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









A SUSTAINABLE SOLUTION TO THE EVOLVING OPIOID CRISIS: REVITALIZING THE 
                 OFFICE OF NATIONAL DRUG CONTROL POLICY

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

                                HEARING

                               BEFORE THE

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 17, 2018

                               __________

                           Serial No. 115-82

                               __________

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







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31-121 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
Virginia Foxx, North Carolina        Jim Cooper, Tennessee
Thomas Massie, Kentucky              Gerald E. Connolly, Virginia
Mark Meadows, North Carolina         Robin L. Kelly, Illinois
Ron DeSantis, Florida                Brenda L. Lawrence, Michigan
Dennis A. Ross, Florida              Bonnie Watson Coleman, New Jersey
Mark Walker, North Carolina          Raja Krishnamoorthi, Illinois
Rod Blum, Iowa                       Jamie Raskin, Maryland
Jody B. Hice, Georgia                Jimmy Gomez, Maryland
Steve Russell, Oklahoma              Peter Welch, Vermont
Glenn Grothman, Wisconsin            Matt Cartwright, Pennsylvania
Will Hurd, Texas                     Mark DeSaulnier, California
Gary J. Palmer, Alabama              Stacey E. Plaskett, Virgin Islands
James Comer, Kentucky                John P. Sarbanes, Maryland
Paul Mitchell, Michigan
Greg Gianforte, Montana

                     Sheria Clarke, Staff Director
                    William McKenna, General Counsel
     Sarah Vance, Health Care, Benefits, and Administrative Rules 
                      Subcommittee Staff Director
                Michael Koren, Professional Staff Member
                    Sharon Casey, Deputy Chief Clerk
                 David Rapallo, Minority Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 17, 2018.....................................     1

                               WITNESSES
                                Panel I

The Honorable John Cornyn, Senator from Texas and Senate Majority 
  Whip
    Oral Statement...............................................     1

                                Panel II

Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy 
  Center
    Oral Statement...............................................     8
    Written Statement............................................    10
Rahul Gupta, MD, MPH, MBA, FACP, Commissioner and State Health 
  Officer, Department of Health and Human Resources' Bureau for 
  Public Health, State of West Virginia
    Oral Statement...............................................    14
    Written Statement............................................    16
Mr. Thomas Carr, Executive Director, Washington/Baltimore, High 
  Intensity Drug Trafficking Areas Program
    Oral Statement...............................................    23
    Written Statement............................................    25
Ms. Gretta Goodwin, Director, Homeland Security and Justice, U.S. 
  Government Accountability Office
    Oral Statement...............................................    31
    Written Statement............................................    33

                                APPENDIX

Representative Gerald E. Connolly Statement......................    68
Response from Dr. Parekh, Bipartisan Policy Center, to Questions 
  for the Record.................................................    70
Response from Dr. Gupta, Bureau for Public Health West Virginia, 
  to Questions for the Record....................................    72

 
A SUSTAINABLE SOLUTION TO THE EVOLVING OPIOID CRISIS: REVITALIZING THE 
                 OFFICE OF NATIONAL DRUG CONTROL POLICY

                              ----------                              


                         Thursday, May 17, 2018

                  House of Representatives,
              Committee on Oversight and Government Reform,
                                                   Washington, D.C.
    The committee met, pursuant to call, at 11:10 a.m., in Room 
2154, Rayburn House Office Building, Hon. Trey Gowdy [chairman 
of the committee] presiding.
    Present: Representatives Gowdy, Sanford, Amash, DesJarlais, 
Meadows, DeSantis, Ross, Walker, Blum, Hice, Grothman, Hurd, 
Palmer, Comer, Cummings, Maloney, Norton, Lynch, Connolly, 
Kelly, Krishnamoorthi, Welch, and DeSaulnier.
    Chairman Gowdy. The Committee on Oversight and Government 
Reform will come to order. Without objection, the presiding 
member is authorized to declare a recess at any time.
    Senator Cornyn, we are thrilled to have you. We realize 
that there are votes that have been called in the Senate. So my 
colleague from Maryland has graciously agreed to allow you to 
make your opening first, and then we will allow you to go vote.
    With that, you are recognized.

