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


                TACKLING FENTANYL: THE CHINA CONNECTION

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

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
                        GLOBAL HUMAN RIGHTS, AND
                      INTERNATIONAL ORGANIZATIONS

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 6, 2018

                               __________

                           Serial No. 115-169

                               __________

        Printed for the use of the Committee on Foreign Affairs
        
        

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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida         BRAD SHERMAN, California
DANA ROHRABACHER, California         GREGORY W. MEEKS, New York
STEVE CHABOT, Ohio                   ALBIO SIRES, New Jersey
JOE WILSON, South Carolina           GERALD E. CONNOLLY, Virginia
MICHAEL T. McCAUL, Texas             THEODORE E. DEUTCH, Florida
TED POE, Texas                       KAREN BASS, California
DARRELL E. ISSA, California          WILLIAM R. KEATING, Massachusetts
TOM MARINO, Pennsylvania             DAVID N. CICILLINE, Rhode Island
MO BROOKS, Alabama                   AMI BERA, California
PAUL COOK, California                LOIS FRANKEL, Florida
SCOTT PERRY, Pennsylvania            TULSI GABBARD, Hawaii
RON DeSANTIS, Florida                JOAQUIN CASTRO, Texas
MARK MEADOWS, North Carolina         ROBIN L. KELLY, Illinois
TED S. YOHO, Florida                 BRENDAN F. BOYLE, Pennsylvania
ADAM KINZINGER, Illinois             DINA TITUS, Nevada
LEE M. ZELDIN, New York              NORMA J. TORRES, California
DANIEL M. DONOVAN, Jr., New York     BRADLEY SCOTT SCHNEIDER, Illinois
F. JAMES SENSENBRENNER, Jr.,         THOMAS R. SUOZZI, New York
    Wisconsin                        ADRIANO ESPAILLAT, New York
ANN WAGNER, Missouri                 TED LIEU, California
BRIAN J. MAST, Florida
FRANCIS ROONEY, Florida
BRIAN K. FITZPATRICK, Pennsylvania
THOMAS A. GARRETT, Jr., Virginia
JOHN R. CURTIS, Utah

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director
                               
                               ------                                

    Subcommittee on Africa, Global Health, Global Human Rights, and 
                      International Organizations

               CHRISTOPHER H. SMITH, New Jersey, Chairman
MARK MEADOWS, North Carolina         KAREN BASS, California
DANIEL M. DONOVAN, Jr., New York     AMI BERA, California
F. JAMES SENSENBRENNER, Jr.,         JOAQUIN CASTRO, Texas
    Wisconsin                        THOMAS R. SUOZZI, New York
THOMAS A. GARRETT, Jr., Virginia
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

The Honorable Kirsten D. Madison, Assistant Secretary, Bureau of 
  International Narcotics and Law Enforcement Affairs, U.S. 
  Department of State............................................     7
Mr. Paul E. Knierim, Deputy Chief of Operations, Office of Global 
  Enforcement, Drug Enforcement Administration, U.S. Department 
  of Justice.....................................................    16
Mr. Joseph D. Coronato, prosecutor, Prosecutor's Office, Ocean 
  County, New Jersey.............................................    39
Bryce Pardo, Ph.D., associate policy researcher, RAND Corporation    51
Daniel Ciccarone, M.D., professor of family and community 
  medicine, University of California, San Francisco..............    67

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

The Honorable Kirsten D. Madison: Prepared statement.............    10
Mr. Paul E. Knierim: Prepared statement..........................    18
Mr. Joseph D. Coronato: Prepared statement.......................    43
Bryce Pardo, Ph.D.: Prepared statement...........................    53
Daniel Ciccarone, M.D.: Prepared statement.......................    70

                                APPENDIX

Hearing notice...................................................    94
Hearing minutes..................................................    95
The Honorable Christopher H. Smith, a Representative in Congress 
  from the State of New Jersey, and chairman, Subcommittee on 
  Africa, Global Health, Global Human Rights, and International 
  Organizations:
  Statement by Don Holman........................................    96
  Statement by Christopher J. Gramiccioni, prosecutor, Monmouth 
    County, New Jersey...........................................   100
  Information on the Blue HART Program...........................   104
  Questions submitted for the record to the Honorable Kirsten D. 
    Madison and to Mr. Paul E. Knierim...........................   106
Questions submitted for the record by the Honorable F. James 
  Sensenbrenner, Jr., a Representative in Congress from the State 
  of Wisconsin...................................................   109

 
                TACKLING FENTANYL: THE CHINA CONNECTION

                              ----------                              


                      THURSDAY, SEPTEMBER 6, 2018

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

         Global Human Rights, and International Organizations,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittee met, pursuant to notice, at 2 o'clock 
p.m., in room 2200 Rayburn House Office Building, Hon. 
Christopher H. Smith (chairman of the subcommittee) presiding.
    Mr. Smith. The committee will come to order. And I want to, 
first of all, thank all of our witnesses including our very 
distinguished witnesses from the administration, one, for your 
tremendous work that you are doing in this opioid crisis, and 
secondly, for taking the time out here to provide expert 
testimony. We do have a second panel of experts who will 
follow, so this, I think, will be a very enlightening and 
hopefully motivating hearing on what do we do next, and of 
course to go very deeply into the nature of the problem and how 
it has been exacerbated almost from month to month it is 
getting worse as we all know.
    Chinese made fentanyl, a synthetic opioid, is killing 
Americans, more than 29,000 in 2017 alone. We must hold the 
Chinese Government accountable. Kirsten Madison, Assistant 
Secretary of State for International Narcotics and Law 
Enforcement Affairs will testify today that China is 
a, quote, deg. ``primary source of illicit synthetic 
drugs coming to the United States.''
    Paul Knierim, Deputy Chief of Operations at the Office of 
Global Enforcement for Drug Enforcement Administration, or DEA, 
stated in his testimony that China is one of the world's top 
producers of precursor chemicals used to manufacture fentanyl 
as well as chemicals used to process heroin and cocaine.
    In our second panel we will hear from again some amazing 
experts. One is Ocean County, New Jersey prosecutor, Joseph 
Coronato, who has called the China-made fentanyl influx into 
the United States a synthetic storm that is ``devastating.'' He 
will thankfully note that local law enforcement is doing 
something about it, like his program, the first in the State of 
New Jersey, to allow drug abusers who voluntarily turn 
themselves in at a police station, and thus far it has been 
over 800 since 2017, without being prosecuted. The idea of an 
engraved invitation that states, ``Come we will help you.'' He 
is obviously very tough on crime but he also has a great 
humanitarian heart and is saying we want to help and treatment 
is a way of intervening for a positive outcome.
    And the program based on statistics has almost certainly 
reduced deaths. Still, Prosecutor Coronato will note that based 
on his medical examiner's toxicology analysis, in 2014, 10 
percent of overdose deaths in the county had fentanyl in their 
systems. Shockingly, in 2018, fentanyl related deaths have 
jumped to over 80 percent or even more. He will tell the 
committee that synthetics will become the predominant type of 
illegal drugs abused within the next 5 years and that in many 
instances is being sold right over the internet.
    I will ask both of our distinguished witnesses from State 
and DEA what the United States is doing to hold China 
accountable for fentanyl in the United States, what kind of 
cooperation are we receiving, are we using existing tools to 
hold bad actors in China accountable? We have tools such as the 
Global Magnitsky Act which targets corrupt officials and human 
rights abusers. Is that under consideration when it comes to 
this crisis that is slaughtering so many Americans?
    Recently, the House passed bipartisan, comprehensive 
legislation to address the opioid crisis including the 
Synthetics and Overdose Prevention Act now pending in the 
Senate. The bill requires the U.S. Postal Service, as private 
carriers like UPS and FedEx are currently required to do, to 
obtain advanced electronic data, or AED provides detailed info 
on the shipper and the addressee and other data, empowering law 
enforcement, Customs and Border Protection and others, to 
target fentanyl and other illegal drug shipments.
    Bryce Pardo of the RAND Corporation will testify today, and 
this is of high significance of course, that the potency of 
fentanyl has sharply increased the number of opioid overdoses 
and that the drug overdose crisis, in his words, now surpasses 
major public health epidemics of prior generations including 
the HIV AIDS epidemic.
    As we all know, every single congressional district in 
America has felt the scourge of the epidemic. Two fathers, Don 
Holman and Eric Bolling, who are both in the audience today, 
both lost their sons to opioid overdoses last year. Don lost 
his son Garrett to an overdose to synthetic fentanyl, and as he 
will show in a written statement submitted to this committee 
for the record, the package came straight from China. His son 
ordered it online not knowing of the poisonous effects fentanyl 
has. His daughter Kristen testified before the House Judiciary 
Committee earlier this year and described how her loving 
brother fell into this trap. Eric's son had a similar ordeal in 
September 2017, losing his beloved son Eric Chase.
    Last week, I spoke at a Mercer County International 
Overdose Awareness Day sponsored by Mercer County Prosecutor 
Onofri and Robinsville Mayor David Fried. Personal testimonies 
offered by survivors and recovering abusers were deeply moving. 
Trenton Police Chief Pedro Medina spoke of the loss of his son 
Petey. And I have known Pedro for decades, loves his son, he is 
a good guy. Not just him but his son, and yet he was overcome 
by this terrible, terrible opioid problem. In his comments he 
talked about how he has relied on God to get him through this 
crisis and said God can help all of you who are surviving, the 
family members and the friends.
    Advocate Mark Manning, who lost his son Christopher, made 
it very clear that his horrors of the addiction in losing his 
son Christopher, and the pain that just doesn't go away is 
ever-present.
    And then we heard from Adrienne Petta who recounted the 
horrors of her addiction. She is one of the lucky ones who was 
able to get through it and she, herself, is now a recovery 
specialist. One of the moving parts of her testimony was she 
said, I have two children, and this was after she was off, she 
thought she was clean. And then she said, if you would have put 
a pack in front of me, a bag, my two kids would take second and 
the bag would come first. That is how strong, as you know so 
well from your good work, this terrible chemical is.
    For the record, Monmouth County Prosecutor Christopher 
Gramiccioni's opioid diversion program steers certain low-
income, nonviolent offenders to treatment rather than 
traditional criminal prosecution. And again Angelo Onofri from 
Mercer County is doing the same thing and announced that every 
municipality in Mercer County had agreed to sign up. And I 
think that is a very important step and a model for every 
municipality in this country to look at this as a disease. Go 
after those who do our hawking it and selling it, put them 
behind bars, but for the victims, treat it for what it is, a 
disease.
    I would like to yield to my good friend and colleague, 
Karen Bass, for any comments you might have.
    Ms. Bass. Thank you. Thank you, good afternoon, and thank 
our witnesses today and Chairman Smith for calling today's 
hearing and bringing attention to fentanyl and the horrific 
effects this drug has had on Americans of every stripe. Some 
foreign affairs issues seem remote and inconsequential to 
everyday Americans, but this issue has eviscerated individuals, 
families, and entire communities here at home.
    Opioid addiction negatively impacts our healthcare system, 
our criminal justice system, our education system, and our 
child welfare system which is where the children go when the 
parents are unable to take care of them. And the primary reason 
that children are removed and put in foster care is substance 
abuse. Sourced mainly from China and Mexico, fentanyl have 
contributed to a dramatic uptick in opioid related overdoses 
and deaths in recent years.
    I have also learned that fentanyl is being sprinkled into 
marijuana in States where marijuana is illegal. So it is not 
just in opioids. According to estimates, foreign-sourced 
fentanyl and its related compounds killed nearly 20,000 
Americans in 2016, more than any other illicit drugs, even more 
than breast cancer. Between 2013 and 2016 these deaths 
increased over 600 percent.
    Beyond death, we also know that fentanyl has insidious 
effects for pregnant mothers and children. The Washington Post 
reported on a recent study that found that learning 
disabilities and other special education needs are common in 
children born with opioid related symptoms from their mother's 
drug use while pregnant. I will say though that I do not 
believe that a child that is exposed to opioid at birth is 
necessarily condemned for side effects for their entire life. 
We actually thought that about the cocaine epidemic and thought 
that children that were exposed to crack would be impacted 
their entire life.
    So we have seen modest progress in international 
cooperation between the U.S. and China. Chinese authorities 
through pressure from the U.S. imposed domestic scheduling 
controls on 116 new psychoactive substances and 10 fentanyl 
analogues in recent years. I don't know if this is something 
that has continued, but we will certainly see through this 
hearing.
    So, obviously much more needs to be done to move the needle 
on the opioid crisis and I look forward to hearing from today's 
panelists. I do want to make note though that one thing that 
has happened in our country over the years is when one drug 
presents itself all of our focus and efforts go on that one 
drug. And although opioid is a horrible scourge and thousands 
of people are dying from it, people are also continuing to die 
from crack, from meth and that might not be sourced from China, 
but when you look at Mexico, when you look at other countries 
where the crack and the meth is coming from, that is still 
impacting our communities terribly.
    And as the chairman said, we need to look to how we prevent 
the drugs from coming into the country, but when they do come 
in the country we need to address it and one way we need to 
address it is through treatment. Twenty years ago when the 
crack cocaine epidemic was here we thought we could incarcerate 
the problem. And I am hoping that given this new epidemic we 
have learned better and when people are addicted it is a health 
problem, as you said, and the way you address a health problem 
is through substance abuse treatment.
    So once again I thank you, Mr. Chairman, and yield back my 
time.
    Mr. Smith. Thank you very much, Ms. Bass. I would like to 
now yield to Dan Donovan who is a former prosecutor from Staten 
Island. He was very involved with combating drug abuse as a 
prosecutor and is a distinguished member of this committee.
    Mr. Donovan. Thank you, Mr. Chairman. I think you and 
Ranking Member Bass described the problem very adequately.
    As the chairman said, I was the elected DA for 12 years in 
Staten Island before I came to Congress. Before that for 8 
years I was Deputy Chief of Narcotics at the Manhattan DA's 
Office. I am very well aware of in 1996 when the physicians who 
used to treat four vital signs--your heart rate, your 
respiratory rate, your blood pressure, and your temperature--
were then tasked with dealing with the fifth vital sign, pain. 
Except that was subjective. They couldn't--they had to trust 
the patient to tell them. I remember in the hospitals the 
smiley faces going down to the frown and a physician or a 
physician's assistant would ask the patient show me where your 
pain is on this chart, because it couldn't be measured.
    And that started the overprescribing of opioids for pain 
relief for people who legitimately had pain. When we did some 
things like InterConnect and formed a nationwide system 
database where people couldn't circumvent the restrictions on 
prescriptions, I on Staten Island had three crossings to New 
Jersey. We curtailed the availability of prescription drugs, 
but my residents just went over one of three bridges to New 
Jersey to get their prescriptions either written or filled. But 
when I got to Congress we got New York included in that 
InterConnect.
    So I understand the problem. I do also understand it took 
us awhile to get our hands around this fentanyl problem. I 
remember the medical examiners during an autopsy of an overdose 
never tested for fentanyl. They would see heroin in the system 
and they would deem it to be a heroin overdose. It took us 
awhile to then start to test for fentanyl and we found that so 
many of those overdoses were the results of this substance.
    So I look forward to hearing from our experts on how we are 
going to deal with the importation of this deadly drug from 
China onto the streets of our nation. And, Mr. Chairman, with 
that I yield back.
    Mr. Smith. Mr. Donovan, thank you very much. I would like 
to now yield to Dr. Bera from California.
    Mr. Bera. Thank you, Mr. Chairman. Thank you to the ranking 
member and to my colleague, Mr. Donovan. I remember that 
because I was practicing at that time and there was a push to 
more adequately assess pain and treat it. And now in this 
position, you know, having sat with parents who have lost their 
children, you know, who may have very legitimately injured 
themselves, you know, we were giving them a prescription of 
Vicodin and then, you know, became addicted and went down a 
dangerous path.
    I am glad that this body and this country is taking this 
epidemic seriously. But as the ranking member mentioned, this 
is just a long chain of other illicit drugs that are out there, 
whether it was the crack epidemic of the '80s and we have been 
dealing with methamphetamines in California for awhile. But 
again I am glad that we are taking this seriously and using the 
language of the fact that this is a disease and thinking about 
it from the perspective of, you know, prevention, but then also 
treatment as opposed to, you know, just looking at it from the 
law enforcement perspective which is absolutely necessary as 
well.
    You know, when I think about what is happening in 
California and even in our four-county Sacramento region, you 
know, we had over 250 deaths, many of them due to fentanyl and 
that is low compared to some of my colleagues. And I think, you 
know, we very much have to get ahead of this. I am glad that we 
are discussing this.
    I am glad that we have through State Department and other 
means, exerted some pressure on China to stop producing some of 
the precursors to fentanyl. I am very much looking forward to 
the witnesses to, you know, get a sense of how effective that 
has been. But I also know that we have to do a lot more. I mean 
we have a lot of folks that currently are addicted and we have 
to use all of our measures to treat those individuals and help 
them rehab their lives and help them put their families back 
together. And in some cases, you know, help entire communities 
put their communities back together.
    So again thank you for having this hearing and I will yield 
back.
    Mr. Smith. Thank you very much, Dr. Bera. I would like to 
yield now to Mr. Castro.
    Mr. Castro. Well, thank you for your testimony today.
    And, you know, for the last several years fentanyl and the 
opioid epidemic has ravaged many communities in many States in 
this country and I am glad that we are having this hearing. 
That we are talking about it for what it is, a health crisis. 
That addiction is a health crisis and hopefully together we can 
determine how best to help treat it. I am convinced that by and 
large the folks who suffer from this addiction want to get on 
with their lives, don't want to be addicted, want to get back 
to their families and back to their work. And so thank you for 
everything you all are doing in that regard.
    Mr. Smith. Thank you, Mr. Castro.
    Mr. Suozzi, the gentleman from New York.
    Mr. Suozzi. Thank you, Mr. Chairman. Thank you, Ranking 
Member. Thank you to all the members here and for everyone 
testifying here today.
    I don't think anyone has to be persuaded that this is a 
major crisis in our country right now, not only opioid 
addiction but the introduction of fentanyl, a synthetic drug 
that people really don't know that they are getting sometimes. 
I have personal experience with this where I have been called 
to the hospital, friends of mine, their son dead on the table 
because he took a pill that he didn't know had fentanyl in it 
and he overdosed immediately.
    This is a very real problem for real families throughout 
America every single day. And I appreciate the chairman and 
ranking member for holding this hearing, for us to try and 
identify whether there is a link between Chinese production of 
fentanyl and whether or not it is being introduced to our 
country in large quantities in illicit ways and if there is 
anything we can do to try and combat the introduction of this 
manufactured substance into our country.
    There are so many other drug problems in our country that 
have been going on and have been pointed out so eloquently by 
my colleagues for many years. It is important that we look at 
this as a health crisis, but we also have to look at where this 
drug is coming from and why it is being shipped here to the 
United States of America and what we can, if anything, do about 
it.
    Mr. Smith. Thank you. I would like to now introduce our 
distinguished panel beginning first with the Assistant 
Secretary for International Narcotics and Law Enforcement 
Affairs, Kirsten Madison, where she is responsible for the 
State Department programs combating illicit drugs and organized 
crime. Prior to her current post, Ms. Madison served in senior 
leadership positions in the executive branch including Deputy 
Secretary in the Bureau of Western Hemisphere Affairs; Director 
for Western Hemisphere Affairs on the National Security 
Council; the Foreign Policy Advisor to the Commandant of the 
Coast Guard.
    She has also served as a senior professional staff member 
and deputy staff member of the U.S. Senate Committee on Foreign 
Relations, as well as legislative director and international 
affairs advisor for Chairman Porter Goss. Outside the 
government, Ms. Madison has held positions of senior advisor to 
the Secretary General of the Organization of American States 
and recently worked at the American Enterprise Institute as 
deputy director for foreign and defense policy studies. She 
holds a master of science from the London School of Economics 
and a B.A. from Goucher College.
    Next, we will hear from the Deputy Chief of Operations, 
Office of Global Enforcement at the DEA, Paul Knierim. In this 
role he is responsible for overseeing operations to dismantle 
national and international drug trafficking organizations and 
supporting DEA investigative operations internationally. Mr. 
Knierim previously served in other positions in the DEA, 
starting his career in 1991 as a Special Agent in the Denver 
Field Division.
    He has served in various posts internationally ranging from 
Ecuador, Costa Rica, and Mexico. Domestically, Mr. Knierim has 
worked in the DEA, Miami Field Division, served as Staff 
Coordinator in the DEA Headquarters Office of Congressional and 
Public Affairs, and as Special Agent in Charge of the Dallas 
Field Operation. He holds a degree from the University of Utah.
    And again I thank both of them for your leadership and, 
without objection, your full statements will be made a part of 
the record, but please proceed as you would like.

