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




AN UNSECURE BORDER AND THE OPIOID CRISIS: THE URGENT NEED FOR ACTION TO 
                               SAVE LIVES

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

                             FIELD HEARING

                               before the

                            SUBCOMMITTEE ON
                               BORDER AND
                           MARITIME SECURITY

                                 of the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 30, 2018

                               __________

                           Serial No. 115-67

                               __________

       Printed for the use of the Committee on Homeland Security
                                     

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                  
        Available via the World Wide Web: http://www.govinfo.gov

                               __________



                       
                    U.S. GOVERNMENT PUBLISHING OFFICE
                
32-928PDF                    WASHINGTON: 2018




                     COMMITTEE ON HOMELAND SECURITY

                   Michael T. McCaul, Texas, Chairman
Lamar Smith, Texas                   Bennie G. Thompson, Mississippi
Peter T. King, New York              Sheila Jackson Lee, Texas
Mike Rogers, Alabama                 James R. Langevin, Rhode Island
Lou Barletta, Pennsylvania           Cedric L. Richmond, Louisiana
Scott Perry, Pennsylvania            William R. Keating, Massachusetts
John Katko, New York                 Donald M. Payne, Jr., New Jersey
Will Hurd, Texas                     Filemon Vela, Texas
Martha McSally, Arizona              Bonnie Watson Coleman, New Jersey
John Ratcliffe, Texas                Kathleen M. Rice, New York
Daniel M. Donovan, Jr., New York     J. Luis Correa, California
Mike Gallagher, Wisconsin            Val Butler Demings, Florida
Clay Higgins, Louisiana              Nanette Diaz Barragan, California
Thomas A. Garrett, Jr., Virginia
Brian K. Fitzpatrick, Pennsylvania
Ron Estes, Kansas
Don Bacon, Nebraska
Debbie Lesko, Arizona
                   Brendan P. Shields, Staff Director
                   Steven S. Giaier,  General Counsel
                    Michael S. Twinchek, Chief Clerk
                  Hope Goins, Minority Staff Director
                                 ------                                

              SUBCOMMITTEE ON BORDER AND MARITIME SECURITY

                  Martha McSally, Arizona, Chairwoman
Lamar Smith, Texas                   Filemon Vela, Texas
Mike Rogers, Alabama                 Cedric L. Richmond, Louisiana
Lou Barletta, Pennsylvania           J. Luis Correa, California
Will Hurd, Texas                     Val Butler Demings, Florida
Clay Higgins, Louisiana              Nanette Diaz Barragan, California
Don Bacon, Nebraska                  Bennie G. Thompson, Mississippi 
Michael T. McCaul, Texas (ex             (ex officio)
    officio)
              Paul L. Anstine, Subcommittee Staff Director
    Alison B. Northrop, Minority Subcommittee Staff Director/Counsel
      
      
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

The Honorable Martha McSally, a Representative in Congress From 
  the State of Arizona, and Chairwoman, Subcommittee on Border 
  and Maritime Security:
  Oral Statement.................................................     1
  Prepared Statement.............................................     4
The Honorable Raul Manuel Grijalva, a Representative in Congress 
  From the State of Arizona......................................     6
The Honorable Kyrsten Sinema, a Representative in Congress From 
  the State of Arizona...........................................     7

                               WITNESSES
                                Panel I

Hon. Douglas A. Ducey, Governor, State of Arizona:
  Oral Statement.................................................     8
  Prepared Statement.............................................    10

                                Panel II

Mr. Guadalupe Ramirez, Acting Director of Field Operations, U.S. 
  Customs and Border Protection--Tucson, U.S. Department of 
  Homeland Security:
  Oral Statement.................................................    16
  Prepared Statement.............................................    18
Mr. A. Scott Brown, Special Agent in Charge, Homeland Security 
  Investigations--Phoenix, U.S. Department of Homeland Security:
  Oral Statement.................................................    23
  Prepared Statement.............................................    25
Mr. Douglas W. Coleman, Special Agent in Charge, Phoenix Field 
  Division, Drug Enforcement Agency, U.S. Department of Justice:
  Oral Statement.................................................    30
  Prepared Statement.............................................    32
Mr. Timothy Roemer, Deputy Director, Department of Homeland 
  Security, State of Arizona:
  Oral Statement.................................................    39
  Prepared Statement.............................................    40

                               Panel III

Dr. Cara M. Christ, Director, Department of Health Services, 
  State of Arizona:
  Oral Statement.................................................    53
  Prepared Statement.............................................    55
Dr. Glorinda Segay, Health Director, Division of Health, The 
  Navajo Nation..................................................    65
Ms. Debbie Moak, Co-Founder, NotMyKid:
  Oral Statement.................................................    67
  Prepared Statement.............................................    69
Mr. Jay A. Cory, CEO and President, Phoenix Rescue Mission:
  Oral Statement.................................................    71
  Prepared Statement.............................................    73
Mr. Wayne Warner, Dean of Men, Teen Challenge Christian Life 
  Ranch:
  Oral Statement.................................................    75
  Prepared Statement.............................................    77

                             FOR THE RECORD

The Honorable Raul Manuel Grijalva, a Representative in Congress 
  From the State of Arizona:
  Statement of Anthony M. Reardon, National President, National 
    Treasury Employees Union.....................................    43

                                APPENDIX

Questions From Honorable Kristen Sinema for Douglas A. Ducey.....    87
Questions From Honorable Raul Grijalva for Guadalupe Ramirez.....    88



 
AN UNSECURE BORDER AND THE OPIOID CRISIS: THE URGENT NEED FOR ACTION TO 
                               SAVE LIVES

                              ----------                              


                        Wednesday, May 30, 2018

             U.S. House of Representatives,
                    Committee on Homeland Security,
              Subcommittee on Border and Maritime Security,
                                                       Phoenix, AZ.
    The subcommittee met, pursuant to notice, at 9:30 a.m., at 
Building 2 Virginia G. Piper Auditorium, University of Arizona 
College of Medicine--Phoenix, 550 E. Van Buren Street, Phoenix, 
AZ, Hon. Martha McSally [Chairman of the subcommittee] 
presiding.
    Present: Representative McSally [presiding] and Lesko.
    Also present: Representatives Grijalva, Schweikert, Sinema, 
and Gallego.
    Ms. McSally. The Committee on Homeland Security, 
Subcommittee on Border and Maritime Security, will come to 
order.
    The subcommittee is meeting today to examine the impact an 
unsecure border has on the opioid crisis.
    Before we proceed any further, as Chair I need to make a 
few important announcements.
    It takes a tremendous amount of work putting this hearing 
together, and I appreciate the interest that is shown by the 
number of people who are in attendance today. I would also like 
to thank the University of Arizona for hosting us today and for 
allowing us to use this excellent facility.
    Because this is an official Congressional hearing as 
opposed to a town hall meeting, we must abide by certain rules 
of the Committee on Homeland Security and the House of 
Representatives. I kindly wish to remind our guests today that 
demonstrations from the audience, including applause, verbal 
outbursts, as well as the use of signs or placards, are 
violations of the Rules of the House of Representatives. It is 
important to respect the decorum and the rules of the 
Committee.
    I would also like to remind everybody that photography and 
cameras are limited to accredited press only.
    I also ask unanimous consent that Mr. Schweikert, Ms. 
Lesko, Mr. Grijalva, Ms. Sinema, and Mr. Gallego be allowed to 
sit on the dais and participate in today's hearing. Without 
objection, so ordered.
    I now recognize myself for an opening statement.
    Opioid abuse has become an epidemic across the entire 
Nation, affecting all 50 States.
    One hundred and fifteen Americans die every single day from 
an opioid overdose. These victims come from all walks of life. 
They are teachers, business professionals, ranchers, students, 
Government officials, and retirees. Here in Arizona there have 
been at least 800 lives lost just last year alone.
    Some estimates conclude that more than 2 million of our 
fellow Americans are addicted to opioids. Chances are every 
single one of us knows someone struggling with opioid 
dependence. No State, no neighborhood, no socioeconomic group, 
no family is immune from the destruction and carnage that it 
brings.
    Too many lives have been lost, too many families have been 
destroyed, and communities all over the Nation are asking what 
more can be done to stop this devastating opioid addiction 
epidemic?
    I have called this hearing today to not only highlight the 
crisis but to discuss both law enforcement and non-law 
enforcement solutions that will ultimately save lives.
    Thankfully, this is not a partisan issue.
    I am grateful to see my colleagues here today, both 
Republicans and Democrats, so we can work together to identify 
the challenges and enact solutions to help families in our 
communities.
    Actions to address this crisis will require multiple State, 
Federal, local, and Tribal governments to work together, in 
concert with non-profit entities and the faith-based community.
    No one can go it alone, because this issue will require a 
whole-of-society approach.
    Addiction often begins after powerful opioids are routinely 
prescribed out of a genuine need to manage pain after surgery. 
However, patients quickly become hooked, often unaware of how 
addicting they are.
    In addition, even after the risks were well-known, 
unethical doctors continued to write prescription after 
prescription, becoming pill mills that now sustain the flow of 
opioids to those who are addicted.
    Last year, four of Arizona's top opioid-prescribing doctors 
were located in the sparsely populated Mohave County. Together, 
they wrote prescriptions for nearly 6 million pills over a 12-
month period.
    An unsecure border enables and exacerbates this crisis by 
providing a strong supply of illicit versions.
    Securing the border is more than just stopping illicit 
movement of people and contraband between the ports of entry, 
which is often the focus. But since I have been Chair of this 
subcommittee, I have also focused on modernizing 
infrastructure, technology, and additional manpower at our 
Nation's ports of entry. In fact, my first bill signed into law 
was fast-tracking our veterans for these critical manning 
positions at the ports.
    It is well-known that the overwhelming majority of drugs, 
maybe as high as 90 percent, that enter our country come in 
through the Nation's ports of entry such as the ones in Nogales 
and Douglas. Illicit opiates are no exception.
    Deep concealment within vehicles or in cargo is the 
preferred method of the drug cartels, and they are very 
successful despite the best efforts of the men and women of 
U.S. Customs and Border Protection.
    To ensure the speedy movement of commerce that powers our 
economy, we can only X-ray a fraction of the vehicles and 
trucks that cross the border every day. We need more detection 
equipment and more tools for CBP to effectively combat the 
illicit drug flow hidden in legitimate travel and commerce.
    I am proud to announce that I will be hosting the Secretary 
of Homeland Security, Secretary Nielsen, tomorrow at two of our 
ports of entry, Douglas and Nogales, so that she can see first-
hand the needs that we have at these ports in Arizona.
    I have been a tireless advocate for the expansion and 
modernization of Douglas not just because of its importance to 
economic growth, but because of its importance to security.
    In addition to the challenges at the ports, fentanyl, an 
opioid 100 times stronger than morphine, is being produced 
illicitly in large quantities, chiefly in China, but also 
increasingly in Mexico. The primary smuggling route from China 
into the United States is through our mail system, where 
vulnerabilities in the postal system are exploited.
    In order to mitigate these illicit pathways, we must secure 
the border and strengthen our postal system. In addition, we 
must increase the detection capabilities of law enforcement on 
every level as they respond to this disaster.
    However, this is just one part of the solution. Law 
enforcement and increased border security alone will never be 
enough. We cannot enforce our way out of this problem.
    We must also tackle this crisis with treatment and recovery 
options that help restore individuals to health and break the 
cycle of addiction.
    Educating patients on the risks of taking properly 
prescribed opioids must be standard medical practice. With 
respect to those doctors who unethically prescribe these 
medications, they must be held accountable.
    Most of all, we must support all those who suffer from 
addiction, their families and loved ones, to ensure that they 
get the help they so desperately need.
    I am very proud to say that the State of Arizona has been a 
National leader in addressing these challenges head on.
    Faced with a growing crisis, Governor Ducey declared the 
opioid crisis a public health emergency in June of last year. 
Then the Governor called a 4-day special session of the State 
legislature at the beginning of this year and signed the 
Arizona Opioid Epidemic Act.
    The legislation takes aggressive steps to address opioid 
addiction, hold bad actors accountable, expand access to 
treatment, and provide life-saving resources to first 
responders, law enforcement, and community partners.
    On the Federal level, Congress has been engaged in tackling 
this problem as well.
    Legislation that passed the Homeland Security Committee and 
later became law provided additional fentanyl and synthetic 
opioids detection equipment to the front-line CBP officers in 
the INTERDICT Act.
    Over the last few months, 57 bills that address this public 
health crisis are making their way through the House of 
Representatives. These bills would provide new authority to: 
Spur urgently-needed research on new non-addictive pain 
medications; ensure medical professionals have access to a 
consenting patient's complete health history when making 
treatment decisions; provide resources for hospitals to develop 
protocols for discharging patients who have presented with an 
opioid overdose; establish comprehensive opioid recovery 
centers that will serve as models for comprehensive treatment 
and recovery; and direct the FDA to work with manufacturers to 
establish programs for efficient return or destruction of 
unused opioids.
    The fiscal year 2018 appropriations bill provided over $4 
billion in funding for the development of opioid alternatives, 
grants for States to respond to the challenge, new funds for 
equipment to inspect more incoming mail packages, as well as 
more X-ray devices at the ports of entry.
    This is a complicated and multi-faceted problem. There are 
no quick or easy solutions. I have invited witnesses today who 
deal with this issue from many different angles to testify.
    On the following panels we will hear from law enforcement 
and border security experts, as well as experienced 
professionals from the public sector, those with a family 
member or who were themselves addicted and found the support 
they needed to get and stay clean.
    I look forward to the testimony from our witnesses today as 
we search for solutions to this grave crisis that affects too 
many of our fellow Americans.
    [The statement of Chairwoman McSally follows:]
                 Statement of Chairwoman Martha McSally
                              May 30, 2018
    Opioid abuse has become an epidemic across the entire Nation, 
affecting all 50 States.
    One hundred fifteen Americans die every single day from an opioid 
overdose. These victims come from all walks of life, they are teachers, 
business professionals, ranchers, students, government officials, and 
retirees. And here in Arizona there have been at least 800 lives lost 
just last year alone.
    Some estimates conclude that more than 2 million of our fellow 
Americans are addicted to opioids. Chances are every single one of us 
knows someone struggling with opioid dependence.
    No State, no neighborhood, no socioeconomic group, no family is 
immune from the destruction and carnage that it brings.
    Too many lives have been lost, too many families have been 
destroyed, and communities all over the Nation are asking what more can 
be done to stop this devastating opioid addiction epidemic?
    I have called this hearing today to not only highlight the opioid 
crisis, but to discuss both law enforcement and non-law enforcement 
solutions that will ultimately save lives.
    Thankfully, this is not a partisan issue.
    I am grateful to see my colleagues, both Republicans and Democrats, 
here today so we can work together to identify the challenges and enact 
solutions to help families in our communities.
    Action to address this crisis will require multiple State, Federal, 
local, Tribal governments to work together, in concert with non-profit 
entities and the faith-based community.
    No one can go it alone, because this issue will require a whole-of-
society approach.
    Addiction often begins after powerful opioids are routinely 
prescribed out of a genuine need to manage pain after surgery; however, 
patients quickly become hooked, often unaware of how addicting opioids 
are.
    In addition, even after the risks were well-known, unethical 
doctors continued to write prescription after prescription becoming 
``pill mills'' that sustained the flow of opioids to those who are 
addicted.
    Last year, four of Arizona's top opioid-prescribing doctors were 
located in the sparsely populated Mohave County. Together they wrote 
prescriptions for nearly 6 million pills over a 12-month period.
    An unsecure border enables and exacerbates this crisis by providing 
a strong supply of illicit versions.
    Securing the border is more than just stopping illicit movement of 
people and contraband between the ports of entry. Since I have been 
Chair of this subcommittee, I have also focused on modernized 
infrastructure, technology, and additional manpower at our Nation's 
ports of entry.
    It is well-known that the overwhelming majority of drugs, maybe as 
high as 90 percent, that enter our country come in through the Nation's 
ports of entry such as the ones in Nogales and Douglas.
    Illicit opiates are no exception.
    Deep concealment within vehicles, or in cargo is the preferred 
method of the drug cartels. And they are very successful, despite the 
best efforts of the men and women of U.S. Customs and Border 
Protection.
    To ensure the speedy movement of commerce that powers our economy, 
we can only X-ray a fraction of the vehicles and trucks that cross the 
border every day. We need more detection equipment and more tools for 
CBP to effectively combat the illicit drug flow hidden in legitimate 
travel and commerce.
    I'm proud to announce that I will be hosting Secretary of Homeland 
Security Nielsen tomorrow at two ports of entry--Douglas and Nogales, 
so that she can see first-hand the needs that we have at ports in 
Arizona.
    I have been a tireless advocate for the expansion and modernization 
of the Douglas port of entry because our economic growth and National 
security rely on well-equipped ports.
    In addition to the challenges at ports of entry, Fentanyl, an 
opioid about 100 times stronger than morphine, is being produced 
illicitly in large quantities, chiefly in China, but also increasingly 
in Mexico. The primary smuggling route from China and into the United 
States is through our mail system, where vulnerabilities in the postal 
system are exploited.
    In order to mitigate these illicit pathways, we must secure the 
border and strengthen our postal system. In addition, we must increase 
the detection capabilities of law enforcement, on every level, as they 
respond to this disaster.
    However, this is just one part of the solution. Law enforcement and 
increased border security alone will never be enough.
    We cannot enforce our way out of this problem.
    We must also tackle this crisis with treatment and recovery options 
that help restore individuals to health and break the cycle of 
addiction.
    Educating patients on the risks of taking properly prescribed 
opioids must be standard medical practice. With respect to those 
doctors who unethically prescribe these medications, they must be held 
accountable.
    And most of all, we must support those who suffer from addiction, 
their families, and loved ones--to ensure that they can get the help 
they so desperately need.
    I am very proud to say that the State of Arizona has been a 
National leader in addressing the challenges of opioid abuse head-on.
    Faced with a growing crisis, Governor Ducey declared the opioid 
crisis a public health emergency in June of last year. Then, the 
Governor called a 4-day special session of the State legislature at the 
beginning of this year and signed The Arizona Opioid Epidemic Act.
    The legislation takes aggressive steps to address opioid addiction, 
hold bad actors accountable, expand access to treatment, and provide 
life-saving resources to first responders, law enforcement, and 
community partners.
    On the Federal level, Congress has been engaged in tackling this 
problem as well.
    Legislation that passed in the Homeland Security Committee and 
later became law provided additional fentanyl and synthetic opioids 
detection equipment for front-line CBP officers--the INTERDICT Act.
    Over the last few months 57 bills that address this public health 
crisis are making their way through the House of Representatives. These 
bills would provide new authority to:
    Spur urgently needed research on new non-addictive pain 
medications.
    Ensure medical professionals have access to a consenting patient's 
complete health history when making treatment decisions.
    Provide resources for hospitals to develop protocols for 
discharging patients who have presented with an opioid overdose.
    Establish Comprehensive Opioid Recovery Centers that will serve as 
models for comprehensive treatment and recovery.
    Direct the FDA to work with manufacturers to establish programs for 
efficient return or destruction of unused opioids.
    And the fiscal year 2018 appropriations bill provided over $4 
billion dollars in funding for the development of opioid alternatives, 
grants for States to respond to this challenge, new funds for equipment 
to inspect more incoming mail packages as well as more X-ray devices at 
ports of entry.
    This is a complicated, and multi-faceted problem.
    There are no quick, or easy solutions. I have invited witnesses who 
deal with this issue from many different angles to testify this 
morning.
    On the following panels we will hear from law enforcement and 
border security experts, as well as experienced professionals from the 
public sector, those with a family member or were themselves addicted 
to opioids and found the support they needed to get and stay clean.
    I look forward to the testimony from our witnesses today, as we 
search for solutions to this grave crisis that affects too many of our 
fellow Americans.

    Ms. McSally. The Chair now recognizes the gentleman from 
Arizona, Mr. Grijalva, for any statement you may have.
    Mr. Grijalva. Thank you very much, Madam Chair, and my 
appreciation to all the panelists that are going to give 
testimony today and respond to the questions from my 
colleagues.
    The subcommittee hearing that the Chair stated was 
entitled: ``An Unsecure Border and the Opioid Crisis and the 
Urgent Need for Action to Save Lives.'' Saving lives indeed. 
With a daily death toll of 116 in this country from overdoses 
and increasing addiction and uses of opioids, both prescription 
and illicit, continues to grow in this country.
    The deaths and addictions have shattered lives, shattered 
families, led to more incarcerations, and the economic and 
community losses are dire in not only the State of Arizona but 
across the country. It is tragic here, and it is tragic 
everywhere.
    I believe, as the reason for this hearing, saving lives 
must be the focus.
    I wondered, Madam Chair, why we don't have a top-level 
pharmaceutical CEO here to give testimony as to their role in 
igniting the demand and use of prescription opioids and what 
they are doing to assist us in stemming this demand and this 
use.
    I hope that in this hearing, because the premise is to save 
lives, that we don't politicize the real crisis with fanciful 
demands and proclamations about walls that cost $30 billion, 
about maximum sentencing as a deterrent, including the death 
penalty, as was mentioned by the Attorney General, and spending 
all the time in this hearing blaming immigrants and 
undocumented people, including moms of children, as the cause 
for this crisis. I think leaving that rhetorical political 
posturing aside, it would be important to talk honestly and 
realistically about the demand and use, cause and prevention, 
and treatment.
    The ports of entry where over 80 percent of seizures of 
opioids have occurred have been historically underfunded in 
terms of personnel, understaffed, with less than the optimum 
technology and infrastructure, as was outlined by the Chair, 
that is needed in that border.
    Bipartisan letters have gone to Homeland Security, to this 
administration, by both senators and a bipartisan group of 
Congressmen from Arizona time and time again to ask for 
additional resources to deal with the people in blue with the 
same emphasis that we are dealing with Border Patrol and ICE. 
Since 57 percent of the seizures in this country occur between 
San Diego and Tucson, it would only seem logical that that 
should be a focus.
    I think we need a strategy that provides a singular focus 
on this issue, a strategy to deal with the organized and 
wealthy crime syndicates whose market is the United States of 
America, where 5 percent of the population consumes over 80 
percent of the opioids, be it prescription or illegal.
    Yes, saving lives hopefully is what this hearing is about. 
Securing the border with fanciful proclamations is not going to 
deal with this issue. If we are going to save lives, it is 
going to require hard work, it is going to require cooperation 
across lines and across political parties. I prefer to do that 
hard work.
    At this point, Madam Chair, with the remaining time, I 
would yield to my colleague, Congresswoman Sinema, for the time 
left on my opening statement.
    Ms. Sinema. Thank you, Congressman Grijalva, for yielding a 
moment of time. Thank you to Chairwoman McSally for holding 
this field hearing.
    Like all Arizonans, we share a commitment to a more secure 
border and to addressing the opiate crisis. Washington needs to 
get serious about taking action. In the past year, more than 
8,000 Arizonans overdosed on opiates. Over 1,200 of those lives 
couldn't be saved.
    Congresswoman McSally, we have worked together to help stop 
the flow of dangerous drugs into our communities. We have 
offered three bills together to identify the greatest threats 
to Arizona's border, improved deployment of new border 
technologies, and prevent spotters who facilitate illegal 
crossings. We have also worked across the aisle to support and 
pass the recent Government funding bill which invests billions 
in border security resources, including counter-drug missions, 
and in treatment, prevention, and law enforcement efforts 
targeting the opiate crisis.
    It is important that we put politics aside so we can 
protect and help Arizona communities and families. Our work 
should support work at the State level to win this fight.
    Recently I co-introduced the COMPASS Act with Republican 
Congressman Roskam to help doctors cut down on over-prescribing 
and to help Arizonans better manage their medications. My 
bipartisan bill, which is expected on the House floor in June, 
reinforces the great work done by Governor Ducey and the State 
legislature through the Arizona Opiate Epidemic Act. I look 
forward to continuing to work with everyone here today to 
protect our communities, secure our border, and address the 
opiate crisis.
    Thank you, and I yield back.
    Ms. McSally. The gentle lady yields back.
    Does the gentleman yield back?
    Mr. Grijalva. I yield back.
    Ms. McSally. We are honored on our first panel today to 
have Governor Ducey. Governor Doug Ducey became the Governor of 
Arizona in January 2015. Previously he served as Arizona's 32nd 
State treasurer, a position he held since his appointment in 
January 2011. Mr. Ducey, Governor Ducey joined Proctor and 
Gamble and began a career in sales and marketing. Then he was 
trained in management, preparing him for his role as a partner 
and CEO of Cold Stone Creamery. Governor Ducey also served as 
the Chairman of Arizona's State Board of Investment and State 
Loans Commission.
    I now recognize Governor Ducey to testify.

 STATEMENT OF HON. DOUGLAS A. DUCEY, GOVERNOR, STATE OF ARIZONA

    Governor Ducey. Chairwoman McSally, Congressman Grijalva, 
distinguished Members of the subcommittee, and other Members in 
attendance, thank you for this opportunity to appear before you 
to discuss one of the most significant public health and safety 
emergencies our Nation and the State of Arizona has faced in a 
generation, the opioid crisis and the interrelated priority of 
securing our Nation's borders.
    Let's start with the need to secure the border.
    From the earliest days in my administration, I have had the 
opportunity to spend time with Arizona's border sheriffs and 
numerous everyday residents, citizens, and ranchers in our 
border communities. The concerns they have expressed for their 
safety and security are real, and it is our job to listen and 
take action.
    I am grateful for the strong partnerships our State has 
with local law enforcement, and we have established these as 
well with the U.S. Department of Homeland Security over these 
many years.
    In 2015, Secretary of Homeland Security Jeh Johnson was in 
town helping to coordinate security efforts for the Super Bowl. 
We had such great success working together that I thought, why 
can't we continue this type of collaboration to also secure our 
border?
    Working with that cooperative spirit in partnership with 
the Department of Homeland Security, in 2015 we established the 
Arizona Border Strike Force. This intra-agency team has, 
without a doubt, made Arizona and our entire country safer.
    One example of many large-scale efforts by the Border 
Strike Force is Operation Organ Grinder, which resulted in the 
seizure of more than 4,000 pounds of marijuana and the arrest 
of 73 felons.
    To date, the Border Strike Force has kept 15.3 million hits 
of heroin off our streets.
    It is not just drugs. What began as a traffic stop in 
Cochise County led to the discovery of a juvenile runaway who 
was the victim of horrific sex trafficking crimes. The primary 
suspect was sentenced to 20 years in prison and will face a 
lifetime of supervised probation and sex offender registration.
    We are grateful that the new administration has amplified 
these efforts even further. President Trump's deployment of the 
National Guard has brought additional boots on the ground to 
our border. They are needed and they are welcomed.
    Both General John Kelly and current DHS Secretary Kirstjen 
Nielsen have not only visited our State to tour the border with 
me, but they have delivered on both support and resources. They 
are finally making Washington, DC listen. After recently 
visiting all four of our border counties, I can tell you that 
the residents in these communities could not be more grateful.
    When it comes to the opioid epidemic, overdoses and deaths 
have indeed reached crisis levels. Last year alone, 800 Arizona 
moms, dads, brothers, sisters, family members, and friends were 
claimed by this scourge. This is why we are all here today, 
from across the State and from both political parties, because 
we have all seen the consequences, and we all know this is not 
a partisan issue.
    The collaborative process under which our plan was 
developed, with stakeholders from across the State, and the way 
Democrats and Republicans came together to pass it unanimously 
is an example to our Nation of what can be accomplished when we 
do put politics aside.
    The public health state of emergency I declared last June 
began a process of collaboration between the Arizona Department 
of Health Services, law enforcement, hospitals, medical 
professionals, addiction specialists, and other community 
stakeholders to fight this crisis head on.
    The declaration allowed us to collect information on opioid 
overdoses, deaths, cases of newborns experiencing withdrawal 
from opioids, and naloxone use on a 24-hour basis, something no 
other State has done.
    From there, our Department of Health Services worked to 
analyze the data and identify solutions focused on prevention 
and treatment.
    For Arizonans dealing with chronic pain and participating 
in a responsible treatment plan, we know how critical these 
medications are. So we made sure that they were involved every 
step of the way, too.
    During a special session last January, we addressed every 
facet of this fight, from the need to protect Good Samaritans 
and end pill mills, right down to the physical packaging of the 
drugs themselves. In fact, all opioid prescription bottles in 
our State will now have red caps to alert patients to the high 
risk of these drugs and the need to keep them away from 
children.
    One of our most significant accomplishments was a result of 
bipartisan collaboration to improve access to treatment with a 
$10 million investment that will help uninsured and 
underinsured people get the treatment they need.
    Since declaring a State of emergency last June, we have 
come a long way. In fact, every directive I gave in that 
declaration has been completed.
    New reporting and information-sharing procedures are now 
codified in policy and rule.
    Almost 1,000 law enforcement officers State-wide have been 
trained to provide naloxone. We have also seen a 355 percent 
increase in the number of naloxone doses dispensed by 
pharmacists to communities.
    Our health care institutions now have rules for opioid 
prescribing and treatment.
    Arizona Opioid Prescribing Guidelines have been updated and 
distributed.
    Our comprehensive Opioid Epidemic Act went into effect in 
Arizona on April 26.
    The 12 recommendations of our Opioid Action Plan will be 
fully implemented by the end of June.
    With these items completed, our emergency declaration has 
served its purpose.
    That is not all the positive news we have to report.
    March and April 2018 saw a 33 percent reduction in the 
number of opioid prescriptions State-wide compared to March and 
April 2017.
    Since last June, we have seen a 38 percent increase in the 
number of people referred to behavioral health treatment from 
hospitals after an overdose.
    Since July 2017, we have seen a 60 percent reduction in the 
number of patients potentially doctor shopping through our 
CSPMP threshold report.
    Since this April, over 200 prescribers have utilized our 
newly-established Opioid Assistance and Referral Line to get 
expert advice on treating patients.
    In addition, we have worked with 100 percent of Arizona's 
academic partners who train prescribers to develop a State-wide 
curriculum on opioid prescribing, treatment of opioid use 
disorder, and management of chronic pain. This could be 
implemented in our schools as early as this coming fall.
    We have certainly made progress, but we know that this 
fight remains deadly and that it is far from over. Continuing 
to work with each other and across the aisle as we have done, I 
know this is a fight we can win.
    Again, thank you for having me here today.
    [The prepared statement of Governor Ducey follows:]
                 Prepared Statement of Douglas A. Ducey
                              May 30, 2018
    Chairwoman McSally, Congressman Grijalva, distinguished Members of 
the subcommittee, and other Members in attendance, thank you for this 
opportunity to appear before you to discuss one of the most significant 
public health and safety emergencies our Nation and the State of 
Arizona has faced in a generation--the opioid crisis and the 
interrelated priority of securing our Nation's borders.
    Let's start with the need to secure the border.
    From the earliest days in my administration, I've had the 
opportunity to spend time with Arizona's border sheriffs along with 
numerous everyday residents, citizens, and ranchers in our border 
communities.
    The concerns they have expressed for their safety and security are 
real and it's our job to listen and take action.
    I am grateful for the strong partnerships our State and local law 
enforcement have established with the U.S. Department of Homeland 
Security over many years.
    In 2015, former Secretary of Homeland Security Jeh Johnson was in 
town helping coordinate security efforts for the Super Bowl. We had 
such great success working together that I thought, ``Why can't we 
continue this type of collaboration to secure the border?''
    Working with that cooperative spirit, in partnership with the 
Department of Homeland Security, in 2015 we established the Arizona 
Border Strike Force.
    This intra-agency team has without a doubt made Arizona and our 
entire country safer. One example of many large-scale efforts by the 
Border Strike Force is Operation Organ Grinder which resulted in the 
seizure of more than 4,000 pounds of marijuana and the arrest of 73 
felons.
    To date, the Border Strike Force has kept 15.3 hits of heroin off 
our streets.
    And it's not just drugs. What began as a traffic stop in Cochise 
County led to the discovery of a juvenile run-away who was the victim 
of horrific sex trafficking crimes.
    The primary suspect was sentenced to 20 years in prison and will 
face a lifetime of supervised probation and sex-offender registration.
    We are grateful that the new administration has amplified these 
efforts even further. President Trump's deployment of the National 
Guard has brought additional boots on the ground to our border--they 
are needed and welcomed. And both General John Kelly and Current DHS 
Secretary Kirstjen Nielsen have not only visited our State to tour the 
border with me, but they have delivered on support and resources.
    They are finally making Washington, DC. listen. And after recently 
visiting all four of our border counties--I can tell you: The residents 
in these communities could not be more grateful.
    When it comes to the opioid epidemic, overdoses and deaths have 
indeed reached crisis levels.
    Last year alone, 800 Arizona moms, dads, brothers, sisters, family 
members, and friends were claimed by this scourge.
    It's why we are all here today. From across the State, and from 
both political parties--because we've all seen the consequences, and we 
all know this is not a partisan issue.
    The collaborative process under which our plan was developed, with 
stakeholders from across the State, and the way Democrats and 
Republicans came together to pass it unanimously, is an example to our 
Nation of what can be accomplished when we put politics aside.
    The Public Health State of Emergency I declared last June began a 
process of collaboration between the Arizona Department of Health 
Services, law enforcement, hospitals, medical professionals, addiction 
specialists, and other community stakeholders to fight this crisis 
head-on.
    The declaration allowed us to collect information on opioid 
overdoses, deaths, cases of newborns experiencing withdrawal from 
opioids, and naloxone use on a 24-hour basis--something no other State 
has done.
    From there, our Department of Health Services worked to analyze the 
data and identify solutions focused on prevention and treatment.
    For Arizonans dealing with chronic pain and participating in a 
responsible treatment plan, we know how critical these medications are. 
So we made sure that they were involved every step of the way too.
    During a special session this January, we addressed every facet of 
this fight, from the need to protect Good Samaritans and end pill 
mills, right down to the physical packaging of the drugs themselves.
    In fact, all opioid prescription bottles in our State will now have 
red caps to alert patients to the high-risk of these drugs and the need 
to keep them away from children.
    One of our most significant accomplishments was a result of 
bipartisan collaboration to improve access to treatment with a 10 
million dollar investment that will help uninsured and underinsured 
people get the treatment they need.
    Since declaring a State of Emergency last June, we've come a long 
way. In fact every directive I gave in that declaration has been 
completed:
   New reporting and information-sharing procedures are now 
        codified in policy and rule.
   Almost 1,000 law enforcement officers State-wide have been 
        trained to provide naloxone. We have also seen a 355 percent 
        increase in the number of naloxone doses dispensed by 
        pharmacists to communities.
   Our health care institutions now have rules for opioid 
        prescribing and treatment.
   Arizona Opioid Prescribing Guidelines have been updated and 
        distributed.
   Our comprehensive Arizona Opioid Epidemic Act went into 
        effect on April 26.
   And the 12 recommendations of our Opioid Action Plan will be 
        fully implemented by the end of June.
    With these items completed, our Emergency Declaration has served 
its purpose.
    And that's not all the positive news we have to report:
   March and April 2018 saw a 33 percent reduction in the 
        number of opioid prescriptions State-wide compared to March and 
        April 2017.
   Since last June, we have seen a 38 percent increase in the 
        number of people referred to behavioral health treatment from 
        hospitals after an overdose.
   Since July 2017, we have seen a 60 percent reduction in the 
        number of patients potentially doctor shopping through our 
        CSPMP threshold report.
   And since this April, over 200 prescribers have utilized our 
        newly-established Opioid Assistance and Referral Line to get 
        expert advice on treating patients.
   In addition, we have worked with 100 percent of Arizona 
        academic partners who train prescribers to develop a State-wide 
        curriculum on opioid prescribing, treatment of opioid use 
        disorder, and management of chronic pain. This could be 
        implemented in our schools as early as this coming fall.
    We have certainly made progress, but we know that this fight 
remains deadly and that it is far from over. Continuing to work with 
each other, and across the aisle as we have done, I know this is a 
fight we can win.
    Thank you again for having me today.

