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


                    CHALLENGES AND SOLUTIONS IN THE 
                             OPIOID CRISIS

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

                                HEARING

                               BEFORE THE
                               
                       COMMITTEE ON THE JUDICIARY
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 8, 2018

                               __________

                           Serial No. 115-57

                               __________

         Printed for the use of the Committee on the Judiciary
         
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                       COMMITTEE ON THE JUDICIARY

                   BOB GOODLATTE, Virginia, Chairman
F. JAMES SENSENBRENNER, Jr.,          JERROLD NADLER, New York
  Wisconsin                           ZOE LOFGREN, California
 LAMAR SMITH, Texas                   SHEILA JACKSON LEE, Texas
 STEVE CHABOT, Ohio                   STEVE COHEN, Tennessee
 DARRELL E. ISSA, California          HENRY C. ``HANK'' JOHNSON, Jr., 
 STEVE KING, Iowa                        Georgia
 LOUIE GOHMERT, Texas                 THEODORE E. DEUTCH, Florida
 JIM JORDAN, Ohio                     LUIS V. GUTIERREZ, Illinois
 TED POE, Texas                       KAREN BASS, California
 TOM MARINO, Pennsylvania             CEDRIC L. RICHMOND, Louisiana
 TREY GOWDY, South Carolina           HAKEEM S. JEFFRIES, New York
 RAUL LABRADOR, Idaho                 DAVID CICILLINE, Rhode Island
 BLAKE FARENTHOLD, Texas              ERIC SWALWELL, California
 DOUG COLLINS, Georgia                TED LIEU, California
 RON DeSANTIS, Florida                JAMIE RASKIN, Maryland
 KEN BUCK, Colorado                   PRAMILA JAYAPAL, Washington
 JOHN RATCLIFFE, Texas                BRAD SCHNEIDER, Illinois
 MARTHA ROBY, Alabama                 VALDEZ VENITA ``VAL'' DEMINGS, 
 MATT GAETZ, Florida                     Florida
 MIKE JOHNSON, Louisiana
 ANDY BIGGS, Arizona
 JOHN RUTHERFORD, Florida
 KAREN HANDEL, Georgia
 KEITH ROTHFUS, Pennsylvania
          Shelley Husband, Chief of Staff and General Counsel
       Perry Apelbaum, Minority Staff Director and Chief Counsel
                            
                            
                            C O N T E N T S

                              ----------                              

                              MAY 8, 2018

                           OPENING STATEMENTS

                                                                   Page
The Honorable Bob Goodlatte, Virginia, Chairman, Committee on the 
  Judiciary......................................................     1
The Honorable Jerrold Nadler, New York, Ranking Member, Committee 
  on the Judiciary...............................................     2

                               WITNESSES

Robert W. Patterson, Acting Administrator, Drug Enforcement 
  Administration, Panel I
    Oral Statement...............................................     4
Dr. Timothy Westlake, M.D., Hartland, Wisconsin, Panel II
    Oral Statement...............................................    51
J. Spencer Morgan III, Commonwealth's Attorney, Accomack County, 
  Virginia, Panel II
    Oral Statement...............................................    53
Kristen Holman, Lynchburg, Virginia, Panel II
    Oral Statement...............................................    54
Dr. Josiah Rich, M.D., Providence, Rhode Island
    Oral Statement...............................................    56

 
             CHALLENGES AND SOLUTIONS IN THE OPIOID CRISIS

                              ----------                              


                          TUESDAY, MAY 8, 2018

                        House of Representatives

                       Committee on the Judiciary

                            Washington, DC.

    The committee met, pursuant to call, at 10:00 a.m., in Room 
2141, Rayburn House Office Building, Hon. Bob Goodlatte 
[chairman of the committee] presiding.
    Present: Representatives Goodlatte, Sensenbrenner, Smith, 
Chabot, King, Gohmert, Marino, Collins, DeSantis, Buck, 
Ratcliffe, Gaetz, Johnson of Louisiana, Biggs, Handel, Rothfus, 
Nadler, Lofgren, Jackson Lee, Cohen, Johnson of Georgia, 
Deutch, Bass, Richmond, Cicilline, Swalwell, Lieu, Raskin, 
Jayapal, and Demings.
    Staff Present: Shelley Husband, Staff Director; Branden 
Ritchie, Deputy Staff Director; Zach Somers, Parliamentarian 
and General Counsel; Anthony Angeli, Counsel, Subcommittee on 
Crime, Terrorism, Homeland Security, and Investigations; Joe 
Graupensperger, Minority Chief Counsel on Subcommittee on 
Crime; Monalisa Dugue, Minority Deputy Chief Counsel, 
Subcommittee on Crime, Terrorism, Homeland Security, and 
Investigations; David Greengrass, Minority Senior Counsel; and 
Veronica Eligan, Minority Professional Staff Member.
    Chairman Goodlatte. Good morning. The Judiciary Committee 
will come to order, and, without objection, the chair is 
authorized to declare recesses of the committee at any time. We 
welcome everyone to this morning's hearing on challenges and 
solutions in the opioid abuse crisis. I will begin by 
recognizing myself for an opening statement.
    America is in the middle of an epidemic it has never seen 
before. The opioid crisis knows no bounds. It is affecting 
individuals and families in every congressional district. Its 
consequences, ranging from personal health to the economy, are 
devastating. The opioid epidemic represents the convergence of 
the abuses of opioids, heroin, and synthetic drugs like 
fentanyl. Individuals suffering from addiction often switch 
between using opioids and heroin, based on a variety of factors 
including cost and purity.
    Drug traffickers are further exploiting personal misery by 
adding deadly fentanyl analogues to the heroin and the illicit 
opioid supplies to increase their profits. Sadly, unwary and 
unsuspecting users are suffering deadly results. More 
frequently, pure fentanyl analogues in the illicit drug supply 
are resulting in overdose deaths and injuries to first 
responders. Since these analogues can be deadly in quantities 
as little as two milligrams, police and other first responders 
can unknowingly inhale airborne fentanyl or have it come in 
contact with their skin, causing them to overdose and suffer 
other severe reactions.
    Tragically, more than 64,000 Americans died from drug 
overdoses in 2016. The sharpest increase occurred among deaths 
related to synthetic opioids, with over 20,000 overdose deaths. 
Not only has the total number of opioid pain relievers 
prescribed in the United States skyrocketed in the past 25 
years, but recently studies have shown that over half of 
chronic prescription drug abusers receive the pills from 
friends or family. In 2018, more than 2 million Americans will 
suffer from addiction to prescription or illicit opioids.
    Over the past 2 years, the House Judiciary Committee and 
Congress have passed several bills to address the opioid 
crisis. These bills include the Comprehensive Addiction and 
Recovery Act, or CARA, enacted in July of 2016, and the Stop 
Importation and Trafficking of Synthetic Analogues Act, or 
SITSA, approved by the House Judiciary Committee in July of 
2017. While much work has been done, we must redouble our 
efforts to turn the tide in this crisis.
    We know now more than ever that a crisis like this requires 
dynamic and outside-of-the-box solutions. Today's hearing will 
examine what is working and what needs to be looked at again in 
the opioid crisis. We will learn about best practices in 
international and domestic enforcement, and promising solutions 
in treatment and prevention. We will also hear about the 
devastation ravaged by this epidemic from a firsthand 
perspective.
    I want to thank all of our witnesses for appearing today 
and I look forward to hearing their responses to our questions. 
And it is now my pleasure to recognize the ranking member of 
the Judiciary Committee, the gentleman from New York, Mr. 
Nadler, for his opening statement.
    Mr. Nadler. Thank you, Mr. Chairman. I welcome today's 
hearing as an opportunity to explore ways in which we can best 
address the crisis of opioid abuse in our country. I believe it 
is critical that we do so in order to identify what works and 
what does not work, so that we do not repeat mistakes we have 
made in the past.
    In the United States, drug overdoses are the leading cause 
of accidental death. With opioids being involved in nearly two-
thirds of overdose deaths. Overall, the number of drug overdose 
deaths has nearly quadrupled over the past 20 years. Although 
effective for the treatment of pain, prescription opioids are 
highly addictive, and nearly half of all U.S. opioid overdose 
deaths involve a prescription opioid. Deaths related to heroin 
have similarly increased, as individuals often transition from 
more expensive prescription opioids to cheaper heroin.
    As this crisis has intensified, Congress has contemplated 
various responses, and, in some instances, adopted legislation. 
In 2016, 2 years ago, we enacted the Comprehensive Addiction 
and Recovery Act, a law that included a wide array of 
provisions advanced by many of our committees. The provisions 
in the jurisdiction of this committee included a number of 
worthy initiatives, such as programs to expand treatment as an 
alternative to incarceration. It is impossible not to see the 
contrasts without Congress' response to the opioid crisis in 
comparison to their responses to some other drugs, particularly 
crack cocaine.
    While I agree that we should develop and implement the 
comprehensive strategy with respect to opioids, with the 
emphasis being on preventing and treating abuse, we did not 
take this approach with crack cocaine. There, focusing our 
response on the enactment of lengthy, mandatory minimum 
sentences, and treating the use of crack as a law enforcement 
issue.
    That approach was wrong and continues to be wrong, 
disparately impacting African-American communities while 
fueling mass incarceration. We must not make that same mistake 
with any of the drugs classified as opioids, and we must 
reverse and rectify the mistakes we have made in other drugs 
such as crack, through an increased emphasis on prevention and 
treatment and by changing our counterproductive and unjust 
sentencing laws.
    Certain opioids, such as heroin and fentanyl, are already 
subject to mandatory minimum penalties, and these penalties 
have not prevented the current crisis, and increasing them 
would also not be effective. We also do not need more ``get 
tough'' rhetoric from President Trump or Attorney General 
Sessions about imposing the death penalty for drug crimes, and 
we should not be telling prosecutors to ratchet up criminal 
charges and penalties for drug offenders. None of that solves 
the problem. Instead of doubling down on failed policies that 
do nothing more than proliferate misery, we need real 
leadership, involving a commitment to increase resources for 
alternatives that we know are actually effective.
    There are a number of proven alternatives that are being 
implemented in the States, and we must commit to supporting 
them. For instance, law enforcement assisted diversion 
programs, known as LEAD, allow law enforcement to divert 
appropriate arrestees from criminal court, instead providing 
treatment and other services that address addiction and reduce 
recidivism.
    Developed and initially implemented in Seattle, the LEAD 
approach is now being used with success in other areas. We 
should support efforts such as LEAD, as well as other 
approaches at the local level, including medication-assisted 
treatment, supervised injection facilities, expanding the 
availability of overdose reversal drugs, and better education 
of doctors and the public about the proper prescription and use 
of opioids as pain medication.
    We will not be able to arrest and incarcerate our way out 
of a drug abuse problem that has many causes. Instead, we must 
support the development and implementation of a variety of 
solutions. I hope this will be the path of the committee as we 
consider our contribution to addressing this crisis. I yield 
back the balance of my time.
    Chairman Goodlatte. Thank you, Mr. Nadler. Without 
objection, all other opening statements will be made a part of 
the record.
    We welcome our distinguished witness on our first panel. 
And, Mr. Patterson, if you would please rise, I will begin by 
swearing you in.
    Do you swear that the testimony that you are about to give 
shall be the truth, the whole truth, and nothing but the truth, 
so help you God? Thank you very much. Let the record show the 
witness answered in the affirmative.
    Mr. Rob Patterson is the acting administrator of the U.S. 
Drug Enforcement Administration. He is the principal advisor to 
the Attorney General on international drug control policy and 
related operations in the United States.
    Mr. Patterson, welcome. Your entire statement will be 
entered into the record in its entirety, and we ask that you 
summarize your testimony in 5 minutes. There is a timing light 
on the table that will indicate when 4 of those 5 minutes have 
gone, and then, when it turns to red, your 5 minutes are up. We 
thank you for indulging us, and Mr. Patterson, you may begin. 
Thank you.