   STATEMENT OF THE HONORABLE KIRSTEN D. MADISON, ASSISTANT 
     SECRETARY, BUREAU OF INTERNATIONAL NARCOTICS AND LAW 
         ENFORCEMENT AFFAIRS, U.S. DEPARTMENT OF STATE

    Ms. Madison. Chairman Smith, Ranking Member Bass, 
distinguished members of the subcommittee, thank you for your 
efforts to highlight the tragic impact of synthetic opioids 
across this country. Across this administration, agencies are 
working to combat the illicit opioid threat and to blunt its 
impact on Americans.
    My INL team understands that the work the State Department 
does to forge partnerships and consensus, to secure 
international cooperation, and to use foreign assistance to 
build the capacity of our partners to help disrupt the flow of 
opioids and other illicit narcotics is really just about one 
thing. It is about contributing to a larger effort to save 
American lives.
    Traffickers have capitalized on the boom and global access 
to information and technology to facilitate their lethal trade. 
Illegal drug producers exploit the anonymity and convenience of 
the dark Web, encrypted peer-to-peer messaging applications, 
and other information platforms to market and sell aggressively 
to global clients including directly to American drug 
consumers. It is a new frontier in illicit trafficking and 
therefore a new frontier in our efforts to push back.
    And I would just pick up on what some of the members of the 
panel have said, this I think is not displacing other parts of 
the drug market. We can't stop paying attention to 
methamphetamines, cocaine, or anything else. Those are all 
still real threats. This is additive not displacement.
    With China, the Department is building upon the commitments 
made in President Trump's November 2017 meeting with President 
Xi to deepen bilateral counternarcotics cooperation. This 
effort has yielded concrete results including arrests, 
seizures, and take-downs of clandestine labs by Chinese law 
enforcement. Law enforcement information sharing has increased, 
including information used to combat the export of drugs that 
are controlled here but not in China.
    Additionally, China has taken significant action to 
domestically control 175 substances with the 32 that were added 
to that list just last week including fentanyl analogues and 
key precursors to fentanyl production. We continue to press 
China to use every available tool to aggressively counter 
illegal production and the trafficking of synthetic opioids. 
Some synthetic opioids from China are flowing through Mexico 
where traffickers sometimes mix them, often mix them with 
cocaine and heroin before shipping them across our southwest 
border. Countering this flow is part of our partnership with 
the Mexican Government to disrupt drug production, dismantle 
drug distribution networks, prosecute drug traffickers, and 
deny transnational criminal organizations access to illicit 
revenue.
    State also works multilaterally to address the 
proliferation of illicit synthetic drugs and uses foreign 
assistance working through international organizations to 
support real-time coordination and information sharing between 
law enforcement and forensic officials around the world. This 
increases the identification, detection, and tracking of 
synthetic drugs and precursor chemicals worldwide.
    Working through multilateral organizations, we also deliver 
specialized training to strengthen the ability of key countries 
to intercept suspicious drugs and chemicals sold online and 
shipped through the mail and express consignments. The 
international tools that we use must actually be capable of 
addressing the 21st century challenge that we are facing. And I 
think this includes supporting an acceleration of the rate at 
which drugs are controlled at the international, regional, and 
national level. As is the case with China, international 
controls lay the groundwork for enhanced law enforcement 
cooperation with the U.S.
    In March 2018, we mobilized countries at the U.N. 
Commission on Narcotic Drugs to control the deadly opioid 
carfentanil, for example, plus additional fentanyl analogues. 
The CND was also the venue in 2017 to assert controls on two 
primary fentanyl precursor chemicals, NPP and ANPP. And, at the 
U.S. instigation, the International Narcotics Control Board 
recently issued a call to all nations to voluntarily restrict 
93 new substances that have no known medical use.
    To have impact these controls have to be implemented. So in 
INL we are helping countries actually institute the treaty-
mandated controls that they are supposed to at a national 
level. My team and I have been looking as well at additional 
ways that we can adapt INL's work to address the dynamic threat 
that is presented by illicit synthetics and to help our 
partners both in the U.S. Government and law enforcement and in 
the international community to tackle, really, all of the links 
in the illicit synthetic supply chain.
    For example, we are developing new partnerships to expand 
global capacities to detect and interdict synthetic drugs 
shipped through the mail and express consignment shipping, 
including by expanding the global collection and sharing of 
advanced electronic data. INL also aims to broaden its 
cooperation with U.S. law enforcement partners to expand 
training and the use of technology to detect and interdict 
suspicious mail.
    INL is also considering what additional practical steps it 
can take with international partners to prevent the diversion 
of legitimate chemicals for illegal uses and to support partner 
governments' ability to seize and dispose of diverted chemicals 
and build law enforcement capacities to detect and safely 
dismantle clandestine labs. As part of this effort, we believe 
firmly that we will need to seek increased cooperation with 
industry to make licit modes of commerce more inhospitable to 
criminals without encumbering licit activity.
    In addition to its other work, INL will be tapping into 
U.S. law enforcement expertise to provide foreign law 
enforcement counterparts with the skills to investigate, 
prosecute, and dismantle online drug vendors and to help our 
partners follow the digital money trail when vendors use crypto 
currencies to facilitate transactions.
    I think, finally, we must respond to the global nature of 
this threat and prepare for the proliferation of synthetic drug 
production distribution and abuse well beyond China and the 
countries currently impacted. This problem requires a strategic 
and coordinated international response. In practical terms, 
this means that we are not alone and that our diplomacy needs 
to focus on ensuring that other countries share our commitment 
and dedication to tackling this issue.
    Mr. Chairman, Ranking Member Bass, and members of the 
subcommittee, I can assure you that the Department is fully 
committed to the effort to address the threat posed by 
synthetic drugs and to address the impact that they are having 
on our citizens, on our communities, and on our families. Thank 
you for your time and I look forward to your questions.
    [The prepared statement of Ms. Madison follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
                              ----------                              

    Mr. Smith. Secretary Madison, thank you for your testimony 
and for leadership.
    I would like to now recognize Mr. Knierim.