    Ms. McSally. Thanks, Governor Ducey. I really appreciate 
it. I understand you have a hard stop in just a few minutes, 
but you are willing to graciously take some of our questions. 
In order to be mindful of your schedule, we will reduce the 
time that each member has to 2 minutes. That means short 
questions and allowing the time for answers.
    You have taken bold action here in Arizona. We appropriated 
$4 billion this year at the Federal level. What else can the 
Federal Government do in order to support your efforts in 
Arizona?
    Governor Ducey. I am proud of the efforts that we were able 
to take in the State of Arizona on a bipartisan level in terms 
of urgency and action and thoughtfulness and thoroughness on 
the opioid epidemic. I do think a wide open and unprotected 
border is a reality in this State, and law enforcement efforts 
in coordination, along with health care professionals and 
prescribers who understand this epidemic and the scourge that 
we are fighting in the State, will help us continue to improve 
not only for Arizona but for the rest of the United States, 
which is where many of these drugs are transported through our 
State, unfortunately.
    Ms. McSally. Great. Thanks.
    I am going to yield back for time.
    The Chair now recognizes the acting Ranking Member, Mr. 
Grijalva.
    Mr. Grijalva. Thank you very much.
    Thank you, Mr. Governor, for being here, appreciate it very 
much.
    The point of security that you made, and I noted in my 
opening statement that the overwhelming majority of seizures of 
opioids entering this country illegally happen at the ports of 
entry. There has been a persistent issue, especially in Tucson 
and the other ports of entry, a persistent issue of 
understaffing, a persistent issue of infrastructure and 
technology not being up-to-date, efforts time and time again.
    As part of the security umbrella that you mentioned in your 
talk, where do you see ports of entry in this fight?
    Governor Ducey. Mr. Grijalva, I agree with you. I think 
this is an all-of-the-above solution that we need to bring to 
this. So it is not only the ports of entry and the brave men 
and women who wear the blue shirts in our Federal Government, 
it is also the border agents and the people that wear the green 
shirts.
    You are talking about the amount of drugs that are seized 
at the ports of entry, and that is a fact. But what we don't 
know are about the drugs that are not seized and that are 
getting to our cities and streets and high schools across the 
country. Those are ones that are somehow either evading the 
technology that is at the ports of entry, or it is coming 
through the border.
    So I would be for an all-of-the-above approach in terms of 
law enforcement.
    Mr. Grijalva. I yield back, Madam Chair.
    Ms. McSally. The gentleman yields back.
    The Chair now recognizes Mr. Schweikert for 2 minutes.
    Mr. Schweikert. Governor Ducey, I always have to break the 
habit of not calling you Doug.
    Look, your office has always been incredibly good reaching 
out to ours when we are working on the reimbursements, the 
mechanisms, the prior authorization, and we appreciate that 
because it is complicated, and for a lot of us here, my hunger 
is for a holistic approach. Yes, there is a problem on the 
border. Yes, there is a health care problem. There is a problem 
with the mail. How do we get our heads around something that is 
this complicated?
    You said something that both brings me joy but I would love 
to understand. You were saying that in the beginning of this 
year, in a couple of those months, you were seeing almost a 
one-third fall. I know a couple of months is really hard to get 
data from, but do you have a perception of what are we doing 
right to actually create that one-third fall, and how do we do 
more of it?
    Governor Ducey. Thank you, Mr. Schweikert.
    Mr. Schweikert. You can call me David.
    Governor Ducey. The same temptation, David.
    I think this idea of our State legislature taking action on 
this, the people that you will hear after me who will provide 
testimony focusing on this epidemic, and understanding that 
these drugs, for someone who is in chronic pain, these can be a 
miracle solution. But the way that they were being distributed, 
the way that they were being sold, the way that they were being 
prescribed provided a tremendous problem in our State.
    One thing I want to give credit to is to Secretary Jeh 
Johnson, because it was that cooperation that we saw when 
Arizona hosted the Super Bowl in 2015 that we could work 
together in partnership with the Federal Department of Homeland 
Security, and I want to credit President Trump and Secretary 
Nielsen, who is working with Colonel Frank Milstead, our border 
sheriffs and sheriffs across the State, along with local law 
enforcement.
    I do think this is a holistic solution that we have to come 
at from a standpoint of not only the rule of law, but then the 
best medical practices in how we handle these prescription 
drugs, and other drugs. I know that fentanyl was mentioned. The 
rise and spike in heroin is a result of this opioid epidemic.
    So this is an all-hands-on-deck. It is not just for border 
States, because it may be border States where these drugs come 
through, but they are being distributed all across our Nation.
    Mr. Schweikert. Governor, forgive me. It is the tyranny of 
the clock.
    I yield back.
    Ms. McSally. The gentleman's time has expired.
    The Chair now recognizes Ms. Sinema for 2 minutes.
    Ms. Sinema. Thank you.
    Governor Ducey, as you know, Medicaid ensures access to 
treatment and recovery services for 4 in 10 adults suffering 
from opioid addiction in Arizona. It is one of the reasons I 
voted against bills that threaten Medicaid benefits that more 
than 400,000 Arizonans count on via our AHCCCS program.
    Could you tell us about the role that AHCCCS plays in your 
State-wide plan to ensure that Arizonans have access to the 
services and treatment that they need?
    Governor Ducey. Thank you, Ms. Sinema. Of course, AHCCCS in 
Arizona is a safety net for those that need it most and the 
most vulnerable, but it is not just about Medicaid. As I 
mentioned, we added $10 million to help those that the 
Affordable Care Act left behind, those that were uninsured or 
underinsured; also with providing dollars for those that need 
health care inside of our prisons.
    I am concerned with what is happening with the Affordable 
Care Act from the standpoint of providers that are in the State 
of Arizona. If we were to go back a decade ago, we would have 
had 24 providers available in our 15 counties. Today we have 
one provider available in 14 of our 15 counties. So this is 
something that I will challenge Congress to act on. It is 
something that as a Governor and as an AHCCCS department and a 
department of health services, we will be a partner in 
reforming what is necessary for access to affordable and 
accessible health care in Arizona.
    Ms. Sinema. Thank you.
    Ms. McSally. The gentle lady yields back.
    The Chair now recognizes Ms. Lesko for 2 minutes.
    Ms. Lesko. Thank you, Madam Chair.
    Thank you, Governor Ducey. I had the privilege of serving 
with the Governor while I was in the State legislature, and I 
was on the health committee, so we actually got to listen to 
testimony on this very important issue of opiate addiction. I 
applaud you and the State legislature for your work on this. It 
is very important, a very devastating problem in Arizona and 
throughout our country.
    I know that, if my memory serves me correctly, in the 
Senate Health Committee, one of the things that we did in the 
legislature and that you promoted was having pharmacists check 
a registry of sorts to make sure that the patient wasn't 
getting over-prescribed with opiates. I think, if I remember, 
it was a balancing act of not over-regulating pharmacists and 
doctors and that type of thing.
    Can you update us on what transpired on that and what the 
success has been with that program?
    Governor Ducey. Sure. Thank you, Ms. Lesko. We miss you 
very much in the Arizona State legislature, but Arizona's loss 
has been our United States Congress' gain.
    This focus on the use of technology has reduced doctor 
shopping. This was what was happening oftentimes with people 
that were addicted, and this is a different type of drug 
because it is found behind the pharmacy window.
    The addition of the red caps that are there so that people 
understand that this is a medicine to be taken seriously, 
should not be available to children or left in medicine 
cabinets. I think while it has only been a few months, the 
trend is incredibly positive, and it is a result of these 
actions.
    You will also have some experts that will follow me--
Director Cara Christ, Debbie Moak--that helped put these 
regulations in place that would allow us to provide the best 
possible health care, but to protect Arizonans' health and 
safety. To lose 800 Arizonans in the last 16 months, those were 
avoidable deaths, far too many. Then Tim Roemer will also be 
testifying from a law enforcement perspective, and I do think 
it is that partnership of health care and law enforcement that 
can best address this epidemic to our country.
    Ms. Sinema. Thank you.
    I yield back.
    Ms. McSally. The gentle lady's time has expired.
    The Chair now recognizes Mr. Gallego for 2 minutes.
    Mr. Gallego. Thank you, Madam Chair.
    Governor, it is good to see you again.
    Definitely one of my proudest moments was working with 
Governor Brewer and other Republicans to pass Medicaid 
expansion, something that I think has been beneficial to this 
State, especially our critical care hospitals in urban areas, 
as well as our rural areas, which also are being harder hit 
when it comes to the opioid epidemic.
    What we have heard so far is that we need a whole 
Government approach to this. But at the same time, the actions 
of the Arizona government and some of your proposals are 
actually to diminish Medicaid expansion and try to get people 
off Medicaid when we just heard that many of them actually end 
up using Medicaid to deal with their addiction.
    So what I am kind of trying to bring together is how can we 
fight opioid addiction, how can Arizona take it seriously while 
at the same time we are taking efforts to gut Medicaid?
    I will give you a good example. One of the efforts that you 
are pushing is to deal with the retrospective Medicaid 
eligibility, RME, specifically if you are Medicaid-eligible and 
you go to a hospital, that hospital will not only treat you 
that day, make you Medicaid-eligible, you go back 3 months 
beyond that to actually be able to bring in funds for any type 
of fees that you incurred in the hospital, which is very 
important, as you know, for a lot of these rural hospitals. But 
under your proposal, you have actually asked to get rid of 
that.
    So how are you balancing this out? Make me understand, if 
we are really serious about the opioid addiction on the 
enforcement side, how come we aren't actually dealing with it 
on the Medicaid side? Bring this all together.
    Governor Ducey. Well, I don't think these two issues are 
mutually exclusive. I think when you talk about the reform of 
Medicaid, I have been outspoken that I don't want to see any 
Arizonan have the rug pulled out from underneath them.
    Now, I expressed the very real issue that we only have one 
provider in 14 of our 15 counties in the State of Arizona.
    Mr. Gallego. That is ACA. Medicaid has nothing to do with 
that. Medicaid is separate from ACA.
    Governor Ducey. When we are trying to move people off of 
Medicaid into work and private insurance, I think that is a 
preferable structure when it can be done. We have had a growing 
economy here in the State of Arizona, so we have tried to put 
policies forward that would incent people to take employment so 
that they could have private insurance, and we will continue to 
do that.
    Ms. McSally. The gentleman's time has expired.
    Mr. Gallego. Thank you.
    Ms. McSally. I thank the Governor for his testimony and the 
Members for their questions. The Members of the committee may 
have some additional questions for the witnesses. We would ask 
that you respond to these in writing.
    With that, I will dismiss this first panel.
    We will quickly take a recess. I request the Clerk prepare 
the witness table for the second panel.
    [Recess.]
    Ms. McSally. Our first witness is Mr. Guadalupe Ramirez, 
who is the acting director of field operations for U.S. Customs 
and Border Protection in the Tucson Field Office. Previously he 
served as the assistant director of field operations trade, and 
oversaw cargo and agricultural operations within the Tucson 
Field Office. The Tucson Field Office annually collects $30 
million in revenues and processes 380,000 commercial trucks 
that transport $20 billion in trade.
    Scott Brown is a special agent in charge of Homeland 
Security Investigations, or HSI, in Arizona. Mr. Brown has 
oversight of the full spectrum of Immigration and Customs 
Enforcement, or ICE, investigative activities in the State of 
Arizona. He has more than 500 personnel assigned to offices in 
Phoenix, Tucson, Douglas, Nogales, Yuma, Costa Grande, and 
Flagstaff.
    Doug Coleman is the special agent in charge of the DEA's 
Phoenix Field Division. In this position, Special Agent Coleman 
is responsible for the leadership and management of all DEA 
operations in the State of Arizona. A 27-year veteran of the 
DEA, Special Agent Coleman began his law enforcement career in 
1988.
    Mr. Tim Roemer--did I pronounce that correctly? Tim Roemer 
currently serves as the State of Arizona's deputy director of 
homeland security and is Governor Ducey's public safety policy 
advisor. Prior to joining Arizona Department of Homeland 
Security, Mr. Roemer served in the Central Intelligence Agency 
for over 10 years.
    I now recognize Director Ramirez to testify.

   STATEMENT OF GUADALUPE RAMIREZ, ACTING DIRECTOR OF FIELD 
 OPERATIONS, U.S. CUSTOMS AND BORDER PROTECTION--TUCSON, U.S. 
                DEPARTMENT OF HOMELAND SECURITY

    Mr. Ramirez. Thank you, Chairwoman McSally, Ranking Member 
Grijalva, and distinguished Members of the----
    Ms. McSally. Can you pull the microphone a little closer so 
we can hear? Thank you.
    Mr. Ramirez. How about there?
    Ms. McSally. Thank you.
    Mr. Ramirez. Chairwoman McSally, Ranking Member Grijalva, 
and distinguished Members, thank you for the opportunity to 
appear today and discuss the role of U.S. Customs and Border 
Protection, CBP, in combatting the flow of illicit opioids, 
including synthetic opioids such as fentanyl, into the United 
States.
    My name is Guadalupe Ramirez. I am the acting director of 
field operations for CBP's Office of Field Operations in 
Tucson.
    Since I began my career in Government in 1985, I have 
worked to facilitate legitimate trade and travel and protect 
our borders. In my more than 30 years of Federal service, I 
have seen a great deal of change. I began serving in the Tucson 
Field Office in 2009. Since then, I have seen a marked increase 
in the volume and potency of drugs interdicted at the ports of 
entry by CBP. I have seen interdictions of heroin, 
methamphetamine, and fentanyl increase dramatically; 357 
percent more heroin was seized in the Tucson Field Office ports 
in 2017 than in fiscal year 2009. The number of heroin seizures 
has increased five-fold since 2009.
    In fiscal year 2009, there were 23 heroin seizures at the 
Arizona ports, averaging 8.3 pounds each. In fiscal year 2017, 
there were 114 heroin seizures, averaging 10.1 pounds each. 
Today, heroin seizures are currently 28 percent ahead of last 
year's pace. Seizures of fentanyl in 1 year increased 458 
percent from 2016 to 2017.
    In the land border environment, my area of experience, 
smugglers use a wide variety of tactics and techniques to 
conceal drugs. CBP officers regularly find drugs taped to 
individuals' bodies, hidden inside vehicle seats, gas tanks, 
tires, dashboards, as well as commingled in commercial 
shipments and concealed in commercial conveyances.
    Seizures like these often involve the use of technology, 
canines, or both. CBP officers utilize non-intrusive inspection 
equipment, NII, including Z-Portal, high-energy mobile, and 
gamma ray imaging systems to detect the illegal transit of 
synthetic drugs hidden in passenger vehicles, cargo containers, 
and other conveyances entering the United States.
    Canine operations are also an invaluable component of CBP's 
counter-narcotics operations. For example, on May 1, 2018, a 
CBP narcotics detection canine at Nogales, Arizona port of 
entry alerted officers to almost 11 pounds of heroin wrapped 
around the mid-section of an individual entering the United 
States. The heroin had an estimated street value in excess of 
$188,000. Officers seized the drugs and turned the arrested 
subject over to Homeland Security Investigations.
    We are also actively engaging with our Federal, State, 
local, Tribal, and international partners to streamline our 
counter-narcotics efforts. Tucson Field Office is actively 
engaged with the Joint Port Enforcement Group alongside 
Homeland Security Investigations to ensure higher rates of 
contraband prosecution by assigning CBP officers to HSI to 
assist with casework. By working together to respond to, 
investigate, and prosecute illicit contraband seizures at the 
Arizona ports of entry, prosecution rates have increased to 97 
percent.
    We are also working with the government of Mexico in 
implementing unified cargo processing at commercial facilities 
in Nogales, Douglas, and San Luis. This brought Customs 
inspectors from Mexico into U.S. commercial facilities for 
joint processing and joint inspection of cargo coming from 
Mexico. Currently, 16 percent of all commercial cargo processed 
at the Arizona ports of entry is tied to this program, with 
expectations for increase. This has significantly changed cargo 
processing and is considered a best practice along the 
Southwest Border ports.
    In coordination with our partnership, and with the support 
of Congress, we will continue to refine and enhance the 
effectiveness of our detection and interdiction capabilities to 
prevent the entry of opioids and other illicit drugs into the 
United States.
    Chairwoman McSally, Ranking Member Grijalva, and 
distinguished Members, thank you for the opportunity to testify 
today. I look forward to your questions.
    [The prepared statement of Mr. Ramirez follows:]
                Prepared Statement of Guadalupe Ramirez
                              May 30, 2018
                              introduction
    Chairwoman McSally, Ranking Member Vela, and distinguished Members 
of the subcommittee, thank you for the opportunity to appear before you 
today to discuss the role of U.S. Customs and Border Protection (CBP) 
in combating the flow of dangerous opioids, including synthetic opioids 
such as fentanyl and fentanyl analogues, into the United States. The 
opioid crisis is one of the most important, complex, and difficult 
challenges our Nation faces today, and President Trump ordered the 
declaration of a National Public Health Emergency to address the opioid 
crisis in October of last year.\1\
---------------------------------------------------------------------------
    \1\ https://www.whitehouse.gov/briefings-statements/president-
donald-j-trump-taking-action-drug-addiction-opioid-crisis/.
---------------------------------------------------------------------------
    As America's unified border agency, CBP plays a critical role in 
preventing illicit narcotics, including opioids, from reaching the 
American public. CBP leverages targeting and intelligence-driven 
strategies, and works in close coordination with our partners as part 
of our multi-layered, risk-based approach to enhance the security of 
our borders and our country. This layered approach reduces our reliance 
on any single point or program, and extends our zone of security 
outward, ensuring our physical border is not the first or last line of 
defense, but one of many.
              opioid trends, interdictions, and challenges
    In fiscal year 2018 to date, the efforts of Office of Field 
Operations (OFO) and U.S. Border Patrol (USBP) personnel resulted in 
the seizure of more than 545,000 lbs. of narcotics including over 
38,000 lbs. of methamphetamine, over 35,000 lbs. of cocaine, and over 
2,700 lbs. of heroin.\2\ CBP seizures of illicit fentanyl have 
significantly increased from approximately 2 lbs. seized in fiscal year 
2013 to approximately 1,131 lbs. seized by OFO and USBP in fiscal year 
2017.\3\ Approximately 1,218 lbs. of illicit fentanyl have already been 
seized in fiscal year 2018.\4\ Fentanyl is the most frequently seized 
illicit synthetic opioid, but CBP has also encountered 18 fentanyl 
analogues.\5\
---------------------------------------------------------------------------
    \2\ https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics.
    \3\ https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics.
    \4\ https://www.cbp.gov/newsroom/stats/cbp-enforcement-statistics.
    \5\ These include: acetylfentanyl, butyrylfentanyl, b-
hydroxythiofentanyl, a-methylacetylfentanyl, p-fluorobutyrylfentanyl, 
p-fluorofentanyl, pentanoylfentanyl (a.k.a. valerylfentanyl), 2-
furanylfentanyl, p-fluoroisobutyrylfentanyl, n-hexanoylfentanyl, 
carfentanil, benzodioxolefentanyl, acrylfentanyl, 2,2-
difluorofentanyl, methoxyacetylfentanyl, benzoylfentanyl, 
cyclopropylfentanyl, and hydrocinnamoylfentanyl.
---------------------------------------------------------------------------
    Illicit drug interdiction in the border environment is both 
challenging and complex. Drug Trafficking Organizations (DTOs) and 
Transnational Criminal Organizations (TCOs) continually adjust their 
operations to circumvent detection and interdiction by law enforcement, 
quickly taking advantage of technological and scientific advancements 
and improving fabrication and concealment techniques.
    DTOs seek to smuggle opioids, most commonly heroin, across our land 
borders and into the United States at and between our Ports of Entry 
(POEs), and Mexican manufacturers and traffickers continue to be major 
suppliers of heroin to the United States.\6\ The reach and influence of 
Mexican cartels, notably the Sinaloa, Gulf, and Jalisco New Generation 
Cartels, stretch across and beyond the Southwest Border, operating 
through loose business ties with smaller organizations in communities 
across the United States. The threat of these cartels is dynamic; rival 
organizations are constantly vying for control, and as U.S. and Mexican 
anti-drug efforts disrupt criminal networks, new groups arise and form 
new alliances.
---------------------------------------------------------------------------
    \6\ Heroin is also sometimes transported by couriers on commercial 
airlines. Heroin intercepted in the international commercial air travel 
environment is from South America, Southwest Asia, and Southeast Asia.
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    Smugglers use a wide variety of tactics and techniques for 
concealing drugs. CBP officers regularly find drugs concealed in body 
cavities, taped to bodies, hidden inside vehicle seat cushions, gas 
tanks, dashboards, tires, packaged food, household and hygiene 
products, in checked luggage, and concealed in construction materials 
on commercial trucks. For example, during the weekend of May 4, 2018 
CBP officers at Arizona's San Luis POE arrested two individuals in 
connection to separate failed drug smuggling attempts in personal 
vehicles. In the first case, CBP seized approximately 113 lbs. of 
methamphetamine, worth nearly $338,000, and approximately 5 lbs. of 
heroin, worth more than $86,000, which the officers discovered hidden 
throughout the vehicle. During a second vehicle inspection, CBP 
officers discovered nearly 35 lbs. of methamphetamine, worth almost 
$105,000, concealed in the vehicle's seats and rear door. CBP officers 
turned the drugs, vehicles, and arrested subjects over to U.S. 
Immigration and Customs Enforcement--Homeland Security Investigations 
(ICE-HSI).\7\
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    \7\ https://www.cbp.gov/newsroom/local-media-release/san-luis-cbp-
officers-seize-529k-meth-and-heroin.
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    While most illicit drug smuggling attempts occur at Southwest land 
POEs, the smuggling of illicit narcotics in the international mail and 
express consignment courier (ECC) environments also poses a significant 
threat. Illicit narcotics can be purchased from sellers through on-line 
transactions and then shipped via the United States Postal Service 
(USPS) or ECCs. DTOs and individual purchasers move drugs such as 
illicit fentanyl and fentanyl analogues in small quantities, making 
detection and targeting a significant challenge. However, these are 
often significantly more potent and therefore more deadly than the 
shipments seized along the border. Follow-on investigations, which are 
conducted by ICE-HSI, are also challenging because these shippers are 
often not the hierarchically structured DTOs we encounter in other 
environments. To combat this threat, CBP operates within nine major 
international mail facilities (IMF) inspecting international mail 
arriving from more than 180 countries, as well as 25 ECC facilitates 
located throughout the United States.
    Between the POEs, DTOs and TCOs strategically send smugglers to 
vulnerable spots along the Southwest Border with limited infrastructure 
and technology to gain access into the illicit drug market. CBP plays a 
key role in the DHS and U.S. Government strategy to combat TCOs at home 
and with our international partners. We must combat these criminal and 
drug trafficking organizations with a systematic approach to border 
security. Our approach includes interagency coordination, legislative 
reform, as well substantial investments in impedance and denial 
capabilities, surveillance technology, access and mobility, mission 
readiness, and personnel.
cbp resources and capabilities to detect, target, and interdict opioids
    CBP, with the support of Congress, has made significant investments 
and improvements in our drug detection and interdiction technology and 
targeting capabilities. These resources, along with enhanced 
information sharing and partnerships, are critical components of CBP's 
ability to identify and deter the entry of dangerous illicit drugs in 
all operational environments. Additionally, thanks to the support of 
Congress, the International Narcotics Trafficking Emergency Response by 
Detecting Incoming Contraband with Technology Act, or the INTERDICT 
Act, authorized the appropriation of $9 million to CBP to ensure that 
CBP has sufficient resources and personnel, including scientists and 
chemical screening devices, to enhance CBP's drug interdiction mission 
and provide for additional scientists to process lab tests 
expeditiously.
Advance Information and Targeting
    An important element of CBP's layered security strategy is 
obtaining advance information to help identify shipments that are 
potentially at a higher risk of containing contraband. Under section 
343 of the Trade Act of 2002 (Pub. L. No. 107-210), as amended, and 
under the Security and Accountability for Every Port Act or SAFE Port 
Act of 2006, (Pub. L. No. 109-347), CBP has the legal authority to 
collect key cargo data elements provided by air, sea, and land 
commercial transport companies (carriers), including ECCs and 
importers.\8\ This information is automatically inputted into CBP's 
Automated Targeting System (ATS), a secure intranet-based enforcement 
and decision support system that compares cargo and conveyance 
information against intelligence and other enforcement data. CBP, in 
conjuncture with our Federal and international partners, is working to 
expand the availability of advanced electronic data (AED) to enhance 
our targeting in the international mail environment as well.
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    \8\ Under TSA requirements, inbound international mail destined for 
the United States is treated similar to other cargo and subject to 
security controls. These security controls, which include screening for 
unauthorized explosive, incendiary, and other destructive substances or 
items in accordance with TSA regulations and security program 
requirements, are applied to international mail prior to transporting 
on aircraft at Last Point of Departure locations to the United States. 
49 U.S.C. 44901(a) states: ``The Under Secretary of Transportation for 
Security shall provide for the screening of all passengers and 
property, including United States mail, cargo, carry-on and checked 
baggage, and other articles, that will be carried aboard a passenger 
aircraft.'' Under 49 C.F.R. 1540.5, Cargo means property tendered for 
air transportation accounted for on an air waybill. All accompanied 
commercial courier consignments whether or not accounted for on an air 
waybill, are also classified as cargo. Aircraft operator security 
programs further define the terms ``cargo''. These requirements are not 
dependent on advance electronic manifest data, as provided by ECC 
operators and other participants in the Air Cargo Advance Screening 
(ACAS) pilot program.
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    At CBP's National Targeting Center (NTC), advance data and access 
to law enforcement and intelligence records converge to facilitate the 
targeting of travelers and items of cargo that pose the highest risk to 
our security in all modes of inbound transportation. The NTC takes in 
large amounts of data and uses sophisticated targeting tools and 
subject-matter expertise to analyze, assess, and segment risk at every 
stage in the cargo/shipment and travel life cycles. The NTC leverages 
classified, law enforcement, commercial, and open-source information in 
unique, proactive ways to identify high-risk travelers and shipments at 
the earliest possible point prior to arrival in the United States.
    To bolster its targeting mission, the dedicated men and women of 
the NTC collaborate with critical partners on a daily basis including 
ICE-HSI, the Drug Enforcement Administration (DEA), the Federal Bureau 
of Investigation (FBI), members of the intelligence community, and the 
United States Postal Inspection Service (USPIS). Investigative case 
data is fused with CBP targeting information to bolster investigations 
targeting illicit narcotics smuggling and trafficking organizations. 
Moreover, NTC works in close coordination with several pertinent task 
forces including the Organized Crime Drug Enforcement Task Force, the 
High Intensity Drug Trafficking Areas, and the Joint Interagency Task 
Force-West, as well as the Department of Homeland Security's (DHS) 
Joint Task Forces (JTF).
    Some of the precursor chemicals that can be used to synthesize 
fentanyl and fentanyl analogues are currently non-regulated and many 
have legitimate uses. However, CBP has sufficient authority to seize 
precursors if they can be identified as having illicit end-use 
intentions, including the production of illicit drugs. CBP targets 
precursor chemicals transiting the United States with destinations to 
Mexico and other countries. When these shipments are identified through 
interagency collaboration as having illicit end-use intentions, the 
shipments are offloaded for further inspection and enforcement action 
by external agencies such as DEA and ICE-HSI.
    In addition to targeting illicit substances directly, CBP also 
targets related equipment such as pill presses and tablet machines. DEA 
regulates pill press/tablet machines and there is an ICE Diversion 
Coordinator assigned to the DEA Special Operations Division who 
oversees the investigations of pill press and tablet machine imports 
being diverted for illicit uses. The Diversion Coordinator works 
closely with the NTC to identify and target individuals importing and 
diverting pill presses and tablet machines to press fentanyl, fentanyl 
analogues, and other synthetic drugs into counterfeit pills. In fiscal 
year 2014, 24 seizures of pill presses and tablet machines were made by 
OFO. The number increased to 92 in fiscal year 2017.
Non-Intrusive Inspection Equipment
    At our POEs and in the international mail and express consignment 
environments, CBP utilizes technology, such as non-intrusive inspection 
(NII), X-ray, and gamma ray imaging systems to detect the illegal 
transit of synthetic drugs hidden on people, in cargo containers, and 
in other conveyances entering the United States. Since October 2010, 
CBP has conducted more than 83 million NII examinations, resulting in 
more than 18,500 narcotics seizures, and more than $79 million in 
currency seizures. For example, on April 15, 2018 CBP officers at the 
Veterans International Bridge in Brownsville, Texas utilized NII 
technology to discover 12 lbs. of heroin and 1.3 lbs. of 
methamphetamine in a personal vehicle. The combined estimated street 
value of the narcotics from the seizure is $348,000. CBP officers 
seized the narcotics along with the vehicle, arrested the driver, and 
turned him over to the custody of ICE-HSI for further investigation.\9\
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    \9\ https://www.cbp.gov/newsroom/local-media-release/brownsville-
port-entry-cbp-officers-seize-over-300k-heroin-and.
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    CBP is committed to continuing to improve its ability to interdict 
illicit narcotics and is currently joining with the DHS Science and 
Technology Directorate (S&T) to evaluate existing detection solutions, 
such as the Handheld Illicit Drug Explosives Trace Detector (HID-ETD) 
and the X-ray imaging contract, and to develop advanced capabilities 
through a prize challenge for inventors to create or modify existing 
technology capable of accomplishing this.
Canines
    Canine operations are an invaluable component of CBP's 
counternarcotic operations. The CBP Canine Training Program maintains 
the largest and most diverse law enforcement canine training program in 
the country. At our Nation's POEs and at preclearance locations abroad, 
CBP officers utilize specially-trained canines for the interdiction of 
narcotics, firearms, and undeclared currency, as well as in support of 
specialized programs aimed at combating terrorism and countering human 
trafficking. Concealed Human and Narcotic Detection Canines are trained 
to detect concealed humans and the odors of marijuana, cocaine, heroin, 
methamphetamine, hashish, ecstasy, fentanyl, and fentanyl analogues.
    The use of canines in the detection of narcotics is a team effort. 
CBP's Laboratories and Scientific Services Directorate (LSSD) produces 
canine training aids and provides analytical support to the CBP Canine 
Training Program, including controlled substance purity determinations, 
pseudo training aid quality analyses, and research on delivery 
mechanisms that maximize safe vapor delivery during training exercises. 
Most recently, OFO's National Canine Program, in coordination with 
LSSD, assessed the feasibility of safely and effectively adding 
fentanyl as a trained odor to deployed narcotic detection canine teams. 
On June 23, 2017, the Office of Training and Development's CBP Canine 
Training Program successfully completed its first Fentanyl Detection 
Pilot Course. This added the odor of fentanyl and fentanyl analogues to 
6 OFO canine handler teams in the international mail and ECC 
environments. Beginning October 1, 2018, all-new OFO canine handler 
teams graduating from the CBP Canine Training Program will have 
successfully completed a comprehensive CBP Canine Detection Team 
Certification to include the odor of fentanyl and fentanyl analogues. 
Today, all OFO Concealed Human and Narcotic Detection canine teams 
across all of OFO's operational environments have completed fentanyl 
training.
    During fiscal year 2017, OFO canine teams were responsible for 
$26,813,863 in seized property, $1,905,925 in fines, $36,675,546 in 
seized currency, $29,674,839 in Financial Crimes Enforcement Network 
(FINCEN) actions, 197 firearms and 22,356 rounds of ammunition, 79 
concealed humans, and 384,251 lbs. of narcotics. In fiscal year 2018 to 
date, OFO canine teams have been responsible for $7,322,522 seized 
property, $411,073 in fines, $7,951,376 in seized currency, $9,178,971 
in FINCEN actions, 150 firearms, 5,418 rounds of ammunition, 105 
concealed humans, and 187,409 lbs. of narcotics.\10\
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    \10\ Effective 4/24/18.
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    For example, on May 1, 2018, a CBP Concealed Human and Narcotic 
Detection canine at the Nogales, Arizona POE alerted officers to almost 
11 lbs. of heroin wrapped around the midsection of an individual 
entering the United States. The heroin had an estimated street value in 
excess of $188,000. Officers seized the drugs, and turned the arrested 
subject over to ICE-HSI.\11\
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    \11\ https://www.cbp.gov/newsroom/local-media-release/nogales-cbp-
officers-seize-188k-heroin.
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Laboratory Testing
    As the narcotics seized through the international mail and at ECC 
facilities usually have a very high purity, CBP officers at IMFs and 
ECC facilities use various field testing devices to rapidly screen 
suspected controlled substances and obtain presumptive results. Using 
CBP's LSSD Field Triage Reachback Program, CBP officers can transmit 
sample data directly to LSSD for scientific interpretation and 
identification. When any synthetic opioids are detected by the 
Reachback program, LSSD notifies key CBP personnel at the NTC, as well 
as our liaisons at DEA. CBP is working to expand the field testing 
program, along with the scientific assets and personnel who are able to 
provide real-time chemical composition determinations.
    In 2016, a CBP pilot program tested four hand-held tools and a new 
test kit to provide immediate presumptive testing for fentanyl. Based 
on the results of the pilot, OFO procured 12 systems for further 
testing across San Diego, Tucson, El Paso, and Laredo Field Offices. 
Last year, CBP purchased over 90 handheld analyzers for deployment. 
Handheld analyzers improve officer safety, and provides a near-real 
time capability to increase narcotic interdiction.
            information sharing and operational coordination
    Substantive and timely horizontal and vertical information sharing 
is critical to targeting and interdicting illicit drugs. CBP works 
extensively with our Federal, State, local, Tribal, and international 
partners and provides critical capabilities toward the whole-of-
Government approach to address drug trafficking and other transnational 
threats at POEs, in our IMFs and ECCs, and along the Southwest Border, 
Northern Border, and coastal approaches. Our targeting, detection, and 
interdiction efforts are enhanced through special joint operations and 
task forces conducted under the auspices of multi-agency enforcement 
teams that target drug and transnational criminal activity, including 
investigations involving National security and organized crime.
    Additionally, CBP hosts monthly briefings/teleconferences with 
Federal, State, and local partners regarding the current state of the 
border--the Northern Border and Southwest Border--to monitor emerging 
trends and threats and provide a cross-component, multi-agency venue 
for discussing trends and threats. The monthly briefings focus on 
drugs, weapons, and currency interdictions and alien apprehensions both 
at and between the POEs. These briefings/teleconferences currently 
include participants from: The government of Canada; the government of 
Mexico; ICE, U.S. Coast Guard (USCG); DEA; FBI; U.S. Northern Command; 
Joint Interagency Task Force-South; Bureau of Alcohol, Tobacco, 
Firearms, and Explosives (ATF); U.S. Attorneys' Offices; Naval 
Investigative Command; State and Major Urban Area Fusion Centers; and 
other international, Federal, State, and local law enforcement as 
appropriate.
    CBP is a critical member in the S&T-led interagency Illicit Drug 
Detection Working Group. This Working Group assists in coordinating 
communications between various Government stakeholders inside and 
outside of DHS, including four other DHS components, the Department of 
Defense, DEA, and the Department of Justice (DOJ), on synthetic opioid 
information, such as seizure and profile data, and approaches for 
detection and best practices for safe handling. The Working Group, with 
the specific support of the National Institute of Standards and 
Technology, is also working on the development of detection standards 
for illicit drugs to allow the consistent test and evaluation of 
detection equipment and inform protocols for operational use. Further, 
these illicit drug detection standards generated by the Working Group 
will guide industry in their development of detection equipment that 
will meet the operational needs of DHS.
    CBP is a key participant in the implementation of the Office of 
National Drug Control Policy's (ONDCP) Heroin Availability Reduction 
Plan (HARP). CBP also utilizes the DOJ's Nation-wide Deconfliction 
System operated by DEA, conducting interagency deconfliction and 
coordination, and is working with the Heroin and Fentanyl Working Group 
at the DEA Special Operations Division, alongside ICE-HSI.
    Collaboration with our partners yields results. For example, the 
Chicago Field Office Tactical Analytical Unit initiated ``Operation Mad 
Dog'' in February 2017 to target international mail shipments suspected 
of containing illicit fentanyl and refer those shipments to law 
enforcement partners across the country--including ICE-HSI and State, 
local, and Tribal partners--for action. Targeted suspect shipments were 
intercepted and examined in IMFs based on information provided by our 
law enforcement partners and the NTC, as well as open-source 
information. Controlled deliveries have resulted in 37 arrests. 
Successes attributed to this operation to-date also include the seizure 
of over 57 lbs. of fentanyl, firearms, cash and crypto-currency, and 
the disruption of a major domestic dark web distributor of illicit 
fentanyl.
International Collaboration and Cooperation
    USPS receives international mail from more than 180 countries. The 
vast majority of this mail arrives via commercial air or surface 
transportation. An increasing number of foreign postal operators 
provide AED to USPS, which is then passed on to CBP. CBP is working to 
expand the availability of AED globally to enhance the security of the 
international mail. For international mail arriving from foreign postal 
operators who do not provide AED, CBP officers utilize experience and 
training to identify items that potentially pose a risk to homeland 
security and public safety, while facilitating the movement of 
legitimate mail. CBP and USPS now have an operational AED targeting 
program at five of our main IMFs with plans for further expansion. USPS 
is responsible for locating the shipments and delivering them to CBP 
for examination. Thus far in fiscal year 2018, CBP has interdicted 186 
shipments of fentanyl at the John F. Kennedy International Airport 
(JFK) IMF, a participant in the AED program. One hundred and twenty-
five of those interdictions can be attributed to AED targeting. CBP and 
USPS continue to work with foreign postal operators to highlight the 
benefits of transmitting AED.
    CBP, in close coordination with USPS and U.S. Food and Drug 
Administration, provided technical assistance on the ``Synthetics 
Trafficking and Overdose Prevention (STOP) Act'', which were largely 
incorporated into the pending ``Securing the International Mail Against 
Opioids Act of 2018'', which was recently reported favorably by the 
House Committee on Ways and Means. This legislation seeks to address 
these challenges in a multi-phase process which emphasizes risk-
assessment, technology, and collaboration across the Federal Government 
and with our international partners. We support efforts to expand the 
ability of USPS to greatly increase the availability of AED (which is 
the foundation of a sound targeting mechanism) for international mail, 
to develop new scanning technology, and to collect fees to help cover 
the cost of customs processing of certain inbound mail items.
    Because DTOs are also known to use legitimate commercial modes of 
travel and transport to smuggle drugs and other illicit goods, CBP 
partners with the private sector to provide anti-drug smuggling 
training to air, sea, and land commercial transport companies 
(carriers) to assist CBP with stopping the flow of illicit drugs; to 
deter smugglers from using commercial carriers to smuggle drugs; and to 
provide carriers with the incentive to improve their security and their 
drug smuggling awareness. Participating carriers sign agreements 
stating that the carrier will exercise the highest degree of care and 
diligence in securing their facilities and conveyances, while CBP 
agrees to conduct site surveys, make recommendations, and provide 
training.
    The trafficking of synthetic opioids like fentanyl and fentanyl 
analogues is a global problem, and CBP continues to work with our 
international partners to share information and leverage resources to 
combat this threat. CBP's Office of International Affairs International 
Technical Assistance Division (INA/ITAD) conducts International Border 
Interdiction training, coordinated and funded by the Department of 
State, for various countries world-wide. These courses provide 
instruction on multiple aspects of border security, including targeting 
and risk management, interdiction, smuggling, search methodologies, 
analysis, canine enforcement, and narcotics detection identification. 
INA/ITAD has conducted anti-smuggling training in opiate source 
countries such as Panama, Guatemala, Colombia, Ecuador, Peru, Mexico, 
Indonesia, India, Thailand, Afghanistan, Kenya, Cambodia, and the 
Philippines. CBP also provides an Identification of Drugs and Precursor 
Chemical training course to Mexico and other drug source and transit 
countries to provide important insight to foreign Customs Officers on 
the vast resources of precursors available to narcotics producers and 
traffickers world-wide.
    Through the 21st Century Border Management Initiative, the U.S. 
Government and the government of Mexico are working to strengthen our 
collaborative relationship and efforts to secure and facilitate the 
cross-border flows of people and cargo. We receive information from 
Mexican authorities on a daily basis that helps us better target drug 
smugglers at the border and continue to work closely to expand joint 
efforts to combat illicit drug cultivation, production, and 
trafficking, and sharing more information on smuggling routes and 
networks. This information sharing, facilitated by the CBP attache 
office in Mexico, has allowed for an unprecedented exchange of real-
time information through deployments of personnel between our 
countries. Today, CBP personnel are assigned to Mexico City under the 
Joint Security Program where we exchange alerts on suspicious DTO 
movements through the monitoring of our Advance Passenger Information 
System. This information sharing has also led to numerous seizures and 
cases within Mexico that serve to disrupt the activities of DTOs 
throughout the Western Hemisphere.
                               conclusion
    In coordination with our partners and with the support of Congress 
CBP will continue to refine and enhance the effectiveness of our 
detection and interdiction capabilities to prevent the entry of opioids 
and other illicit drugs into the United States, including strengthening 
our ability to detect and interdict drugs entering via the mail and 
express consignment systems. Chairwoman McSally, Ranking Member Vela, 
and distinguished Members of the subcommittee, thank you for the 
opportunity to testify today. I look forward to your questions.

