued the first advisory in 13 years calling for expanded 
access to it. He wrote that ``Increasing availability and 
targeted distribution of naloxone is a critical component of 
our efforts to reduce opioid-related overdose deaths.''
    Ms. Roberts, I understand you are a registered nurse, and 
you obviously worked in the public health field for a long 
time. So, I would like to ask you is access to this critical 
for first responders and others working on the ground to save 
lives?
    Ms. Roberts. Well, as someone who has worked extensively 
with the drug naloxone, I think I can say that it is absolutely 
imperative, especially at this time when we are having a 
national crisis. But naloxone is a prescription drug, and so, 
therefore, it is subject to all of the rules and regulations 
that surround a prescription drug. In some other countries it 
is not necessary. It is an over-the-counter drug, and so it is, 
you know, sold over the counter, it is very cheap, and all of 
that kind of stuff.
    So, it I a little bit difficult to navigate the system 
sometimes because of the rules and regulations that control it 
as far as who can dispense it, who can, you know, prescribe it, 
and all of those things. So, in Ohio we have actually had to 
navigate that system for several years, and have managed to be 
able to get it to a point where we are able to have it 
available at certain pharmacies through a corporate protocol. 
There has to be a licensed prescriber in the loop someplace, 
which makes things a little bit difficult.
    And so, we have been able to get it to where people can get 
it without a prescription by going to a certain pharmacy, and 
it is covered by insurance. However, as far as supplying it to 
law enforcement and fire departments and these sort of non-
traditional first responders, the fact that the price does 
increase frequently, you know, really does kind of impede our, 
we kind of fly by the seat of our pants all the time in terms 
of coming up with the medication.
    Ms. Kelly. Well, and mentioning that, several of my 
Democrats colleagues did write to President Trump in September 
of last year asking that he take action to lower the prices. 
And this morning actually, Ranking Member Cummings sent yet 
another letter to President Trump urging him to adopt his own 
commission's recommendation to negotiate lower prices, and 
ensure that this lifesaving drug is available to all who need 
it.
    I know my time is over, so thank you.
    Mr. DeSantis. [Presiding.] Thank you. The chair now 
recognizes the gentleman from Kentucky for 5 minutes.
    Mr. Comer. Thank you, Mr. Chairman. Ms. Roberts and Ms. 
Haskins, I represent a very rural district in Kentucky that has 
been hit especially hard by the opioid epidemic. How have you 
seen the opioid epidemic uniquely affect rural communities?
    Ms. Haskins. Especially in our community, much like Ms. 
Roberts said, it is a form of income for a lot of people in a 
location where there are no other jobs. Luckily for us with DFC 
funding, we are able to do some prevention with the children of 
those families and parents who are using a lot and abusing and 
selling, helping them create goals, and figuring out that there 
are some other options in life other than utilizing 
prescription drugs or some other form of a substance.
    In particular, we have many of our elementary schools in 
Jackson County that are seeing difficulties just now with 
students coming up through the school system. They cannot 
retain information. This is pretty much the first wave of 
children who are coming through the school system from opioid. 
You know, I mean, they are opioid-exposed babies, and they are 
having difficulty retaining information that is being taught. 
That is not the fault of the teacher. That is not the fault of 
the school system itself. And we do not know how to deal with 
these children because they cannot get qualified for special 
ed. They are not learning disordered as far as what the school 
parameters are. So, we are having difficulties even with 
behavior in our school systems. That is probably one of the 
most recent happenings from how it has affected our community.
    Mr. Comer. Right.
    Ms. Roberts. In answer to your question, I have seen 
opioids affect our community in so many negative ways. And so, 
prescription opioids really just sort of landscape. In 
Appalachia, we had never really had a heroin problem. Heroin 
was a problem that was associated with big metropolitan areas. 
And so, heroin is now a problem in Appalachia, and because of 
that, you know, we are absolutely seeing children who are, you 
know, having to live in families where substance use is a 
problem.