                       WITNESS STATEMENTS

                            PANEL I

               STATEMENT OF THE HON. JOHN CORNYN

    Senator Cornyn. Thank you Chairman Gowdy and Ranking Member 
Cummings. I appreciate your courtesy and the opportunity to be 
here today to address America's drug addiction crisis.
    From 1999 to 2016, more than 350,000 Americans have died 
from an overdose involving opioids, more people than in the 
current population of the city in St. Louis. This epidemic is 
hitting every community in every State, with more than 2,800 
deaths in my home State of Texas in 2016.
    But, of course, this didn't happen overnight. The Centers 
for Disease Control and Prevention has outlined the rise of the 
opioid overdose deaths in three distinct waves.
    The first began in 1999 with increasing overdose deaths 
attributed to prescription opioids. Then, in 2010, we saw a 
rapid increase in overdose deaths involving heroin, which is 
cheaper than diverted prescription opioids.
    The third wave began in 2013 with significant increases in 
overdose deaths involving synthetic opioids like illicitly 
manufactured fentanyl. Of the more than 64,000 overdose deaths 
in 2016, more than half were the result of heroin and synthetic 
opioids, not prescription drugs.
    What is clear is that addressing only prescription opioids 
will not remedy this crisis. We must also halt the flow of 
illicit drugs like heroin and fentanyl, including through 
increased detection and intervention efforts at America's 
borders and ports of entry.
    Transnational criminal organizations and drug cartels will 
stop at nothing to exploit Americans who are addicted to these 
narcotics that are tearing apart our families and our 
communities. And sadly, demand for the illicit drugs being sold 
by these criminal organizations has only increased as we have 
stepped up efforts to limit prescription opioid diversion.
    Now more than ever, we need to carry out a comprehensive 
and coordinated strategy across all levels of government to 
address both the supply and the demand for illegal narcotics in 
the United States.
    That is why I am pleased to have worked with Senator Dianne 
Feinstein to introduce the Substance Abuse Prevention Act of 
2018 of the Senate. I hope you all will take a look at that.
    Our bill strengthens and reauthorizes the Office of 
National Drug Control Policy, which oversees all executive 
branch efforts on narcotics control, implements a national drug 
control strategy, and strengthens and complements State and 
local antidrug activities.
    This includes the High Intensity Drug Trafficking Area 
program, which provides resources for Federal, State, and local 
law enforcement task forces operating in our most critical drug 
trafficking regions.
    The bill also improves the program by targeting funds for 
the implementation of a coordinated drug overdose response 
strategy. It reauthorizes the Drug-Free Communities Program, 
one of our most important programs for preventing substance 
abuse and reducing demand for illicit narcotics at the 
community level.
    The Drug-Free Communities Program has been a central 
bipartisan component of our Nation's demand reduction strategy 
since its passage in 1998, because it recognizes that the drug 
issue must be dealt with in every hometown in America.
    Solving our drug addiction crisis requires more than just 
law enforcement solutions. Families and communities must work 
together to implement evidence-based approaches that prevent 
drug addiction.
    This is exactly the mission being carried out by Drug-Free 
Communities Coalition partners, and their efforts are critical 
to solving the drug abuse crisis.
    And while we hope to prevent substance abuse from becoming 
a criminal matter, there is no avoiding the fact that our 
courts will always have a role to play in addressing drug 
addiction challenges.
    That is why this legislation would also reauthorize the 
Department of Justice's Drug Court Program, which helps provide 
judicial and law enforcement officials on the front lines with 
the tools and the resources they need to help criminal 
defendants seek treatment and rehabilitation instead of 
repeating the tragic cycle of addiction and incarceration 
without an opportunity to break that cycle.
    Finally, the Substance Abuse Prevention Act also builds on 
the achievements of the Comprehensive Addiction and Recovery 
Act of 2016, known as CARA, to help families in substance abuse 
challenges by providing resources for sobriety, treatment, and 
recovery teams that pair social workers and peer mentors with 
these families.
    This legislation that I have described here is supported by 
a broad coalition of 102 organizations, including the Community 
Anti-Drug Coalitions of America, the Addiction Policy Forum, 
the National Association for Children of Addiction, the 
National Council for Behavioral Health, and the Fraternal Order 
of Police.
    Mr. Chairman, I know that you will soon introduce 
legislation that would also reauthorize and strengthen the 
ONDCP to address many of the issues that I have talked about 
today. I look forward to working with you and your committee as 
these bills move forward in our respective bodies so that we 
can be sure that the Federal Government is doing everything in 
our power to respond to this grave challenge facing our Nation.
    I hope this committee and Members on both sides will 
continue their efforts to find consensus solutions to our 
substance abuse crisis. Saving our children, our families, and 
our communities from drug addiction is a humanitarian issue, 
not a partisan issue.
    Mr. Chairman, thank you for allowing me to provide these 
comments and for your many courtesies today.
    Chairman Gowdy. Senator Cornyn, I know I speak on behalf of 
all of the members on both sides of the aisle when we thank you 
for your career in public service, in the justice system, in 
law enforcement, and most recently, the United States Senate, 
and for your leadership on this very important issue. And we 
have benefited from your opening statement, and we thank you.
    Senator Cornyn. Thank you, Mr. Chairman. I appreciate the 
visa that allows me to visit the House side. And I will return 
it promptly.
    Chair Gowdy. You are welcome any time. Yes, sir.
    We will briefly stand in recess while the second panel 
assembles. And then Mr. Cummings and I will make our opening 
statements.
    [Recess.]
    Chairman Gowdy. We welcome our second panel of witnesses. 
Mr. Cummings and I will make our opening statements, then we'll 
recognize you for your opening statements.
    Our country is in an opioid crisis, and it's getting worse. 
Statistics can be helpful because statistics help us quantify 
and provide scope and scale. But statistics are what usually 
happen to other people.
    What paints the most vivid image of this crisis are those 
who have lost children to overdose, those who are now and will 
forever be in the throes of addiction, and those whose lives 
have been ended, upended, and are in fear of retreat back 
toward addiction.
    The increasing reality is more and more as our fellow 
Americans have come face to face with this crisis within their 
own families, to say nothing of within their own communities 
and the broader American family.
    Each year over 64,000 Americans die from a drug overdose. 
That's more than the number of Americans killed in the entirety 
of the Vietnam war, a war which has consumed parts of the 
American consciousness for over half a century.
    And while consensus exists on the depth of this challenge 
and the need to confront it in an apolitical way, the problem 
is worsening as more potent drugs emerge and the online market 
for illicit distribution expands.
    Our country is in desperate need of a central coordinated 
response. The issue knows no geographic boundary, is no 
respecter of State lines, which means we need a coordinated 
governmental response at the national level.
    So 30 years ago, Congress created the Office of National 
Drug Control Policy. This office is designed to play a central 
role in coordinating the Nation's drug control policy and 
programs. National drug control efforts are spread across 16 
departments and agencies implementing programs and operations 
throughout the U.S.
    So a central coordinating body is essential to ensuring 
effective evidence-based drug control programs. Drug control 
efforts should be synchronized and targeted at achieving 
specific strategic goals.
    While the ONDCP continues to receive annual appropriations 
from Congress, it nevertheless operates under an expired 
authorization. Reauthorizing ONDCP with revamped and enhanced 
authorities will improve coordination and effectiveness of 
Federal agencies and their diverse drug control efforts.
    ONDCP is also tasked with administering two grant programs, 
HIDTA and the Drug-Free Communities. ONDCP is uniquely 
positioned to administer these programs in a way that gives 
those working at the State and local level a prominent seat at 
the table.
    As Congress appropriates increasing levels of funding, the 
need for a national coordinating office is more important than 
ever. And to be sure, our Nation's drug crisis will not be 
curtailed merely by appropriating money. The money must be 
spent in an effective way rooted in evidence, experience, and 
expertise.
    Last week our committee shared a discussion draft of 
reauthorization text for the ONDCP. The committee has held 
hearings and roundtable discussions to better inform our 
reauthorization efforts. And through the posting of our draft 
text online we've received constructive feedback from the 
general public.
    Today, we want to hear from partners about the importance 
of reauthorizing ONDCP. By ensuring a synchronized national 
effort we're better positioned to achieve our common goal of 
ending this devastating crisis.
    This week is the week we set aside each year in Congress to 
honor law enforcement. So I want to end it by honoring someone 
in law enforcement, an old narcotics officer by the name of 
Kevin Simmers.
    Kevin dedicated his career to the interdiction and 
detection and apprehension of drug dealers. He wanted to do his 
part to keep his community free from the scourges of addiction 
and trafficking. He felt like he was doing the Lord's work.
    But Kevin was not just a law enforcement officer. He was 
also a father to a beautiful daughter named Brooke. Well, we 
know addiction is no respecter of people, not even of law 
enforcement officers who dedicate their lives to keeping drugs 
away from other people's children. No one is immune.
    So when Kevin's daughter Brooke developed an addiction, he 
did everything a father could do. He tried treatment, he tried 
unconditional love, he tried tough love. He tried treatment 
again. Even tried jail.
    You can imagine how hard it would be for a father to leave 
his daughter in jail. But he did so because he wanted her to be 
clean.
    He came home from work and parked his police car behind his 
daughter's car so he could block off, not just her car, but 
also her path back to addiction. He wanted to keep his daughter 
from leaving in the middle of the night. He wanted to separate 
her, he wanted to protect her, he wanted to trap her. A 
father's love can be a benevolent trap. But heroin is a trap, 
too.
    So Kevin woke up one morning to the ominous sound of an 
empty house and the ominous sight of tire tracks through the 
front yard. His little girl was gone again, 6 o'clock in the 
morning.
    Brooke went to a gas station. She called her sponsor. Her 
sponsor said, ``Call your dad.'' But she didn't want to 
disappoint her father again. So she drove to a church where she 
played basketball as a child, crawled into the backseat of her 
car, and overdosed on heroin.
    It's not the statistics. It's not the money. It's something 
you can't count. It's the grief of parents burying their child.
    The gentleman from Maryland is recognized.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    The first overdose death that I heard of, I was 6 years 
old, 6. I'm 67 now. And this young man was a hero in our 
neighborhood, and I didn't even know what drugs were.
    Then I had an opportunity later on in my life, as a 15-year 
old working in the drugstore, to watch people come in trying to 
get Robitussin. Do you remember that? Trying to get high. 
People that were in so much pain, they didn't even know they 
were in pain, of all colors.
    That was 50-some years ago. And I am glad that we are 
moving to this moment, because I do believe that this is a 
destiny moment where we say enough is enough.
    Fighting the opioid epidemic has been one of my top 
priorities for several years. I had a family member to die from 
this. Not only because it's a terrible thing that has destroyed 
so many Baltimoreans lives, but also because it's devastating a 
Nation, in red states, in blue states, in purple states.
    It is time that we finally recognize this epidemic for 
truly what it is, a national emergency that is killing 115 
Americans every single day, 115, and counting.
    In December, the Centers For Disease Control and Prevention 
warned that life expectancy in the United States dropped for 
the second year in a row, and drug overdoses are the single 
biggest reason why. In 2016, nearly 64,000 Americans died from 
drug overdoses. These numbers are only getting worse with every 
passing minute.
    I understand that today's hearing is supposed to be about 
proposals to reauthorize the Office of National Drug Control 
Policy. But it's hard to do that when we have not been able to 
speak to the acting director of that office. We asked for him 
to testify here today, but our request was denied.
    It's also hard to do it when we will not be hearing from 
other stakeholder agencies that are involved in this fight, 
like the DEA and the Coast Guard.
    We're supposed to markup a bill next week, but we have not 
received any official feedback or technical assistance from the 
administration. We had a roundtable meeting with ONDCP 
staffers, and I thank you, Mr. Chairman for that, but I'm 
concerned that this legislation may not be ready for primetime.
    Compounding this problem is the Trump administration's 
total lack of leadership on this issue, and they are simply 
missing in action. The National Drug Control Strategy was due 
in February, but they did not submit one. Remember what I said. 
We've got 115 people dying a day, but no drug control strategy.
    Now, the President has just assumed office. I got that. So 
maybe it is understandable. But this February also came and 
went, and he still has not submitted a strategy, 115 people 
dying a day.
    ONDCP staff told us that Kellyanne Conway is calling the 
shots. I sent a letter to the chairman on February 16, 2018, 
asking for a briefing from her, or anyone, from the White House 
who could tell us what's going on. But that never happened.
    Ladies and gentlemen, this is the most deadly national 
health crisis we have seen in three decades, in three decades. 
Where President Trump has shown no leadership, Congress must 
step into the void and demonstrate a bipartisan commitment to 
taking on this fight in an effective and efficient manner.
    We could talk all we want about how we might want to 
reorganize ONDCP, require new reports, and reshuffle the lines 
of authority. But they are not doing their jobs now. They are 
already failing to do what Congress required. So I have little 
hope that these kinds of changes alone will make a difference.
    Here is the main point I would like to convey today, and I 
would like to place it in the DNA of every cell of our brains. 
Reauthorizing ONDCP is an important step. We want to ensure 
that we have a coordinated, effective, and efficient and 
evidence-based strategy.
    But rearranging the deck chairs is not enough. Nibbling at 
the edges is not adequate. If someone has a gaping wound, we 
cannot just slap a Band-Aid on it. If someone is fatally 
hemorrhaging, we cannot just hand them a new organizational 
chart for a government office. They need expert medical care.
    As a Nation, we need to dedicate significant and sustained 
new funding for treatment to combat this epidemic. The 
Department of Health and Human Services estimates that more 
than 2 million people in this country have opioid use 
disorders, which is likely an undercount. Yet, only 10 percent 
are able to access the specialty treatments they need.
    Imagine 10 people with cancer and you tell them that only 
one of you can get the treatment in the United States of 
America, with one of the greatest health systems ever found. 
Something is wrong with that picture. We cannot stop this 
crisis if 90 percent of those affected cannot be treated.
    Last month, I introduced the CARE Act with Senator 
Elizabeth Warren to start treating the opioid crisis like the 
public health crisis it is. Our bill is modeled directly on the 
Ryan White Act, which Congress passed with bipartisan support 
in 1990 to address the AIDS crisis. This has been endorsed by 
more than 30 organizations, including health advocacy groups, 
nursing organizations, local government associations, and 
public health organizations.
    I urge all of my colleagues on both sides of the aisle to 
join our bill. My staff has already contacted each of your 
offices, and my door is open to answer any your questions.
    To conclude, I want to thank our witnesses for being here 
today, including Ms. Goodwin from GAO, Mr. Parekh from the 
Bipartisan Policy Center.
    I look forward to hearing from Mr. Carr, an old friend and 
the executive director of the Washington/Baltimore HIDTA, 
Intensity Trafficking Area. I appreciate his effective 
leadership and I thank him for his endorsement of the CARE Act.
    Finally, I thank Commissioner Gupta of the West Virginia 
Bureau for Public Health for joining us today.
    And as I close, let me say this. This is our watch. This is 
our watch. And it is our duty to protect our neighbors. I think 
the chairman said it quite eloquently. We've got to do things 
to protect our neighbors.
    And it will affect all of us. There was one time that it 
seemed that the only place that was affected was the areas like 
the one I live in today and lived in for 35 years, the Black 
community.
    Well, hello, there's a big difference now. It's everywhere. 
And so we have to address this in a bipartisan way, and I'm 
looking forward to it.
    And, Mr. Chairman, I want to thank you for working with me 
and for your indulgence.
    Chairman Gowdy. The gentleman from Maryland yields back.
    We're pleased to introduce our second panel of witnesses. 
Dr.Anand Parekh, chief medical advisor of the Bipartisan Policy 
Center. Dr.Rahul Gupta, commissioner and State health officer 
of the Department of Health and Human Resources' Bureau for 
Public Health, State of West Virginia. Mr. Thomas Carr, 
executive director of the Washington/Baltimore High Intensity 
Drug Trafficking Areas Program. And Ms. Gretta Goodwin, 
Director of Homeland Security and Justice at the Government 
Accountability Office.
    We welcome all of you. Pursuant to committee rules, I must 
administer an oath, so I would ask you to please stand and 
raise your right hand.
    Do you solemnly swear that the testimony you are about to 
give should be the truth, the whole truth, and nothing but the 
truth, so help you God?
    May the record reflect all the witnesses answered in the 
affirmative.
    You may take your seats.
    There's a series of lights that should inform and instruct 
you. Just be aware that all members have your opening statement 
in full, so if you could summarize the salient points within 
the 5 minutes, that will allow more time for the members to ask 
questions.
    With that, Dr.Parekh, you are recognized.

                            PANEL II

                   STATEMENT OF ANAND PAREKH

    Dr. Parekh. Chairman Gowdy, Ranking Member Cummings, and 
members of the committee, thank you for the opportunity to 
appear before you today.
    I applaud the committee's efforts over the last year to 
identify ways to strengthen the White House Office of National 
Drug Control Policy and enhance the Federal response to the 
opioid epidemic.
    My testimony today is based on my perspective as a 
physician, a former deputy assistant secretary of health at the 
Department of Health and Human Services, and now currently as 
chief medical advisor at the Bipartisan Policy Center, a 
nonprofit organization that combines the best ideas from both 
parties to promote health, security, and opportunity for all 
Americans.
    As the chairman and the ranking member noted, in 2016 
alone, 2.1 million Americans had an opioid use disorder and 
over 42,000 Americans died from overdosing on opioids. This 
crisis, 20 years in the making, will get worse before it gets 
better.
    Fortunately, there are evidence-based interventions and 
solutions that, if scaled by the combined efforts of the public 
and private sectors, can bend the curve of the epidemic.
    The Bipartisan Policy Center's Governors Council, made of 
up former governors, has previously recommended four critical 
approaches to tackling the opioid epidemic.
    Number one, curbing overprescribing. In 2016, 91.8 million 
adults, nearly 4 in 10 adults in this country, used 
prescription opioids. As a physician, I can tell you there is 
no reason, neither for acute pain nor chronic pain, that this 
many Americans should be prescribed or be using these drugs.
    Number two, curbing the illicit supply, specifically heroin 
and synthetic opioids, which are currently driving the 
evidence.
    Number three, facilitating treatment and recovery through 
increased training of healthcare professionals and medication-
assisted treatment, public and private insurance coverage of 
these services, and increased funding to support the treatment 
infrastructure. We have made it far too difficult in this 
country to treat opioid addiction.
    And number four, educating America to reduce stigma and 
expand evidence-based harm-reduction strategies, such as making 
Naloxone more widely available.
    In order to coordinate the Federal response the Bipartisan 
Policy Center's Governors Council has also recommended that 
ONDCP be reauthorized, adequately funding and staffed, and 
empowered to track all Federal drug control initiatives.
    On that issue, I would like to make three key points to the 
committee today in response to the bipartisan discussion draft 
to codify ONDCP.
    First, the opioid epidemic is a multidimensional public 
policy challenge spanning public health, criminal justice, 
macroeconomics, international diplomacy, and homeland security.
    In order to comprehensively tackle the opioid epidemic, it 
is critical that States and communities have a Federal partner 
that has itself coordinated. The Federal response requires a 
leadership office, such as ONDCP, to ensure coordination and 
collaboration of executive branch agencies and departments that 
have a role in addressing the supply side and demand side of 
this epidemic.
    The committee's envisioned National Opioid Crisis Response 
Plan, with goals, measures, targets, action steps and 
designations of responsible offices or officials, is urgently 
needed. This plan would also more clearly inform Congress about 
the appropriate Federal funding levels necessary to address the 
epidemic over the next several years.
    Second, the robust performance measurement and data 
collection activities that the committee envisions for ONDCP 
will require sufficient funding and staffing support. I 
encourage the committee to ensure ONDCP tracks both process 
measures and outcome measures to gauge progress in combating 
the epidemic.
    The critical drug control information and evidence plan the 
committee is envisioning should include assurances from ONDCP 
that performance metrics can be tracked using existing data 
surveillance systems or that systems be developed if not 
currently in operation.
    I also encourage the committee to build in some flexibility 
with respect to performance measurement. The committee should 
ensure agency accountability while not being overly 
prescriptive.
    And third, for ONDCP to truly succeed it must be empowered 
by Congress and supported by the administration. The President 
should underscore ONDCP's authorities to Federal agencies and 
departments who must be accountable for their role in 
implementation of the response plan.
    Ultimately, ONDCP needs to be the quarterback of the 
Federal response to the opioid epidemic and needs the staffing, 
funding, and authority so it can lead and inspire disparate 
agencies and departments in tackling the opioid epidemic and 
other threats that may come down the road.
    Thank you for the opportunity to address this committee. 
And I look forward to your questions.
    [Prepared statement of Dr. Parekh follows:]


  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
  
    
    Chairman Gowdy. Thank you,Dr. Parekh.
    Dr.Gupta.