   STATEMENT OF ROBERT PATTERSON, ACTING ADMINISTRATOR, DRUG 
                   ENFORCEMENT ADMINISTRATION

    Mr. Patterson. Thank you, sir. Chairman Goodlatte, Ranking 
Member Nadler, and distinguished members of this committee: 
thank you for holding this hearing on the opioid crisis. Our 
Nation has been devastated by opioid abuse, an epidemic fueled 
in part, and for a significant period of time, by a change in 
prescribing practices. This has helped create a generation of 
opioid abusers presently estimated at more than 3 million 
Americans.
    Effectively combating this crisis requires addressing it 
from multiple angles: enforcement, education, and treatment. 
DEA's enforcement strategy utilizes a full spectrum of 
criminal, civil, and administrative tools to attack the 
trafficking of illicit and the diversion of licit supply.
    We know that most new heroin users continue to begin their 
cycle of addiction with prescription pills, so we are 
constantly evaluating ways to ensure that our more than 1.7 
million registrants comply with the law. Leveraging traditional 
enforcement methods with diversion authorities, DEA has 
established 77 tactical diversion squads and two mobile teams 
solely dedicated to investigating and dismantling criminal 
diversion schemes. In curbing diversion, we continue to 
integrate and strengthen our intelligence and enforcement 
efforts.
    For example, in January, we analyzed DEA data alongside HHS 
and some State PMP data to identify prescribers and pharmacies 
whose activities warranted investigation. This analysis 
identified more than 400 leads, which were then provided to our 
22 field divisions.
    The resulting surge led to 188 active investigations, 28 
arrests, 283 administrative actions, and removing the ability 
of 147 registrants to handle controlled substances. The complex 
nature of the epidemic requires data sharing and deconfliction, 
and fully committed to doing this better across the board.
    Over the last 6 months, DEA has developed information 
sharing agreements with our State counterparts to share ARCOS 
data. Likewise, we need all States to find paths forward to 
share their PMP data, a vital piece of this puzzle.
    Through a number of efforts we will discuss today, combined 
with an increased public awareness of the opioid epidemic, DEA 
has seen a corresponding decrease in prescriptions for opioids. 
While this is a very positive step, we still face many 
challenges. As an example of these ongoing efforts, we continue 
to review proposed changes to our quota program with a goal of 
utilizing multiple data sets thoughtfully to assess production 
needs while avoiding shortages for patients.
    We are, however, seeing a dramatic and disturbing shift 
from licit opioids to the illicit market. Criminal 
organizations have filled this void by producing and 
distributing cheap powder heroin, often mixed with illicit 
fentanyl and related substances, and then selling it in 
powdered form or pressed into counterfeit pills resembling 
licit pharmaceuticals.
    The changing chemical composition of synthetics makes it 
difficult to intercept these deadly substances before they hit 
our streets, and prosecutions are hindered by labor-intensive 
court proceedings. For example, to meet standards set forth in 
the Federal Analogue Act, prosecutors must prove in each case a 
substance substantially similar in chemical structure and 
pharmacological effect to a schedule I or schedule II 
substance.
    DEA has moved aggressively to place temporary schedule I 
controls on new and emerging synthetic drugs, including 17 
fentanyl analogues. Unfortunately, the temporary emergency 
scheduling process of a substance is reactive, requiring us to 
first observe the deadly consequences of synthetic drug abuse 
before initiating control.
    In February, DEA proactively placed temporary emergency 
controls on the entire class of fentanyl-related substances, in 
the attempt to help curb fentanyl-related overdose deaths. This 
is an aggressive step to combat an unprecedented threat.
    The logistics of how this poison reaches the U.S. is yet 
another challenge. Movement of fentanyl varies from the direct 
mailing of small amounts to cartels moving bulk quantities 
through their already-established transportation networks.
    Complicating the issue, especially on the direct mailing, 
is technology that allows sellers and purchasers to conduct 
seemingly endless and relatively anonymous transactions on the 
web. However, with agencies working together, FBI, U.S. Postal, 
HSI, CBP, and others, and our critical international partners, 
no issue is insurmountable. The seizure of the dark web 
marketplace AlphaBay and subsequent darknet cases are prime 
examples demonstrating that no criminal network is untouchable.
    While DEA's top priority is enforcement, there is also a 
natural fit for us in education. We have partnered with leaders 
in prevention and education to provide direct outreach to young 
people and parents on the dangers of prescription and illicit 
drugs. Simultaneously, DEA has worked to improve communication 
and cooperation with the registrant community, offering year-
round free training to doctors, pharmacists, distributors, 
importers, and manufacturers. Ultimately, to fundamentally 
change this epidemic, we must decrease demand for these 
substances, working collaboratively on all fronts.
    I am extremely appreciative of your commitment and support 
to tackling this epidemic. DEA has reviewed more than 60 pieces 
of pending legislation and appreciates the opportunity to 
provide technical assistance wherever appropriate. Thank you 
for the invitation to be here before you, and I look forward to 
your questions.
    Chairman Goodlatte. Thank you, Mr. Patterson. We will now 
proceed under the 5-minute rule with questions, and I will 
begin by recognizing myself.
    Mr. Patterson, I have been watching with interest the 
investigation currently ongoing at the Energy and Commerce 
Committee about the distribution of opioids to West Virginia. 
As you may know, my district is just across the border, and I 
have no doubt that some of the opioids from pill mills in West 
Virginia have ended up on my side of the border. Earlier this 
year, you testified about some of the DEA's historical failures 
to identify and stop these pill mills. What did the DEA learn 
from these failures, and what are you doing differently today 
as a result?
    Mr. Patterson. Sir, I appreciate that question, mainly 
because, as we talk about the period of 2006 through 2010, 
which is where a lot of those events really started and 
blossomed in West Virginia, we and others did not do a great 
job with the data that we had. Part of that was how we got the 
data, and part of that was our responses to certain things that 
we saw, right. There was not a real-time look on these things. 
The compliance with the industry was also problematic.
    I think the huge difference that we see now is that we 
understand more than ever, especially working with the States, 
how to use the various data sets that we have. And as I just 
explained, you know, the HHS data that we are able to obtain--
DEA's ARCOS data, the State PMP programs, where they are 
participating with us--all essentially allow us to see the 
outliers. The key piece to us doing enforcement actions and 
trying to hold distributors and others accountable really comes 
from us being able to find where those pills ultimately end up 
on the streets. The key to that is that PMP data set, and when 
we move back from that.
    So, we have got a ton of lessons learned. I know both you 
and Mr. Nadler started this way, and I think we are all growing 
and expanding from what works as opposed to what has not worked 
in the past, and important lessons learned.
    Chairman Goodlatte. Thank you. In a recent press release, 
the Department of Justice highlighted the DEA's continued 
efforts to reduce drug quota, the ability of approved 
manufacturers to make certain quantities of controlled 
substances, including powerful ones like opioids.
    Could you please explain the proposed rule, and how this 
will help with preventing diversion? And, also, give us some 
assurance that when drugs that are used as means of getting 
people off of, other drugs like methadone and so on, to make 
sure that supply is still available to those who are 
prescribing it for people who are trying to overcome their 
addiction.
    Mr. Patterson. No, I understand. And thanks, again, for 
that question, sir. So, quota is a delicate balance. The 
reality is that DEA, for a long time, essentially bumped quota 
up to ensure that there would be full access for manufacturers 
to produce X amount of product.
    In hindsight, looking back on how we dealt with quota, the 
more you allow manufacturers to produce, it is a business. They 
have more incentive to sell additional, which then drives more 
usage. So, what we have done over the last handful of years is 
to try and pull slack space out of that, for lack of a better 
word.
    And now, the proposals that we put forward and that we are 
making are out there, and we just got comments back on, to take 
a look at other factors as we develop quota. And this is more 
on the prescribing side, as to the medical-assisted treatment 
side, but it has to deal with us taking in additional data 
sets, how we look at that, understanding the diversion in what 
we see.
    And, quite frankly, I give credit to a lot of the States 
who have enacted legislation, and prescribers that have changed 
their methodology of a 5-day or a 7-day supply up front, which, 
all is pulling down how much pharmaceutical needs to be made. 
DEA has to be aggressive with essentially making sure that 
number is where it needs to be, with a heavy emphasis, though, 
on making sure that patients that need access to medicine have 
that access.
    Chairman Goodlatte. In your written testimony, you state 
that DEA is witnessing the transition from controlled 
prescription drugs to heroin and fentanyl and related synthetic 
analogues. What efforts is the DEA making to address this 
fundamental shift?
    Mr. Patterson. So, I think, look, this trend has changed 
over the last couple of years, and we are trying to be much 
more aggressive on where our problem set really is. Fentanyl 
accounted for approximately a third of our overdose deaths, so 
the transition has really happened. As we see again, the licit 
market, or the pharmaceutical market, continues to come down. 
It creates a natural void where these criminal organizations 
will fill that void with their product for people that are 
truly addicted. And that is the struggle that we have.
    Fentanyl, like I said, comes, essentially, to the United 
States in two forms: one is through smaller, much higher-
percentage purity packages coming out of China, and then what 
we see coming across our southern border with the traditional 
organizations that have shipped heroin and methamphetamine and 
other drugs into this country for years, much lower 
concentration, although the volume is much higher. These are 
struggles that we are dealing with. The good piece of this is 
that all of your law enforcement agencies in this country are 
centering their efforts on theillicit market as we see this 
continuing to be the problem set moving forward.
    Chairman Goodlatte. Thank you. The chair recognizes Mr. 
Nadler for 5 minutes.
    Mr. Nadler. Thank you. Mr. Patterson, in February of this 
year, the Department of Justice announced it would emergency 
schedule all illicit fentanyl. In its public announcement, the 
Department of Justice noted that this emergency scheduling 
action would mean that, ``Federal agents and prosecutors can 
take swift and necessary action.''
    The Department of Justice has highlighted difficulty with 
prosecuting individuals for offenses under existing analogue 
control laws involving a suspected analogue of a controlled 
substance. Has this emergency scheduling action by the 
department facilitated the prosecution of individuals with 
suspected analogues of a controlled substance?
    Mr. Patterson. Specific to fentanyl, sir? Specific to 
fentanyl, yes. So, the key for this, and I think this is where 
the struggle sits, is this is an aggressive use of scheduling 
on the fentanyl class.
    And, again, when we talk about the balancing, HHS and 
others, you know, and their desire to do research and find 
actual medicines out of these medicines, when before we took 
the scheduling action, we went in and sought to see if anybody 
was looking at any of these classes of fentanyl that already 
existed.
    Remember, this scheduled fentanyl that had not even come 
onto the market yet, as well. But, to look to see if anybody 
was trying to do research, and that answer was no, to the best 
of their ability to do that search. In addition, since we 
scheduled it in February, I am unaware and I have not been told 
by anybody about the efforts to do research in that class.
    Mr. Nadler. Sorry, so, you are saying you are unaware?
    Mr. Patterson. Unaware, sir.
    Mr. Nadler. Of research?
    Mr. Patterson. Of anybody asking to do research on the 
existing class of fentanyl that we see. The key to this really 
comes down to, sir, is the ability to charge criminal 
organizations that are importing the fentanyl as a substance. 
Using the Analogue Act, it is difficult, right? It is a time-
consuming process for prosecutors and the reality is that this 
was the only way we could try and balance that out. And, again, 
balance being the key word here.
    Mr. Nadler. Okay. Now, do you think that drug manufacturers 
should have more of a role in ensuring compliance with the 
Controlled Substance Act?
    Mr. Patterson. Should drug manufacturers?
    Mr. Nadler. Yes.
    Mr. Patterson. Have more control.
    Mr. Nadler. Have more of a role in ensuring compliance.
    Mr. Patterson. Absolutely. I mean, one of the frustrations, 
I think, with the manufacturing population, so manufacturing 
and distributing somewhat lumped together, they are aware of 
the problems. They have been aware of the problems.
    Frankly, we have done a lot of civil fines, but when you 
look at major businesses, civil fines seem to have little 
impact. And I think that is part of the frustration. In cases 
where we have not seen this behavior yet fixed, and we are 
talking about behavior that we have seen for the last decade, I 
think we have to hold them more accountable.
    And that is why DEA, I think, is also taking a posture of, 
``Make sure that they are best informed.'' We have to work with 
them, which sometimes feels a little bit contradictory to do, 
as you are also investigating them. But we have to work to make 
sure that they understand their role in this place.
    Mr. Nadler. And what is the total budget for the DEA for 
the current fiscal year?
    Mr. Patterson. 2018 was just under $2.2 billion.
    Mr. Nadler. Just under 2.2?
    Mr. Patterson. Yes, sir.
    Mr. Nadler. And how much Federal money is allocated for 
drug treatment this year?
    Mr. Patterson. I actually do not know, ultimately. I know 
that at one point, though, there were conversations. I do not 
know what is allocated, sir. I know there were conversations 
about, I believe, $6 billion.
    Mr. Nadler. All right, six. Okay. Now, in the past, you 
have stated that prescription monitoring programs, which 
involve State-to-State data sharing and mandatory prescriber 
registration, are important to helping create a clear image of 
where opioids are being distributed to the population. Can you 
discuss further the benefits of States participating in PMPs?
    Mr. Patterson. So, I think that vast majority of States, 
and as we have gone and talked to people, I think doctors feel 
the same way, want to be able to do right in this space and be 
able to see what their patients are doing and what pharmacists 
are doing and prescribing, or what is going out. I should say, 
ultimately, to the user population, right, or the patients, in 
this case.
    I think the key to it is where States either do not have 
the ability to connect with each other, or the systems actually 
are not being used, is highly problematic. So, you know, as I 
talked about in the opening, ARCOS is a critical first step for 
us to be able to take a look at where pills are going in, and 
we should take a look at that to understand where they are 
going into pharmacies. The key piece, frankly, is where you are 
seeing that diversion happening from the pharmacy area and from 
doctors, in some cases, out into the general public.
    Mr. Nadler. Okay. I have one more quick question, thank 
you. Since 2011, the number of immediate suspension orders, 
which allow the DEA to free suspicious shipments of controlled 
substances when there is an imminent danger to public health or 
safety has significantly declined. Can you explain why this has 
happened in the midst of the opioid epidemic?
    Mr. Patterson. Yes, sir. I would be happy to do so. So, 
there is two factors on this, and as I have gone around and 
spoken to a number of the members, one is that tool is an 
aggressive use of the tool against distributors. It is not a 
tool that was generally used against distributors. The case of 
using that only had happened a handful of times in the previous 
number of years prior to 2011, 2012.
    The other piece of it is when the bill did change, the 
Ensuring Patient Access bill changed, it raised that standard 
to where the conduct would have to be much more egregious for 
us to be able to prove at the distributor level.
    I understand, in talking to a number of folks, you know, 
again, through the various members, that there was confusion in 
the industry. And I think the importance here is to strike a 
healthy balance of making sure the industry understands exactly 
where the rule is in giving us a tool back that we can then use 
to essentially work forward.
    Mr. Nadler. Thank you.
    Chairman Goodlatte. The chair recognizes the gentleman from 
Wisconsin, Mr. Sensenbrenner, for 5 minutes.
    Mr. Sensenbrenner. Thank you, Mr. Chairman. We have heard 
an awful lot about fentanyl analogues in the two previous 
series of questions. I have a bill in to schedule fentanyl 
analogues. Does the DEA support this legislation?
    Mr. Patterson. So, let me do it this way to keep myself out 
of trouble, which is: we have emergency scheduled the entire 
class of fentanyl analogues, and we need a legislative fix to 
keep this and have this remaining in schedule I.
    Mr. Sensenbrenner. How long does the emergency schedule 
last?
    Mr. Patterson. So, it started in February. It will go for 2 
years, and we can extend that for 1 year.
    Mr. Sensenbrenner. So, at the end of 3 years from 
February--which puts us at February 2021--you cannot do anymore 
without legislation?
    Mr. Patterson. That is correct, and we will be back to the 
same problem of having to do one at a time and go through a 
decision.
    Mr. Sensenbrenner. Is it hard for a prosecutor to obtain a 
conviction based on an emergency schedule, rather than having 
this schedule done by legislation?
    Mr. Patterson. I think it poses risks, as we get closer and 
closer to that 2021 date with how prosecutors would charge 
their cases. Because, in theory, they would have to charge both 
under the Analogue Act, as well as using fentanyl as a schedule 
I, because the balance would then come in to: if they charge a 
case and it has not gone to trial, my understanding is that, 
come February of 2021, that fentanyl drops off or we have not 
yet been able to do our emergency scheduling, it would be 
unscheduled. So, the answer is yes, it does pose challenges.
    Mr. Sensenbrenner. All right. I hope we can get this bill 
passed this year, because I think there is an urgency, rather 
than having to start over after the election of the next 
Congress. And I yield back the balance of my time.
    Mr. Patterson. And if I could just add one other thing, 
sir. We look forward to providing any technical assistance on 
that, because it does require a legislative fix.
    Mr. Sensenbrenner. Thank you.
    Mr. Patterson. Thank you.
    Chairman Goodlatte. The chair recognizes the gentlewoman 
from California, Ms. Lofgren, for 5 minutes.
    Ms. Lofgren. Thank you, Mr. Chairman. I was very interested 
in your testimony starting on page two. And I think trying to 
understand what is going on here in our communities is 
important to coming up with the proper solution.
    You say that in 2016, almost 3.4 million Americans aged 12 
or older reported misusing prescription pain relievers in the 
last month. And that prescription misuse is more common than 
use of any category of illicit drug, absent marijuana, which 
has now been legalized in half the States for one purpose or 
another. And that 75 percent reported non-medical use of 
prescription opioids before initiating heroin use.
    Now, you go on to say that the reasons an individual may 
shift from one opioid to another will vary, but it is less 
expensive than the prescriptions. So, I am getting a picture, 
not just from you but from other witnesses at other hearings, 
that most people do not just start using heroin. For one reason 
or another, often times they are prescribed or over-prescribed 
for some remedy an opioid, and they get hooked. And then they 
go on to use and overuse, and then when they cannot get the 
opioids, to go to the illegal provisions. Is that your 
understanding? Or, if I am wrong, correct me.
    Mr. Patterson. No, I think that is a completely accurate 
understanding. And if I could add, you know, it always feels 
odd, but for me to be efficient in our law enforcement efforts, 
we have to understand the back-end problem of this, which is 
treatment, and what these people, or addicts, go through.
    Ms. Lofgren. Oh, absolutely.
    Mr. Patterson. Frankly, when we go out and speak with them 
and understand their problems, I hear the same story over and 
over again, which is at some point, this opioid high that you 
get from it, and sometimes it is very quickly, becomes an issue 
of not being sick. And that is what then drives the switch from 
licit opioids, which they, you know, run into a problem of not 
being able to afford, and then, into the world of heroin.
    In 2011, 4 out of 5 people started, prior to heroin, by 
misusing opioids. That number dropped down, I think, in 2016, 
to 3 out of 5, but that is still a stunning number, that 60 
percent of your people started with a licit pill.
    Ms. Lofgren. Well, you know, if that is the case, it seems 
to me one of the most effective things we could do would be to 
focus on why people are using so much prescriptions. I mean, if 
you compare the use. You know, I am not one who says the cancer 
victim, you know, should die in agony. You know, that is not 
really what we are talking about.
    But we had a witness in an immigration subcommittee hearing 
a few months ago who said that some of these companies were 
providing so much opioids, it would be enough for, you know, 10 
pills for every adult in the town that was sent to the 
pharmacy. Obviously, someone must know that that is not a 
proper use.
    And so, the question is, ``What are we doing about that?'' 
We have got companies that should know--they must know--that 
what they are developing is fueling this opioid crisis, and 
they are doing it anyhow, to make money. What is our strategy 
on that?
    Mr. Patterson. So, again, I think this gets back to the 
education of Americans. The companies are not going to change 
their behavior.
    Ms. Lofgren. Well, let me interrupt if I may, because I 
believe in the education of Americans. I think people, you 
know, who break a leg, can say, ``I do not want 50 opioid 
pills, you know, I want two.'' You know, but that does not get 
to the root of the problem, which is you have got people 
profiting, companies--real companies, not drug dealers--
incorporated companies profiting out of starting this 
addiction. What is our strategy to go after that?
    Mr. Patterson. So, the strategy, again, is to work with 
industry, and try and make them understand their role, whether 
they change their practice or not. But I will give you another 
fact that you can add to that toolbox of the argument of 
overprescribing. So, DEA has done these take back events for 
the last, you know, number of years. In total, it has been just 
about 10 million pounds we have taken back. So, in April, we 
took back----
    Ms. Lofgren. If I may interrupt? I do not mean to be rude, 
but we only have 5 minutes, and I have got 10 seconds left. I 
will just say that I am for educating people, I am for 
buybacks, but to allow certain companies to profiteer by 
addicting wide swaths of the country, and our action is, ``We 
are going to work with them,'' I think that is insufficient. 
That is lame.
    And I do not blame you; you are administering the law, but 
we need a very different strategy than we appear to have now. 
And I know my time is up, Mr. Chairman, so I yield back, and I 
thank you, Mr. Patterson, for being here.
    Mr. Patterson. Could I just finish one thing real quick, 
sir?
    Chairman Goodlatte. Yes.
    Mr. Patterson. So, I agree with you, ma'am. It has to start 
there. My point on bringing back the take back: every 6 months, 
we take in about 1 million pounds of pharmaceutical drugs. That 
is a conversation that has to be had. If we are returning that 
every 6 months, what are we doing wrong?
    Ms. Lofgren. Thank you, sir.
    Chairman Goodlatte. The chair recognizes the gentleman from 
Pennsylvania, Mr. Marino, for 5 minutes.
    Mr. Marino. Administrator, I have never worked with a finer 
agency than the DEA, and I see the positive move under your 
leadership.
    In October 2017, the Washington Post and 60 Minutes put out 
a joint report on the Ensuring Patient Access and Effective 
Drug Enforcement Act, a bill which I was the House sponsor, 
because I heard from seniors and pharmacists in my district 
that they were not able to get prescriptions, especially for 
terminally ill patients.
    This report was filled with falsehoods that completely 
misrepresented the law and its effects. After my legislation 
passed the House by unanimous vote, the Senate introduced their 
version of the bill, where my language of ``foreseeable risk'' 
was changed to ``substantial likelihood,'' which is a much 
higher burden for the DEA to satisfy.
    But this was language the DEA had asked for, and in Senate 
Judiciary hearing last year, when asked about the language, Ms. 
Demetra Ashley stated that the DEA supported the legislation 
and the version that passed. The bill then passed the Senate by 
unanimous consent, passed the House,again, by unanimous 
consent, was signed into law by President Obama at the 
recommendation of DOJ and DEA.
    The DEA has now testified twice that the bill has in no way 
stopped the DEA from doing its job. In October 25, 2017 energy 
and commerce hearing, Mr. Neil Doherty, the deputy assistant 
administrator of the Office of Diversion Control testified, in 
court, it did not stop the DEA from doing its job in the 
diversion space.
    In December 12, 2017 Senate Judiciary hearing, Ms. Demetra 
Ashley, the acting assistant administrator in the Office of 
Diversion Control stated that, ``I agree wholeheartedly that it 
did not stop us from doing our job.'' She later stated, ``Has 
it impacted our ability to issue ISOs? No, sir, it has not.''
    Since 2012, the DEA did not issue an Immediate Suspension 
Order, or ISO, against a drug distributor until 4 days ago, 
using the new ``substantial likelihood'' standard. Ensuring 
Patient Access and Effective Drug Treatment Act was signed into 
law in 2016. So, for 4 years, the DEA did not issue an ISO 
under the prior standard. Taking all this into account, it 
would appear that the DEA shifted to using other tools to go 
after the opioid epidemic, rather than using ISOs against 
manufacturers, that the law did not hamper or stop the DEA from 
doing their job in any way, and that, very recently, the DEA 
used ISOs against a manufacturer, effectively showing that this 
language does not stop you from using an ISO.
    The DEA now says they want to change the law and would like 
to see the ``substantial likelihood'' that the Senate passed, 
at the request of the White House, language to ``probable 
cause.'' My language that was in the original bill and passed 
in the House was ``foreseeable,'' which is a lower standard 
than either ``probably cause,'' and much lower than 
``substantial likelihood.''
    I understand that the DEA is still advocating for probable 
cause, but I would be willing to consider a lower standard that 
would give DEA an even more flexible use of what you are 
currently asking for.
    As I mentioned, my original language that passed the House 
was ``foreseeable risk,'' which is the lower standard. During 
the Senate Judiciary Committee hearing, Senator Blumenthal 
asked, ``But you had to show some likelihood before?'' and this 
was Ms. Ashley, the assistant administrator.
    Her response was, ``We were aiming to prevent diversion 
because it is foreseeable. If drugs are diverting, they get to 
someone who should not have them. It is foreseeable that there 
will be harm.'' From reading that, it certainly seems that the 
DEA was also using a foreseeable standard before, in regards to 
the ISOs. That is the standard that was in my legislation.
    I want to explain something here as far as ``foreseeable.'' 
The courts have ruled an act must be sufficiently likely before 
it may be foreseeable, in the legal sense. That does not mean 