 STATEMENT OF MR. PAUL E. KNIERIM, DEPUTY CHIEF OF OPERATIONS, 
OFFICE OF GLOBAL ENFORCEMENT, DRUG ENFORCEMENT ADMINISTRATION, 
                   U.S. DEPARTMENT OF JUSTICE

    Mr. Knierim. Good afternoon, Chairman Smith, Ranking Member 
Bass, and members of the subcommittee. It is an honor to be 
here today and speak with you about DEA's cooperation with 
China, Mexico, and our worldwide enforcement efforts to combat 
the opioid crisis. Heroin, fentanyl, and related analogues are 
the number one drug threat to our nation. Sadly, the use of 
these illicit drugs is destroying individuals, families, and 
American communities on a daily basis and in record numbers.
    Over the last several years, we have witnessed a dangerous 
new trend, the convergence of synthetic drug threat and the 
epidemic opioid abuse. Recent preliminary CDC reporting for 
2017 indicates that an estimated 49,000 Americans lost their 
lives to an opioid overdose. Similar to 2016, the increase in 
overdose deaths is being fueled by synthetics, primarily 
fentanyl and its analogues coming from China and Mexico.
    Fentanyl and related analogues are often shipped directly 
to the U.S. via postal or express mail from China. These 
synthetic drugs are cheap to make, hard to detect, and 
dangerously potent. A kilogram of fentanyl from China can be 
purchased for less than $5,000 and potential profits from the 
sale of that kilogram yields roughly $1.5 million.
    Further complicating the crisis are transnational criminal 
organizations. Let me be clear, the most significant criminal 
threat to the U.S. today are the Mexican drug cartels. The 
cartels continue to be the primary source of illicit drugs that 
are decimating our communities. Now Chinese and Mexican 
nationals are increasingly operating in concert resulting in an 
alignment responsible for the proliferation of heroin, 
fentanyl, and related synthetics coming across the southwest 
border.
    This leads me to what DEA is doing to counter the threat. 
We recognize this will take persistent efforts across a broad 
spectrum to include interagency and global partnerships. For 
decades, we have maintained a worldwide presence to address the 
source of drugs and in this case we have a robust presence and 
critical partnerships in both China and Mexico.
    Over the past decade, our relationship with China has 
steadily progressed. Many of the synthetic drugs encountered in 
the U.S. were not controlled in China. Through continued 
engagement by DEA and DOJ highlighting this serious issue, 
China passed legislation in 2015 that improved their ability to 
more effectively control newly identified destructive 
substances. China has now controlled 175 new psychoactive 
substances and precursor chemicals which have a direct and 
immediate impact and effect on the availability of these drugs 
in the United States. We are also encouraged by recent 
discussions with China drug control officials about the 
prospect of scheduling fentanyl as a class. This would 
eliminate the need to control fentanyl and related substances 
one by one.
    While we are appreciative of China's scheduling actions and 
enhanced cooperation on investigations, there is opportunity 
for more to be done. In 2019, DEA will be opening a new office 
in Guangzhou, China, where much of the shipping of fentanyl and 
other illicit drugs originate, to facilitate greater 
collaboration with our law enforcement counterparts and INL. We 
are also looking at opening an office in Shanghai as well.
    In Mexico, DEA continues to synchronize and expand 
capabilities to combat the growing epidemic. We have developed 
the bilateral heroin strategy for intelligence sharing, 
coordinated investigations, training, increased sharing of 
forensic information, and the control of precursor chemicals. 
We participate in the North American Drug Dialogue along with 
Federal Government officials from Mexico, Canada, and the 
United States to include INL which focuses on building a 
strategy to attack the production, trafficking, consumption, 
and misuse of illicit narcotics in North America.
    Domestically, DEA has moved aggressively to place temporary 
schedule controls on new and emerging synthetic drugs. 
Unfortunately, the temporary emergency scheduling process of a 
substance is reactive, requiring us to first observe deadly 
consequences and synthetic drug abuse before initiating 
control. Given the proliferation of synthetic substances 
including fentanyl across the nation, it is necessary to 
explore novel solutions to more expeditiously schedule these 
new substances. On February 6th, 2018, DEA proactively placed 
temporary emergency controls on the entire class of fentanyl 
related substances to curb fentanyl related overdose deaths. 
This is an unprecedented step to combat an unprecedented 
threat.
    In closing, we are grateful for the tremendous support that 
Congress has provided to DEA to combat this national crisis. In 
addition to increased resources, the House passed H.R. 2851, 
Stop the Importation and Trafficking of Synthetic Analogues 
Act, which DEA believes is critical to combat the synthetic 
analogue threat and save lives.
    We look forward to continuing our work with Congress to 
identify the resources and authorities necessary to address 
this devastating crisis and have a positive impact on our 
communities. Thank you for the opportunity to testify before 
your committee on this important issue today and I look forward 
to your questions.
    [The prepared statement of Mr. Knierim follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
                              ----------                              