                    STATEMENT OF RAHUL GUPTA

    Dr. Gupta. Chairman Gowdy, Ranking Member Cummings, and 
distinguished committee members, thank you for the opportunity 
to appear in front of you today to discuss an issue of 
significant importance to the lives the American people, the 
opioid epidemic.
    State and territorial health agencies are on the front 
lines responding to the current crisis of substance misuse, 
addiction, and drug overdose.
    As a public health official and as a practicing physician 
for nearly 25 years, I have witnessed the consequence of this 
crisis in the form of overdose deaths, substance-related 
interaction with the criminal justice and welfare systems, HIV, 
hepatitis, prenatal substance exposure effects, and the burden 
on the healthcare system.
    This crisis is unweaving the very fabric of our society.
    In West Virginia, we continue to experience the highest 
rate of overdose fatalities in the Nation. We are also enduring 
a surge in the rate of neonatal abstinence syndrome among 
infants, a condition in which babies are born drug-dependent. 
Currently, 1 in 20 babies are diagnosed with NAS, and 1 in 6 
expecting mothers are found to have intrauterine exposure to 
drugs.
    Children are being placed in foster care at a higher rate 
than ever before, causing a tremendous demand on the social and 
early childhood resources. In fact, we estimate that there is 
an additional cost of at least $1 million for each baby born 
with NAS diagnosis.
    Our State is not alone. The number of babies born in the 
United States with a drug withdrawal symptom has quadrupled 
over the last 15 years.
    Under the leadership of Governor Jim Justice, West Virginia 
has made significant strides to take major steps in the right 
direction. Last year, we conducted a social autopsy of deaths 
and then engaged the public, a broad array of stakeholders and 
experts, to inform policymaking.
    Throughout this initiative, there was significant support 
for reducing the harms of overprescribing, improving access to 
evidence-based treatment, and increasing the use of Naloxone 
and other harm-reduction strategies. I would be happy to share 
with you the findings today.
    Recently, as a practicing internist, I saw a young woman 
who was brought into the clinic by her teenage daughter, being 
afraid of going through withdrawals, and having received 
Naloxone so many times that she was told she would not get it 
again. She was desperate to enter treatment. And we got her 
into treatment, but it wasn't easy.
    But for three other patients that afternoon, I tried every 
possible way, but the best I could do was to listen to their 
story, their struggles, counsel them, offering them help 
whenever they were ready.
    As I left the clinic that afternoon, I sincerely hoped we 
would be able to help these folks before they became a 
statistic.
    Today, as we keep these real Americans in mind, I would 
like to stress upon three major points in my testimony.
    One, to develop a sustainable solution to this contemporary 
challenge, we must have authentic national leadership that can 
envision and coordinate robust and wide-ranging, cross-cutting 
support from multiple organizations to develop an evidence-
based comprehensive response strategy.
    ONDCP provides this leadership. As the committee explores 
the reauthorization, its position should be strengthened, 
resourced, and allowed the expertise to develop robust 
leadership potential. ONDCP has done in recent years more to 
narrow the divide between public health and public safety than 
any other agency.
    Second, Congress and States must work towards further 
expanding access to evidence-based treatment. We know that 
there are a number of barriers in accessing treatment, 
including stigma, homelessness, and poverty.
    Individuals often need ancillary services, such as housing, 
recovery support, employment assistance and training, childcare 
support, and others.
    Therefore, we should consider establishing a program to 
provide treatment and services to individuals with substance 
use disorders modeled on the Ryan White program, which provides 
treatment for AIDS patients.
    With that in mind, I urge you to ensure that any changes in 
statute are building upon the existing system and programs that 
currently exist without creating an undue burden to State and 
local communities.
    And finally, we must understand that this fight has to be 
fought on multiple fronts. In order to fully address this 
epidemic as well as substance use and misuse disorders as a 
whole, we must move further upstream to address the exposures 
during the life course that can lead to addiction, such as 
toxic stress in infants and adverse childhood experiences.
    We must bolster efforts to work with schools, school-age 
children, build resilient communities, and increase investments 
in programs that work to address the social-psychological 
determinants of health.
    In conclusion, the opioid crisis and substance misuse will 
not be solved by an individual agency or State. Instead, we 
need a comprehensive science-driven approach. As my patient 
rebuilds her life, she is going to need addressing her health, 
her home, her community, and the relationships with having a 
purpose in life.
    So I applaud your commitment, and I implore the committee 
to take swift action.
    Thank you.
    [Prepared statement of Dr. Gupta follows:]

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    Chairman Gowdy. Thank you, Doctor.
    Mr. Carr.

                    STATEMENT OF THOMAS CARR

    Mr. Carr. Chairman Gowdy, Ranking Member Cummings--and, 
Congressman, it's nice to see you back in the office again.
    Mr. Cummings. It's good to be back.
    Mr. Carr. And distinguished members of the committee, it's 
an honor to appear before you today to discuss the proposed 
transfer of the HIDTA Program and the revitalization of the 
Office of National Drug Control Policy.
    I come to you today as a representative of the National 
HIDTA Directors Association, but also with a sense of deja vu, 
since 13 years ago to this month I testified against a similar 
proposal that was before this committee. That proposal would 
have transferred HIDTA to the Department of Justice, and I'm 
glad to say it was rejected by Congress, and I urge you to do 
the same with this iteration.
    The administration's rationale for the proposed transfer is 
to improve coordination among drug enforcement efforts. I 
submit the coordination that the proposal claims to seek 
already exists in the HIDTA program.
    The most significant feature of the HIDTA program is a 
longstanding policy that each HIDTA is managed by an executive 
board. Moreover, the voting power on that executive board must 
be equally divided between Federal and State and local and 
tribal agencies.
    The executive board is vital to the success of the HIDTA 
program, and it has unlimited discretion over activities and 
ensures that each HIDTA can tailor its strategy to the 
situation in that neighborhood.
    In 2017, HIDTA has funded 825 initiatives. More than 22,000 
personnel participated in these initiatives. As a result of the 
discretion afforded the executive boards, the makeup of the 
executive boards, and the top-to-bottom commitment to 
interagency cooperation, HIDTAs have established a track record 
of quickly devising and implementing creative responses to the 
drug challenges.
    I said earlier I had a sense of deja vu. And I think you 
should know that since 2005, HIDTAs have disrupted on average 
2,882 drug trafficking organizations each year. They've 
dismantled 17,000 methamphetamine labs, taken more than 7,700 
tons of drugs off the street, including 44 tons of fentanyl, 
heroin, and prescription drugs, seized $8.5 billion in cash, 
and provided training for 556,000 personnel.
    Now, as impressive as these statistics are, they don't tell 
the whole story, so let me tell you a little bit more about it.
    One of the things we did was we developed something called 
the Heroin Response Strategy. This is the first 
multidisciplinary approach that I'm aware of that was focused 
on combating heroin and opium. The initiative brings public 
health and public safety partners together to reduce overdose 
fatalities. Common sense, if you ask me.
    The HRS includes 10 HIDTAs in 22 States. And I think it's 
important to note that in their recent review of the HIDTA 
program the GAO states, and I quote: ``As demonstrated through 
its management of programs like HIDTA's HRS, an agency like 
ONDCP is uniquely positioned to collaborate with its law 
enforcement and public health counterparts.''
    GAO also recognized that a major obstacle to dealing with 
the opioid crisis has been the lack of shared methodology to 
track overdoses in real time across jurisdictions.
    In 2017, the Washington/Baltimore HIDTA developed what we 
call ODMAP to address this need. ODMAP tracks overdoses as one 
would track a disease and issues alerts to public safety and 
health agencies about overdose spikes. More than 650 agencies 
across the country are now using ODMAP to share information.
    So what makes this all possible? Well, we believe the 
discretion, balance, and independence of the executive boards 
is a direct result of the HIDTA program being administered by 
the Office of the National Drug Control Policy.
    As you're well aware, ONDCP is charged with preparing a 
National Drug Control Strategy. Key to ONDCP's strength is its 
ability to coordinate the formulation of the President's drug 
control budget. It needs that hammer.
    ONDCP's responsibilities cross the entire spectrum of drug 
activities, including enforcement, treatment, and prevention, 
and we believe those responsibilities give ONDCP the unique 
perspective to accept a wide variety of approaches to the 
opioid epidemic.
    It is more urgent today than ever before for ONDCP to be 
reauthorized to continue its mission. Our members and our 
executive boards believe that the HIDTA program has been 
extremely efficient and effective under ONDCP and there's no 
evidence that demonstrates any benefits from moving the HIDTA 
program out of ONDCP.
    We think the neutrality of the HIDTA program is a key 
ingredient for its success, and we also know that it would be 
difficult for DOJ to remain neutral and objective should they 
become our parent agency. Further, our non-DOJ representatives, 
and there are many, believe DOJ cannot operate as a neutral 
broker as well as ONDCP.
    The success of the DOJ is determined by how well each of 
its agencies fulfills the mission of the Attorney General. The 
success of the HIDTA is determined by how well it carries out 
the assignments given to it by the executive board.
    So as was cited before, we have 115 people dying every day 
from this crisis. We cannot afford now to abandon the ONDCP, 
abandon our mission, and we have to move forward.
    And I thank you very much.
    [Prepared statement of Mr. Carr follows:]
    
    
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    Chairman Gowdy. Thank you.
    Ms. Goodwin.

                  STATEMENT OF GRETTA GOODWIN

    Ms. Goodwin. Chairman Gowdy, Ranking Member Cummings, and 
members of the committee, I am pleased to be here today to 
discuss GAO's recent work on combating the opioid problem, 
including the role of the Office of National Drug Control 
Policy, ONDCP.
    Today, I will talk with you about two topics.
    First, Federal agencies' opioid-related strategies and the 
extent to which each agency is measuring its performance.
    Second, Federal agencies' efforts to enhance collaboration 
and information-sharing to limit the availability of illicit 
opioids, the ongoing challenges to doing so, and ONDCP's role 
in that process.
    In particular, there are five strategies that ONDCP and the 
Department of Justice have implemented to specifically combat 
illicit opioids. These include ONDCP's Heroin Availability 
Reduction Plan, HARP, and DOJ's 360 Strategy, which the Drug 
Enforcement Administration implements.
    We found that of the five strategies, only one, HARP, 
included outcome measures or measures that are results-
oriented. The others either did not include performance 
measures at all our measured outputs instead of outcomes.
    For example, one of the goals in the HARP is to 
significantly reduce the number of heroin-involved deaths. 
ONDCP measures its progress towards this goal in part by using 
cause-of-death data. This is an example of a strategy with a 
clearly defined goal and a quantifiable measure that helps 
officials understand outcomes.
    Most importantly, an outcome measure of this kind helps the 
agency understand if what it is trying to achieve is actually 
happening.
    In contrast, the 360 Strategy captures the number of 
participants attending its activities, which is an output. 
Measuring outputs has some utility, but it does not allow the 
agency to assess the impact of its efforts or whether or not 
the resources it is investing are yielding the intended result.
    We recommended that ONDCP and DOJ develop outcome-oriented 
performance measures for their respective strategies. ONDCP 
raised concerns about the recommendation, and DOJ disagreed, 
stating that it would be difficult to do so.
    We continue to believe that our recommendations are valid 
and that finding meaningful ways to measure the effectiveness 
of these approaches is essential, despite being difficult.
    With respect to coordination, I will touch on some of the 
challenges agencies are experiencing and the role we 
recommended for ONDCP.
    Federal law enforcement agencies are increasingly 
coordinating with the public health sector to share overdose 
information. However, both sectors reported ongoing data-
sharing obstacles and related challenges with the timeliness, 
accuracy, and accessibility of overdose data.
    For example, toxicology results can take months to obtain, 
and this affects the timeliness of data on overdose deaths. 
These data are needed to anticipate and respond to threats.
    Additionally, some of the data can be incomplete because 
medical examiners or coroners may not always test for opioids, 
especially synthetic opioids, thereby leading to inaccurate or 
incomplete data.
    Further, legal restrictions to protect patient privacy on 
how data can be shared and analyzed affect how much information 
law enforcement and public health officials can access and 
share, respectively.
    ONDCP is uniquely positioned to collaborate with its law 
enforcement and public health counterparts to identify 
solutions to these challenges. We recommended that ONDCP lead a 
specific review on ways to improve the timeliness, accuracy, 
and accessibility of overdose data. ONDCP neither agreed nor 
disagreed with our recommendation, but did say it would 
consider it.
    I will note that during our review the lack of timely, 
accurate, and accessible information was one of the most 
pervasive concerns we heard from the public health and law 
enforcement officials we interviewed.
    Given ONDCP's role in framing a national strategy, GAO 
believes the agency should bring together law enforcement and 
public health officials to improve national-level data and 
support data-improvement efforts at the State and local levels.
    Chairman Gowdy, Ranking Member Cummings, and members of the 
committee, this concludes my remarks. I am happy to answer any 
questions you have.
    [Prepared statement of Ms. Goodwin follows:]