simply imaginable or conceivable. Now, I am going to switch to 
probable cause.
    What the Supreme Court says were, ``the facts and 
circumstances within the officers' knowledge, and of which they 
have reasonable trustworthy information, are sufficient in 
themselves to warrant a belief by a man reasonably cautioned 
that a crime is being committed.'' That definitely is a higher 
standard. Would you agree with me, sir, that ``foreseeable'' is 
a lower risk than ``substantial,'' ``probable'' cause, and that 
is the lowest hurdle that you would have to get over?
    Mr. Patterson. So, ``foreseeable'' is certainly lower than 
``probable'' cause, and as I have discussed with you and 
others, I appreciate the ability to get that level as low as 
possible. The reason why we have picked ``probable cause'' is 
it is a well-defined, essentially, standard for our agency. As 
we looked as all of these issues, we found that we could meet 
probable cause every time. So, I appreciate your effort to go 
to ``foreseeable.'' At the same time, I think that using 
``probable cause'' strikes a balance between the industry and 
understanding where that is.
    Mr. Marino. And I will support that, if that is what the 
agency wants. With that, I have run out of time. Mr. Chairman, 
could I enter some things into the record?
    Chairman Goodlatte. What do you have?
    Mr. Marino. I ask unanimous consent, I would like to place 
in the record the transcript from the House Energy and Commerce 
hearing on Wednesday, October 25, 2017, as well as the 
transcript from the Senate Judiciary Committee hearing on 
December 12, 2017 and December 17, 2017, a 60-minute transcript 
of David Schiller, a former DEA supervisor who said, ``With the 
opioid epidemic getting worse year by year, special agent 
Schiller and his team wanted to send a message to the 
pharmaceutical industry. They wanted to fine the company a 
billion dollars to revoke registration distribution.''
    On to say that he was asked, ``Did the DEA attorney 
actually tell you that they were not going to pursue that case 
because they had lawyers who went to Harvard and Yale?'' 
Schiller said, ``they told me those exact words because the 
case would take too much time and too much effort, by the way, 
and what if we lost,'' and this was a statement that came from 
the DEA and the Department of Justice back in 2014.
    Chairman Goodlatte. Without objection, they will be made a 
part of the record.
    The chair recognizes the gentleman from Tennessee, Mr. 
Cohen, for 5 minutes.
    Mr. Cohen. Thank you, sir. Mr. Patterson, first, welcome. 
The DEA has always been a position, I think, of great 
importance, and it is important that the DEA administrator stay 
current with what the people have shown, by their actions and 
their statements, what they believe is the right priorities for 
DEA.
    And it has been pretty clear, as Ms. Lofgren mentioned, 
that 29 or 30 jurisdictions, in some way or another, have 
legalized marijuana for one purpose or another. And yet, 
because of the inaction of the DEA, marijuana is still a 
schedule I drug, along with heroin and ecstasy and acid. Do you 
believe that marijuana should be classified as the same as LSD, 
ecstasy, and heroin?
    Mr. Patterson. So, the reason why it remains in schedule I 
is because of the science.
    Mr. Cohen. The science?
    Mr. Patterson. The science. So, FDA does its eight-factor 
analysis, DEA does its review, and therefore, it remains in 
schedule I.
    Mr. Cohen. Before we talk about the science, and I am happy 
to hear that you believe in science, that is refreshing. What 
do you think? Do you think marijuana should be schedule I? 
Based on your knowledge of the harm that marijuana causes, as 
distinguished from the harm that heroin causes the public and 
society?
    Mr. Patterson. So, I am going to give you my honest 
opinion. And this actually does not shape how we do enforcement 
at DEA, because our priorities are the biggest priorities that 
we face, which is the opioid issue, methamphetamine, cocaine is 
now on the resurgence.
    So, marijuana, obviously, is lower on the scale of what we 
do. And where we look to deal with that is in States where we 
see the importation of crime into those States from other 
States that are growing to distribute it back out, or 
exportation from those States, groups that are violent, other 
actions that are going on. So, that is where DEA prioritizes.
    I fear--and I am just giving you my honest opinion--that we 
are going down a bad path with marijuana. And I will tell you 
the reason why I say that. This is not from, necessarily, the 
law enforcement person, because if I give you the law 
enforcement version, it is discounted as law enforcement. All 
of the driving conversations of this generally go around 
revenue. And that is unfortunate to me.
    And I think 10 years ago we would sit here, and we could 
have this debate as to what is better, what is worse, you know? 
Is heroin worse than marijuana? And I am not going to debate 
that because I think, to me, they are two completely different 
things. Right?
    I think the concern we see is we now have a body of 
evidence in States that have run what I call ``the social 
experiment'' for 10 years. Right? So, Colorado is a great one. 
And if we have an honest conversation about what we are 
starting to see in Colorado, my fear is that in 10 years, and I 
will not be sitting here, but you will all have someone here 
from DEA or some other agency saying, ``Why was no one saying 
something?'' I see that path coming.
    And frankly, if you look back 20 years ago on the 
pharmaceutical world, people were screaming into the wind. It 
was a small percentage of people really concerned about what 
they were seeing. You have extremely high THC and, putting all 
the other things aside, right, property values in Colorado, or 
the fact that revenue is not essentially making up for what the 
costs are, issues with children, all these other things.
    If you take that all and just put it aside, and simply ask 
the question to the adults in this country, which is, ``At what 
point did we determine that revenue was more important than our 
kids?''
    Mr. Cohen. Mr. Patterson, I appreciate your statements, and 
I can see where you have a different perspective than some 
previous DEA administrators, at least your honesty. Because I 
think the last one under Obama, I think, thought like you did 
but did not talk like you did.
    I think most adults do not see it as dollars and cents. 
Most adults see it as a freedom issue and taking somebody's 
liberty from them for smoking marijuana.
    And the fact that three and a half times more African-
Americans than Caucasians are arrested and lose their liberty, 
and possibly their hope in the future, for educational Pell 
Grants or education scholarships or public housing if they need 
it, is taken away from them because of smoking a plant that is 
legal and that does not cause people to die. I look at it, most 
adults look at it as a freedom issue and, as you put it as 
beneath three other drugs, I think. And I am sure you put meth 
above it, as well.
    Mr. Patterson. Probably farther down than that.
    Mr. Cohen. Yeah. And I mean, meth kills people. Crack can 
kill people. You get addicted. Opioids, you get addicted, and 
heroin, you die, kill people. Marijuana is not the same thing. 
So, there is a limited amount of resources the DEA has, police 
officers have, judicial law enforcement, everybody, and there 
is an opportunity cost. And when you spend time dealing with 
marijuana, all you are doing is taking time away from drugs 
that kill people and cause crimes.
    Mr. Sensenbrenner [presiding]. The gentleman's time has 
expired.
    Mr. Cohen. So, I thank you for your honesty and appreciate 
the time, and you can answer some more, if you would like.
    Mr. Patterson. If I could just add one comment on the end. 
So, DEA does not expend its resources on users of marijuana. 
And quite frankly, I am not sure what State is. So, I think 
that you see, even States where it remains illegal, I do not 
see a huge enforcement presence. That is a good conversation to 
have, but I hear this statistic all the time, that there is 
mass incarceration of users, not just of marijuana but of drugs 
in general, and I do not see it. So, it would be a conversation 
I would like to have further, to be honest with you.
    Mr. Cohen. Thank you, sir.
    Mr. Sensenbrenner. The chair recognizes the gentleman from 
Florida, Mr. DeSantis.
    Mr. DeSantis. Thank you, Mr. Chairman. Good morning, Mr. 
Patterson. So, if you look at the opioid crisis, what is the 
driving force right now? Because I know that, you know, there 
is a history of the prescription medications and the addictive 
qualities of that. But I look at what is happening with the 
fentanyl and some of this stuff pouring into the country. This 
stuff is poison. It is very lethal. And it seems to me, 
prescriptions are down for some of the pain killers, and I know 
they are all important. But is it more being driven right now 
on the prescription side, or on the street drug side?
    Mr. Patterson. No, I think, and we had started off by 
having that conversation, we have crossed the paths, of where 
the licit, or the prescription side, is now the leading 
problem. Fentanyl and heroin and other adulterants out there 
are our problem. And frankly, what drives this now is an abuser 
population of 3-plus million people that we have to work with, 
and that then comes hand in hand with treatment and other 
issues that we have to deal with there. But, as we have seen 
with every other illicit drug, there are cartels and groups 
that are willing to fill this space to meet that need.
    And you know, we are here on an opioids conversation. We 
have a massive methamphetamine problem in this country, too, 
that most of your States are struggling with, that does not get 
a lot of conversation. But we have a drug abuse problem in this 
country, and it occupies the illicit space, and these 
organizations will continue.
    Mr. DeSantis. And that is being driven by organizations 
that are bringing it across the southern border, primarily?
    Mr. Patterson. Certainly. Southern border and off into the 
areas of China and India.
    Mr. DeSantis. That is an interesting thing, because we did 
a bill, President signed it a couple months ago, to try to let 
the Post Office intercept some of this stuff that gets mailed 
in. If they try to mail it Federal Express, FedEx will stop it, 
but the Post Office just kind of comes in.
    So, have you seen any change of the Post Office's ability 
to interdict some of the stuff that is being shipped from China 
in the last, you know, month or two, since this bill has been 
in effect?
    Mr. Patterson. So, I do not know if it is specific to the 
bill, because I am not familiar with that bill, sir, but the 
U.S. Postal Service has done an amazing amount of work with 
trying to get additional data to help them. We are trying to 
fuse that as a law enforcement body with all the data that we 
have.
    So, in other words, where we see issues and problem spots 
coming up, so that they can be more nimble. But the reality is 
that you have a volume problem, when we talk about the 
logistics of packages coming in. So, that is not a southern 
border problem. The southern border problem is the roots that 
we have always dealt with, the Mexican cartels. Really, when 
you get into U.S. Postal's lane, that has to do more with the 
packages that are coming out of China and other places around 
the world, and that is a pure volume problem.
    So, we have to be smarter, as an overall group, as to how 
we target and use those resources the best way. I do not know 
if we will ever get to a point where we will be able to scan 
through every piece of mail. And remember, you know, ounces, 
right? Not even ounces, right? You know, grams of fentanyl 
produce thousands of dosage units. And if you can think about 
that, that means that I am just putting, you know, a couple of 
grams, or a sugar pack, in an envelope, and asking U.S. Postal 
to find that as it comes in. It is highly problematic.
    Mr. DeSantis. Now, what is the typical profile? And I know 
these things vary. But, so, someone overdoses on fentanyl. Is 
this somebody who was starting to do prescription drugs and 
then ended up going to street drugs? Did they start with 
marijuana and then go? I mean, I am sure it varies, but just 
give me a sense of how it gets to the point where we have users 
of a very highly lethal, highly addictive product.
    Mr. Patterson. Right. So, I think when you look at the 
overdose population, and there are probably better people than 
myself to speak to this. The unfortunate thing is it can be one 
of a host of things, right? So, you have your heroin user where 
it is adulterated with fentanyl. We are seeing it now in 
cocaine, as well. In fact, there was just a recent article that 
came out on all these cocaine users, that the ones that 
survived had no idea that there was fentanyl in the cocaine. 
That is also a disturbing trend we see. But you also have the 
people that go out and believe they are buying a licit pill, 
right, that is nothing more than binder and fentanyl. And I 
think this is the problem.
    And as you listen to the stories, I stopped using the 
number of overdose deaths a long time ago. Because, to me, the 
individual stories are what is critical here. And they all have 
the same kind of feeling, right? ``I did not understand that it 
was happening in my family,'' ``did not understand the 
addiction of my loved one,'' but it happens in so many various 
ways, and that is part of the challenge that we have here.
    Mr. DeSantis. What can States do to help what the DEA is 
doing?
    Mr. Patterson. So, look, again, the continued number to 
drive down is that population that is using or abusing opioids. 
And that still comes on the prescription side. So, I see States 
being very aggressive in that space.
    I am happy that groups like ADA, the American Dental 
Association, has come out and talked about prescribing rates. 
We have to fix that problem. And although it is a good trend 
down, we can not let that continue any other way than down. And 
we see a handful of States where it is either flat or still 
continuing to go up. That is where we are putting our efforts 
in on the prescription side.
    On the illicit side, it is going to be essentially, again, 
an educational problem mixed with law enforcement.
    Mr. DeSantis. Thank you. My time is up.
    Mr. Sensenbrenner. The gentleman's time has expired. The 
gentlewoman from Texas, Ms. Jackson Lee.
    Ms. Jackson Lee. Mr. Patterson, welcome. Thank you and your 
men and women for the work that you do. In particular, let me 
acknowledge the team you have in Houston, Texas, and the 
``bring your drugs in'' or ``bring your drugs back'' day that 
you had all over the country, I believe, just a week or so ago, 
if I am clear on the one that we had here in Houston, or 
forthcoming. So, thank you for that kind of work.
    Let me just remind you of the ways of different drugs from 
the crack cocaine, heroin, of course, fentanyl is something 
that this committee has addressed, and it is a sensitive issue 
when you begin to think of mandatory minimums and the impact. 
You all are the enforcers, but you know what happened with 
mandatory minimums. Sick people went to jail, if you will, or 
people that were using small amounts, and we do not know if it 
benefitted or not.
    So, let me just ask you this question: with respect to 
people being incarcerated who are addicted or users and they 
were caught up, probably may have had a mandatory minimum, do 
you think it is on the recidivism side of it, because you see 
those individuals back in your cycle, that there should be a 
major component of drug treatment in the incarceration mode, in 
the prison system? That that should be an aspect for those 
individuals, as relates to recidivism?
    Mr. Patterson. So, thank you for that question, and I go 
back to what I just said a few minutes ago. So, I think DEA 
predominately sees--and I should not even say predominately, I 
mean, we deal with the distribution end of this. I think a 
State and local approach is a very different feel, right? They 
are dealing with people that are generally impacted. And I am 
not saying that people that we want to arrest in the 
distribution stream also do not have substance abuse problems.
    I think there is a host of programs out there where States 
are trying. I am probably not the right guy to speak to that. I 
think that I am certainly a person, though, that believes that 
people that are impacted by drug abuse need help.
    And, you know, there are times and I have had conversations 
with, you know, first responders, EMS, State and local police, 
local prosecutors, in which, frankly, the arrest is saving 
certain peoples' lives. Right? Because it puts them down a path 
of treatment. But you have to want to be treated, as well. I 
think this is one of the delicate balances and I do not feel 
comfortable speaking for the States as they look at that, 
because we do not necessarily deal in that space, if that makes 
sense to you.
    Ms. Jackson Lee. No, it does make sense. We do have that 
problem in the Federal system, though. There are people in the 
system that are addicted. But I appreciate the thoughtful 
response.
    Let me ask you, as relates to distributors: do you think 
there are adequate consequences? Or, well, let me just say 
this: under the Controlled Substances Act, the applicable 
regulations require the distributors to report orders of an 
unusual size, orders deviating substantially from a normal 
pattern, and orders of unusual frequency, to the DEA. Is that 
correct? Are they supposed to do that?
    Mr. Patterson. That is correct. Suspicious activity 
reports.
    Ms. Jackson Lee. Thank you, and I like it in that context: 
suspicious activity. Do you think there are adequate 
consequences for distributors that fail to report orders of 
unusual size, orders that deviate from the norm, redundancy, 
and orders of unusual frequency?
    Mr. Patterson. So, I do not believe that is happening as 
much as it should be in the distribution world. We are trying 
to make efforts at DEA to get additional information out there 
to help in this.
    Ms. Jackson Lee. But do you think there are consequences 
for those entities that are engaged who fail to report unusual 
size, and sales that deviate from the norm, and orders that are 
unusual frequency? Are the consequences strong enough?
    Mr. Patterson. The consequences have traditionally been 
fines, civil fines. And you recognize that there are certain 
companies out there, certainly when you look at the bigger 
manufacturers, those fines have, unfortunately, become the 
price of doing business. There has to be more accountability in 
that space, but DEA also needs to do a better job in terms of 
how we look at those and hold people to that level of 
accountability.
    Ms. Jackson Lee. Let me ask you this final question: in the 
landscape of drug containment, or responding to the vast drug 
world, where are we in 2018? Staffing, with DEA, and as well, 
success.
    Mr. Patterson. So, staffing is a challenge, has always been 
a challenge for us. The good news is that we have a healthy 
influx of State and local partners that come on to our task 
forces. We just announced recently that we got funding, and I 
appreciate the funding that we did get, to bring on an 
additional 400 State and local task force officers. That is our 
true quick force multiplier, is we try and ramp up. But 
staffing, I think, will always be a problem.
    Mr. Sensenbrenner. The gentlewoman's time has expired.
    Ms. Jackson Lee. Thank you very much. Thank you for your 
service.
    Mr. Sensenbrenner. The gentleman from Texas, Mr. Gohmert.
    Mr. Gohmert. Thank you, Mr. Chair, and we appreciate your 
being here, Mr. Patterson. It has been several years ago, but 
Steve Chabot and I had journeyed down to Colombia and met with 
DEA officials there and went out into the jungles, basically, 
and looked at all the efforts we had at trying to help Colombia 
combat cocaine. And it was a huge problem at that time, and the 
FARCs were pretty much running things when we were there. But 
it made a great deal of impact and seemed to dramatically cut 
the amount of coca that is raised and cocaine that is sent up.
    We were told that two-thirds of the cocaine came up by fast 
boats on the Caribbean side, Gulf of Mexico side, and about a 
third went up to California. And then, they put in in Mexico--
and I asked why they did not just go ahead to the beach in 
Texas or California, and our eight DEA agents said it was 
because they are business people, and the odds of getting it 
across the Mexico-U.S. border were so much better than if they 
landed even on an abandoned beach.
    Back then, we did not have drones that could be used, and 
my understanding, and I want to know if it is correct, is that 
we have dramatically impacted the amount of cocaine coming up 
from Colombia, is that correct?
    Mr. Patterson. I think, for a period of time. I think with 
the peace process with the FARC--and this is a relatively long 
answer and I think you may have more that you want to talk 
about--I mean, I would be happy to come and sit down with you. 
There is a real issue with the production of cocaine in 
Colombia, yet again, that I think we have to wrestle with. We 
have had these conversations with the government of Colombia 
and our counterparts in the law enforcement world. There are a 
lot of challenges in this space, in what they were dealing 
with, with the FARC, but it is problematic, in terms of 
production, again.
    Mr. Gohmert. Is it still true that most of what they send 
north to United States goes across the water, puts into Mexico, 
and comes across our Mexico-U.S. border?
    Mr. Patterson. Yeah. Central America into Mexico, Mexico 
up, or directly into Mexico. Correct.
    Mr. Gohmert. Yeah. Do they skip most of the Central 
American countries and just come in at Mexico?
    Mr. Patterson. I think it depends on the organization, sir. 
So, I mean, regardless, it is coming across our southern 
border.
    Mr. Gohmert. Okay. Now, I know there has been great issue 
raised in recent years about the disparity in Federal penalties 
for possession for crack cocaine as opposed to powdered 
cocaine. And Dan Lungren that was here had pointed out that in 
the 1980s, most of the Republicans were following the lead of 
the Congressional Black Caucus members who were saying, like 
Charlie Rangel, that this crack cocaine is a scourge on the 
African-American community.
    And if you are not willing to really come down with 
powerful punishments even more so for crack than for powder, 
then, you know, you are discriminating against the black 
community. And for that reason, people like Dan said, ``We 
voted for it because that is what they said was best for the 
black community.'' Obviously, since then, we have found there 
really should not be a disparity.
    And I realize I have just got 1 minute, so let me just go 
directly to this question: we now have drones. How much help do 
you think you could use from drones? Have you made a specific 
request for a fleet of drones to help patrol both our Mexico-
U.S. border and the Gulf of Mexico and Pacific?
    Mr. Patterson. So, sir, we have not specifically.
    Mr. Gohmert. Do you not think they would help?
    Mr. Patterson. I know that we work well with, obviously, 
CBP. So, I view it more as we would pass actionable 
intelligence to CBP to work on that particular issue on the 
border.
    Mr. Gohmert. You would not want a fleet of drones for DEA's 
own use?
    Mr. Patterson. That is a good question. I think, in terms 
of border security, we are going to leave that to CBP and 
others to work on that.
    Mr. Gohmert. Well, I understand, but you have got the Gulf 
of Mexico and you have got California.
    Mr. Patterson. Right. It is something I would certainly 
think about and come back to you.
    Mr. Gohmert. We would encourage that. Thank you. I yield 
back.
    Mr. Sensenbrenner. The gentleman from Georgia, Mr. Johnson.
    Mr. Johnson of Georgia. Thank you, Mr. Chairman. Sir, of 
the 64,000 drug overdose deaths in 2016, you are familiar with 
that figure, right? 64,000. What percentage of the 64,000 were 
for nonprescription opioids; in other words, heroin and 
fentanyl?
    Mr. Patterson. So, fentanyl alone makes up for about 
20,000, so roughly a third. And where heroin and fentanyl came, 
combined, I do not recall. Overall, ``opioids'' was 44,000 of 
that 64,000.
    Mr. Johnson of Georgia. And, of the 64,000, how many deaths 
came as a result of overdosing on marijuana?
    Mr. Patterson. I do not recall even seeing that on the 
chart.
    Mr. Johnson of Georgia. So, in other words, you do not have 
any information that there is any death that marijuana is 
responsible for, within that 64,000?
    Mr. Patterson. I am aware of a few deaths from marijuana.
    Mr. Johnson of Georgia. You are aware of a few deaths from 
overdosing on marijuana?
    Mr. Patterson. I do not recall if it was overdosing, but 
deaths attributed to the use of marijuana.
    Mr. Johnson of Georgia. Deaths attributed, okay. What do 
you mean by that?
    Mr. Patterson. I do not recall whether it had been 
adulterated with something else. I would be happy to go back 
and look.
    Mr. Johnson of Georgia. I would love for you to do that.
    Mr. Patterson. I understand the issue here, which is, one 
is not comparable to the other, I think is what you are asking 
me.
    Mr. Johnson of Georgia. How many drug arrests throughout 
the country in 2016 for all illegal substances, drugs?
    Mr. Patterson. I do not know.
    Mr. Johnson of Georgia. According to a Washington Post 
article, which I just had here, which is dated September 26 of 
2017 by Christopher Ingraham, he notes that more people were 
arrested last year over pot than for murder, rape, aggravated 
assault, and robbery combined. About 800,000 arrests for pot in 
2016.
    Now, you stated, in response to Mr. Cohen's question, you 
pretty much intimated that marijuana arrests were not that 
profound, not too many. But 800,000 is quite a big number, is 
it not?
    Mr. Patterson. Again, I am referencing what I see in the 
space we work at.
    Mr. Johnson of Georgia. And that is just for marijuana.
    Mr. Patterson. Right. But again, the task forces that we 
participate with, DEA as a whole, these are certainly not our 
numbers and what we see.
    Mr. Johnson of Georgia. Yeah. The ACLU did a study which 
determined that African-Americans are 3.73 times more likely 
than whites to be arrested for marijuana. Do you agree or 
disagree with that number?
    Mr. Patterson. I have no reason to dispute the number.
    Mr. Johnson of Georgia. Do you believe that marijuana being 
listed under schedule I has anything to do with Federal, State, 
local law enforcement policy, with respect to those 800,000 
arrests?
    Mr. Patterson. Well, again, I would go back on the Federal 
policy. I just do not see those arrests happening in the 
Federal space, and I would not be the person to address State 
and local arrests.
    Mr. Johnson of Georgia. Okay. I am going to yield the 
balance of my time to Mr. Cohen.
    Mr. Cohen. Thank you, Mr. Johnson, I appreciate that. Mr. 
Patterson, you said the science had to be looked at, and it 
does, but I think the science has got to be faulty. The basis 
to list a drug in the schedule is likelihood of propensity to 
making someone addicted. Marijuana does not cause addiction, 
does not cause addiction.
    And the second thing is uses that can be seen in medicine, 
for health, and there are lots of people, veterans in 
particular, who say that the pain relief that marijuana gives 
them is so much better than opioids, and it keeps them off 
opioids, that it also helps people with their appetites, et 
cetera, et cetera. So, the science is wrong, and I hope you 
could try to see a new scientific study that reflects the 
science that is real and that reflects today's values.
    And as far as you said of Colorado, do you think marijuana 
is worse than alcohol for Colorado, as far as traffic deaths, 
domestic violence, assaults, murders?
    Mr. Sensenbrenner. The gentleman's time has expired.
    Mr. Cohen. Can he respond?
    Mr. Sensenbrenner. The gentleman's time has expired.
    Mr. Cohen. But the answer has not expired.
    Mr. Sensenbrenner. The gentleman's time has expired. 
Welcome to Rome. We will now hear from the gentleman from 
Colorado, Mr. Buck.
    Mr. Buck. Thank you, Mr. Chairman. If the witness would 
like to answer the last question, please feel free to do so.
    Mr. Patterson. So, sir, to wrap up on your question, I do 
not like getting into the comparison of one being better than 
the other. I think we have a substance abuse problem in this 
country and to add to that is problematic.
    Mr. Buck. Good morning. First of all, thank you very much 
for meeting with me a few months ago. I am concerned about 
sanctuary city policies and their effect on the opioid crisis. 
When I was at the U.S. Attorney's Office in Denver, Denver was 
a hub city for heroin and cocaine and other serious drugs that 
were imported into the country, and from Denver, drugs were 
transported all the way to the Canadian line and Nebraska, 
Kansas, Utah. And I contacted some friends in law enforcement 
just recently, within the last couple of months, and they tell 
me that Denver is still a hub city for heroin in particular. 