    However, the Drug-Free Communities grant has allowed as a 
coalition to address parental substance use because that has 
such a negative effect on children. One of our sector leaders 
is the juvenile court judge, and he actually has started a 
family drug court to help families that are struggling with 
opioid use disorder so that they can retain their children and 
keep the family intact.
    Mr. Comer. Now, one of the things that Chairman Jordan 
mentioned with the expansion of Medicaid is that, the question 
he asked was did that make the opioid epidemic worse. And the 
source of most of the opioids in my rural county, according to 
my law enforcement, from people on Medicaid for which you 
mentioned, a source of income.
    Ms. Haskins. Absolutely.
    Mr. Comer. And that is something that, you know, you think 
about it, that is being paid for by the tax dollars. That is 
not coming in from drug cartels. That is coming from citizens 
in the communities that are getting free prescription drugs and 
turn around and selling them, which is having devastating 
effects on a community that has already been devastated by the 
new economy. So, that is something that I think we need to look 
into.
    And do you have any advice on how to prevent that, 
alternative sources of payment? I mean, I do not know. There 
are certainly over prescribing that is going on in rural 
communities.
    Ms. Haskins. You know, in our particular community, at this 
point I do not think it is an over prescribing issue. It truly 
is an access issue. We have a needle exchange program that we 
just started in our health department, and I can tell you that 
most of our individuals that come through our program are 
actually using Suboxone, and Subutex, and crystal meth, you 
know, so, again, access is an issue.
    I think one of the main fixes would be to have some 
additional quality mental health counseling available because 
right now in West Virginia, that is seriously lacking, and I am 
sure it would be similar in Kentucky as well, because until you 
deal with the root of the problem, and, you know, most people 
will tell you that with substance use there is some underlying 
mental health issue that is not being dealt with, they are 
going to continue to use.
    Mr. Comer. Thank you, Mr. Chairman. I yield back.
    Mr. DeSantis. The gentleman yields back. The chair now 
recognizes the gentlewoman from the District of Columbia.
    Ms. Norton. Thank you, Mr. Chairman. I particularly thank 
the witnesses who have testified, whose testimony has already 
clarified much for me.
    I want to make sure I know what we are talking about. I 
think it was you, Ms. Ayala, who talked about how people on 
heroin transition to opioid addiction, one of you did. And I 
think it is useful that we are using what looks like a broad 
term to describe what we are talking about when we hear 
``substance abuse,'' sometimes is a term used. But I would like 
to know essentially what we are dealing with.
    One of you indicated, or perhaps it was my colleague, that 
it was called ``hillbilly heroin'' in his rural area. Well, 
obviously it is not called that in mine. I represent the 
District of Columbia, and big cities are where you had heroin 
abuse. Now you have something else, and it looks like 
physicians and the medical community is implicated.
    And so, I would like to know exactly what we are talking 
about. When we talk about an opioid crisis, most people will 
think that are prescribed or highjacked medicines. I do not 
think they understand the relationship to heroin. So, anything 
any of you could do to clarify that I think would be useful for 
this hearing.
    Ms. Roberts. I would like to clarify that. Prescription 
opioids are commonly called ``pain pills, ``pain killers.'' 
They are manufactured by pharmaceutical companies, and they 
have some molecular structure that includes morphine.
    Ms. Norton. Well, I understand that there is a difference 
between ----
    Ms. Roberts. Yeah, okay.
    Ms. Norton. I am trying to find out how these substances, 
why you find some in some place, some in the others.
    Ms. Roberts. Okay.
    Ms. Norton. Why there is a crossover. Even if you think 
that they are hillbilly heroin in some places, was there any 
heroin there before?
    Ms. Roberts. No.
    Ms. Norton. I do not understand how this got started. I do 
not understand whether it is sectional, whether we need 
different approaches for different parts of the country since 
apparently they all transition between and across one another.
    Ms. Roberts. Molecularly, heroin and prescription opioids 
are very similar, so you can kind of think of them as being 
interchangeable. When somebody becomes addicted or dependent to 
prescription opioids, then heroin will fill the same need. It 
is also cheaper. It comes from a different place, so ----
    Ms. Norton. Heroin is cheaper?