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    Chairman Gowdy. Thank you.
    The gentleman from Alabama is recognized for his questions.
    Mr. Palmer. Thank you, Mr. Chairman. We've talked about the 
overdose deaths, the crisis that we have there. And first of 
all, I think we're talking about 64,000 people possibly that 
died last year. I think that is understated.
    Dr.Parekh, in your experience, are you seeing where the 
death certificate does not show death by overdose but perhaps 
natural causes?
    Dr. Parekh. I think you're right. I think that's probably 
an underestimate. Certainly, the 42,000 for opioids is likely 
an underestimate as well. A lot of times the death certificates 
don't get into the specific cause of drug overdose deaths. 
Toxicology reports take a long time.
    So, unfortunately, these are likely underestimates, and 
these numbers will get worse, Congressman.
    Mr. Palmer. That's what concerns me. I think Ranking Member 
Cummings made this point, that the CDC has lowered the life 
expectancy for Americans is not just because of drug overdoses, 
it's also because of suicide. For people 10 to 24 years old, 
the second-leading cause of death is suicide.
    And to follow up with you, are we seeing suicides that are 
linked to drug abuse?
    Dr. Parekh. We are. And these are overall called the deaths 
of despair. So you see drugs, alcohol, suicides taking a toll 
across the country, leading to the reductions in life 
expectancy, as you suggested.
    There are lot of factors here, economic factors as well, 
that lead to this, but they all, unfortunately, interrelated 
and driving the lowering of life expectancy, as you cited.
    Mr. Palmer. Well, it ought to be shocking to people that 
the suicide issue for 10-year-olds to 24-year-olds is the 
second-leading cause of death.
    And I'm going to get into some area I probably shouldn't 
get into right here, but it has to do with the number of 
children, the percentage of children that are on psychotropic 
drugs that have adverse effects that might lead them to other 
issues like opioid abuse.
    I mean, in my own district it's no longer shocking to hear 
that a young high school student has committed suicide. We had 
a 1-week period where a high school that's 4 miles from my 
house had two in 1 week, and another one just a few miles from 
there.
    Mr. Palmer. And I think when we're looking at this crisis, 
we've got to look at the totality. It's just not the people who 
are dying from overdose, it's also the suicide aspect and link 
it all together. I think if we did, we would all just be 
shocked at the total numbers.
    I mean, we've got veterans, 22 a day committing suicide. I 
wonder if any of you have any information about that, any of 
those related to adverse reactions to drugs that cause them to 
have these suicidal tendancies. Do you know anything about 
that?
    Dr. Parekh. I think they're all--I'll start--I think 
they're all--they can all be related, they're interrelated. I 
think, Congressman, what you're getting at is the overall 
importance of looking at the determinants of health and taking 
a prevention approach.
    Mr. Palmer. Exactly.
    Dr. Parekh. I think the Drug-Free Communities Program, for 
example, is trying exactly to do that with community 
coalitions. But that's what we need to do, prevention, 
prevention, prevention, look at the underlying causes, the 
determinants of health. That's the best way to reduce all these 
deaths of despair, whether it's drugs, alcohol, or suicide.
    Mr. Palmer. Well, there is profiling can be done through 
looking at DNA before anyone is prescribed a drug that would 
lay down some markers about the effectiveness of the drugs and 
the propensity to lead them to other things. I think that might 
be part of the solution.
    Mr. Carr, we're talking about fentanyl, and one of the 
things that I talked about with some of the folks in law 
enforcement is that they're now deploying dogs that can sniff 
this out, particularly what's coming in the mail. A lot of this 
is coming from China. A lot it is produced by North Koreans.
    I made this comment to former Governor Chris Christie, that 
we've gone from a war on drugs to a war with drugs, it seems 
like, and thousands of Americans are falling victim.
    One of my concerns is, and I don't know if you can answer 
this, is that if we're going to try to interdict this through 
the mail, what are we doing to interdict it through the mail 
that goes from Mexico and to Central America and Canada that 
comes across our border?
    Mr. Carr. Congressman, that's a big problem. One of the 
biggest facilitators of drug trafficking by virtue of the fact 
that they are such good shippers is the U.S. Postal Service.
    I know there are efforts underway that the U.S. Postal 
Inspection Service has that are using computers and computer 
programs to profile packages. We're working with them right now 
with our ODMAP project, because when we detect spikes in 
overdoses in geographic areas, then we hope to work backwards 
and target the packages that did come and are coming into that 
particular area so we can be more effective in the 
interdiction.
    But one of the problems with the way that they are shipping 
now is the fact that they are shotgunning. They are not sending 
big loads, they are sending multiple, multiple smaller loads. 
So it takes a lot of manpower and time to pick off those loads. 
And so if we got to 10 percent--I'll pick a number out of the 
air--we got 10 percent of them, 90 percent of them are still 
getting through, which is still a problem.
    Can I go back to one comment you made, and it touched on 
prevention. We're using the ACEs model, Adverse Childhood 
Experiences, to help us profile young children.
    We are working with the schools in Jefferson County, West 
Virginia, particularly the city of Martinsburg, the police, the 
schools, the board of education, the counselors in the schools, 
public health officials, all working together to identify those 
kids most at risk and to do something not only with them, but 
with their parents.
    And that's the future of this, we have to look at long-term 
prevention if we're going to be successful in it.
    Mr. Palmer. I agree 100 percent.
    Mr. Chairman, if I may, I just want to comment on your 
opening comments. One of the things that indicates how 
widespread and serious this crisis is, I don't think I know 
anyone who does not have a personal story of a friend or a 
colleague or a family member similar to what you delivered. And 
I thank you for that and for your indulgence.
    And I yield back.
    Chairman Gowdy. The gentleman from Alabama yields back.
    The gentleman from Massachusetts is recognized.
    Mr. Lynch. Thank you, Mr. Chairman.
    And I want to thank the witnesses for coming here and 
trying to help us grapple with this problem.
    Just referring back to the gentleman from Alabama's 
comments regarding suicide, in my district a few years ago we 
had a suicide cluster. And I lost 14 young boys, the oldest 
probably 17, the youngest probably 14, in a very short period.
    And there is definitely a correlation between this opioid 
epidemic, not one-to-one correlation, but there is definitely a 
connection there with the desperation that comes with 
addiction, and then these young people have no way out.
    The problem is bigger than that, but I think the gentleman 
from Alabama is spot on in trying to identify, drill down on 
that, and deal with that.
    In our community I didn't know what to do. I reached out to 
CDC and a lot of other folks. I reached out to my construction 
unions. We actually built a residential facility for young 
people. Because up to that point we were actually collocating 
kids with adults, which is a bad situation.
    But we established a Cushing House for boys, and now we've 
established a Cushing House for girls. It is an adolescent 
residential facility dealing with this problem. And got the 
support of the Tufts Medical Center and also my local community 
health center and set it up. But the line is out the door. 
We've got 40 beds and I've got a list probably several hundred 
long trying to get in.
    I was touched by the chairman's initial remarks. There's 
42,000 stories out there last year alone of similar situations 
with families losing their kids.
    I do want to say that step one, though, is to have the 
director of the Office of National Drug Control Policy at this 
hearing, at that table right there. And we did not ask him to 
come here, and that just blows my mind. Because this is all 
about accountability.
    And I'm proud of Congress because the last bill that we put 
out has $3.5 billion to deal with this problem and we don't 
have a director here who is willing to testify. We don't have a 
President that has a drug policy that we can articulate to 
families out there that are in the situations that we just 
described. We are dragging our feet on this and this is 
inexcusable.
    And each witness here has talked about having leadership on 
this issue and a direction and a strategy on this issue, and we 
have a big fat zero because President Trump has somebody there 
for 8 months and that didn't work out. And now we've got a new 
person and we won't even ask him to come here and describe what 
the President's policy is because we don't have one. So we've 
got $3.5 billion to support a policy that does not exist at 
this point, and that is inexcusable.
    I've got 2 minutes left.
    Let me ask you, Dr. Parekh and Dr. Gupta, so there's a 
strategy for the Suboxone. It is a replacement therapy when our 
kids are hooked on opioids. And they are handing this stuff out 
like candy. And we're replacing opioid addiction with Suboxone 
addiction, which is also an opiate.
    And I don't see any improvement there. We're just 
substituting drugs, one drug for another drug, and we're 
spending a lot of money on it. And I end up with an addict in 
each case.
    Can I get your sense of this?
    Dr. Parekh. Thank you, Congressman.
    So I think the short answer is, in fact, they are different 
drugs. One is a full opioid, the other is a partial opioid. 
That makes a big difference. And it allows this Buprenorphine 
or Suboxone to actually treat opioid addiction. And the best 
evidence we have, the gold standard evidence for treatment of 
opioid----
    Mr. Lynch. I'm down to 45 seconds.
    My follow up, Dr. Gupta, Vivitrol, it's another version, 
it's a nonopiate, it doesn't seem to have the abuse potential 
that some others do. I that you didn't come prepared for this, 
but that's my question, is it better?
    Dr. Gupta. Congressman, what I would say, just like 
diabetes or any other chronic disease, this is a chronic brain 
relapsing disease. We wouldn't tell somebody with diabetes 
don't take insulin, because otherwise you are artificially 
giving insulin, what your body's missing. Just like this.
    These drugs go, they have been studied, they do four 
things. They prevent relapse into the system, they prevent 
overdoses and deaths, they reduce infectious disease risk, and 
lastly, they reduce the risk of somebody having criminal 
activity.
    So there are documented, evidence-based measures behind the 
use of MAT in the population. The best science we have today, 
it seems to work.
    Mr. Lynch. Okay.
    Mr. Chairman, thank you for your indulgence, and I yield 
back.
    Chairman Gowdy. The gentleman from Massachusetts yields 
back. I will tell the gentleman, my friend from Massachusetts, 
that the nominee was invited to the roundtable. And I am 
disappointed that he did not come. The membership participation 
was good and----
    Mr. Lynch. Well, I apologize then.
    Chairman Gowdy. No, no, no.
    Mr. Lynch. I did not know that he was invited.
    Chairman Gowdy. He was invited.
    Mr. Lynch. You ought to subpoena him if he didn't come.
    Chairman Gowdy. I think it would have benefited him and us 
to have him present, but he decided not to do so.
    The gentleman from North Carolina, Mr. Meadows.
    Mr. Meadows. Thank you, Mr. Chairman.
    And I thank both sides of the aisle for their heart and 
passion on this particular issue, because it does affect every 
community.
    And yet, at the same time, it is critically important that 
we recognize that as important as it may be to have a new 
director of this agency/subset of the executive branch, it is 
far more critical that we actually start doing something about 
it. Because this did not start with this administration. We've 
had this issue for a long time. And I know the gentleman from 
Massachusetts would agree with that.
    I do agree that it should be all hands on deck. And I think 
the problem that you're hearing is a frustration of the fact 
that we have a drug that is being used and there are so many 
deaths each and every day, as, Ms. Goodwin, as you pointed out 
that, that we've got to deal with it.
    Now the other thing is--and I would encourage--the ranking 
member of this committee has been very vocal in this area and I 
appreciate his leadership. It also goes into other areas, like 
FDA. We've got to find other alternatives for pain management 
that are, quite frankly, in the hopper waiting to be approved.
    And so we need to work in a bipartisan way on areas that 
perhaps have a less addictive nature. This was supposed to be 
the wonder drug and it has really taken over in a critical 
area.
    Ms. Goodwin, I want to come to you, because you talked 
about the coordination and where we are and that it's critical 
that we have coordination. And yet I think what I understand 
is, is so whether it's the DEA coordinating with the Coast 
Guard, coordinating with other areas on domestic illegal 
synthetic opioids, GAO found that only one of five strategies 
it reviewed actually included a results-oriented matrix or 
measurement. Is that correct?
    Ms. Goodwin. That's correct. So we looked at the five 
strategies that are out there and the only one that had a 
performance-related metric was the HARP program.
    Mr. Meadows. Okay. So if we have five programs and only one 
of them has a measurement, how do we know when we're succeeding 
or making progress? Is it all just----
