[Senate Hearing 115-193]
[From the U.S. Government Publishing Office]






                                                        S. Hrg. 115-193

                   STOPPING THE SHIPMENT OF SYNTHETIC
      OPIOIDS: OVERSIGHT OF U.S. STRATEGY TO COMBAT ILLICIT DRUGS

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

                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS


                             FIRST SESSION

                               ----------                              

                              MAY 25, 2017

                               ----------                              

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

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs




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                                                        S. Hrg. 115-193

                   STOPPING THE SHIPMENT OF SYNTHETIC
      OPIOIDS: OVERSIGHT OF U.S. STRATEGY TO COMBAT ILLICIT DRUGS

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

                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS


                             FIRST SESSION

                               __________

                              MAY 25, 2017

                               __________

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

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs



[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]









                         U.S. GOVERNMENT PUBLISHING OFFICE 

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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                    RON JOHNSON, Wisconsin, Chairman
JOHN McCAIN, Arizona                 CLAIRE McCASKILL, Missouri
ROB PORTMAN, Ohio                    THOMAS R. CARPER, Delaware
RAND PAUL, Kentucky                  JON TESTER, Montana
JAMES LANKFORD, Oklahoma             HEIDI HEITKAMP, North Dakota
MICHAEL B. ENZI, Wyoming             GARY C. PETERS, Michigan
JOHN HOEVEN, North Dakota            MAGGIE HASSAN, New Hampshire
STEVE DAINES, Montana                KAMALA D. HARRIS, California

                  Christopher R. Hixon, Staff Director
               Margaret E. Daum, Minority Staff Director
                     Laura W. Kilbride, Chief Clerk
                    Bonni Dinerstein, Hearing Clerk


                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                       ROB PORTMAN, Ohio Chairman
JOHN McCAIN, Arizona                 THOMAS R. CARPER, Delaware
RAND PAUL, Kentucky                  JON TESTER, Montana
JAMES LANKFORD, Oklahoma             HEIDI HEITKAMP, North Dakota
STEVE DAINES, Montana                GARY C. PETERS, Michigan

           Andrew Dockham, Staff Director and General Counsel
                John Kilvington, Minority Staff Director
                      Kate Kielceski, Chief Clerk
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                      
                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Portman..............................................     1
    Senator Carper...............................................     5
    Senator Klobuchar............................................     8
    Senator Lankford.............................................    19
    Senator McCaskill............................................    24
    Senator Hassan...............................................    29
    Senator Tester...............................................    32
    Senator Daines...............................................    34
    Senator Heitkamp.............................................    36
    Senator Peters...............................................    55
Prepared statements:
    Senator Portman..............................................    65
    Senator Carper...............................................    72

                               WITNESSES
                         Thursday, May 25, 2017

Hon. Gregory D. Thome, Director, Office of Specialized and 
  Technical Agencies, Bureau of International Organization 
  Affairs, U.S. Department of State..............................    11
Robert Cintron, Vice President, Network Operations Management, 
  United States Postal Service...................................    13
Robert E. Perez, Executive Assistant Commissioner, Office of 
  Operations Support, U.S. Customs and Border Protection, U.S. 
  Department of Homeland Security................................    14
Tammy L. Whitcomb, Acting Inspector General, United States Postal 
  Service, Office of Inspector General...........................    16
Norm T. Schenk, Vice President, Global Customs Policy and Public 
  Affairs, United Parcel Service.................................    17
Thomas P. Gilson, M.D., Medical Examiner, Cuyahoga County Medical 
  Examiner, Cleveland, Ohio......................................    42
Hon. Michael Botticelli, Executive Director, Grayken Center for 
  Addiction Medicine, Boston Medical Center......................    46
Terry L. Horton, M.D., Chief Division of Addiction Medicine, and 
  Medical Director, Project Engage, Christiana Care Health 
  System, Wilmington, Delaware...................................    48
Thomas Synan, Jr., Chief of Police, Newtown, Ohio, Police 
  Department.....................................................    50

                     Alphabetical List of Witnesses

Botticelli, Hon. Michael:
    Testimony....................................................    46
    Prepared statement...........................................   146
Cintron, Robert:
    Testimony....................................................    13
    Prepared statement...........................................    86
Gilson, Thomas P.:
    Testimony....................................................    42
    Prepared statement with attachments..........................   113
Horton, Terry L. M.D.:
    Testimony....................................................    48
    Prepared statement...........................................   152
Perez, Robert E.:
    Testimony....................................................    14
    Prepared statement...........................................    92
Schenk, Norm T.:
    Testimony....................................................    17
    Prepared statement...........................................   106
Synan, Thomas Jr.,:
    Testimony....................................................    50
    Prepared statement...........................................   157
Thome, Hon. Gregory D.:
    Testimony....................................................    11
    Prepared statement...........................................    82
Whitcomb, Tammy L.:
    Testimony....................................................    16
    Prepared statement...........................................   101

                                APPENDIX

Responses to post-hearing questions for the Record from:
    Mr. Thome....................................................   161
    Mr. Cintron..................................................   173
    Mr. Perez....................................................   199
    Ms. Whitcomb.................................................   238

 
                   STOPPING THE SHIPMENT OF SYNTHETIC
      OPIOIDS: OVERSIGHT OF U.S. STRATEGY TO COMBAT ILLICIT DRUGS

                              ----------                              


                         THURSDAY, MAY 25, 2017

                                   U.S. Senate,    
              Permanent Subcommittee on Investigations,    
                    of the Committee on Homeland Security  
                                  and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 9:33 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Rob Portman, 
Chairman of the Subcommittee, presiding.
    Present: Senators Portman, Lankford, Daines, Carper, 
Tester, Heitkamp, and Peters.
    Also present: Senators McCaskill, Klobuchar, and Hassan.