Heroin is not grown in this country, am I correct?
    Mr. Patterson. That is correct.
    Mr. Buck. And is it your opinion that Denver is still a hub 
city for the distribution of dangerous drugs like heroin?
    Mr. Patterson. Yes, sir.
    Mr. Buck. And the importation of those drugs like heroin 
comes from other countries and then goes into Denver. And how 
does that transportation happen?
    Mr. Patterson. You are talking about the routes that go 
into Denver? Predominately, I would say through vehicles, 
right? Trucks or smaller passenger vehicles.
    Mr. Buck. Okay. So, it typically comes across the southern 
border?
    Mr. Patterson. Yes, sir.
    Mr. Buck. It may come in by sea, but typically comes across 
the southern border, and is transported by human beings in 
vehicles to a place like Denver.
    Mr. Patterson. Right. When you are talking about the 
traditional cartels, that is correct.
    Mr. Buck. And typically, those individuals that are 
transporting the heroin are illegal immigrants. They are 
illegally in this country. Is that fair to say?
    Mr. Patterson. I think that is a fair statement.
    Mr. Buck. Okay. So, a city like Denver, that gives 
sanctuary to illegal immigrants that are involved in the drug 
trade, is in fact aiding and abetting--or, I will let you use 
your words, but my words, ``aiding and abetting''--the opioid 
epidemic that we have in the Rocky Mountain region.
    Mr. Patterson. I think that where this really becomes 
problematic is the ability for State and locals to impact and 
work those types of cases. Obviously, on the Federal level we 
still can, but it impacts our partners in that fight. And as I 
just talked about before, the State and local population and 
how we worked those cases is a critical piece.
    Mr. Buck. You were former law enforcement, before you got a 
cushy desk job, as I might put it. You actually worked the 
streets. And you knew, and I am hearing this from narcotics 
officers with the Denver Police Department, and I say ``cushy'' 
with tongue in cheek, please.
    Mr. Patterson. It does not feel that way most days.
    Mr. Buck. Especially now, I would guess. But they tell me 
that in a typical drug transaction, you have one person that 
accepts the money from the buyer. You have another person who 
delivers the drugs to the buyer. And you have one or two 
lookouts who are making sure that if they see anything 
suspicious with the police, they can signal the other two 
people.
    So, in a drug transaction like that, with four individuals, 
you have two individuals that you can arrest and prosecute for 
the crime of distributing a dangerous drug. You have two other 
people that are very difficult to prosecute unless they 
actually get involved in the hand to hand in one way or 
another.
    And so, typically, what would happen in that drug 
transaction is ICE would be called in, and the two individuals 
that were lookouts could be deported if they were in this 
country illegally, but maybe not prosecuted. And I will give 
you the remainder of my time here, but in that situation, is it 
important in the fight against the opioid crisis?
    Is it important in the fight against heroin distribution 
for State and local officials to be able to work with the 
Federal Government to disrupt drug organizations, so that we 
are safer in our communities and we stop hub cities from 
spreading this poison throughout the region?
    Mr. Patterson. Absolutely. It is not really a long answer, 
right? Our ability to work with those partners and the 
intelligence and evidence that they gather at the State and 
local level, is critical to how we do our job.
    Mr. Buck. And I guess my point is that it is not always 
prosecutable cases that disrupt organizations, right?
    Mr. Sensenbrenner. The gentleman's time has expired. The 
gentleman from Louisiana, Mr. Richmond.
    Mr. Richmond. Thank you, Mr. Chairman, and thank you, Mr. 
Patterson for being here. I asked you a series of questions and 
you have been very kind today in answering, either in your 
professional opinion or your life experiences being a law 
enforcement officer. And I would like to just keep doing that, 
but just let us know when you are answering as DEA 
administrator and, too, from just your life experiences. But 
let me give you some stats first and ask if you have any reason 
to disagree.
    At the height of the crack cocaine epidemic, you had maybe 
2,500 deaths associated with crack cocaine, only in terms of 
the health aspect of it, not with the crime associated with it. 
Would you have any reason to disagree with that?
    Mr. Patterson. No, I believe that is consistent with what I 
have read in the past.
    Mr. Richmond. And I think what we heard today, overdose 
numbers are somewhere around 64,000 in the U.S.
    Mr. Patterson. For all drugs, correct.
    Mr. Richmond. Correct. And fentanyl and other opioids, I 
think, is somewhere around 20,000?
    Mr. Patterson. Opioids, in total, is 44,000.
    Mr. Richmond. And the other research shows that about 80 
percent of the opioid deaths are white, 10 percent black, 8 
percent Hispanic. Any reason to dispute that?
    Mr. Patterson. Honestly, sir, I do not know the breakdown 
of what that is. I know it goes across all spectrum of people.
    Mr. Richmond. And do you think that our addiction substance 
abuse treatment infrastructure in this country is adequate?
    Mr. Patterson. No.
    Mr. Richmond. Do you think that if we, in 1980, when we 
first had a drug epidemic, if we would have answered that with 
the substance abuse treatment model that we are trying to do 
now, that we would be ahead of the curve in terms of creating 
that substance abuse infrastructure, so that today we would not 
find ourselves in such an inadequate manner to treat the 
substance abuse we have in this country?
    Mr. Patterson. So, I am going to give you my personal 
opinion here, which is, the infrastructure is important. I 
think, in dealing with the opioid issue, you have a much 
different issue than cocaine or crack cocaine, sir.
    Mr. Richmond. Well, if you can briefly tell me the 
difference, I would love to hear it.
    Mr. Patterson. So, the opioid path to recovery, in talking 
to treatment folks, is amazingly hard, and a long-standing 
problem that they are going to have to deal with for years to 
come. I think there is a more treatable solution when you talk 
about cocaine.
    Mr. Richmond. Which actually stuns me because, if you are 
telling me it is a lot easier--well, you did not say a lot, but 
you said it was easy--to break the cocaine addiction, or at 
least treat the cocaine addiction. Then it would just make 
sense to me, instead of the path we took, which was mass 
incarceration, mandatory minimums, to take a health approach, 
which is what we are doing now in terms of the public health 
crisis, and treat the addiction as well as fight the violence 
and the distribution.
    But we did not treat the addiction. And I just believe 
that, had we treated the addiction in the 1980s, we would 
actually have some addiction treatment infrastructure in this 
country that would help us become the framework for how we save 
all of these lives that we are losing today. Am I wrong for 
drawing that conclusion?
    Mr. Patterson. I would not say you are wrong. I think, 
look, there is obviously an evolving process of all best 
practices as we move forward. And I think, look, hindsight is 
always, you know, a good thing to go back on. I do not dwell, 
necessarily, in the past, but we learn lessons every day. So, 
to your point, you know, look, if things had been different in 
the '80s, would they be different in 2018? It is very 
conceivable that the answer is yes.
    Mr. Richmond. And I do not want to dwell on the past, but I 
think that we have to learn from the mistakes in the past, and 
part of our mistakes in the past, some of those people are 
still incarcerated today. And every dollar we spend on 
incarceration actually makes every neighborhood, every mother, 
every father, every grandmother less safe, because it is money 
that could go to something that would actually prevent a crime.
    For example, we do not call opioid-addicted children 
``crack babies.'' I mean, there is just a difference, and I 
will just close with this. I have 10 seconds left. But with the 
crack epidemic, when we found a grandson in public housing with 
cocaine, law enforcement pushed to evict the mother, we passed 
Federal law to do that.
    Mr. Sensenbrenner. The gentleman's time has expired.
    Mr. Richmond. Are we doing that with opioids?
    Mr. Sensenbrenner. The gentlewoman from Georgia, Mrs. 
Handel.
    Mrs. Handel. Thank you, Mr. Chairman, and thank you, Mr. 
Patterson, for being here. This has been very, very helpful. I 
wanted to touch on neonatal abstinence syndrome. As you can 
imagine, with the opioid crisis, we are seeing an increase in 
babies born with addiction. Yet, DEA does have a policy where 
it is maintenance only for an addicted mother, versus being 
able to move that mother off so that the baby is not born with 
that syndrome.
    There has been some compelling research out of the Medical 
College of Georgia, Augusta University, looking at being able 
to do programs to move that mother off of addiction. That has 
significantly reduced the neonatal abstinence syndrome. Is that 
policy something that DEA is looking at to, perhaps based on 
some additional research, you might adjust?
    Mr. Patterson. I would be happy to go back and go through 
the details with you on the policy and any implications it has. 
I mean, my exposure to this has been primarily in people I talk 
to in treatment more than anything else, in terms of the issues 
related to pregnancy and addiction, and the concerns, quite 
frankly, of bringing addicted people off during their 
pregnancy.
    Mrs. Handel. Could I follow up with your office and share 
this new research with you? Maybe I could work with someone.
    Mr. Patterson. Absolutely. I would be happy to read it, 
because, like I said, me being better educated helps us make 
better decisions in this space.
    Mrs. Handel. Great. Wonderful. I wanted to also follow up; 
my colleague, Representative DeSantis was talking a little bit 
about fentanyl coming in from China. And I know that last 
month, the Justice Department arrested 55 indictments in 
international opioid and fentanyl trafficking rings. Can you 
just give us a sense of what degree of a dent, small, medium, 
large, that is even making? And just really the bigger picture 
about China and the influx of fentanyl.
    Mr. Patterson. So, I think the critical thing to understand 
here is that our efforts with DEA and our other law enforcement 
counterparts in the United States, working with especially the 
Ministry of Public Security in China, kind of the DEA of 
China--we are learning more and more not only about the 
fentanyl itself but the precursors that are then going down 
into the South and Central America for not just this but 
methamphetamine and other drugs.
    So, there is a good and healthy relationship in terms of 
how we are trying to work together, recognizing the challenges. 
The DEA is putting additional people in China, in Guangzhou and 
looking at some other places to try and leverage better where 
we can share information back and forth.
    I think the key to this is, you know, we have a demand 
problem that is always going to continue to pull drugs, and so, 
as we work better with China, we are going to have to then deal 
with India or other places. So, you know, as you squeeze one 
part of the balloon it goes someplace else. Demand is a 
critical piece of this.
    I would love to tell you that law enforcement, you know, 
this could sit at the feet of us, and we could get this fixed, 
but that is why I always go back to it is got to be a three-
piece approach to this.
    Mrs. Handel. And one last question. If right now, today, 
you could have two pieces of legislation, additional authority 
resources, two things that you could say to us in this room 
that if you had this today or tomorrow it would help you in 
your effort, what would that be?
    Mr. Patterson. SITSA is one. The second is, as I stated off 
by starting with this, we have to deal with this fentanyl 
issue, so, whatever piece of legislation ultimately we come up 
with, we have to permanently schedule that in Class I.
    Mrs. Handel. Great. Thank you very much. Mr. Chairman, I 
yield back.
    Mr. Patterson. Thank you.
    Mr. Sensenbrenner. The gentlewoman's time has expired. The 
gentleman from California, Mr. Swalwell.
    Mr. Swalwell. Thank you, Chairman. Mr. Patterson, first, 
thank you and your agents for the work that they do in our 
communities, putting their lives in harm's way every day. It 
does mean a lot to me and my constituents. You have a presence 
in our district, and you have worked very closely with our 
local law enforcement, and I do appreciate that.
    There are a number of different, I think, tracks to take to 
address opioids in America and what we can do to reduce 
addiction. And I also want to associate myself with Mr. 
Richmond and a lot of his concerns about just some of the 
issues and lessons that we should learn from the past. But I 
want to focus on teenagers.
    I have met with families in my district who have lost a 
teenager, a high schooler, to opioid addiction, and, you know, 
for many of them, as you described earlier, they describe the 
same symptoms; they describe the same pattern of behavior. And 
then, oftentimes it is too late, and the loss, you know, is 
quite overwhelming to go back and fully understand what they 
could have done differently.
    But what can we do differently with high schools, with the 
physicians and dentists to these young men and women? I fear 
that, you know, there is an over-prescription, particularly 
with young people who do not necessarily appreciate the 
effects, and then they are down a rabbit hole that they can 
never get out of. So, if you could first just talk about what 
we could do with the teenage population as far as awareness, 
you know, whether it is in the schools, local communities, or 
the physician community.
    Mr. Patterson. I will say, I appreciate that. And so, DEA 
has a program called Operation Prevention which is in the 
schools, it was done in public-private partnership with 
Discovery Channel. The key to this, and I think to your point, 
is we have to start with education and not at high school. It 
has got to be before high school. I think we all recognize that 
kids that are now 10 or 11 are probably where we were maybe 
when we were in our early 20's.
    I mean, they are bombarded with technology, they understand 
things in a much different way, and they have grown up much 
quicker than we did. So, the key is to get to that age. And I 
hate to do this, but I am going to do it to you, and this is 
what concerns me about marijuana. Right? Because those same 
stories I hear all the time, I generally hear marijuana 
introduced.
    And again, I am not going to compare what is better, what 
is worse. I am not going to say it is a gateway; I am not--the 
problem is that these things all seem to dovetail together, and 
my concern is--and again, I will take my DEA hat off for a 
second--as a person in the United States, what message do we 
send as we try and navigate this space in terms of that? And I 
think that is problematic. So, the education of our youth is 
important.
    Where it really seems to hurt, and more than anything else, 
is we have these pharmaceuticals that all sit in our house. And 
I recognize I am going to run you out of time here, and you 
probably have other things. But we have to get those out, 
because, like I said, every one of these stories generally 
sounds the same, and they all hurt. For me, they personally 
hurt, because it is something that has happened yet again that 
we feel like we talk about all the time, and for some reason it 
does not get heard.
    Mr. Swalwell. And Mr. Administrator, can I just ask--when I 
say teenagers I also include 19-year-old, and the issue I have 
seen there--even into the early 20's--is that many parents--you 
know, they still consider the 19-year-old or the 20-year-old, 
you know, their son or daughter, and they lose their rights, 
you know, to make healthcare decisions for them, obviously, at 
18. And so many parents have told me, ``There has to be a way 
that I can fight for my kid, even though they are 19, 20 years 
old. I see that they are incapable of, you know, making healthy 
choices for themselves.''
    And I understand, like, you know, it is the law, for very 
good reasons, that you are an adult at 18. But is there--do you 
have any ideas on what we can do if a parent sees a 19-year-old 
struggling with addiction, and they are now incapable of, you 
know, being a part of healthcare decisions or, you know, 
getting them, you know, the treatment that they need? I do not 
know if you have encountered this at all.
    Mr. Patterson. I mean, look, we have, I think, an enormous 
problem in that college range. It is the big experimentation. 
Your parents are not over your shoulder every day; you are now 
amongst your peers. We see this especially in the issue with 
pharmaceutical pills. And there have been some very public 
stories about people buying what they believe is a Xanax or 
something else, and it is not.
    So, this space is important and critical. And again, this 
gets back to an ongoing dialogue, and we in this country tend 
to like to put a blame on someone and fix it that way, by them 
being the problem. We all have to admit that this is a 
nationwide problem, and we have to stop looking at it: ``It is 
this person, or it is that person, or it is this group.'' And 
maybe this is now the time.
    Mr. Sensenbrenner. The gentleman's time has expired. The 
gentleman from Pennsylvania, Mr. Rothfus.
    Mr. Rothfus. Thank you, Mr. Chairman. It is good to see 
you, Mr. Patterson. The last time we spoke, you and your 
colleagues were hosting me for a briefing at DEA. I appreciate 
your participation here today and trust my colleagues are 
giving your testimony the way the weighty consideration that I 
think it deserves.
    There are some scary portions of your testimony regarding 
fentanyl and other similar synthetic drugs. You also mentioned 
increased trend of fentanyl being mixed with heroin and 
traffickers now making counterfeit pills that appear like other 
pharmaceuticals, primarily CPDs, but actually contain fentanyl 
and other synthetics. What can Congress do to stop pill presses 
from coming into Mexico and the U.S. to illicitly produce such 
counterfeit pills?
    Mr. Patterson. So, sir, we had put out a regulation some 
time ago, I guess probably about 9 or 10 months ago now, on 
pill presses that I think we are still trying to evaluate how 
helpful this is in trying to get people to acknowledge pill 
presses coming into the United States. I think there is space 
here, that the question is: how much are we able to impact 
through legislation these folks that are importing them?
    I think that the production of counterfeit pills is a 
problem that we are going to struggle with for some time, and 
pill presses certainly are part of that equation. So, 
legislation that would be proposed and that we can offer 
technical assistance on I think would be great.
    Mr. Rothfus. So, you think there might be some room for 
some additional legislation to address this issue?
    Mr. Patterson. I do, sir.
    Mr. Rothfus. Well, we look forward to following up with you 
on that. Are we seeing a corresponding trend of increased 
overdoses from counterfeit pills with fentanyl?
    Mr. Patterson. That is correct.
    Mr. Rothfus. As far as, you know, looking where this is 
heading, do you see this getting significantly worse with these 
counterfeit pills?
    Mr. Patterson. So, again, as the licit market; as we 
tighten that and make it harder and harder for licit pills to 
be there, I think that it naturally pushes and makes the 
potential for counterfeit pills to become much more of a 
problem for us.
    Mr. Rothfus. Given the demand that is out there for 
fentanyl--and actually, I hear from back home where people look 
for tar-fentanyl--given how cheap these are to transport and 
produce, do you see criminal organizations switching from 
heroin to these substances?
    Mr. Patterson. I do. The profit margins make them appealing 
to organizations that are willing to participate in selling.
    Mr. Rothfus. You referenced Mexico-based transnational 
criminal organizations in your testimony like Sinaloa and how 
they are extremely violent, sophisticated, and with large 
networks. I am also very concerned about the growing 
interconnectedness of these TCOs globally and potential 
overlaps with terrorist organizations. Is the administration 
giving DEA and other agencies the resources and support you 
need to confront this interconnectedness?
    Mr. Patterson. I think it is incumbent upon all the 
agencies that work under this administration to ensure that 
they are sharing information. We have good centers to do that 
that are already established, but I think, to your point, the 
world has gotten very small for these organizations, and the 
interconnectedness is there. That also gives us opportunity, 
though, as well.
    Mr. Rothfus. Now, you know, when I started looking at this 
a number of years ago I was surprised to learn that the heroin 
that we are seeing, that it predominately is coming from 
Mexico; almost all of it. Is that still the case?
    Mr. Patterson. It is. More than 90 percent of our seizures 
come from heroin produced in Mexico.
    Mr. Rothfus. Well, internationally, in the world, 90 
percent of the heroin is coming from Afghanistan. It is coming 
from Afghanistan, across the world, not just the United States, 
but worldwide.
    Mr. Patterson. Certainly we do not see the presence in the 
United States, but they do produce a good portion of the rest 
of the world's heroin.
    Mr. Rothfus. Does the supply coming out of Afghanistan 
impact the price in United States?
    Mr. Patterson. Probably not.
    Mr. Rothfus. We do have resources in Afghanistan, DEA 
resources, yes?
    Mr. Patterson. We do.
    Mr. Rothfus. Not nearly what we used to have, correct?
    Mr. Patterson. No, sir.
    Mr. Rothfus. Are there sufficient resources, in your 
opinion? Because I understand last fall we started targeting 
sites for manufacturer in Afghanistan--our forces did.
    Mr. Patterson. Right. So, again working with the assets 
that we have and the resources we have, the best we can do is 
put intelligence out to that region for them to take action. I 
think part of the problem is other agencies, and the military 
has pulled out. It became much harder. You reference it; we are 
down obviously substantially in our people there. It is much 
harder for us to work in countries----
    Mr. Rothfus. Well, given that, you know, most of the heroin 
in our country is coming from Mexico, do you think other 
countries that have heroin problems originating in Afghanistan 
are stepping up enough? Could they be doing more--other 
countries--with respect to interdiction efforts in Afghanistan?
    Mr. Patterson. You are talking about internal, in their own 
country?
    Mr. Rothfus. Well, also internationally, deploying 
resources to Afghanistan.
    Mr. Patterson. No, I do not think that most countries are 
putting the resources they need to when they are production 
countries.
    Mr. Rothfus. I yield back.
    Mr. Sensenbrenner. The gentleman from California, Mr. Lieu.
    Mr. Lieu. Thank you, Mr. Chair. Thank you, Mr. Patterson, 
for being here. Thank you for your public service. You have an 
important job, and this is an important topic. I apologize, I 
was not here earlier as I at another hearing, so if I ask 
questions you have answered before, it is because I have not 
heard them.
    When I was in California State Senate before Congress I 
worked on the opioid issue, and I helped put in the 
prescription drug monitoring program that California has, and 
you have put in your written statement that you view that as 
important for States to have these. I have a question. What 
happens if someone is in Nevada and gets a prescription, then 
crosses into California? Do those two databases talk to each 
other? How does it work when people cross State lines?
    Mr. Patterson. I do not know specifically the State-to-
State connections. That is probably the most critical piece of 
any PMP, that States, especially where they have borders, are 
able to see each other's. Because that is what we see all the 
time in the licit diversion of pharmaceuticals: People crossing 
State boundaries to essentially go pick that up. I was just out 
in California and speaking to our office out there; that is one 
of the better PMP programs that is out there.
    Mr. Lieu. Is there any movement towards a national database 
that would prevent that, or is that too complicated to do?
    Mr. Patterson. It should not be too complicated, and it is 
absolutely necessary.
    Mr. Lieu. Would that require legislation, or could the DEA 
start doing that? What would be needed if we wanted to -
    Mr. Patterson. Look, it could come in a couple of different 
forms. One, obviously--probably the easiest--would be 
legislation. We have tried to push the States to have more 
interconnectivity. I think there are a number of people that 
have already put this forward, and again, we would be happy to 
provide assistance in what we see on that. I think the key is 
we hear this all the time from pharmacies and doctors as well, 
is that inability to see these patterns impacts them being able 
to make good decisions. So, where States fall short on this; 
this is the place that for me is highly problematic.
    Mr. Lieu. Thank you. I also work on the issue of people 
able to buy opioids on Craigslist and other internet websites. 
Has that increased, decreased, or remained the same the last 
few years?
    Mr. Patterson. I think, unfortunately, it is probably 
increased. I think you still see it across the spectrum of the 
internet. We are looking at, obviously, the darknet and 
Clearnet as to these locations, in essence for information that 
we can then use to target some of these folks. It would be nice 
if we could work better with the industry in having all of 
these sites pulled down. They recognize the challenges with 
that, but I think from a governmental standpoint, from a law 
enforcement standpoint, I think at some point we have to start 
dealing with known crimes that are occurring over the internet.
    Mr. Lieu. If you have any ideas, let this committee and let 
us know regarding the internet trafficking. It is a hard issue. 
At the time, I was working on it, Purdue Pharma said they made 
oxycontin a different form that made it hard to use it legally. 
Did that work?
    Mr. Patterson. I believe people figured out how to abuse 
that as well.
    Mr. Lieu. Okay, so that did not really work.
    Mr. Patterson. People with problems find ways to abuse 
drugs when they need to abuse drugs.
    Mr. Lieu. In your written testimony you stated that there 
was a 70 percent increase in emergency visits related to 
opioids in the Midwest. You had some other regions; it was 20 
percent in the Southwest. Why was there such a large spike in 
the Midwest?
    Mr. Patterson. I think there are a couple things that 
factor into why we see spikes, and I do not necessarily know if 
it has changed it. Now, obviously, with emergency room visits 
we have seen a shift. We look at States that traditionally have 
not had this problem. I look at New Mexico, Utah, some of some 
of those States that have all of sudden had kind of a pick-up 
in this area, and it is incumbent upon us to be able to react 
and pay attention to that. That is why we are, unfortunately, 
tracking overdoses, overdose deaths, so that we can position 
ourselves to help those communities as it goes.
    As we look at the Northeast and see some promise there, we 
have to be nimble enough to move our resources around to where 
we are seeing problems. But I think you see pockets showing up 
all over, and I know, certainly in terms of overdose deaths, 
sometimes those spikes end up being additional work that is 
being done in the ME or the coroner offices.
    Mr. Lieu. Thank you. It also seems part of problem are 
patients who get prescriptions for doctors who treat pain, and 
then they get addicted to opioids. Do you know if doctors are 
being trained to recognize this more broadly, or is there 
continuing medical education or medical schools are onto this? 
Are they trying to train their doctors in a different way than, 
let's say, 10 years ago?
    Mr. Patterson. I hope. I mean, look, we strongly support 
CME, or continuing medical education, in this space. I think 
that is a critical piece of what we see. DEA does outreach on a 
voluntary issue with the doctors, and I think the other thing 
that we are doing is trying to communicate much better with the 
1.7 million registrants through the ability that we have to 
send them notifications and things; again, all voluntary. But I 
go back to the fact that I look at the vast majority of 
doctors: 99.99 percent are all trying to do right by their 
patients. So, I think the key is to, again, keep working on it 
educational process.
    Mr. Sensenbrenner. The gentleman's time has expired. The 
gentleman from Arizona, Mr. Biggs.
    Mr. Biggs. Thank you, Mr. Chairman, and thank you, Mr. 
Patterson, for being here today. It has been a very informative 
hearing. If I understand right, the vast majority of fentanyl 
and its derivatives are coming from China through Mexico across 