    Ms. Goodwin. Well, that's something we recommended. In our 
recommendation we submitted to ONDCP we talked about the need 
for them to come together and kind of pull all of those 
strategies together, have a conversation, and help each of 
those strategies develop metrics. Because you can't really get 
to the heart of the problem or begin to address the problem if 
you don't have evidence-based information.
    Mr. Meadows. So if it is evidence-based, I think we will 
find Democrats and Republicans alike that will want to look and 
say: Are we making progress here?
    And what you're saying is, is that the only progress that 
we see currently is really whether deaths go down from 
overdose? I mean, how do we measure whether we're making 
progress with any policy, no matter how great it is? What would 
be your recommendation?
    Ms. Goodwin. We didn't talk through or we don't put out 
there as GAO like what each of the entities are supposed to do. 
We ask that ONDCP start a review to develop a strategy that 
crosses all of the different stakeholders.
    And working very closely with the public health officials, 
law enforcement, and the other stakeholders, we think that's a 
way to come to a strategy and begin to think about----
    Mr. Meadows. Yeah, let me interrupt because I've only got 1 
minute left. And I appreciate your answer.
    But I guess my question is, if you've identified it as a 
concern, you obviously have areas that you believe need to be 
measured, do you not?
    Ms. Goodwin. Yes.
    Mr. Meadows. So have you made those recommendations in the 
areas that need to be measured? Because you just said you 
didn't make a recommendation. But when you're doing the 
analysis, you have to run across what your areas of concern 
are.
    Ms. Goodwin. Yeah, one of things we are look for when we 
are doing our analysis, when we looked at HARP we noticed that 
they were actually collecting data, paying attention to the 
information, and reporting out. The other four strategies we 
looked at were just measuring whether someone showed up to a 
meeting or participated in an activity. We didn't feel like 
that that went a long enough way----
    Mr. Meadows. Far enough.
    Ms. Goodwin. --went far enough to actually getting at a 
conversation about what's the extent of the problem, what's the 
nature of the problem, and how can you best develop strategies 
around that.
    So when GAO goes in to look at something the first thing we 
want to know is, where are the data? And we weren't finding the 
type of data we thought would be useful for this conversation.
    Mr. Meadows. So, Mr. Chairman, may I offer this. In a 
bipartisan fashion, I know you have made this a priority for 
the reauthorization and really moving forward.
    Mr. Chairman, I know where your heart is, I know where the 
heart of the ranking member is on this particular issue. And if 
we only reauthorize, to not actually have a plan that 
implements with a measurable tool like Ms. Goodwin did, we will 
have failed.
    And so I'm committed to work in a bipartisan fashion with 
both of you on the leadership on this particular issue. I thank 
you.
    Chairman Gowdy. I thank the gentleman from North Carolina.
    The gentlelady from Illinois is recognized.
    Ms. Kelly. Thank you, Mr. Chair.
    And I just wanted to let the ranking member know that I can 
really relate to what you were saying. When I was much, much, 
much younger than I am now, a little girl, I lost an aunt to 
heroin. She had three children and her oldest daughter died of 
a heroin overdose, a dirty needle. So this is something near 
and dear to me.
    One of the most critical tools in addressing the opioid 
epidemic is the overdose reversal drug Naloxone. Naloxone is a 
generic drug. It was first approved in 1971. Yet the prices of 
these products have increased so dramatically in recent years 
that State and local communities are now having trouble 
stocking the drug. They are being forced to ration. One of 
these products, an auto injector like the EpiPen, now costs 
$4,500 for a pack of two.
    Dr. Gupta, as part of West Virginia's opioid response plan, 
all first responders are now required to carry Naloxone. Is 
that correct?
    Dr. Gupta. Yes, Congresswoman.
    Ms. Kelly. And some of the first responders are from 
volunteer organizations. Isn't that correct?
    Dr. Gupta. That is very true.
    Ms. Kelly. So how does the price of Naloxone affect the 
ability of first responders to adequately equip themselves?
    Dr. Gupta. I think that's the important part. So one of the 
things that Governor Justice did, he actually put money behind, 
State money. So he's put about $10 million into the plan, with 
specifically $1 million, and repurchased over 37 doses of 
Naloxone with State money. And we got about $26 a piece. But 
smaller agencies do not have that capacity and ability to have 
the purchasing power to do that.
    And we are very worried that the price increases and the 
price policies that are created are going to be a stumbling 
block no matter how many discounts are given, how many free 
Naloxone is distributed.
    We're afraid that the average person who needs it isn't 
going to be able to get it because they feel it's something 
that's, while life saving, is also extremely expensive in their 
perspective.
    Ms. Kelly. One of my hospitals I know has a program and 
they give it to our law enforcement in my rural area of my 
district.
    We've heard similar testimony from county officials who 
testified at a hearing on the opioid epidemic last month in our 
Health Subcommittee. One witness said because of price 
increases local communities have to, and I quote, ``fly by the 
seat of our pants all the time in terms of coming up with the 
medication.''
    Dr. Gupta, from a public health perspective, how do these 
pricing issues affect your ability to truly combat this 
epidemic?
    Dr. Gupta. Congresswoman, I can tell you from data, when we 
conducted a social autopsy we found that of the people EMS went 
to who have died from overdose, only a third of them actually 
got the Naloxone. And when we talk about elderly and African 
American, it was even worse.
    So what we're seeing is that people are having--we have 
evidence to show that people--first responders are having to 
decide who to give, who not to give. And then there is always 
the issue of stigma because folks think that maybe the elderly 
aren't dying because of overdose. So that adds to the problem.
    Ms. Kelly. The CARE Act, which I am cosponsoring, would 
invest $500 million per year in a Naloxone distribution 
program. Under this program the Federal Government would 
negotiate discounted prices for the product and then distribute 
it to the States, to first responders, local health officials, 
and the public.
    Would this kind of Federal role in negotiating, purchasing, 
and distribution of the product help West Virginia equip your 
first responders in your community?
    Dr. Gupta. Yes, Congresswoman, that would be critical in 
ability to help that person. Because, again, if they have to 
have breath in their lungs in order to meaningfully have a 
chance to enter treatment, then we have to build the rest of 
the system as well to make sure that those folks, we save them 
first and then provide them the help. But this would be very 
helpful.
    Ms. Kelly. And I think we would all agree that it is 
unacceptable that communities all across the country are health 
hostage by these arbitrary price increases, especially for a 
life-saving drug. And it is also unacceptable that drug 
companies would use the opioid crisis as a way to profiteer at 
the expense of all of our constituents.
    And I'm interested in working in a bipartisan way to see 
how we can combat this issue. And also I hope my colleagues 
will help by cosponsoring the CARE Act so we can bring these 
prices down and provide States and local communities with the 
tools they need to address the problem.
    I yield back.
    Chairman Gowdy. The gentlelady yields back.
    Dr. DesJarlais.
    Mr. DesJarlais. I thank the chairman and thank the panel 
for being here today.
    Ms. Goodwin, I'll start with you. I've met with many groups 
over the years that stress the importance of instituting a 
nationwide prescription database. As you know, or may know, 
Tennessee borders eight different States and the congressional 
district I represent borders two.
    This poses a unique problem because in the absence of a 
nationwide prescription database, drug abusers in my district 
will frequently get a prescription for an opioid in Tennessee 
and then simply cross the border into Alabama or Georgia and 
attempt to fill another.
    What steps are you taking to address this problem?
    Ms. Goodwin. So GAO has not looked into that specifically. 
When we did some of our review, we did talk to a number of 
representatives from the HIDTA program. So I think actually Mr. 
Carr can speak more eloquently to that than GAO could.
    Mr. Carr. Thank you, Congressman. I'll try.
    Several years ago we were detecting people that were 
getting prescriptions written for them in Kentucky and they 
were driving to Miami to fill them. I don't know how many 
pharmacies they passed on the way. So I think you can know what 
they are up to.
    With the PDMP that's been implemented, prescription drug 
monitoring program, I think that's a good first step. There are 
some issues with PDMP in that they are all activated at the 
State level. So in some cases doctors are required in that 
State to look at the PDMP to find out if their patient before 
them has in fact been given a prescription for an opioid or the 
like by another doctor.
    In other States however, it is only recommended and they 
don't have to look. So I think we need to do some more work on 
that.
    I think, personally speaking, I think a national database 
makes sense, especially as fluid as our population is today.
    Mr. DesJarlais. And I would agree with you. Thank you.
    This is for any of the panelists, regarding hospice care. 
Under the current law, to my understanding, hospice care staff 
are not allowed to dispose of the patient's prescriptions when 
the patient passes away. This often leaves the family sometimes 
taking narcotics or opioids home with them, or they may end up 
in their medicine cabinet and be forgot about, or somehow taken 
out of the home. And it leads to an increase of the drugs being 
distributed back into the community.
    What safeguards can we enact to ensure that this problem is 
dealt with?
    Dr. Gupta. Thank you, Congressman.
    I think it's important for us to be able to have either, 
again, the take back days, as well as enhanced efforts to 
destroy the medications going back to.
    I think we're get to go a place where opioids as they are 
in the market are going to have to have companion mechanisms 
dispensed to patients to be able to destroy the medications.
    Also a blister pack. We've just enacted laws to limit the 
initial prescribing in ERs and outpatient. So what happens? We 
would like to see blister packs for 3 days' or 7 days' use and 
then a parallel system where they can put it in a package and 
then destroy it. So I think that technology is needed.
    Nationalizing, I just want to be real careful about that, 
because we need systems that will connect State PDMPs with 
other State PDMPs, rather than federalizing or nationalizing, 
because we are able to use our data in ways, creative ways in 
advance as a laboratory in States that would be a little bit 
difficult from federalizing the PDMP.
    Dr. Parekh. Congressman, I'll just add that FDA, I think 
Dr. Gupta is absolutely correct, FDA is looking into this 
blister pack idea and I think that's very, very promising.
    To your point, there are 15 billion pills of opioids 
dispensed every year. Only 6 billion, 40 percent, are consumed. 
So 9 billion pills are, as you suggest, going different places 
and oftentimes end up in families' medicine cabinets.
    Mr. DesJarlais. If you can answer this for me, I've heard 
that of the prescription opioid related deaths, over 90 percent 
of those are not the person that the drug was originally 
prescribed to. Is that your understanding?
    Dr. Parekh. I think it's a large number. There are 11 
million Americans who are misusing opioids. Either they didn't 
have a prescription or they are not following the prescription.
    Mr. DesJarlais. So I mean think that's a really important 
point to drive home, is that the physicians that are 
prescribing the opioids were doing that at a lower rate, but 
the opioids are getting in the wrong hands. And there needs to 
be a focus on punishment for distributing controlled 
substances, and the patients need to be educated before they 
leave the office and probably at the pharmacy as well.
    And if the chairman would indulge just one last question, I 
recently met with a group of pharmacists that explained to me 
how e-prescribing can prevent overprescribing opioids by 
allowing healthcare providers to see a patient's medication 
history at the point of care, thereby helping them determine if 
the patients are doctor shopping.
    Have any of you all been paying attention to this movement 
in States toward electronic prescribing for controlled 
substances? And if so, have the results been positive?
    Dr. Gupta. Congressman, I would say that we have attempted 
to do that in West Virginia. One of the challenges, I go back 
to this rural America divide, is that we have places we don't 
even have broadband in West Virginia. We have places where 
physicians rely on fax to transmit data.
    So I think this links to another issue that we really have, 
which is e-prescribing is only good as the ability to get to 
our practices in sometimes the rural parts of the State, and 
that's a limiting factor. But we do have some type, but it is 
very hard to be more robust in that.
    Mr. DesJarlais. I thank the panel for their expertise.
    I yield back, Chairman.
    Chairman Gowdy. The gentleman yields back.
    Mr. DeSaulnier.
    Mr. DeSaulnier. Thank you, Mr. Chairman. I want to thank 
you for this hearing.
    And I want to thank the ranking member for his passion and 
his urgency.
    And I want to thank the panel members. This has been really 