              OPENING STATEMENT OF SENATOR PORTMAN

    Senator Portman. The Committee will come to order. We will 
get started. We have a great group of Members who are here, and 
everybody has a lot of different commitments this morning. We 
also are very eager to hear from our witnesses and talk about a 
critical issue facing our country.
    It is really a crisis in our communities, and it is getting 
worse, not better. The crisis is the opioid epidemic. Our 
country is being gripped by it. My State is, as are the States 
of every Senator around the table.
    It is a crisis that does not discriminate. It is in every 
corner of my State. Earlier this month, a police officer named 
Chris Green in East Liverpool, Ohio, had a near-fatal fentanyl 
overdose following a routine traffic stop. He went up to a car 
for a routine stop and noticed there was white powder spread 
around the car. He did the right things. He put on his mask, he 
put on his gloves, and arrested some individuals.
    He went back to the police station, and he noticed that on 
his shirt there was some powder, so he reached up and brushed 
the powder off his shirt. This guy is 6-foot-3, 225 pounds, a 
big man, and he fell to the floor unconscious and overdosed. 
They administered Narcan immediately, but it was not enough. 
They had to rush him to the hospital where two more Narcan 
doses were administered, and luckily, his life was saved. As 
his police chief said, he would have died had he been alone. 
The police chief also said, ``What if he had gone home with 
that powder on his shirt and hugged his kid?''
    That is just an example of what we are facing. It is 
obviously devastating our communities and families, but also 
creating quite a danger for our law enforcement and other first 
responders.
    Fentanyl is 30 to 50 times more powerful than heroin and 
100 times stronger than morphine, and a lethal dose can be as 
little as two milligrams. We had some floor speeches this week 
about it. We were able to show that just a tiny amount of 
fentanyl can be deadly. We also know about U-4 and carfentanil 
and other synthetic drugs that are coming into our country.
    This issue is getting worse. As I said, the number of 
overdoses and deaths have increased dramatically. Earlier this 
month, you may have seen that the Director of National 
Intelligence (DNI), Dan Coats, our former colleague, actually 
included synthetic opioids in his World Wide Threat Assessment, 
and he noted in his comments that deaths had increased 73 
percent just between 2014 and 2015, the last year for which 
they have records. So sadly, that death toll continues to 
climb, and we will hear about that this morning.
    In one county in Ohio, for instance, fentanyl was 
responsible for 394 overdose deaths in 2016. One county. Tom 
Gilson, whom you will hear from later, the Cuyahoga medical 
examiner (ME), will tell you he is projecting 581 fentanyl-
related deaths out of 850 total fatal drug overdoses this year. 
In other words, fentanyl is by far our biggest killer.
    A lot of these deaths are due to mixing fentanyl with 
heroin and other drugs, leaving the user with no idea what they 
are taking. An example of this is a new opioid cocktail called 
``gray death.'' Gray death includes a mixture of heroin, 
fentanyl, carfentanil, and U-4770. Heroin is the weakest drug 
in that mix. Think about that. This is available on the street, 
this opioid cocktail, for as little as $10 to $20. Even though 
these drugs are selling very inexpensively, fentanyl has a 
extremely high profit margin, making it appealing to the drug 
dealer.
    The Drug Enforcement Agency (DEA), estimates that a 
kilogram of fentanyl can be purchased from a Chinese supplier 
for a few thousand dollars. A kilogram for a few thousand 
dollars can be used to make hundreds of thousands of pills with 
profits in the millions.
    So, bottom line, we need to stop this flow of illegal, 
illicit fentanyl. And, unbelievably, it comes through the U.S. 
mail system. This is a shock to many of my constituents and 
others who are learning about this. While some of this fentanyl 
is smuggled into the United States from Mexico and Canada, 
primarily it comes directly into the United States. According 
to law enforcement, including some folks who are here this 
morning who will tell us about this, it primarily comes from 
one place, which is China. It is produced in laboratories 
there, and our understanding from law enforcement is that most 
of that fentanyl produced in China is intended for export to 
one place, and that is the United States of America.
    There are a number of Chinese websites ready to ship. Do a 
Google search for ``fentanyl for sale,'' and it produces a 
number of websites where the drug--and many others--appear to 
be readily available.
    On one website, you can purchase a gram of fentanyl for 
$250, but it says, ``The more you buy, the less you pay,'' 
offering discounts for larger volumes.
    To ease any concern about whether the purchaser would 
receive his order, the website guarantees discreet shipment 
``with undetectable and careful packaging.''
    While shipment was available to any number of countries, 
the website knew its audience and offered express delivery to 
the United States. Many of these websites are so sure that 
their shipment will not be stopped by law enforcement that they 
will guarantee that if the original somehow gets lost or 
seized, they will send you another one for free.