    Ms. Roberts. Absolutely.
    Ms. Norton. Initially opioid has to come from a physician, 
I guess, from a prescription, how does that get to be like 
heroin so they are simply passed all around the community?
    Ms. Roberts. Well, prescription opioids come from a 
physician, and they have been used widely for the last 20 years 
due to some changes that took place with something called a 
pain scale. There was a belief that we under treating pain in 
the United States, and so you saw prescription opioids, 
especially, you know, some very potent ones, come on the market 
and end up being very liberally prescribed. When I mentioned 
that ----
    Ms. Norton. So, they are liberally prescribed. Now, all 
right, I get a prescription. I go around selling that 
prescription. Is that really the only way people are able to 
market this as a drug? They keep going back. Where do they keep 
getting prescriptions from?
    Ms. Roberts. Well, they can find a prescriber that will 
give them the prescription, and so ----
    Ms. Norton. So, it looks like Congress or somebody needs to 
do something.
    Ms. Ayala: So, if I could just interject. The prescription 
drug monitoring programs that have been established on a State-
by-State basis have been very successful in addressing the 
multiple attempts by an individual to go to multiple 
prescribers and game for additional prescriptions. However, the 
flip side of that is once that source is diminished, then that 
individual tends to turn to street heroin both because of the 
availability as well as the price. So, that happens on a 
system-wide basis, but it also happens on an individual basis.
    Ms. Norton. Yeah, that is important to understand how that 
occurs. They become addicted whether with heroin or opioids, 
and it does not matter, they are addicted. Now, Governor 
Christie of New Jersey headed the President's commission on 
combatting drug addiction. And I just want to read to you what 
he said to find out what in the world Congress needs to do, 
because this is a crisis that is getting worse. This does not 
always happen. I mean, there was an Ebola crisis. That was very 
different, but we got a hold of it. Swine flu, we got a hold of 
it. This thing is running away from us.
    Governor Christie said, ``One of the most important 
recommendations in this final report is getting Federal 
funding, support more quickly and effectively to State 
governments who are the front lines of fighting this 
addiction.'' Do you believe this is the key to quelling the 
addiction you find in your communities, and I would like to 
have answers from all of you, increased funding from the 
Federal government.
    Ms. Haskins. Absolutely, increased Drug-Free Communities 
funding because that is letting local communities deal with 
whatever trends are coming through their communities. It is not 
a one-size-fits-all answer unfortunately.
    Ms. Norton. Ms. Roberts?
    Ms. Roberts. I would have to agree with Ms. Haskins. Drug-
Free Communities is extremely important. It does allow you to 
be fluid and to shift your focus when necessary, and the opioid 
epidemic is a good example of when that has happened. We have 
prescription opioids, kind of deal with that, took care of 
that, now we have a heroin problem.
    Many Federal grants are very restrictive, and they will 
say, well you can only deal with prescription opioids. So, what 
do you halfway through when a heroin problem comes? You are 
kind of stuck. And so, Drug-Free Communities is very important 
because they allow us to kind of shift gears midstream when we 
need to along with the HIDTA program, because supply reduction 
is extremely important now, too.
    Mr. DeSantis. The gentlewoman's time has expired. The chair 
now recognizes himself for 5 minutes.
    Ms. Roberts, I wanted to follow up with you. Chairman 
Jordan asked you about the Medicaid expansion. There has been 
testimony before the Congress and some data suggesting that 
that has fueled the epidemic, and I think the argument is, you 
know, you are expanding to able-bodied adults. The program is 
not really good for long-term quality care and things like 
that, but it does provide access to the prescription drugs.
    And so, the stats, I think, are 13 of the 15 States with 
the highest opioid overdose rates are Medicaid expansion 
States. I think your testimony was you think it has helped 
mitigate the problem, not exacerbate it. And so, what is your 
basis for saying that and have you seen data that would 
substantiate your view?
    Ms. Roberts. Well, thank you for the question. So, they are 
saying that prescription opioids become more liberally 
prescribed in States that expand Medicaid because now people 
have more Medicaid and have a way to access them. Am I correct? 