    Mr. Smith. Thank you very, very much for your testimony. 
Let me just begin, if I could, with some questions and I will, 
since we have a large attendance today I will throw out a few 
questions right off the bat and then come back later if we 
don't get everything covered.
    Chinese officials have repeatedly dodged the blame for 
contributing to the fentanyl crisis, as you know. Liu Yuejin, 
Deputy Chief of China's National Narcotics Control Commission, 
stated in June that and I quote Liu, the U.S. should adopt a 
comprehensive and balanced strategy to address fentanyl demand, 
remarking that when fewer and fewer Americans use fentanyl 
there will be no market for it.
    As recently as last month, Yu Haibin, an official with 
China's National Narcotics Control Commission, stated, ``The 
United States has no proof that most fentanyl in the country 
comes from China.'' And both of you have obviously testified 
otherwise. Despite the banning of multiple variations of 
fentanyl by the Chinese Government, the export of fentanyl from 
China to the U.S., as we know, persists.
    I wonder if you could tell us law enforcement, all laws all 
that well, you can have the greatest law in the world, if it is 
not enforced what good is it. Those kinds of high level 
statements send a shiver down my spine about how you may on an 
operational level be working with some very dedicated Chinese 
colleagues, but if at the very top or at other places in the 
chain of command there is a dismissal that most of the fentanyl 
is not coming from China, it certainly raises questions.
    I know that the President, mid-August, called for stronger 
action and I know he directed his Attorney General to do so. 
You might speak to what has been done in terms of mobilizing 
any additional resources or policies.
    What other countries are known sources of fentanyl? Is 
India one of those countries, for example, you might want to 
speak to that. Because when we say majority coming, or most, 
where is the rest of it coming from? What holes in existing 
legislation need to be fixed? As I have said, and you said it 
just a moment ago, the idea of getting the Postal Service to 
finally adopt a system that at least gives another tool to 
border security and others to make sure that we know where it 
is coming from and where it is going, because they can ship it 
in small packages, unlike big hauls that they are taking 
through other routes.
    And let me also ask if I could, the April announcement by 
DOJ of Chinese nationals' indictments, do we expect others to 
follow? What has been the progress on that indictment? I was 
encouraged when I saw it, I think most of us were, that DOJ is 
taking this very seriously, but obviously it is very hard when 
people are in China to apprehend them.
    Is there any kind of ability for the Chinese Government to 
allow us to prosecute or at least to have them prosecute? How 
many arrests of Chinese narco traffickers has DEA made in 
cooperation with the Chinese authorities? It is cooperation 
with a capital C, or with a small C? Are they really working 
with us?
    I think your statement moments ago about the opening in 
Shanghai and elsewhere of new efforts is an encouraging sign. 
But I have been in Congress 38 years. I have worked on Chinese 
human rights since the day I got here and human rights all over 
the globe. The Chinese have been masters at purporting to be in 
compliance with international treaties including the U.N. 
treaty, the International Covenant on Civil and Political 
Rights, they milked that big time for years when high level 
officials would come and say we have signed it, but they 
wouldn't ratify it. And they would get this big upsurge that 
they are cooperating and yet at the level of human rights 
abuse, torture, and all the other abuses have gotten worse 
under Xi Jinping.
    So I am wondering, what is your true assessment? Is that 
cooperation real, robust? I know that they could take offense 
at something any of us say here, but we have to be candid. Our 
American brothers and sisters are dying in every one of our 
districts. We have so many people who are dying from fentanyl 
and it is sneaking into so many other drugs as well, especially 
heroin. And so the idea would be to say there is a line here of 
real seriousness. And of course we combat all the other bad 
drugs as well, crack, everyone is on board with that. But this 
one kills so fast and so surreptitiously and it is so powerful 
that this calls for extraordinary efforts.
    I did ask in my opening comment whether or not you think 
the Magnitsky Act would have applicability here. I think it 
does. I was the House sponsor of that legislation and believe 
that when you hold public officials especially accountable for 
egregious behavior, human rights violations, killing Americans, 
when you send fentanyl to the U.S. Americans will die, or 
anywhere else where you send it. So to me that is a gross 
violation of human rights which would fit the definition of the 
Magnitsky Act.
    So if you could begin with that.
    Ms. Madison. Thank you for your questions, Mr. Chairman. I 
will start at the beginning which is this question of Chinese 
rhetoric and the pushback that you have seen with regard to 
treatment and demand reduction. It reminds me very much of back 
in the day, the kind of conversations we would have with Mexico 
and we have sort of evolved beyond that point.
    And I think from my perspective, I think what is important 
with the Chinese is what they are actually doing. Personally, I 
know I have raised this issue with the Embassy of China, this 
issue of their rhetoric on demand reduction being the only 
answer, but I think what they are doing is what is important. 
They are working with us on controlling more substances. They 
are working with us in multilateral fora to advance controls. 
They are working through multilateral fora on real-time law 
enforcement cooperation. They are working with us on advanced 
electronic data for the mail.
    And I think as disconcerting as the rhetoric might be, I 
think the results that we get out of them in terms of how they 
cooperate in practical terms is more meaningful. I think there 
is plenty of places where the rhetoric between our two 
governments is, you know, there are rub points. But I think as 
long as we are getting the cooperation we need out of them that 
is the most important thing.
    I would imagine that Paul might have some things to say 
about that cooperation just as a----
    Mr. Smith. If I could on that point and maybe weave it 
further into your answer, I was the sponsor of the global 
online security act, held a series of hearings that began in 
'06 about the police state and how their surveillance is second 
to none in the world. The police state knows what people are 
doing, when they are doing it and in order, in my humble 
opinion, for such huge amounts. I know they can be done in 
small environs, but it doesn't take much for a police state 
like China if it is serious to crackdown. They certainly 
crackdown on dissent. They crackdown on labor unions. They 
crackdown if you want a labor union in China, good luck, you 
are going to jail. They know what people are saying when they 
go on Facebook or any of the other social media. You know, 
their abilities they are incredible.
    So my question again further to your answer, cooperation 
with a capital C, are they employing those kinds of assets 
where they say we are serious about this, the way they are 
about even to some degree serious about surveilling their own 
people 24/7?
    Ms. Madison. I think that--and again Paul may have more to 
add on the law enforcement side. I think that we are actually 
seeing real cooperation with them on taking down labs, on 
helping us to get to end game on law enforcement and so I think 
that that is not to be taken lightly. I think even, you know, a 
year ago we were not where we are today with the Chinese. Is 
there much more to be done, without a doubt, but I do think 
that we are making progress.
    Do you have anything?
    Mr. Knierim. Thank you. I would just like to echo a few 
things that my friend and colleague Assistant Secretary Madison 
has mentioned. I can tell you that our cooperation and our 
coordination and collaboration with China, in my estimation, 
has expanded tremendously over the last several years. I firmly 
believe that they understand the nature of the threat. That 
they are working with us, I think, is evident by the fact that 
they have controlled 175 chemicals and new psychoactive 
substances, precursor chemicals and the like, fentanyl related 
substances as well.
    I do believe that the relationships that have been 
established over three decades of presence in China are 
significant. I believe that those relationships are leading to 
a very robust dialogue and engagement. There is exchange of 
information both ways and it is very helpful to identify those 
substances and the individuals responsible which is our main 
focus to identify the persons and the organizations responsible 
for trafficking these substances to the United States.
    I would also like to add that I think over the last few 
years it has also been evident that, you know, the impact of 
them controlling these substances through our high level 
engagements and our direct personal relationship and engagement 
with them does have an immediate impact on the substances that 
are analyzed in our laboratories. So we do see when they 
control and regulate those substances through the engagement 
with us and really working with us on a significant way does 
have an immediate impact at home.
    And we are talking about the illicit fentanyl situation and 
the ability of these manufacturers to change the molecular 
structure in order to circumvent the controls, so that is 
really a very challenging situation. And I think it is also 
important to highlight the subject matter exchanges and 
technical exchanges in order to identify for them the 
substances that we are finding so that they can work with us on 
a very significant way to take action and control those 
substances as well.
    Mr. Smith. Is fentanyl a problem in China itself?
    Mr. Knierim. Fentanyl is not currently a problem in China.
    Mr. Smith. So it is an export?
    Mr. Knierim. So it is, they are, these organizations and 
individuals are exporting it to the U.S., Mexico, and Canada 
and then it is brought in to the United States directly from 
China or through Mexico, but it is not a substance abuse issue 
in China.
    Mr. Smith. Now with crystal meth when they realized, they 
being the Chinese Government, that that was a serious problem 
for them, there has been a very significant crackdown on the 
mainland of China. A hundred and fifty tons, according to the 
Sydney morning news, was apprehended. And they are very serious 
because it is so horrifically affecting the Chinese people. 
Thousands of police are now engaged in the meth crisis that 
they are experiencing. Do we see any sign that there is any 
kind of mobilization like that vis-a-vis fentanyl? And if I 
could, is there any sign of complicity of high government 
officials or even operatives at midlevels with regards to 
fentanyl?
    And I say that because, again, I have chaired 65-plus 
hearings on Chinese human rights abuses, and the complicity of 
the Chinese Government and human rights abuse is legendary. It 
is so awful. Even the U.N. has found that--Manfred Nowak when 
he did his piece on torture found it was everywhere in their 
laogai and prison system. If you are arrested you will be 
tortured. And if you are a political prisoner or a religious 
prisoner you are going to be tortured, horribly.
    And so with all kinds of high government buy-ins to that 
again underscoring the need perhaps at least to have as a tool, 
utilization of the Magnitsky sanctions against individuals. 
Then I will go to Mr. Castro.
    Do you want to speak to that?
    Mr. Knierim. Regarding the Magnitsky Act, sir, honestly I 
am not familiar with that so I will have to take that back and 
work with you on getting a response for you at that later.
    Ms. Madison. So if----
    Mr. Smith. We need to be looking to see if high government 
officials are looking the other way or complicit, getting 
money. I mean this is, the money that can be gleaned from this 
is astronomical.
    Ms. Madison. And Global Magnitsky, it is a tool I am 
familiar with because we considered it on the Foreign Relations 
Committee when I was on the staff.
    Mr. Smith. Sure.
    Ms. Madison. I do not personally have any information to 
suggest the complicity of specific individuals but I understand 
the point, which is that Global Magnitsky is another tool that 
allows you to go after corruption and we are happy to sort of 
take that back and look at the question. But I understand the 
point which is it is another tool.
    Mr. Smith. Please go back and maybe get back to the 
subcommittee as soon as you can.
    Mr. Castro?
    Mr. Castro. Sure.
    Let me ask you a practical question. Can you describe the 
tools and practices that you employ to detect fentanyl? For 
example, what tools do you use in regard to mail routed through 
the postal system?
    Mr. Knierim. Go ahead.
    Ms. Madison. So INL's piece of this, we are not law 
enforcement on the front lines. CBP really owns the front line 
on this as stuff enters the country because they have the 
authorities to intercept and actually look at things as they 
enter. From an INL perspective, from a State Department 
perspective what we try to do, what we are working on is trying 
to get countries to provide more advanced electronic data that 
would allow our law enforcement folks to actually go after 
this. And we also work with countries like Mexico to provide 
fentanyl sniffing dogs and port inspection mechanisms and to 
work with them on controlling their port.
    So our piece of it is the piece where we are trying to line 
up the tools that would actually help our law enforcement. And 
the advanced electronic data, CBP and the U.S. Postal 
Inspection Service have said that they need more data and it 
would be extraordinarily helpful to them as they try and 
control inbound packages.
    So from a State Department perspective, we are working in 
the Universal Postal Union to try and continue to advance a 
requirement that all countries provide advanced electronic 
data. The second piece of that is, the challenge of that is 
there is a soft requirement for countries actually to do 100 
percent advanced electronic data by 2020. Many countries are 
not capable of it.
    So INL, one of the new partnerships that we are trying to 
build is a partnership with UPU. They have a training program 
that they have 13 countries in a pilot project trying to build 
their capability to provide advanced electronic data. So one of 
the things that the State Department is doing is we are 
negotiating with UPU to actually expand that program and to tap 
into their training. And really we would have to identify the 
priority countries that are the transport points for mail 
packages, but if we can help build the capacity of some of 
these countries to provide advanced electronic data that 
supports our law enforcement folks who are at the border.
    I don't know if you have more to add, Paul.
    Mr. Knierim. Well, I can't respond directly to what 
technical and tools are being used by CBP and the Postal 
Service. What I can tell you, however, is that we have a very 
robust interaction and collaboration with both CBP and the 
Postal Service to identify the organizations and have an impact 
on the availability.
    One of the things that is very difficult and challenging 
and I will use this as a little demonstration, is if this 
were--this is about one gram. If this were a packet of fentanyl 
there is approximately 500 lethal doses in here. So we are 
looking for very small amounts at certain times. These aren't 
the tons that are coming in specific shipments through maritime 
efforts and things like that.
    So it does represent challenges, but I do want you to 
understand and be aware that there is a very robust interaction 
amongst law enforcement to address this issue and work with our 
CBP and U.S. Postal Service partners. And also with our foreign 
partners, I think the Assistant Secretary made a very valuable 
point in recognizing that we are providing opportunities for 
training and capacity building so that our counterparts can 
also be prepared to handle and understand the significance of 
these threats from a safety and security perspective from their 
investigators as well.
    Mr. Castro. Thank you. Just one more question from me which 
is of all the fentanyl in the United States how much of it 
comes from China versus Mexico versus somewhere else? Do you 
all have a sense for that?
    Mr. Knierim. Sir, I don't know if we have a specific sense. 
One of the things that we do use as an identifier or origin is 
the purity. What we understand and find is that if it is coming 
directly from China it is over 90 percent pure. And if it is 
coming from Mexico it is generally less than 10 percent. We see 
it coming----
    Mr. Smith. Will the gentleman yield on that point?
    Mr. Castro. Sure.
    Mr. Smith. Through Mexico, but what would be the origin?
    Mr. Knierim. We see the origin coming from China as well. 
So when it gets to Mexico it is mixed in with heroin or other 
adulterants and also made and pressed into pills that would 
mimic or look like pharmaceuticals. So that is when we see it 
come, when it comes across the southwest border it is generally 
a little less than 10 percent.
    Mr. Castro. And is any of it native to the United States?
    Mr. Knierim. From the licit side or from the illicit sides? 
From the illicit side again coming in from China, and this does 
create a challenge as well because it is creating individuals 
who are capable of being non-cartel affiliated traffickers. 
There was an example of one in Utah where one individual was 
responsible for shipping over 400,000 packages throughout the 
United States. He was getting it on the Web and purchasing it 
and then putting it in and manufacturing it into fake pills in 
the basement of his mother's residence.
    So it does create a challenge identifying those types of 
non-cartel affiliated individuals as well.
    Mr. Castro. All right, thank you. I am going to have to 
leave you, Chairman. I have my other subcommittee at the same 
time.
    Mr. Smith. I am going to be there too.
    I would like to now yield to Mr. Donovan.
    Mr. Donovan. Thank you, Chairman. Most of my questions are 
already asked. I was going to ask the question about does China 
have a fentanyl problem as well and if they don't they really 
don't care what it is doing to our citizens. If it is so 
inexpensive why aren't we making it here? If it is made in 
labs, it is synthetic, why aren't our drug dealers making it, 
does anybody know?
    Mr. Knierim. The precursor chemicals are controlled. So I 
think identifying and obtaining the precursor chemicals is----
    Mr. Donovan. Is it difficult?
    Mr. Knierim [continuing]. More challenging than obtaining 
the substance.
    Mr. Donovan. It is just easier to buy. And I think you hit 
on it before that there is detection methods, you know, our 
dogs hit on cocaine packages or coffee beans or Ty-D-Bol cubes, 
whatever they are called. So are there methods that we are 
detecting fentanyl as it comes through the country that you are 
aware of?
    Ms. Madison. So from INL's work in Mexico it is the dog 
program that we have found to be the most effective. I don't 
know if there are other technical methods but that is 
certainly--and that is actually something that came out of the 
North American Drug Dialogue with the Canadians because the 
Canadians were the first to say hey, the dogs are actually the 
most effective way to detect this.
    And the RCMP is, actually they started the training in 
Mexico, for example, which again it is a shared border so that 
is in our interest. And we in INL have supported the program in 
Mexico with dogs and additional training. So that is the 
primary one we work on in INL.
    Mr. Knierim. And, sir, one thing I can highlight is the 
fact that there is technical equipment that does detect it, but 
we are still at least from my understanding within DEA looking 
at the technology to see what is the most effective. My 
understanding is that CBP does have some of this that they are 
using. I don't know specifically what it is, but I can take 
that back and find that out for you and get back to you.
    Mr. Donovan. What are the sizes that we are seizing when 
they come across? I mean, you know, we used to do cocaine 
seizures of hundreds of kilos. We are not seeing that with 
fentanyl, right?
    Mr. Knierim. We have seen some very significant seizures in 
Mexico in particular, upwards of 50 to 60 kilograms and then 
you are getting into the thousands of pills. So it is coming 
across in significant numbers and those are some seizures that 
have happened, some polydrug seizures recently by our Mexican 
counterpart.
    Mr. Donovan. Do we see any other substances, narcotics 
being shipped, heroin from the Far East, cocaine from the south 
being shipped by mail, or is it fentanyl the predominant 
substance that we are seeing shipped by mail?
    Mr. Knierim. In my experience, cocaine and meth is getting 
here in every way conceivable to include through the southwest 
border, being shipped through the mail, couriers, maritime; so 
they use all the available resources to get it across.
    Mr. Donovan. Thank you, Mr. Chairman, I yield back.
    Mr. Smith. Thank you very much, Mr. Donovan.
    Mr. Suozzi?
    Mr. Suozzi. So, first, I have a preliminary question. 
Fentanyl is used for legal purposes as well, it is used for 
anesthesia and things like that; is that correct?
    Ms. Madison. It is correct. The synthetics are actually 
used for licit purposes as well.
    Mr. Suozzi. And when you talked about the precursor 
chemicals before and the lack of availability of the precursor 
chemicals here in America because it is regulated, but the 
unregulated nature of the precursor chemicals in China, for 
example, what are the precursor chemicals?
    Mr. Knierim. That is a great question and I do want to just 
reiterate that precursor chemicals have been regulated by China 
and there are two specifically. One is NPP and one is 4ANPP, 
both have been controlled by China.
    Mr. Suozzi. Okay. I am not going to try and get you to tell 
me what NPP stands for, right?
    Mr. Knierim. I couldn't do it, sir.
    Mr. Suozzi. Okay. All right, so just I want to try and get 
some clarity. So there are four parts that contribute to this 
problem. One is the lack of, we think, Chinese enforcement to 
go after these drugs being manufactured in China and then being 
shipped here. Two is detection of these drugs as they are 
entering our border, and I want you to talk about that just to 
clarify for me that you think mainly the way it is coming in is 
through the mail.
    Three is the prosecution of the substances, the possession 
for these substances based upon the fact that they are these 
different analogues and they change the makeup and they are not 
all necessarily scheduled drugs that can be prosecuted for. And 
four of course is, you know, the demand for the drugs itself.
    So are those the four big areas and can you just talk a 
little bit about each one like what is the biggest parts of the 
problem? Is it the lack of Chinese enforcement? Is it the 
failure or inability to detect the stuff coming across the 
border? Is it the inability to prosecute because of the 
different analogues or is it just simply because people are 
using this stuff too much? Or is there something I am leaving 
out?
    Ms. Madison. Paul will add after I do, but from my 
perspective I think all of these things are part of the 
challenge. I think you have a very agile part of the drug 
market, right. You have synthetics that are able to be produced 
and altered very rapidly. It is the reason we are asking China 
to control as a class, because basically if they tweak a 
formula and on a particular drug it is suddenly no longer 
controlled. I think it is very agile.
    I think another big----
    Mr. Suozzi. So just China right now. You know, they are 
doing better now, they have gone after some precursor drugs. 
From 1 to 10, 10 doing the great job of enforcement and 1 they 
are not doing a great job of enforcement, how would you rank 
them from 1 to 10?
    Mr. Knierim. What I would like to say is that they are 
working with us on a collaborative basis on our investigative 
efforts and so I think that over the last few years and what I 
have seen is that investigative cooperation and that exchange 
and those partnerships have significantly increased. So they 
have exchange information with us and us with them, they have 
taken action on the investigative information that is being 
passed. So I believe that those relationships are going to 
continue to strengthen. In particular, why we are opening an 
office in Guangzhou and looking at opening an office in 
Shanghai, because those partnerships and those relationships 
develop further investigative efforts and joint investigations.
    I think on the detection piece, it is coming through the 
mail, right, so that does present challenges for us. I think we 
are looking at the cartels. And to your point about that with 
the prosecution and those types of things, I think again want 
to recognize and thank Congress for SITSA, because we do feel 
that that is a very important legislative issue. As evidenced 
by our emergency scheduling, we also think any additional 
legislation that would permanently schedule these as a class 
would be very helpful as well.
    Mr. Suozzi. Anything you want to add, Ms. Madison?
    Ms. Madison. Just to say that I do think in addition to 
the----
    Mr. Suozzi. I am letting you off on the 1 to 10 thing 
because you obviously don't want to answer that.
    Ms. Madison. It is very merciful of you.
    I would say, you know, that the issue of the scheduling as 
a class is so important because of the agility of the 
synthetic, illicit synthetic producers. I think the mail 
presents a really profound challenge because it is very 
diffuse. You know, this is not our old school interdiction 
approach. It is not what we have done with cocaine. It is not 
what we have done with----
    Mr. Suozzi. It is not some people taking a boat across the 
Caribbean and coming in some places, no border control and 
sneaking in that way.
    Ms. Madison. Right. And then there is the dark Web piece of 
it. It is very--this is not the word I want to use, but it is 
sort of democratized access, right. People can go online. They 
can go onto the dark Web. They can make these purchases. They 
can pay for them with crypto currencies and they can get them 
dumped in the mail and shipped to them. And then we are in a 
position where CBP is trying to stop it all at the border. So 
this is a very different kind of business model and it is a 
sort of new horizon in the challenge.
    So, and I think that--and you can't ignore any piece of 
what you talk about. The demand piece of it is very important. 
It is not the work that the State Department does or DEA does, 
but it is a piece of this puzzle. But I think this is a very, 
very agile piece of the illicit drug market and it is requiring 
us to think differently and develop new techniques because it 
is not the old school way of trafficking or selling drugs.
    Mr. Suozzi. And how, is there a way that it could be 
detected in the mail if we changed the procedures or processes? 
I mean how we could we, I mean if it is coming in these small 
packages and that could be wrapped in something else and 
wrapped in something else, I mean how would we--it is not an x-
ray thing. It is not a smell. How would you detect it in the 
mail?
    Mr. Knierim. I think through the mail facilities is what 
CBP and U.S. Postal is trying to do through the express mail 
consignment. Shipping the volume is significant of the mail 
that is coming in from China. So I think from our perspective 
it is also continuing to focus our interagency efforts on 
identifying those individuals and organizations responsible and 
heading it off in that perspective and prosecuting them.
    I think to piggyback on something that the Assistant 
Secretary said with regard to the internet and I previously 
mentioned it, this has created non-cartel affiliated 
trafficking opportunities for some individuals. So the robust 
efforts and our interagency efforts to address the internet and 
not just the dark Web but the open Web as well, and then to 
follow up with our, you know, money laundering investigations 
to identify the flow and to identify those assets for seizure 
is also something that we take very seriously.
    You know, this is a top priority and so I think our 
interagency efforts and our international efforts collectively 
are going to continue to strengthen and improve as we identify 
these other areas of mutual interest.
    Mr. Suozzi. The last thing, so you are talking about, you 
know, we need to do a better job surveilling the dark Web, 
surveilling the open Web, and watching for where people get 
access to this stuff in the first place. And then there is a 
concern about surveilling the mails about where the origination 
point is for these drugs and then trying to track where they 
end up in the United States and look for patterns and processes 
of where the drugs are going related to where the overdoses are 
taking place or the use is taking place which will raise 
concerns of the libertarians and civil liberties folks that, 
you know, we are watching too much of what everybody is doing.
    But you are saying that is the only way you can really 
track what is going on or am I putting words in your mouth?
    Mr. Knierim. I think it is a combination of investigative 
efforts to include and incorporate the information and the 
investigations that we have that utilize the mail, utilize the 
internet, the cartel involvement, the non-cartel affiliated 
traffickers. So it is really a combined and faceted, 
multifaceted approach to address this significant problem.
    Mr. Suozzi. Thank you. Thank you, Mr. Chairman.
    Mr. Smith. I have some other additional questions, but we 
do have a vote series, five votes that are up, regrettably, in 
terms of time. I apologize for the inconvenience to our next 
panel, because we will have to take a short recess.
    But I would, for the record you didn't say it when I asked 
it earlier, but maybe for the record you could provide it, how 
many arrests have Chinese narco traffickers had with the DEA? 
What kind of, I mean what are the numbers? Are they working 
with us? What is the outcome of the announced April 
indictments? Where is that if you could bring us to successful 
prosecution sometimes breeds more successful prosecution 
showing that it is doable and of course we learn lessons on 
cooperation when we actually do it and cooperate.
    So I do have those questions. If you could provide that for 
the record I would appreciate that. And again getting back to 
enforcement, you have made the point that they have legal 
controls on the precursors. Again just my experience, I could 
be dead wrong, but by and large when the government gives an 
assurance of something that it has no willingness to execute, 
and nowhere is that more notorious than their utter failure to 
respect the human rights of their own people in a myriad of 
categories, they will have a piece of paper that says look, it 
is right here it is outlawed, and yet the proof has to be in 
how are you executing it.
    So if you could get back to us with maybe some additional 
insight on how they are executing. Like I mentioned with the 
methamphetamine, they are serious about that one because 
Chinese citizens are dying from it and of course that is made 
in a lab too. So please get back to us on that one as well 
unless you wanted to comment right now.
    Mr. Knierim. We will be happy to get back to you, sir.
    Mr. Smith. I appreciate that. Thank you.
    I will do the introductions to our next panel and again I 
deeply apologize to the next panel.
    And thank you again for your testimonies.
    And then we will come back right after the vote to 
reconvene.
    Maybe we will go in brief recess and then I will invite 
everybody to the witness table in a few moments. Thank you.
    [Recess.]
    Mr. Smith. The subcommittee will resume its sitting and I 
do want to apologize for that hour delay or a little over 
because of votes. We did have five votes. So, but please accept 
that apology and I thank you for your patience most of all.
    Let me begin, first of all, with our first witness on Panel 
2, Joseph Coronato who has served as the prosecutor in Ocean 
County, New Jersey since 2013. Prior to his current position, 
Mr. Coronato established a private practice in Toms River, New 
Jersey, specializing in municipal prosecution, civil 
litigation, criminal matters, and personal injury, among other 
things.
    He also served as assistant prosecutor at the Atlantic 
County Prosecutor's Office and was appointed deputy attorney 
general by the attorney general of New Jersey back in 1976, 
where he investigated and tried organized crime, narcotics, and 
white-collar crime as well, and worked in the Organized Crime 
Special Prosecutor Section of the Attorney General's Office.
    Secondly, we will hear from Bryce Pardo who is an associate 
health policy researcher at the RAND Corporation where his work 
focuses on drug policy, specifically in the areas of cannabis 
regulation, opioid control, and new psychoactive substance 
markets. Prior to his current position, Mr. Pardo worked for 5 
years as a legislative and policy analyst at the Inter-American 
Drug Abuse Control Commission within the OAS, the Organization 
of American States, and has independently consulted with 
multilateral institutions such as PAHO, the Pan American Health 
Organization and U.N. Office on Drugs and Crime.
    In 2015, Mr. Pardo served as an analyst with BOTEC Analysis 
Corporation assisting the Government of Jamaica in drafting 
medical cannabis regulations. Mr. Pardo holds a doctorate of 
philosophy in public policy from the University of Maryland, an 
M.A. in Latin American studies, and a B.A. in political science 
from George Washington University.
    And then finally we will hear from Dr. Dan Ciccarone who is 
a professor in the Department of Family and Community Medicine 
at the University of California San Francisco. He specializes 
in family medicine and addiction medicine, has been principal 
or co-investigator on numerous NIH-sponsored public health 
research projects.
    He currently leads the Heroin in Transition Study which 
aims to examine the rise in heroin use, the expanding diversity 
of heroin source forms, and illicitly made synthetic opioids 
such as fentanyl and their relationship to the increase in 
illicitly opioid involved mortality as well as morbidity. He is 
the associate editor of the International Journal of Drug 
Policy and recently edited a special issue of the Journal on 
opioids, heroin, and fentanyl in the United States.
    Three outstanding experts to inform the panel and, by 
extension, to inform the Congress, so I thank you for being 
here. And, Mr. Coronato, if you could begin.