    Several websites we reviewed made it clear they exclusively 
used Express Mail Service (EMS), as their courier. EMS, of 
course, is the international postal service offered by members 
of the Universal Postal Union (UPU). Packages delivered through 
EMS are passed to the United States Postal Service (USPS) as 
they enter the United States.
    So, our shared goal today is to try to stop these drugs 
from exploiting our own streams of mail into our country. Every 
Member around this dais this morning has been involved in this 
issue on prevention and education, on treatment and recovery. 
We have actually passed two significant new legislative 
initiatives in the last year in this Congress focused on this 
issue. We understand it is much broader than just interdicting, 
but we have to do a better job of interdicting.
    Following September 11, 2001 (9/11), Congress identified 
weaknesses in international shipping standards as a significant 
problem and made clear that requiring advance electronic data 
(AED) would make our country safer. This was 15 years ago. But 
when Congress first legislated, it did so, however, and left a 
gaping loophole.
    The Trade Act of 2002 mandated that commercial carriers 
provide advance electronic data that could be used to identify 
certain packages being shipped into the United States. In that 
2002 legislation, Congress asked the Secretary of Homeland 
Security and the Postmaster General to decide if the Postal 
Service should be subject to the same requirements that they 
were putting in place for all private carriers. To date, no 
determination has been made, and our country is less safe as a 
result.
    As such, the difference between the information that 
private commercial carriers are required to provide is very 
different from the Postal Service, but both serve the same 
function: delivering packages into our communities.
    At the same time, the Postal Service handles a much higher 
volume of international packages than the commercial carriers 
combined.
    Prior to any shipment arriving in the United States, 
commercial carriers are required to electronically provide data 
to law enforcement, including Customs and Border Protection 
(CBP), with the basic information, including: what the shipper 
name and address is; the name and address of the person 
receiving the package; a description of the contents; the piece 
count; the weight; and the value of the contents. This 
information is then transmitted to Customs and Border 
Protection and 47 other Federal agencies at the National 
Targeting Center. Based on this information, CBP targets 
suspect shipments for additional scrutiny and selects the 
packages it wants to inspect when they arrive in the United 
States.
    Commercial carriers are also charged $1 per package by CBP 
which most commercial carriers pass on to the shipper. None of 
this applies to the Postal Service, and the Postal Service 
handles hundreds of thousands of packages every day.
    All international packages shipped through the Postal 
Service are routed through five international service centers, 
with the New York center at John F. Kennedy (JFK) Airport 
receiving the overwhelmingly majority of those packages. How 
these packages are processed is completely different at each of 
these centers. For the most part, CBP is tasked with 
identifying packages or shipments it wants to inspect, and the 
Postal Service locates those packages or shipments and presents 
them to CBP.
    However, it is not that easy. Due to the hundreds of 
thousands of packages, the Postal Service is left to manually 
sort through large shipments trying to identify what CBP is 
looking for. All internationally shipped packages are already 
required by the Universal Postal Union to have certain 
information attached to them including: the sender, the 
recipient, a description of the contents, weight, and value.
    The problem is that information is not electronic, and it 
is not transmitted in advance. So it is not useful to law 
enforcement. Essentially, it is useless.
    The UPU has indicated it will require member countries to 
place a bar code on every package starting in 2018. That is 
fine. However, the shipper will not be required to load any 
electronic information on that bar code until 2020. Meanwhile, 
we have a crisis.
    Realistically, the target date to implement this 
requirement is closer to 2022, we are told, but there is no 
guarantee that it will even happen by then. For 15 years, the 
Postal Service has been on notice of the need to collect 
advance electronic data about its packages. We cannot wait any 
longer. As Americans are dying every day from these poisonous 
drugs flowing into our country, we must act. And we have to 
stop this fentanyl, carfentanil, and other synthetics from 
coming in.
    The Postal Service is trying to use electronic information 
at JFK to help CBP identify these packages. It is a pilot 
program. The Postal Service is providing electronic data to CBP 
for packages that weigh less than 4.4 pounds, so-called 
ePackets. Once the Postal Service shares the information, CBP 
uses the information to identify the packages it wants to 
inspect. The Postal Service then locates and presents those 
selected packages for CBP inspection. This is a step in the 
right direction, in my view. After nearly 15 years of not doing 
this, the results to date are lacking, however.
    In December 2016, late last year, the Inspector General 