    Ms. McSally. Thank you, Mr. Ramirez.
    The Chair now recognizes Mr. Brown to testify for 5 
minutes.

STATEMENT OF A. SCOTT BROWN, SPECIAL AGENT IN CHARGE, HOMELAND 
 SECURITY INVESTIGATIONS--PHOENIX, U.S. DEPARTMENT OF HOMELAND 
                            SECURITY

    Mr. Brown. Good morning, Chairwoman McSally, attendees from 
the Arizona congressional delegation. Thank you for the 
opportunity to appear before you today to discuss the opioid 
crisis in the United States, particularly along the border here 
in Arizona, and the efforts of U.S. Immigration and Customs 
Enforcement to target, investigate, disrupt, dismantle, and 
bring to justice the criminal elements responsible for the 
manufacturing, smuggling, and distribution of dangerous 
opioids.
    As the largest investigative agency within the U.S. 
Department of Homeland Security, or DHS, ICE Homeland Security 
Investigations, or HSI, investigates and enforces more than 400 
Federal criminal statutes. HSI special agents use their broad 
authority to investigate all kinds of cross-border criminal 
activity and work in close collaboration with U.S. Customs and 
Border Protection and the Drug Enforcement Administration in a 
unified effort with both domestic and international law 
enforcement partners to target transnational criminal 
organizations, or TCOs, that are supplying illicit substances 
to the United States.
    Today I would like to highlight our efforts to reduce the 
supply of illicit opioids such as heroin and fentanyl from 
coming into the United States along the Southwest Border in 
Arizona and the operational challenges we encounter.
    The United States is in the midst of an opioid epidemic 
that is being fueled by the smuggling and trafficking of heroin 
and illicit fentanyl. Based on our investigative efforts, U.S. 
law enforcement has identified China and Mexico as primary 
sources of the U.S. illicit opioid threat.
    Illicit fentanyl, fentanyl analogues, and their immediate 
precursors are most often produced in China. From China, these 
substances are shipped primarily through mail carriers directly 
to the United States or are alternatively shipped directly to 
the TCOs in Mexico.
    Once in the Western Hemisphere, often in Mexico, fentanyl 
or its analogues are mixed with other narcotics and fillers 
and/or pressed into pill form, then moved to the illicit U.S. 
market where demand for prescription opioids and heroin remain 
at epidemic levels.
    Mexican cartels have seized upon the profit potential of 
opioids, including synthetic opioids, and seem to have invested 
in growing their share of this illicit market. We are even 
seeing an increased number of instances in which precursors 
originating in China and smuggled into the United States have 
traveled through the United States, destined for the Southwest 
Border locations to include here in Arizona. The Mexican 
cartels then attempt to smuggle the precursors out of the 
United States, allowing them to synthesize them into fentanyl 
in Mexico, with the intent to smuggle the finished product back 
into the United States for distribution and consumption. The 
final product is sold as heroin or as a prescription opioid, 
and the end-user may not be aware of the presence of fentanyl.
    The vast majority of heroin and fentanyl entering and 
transiting Arizona is smuggled across the shared border with 
Mexico via the land border ports of entry. Like other narcotics 
supplied by Mexico, heroin and fentanyl are often smuggled 
utilizing deep concealment in passenger vehicles as the TCOs 
exploit the high volume of legitimate cross-border traffic at 
our ports of entry as part of the concealment of their 
smuggling efforts. Heroin and fentanyl loads are also smuggled 
by pedestrians into the U.S. ports of entry, often concealed on 
their person or in their bags or backpacks.
    Almost all the Mexico-sourced drugs entering the United 
States via the border in Arizona can be attributed to the 
Sinaloa Cartel. HSI continues to investigate and identify the 
leadership of the Sinaloa Cartel and attack the critical 
organizational nodes of smuggling facilitators and financial 
networks that sustain their operations. It is imperative that 
we continue to focus our efforts on disrupting and dismantling 
the Sinaloa Cartel, which not only smuggles opioids but other 
narcotics like methamphetamine and cocaine that also have a 
devastating impact on our communities.
    HSI has made significant strides in fiscal year 2017 in 
combatting the fentanyl epidemic in the United States as 
evidenced by a 400 percent increase in fentanyl-related 
seizures. However, even with these advances, there is no single 
solution or Government entity that can stop the flow of 
dangerous and illicit opioids like fentanyl into the United 
States or keep them from harming the American public. Tackling 
this complex threat involves a united, comprehensive, and 
aggressive approach across law enforcement in collaboration 
with experts in the medical, science, and public health 
communities.
    HSI will continue to work with our Federal, State, local, 
and Tribal partners to improve the efficiency of information 
sharing and operational coordination to address the challenges 
and threats posed by illicit narcotics smuggling into the 
United States.
    Thank you for the opportunity to appear before you today. I 
will answer any questions you have.
    [The prepared statement of Mr. Brown follows:]
                  Prepared Statement of A. Scott Brown
                              May 30, 2018
    Chairman McSally, Ranking Member Vela, and distinguished Members: 
Thank you for the opportunity to appear before you today to discuss the 
opioid crisis in the United States, particularly along the border here 
in Arizona, and the efforts of U.S. Immigration and Customs Enforcement 
(ICE) to target, investigate, disrupt, and dismantle the criminal 
networks responsible for the manufacturing, smuggling, and distribution 
of dangerous opioids.
    As the largest investigative agency within the U.S. Department of 
Homeland Security (DHS), ICE Homeland Security Investigations (HSI) 
enforces more than 400 Federal criminal statutes to include the 
Immigration and Nationality Act under (Title 8), U.S. Customs laws 
under (Title 19), general Federal crimes under (Title 18), and the 
Controlled Substances Act under (Title 21). HSI Special Agents use this 
authority to investigate all types of cross-border criminal activity 
and work in close coordination with U.S. Customs and Border Protection 
(CBP), the Drug Enforcement Administration (DEA), the United States 
Postal Inspection Service (USPIS) and our State, local, Tribal and 
international partners in a unified effort, to target the Transnational 
Criminal Organizations (TCOs) that are supplying illicit substances, to 
include opioids, to the United States.
    Today, I would like to highlight our efforts to reduce the supply 
of illicit opioids, such as heroin, fentanyl, and fentanyl analogues 
from coming into the United States along the Southwest Border in 
Arizona and the operational challenges we encounter.
                introduction to illicit opioid smuggling
    The United States is in the midst of an opioid epidemic that is 
being fueled by the smuggling and trafficking of heroin, illicit 
fentanyl, and fentanyl analogues. Based on investigative efforts, 
United States law enforcement has identified China and Mexico as 
primary sources of the U.S. illicit fentanyl threat.
    Illicit fentanyl, fentanyl analogues, and their immediate 
precursors are most often produced in China. From China, these 
substances are shipped primarily through international mail or express 
consignment carriers (such as DHL, FedEx, or UPS) directly to the 
United States or, alternatively, shipped directly, via express 
consignment, postal or commercial carriers to TCOs in Mexico. Once in 
the Western Hemisphere, fentanyl or fentanyl analogues are prepared and 
mixed with other narcotics and fillers and/or pressed into pill form, 
and then moved to the illicit U.S. market where demand for prescription 
opioids and heroin remain at epidemic levels. In some cases, regional 
distributors smuggle industrial pill presses and components into the 
United States to operate fentanyl tableting operations domestically.
    Mexican cartels have seized upon the profit potential of synthetic 
opioids, and seem to have invested in growing their share of this 
illicit market. Low cost coupled with high potency (one kilogram of 
fentanyl can be purchased in China for $3,000-$5,000) can generate 
upwards of $1.5 million in revenue on the illicit market. We are now 
seeing instances in which precursors originating in China and smuggled 
into the United States have traveled through the United States, 
destined for the Southwest Border locations, to include Arizona. The 
Mexican cartels have then smuggled the precursors out of the United 
States, synthesize them into fentanyl, and imported the finished 
product back into the United States for distribution and consumption. 
The final product may be advertised as heroin, and the end-user may not 
be aware of the presence of fentanyl.
illicit opioid shipments via international mail and express consignment 
                               facilities
    Though fentanyl seizures made at land border ports of entry are 
higher in number and larger in volume, the fentanyl seizures from mail 
and express consignment carrier (ECC) facilities are much higher in 
purity. Laboratory results of tested fentanyl has identified that the 
majority of illicit fentanyl seized in the international mail and ECC 
environments is shipped in concentrations of over 90 percent, whereas 
the majority of fentanyl in the land border port of entry environment 
is seized in concentrations of less than 10 percent. Illicit opioids 
like fentanyl can be purchased easily through open source and dark web 
marketplaces.
    Just as TCOs attempt to hide illicit smuggling attempts at the land 
border ports of entry by blending into the voluminous daily legitimate 
cross-border traffic, TCOs are exploiting the great volumes of mail and 
parcels entering and crossing the United States as a means to conceal 
their criminal activity. In an effort to combat opioid trafficking 
through the mail and express consignments, HSI is targeting supply 
chain networks, coordinating with domestic and international partners, 
and providing field training to highlight officer safety, trends, and 
collaboration benefits with partners such as CBP, DEA, and the USPIS.
    In April 2017, CBP officers assigned to an express consignment 
facility in Memphis, Tennessee intercepted a parcel from China found to 
contain more than two kilograms of a white powder, which after lab 
testing was found to be the fentanyl precursor 4-ANPP. The parcel was 
destined for a warehouse in Nogales, Arizona. The CBP officers 
coordinated with HSI special agents assigned to the Memphis Border 
Enforcement Security Task Force (BEST), who in turn coordinated with 
HSI Nogales to conduct a controlled delivery of the parcel. Through its 
investigative efforts, HSI Nogales identified the unwitting courier 
hired to pick up the parcel, and developed significant information 
about the organization in Mexico that was coordinating the smuggling 
effort. While this investigation is on-going, the intelligence 
developed from interviewing the courier about his likely conspirators 
has permitted HSI to impede operation of a precursor pipeline feeding 
fentanyl production in Mexico.
    HSI is fully engaged with the DEA Special Operations Division (SOD) 
and the CBP National Targeting Center (NTC) to identify shipment routes 
and to target parcels that may contain illicit opioids and 
manufacturing materials. Full financial and investigative analyses are 
also conducted. While this is a good start, we recognize much more 
needs to be done.
    Recognizing the need for greater action, HSI, CBP, and the USPIS 
are collaborating in the development of a more robust, Nation-wide 
effort to interdict illicit opioids transiting through mail facilities 
including by obtaining advanced data to improve our targeting. HSI is 
expanding the number of its trained investigators assigned to 
international mail facilities. These additional investigators will be 
seeking to conduct long-term, complex, criminal investigations into 
opioid trafficking activities, with the goal of achieving additional 
significant seizures and arrests. These seizures and arrests will help 
disrupt the movement of illicit opioids and opioid precursors 
transiting through the mail and ECCs, and will aid in the dismantling 
of distribution networks. The ultimate goal of course, is to reduce 
overdose deaths in the United States.
   smuggling of fentanyl and heroin across the arizona/mexico border
    The vast majority of fentanyl and heroin entering or transiting 
Arizona is smuggled across the shared border with Mexico via the land 
border ports of entry. Like other narcotics supplied by Mexico, heroin 
and fentanyl loads are often smuggled utilizing deep concealment within 
passenger vehicles, as the TCOs exploit the high volume of cross-border 
traffic at our ports of entry as part of their smuggling efforts. 
Heroin and fentanyl loads are also smuggled by pedestrians entering the 
United States at ports of entry, often concealed on their person, or in 
their bags or backpacks.
    Loaded vehicles often contain multiple types of illicit drugs, 
which we refer to as ``poly loads'' or ``mixed loads''. It seems that 
the traditional drug supplying organizations have diversified their 
illicit product inventory to include increased amounts of heroin and 
fentanyl while also continuing to source methamphetamine, cocaine, and 
other drugs. HSI, as the investigative agency responsible for 
investigating smuggling at the ports of entry, works closely with CBP 
every day, to ensure that every smuggling incident is vigorously 
investigated, and expanded to the networks behind the smuggling 
attempt. Additionally, intelligence developed through HSI's 
investigative efforts is shared with CBP to enhance and refine their 
targeting and interdiction efforts at the ports of entry.
    Almost all the Mexico-sourced drug supply entering the United 
States via the border in Arizona can be attributed to the Sinaloa 
Cartel. HSI continues to investigate and identify the leadership of the 
Sinaloa Cartel and attack the critical organizational nodes of 
smuggling facilitators and financial networks that sustain their 
operations. However, every law enforcement success against the cartels 
is challenged by the fact that the cartels are highly networked 
organizations with built-in redundancies that adapt on a daily basis 
based on their intelligence about U.S. border security and law 
enforcement. Mexican cartels, notably the Sinaloa Cartels, stretch 
across and beyond the Southwest Border, where they have strategically 
situated people in cities across the United States who have established 
networks and loose affiliations with smaller organizations for the 
purpose of smuggling.
    Our vigorous response to these threats must include increased 
border security infrastructure, personnel, and technology; a system of 
systems if you will. Effective physical barriers, advanced technology, 
and strategic deployment of law enforcement personnel is essential, but 
it should be bolstered by interior enforcement and administration of 
our immigration laws in a manner that serves the National interest.
             ice's collaborative lines of effort in arizona
    There is no single entity or solution that can stop the flow of 
dangerous illicit drugs such as fentanyl and fentanyl analogues into 
the United States or keep them from harming the American public. 
Tackling this complex threat involves a united, comprehensive strategy 
and aggressive approach by multiple entities across all levels of 
government. Therefore, ICE, through its investigative arm, HSI, has 
long had inter-agency collaboration as one of its operational pillars. 
Law enforcement partnerships in Arizona are strong, and all agencies 
are committed to doing everything they can to defeat the heroin and 
fentanyl crisis that is gripping our Nation. Through partnerships 
across Arizona, across the Nation, and across the globe, HSI's 
commitment to collaboration is having a significant and positive 
impact.
Border Enforcement Security Taskforces (BESTs)
    Border Enforcement Security Taskforces (BESTs) are DHS's primary 
platform to investigate opioid smuggling domestically. ICE currently 
operates BESTs in 62 locations throughout the United States. During 
fiscal year 2017, the number of BESTs increased 30 percent in response 
to the President's Executive Order 13773, Enforcing Federal Law with 
Respect to Transnational Criminal Organizations and Preventing 
International Trafficking. BESTs leverage the participation of more 
than 1,000 Federal, State, local, Tribal, and foreign law enforcement 
agents and officers representing over 100 law enforcement agencies to 
target opioid smuggling. In Arizona, HSI oversees 7 BESTs, one in each 
of all our front-line border offices: Douglas, Nogales, Sells, and 
Yuma, as well as Tucson, Casa Grande, and Phoenix. BESTs not only 
leverage the abilities and authorities of the participating agencies by 
unifying all under a single DHS effort; but they also provide a common 
case management and intelligence platform, which greatly increases the 
speed, completeness, and transparency of investigative and intelligence 
information sharing.
    This level of information sharing is critical for combatting the 
TCOs that smuggle fentanyl and other drugs across the Arizona Border 
and distribute it in our heartland. The common case management and 
intelligence platforms enable the information obtained from a port 
seizure in Nogales, to be shared immediately with a BEST investigating 
a transportation cell in Phoenix, and a BEST investigating at a 
distribution network in Ohio.
    So, to cite a real-world example, in support of an on-going 
investigation of a Nogales Sonora-based cell of the Sinaloa Cartel that 
smuggles opioids and other hard narcotics through the Nogales ports of 
entry, HSI agents and Maricopa County Sheriff's Detectives were able to 
identify a recipient of the narcotics in Phoenix. During a traffic 
stop, the recipient was found to be in possession of 175 grams of 
fentanyl in pill form. Agents were also able to detain a package the 
recipient had dropped off at a post office, and working with U.S. 
postal inspectors, obtained a search warrant for the package, which was 
found to contain 1.3 kilograms of methamphetamine. HSI special agents 
were able to immediately and effectively coordinate with their 
counterparts in Little Rock, Arkansas, where the package was destined, 
and ultimately effected the arrest of the intended recipient. Both 
subjects have been charged Federally with Possession with Intent to 
Distribute Narcotics and Conspiracy to Possess and Distribute 
Narcotics.
Joint Port Enforcement Groups (JPEGs)
    Across Arizona and now expanded across the Southwest Border, HSI 
and CBP have formed collaborative partnerships designated as Joint Port 
Enforcement Groups (JPEG) to more effectively address smuggling, to 
include opioid smuggling, at the ports of entry, while addressing 
staffing challenges and breaking down historical stovepipes. Under HSI 
supervision, CBP officers and Border Patrol agents have been trained on 
port response investigations. This ensures, particularly at remote 
ports of entry, that investigative efforts are started promptly, and 
information is shared quickly. The JPEGs also ensure clear and 
unfettered information sharing between ICE and CBP, breaking down 
historical barriers between DHS component agencies. This dramatically 
improves our ability to arrest and prosecute those who would attempt to 
smuggle opioids or other contraband into the country, while freeing up 
limited HSI resources to pursue more complex investigations targeting 
the entire smuggling network.
High Intensity Drug Trafficking Areas (HIDTAs)
    Created by Congress through the Anti-Drug Abuse Act of 1988, the 
HIDTA program provides assistance to Federal, State, local, and Tribal 
law enforcement agencies operating in areas determined to be critical 
drug trafficking regions of the United States. The Office of National 
Drug Control Policy administers the HIDTA program, providing funding 
and working with Congress to designate localities eligible for the 
program. Like the BESTs, the HIDTA Task Forces ensure that the concerns 
of all the participating agencies, to include the State, local, and 
Tribal agencies, are included in investigative priorities; which 
certainly includes the impact of heroin and fentanyl on their 
communities. HSI works very closely with all Arizona HIDTA member 
agencies. In Nogales, HSI leads and houses the Santa Cruz County HIDTA 
Investigative Task Force.
    On the Tohono O'Odham Nation, HSI houses and predominantly staffs 
the Native American Targeted Investigation of Violent Enterprises 
(NATIVE) Task Force. The HIDTA and NATIVE task forces then apply the 
full force of the participating agencies' authorities and abilities to 
disrupt and dismantle the threat. In collaboration with Border Patrol, 
and in close coordination with the U.S. Attorney's Office, the NATIVE 
Task Force has led a multi-layered initiative to disrupt and dismantle 
the extensive scouting and re-supply networks that have long enabled 
prolific smuggling in Arizona's West Desert Region. For years, law 
enforcement operating in the West Desert has been hampered by scouts 
for the drug cartels who sit on the highpoints and relay law 
enforcement movement to smuggling groups moving across the remote 
terrain. Challenges have included bringing effective prosecutions to 
the scouts, as they are geographically separate from the drugs they are 
helping to smuggle. By employing a comprehensive strategy, that 
identified and attacked the critical nodes that have made the West 
Desert one of the Nation's most notorious smuggling corridors, these 
on-going efforts have already resulted in a significant degradation to 
operations of the Sinaloa Cartel in the area.
Joint Task Force--West Arizona Corridor
    HSI is a critical participant in the Joint Task Force--West (JTF-
W)--to include in the Arizona Corridor. JTF-W is a collaborative effort 
across DHS components in support of the DHS Secretary's Southern Border 
and Approaches Campaign. In the Arizona Corridor, JTF-W conducts an 
annual cross-component threat assessment to ensure that DHS is aligning 
its resources and operating within a unity of effort to address cross-
border threats, to include heroin and fentanyl smuggling.
Alliance to Combat Transnational Threats
    The Alliance to Combat Transnational Threats is similar to the JTF-
W, but expands the collaborative structure to include other Federal, 
State, local, and Tribal partners. Through this forum, joint operations 
to promote border security and counter the threat of smuggling are 
prioritized and planned. Additionally, intelligence and best practices 
are shared. One recent Unified Command meeting featured a presentation 
on personal protective equipment and fentanyl testing procedures to 
minimize the risk of exposure to fentanyl to law enforcement officers.
  ice's use of collaboration centers outside of arizona to attack the 
                           threat in arizona
National Targeting Center--Investigations (NTC-I)
    ICE HSI participates at CBP's NTC program through the National 
Targeting Center--Investigations (NTC-I), which leverages intelligence 
gathered during HSI investigations and exploits it using CBP data sets 
to target the flow of drugs into the United States. The NTC-I works to 
share information between CBP and ICE HSI entities world-wide.
    ICE HSI has assigned special agents to work within the NTC Cargo 
(NTC-C) Narcotics Division. These special agents serve as liaisons 
between the NTC and ICE HSI personnel in both domestic and 
international posts. HSI investigative case data is fused with CBP 
targeting information to bolster investigations targeting illicit 
opioid smuggling and trafficking organizations. HSI and CBP in Arizona 
share all heroin and fentanyl seizure data and intelligence with the 
NTC to ensure the maximum exploitation of our combined efforts, more 
complete targeting, and more robust and impactful investigations. HSI 
in Arizona has consistently detailed special agents to the National 
Targeting Center to assist in these efforts.
    NTC-I conducts post-seizure analysis based on ICE seizures in the 
field and CBP seizures at the ports of entry. The analysis is critical 
to identifying networks that transport illicit opioids throughout the 
United States. The resulting products are then shared with the affected 
HSI offices in the form of investigative leads. Another key component 
of the post-seizure analysis is the financial investigation. The NTC-I 
focuses on the financial element of the smuggling organization by 
exploiting information gathered from multiple financial databases.
Cyber Crimes Division
    The ICE HSI Cyber Crimes Division provides support and assistance 
to field cyber investigations targeting dark net illicit marketplaces, 
where fentanyl and chemical precursors proliferate. This includes 
support to active investigations in Arizona. Recognizing the need to 
proactively target on-line opioid trafficking, the ICE HSI Cyber Crimes 
Division is identifying on-going investigations and facilitating the 
coordination of on-line and in-person undercover operations conducted 
in furtherance of dark net illicit marketplaces.
    As criminal activity, and especially the trade of illicit opioids, 
continues to migrate to the on-line world, ICE HSI faces growing demand 
for cyber investigative assistance. Through the Human Exploitation 
Rescue Operative (HERO) program, the Cyber Crimes Division is training 
former warfighters to continue their service to the Nation in the field 
of computer forensics. HSI in Arizona currently has one HERO intern, 
and has converted four former HERO interns, all of whom completed their 
internships in Arizona, to full-time computer forensic agents to 
bolster our ability to fight cyber-enabled crimes.
Special Operations Division (SOD)
    The DEA's Special Operations Division (SOD) Heroin and Fentanyl 
Task Force (HFTF) is supported by ICE, CBP, DEA, USPIS, and several 
other Federal agencies. The SOD-led, interagency task force exploits 
electronic communications to proactively identify, disrupt, and 
dismantle the production, transportation, and financial networks behind 
the heroin and illicit fentanyl distribution organizations that impact 
the United States.
    The HFTF focuses on the collaborative authorities and efforts of 
each invested agency's resources, in order to better share and 
deconflict information. The HFTF works together to target international 
and domestic organizations by proactively working with field offices. 
The task force also assists in coordinating and linking investigations 
from the street-level dealer to the international supply source.
    HSI in Arizona has consistently detailed special agents to SOD. 
These special agents advance the mission of SOD through their unique 
and in-depth knowledge of the Sinaloa Cartel. This expertise, honed 
through their investigative experience in Arizona, combined with the 
resources of SOD and the HFTF, contributes significantly to 
investigations, not only by HSI, but by other agencies, in Arizona and 
beyond.
Financial Division
    Identifying, analyzing, and investigating the payment systems that 
facilitate the purchase and smuggling of opioids is critical to the 
disruption and dismantlement of networks that smuggle fentanyl and 
other illicit opioids into the United States. ICE HSI conducts 
proactive investigations that focus on the two key payment systems, 
which support illicit procurement of opioids: Money service businesses 
(MSBs) and cryptocurrencies. Generally, illicit opioids that are 
purchased on the ``indexed'' internet are paid for through licensed 
mainstream MSBs. On dark net marketplaces and other ``unindexed'' 
websites, purchases are often paid for with cryptocurrencies such as 
Bitcoin. In support of its diverse financial investigative efforts, ICE 
HSI uses undercover techniques to infiltrate and exploit peer-to-peer 
cryptocurrency exchangers who typically launder proceeds for criminal 
networks engaged in or supporting dark net marketplaces. Furthermore, 
ICE HSI leverages complex Blockchain technology exploitation tools to 
analyze the digital currency transactions and identify users. Several 
HSI special agents assigned to Arizona have received Blockchain 
technology training which gives them the tools necessary to pierce the 
anonymity relied upon by dark net users.
    ICE HSI created the Money Service Business Initiative to enable the 
application of advanced data analytics across large amounts of MSB data 
to isolate criminal networks, highlight suspicious transactions 
indicative of illicit activity, and provide predictive intelligence. 
The power of this type of advanced analytics truly shines when MSB data 
is integrated with additional Government data holdings, open-source and 
social media information, and communication records such as phone toll 
records, internet protocol (IP) address activity records, email search 
warrants, and Title III wire intercepts.
    With support of its headquarters Financial Division and NTC, HSI in 
Arizona regularly pursues complex investigations of the cartels' 
exploitation of our legitimate financial systems, and the laundering 
and movement of their illicit proceeds via trade-based money 
laundering. Given the volume of legitimate trade between the United 
States and Mexico that occurs in Arizona, the ability to launder funds 
through the movement of goods versus dollars is a particular 
vulnerability here. In a joint effort to combat this threat, on May 25, 
2017, on behalf of ICE HSI, I entered into a Memorandum of 
Understanding with the CBP Office of Field Operations, Tucson, 
officially launching the Nation's first land border Trade Enforcement 
Coordination Center in Nogales.
                      international collaboration
    ICE HSI in Arizona recognizes that all of our investigations have 
an international nexus. With ICE HSI's international presence of 67 
offices in 50 countries, we are constantly looking to push our 
investigations beyond our borders. In Arizona this means near-daily 
collaboration with our ICE HSI attache and assistant attache offices in 
Mexico. Through strategic and targeted intelligence sharing, and joint 
investigative efforts, the impacts of our investigations are magnified. 
Whether through bi-national operations to arrest cartel leadership, or 
through sharing a piece of intelligence that may illuminate a 
previously unknown network, the building and strengthening of these 
partnerships is key to our efforts to combat the cartels and to stop 
threats, to include illicit opioids, before they reach our borders.
                               conclusion
    Thank you again for the opportunity to appear before you today and 
for your continued support of ICE HSI and its law enforcement mission. 
ICE HSI is committed to battling the U.S. opioid crisis. This includes 
ICE HSI's collaborative efforts to reduce and ultimately stop the flow 
of these dangerous drugs across the border here in Arizona and tackling 
the significant challenges we see in increased smuggling through the 
mail and express consignment systems. ICE HSI will continue to 
vigorously pursue the cartels that bring not only heroin and fentanyl 
to the United States, but other narcotics that have a dangerous, and 
too often deadly, impact on our communities. The opioid crisis is an 
epidemic that demands continued urgent and immediate action across law 
enforcement agencies and in conjunction with experts in the scientific, 
medical, and public health communities. I appreciate your interest in 
this important issue and look forward to your questions.

    Ms. McSally. Thank you, Mr. Brown.
    The Chair now recognizes Mr. Coleman to testify for 5 
minutes.