 STATEMENT OF MR. JOSEPH D. CORONATO, PROSECUTOR, PROSECUTOR'S 
                OFFICE, OCEAN COUNTY, NEW JERSEY

    Mr. Coronato. My name is Joe Coronato and I am the 
prosecutor in Ocean County. Ocean County is the second largest 
landmass county in New Jersey. Our population is slightly over 
600,000 which is the fifth largest, But during the summer 
months our population exceeds 1.2 million. That is due to our 
beaches along the Atlantic coast.
    I was sworn in as prosecutor back in March 2013. As the 
prosecutor, I am the chief law enforcement officer for the 
county. As such, the police chiefs of 32 police departments and 
approximately 1,600 sworn officers report to my authority. My 
office itself consists of 200 employees: 50 assistant 
prosecutors, 95 detectives, and agents and support staff, just 
to show that we are an average county within not only the State 
of New Jersey but probably throughout the country.
    Within 2 weeks of being sworn in as prosecutor there were 
eight overdose deaths in Ocean County. All the victims were 
under the age of 28. I had one young girl 18 years of age died 
in a motel room. This young woman was doing 50 packs of heroin 
a day, 25 in the morning and 25 at night. As a father of two 
children, I knew it was my responsibility to use every effort 
possible to address this epidemic.
    Ocean County has become ground zero for the overdose deaths 
in New Jersey in the last several years. Back in 2012, before I 
was prosecutor, it was 53 overdose deaths due to opiates. In 
2013 it went up to 112. In 2014 it went down to 106 and that is 
because of Narcan. In 2015 it went back up to 120. In 2016 it 
was the year where we had 217 people in my county died. I will 
note that in 2017 there was 174 people died. It was a 20 
percent reduction and I will explain that later on.
    The Ocean County Prosecutor's Office and its local and 
State and Federal partners have attacked the opiate epidemic 
and it appears that we are having some success in this regard. 
But that being said, the impact of what I call the synthetic 
storm, the addition of fentanyl to the mix has been devastating 
and continues to be a major concern.
    Based on our medical examiner toxicology analysis, in 2014, 
10 percent of my dead bodies had fentanyl in them. In 2015, 30 
percent of my dead bodies had fentanyl in it. In 2016, 60 
percent of my dead bodies had fentanyl in it. In 2017, 65 
percent of my dead bodies had fentanyl in it. And now 2018, 80 
percent of my dead bodies have fentanyl and I do say by the end 
of the year probably will rise to about 85 percent.
    A brief summary from Ocean County Forensic Laboratory for 
2017 and 2018 is also startling. The number of fentanyl-laced 
submissions rose from 37 percent, meaning of what we tested in 
2017 to about 52 percent of our submissions now have fentanyl 
in it in 2018. Fentanyl-laced submissions now appear to be 
frequently combined with at least 14 other drugs such as 
cocaine, methamphetamine, and alprazolam. Our county labs are 
consistent with the New Jersey State Police Forensic Science 
Lab. So far the State lab is showing a 53 percent increase in 
fentanyl-laced submissions statewide in 2018.
    Ocean County has been tracking the opioid death rate on a 
monthly basis since 2014. To further emphasize the impact of 
synthetic opioids, in February 2017 there were seven overdose 
deaths. In February 2018 there was a dramatic increase to 20 
deaths. The increase can be attributed to a free heroin day 
that was promoted by the drug dealers in Camden, New Jersey. On 
that day there was no charge for heroin wax folds. Ocean County 
suffered eight deaths within a 3-day period. It should be noted 
that Camden and surrounding counties, Gloucester and 
Cumberland, had similarly high death rates for that same 
period. Essentially, a bad batch of synthetic-laced opioid was 
the cause.
    To note, on June 25th, 2018, this year, the Customs and 
Border Protection seized 110 pounds of fentanyl in 
Philadelphia. The U.S. Customs and Protection agents in 
Philadelphia last week discovered 100 pounds inside barrels of 
iron oxide being shipped from China. The seizure occurred on 
June 25th and netted fentanyl with a street value of $1.7 
million. An agency spokesman said the cargo was flown into 
Chicago then shipped by truck through Philadelphia, but the 
officials that are not going to specify exactly where the 
seizure occurred or identify the cargo's intended final 
destination.
    That seizure further illustrates a significant impact that 
synthetic opioids have on the drug trade not only in New Jersey 
and Philadelphia area, but throughout the entire country. The 
drug traffickers are businessmen who are seizing the 
opportunity to maximize their profits simply through their 
distribution of same. Why grow a plant when you can 
synthetically produce and manufacture at a significantly lesser 
cost.
    In recognition of that threat that heroin and opioids 
presents in my region, the DEA and HIDTA recently established a 
Monmouth County Post of Duty Task Force which will focus 
additional law enforcement resources to our problem. To that 
end, I really want to thank Chairman Smith, Senator Booker, and 
also Congressman Tom MacArthur who helped me get Ocean County 
to be part of that HIDTA task force.
    As a result of that already strong working relationship 
between my office and federal, state, and local authorities, a 
drug investigation was recently conducted which involved six 
counties in New Jersey, New York, and the Dominican Republic. 
One of the target dealers, investigators from Jersey City--and 
basically what happened is that we were able to trace the drug 
dealer through Ocean County through Monmouth, up to Middlesex, 
up to Hudson County into Jersey City. That dealer then went 
over to the Bronx and then flew from the Bronx down to Miami, 
eventually going to the Dominican Republic.
    We then were able to track that individual back into Miami, 
who then flew to California, and eventually was stopped 
crossing the United States. And when we did that stop was 
transporting 40 pounds of cocaine and 40 pounds of meth that 
was designated for the East Coast. And I use that to show how a 
county prosecutor can show how it becomes an international 
source of drug dealing that actually leaves our shore, goes to 
another country, and comes clear across the State.
    In my opinion, synthetics will become the predominant type 
of illegal drugs abused within the next 5 years. In fact, we 
now can see in Ocean County that synthetic drug transactions 
are being transacted at an alarming rate, in many instances 
right over the internet from sites located abroad. The 
subsequent delivery of the internet synthetic drugs is 
literally to the doorstep of our abusers and dealers by the 
U.S. Postal Service, Federal Express, and other delivery 
services as the case may be.
    At least in Ocean County we have created a partnership 
between law enforcement and the healthcare community and 
additional services which has had a substantial impact on 
reducing our overdose rate by 20 percent of the synthetic 
storm. The death rate in Ocean County for 2018 matches our 
death rate of 2017 which means that we are holding our own.
    While I am very proud of our anti-heroin/opiate programs we 
have implemented in Ocean County, I am most proud of our Blue 
HART Program. Blue HART allows an addict to voluntarily turn 
themselves into one of our eight police departments in our 
county and without fear of prosecution be referred to a long-
term rehab center.
    Since we rolled the program out and starting in January 
2017, over 800 individuals have availed themselves of this 
program. Because of these synthetic opiates, our efforts to 
reduce overdose deaths here in Ocean County and elsewhere will 
be increasingly more difficult. I look forward to Congress to 
take the lead in this synthetic epidemic and to assist law 
enforcement and healthcare communities with adopting 
comprehensive legislation to address this epidemic.
    I believe there are a couple recommendations this committee 
can consider in helping to stop the international illegal sale 
of fentanyl. First, I believe our Federal law enforcement needs 
to develop new partnership with law enforcement in China and 
other countries where we have traditionally not had a 
significant presence. It is extremely important to control the 
production and distribution of synthetic opioids worldwide, and 
I think we need to do that through the partnership of law 
enforcement agencies.
    Secondly, I would also recommend to the committee to 
consider new investigative techniques needed to implement in 
this illegal drug trade. We have seen especially with fentanyl 
internet purchases with home delivery of this dangerous drug. 
Traditional drug enforcement needs to adapt to this change in 
distribution patterns and Federal resources need to be devoted 
to this issue. The internet ordering of illegal drugs including 
fentanyl and delivery of that drug to your doorstep is the next 
storm.
    I would like to thank you for the opportunity to address 
this committee and express my thoughts and concerns. I would 
like to add one other thing, if I may. When I talk about the 
Blue HART Program, okay, that all kind of evolved out of 
Narcan. When it came in 2014, I could see that our death rate 
was climbing alarmingly. We turned to Narcan. We were the first 
county in the State of New Jersey to give out Narcan to the law 
enforcement officials. We gave it to all the police departments 
and we used forfeiture funds to fund the Narcan within each of 
the departments.
    But I soon learned even though our death rate started to go 
down as a result of giving out the Narcan that that was only a 
temporary fix. So the next program that we worked on in 2015 
and 2016 was what we called the OORP program, which is the 
Opioid Overdose Response Program. And that meant that once an 
individual that was sprayed with Narcan and brought to the 
hospital, there would be a recovery coach that would approach 
him in that hospital, so we would have somebody available 7 
days a week, 24 hours a day in the hospital that would be able 
to, as I would call them, catch that individual, tell them they 
were at death's doorstep, and get them into help. So we did 
that in 2015 and 2016.
    But then it became upon me to say, wait a minute. The only 
way we are helping these people is that they almost have to die 
and almost have to be at death's doorstep to help them, and 
that is when the Blue HART Program came into being where you 
can walk into a police station without fear of being charged 
and that we would get help. I never thought in my wildest 
dreams that 800 people would be walking into my police stations 
to do that. But what that does show is why did they come into a 
police station and not present themselves to a hospital?
    There is a gap there and obviously that is something that 
we needed to work with, with the hospitals to understand 
because this is a medical issue. It is a disease that needs to 
be worked upon. I really would believe that the next phase is a 
step-down unit within the hospital. I truly believe that we 
can't tie up the emergency room and have a throughput issue in 
the emergency room, but that we need to develop within the 
hospital a step-down unit where almost where we can hold them 
for 24 that may be up to 72 hours, that there be a clinical 
evaluation done and that we would then be able to process them 
through the system.
    I think it also would give the State Health Department a 
better feel as to what the volume is going to be because we 
would have these step-down units located throughout the State. 
They would be able to better track and better assess the 
problems as they go forward. I think it is also a one-step, a 
one-flow issue because it would not only be limited to opiates, 
but it would also be for alcohol problems, mental health 
problems. I think that it would be broad-based as a result.
    And then we would then, once we have these entries into 
this river as I call it to one, we should improve our river 
system and improve our recovery system as it goes through. So I 
think there is a lot of work. I think there is a bright future. 
I think you can see by the standard that we created that 
despite the fact that we have this storm and despite that we 
have fentanyl coming in that there is a possibility that we can 
work around this problem and actually reduce the death rate. 
Thank you.
    [The prepared statement of Mr. Coronato follows:]
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. Thank you very much, Mr. Coronato, a tough 
prosecutor with a great big heart for those who are suffering 
from drug abuse, so really appreciate it.
    Dr. Pardo.