(IG) found the Postal Service failed to present all of the 
packages CBP selected for inspection and a substantial number 
of ePackets lacked any advance electronic data associated with 
it.
    I understand the Postal Service is starting to take steps 
to remedy this issue of presenting packages to CBP for 
inspection, and I look forward to hearing the details of that 
today. But without advance electronic data, we will continue to 
miss a significant portion of these packages.
    Further, the pilot program is only happening at one 
location. At the other four centers, the Postal Service is 
stuck sifting through millions of packages, like trying to find 
a needle in a haystack. We cannot continue like this. We need 
the electronic data, and we need it now.
    We have been working in a bipartisan way to solve this 
problem. That is why we introduced legislation called the 
Synthetic Trafficking and Overdose Prevention (STOP) Act. My 
co-author is here with us today, and she will speak in a 
moment. It is aimed at providing advance information that the 
Postal Service should be providing for international mail.
    We have 16 cosponsors in the Senate--eight Democrats and 
eight Republicans. In the House, there is separate, companion 
legislation that has 128 bipartisan cosponsors. Our focus today 
is getting input from this panel of witnesses so we have a 
clear understanding from all of the key stakeholders as we move 
forward on this.
    Again, thank you all very much for being here. I thank my 
colleagues for being here. I would now like to turn to the 
Ranking Member, Senator Carper.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. In the Navy, we talk about special moments. 
We call them ``all hands on deck.'' This is an ``all hands on 
deck'' moment for not just those of us in this room, not just 
in the Senate, not just Delaware or Ohio or any other States 
that are represented. This is an ``all hands on deck moment'' 
for our country, and we welcome all of our witnesses, this 
panel and the second panel.
    I want to thank our Chairman and I want to thank Amy 
Klobuchar for the good work that they have done and others on 
this Committee have done to get us ready for this day.
    The focus on today's hearing is more about at least one of 
the ways these drugs are getting into communities and what we 
can do to stop them. We look forward to hearing from our 
witnesses on the first panel to better understand the processes 
used by the Postal Service, by private shippers, and by CBP to 
screen international mail shipments and to identify and stop 
potentially illicit packages.
    I also look forward to learning more about where the 
coordination between shippers and Federal agencies is working 
well, while identifying areas where we need to push for 
improvements.
    Joining in today's discussion is the Postal Service which, 
in partnership with CBP, is our first line of defense in 
preventing the flow of illegal drugs and contraband into our 
country.
    As some of you may recall, protecting and improving the 
mail system in this country has been one of our biggest 
priorities, certainly one of my biggest priorities, on this 
Committee for a number of years. The Postal Service is vital to 
our economy. It is the linchpin of a trillion-dollar mailing 
industry. Yet, the agency is facing insolvency if Congress does 
not act in the coming months to pass comprehensive postal 
reform.
    Enacting that legislation will free up billions of dollars 
that the Postal Service can use not only to invest for the 
future and improve customer service, but also shore up mail 
security.
    It is worth noting that, despite the financial uncertainty 
facing the Postal Service, its inbound international package 
volume has grown significantly in the past three years. In 
fact, it has nearly doubled, growing from 150 million pieces in 
2013 to more than 275 million in 2016.
    There is no question that handling that increased volume, 
in addition to the increase in domestic packages that we are 
seeing--we welcome that, but it is putting a strain on an 
already stretched resource.
    Unlike private carriers, the Postal Service is required to 
deliver all mail it receives from foreign posts in a timely 
manner. This is due to our membership in the Universal Postal 
Union, which sets international mailing standards. It also 
ensures that we can send mail ourselves to friends, to 
families, and to business partners overseas.
    The State Department represents the United States at 
something called the Universal Postal Union, and they are going 
to be here with us today to discuss our involvement and their 
involvement in this key organization. We look forward to 
hearing from our Postal Service and State Department witnesses 
about our commitment to promoting the exchange of advance 
electronic data among the Union's 192 member countries as a 
means of combating the shipment of drugs and other illegal 
goods.
    While all packages are screened initially by CBP before 
being presented to the Postal Service, CBP can, and often does, 
target packages for additional screening. CBP, which is also 
joining us today, can target packages based on the country of 
origin or scans done by the Postal Service. Recently, the 
Postal Service and CBP have been working closely together on a 
pilot program that allows CBP to use advance electronic data on 
small packages from China arriving at JFK Airport.