Is that what is being said?
    Mr. DeSantis. And I think, you know, you access it with, I 
think, pretty much no cost to the patient.
    Ms. Roberts. Yeah, and there could very well be some truth 
to that. But what I can say about Ohio is that Ohio did not 
expand Medicaid until probably 2014 or 2015. At that time, my 
county had the highest distribution rate in the State of Ohio, 
so we had plenty of opioids before Medicaid expansion. What I 
saw Medicaid expansion do for Ohio was allow many of the people 
that we were not able to help get access to addiction 
treatment. So, I think it is just probably going to be one of 
those double-edged swords.
    Mr. DeSantis. Right, because I think some of the graphs, I 
mean, since 2013, I mean, you have seen, it is noticeable the 
increase in the Medicaid expansion States. Let me ask you this. 
Is the bigger problem too many prescriptions and abuse of that 
right now, or is a bigger problem the street drugs?
    Ms. Roberts. Well, that depends on where you live.
    Mr. DeSantis. What is your experience?
    Ms. Roberts. Well, where I live right now the bigger 
problem, we have seen almost a hundred percent transition to 
heroin. And that happened relatively quickly when the 
prescription opioids less easy to access. We have seen the 
analog drug fentanyl products show up in heroin, and now they 
are showing up in other illicit drugs, such as cocaine and 
crack. And so, we are starting to see our entire drug supply 
become contaminated with these analog drugs that are highly 
lethal.
    Mr. DeSantis. Where is that coming from?
    Ms. Roberts. Primarily it is coming from China. There have 
been many labs that have been ----
    Mr. DeSantis. So, China sends it where?
    Ms. Roberts. It is a very condensed product. It is very 
small, so it is very easy to send in the postal system. And so, 
it can be mailed to different parts of Canada, driven across 
the border. It can also be mailed to the United States.
    Mr. DeSantis. Well, I think that is true, and it is 
interesting, they will not use Federal Express or UPS for that 
because it will be identified. The Post Office has had a tough 
time. We passed a bill recently to try to provide some tools to 
deal with that, and so it does come in the mail, but a lot of 
it, you know, comes in, you know, across the border. And I 
think that if you look at this crisis, it shot up around the 
same time where we have had a lot of problems at the border.
    And I think that, you know, there are issues with what 
taxpayers have to shoulder when we do not have a secure border. 
There are issues with the rule of law that are very important. 
But this drug issue is a huge deal, and this garbage is coming 
into our country. And I think the prescription stuff, you know, 
obviously has been an issue, still is. But the prescriptions 
are going down now, and yet this stuff out there is just 
absolutely killer.
    So, we have got to get a handle on this. And I am all for 
treatment, I am all for, you know, fighting it on the demand 
side, but you have got to fight it on the supply side as well. 
There is no way you could just let our country just be an open 
field for this stuff and not think that we are going to have 
some really negative consequences.
    And with that, my time has expired, and I will recognize 
the gentleman from Wisconsin for 5 minutes.
    Mr. Grothman. Okay. We have a few questions here for the 
experts. We have heard how much the opioid crisis has gotten, 
and it has gotten much worse. And, of course, you know, we are 
spending billions of dollars between law enforcement or 
treatment, or whatever. Are there any examples around the 
country of States or large or small municipal areas in which 
there has been a precipitous drop in the number of deaths 
caused by opioids that we could say these people know what they 
are doing? Are there any examples of that around the country?
    Ms. Haskins. I think in Huntington, West Virginia, they 
would be a good example. The health department there started a 
harm reduction program. Their issue is mainly heroin. They have 
provided thousands and thousands of doses of naloxone, and they 
have seen those drop.
    Mr. Grothman. And how big is Huntington? How many people 
live in Huntington?
    Ms. Haskins. I would say probably about 70 or 80,000.
    Mr. Grothman. Okay, and do you know what ----
    Ms. Haskins. That is a large metropolis in West Virginia.