 STATEMENT OF BRYCE PARDO, PH.D., ASSOCIATE POLICY RESEARCHER, 
                        RAND CORPORATION

    Mr. Pardo. Chairman Smith, Ranking Member Bass, and other 
distinguished members of the subcommittee, thank you very much 
for the opportunity to testify before you today.
    For almost 30 years, the RAND Drug Policy Research Center 
has worked to help decision makers in the United States and 
throughout the world understand and address issues involving 
alcohol and other drugs. I was asked to speak to you today 
about ongoing developments related to the opioid crisis in the 
United States and China's role in supplying synthetic opioids.
    First, I briefly describe the emergence of these drugs. I 
then focus on elements related to the production and supply of 
substances coming from China. Finally, I conclude with some 
policy options aimed at the new challenges posed by synthetic 
opioids. The opioid crisis was originally fueled by oversupply 
of prescription painkillers, yet by 2017, synthetic opioids 
such as fentanyl were involved in approximately 60 percent of 
the almost 50,000 opioid overdose deaths that year. Similarly, 
in 2016, about 40 percent of fatal cocaine overdoses included 
synthetic opioids.
    The upward trend in synthetic opioid overdoses is mirrored 
by supply-side indicators. Customs and Border Protection seized 
675 kilograms of fentanyl in fiscal year 2017, up from just one 
kilogram in fiscal year 2013. Calculations in my written 
statement show that approximately 80 percent of the purity 
adjusted fentanyl seized by CBP in fiscal year 2017 occurred in 
the international postal and express consignment systems, 
almost all originating from China. This supports law 
enforcement's assessments that that country is a substantial 
source of synthetic opioids.
    China is an important source of many legitimate chemicals 
and pharmaceutical ingredients. Today it is the world's largest 
exporter of active pharmaceutical ingredients and a leading 
exporter of chemicals for industrial and commercial use. 
However, economic growth in these sectors has outpaced the 
central government's ability to monitor producers.
    As detailed in my written statement, there are several 
factors that allow for unscrupulous manufacturers to operate 
with impunity. First, regulatory design and enforcement is 
scattered across a handful of agencies creating gaps and 
oversight. Second, misaligned incentives between those who 
write the rules and those who enforce them allow for regulatory 
capture and corruption. And third, the central government's 
enforcement capacity is limited given the number of producers 
and distributors. Such conditions create a favorable 
environment for firms to operate in the legal margins allowing 
them to produce and export synthetic drugs to global markets.
    This problem is not unique to pharmaceuticals or illicit 
drugs. Chinese manufacturers have been implicated in cutting 
corners at the expense of consumer safety. This includes 
manufacturing pet food that contained melamine, toothpaste 
tainted with antifreeze, children's toys painted with lead, and 
contaminated blood thinners.
    Considering the future, there are several things that 
Congress or Federal authorities could do. However, given the 
scope of this problem and the new challenges it presents, 
Congress must look beyond traditional and existing drug policy 
tools. First, given the lack of information on supply and 
demand Congress could ensure improved and streamlined data 
collection and analysis methods by Federal agencies. This 
includes directing law enforcement and public health 
authorities to improve measurement and analysis of seizures and 
other outcomes such as overdoses. Most of our drug policy 
collection and data analysis systems are inadequate to 
appropriately assess developments related to the arrival of 
these new and emerging drugs.
    Second, Congress could encourage Federal authorities to 
utilize supply-side interventions strategically by working with 
Chinese counterparts to strengthen the country's regulatory and 
interdiction capabilities. Congress could consider 
appropriating additional resources to aid U.S. authorities that 
work with international partners as well as direct the FDA, the 
DEA, and the Department of State to improve interagency 
coordination and cooperation with the Chinese Government, 
encouraging it to close regulatory gaps, move more quickly with 
scheduling decisions, and increase enforcement capacity.
    Third, Congress could encourage Department of State to 
engage diplomatically with China for the purposes of discussing 
an extradition agreement to prosecute and deter suppliers. Lack 
of such an agreement impedes U.S. law enforcement's ability to 
prosecute Chinese nationals that traffic synthetic opioids. And 
lastly and most importantly, Congress could increase demand 
reduction efforts at home. This includes encouraging the 
expansion of pharmacological treatments covered by private and 
public insurance, subsidizing the cost of medication therapies 
for those who cannot afford them, and reviewing and reducing 
regulatory barriers on their provision.
    The arrival of illicitly manufactured synthetic opioids 
creates uncertainty in retail drug markets raising the risk of 
overdose. These substances are changing the drug policy 
landscape and stretching our ability to respond effectively. 
Decision makers will need to consider the new challenges 
presented by fentanyl and related substances to stem the rising 
trend in overdoses.
    Thank you and I look forward to your questions.
    [The prepared statement of Mr. Pardo follows:]
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. Thank you very much, Dr. Pardo.
    Dr. Ciccarone.

 STATEMENT OF DANIEL CICCARONE, M.D., PROFESSOR OF FAMILY AND 
  COMMUNITY MEDICINE, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