    While the Postal Service provides other countries with 
advance electronic data about mail originating in the United 
States, we do not always get that same information from other 
countries. This makes it harder for CBP to do its job as 
packages arrive here. The pilot program at JFK is a rare 
exception, so I hope we can learn today whether there are any 
recommendations to improve and expand this program.
    As my colleagues here have heard me say many times, find 
out what works, do more of that. Private carriers, like United 
Parcel Service (UPS)--which is also joining us today--already 
provide CBP with advance electronic data on packages destined 
for our country. And unlike the Postal Service, private 
carriers have integrated, automated systems in locations around 
the world and can refuse to accept a package at origin that 
does not contain any shipping manifest data. Learning how this 
process is yielding success in interdicting shipments of 
illicit drugs can hopefully help us cover the gaps exploited by 
smugglers.
    I also look forward to identifying methods that Congress 
can ensure that Federal agencies, as well as our State and 
local partners, have the resources that they need to combat the 
opioid crisis on the ground. Specifically, I am eager to hear 
from our witnesses on the second panel, each of whom serve on 
the front lines of the Nation's opioid epidemic in various 
capacities, from law enforcement to medical doctors, and 
addiction experts. These witnesses will give us firsthand 
perspectives of the challenges we face in fighting opioid 
addiction and the strategies that have proven effective, 
particularly in Delaware and Ohio, and nationwide.
    While I look forward to a discussion of ways to reduce 
Americans' access to and use of synthetic opioids, this is only 
part of the equation. We must not lose sight of the need to 
focus on the root causes of our Nation's considerable demand 
for drugs--not just on the symptoms but on the root causes of 
those considerable demands for drugs. Until we do that, the 
crisis will only continue to worsen and smugglers will continue 
to look for and find ways around the defenses we put in place 
to block the supply of dangerous drugs.
    Today's opioid crisis is arguably the worst in American 
history. According to the Centers for Disease Control (CDC), 
over 33,000 Americans suffered an opioid-related death in 2015. 
That is roughly the population of our capital in Dover, 
Delaware. My home State of Delaware has not been immune. None 
of our States have been immune. According to Delaware's 
Division of Forensic Science, there were 222 overdose deaths in 
Delaware in 2014, 228 in 2015, and last year 308. These numbers 
are staggering for a little State. Unfortunately, they are even 
worse in some communities in Ohio and elsewhere in the States 
that are represented on this dais.
    Substance abuse is a complex problem with consequences for 
everyone, and we cannot pay attention only to the symptoms of 
the problem without trying to address the underlying causes.
    We know that overdose deaths are preventable, so as the 
crisis worsens, we need to work together to provide critical 
and robust funding to help save lives.
    In closing, I believe it is critical to note that access to 
health care plays a pivotal role in combating addiction. 
Unfortunately, current proposals to repeal the Affordable Care 
Act (ACA) threaten to undermine much of the recent bipartisan 
progress in addressing the Nation's opioid epidemic and 
strengthening our Nation's mental health system.
    As we all know, Medicaid is the single largest payer of 
substance abuse services in our Nation, paying for one-third of 
all medication-assisted treatments (MAT). Current plans to 
repeal Medicaid expansion and add program caps threaten to make 
this opioid crisis worse, as millions will be at risk of losing 
coverage for substance abuse prevention, treatment, and 
recovery services, at the time we need those services the most.
    Going forward, I look forward to working even more 
effectively with our colleagues on both sides of the aisle to 
address the underlying causes of this opioid epidemic and to 
learn what we can do and how we can bring about substantial, 
lasting change.
    Thank you so much. Thank you, Mr. Chairman.
    Senator Portman. I thank the Ranking Member.
    As Senator Carper noted, we have one of our colleagues with 
us today who is not on the Committee, and that is Senator Amy 
Klobuchar. She is the co-author of the STOP Act and we 
appreciate her interest in the topic. We welcome her 
participation and I would like to ask unanimous consent that 
even though she is not a Member of the Committee that she be 
allowed to participate in today's hearing. And without 
objection---- [Laughter.]
    That is why I was moving quickly. I was worried. Without 
objection----
    Senator McCaskill. This is what we are giving her for her 
birthday.
    Senator Klobuchar. Thank you.
    Senator McCaskill. She wanted to come to this hearing since 
today is her birthday.
    Senator Portman. You chose to spend your birthday with us. 
I would like to recognize Senator Klobuchar. Senator Carper and 
I talked about this in advance and for that matter, if other 
Members would like to make a brief opening statement, that is 
all right. But I know she has another markup that she is 
supposed to be at right now. So, Senator Klobuchar, if you 
would make a few remarks, we would appreciate it.