   STATEMENT OF DOUGLAS W. COLEMAN, SPECIAL AGENT IN CHARGE, 
     PHOENIX FIELD DIVISION, DRUG ENFORCEMENT AGENCY, U.S. 
                     DEPARTMENT OF JUSTICE

    Mr. Coleman. Distinguished Members of the committee, on 
behalf of Acting Administrator Patterson and the men and women 
of the Drug Enforcement Administration, I appreciate your 
invitation to testify today about the growing threat of opioid 
trafficking across the Southwest Border and the impact that 
these activities of narco-trafficking organizations are having 
on Arizona.
    For DEA, the opioid crisis is and unfortunately will 
continue to be the top drug threat facing our Nation. This 
epidemic includes not only prescription opioid medications but 
also the proliferation of heroin, illicit fentanyl, and 
fentanyl analogues. Despite record numbers of overdose deaths, 
nearly 64,000 in 2016 alone, we are making progress on the 
prescription drug front. However, we are witnessing a 
fundamental shift toward cheaper, easier-to-obtain heroin and 
illicit fentanyl and its related analogues.
    Over the last few years, Mexican drug cartels have 
exploited the increased demand for heroin and boosted their 
heroin production, transportation, and trafficking operations 
to get more heroin into the United States, predominantly across 
the Southwest Border. In addition, Chinese manufacturers began 
to produce fentanyl and fentanyl analogues and ship them to the 
United States via mail, or to Mexico, to be mixed into the U.S. 
domestic heroin supply, or pressed into a pill form and then 
moved to the illicit U.S. market where demand for prescription 
opioids and heroin remain at epidemic proportions.
    More recently, Mexican DTOs are acquiring precursor 
chemicals and manufacturing fentanyl and its analogues to 
compete with the Chinese suppliers. The DEA in Arizona has been 
at the forefront of recognizing and responding to this 
increased heroin and fentanyl trafficking from the Mexican 
cartels. The Sinaloa Cartel is the primary drug threat to 
Arizona, as its organization influences and controls virtually 
all transportation and entry point importation along the 
Arizona-Mexico border. Additionally, the Sinaloa Cartel directs 
command-and-control cells in Phoenix and Tucson who are the 
choke points for both the drugs coming into the United States 
and the illicit proceeds returning to Mexico.
    DEA's Phoenix Field Division's response has been multi-
layered and comprehensive. No group in American law enforcement 
knows the Sinaloa Cartel and their operations better than the 
DEA in Arizona, and our strategy was developed based on this 
long-term knowledge of how this organization operates.
    The first pillar of the strategy involves increasing our 
focus on the command-and-control cells operating in Phoenix and 
Tucson. These cells are often difficult to penetrate and 
require lengthy, complex investigations targeting communication 
facilities and cartel members who direct operations throughout 
the United States and coordinate with high-level cartel 
leadership in Mexico.
    Working with our State, local, Tribal, and Federal 
partners, we have increased these types of complex conspiracy 
investigations targeting opiate trafficking by more than 60 
percent over the last 3 years, resulting in the arrests of 
hundreds of high-level traffickers and the seizure of thousands 
of pounds of heroin and fentanyl, as well as the disruption and 
dismantlement of many of these cells.
    The next pillar of our strategy was to increase our ability 
to directly support State and local law enforcement efforts 
targeting overdose deaths and community impact. To do this, we 
created a Heroin Enforcement Action Team, or HEAT, to directly 
respond to local area opioid-related overdoses, attempting to 
expand overdose investigations to identify and target those 
directly responsible for supplying heroin/fentanyl to the 
overdose victims. By doing this, HEAT is a force multiplier to 
any State and local heroin investigation and allows us to 
target and bring to justice those individuals having the 
greatest negative impact in the local community.
    Since its inception, the HEAT team has expanded to include 
relationships with over 40 governmental law enforcement 
agencies in Arizona and has arrested and prosecuted many 
individuals who were directly responsible for distributing 
opioids resulting in overdoses. The HEAT has been an incredibly 
beneficial program to local law enforcement, and we continue to 
expand both its footprint and operations throughout the State.
    The final pillar of our strategy involves a robust and 
comprehensive public awareness and education campaign. In 2015 
and 2017, we partnered with Arizona State University on two 
``Hooked'' television specials about the dangers of heroin and 
diverted controlled prescription drugs that reached over 2 
million Arizonans. We also conducted over 135 community 
outreach events over the past 3 years, educating thousands of 
Arizona residents about the dangers of heroin and opioid abuse. 
Finally, DEA officials have appeared on Arizona media--TV, 
radio, and newspaper--over 100 times in the past 3 years 
discussing the opioid addiction issue in a variety of forums.
    While DEA in Arizona has a robust and comprehensive 
strategy to combat opioid abuse and trafficking in our State, 
we realize that our efforts, while having a significant impact 
and many successes, must be maintained and expanded to continue 
to best serve the citizens of Arizona and the United States. 
Rest assured that the men and women of DEA in Arizona will 
never relent, and we will continue to do everything in our 
power to do our part to help end this deadly epidemic.
    On behalf of DEA, I thank the committee for the opportunity 
to speak today, and I am happy to answer any questions.
    [The prepared statement of Mr. Coleman follows:]
                Prepared Statement of Douglas W. Coleman
                              May 30, 2018
    Chairman McSally, Ranking Member Vela, and Members of the 
subcommittee, on behalf of the approximately 9,000 employees of the 
Drug Enforcement Administration (DEA), thank you for the opportunity to 
discuss the threat posed by the flow of heroin, fentanyl, and fentanyl 
analogues across our borders, specifically in Arizona, and DEA's 
efforts, along with our Federal, State, and local partners, to combat 
this crisis.
    Today, Mexican Transnational Criminal Organizations (TCOs) remain 
the greatest criminal drug threat to the United States; no other group 
can challenge them in the near term. These Mexican poly drug 
organizations traffic heroin, fentanyl, fentanyl analogues, 
methamphetamine, cocaine, and marijuana throughout the United States, 
using well-established transportation routes and distribution networks. 
They control drug trafficking across the Southwest Border (SWB) and are 
moving to expand their share of distribution and sales in U.S. domestic 
illicit drug markets, particularly heroin markets. At the same time, we 
face significant challenges with the emergence of fentanyl being hidden 
in the enormous volume of international parcel traffic by mail and 
express consignment couriers.
    Drug overdoses, suffered by family, friends, neighbors, and 
colleagues, are now the leading cause of injury-related death in the 
United States, eclipsing deaths from motor vehicle crashes or 
firearms.\1\ According to the Centers for Disease Control and 
Prevention (CDC), there were nearly 64,000 overdose deaths in 2016, or 
approximately 174 per day. Over 42,200 (66 percent) of these deaths 
involved opioids. The sharp increase in drug overdose deaths between 
2015 to 2016 was fueled by a surge in fentanyl and fentanyl analogues 
(synthetic opioids) involved overdoses.\2\ Maricopa County is the most 
populated county in Arizona and encompasses the Phoenix metropolitan 
area. The Maricopa County Office of the Medical Examiner (MCOME) 
reported that in 2016 there were 647 overdose deaths while preliminary 
reporting for 2017 reflects an increase of opioid-related drug overdose 
deaths to 674. That number is expected to rise as toxicology reports 
are retuned and investigations finalized.
---------------------------------------------------------------------------
    \1\ Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, & R. Matthew 
Gladden. Increases in Drug and Opioid Overdose Deaths--United States, 
2000-2014 Morbidity and Mortality Weekly Report, 2016;64:1378-1382.
    \2\ CDC WONDER data, retrieved from the National Institute of 
Health website; http://www.drugabuse.gov as reported on NIDA's website.
---------------------------------------------------------------------------
    The incidence of misuse of controlled prescription drugs (CPDs) and 
the growing use of heroin, fentanyl, and fentanyl analogues are being 
reported in the United States at unprecedented levels. According to the 
Substance Abuse and Mental Health Services Administration (SAMHSA) 2016 
National Survey on Drug Use and Health (NSDUH), an estimated 6.2 
million people over the age of 12 misused psychotherapeutic drugs 
(e.g., pain relievers, tranquilizers, stimulants, and sedatives) during 
the past month.\3\ This represents 22 percent of the 28.6 million 
current illicit drug users, and is second only to marijuana (24 million 
users) in terms of usage.\4\ There are more current misusers of 
psychotherapeutic drugs than current users of cocaine, heroin, and 
hallucinogens combined.\5\
---------------------------------------------------------------------------
    \3\ Substance Abuse and Mental Health Services Administration. 
(2017). Key substance use and mental health indicators in the United 
States: Results from the 2016 National Survey on Drug Use and Health 
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: 
Center for Behavioral Health Statistics and Quality, Substance Abuse 
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
    \4\ Substance Abuse and Mental Health Services Administration. 
(2017). Key substance use and mental health indicators in the United 
States: Results from the 2016 National Survey on Drug Use and Health 
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: 
Center for Behavioral Health Statistics and Quality, Substance Abuse 
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
    \5\ Substance Abuse and Mental Health Services Administration. 
(2017). Key substance use and mental health indicators in the United 
States: Results from the 2016 National Survey on Drug Use and Health 
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: 
Center for Behavioral Health Statistics and Quality, Substance Abuse 
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
---------------------------------------------------------------------------
    The increase in the number of people using heroin in recent years--
from 373,000 past year users in 2007 to 948,000 in 2016--is 
troubling.\6\ More alarming is the proliferation of illicit fentanyl 
and fentanyl analogues. DEA investigations reveal that fentanyl and its 
analogues are increasingly being added to heroin and frequently pressed 
into counterfeit tablets resembling CPDs. Because of its high potency, 
the more illicit fentanyl and fentanyl analogues are introduced to the 
11.5 million people that misused a pain reliever in the previous year, 
the more likely that drug overdoses will continue to climb.\7\ In 
short, we are witnessing the transition from CPDs to heroin, fentanyl, 
and fentanyl analogues as the primary killer and peril within the 
opioid epidemic.
---------------------------------------------------------------------------
    \6\ Center for Behavioral Health Statistics and Quality. (2017). 
2016 National Survey on Drug Use and Health: Detailed Tables. Substance 
Abuse and Mental Health Services Administration, Rockville, MD
    \7\ Center for Behavioral Health Statistics and Quality. (2017). 
2016 National Survey on Drug Use and Health: Detailed Tables. Substance 
Abuse and Mental Health Services Administration, Rockville, MD
---------------------------------------------------------------------------
    DEA's focus is targeting the most significant, sophisticated, and 
violent trafficking organizations that profit from exploiting persons 
with substance use disorders. DEA's strategic priorities include 
targeting Mexican Consolidated Priority Organization Targets (CPOTs) 
and Priority Target Organizations (PTOs), which are the most 
significant international and domestic drug trafficking and money-
laundering organizations.
                  controlled prescription drugs (cpds)
    Black-market prices for sales of opioid CPDs are typically 5 to 10 
times their retail value. DEA intelligence reveals the ``street'' cost 
of prescription opioids steadily increases with the relative strength 
of the drug. For example, hydrocodone combination products (a Schedule 
II prescription drug and also the most prescribed CPD in the 
country)\8\ can generally be purchased for $5 to $10 per tablet on the 
street. Slightly stronger drugs like oxycodone combined with 
acetaminophen (e.g., Percocet) can be purchased for $7 to $10 per 
tablet on the street. Even stronger prescription drugs are sold for as 
much as $1 per milligram (mg). For example, 30 mg oxycodone (immediate 
release) and 30 mg oxymorphone (extended release) cost $30 to $40 per 
tablet on the street. The costs that ensue with greater tolerance make 
it difficult to purchase these drugs in order to support a developing 
substance use disorder, particularly when many first obtain these drugs 
for free from the family medicine cabinet or from friends.\9\
---------------------------------------------------------------------------
    \8\ On October 6, 2014, DEA published a final rule in the Federal 
Register to move hydrocodone combination products from Schedule III to 
Schedule II, as recommended by the Assistant Secretary for Health of 
the U.S. Department of Health and Human Services.
    \9\ Substance Abuse and Mental Health Services Administration. 
(2017). Key substance use and mental health indicators in the United 
States: Results from the 2016 National Survey on Drug Use and Health 
(HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: 
Center for Behavioral Health Statistics and Quality, Substance Abuse 
and Mental Health Services Administration. Retrieved from https://
www.samhsa.gov/data/.
---------------------------------------------------------------------------
                                 heroin
    The vast majority of heroin consumed in the United States is 
produced and distributed by powerful Mexico-based TCOs, such as the 
Sinaloa Cartel and Jalisco New Generation Cartel, and transported to 
the United States across the Southwest Border. These TCOs are extremely 
dangerous, violent, and will continue to leverage established 
transportation and distribution networks within the United States.
    Not surprisingly, some people who misuse prescription opioids turn 
to heroin. Heroin traffickers produce high purity white powder heroin 
that costs approximately $10 per bag, and usually contains 
approximately 0.30 grams per bag. This makes heroin significantly less 
expensive than CPDs. Heroin produces a ``high'' similar to opioid CPDs, 
and can keep some individuals who are dependent on opioids from 
experiencing painful withdrawal symptoms. For some time now, law 
enforcement agencies across the country have been specifically 
reporting an increase in heroin use by those who began misusing 
prescription opioids.\10\
---------------------------------------------------------------------------
    \10\ U.S. Department of Justice, Drug Enforcement Administration, 
2016 National Heroin Threat Assessment Summary, DEA Intelligence 
Report, April 2016, available at: https://www.dea.gov/divisions/hq/
2016/hq062716_attach.pdf.
---------------------------------------------------------------------------
    According to reporting by treatment providers, many individuals 
with serious opioid use disorders will use whichever drug is cheaper 
and/or available to them at the time.\11\ Heroin purity and dosage 
amounts vary, and heroin is often adulterated with other substances 
(e.g., fentanyl and fentanyl analogues). This means that heroin users 
run a higher risk of unintentional overdose because they cannot predict 
the dosage of synthetic opioid in the product they purchase on the 
street as heroin.\12\ Additionally, varying concentrations found in 
diverted or counterfeit prescription opioids purchased on the street 
have led to increased unintentional drug overdose deaths. Roughly 75 
percent of heroin users reported nonmedical use of prescription opioids 
before initiating heroin use.\13\ The reasons an individual may shift 
from one opioid to another vary, but today's heroin is high in purity, 
less expensive, and often easier to obtain than illegal opioid CPDs.
---------------------------------------------------------------------------
    \11\ U.S. Department of Justice, Drug Enforcement Administration, 
2014 National Drug Threat Assessment Summary, November, 2014.
    \12\ Stephen E. Lankenau, Michelle Teti, Karol Silva, Jennifer 
Jackson Bloom, Alex Harocopos, and Meghan Treese, Initiation into 
Prescription Opioid Misuse Among Young Injection Drug Users, Int J Drug 
Policy, Author manuscript; available in PMC 2013 Jan 1, Published in 
final edited form as: Int J Drug Policy, 2012 Jan; 23(1): 37-44. 
Published on-line 2011 Jun 20. doi: 1016/j.drugpo.2011.05.014. and; 
Mars SG, Bourgois P, Karandinos G, Montero F, Ciccarone D., ``Every 
`Never' I Ever Said Came True'': Transitions From Opioid Pills to 
Heroin Injecting, Int J Drug Policy, 2014 Mar; 25(2):257-66. doi: 
110.1016/j.drugpo.2013.10.004. Epub 2013 Oct 19.
    \13\ Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. (2014). The 
changing face of heroin use in the United States: a retrospective 
analysis of the past 50 years. JAMA Psychiatry.71(7):821-826.
---------------------------------------------------------------------------
    Overdose deaths involving heroin are increasing at an alarming 
rate, having increased more than fivefold since 2010.\14\ Today's 
retail-level heroin costs less and is more potent than the heroin DEA 
encountered two decades ago. It is also not uncommon for heroin users 
to seek out heroin dealers claim is ``hot,'' meaning it is likely cut 
with fentanyl or its analogues. Users seeking ``hot'' heroin is an 
indicator that as higher opioid tolerance levels develop, users will 
seek out ever more potent forms of opioids.
---------------------------------------------------------------------------
    \14\ CDC WONDER data accessed on 10/15/17, as reported at NIDA's 
website: 3,036 heroin overdoses in 2010; 15,446 overdoses in 2016. 
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-
death-rates.
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                    fentanyl and fentanyl analogues
    Fentanyl is a Schedule II controlled substance produced in the 
United States and widely used in medicine. It is an extremely potent 
analgesic indicated for use anesthesia and pain control in people with 
serious pain problems, and only for individuals who have high opioid 
tolerance.
    Illicit fentanyl, fentanyl analogues, and their immediate 
precursors, are often produced in China. From China, these substances 
are shipped through private couriers or mail carriers directly to the 
United States, or alternatively shipped directly to TCOs in Mexico, 
Canada, or the Caribbean. Once in the Western Hemisphere, fentanyl or 
fentanyl analogues are prepared to be mixed into the U.S. domestic 
heroin supply, or pressed into a pill form, and then moved to the 
illicit U.S. market where demand for prescription opioids and heroin 
remain at epidemic proportions. In some cases, traffickers set up 
Chinese pill presses in the United States, and press fentanyl pills 
domestically. Mexican TCOs have also seized upon this business 
opportunity because of the profit potential of synthetic opioids, and 
have invested in growing their share of this illicit market. Because of 
its low dosage range and high potency, one kilogram of fentanyl 
purchased in China for $3,000-$5,000 can generate upwards of $1.5 
million in revenue on the illicit market.\15\
---------------------------------------------------------------------------
    \15\ U.S. Department of Justice, Drug Enforcement Administration, 
2017 National Drug Threat Assessment Summary, October 2017.
---------------------------------------------------------------------------
    According to the DEA National Forensic Laboratory Information 
System (NFLIS), from January 2013 through December 2016, over 58,000 
fentanyl exhibits were identified by Federal, State, and local forensic 
laboratories.\16\ During 2016, there were 36,061 fentanyl reports 
compared to 1,042 reports in 2013,\17\ an exponential increase over the 
past 4 years. The consequences of fentanyl misuse are often fatal and 
occur amongst a diverse user base. According to a December 2017 CDC 
Data Brief, from 2015 to 2016, the death rate from synthetic opioids 
other than methadone, a category that includes fentanyl, doubled from 
9,580 (age adjusted rate 3.1) to 19,413 (the age-adjusted rate of drug 
overdose deaths involving synthetic opioids other than methadone [drugs 
such as fentanyl, fentanyl analogs, and tramadol] doubled between 2015 
and 2016, from 3.1 to 6.2 per 100,000).\18\
---------------------------------------------------------------------------
    \16\ U.S. Department of Justice, DEA, NFLIS, actual data queried on 
October 13, 2017.
    \17\ U.S. Department of Justice, DEA, NFLIS, actual data queried on 
October 13, 2017.
    \18\ Rose A. Rudd, Noah Aleshire, Jon E. Zibbell, & R. Matthew 
Gladden, Hedegaard, H., Margaret Warner, and Arialdi M. Minio. Drug 
Overdose Deaths in the United States, 1999-2016 Increases in Drug and 
Opioid Overdose Deaths--United States, 2000-2014 Morbidity and 
Mortality Weekly Report NCHS Data Brief, 2016; 64:1378-1382 No. 294, 
Dec 2017. https://www.cdc.gov/nchs/data/databriefs/db294.pdf.
---------------------------------------------------------------------------
    More disturbing is the production of fentanyl pills disguised as 30 
milligram oxycodone pills. In 2017, over 100,000 such pills were seized 
in Arizona.\19\ Alarmingly, intelligence reflects that traffickers may 
be changing their methods and pressing fentanyl into the form of other 
prescription drugs, as they have experienced success in disguising 
fentanyl as oxycodone. Fentanyl-related deaths have been reported in 
Florida where fentanyl was made to look like Xanax pills; and in 
California, where pills were made to look like Norco.\20\ In addition 
to the fake oxycodone pills, 22 kilograms of fentanyl were seized in 
Arizona in calendar year 2016 and 125 kilograms were seized in calendar 
year 2017.\21\ In July 2017, the first carfentanil seizure occurred in 
Arizona, by the Salt River Police Department, where 397 blue tablets 
were also designed to resemble pharmaceutically manufactured 
oxycodone.\22\
---------------------------------------------------------------------------
    \19\ EPIC National Seizure System.
    \20\ DEA Intelligence Brief/(U//FOUO) Counterfeit Prescription 
Pills Containing Fentanyls: A Global Threat--May 2016.
    \21\ EPIC National Seizure System.
    \22\ Joint Arizona HIDTAS/DEA Officer Safety/Situaltional Awareness 
Report--First Carfentanil Seizure in Arizona--May 2018.
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                    current assessment of the threat
Threats at the Southwest Border
    Based on active law enforcement cases, the following Mexican TCOs 
are operating in the United States: the Sinaloa Cartel, Beltran-Leyva 
Organization (BLO), Jalisco New Generation Cartel (Cartel de Jalisco 
Nueva Generacion or CJNG), the Los Cuinis, Gulf Cartel (Cartel del 
Golfo or CDG), Juarez Cartel, La Linea, Michoacan Family (La Familia 
Michoacana or LFM), Knights Templar (Los Caballeros Templarios or LCT), 
and Los Zetas. While all of these Mexican TCOs transport wholesale 
quantities of illicit drugs into the United States, the Sinaloa Cartel 
remains the most active supplier and is the primary source for 
wholesale traffickers impacting Arizona. The Sinaloa Cartel leverages 
its expansive resources and organizational structure in Mexico to 
facilitate the smuggling and transportation of drugs throughout the 
United States.
    Mexican TCO operations in the United States typically take the form 
of a supply chain system that relies on compartmentalized operators who 
are only aware of their own specific function, and who remain unaware 
of other operational aspects. In most instances, transporters for the 
drug shipments are independent third parties who work for more than one 
Mexican TCO. Since operators in the supply chain are insulated from one 
another, if a transporter is arrested, the transporter is easily 
replaced and unable to reveal the rest of the network to law 
enforcement.
    The foundation of Mexican TCO operations in the United States is 
comprised of extensive and well-entrenched transportation and 
distribution networks based throughout the United States. Frequently, 
members of Mexican TCOs are sent to important U.S. hub cities to manage 
stash houses containing drug shipments and bulk cash drug proceeds. 
While operating in the United States, Mexican TCOs actively seek to 
maintain low profiles and avoid violent confrontations with other, 
rival TCOs, or U.S. law enforcement.
    Mexican TCOs transport illicit drugs over the SWB through ports of 
entry (POE) using passenger vehicles or tractor-trailers. In Arizona, 
the Nogales POEs are the primary entry points for heroin and fentanyl, 
and along with other drugs, are typically secreted in hidden 
compartments when transported in passenger vehicles, or comingled with 
legitimate goods when transported in tractor-trailers. Once across the 
SWB, Mexican TCOs will initially utilize stash houses in a number of 
hub cities, including Dallas, Houston, Los Angeles, Atlanta, Phoenix, 
and Tucson. The illicit products will then be transported via these 
same conveyances to distribution groups in the Midwest and on the East 
Coast. Mexican TCOs also smuggle illicit drugs across the SWB using 
other methods, including tunnels, maritime conveyances, aircraft, and 
body-carriers through pedestrian lanes at POEs.
Importation vs. Domestic Production and Use of the Internet
    Fentanyl, fentanyl analogues, and other synthetics, are relatively 
inexpensive, available via the internet, and are often manufactured in 
China. From there, they may be shipped (via U.S. mail or express 
consignment couriers) to the United States, or alternatively directly 
to transnational criminal organizations in Mexico, Canada, and the 
Caribbean. Once in the Western Hemisphere, fentanyl and fentanyl 
analogues in particular are combined with both heroin or binders and 
pressed into counterfeit pills made to look like controlled 
prescription drugs containing oxycodone or hydrocodone, and then sold 
on-line from anonymous dark net markets and even overtly operated 
websites. The combination of: The questionable legal status of these 
substances, which are not specifically named in the Controlled 
Substances Act (CSA) itself or by DEA through scheduling actions; the 
enormous volume of international parcel traffic by mail and express 
consignment couriers; and the technological and logistical challenges 
of detection and inspection, make it extremely challenging for the U.S. 
Customs and Border Protection (CBP) to effectively address the threat 
at ports of entry and pave the way for non-cartel-affiliated 
individuals to undertake fentanyl trafficking. DEA is working with CBP 
to increase coordination on seized parcels.
Use of Freight Forwarders
    Traffickers often use freight forwarders to ship fentanyl, fentanyl 
analogues, and other new psychoactive substances (NPS) from China. 
Several DEA investigations have revealed that the original supplier 
will provide the package to a freight forwarding company or individual, 
who transfers it to another freight forwarder, who then takes custody 
and presents the package to customs for export. The combination of a 
chain of freight forwarders and multiple transfers of custody make it 
difficult for law enforcement to track these packages. Often, the 
package will intentionally have missing, incomplete, and/or inaccurate 
information.
                    significant enforcement efforts
Heroin Fentanyl Task Force
    The DEA Special Operations Division (SOD) Heroin/Fentanyl Task 
Force (HFTF) working group consists of several agencies using a joint 
``whole-of-Government'' approach to counter the fentanyl/opioid 
epidemic in the United States. The HFTF consists of personnel from DEA, 
U.S. Immigration and Customs Enforcement, Homeland Security 
Investigations (HSI) and CBP; supplemented by the Federal Bureau of 
Investigation and the U.S. Postal Inspection Service. HFTF utilizes 
every resource available, including support from the Department of 
Justice's Organized Crime Drug Enforcement Task Forces (OCDETF), OCDETF 
Fusion Center (OFC), and the Criminal Division, the Department of 
Defense (DOD), the intelligence community (IC), and other Government 
entities, and provides field offices (all agencies) with valuable 
support in their respective investigations.
    The HFTF mission aims to:
   Identify, target, and dismantle command-and-control networks 
        of national and international fentanyl and NPS trafficking 
        organizations.
   Provide case coordination and de-confliction on all domestic 
        and foreign investigations to ensure that multi-jurisdictional, 
        multi-national, and multi-agency investigations and 
        prosecutions have the greatest impact on targeted 
        organizations.
   Provide direct and dynamic operational and investigative 
        support for domestic and foreign field offices for all 
        agencies.
   Identify new foreign and domestic trafficking, 
        manufacturing, importation, production, and financial trends 
        utilized by criminal enterprises.
   Analyze raw intelligence and documented evidence from 
        multiple resources to develop actionable leads on viable 
        target(s) involved in possible illicit pill production and/or 
        distribution networks.
   Educate overall awareness, handling, trafficking trends, 
        investigative techniques, and safety to domestic and foreign 
        field offices for all law enforcement, DOD, IC, and 
        Governmental agencies.
   Facilitate, coordinate, and educate judicial districts 
        during prosecutions of fentanyl and other NPS-related cases.
    Close interagency cooperation via the HFTF has led to several large 
enforcement actions, including the first-ever indictment, in two 
separate OCDETF cases, of two Chinese nationals responsible for the 
manufacturing and distribution of illicit fentanyl in the United States 
in October 2017. On October 17, the deputy attorney general and the DEA 
acting administrator announced the indictments of the Chinese 
nationals, who were the first manufacturers and distributors of 
fentanyl and other opiate substances to be designated as CPOTs. CPOT 
designations are of those who have ``command-and-control'' elements of 
the most prolific international drug trafficking and money laundering 
organizations operating in the world.
    In addition, SOD's HFTF played an integral role in the July 2017 
seizure and shutting down of the largest criminal marketplace on the 
internet, AlphaBay. As outlined by the attorney general and the DEA 
acting principal deputy administrator, AlphaBay operated for over 2 
years on the dark web and was used to sell deadly illegal drugs, stolen 
and fraudulent identification documents and access devices, counterfeit 
goods, malware and other computer hacking tools, firearms, and toxic 
chemicals throughout the world. The international operation to seize 
AlphaBay's infrastructure was led by the United States and involved 
cooperation and efforts by law enforcement authorities in Thailand, the 
Netherlands, Lithuania, Canada, the United Kingdom, and France, as well 
as the European law enforcement agency Europol. Multiple interagency 
OCDETF investigations into AlphaBay revealed that numerous vendors, 
including many in China, sold illicit fentanyl and heroin on the site, 
and that there have been a substantial number of overdose deaths across 
the country attributed to such purchases.
Cooperation with Mexico
    DEA's presence in Mexico represents our largest international 
footprint. The ability to have DEA special agents assigned to 11 
different offices throughout Mexico is a reflection of the level of 
cooperation that we continue to enjoy with our Mexican counterparts. 
DEA supports bi-lateral investigations with the government of Mexico by 
providing information and intelligence to develop investigations that 
target leaders of TCOs throughout Mexico. The United States and Mexico 
have established a strong and successful security partnership in the 
last decade and, to that end, the U.S. Government stands ready to work 
with our Mexican partners to provide any assistance, as requested, to 
build upon these successes.
DEA Phoenix Field Division Response
    DEA's Phoenix Field Division response has been multi-layered and 
comprehensive. No group in American law enforcement knows the Sinaloa 
Cartel and their operations better than DEA in Arizona, and our 
strategy was developed based on this long-term knowledge of how this 
organization operates.
    The first pillar of the strategy involved increasing our focus on 
the command-and-control cells operating in Phoenix and Tucson. These 
cells are often difficult to penetrate and require lengthy, complex 
investigations targeting communication facilities and cartel members 
who direct operations throughout the United States and coordinate with 
high-level cartel leadership in Mexico. Working with our State, local, 
Tribal, and Federal partners, we have increased these complex 
conspiracy investigations targeting opiate trafficking by more than 60 
percent over the last 3 years, resulting in the arrest of hundreds of 
high-level traffickers, the seizure of thousands of pounds of heroin 
and fentanyl, and the disruption and dismantlement of many of these 
cells.
    The second pillar of the strategy is enhancing DEA's ability to 
directly support Arizona State and local law enforcement efforts 
targeting overdose deaths and community impact. In 2016, the DEA 
Phoenix Field Division created the Heroin Enforcement Action Team 
(HEAT) in response to the growing opioid epidemic in Arizona. HEAT is 
an intelligence-driven enforcement approach partnered with our law 
enforcement, first responders, community outreach programs, and State 
health officials. DEA built a relationship with the Maricopa County 
Office of the Medical Examiner to receive nearly real-time 
investigative reports, leads, and statistics--information previously 
collected, but rarely utilized. This information led HEAT intelligence 
analysts to review overdose cases and then disseminate leads based on 
objective enforcement criteria. Further, the HEAT program also 
conducted overdose investigation training for our Task Force Officers 
(TFOs) and their local departments, then used these TFOs as ``force 
multipliers''--conduits for both potential cases and evidence 
collection. For the first time in the Phoenix Division's history, DEA 
investigators responded directly to heroin and fentanyl overdose scenes 
in order to identify the source of supply. To date, DEA investigations 
in Arizona have resulted in the Federal indictment of three subjects 
for Distribution of a Controlled Substance Resulting in Death and 
Serious Bodily Injury 21 USC 1A 841(a)(1) and 841(b)(1)(C), and one 
plea to a State negligent homicide charge (ARS 13-1102) in Pima County.
    In addition to the HEAT, DEA in Arizona hosts two Tactical 
Diversion Squads (TDS) in Phoenix and Tucson. TDS investigate suspected 
violations of the CSA and other Federal and State statutes pertaining 
to the diversion of controlled substance pharmaceuticals and listed 
chemicals. These unique groups combine the skill sets of special 
agents, diversion investigators, and a variety of State and local law 
enforcement agencies. They are dedicated solely toward investigating, 
disrupting, and dismantling those individuals or organizations involved 
in diversion schemes (e.g., ``doctor shoppers,'' prescription forgery 
rings, and DEA registrants who knowingly divert controlled substance 
pharmaceuticals). Between March 2011 and present, DEA increased the 
number of operational tactical diversion squads (TDSs) from 37 to 77. 
In addition, DEA established two mobile TDS that can deploy quickly to 
``hot spots'' around the country in furtherance of the Diversion 
Control Division's mission. Last year, the Phoenix TDS shut down two 
pharmacies and arrested a pharmacist engaged in the distribution of 
controlled substances,\23\ and the Tucson TDS, in partnership with the 
Arizona Attorney General's Office, recently indicted a Tucson doctor on 
26 State charges for unlawfully prescribing opioids.\24\
---------------------------------------------------------------------------
    \23\ https://www.dea.gov/divisions/phx/2017/phx070717.shtml.
    \24\ https://www.dea.gov/divisions/phx/2018/phx040518.shtml.
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Community Outreach
    The final pillar of DEA's strategy in Arizona involves a robust and 
comprehensive public awareness and education campaign. DEA and the 
Southwest Border High Intensity Drug Trafficking Area (HIDTA)--Arizona 
Region, joined efforts to organize the first Arizona Opioid Summit: 
Turning the Tide in January 2017, followed by a second summit in 
February 2018. The summits promoted the communication between 
traditionally isolated professions and furthered the collaboration 
between law enforcement, treatment, and prevention specialists. This 
past February, DEA and HIDTA partnered with the Institute for the 
Advancement of Behavioral Healthcare, who provided their National 
expertise and sponsorship of an additional 2 days of educational 
courses for medical professionals following the second summit. Over 400 
law enforcement representatives, treatment and prevention specialists, 
medical practitioners, and community advocates attended this year's 
event. Additionally, the Phoenix Field Division has issued three alerts 
to the media and the public regarding new trends observed by DEA in 
Arizona,\25\ including warnings of the first overdose fatalities 
attributed to the synthetic opioid U-47700, the prevalence of overdoses 
attributed to blue fentanyl pills, and the first report of an overdose 
death attributed to the powerful opioid carfetanil. These alerts were 
significant in fostering communication with the community as citizens 
themselves observe and subsequently report information to DEA's Tip 
Line. Furthermore, DEA routinely engages with the media in an effort to 
continue educating the public about the opioid crisis and its impact on 
the State, as well as the Nation. DEA in Arizona has been featured in 
over 100 media broadcasts related to the opioid crisis, most notably, 
two 30-minute investigative reports regarding heroin and diverted CPDs 
produced by Arizona State University's Walter Cronkite School of 
Journalism and Mass Communication. In a unique collaboration with local 
media entities, both reports, Hooked: Tracking Heroin's Hold on Arizona 
and Hooked Rx: From Prescription to Addiction, aired commercial-free 
and during prime time hours and reached over 2 million Arizonans.
---------------------------------------------------------------------------
    \25\ https://www.dea.gov/divisions/phx/2017/phx011017.shtml, 
https://www.dea.gov/divi- sions/phx/2017/phx032117.shtml, https://
www.dea.gov/divisions/phx/2018/phx041618.shtml.
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                               conclusion
    Mexican TCOs remain the greatest criminal drug threat to the United 
States. These Mexican poly drug organizations traffic heroin, 
methamphetamine, fentanyl, cocaine, and marijuana throughout the United 
States, using established transportation routes and distribution 
networks. They control drug trafficking across the SWB and are moving 
to expand their share of U.S. illicit drug markets. Their influence up 
and down the supply chain, their ability to enter into new markets, and 
associations with gangs, are of particular concern for DEA. DEA will 
continue to address this threat domestically and abroad by attacking 
the crime and violence perpetrated by the Mexican-based TCOs, which 
have brought tremendous harm to our communities. In addition, DEA will 
extend its on-going public awareness campaign about the dangers of 
opioids and other drugs as part of its efforts to educate the community 
and other stakeholders who combat, treat, or are otherwise affected by 
this crisis every day. DEA will also work with our partners to address 
the significant challenge presented by new trend of deadly synthetics 
entering our country through the mail and express consignment systems.

    Ms. McSally. Thank you, Mr. Coleman.
    The Chair now recognizes Mr. Roemer for 5 minutes to 
testify.