    Dr. Ciccarone. Chairman Smith, Ranking Member Bass, and 
other distinguished members of this subcommittee, thank you for 
the opportunity to testify before you today.
    I have been a clinician for the past 30 years. I am also an 
academic researcher who has been focused on the public health 
consequences of heroin for the past 20 years. I have been asked 
to speak today on the public health dimensions of the fentanyl 
crisis in America. This is a drug crisis of historic 
proportions. For the first time in two generations, the U.S. 
death rate has gone up 2 years in a row. Driving this is drug 
poisoning deaths.
    Since the beginning of the opioid epidemic, \1/2\ million 
Americans have died from drug poisoning. Annual deaths due to 
drug overdoses now exceed deaths due to gun violence, motor 
vehicle accidents, and even HIV at the height of the 1990s 
epidemic. The leading cause of drug poisoning is due to 
opioids. We are witnessing a triple wave epidemic of overdoses 
from three classes of opioids: Prescription pills followed by 
heroin and now fentanyl. Each wave is crested on top of the one 
before, such that fentanyl deaths now exceed heroin deaths and 
heroin deaths exceed those from opioid pills.
    For a drug epidemic to get to this size it requires both 
forces of supply and demand to create the enormous wave of 
consumption and consequences we are witnessing. Supply forces 
include an iatrogenic source with the tripling of opioid pill 
prescribing. In the second wave a new, unrecognized source of 
technologically advanced heroin from Mexico. And in the third 
wave, a new illicit opioid class, fentanyl, from a new source, 
China.
    We also see demand in play. There are large-scale social 
and economic root causes driving pain pill demand and 
population dependency on opioid pills leading to spillover 
effects, driving heroin and subsequently fentanyl demand. 
Fentanyl is a synthetic opioid and is a well-regarded 
pharmaceutical. It is a highly potent drug, about 80 to 100 
times as potent as morphine by weight.
    The fentanyl we are discussing today is not a diverted 
pharmaceutical. It is illicitly manufactured and clandestinely 
distributed fentanyl. It is part of a chemical family that 
includes a number of analogues some of which are less potent 
than fentanyl, and some like carfentanil have much greater 
potency.
    What is most telling in terms of supply is how regionally 
problematic the fentanyl epidemic is. Drug seizure data and 
overdose data are highest in the Midwest, down to Appalachia, 
over to the Mid-Atlantic, and up to New England. This strong 
regional distribution suggests that a large supply player or 
players are involved.
    The demand side of the equation is complicated. Fentanyl is 
integrated into the illicit drug supply and sold as heroin in 
powder form or as counterfeit pills. Its intentional use is far 
outweighed by non-intentional use. That is, street users of 
illicit opioids are looking for heroin or pills and the 
fentanyl comes along as an unexpected adulterant.
    I have noted in my street-based research the lack of lingo 
or slang for fentanyl. Desired drugs have strong slang for 
them. This supports the notion that this fentanyl wave is 
supply not demand driven. However, there is still a demand 
element. Recall that demand for opioid pills feeds demand both 
directly and indirectly for heroin. Demand for heroin is 
indirectly feeding demand for synthetics as substitute.
    Now onto addressing the fentanyl crisis. Fentanyl 
represents a strong supply shock in the U.S. illicit drug 
market. Thus, it is tempting to focus our efforts on 
controlling supply. The evidence shows that supply side 
interventions can work if part of a comprehensive program that 
includes demand reduction. Unipolar supply side interventions 
may actually cause paradoxical or unwanted results and we may 
have already seen some of this in play in the current crisis.
    Considering source control we need to work, as has been 
mentioned a number of times today, diplomatically with the 
Chinese Government to curtail production and export of 
synthetic opioids. Considering interdiction, this is where it 
gets challenging given the size of the fentanyl flows. 
Fentanyl's potency allows it to be packaged in very small 
quantities. According to the congressional testimony given by 
Richard Baum, former Acting Director of ONDCP, an estimated 668 
kilograms of illicit fentanyl was seized in 2016. This volume 
would fit into approximately three industrial drum barrels. A 
tiny volume that if divided up over the huge Pacific Rim is 
analogous to finding the proverbial needle in the haystack.
    In constraining fentanyl supply we must be cognizant of 
potential balloon effects. There are dozens of known fentanyl 
analogues. It has been calculated that the number of potential 
analogues in this chemical family could exceed 600. We need to 
be careful not to foster the ingenuity and creativity of the 
illicit drug manufacturers to push in even more dangerous 
directions.
    So I have heard today that one of the recommendations for 
that is to regulate the entire class and I would support that. 
One supply side intervention with potential wide impact is drug 
surveillance. There is an opportunity here with the rapidly 
evolving synthetic opioids to improve our surveillance 
techniques so that we can better detect the chemicals, their 
flows, and their mixtures.
    Government officials have called for greater public safety 
and public health collaboration to address this crisis and the 
collection and sharing of this data is one key to that 
collaboration. Surveillance will help us in the low prevalence 
states. I am reminded that one of our subcommittee members is 
from California. In the low prevalence States we need to stay 
ahead of the curve. Drug surveillance will help us with that.
    In addition, we also need to invest heavily in demand 
reduction which would include prevention, medical treatment, 
and harm reduction. Opioid use disorder has a number of 
effective treatment options including opiate agonist therapy. 
Low-barrier programs such as the Blue HART program in New 
Jersey are outstanding and need to be promoted. They also fit 
along with that public safety/public health collaboration.
    We also must consider the benefits of harm reduction 
programs. The Surgeon General has called for greater 
distribution of naloxone, the antidote for opioid overdose. 
Harm reduction programs can aid in the prevention not just of 
overdose, but also in Hepatitis C and HIV transmission. We need 
a crisis-level response. The HIV epidemic of the 1990s provides 
an example of government intervention to curtail a crisis. The 
Ryan White Care Act led to a dramatic increase in funding for 
HIV prevention and treatment and for basic science. That 
fostered medical progress leading to a dramatic decrease in HIV 
incidence and mortality. The same can happen in this crisis.
    Thank you for listening and I look forward to answering any 
questions you have.
    [The prepared statement of Dr. Ciccarone follows:]
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    Mr. Smith. Thank you, Dr. Ciccarone, for your testimony and 
your leadership, all of you. I have a lot of questions but I 
will try to narrow it just because of the lateness of the hour 
because you have been so patient.
    Is there any way, generally speaking, that someone who is 
intent on using heroin, for example, can detect the presence of 
fentanyl? Are many of these deaths inadvertent in the sense 
that they had no idea fentanyl was laced with the heroin that 
they are consuming?
    Mr. Coronato. I mean from my standpoint I will say this, I 
don't think that the user has any idea what they are consuming. 
They think it is heroin. They think it is good heroin. And 
certainly the answer would be I think they have no idea that 
they are taking fentanyl.
    Mr. Smith. Yes, Dr. Pardo?
    Mr. Pardo. No, I definitely agree. The fact that 40 percent 
of cocaine overdose deaths in 2016 included mention of 
synthetic opioids is a shocking statistic. Users are just not 
aware.
    Dr. Ciccarone. Most people are consuming it unknowingly. 
There is some ability to detect it. I have observed, I have 
listened to a lot of users as they consume. There is some sense 
they can detect, it is just clearly not good enough because 
people are still dying.
    Mr. Coronato. And I have one other comment if I can.
    Mr. Smith. Sure.
    Mr. Coronato. It used to be and I used to believe that you 
would go to get your marijuana dealer, you would go to your 
cocaine dealer, and you would go to your heroin dealer. I think 
now the dealers are all encompassing. I think that you go to 
your dealer and they will provide you with marijuana, they will 
provide you with cocaine, they will provide you with meth.
    In that respect I think that you now can see that the 
fentanyl is in the heroin, it is in the meth, it is in the 
cocaine, and, you know, now starting to come into the 
marijuana. So I think the answer is nobody would know that they 
are consuming that and it is what they are looking to do is to 
kind of capture that individual so that, you know, it was a 
unique feeling that they got so this way they would come back. 
It is almost a marketing tool.
    Mr. Smith. We know that some people die from their first 
use of fentanyl. What is the common denominator there in terms 
of the number of times somebody might take it, say, with heroin 
and maybe on the fifth time that is when it takes their life? 
Or is it often the first?
    Mr. Coronato. I will try to answer that. I will tell you 
this. From my opinion, I think very few people take fentanyl 
the second or third time. I think that they aren't used to it. 
I think their body all of a sudden it is so strong it causes a 
reaction. The only difference that may happen is that if they 
take it and they are younger, and I know it sounds crazy but 
there happens to be somebody else present at the time there is 
a possibility that they can call 9-1-1, they can call the 
police, or they may have some Narcan and they may apply it.
    But normally what happens is if they take it and they are 
by themselves, okay, it is not--if it is one, they are going to 
die.
    Mr. Smith. Let me just ask you--oh, did you, Dr. Pardo?
    Mr. Pardo. I mean I would go again to the fact that if an 
individual, if these are entering non-opioid markets that is a 
serious concern. As individuals who are not tolerant of opioids 
coming into contact with fentanyl that presents a huge risk of 
overdose for those non-opioid markets, the methamphetamine and 
cocaine in particular.
    As far as opioid users----
    Dr. Ciccarone. I will agree with Dr. Pardo that if the 
fentanyl is contaminating a non-opiate such as methamphetamine 
or cocaine, the danger looms large for those folks because they 
do not have any tolerance. Among folks that are opioid 
tolerant, and that it would be a daily heroin user, there are a 
couple to several million daily heroin users in this country 
right now who are using fentanyl safely every day. It is a bit 
like Russian roulette because they don't know when the analogue 
is going to change or the purity is going to bump up or there 
is another powerful adulterant in there.
    In our research what we found is that the drug supply, 
because of the mixtures of analogues and because of the 
unevenness of what is going on in the heroin market right now, 
is changing on a daily or weekly basis and those vicissitudes 
are quite likely causing the danger that we are seeing.
    Mr. Smith. As I think all of you know, on August 18th, the 
President at a Cabinet meeting admonished Jeff Sessions to 
really increase significantly the efforts regarding to fentanyl 
and to the opioid crisis. You heard two of our witnesses 
earlier today for the administration speak of things that they 
are doing and I wonder if you could give any insights as to if 
you think we are doing enough.
    There is a bill, H.R. 6 that passed, a comprehensive bill 
pending in the Senate. It does include another bill that had 
passed independently that has stalled in the Senate with 
regards to the ability for the Postal Service to gather more 
information when packages are sent from there to here. But I am 
just wondering if you feel that we are doing enough.
    Some of the answers that they will get back to leaves open, 
I think, some question as to whether or not this is an all-out 
effort. Added to that, I am the prime author of the Trafficking 
Victims Protection Act of 2000. It is our primary landmark law, 
government-wide, domestic and international to combat human 
trafficking. For years, administrations would not put China on 
what we call tier 3, egregious violator for labor and sex 
trafficking. This administration thankfully last year and again 
just a month ago or so did that, 2 months ago, made it very 
clear that they are horrible.
    The Chinese reaction was predictable. It was filled with 
lie and deception because they are not doing anywhere near 
enough to mitigate this modern-day slavery. On international 
religious freedom they do the same thing. They had been 
designated a Country of Particular Concern and I wrote a law on 
that as well, the Frank Wolf International Religious Freedom 
Act. He did the original in 1998 and China gets on that list 
because of their attacks on all faiths from Falun Gong to 
Christians to the Tibetan Buddhists, Muslims, Uyghers to the 
Dalai Lama and Buddhists.
    It is an all-out assault on religion and to hear the 
Chinese Government's response is as if religious freedom 
flourishes within the PRC. So you see time and again in human 
rights abuses there is no candor and which is why in my earlier 
questions to the administration we need to see concrete 
results, how many convictions, where are we really 
collaborating, you know, the DEA and their counterpart in the 
PRC? And added to that--and, Doctor, you might want to speak to 
this.
    There are reports that they are cracking down on meth labs 
because it is taking a terrible toll on Chinese citizens and I 
am glad they are because all human life is absolutely valuable. 
But because fentanyl does not affect Chinese, per se, it is 
affecting Americans primarily, there seems to be a laissez-
faire, if not an enabling response, on the part of the Chinese.
    So the question is, is it time for some asymmetrical--do we 
need to be levying? You try to work with them, be disappointed 
as I am, you know, maybe they will do some things. Putting 
these precursor chemicals on a no-list or a controlled list, 
what does that really mean if there is no enforcement, or 
minimal enforcement that is PR oriented?
    So if you could speak to that because I think, you know, if 
we don't get serious about this and, Mr. Coronato, you talked 
about the next 5 years. This is where the drugs are going, 
synthetic. We are in an epidemic and you had said three waves.
    And, Dr. Pardo, you talked about it being worse than the 
HIV's pandemic and Congress did step up on that both 
domestically and with the President's Emergency Plan for AIDS 
Relief.
    And I am the author--it hasn't passed yet--of a 5-year 
renewal of that tremendous program started by President Bush. 
You know, if don't really attack it and say real resources and, 
if necessary, real penalties levied on the Chinese. They rely 
on exports in all things. That is their economy. They are 
killing Americans. Your thoughts on that?
    Dr. Ciccarone. Well, first, Chairman Smith, thank you for 
your leadership on human trafficking. It has been outstanding 
work and a big success. So, in short, to your first question is 
the Federal Government doing enough, I am sorry to say the 
answer is no. The death rate continues to increase year over 
year without end. We do not foresee how this turns around or 
how this ends.
    We do need a crisis level response. I do believe that 
supply control--I am not an expert here. Supply control does 
have a role. I don't know how they are going to do it with such 
small volumes. But I agree with you that as much pressure 
diplomatic and otherwise on the Chinese Government is 
necessary. They do have responsibility here. They are the main 
source.
    And then I will say the crisis level response has to 
include demand reduction. There are estimates from $60 billion 
to $100 billion are needed just on the demand side. We need to 
make our communities more resilient. As was mentioned earlier, 
I think it was by Representative Bass, we seem to have a decade 
over decade, continuous one drug morphing into another kind of 
problem. The way you address that is by addressing the root 
causes. The root causes are social, psychological and 
spiritual, and probably even economic. We need to kind of 
finally get serious.
    Fentanyl might be the end game in terms of interdiction. We 
may not be able to stop the supply adequately. It is a 600-
analogue family and processes to make these drugs are not that 
complicated. If we stop it in China how do we know it won't go 
to India or to somewhere else in Latin America? And so, multi-
pronged, multilateral approaches and unfortunately the price 
tag will be big. The cost is estimated at $78 billion per year 
in loss of productivity for the current opioid crisis. Seventy-
eight billion dollars. So to address it with $100 billion over 
5, 10 years is not unreasonable.
    Mr. Pardo. I would echo a lot of what Dr. Ciccarone said. 
To add specifically to the point about what the Federal 
Government is doing with regard to China, there were a lot of 
high level engagements with DEA and State with Chinese 
counterparts. Those haven't really happened as of recent so 
fostering high level cooperation would be encouraging.
    Getting China to move more quickly with scheduling would 
also be encouraging. Adopting some sort of reciprocal 
scheduling system has been on the table, but that as far as I 
know has kind of stalled. So getting back to basics here and 
just trying to engage with them, trying to help them really 
improve their own capacity to enforce their own manufacturers 
and really clean house, I think, is key.
    China has recently started to move in the area of 
restructuring its food and drug administration. It has taken 
efforts to increase inspector capacity to focus on this problem 
specifically in addition to all active pharmaceutical 
ingredient manufacturers. So working with our Chinese 
counterparts would be one way of trying to improve our ability 
to seize, detect, and regulate these substances coming out of 
China. I think I will stop with that.
    Mr. Coronato. Well, I would say I don't think that there is 
a magic bullet that is going to solve our problem. I would say 
Chairman Smith that we need to do it all. Look, this epidemic 
is killing our children. It is ripping apart our families and 
our family life. I think that you need to go back to the source 
and the source right now happens to be China.
    And it doesn't necessarily have to come directly from 
China. It could be going through from China to either Mexico to 
China to India to China to Russia and then working its way back 
to the United States. We need to attack that and we need from 
the law enforcement standpoint to hold those people accountable 
for their actions because they are killing our children.
    More importantly, I think that if we are going to look on 
the short term to save lives I think law enforcement has to 
communicate better and work with the healthcare community 
because this is a disease. And we need to treat it as a 
healthcare epidemic that is taking place and we need to treat 
it at the cause to help these people understand that we don't 
need, we need to defer them from the legal system not put them 
through the legal system.
    And we need to be able to take these individuals--again 
that is why we use recovery coaches in New Jersey. We need to 
be able to communicate to get them the help that they need and 
then we need to have a better follow-up or a better tracking 
once they are in that system so we can make sure that they are 
going to complete the system and do it and not fall off the 
wagon after 30 days or 45 days, because quite honestly that is 
when they become more vulnerable.
    To answer the question, they are going to go back and use 
again. They are going to use something that is really more 
powerful and actually what we are doing is killing them. So the 
bottom line for me is that we need to do it all.
    Mr. Smith. Let me ask you, Mr. Coronato, you were the first 
with your Blue HART program in the State of New Jersey to swing 
open the doors of our police departments and say you are 
welcome, we want to help you because this is a disease. I was 
just with Angelo Onofri. They have done that in Mercer County 
now, the prosecutor there, and they finally got the last 
municipality to join in that fight by being on the side of 
disease mitigation and intervention.
    Any of you if you could, what are the other States and 
municipalities doing with regards to this? Is this a model that 
needs legislation and perhaps incentive grants coming out of 
the Federal Government? Is this perhaps a role for some new 
legislation to say let's take what you have done and perhaps 
what others have done, best practices, and get the police--I 
have found every police chief I talk to and every cop, because 
there were a lot of cops at last week's gathering in 
Robinsville, New Jersey with Mayor Fried, are gung-ho on this, 
you know, they want to help. They realize like you said it is a 
disease.
    So I am just wondering, how do we roll this out to the 
country? Does it take legislation? Because we have to get ahead 
of this. Every municipality should have this.
    Mr. Coronato. I think an initiative, a financial initiative 
would make a difference, would make a difference with regard to 
it. I think in New Jersey, again the county prosecutor is the 
chief law enforcement so when I sat with my police chiefs they 