    Mr. Grothman. Okay. Yeah, I know, I got a district like 
that, too. Okay. So, there was not even a reduction in the use 
of the opiates. It was really just they got the shot to a lot 
of these people in time, right?
    Ms. Haskins. Yes. But now, as far as reduction and use, I 
think you look at any Drug-Free Communities grantee program 
recipient, and you will see a reduction in usage rates in their 
areas.
    Mr. Grothman. Yeah, can you give me an example of a city 
that if I look up or call their county, there has been a drop 
of deaths, and it is attributed to a drop in usage?
    Ms. Haskins. Well, I mean, if you look at Jackson County, 
West Virginia, we have had a drop in overdose deaths among 
adults and specifically youth.
    Mr. Grothman. Okay. Next question I have in general, one of 
the tragic things about this opioid epidemic is it strikes very 
good families, however we describe ``good families.'' And it 
just must be shocking for parents who did everything right and 
have this happen. Nevertheless, I always do wonder about 
overall statistics on family background of people who wind up 
in this situation. Do we have any statistics on that?
    Ms. Haskins. On family backgrounds?
    Mr. Grothman. Correct.
    Ms. Haskins. No, but, I mean, science has proven that if 
you have addiction somewhere in your family tree, you are 
almost ----
    Mr. Grothman. Right.
    Ms. Haskins.--you know, 50 percent more at risk to have an 
addiction.
    Mr. Grothman. Right, so we have no ----
    Ms. Ayala: If I could add.
    Mr. Grothman. Sure.
    Ms. Ayala: Most of our information is anecdotal and is 
geographic and demographic dependent, meaning whatever the 
representation of the community, that is what we are seeing 
reflected in the overuse and death data. So, for DuPage County, 
Illinois, the vast majority of our overdose reversals occur to 
young white males between the ages of 19 and 29 years old. That 
also happens to be the largest demographic in our community. 
So, it is absolutely agnostic when it comes to ----
    Mr. Grothman. Well, let me cut you off because I only have 
so much time. It is kind of meaningless if you say the largest 
demographic has the most deaths. That is kind of expected. What 
I am wondering is are there any studies out there given the sea 
of money we are throwing at this who can give us some 
statistics on family background or parental background and that 
sort of thing?
    Ms. Ayala: By the time an individual gets to the point of 
being addicted, many times they do not enjoy the support of 
their family regardless of where they started.
    Mr. Grothman. Well, you are not answering my question.
    Ms. Ayala: Okay, I am sorry.
    Mr. Grothman. I am sure that is true. Do we have any 
statistics?
    Ms. Ayala: We do not.
    Mr. Grothman. Okay.
    Ms. Haskins. Not that I am aware of.
    Mr. Grothman. Do you think it would be a good idea to get 
statistics like that given the gravity of the problem? It would 
be. Okay. Next question. One of the benefits of your program is 
that you have flexibility to do different things in different 
counties, right? Can you give me a solid example of how you 
should one strategy in Huntington and a different strategy in 
another type of city, or any city?
    You know, one of the reasons we are talking about this 
program being good is you can adapt locally.
    Ms. Haskins. Right.
    Mr. Grothman. Which presumably means it is not one-size-
fits-all. So, I am looking to kind of give you a softball 
question in which you guys can tell me, you know, we did this 
in this city and it worked, but it would not have worked in 
this city where we did something else.
    Ms. Haskins. Well, I can tell you, for example, Huntington, 
West Virginia, they began the harm reduction program. They 
offer naloxone classes once a week. They give out thousands and 
thousands of doses of naloxone and save lives every day with 
that. In our particular community an hour north of Huntington, 
naloxone would not help in our community with what is being 
utilized at this point because what is being utilized by our 
adults at this point is Suboxone, Subutex, and meth. Naloxone 
is not going to save your life if you are using one of those 
three things, so.
    Mr. Grothman. I guess are there differences by community 
other than just the type of drugs that are being used?
    Ms. Haskins. Absolutely, I mean, other than socioeconomic. 