interesting.
    I guess my question is in two parts. One part is the 
urgency of getting this right and the suffering that the 
ranking member talked about.
    And all of us, I think, anecdotally have had experiences, 
personally perhaps, but definitely professionally in this 
regard. I have constituents who have come to me over the years 
who have lost sons and daughters, and many of them are from 
very diverse economic aspects of my district in the bay area.
    So my question is, Dr. Gupta, you are really in a very 
unique position, I think, given the challenges of West 
Virginia, so the urgency of getting out now. But you said at 
some point we have to go upstream to look at the real cause and 
effect.
    So there are stories in the book of ``Dreamland,'' which is 
a compelling book that you've had a chance to read about, the 
evolution and the causes of this, some of it ascribed to Purdue 
Pharma and aspects of their marketing. So in that case, there's 
pretty good evidence that they targeted the marketing 
specifically to West Virginia and other areas where they knew 
there was a lot of manual labor. Surely it seems intuitively 
that they targeted the worker's compensation system, permanent 
disability.
    So how does that make you feel? And if you have evidence. I 
know my county just joined a whole group of counties in 
California in suing Purdue Pharma and others, because they have 
caused us to spend money, as you said, $1 million per child.
    And the context of my question is, I'm a survivor of an 
incurable cancer. I have remarkable medicine that will keep me 
alive, keep my quality of life high. I just had a meeting with 
constituents who work at the University of California were 
involved in the CRISPR system there. Looked like, very 
promisingly, we can use genetics to identify bacteria in our 
system.
    So I look at the system and the sustainability question of 
the urgency of now. But then how can we learn from this to 
really transform, given the context of what medical research is 
giving us right now?
    If we could take the money that we're spending on that 
child, multiplied towards whatever number, and put it into 
these programs that can avoid this thing happening in the first 
place, including private sector companies or organized crime, 
using the system to divert our limited resources to stop this.
    So you were at the front lines of this. Could you respond 
to that?
    Dr. Gupta. Thank you, Congressman, very much for that 
question.
    You know, we as physicians began prescribing for pain, and 
we ended up over the years treating suffering instead of pain. 
And that's what we have today.
    When we conducted our social autopsy of all the deaths in 
2016 from overdoses in West Virginia what we found was four out 
of five people actually came in contact with the health system. 
We were having a lot of lost opportunities that we could have 
helped these people.
    But as a result, what we found was if you're 35 to 54 years 
old, single, male, less than high school educated or high 
school, and work in a blue collar industry, you have a very 
high risk of dying because of an opioid overdose.
    How we work is we are also seeing, again, a tremendous and 
such a demand on child welfare. We worry about the next 
generation as we sit here. We're losing 10, 15 years from now 
those babies being born now that are going into schools. These 
are the kids who are going to have lifelong traumatic 
experiences.
    So as we work to address social determinants of health, as 
my colleagues have mentioned, we have got to look at those 
things. We've got to look at childhood experiences, we have got 
to look at traumatic communities, and we have to then work.
    NAS, for example, we have programs now looking at long-
acting reversible contraceptives as part of the corrections 
system. Our corrections officers know the way they are making 
the math right now, doing the math, they are saying 33.5 
correction officers equals $1 million a year investment, 37 
inmates equals $1 million dollars a year.
    So they are saying we have thousands and thousands of 
people that need MAT. We don't we start doing MAT instead of 
putting people in prison?
    So there's this relationship that is developing in trying 
to get folks to actually go through science- and evidenced-
based treatment on one hand, save lives on the other hand, and 
are connecting those for treatment, and then really working 
upstream.
    It's really not a partisan issue for us to look at how do 
we help a woman actually get into treatment before she starts 
to plan a family? I mean, this is just a social responsibility 
because we are seeing the other side of this in society so 
much.
    We recently had a person, 82-year old great-grandmother, 
taking custody of a child. Those are the examples we are seeing 
on the ground every single day.
    Mr. DeSaulnier. I really appreciate that.
    And to the chair and the ranking member, I really think 
this is an amazing opportunity for us in Congress to change the 
dynamics on these reoccurring public health crises, to really 
look at the cause and effect. And not to ascribe blame to the 
private sector or anybody, but to look at evidence-based and 
say, not only can we sell the opioid program, but all of us can 
remember being told 20 years ago that crack babies were going 
to cost us money. We fall in this pattern of these reoccurring 
public health crises that maybe we can approach in a different 
way and avoid these unnecessary costs in human suffering 
dollars.
    Thank you, Mr. Chairman.
    Chairman Gowdy. The gentleman yields back.
    The gentleman from Maryland is recognized.
    Mr. Cummings. First of all, I want to thank all of you for 
this excellent testimony.
    You know, one thing you didn't mention, Dr. Gupta, and I 
was looking at a CNN piece on West Virginia, was foster care, 
the cost of foster care, because the parents are dead or they 
are on drugs. Can you comment on that very, very briefly?
    Dr. Gupta. Yes. Thank you, Mr. Ranking Member.
    We are not even able to now find parents to foster the 
children, it has become so bad. West Virginians are great, 
giving people, but we at the point that we have the highest 
levels we've ever seen in the history of the State in kids 
entering into foster care. It is the biggest, unquestionable, 
challenging burden of the future for our State and we are very 
worried about that.
    Dr. Gupta. Dr. Gupta, you are from West Virginia. Your 
State has been hit extremely hard by this epidemic. This issue 
does not discriminate based on politics. It affects red States, 
blue States, and purple States.
    Last November we held a hearing with Governor Chris 
Christie of New Jersey who chaired the President's opioid 
commission. The commission stated only about 10 percent of 
those who need treatment receive it and they warned that people 
are, and I quote, ``losing their lives as a result of it.''
    Dr. Gupta, is that right? Are people dying today because 
they simply can't access treatment? Is that true?
    Dr. Gupta. That's absolutely correct and very true. And 
part of the reason is the stigma. It's not just they can't 
receive treatment. Some people worry they are going to lose 
their job. Some people think that they don't have enough 
coverage, they can't travel to get treatment. They have to in 
West Virginia average wait 30 to 60 days before they can enter 
outpatient treatment.
    So we have so many barriers, including stigma, why people 
can't get treatment and as a result end up dying.
    Mr. Cummings. You know, I mean, there's a big elephant in 
the room, Doctor, okay? Anybody who has ever been around drug 
addicts knows that quite often they end up being another 
person. In other words, they begin to lie, steal.
    One of my earliest cases as a lawyer was a fellow who 
literally killed his--hatcheted his grandmother to death trying 
to get money for drugs.
    So they turn into another person. They look like the same 
person, but to somebody else.
    So I guess for an employer that's a kind of difficult 
situation. I was just with the railroad people yesterday and 
they were telling me how hard it is for them to get people to 
hire, because people simply cannot pass the drug tests. And 
they worry about accidents big time, and they should.
    In January your State of West Virginia instituted an opioid 
response plan that also called for expanded access to 
treatment. It states, and I quote, ``One of the most important 
actions that any State can take to address the opioid crisis is 
expanding access to effective treatment.'' Is that right?
    Dr. Gupta. Yes, sir, that's absolutely correct. One of the 
things we did was we had State regulations for MAT clinics. 
We've created exemptions for physicians so they don't have to 
pay the registration, they don't have to go through the whole 
process if they want to treat their own patients up to 30. We 
have also cut down on onerous regulations within our State.
    We are making every effort possible to make MAT treatment--
and MAT is just not drugs, it's a whole host of behavioral, 
social, cognitive therapies that go along with it--as the 
primary focus of our effort to make sure that every West 
Virginian who has an opportunity, wants to get into treatment, 
has no delay, treatment on demand type of----
    Mr. Cummings. And I gave you the 10 percent figure 
nationally that are able to get treatment. What's it like in 
West Virginia? Do you have any idea?
    Dr. Gupta. We have wait times, as I mentioned. There is a 
great COAT Program at West Virginia University and their 
average wait times are between 30 and 60 days.
    So you can imagine what happens in those 30 days, because 
people don't wait 30 days when they have this monster on their 
head that they have to worry about every time, getting a dose 
in 3, 6 hours, sometimes even more frequent.
    Mr. Cummings. So here is the big question. We here on the 
committee can talk about organizing ONDCP. We can discuss 
moving things around on an organizational basis. We can even 
ask ONDCP to send us more reports. But if that's all we do, if 
we fail to ensure sustained funding to expand access to 
treatment, will we be able to turn this crisis around as a 
Nation?
    And I know I've run out of time, but I want you also to 
just speak very briefly. We spend a lot of time talking about 
deaths, but we've got a pipeline. I'm talking about the living 
and the dead. Because a pipeline car is far bigger than the 
folks, the 1 in 15 I am talking about, that are dying daily.
    So would you comment on that, Dr. Gupta?
    Dr. Gupta. Certainly, sir. One of the things I would say is 
that every person who has an opioid overdose, nonfatal, that 
comes in, it's a cry for help basically. What they are saying 
is that is suicide attempt, because they know every time it's 
Russian roulette when they inject that drug.
    The question is, are we able to then connect that cry for 
help and get those people immediate treatment? We are working 
on that in West Virginia, trying to make sure that every 
emergency room visit, first of all, that it doesn't happen, but 
if it happens, how do we connect that cry for help back to 
treatment, they get that treatment. There's a lot more people, 
it's the tip of the iceberg beneath that.
    So the first thing is to avoid deaths. This is a 
preventable problem. This is something we can prevent and get 
people into treatment. Everyone that dies we see, they had, 
four out of five people, came into context with the health 
system and we failed them, to be really honest.
    Mr. Cummings. How do you see us getting past the stigma? 
And that's a tough one. The stigma on the part of the patient--
I mean, the drug addict.
    But there's another stigma, too, that we haven't talked 
about here: the doctor. A lot of doctors don't know how to 
treat this stuff. You know, they see a drug addict come in and 
they say: Aw, no, no, no, no, no, no. They don't want to touch 
it.
    So talk about that and how you deal with that end of it in 
West Virginia.
    Thank you, Mr. Chairman.
    Dr. Gupta. Yes, sir. The most important part of this 
disease, how we differentiate this from perhaps the HIV, even, 
the epidemic, is that the stigma of this is across the 
communities, it's across the healthcare system, law 
enforcement.
    And there's a lot of good-intentioned, good-faith folks 
trying to help, but that stigma continues. And it is that 
reason that we need to have programs like harm-reduction 
strategies, that people will come in, be treated in a very 
nonjudgemental manner.
    We have to redo the way we look at folks, we have to redo 
the way we treat folks, address this problem. People don't 
choose not to get treated. Folks have told me, every five times 
before, we were telling them they need help, they listened, 
they weren't dead and not listening. It's just that it didn't 
filter in until the time they were ready.
    We have to build a supportive system of that stigma, 
whether it's police officers, whether the treatment, 
physicians, hospitals, criminal justice system, as well as the 
court system, the entire society.
    I think we're far away from being able to entirely remove 
stigma. We have stigma websites. We're doing everything in West 
Virginia and a lot of organizations are working together. But 
it's going to take every fabric of that society to undue the 
stigma aspect of this problem. It's a big problem.
    Mr. Cummings. I yield back.
    Chairman Gowdy. The gentleman yields back.
    The gentleman from Wisconsin is recognized.
    Mr. Grothman. Sure. A couple of questions.
    I agree with you, Dr. Gupta, that I think whenever anybody 
takes heroin--and as I understand it, everybody who takes it 
knows people who've died from it--there is an element, suicide 
is too strong a word you, but at least you're saying that it's 
not the end of the world if I die. And that's a problem.
    I think it was Dr. Parekh who told--one of the two of you 
in your original testimony, and I didn't see it in your written 
testimony--said the number of people in this country every year 
who are prescribed some sort of painkillers that could be 