the southern border. Is that a fair takeaway?
    Mr. Patterson. There are two different trends. So, you have 
bulk, you know, the larger quantities coming across the 
southern border. I think you have much more smaller packages 
coming directly in through China into the United States.
    Mr. Biggs. And I think in the second panel there will be a 
lady testifying of a young man who received it directly from 
China. But in this instance, I was curious about the role of 
Phoenix and the Tucson corridor for both transfers across the 
border. Can you elaborate on that a little bit, and also the 
efforts to interdict?
    Mr. Patterson. All of those points of entry into our 
country have been blitzed with not just opioids but 
methamphetamine and other drugs coming across the southern 
border. Our border offices--so, you know, Texas, certainly 
Phoenix, or Phoenix division, San Diego, and El Paso, where 
these places are--it is the bulk of our work trying to deal 
with the mass quantities coming across the border, and that is 
where those folks primarily focus their efforts.
    Mr. Biggs. You talked about China, and then, as you squeeze 
the balloon, you are seeing that there is a potential moving to 
India, trying to fill a void if you are able to suppress China. 
And in your written testimony you elaborated quite a bit about 
China, and you talked about DEA liaison in in China. Can you 
tell me, what does that liaison do exactly, and how is that 
helping to slow the flow?
    Mr. Patterson. So, our personnel that sit in China 
currently--the key is that intelligence sharing back and forth 
and an ongoing dialogue of things that they can do to help us 
in our process, and, frankly, training each other. So, we have 
had a number of them come over to understand from a chemistry 
side how to look at things that we are seeing. And a lot of 
this goes back to them trying to schedule the various analogues 
over in China, because we do see that when they do scheduling 
actions it has an impact in that country, which ultimately 
impacts us and what we are seeing here.
    Mr. Biggs. I am glad you said that, because that was my 
next question. Have the joint efforts produced some kind of 
positive reduction?
    Mr. Patterson. They have, but again, these are chemists, 
and they will constantly change structures to avoid that. Part 
of the reason for us scheduling fentanyl as a class the way we 
did was to try and persuade China to do that in kind, to do the 
similar type of thing, and we are continuing to work through 
that effort. And they have done a number of fentanyl analogues 
and precursor chemicals, which is critically important.
    Mr. Biggs. Okay, so, if they open up the schedule or 
regulation of the schedule to a broader segment of fentanyl and 
its analogues, that is one way. But are they doing anything 
else to physically interdict shipments to the U.S., either 
through, like you are talking about, both the small transfers--
direct mail, if I can put it that way--and bulk?
    Mr. Patterson. Yeah, there have been seizures made over in 
China, and I think the key for us is being able to share data 
back and forth in a productive way of understanding the targets 
where those folks are shipping to the United States, and there 
has been a good pass of information back and forth in that 
realm.
    Mr. Biggs. Okay. You mentioned in your written testimony 
that in 2015 there was enhanced collaboration, and I am 
wondering what the next steps are with China. And what do you 
see the next steps working with China would be?
    Mr. Patterson. I think the key for us is to get more 
resources there. We have a limited staff in China. Like I said 
before, you know, we are going to put additional personnel in 
Guangzhou, which is a big shipment point out of China, to try 
and really deal with these issues. But there is a willingness, 
certainly, at the agency level to participate and work fully in 
doing that.
    One of the other huge pieces that we are trying to do is 
the precursors that are leaving China, going down into Central 
America, into Mexico, because that is a huge piece of not just 
the opioid side or what potentially could be an opioid problem, 
but the methamphetamine piece that we are dealing with in this 
country.
    Mr. Biggs. So, if we are successful in the Chinese 
interdiction, or at least to slow that down, and you anticipate 
maybe someplace like India or someplace else. What are the 
anticipated efforts that that are going to be necessary in 
those future countries?
    Mr. Patterson. It will be taking that playbook that we 
learn from in China on how to work, essentially, the chemicals, 
which are the critical piece of this, and into India and other 
regions.
    Mr. Sensenbrenner. The gentleman's time has expired. The 
gentleman from Maryland, Mr. Raskin.
    Mr. Raskin. Thank you, Mr. Chair. Mr. Patterson, thank you 
for your service and your testimony today. Sixty-four thousand 
overdose deaths in 2016, which is more than the number of 
Americans who died in the entire Vietnam War; two-thirds of 
those 64,000 deaths opioid-related. Are we winning the war on 
opioid abuse? Are we losing it? Is it a stalemate? What is the 
report to the American people today?
    Mr. Patterson. I think the issue that we have is, one, it 
is not a win. So, I mean, again, the number is problematic for 
me. I think what we see is that we are going to have to deal, 
you know, whether it is for the year or for in the next couple 
years, with a population that has been abusing opioids and what 
that will mean for us as a Nation.
    Mr. Raskin. And, you know, in your effort you reported a 
huge number of Take Back drugs that DEA receives. What 
percentage of the Take Back drugs are opioids?
    Mr. Patterson. So, we do not break those out, sir. I will 
tell you that I think, you know, most of us in our homes have 
had those bottles of opioids sitting around, so there is a 
percentage of it. You know, you could even put it at a small 
percentage and realize that we have a problem with 
overprescribing in this country in terms of the volume that we 
prescribe.
    Mr. Raskin. Okay. I found one academic article online just 
as you were speaking, because it sounded promising, that there 
were tons of Take Back drugs, but this one article says that 
only 0.3 percent of Take Back drugs are opioids, and most of 
them are aspirin or Flintstone vitamins. Is that right?
    Mr. Patterson. I would find that statistic to probably not 
be accurate, sir.
    Mr. Raskin. What would you estimate it as?
    Mr. Patterson. I do not know.
    Mr. Raskin. They are saying it is less than 1 percent.
    Mr. Patterson. Even if you put it at 2 or 3 percent, it is 
still a pretty dramatic number of opioids. And we do not go 
through that and count up which it would be; our quest is to 
get the volume of prescription drugs out of the homes. And I do 
not know if we have any analysis, but if I find out that we do 
I will get back to you.
    Mr. Raskin. Please. I would be very curious to know. So, I 
was interested in your colloquy with my colleagues Johnson and 
Cohen about science, and I was glad to hear you testify in 
favor of science. Do you favor a rigorous and comprehensive 
scientific study about the addictiveness, the lethality, and 
the negative and positive health effects of marijuana?
    Mr. Patterson. So, I think we have been pretty vocal about 
our belief in the research towards the medicine that could come 
from marijuana. I think our application process that we put in 
August of 2016 showed that we were trying to help the industry 
in terms of understanding where that research may go with 
giving additional growers.
    Mr. Raskin. So, you would favor a comprehensive scientific 
health study on the effects of marijuana?
    Mr. Patterson. Absolutely.
    Mr. Raskin. Okay. Let me ask you. We are in such a terrible 
situation with the opioid crisis as well as with drug abuse 
generally, as you are saying. Tell me how America's experience 
with liquor prohibition informs your analysis of the most 
effective strategies we can be using in order to address this 
public health crisis.
    Mr. Patterson. I am not your person to talk about liquor 
analysis, so I cannot help you on that topic, sir, in terms of 
how that correlates with, I think, the drug issue in the United 
States.
    Mr. Raskin. Okay. I ask this question not rhetorically but 
seriously: do you favor, speaking either as the head of the DEA 
or personally, the 21st Amendment and the repeal of prohibition 
of alcohol? Obviously, there remain tens of thousands of people 
who die every year from alcohol abuse, both in terms of health 
effects but also because of drunk driving on the highways. Do 
you have a position on that?
    Mr. Patterson. To repeal it?
    Mr. Raskin. Well, the 21st Amendment repealed prohibition, 
the Eighteenth Amendment. Do you support the 21st Amendment, or 
do you think we made the wrong decision then? Would it have 
been better to continue with prohibition of alcohol?
    Mr. Patterson. I think this goes back to it is a personal 
use decision to be made. So, I mean, I would not sit here and 
tell you that I think that was a bad decision. I do think that 
all these factors, like I said, we all have to be the adults in 
the room.
    Mr. Raskin. And I appreciate your answer very much, because 
I certainly tell my kids that I think using alcohol is a bad 
decision. We have a relative who was killed by a drunk driver; 
I feel very seriously about it. On the other hand, I think that 
our experiment with prohibition failed because there was a 
public demand for it for the reason you say, that people like 
to experiment with their consciousness in different ways. Do 
you think that, after decades of criminalizing marijuana, that 
experiment in prohibition has proven to be a failure, and it is 
time to call it off?
    Mr. Patterson. So, I will give you my personal opinion on 
this, which is I think over the last decade my opinion has 
changed on this. Ten years ago, I may have told you yes, and I 
think now, more than ever before, as I see what fuels some of 
our addiction problems in this country, starting with 
marijuana, I have gotten a much more stronger opinion as to 
that. I believe that we are now in a dangerous environment in 
terms of what we are doing with legalization.
    Mr. Rothfus [presiding]. The time of the gentleman has 
expired. The chair recognizes the gentleman from Louisiana, Mr. 
Johnson, for 5 minutes.
    Mr. Johnson of Louisiana. Thank you, Mr. Chairman. Mr. 
Patterson, thanks for being here. As you know, an ISO was 
issued on Friday afternoon against a large distributor in my 
district, accompanied by a DEA press release. And I just have 
two kind of categories of questions related to that, one with 
regard to the patients that are affected by this ultimately, 
and second, with regard to process.
    Regarding the patients, by Monday I had already received 
multiple constituent inquiries about all this, including a 
local hospital who said that this was creating a serious 
situation for them and an affidavit from the Louisiana 
Independent Pharmacy Association expressing the immeasurable 
impact this decision is going to have on the many hospitals and 
pharmacies and patients throughout my State, and really the 
Nation, because this distributor serves many States around the 
country. Mr. Chairman I would like to ask unanimous consent to 
enter into the record a copy of this affidavit.
    Mr. Rothfus. Without objection.
    Mr. Johnson of Louisiana. Thank you. The affidavit is from 
the CEO and president of Louisiana Independent Pharmacy 
Association, and he says in a three-page affidavit--the most 
important language, I think, is at the end. He says, ``This 
suspension has already caused a disruption in the supply chain 
for our members''--all the independent pharmacies--``and is 
currently impacting the delivery of care to the patients those 
members serve.
    Affiant believes that continued suspension will worsen the 
problem, causing patients served by independent pharmacies to 
have their care delayed and perhaps be denied. The most 
significant impact is to the patients who are unable to find 
the pharmacy healthcare and necessary prescription drugs in 
their community and to find the continuity of care to help 
maintain and improve their health and health outcomes.''
    The question is: when an immediate suspension order is 
issued, is there any consideration at all given to the patients 
that rely on these lifesaving drugs that are effectively left 
without access to critical medication overnight?
    Mr. Patterson. There absolutely is.
    Mr. Johnson of Louisiana. I mean, what did you do in this 
situation, by way of example?
    Mr. Patterson. So, again, as we spoke about earlier, the 
issue for us here is we have not heard from these same 
hospitals that have now provided--and I have not seen that 
affidavit--an affidavit, obviously for the temporary 
restraining order that is going to be filed today, and there is 
a process by which the company down there can go and go about 
that. We have not heard the same concerns, as----
    Mr. Johnson of Louisiana. Let me stop you, because I am 
short on time. Let's just apply common sense here. Let me 
assume, for the record, that you have not heard since this 
happened Friday afternoon, and we are here on Tuesday morning; 
you have not had time to hear from a lot of these folks. Would 
you take my word for it that many are affected? And if you do 
not take my word for it, use common sense.
    This distributor, for example, supplies hundreds of 
hospitals in Louisiana and the surrounding region, hundreds of 
Louisiana pharmacies totaling hundreds of millions of doses per 
year. So, is it safe to say that that puts patients affected, I 
mean, at least in the numbers of tens of thousands, if not 
hundreds of thousands of patients, in some immediate jeopardy? 
Some of those are lifesaving medications, are they not?
    Mr. Patterson. I understand that, and simply what I will 
counter with you is that the hospitals or pharmacies that we 
have talked to have secondary supplies, as most generally do.
    Mr. Johnson of Louisiana. How many have you spoken to on 
this case?
    Mr. Patterson. I do not know. I think less than 10 have 
reached out to us. So, every one of those people that have the 
ability to distribute narcotics or distribute schedule I or 
schedule II, in this case, have backup sources, and those that 
do not have already reached out to DEA to seek remedy.
    Mr. Johnson of Louisiana. Well, this affidavit from the 
Louisiana Independent Pharmacy Association, they have at least 
85 pharmacies, about 82 million prescriptions filled each year, 
and they are directly affected. So, you might want to consider 
that. I am concerned about going forward in other cases, before 
you issue an ISO, which I understand is a rare occasion, there 
ought to be some regard paid to all these patients.
    I have a lot of constituents who are literally some on 
their death bed today; I am not using hyperbole. They cannot 
get their necessary medications because the DEA decided to do 
this. I am concerned about the process. And let me ask you, in 
a case like this, would the DEA consider, as they have in the 
past, this example? This company, for example. Will they have 
an opportunity to offer a remedial plan rather than just 
instantly removing access to millions of doses a year for all 
these patients? Are they going to have a chance to correct?
    Mr. Patterson. There is. There is a process in which they 
will have the chance to correct. But I go back to the fact of 
if you have a company that shows woeful neglect and continued 
bad behavior, we have to hold these folks accountable.
    Mr. Johnson of Louisiana. Well, it is not for you and I to 
litigate the specific facts of this case.
    Mr. Patterson. I agree.
    Mr. Johnson of Louisiana. That is for the court. But is it 
a normal process, a normal procedure, for the DEA to allow an 
alleged offender to present a remedial action plan?
    Mr. Patterson. The corrective action plan is part of the 
process.
    Mr. Johnson of Louisiana. And would they be afforded that 
in this case?
    Mr. Patterson. Yes.
    Mr. Johnson of Louisiana. I am almost out of time. One more 
question about process: if it comes to light that the DEA acted 
prematurely or that evidence did not support the claims in this 
case, for example, are there processes in place to offer 
restitution? So, for example, if a company goes out of business 
because of this delay, what remedy do they have against the 
Federal Government? I am out of time, but you can answer.
    Mr. Rothfus. The gentleman's time has expired. The chair 
recognizes the gentlewoman from California, Ms. Bass, for 5 
minutes.
    Ms. Bass. Thank you. I actually want to follow some of the 
questioning of my colleague here. And I know, you know--excuse 
me--we are back and forth; we all have hearings the same time, 
and some of these questions you might have been asked before.
    But I really wanted to talk about the drug manufacturers, 
even before they get to the point of distributing it. You know, 
this problem has not existed forever. I mean, it has been many 
years since I worked in the medical field, but when I was 
working in the medical field we did not have this problem.
    And so, before the drugs are even distributed to individual 
pharmacies, what relationship do you have with the 
manufacturers to begin with? Because one has to question why 
they are manufacturing millions and millions of opioids when 
they were not needed before? So, how do you work at the point 
of manufacturing with the manufacturer?
    Mr. Patterson. I think this is really where the rubber 
meets the road on this issue. We can fight this downstream, 
right, with doctors and pharmacies and diversion of 
pharmaceuticals, but you have to elevate this conversation back 
to the prescribing practices the United States.
    Ms. Bass. Well, the prescribing practices, absolutely. I 
agree with you. But I am talking about even before the 
prescribing practices. I mean, the companies that make these 
drugs: does the DEA put pressure on them for producing and 
manufacturing the volume that they do?
    Mr. Patterson. So, under the quota process we do, but what 
I was going to finish up on that last sentence is the 
prescribing practices cannot be driven by industry. They need 
to be driven by the medical community, and I think that is 
where the disconnect is there.
    So, DEA has done more and more education with distributors, 
and even in the manufacturing space, to explain the problem, 
but where this has to change is in the prescribing practices, 
because there are corporations that are making pills. As long 
as that continues to get put out in the same manner, we have a 
problem.
    Ms. Bass. But you do know the relationship, right? So, you 
know that the distributors go to doctors' offices and promote 
the prescribing practices? I mean, when I listen to my 
colleague there talk about the tens of thousands of people that 
need opioids in his district, I really have to raise the 
question: do they really?
    Mr. Patterson. You are asking the wrong guy that question, 
because I will give you the law enforcement answer, which is 
no. I mean, it does not need to be. And there are some good 
studies out there to show that opioids--the VA just did one 
where opioids had the same impact that Tylenol did when you do 
blind studies. So, I mean, there is science out there, again, 
to go back to that word.
    Look, we have to change our culture, and that is why I said 
this is not a one-size-fits-all answer to anything. We have to 
change a culture in this country. But it goes across all of us. 
Right? So, whether it is legislation capabilities to fix this 
problem; whether it is, you know, the pharmaceutical industry 
ultimately recognizing the harm that is being done; whether it 
is law enforcement and their efforts; I mean, we all have to 
work collectively together on this problem.
    Ms. Bass. Yeah, I agree with you, but at some place we have 
to figure out how to hold the companies responsible, because 
they push the medication on the doctors. They hand out free 
supplies; they put on lunches and dinners. I mean, I worked in 
many medical offices before, and I also have a hard time 
understanding.
    And I hear about--I do not know that this exists in Los 
Angeles, but I do think it exists in a number of your 
districts--where you have these ``pharmacies,'' and people will 
get off the freeway offramp and go pick up huge volumes of 
opioids that there is no way in the world you can say that that 
has a medical use, and that is allowed. And I do not understand 
that. I do not understand how those type of pharmacies can even 
exist.
    Mr. Patterson. No, and that is where law enforcement does 
have to step in. So, once you have moved from the manufacturing 
into the distributor and then the pharmacies and the doctors 
and that relationship there, we have to do a much better job. 
And I know you had not been here earlier, but where we interact 
with States and then using HHS data and others to find these in 
a real, efficient, and timely manner to stop that harm, because 
that is ultimately where those pharmaceuticals get introduced 
to the general public.
    Ms. Bass. Right, but they would not have those if the 
manufacturers were not producing it at such a volume. Thank 
you.
    Mr. Patterson. Thank you.
    Ms. Bass. I yield back.
    Mr. Rothfus. The gentlewoman yields back. The chair 
recognizes the gentleman from Iowa, Mr. King, for 5 minutes.
    Mr. King. Thank you, Mr. Chairman. First, Mr. Patterson, I 
want to thank you for your direct testimony, and my sense of 
your testimony here today is you came here to help inform this 
Congress of the job we all have ahead of us. Sometimes we get 
evasive witnesses, and you are not one. So, thank you. Maybe I 
would start with this. Do we have a decent idea on how many 
drug misusers we have in America?
    Mr. Patterson. Overall, or for in the opioid space?
    Mr. King. Overall.
    Mr. Patterson. Overall, it is obviously in the millions, 
probably, you know, 10 or so million, 11 million.
    Mr. King. Okay. And I am looking at a number around 11.5 
million, so that is in the zone. And I am not going to ask you 
to answer the components of this now, but is it something you 
could put together for us to build us a pie chart that would 
tell us the overall population of drug misusers, and then break 
it down by the different types of drugs so we could get a 
better handle on the scope of this drug abuse problem we have 
in America?
    Mr. Patterson. I would be happy to do that, sir.
    Mr. King. Good. I appreciate that, and I will be looking 
forward to seeing that. Do we know what the street value is of 
the illegal drugs consumed in America? The illegals?
    Mr. Patterson. Yeah. Across, again, the platform of all 
narcotics, yes, we do.
    Mr. King. What is that number? The street value?
    Mr. Patterson. The street value?
    Mr. King. Yes.
    Mr. Patterson. Maybe I am misunderstanding your question. I 
thought you meant like what someone would pay for a dose of a 
certain thing. You are talking about the total off----
    Mr. King. No, I am interested in how many dollars out of 
our U.S. GDP are spent on illegal drugs? What does it do to our 
economy?
    Mr. Patterson. It is a massive drain on our economy.
    Mr. King. Do you have to guess at that, though? I mean, I 
saw a number reported by Fox about 4 years ago of $40 billion; 
I saw a number reported, $60 billion. We have got $60 billion 
or more that are transferred south of the border for some 
reason. Some of that is laundered money. So, do you think that 
number is up from those estimates I am seeing?
    Mr. Patterson. I do, but part of the issue here is whenever 
you see these numbers it depends on what is being factored into 
it. Right? A lot of them do loss of wages; loss of 
productivity; cost to, you know, Medicare, Medicaid, and 
prescription; all these other things. So, I would be more than 
happy to come back and give you some real numbers as to what we 
see.
    Mr. King. I would very much like that, and we can flesh 
that question out in a little more detail, perhaps, off the 
panel. Let's see. What percentage of the illegal drugs consumed 
in America come from or through Mexico?
    Mr. Patterson. I would suggest that, for the bulk number, 
probably of the vast majority.
    Mr. King. If I remember a previous discussion with DEA some 
years ago, their estimate was between 80 and 90 percent. That 
would be in the zone that you understand today?
    Mr. Patterson. I think that is certainly a fair estimate.
    Mr. King. Okay. And then, what percentage of the illegal 
drug distribution chains include at least one link that is an 
illegal alien?
    Mr. Patterson. One link that is an illegal alien?
    Mr. King. Yes.
    Mr. Patterson. I would assume almost all of them.
    Mr. King. That has been consistent with the responses I 
have gotten with others as well. And so, then, do we have any 
data? I know some of these estimates you mention address the 
American productivity, so we can flesh that question out a 
little bit more, too. I want to get a better scope on what it 
does to our economy; what it does to our families; the impact 
on our children. I do not see very good estimates of that that 
are quantified, and that might fall in the line of sound 
science.
    But you made a statement here that--first, I want to put 
another thing into your ear. If I do the math on this, 11.5 
million drug misusers in America; 64,000 of them died in the 
year 2017. So, if I just divide the 64,000 into 11.5 million, I 
come up with a number one out of 180 drug--I call them drug 
abusers--die to overdose in any given year. If they are going 
to use drugs for 10 years, they have got a 1-in-18 chance 
rather than a one-in-180 chance. In 20 years, it is one in 
nine. That is the scope of the devastation that we are seeing 
in our society.
    But you made a very important point here, and I think it is 
the most important one of the whole panel, and it says, ``We 
have to change the culture in this country.'' That really does, 
I think, ring the bell as close to the center of the truth that 
we are dealing with here, as complex as it is. And so, I want 
to pose an approach to this, and then it is this: if society 
were determined to solve this problem, I believe we would do 
this.
    First, we would test in the workplace, then we would test 
in education, and we would test certainly in government as 
well, and then we would test in welfare. And if we did that, 
theoretically, we would dramatically reduce the drug abuse in 
each of those arenas. Those left would be the dealers and 
stealers, and they would be the ones that law enforcement would 
contend with, and we should be able to handle that if that is 
the only ones left out of the universe.
    And so, I pose that, but the big question still is, how do 
we get the culture change to accept such a change? And I think 
recognizing the reality of those deaths that we are having and 
the damage to our society and quantifying it would be a very 
good step to follow along. I look forward to continuing to work 
with you, and I appreciate the job you are doing and the 
testimony that you provided today, Mr. Patterson. Thank you, 
and I yield back.
    Mr. Rothfus. The time of the gentleman has expired, and the 
chair recognizes the gentleman from Florida, Mr. Deutch, for 5 
minutes.
    Mr. Deutch. [inaudible].
    Mr. Gaetz. Mr. Chairman, can I ask the gentleman to turn 
his microphone so I can hear him?
    Mr. Deutch. I apologize. Thank you. Florida was the 
epicenter of the explosion of opioid abuse over a decade ago. 
In Florida, opioid addiction-related deaths increased 80 
percent from 2003 to 2009. Addiction is cruel, ruthless, and 
unforgiving. Opioid pills prescribed after an injury or to 
treat chronic pain can too easily drag anyone in pain into the 
depths of addiction. The crackdown on pills has meant turning 
to street drugs for thousands of Floridians.
    Mr. Chairman, we have used mandatory minimum sentences as 
1951, and we boosted penalties through the last 3 decades of 
the twentieth century at the height of the war on drugs. But 
tough mandatory minimums for drug charges have not cut off 
access to drugs in the past, and they are not likely to stop 
the brutal tide of overdoses that we are facing today. I would 
like to share a story that I heard from Broward County public 
defender Howard Finkelstein, just to caution the work of this 
committee.
    He told me about a 40-year-old woman in Broward County, 
Florida, who had no criminal record and was unable to work due 
to a disability. She was described by those who knew as a sweet 
lady. After being pursued multiple times by a confidential 
informant seeking pills, she gave in. She sold 35 Lorcet pills, 
a blend of Tylenol and hydrocodone, to the informant. After 
living 40 years without a criminal record, she was sentenced to 
a mandatory minimum sentence of 25 years in prison.
    Does keeping this woman in prison until she is 65 do 
anything to help her, to help her family continue without their 
mom in the home, to help others who are addicted, to our 
society now paying for her incarceration? This committee needs 
to take a close look at the impact of our policing and 
prosecution policies around the country that do a lot to drive 
up the numbers of arrests, convictions, and fill our prisons, 
but may not be helping treat addiction or save lives.