  STATEMENT OF TIMOTHY ROEMER, DEPUTY DIRECTOR, DEPARTMENT OF 
              HOMELAND SECURITY, STATE OF ARIZONA

    Mr. Roemer. Good morning, Chairwoman McSally, Ranking 
Member Grijalva, Congressman Gallego, Congresswoman Lesko, and 
Congressman Schweikert. Thank you for the opportunity to 
testify today on Arizona's efforts to combat the opioid 
epidemic and to combat illegal activity happening on our 
Southern Border.
    Illegal activity perpetrated across the Southern Border of 
the United States infiltrates communities across Federal, 
State, local, and Tribal jurisdictions, making it absolutely 
necessary for law enforcement agencies at every level to work 
together in order to stop these threats.
    Arizona's border county sheriffs, police chiefs, and their 
teams are on the front lines, protecting their communities 
every day. No one knows the effects of transnational crime on 
our citizens better than they do. They see the devastation of 
human trafficking on victims and their families. They see the 
destructive power that illegal drugs, overdoses, illegal 
weapons, and ammunition have on human lives, and they are 
dedicated to stopping it.
    Formed in 2015, Arizona's Border Strike Force, led by the 
Arizona Department of Public Safety, is truly unique in the 
United States in that it harnesses the expertise and dedication 
of our local law enforcement and combines it with the power of 
the Federal Government to keep America safe. This team's intra-
agency collaboration is unparalleled, and they have results to 
prove it.
    No day or night is routine for this team, and I want to 
share a little more of what they have been interdicting on our 
behalf. A vehicle is stopped going north on I-17 and 5 pounds, 
or almost 225,000 hits of heroin, are found concealed in the 
spare tire. Yet another vehicle is stopped going westbound on 
I-10. Indicators of criminal activity prove true when 6 pounds 
of fentanyl are found wrapped in a gift bag.
    To give you some perspective, a 2- to 3-milligram dose of 
fentanyl is known to be lethal. So in that one car driving down 
I-10 was enough to kill anywhere from 900,000 to over 1.3 
million people. Those aren't even the large-scale operations 
like Operation Cascabel One and Two that resulted in the 
seizure of 131 pounds of meth, 12 pounds of cocaine, 618 pounds 
of marijuana, and 32 stolen vehicles, along with the arrest of 
39 felons.
    I want to emphasize that we can quantify results in a 
number of ways, but there is one metric we can't account for, 
and that is the number of lives that have been saved. Every 
human trafficker caught is one less wreaking havoc in the lives 
of their victims. Every dose of narcotics seized is one less 
destroying lives within our communities in Arizona.
    We are saving lives because the Border Strike Force, and 
our Federal partners across two Presidential administrations, 
are taking the fight to heavily-armed drug cartels and those 
who would do us harm.
    Arizona is also doing more, in real time, to prevent deaths 
from the scourge of opioid overdoses. Since Arizona's opioid 
emergency was declared in June 2017, we have provided over 
6,000 kits or more than 12,000 doses of the overdose reversal 
drug Naloxone. This has been distributed to 63 law enforcement 
agencies across our State.
    Nearly 1,000 law enforcement officers have been trained to 
recognize and treat an opioid overdose. These officers have 
administered Naloxone to 364 individuals, all but 9 of whom 
survived the immediate out-of-hospital event. Also since June, 
approximately 84 percent of the suspected non-fatal overdoses 
received Naloxone pre-hospital from EMS, law enforcement, or 
community members.
    In closing, I want to say thank you once again to our 
Federal partners and everyone at the State, local, and Federal 
levels who support our efforts. I am confident that as our 
partnerships continue to grow in the form of information 
sharing, manpower, and monetary support, more lives will be 
saved, and we are grateful for that.
    Thank you again for affording me the opportunity to testify 
this morning.
    [The prepared statement of Mr. Roemer follows:]
                  Prepared Statement of Timothy Roemer
                              May 30, 2018
    Chairwoman McSally, Congressman Grijalva, distinguished Members of 
the subcommittee, and other Members in attendance, good morning and 
thank you for giving me the opportunity to testify on Arizona's efforts 
to combat the opioid crisis and criminal activity across our Southern 
Border.
    Illegal activity perpetrated across the Southern Border of the 
United States infiltrates communities across Federal, State, local, and 
Tribal jurisdictions making it absolutely necessary for law enforcement 
agencies at every level to work together in order to stop the threats.
    Arizona's border county sheriffs, police chiefs, and their teams 
are on the front lines, protecting their communities every day.
    No one knows the effects of transnational crime on our citizens 
better than they do.
    They see the devastation of human trafficking on victims and their 
families.
    They see the destructive power that illegal drugs, overdoses, 
illegal weapons, and ammunition have on human lives--and they are 
dedicated to stopping it.
    Formed in 2015, Arizona's Border Strike Force, led by the Arizona 
Department of Public Safety is truly unique in the United States in 
that it harnesses the expertise and dedication of our local law 
enforcement and combines it with the power of the Federal Government to 
keep America safe.
    This team's intra-agency collaboration is unparalleled and they 
have results to prove it.
    No day or night is routine for this team, and I want to share a 
little more of what they interdicting on our behalf: A vehicle is 
stopped going north on I-17 and 5 pounds or almost 225,000 hits of 
heroin are found concealed in the spare tire.
    And yet another vehicle is stopped going west-bound on I-10. 
Indicators of criminal activity prove true when 6 pounds of fentanyl 
are found wrapped in a gift bag.
    To give you some perspective, a 2-3 milligram dose of fentanyl is 
known to be lethal. So in that one car driving down I-10 was enough to 
potentially kill anywhere from 900,000 to over 1.3 million people.
    And those aren't even the large-scale operations like Operation 
Cascabel One and Two that resulted in the seizure of 131 pounds of 
meth, 12 pounds of cocaine, 618 pounds of marijuana, and 32 stolen 
vehicles along with the arrest of 39 felons.
    I want to emphasize that we can quantify results in a number of 
ways, but there's one metric we can't account for--and that's the 
number of lives that have been saved.
    Every human trafficker caught is one less wreaking havoc in the 
lives of their victims.
    Every dose of narcotics seized is one less destroying lives within 
our communities.
    We are saving lives, because the Border Strike Force, and our 
Federal partners--across two Presidential administrations--are taking 
the fight to heavily armed drug cartels and those who would do us harm.
    Arizona is also doing more, in real time, to prevent deaths from 
the scourge of opioid overdoses.
    Since Arizona's opioid emergency was declared in June 2017, we have 
provided over 6,000 kits or more than 12,000 doses of the overdose 
reversal drug Naloxone to 63 law enforcement agencies across our State.
    Nearly 1,000 law enforcement officers have been trained to 
recognize and treat an opioid overdose. These officers have 
administered naloxone to 364 individuals, all but 9 of whom survived 
the immediate out-of-hospital event.
    Also since June, approximately 84 percent of the suspected non-
fatal opioid overdoses received naloxone pre-hospital from EMS, law 
enforcement, or community members.
    In closing, I want to say thank you once again to our Federal 
partners and everyone at the State, local, and Federal levels who 
support our efforts.
    I am confident that as our partnerships continue to grow in the 
form of information sharing, manpower, and monetary support, more lives 
will be saved--and we are grateful for that.
    Thank you again for affording me the opportunity to testify this 
morning.

    Ms. McSally. Thank you, Mr. Roemer.
    I now recognize myself for 5 minutes for questions.
    Director Ramirez, the INTERDICT Act came out of our 
committee and was signed into law in January, which provided 
CBP $9 million to procure new opioid and other illicit 
substance screening devices, lab equipment, facilities, 
personnel, for all operational hours to expedite the testing of 
suspected opioids seized at the border and ports of entry.
    Have you seen any of that flow into Arizona yet and making 
an impact at our ports of entry here?
    Mr. Ramirez. Yes, ma'am, Chairwoman McSally.
    Ms. McSally. Can you just speak up?
    Mr. Ramirez. For some reason this mic really wants to be 
very close to me.
    We have. We have in a couple of areas. One of the biggest 
concerns we have, as you know, with fentanyl, as deadly as it 
is, is to ensure that as we dismantle vehicles and get the 
narcotics and we test them, that we do not contaminate any of 
our officers or the traveling public.
    The technology that we are using, now thanks to the support 
of Congress, is our testing equipment, which is basically 
laser-based. Instead of having to take the narcotics and put it 
into a little pouch, you have the Gemini system which will read 
it, and we also have the glove boxes, which is a sealed 
compartment where you put the narcotics in, and then you put 
your hand in through gloves. It is completely sealed, and you 
test the narcotics. That, along with X-ray equipment, which is 
always welcome at the ports of entry, has been a great help.
    Ms. McSally. Great. Thank you.
    This whole panel is about the supply, the easy supply that 
is out there for people to become addicted. Our next panel will 
be talking more about a whole-of-society approach to address 
some of the other root issues. But as we are looking to crack 
down on the supply, is it fair to characterize it as efforts 
have been made to crack down on the over-prescription and the 
pill mills and those types of things?
    You have people who are addicted that are now going on to 
the illicit market because it is cheaper for them to get the 
product they need to feed their addiction, and that is where 
the dangers are increased because it can be laced with higher 
doses than expected, or other drugs, and people are overdosing 
and dying because they are being driven to the illicit market. 
Is that a fair characterization of what has happened and our 
level of awareness has gone up and how the dangers are 
increasing? If anybody wants to answer.
    Mr. Roemer. I believe so, if I may, Chairwoman. Four out of 
every five new heroin users start addicted to a painkiller, a 
prescription painkiller. So, as we have seen, as the Governor's 
testimony and all the great efforts of the State of Arizona, 
Dr. Cara Christ leading the Department of Health Services, as 
we have seen those statistics plummet of the number of opioids 
prescribed, that is going to make a huge dent in those new 
heroin users.
    Ms. McSally. Yes. Does anybody else want to comment on 
that?
    Mr. Coleman. I think you hit it right on the head. The 
reality is that as we have seen our prescription drug epidemic 
increase, the Mexican cartels, as they always do, have taken 
advantage of the fact that we have so many. What has happened 
is that the increased heroin has created more competition for 
them, which has led to the increased production and 
distribution of fentanyl to make a stronger product to compete 
against each other to make sure they keep those repeat 
customers.
    Ms. McSally. OK, thanks.
    So, we hear the number often that 90 percent of drugs that 
come over the border come through the ports of entry. When we 
are talking specifically about opioids, heroin, fentanyl, like 
everything that is related to this crisis, I don't know who can 
answer this, but do we have a percentage or understanding of 
what is coming through the ports of entry and what is coming 
through the mail from China?
    Mr. Coleman. A difficult question to answer. The answer is 
if I knew where all of it was coming from, I would seize all of 
it.
    Ms. McSally. From what we know, just what we know.
    Mr. Coleman. What we know is that the reality is that most 
of our large shipments of hard drugs are coming across the 
border. We do see a significant portion coming through the mail 
of the smaller quantities, especially when it comes to 
fentanyl. So I don't know if there is a percentage we could put 
on it. Ninety percent probably seems a little bit high, but 
there is a very significant portion of it----
    Ms. McSally. But of that coming across the border, what 
number is coming through the ports of entry versus----
    Mr. Coleman. For the hard drugs, it is probably 90 percent, 
at least. But marijuana and softer drugs come through--they 
walk across.
    Ms. McSally. So the reality is, obviously, because it is 
still so cheap on the streets, that a lot is getting through 
that we are not detecting. What else can we do in order to be 
able to detect it? We have some additional non-intrusive 
inspection capabilities. Is there anything else, Mr. Ramirez, 
that we can do? Because we are missing a lot of it, not related 
to the professionalism of your teams here. It is just very 
difficult to detect and intercept. So what else can be done?
    Mr. Ramirez. I thank the continued support we have seen 
from Congress. When it comes to staffing, thank you for your 
support with the VRA. Staffing is a huge part of it, 
infrastructure and technology. So the continued support in 
those areas will absolutely help us dramatically in our efforts 
at the ports of entry.
    Ms. McSally. OK, great. I am going to yield back my 2 
seconds.
    The Chair now recognizes the Ranking Member, Acting Ranking 
Member, Mr. Grijalva, for 5 minutes.
    Mr. Grijalva. Thank you very much, Madam Chair.
    Mr. Ramirez, following up on the Chair's question--if I 
may, Madam Chair, if there is no objection, enter into the 
record a statement by Mr. Anthony Reardon, National President, 
National Treasury Employees Union, on the topic of this 
hearing.
    Ms. McSally. Without objection.
    Mr. Grijalva. Thank you very much.
    [The information follows:]
Statement of Anthony M. Reardon, National President, National Treasury 
                            Employees Union
                              May 30, 2018
    Chairman McSally, Ranking Member Vela, distinguished Members of the 
subcommittee, thank you for the opportunity to provide this testimony 
on the role of Customs and Border Protection (CBP) in addressing the 
Nation's opioid crisis. As president ofthe National Treasury Employees 
Union (NTEU), I have the honor of leading a union that represents over 
25,000 CBP officers, agriculture specialists, and trade enforcement 
specialists stationed at 328 land, sea, and air ports of entry across 
the United States and 16 PreClearance stations.
    Any discussion of the opioid crisis and the resources needed to 
stop the movement of opioids across the border must include the role of 
CBP officers at the ports of entry and the need to hire new CBP Office 
of Field Operations (OFO) personnel. Between 2013 and 2017, 
approximately 25,405 pounds, or 88 percent, of all international 
arrivals of opioids, were seized by CBP officers at the ports of entry.
    CBP OFO is the largest component of CBP responsible for border 
security--including anti-terrorism, immigration, anti-smuggling, trade 
compliance, and agriculture protection--while simultaneously 
facilitating lawful trade and travel at U.S. ports ofentry that are 
critical to our Nation's economy. CBP OFO has a current need to hire 
2,516 additional CBP officers and 721 agriculture specialists to 
achieve the staffing target as stipulated in CBP's own fiscal year 2018 
Workload Staff Model (WSM) and Agriculture Resource Allocation Model 
(AgRAM.) According to CBP's Congressional Affairs Office, as of May 4, 
2018, CBP OFO has 23,147 CBP officers on-board at the ports of entry--
1,328 short of the authorized staffing level of 24,475.
    Trade and travel volume continue to increase every year, but CBP 
OFO staffing is not keeping pace with this increase. New and expanded 
Federal inspection facilities are being built at the air, sea, and land 
ports, yet CBP OFO staffing is not expanding. For example, in June, a 
new Federal inspection terminal will open at the San Diego Airport. 
Inspection volume will increase from 300 air passengers an hour to 
1,000 air passengers an hour. Currently, there are a total of 53 front-
line officers split between the airport and seaport. CBP needs to hire 
and assign an additional 38 officers to the airport alone to staff this 
new inspection facility. At the San Ysidro land port, 12 new pedestrian 
lanes and 8 new vehicle lanes come on line in June. There are no new 
CBP officers assigned to this port and beginning on April 1, 2018, 150 
CBP officers have been sent from other short-staffed ports to the 
seriously short-staffed ports of Nogales and San Ysidro for 90-day 
temporary duty assignments.
    To address CBP OFO staffing shortages, and to address the expected, 
ever-increasing volume of trade through the ports of entry in the 
future, Ranking Member Vela and others recently introduced H.R. 4940, 
the Border and Port Security Act, stand-alone, bipartisan legislation 
that would authorize the hiring of 500 additional CBP officers, 100 CBP 
agriculture specialists, and additional OFO trade operations staff 
annually until the staffing gaps in CBP's various Workload Staffing 
Models are met. NTEU strongly supports this CBP officer and agriculture 
specialist--only staffing authorization bill and urges every Member of 
Congress to support this bill.
    NTEU also asks Committee Members to request from the House 
Appropriations Committee up to $100 million in fiscal year 2019 direct 
appropriations for the hiring of 500 CBP officers, 100 CBP agriculture 
specialists, and additional needed non-uniformed Trade Operations and 
support staff.
    The President's fiscal year 2019 budget request does support the 
hiring of new CBP officers to meet the current staffing need of 2,516, 
but seeks to fund these new positions by increasing user fees. The 
President's budget proposal only provides appropriated funding to hire 
60 new CBP officer positions at the National Targeting Center. The 
President's request seeks no appropriated funding to address the 
current CBP officer staffing shortage of 2,516 additional CBP officers 
as stipulated by CBP's own fiscal year WSM or to fund the additional 
721 CBP agriculture specialists as stipulated by CBP's own fiscal year 
2018 AgRAM.
    User Fees.--As in the past, the administration's budget proposes 
significant realignment of user fees collected by CBP. Currently, 33 
percent of a CBP officer's compensation is funded with a combination of 
user fees, reimbursable service agreements, and trust funds. The fiscal 
year 2019 budget proposes to reduce OFO appropriated funding by 
realigning and redirecting user fees, including redirecting the 
Electronic System for Travel Authorization (ESTA) fee that would 
require a statutory change. The fiscal year 2019 budget proposal would 
redirect approximately $160 million in ESTA fees from Brand USA to CBP. 
Rather than redirecting the ESTA fees to fund the additional 2,516 CBP 
officer new hires needed to fully staff CBP officer positions in fiscal 
year 2019 and beyond, as stipulated by CBP's WSM, the budget would in 
fact reduce CBP's appropriated funding by $160 million. Therefore, 
while the budget proposes to increase the number of CBP officer 
positions funded by ESTA user fees by 1,093, it decreases appropriated 
funding by $160 million, and reduces the number of CBP officer 
positions funded by appropriations by 1,093 positions.
    Once again, the President's budget includes CBP officer staffing 
numbers that are dependent on Congress first enacting changes to 
statutes that determine the amounts and disbursement of these user fee 
collections. To accomplish the ESTA fee change in the President's 
budget, Congress must amend the Travel Promotion Act of 2009 (Pub. L. 
111-145). The President's request also proposes fee increases to the 
Immigration and Consolidated Omnibus Budget Reconciliation Act of 1985 
(COBRA) user fees, not a direct up-front appropriation, to fund CBP 
officer new hires as stipulated by the WSM. However, Immigration and 
COBRA user fees cannot be increased without Congress first enacting 
legislation. A proposal to increase user fees has been part of the 
administration's annual budget submission since fiscal year 2014 to 
fund the hiring of new CBP officers. These user fee increase proposals 
are again in the fiscal year 2019 budget request, even though the 
committees with jurisdiction have never shown any interest or even held 
a hearing to discuss this long-standing legislative proposal, and the 
administration has not pressed upon these committee chairs to do so.
    Opioid Interdiction.--CBP OFO is the premier DHS component tasked 
with stemming the Nation's opioid epidemic--a crisis that is getting 
worse. In a report released on May 10, 2019, by the Senate Homeland 
Security and Governmental Affairs Committee Minority titled 
``Combatting the Opioid Epidemic: Intercepting Illicit Opioids at Ports 
of Entry'', CBP officers at the ports of entry were found to ``play a 
key role in stopping opioids and that CBP has significant shortages of 
Port Officers that may be compromising efforts to seize additional 
opioids before they can reach U.S. communities.''
    The smuggling of fentanyl and other opioids has increased markedly. 
According to the report, ``between 2013 and 2017, approximately 25,405 
pounds, or 88 percent of all opioids seized by CBP, were seized at 
ports of entry. The amount of fentanyl seized at the ports of entry 
increased by 159 percent from 459 pounds in 2016 to 1,189 pounds in 
2017.''
    The scourge of synthetic opioid addiction is felt in every State 
and is a threat to the Nation's economic security and well-being. The 
majority of fentanyl is manufactured in other countries such as China, 
and is smuggled primarily through the ports of entry along the 
Southwest Border and through international mail and express consignment 
carrier facilities (e.g. FedEx and UPS).
    According to CBP, on March 24, 2018, CBP officers arrested an 
individual at Arizona's San Luis port of entry after discovering 3.5 
pounds of methamphetamine, worth nearly $11,000, wrapped around his 
torso. Also, at San Luis, on April 27, 2018, a CBP canine team alerted 
CBP officers to a vehicle that was found to have concealed within its 
quarter panels more than 70 pounds of methamphetamine worth over 
$210,000.
    As the Senate report states, CBP officers are, ``in the majority of 
cases, the last line of defense in preventing illicit opioids from 
entering the United States . . . CBP's current shortage of over 4,000 
port officers is directly influencing operations and staffing these 
positions could increase CBP's ability to interdict opioids.''
    Also, according to CBP, over the last 3 years, there were 181 CBP 
employees assigned to the five Postal Service International Service 
Centers and 208 CBP employees assigned to the Private Express Carrier 
Facilities.
    According to the report, on average, CBP officers only inspect 100 
of the 1.3 million in-bound international packages that arrive daily by 
international mail. In 2016, 65 million packages arrive via express 
carriers, which are required by law to provide advanced electronic 
data. However, this data can be incomplete. ``For example, from 2014 
and 2016, CBP issued over 5,000 penalties for incomplete manifest 
information and assessed over $26 million in fines. However, express 
shippers successfully negotiated penalties down to just over $4 
million.''
    In the past year, the FedEx hub in Memphis processed 38 million 
imports and 48 million exports--equaling 86 million in total package 
volume. There are approximately 24 CBP officers in total screening all 
86 million shipments, and on average, about 15 CBP officers are working 
the main overnight FedEx ``sort'' shift. Considering the volume at the 
FedEx hub, NTEU has been told that the port requires a minimum of 60 
CBP officers to facilitate the flow of legitimate freight and ensure 
successful interdiction of these synthetic chemicals. NTEU's CBP OFO 
appropriation request supports both the critical need at the air, sea, 
and land ports of entry, but also at international postal and express 
consignment hubs.
    Last, the Nation's busiest land port of entry San Diego, along with 
the Tucson area land ports, account for ``57 percent of all opioids 
seized by ports of entry, including 75 percent of all fentanyl and 61 
percent of all heroin seized.'' These two land ports are also the most 
critically understaffed. According to CBP, ``these long-term staffing 
shortfalls continue to stretch the limits of operational, enforcement 
and training capabilities at the ports of entry.'' To address these 
shortfalls, CBP solicits non-supervisory officers to serve in Temporary 
Duty (TDY) assignments. Since November 1, 2015 between 80 and 200 CBP 
officers per quarter have been TDYed to the San Diego and Tucson land 
ports. The continuing lack of CBP officer staffing at these ports of 
entry results in forced overtime shifts, multiple deployments away from 
home, and low morale.
    Agriculture Specialist Staffing.--Despite CBP's release of its 
risk-based AgRAM that documents an on-going shortage of CBP agriculture 
specialists--by 721--at the ports of entry, the budget request includes 
no direct appropriation to hire these critical positions needed to 
fulfill CBP's agriculture quarantine inspection (AQI) mission of pest 
exclusion and safeguarding U.S. agriculture and natural resources from 
the risks associated with the entry, establishment, or spread of 
animal, plant pests, and pathogens. NTEU's appropriations request 
includes a direct appropriation to begin to hire the 721 agriculture 
specialists as stipulated in their fiscal year 2018 AgRAM.
    CBP Trade Operations Staffing.--CBP has a dual mission of 
safeguarding our Nation's borders and ports as well as regulating and 
facilitating international trade. CBP employees at the ports of entry 
are the second-largest source of revenue collection for the U.S. 
Government. In 2017, CBP processed more than $2 trillion in imports and 
collected approximately $40 billion in duties, taxes, and other fees. 
Since CBP was established in March 2003, however, there has been no 
increase in non-uniformed CBP trade enforcement and compliance 
personnel even though inbound trade volume grew by more than 24 percent 
between fiscal year 2010 and fiscal year 2014. Additionally, CBP trade 
operations staffing has fallen below the statutory floor set forth in 
the Homeland Security Act of 2002 and stipulated in the fiscal year 
2017 CBP Resource Optimization Model for Trade Positions. NTEU strongly 
supports the funding through direct appropriations of 140 additional 
positions at the CBP Office ofTrade to support implementation of the 
Trade Enhancement and Facilitation Act (Pub. L. 114-125) requirements.
    Hiring Contract.--A funding proposal of concern to NTEU is a $297 
million contract that CBP recently awarded to Accenture Federal 
Services ``to manage the full life cycle of the hiring process from job 
posting to processing'' of 7,500 CBP Border Patrol, Air and Marine, and 
OFO new hires. NTEU has seen reports that the 5-year contract cost is 
approximately $39,600 per hire--nearly the same as the starting salary 
of a CBP officer. NTEU strongly believes that these Federal funds would 
be better spent actually hiring new CBP employees using CBP's in-house 
human resources department rather than in contracting out to a private-
sector consultant ``to augment our internal hiring capabilities.''
    The best recruiters are likely current CBP officers. Unfortunately, 
morale continues to suffer because of staffing shortages and a 
threatened pay freeze, and the administration's proposed cuts to 
retirement, health care, and workers' compensation programs. In 
addition to being overworked due to excessive overtime requirements, 
temporary duty assignments are a major drag on employees, especially 
those with families. Based on their experiences, many officers are 
reluctant to encourage their family members or friends to seek 
employment with CBP. I have suggested to CBP leadership that they look 
at why this is the case.
    NTEU strongly believes that addressing OFO hiring shortages by 
funding needed new CBP officer and agriculture specialist to fill the 
fiscal year staffing gap will do more to improve morale and encourage 
peer-to-peer recruitment than funding a private contractor to help 
recruit and hire new CBP employees.
    Increasing CBP officer staffing at the ports-of-entry is an 
economic driver for the U.S. economy. According to the Joint Economic 
Committee (JEC), ``every day 1.1 million people and $5.9 billion in 
goods legally enter and exit through the ports of entry'' and finds 
that border delays cost the U.S. economy upwards of $5 billion each 
year. CBP estimates that the annual hiring of an additional 500 CBP 
officers at the ports of entry would increase yearly economic activity 
by $1 billion and result in an additional 16,600 jobs per year to the 
U.S. economy.
    Thank you for the opportunity to submit this statement on the CBP 
OFO resources needed to secure and protect the United States on behalf 
of the men and women represented by NTEU at the Nation's ports of 
entry. On behalf of our CBP members, NTEU requests are for Homeland 
Security Committee Members to cosponsor the bipartisan CBP OFO staffing 
authorization bill, H.R. 4940, and to ask the House Appropriations 
Committee for $100 million in direct appropriated funding for new CBP 
officers, agriculture specialists, and support staff to build on the 
CBP OFO staffing advances made in the fiscal year 2018 Omnibus measure.

    Mr. Grijalva. To address the CBP staffing shortages, and to 
address the ever-increasing volume of activity at the ports of 
entry, that involves also the economics of it, as you have 
explained to me in terms of trade, import/export at the ports 
of entry, not just now but in the future. Ranking Member Vela 
from this committee introduced H.R. 4940, a bipartisan bill, 
the Border and Port Security Act, that would authorize the 
hiring of 500 additional CBP Customs officers, 100 CBP 
agricultural specialists, and an additional Trade Operations 
staff annually until you begin to close the staffing gaps at 
the ports of entry.
    Your reaction to that piece of legislation? Do you see that 
as part of the deterrence that we are talking about today and 
the seizures that we are talking about today?
    Mr. Ramirez. Absolutely. That is welcome news, Congressman 
Grijalva. When we talk about our complex jobs at the ports of 
entry, as you know, it is a balance between facilitating 
legitimate trade and travel and interdicting bad people and bad 
things. So our job is to encourage travel and trade, not 
discourage it.
    So obviously, staffing is a big part of it. We have 
implemented a huge recruitment effort in our agency where 
basically every recruiter Nation-wide at this point is 
recruiting for Arizona. Having those extra bodies allows us not 
just to open additional lanes but to provide better service to 
the traveling public and the trade community, and again operate 
more of our canines, our X-rays, and have a stronger 
enforcement posture at our ports of entry. So, thank you very 
much.
    Mr. Grijalva. Thank you.
    Mr. Coleman, if I may, the process of coordination of all 
these activities, interagency coordination, across 
jurisdictions coordination, and with stakeholders in various 
communities and others, I know it is rare but there are some 
turf issues sometimes. It certainly doesn't happen with Members 
of Congress----
    [Laughter.]
    Mr. Grijalva. But I am sure it is the same experience that 
you have.
    [Laughter.]
    Mr. Coleman. Welcome to my district.
    Mr. Grijalva. Tell me a little bit about the DEA, the 
principal agency, but also Homeland Security now having broad 
authority over the same subject. Tell me about that interagency 
issue.
    Mr. Coleman. I think that, having been a 30-year law 
enforcement officer, I can tell you that--and I have worked all 
over the country and the world--I think that the relationships 
between Arizona law enforcement agencies at the Federal, State, 
and local level is unprecedented in my career. While we 
occasionally get into spats over issues, there is nothing that 
we haven't been able to solve in the time I have been here, 
which is 11 years now. Scott's people are integrated in my 
offices, and my people are integrated in his offices. We work 
very closely together. We are partners on many task force 
groups. I have over 80 State and local officers assigned to my 
task forces. He probably has a similar number. So our 
integration is complete as much as we can be in the State.
    Mr. Grijalva. Thank you.
    My last point, Mr. Roemer, you mentioned all those other 
things. You mentioned quickly about weapons. Seventy percent, 
based on statistics from 2009 to 2014, of weapons seized across 
the border, in Mexico primarily, came from the United States. 
That is the origin. It is legal, weapons possession in Mexico. 
It is legal to have them, and they are primarily in the hands 
of cartels, and they have savaged that country as well.
    So what do you see in terms of what we are able to do in 
terms of what is going from here to there?
    Mr. Roemer. Sure. Ranking Member Grijalva, just the Border 
Strike Force--it is a huge concern for us from a public safety 
perspective. Just the Border Strike Force alone----
    Mr. Grijalva. But statistically, you mentioned tonnage and 
all that. Have you re-arrested people?
    Mr. Roemer. Absolutely. So, 280 firearms have been seized 
just by the Border Strike Force during Border Strike Force 
operations. But staying up-to-date on a daily basis on what Mr. 
Ramirez and all of CBP is doing and the success they are 
having, they are interdicting more weapons going south-bound 
across the border. I don't have the exact statistics for you, 
but I will tell you that I have been very pleasantly surprised 
at the number of success stories coming out of CBP on those 
weapons going south-bound.
    Mr. Grijalva. I yield back, Chairwoman.
    Ms. McSally. The Chair will now recognize Mr. Schweikert 
for 5 minutes.
    Mr. Schweikert. Thank you, Madam Chairwoman.
    That is an interesting point. The leaky border basically 
devastates people on both sides, and there becomes the 
discussion of what do we do to lock it down.
    Forgive me, this may be more for Mr. Brown than Mr. 
Coleman, a quick thought experiment. Many have been working on 
pieces of legislation. We are blessed that they look like they 
are going to move, prior authorization for opioids, some 
changes within the way opioids are prescribed, the ability for 
pharmacies, the data to see it.
    What happens if we are successful, that the prescription 
level of opioids crashes? Do the bad actors come and say, well, 
you are cutting our future profits because the migration we 
were hearing before of medical opioids that in the future 
potentially becoming a customer for heroin, eventually a 
customer maybe for fentanyl, do the bad actors try to find 
another way to continue the level of usage and devastation in 
our society?
    Mr. Roemer. I think over the short term that will happen. I 
think there is no question that we have to lower the amount of 
these prescriptions that we are writing to get hold of the 
actual number of addicted that we have here. I do think that 
the cartels will make moves to try to keep that addicted 
population addicted so they can continue.
    Mr. Schweikert. Do they go out and try to find new 
customers?
    Mr. Roemer. That is what they do. They recruit customers, 
and they also introduce new products into the system, fentanyl 
and its analogues and things like that, to get people more and 
more hooked.
    Mr. Schweikert. OK, that is partially where I wanted to go.
    Mr. Brown.
    Mr. Brown. I would echo what Doug said, and I would add I 
think one of the things we are seeing commonly is they are 
pressing fentanyl into a pill form.
    Mr. Schweikert. As you know, yesterday there was a large 
bust of what we thought was a prescription. It turns out it was 
a derivative of a fentanyl product.
    Mr. Brown. So I think that is a way of kind of marketing it 
to those people that started out with a legitimate opioid 
addiction. I think the reality is there are going to be some 
people that, when they recognize that I am going to a wholly 
illegal source to get my drugs, that will scare a couple of 
people away and scare them into the treatment that they need. 
To save those couple of lives, I would agree with Doug that we 
need to work----
    Mr. Schweikert. It is an interesting thought experiment 
that will our success on one side, because there we can treat 
it as a medical crisis, ends up moving that population into 
almost a criminal, much more difficult to identify populations 
to help.
    Mr. Ramirez, help me understand. I sat through a security 
briefing almost a year ago. It was a very small one, a little 
geeky. We actually did the chemical compounds that are in 
fentanyl, and I think they were using some other derivatives of 
fentanyl, and just the stunning addictive, poisonous--how small 
it was.
    How do you capture--how do you find it when something the 
size of your pinky is the death of all of us in this room?
    Mr. Ramirez. It is a very scary proposition, Congressman. 
At the ports of entry, what we are encountering is large 
quantities. It is amazing when I look, as I said, 30 years in. 
I remember when I started with Customs in El Paso, if you 
caught 1 kilo of heroin back then, you were the man for a year.
    Today, when we see 60 or 70 pounds, and what they are 
coming in, the packages are coming with multiple pills in the 
package----
    Mr. Schweikert. My concern, though--and this may be more of 
a question for a chemist. Heroin, fentanyl, for the same market 
value, or for the same addictive quality, what is my volume 
difference?
    Mr. Ramirez. We don't know that until we send it to the 
labs, including the DEA labs, and have them test it. I believe 
that would be a question more suited for Mr. Coleman.
    Mr. Schweikert. Mr. Coleman.
    Mr. Coleman. Fentanyl is obviously much stronger than 
heroin, and what we see is the profit margin on a kilogram of 
fentanyl, $30,000 for a kilo, $1.5 million is the profit you 
can make off of that.
    Mr. Schweikert. So you strain to see a movement away from 
heroin products to----
    Mr. Coleman. Unfortunately, we see both coming in. We have 
seen massive increases in the fentanyl and massive increases in 
the heroin to feed that addicted population.
    Mr. Schweikert. My understanding is there are some new 
chemical derivatives of fentanyl that are even more dangerous 
than----
    Mr. Coleman. Yes. When you talk about fentanyl, it is a 
synthetic opioid, so with just very small chemical changes you 
can create different drugs--carfentanyl, U47-700. Some of those 
drugs are hundreds of times more powerful than fentanyl.
    Mr. Schweikert. The carfentanyl was fascinating chemically.
    Madam Chairman, forgive me, I know I am over time. But for 
all of us on the panel, it is worth a bit of a thought 
experiment--and I don't want to speak out of what was given to 
us in the SCIF, but if that type of product ended up in 
something we are all publicly consuming, could you imagine the 
brutality that comes with that?
    Ms. McSally. The gentleman's time has expired.
    Ms. Sinema had to go, so the Chair now recognizes Mr. 
Gallego for 5 minutes.
    Mr. Gallego. Thank you, gentlemen.
    Director Ramirez, I am very lucky to serve on the Armed 
Services Committee, and in that we have to make decisions 
between whether we are going to buy tanks, aircraft carriers, a 
whole lot of things. It ranges from bullets to bombs, and I 
have to make those decisions every year through the National 
Defense Authorization Act.
    When it comes to fighting the opioid epidemic, we don't 
have an unlimited amount of resources either for this, right? 
If you haven't heard, we are in debt. We are going even more 
into debt because of this latest tax plan, and we will probably 
do that for the next 10 years.
    If I had the opportunity to get you $25 billion and you had 
to choose between a wall or to put more men at Customs and the 
border, men and women, professionals at our Customs and ports 
of entry, where would you choose your resources to be in terms 
of trying to fight the opioid epidemic?
    Mr. Ramirez. That is a little unfair.
    Mr. Gallego. I know, that is why I asked it.
    [Laughter.]
    Mr. Gallego. If it was fair, I wouldn't ask it.
    Mr. Ramirez. Because you are not going to find a port 
director who is going to say that he cannot do without more men 
or women.
    Mr. Gallego. OK. I don't want to get you into trouble, so 
we will stop there. I appreciate the honesty.
    One of the other areas that Congresswoman McSally has 
talked about, Congresswoman Sinema has talked at great length 
about this also, is because of the understaffing at the ports 
of entry, we are actually essentially using temporary personnel 
right now to fill those gaps. In terms of operational outcomes, 
what is that causing in terms of the consequences of that on an 
everyday basis, or just in terms of long-term sustainability?
    Mr. Ramirez. Well, long term, with our new recruiting 
efforts and the fact that we finally have people in the 
pipeline both pre-academy and academy and post-academy, it 
looks like there is light at the end of the tunnel. Long term, 
it actually benefits the agency when you bring people from 
other ports of entry.
    As you know, the Southwest Border is very unique when it 
comes to our jobs, very exciting and action-filled, very 
different from someone who sits in an airport or a Northern 
Border port. So when they have an opportunity to come and work 
side-by-side with the men and women assigned to the ports of 
Arizona, it is a learning experience which they take back to 
their ports of entry, and in turn it strengthens the operations 
at those ports of entry.
    I hear it from port directors who are not happy about 
having to give up resources for a short time, but when those 
resources get back, they are very pleased with what they find.
    Mr. Gallego. Then to dive a little deeper, in terms of what 
we are looking at in terms of shortages right now for permanent 
staff, how many would you say do we need to fill the gap, 
especially in the Tucson sector?
    Mr. Ramirez. In the Tucson Field Office, I believe we are 
still a few hundred positions short. Like I said, we have had 
success in hiring, but with attrition, it is a couple of steps 
forward, one step back kind of thing. So we are still a few 
hundred overall short.
    Mr. Gallego. Is the attrition because of Baby Boomers aging 
out, or just because people find that the strain of the job is 
just too much for their family, or just for personal income 
reasons?
    Mr. Ramirez. No, it is really more that blood is thicker 
than water. A lot of folks, we hire them from other parts of 
the United States, and in time they want to get back to family. 
We have had some of our officers who have transferred to get 
closer to family who have since come back to help us out in 
temporary assignments, and they will tell you that they miss 
the camaraderie, they miss the esprit de corps at the Arizona 
ports of entry, and they actually miss living in Arizona. So 
most of it is people rotating out, trying to get closer to home 
and family.
    Mr. Gallego. So, unfortunately, the cartels, they are very 
well-funded themselves. They are innovative. They have a 
product they need to sell, and they have a market that wants 
it. What are we doing in terms of technology to keep up with 
all the ways that they are trying to get their illicit drugs 
into this country, and is there more we can do along those 
lines to basically ratchet up our levels to make sure we are 
matching their levels?
    Mr. Ramirez. You know, one of the best X-ray systems that 
we have right now, newly implemented, is the Z-Portal 
technology, which is actually a low-energy system where the 
travelers do not have to get out of their vehicles. You just 
drive right through. That is one of the best tools. We just 
finished installing the latest one in San Luis. We have one in 
Douglas.
    Mr. Gallego. How many more of those do we need?
    Mr. Ramirez. I would like to see one at every port of 
entry, and we are almost there, especially our larger ports of 
entry. We already have them in Douglas, Nogales, San Luis, and 
in Lucasville. So we are about there.
    Mr. Gallego. Excellent.
    Mr. Ramirez. But those have been a great addition to our 
enforcement posture.
    Mr. Gallego. Thank you. I yield back.
    Ms. McSally. The gentleman yields back.
    The Chair now recognizes Ms. Lesko for 5 minutes.
    Ms. Lesko. Thank you, Madam Chair.
    I want to say to the panel, thank you for your service to 
our country, and thank you to all the law enforcement that 
works to protect our communities and our country. I really 
appreciate it.
    I think you testified--and this is to any of you--that most 
of the illicit opioids come through the ports of entry. From 
the data that I see here, it mostly is coming through the San 
Diego sector, it looks like. Correct me if I am wrong.
    My question is if people are being inspected, if they know 
they are going through a port of entry and they know they are 
going to be inspected, why would they come through the ports of 
entry, and how do you know that there is not a bunch of drug 
traffickers coming through other parts of the border?
    Mr. Coleman. From a DEA perspective I can tell you that the 
reality is that they certainly know that some of them are going 
to get taken off as they come across, but they will send 
multiple people through at a time. When CBP catches them, moves 
them away, then four others can sneak in behind them. So they 
use a variety of techniques. But they build into their business 
model the fact that they are going to lose a significant 
portion of them that come across. So they flood us, 
essentially, with more people coming across than we can catch.
    Ms. Lesko. Thank you for that answer. But my question is 
you testified--well, not you specifically, but that they strap 
it on their body and that type of thing. But how do you know 
that a bunch of people aren't coming through other areas of the 
border, not ports of entry, that have strapped-on illicit drugs 
because they are not going through a port of entry where there 
is going to be any type of inspection?
    Mr. Brown. Again, we have procedures made by Border Patrol 
that they really aren't encountering hard narcotics between the 
ports of entry. The reality is if you cross at a non-port of 
entry, if you are detected, you are going to be stopped, you 
are going to be apprehended, you are going to be searched.
    If you are coming through a port of entry, you are blending 
in with a huge volume of traffic, of which we can only inspect 
a small portion of those vehicles and pedestrians, so it is 
playing the odds. Again, you are automatically doing something 
wrong and are going to be more heavily scrutinized if you are 
coming across between ports of entry.
    Ms. Lesko. Thank you.
    Madam Chair and anyone from the panel, I know that you may 
not know the exact answer to this, but for every amount of 
illicit drugs that you detect, how much do you think is 
undetected? It is hard to know, I know, but you probably have a 
guess.
    Mr. Coleman. There is a significant portion that gets 
through, obviously. At DEA we work around the entire world, so 
we see the expansion of these drugs coming in and landing in 
other States, stuff that we know came through the port of 
entry. Our cases lead us from other parts of the country back 
to Arizona. So we know that there is a lot that gets through. I 
shudder to hazard a guess, but there is a significant amount 
that gets through all of us.
    Ms. Lesko. Thank you.
    I yield back my time.
    Ms. McSally. The gentlelady yields back.
    I do want to note that the appropriations bill included 
$284 million for port and drug inspection technologies within 
CBP, and $71 million specifically for opioid detection. So 
hopefully we are seeing more flow to the different ports of 
entry, more technology flow to the ports of entry for that non-
intrusive inspection.
    We have a lot more to talk about, but we don't have a lot 
of time, so I just want to say thanks to our witnesses for all 
that you do in order to keep our communities safe, and 
everything that all of your members do every single day to keep 
us safe and to address this issue.
    There is a lot more that we can do together to solve, so 
this is just really a platform for us, and we look forward to 
continuing to work with you moving forward to address this 
crisis.
    I want to thank all the witnesses for their testimony and 
the Members for their questions. The Members of the committee 
may have some additional questions for the witnesses. We will 
ask you to respond to those in writing.
    With that, I will dismiss this panel and request that the 
Clerk prepare the witness table for our third panel.
    [Recess.]
    Ms. McSally. While the last panel was very much focused on 
the supply of these addictive opioids and other substances, 
this panel is going to be talking more about solutions within 
society, civic society, and all elements, what can we be doing 
to have early identification and prevention and treatment to 
provide wholeness for people who have struggled with 
addictions. So, I am really looking forward to the discussion 
on this panel.
    I am pleased to welcome five distinguished witnesses for 
our third and final panel today. First is Dr. Cara Christ, who 
serves as director of Arizona Department of Health Services. 
She has worked for the agency for more than 9 years in multiple 
positions. In May 2015, Dr. Christ was appointed as director by 
Governor Doug Ducey.
    The second witness is Dr. Glorinda Segay, who became the 
health director of Navajo Nation in July 2017. In this position 
she is responsible for overseeing the direction of 14 different 
programs which include direct patient care as well as the 
provision of Medicaid and Medicare for the Navajo people. 
Previously she provided psychotherapy and group therapy 
treatments, as well as working on suicide prevention.
    Ms. Debbie Moak became the director of the Governor's 
Office of Youth, Faith, and Family in 2015. She served as 
director under Arizona Governor Ducey until June 2017. 
Previously she worked as an elementary school teacher for 10 
years. In 1999 she co-founded notMYkid, an anti-substance abuse 
non-profit, with her husband. The non-profit aims to help young 
people make positive choices.
    Mr. Jay Cory has served as the president and CEO of the 
Phoenix Rescue Mission since September 2011. Mr. Cory has over 
25 years of senior leadership experience in religious-based 
rescue and recovery ministries, with a proven track record of 
success in building ministry and recovery programs.
    Mr. Wayne Warner is a graduate of Teen Challenge, a faith-
based program with practical solutions for men and women with 
life-controlling issues. I am very familiar with Teen 
Challenge. I was a former board member of Teen Challenge. 
Initially a skeptic, Wayne graduated in 2014 and is now a firm 
advocate for the program which helps people ``become mentally 
sound, emotionally balanced, socially adjusted, physically 
well, spiritually alive, and employment ready.''
    The Chair now recognizes Dr. Christ to testify.