             OPENING STATEMENT OF SENATOR KLOBUCHAR

    Senator Klobuchar. Well, thank you very much Mr. Chairman 
and thank you Senator Carper. It is a very celebratory moment 
to be here with the Subcommittee for my birthday. Thank you. 
And it was really an amazing moment to meet some of the 
witnesses out there and I think you will all really learn a lot 
by hearing from them. I have never heard the coroner speak on 
this, but the medical examiner here really hits home how 
dangerous this is.
    We take this personally in my State. We lost Prince to 
fentanyl, and that investigation is still going on and includes 
finding out where he obtained that drug. But it was not just 
Prince. It is also a mom in Rochester, Minnesota, a student in 
Duluth, and like every State we see opioid deaths on the rise, 
now exceeding homicides in our State.
    I look at this in three ways--when we passed this 
framework, I think we started thinking this way. I want to 
thank Senator Portman for his leadership on that bill and we 
worked in a bipartisan way with Senator Ayotte and Senator 
Whitehouse and myself. But, the three things are:
    One, trying to reduce the number of people getting hooked 
on legal opioids and that means everything from our 
prescription drug monitoring bill to the work that we are 
trying to get changes in how prescriptions are given out and 
how many drugs are given for simple things like wisdom teeth.
    The second, of course, is treatment and we did some good 
work, all of us did, with the Cures Act. We are going to have 
to continue to do work with the budget. I appreciate your 
leadership on the Republican side, Senator Portman, in 
objecting to these Medicaid cuts that we heard from the House. 
I think that is going to be really important.
    But the third is that we all know as people are migrating 
over to the illegal drugs because they are either cheaper or 
easier to get, we are going to see more of these kinds of 
overdoses from things like fentanyl. Just in the last few 
months in my State, we have had 11 people die from carfentanil, 
which is an even more powerful form of fentanyl. It is 100 
times more potent than fentanyl. A dose the size of two grams 
of salt can be fatal.
    On our Judiciary Committee we heard from Customs just last 
week and the numbers we heard is that in 2013 fentanyl seizures 
were at two pounds and now last year 440 pounds, to give you a 
sense of this tremendous increase. That is why I am proud to be 
the lead Democrat on our bill. Senator Portman and I have the 
STOP Act, which he has described well. I think it is really 
important that we start using modern technology so that we are 
as sophisticated in tracking down these perpetrators as the 
ones that are getting our kids hooked and killing people in our 
country.
    The second thing that I want to mention is the SALTS Act, 
which is a bill I have with Senator Lindsey Graham. It makes it 
easier to prosecute these kinds of cases. I know Senators 
Heitkamp and McCaskill were here earlier as people who worked 
as prosecutors. They also see this as a real issue because you 
have drug dealers who are basically changing, sometimes over 
the Internet, the components in these drugs and they are doing 
it with fentanyl as well. And then they make it harder for us 
to prosecute them, especially in our rural areas where it is 
not easy to call a medical expert up like we have here today in 
Washington.
    And so, we are feeling good about this bill because Senator 
Grassley is on it and Senator Feinstein, the two leads of the 
Judiciary Committee, and we urge others to look at the bill. 
But it simply makes it easier to prove up analogs when they 
change the composition of synthetics. So that is another thing 
I would suggest.
    But I mostly want to thank Senator Portman for his 
leadership and his willingness to work across the aisle on this 
really important issue, and thank you as always, Senator 
Carper. Thanks.
    Senator Portman. Thank you, Senator Klobuchar.
    Would any other Members like to make brief opening 
statements?
    [No response.]
    All right. We are going to go to our first panel of 
witnesses, and we have a very distinguished panel. Some of you 
were here for a roundtable in this very location last year 
where, frankly, the STOP Act first originated, because we were 
able to identify this problem. I would like to call the 
witnesses individually.
    First, Gregory Thome, thank you for being here, Director of 
the Bureau of International Organization Affairs at the State 
Department, which, of course, works to advance U.S. national 
interests through multilateral engagements. Prior to joining 
the State Department in 1991 here in Washington, he held senior 
Foreign Service positions in Morocco, Iraq, Finland, Brazil, 
and other countries.
    Robert Cintron is here. Robert Cintron is the Vice 
President of Network Operations at the Postal Service. Mr. 
Cintron began his Postal Service career 31 years ago as a clerk 
in Rochester, New York. In his current role, he oversees the 
Postal Service's distribution network, including overall 
network design, policies, and programs for processing sites, 
logistics required to move mail, and maintenance policies and 
programs that support the postal network.
    Third, we have Robert Perez here. Robert is the Acting 
Assistant Commissioner Operations Support at U.S. Customs and 
Border Protection. Previously, Mr. Perez served as director of 
Field Operations for CBP's New York Field Office where last 
year he oversaw the arrival of more than 21 million 
international travelers and $240 million in imported goods. 
Over the course of his distinguished career, Mr. Perez has 
represented CBP as a border security expert all over the world 
at many different international business conferences, on 
official assignments, and as a guest lecturer as a border 
security expert.
    We have Tammy Whitcomb with us today, who is the Acting 
Inspector General for the U.S. Postal Service. Ms. Whitcomb 
came to the Postal Service as an audit director in 2005, and 
has served as Deputy Inspector General since 2011. Prior to her 
time at the post office, she also worked at both Internal 
Revenue Service (IRS) Inspection Service and the U.S. 
Department of Treasury Inspector General for Tax 
Administration.
    And, finally, we have Norm Schenk with us today. Norman 
Schenk is the vice president of Global Customs Policy and 
Public Affairs for the United Parcel Service (UPS). With UPS, 
Mr. Schenk has spent the last 30 years working directly with 
government leaders around the world on reducing trade barriers, 
simplifying customs processes, and most recently with supply 
chain security issues. Mr. Schenk previously testified to 
Congress on drug enforcement issues and he currently serves on 
advisory committees to the World Customs Organization and the 
U.S. Department of Commerce. Mr. Schenk also currently chairs 
the International Chamber of Commerce Commission on Customs and 
Trade.
    Again, I appreciate every one of our witnesses being here 
this morning, and we look forward to hearing your testimony. It 
is the custom of this Subcommittee to swear in the witnesses, 
so at this time I would ask you to please stand and raise your 
right hand. Do you swear the testimony you will give before 
this Committee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Mr. Thome. I do.
    Mr. Cintron. I do.
    Mr. Perez. I do.
    Ms. Whitcomb. I do.
    Mr. Schenk. I do.
    Senator Portman. Thank you. Please be seated.
    I would note that all of the witnesses indicated that they 
were prepared to testify under oath, and let the record reflect 
that they all answered in the affirmative. Your written 
testimony will be made part of the record, and I would ask you 
to try to keep your oral comments to five minutes each so that 
we can get to the questions.
    Mr. Thome, I would like to start with you.