    Hyper-deadly drugs like fentanyl are finding a way into our 
communities. The rise of these synthetic opioids requires that 
we meet this challenge on its own terms. Their extreme potency 
makes it harder for law enforcement to stop them. With a few 
clicks on the internet, there is no longer a need for cartels 
or street dealers. Last year, Florida passed a law to impose 
mandatory minimum sentences for possession of fentanyl and 
other synthetic drugs, but evidence shows that boosting 
punishment is unlikely to stop the spread of these drugs.
    This March, I held a roundtable on the opioid crisis with 
my colleague, Congresswoman Wasserman Schultz, in my district 
to talk with law enforcement, public health officials, and 
families about the response to the needs of our community. And 
what we heard was that, fundamentally, addiction is about 
mental health, and to save the lives of those in the grip of 
addiction, we need to get them help, not lock them up. 
Criminalizing addiction locks people out of our healthcare 
system and cuts off a real chance at recovery.
    We need a comprehensive solution. I think we have delayed 
too long in getting a comprehensive response through the House 
to address this crisis. We need to focus on broadening access 
to addiction treatment that would truly save lives. Instead, 
just over a year ago, my Republican colleagues celebrated a 
vote to overturn Obamacare that would have taken comprehensive 
coverage from over 20 million people. Some Republican States, 
including my own State of Florida, have failed to expand access 
to care with Federal dollars by expanding Medicaid.
    Expansion can allow more than 800,000 Floridians to gain 
access to comprehensive health coverage that includes mental 
health and substance abuse treatment as essential benefits. It 
is estimated that 300,000 of those 800,000 Floridians already 
need some level of care right now, and they are struggling to 
get it, but, apparently, my colleagues who voted for Trumpcare 
last year think that we should go the other direction, that we 
should end Medicaid expansion and fundamentally change the 
program structure.
    It would replace guaranteed funding with a limited account 
for opioid treatment; to lock recovery clinic doors to those 
who desperately need help. It will undermine the emergency 
response needed to pull up the deep roots of Florida's 
addiction crisis. Twelve Floridians are lost every day to the 
scourge of addiction. It is a public health emergency, and 
treatment can help save the lives of our fellow Floridians.
    Mr. Patterson, I would just ask you, given your experience, 
do you think a broader access to substance abuse and mental 
health coverage would help people struggling with addiction 
treatment stay in treatment?
    Mr. Patterson. So, we are talking about addicted 
populations? You had a couple things combined in there.
    Mr. Deutch. Okay.
    Mr. Patterson. The sentencing issues put aside, I think for 
people that are not distributing drugs--and, obviously, DEA 
does not, you know, look at a certain level.
    Mr. Deutch. I understand.
    Mr. Patterson. The treatment availability should be there 
for those that are addicted to drugs. I think distribution is a 
different issue, though, than what you just talked about.
    Mr. Deutch. Thank you very much. Thank you, Mr. Chairman.
    Mr. Rothfus. The time of the gentleman is expired. The 
chair recognizes the gentleman from Florida, Mr. Gaetz, for 5 
minutes.
    Mr. Gaetz. Thank you, Mr. Chairman. Earlier in your 
testimony you said in response to a medical marijuana question, 
``We have a substance abuse problem, and we do not want to add 
to it.'' Is it the position of the DEA that democratizing 
access to medical marijuana will add to the substance abuse 
problem in this country?
    Mr. Patterson. I think it is a conversation that we have to 
have. Again, when you say medical marijuana, is it a medicine 
that has been made from marijuana, or the current standard of 
the State has now said that marijuana is medicine?
    Mr. Gaetz. Well, in either of those circumstances. But 
let's just take the circumstance where a State is said 
marijuana is medicine. Is it your view that that adds to the 
substance abuse problem?
    Mr. Patterson. It is.
    Mr. Gaetz. Opioids are prescribed principally as a chronic 
pain solution, right?
    Mr. Patterson. Correct.
    Mr. Gaetz. The National Academy of Sciences issued a report 
in 2017 entitled The Health Effects of Cannabis and 
Cannabinoids. Are you familiar with that work product?
    Mr. Patterson. No, sir.
    Mr. Gaetz. I will quote from it. It says, ``There is 
conclusive or substantial evidence that cannabis or 
cannabinoids are effective for treatment of chronic pain in 
adults.'' Do you have any basis, scientifically or from any 
evidentiary standpoint, to disagree with that conclusion?
    Mr. Patterson. Again, this is why I think we always talk 
about the research of the benefits of marijuana.
    Mr. Gaetz. So, you support research into medical marijuana?
    Mr. Patterson. We have said that all along, that we support 
the research of marijuana.
    Mr. Gaetz. And after you implemented a rule in August of 
2016 pushing the Department of Justice to create more research-
based cannabis, they have not issued any more of those permits, 
have they? Or have not granted any.
    Mr. Patterson. So, they have not been granted, but I think 
there is an important distinction that has to be understood. 
So, when we put that rule out it was in the efforts to help the 
research community.
    Mr. Gaetz. But if none of the research permits have been 
granted, how has it helped them?
    Mr. Patterson. Because there is an issue with how we put 
that solicitation out of that rule out, and that has to do with 
the single treaty, which I know, you know--I had to get up to 
speed on it. I did not understand it at first when I was told. 
But the reality is that the department has worked through this; 
once they have made their ruling, DEA will figure out how this 
looks moving forward.
    Mr. Gaetz. But you have taken the position that medical 
cannabis--in response to my questions--adds to the problem. So, 
you have also agreed that opioids are prescribed for chronic 
pain, so I want to use my remaining time to delve into the 
extent to which medical cannabis in some places has been used 
as an appropriate substitute.
    The Minnesota Department of Health had a research project 
with over 2,000 patients who had intractable pain that used 
medical cannabis. And those patients saw opioids prescribed at 
a rate 38 percent less than people who were not using medical 
cannabis. Do you have any basis with which to disagree with 
that finding that those patients saw a reduction in the need 
for opioids when they had access to medical cannabis?
    Mr. Patterson. So, I am not familiar with that study. I 
think there are a number of studies out there that talk when 
people are presented, whether--I guess it would be with medical 
marijuana or with Tylenol or others--that there are many 
alternatives to opioids.
    Mr. Gaetz. So, do you acknowledge, then, that medical 
marijuana is an alternative to opioids?
    Mr. Patterson. No, I am saying I do not know that study. 
So, I mean--
    Mr. Gaetz. What studies show that medical marijuana would 
increase the use of opioids? Are there any?
    Mr. Patterson. I do not know.
    Mr. Gaetz. So, you are the acting administrator of the DEA; 
you cannot cite a single study that indicates that medical 
marijuana creates a greater challenge with opioids. And you are 
unaware of the studies, including studies from the National 
Academy of Sciences, that demonstrate that medical marijuana 
can be an acceptable alternative to opioids. Is that what I am 
understanding?
    Mr. Patterson. Yes.
    Mr. Gaetz. The American Geriatric Society surveyed 
patients, and they found a 68 percent reduction in opioid use. 
Are you familiar with that?
    Mr. Patterson. No, sir.
    Mr. Gaetz. In New Mexico, medical cannabis patients saw a 
70 percent reduction not only in opioids but in all scheduled 
drugs. Is that something you are familiar with?
    Mr. Patterson. No, sir.
    Mr. Gaetz. So, the sum of evidence from the States that 
have democratized access to medical cannabis--have you analyzed 
any data that looks at opioid death rates in medical cannabis 
States versus nonmedical cannabis States?
    Mr. Patterson. No, sir.
    Mr. Gaetz. You indicated earlier, and I am grateful for it, 
that that is an appropriate conversation to have. I wanted to 
take my last few moments to thank Chairman Goodlatte; he has 
signed on as a cosponsor to the Medical Cannabis Research Act, 
which I think builds on the work of DEA to push the Department 
of Justice to stop their obstruction when it comes to 
researching medical cannabis. Can we count on the DEA to be a 
partner in pushing for more research so that we can either 
validate or dismiss this information we are receiving from 
States?
    Mr. Patterson. And I think we have been consistent in that 
message for the last number of years.
    Mr. Gaetz. Thank you, Mr. Chairman.
    Mr. Rothfus. The time of the gentleman has expired. The 
chair recognizes the gentlewoman from Washington, Ms. Jayapal, 
for 5 minutes.
    Ms. Jayapal. Thank you, Mr. Chairman, and thank you, 
Administrator Patterson for being here and for your work. I am 
unfortunately going to miss the second panel, and so I did want 
to just raise something before turning to my questions for you 
that I was going to say in the second panel.
    And that is in my hometown of Seattle we recognized early 
on that we cannot arrest our way out of the situation, not just 
for opioids but on other low-level crimes as well, and in 2011 
we launched the Law Enforcement Assisted Diversion program, the 
LEAD program. It was the first known prebooking diversion 
program for people arrested on narcotics and prostitution 
charges in the United States, and it is a very, very unique 
collaboration between local law enforcement, prosecutors, 
treatment services, the Department of Corrections, public 
defenders, and the ACLU and others.
    And actually, among LEAD participants, 60 percent are less 
likely to be arrested; 89 percent more likely to have a place 
to live; 46 percent more likely to have a job in the 6 months 
following enrollment.
    Mr. Chairman, I seek unanimous consent to enter into the 
record an article on LEAD, as well as a University of 
Washington study on the efficacy of LEAD.
    Mr. Rothfus. Without objection.
    Ms. Jayapal. Thank you. And I want to thank Mr. 
Sensenbrenner, Mr. Johnson, and a number of Republicans that 
helped me to get some funds into the last budget omnibus 
spending bill that expands the LEAD program across the country 
into some of these critical areas that are dealing with 
opioids.
    So, Mr. Patterson, according to a 24-page report that was 
prepared by the DEA last May, drugs frequently do not enter 
through land routes. The report provided numerous examples of 
this, noting, for instance, that the majority of heroin found 
in New Jersey is primarily smuggled into the United States by 
Colombian and Dominican groups via human couriers on commercial 
flights to the Newark International Airport.
    You have been quoted previously saying, and this is your 
quote, ``This is not an easy thing to fix. If there were two or 
three answers to solve this problem, then I should be fired. 
There are thousands of things that need to be addressed.''
    And I wanted to bring up the fact that there have been many 
attempts to assert, by the White House and by Republican 
colleagues on the other side, that building a border wall is 
somehow going to solve the problem of the flow of illegal drugs 
into the United States. Did your intel report recommend 
building a border wall as a solution to the flow of drugs into 
the United States?
    Mr. Patterson. That report--I do not recall specifically 
what its recommendations were--I will simply sum it up this 
way: Our current ports of entry are access points into this 
country where there is staffing. Now, I am not a border 
security person; I think we need secure borders, and 
ultimately, what that looks like I am not the right person to 
answer. If there is additional security on the border that 
allows additional CBP assets or others to work those points of 
entry, that is a critical piece.
    Ms. Jayapal. Thank you, Mr. Patterson. I do have the 
report, and I can tell you it does not say anything about a 
border wall as a solution to the problem. In fact, does your 
own report not detail that, as you just said, drugs are 
entering the country not on the backs of human smugglers but 
actually in small quantities? Even if they are crossing the 
southern border, they are in the backs of legal vehicles; they 
are hidden away in little pieces; they are in tractor-trailers.
    They are not being transported by individuals across the 
border, and a border wall that stops people from coming in is 
not the issue. It is these legal ports of entry that people are 
manipulating to get those drugs across. Is that correct?
    Mr. Patterson. I do not discount that you do have people 
that smuggle smaller quantities across the border, you know, 
whether it is through their person or other means. I think the 
bulk that is coming out of Mexico is coming through the points 
of entry, or, as you brought up, other routes that we see: The 
Dominican Republic; directly out of China; you know, those 
types of events.
    Ms. Jayapal. Thank you. So, would you support increased 
funding, for example, for the Coast Guard, something that the 
President had initially recommended decreasing funding? But the 
Coast Guard is actually responsible for the interdiction of 
drugs within our waters, for example.
    Mr. Patterson. The Coast Guard is one of our most important 
assets when it comes to the control of especially cocaine 
coming out of South America, and I believe they could use more 
resources.
    Ms. Jayapal. So, let me reiterate that a border wall does 
not solve the problems of drugs across into the United States. 
You have mentioned many times during your comments, and I have 
read some comments you have made before, that addressing demand 
is absolutely critical here. Can you comment on--and you only 
have 10 seconds--but the one or two most important things to 
address demand?
    Mr. Patterson. So, demand, I think, comes through 
education, and the other piece is the conversations about 
prevention before it starts. I mean, I think a lot of the 
issues that come out in this is that once substance abuse 
starts, treatment is hard. Not necessarily in all drugs, but in 
most drugs, it is.
    Ms. Jayapal. Thank you Mr. Patterson. I yield.
    Mr. Rothfus. The time of the gentlewoman is expired. The 
chair recognizes the gentleman from Rhode Island, Mr. 
Cicilline, for 5 minutes.
    Mr. Cicilline. Thank you, Mr. Chairman. Thank you, Mr. 
Patterson. First, I want to thank the chairman and the ranking 
member for calling this hearing. And it is important to 
remember that drug overdose is the leading cause of injury 
deaths in the United States; 115 Americans die every day due to 
opioid overdose. In my home state of Rhode Island, last year we 
lost almost one Rhode Islander per day to this disease, and 
nearly half of those overdose deaths involve a prescription 
opioid.
    And so, my first question is, my understanding is that 
there is a discrepancy between the Comprehensive Addiction 
Recovery Act, CARA, and the current DEA regulations on 
providing for a partial fill of a prescription. In the past 
partial fills could be made at the pharmacy when a pharmacy did 
not physically have enough quantity on hand. Under CARA, a 
partial fill can be made under several circumstances, including 
when a State has acted to limit prescriptions of opioids or a 
patient or prescriber requests an initial fill of an opioid 
prescription for a shorter time period.
    This sort of discrepancy between the law that is CARA and 
DEA regulations is problematic for pharmacists. Can you tell me 
what steps the DEA is taking to bring its regulations into 
alignment with CARA and when we might expect those regulations 
to be promulgated and updated?
    Mr. Patterson. I appreciate the question, sir, and it goes 
back to something I started off with, which is States in a lot 
of cases have already taken this on their own backs of fixing 
the, you know, State laws for much smaller initial 
prescriptions. And this is something that we obviously still 
owe related to our regulations in this space. It is critically 
important; we need to get it done. And it also, then, impacts 
the additional issues of quota and other type----
    Mr. Cicilline. It is on your agenda. Thank you. The 
Responsible Drug Disposal Act of 2010 gave authority to DEA to 
enable pharmacies and other entities who are licensed to handle 
controlled substances to collect unused medication from the 
public and destroy it. However, the Government Accountability 
Office found very low participation among pharmacies.
    I am just wondering if you have a sense of why that is. Do 
you think it would be beneficial if more pharmacies 
participated, and what can we do to accelerate that 
participation?
    Mr. Patterson. So, we have seen an uptick in the 
collection. I think it poses a number of challenges that--you 
know, distribution points, pharmacies, others--whether it is 
safeguarding or other issues that surround that. But I think 
this is a place where, again, our educational presence and us 
talking to people about getting these medications brought back 
in is absolutely critical, because we see so much diversion 
happening in that space still.
    Mr. Cicilline. And if you think there are things we can do 
to further enhance that, I trust you will let us know. Mr. 
Patterson, does the DEA offer any ongoing medical education or 
training to prescribers on the dispensing or prescribing of 
opioids? And if not, do you think your agency, if charged with 
that, has the ability to provide that kind of medical training?
    Mr. Patterson. So, we obviously provide information through 
our outreach to both prescribers and to pharmacies as well as 
distributors and manufacturers. We cannot mandate CME, but I 
think it is probably one of the most valuable things that can 
be done. So, we use our registration or distribution list of 
our registrants to send out information. Again, I cannot make 
it mandatory that they----
    Mr. Cicilline. But there is no question. You think it would 
be beneficial if people----
    Mr. Patterson. Absolutely.
    Mr. Cicilline. Okay. And my final question, because I know 
I do not have a lot of time. You mentioned that the DEA could 
do better in terms of disrupting or taking note of these 
distributors who are distributing orders that deviate from the 
norm, or unusual frequency, unusual quantities, and that there 
is in place only a civil fine; DEA needs to do a better job of 
that. Are there things we can be doing in Congress to give you 
additional resources or authority?
    It seems to me if, as you described, it is just a cost of 
doing business, then that is not a great disincentive to do it. 
If, in fact, loss of licensure, criminal penalties, or other 
things were in place--why is DEA not doing a better job in the 
current framework, and what can we do to strengthen your 
ability to try to interrupt or prevent these distributions 
which are clearly problematic?
    Mr. Patterson. I think it is a valid question, and 
hopefully I did not misspeak. Obviously, we have criminal tools 
in this space as well. I think probably all too often, though, 
we end up at the point of having a civil fine. And some of 
those are important, because again, as we heard earlier from 
one of the members, the change of a distribution center has a 
ripple effect. We know that, and we are cognizant of that.
    There are times, however, when we have egregious behavior 
that we have to deal with, and I think there is definitely a 
change in the philosophy in the prosecutor's offices and with 
DEA, that we need to hold people more accountable than just a 
civil fine.
    Mr. Cicilline. Thank you. I yield back, Mr. Chairman.
    Mr. Rothfus. The gentleman yields back. The gentlewoman 
from Florida, Ms. Demings, is recognized for 5 minutes.
    Ms. Demings. Thank you so much, Mr. Chairman, and Mr. 
Patterson, thank you so much for the job that you do. It is a 
moving target. One day you are the answer, and the next day you 
are the problem. But I think that not only should DEA be held 
accountable, but all of the stakeholders, including Congress, 
should be held accountable for the job that we do.
    You talked a little bit about that with my colleague from 
Rhode Island, about some of the things that DEA could do 
differently in terms of accountability. I heard what you said 
to him, but could you just kind of elaborate just a little bit 
more on that particular issue? And how can Congress, as we deal 
with this crisis throughout our country, be more accountable as 
well in terms of helping to find solutions and not creating 
more problems?
    Mr. Patterson. Right. Let me start with the second piece 
first. So, in the legislation space that provides us great 
assistance, and I recognize that every piece of legislation 
sometimes has its unintended consequences. There are more than 
60 pieces that are out there right now in this opioid space, 
and you all should be applauded for the efforts you have done.
    And we all need to make sure that when we see those 
unintended consequences, as we have seen in the past, we have 
to be very vocal about it with you so you know what is going to 
happen. DEA and HHS debate all the time over research, and 
research is critically important in this space as well, and we 
have to find common ground to address these problems.
    Going back to the things that DEA needs to continue to do 
better--and this is the piece--and I greatly appreciate this 
hearing, actually, today, because I feel like this is one of 
those good days as opposed to the day that we are the enemy. We 
have made tremendous strides, I think, in this space over the 
last handful of years. So, it is using our data; it is figuring 
out ways to share our data. Right?
    We have all had these stovepipes of information that we, 
for whatever reason, either do not feel we can share or cannot. 
The law enforcement community is all pulled together behind 
this, and you do not see the badges anymore; what you see is a 
combined effort. And I feel this even across the industry. 
Right? I mean, it truly feels like the moment where people are 
understanding that this is a disaster, and it is not just a 
talking point for people. It is a true movement of what is 
said. So, as a 30-year veteran of drug law enforcement, it is 
nice to see that even though a decade ago we had 35,000 
overdoses, for whatever reason, this has truly woken everyone 
up.
    So, our participation with our State and local partners, 
all these other things--but DEA has to continue to be more 
aggressive in terms of what it does. And not aggressive in a 
reckless way, but again holding people accountable, making sure 
that we are outspoken on where we see issues, and, frankly, not 
being afraid to push into that space.
    When we talk about quota, quota is a tricky space for us to 
deal with. And all of these are balancing acts that we are 
going to have to deal with, but we should not be embarrassed--
we probably should be embarrassed--but the mistakes that we 
made the past we learn from, and we have to move forward on 
that. That is why I appreciate today to at least highlight some 
of those things in what we are doing.
    We see that all the time with the States right now. There 
are best practices; you know, the LEAD program got talked about 
a little bit earlier, though we did not really get to talk 
about it. You see these all over the country right now, and 
some are very successful, and some are failures.
    I was just out in California; one of the things I talked to 
them about is ``You do not have to reinvent this wheel; we can 
tell you where the things are going to work and are not going 
to work.'' It does not mean that they do that for every 
community, but these are the things that we all need to come 
together and we work on.
    Ms. Demings. You talked about fines having little impact 
on, say, drug manufacturers. What else do you believe could be 
done to ensure greater compliance?
    Mr. Patterson. I think at some point we are going to have 
to hold these companies criminally accountable for some of 
their activities. And again, that is a tough balance to try and 
come to the right point on. Some are innocent mistakes, and 
generally we would never use an ISO on an innocent mistake. We 
want to work with the industry; we want to correct their 
behavior. But you see, it is not just in the drug distribution. 
You see it in banking; you see it in other places where civil 
fines just do not seem to catch anyone's attention.
    Ms. Demings. And finally, with hiring and retention, any 
challenges in that particular area? I know you spoke earlier a 
little bit about it. But any particular challenges with hiring 
and retention?
    Mr. Patterson. Yes. So, I think these are struggles that we 
have dealt with for a host of reasons in hiring and positions. 
Like I said, the good news is that we can lean heavily on our 
State and local partners as we try and catch up, but there is a 
lot of challenges in that space. Retention; people seem to 
still like coming to work for DEA, so we are doing a good job 
there.
    Ms. Demings. Thank you very much. Mr. Chairman, I yield 
back.
    Mr. Rothfus. The gentlewoman yields back. We thank Director 
Patterson for his attendance at today's hearing. That concludes 
our first panel, and we are going to invite our second panel to 
come up.
    I would like to welcome our distinguished witnesses for a 
second panel. If you would please rise, and I can begin by 
swearing you in.
    Do you swear that the testimony you are about to give is 
the truth, the whole, truth and nothing but the truth, so help 
you God? Let the record show that the witnesses answered in the 
affirmative. Thank you.
    I would like to introduce the panel. Dr. Tim Westlake is a 
full-time emergency physician and is the emergency department 
director at Oconomowoc Memorial Hospital in Wisconsin. Among 
his many collateral responsibilities, Dr. Westlake is the vice 
chairman of the Wisconsin State Medical Examining Board and 
executive committee member of the Wisconsin EPDMP design team 
and cochairman of the Wisconsin State Coalition for 
Prescription Drug Abuse and Reduction.
    Mr. Spencer Morgan is a Commonwealth's attorney for 
Accomack County, Virginia. Mr. Morgan started his professional 
career as a staff assistant in the office of our former 
colleague, Mr. Randy Forbes. Later, Mr. Morgan was a 
legislative assistant for the House Judiciary Committee 
Subcommittee on Crime, Terrorism, and Homeland Security. 
Welcome back.
    Ms. Kristen Holman is the older sister of Garrett Holman. 
Garrett lost his life earlier last year to addiction. Ms. 
Holman has witnessed firsthand the devastation wrought by a 
destructive combination of drugs, including marijuana, ADHD 
medication, and synthetic opioids.
    I would like to recognize my colleague, Mr. Cicilline of 
Rhode Island, to introduce our final witness on this panel, Dr. 
Josiah Rich.
    Mr. Cicilline. Thank you, Mr. Chairman. I appreciate the 
courtesy. It is a great honor for me to welcome Dr. Rich to the 
House Judiciary Committee. Dr. Rich is a professor of medicine 
at the Warren Alpert School of Medicine at Brown University and 
a practicing infectious disease specialist since 1994 at the 
Miriam Hospital Immunology Center, providing clinical care for 
over 22 years, and at the Rhode Island Department of 
Corrections, caring for prisoners with HIV infection and 
working on it in the correctional setting, doing research.
    He has spent nearly a quarter of a century in public health 
and has been an extraordinary partner with local, State, and 
Federal Government in helping to develop good public policy. I 
have worked with him, and he has had the misfortune of being 
represented by me for 24 years in public life. But he was 
recently appointed by our Governor of Rhode Island, Governor 
Gina Raimondo, to the Overdose Prevention and Intervention Task 
Force expert team selected to advise the task force and 
formulate a strategic plan to address addictions and stop 
overdose in Rhode Island.
    He is a cofounder of the nationwide Centers for AIDS 
Research Collaboration in HIV in Corrections Initiative and has 
served as an expert for the National Academy of Sciences, the 
Institute of Medicine, and many others; a real expert in issues 
of public health and addiction and the development of good 
public policy. And someone I have relied on for guidance over 
many years and really delighted that he will share his wisdom 
with this committee. I welcome Dr. Rich and thank you and yield 
back.
    Mr. Rothfus. Your written statements will be entered into 
the record in their entirety, and we ask that you summarize, 
each of you, your testimony in 5 minutes. To help you stay 
within that time, there was a timing light on your table. When 
the light switches from green to yellow you have 1 minute to 
conclude your testimony; when the light turns red it signals 
your 5 minutes have expired. Dr. Westlake, you may begin. And 
if you could press the button so that your mic is on, please.