  STATEMENT OF CARA M. CHRIST, M.D., DIRECTOR, DEPARTMENT OF 
               HEALTH SERVICES, STATE OF ARIZONA

    Dr. Christ. Chairwoman McSally and other Members in 
attendance, thank you for this opportunity to share our 
progress toward Arizona's public health emergency, the opioid 
epidemic.
    The opioid crisis is different than other drug epidemics. 
While heroin and other illicit opioids present a problem in our 
communities, the start for many who develop opioid use disorder 
begins in a doctor's office in an attempt to relieve pain.
    It wasn't until recently that medical professionals 
realized how dangerous these medications are. Merely taking 
them as directed for 6 days or more significantly increases 
your chance of dependence. Four out of five new heroin users 
started as opioid medication users.
    We knew to address this issue our response required a 
coordinated, multifaceted approach from all sectors, including 
public health and medical professionals, law enforcement, 
patients, and many others in our communities.
    Last year my agency, the Arizona Department of Health 
Services, issued our report on opioid deaths, showing more than 
two Arizonans died each day in 2016 from these dangerous drugs. 
Upon release of that report, Governor Ducey took decisive 
action and declared a public health emergency, mobilizing 
resources and allowing us to collect real-time data. Within 
hours of the declaration, our Health Emergency Center began 
analyzing data, gathering partners, and identifying solutions.
    The numbers reported are staggering. Since June 2017, over 
1,200 suspected opioid deaths, 8,000 overdoses, and 760 babies 
with neonatal abstinence syndrome have been reported to the 
Department. After over 50 stakeholder meetings involving over 
1,350 partners, the Department issued our Opioid Action Plan.
    During the past year, Arizona has been implementing our 
plan and completing the activities Governor Ducey directed in 
the emergency declaration, and we have made great progress. The 
reporting and information-sharing requirements first 
established through the enhanced surveillance activity are now 
codified in rule. Almost 1,000 law enforcement officers State-
wide have been trained to provide Naloxone, and to date we have 
provided over 6,100 Naloxone kits to over 63 law enforcement 
agencies throughout Arizona, allowing our officers to save 
lives by reversing overdoses in the field.
    Our health care facilities now have rules for opioid 
prescribing and treatment, ensuring they have policies and 
procedures aimed at preventing opioid use disorder. We are also 
in the process of developing rules to regulate pain management 
clinics and end pill mills.
    Our Arizona Opioid Prescribing Guidelines have been updated 
to incorporate the newest information from the Centers for 
Disease Control and Prevention, encourage a shift in pain care 
to avoid unnecessary exposure to opioids, and emphasize the use 
of non-stigmatizing language.
    We have created a free, 24/7 State-wide consultation opioid 
assistance and referral line. This is for prescribers seeking 
advice about prescribing opioids and caring for patients with 
opioid use disorder.
    One hundred percent of Arizona's health professional 
schools participated in the development of the Nation's first 
State-wide curriculum across all prescriber training programs 
for pain and addiction using a whole-person approach. 
Integration of this curriculum is said to begin during the 
2018-19 school year.
    We have also partnered with the Arizona Department of 
Corrections to pilot a program that provides free Naloxone for 
individuals at high risk of overdose who are released from our 
correctional facilities. Multiple State agencies, including 
AHCCCS, the State's Medicaid program, the Governor's Office of 
Youth, Faith, and Family, and the Arizona Board of Pharmacy 
have come together to increase access to peer support, enhance 
youth prevention programs, and improve the Controlled 
Substances Prescription Monitoring Program.
    However, one of the biggest successes is the unanimous 
bipartisan passage of the Comprehensive Arizona Opioid Epidemic 
Act that went into effect on April 26. The Act consists of a 
number of life-saving policy initiatives, including a $10 
million investment to enhance access to treatment for uninsured 
or underinsured Arizonans, a Good Samaritan law to allow people 
to call 9-1-1 for a potential opioid overdose, requiring 
insurance companies to make one form of medication-assisted 
treatment available without a prior authorization, and limiting 
the first fill of an opioid prescription to 5 days for all 
opioid-naive patients while protecting chronic pain patients 
currently on these medications.
    While this legislation just went into effect, we are 
already seeing improvements based on our comprehensive efforts. 
In addition to the statistics that Governor Ducey presented 
earlier, we have also seen a 50 percent decline in the number 
of high-dose prescriptions when you look at this since last 
April.
    Though we have completed all of the directed activities and 
the emergency declaration has been terminated, we know that our 
work is just beginning. Arizona has an on-going commitment to 
continue to identify and implement new solutions to prevent 
future overdoses and deaths.
    Thank you for allowing me to talk about our progress today.
    [The prepared statement of Dr. Christ follows:]
                  Prepared Statement of Cara M. Christ
                              May 30, 2018
    The Arizona Department of Health Services (ADHS) released the 2016 
Arizona Opioid Report on June 1, 2017. This report revealed that in 
2016, 790 Arizonans died from opioid overdoses--more than 2 people per 
day. Arizona has experienced an alarming increase in opioid deaths of 
74 percent since 2012. In the past decade, 5,932 Arizonans died from 
opioid-induced causes with death rates starting to rise in the late 
teens and peaking at ages 45-54. This data highlighted a need for 
action. On June 5, 2017, Governor Doug Ducey declared a public health 
emergency to address the increase in opioid deaths in Arizona.
                   health emergency operations center
    The ADHS team immediately sprang into action and activated the 
Health Emergency Operations Center (HEOC) within hours of the 
Governor's emergency declaration. More than 75 agency staff across ADHS 
responded to the Governor's calls to action. As part of the declared 
state of emergency, ADHS was given the responsibility to:
   Provide consultation to the Governor on identifying and 
        recommending elements for an Enhanced Surveillance Advisory.
   Initiate emergency rulemaking for opioid prescribing and 
        treatment within health care institutions.
   Develop guidelines to educate providers on responsible 
        prescribing practices.
   Provide training to local law enforcement agencies on proper 
        protocols for carrying, handling, and administering naloxone in 
        overdose situations.
   Provide a report to the Governor on findings and 
        recommendations by September 5, 2017.
                     enhanced surveillance advisory
    With consultation from ADHS, Governor Ducey issued an executive 
order on June 15, 2017 to require the reporting of opioid-related data, 
allowing State health officials to receive information within 24 hours 
of specific events. This was a first step toward understanding the 
current opioid burden in Arizona and building recommendations to better 
target prevention and intervention. These reporting requirements 
greatly increased the Department's ability to assess and apply timely 
interventions in comparison with traditional data sources, which are 6 
to 18 months delayed. The specific health conditions required in the 
enhanced surveillance advisory included suspected opioid overdoses, 
suspected opioid deaths, naloxone doses administered in response to 
either condition, naloxone doses dispensed, and neonatal abstinence 
syndrome.
    To facilitate collection of data, the agency's secure web-based 
surveillance systems, Medical Electronic Disease Surveillance 
Intelligence System (MEDSIS) and Arizona Prehospital Information & EMS 
Registry System (AZ-PIERS), were utilized for designated reporters to 
electronically submit mandatory surveillance data. These systems were 
quickly modified to accommodate data submitted from 209 unique MEDSIS 
reporters and 143 AZ-PIERS reporters. ADHS coordinated a series of 
three webinars that trained a total of 171 health care, EMS, and law 
enforcement reporters. Arizona State Public Health Laboratory 
established the capability to receive postmortem blood specimens from 
Medical Examiners Offices to screen suspected opioid overdoses for 
opioids and other substances as of April, 2018.
                       treatment capacity survey
    In order to ascertain the current capacity and occupancy for 
substance abuse treatment in the State, ADHS requested the completion 
of an anonymous behavioral health, substance abuse treatment, and 
health care facilities survey. The survey was disseminated through the 
Regional Behavioral Health Authority system. Survey data was used to 
gain a better understanding of the distribution of services across the 
State, understand the utilization and availability of treatment, and 
better target future resources for treatment capacity in Arizona. 
Overall, the data collected demonstrated that there are not an adequate 
number of treatment services available in the State. It was also noted 
that when seeking care, many individuals may be turned away or placed 
on waiting lists. Starting in September 2018, ADHS will be collecting 
treatment capacity data from health care facilities and will issue 
quarterly reports noting gaps and recommendations.
                         emergency rule making
    As directed in the emergency declaration, the Department rapidly 
initiated emergency rule making for opioid prescribing and treatment 
practices in licensed health care institutions. Rules were completed in 
coordination with Arizona's Attorney General's Office and approved by 
the Secretary of State for immediate implementation on June 28, 2017. 
These emergency rules focus on health and safety; provide regulatory 
consistency for all health care institutions; establish, document, and 
implement policies and procedures for prescribing, ordering, or 
administering opioids as part of treatment; include specific processes 
related to opioids in a health care institution's quality management 
program, and require notification to the Department of a death of a 
patient from an opioid overdose. To support the agency's stakeholders 
and partners, a series of four webinars on the emergency rules were 
held, training a total of 458 attendees.
    After the emergency rule implementation, the Department initiated 
the regular rule-making process, which included opportunities for 
stakeholder input on the final rules through several stakeholder 
workgroup meetings and surveys in September and October 2017. An oral 
proceeding was held on December 18, 2017. Written comments were 
accepted through December 18, 2017. The final rules went into effect 
March 6, 2018.
    In addition, ADHS drafted and submitted emergency opioid-related 
reporting rules to the Attorney General's Office in order to maintain 
reporting requirements initiated by the Enhanced Surveillance Advisory. 
These rules require continued reporting of suspected opioid deaths, 
suspected opioid overdoses, naloxone doses administered in response to 
a suspected opioid overdose, naloxone doses dispensed, and neonatal 
abstinence syndrome cases. On-going reporting requirements will allow 
sustainable and continued collection of timely data throughout Arizona 
to better target prevention. Following stakeholder meetings and surveys 
through the regular rule-making process, the opioid-related reporting 
rules went into effect on April 5, 2018.
                     opioid prescribing guidelines
    ADHS utilized the Arizona Prescription Drug Initiative Health Care 
Advisory Team, which has been in place since 2015, to review and update 
the Arizona Opioid Prescribing Guidelines published in 2014. The Rx 
Initiative Health Care Advisory Team, made up of professional health 
care associations, practicing clinicians, and subject-matter experts, 
met 9 times since June 2017 to review and update the guidelines. The 
Guidelines are a voluntary, consensus document that promotes patient 
safety and best practices if prescribing opioids for acute and chronic 
pain. Nineteen Arizona healthcare organizations have endorsed the new 
guidelines. The content of the guidelines was finalized in December 
2017, and the final version is posted at www.azhealth.gov/
opioidprescribing/.
    Current updates reflect:
   Incorporation of the most recent evidence, National 
        guidelines (including the VA/DoD Clinical Practice Guideline 
        for Opioid Therapy for Chronic Pain, 2017 and CDC Guideline for 
        Prescribing Opioids for Chronic Pain, 2016), best practices 
        from other States, and Arizona data.
   A shift in pain care that avoids unnecessary exposure to 
        opioids in order to reduce the risk of adverse outcomes. 
        Previous guidelines focused on the ``safe prescribing'' of 
        opioid therapy, while these guidelines aim to prevent 
        initiating unnecessary opioid therapy while addressing 
        patients' pain from a whole-person perspective.
   Emphasis on non-stigmatizing language. Health care providers 
        can counter stigma by using accurate, nonjudgmental language. 
        These guidelines employ person-first language (``Patients with 
        substance use disorder'' instead of ``addicts''), nonjudgmental 
        terminology (``negative urine drug test'' instead of ``dirty'') 
        and supportive terms (``recovery'' instead of ``no cure'').
   Increased focus on prevention, recognition, and treatment of 
        opioid use disorder in patients receiving long-term opioid 
        therapy for chronic pain, given the high risk of developing 
        opioid use disorder in this population.
   Integration into clinical workflow (operationalization). A 
        key element of success of guideline implementation is how 
        seamlessly it can be incorporated into a clinician's normal 
        activities. This revised version includes specific 
        operationalization actions under each guideline.
                      expanding access to naloxone
    ADHS identified a need to train local law enforcement agencies on 
proper protocols for carrying, handling, and administering naloxone in 
overdose situations, in order to positively impact the opioid epidemic 
through rapid treatment of encountered suspected overdoses. 
Approximately 1,000 law enforcement officers have been educated through 
training events held throughout the State since June 2017. ADHS is 
coordinating continuing requests for law enforcement training with the 
Arizona Peace Officer Standards and Training Board (AZ-POST).
    Progress on naloxone distribution includes:
   ADHS has free naloxone kits available for law enforcement 
        agencies and first responders who are unable to bill for 
        naloxone. Agencies can request naloxone by completing the 
        request form on the ADHS website.
   ADHS has provided 6,316 naloxone kits for 63 law enforcement 
        agencies since June 2017.
   ADHS received a SAMHSA grant to support training of first 
        responders in naloxone administration and conducting screening, 
        brief intervention, and referral to treatment. AzPOST and the 
        University of Arizona are partnering with ADHS to implement 
        grant activities.
   Eighty-four percent of people experiencing non-fatal 
        overdoses since June 15, 2017 when enhanced surveillance was 
        initiated received naloxone pre-hospital.
   Law enforcement officers have administered naloxone 482 
        times to 364 people since June. In all but 9 cases, the 
        individual survived the immediate out-of-hospital event.
    In order to support increased use of naloxone to save lives in 
Arizona, ADHS Director Dr. Cara Christ signed standing orders that 
allow pharmacists to dispense naloxone to any individual in the State 
and allow ancillary law enforcement, correctional officers, and EMS to 
use naloxone for suspected opioid overdoses. A naloxone pamphlet was 
developed in both English and Spanish to assist in public education of 
opioid safety and naloxone use.
              goal council 3: opioid breakthrough project
    With Director Cara Christ as the lead of the Governor's Goal 
Council 3 on Healthy People, Places, and Resources, the ADHS team 
assisted Director Christ in launching several subgroups to recommend 
actions that will reduce opioid deaths. On June 26, 2017, partners from 
across the State convened to learn more about the opioid emergency and 
the work of the Goal Council on Healthy People, Places, and Resources.
    Participants were asked to join one or more subgroups to help 
define problems, set goals, and determine what actions would be most 
impactful to prevent and reduce opioid deaths. Subgroups worked 
together in July and August 2017 to identify recommendations and 
convened again on August 23, 2017 to share draft recommendations. 
Approximately 200 committed Arizonans volunteered their time to 
contribute ideas and prioritize recommendations that shaped much of the 
content of the recommendations in Opioid Action Plan delivered by ADHS 
to Governor Ducey. Over the course of the emergency declaration, ADHS 
has held over 50 stakeholder meetings and engaged over 1,350 Arizonans 
State-wide.
                      communication and resources
    ADHS has developed several mechanisms to allow for partner 
interaction and information distribution. One such mechanism is the 
development of a dedicated webpage, azhealth.gov/opioid. This webpage 
organizes resources and allows stakeholders to quickly access up-to-
date opioid-related information. Within these webpages the Department 
has posted numerous unique resources covering various topics including 
FAQs, reporting-related case definitions, publicly released data, 
setting-specific guidance and resources, and a 50 State Review on 
Opioid Related Policy. A centralized email, [email protected], and 
digital interface within the opioid webpage allow for direct 
stakeholder communication for concerns and interest in partnering with 
the Department.
    ADHS recently formed a drug overdose mortality review team, per  
A.R.S. 36-198, to develop a data collection system regarding drug 
overdoses, conduct an annual analysis relating to drug overdose 
fatalities, develop standards and protocols, provide training and 
technical assistance to local overdose review teams, and develop 
investigation protocols for law enforcement and the medical community. 
The first meeting of the State Drug Overdose Fatality Review Team was 
held on November 28, 2017.
    ADHS is also launching a new approach adopting chronic pain as a 
public health issue. In follow-up to a chronic pain summit held in May 
2017, ADHS developed a dedicated webpage, azhealth.gov/
chronicpainmanagement, to increase public awareness and utilization of 
safe, effective approaches to managing chronic pain. With an emphasis 
on promoting non-pharmacological therapies that are proven to ease pain 
and increase function, ADHS aims to help Arizonans with chronic pain 
resume daily activities and maximize their quality of life. A major 
component of this initiative will be a new media campaign emphasizing 
options and self-management strategies for addressing chronic pain.
                       arizona opioid action plan
    The public health emergency declaration directed the Arizona 
Department of Health Services to submit a report of the accomplished 
activities and identify recommendations for combating the opioid 
epidemic in Arizona. ADHS submitted the Opioid Action Plan to Governor 
Ducey on September 5, 2017. The Opioid Action Plan includes 12 major 
recommendations with over 50 actions slotted for completion by June 30, 
2018.
    Goals to address the opioid epidemic:
   Increase patient and public awareness and prevent opioid use 
        disorder.
   Improve prescribing and dispensing practices.
   Reduce illicit acquisition and diversion of opioids.
   Improve access to treatment.
   Reduce opioid deaths.
    Recommendations, created through multiple meetings with partner 
agencies, impacted stakeholders, Goal Council 3 subgroups, and policy 
makers to address the above goals include:
    1. Enacting legislation that impacts opioid deaths by addressing 
        identified barriers;
    2. Creating a free, State-wide consultative call line resource for 
        prescribers seeking advice about prescribing opioids and caring 
        for patients with opioid use disorder;
    3. Requiring Arizona medical education programs to incorporate 
        evidence-based pain management and substance-use disorder 
        treatment into their curriculum;
    4. Engaging the Federal Government to address necessary Federal-
        level changes;
    5. Establishing a regulatory board workgroup to identify 
        prescribing trends and enforcement issues;
    6. Encouraging law enforcement agencies to expand the Angel 
        Initiative and other existing diversion programs and assist the 
        DEA with filling local vacancies on the Tactical Diversion 
        Squad;
    7. Increasing access to naloxone for high-risk individuals released 
        from correctional facilities;
    8. Pulling together experts into task forces to address identified 
        barriers by:
     Identifying specific improvements to enhance the Arizona 
            Controlled Substance Prescription Monitoring Program;
     Identifying, utilizing, and building upon Arizona's 
            existing peer recovery support services;
     Providing recommendations regarding insurance parity and 
            standardization of substance abuse treatment and chronic 
            pain management across the State; and
     Identifying and implementing school-based prevention 
            curriculum, expanding after school opportunities and 
            identifying resource needs.


------------------------------------------------------------------------
                                                      Progress to Date
            Goal                 Recommendations         (May 2018)
------------------------------------------------------------------------
Reduce Opioid Deaths........  Enact legislation     On January 26, 2018,
                               that impacts opioid   Governor Ducey,
                               deaths by reducing    with unanimous,
                               illicit acquisition   bipartisan support
                               and diversion of      of the Arizona
                               opioids, promoting    Legislature, passed
                               safe prescribing      the Arizona Opioid
                               and dispensing,       Epidemic Act, or
                               decreasing the risk   Senate Bill 1001, a
                               of opioid use         comprehensive
                               disorder, and         approach to
                               improving access to   addressing opioid
                               treatment.            related issues
                                                     State-wide.
Improve Prescribing &         Establish a           ADHS convened three
 Dispensing Practices.         Regulatory Board      meetings of the
                               work group to         Regulatory Board
                               identify              Workgroup and will
                               prescribing trends    submit an Action
                               and discuss           Plan to the
                               enforcement issues.   Governor by June
                              Establish a task       30, 2018.
                               force to identify    The Arizona Board of
                               specific              Pharmacy convened
                               improvements that     the task force and
                               should be made to     identified a set of
                               enhance the Arizona   initial
                               Controlled            improvements
                               Substances            regarding
                               Prescription          registration of
                               Monitoring Program    prescribers and
                               (CSPMP).              improved outreach,
                                                     technical
                                                     assistance, and
                                                     education. New
                                                     training modules
                                                     are available on
                                                     how to use the
                                                     Arizona Controlled
                                                     Substances
                                                     Prescription
                                                     Monitoring Program
                                                     on their website.
Reduce Illicit Acquisition &  Meet with leaders of  ADHS and Homeland
 Diversion of Opioids.         law enforcement and   Security leadership
                               first responder       met with law
                               agencies to expand    enforcement
                               Angel Initiative      leadership in
                               and other OUD         September.
                               diversion programs   Two law enforcement
                               and assist the DEA    agencies are
                               with filling          participating in
                               vacancies in the      the Angel
                               DEA Tactical          Initiative with 136
                               Diversion Squad.      individuals
                                                     enrolled.
Improve Access to Treatment.  Require all           ADHS has worked with
                               undergraduate and     100 percent of
                               graduate medical      Arizona academic
                               education programs    partners to develop
                               to incorporate        a State-wide
                               evidence-based pain   curriculum on
                               management and        opioid prescribing,
                               substance-use         treatment of opioid
                               disorder treatment    use disorder and
                               into their            management of
                               curriculum.           chronic pain.
                              Create a call-in      The Opioid
                               line resource to      Assistance and
                               provide               Referral Line, a
                               consultation to       free 24/7 call
                               prescribers seeking   resource for
                               advice about          prescribers, has
                               prescribing opioids   been implemented in
                               and caring for        partnership with
                               patients with         Arizona's Poison
                               opioid use disorder.  and Drug
                              Establish through      Information
                               executive order a     Centers.
                               work group to        Arizona's Medicaid
                               identify, utilize,    agency and State
                               and build upon        substance abuse
                               Arizona's existing    authority, AHCCCS,
                               peer recovery         has convened the
                               support services.     peer support work
                              Convene an Insurance   group.
                               Parity Task Force    The Task Force
                               to research and       conducted a survey
                               provide               of current
                               recommendations       insurance coverage
                               regarding parity      related to pain
                               and standardization   management and
                               across the State.     opioid use disorder
                              Engage the Federal     treatment. A report
                               Government            with
                               outlining necessary   recommendations
                               Federal changes to    will be submitted
                               assist Arizona with   to the Governor by
                               our response to the   June 30, 2018.
                               opioid epidemic.     The Governor's
                              Increase access to     office sent the
                               naloxone and          letter requesting
                               Vivitrol for          Federal changes to
                               individuals leaving   assist Arizona's
                               State and county      response to the
                               correctional          opioid epidemic.
                               institutions and     ADHS is working with
                               increase access to    the Arizona
                               MAT therapy for       Department of
                               individuals with      Corrections to
                               opioid use disorder   implement a
                               while incarcerated.   naloxone pilot
                                                     program for
                                                     formerly
                                                     incarcerated
                                                     individuals who are
                                                     at high risk for
                                                     overdose after
                                                     release. ADHS has
                                                     provided 1,000
                                                     doses of naloxone
                                                     for Corrections to
                                                     distribute to high-
                                                     risk inmates being
                                                     released. An
                                                     overdose prevention
                                                     and education video
                                                     will be completed
                                                     June 30.
Prevent Opioid Use Disorder/  Utilize Public        The Governor's
 Increase Patient Awareness.   Service               Office of Youth,
                               Announcements         Faith, and Family
                               (PSAs) to educate     developed new PSAs
                               patients,             that began airing
                               providers, and the    in December and are
                               public regarding      scheduled to
                               opioid use and        continue through
                               naloxone.             2018. See
                              Create a youth         www.RethinkRxabuse.
                               prevention task       org.
                               force to identify    The Governor's
                               and implement         Office of Youth,
                               evidence-based,       Faith, and Family
                               emerging, and best    has convened the
                               practice substance    youth prevention
                               abuse prevention/     task force to
                               early                 discuss prevention
                               identification        programs. A report
                               curriculum, expand    with
                               after-school          recommendations
                               opportunities, and    will be submitted
                               identify resource     to the Governor by
                               needs.                June 30, 2018.
------------------------------------------------------------------------


                      arizona opioid epidemic act
    On January 26, 2018, Governor Doug Ducey signed The Arizona Opioid 
Epidemic Act, the first bill to become law in 2018, following a 4-day 
Special Session and unanimous passage in the House and Senate. The 
legislation takes aggressive steps to address opioid addiction, hold 
bad actors accountable, expand access to treatment, and provide life-
saving resources to first responders, law enforcement, and community 
partners. Most provisions of the act went into effect on April 26, 
2018.
    Specific policy initiatives in the Arizona Opioid Epidemic Act 
include:
   Identifying gaps in and improving access to treatment, 
        including for uninsured or underinsured Arizonans, with a new 
        $10 million investment;
   Expanding access to the overdose reversal drug, naloxone, 
        for law enforcement or corrections officers currently not 
        authorized to administer it;
   Holding bad actors accountable by ending pill mills, 
        increasing oversight mechanisms, and enacting criminal 
        penalties for manufacturers who defraud the public about their 
        products;
   Enhancing continuing medical education for all professions 
        that prescribe or dispense opioids;
   Enacting a Good Samaritan law to allow people to call 9-1-1 
        for a potential opioid overdose;
   Cracking down on forged prescriptions by requiring e-
        prescribing;
   Requiring all pharmacists to check the Controlled Substances 
        Prescription Monitoring Program prior to dispensing an opioid 
        or benzodiazepine;
   Developing a social media youth prevention campaign;
   Requiring emergency departments and hospitals to make 
        referrals to treatment for overdose patients;
   Reducing prior authorization time frames for insurers and 
        requiring insurers to make at least one form of Medication 
        Assisted Treatment available without prior authorization;
   And, limiting the first-fill of an opioid prescription to 5 
        days for all opioid naive patients and limiting dosage levels 
        to align with Federal prescribing guidelines. These proposals 
        contain important exemptions to protect chronic pain suffers, 
        cancer, trauma or burn patients, hospice or end-of-life 
        patients, and those receivingdication assistedeatment for 
        substance use disorder.
                     expanding access to treatment
    Arizona is expanding access to opioid use disorder treatment and 
support resources through Federal and State funding.
   Arizona received $24 million dollars through the SAMHSA 
        State Targeted Response (STR) Grant to use toward opioid use 
        disorder prevention and treatment. The Arizona Health Care Cost 
        Containment System (AHCCCS) is expanding access to opioid 
        treatment programs throughout the State using grant funds from 
        SAMHSA. The first of five, 24-hour centers for opioid 
        treatment, including two medication-assisted treatment (MAT) 
        centers and three crises centers, opened in October 2017 to 
        address the growing need for access to opioid use disorder 
        treatment. The 24/7 access to opioid treatment is currently 
        available in Mohave, Yavapai, Maricopa, and Pima counties.
   The Arizona Opioid Epidemic Act provided $10 million in 
        State general fund dollars for substance use disorder services 
        for the uninsured and underinsured. AHCCCS conducted community 
        forums to gather input to target use of the funding and 
        identify priority needs.
                           arizona's progress
   100 percent (18/18) of health professional schools in 
        Arizona participated in development of a curriculum for pain 
        and addiction. This is the Nation's first State-wide curriculum 
        across all prescriber training programs. All schools agreed to 
        a shared vision to redefine pain and addiction as 
        multidimensional, public health issues that require the 
        transformation of care toward a whole-person approach with a 
        community and systems perspective. Academic programs are 
        expected to begin integration of core components of the 
        curriculum during the 2018-19 school year.
   New OARLine: Opioid Assistance + Referral Line for Arizona 
        Providers: 1-888-688-4222 is available for health care 
        clinicians to call for free consultation on patients with 
        complex pain or opioid use disorder. The 24/7 hotline is 
        staffed by experts at the Poison and Drug Information Centers 
        in Arizona. The hotline will be expanded in the future to 
        provide information and referrals to the public.
   ADHS is working with the Arizona Department of Corrections 
        on a pilot to provide released inmates at high risk of opioid 
        overdoses prevention education and naloxone. Training was 
        conducted for corrections supervisors on naloxone, and 1,000 
        naloxone kits have been provided for them to begin distributing 
        to those inmates who are identified at risk for an overdose 
        post-release. (High-risk was defined as overdosing while 
        incarcerated) ADHS is also working on a short educational video 
        to be completed by June 30.
   The Insurance Parity Taskforce conducted a survey of over 50 
        insurers to assess current coverage of pain management 
        treatments and substance use disorder treatments. The Taskforce 
        will make recommendations to Governor Ducey by June 30, 2018.
   ADHS and Governor's Office of Youth, Faith, and Family will 
        be launching a new youth prevention campaign in fall of 2018, 
        which was authorized and funded by the Arizona Opioid Epidemic 
        Act.
   ADHS is working with stakeholders to develop new regulations 
        for pain management clinics. Arizona will license pain 
        management clinics starting January 2019.
    While it is early to evaluate the outcomes associated with 
Arizona's response to the opioid crisis, there are some promising 
indicators of success.
   The 4 & 4 report is a list of patients who have obtained 
        controlled medications from 4 different doctors and 4 different 
        pharmacies in a given month. The Arizona Board of Pharmacy 
        sends any prescriber with a patient on the 4 & 4 list an 
        unsolicited letter to alert the prescriber of the patient's 
        possible doctor and pharmacy shopping. There has been a 60 
        percent decline in the number of patients on this report--from 
        99 in July 2017 to 40 in April 2018.
   The percent of patients receiving referrals to behavioral 
        health or substance abuse treatment services after an overdose 
        has increased from 41 percent in June 2017 to 63 percent in 
        April 2018.
   The number of naloxone prescriptions dispensed by 
        pharmacists has increased significantly in recent months. July-
        September 2018, fewer than 900 naloxone kits were dispensed 
        each month. In April 2018, 3,143 kits were dispensed to the 
        public. See attachment 1.
   The number of opioid prescriptions filled and the number of 
        prescriptions with high doses exceeding 90 morphine milligram 
        equivalents has declined, as illustrated in the graphs in 
        attachments 2 and 3.
                    lessons from opioid surveillance
    ADHS has been collected data on suspected opioid overdoses since 
June 15, 2017. Over this period of time, the surveillance has 
indicated:
   Most overdoses (59 percent) occur among men.
   People ages 25-34 years old had the highest percent of 
        suspected opioid overdoses.
   Chronic pain (e.g. lower back pain, joint pain, arthritis) 
        is the most common pre-existing physical condition reported for 
        those who had a verified opioid overdose, followed by 
        depression and history of substance use disorder, including 
        alcohol.
   About 40 percent of people who had a suspected overdose 
        (between June 15, 2017 and March 26, 2018) had 9 or more 
        prescriptions for opioids filled.
   More than 40 percent of people who had a suspected opioid 
        overdose were prescribed opioids by 10 or more providers since 
        January 2017.
   Most reported overdoses involve multiple drugs. Polydrug use 
        was indicated in 2/3 of the overdose fatalities. The charts in 
        attachments 4 and 5 detail the drugs identified in the reported 
        opioid overdoses.
            number of naloxone kits despensed by pharmacies
controlled substances prescription drug monitoring program data july 1, 
                           2017-may 17, 2018
                           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

     opioid prescriptions filled per month. controlled substances 
  prescription drug monitoring program data jan. 1, 2017-may 10, 2018
  
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

 number of opioid prescriptions for mme 90 or above filled per month. 
controlled substances prescription drug monitoring program data jan. 1, 
                           2017-may 10, 2018
                           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

   oxycodone and heroin were the opiate drugs most commonly noted in 
   overdoses determined to be due to opioids during review. overdose 
              surveillance data june 15, 2017-may 17, 2018
              
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

number of naloxone kits despensed by pharmacies. overdose surveillance 
                    data june 15, 2017-may 17, 2018
                    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Ms. McSally. Thank you, Dr. Christ.
    The Chair now recognizes Dr. Segay to testify for 5 
minutes.