   TESTIMONY OF THE HONORABLE GREGORY D. THOME,\1\ DIRECTOR, 
    OFFICE OF SPECIALIZED AND TECHNICAL AGENCIES, BUREAU OF 
  INTERNATIONAL ORGANIZATION AFFAIRS, U.S. DEPARTMENT OF STATE

    Mr. Thome. Thank you, Chairman Portman, Ranking Member 
Carper, Members of the Subcommittee. Good morning and thank you 
again for the opportunity to appear today to discuss the issue 
of illicit drugs, including synthetic opioids, in international 
mail. The supply side of the synthetic opioid crisis presents a 
complicated picture with multiple pathways for these drugs to 
enter the country. In addition to shipments that find their way 
into the United States from across our land borders and through 
express delivery services (EDS), illicit fentanyl and other 
illicit drugs also enter the country through international 
mail, typically in small shipments purchased online by 
individual customers.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Thome appears in the Appendix on 
page 82.
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    The Department of State is aware that these small shipments 
pose unique challenges to U.S. Customs and Border Protection--
challenges that the exchange of advance electronic data can 
help mitigate. Consequently, the Department of State works 
closely with CBP and the U.S. Postal Service to take steps, at 
the global level, to increase the availability of advance 
electronic information (AEI) for international mail. And we are 
committed to helping enhance CBP's ability to interdict drugs 
in this channel.
    Before discussing these efforts, I should explain that the 
Postal Accountability and Enhancement Act of 2006 identifies 
the Department as the lead agency for international postal 
policy. The main forum for our work is the Universal Postal 
Union. The UPU is an intergovernmental organization of 192 
countries that have committed to delivering one another's mail 
on the basis of reciprocity.
    The UPU Congress and its 40-member Postal Operations 
Council (POC), write and adopt the Acts of the Union, which are 
the rules of the road for international mail exchange. At the 
UPU Congress of 2012, the United States was successful in 
securing amendments to the UPU Convention that committed each 
member State to adopt and implement a security strategy which 
includes complying with requirements for providing AEI.
    And at the most recent UPU Congress in 2016, the United 
States was re-elected to the POC and was selected to co-chair 
the POC's Committee on Supply Chain. This committee oversees 
all UPU work on customs, security, transportation, and 
standards. The United States also chairs the Committee's 
Standing Group on Postal Security. These leadership roles 
position us extremely well to ensure that high priority 
security issues--especially AEI--move forward as quickly as 
possible. And we have made significant progress toward that 
goal.
    With active participation and technical input from the 
United States, the UPU cooperated with the World Customs 
Organization to develop an electronic data system to allow for 
the capture, transmission, and receipt of AEI. In February of 
last year, the POC adopted a new regulatory framework for the 
exchange of AEI called the ``Roadmap for AEI Implementation.'' 
The United States now leads the steering committee coordinating 
the work required to reach the roadmap's milestones, which 
include final adoption of the technical messaging standard for 
item-level data. Adoption of that standard should take place at 
this fall's POC meeting.
    As significant as these achievements are, they are only 
part of the picture and there are obstacles to overcome. The 
main impediment to widespread AEI is the limited ability of 
most postal services to collect and transmit it. The UPU 
Business Plan adopted in 2016 calls for all postal services to 
have the capability to exchange item-level data by the end of 
2020.
    However, the technical ability to exchange this data does 
not translate directly into the ability to collect or enter it. 
Many post offices in the developing world do not have Internet 
connectivity or even reliable sources of electricity, which 
makes collection of data and transmission of data extremely 
difficult. And even in developed countries, some postal 
services have been slow to invest in the needed infrastructure 
for item-level electronic data exchange. Currently few, if any, 
countries have the ability to provide it for 100 percent of 
their mail requiring customs declarations.
    Our approach has been to support the UPU to provide 
capacity building that enables AEI. The UPU is devoting half of 
its cooperation budget over the next four years to a project 
designed to position postal services in developing countries to 
obtain this capacity. And the major focus of this program is 
AEI.
    We will continue to support and encourage these efforts but 
recognize that rapid acceleration of investment in, and use of, 
electronic data for customs and security will also be driven by 
the business needs of postal operators themselves. Postal 
operators now understand that delays caused by necessary 
customs processing are a major impediment to their own ability 
to grow their business model and adapt to the rapid growth of 
e-commerce transactions. Exchange of AEI is the only real 
solution to this problem. Consequently, while the United States 
was once a voice in the wilderness almost alone in calling for 
AEI exchange, we are now leading a chorus of countries--
developing and developed--that demand AEI.
    Another significant development with implications for AEI 
is the UPU's decision to launch the Integrated Product Plan 
(IPP), which aims to modernize UPU product offerings with an 
eye toward e-commerce. This far-reaching effort has clear 
benefits for the customs processing of mail. Phase 1, which 
begins in January 2018, will introduce segregation of mail into 
items containing documents and those containing goods. This 
split will facilitate compliance with customs requirements, 
including AEI. Phase 1 also requires mail items containing 
goods to have a UPU standard bar code label, which is critical 
to enabling AEI.
    Furthermore, UPU approved regulations in February 2016 
which will allow members to impose AEI requirements on items 
containing goods, provided they take into account whether the 
requirements they are imposing can be met by those to whom they 
apply. The thinking behind the regulation was that demanding 
something that is impossible immediately as a condition for 
delivering another country's mail is the same as refusing to 
receive it at all. Such a requirement would undermine the 
reciprocity that is at the heart of the UPU.
    In conclusion, I would like to assure the Subcommittee that 
the State Department is fully committed to accelerating all 
countries' ability to provide AEI. To that end, we will spare 
no effort to ensure swift implementation of the UPU Roadmap and 
the Integrated Product Plan. As these programs move forward, we 
are confident that the number of countries able to provide AEI 
and the portion of their mail stream that it covers will 
continue to grow.
    Thank you Mr. Chairman. I look forward to answering your 
questions.
    Senator Portman. Thank you, Mr. Thome. Mr. Cintron.