 STATEMENTS OF TIMOTHY WESTLAKE, M.D., HARTLAND, WISCONSIN; J. 
 SPENCER MORGAN III, COMMONWEALTH'S ATTORNEY, ACCOMACK COUNTY, 
VIRGINIA; KRISTEN HOLMAN, LYNCHBURG, VIRGINIA; AND JOSIAH RICH, 
                 M.D., PROVIDENCE, RHODE ISLAND

                 STATEMENT OF TIMOTHY WESTLAKE

    Dr. Westlake. Thank you. Chairman Rothfus, committee 
members, I appreciate the opportunity to talk to you today and 
for your leadership in addressing this issue. In my role on the 
Wisconsin Medical Examining and Controlled Substance boards I 
became the physician architect of the State's prescription 
opioid reform strategy and an expert on opioid scheduling. As 
an emergency physician on the front lines of the opioid battle 
field for the past 20 years, I have witnessed more tragedy than 
I care to recall.
    Like you, I am laser-focused on what can be done to stop 
this senseless loss of life. It is why I am grateful for the 
opportunity to talk with you today and share a legislative 
solution that is actually working in Wisconsin right now. But 
first, a brief story about a young man named Archie Badura.
    Every Sunday, we sat next to Archie and his family in 
church, where he was an altar server alongside my daughters. 
Archie got hooked on marijuana first, then prescription opioids 
pills; heroin followed shortly, and eventually fentanyl, a 
tragically all-too-familiar slide. The last time I saw Archie 
alive he was my patient in the ER. I had to resuscitate him 
with Narcan after he overdosed on fentanyl. Before discharging 
him, we pulled out a body bag, unzipped it, and pretended to 
fit him for it. It was a wakeup call.
    Archie became serious about getting clean and started 
following recovery principles. He told his family he was going 
to beat the odds and not end up in a body bag. He stayed drug-
free for 6 months after this. Sadly, he eventually relapsed on 
fentanyl and died at age 19. His mom, my friend Lauri, vividly 
remembers Archie being zipped up into a body bag identical to 
the one she had seen me showing him months earlier. In his 
honor, Lauri founded SOFA, Saving Others for Archie, and now 
helps others who are desperately trying to save their loved 
ones.
    It is incontrovertible that the increased availability of 
prescription opioids has fueled the opioid epidemic. As a 
medical regulator, I have spent countless hours working to 
identify and implement best practices. For starters, we need 
more judicious prescribing practices. We are doing that in 
Wisconsin, not with top-down mandates but through education and 
partnerships within the medical community. In my written 
testimony I provide more detail about the cutting-edge 
prescription drug monitoring program reforms and educational 
reforms that we have put into place.
    The fact is that the lion's share of medical regulation 
does and should occur at the State medical licensing board and 
health system levels. Where Congress can and has and can 
continue to be helpful is in law enforcement and in providing 
flexible funding to the States themselves to invest in 
communities where the dollars are most needed. When government 
intervenes too much, for example, with the development of the 
pain scale and pain as the fifth vital sign, there is too much 
room for unintended consequences.
    By far, the deadliest front in the opioid war is the danger 
posed by creation of fentanyl-related substances. These deaths 
now surpass heroin deaths. The lethal dose of fentanyl is two 
milligrams, which means that there could be enough fentanyl, if 
this box were filled with fentanyl, that it would kill 900,000 
people, which would be more than the entire population of 
Washington, D.C.
    Fentanyl variations and related substances are so deadly 
that they can be used and are actually classified as chemical 
weapons. They are not just drugs. They are actually considered 
weapons of mass destruction. The bad guys use loopholes in the 
existing scheduling laws to create new legal fentanyl variants. 
These untested chemicals are then produced mostly in China and 
introduced into the opioid supply.
    As our prescription opioid reforms take effect and the 
medical community returns to more judicious decision 
prescribing practices, the market for counterfeit pills 
continues to explode. Most illicit opioid users have no idea 
what they are consuming. With the advent of counterfeit pill 
production, they believe they are ingesting a safe, trade-name 
manufactured pill, when actually it is a fentanyl-related 
counterfeit substance. These pills can be alarmingly more 
strong than what they are purported to be, up to hundreds of 
times stronger.
    The singer Prince died from a counterfeit Vicodin pill 
ingestion that he thought it was Vicodin; it was actually 
Fentanyl. During 2016, in one weekend there were 12 deaths in 
Milwaukee from counterfeit pills that contain cyclopropyl 
fentanyl, which at that time was legal and was shipped in on 
the Internet.
    We saw this coming in Wisconsin, years ago. We worked 
closely with the DEA to get ahead of it. We created an 
enacting, novel scheduling language now being modeled 
nationally, X60 or the SOFA Act, Stopping Overdose of Fentanyl 
Analogues in homage to Saving Others for Archie. It controls by 
structure all likely and possible bioactive chemical fentanyl 
modifications. The novel catchall legislative language allows 
us to schedule proactively and not wait for loved ones to die 
before we can schedule each new modified fentanyl variant. So, 
instead of playing whack-a-mole with the variants as people die 
and we discover them, it unplugs the entire fentanyl machine.
    The week after Wisconsin enacted SOFA, DEA published the 
identical scheduling language in the Federal Register as the 
method of Federal temporary scheduling. Chemists around the 
world and in China must be paying attention, because since that 
announcement 6 months ago, there have been no new fentanyl 
variants found.
    In the previous 2 years, there were 17 that were found and 
scheduled, which represented hundreds of deaths. But the 
language needs to be written into the U.S. code, as the DEA 
administrator said, for the best permanent scheduling 
solutions. Many thanks to Mr. Sensenbrenner and Senator Ron 
Johnson who have the Federal SOFA Act, and thank you for their 
leadership on that.
    When asked how often I see fentanyl overdoses, the answer 
is tragically far too often. The last shift I worked was 2 days 
ago on Sunday, and I was preparing my testimony, and I was 
interrupted to go resuscitate a fentanyl overdose. It is for 
this reason that I urge you to pass the legislation and make it 
so. Thank you for your time and consideration, and I look 
forward to answering any questions.
    Mr. Rothfus. Thank you, Dr. Westlake. Mr. Morgan, you are 
recognized for 5 minutes.

               STATEMENT OF J. SPENCER MORGAN III

    Mr. Morgan. Thank you, Mr. Chairman, ranking member, and 
members of the committee: thank you for inviting me to testify 
on this important topic. I intend to address several issues 
concerning opioid addition and the increased amounts of heroin 
and fentanyl from the perspective of a local prosecutor. Simply 
put, in the words of the Worcester County drug task force 
coordinator--or the equivalent of the criminal enforcement team 
there--there has never been a more dangerous time to purchase 
illicit drugs.
    Little bit about Accomack County, we are at the southern 
tip of the Delmarva Peninsula. Accomack is a unique mixture of 
agriculture, tourism, and aerospace in industry through Wallops 
Island space port. Current population is right around 32,000 
people.
    When I first arrived in Accomack County in the fall of 2011 
after graduating law school and taking the bar, opioids and 
heroine had really yet to make a huge widespread public impact 
on the county. Arrests were generally low, and we were aware of 
prescription medication abuse. However, the full extent of the 
problem had not been revealed.
    At the same time, I did learn Worcester County, Somerset 
County, they were beginning to experience significant amounts 
of heroine at that time. In Accomack, the harbinger of what was 
just below the surface really became the widespread abuse of 
buprenorphine, or Subutex as the brand name is.
    The drug used in the treatment, generally where the addict 
is treated with, in conjunction with drug treatment and 
counseling, and then titrated off the drug, which helps them 
manage the symptoms of opioid addiction became a currency among 
addicts for maintaining their addiction and trading for more 
powerful narcotics.
    Once we began to see this, it was not long before we were 
seeing the substance attempted to be smuggled into our jails. 
And then, prosecuting those offenses and ultimately, and 
ironically, I ended up prosecuting someone involved in such a 
scheme for cleaning up the scene of an overdose death, where 
her boyfriend was found unresponsive, and police responded, 
EMTs responded, and she went back in while they were trying to 
save his life and hid away, or secreted away the signs of the 
heroin abuse.
    I will note, however, that recently with the advents of 
Suboxone, a substance which contains naloxone, the inhibitor to 
prevent opioid interaction. We have seen decreased abuse of 
Suboxone, but by then, we were learning that we had dealers at 
the northern end of our county, who when they would serve 
clients with cocaine, they were providing gratis a bag of 
heroin and suggesting that the addicts return back when they 
wanted more of that.
    Some of the challenges we have seen, not the least of which 
are the deadly nature of this substance, the substance fentanyl 
and carfentanil substances, carfentanil, fentanyl, certainly 
are deadly. And one of the most tragic things I have 
experienced is the death of defendants and witnesses beyond 
availability of those people before we have a chance to go to 
even trial, or offer any of them any programs through the 
justice system that we have in Virginia for those addicts.
    Some of these substances are so deadly, as Dr. Westlake has 
testified, that we have stopped field testing narcotics in 
Accomack County for fear of officer safety. The problem with 
our field testing is that if an officer were to come into 
contact with those substances, they could potentially overdose 
on the scene.
    My time is running low, but I will say that there has been 
substantial headway in Accomack County. We currently are 
enjoying a level of cooperation between the medical treatment 
providers, substance abuse counselors and law enforcement than 
I think has ever been seen before. We have produced 
informational packets, which we supply our officers who can 
give addicts, be it a defendant or a suspect, a witness or a 
victim to crime in order to help get as many people in to 
substance abuse treatment and recovery as possible. We see it 
as a public health threat, where law enforcement can certainly 
partner with treatment providers and I will yield back the rest 
of my time, and happy to answer any questions.
    Mr. Rothfus. Thank you, Mr. Morgan. The chair recognizes 
Ms. Holman, for your opening statement. Five minutes.

                  STATEMENT OF KRISTEN HOLMAN

    Ms. Holman. Thank you. February 17th, 1996 was one of the 
best days of my life. My parents brought home the baby brother 
I had been asking for since I was able to speak. My little 
brother Garret grew to be one huge hardy kid, who always had 
the room laughing. His smile was contagious, and he always 
demanded everyone's attention.
    We grew up in Forest, Virginia, and we had the best 
childhood. We were always outside, making up games, riding four 
wheelers, and meeting with friends throughout our neighborhood. 
Garret cared so deeply for everyone he loved. My brother had a 
bigger personality than words can describe. My brother would be 
the first one to stick up for someone, and he would be the 
first to stand out in a crowd.
    Garret was diagnosed with ADHD very early in life. He was a 
hyper kid. He consumed everyone's energy at all times. When he 
became of age to make the decision to get off his medications 
for ADHD, he began to self-medicate. It started with marijuana.
    With marijuana, Garret was able to self-medicate his 
condition on his own terms. He was able to function without 
feeling like he was forced to take a prescription medicine. He 
realized that this alternative would not work when he went to 
get a job, and realized he would be drug tested for any job he 
applied to. This is when he turned to more dangerous 
alternatives that did not show up on a drug test at the time.
    There was no explaining to him the dangers of quitting 
these prescription meds so abruptly, and there was nothing that 
we could say or do that he wanted to hear. We were just forced 
to watch him choose this path while hoping and praying he would 
see the light and reach out to accept our help.
    I watched my brother change from an amazing heartfelt, 
selfless person to someone I did not recognize. There was a 
darkness in his eyes, and an overall loss of life and love. Not 
only did I watch my brother change, I watched my parents and 
then myself slowly fade into that same dark place. The 
inability to help him made us all feel like we were not doing 
enough, when in reality, we became so heavily involved in him 
that we all lost ourselves. We lived life never knowing where 
we would get that one phone call that no one wants to hear.
    As a sibling, I played referee between my mom and my dad, 
my parents and my brother, while often being angry at one or 
all of them, just because none of us had the answer. Addiction 
is a subject that many feel ashamed to speak of, and because of 
this feeling, we were left to suffer alone. Close family and 
friends knew of Garret's addiction, but no one but the four of 
us knew the true extent of it. Small talk and even such that 
should be fine became hard, and having conversations with 
people to worry my brother what he was constantly doing, and if 
I would see him again became the only thing I truly cared 
about.
    Living in fear of losing my brother every day played a 
major stress role in my life, and I constantly dropped 
everything to be wherever I needed to be for Garret and my 
family. I spent hours and hours trying to talk to him, and 
trying to let him see how much love we all had for him. Garret 
was angry with himself over his addiction. He wanted to be 
happy and he could not. He tried so hard, and when he lashed 
out at us, it made it that much more hard for him.
    In December of 2016, I received the news that my brother 
had overdosed. My dad revived him, and he was sent to the 
hospital. I remember getting that news and dropping everything 
and rushing to the car. When he finally woke up and we told him 
how lucky he was that he was still alive, he did not even 
blink. He was not thankful. He was not relieved. And that was 
because he was already gone. My little brother was not the 
person looking back at me anymore, and I did not recognize this 
person. And I could not understand why he was not hugging us 
and crying tears of excitement over getting a second chance at 
life.
    My family knew we needed to do something drastic. We needed 
outside help. Our normal interventions were no longer buying us 
time with my brother. We needed a solution and an action plan. 
My parents forced him into a mental health evaluation, which he 
was only required to stay at for 5 days. After the 5 days, he 
reluctantly went to a 30-day in-house treatment program.
    One week after he was released, my dad found him overdosed 
again, and revived once more. My dad forced a second 
evaluation, but the judge released him on February 6th, 2017. I 
lost my little brother and only sibling on February 9th, 2017 
to a synthetic opioid that was delivered straight to him in the 
mail from China.
    I cannot explain why this happened to my brother, and I do 
not know how to fix it. And I do not know what my family could 
have done differently. What I do know is that the drug 
addiction did not just take the life of my brother, but it took 
a big piece of my family's life. There are empty silences in 
conversations where he should be present. And there is a fight 
in all of us that still does not want to give up, and I do not 
believe it ever will.
    Garret was not just a good person, he was a great person 
who fell into a terrible trap that none of us could get him out 
of. But we tried and tried and tried. My family feels that we 
failed Garret, but the truth is, this is something that 
millions and millions of families are dealing with. And people 
feel ashamed. And they do not want to speak out about what is 
going on. And that just leads people to suffer in silence.
    Although it is too late for Garret, he is in my heart and 
head every day, and it only feels right for him to reach people 
at a national level. I cannot be any more inspired at this 
point to do whatever I can to reach out to families like mine. 
Thank you.
    Mr. Rothfus. That was incredibly courageous. Garret would 
be proud of you. Thank you. The chair recognizes Dr. Rich for 5 
minutes for his opening statement.