STATEMENT OF GLORINDA SEGAY, M.D., HEALTH DIRECTOR, DIVISION OF 
                   HEALTH, THE NAVAJO NATION

    Dr. Segay. Thank you, Madam Chair. I am Dr. Segay, Navajo 
Nation executive director for Department of Health. The 
president and vice president also send their regards. Thank you 
for having me here today, and thank you for all that you do for 
us.
    I just want to also inform you that opioid abuse does exist 
on the Navajo Nation. Recently we had created an opioid task 
force team, and basically this is a collaboration with our 
Indian Health Service. We do have five facilities there on 
Navajo, and also our Public Law 93-638 facilities which we also 
have there.
    Basically, we have been talking about how and what is this 
opioid to the Navajo Nation. Our people there have a low health 
literacy rate in regards to understanding what is happening in 
their health, so that is what we have been talking about, APSA 
and creation of educating our Navajo Nation in ways that 
opioids that are being used on Navajo, which we discussed, is 
the pill form, the smoking, the snorting, mixing with 
substances, skin patches. So basically we are working on a PSA 
again so that we can educate our Navajo people.
    One barrier we do have is our language. Navajo language is 
very complex, so it is a lot of descriptive details that we 
need to include while we are translating. So we do have issues 
with funding there, so we do need and request more funding so 
that we can provide adequate services in educating our Navajo 
people.
    We do have distributors there on Navajo. The main 
distributor is Indian Health Service, and also our Public Law 
638 facilities. We do have border towns there, such as 
Flagstaff and Gallup, so they do have their private 
distributors such as Walmart, Walgreens, and Safeway, which we 
have no control of, so that is an issue for us.
    It is also furthermore requesting as far as Tribal direct 
funding. It is very hard when the Government sends money to the 
State and then it trickles to the Tribes. There are 
restrictions and there is not enough funding.
    I also just want to make mention that AHCCCS is 
underfunded. So if we can get more funding to AHCCCS to help us 
to fight opioid there with Navajo as well as Indian Country. We 
have been talking with AHCCCS, and what we do have is a 
strategic plan that has been shared with us. Part of the 
strategic plan is basically strengthening our public health 
data and reporting and collecting. We want to focus on 
actionable data for target interventions so that we can provide 
services.
    I just also want to make mention that with Navajo, one of 
our methods of treatment is through our traditional Native 
medicine. So we still do use our elders. We still use our 
cultural practices through prayers and songs and chants with 
our ceremonies, and that is very effective for us. So we do 
also want that to be recognized as a form or method of 
treatment.
    Furthermore, just going on with our strategic plan, we have 
an advanced practice of pain management to enable access to 
high-quality, evidence-based pain care that decreases the 
burden of pain for individuals, families, and society, while 
also reducing them in appropriate use of opioids and opioid-
related harms.
    So again, going into the crime rate, we do have a high 
level of crime, underlying issues with domestic violence. We 
also have human trafficking there on Navajo because of opioids, 
as well as other substances.
    We want to improve access for patients as far as treatment, 
prevention, and recovery services so that we can prolong the 
life of each of our Navajo people. They are important to us. We 
also want to target the availability and distribution of 
overdose medication to ensure the provision of these drugs to 
people likely to experience or respond to an overdose, with a 
particular focus on targeting high-risk population.
    I also want to make mention that we also want to support 
cutting-edge research that advances our understanding of pain 
and addiction that leads to development of new treatment and 
identifies effective public health interventions to decrease 
opioids. So right now what we are basically doing is a lot of 
prevention education. We do have a collaboration with our 
community health representatives, who also go out into the 
community and pretty much provide education in the Navajo 
language, and we also feel our Navajos learn more visually. So 
they are out there with their charts, especially with our 
elders and speaking about what are the signs and the symptoms, 
what are some concerns, because a lot of our people who use 
opioids still live with their elderly parents. So we want to 
inform the elderly parents because, again, it is a safety 
concern. We get a lot of elders who come to us and tell us that 
they are afraid of their adult children, especially when they 
are on any sort of influence as far as substances go.
    I also want to make mention that Navajo Nation president 
has made mention several times there in the District of 
Columbia that the DEA needs to be involved and that we feel as 
Navajo they need to place extreme restrictions on opioids.
    Basically, that is what I wanted to share with you all. 
Thank you for this time.
    Ms. McSally. Thank you, Dr. Segay.
    The Chair now recognizes Ms. Moak for 5 minutes to testify.

        STATEMENT OF DEBBIE MOAK, CO-FOUNDER, NOT MY KID

    Ms. Moak. Chairwoman McSally and distinguished Members of 
Congress, thank you for having me here today. It is an honor.
    Generally, when we talk about opioid abuse or drug abuse in 
general, we think about three different buckets: Supply, 
demand, and harm reduction strategies. I am going to focus my 
comments primarily on demand and touch on harm reduction 
strategies.
    In the midst of an opioid epidemic, I want to see people 
find access to treatment to save lives while preventing the 
next generation from starting down this path. We must do both 
simultaneously.
    About a decade before we founded notMYkid, drug abuse was 
the No. 1 issue on the minds of Americans. This country went to 
work, and we made huge strides in and from all sectors. Yes, it 
was law enforcement, but it was also everyone else too, 
including Hollywood, churches, sports professionals. This 
country knows how to take an issue, like we have done with 
tobacco use, seriously when it wants to, and in the late 1980's 
and early 1990's, we did that.
    The results were nearly miraculous. We reduced drug abuse 
in this country by over 50 percent by 1993 when we got focused. 
We did in this country what we too often do: We felt we solved 
it, and we moved on. So we should look back to those years and 
look at those strategies of what worked.
    I will tell you this: We need to adopt those strategies and 
funding consistently and grind them out without gaps year after 
year.
    Too often I am dismayed because I hear smart, responsible 
citizens tell me that it is impossible to turn back our drug 
use problem here in the United States, and I say you are wrong. 
It must start first with our will to do so. The mass poisoning 
of millions can be stopped with a serious effort.
    We have addressed drug crises like crack cocaine, crystal 
meth, and now must employ similar strategies for the opioid 
epidemic. We actually know what to do. We have been here 
before. But every single American has a role to play.
    Yes, I said substance use, because I don't just single out 
opioids, even in the midst of a crisis. America has a drug use 
problem. Of course, we see whatever is coming across our 
borders, what is coming through our postal system, and what is 
being produced here in America. That will trend what we are 
seeing that ends up in our homes, depending on what the supply 
is. Addressing demand or use of all substances needs to also be 
done simultaneously. That is the best evidence-based practice, 
versus singling out one substance.
    I want to share with you some effective programs that are 
happening here in Arizona that can be employed more widely. Our 
Arizona Use Survey of 2016 is a road map for us. It tells us 
that youth use drugs for the following reasons, and in order: 
To have fun, to feel good, to deal with stress, and to avoid 
being sad. In other words, youth want to alter how they feel. 
Sadly, adults have sent them many messages that impact that 
thinking.
    We have told kids that things like marijuana is medicine 
when we vote to change medicine to recreate with it. We see 
commercials every time we turn on the TV that tell us there is 
a fix for every feeling that we have.
    The survey also gives us a road map, however, for how to 
keep kids from using drugs. The top reasons why kids don't use 
drugs are: It is of no interest to them; they understand the 
harmful effects; they don't want to disappoint their parents; 
and that they are illegal. These are all points of data.
    Arizona has a campaign unlike the ``Just Say No'' campaign. 
Arizona has a campaign called--I call it a ``Just Say Yes'' 
campaign. Say yes to I have something better to do. We connect 
youth to local opportunities in their counties to play sports, 
hike mountains, go to a concert, volunteer and, quite frankly, 
get reengaged with their own families.
    We have to inspire kids to seek out their passions and 
dreams and help them to get there. When was the last time we 
have seen a great PSA or campaign continued not only throughout 
the year without interruption here in Arizona and certainly 
across the United States? We can do that, and Arizona already 
has a great campaign ready to be scaled.
    We also know that talking to our kids with an educated 
parent may reduce substance abuse by 50 percent. Yet, the 
Arizona Youth Survey shows us that only 50 percent of 8th 
graders have had that conversation with a parent in the last 
year. Sixty percent of seniors have not had that conversation 
with a parent in a year. Fix that. Focus on that. Mandatory 
parent, youth, and faculty involvement in prevention 
programming that educates youth, parents, and faculty at the 
same time exists here in Arizona. However, that program has 
great data provided by ASU in its reach, and we won't have 
funding for it next year.
    SBIR, one of the 56 Opioid Commission recommendations: 
Screening, brief intervention, referral to treatment. Yes, 
screen all high school students for mental health and substance 
use. Ninety percent of all addiction occurs from what kids do 
during the teen years. That gives us our target and a bulls-
eye. Screen youth during these years to support and intervene 
early when it is easy to turn the situation around, when it is 
least costly to youth and society. We used to screen kids for 
things like vision or scoliosis, and when we screen all kids, 
it is not weird and no one gets singled out or stigmatized.
    When notMYkid has a program where kids are being funneled 
there who have been caught with first use, and it has tripled 
in a year in its size because schools are desperate for this, 
it is called Project Rewind.
    So on first use of a kid, we work with them. Kids shouldn't 
be kicked out of school. We should help them and their families 
receive appropriate resources; again, something else that 
already exists and we can scale.
    Youth feel loved and protected when adults set boundaries 
and offer support. Today's youth feel alone, isolated, and 
stressed more than ever. This is a place for adults to get 
educated and connect, and I am letting you know that embedding 
behavioral health in our schools is key.
    Ms. McSally. Ms. Moak, can you wrap up your testimony and 
we will continue on with the questions?
    Ms. Moak. Oh, I am so sorry. Yes, ma'am. I am so sorry.
    Ms. McSally. That is OK.
    Ms. Moak. As you can see, I am quite passionate.
    Ms. McSally. You are.
    Ms. Moak. Then in closing I will just say there are five 
things I would like you to remember.
    Prevention is the healthiest and cheapest.
    The Federal Government must provide visible leadership to 
convene all parties.
    We must recognize behavioral health as important as 
education in school settings.
    We need on going public- and private-sector commitments.
    We must make access to treatment available.
    Thank you.
    [The prepared statement of Ms. Moak follows:]
                   Prepared Statement of Debbie Moak
    I want to thank this committee for addressing this serious issue, 
this most serious of issues. Generally, when speaking to an audience 
like this I would address supply, demand, and harm reduction 
strategies. Knowing the expertise of the other panel members today I 
will focus my comments on demand and touch on harm reduction. In the 
midst of an opioid epidemic I want to see people find access to 
treatment to save lives, while preventing the next generation from 
starting down this path. We must do both simultaneously.
    The context for my comments today come from 10 years as a classroom 
teacher, behavioral health education, 20 years in non-profit 
prevention, previous director for Governor Ducey's Office of Youth, 
Faith, and Family and someone who's been in the trenches with her own 
family and thousands of other families for 20 years with addiction.
    About a decade before we started notMYkid, drug abuse was the No. 1 
issue on the minds of Americans. This country went to work and we made 
huge strides--in and from all sectors. Yes, it was law enforcement, but 
it was also everyone else, too--from schools to churches to synagogues 
to Hollywood to professional sports. This country knows how to take an 
issue, like we've done with tobacco use, seriously when it wants to and 
in the late 1980's and early 1990's we did.
    The results were nearly miraculous. We reduced drug abuse in this 
county by over 50 percent by 1993. And then we did in this country what 
we too often do: We moved on. We should look back to those years and 
use those successful strategies. We've done this before, we can do this 
again. We must first have the will and focus to grind these strategies 
out, year after year without fail. This should be one of our most 
diligent efforts and focused priorities as a Nation. Too often I hear 
smart, responsible citizens say that it's impossible to turn America's 
drug use around and I say, you're wrong! The mass poisoning of millions 
can be stopped with a serious effort. Anyone who actually believes that 
we can't do this is part of the problem, not the solution.
    We have addressed drug crisis before including crack cocaine, 
crystal meth, and now must employ similar strategies to the latest 
epidemic, opioids. We actually know what to do as we've been here 
before. Every single American has a role to be played in reducing 
substance use. Yes, I said substance use vs. singling out opioids. 
America has a drug USE problem. Of course we see use trends spike as 
different drugs make it across our borders, through our U.S. Postal 
Service and onto our streets. Yes we must specifically address the 
opioid epidemic with urgency, but we must also begin to see the 
pattern. Both what comes across our borders and what is produced here, 
be it spice, molly, bath salts and more, are what citizens will use. In 
short, we have a USE problem in the United States. Addressing demand or 
use on-going of ALL substances must be consistent and evidenced based 
year after year.
    Let's first take a look at some successful prevention strategies 
employed here in Arizona, but with intermittent or no continued funding 
sources to continue annually. We must prevent future generations from 
following the path of drug use and abuse.
    The Arizona Youth Survey 2016 tells us that youth use drugs to have 
fun, feel good, deal with stress and avoid being sad. In other words, 
youth want to alter how they feel through a drug, and adults have sent 
them that message in so many ways. We've told kids things like 
marijuana is medicine when we vote to change medicine so we can 
recreate with it, we see commercials every time we turn on the TV that 
tell us there's a fix for every feeling we have just ask your doctor 
for this pill. But the survey also gives us a roadmap for how to keep 
them from using drugs. The top reasons why kids don't use drugs are: 
It's of no interest in them, they understand the harmful effects, they 
don't want to disappoint their parents, and they're illegal. All points 
of data that we can implement like the campaign we started here in the 
State of Arizona. Instead of the ``Just Say No'' campaign Arizona has 
created a just say yes campaign. Say yes to ``I've Got Something Better 
To Do''. Connecting youth to local opportunities to play sports, hike 
the mountains, listen to a concert, or volunteer connects them to their 
passions, dreams, and families. When people in our country shame, 
stigmatize, and don't want to spend money to help those with a chronic, 
relapsing, brain disease, I often think, do they not remember that the 
average age of first use in this country is 13. We're talking about 
helping people who began their drug use as a teenager. Funding for this 
campaign is intermittent at best and must be sustained year-round for 
maximum impact.
    We all know that talking regularly with an educated parent about 
substance abuse can reduce drug use by about 50 percent. Yet, the 
Arizona Youth Survey shows us that 50 percent of AZ 8th graders and 
their parents didn't talk about drugs in the last year and almost 60 
percent of seniors didn't hear from their parents either. Fix that, 
focus on that, mandatory parent, youth, and faculty involvement in drug 
education like the program we launched in Arizona, Healthy Families 
Healthy Youth, prevention programming that educates youth, parents, and 
faculty at the same time. These are researched-based and have great 
data to support the effectiveness of this program, but as is the norm, 
there will be no money to continue this cost effective, data-driven 
prevention program next year.
       sbirt-screening, brief intervention, referral to treatment
    Yes, screen ALL high school students for mental health and 
substance use. Ninety percent of all addiction start in the teen years. 
Screen youth during these years to support and intervene early when 
it's easiest to turn the situation around, when its least ``costly'' to 
our youth and society. When we screen all youth in a school setting no 
one gets singled out, no one is weird, like vision screening used to 
be: It's preventative and helpful to connect youth and their families 
to resources. One such intervention program at notMYkid has tripled in 
size rapidly through school referrals, Project Rewind. When a kid is 
first caught with a substance we need to intervene to stop its 
progression vs. kicking them out of school. As we look at our schools 
across the country, I don't think anyone can deny that it's about 
schools, prevention, early diagnosis and connecting kids to resources. 
As we look back at all the school violence, someone or multiple 
someones knew there was a problem with the school shooters. We need to 
change school culture and create meaningful prevention programs with 
access to resources early. Youth feel loved and protected when adults 
set boundaries and offer support. Today's youth feel alone, isolated, 
and stressed more than ever. This is a place for adults to get educated 
and connect to our youth facilitated in school settings.
    As we moved on from the early 1990's, the crisis came back and 
today we are at epidemic portions with over 64,000 Americans dying a 
year from drug overdoses. Every year now, we lose more people to drug 
overdose deaths than all the names gathered over 18 years on the 
Vietnam Memorial Wall. In the District of Columbia.
    That, of course, is the worst of it--we haven't even begun to 
account for family breakup, social services being stretched, criminal 
activity and costs, workplace accidents, dropouts, and education 
deficits, ER admissions, lost productivity. Once we do--we're talking 
hundreds of billions of dollars to America on this one problem, this 
one problem that drives so many other problems. Please let me be clear, 
although I have written my share of checks to organizations to help 
someone get off the streets, find a treatment bed, or pay for a meal, 
I'd much prefer to invest in a system of prevention which offers the 
greatest rewards to the individual and society.
    To those of us who know friends and family in rehab we know two 
things: (1) Those are the lucky ones, the fortunate ones. Most don't 
get to or find rehab. Approximately 23 million people need treatment 
for a substance use disorder annually, yet sadly, only about 10 percent 
will receive it. (2) Sobriety is a life-long commitment that is 
addressed every day. Recovery is not linear, but relapse does not have 
to be a part of a person's story. Relapse is all too common and I don't 
accept that norm. I have lived through this personally with a son and a 
sister. Fortunately my son is with me, but my sister is not.
    I have spent, as do others, tens of thousands of dollars on detox 
and treatment just to see my investment of love and resources lost with 
a relapse. The scariest day of a recovering addict's life is the day 
they leave the treatment center. We literally have built and funded a 
system for decades that hasn't changed and worse yet, rewards failure 
by bad actors. To be clear, there are many wonderful treatment centers 
and even more trained and compassionate counselors who want to help 
people. But I fear, and my experience has been, that there are far too 
many in this field who prey upon individuals and families at one of 
their most vulnerable times in life. Most business models would be 
rewarded for success and innovation in their fields, but we financially 
reward those in this field more when they have terrible outcomes or no 
outcomes at all! Let's hold treatment centers accountable for 
verifiable outcomes. I know you're thinking that's impossible, but I 
assure you it is not. Through technology-assisted care, peer support 
programs, drug testing, and more we can and must know which treatment 
centers are doing the best job and reward them. This type of 
programming actually already exists. In all candor, I share with you 
the only technology that does all of this today, that I am aware of, 
which was created by my son Steve who is here with me today. That 
program is called True After Care. There are likely others in the field 
who do something similar and I want to know more about them as well. 
The bottom line is, let's fund what works and demand verifiable 
outcomes! Recovery needs to be a part of treatment. No one should leave 
a 30-day treatment program without a serious support system like True 
After Care to complete their journey into long-term sobriety.
    So in conclusion I want you to remember five things: (1) Prevention 
is the healthiest and most affordable choice we can ever make 
decreasing demand for drugs, (2) The Federal Government must provide 
visible leadership to create and convene all Americans in this effort, 
(3) We must recognize behavioral health as equally important as getting 
an education and imbed programs into our schools, (4) We need on-going 
public- and private-sector commitments, (5) Last, we must make access 
to treatment widely available.
    Drugs will always be here, so our message of prevention must be the 
louder of the two. We've done this before, we can and must do this 
again as it is not an unknown science.

    Ms. McSally. Thank you.
    The Chair now recognizes Mr. Cory for 5 minutes to testify.

  STATEMENT OF JAY A. CORY, CEO AND PRESIDENT, PHOENIX RESCUE 
                            MISSION

    Mr. Cory. Thank you, Chairwoman McSally and committee, for 
allowing me to be here to share today.
    Arizona faces an epidemic of substance abuse that 
translates into staggering costs to our State. It is one of the 
leading causes of homelessness, poverty, crime, rising medical 
costs, incarcerations, repeat offenders, recidivism, child 
removal into State custody, and family deterioration.
    I am going to dispense with statistics, as we have heard 
plenty.
    The opioid crisis is a wake-up call. However, substance 
abuse, other addictions, and negative behavioral manifestations 
such as violence and abuse continue to rise as well. Society 
continues to increase its desire for instant gratification, 
self-medication, and escape.
    The problem is greater than just availability of chemicals. 
Our society is declining spiritually. We have seen the 
breakdown of the family with more fatherless households and a 
growing number of those who cannot sustain themselves and 
afford the cost of living.
    The problem does not operate in isolation. There is a large 
underserved population of men, women, and families facing 
poverty, homelessness, and trauma in Arizona, and especially in 
the Phoenix metropolitan area.
    Poverty. There are over 1.1 million persons, or 16.4 
percent of Arizona, below the poverty line.
    Homelessness. There are more than 37,000 persons who 
experience homelessness in Arizona, and there may be as many as 
8,900 homeless on any given night. In Maricopa County there 
were 22,000 experiencing homelessness, or 54 percent of the 
State's total, with more than 5,600 on any given night.
    Lack of affordable housing. There is grossly insufficient 
affordable housing in Arizona, and often it is not safe and 
healthy. Many leave recovery programs or incarceration and go 
right back to use because they can't afford to live.
    Recommended solutions. Phoenix Rescue Mission applauds the 
efforts to reduce supply and efforts toward prevention of 
substance abuse. Phoenix Rescue Mission also supports the 
efforts of medication-assisted treatments to reduce cravings 
for and effects of opiates.
    There is an immediate, drastic need for increased capacity 
for cost-effective, comprehensive residential and non-
residential programs that provide pathways out of poverty, 
homelessness, addiction, and other life-controlling problems. 
Most need more than just temporary relief or short-term 
programs and are unprepared for direct placement into housing. 
These programs should include a crisis component, crisis 
stabilization, get people out of situations that they are in, 
bring them to a safe place where they can be assessed and 
properly placed.
    There needs to be a drastic increase in comprehensive 
recovery programs, both short- and long-term, ``comprehensive'' 
meaning case management services, academic assistance, English 
as a second language, vocational development, job placement, 
spiritual growth, and counseling.
    Reentry. There needs to be expanded capacity for housing 
and support services for persons completing residential work.
    Recommended solution. Work in partnership with faith-based 
providers. Example: Association of Gospel Rescue Missions. 
Phoenix Rescue Mission is a member of the Association of Gospel 
Rescue Missions. There are seven member missions in Arizona. 
Now in its 105th year, the Association is North America's 
oldest and largest network of independent crisis shelters and 
rehabilitation centers. Each year AGRM members serve more than 
65 million meals, 24 million nights of lodging, 36,000 people 
find independent housing, and they assist about 45,000 people 
in finding employment, and 17,000 people from addiction 
recovery programs are placed into productive living.
    Just a little experience, recent experience from the 
Phoenix Rescue Mission. The first step into admission into all 
residential programs is called RAP, which is a 7-day triage 
program. Statistics for the last 10 months, ending April 30, we 
admitted 542 unduplicated men. The top three presenting 
problems were homelessness, financial crisis, and substance 
abuse. The top disclosed drugs of choice for substance abusers 
were alcohol, stimulants, cannabis, and opioids. Opiates were 
38 percent. Three hundred and ninety-two, or 72 percent of the 
men were successfully placed in appropriate solution 
programming, with 254 or 47 percent being placed in our first 
phase recovery program. People are getting off the streets, and 
they are getting plugged into treatment programs.
    On the women's side, we had 217 unduplicated women, the 
same basic breakdown of presenting problems, with a 40 percent 
opiate. So we are out on the streets.
    A couple of anecdotal points. Because of our street teams 
that go out on the street, we have two vans out there every 
day. They are younger. Obviously, heroin is increasing as a 
drug of choice. It is less expensive. We are seeing that the 
results of our efforts to reduce prescription meds on the 
street is taking effect because they are becoming more 
expensive. However, people are turning to a cheaper alternative 
such as heroin.
    Thank you for allowing me to share.
    [The prepared statement of Mr. Cory follows:]
                   Prepared Statement of Jay A. Cory
                              May 30, 2018
                              the problem
    Arizona faces an epidemic of substance abuse that translates into 
staggering costs to our State. Substance abuse is one of the leading 
causes of homelessness, poverty, crime, rising medical costs, 
incarcerations, repeat offenders, recidivism, child removal into State 
custody, and family deterioration.
    According to AZ DHS website for the period 6/15/17-5/24/18, there 
were:
   1,238 Suspected opioid-related deaths,
   8,022 Suspected overdoses,
   766 Neonatal Abstinence Syndrome,
   5,262 Naloxone doses administered,
   347,816 Opioid prescriptions dispensed last month.
    The opioid crisis has been a wake-up call. However, substance 
abuse, other addictions, and negative behavioral manifestations such as 
violence and abuse continue to rise as well. Society continues to 
increase its desire for instant gratification, self-medication, and 
escape.
    The problem is greater than just availability of chemicals. Our 
society is declining spiritually, we have seen the breakdown of the 
family unit with more fatherless households, and a growing number of 
those who cannot sustain themselves and afford the cost of living.
    The problem does not operate in isolation. There is also a large 
underserved population of men, women, and families facing poverty, 
homelessness, and trauma in Arizona and especially in the Phoenix 
metropolitan area.
   Poverty.--PRM provides services in some of the most poverty-
        stricken areas of our community and Nation. Many lack the 
        basics needed to sustain themselves and are often only one step 
        away from homelessness. They are often unaware or unable to 
        connect to services that may assist them. There are over 
        1,100,000 persons or 16.4 percent in AZ below poverty line 
        ranking 43rd in the Nation. More efforts are needed to provide 
        elevation through vocational development and education.
   Homelessness.--According to AZ DES 2017 report, more than 
        37,000 persons experienced homeless in AZ and there may be as 
        many as 8,900 homeless on any given night. In Maricopa County 
        there were over 22,000 experiencing homelessness or 54 percent 
        of the State's total with more than 5,600 on any given night. 
        Of those experiencing homelessness, 67 percent were single 
        adults, 12 percent were adult members of families, and 21 
        percent were children in families. Causes include economic 
        factors, substance abuse, mental health issues, and domestic 
        violence.
   Lack of Quality Affordable Housing.--There is grossly 
        insufficient affordable housing in Arizona and often it is not 
        in a safe and healthy environment. Many leave recovery programs 
        or incarceration and go right back into a war zone. Housing is 
        the fundamental intervention that moves an individual or family 
        from homelessness to self-sufficiency. Without housing, all 
        other intervention programs are less effective. There is a 
        great need to provide healthy supportive housing communities.
                         recommended solutions
    Phoenix Rescue Mission (PRM) applauds the efforts to reduce supply 
and efforts toward prevention of substance abuse.
    PRM also supports the efforts of medication-assisted treatments to 
reduce cravings for and effects of Opioids (example--Vivitrol).
    There is an immediate drastic need for increased capacity for cost-
effective comprehensive residential and nonresidential programs that 
provide pathways out of poverty, homelessness, addiction, and other 
life-controlling problems. Most need more than just temporary relief or 
short-term programs and are unprepared for direct placement into 
housing. Their life-controlling problems are often complex and need 
comprehensive community and residential services. These programs should 
include:
   Rescue--Crisis Response and Stabilization to prevent further 
        decline by meeting basic needs, providing stability, support, 
        assessment, and guidance in developing and executing a solution 
        plan. Motivated persons must have their immediate needs met or 
        brought to a safe place so they can be properly assessed and 
        placed into the right solution pathway.
   Recovery from Life-Controlling Problems--Comprehensive 
        services to address the total person toward solutions and 
        sustainability. Services such as case management, connection to 
        services, academic assistance such as GED/High School Diploma, 
        and English as a Second Language, vocational development and 
        job placement, spiritual growth, counseling, life skill 
        development, short- and long-term addiction recovery.
   Re-Entry--Expanded capacity for housing and support services 
        for persons completing residential recovery programs, existing 
        incarceration, and other populations so that they can continue 
        forward momentum.
    Work in partnership faith-based providers. Many do excellent work 
and receive little to no Federal funding. Remove barriers and provide 
equal opportunity for funding. An example:
   AGRM--PRM is a member of the Association of Gospel Rescue 
        Missions. There are 7 member missions in Arizona. Now in its 
        105th year, AGRM is North America's oldest and largest network 
        of independent crisis shelters and rehabilitation centers. AGRM 
        has nearly 300 rescue mission members across North America. 
        Each year AGRM members serve more than 65 million meals, 
        provide more than 20 million nights of lodging, and help more 
        than 36,000 people find independent housing, assist about 
        45,000 people in finding employment, bandage the wounds of 
        thousands of abuse victims, and graduate nearly 17,000 people 
        from addiction recovery programs into productive living. Every 
        year, AGRM members use 300,000 volunteers and 10,000 full-time 
        staff to serve.
                        prm's recent experience
    Rescue-Assess-Place (RAP) Program.--Is the first step for admission 
into all PRM programs and is a maximum 7-day residential triage program 
for motivated adult men, women, and mothers with children under the age 
of 12 facing homelessness and/or seeking recovery from addiction or 
other life-controlling problems. PRM Rescue-Assess Place (RAP) Program 
statistics for last 10 months 7/1/17-4/30/18.
   PRM admitted 542 unduplicated men into RAP. The top 3 
        presenting problems disclosed were homelessness (513 or 95 
        percent), financial (434 or 80 percent), and substance abuse 
        (337 or 62 percent). The top disclosed drugs of choice for 
        substance abusers were alcohol, stimulants, cannabis, and 
        opioids (38 percent). Note: 392 or 72 percent of men were 
        successfully placed in an appropriate solution program with 254 
        or 47 percent being placed in PRM's Foundations (phase 1 
        recovery program).
   PRM admitted 217 unduplicated women into RAP. The top 3 
        presenting problems disclosed were substance abuse (170 or 78 
        percent), homelessness (103 or 47 percent), and financial (91 
        or 42 percent). The top disclosed drugs of choice for substance 
        abusers were stimulants, alcohol, and opioids. (40 percent). 
        Note: 177 or 82 percent of women were successfully placed in an 
        appropriate solution program with 117 or 54 percent being 
        placed in Foundations.
    Street Outreach.--PRM's Street Outreach ministries go out in Hope 
Coach vans to engage unsheltered homeless individuals to rescue them 
off the streets and into appropriate solutions. Basic survival needs 
such as water and hygiene kits are provided. Street Outreach partners 
with law enforcement and first responders and caseworkers to provide 
solutions to homeless individuals and the neighborhoods affected by 
homeless camping. PRM's street teams are trained and equipped in the 
use of Naloxone (Narcan). From 7/1/17-4/30/18 Street Outreach:
   Engaged over 650 individuals for attempted rescue.
   95 were engaged off the street and transported off the 
        street and connected to services.
   25 percent of those rescued were admitted opioid abusers.
   55 were admitted to PRM's RAP program.
    Anecdotal observations from the street teams over the past few 
months:
   The three greatest segments of those on the streets are 
        substance abusers, mentally ill, and service resistant. 
        Particularly among the substance abusers there is a large 
        number that are responsive to ``hand-up'' options when properly 
        engaged and the timing is right.
   Heroin continues to be prevalent on the streets and is 
        rapidly ascending as a drug of choice. It is available and less 
        expensive than many other choices.
   There is a growing number of heroin addicts that started as 
        result to addiction to pain medication. Many of these are 
        relatively inexperienced in homelessness and are vulnerable.
   Pain medication is decreasing in supply and becoming more 
        expensive. Heroin is a much less expensive option and more 
        readily available.
   Many panhandlers are substance abusers with an increasing 
        number addicted to heroin.
    PRM has experienced success in working with clients in recovery 
from opioid addiction particularly in its long-term ``Transformations'' 
recovery program. Currently both the men's and women's RAP program are 
run by graduates each with over 5 years sobriety. Graduates are also in 
leadership positions with our Street Outreach and Foodbank operations. 
To see many of PRM's stories of success, please visit 
www.phoenixrescuemission.org.
    PRM has current plans to expand its residential capacity for men's 
recovery by over 300 beds with anticipated construction beginning by 
the end of 2018.

    Ms. McSally. Thank you, Mr. Cory.
    The Chair now recognizes Mr. Warner for 5 minutes to 
testify.