described as opiates, could you repeat that statistic again?
    Dr. Parekh. Sure. So this is the National Survey on Drug 
Use and Health in 2016. So 91.8 million American adults, nearly 
4 in 10, say they've used opioids in the preceding 12 months. 
Now, that could be that they were prescribed or they are 
misusing.
    And the misusing number is 11.5, so 11.5 million Americans 
are misusing opioids. So either they didn't have a prescription 
in the first place, they got it from family, friends, or they 
had a prescription.
    Mr. Grothman. Could you tell us the equivalent number from 
other countries?
    Dr. Parekh. I think, unfortunately, Congressman, this is a 
uniquely American problem. We have 5 percent of the world's 
population, we consume 80 percent of the world's opioids.
    Mr. Grothman. Wow. So that would show it's an American 
problem and it shows that other countries don't seem to have 
this problem. So you wonder what they're doing differently.
    Have we looked into at all the background of the average 
heroin user? Do we ever study family background, religious 
background, what have you?
    Dr. Parekh. Other panelists may want to jump in, but I 
think one statistic that is important to note is if you look at 
first time heroin users, 80 percent of them first started 
abusing prescription opioids. And I think that is a critical 
piece.
    Mr. Grothman. Okay. I mean, do we have anything else, 
though, as far as demographic examples, family background, 
educational background, age? Do we have those statistics, Dr. 
Gupta?
    Dr. Gupta. Yes, Congressman. We conducted a social autopsy 
of everyone who died in 2016 in West Virginia from overdose. 
What we found was typically individuals are 35 to 54 years old, 
male, high school educated or less, single, and working in blue 
collar industry. So this is the social autopsy.
    Mr. Grothman. Single people. What about their parents? What 
did we find out about their parents?
    Dr. Gupta. Well, I think what we find is basically it's one 
of those situations of hope.
    Mr. Grothman. Not hope. But what was their background, what 
type of family background did the people grow up in?
    Dr. Gupta. I couldn't--yeah, I'm sorry.
    Mr. Grothman. Put enough money into it. Next time you do a 
study, you should check into that.
    At least I felt heroin's been around this country a long 
time. There was a time the stigma against taking heroin, I 
mean, there was a bright line, I think, between alcohol and 
marijuana or even cocaine and heroin. I know there's been a lot 
of emphasis on removing the stigma.
    Are you sure we want to remove that stigma? There used to 
be a stigma. And I think at the time there was a stigma and 
less people took heroin. But are you sure we want to remove 
that stigma?
    Dr. Gupta. Congressman, I'll give you an example. So 71-
year-old woman living with her children--her children living 
with her--every time she started to use heroin for postherpetic 
neuralgia, that's pain after you get shingles, because her 
doctor took her off the Percocet, and she uses three syringes.
    The first time she injects a small dose, back in a bigger 
dose to make sure there's not enough fentanyl to kill her, and 
then she gives herself the main dose. And that's all because 
she actually trusts her dealer.
    So, yeah, there's a lot of that because she wouldn't go and 
get help because she thinks her family will find out and it 
would be a bad thing for people to know a 71-year-old is using 
heroin. So there's a tremendous amount of stigma.
    Mr. Grothman. I'll give you another question. I recently 
had something in my district in which a member of law 
enforcement was very concerned. Somebody was pulled over with a 
substantial amount of heroin, clearly a dealer, and they were 
given time served or something. It really bothered the law 
enforcement person because these people are probably as 
dangerous as can be.
    I know we're stuck on kind of a trend of saying too many 
people are in prison, and there may be too many people in 
prison. But to me heroin and related drugs are a new thing.
    I am very concerned on hearing stories, and particularly in 
more liberalish areas, of people who are dealers not really 
going to a prison for a long period of time. And I know in 
other countries that don't have these problems who are not as, 
oh, so afraid to put somebody away, they don't have these 
heroin problems either.
    Usually the police aren't the problem, the police want to 
put them away. But do you think our judges or the rest of the 
judicial system is getting too involved in this treatment stuff 
and are not sending a strong enough message to the dealers by 
putting them away for long periods of time since they are 
killing so many people?
    Chairman Gowdy. The gentleman is out of time, but you may 
answer his question.
    Dr. Gupta. Congressman, I think the distinction to be made 
between dealers, which obviously are bad guys, and every year 
that they could be in prison for, versus the folks who have 
actually gotten into this and don't understand it and have 
something called substance use disorder or opioid use disorder 
that actually need help, and they can be productive. It's 
because the people, the majority of people we are dealing with, 
they are actually workers. They are work-engaged populations. 
We are losing work productivity in this country at a rate like 
never before.
    Chairman Gowdy. The gentleman yields back.
    Mr. Grothman. I'll just point out he didn't answer my 
question. But okay.
    Chairman Gowdy. The gentleman yields back.
    My friend from Vermont is recognized.
    Mr. Welch. Thank you, Mr. Chairman. Thanks for having this 
hearing. And I appreciated your opening statement.
    And our ranking member, Mr. Cummings, I also want to thank 
you for your incredible leadership on this, and I want to thank 
the panel.
    I'm from Vermont. I'm going to take advantage of the 
opportunity to talk a little bit about Vermont, and I'll ask a 
few questions. But I am going to take advantage of that 
opportunity.
    Our Governor was the first, Governor Shumlin, to dedicate 
his entire State of the State, in 2011, to the problem we saw 
emerging in Vermont of opioid dependence and addiction.
    And I remember coming back here after the Governor did that 
and my colleague saying, ``Peter, why did the Governor do that? 
That's bad press for Vermont.'' And the answer from our 
Governor was: We acknowledge our problem and try to face it. 
That's what we did.
    And then a few weeks later one colleague after another 
would come up to me and say, ``You know what, we've got a 
problem that's as bad or worse in my State, my district.''
    And I think the fact that there was a focus on 
acknowledging the issue has helped us in Vermont establish a 
pretty good treatment program, the Hub and Spoke program, that 
is having some significant success.
    But in the past year I've been having roundtables in one 
community after another, Brattleboro, Bennington, Newport, St. 
Albans, and just this question of who are the victims. It's 
everybody is the victim.
    I mean, there are some folks who work, some folks who got 
on it because they had a proclivity to use excess drugs, some 
who started out with a work-related injury and got opioid 
prescriptions and it led to bad things and they couldn't get 
off it, others who are having a crisis of hope.
    And Dr. Gupta you're ground zero in West Virginia, which 
I've traveled to. And there is the real crisis here of good 
people.
    I don't meet people who are addicted that want to be 
addicted. You know, the dealers are a separate question and 
throw the book at them as far as I'm concerned, but it's a lot 
of good everyday citizens who would prefer to be in the 
workforce and aren't.
    And this is affecting all of our communities, especially, 
in my view, rural America, where there is a collapse in the 
local economy. And a lot of the local institutions that have 
been so important to help people have a sense of purpose and 
live those rural values of helping one another, helping their 
community, that's all being frayed. And we have got to have as 
part of our response a revitalization of rural America. That's 
my view.
    But while we're trying to get there, I do believe that we 
must have a Marshall Plan for attacking this, much like we did 
with the HIV epidemic with the Ryan White bill. This has got no 
partisan preference. Every one of us who represents our 
districts have people in it who are really suffering.
    And the Cummings bill, which does have a Marshall Plan 
agenda, significant resources that are applied to dealing with 
this issue, that is absolutely what we need. This crisis is not 
going to help itself.
    And by the way, on the stigma question, one of the biggest 
preventions of people making that step to go into treatment is 
the apprehension of how they will be labeled. And in our 
roundtables, the people that were most compelling to me were 
two groups.
    One was the people in recovery. And every single one of 
them said it was their ability to cross that line, from being 
private and secret to being open and public, which is what 
empowered them to take the difficult next step. And it's what 
opened up the opportunity for other people in similar 
situations to provide mutual support, ultimately something 
really essential, as I see it.
    The other group that I was really impressed with, I mean 
all of them really, was law enforcement. They do not like the 
dealers. Their job is to arrest people. But their message to 
us: We're not going to arrest our way out of this problem. It's 
not going to happen. So they saw treatment is absolutely 
essential. And the biggest, biggest challenge was that people 
who had gotten to that point, where they're ready for 
treatment, there was no treatment available.
    And that's why I believe the Cummings bill is absolutely 
essential. That's the Marshall Plan that we need in order to 
give folks who were ready to make that step and rid themselves 
of this addiction can take it successfully.
    Mr. Chairman, I'm at the end of my time.
    And I thank the panel for listening to me. I really thank 
you all for your work. And I'm just speaking out on behalf of 
Vermonters. Thank you.
    Chairman Gowdy. The gentleman from Vermont yields back.
    The gentlelady from New York is recognized.
    Mrs. Maloney. I thank you, Mr. Chairman. I want to thank 
you and all the panelists and Mr. Cummings for focusing on what 
has really become a national crisis. And I am pleased that we 
are jointly looking at this.
    In recent years pain has come to be called the, quote, 
``fifth vital sign,'' end quote. And in many clinical settings, 
including hospitals, patient pain levels have been measured 
obsessively, including with the use of sad and smiley faces, 
and many have warned that this focus on eliminating all pain 
and getting all patients to select smiley faces spurred the 
extensive use of opioids in clinical settings. And well-
intentioned policies that incorporate patient pain into quality 
ratings and other measurements may have aggravated the problem.
    So I want to ask Dr. Gupta, who probably has more 
experience on the level with the people with the illnesses, we 
want to ensure that individuals who are experiencing serious 
pain, including those that are at the end of their life, get 
the pain relief that they need. But on the other hand, we don't 
want to move to the point that people are being inappropriately 
prescribed more pain pills that they really need.
    I mean, I've read some stories where patients were getting 
pain treatment and got addicted, which is a tragedy. And 
apparently it's a very hard deal to get off this addiction.
    So one of the recommendations of the opioid response plan 
you just issued in West Virginia was, and I quote from your 
report, ``West Virginia should expand the authority of medical 
professional boards and public health officials to address 
inappropriate prescribing of pain addiction and medications.''
    So, Dr. Gupta, what additional authorities do professional 
boards and public health officials need in your State to 
address inappropriate prescribing? And do you think that there 
has been any inappropriate prescribing, in your overview?
    Dr. Gupta. Thank you, Congresswoman.
    There certainly has been. There were over 780 million pills 
that were shipped into small towns of West Virginia. We know 
that West Virginia had one of the highest prescribing rates for 
opioids.
    But there's good news. We've seen from 2017 data that we've 
made the most progress of any State in the Nation in curbing 
those prescriptions.
    Specifically----
    Mrs. Maloney. May I ask, of these pills that went into West 
Virginia, were they illegal drugs or were they prescribed 
through doctors?
    Dr. Gupta. These were distributed prescription drugs that 
were distributed through distributors that came in without 
necessarily a check.
    Governor Justice sponsored and passed with wide bipartisan 
support earlier this year a bill that limits the prescription 
of opioids in ER settings to 4 days, in outpatient settings for 
dentists, primary, optometrists, and veterinarians to 3 days, 
and for other physicians to 7 days.
    So one of the things we have to do is we have to turn the 
tap off for initial prescribing. Initial prescribing is sort of 
your tap to getting people hooked later on, and we know from 
science that beyond 3 to 5 days of prescribing really in 
vulnerable population leads to this disease of addiction.
    Mrs. Maloney. Whoa, 3 to 5 days? That's astronomical.
    Now, is there anything that the Federal Government can do 
to help you in your efforts in West Virginia in this 
overprescribing?
    Dr. Gupta. I think one of the things, Congresswoman, that 
can do done as we move forward, we have to be cognizant about 
the people when have legitimate pain. So as we go and we see 
the crackdown that happens with our State and Federal partners 
on pain clinics, illegitimate pain clinics, we have got to find 
folks who have genuine pain to be connected back into 
appropriate physicians who do prescribe.
    So we want to make this where it's okay to have legitimate 