I mean, the way that your communities are structured. We have 
wonderful relationships with our board of education, with our 
law enforcement, with our local city councils and mayors that 
come together for this issue, whereas Huntington may not have 
that type of partnership with their organizations and their 
movers and shakers.
    Mr. Siegle. In Cleveland, Ohio, the medical examiner has 
been pretty active in putting out statistics and things that he 
sees. And it is kind of back to your question, but he has found 
that in the Cleveland, Ohio area, which is Cuyahoga County, 
which leads the State in overdose deaths, that what he has seen 
is primarily white males in their 30s and 40s. But there is a 
correlation between their education level, and most of them 
work in the trades.
    And I think when you say they work in the trades, I think 
that is back to the pain pills that started because, you know, 
their back hurt or their something got hurt as they are working 
on one of the construction trades. So, there seems to be a push 
to educate and reach out to those trade unions to help educate 
their members.
    Mr. Grothman. When I said ``background'' ----
    Mr. Palmer. [Presiding.] The gentleman's time has expired.
    Mr. Grothman. Okay.
    Mr. Palmer. I now recognize myself for questions. I want to 
point out, I want to ask Ms. Haskins, you talked about children 
with learning disabilities or other issues ----
    Ms. Haskins. Yes, sir.
    Mr. Palmer.--or children and parents who are addicted to 
opioids. Have you seen any disparity demographically between 
children of people who are enrolled in Medicaid versus children 
who are not enrolled? Is there a greater population of children 
with these issues who are from homes where the parents or 
parent are on Medicaid?
    Ms. Haskins. I would have to look at the school system for 
that, but just anecdotally from what we hear in our community 
and from my observation, a large number of the children that 
are in that situation are certainly parents who are either 
uninsured or on Medicaid. But having said that, we also have a 
lot of children who are being raised by grandparents whose 
parents are very financially well off, and able to provide 
whatever it is that they want, but because of their addiction, 
they are living with family members.
    Mr. Palmer. I understand, but the point, and you verified 
and it is consistent with the data that I have seen. There was 
a CDC study in Washington State that showed persons on Medicaid 
are 5 to 7 times more likely to die an opioid-related death 
than someone not on Medicaid. It also said that the opioid 
prescription rate among Medicaid enrollees is at least twice 
the rate for persons on private insurance. So, you would 
naturally look at that data and conclude that some of the 
issues that you brought up about children having these learning 
disabilities would disproportionately come from households 
where they are on Medicaid, and I think that is a real issue 
with this.
    Mr. Siegle, Ohio enrolled more than 700,000 adults in the 
expansion of Medicaid, and is now seeing unprecedented problems 
with opioid addiction. As a matter of fact, last year Ohio was 
on pace to have more opioid-related deaths than the entire 
United States did in 1990. That is one problem. I also want to 
know if you have also seen more trafficking of opioids that 
drew Medicaid enrollees.
    Mr. Siegle. I do not know if I have any basis or statistics 
to support that one way or another. Most of the HIDTA funded 
counties in Ohio are centered in the major population areas. We 
only have one task force that operates down in Portsmouth in a 
rural area. And so, most of what I see coming from our 
interdiction efforts and enforcement efforts are in the larger 
metropolitan areas, and we are in 17 of the 88 counties, 14 of 
the 88 counties in Ohio. So, in those rural counties I really 
do not have a basis.
    Mr. Palmer. Well, it would not be rural versus urban. It is 
more are people getting prescribed opioids and then selling 
them. There are a number of issues here that are related to 
this ----
    Mr. Siegle. We are--we are ----
    Mr. Palmer.--but we are seeing this across a number of 
programs where there is trafficking, whether it is a SNAP 
benefit card or opioids that someone got as a result of a 
Medicaid prescription.
    Mr. Siegle. We are interdicting less pills and seizing less 
pills than before. Most of what we are getting now is the 
fentanyl, and it has actually overtaken heroin. So, if you want 
to make a correlation, I do not know if you can, between less 
pills and more people on Medicaid getting pills. But we are 
seeing and seizing less pills.