                    STATEMENT OF JOSIAH RICH

    Dr. Rich. Thank you. It is a tremendous honor to be here 
and I want to thank Ms. Holman for such a courageous testimony. 
I have spent 25 years caring for people both in the community 
and behind bars. And, when I first went behind bars, it was to 
take care of people with HIV. And now, I found myself mostly 
taking of people with opiate use disorder. This rapidly 
evolving deadly epidemic demands a sustained public health 
approach, similar to the Ryan White CARE Act for the AIDS 
epidemic.
    Opioid addiction is highly stigmatized, poorly understood 
by most people, and it is characterized by ongoing use despite 
negative consequences. Now, opiates are different than other 
addictive substances by two physiological properties, tolerance 
and withdrawal. Tolerance means you need an ever-increasing 
dose to get the same effect. And withdrawal is extremely 
painful when you abruptly stop opiates. You literally feel like 
you are dying.
    So, this disease wraps around you like a boa constrictor. 
Every time you breathe out, it tightens, so when you try and 
breath in, you cannot. That results in changes in the brain 
chemistry and the brain pathways, and your response to stimuli. 
And it feels like you need opiates for your very survival. Just 
like you need to breath, you need to drink, you need to eat. 
So, people get desperate, because their ongoing use increases. 
They resort mostly to stealing, getting involved in the sec 
trade, getting involved in the drug trade.
    So, what can we do about this? Our punitive approach has 
clearly failed. And, you would predict that from knowledge of 
the disease. So, treatment. Now, when we talk about treatment, 
you hear people talk about a treatment bed, a detox, and 
frankly, that does not work. That is an antiquated approach 
based on a drug-free model. And, 90 percent of the time, people 
relapse. And relapsing today, in the age of fentanyl 
contamination of our opiate supply is far more dangerous and 
results in death.
    So, treatment that we have now that is effective, the best 
treatment we have is medications for addiction treatment, MAT. 
We have three FDA medications that when taken, they block the 
high of opiates and they block the withdrawal. And these are 
the two main drivers of ongoing use. They stabilize people 
lives, and allow them to work on their recovery.
    In Baltimore, when they ramped up MAT, they drove overdose 
tests down 80 percent, similar results in France, and in Rhode 
Island, we rolled out MAT in our corrections department, our 
prison and jail, and we drove within year overdose deaths and 
people released from incarceration, we drove them down 60 
percent. So, this is the proof of the concept, that MAT is what 
we need.
    We also need for those who are unable or unwilling to get 
into MAT to outreach to them, to engage them, to give them the 
tools and the education they need to reduce their risks, 
including the lock zone and drug checking. There also have been 
many examples of public health and public safety 
collaborations, include Good Samaritan laws, offering the lock 
zone to first responders who, police and fire. We heard about a 
lead program in Rhode Island. We have safe stations, where the 
fire stations act to engage people and get them into care.
    But, the punitive approach will disproportionally affect 
those most disadvantaged. And we hopefully have learned from 
our punitive approach to the crack epidemic, how it lead to 
mass incarceration of predominantly minority individuals.
    So, the punitive approach will distract attention and 
resources away from what is clearly needed, which is a strong 
and sustained public health approach. Thank you.
    Mr. Rothfus. Thank you, Dr. Rich. The chair recognizes the 
gentleman from Pennsylvania, Mr. Marino, for 5 minutes.
    Mr. Marino. Thank you, chairman. Appreciate it. Thank you 
for being here. I apologize for you having to be the second 
group that has to wait, but I want to pose a concept that I 
have had. I was a prosecutor for 18 years. I was a district 
attorney in Pennsylvania, and I was a US attorney with the Bush 
administration.
    And, first of all, I will still stick to the fact that 
dealers, major dealers, need to be locked up. Period. People 
toting guns and shoving guns in people's side and drug deals 
need to be locked up. So, with that said, I have a concept, and 
I know that quite often, a person addicted to drugs will do 
some deliveries or dealing to get money to supply their habit. 
That is just all part of it. I do not necessarily, unless they 
are violent, want to see those people going to prison.
    And, my concept is this opioid addiction is so much more 
worse than the cocaine and the crack cocaine, particularly 
because of the fentanyl. I want to see, and I tried to do this 
2 years ago, and Karen Bass, a good friend of mine, on the 
other side, we are looking into this again. I want to see 
mandatory inpatient treatment. When a parent sees something 
going on with their child, or when a child sees something going 
on with their parent, we need a system, a central system where 
that person can call and ask for help, because it is the 
toughest thing to do. It is where do I go for help? So, we have 
to have some central location that can get those people, that 
person, or that family directly to someone who can help them in 
their area.
    And, we have many hospitals across the country. We have 
good outpatient treatment facilities. But, to get off the 
opioids, to get off of heroin, that is going to take inpatient 
treatment, and it is going to take a long time. And what I 
think we should do is first of all make it into have that 
family member have the ability to go before the court and have 
an expert testify position that yes, this person is addicted to 
this. And this person needs inpatient treatment.
    They cannot leave. It is going to be a lockdown situation. 
But in addition to the health needs, the mental health needs, 
we need to start working on the family as a whole, educating 
these people. Starting from pulling the bootstraps up. And 
then, the group will make a determination in that particular 
hospital as to when this person can have furlough, when they 
can get out, what we do when they get out. Just do not say, 
``You are out on the street now.''
    And, it is going to be, I think, one of the only ways in 
addition to going after the bad doctors, pharmacists, 
pharmaceutical companies and making them pay as well, one way, 
and/or another. So, what say you? So, you could start Dr. Rich, 
and go down the line.
    Dr. Rich. Sure. Well, lot of material there to work. I 
agree with a number of things you said. I think the need for 
health and treatment and mental healthcare in addressing the 
family, and giving people real opportunities to get a better 
life, and that is really a big part of recovery.
    You mentioned that we have treatment all over the country, 
and we have a need of inpatient. I would say we do not have 
treatment all over the country. We have a very fragmented 
system, and a lot of it is based on faulty thinking, the notion 
that you can get someone to a place, a bed, and that something 
magical is going to happen, and then they are going to come 
out. So, that does not work.
    We do not require the inpatients most of the time. I would 
say that what we need to do is offer effective treatments that 
are proven. And most of the time that is not inpatient. Now, 
there are some cases where, you know, that is being explored in 
Massachusetts, for example they have--they are mandating people 
into treatment, exactly what you said. But instead of treatment 
programs, they have used an old jail. They have in jail cells.
    Mr. Marino. No, you see, mine, mine is----
    Dr. Rich. And they are not getting medications.
    Mr. Marino. Mine is a hospital.
    Dr. Rich. Right. Yep.
    Mr. Marino. With experts making that determination, and I 
see, and almost----
    Dr. Rich. So, I think we can learn a lot from the 
Portuguese example, where that is exactly what they did. They 
did not mandate it. They made it available, made it realistic. 
That is how the rest of----
    Mr. Marino. But in my 18 years, I have never heard a person 
addicted to drugs not say to me, ``I can get off any time I 
want.''
    Dr. Rich. Well, they say different things to me.
    Mr. Rothfus. The gentlemen's time has expired. The chair 
recognizes the gentleman from Rhode Island, Mr. Cicilline for 5 
minutes.
    Mr. Cicilline. Thank you, and thank you to all of our 
witnesses, Ms. Holman. Thank you for being here. I know your 
brother is looking down on you very proudly for your courage. 
So, sadly, I have had many friends who have lost loved ones and 
children to this same disease. And, we all need to be reminded 
that is why we are here, and we need to come up with some 
answers.
    Dr. Rich, I want to just focus a minute on what you just 
described. You know, I think a lot of folks, particularly 
families that are struggling with a loved one who has an 
addiction, the idea of getting them into a treatment facility, 
where they can have the peace of mind to know they are safe, 
seems like, sort of, you know, a natural inclination.
    But it turns out, according to your testimony, that, while 
that may provide you peace of mind, it is actually not the best 
strategy in most cases for really addressing the addiction. And 
you, the work that you have done on what on the medically 
assisted treatment seems to be much more successful.
    So, I am wondering if you could talk a little bit, in the 
face of that data, is it just old thinking? Why is that we 
continue to hear people talk about we need more beds, there has 
to be more placements. Is it just this reluctance on the using 
medicine, or what?
    Dr. Rich. The medications are limited. You know, they are 
not perfect for everybody. They have a lot of side effects. 
They have a lot of problems. But they are the best thing we 
have.
    The problem with the going to a detox is just as tolerance 
goes up very quickly, tolerance also goes down very quickly. 
And so, when you let people out of a detox, as we heard when 
Garret was released, he overdosed right away. Now, probably if 
he had been using up until that point that he took that dose, 
he would have had a much higher tolerance, and would not have 
overdosed right then and there.
    So, we are setting people up for overdose by putting them 
through detox. And, they might not have detoxed 10 years ago, 5 
years ago when we did not have fentanyl. But now we have 
fentanyl, and it is far too dangerous. So, you know, this is 
rapidly evolving. So, we really need to get with the times and 
get people on to these medications.
    Now, there are some cases where, you know, maybe if the 
medication was tried and there is absolutely nothing else we 
can do, then maybe we need to be more of a big brother and be 
more controlling. But, we have already shown that by giving 
people access to, and continuing them on treatment, that they 
are going to reduce their overdose deaths. We need to roll that 
out right away.
    Mr. Cicilline. And that is the work that you have done in 
the prison with success. I think you said 61 percent success 
rate.
    Dr. Rich. Sixty-one percent drop in overdose deaths within 
a year of starting that program, and people coming out of 
corrections. But, that does not have to be corrections. People 
should not have to go be incarceration----
    Mr. Cicilline. That was my impression.
    Dr. Rich [continuing]. In order to get treatment. We can do 
that in pretrial arrest. We can do that in the hospitals, in 
the emergency rooms, in the clinics. We just need to roll it 
out. We need high quality programs that not only give the 
medications, we are really working on recovery work on the 
mental health work, all the other things that the congressman 
was talking about.
    Mr. Cicilline. And what do you think we can do? What can 
Congress do? I mean obviously, you know, providing resources so 
medically assistive treatment is available. Are there other 
things we can be doing in terms of closer regulation of 
prescriber activities? Better coordination through pharmacies? 
How much of that issue do you think is contributing to this 
real growth in opioid overdoses?
    Dr. Rich. We have a whole population that is addicted now. 
And that started with the overprescribing. But they are there. 
And we can shut down the prescriptions. Some of them are going 
to say, ``Oh, I guess I did not need that.'' But, most of them 
are going to go, at least for a time, and find out whatever 
they can find. So, that is very dangerous.
    We also have people that have not started taking opiates. 
And we need to do whatever we can to prevent them from 
starting. And a big part of that is education, understanding 
what is going on.
    Mr. Cicilline. And finally, I know you have been part of 
the work that Governor Raimondo has been leading in Rhode 
Island that I think is really a model in terms of bringing all 
of the stakeholders and affected parties together to really 
develop a strategy and a plan. Maybe you could spend the last 
few minutes just talking about that.
    Dr. Rich. Well, I was fortunate to be involved in that. The 
governor, instead of having a stakeholder process, had an 
expert driven process where they had experts making decisions 
rather than stakeholders saying, you know, fund my program. And 
that led to really looking at the evidence, getting a lot of 
information from the community and from the stakeholders, and 
developing a plan. We had a simple four-point plan expanding 
treatment, and 20,000 out of our population of a million were 
people that needed to be onto MAT.
    And so, identifying where those people interact with 
systems and shutting them over into treatment. So, we have 
started to roll that out, and we think we can--we need to 
continue it, double down on that strategy.
    Mr. Cicilline. Thank you, Dr. Rich.
    Mr. Rothfus. The gentleman's time has expired. The chair 
recognizes the gentleman from Louisiana, Mr. Johnson, for 3 
minutes.
    Mr. Johnson of Louisiana. Thank you, Mr. Chairman. We will 
be very brief. The bells mean that our votes have been called. 
So, we are all sort of, do not want to miss a vote. We are 
going to race out, so you will be just a few more minutes. I do 
not want there to be a perception today that what you have said 
here for the record is not important, just because we do not 
have a quorum. It is a busy day on the Hill. You know how this 
goes. But, your record is important to us. Everyone will review 
it. Your time is well spent here, and we greatly appreciate all 
of you, especially your personal tragedy. It makes a 
difference, it does.
    Real quick practical question, and maybe this for Dr. Rich 
or Mr. Morgan. We referenced today buprenorphine, and I am just 
a constitutional law attorney. I do not know much about all 
this. But, my understanding is buprenorphine is one of the 
medications that is used to wean people off of opioids, is that 
right? It is not an opioid itself, right?
    Dr. Rich. It is an opioid.
    Mr. Johnson of Louisiana. Okay.
    Dr. Rich. And it is what we called a mixed agonist. So, it 
partly turns on the receptor at low doses, and it also blocks 
you from getting high, and blocks you from going into withdraw.
    Mr. Johnson of Louisiana. So, because of the blocking 
agent, it is one of the effective means to try to take people 
down off of their addiction?
    Dr. Rich. Well, so, you know, a lot of people say, ``Well, 
if I start on these medicines''--methadone, buprenorphine, 
commonly known as Suboxone, or deep on naltrexone, the vivitrol 
injection--``if I start this, how long do I have to stay on 
it?'' And the answer is, for many people, a very long time. You 
need to stay on as long as you need to stay on. But, I think 
that the concept that somebody could be put on those medicines 
and weaned off in a short amount of time, and then they are 
going to be fine, this does not work that way.
    Mr. Johnson of Louisiana. And so, what I am hearing, in my 
district back home, I have talked to a couple of pain 
management physicians. And they are feeling pressure from the 
insurance companies, because of perhaps what may be an 
overreaction to all this, to impose access limits or quantity 
limits on those who are appropriately using buprenorphine, or 
one of those derivatives. How do we separate those issues so 
that those patients are not adversely affected and caught up 
into the wave of those who have real addiction?
    Dr. Rich. Buprenorphine, because of its properties, is the 
safest opioid to use. I find it is very effective for a lot of 
people with chronic pain. So, the insurance companies are 
reluctant to allow that, because there is a much bigger market 
of people with chronic pain. And it is an expensive medication. 
I routinely get letters saying, ``Oh, well, have you tried 
oxytocin or, you know, oxycodone, or, others.''
    Mr. Johnson of Louisiana. I have people in my district, the 
insurance company said, ``Why do you not go get on oxytocin?'' 
Because they do not want to pay for buprenorphine anymore.
    Dr. Rich. Exactly. But, we need to roll that out. There was 
mention of buprenorphine being a diverted substance. When we 
have studied people and asked them, ``You know, have you gotten 
diverted buprenorphine?'' They said, ``Yes.'' And then we asked 
them, ``Well, what did you use it for?'' And they used it to 
treat these withdrawal symptoms. So, they are not using it to 
get high.
    They are not going out to party with it. They are trying to 
treat themselves. They are using it as it is really indicated. 
But they cannot get access to it from their physicians, because 
there are not enough prescribers. So, they end up having to get 
it illicitly.
    Mr. Johnson of Louisiana. I am way out of time, but I would 
love to talk with either or both of you later about mechanisms 
we can use for Congress to step in and help make that 
distinction for the people that really need it.
    Dr. Rich. Sure.
    Mr. Johnson of Louisiana. So, thanks for your time.
    Mr. Rothfus. The chairman yields back. The chair recognizes 
himself for 3 minutes, if I can try to get a couple questions 
in before we have to run off for vote. So really, thank you 
everybody for participating in this very informative panel for 
us.
    Mr. Morgan, your testimony referenced the synthetic drugs 
like fentanyl, especially their lethality. I especially 
represent a district in western Pennsylvania that has become an 
epicenter for synthetic opioid trafficking and usage.
    One issue I hear about from other prosecutors are concerns 
dealing with forensic analysis, of blood toxicology and 
overdose death cases. Many times, the medical examiner reports 
list multiple controlled substances on the certificate's 
analysis, and this makes determining the precise cause of death 
difficult, as to which substance was responsible, or whether it 
was a combination of multiple substances. Have you encountered 
this problem regarding overdose cases in your jurisdiction?
    Mr. Morgan. We have not encountered that problem 
specifically. I am aware that it is a problem, when we get a 
certificate or a toxicology report from an ME's report that 
says there are these multiple amounts. The toxicologists in our 
certificate, as I understand it, will try and put that 
percentage by percentage into an equation or an amount in the 
blood, which is representative of the proportion of that 
sustenance.
    Mr. Rothfus. Is proving causation a challenge in that 
context?
    Mr. Morgan. Yes. Proving causation, I imagine, would be a 
challenge. The quickest way I would combat that is I would get 
on the phone with my toxicologist within Virginia, the 
Department of Forensic Science, and speak with them. And look 
for an expert opinion to be tendered, ultimately a trial that 
says that this amount of fentanyl or this percent of fentanyl 
would be a cause of death or could be a cause of death.
    But, in my experience, I think if I see fentanyl, it is 
going to be usually mixed with heroin. So, between fentanyl and 
heroin, I think I have good grounds to say beyond a reasonable 
doubt that this would be the cause of death. But I would need a 
toxicologist there, and that has presented problems in the past 
due to the volume of these types of cases around the State.
    Mr. Rothfus. Dr. Westlake, you talked a little bit about 
some voluntary, as opposed to mandated--I think it is the 
context of prescription guidelines. I mean, part of the 
Comprehensive Addiction Recovery was to have Federal agencies 
take a look at this issue. I mean, can that help to establish 
some kind of standard of care, so that physicians at least can 
be aware of what would read a range of normal?
    Dr. Westlake. Yeah, I mean, I think that has already 
happened. I think with the release of the CDC guidelines, and 
then a lot of different States, in Wisconsin, for example, we 
had the State law passed that would promulgate guidelines from 
the medical examining board. And I think that is a key factor 
is that what I alluded to in my testimony was that we want the 
intervention into medicine to be from medicine itself and not 
from the legislature. I mean, if we look at the cause of the 
pain scale, pain crisis, opioid crisis to begin with, a lot of 
it came out the pain scale.
    And so, I think we got to be really careful about 
interventions. But they are definitely necessary. And I think 
those educational interventions are already happening. And the 
CDC guidelines kind of lead the front of that. And I think 
education is happening. And we will see the results a couple 
years from now.
    Mr. Rothfus. Ms. Holman, you know, what kind of options 
were presented for your brother when subjected to treatment?
    Ms. Holman. I mean, when we were seeking treatment?
    Mr. Rothfus. Right.
    Ms. Holman. It was really hard to get anything, honestly. 
He got himself into trouble with law enforcement, so, he spent 
time in jail, and it seemed like it was easier to get him there 
than any kind of treatment.
    Mr. Rothfus. You know, I really appreciate you being here. 
Your being here is going to help other families.
    Ms. Holman. I hope so.
    Mr. Rothfus. So, I really encourage you to continue the 
work you are doing with your family.
    Ms. Holman. Thank you.
    Mr. Rothfus. And know that you are not alone. And I think 
Dr. Rich talked about the stigma that has been out there, but I 
think your being here is going to help address that issue and 
help other folks find treatment. Dr. Rich, I appreciate where 
you are coming from, with respect to the punitive nature of 
what we have talked about, but do you draw any distinction at 
all between the user and the pusher?
    Dr. Rich. Sure.
    Mr. Rothfus. I look at this thing as a prevention 
enforcement treatment, prevention, enforcement, treatment. All 
three are important. And when you have people who come into or 
join this network of distribution, of this poison, that is 
responsible for the deaths of 10s of thousands of people in 
this country, you know, I want to go after those folks who are 
pushing this poison.
    Dr. Rich. It is impossible to hear the tragedy that Ms. 
Holman described and not be angry about it. And, I share that 
anger. And people that are profiting from it, you know, it is a 
human response to want to punish them. We have tried that for 
30 years, and the result is a disaster.
    So, you know, I think we are going to get a much better 
result. Now, that does not mean I think we should legalize. I 
think we should try and clamp down as much as we can. But, if 
you have mandatory minimums, and you are sending 40-year-old 
mothers to----
    Mr. Rothfus. I think you can look at things like that. But 
again, the premise being if you are pushing poison in our 
communities, you are going be held accountable with that. I am 
sorry, I have to go and vote. We are almost out of time. But I 
do want to thank everybody for coming in today.
    This concludes today's hearing. Thank you to our 
distinguished witnesses for attending. Without objection, all 
members will have 5 legislative days to submit additional 
written questions for the witnesses or additional materials for 
the record. The hearing is adjourned.
    [Whereupon, at 1:26 p.m., the hearing was adjourned.]

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