were all on board. Again we were the first county to use 
Narcan. And once the other police departments and the other 
county prosecutors saw how successful we were in using Narcan 
it spread throughout the entire State.
    I think the same thing is happening with Blue HART. I think 
the problem with Blue HART though quite honestly is that you 
need a clinical evaluation that is going to take place. There 
is not enough beds. There is not enough availability. And that 
is why you kind of need to shift it into partnering up with the 
health care to be able to make a better assessment.
    The bottom line is that we need to work cooperatively and 
also what we need to do is work more efficiently. Sometimes it 
is not that we need more money, it just needs--the money needs 
to be put in the right place. I think that really would make a 
difference.
    Mr. Smith. Well, Dr. Ciccarone had said about a crisis 
level response. Would this be part of that crisis level 
response?
    Dr. Ciccarone. Oh yes. I have had the privilege of working 
in my research in a number of hotspot areas including 
Charleston, West Virginia, Baltimore, towns in Massachusetts 
and Chicago, as well as my hometown of San Francisco. There are 
a number of creative initiatives which would be under this 
umbrella of public safety/public health partnerships and I 
really applaud them. I mean I think this idea of diversion 
works, i.e., of recognizing that people have a chronic disease 
that we can enable treatment capture and also work on, you 
know, treatment longevity. However, I don't know of any place 
that if you asked them, do you have enough resources to do what 
you want to do where the answer is yes. They will either say I 
have a labor shortage, I don't have enough docs, or they will 
say I have a financial resource problem where we liked this 
program, but we had to cap it at a certain number of people, 
and there are people knocking on the door but we had to cap it 
because we ran out of money.
    We also need consistent flows of money, and maybe I will 
let Dr. Pardo jump in here because we were talking last night 
about this about how a lot of places are worried that, you 
know, the money is here this year, will it be here next year? 
Do I start a program, how big do I start a program because I 
don't know if I am going to have money in the next fiscal year? 
So, just like businesses in America, they want to know that 
there is some steady trajectory in the U.S. policy regarding 
fill in the blank.
    Mr. Pardo. I mean, yes, to get to that we do know that drug 
addiction is a chronic relapsing disorder so we do need to have 
more sustained Federal funding or funding in general to treat 
and address this. But to get to both of these points, really 
what we need to, given this crisis what we need to be thinking 
about are kind of a broad branch approach to extracting 
individuals from these markets. So whether that is using the 
public safety system to get them into some sort of treatment 
facility or just reviewing regulations and limits on access and 
provision to medication therapies.
    Talking with Dr. Ciccarone last night, the problem that 
some States still have moratoriums on opiate treatment 
provision, the fact that it is difficult for some people to 
access methadone and buprenorphine that puts a serious, it 
really hinders our ability to combat this problem at the 
domestic level.
    Mr. Smith. Now has the administration, DOJ, HHS, any others 
reached out for these kinds of insights that you are providing 
today? I mean they have good people I know around them, but you 
had said, Dr. Ciccarone, that we are not doing enough in 
response to that request for an answer and I appreciate your 
candor. Not doing enough means more dead people. Any thoughts 
that you have for what model legislation might look like we 
would appreciate it, even if it wasn't legislation, executive 
order, something that could be done overnight to further 
mobilize us.
    Mr. Coronato. I would want to add one thing. We have been 
talking about substance abuse the whole day today. But this is 
co-occurring. There is a mental health component of it. And I 
think that if you don't do both, if you don't attack both and 
go both at the mental health and also at the substance abuse 
and attack it at the same time--that is why the clinical 
evaluation is so important. And there is a benefit and there is 
a cost benefit because I will tell you this, the other benefit 
that we had in 2017, we were the only county in the State of 
New Jersey that had a reduced death rate and it was at 20 
percent. It was significant. Not only did my death rate go 
down, but my spray rate went down. We sprayed 35 percent less 
people in Ocean County with Narcan in 2017, so it was a 
correlation.
    Then I went back and took a look. My crime rate went down. 
My larceny rate went down. My shoplifting rate went down. The 
bottom line is, is that there are benefits if we do the job 
right. We are kind of defective in how we handle this and there 
is not a good, what I would call follow-through and not--it has 
to be outcome-based. I am really looking at outcomes. What I 
don't want to do is just recycle these individuals. I want to 
attack the problem and have good outcomes and that what we need 
to hold people accountable for. That is law enforcement.
    Mr. Smith. I did ask the previous panel a couple of times, 
they deferred, what other countries perhaps is this coming 
from, and I asked specifically whether or not India has become 
because they are a major producer of drugs that end up in our 
pharmacies. And I am just wondering if China were to get a 
handle on this does the labs just move and relocate?
    Mr. Pardo. Yes. That is definitely a fear. That is a 
concern. They do have a robust pharmaceutical industry. There 
has been instances where they are producing controlled 
substances for export illicitly. So there are instances where I 
mean it definitely is a concern from a drug policy perspective. 
So thinking about this more holistically we do need to address, 
and getting back to Dr. Ciccarone's point, we need to really 
think about demand reduction as well as getting countries to 
focus on supply side initiatives.
    Mr. Smith. Is there anything else you would like to add?
    Dr. Ciccarone. So just two comments, one is there is 
another major source of illicit fentanyl and that is Estonia 
with Russian connections. I don't think that will affect the 
U.S. market, it is more likely to affect the European market. 
The synthetic, you know, as Mr. Coronato said, the synthetic 
cat is out of the bag, right. The future of illicit drugs is 
going to be increasingly lab-based and less plant-based. We 
need to prepare for that future and understand what the 
chemicals are, what mixtures are coming in, what purities, what 
flows--back to the surveillance suggestion that is in my 
written testimony.
    And then a comprehensive approach that allows not just a 
crisis response now, but a long response. We have been 15 years 
into this epidemic. It will quite likely last another 15 years. 
Drug epidemics do naturally cycle downward, but this is a long 
one. This is big one. This could go on for another almost 
generation if we don't act. If we do act, then we can see the 
curve that we saw with HIV in the 1990s with the Ryan White 
Care Act and technological and scientific medical progress: The 
death rate came plummeting down within a few years.
    The same opportunity exists here. We have three medications 
that work. They need to be expanded. We need to work with 
SAMHSA and other regulatory agencies to allow greater access. 
Right now, docs are limited. They can prescribe. They have a 
certain number of patients that they can have put on 
buprenorphine. Why? I don't know of any other medication that 
limits a doctor's prescribing ability.
    So I agree with you, Chairman Smith, that Congress can take 
leadership here, both in terms of dollars, but also in terms of 
working with the regulatory system, HHS and the subdivisions of 
HHS, to allow them the creative freedom, if you will, to 
explore new options given this crisis, even if they are 
temporary provisions. We don't want to, you know, liberalize 
the rules on buprenorphine forever, but what about a 5-year 
change, you know, so that we can get through this crisis? 
Buprenorphine is a high-benefit, low-risk drug. It has some 
risks. Not zero. No drug, no pharmaceutical we make has zero 
risks. A high-benefit, low-risk drug that is very useful in 
this current crisis.
    Mr. Smith. Would a White House--oh, I am sorry, Dr. Pardo.
    Mr. Pardo. No, I would just to extend onto that we were 
talking last night and the fact that a doctor doesn't need a 
waiver to prescribe fentanyl transdermal patches to treat 
chronic pain but needs a waiver to prescribe buprenorphine to 
treat an individual's addiction problem is a notable problem 
here.
    So thinking about this problem in terms of stock and flow, 
we have a massive stock of individuals who are potentially 
addicted to prescription painkillers. Trying to intervene 
before they enter the illicit market is probably the best way 
to save lives. So getting them to some sort of medication 
therapy before they enter the illicit markets, so expanding 
access to prescription buprenorphine or methadone is one thing 
that Congress should be looking into more aggressively.
    Mr. Coronato. I would agree with my esteemed colleagues, 
but the one thing I would say, and I believe in MAT treatment, 
is that we need best practices, true best practices that can be 
applied by the doctors. And I think that if we were going to go 
in that direction and I would advocate that we go in that 
direction, I really would want to see best practices both for 
methadone, suboxone, and also for Vivitrol as we go through and 
to make sure that the mental health component is being 
adequately addressed and not just a substance abuse.
    Mr. Smith. USAID does great work with infectious diseases, 
but health diplomacy is largely handled by HHS. What is your 
assessment as to how well or poorly how our efforts with WHO, 
PAHO--and I know you have worked with them in the past--other 
organizations like the African Union although this may not be 
an issue there, but it certainly is with PAHO and the OAS and 
of course the U.N. and WHO; are we doing enough there?
    Mr. Pardo. So the State Department was very successful in 
working with international partners to get both major fentanyl 
precursors controlled in 2016. They worked with through the 
traditional channels, the Commission on Narcotic Drugs in 
Vienna. They worked with major pharmaceutical manufacturers in 
these countries to understand, you know, who is producing what.
    So there was a very robust effort to get these precursors 
controlled. And we may be seeing, whether or not we see those 
benefits, it is going to take some time to kind of see whether 
or not those supply-side interventions are working. But it is 
true that the Canadians have controlled these substances. The 
Mexicans have controlled these precursor substances. The 
Chinese as well have started to control these precursor 
substances. So working with our international partners is one 
way to put some of the, you know, put some control measures on 
these firms that are producing these things in kind of these 
gray areas in underregulated industry so to speak.
    Mr. Coronato. And I will make one other comment if I could. 
In the State of New Jersey under Governor Christie and the 
legislature what they did is they limited the amount of 
prescription drugs that you can get right initially. I think 
you can get 5 days' worth of drugs initially. To me, I think if 
you set up a national standard with regard to that because it 
is clear that the pills is what really fueled this both in the 
'90s and the early 2000, I think that the government can come 
back and again regulate the distribution through the 
prescription plans that are being done, basically saying that 
you get 5 days' worth of prescriptions and then you have to go 
back to the doctor and you can monitor it.
    Because the significance between the fifth day and the 
sixth day is tremendous, it is like a 60 or 70 percent 
addiction rate when you go from the fifth day to the sixth day. 
So, and you know that would also be another regulation I think 
that the Federal Government should look at.
    Mr. Smith. Let me just--is there any fear given that China 
has been expert at weaponizing so many things, even locally in 
my hometown of Hamilton Township when we got hit with the 
anthrax crisis that killed a couple of people here in 
Washington, and we had people sickened in Hamilton Township 
Post Office. Weaponized anything can be a very serious danger.
    This is an outlier question, but is there any concern that 
somehow this could be weaponized since it is so highly 
concentrated and so lethal?
    Dr. Ciccarone. The super high potency ones, yes. 
Carfentanil has made it into the news a lot about, you know, 
1,000 next to morphine. There are even more potent by volume 
opioids than carfentanil. There are ones that make carfentanil 
look moderate. And so yes, and they could be aerosolized. Yes 
they could contaminate water supplies. So yes, we definitely 
have fears in that direction.
    Mr. Coronato. Yes, I will add this. We don't do, when we do 
our raids right now we don't do onsite any kind of testing 
because just the fact of either inhaling it possibly as it goes 
airborne, also if you touch or touch something that touched 
fentanyl it gets onto your skin and it actually will be 
absorbed right through your skin. And we have had police 
officers I know in Atlantic City and other parts of the State 
that overdosed on the fact of when they did a raid with regard 
going into.
    So the answer is absolutely, depending on the analogue and 
depending on what you have in there. So, and that was a good 
reason why to be honest with you we weren't using dogs to sniff 
it because the dogs would die. So the bottom line is--that the 
K-9. So it is, it is a project. That it is something that we 
need to look at. It is something that has all kinds of 
ramifications and it is evolving as we speak.
    Mr. Pardo. So two points I think that might--it is true 
that first responders are put at higher risk when engaging with 
this. As far as I am aware it is a concern when touching and 
then touching a mucous membrane, so getting in your eye or 
nose. Transdermally, powdered fentanyl from what I understand 
that risk is overstated. Nonetheless, for postal system 
workers, for police officers it can, it does increase the risk 
of overdose.
    The second point is that there is, there was one event in 
Russia where Chechen terrorists were--yes, are you familiar 
with this? So the Russian Government did use two different 
forms of fentanyl to--they aerosolized it and pumped it into 
this theater to knock everybody out. In doing so they ended up 
killing over 120 people. So it could be, in theory, weaponized. 
Beyond that I have not seen any indication that it has been 
though.
    Dr. Ciccarone. And just to add, DOJ has just come out with 
a letter supporting best practices in protecting law 
enforcement and other first responders with regards to 
fentanyl. A quick read of it, it looks very responsible and 
evidence-based.
    Mr. Coronato. We are pushing it out now because----
    Mr. Smith. Now the Department of Education, do you feel 
they are doing enough to warn our students about this dire 
risk?
    Mr. Coronato. I will just jump on the bandwagon on that. 
That is kind of similar to the tobacco industry, how long it 
took to get in schools. It took like what, 25, 30 years before 
we really addressed the tobacco industry in the schools. And I 
think it needs to be embedded in the curriculum. I think that 
it is something that needs--and it shouldn't be just in the 
fifth grade and just in the eighth grade and just in the 
twelfth grade. For me it needs to be repetitive every single 
year. It needs to understand. It needs to start in the first 
grade, because what we are looking at today with today's social 
media, everything is being driven down further and further into 
the grades at least that for me on the boots on the ground type 
thing.
    So to me, if you ask my opinion we should be starting in 
the first grade and every single grade ever talking about drugs 
and how you don't want to put bad chemicals into your body. You 
need to put good nutriments into your body, not bad things into 
your body. And that is how I would start it off.
    Dr. Ciccarone. So our former ONDCP director, Michael 
Botticelli, who is a recovering user himself, spoke very 
eloquently and has written eloquently about reducing stigma. If 
I was in charge of education of Americans, especially at the 
young level, I would tell them that addiction is just another 
problem that comes up with being human. And that we treat it 
medically, we treat it responsibly, we treat it sensitively and 
humanistically just like we treat diabetes or heart disease or 
cancer, which are the biggest killers of Americans.
    Stigma gets in the way of everything that we do. It gets in 
the way of the patient entering the clinic. It gets in the way 
of them staying in treatment. It gets in the way of average 
Americans all the way up to the highest levels of government in 
doing our best in terms of this problem. It is a barrier. So 
reducing stigma, normalization of chemical dependency is what 
we need to do and then with open arms we get people into care, 
all levels of care.
    The beauty of this notion is that people will come into 
care before they are the long-term, heavy, chronic user. They 
will come and they will say, ``Whoa, what was I doing? I don't 
know, I was just messing around with that stuff for 3 months 
and I want off now.'' And they come and they can get help 
getting off sooner and more effectively. Like any disease, if I 
want to prevent cancer I want to screen for it before it is 
stage 3. Just like heart disease, get someone on a statin when 
the lipid levels are going up, but they haven't had a heart 
attack yet, that is prevention. Reducing stigma get us to lower 
stages of disease and makes prevention work better.
    Mr. Pardo. I would agree with both statements. I can't 
speak specifically to what Department of Education is doing 
with regard to fentanyl, but I would state that drug prevention 
education programs do have their, they do have a place in the 
broader drug policy tool system. However, this crisis is an 
acute crisis. These individuals that are using fentanyl or 
coming into contact with fentanyl on the streets, they are 
already drug users in the system. They are already a high risk, 
so it might not do much to think about educating someone, you 
know, who may pick up a substance 10 years from now.
    We need to figure out how to inform them about the risks in 
the illicit system. So trying to create some sort of 
transparency in those markets, letting them know that, for 
example, police seizures this week are showing high potency 
fentanyl in the markets, letting users know that the toxicity 
of those substances are in those markets might be one way of 
kind of reducing their harm or reducing their exposure to these 
substances in these markets today.
    Mr. Coronato. I am going to say something funny and I don't 
mean to criticize because these guys are great. But I tried 
that and it actually backfired. We used to come out and say, 
wait a minute, don't buy this type of bag of heroin that is 
stamped bud light or whatever it was stamped, and we drove the 
individuals to go and buy it. It was the most incredible sight 
that I have ever seen.
    So we don't say that anymore because if we did we would 
actually market it for the drug dealers because then all of a 
sudden they are all going out looking out for this great stuff 
that is stamped bud light. It is the most--it is the exact 
opposite of what you would think it would be.
    And I will just end up with this. I actually think that we 
all bear a certain amount of responsibility for where we are 
today. And what I mean by that is that when we raise our 
children we always seem to say this is a magic pill that is 
going to help you, that is going to solve your problem that is 
going to get you out of this cold, it is going to get you out 
of this infection.
    And then before you know it, if a kid has a headache and 
they are 3 years old and but wait a minute they weigh 40 pounds 
and you now can take two tablets instead of three tablets 
depending on your weight, we teach our children to self-
medicate and as a result everybody thinks they know their body. 
So they say, you know, this is what it is supposed to do, but I 
know my body, I can tolerate that. And by the time they are in 
their teens and their 20s, they say, you know, I know what I 
can tolerate, what I can't tolerate. I know what my body can 
handle.
    And we all have a hand in this epidemic. That is what I am 
trying to say. So I think that the bottom line is that we need 
to educate our children. I think that we need to be woven into 
the school system because what it is, it is attack on our 
children. It is attack on our family, it is on an attack of way 
of living and unless we get a handle on this we are going to 
suffer the consequences.
    Mr. Smith. I want to thank you. If you have anything 
further you would like to add, your expertise is tremendous and 
I thank you for that on behalf of the committee. We will follow 
up as a committee and me as chairman. You have given us so much 
to digest and convey to different parts of the government 
including the White House and I thank you for that.
    And without any further comments, the hearing is adjourned. 
And I thank you.
    [Whereupon, at 5:18 p.m., the subcommittee was adjourned.]

                                     
                                     

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