    Mr. Palmer. Well, you mentioned fentanyl. It was recently 
reported that there were three people arrested who enough 
fentanyl to kill everybody in Toledo. In my district, there was 
a gentleman arrested who had 38,000 lethal doses of fentanyl 
that he bought on the dark web and paid for it with bitcoins. 
But, Ms. Roberts, you were talking about it is produced in 
China. I would also add that the North Koreans are doing this.
    I was in a field hearing at Johns Hopkins Hospital with the 
former governor of New Jersey, Chris Christie, and I asked him 
if we had gone from a war on drugs to a drug with drugs, and 
that the 70,000 or so people who have died from overdoses, are 
they casualties of this war. But it is interesting to me that 
when you talk about how it gets into the country, it comes in 
the mail, but it is largely coming across the border. And you 
only mentioned the Canadian border, and perhaps that is because 
Ohio shares a border with Canada.
    But I do think that this is the real issue of border 
security, and a lot of people lose sight of this, that we are 
in a war with drugs, and it is coming across the border. And 
the fentanyl issue I think is something that we are going to 
have to address outside of just drug policy because it is 
lethal. Any comment on that, Mr. Siegle, in your efforts?
    Mr. Siegle. I would agree with you, it is coming across the 
border, and some of that is coming from China to Mexico and 
then up. And there is also a strong belief that the Mexican 
drug cartels are starting to produce their own fentanyl and 
transporting it up. But fentanyl, heroin, cocaine, all the 
major drugs are coming up from the south of border into Ohio 
and most of the HIDTAs. There is very little activity from 
other parts of the world. Some of the East Coast still see some 
from the Asia part of the world, but most of it is coming up 
through Mexico, at least in the Ohio HIDTA.
    Mr. Palmer. One last issue here, Ms. Ayala. I raised this 
question in the field hearing as well about the fact that 
hospitals have quality surveys that they provide for their 
patients, and one of those was on pain management. And when you 
are tying the Federal government's reimbursement rate to the 
hospitals or to physicians based on the outcomes of these 
quality surveys and you include pain management, that creates 
an incentive to over prescribe. And I think we cannot address 
this whole issue of opioids without addressing that.
    And it is my understanding, and I hope they are doing this, 
that beginning of the first of this year, they removed that as 
one of the criteria. Do you have any information about that? 
Any of you know anything about that? Have you seen any changes 
in that?
    Ms. Ayala: That is my understanding as well from our own 
Senator Durbin's staff. That is our understanding. The issue, 
however, is still with patient satisfaction. It may not be 
directly tied to pain management, but if I went to the doctor 
with the expectation of getting an opioid prescription and I 
left without one, then my satisfaction in general is going to 
be decreased. So, I think that your point is right on, and we 
need to do additional kinds of analysis around those policies.
    Mr. Palmer. I would like to thank the witnesses again for 
appearing before us today. Are there any other members? You 
wanted to ask? I recognize the gentleman from Illinois for one 
question?
    Mr. Krishnamoorthi. Two questions.
    Mr. Palmer. Two questions.
    Mr. Krishnamoorthi. Thank you, Mr. Chair. Okay, two final 
questions. One is a very, like, tangible question based on what 
I have been hearing, which is I think each of you have kind of 
developed a program or strategy that was effective in combating 
the crisis. If there is one thing that you could share with the 
rest of the communities who are paying attention to this 
hearing or the others who are paying attention, what would it 
be? Like, what would be the most effective thing that you did 
in kind of dealing with the opioid crisis in your community?
    Ms. Haskins. I would say looking at data, analyzing and 
figuring out exactly what the root of the problem is.
    Mr. Krishnamoorthi. Okay, thank you. Ms. Roberts?
    Ms. Roberts. I would say learning how to think 
strategically in long term, such as what is taught at the 
Community Anti-Drug Coalition Institute which we went to, which 
changed the way that we dealt with this all together. And the 
importance of data in being able to monitor, and, like Mr. 
Siegle said, live monitoring. You know, data that is a couple 
of years old is not real useful. So, I would say that Drug-Free 
Communities actually taught us how to do all of those things.