pain and have prescriptions, a very important piece for a 
treatment armamentarium until we develop those nonopioid 
treatments.
    Mrs. Maloney. Let me ask you, are the majority of people 
that are overdosing in West Virginia taking opioids that have 
been prescribed, either to them or someone else, or are they 
taking street drugs such as the fentanyl?
    Dr. Gupta. We found 9 out of 10 had prescription history; 
49 percent of women filled the prescription within 30 days of 
their death. Yet the death we're seeing is because of street 
fentanyl and heroin. So what's happening is there is a 
crossover happening, but prescription drugs still remain a 
critical component of that.
    Mrs. Maloney. Okay. Do harm-reduction efforts create 
important opportunities to get individuals with substance use 
disorders into treatment?
    Dr. Gupta. Very important opportunities. We need to look at 
harm reductions, such as syringe exchange programs, Naloxone 
distribution, and a host of social services that go along with 
that, including screening for diseases, and that as a gateway 
to treatment.
    Mrs. Maloney. Well, I want to thank you.
    My time has expired. And I believe this is a bipartisan 
issue we can work together on for treatment. Thank you.
    Chairman Gowdy. The gentlelady yields back.
    The gentleman from Virginia is recognized.
    Mr. Connolly. Thank you, Mr. Chairman.
    And welcome to our panel.
    Dr.Gupta, the Senator from your State, Joe Manchin, did his 
own report using the methodology used by the Council of 
Economic Advisers and came up with the cost of the opioid 
crisis in your State alone of $8.7 billion. Does that sound 
right to you?
    Dr. Gupta. Yes, sir. That's about 12 percent of the State's 
GDP.
    Mr. Connolly. Yeah.
    Dr. Gupta. And that's extreme. But there's many other 
States similarly placed, if not exact same position.
    Mr. Connolly. So that would suggest whatever we're 
investing or need to invest in treatment will have a huge 
return on it, given that cost.
    Dr. Gupta. Yes, sir.
    Mr. Connolly. And obviously we're underfunding treatment 
right now?
    Dr. Gupta. Yes, sir.
    Mr. Connolly. I don't know where to begin.
    So I had a constituent whose son died. He was an athlete at 
a major university in the Northeast. He had an injury. He was 
prescribed opioids and he developed an addiction. He was a 
motivated young man and did everything in his power to try to 
kick it. He went into rehab, he went into treatment facilities. 
The treatment was wrong and ultimately led him to need the 
high, he moved to heroin, and he died of an overdose. Tragic, 
tragic story.
    I'll ask either one of you, Dr.Parekh or Dr.Gupta, are 
treatment facilities regulated for this crisis, for this 
problem?
    Dr. Parekh. I think treatment facilities are regulated at 
the State level. I think that the issue, Congressman, is that 
not enough treatment facilities are offering the gold standard, 
which is medication-assisted treatment.
    Mr. Connolly. Well, let me go back to certification, 
though. Can I put out a shingle and say, ``We've got the 
expertise here to deal with your opioid crisis, give us a 
call''?
    Dr. Parekh. Unfortunately, that is being done right now.
    Mr. Connolly. That's right. That is my point. It's not 
regulated, not uniformly.
    And so treatment, the idea of going for treatment, well, 
what treatment? For example, the example I gave of my 
constituent's son. As I understand it, correct me if I'm wrong 
medically, but one of the treatment centers he went to embraced 
the AA model: Go cold turkey and follow the 10 steps or 12 
steps.
    Well, it turns out, according to my constituent, that is 
exactly the wrong thing to do. You cannot simply go cold turkey 
with this addiction. It's different than alcohol. And if you 
don't have some intervening treatment, you put yourself at 
enormous risk. And the craving for that high will absolutely 
move you to something else, heroin or fentanyl, for example, 
leading to worst outcomes.
    I see you shaking your head, Dr.Gupta. Is that accurate?
    Dr. Gupta. Yes, Congressman. Only half of the private 
treatment facilities across this country actually offered MAT. 
And in that, only a third actually get MAT. MAT is the best 
science-based treatment available, yet we struggle across 
States.
    There is going to be a small silver of the population that 
maybe the 12-step works for them. But there often seems to be a 
prohibition for using any mind-altering drug.
    Mr. Connolly. I'm running out of time, forgive my 
interruption. But my constituent argued it is actually life-
threatening. It was life-threatening for his son to go that 
route, even with the best of intentions.
    Dr. Gupta. Congressman, I'll add one more quick thing. 
People who have opioid use disorder, having other mental 
conditions is the rule, not the exception. So you have to be 
treating other underlying medical conditions. And if 
organization does not accept that treatment for bipolar or 
depression, then you're in trouble.
    Mr. Connolly. So, Ms. Goodwin, in the time I have left, the 
President's own Council of Economic Advisers estimates the cost 
of this crisis to the U.S. economy--we talked about West 
Virginia--is a half a trillion a year. Correct?
    Ms. Goodwin. Correct.
    Mr. Connolly. So certainly, the President has proposed a 
national strategy to deal with this, has he not?
    Ms. Goodwin. Yes.
    Mr. Connolly. He has? And what is that strategy?
    Ms. Goodwin. So that strategy is kind of in the making.
    Mr. Connolly. Oh, in the making?
    Ms. Goodwin. Yes.
    Mr. Connolly. Has the President declared this a national 
emergency, as was recommended to him?
    Ms. Goodwin. Yes, it has been declared a national 
emergency.
    Mr. Connolly. And what flows from that?
    Ms. Goodwin. So the declaration of an emergency will mean 
that the different Federal agencies will start to think through 
and think about how they will address the crisis.
    You may already know that GAO has ongoing work looking at 
public health declarations around this crisis. That's in the 
beginning stages. So we are in the process of designing the 
scope and methodology for that.
    Mr. Connolly. My time is up.
    I want to thank the chair for having this hearing.
    There is no way we can move forward without this being on a 
bipartisan basis. This is a crisis that affects every 
community, every socioeconomic strata. This is not something 
limited to one group or another. And it's reached crisis 
proportions, obviously, in the United States. So we've got to 
work together to find solutions.
    Thank you, Mr. Chairman.
    Chairman Gowdy. The gentleman from Virginia yields back.
    I'm going to go last. So I want to start by thanking the 
panelists for your expertise, your commitment to helping us 
combat this issue.
    Dr.Gupta, what progress, if any, is being made in the 
ability to objectively diagnose pain? As opposed to allowing 
the patient to pick which frowny face, or on a scale of 1 to 
10, which is inherently subjective, is there any progress being 
made in being able to objectively diagnose pain?
    Dr. Gupta. Mr. Chairman, I think there is some work in the 
research and development sort of phase of this. It's been a 
difficult thing from a clinical aspect to be able to diagnose 
something that's very subjective. I do think efforts need to 
happen there from an R&D standpoint in order to get more 
objective signage. But clearly, there's a need for that.
    Chairman Gowdy. Okay. So if I were to present myself at 
either of the doctors--I assume you all are medical doctors or 
are you Ph.D.'s? Medical doctors.
    I present myself, I tell you I have pain. You are not 
totally reliant upon me to quantify that, but it helps. There's 
no test you could administer.
    What are the alternatives to habituating prescriptions? 
What are your pharmacological alternatives to something that is 
habituating right now.
    Dr. Gupta. First of all, we would want to make sure to do 
the proper testing to find out if there's a legitimate physical 
reason for it. But then again, opioids is just one part of it. 
They are not very good a pain treatment to begin with. There's 
other options, including nonpharmaceutical options, as well as 
pharmaceutical options.
    So we're talking about--back pain, for example, very 
common. Most of back pain treats itself in about a couple of 
weeks, so oftentimes you need supportive treatment, not really 
opioids. That's something that opioids were traditionally used.
    Combination of medications like acetaminophen and 
ibuprofen, that really means Tylenol and Motrin put together, 
tends to have, in some studies, better outcomes or better 
impact on pain than does opioids.
    Chairman Gowdy. Okay. You put your finger on something. I 
present to one of your physician practices. I tell you I'm in 
pain. I want something that I consider to be strong. You're 
recommending something I could get at CVS or Walgreens.
    So I've got a couple options. I can either go see another 
doctor and hope for a better result. So you've got--in July we 
were told--and look, I like doctors. I grew up in a house with 
one. I don't get excited talking about prosecuting physicians. 
But the reality is there are illicit drugs that are handled in 
an improper way. And there's money to be made doing that.
    So is this a misinformation issue? I mean, you just said 
there are better alternatives to opiates. I assume doctors know 
that. So if there are better alternatives, is it a lack of 
information that allows them to prescribe it or is it the money 
aspect?
    Dr. Gupta. Mr. Chairman, there's a whole host of issues. In 
my practice, since 2000 or so, I've been told by the industry 
that these are medications that are very highly effective, 
there is no potential for addiction, and all kinds of things. 
If short term doesn't work, we have long-acting medications. 
They are really sold and marketed as the ultimate solution, and 
now we know that that's not the case.
    Chairman Gowdy. All right. But you don't get to be a 
medical doctor by not being bright. So the fact that some 
pharmaceutical rep comes in, gives you a calendar and a key 
chain, and says, ``Hey, look, you really need to prescribe this 
medicine, even though I made straight C's in college, take my 
word for it,'' is a doctor really going to be persuaded by a 
pharmaceutical rep?
    Dr. Gupta. If you look at direct-to-consumer advertising 
campaigns and the pharmaceutical budgets, companies' budgets 
that go into this type of work, at least the evidence 
demonstrates that that strategy tends to have some impact on 
the prescribing habits.
    Chairman Gowdy. This will probably be over my head, but 
we'll try it anyway.
    What is the pharmacology of opiates that makes it so 
difficult to--you know, last week they told us nicotine was the 
toughest drug to beat. In a previous life, I dealt with heroin 
addicts. I would list that as the toughest drug to get off of.
    What is it about the pharmacology that makes it so 
difficult?
    Dr. Gupta. Mr. Chairman, it's the same pharmacology would 
be for heroin, which is it goes and crosses your blood-brain 
barrier and attaches to the receptors, the particular receptors 
that gives you a pleasure to begin with, as well as a number of 
other activities.
    And that's the reason when people have a craving, the need 
for increasing the dose continues. People go to the cheaper, 
readily available street alternative. That is the same action 
of receptors that we work with MAT, whether they block them, 
they are partial agonists to them, or they are pure agonists.
    But ultimately, the idea here is to work on the same 
receptors that opioids have sort of stayed on in terms of 
heroin or prescriptions and almost cause a person to become 
addicted to that and have the disease of addiction.
    Now, we prescriptively do that with drugs like 
Buprenorphine and others to block those or actually partially 
work with those receptors. So it's the same mechanism, it's 
just the drugs that we talk about, MAT, are not something that 
people are going to be able to get high on or overdose from in 
the doses that they are prescribed. But they can, if they also 
use some of the other drugs along with it, the street drugs.
    Chairman Gowdy. All right. I'm out of time, and I want to 
hold myself to same standard I hold my colleagues to. So I'm 
going to give myself one more question after running out of 
time like I do them.
    I was just in your beautiful State 2 weeks ago. It's a 
beautiful, beautiful place to be.
    Are you satisfied with DEA's diversion, not DEA agents that 
wear guns and badges, I mean the diversion, the folks who 
actually monitor pharmacists and physician practices, are you 
satisfied with the presence of DEA diversion in West Virginia?
    Dr. Gupta. Thank you, Mr. Chairman.
    West Virginia is a great State. We are very thankful for 
DEA folks helping us with diversion.
    One of the things that can definitely happen, we in West 
Virginia have a requirement for licensees, like myself, to have 
a mandatory training for opioid prescribing. That is perhaps 
something--I also hold a DEA license--that is something that 
perhaps needs to be nationalized where it's important for every 
physician, every person going to medical school, nursing 
school, anywhere they are going to be close to opioids, be able 
to have a particular curriculum-based training as a part of 
their practice.
    That's something of an outstanding piece, but we're very 
appreciative of DEA's partnership with us.
    Chairman Gowdy. All right. I want to thank the members for 
their participation. I especially want to thank our witnesses 
for your expertise, for your comity, with a ``t,'' with each 
other, and with the members, and look forward to visiting with 
you again.
    The hearing record will remain open for 2 weeks for any 
member to submit written opening statements or questions for 
the record.
    If there's no further business, the committee stands 
adjourned.
    [Whereupon, at 1:13 p.m., the committee was adjourned.]


                                APPENDIX

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