    STATEMENT OF WAYNE WARNER, DEAN OF MEN, TEEN CHALLENGE 
                      CHRISTIAN LIFE RANCH

    Mr. Warner. Thank you, Congressman McSally and Ranking 
Member Grijalva. I want to thank the distinguished Members of 
the subcommittee for allowing us to come today. I also want to 
thank the current and past panels for all their efforts. It is 
an absolute honor to represent Teen Challenge of Arizona today 
as a graduate of the program.
    Like Mr. Cory, I will also be dispensing with statistics 
and simply share my personal experience with addiction.
    My name is Wayne Warner, and I am the dean of men at the 
Teen Challenge Christian Life Ranch in New River, Arizona. 
Miraculously, I am an ex-opioid addict that has had the 
pleasure of not only testifying today but also being alive 
after an extensive period of illicit drug use took me down a 
path of misery and discontent.
    My story begins at 16 years old, when a conflict at school 
left me with the ring and pinky appendage of my left hand 
severed after a door was closed on them. I cite this experience 
not for the trauma or the pain, but the pain management I 
received for my injury. I was a 16-year-old handed narcotics to 
take when I ``needed'' them to manage the pain in my hand. I 
remember this experience vividly, and I still refer to this as 
the day I first felt OK with myself.
    Although I so enjoyed this feeling, the thought of becoming 
a drug addict truly terrified me to my core. It would take a 
few years for my addiction to truly take over my life. After a 
seemingly slow graduation from marijuana to pills again and 
then eventually heroin, I found myself homeless, jobless, and 
nearly lifeless. I had been arrested several times, charged 
with felonies, and sent on my way time and time again. I was an 
angry, injured shell of a human being attempting to carry 
around the fragmented pieces of my life from rehab to rehab 
until I could get enough rest to find the energy to wake up and 
do it all over again.
    Life at this point was meaningless and people were 
pointless. Love was an idea, abandoned and buried in the 
cemetery with my relationships with my family and friends. 
People would die around me and I felt like the lone sailor in 
the sea, waiting for the shark of addiction to come up and 
ambush me from beneath, but I was not afraid of him. I was 
afraid that I would have to wake up when the sun rose and the 
slow and painful torture of withdrawal would begin to set in 
once again.
    I was arrested for the last time on October 28, 2012 after 
I stole a vehicle from the family member of a friend in order 
to pick up a bag of heroin with the last $20 I had to my name. 
As I spoke through the bars of the back window of the Peoria 
Police Tahoe, I recall giving my mother's name and her number 
to my friend and asking him to tell her that I was arrested 
once again and to please just leave me in jail this time.
    Unbeknownst to me, on that very same day, two men from the 
Christian Life Ranch in New River, Arizona would knock on the 
door of a woman's house that desperately needed her son to get 
help. They gave their testimonies, prayed with her, and 
promised her they would pray for her son to get the help he 
needed. That woman's name is Tammy, and she is my mother.
    I was sentenced, I served my time, and I was released. It 
was ordered that one of the conditions of my probation would be 
the completion of the Teen Challenge program. It was also made 
clear to me that in the State of Arizona I would then and 
always carry the legal label of ``felon'' indefinitely.
    Over the following years a few major milestones would be 
achieved in my life. Teen Challenge and adult probation were 
completed. I committed to and completed an internship at The 
Ranch and was later hired on as a full-time employee.
    This might sound like every other redemptive story you have 
heard, and you might be partially correct. There is one thing 
that makes me different, and that is the fact that I have had 
my immediate family and my Teen Challenge family behind me 
every step of the way. They never gave up, never put me down, 
and never stopped loving me.
    I was baptized, affirmed, counseled, and unconditionally 
loved. I owe a debt of gratitude not only to both my family and 
my program but also to Jesus Christ, my personal Lord and 
savior. If it weren't for these relationships being so strong 
and dependable, I would not be where I am today. My life has 
now exponentially improved. I get to be part of a team of 
leaders that is spearheading the effort to discuss and resolve 
the real-life issues that people like me have dealt with and 
some of us have died because of. I am sought after for 
guidance, support, and even advice.
    I will be celebrating 6 years of sobriety this October. I 
will be celebrating my 1-year anniversary with my wife Kendra 
this June, and we will be celebrating the birth of our newborn 
baby boy in July.
    It is through the program of Teen Challenge, programs like 
it, the people that work there, and the grace of God that I am 
able to speak in front of you today.
    There is hope for the epidemic our country and our world is 
currently facing, and that hope is found in love.
    Thank you, and God bless.
    [The prepared statement of Mr. Warner follows:]
                   Prepared Statement of Wayne Warner
    My name is Wayne Warner and I am the dean of men at the Teen 
Challenge Christian Life Ranch in New River, AZ. Miraculously, I am an 
ex-opioid addict that has the pleasure of not only testifying today; 
but also being alive after an extensive period of illicit drug use took 
me down a path of misery and discontent.
    My story begins at 16 years old, when a conflict at school left me 
with the ring and pinky appendage of my left hand severed after a door 
was closed on them. I cite this experience not for the trauma nor the 
pain, but the pain management I received for my injury. I was a 16-
year-old, handed narcotics to take when I ``needed'' them to manage the 
pain in my hand. I remember this experience vividly and still refer to 
this as the day I first felt ``OK'' with myself.
    Although I so enjoyed this feeling, the thought of becoming a drug 
addict truly terrified me to my core; it would take a few years for my 
addiction to truly take over my life. After a seemingly slow graduation 
from marijuana, to pills again and then eventually heroin; I found 
myself homeless, jobless, and nearly lifeless. I had been arrested 
several times, charged with felonies and sent on my way again time 
after time. I was an angry, injured shell of a human being attempting 
to carry around the fragmented pieces of my life from rehab to rehab 
until I could get enough rest to find the energy to do it all over 
again. Life was meaningless and people were pointless. Love was an 
idea, abandoned and buried in the cemetery with my relationships with 
my family and friends. People would die around me and I felt like the 
lone sailor in the sea; waiting for the shark of addiction to come up 
and ambush me from beneath; but I wasn't afraid of him. I was afraid 
that I would have to wake up when the sun rose and the slow and painful 
torture of withdrawal would begin to set in once again.
    I was arrested for the last time October 28, 2012 after I stole a 
vehicle from the family member of a friend in order to pick up a bag of 
heroin with the last $20 I had to my name. As I spoke through the bars 
of the back window of the Peoria Police Tahoe I recall giving my 
mothers' name and number to my friend and asking him to tell her that I 
was arrested once again, and to just leave me in jail.
    Unbeknownst to me, on that very same day, two men from the 
Christian Life Ranch in New River, AZ would knock on the door of a 
woman's house that desperately needed her son to get help. They gave 
their testimonies, prayed with her and promised her they would pray for 
her son to get the help he needed. That woman's name is Tammy and she 
is my mother.
    I was sentenced, I served my time, and I was released. It was 
ordered that one of the conditions of my probation would be the 
completion of the Teen Challenge program; it was also made clear to me 
that in the State of Arizona I would then and always carry the legal 
label of ``felon'' indefinitely. Over the following years a few large 
milestones would be achieved in my life. Teen Challenge and Adult 
Probation were completed; I committed to and completed an internship at 
The Ranch and was later hired as a full-time employee.
    This might sound like every other redemptive story you've heard, 
and you might be partially correct. There is one thing that makes me 
different; that is the fact that I have had my immediate family and my 
Teen Challenge family behind me every step of the way. They never gave 
up, never put me down, and never stopped loving me. I was baptized, 
affirmed, counseled, and unconditionally loved. I owe a debt of 
gratitude, not only to both my family and my program; but also to Jesus 
Christ, my personal Lord and Savior. If it weren't for these 
relationships being so strong and dependable, I would not be where I am 
today. My life has now exponentially improved. I get to be part of a 
team of leaders that is spear-heading the effort to discuss and resolve 
the real-life issues that people like me have dealt with and some of us 
have died because of. I'm sought after for guidance, support, and even 
advice. I will be celebrating 6 years of sobriety this October. I will 
be celebrating my 1-year anniversary with my wife Kendra this June; and 
we will be celebrating the birth of our newborn baby boy in July. It's 
through the program of Teen Challenge, the people that work there and 
the Grace of God that I am able to speak in front of you today. There 
is hope for the epidemic our country and our world is currently facing; 
and that hope is found in love
    Thank you and God Bless.

    Ms. McSally. Thank you, Mr. Warner, for your courage to 
share your personal story with us. It is pretty powerful.
    Mr. Schweikert needs to leave, so I am now going to 
recognize him first for questions.
    Mr. Schweikert. Thank you for that.
    Being raised by a woman who spent much of her later adult 
life in a 12-step program and then became a substance abuse 
counselor right down the street here, trying to recruit drug-
addicted prostitutes off the street, you don't sometimes 
process the human tragedy substance abuse can be.
    I have to leave in a moment, but I do have some questions.
    Dr. Christ, just because it bothered me but also was 
optimistic, you made a comment that we have a 50 percent 
reduction in high-volume prescriptions for opioids.
    Dr. Christ. Yes.
    Mr. Schweikert. For the remaining 50 percent, how much of 
that is palliative, of the remaining 50 percent?
    Dr. Christ. So that would be through our Controlled 
Substances Prescription Monitoring Program. What we are doing 
is the 90. A lot of it is going to be pain management.
    Mr. Schweikert. That is actually where I am going. We have 
all had this issue in our lives, someone who is in hospice, for 
those things. In that case there is going to be pain 
management. My concern is 50 percent reduction is miraculous. 
What if that remaining 50 percent is still bad actors, and what 
if that is just what should be the baseline in our society? I 
know I am asking you to speculate, but you are bathing in the 
data.
    Dr. Christ. Right. We can go back and look. That is a very 
interesting question. I don't know that I have the specifics 
because we would have to go back and match medical records.
    Mr. Schweikert. It is hard, but that is actually one of the 
things I am after. If you are making an argument that opioids 
are different than other types of addictions in our society, 
that this gateway comes through our medical profession, so the 
demographics are different, the population looks different than 
often the youth and other types, but of our population, how 
many should be there? If it is only another 10 percent or so, 
we need to solve that other 40 percent. Am I making sense?
    Dr. Christ. Absolutely.
    Mr. Schweikert. What do we do as Federal policy makers? I 
am working on a technology piece that does a prior 
authorization. That is bipartisan. That will go through. But is 
it a technology solution? Is it a data solution? Is it a human 
solution? Help us find one.
    With that, Madam Chairman, I yield back. Forgive me, I must 
leave.
    Ms. McSally. Absolutely.
    Dr. Christ, do you want to reply at all?
    Dr. Christ. I would say it is probably all three. So it is 
probably going to be a technology solution, a data solution, 
and a human solution. But out of concern for those who do need 
it for hospice or end-of-life or palliative care, that has been 
exempted and they are not required to stick to the dose 
restrictions.
    Mr. Schweikert. We need to understand how much of our 
population prescription usage is that population, and then the 
rest we need to analyze and understand.
    Dr. Christ. Absolutely.
    Mr. Schweikert. Thank you.
    Ms. McSally. The Congressman yields back.
    The Chair now recognizes the acting Ranking Member, Mr. 
Grijalva, for 5 minutes.
    Mr. Grijalva. Thank you very much.
    First of all, Mr. Warner, thank you for sharing with us and 
everybody. Your journey, as difficult as it was, it was a 
light, and we appreciate you taking the time to be with us 
today and sharing that.
    Dr. Christ, at the beginning of my opening statement I said 
I wish somebody from the pharmaceutical industry was here, and 
the reason is that there is no question in terms of linkage 
that much of what we are dealing with right now with this 
opioid crisis began with the prescription painkillers that 
became part and parcel, and now you see an increase in heroin 
and fentanyl as substitutes for that.
    One of the reasons it is a question is that Naloxone, which 
is a life-saving overdose drug was, interestingly enough, in 
2014 it was $288 for an injection. Right now it is over $2,000 
for an injection. I think somebody recognized a market, and 
when local communities, particularly law enforcement and public 
health officials, are attempting to get hold of this as a life-
saving opportunity to have out there, the price has been 
raised. So I think they need to be part of this.
    If you had $76 billion to spend on the opioid crisis 
Nation-wide, where would you prioritize the money? What would 
be your first priority?
    Dr. Christ. I think going back to Ms. Moak's response, I 
think this has to be a two-pronged approach. I think you need 
to provide access to treatment and improve the ability for 
patients that are currently suffering from opioid use disorder 
to have access to the treatment they need. But I think in order 
to respond and deal with this in the future, you really have to 
have targeted prevention and harm reduction efforts.
    Mr. Grijalva. Thank you. One of the studies showed that 
since 2000 the cost of the opioid crisis has been $1 trillion, 
and that in the next few years it could be $500 billion. So I 
appreciate your answer, because I think that is one of the 
focuses that we need to have when we talk about this.
    Mr. Cory, in your experience, in dealing with the fine work 
you do, particularly in outreach and retrieving people to try 
to provide support, I am glad you brought up the issue of 
poverty and other things that are contributing factors that we 
don't talk about enough.
    Do you believe that the majority of opiate users started 
out on heroin and fentanyl?
    Mr. Cory. We are dealing with people that are actually 
right off the streets, people that are coming into our RAP 
unit, which is more like a social detox. I think that there has 
been a heroin problem for a very long time, there has been a 
substance abuse problem for a very long time. I would say that 
there has been an adjustment in the population. We are seeing a 
new element enter into the population. Again, we are focused 
sort-of at the bottom of the safety net in that they are 
younger people that, because of prescription med addiction, 
fell into heroin addiction. So they are younger. There are a 
lot more females on the street than there used to be.
    I don't know if I am answering your question.
    Mr. Grijalva. You did.
    Ms. Moak, in the limited time that I have, your testimony I 
think did a great job of explaining why prevention is so 
important and the various techniques that can be employed to 
fight substance abuse in all forms and dealing with the opioid 
crisis in this hearing.
    Where does border security funding fall as a prevention 
strategy to end the demand for drugs in this country, and how 
do we reconcile the proposed cuts to nutrition, Medicare, 
Medicaid, community development in terms of the efforts at 
prevention?
    Ms. Moak. I think that is a great question. Certainly, that 
is prevention, not having these drugs come across our borders. 
But for me, I like scaling what is most cost-effective and 
makes the most sense, and that is not seeing our youth get 
started using any type of drug. We have this crisis right now. 
We have had others before. We will have others after this.
    So working in the schools and scaling, quite frankly, 
behavioral health right now in our school setting is a great 
use of funds.
    Mr. Grijalva. Dr. Segay and others, my time is up, but I 
have written questions, and I appreciate Dr. Segay bringing a 
perspective that sometimes at these hearings is not heard often 
enough.
    Thank you.
    Ms. McSally. The gentleman yields back.
    I now yield to myself in place of Mr. Schweikert.
    Mr. Warner, thanks for sharing your personal story, and 
congratulations on the coming birth of your daughter. It is 
exciting and hopeful, and I think you know that some decisions 
you made and what may have been intended for evil, God has used 
for good in your redemptive path. So I am really proud of your 
courage to be able to share that story and invest in others.
    If you could talk to your 16-year-old self and look back at 
that moment in time--you obviously had an injury, you were in 
pain--what would you advise be done differently both within 
your choices and those around you, whether it is the doctor or 
others in your life, friends and family, in order to have you 
go on a different path?
    Mr. Warner. I am so glad that I have an opportunity to 
speak more than just my testimony, because I have a lot of 
opinions on this stuff, and so I just appreciate just this 
moment in time.
    First off, as Ms. Moak was speaking about, preventive 
measures have to be taken. We actually do a segment called Stay 
Sharp where we go into middle schools, high schools, and 
elementary schools, and we give our testimonies to adolescent 
children, and the teachers come up to us after and say, hey, 
can you stay back and talk to this one person that I really 
feel needs help? What that tells me is two things: This person 
really doesn't have anybody to talk to at home, and they don't 
have anybody to talk to at school. The teacher doesn't know 
what to do until we just show up out of the blue and they 
think, oh, I am so happy you guys are here, now this person can 
speak. But we have a limited amount of time.
    So having a representative from some type of organization 
that is in the school that has a personal relationship with 
these adolescents would be monumental in terms of being able to 
sense where a person is and how they can help, No. 1; No. 2, 
$76 billion, if we had that--I mean, just being able to fund 
that type of thing inside of public schools and private 
schools, not only are you going to see the addictions start to 
drop because we are heading it off, we are nipping it in the 
bud before it can even get to this epidemic, but then also 
supply is meeting demand right now, and as long as you have 
demand, you will get supply.
    I don't want to diminish the task forces that we have heard 
from today whatsoever, but the fact is that all of the drugs 
that they have taken off the streets, I did not have an issue 
finding them. I am letting you know that right now. It wasn't 
like, hey, guess what? There was a big bust, we are not going 
to get high today, unfortunately. I hate to be crass, but that 
is the reality. It was never an impact.
    So that was what I would have liked to have known, that 
there was somebody there that understood me and that cared 
about me. Thank you for your question.
    Ms. McSally. Thank you, Mr. Warner.
    As we have seen from this panel, we have now two faith-
based organizations and not $1 of Government funding. They are 
changing lives and impacting lives, and a non-profit that is 
also involved and engaged. Not every school needs to have the 
Teen Challenge visitors. Not every school is going to be able 
to have notMYkid. But the complementary nature of all of what 
you are doing, combined with an appropriate Government role, I 
think is really what has come out of this panel a lot, right? 
It has to be all of the above.
    Is there any sort of collaboration or coordination among 
the non-profits with the Government, Dr. Christ, related to, 
hey, we are focused over here, but there is really an issue in 
this geographic area, or we need to be doing more on the 
reservations and cooperating and getting some non-profits 
coming in there? Is there some way for there to be that 
collaboration in order to address this and identify where the 
needs are, an all-of-the-above strategy?
    Dr. Christ. I think that is a fantastic question. Through 
the Governor's Council we did try to bring together 
stakeholders, whether they were patients, associations, faith-
based, non-profits. But I think one of the biggest assets that 
the Governor has is the Governor's Office of Youth, Faith, and 
Family, because they do a fantastic job convening those 
organizations and getting funding to them.
    Ms. McSally. Ms. Moak, and then I want to ask Dr. Segay.
    Ms. Moak. In fact, since I left the Governor's Office, that 
is exactly what I am working on. We know that Federal/State 
funds will never be enough to solve this. One example, one 
small example, I am currently working with Blue Cross Blue 
Shield, and their bottom line was we want to fund what you are 
already doing, we don't want to start something from scratch.
    So we are taking a look, again, at all the initiatives we 
already have that have data and bringing in more private 
sector, like Blue Cross Blue Shield, to scale.
    Ms. McSally. Dr. Segay, Indian Health Services is, 
obviously, critical on the reservation. Are there other non-
profits or others that would be culturally acceptable to be 
able to partner with and help on the reservation for those who 
are struggling with addiction? Are they present there?
    Dr. Segay. Thank you for your question, Madam Chair. The 
reality there on Navajo is that we have been trying to pretty 
much demonstrate the effectiveness of our method of treatment 
with traditional services, and it has been hard. We don't have 
an evidence base as far as what ceremonies are effective or 
disciplined. We have what is effective-based. So right now, all 
of our ceremonies are traditional methods with our traditional 
practitioners, and are not reimbursable. So it is really 
complicated to say here is an evidence-based ceremony that 
needs to be reimbursed.
    In reality, we have been going to CMS and letting them know 
that this needs to be reimbursable, pretty much. I mean, it 
just connects to everything. So collaboration is happening 
among our Tribal programs, our Public Law 93-638 facilities, 
and IHS as far as their satellite, and then the Tribal 
programs, keeping in mind that Navajo is 27,000 square miles, 
with 350 enrolled members. Thank you.
    Ms. McSally. Thanks.
    I am totally out of time. Mr. Cory, I wanted to ask you a 
question, but I want to respect everyone's time.
    The Chair now recognizes Mr. Gallego for 5 minutes.
    Mr. Gallego. Thank you, Madam Chair.
    Ms. Moak, I actually missed it, but I was looking through 
your testimony. You mentioned a program that was run out of U 
of A that ran out of funds. Can you refresh my memory on that?
    Ms. Moak. Yes, sir. It was actually a program that was 
evaluated by ASU. The program was a prevention program where we 
designed the curriculum, scaled it for the past 2 years into 
7th grade, has great data, was loved by students, parents, and 
faculty, very affordable and easy to scale, and literally we 
don't have funding for it this coming year.
    Mr. Gallego. So why don't you have funding for it this 
coming year?
    Ms. Moak. The grants change from year to year.
    Mr. Gallego. The grants are coming from the Federal 
Government or the State government?
    Ms. Moak. Yes, sir. A Federal grant.
    Mr. Gallego. Which department is it?
    Ms. Moak. I apologize, I am blanking on that right now. But 
the grant is not available to us next year.
    Mr. Gallego. OK. If you could provide that information 
tomorrow, I would greatly appreciate it.
    Ms. Moak. Yes, sir, I will.
    Mr. Gallego. Director Christ, you heard my comments earlier 
to Governor Ducey. As someone who is very knowledgeable on 
Medicaid, and someone like me who actually really is proud of 
AHCCCS here in Arizona, I am concerned that there is a missing 
link here among our Arizona government through the Governor, 
that they don't actually quite understand how important 
Medicaid is to preventing both opioid deaths and addiction.
    Could you just give us some examples of how helpful 
Medicaid expansion can be in terms of dealing with our opioid 
epidemic?
    Dr. Christ. Given the 5-minute limitation, I think that 
that is a----
    Mr. Gallego. I will give you 2 minutes of the 5 minutes.
    Dr. Christ. OK. I didn't get to highlight how engaged 
AHCCCS and the Medicaid program have been in Arizona's 
response. We have partnered with Director Betlock and his team. 
They are responsible for administering the $24 million State-
targeted response grant that came through SAMHSA last year. 
They are actually integrating that into the Medicaid program so 
that our substance abuse patients and those who are suffering 
from opioid use disorder get the same services, and especially 
for that $10 million funding that they found for the uninsured 
and underinsured. That will be partnered with our AHCCCS 
program.
    So we are using Medicaid in Arizona as the base for 
expanding our medication-assisted treatment and our treatment 
options.
    Mr. Gallego. To switch gears, in terms of FQHCs--I am 
really bad with acronyms--Federally Qualified Health Clinics, 
there has been a severe cut in terms of funding for FQHCs, 
which deals with a lot of that population. Do you see it as a 
good investment in terms of putting money back into FQHCs in 
terms of trying to curb the human costs of the opioid epidemic?
    Dr. Christ. Absolutely. I think that, luckily in Arizona, 
we have a very strong partnership with our FQHCs and their 
association, and so we are utilizing them. They are a perfect 
resource. They are State-wide. They provide whole-person 
integrated care. They are a great partner for our opioid use 
disorder patients.
    Mr. Gallego. Great. Thank you, Dr. Christ.
    Dr. Segay, as you know, the opioid epidemic's impact on 
Indian Country has been quite profound. Fully 10 percent of 
Native children have used opioids for non-medical purposes, 
which is double the rate of Anglo children. In addition, Native 
women who are pregnant are nearly 9 times more likely to be 
diagnosed with opioid dependency or abuse compared to the 
general population.
    This epidemic has also strained Tribal governments that 
already are facing significant challenges in general.
    In the face of so much suffering, what can we do as the 
Federal Government to step in? I particularly ask this because 
I am going to be the incoming Chairman of the Indian Affairs 
next year and would like to make sure that I am ready and 
prepared to be helping out Indian Country.
    Dr. Segay. Thank you for that. Well, on Navajo, we pretty 
much always try to educate our leaders. So we always make the 
request to our leaders in Washington at the Federal level that 
they come visit Navajo so that they can understand and see how 
our health care delivery system is set up.
    So, for example, in some areas it is 100 miles to the 
nearest facility, and we don't have helicopter service, or even 
our safety response is like a 2- or 3-hour response. So that is 
where there is the golden hour, and that is where we lose a lot 
of our people, especially if there is an opioid overdose.
    Mr. Gallego. Not to take too much time, but this is 
certainly a problem dealing with East Coast politicians. They 
don't understand the concept of a Native American reservation, 
because over there the land is the size of a stamp, and tribal 
lands are the size of States compared to the East Coast. So I 
do agree that we need to have that education for them.
    Dr. Segay. Yes, and more funding for AHCCCS. Thank you.
    Mr. Gallego. One hundred percent. I like how you got that 
in under the wire.
    [Laughter.]
    Mr. Gallego. Thank you so much. Thank you for all your 
testimonies.
    Ms. McSally. The gentleman's time has expired.
    The Chair now recognizes Ms. Lesko for 5 minutes.
    Ms. Lesko. Thank you, Madam Chair.
    Thank you, panel, for everything that you do for our 
community.
    What has become clear to me in this whole hearing today is 
we need a multi-faceted approach, which we are taking, to solve 
this opioid crisis and drug abuse crisis, and I really thank 
you, Mr. Cory, for the work that you do in the community, and 
Mr. Warner for sharing your story. I hope you can continue 
sharing your story. It is very inspirational, very touching. 
What a success story. Thanks for sharing it.
    I have a really kind-of common-sense basic question, not 
about statistics or anything like that. This is something that 
comes up, and I, quite frankly, want to know the answer and see 
what your insight is. That is, I see a huge increase in 
panhandlers on the streets. My district includes Sun City, and 
I am starting to see panhandlers on the streets in Sun City on 
Grand Avenue, which hadn't happened before. The number of 
homeless, too, really seems to be increasing.
    So my first question is do you think that the increase in 
panhandlers is due to drug addiction? Are they trying to get 
money for drug addiction? My follow-up question is, as an 
individual who is compassionate, should I give them money or 
should I not? Maybe all of you can answer it, but I have a 
feeling that Mr. Cory and Mr. Warner probably are the best ones 
to answer those questions.
    Mr. Cory. This is a Rescue referral card so we will come 
pick you up, we will give you free food, we will take care of 
you. So do not give them money is my counsel. I have a bunch of 
them with me, be happy to share them with you.
    So, yes, there is an increase in panhandling, there is an 
increase in homelessness. You see it West Coast. What I see on 
the West Coast really scares me. It is not in our statistics 
yet, I don't believe, but there are people who are in Phoenix 
that actually came from San Diego and different places now. It 
is a mess over there. Addiction is 70 percent, in my opinion. 
That is because it is complicated with dual diagnosis, but 
certainly it is 70 percent substance abuse on the streets. That 
is my opinion. People will disagree with that.
    I have many clients that are successful coming up through 
our program that were panhandlers for years. It is a good 
business. One individual I will refer to in Scottsdale got up 
in the morning from his camp, got on public transportation, 
went to a spot and worked long enough to achieve a target 
dollar amount so he could get his fix and some food, and he 
went and got high until the next day, and he repeated it all 
over.
    So panhandling is a good business. I am not saying it is 
all that way for everybody. We actually have some efforts that 
are in motion. We are launching soon a homeless-to-work program 
that will actually be targeted at giving panhandlers the 
opportunity to work for the day. But, yes, I think it is very 
much related to substance abuse.
    Mr. Warner. Yes. So, Phoenix Rescue Mission, this isn't a 
secret. This is something that they all know about. I want to 
say ``all.'' I want to be very careful with that. The majority 
of people that are looking for help know about Phoenix Rescue 
Mission. They know about Teen Challenge. They know about these 
other organizations that want to help them. What you are seeing 
is somebody who is more than likely avoiding the help in order 
to do what they want to do.
    My advice as a compassionate person, and the practice that 
my wife and I have employed in our relationship is if we run 
into somebody who seems as if they are in need, we ask them 
what their specific need is, and we either take them to go and 
get it or we get that thing for them and bring it to them. We 
don't give them currency. We don't give them things like that 
because if they have a specific need, we will take care of 
that. If you need gas in your car, we will go get you gas. If 
you need a meal, we will get you a meal. But in terms of just 
cold, hard cash, it is not necessary, in my opinion.
    Ms. Lesko. I yield back.
    Ms. McSally. All right. Well, I want to thank the witnesses 
for their valuable testimony, and Members for their questions.
    Members of the committee may have some additional questions 
for the witnesses. I know we didn't get into all the solutions, 
and I am grateful for your time and your passion on this issue. 
If we have other questions, we will ask them in writing, and we 
would ask if you could respond to them in writing.
    Pursuant to Committee Rule VII(D), the hearing record will 
be held open for 10 days.
    Without objection, the committee stands adjourned.
    [Whereupon, at 1 p.m., the subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

      Questions From Honorable Kristen Sinema for Douglas A. Ducey
    Question 1a. An important part of addressing the opioid epidemic is 
reducing overprescribing and preventing doctor shopping. The PASS Act, 
which I have introduced with support from both parties in Congress, 
would require Medicare to notify outlier prescribers--doctors 
prescribing outside of established medical guidelines--that they are 
potentially overprescribing. Do you believe this will be beneficial to 
Arizonans efforts to reduce overprescribing?
    Question 1b. What other actions would you recommend Congress take 
to support Arizona's efforts?
    Answer. The opioid epidemic is a complex problem and there is no 
silver bullet to solve it. We have taken action at the State level in 
Arizona, but we welcome Federal action. The PASS act aims to prevent 
opioid overuse by providing annual notification to outlier prescribers 
of opioids compared to other prescribers in their specialty and 
geographic level. I strongly support this. This information will help 
doctors have a full picture of how their prescribing habits compare to 
their peers. While we have taken similar action on a State level, this 
is very important in the Medicare space given the July 2017 report by 
the Health and Human Services OIG report on high prescribing levels and 
potential doctor shopping in the program.
    In addition to the PASS Act, there are several other steps the 
Federal Government can take to address the epidemic. One of the 
greatest barriers Arizona faces is the prohibition of Medicaid 
reimbursement for inpatient stays longer than 15 days. This Institute 
of Mental Disease (IMD) exclusion impacts approximately 24 facilities 
and 1,700 individuals throughout Arizona. The IMD exclusion prevents 
Arizonans from getting effective inpatient treatment they need to break 
their addiction.
    With a Nation-wide shortage of inpatient beds, health care 
professionals, and treatment programs, this Federal restriction should 
be removed for all States, most critically for substance use disorder, 
immediately. Congress should amend the IMD exclusion to ensure that 
those in need of treatment are able to access it.
    Another critical barrier is the current Medicaid rules restricting 
the coverage of Medication-assisted Treatment (MAT) programs for 
individuals who are in State or county correctional institutions. In 
2017, the Arizona Department of Corrections reported that 77 percent of 
the 42,184 inmates assessed at intake had histories of significant 
substance abuse. Of those identified only 732 were enrolled into an 
addiction treatment program. We must do all we can to help individuals 
who are incarcerated overcome their addictions, including providing 
evidence-based MAT therapy, in order to reduce recidivism, provide 
people with a second chance, and become productive Arizona citizens. 
Indeed, these rules are contributing to a cycle of crime, costly 
incarceration, and a return to crime and prison because of addiction. 
These rules should be suspended and reevaluated to get effective 
treatment to those in State or county correctional facilities.
    A significant contributor to the over-prescribing of opioid 
medication is the Centers for Medicare and Medicaid Services (CMS) 
Hospital Consumer Assessment of Healthcare and Providers and Systems 
(HCHAP) still utilizes a pain satisfaction score in its overall 
hospital ratings which does not align with the current efforts to 
reduce opioid use. This score has already been removed from the HCHAP 
reimbursement formula but this initial assessment score causes Arizona 
to rank below the National average with patients who report that their 
pain was ``always well-controlled.'' The HCHAP should eliminate this 
scale from the survey to further enhance efforts to reduce the number 
of opioids being prescribed. We know that keeping people from getting 
addicted is the one sure way to reduce overdose and death, and 
eliminating this scale from the survey will help empower health care 
providers to make evidence-based decisions.
    While Arizona leads the Nation in gathering real-time data on this 
crisis, a significant Federal barrier to understanding the scope of the 
epidemic are Federal regulations regarding reporting restrictions from 
certain facilities. Currently CFR 42, Chapter I, Subchapter A, Part 2 
prohibits facilities from sharing substance abuse use disorder data 
which is a hindrance to comprehensive health care and surveillance 
program in our State. These privacy protections were certainly well-
intentioned, but are impeding turning the tide on the opioid epidemic. 
The reporting restrictions should be removed and a requirement of 
Federal facilities to meet HIPPA requirements should be instituted.
    Last, the presence of Federally-controlled health care facilities, 
with no State oversight or State reporting requirements presents 
multiple challenges for Arizona. First, we request that Federal health 
care facilities maintain State licensure. Currently, Federal health 
care facilities do not meet the same requirements as other health care 
facilities in our State. This divide creates confusion for our 
citizens, and allows a disparate level of care to be delivered to our 
veterans and members of our Indian Tribes. Arizona wants to ensure that 
members of our community receive quality care regardless ofthe 
facility, be it Federal, State, or privately-owned.
    We would also request a requirement for Federal health care 
providers to input dispensing data into the States' prescription drug 
monitoring programs. Without Federal participation in the States' drug 
monitoring program, there is an increased risk for over prescribing and 
dispensing. This would also include participating in State-based 
communicable and non-communicable disease reporting, allowing Arizona's 
health care professionals access to information about an at-risk 
population and the potential impact to their communities.
    Although these requests are spread across the full spectrum of 
Federal health care agencies, a unified and cooperative approach from 
local, State, and Federal health care providers is the only way that we 
can have an immediate and sustainable impact to this ever-growing 
crisis affecting not only Arizona but our country as a whole.
    Question 2. Here in Arizona, the Sinaloa drug cartel and other 
transnational criminal organizations continue to bring heroin and 
methamphetamine into our State, in addition to other crime. In March of 
this year, the House passed legislation I co-introduced to crack down 
on international criminal gangs that threaten our safety. Our bill 
requires the administration to develop and execute a strategy that cuts 
off funding and other resources for organizations like Sinaloa. As a 
border State, what more can we do to enable State and Federal law 
enforcement to work together to combat the illicit financing of 
transnational criminal organizations, like those smuggling opioids and 
synthetic opioids into our State?
    Answer. In order to effectively disrupt and dismantle transnational 
criminal organizations operating in our State, we must seize their 
illegal drugs and prosecute the criminals responsible for trafficking 
those drugs. The best way to counter their illicit financing is to 
destroy their profits. Although these organizations have been 
transitioning to more modern means of currency, the bottom line is that 
we must prevent their drugs from coming into the country, then we can 
put them out of business. This can be accomplished with increased 
interdiction operations in Arizona.
    The best way for Congress to help us accomplish this goal is to 
provide State and local law enforcement agencies the resources they 
need to counter the drug cartels. Arizona is proud of our Department of 
Public Safety, Sheriffs, and Police Chiefs, and we know they could be 
of greater assistance to the Federal Government on the front lines of 
this problem, if they were to receive more funding. Through our Border 
Strike Force, Arizona has proven our commitment and capabilities to 
counter these criminal organizations, but so much more could be 
accomplished with more Federal resources. As the Federal Government 
faces many challenges hiring and retaining the workforce they need 
within the Department of Homeland Security, State and local agencies 
can be major contributors and a force-multiplier for these efforts.
    Additionally, more U.S. attorneys are needed to prosecute drug 
traffickers. Increased funding to the Department of Justice for more 
prosecutors would help ensure that all of these criminals are brought 
to justice.
      Questions From Honorable Raul Grijalva for Guadalupe Ramirez
    Question 1a. CBP has relied on temporary duty assignments to meet 
regional staffing demands in recent fiscal years. How many officers 
have you needed to bring in from other parts of the country to staff 
the Tucson port of entry over the past year?
    Answer. For fiscal year 2018 to date, a total of 300 officers have 
been temporarily assigned to the Tucson Field Office to assist with 
staffing demands at the various ports of entry. This assignment has 
been completed quarterly. Each quarter, a total of 100 officers are 
assigned to the Tucson Field Office.
    Question 1b. How many more do you anticipate needing through the 
rest of the fiscal year?
    Answer. Seventy-five CBP officers were temporarily assigned to the 
Tucson Field Office for the fourth quarter of fiscal year 2018.