    Mr. Krishnamoorthi. Great. Mr. Siegle?
    Mr. Siegle. I think the bringing of all the levels of law 
enforcement together, but also developing those systems that I 
talked about from ODMAPs to the intake form, and the sharing of 
information back out to all aspects of fighting this battle, 
the prevention, education, treatment, and enforcement. And I 
think the one area that we all tend to, I do not want to say 
``overlook,'' but I think is part of the prevention side is 
education. And, you know, what are going to do with future 
generations to look at the information we give them to process, 
and the training, and the educations in school to prevent this 
from happening down the road I think would be important.
    Mr. Krishnamoorthi. Got it. Ms. Ayala?
    Ms. Ayala: I believe that it is two parts. So, the 
opportunity to discuss with our residents that issues of 
substance use disorder in the terms of public health and 
overall health of the community have probably been the most 
profoundly liberating aspects of our work. The other is to 
acknowledge that infrastructures for substance use disorder 
treatment is extremely limited.
    Mr. Krishnamoorthi. Well, that transitions to my last 
question, which is, you know, the 2018 omnibus package 
appropriated $3.2 billion to address the opioid crisis. We are 
still trying to figure out exactly how that money is going to 
get spent. But at least in my understanding, I do not think it 
is going to be directed so much to DFC, Drug-Free Communities, 
or the HIDTA programs, more to certain treatment programs, 
which is also a huge unmet need as well. But, I mean, what is 
your kind of impression of the amount of money that was 
appropriated, and, you know, what are some of the unmet needs 
that we really need to address that maybe we are not addressing 
even in this package. Ms. Haskins and just down the row. Very 
briefly, please.
    Ms. Haskins. You will never be able to treat your way out 
of this problem regardless of how much money you throw at it. 
So, unless you continue to fund and at additional funding 
levels, unless you continue fund prevention ----
    Mr. Krishnamoorthi. Right.
    Ms. Haskins.--you will never have enough money for 
treatment.
    Mr. Krishnamoorthi. Right, thank you. Ms. Roberts?
    Ms. Roberts. I would have to agree with Ms. Haskins. It has 
been typical for a long time for most of the money to go 
towards these sort of downstream crisis problems and less money 
to go towards preventing them in the first place. And I think 
that is one of the reasons why we are seeing this crisis now.
    Mr. Krishnamoorthi. Thank you. Mr. Siegle?
    Mr. Siegle. I would agree also, prevention. You know, also 
we cannot arrest our way out of it. We cannot treat our way out 
of it. And I think we need to avoid getting those people at 
that level because we have lost them by that point.
    Mr. Krishnamoorthi. Thank you. Ms. Ayala?
    Ms. Ayala: And although I absolutely agree and support 
everything that has been said, I also do not think we can 
ignore this large population that now find themselves ensnared 
in the chemical dependency. And so, I would say we have some 
obligation as a civil society to address their needs.
    Mr. Krishnamoorthi. Thank you. Thank you, Mr. Chair.
    Mr. Palmer. I would just add I agree with all four of your 
responses on that, and just add this, and it is in regard to 
the Medicaid expansion. I think we cannot ignore this, that 
there has been a dramatic increase in addiction in the States 
that have expanded, and that we are better off, as each of you 
said, directing Federal funding on prevention. We cannot ignore 
the addiction issue either, that we have go to deal with it. 
But I think that we have also got to recognize that there is a 
problem, that we have created a problem with the expansion. 
And, you know, my previous career was with a think tank. Part 
of that was engineering, and one of the things that we 
fundamentally understood is you cannot solve a problem until 
you properly define it.
    With that, again, I would like to thank the witnesses for 
appearing and for your testimony. The hearing record will 
remain open for 2 weeks for any member to submit a written 
opening statement or questions for the record.
    [The information follows:]
    Mr. Palmer. If there is no further business, without 
objection, the Subcommittee on Healthcare, Benefits, and 
Administrative Rules stands adjourned.
    [Whereupon, at 11:37 a.m., the subcommittee was adjourned.]


                                APPENDIX

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