    TESTIMONY OF ROBERT CINTRON,\1\ VICE PRESIDENT, NETWORK 
            OPERATIONS, UNITED STATES POSTAL SERVICE

    Mr. Cintron. Good morning, Chairman Portman, Ranking Member 
Carper, and Members of the Subcommittee. Thank you, Chairman 
Portman, for calling this hearing.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Cintron appears in the Appendix 
on page 86.
---------------------------------------------------------------------------
    My name is Robert Cintron. I am the Vice President, Network 
Operations, for the United States Postal Service. I oversee the 
Postal Service's national distribution network, including its 
international operations.
    Congress has given U.S. Customs and Border Protection the 
responsibility and authority to screen items at the first point 
of entry into the United States. At entry, Customs has the 
authority to open and inspect all inbound items without a 
warrant to identify prohibited items.
    Inbound international mail from foreign postal operators 
arrives by plane at one of our International Service Centers 
(ISCs). It typically arrives in large bags packed in 
containers. After an initial bulk screening by Customs, inbound 
shipments receive an initial receipt scan by the Postal 
Service. At this point, items requested by Customs are 
presented for further inspection.
    For those items for which advance electronic data is 
furnished, Customs has an enhanced ability to target items for 
inspection.
    Today the Postal Service collects AED for more than 90 
percent of its outbound international packages and receives 40 
to 50 percent of this information for inbound packages. To put 
this in perspective, comparing data from fiscal year (FY) 2015 
to the present, AED for inbound international packages has 
increased from approximately one percent to its present range, 
between 40 and 50 percent. In other words, the Postal Service 
currently receives data on a substantial amount of inbound 
shipments, including those originating in China.
    The percentage of inbound items with AED is expected to 
continue to grow, especially as more countries develop their 
capacities.
    In an effort to further expand the provision of AED for 
international inbound volume, the Postal Service is 
prioritizing obtaining AED from the largest volume foreign 
postal operators, which collectively account for over 90 
percent of all inbound volumes.
    For example, we have entered into bilateral agreements that 
require AED with foreign postal operators of China, Korea, Hong 
Kong, and Australia. And we have entered into voluntary data-
sharing agreements with more than 30 foreign posts to 
facilitate the exchange of AED.
    Additionally, the Postal Service has a pilot program in our 
New York ISC that allows Customs to use inbound AED for more 
advance targeting. With the lessons learned from this pilot, we 
are working with Customs to expand this approach to our other 
ISCs.
    Unlike private companies, the Postal Service must accept 
and deliver mail from nearly every country in the world. The 
Postal Service does not control the induction of foreign mail 
destined for the United States, so we cannot control the 
collection of AED abroad.
    However, the Postal Service, in collaboration with the 
State Department and Customs, plays a leadership role in 
advocating for the global collection and exchange of AED.
    Through negotiation and advocacy and by targeting nations 
with greater capacity like China, inbound AED has grown 
enormously in the past few years.
    In conclusion, we share your concerns about America's 
opioid epidemic and we continue to work with Customs to enhance 
the interdiction of illegal drugs and contraband. The post is 
committed to taking all practicable measures to ensure our 
Nation's mail security and provide the American public the best 
and most efficient service possible.
    Again, thank you for this chance to testify, and I look 
forward to your questions.
    Senator Portman. Thank you, Mr. Cintron. Mr. Perez.

     TESTIMONY OF ROBERT E. PEREZ,\1\ EXECUTIVE ASSISTANT 
 COMMISSIONER, OFFICE OF OPERATIONS SUPPORT, U.S. CUSTOMS AND 
    BORDER PROTECTION, U.S. DEPARTMENT OF HOMELAND SECURITY

    Mr. Perez. Good morning, Chairman Portman, Ranking Member 
Carper, and distinguished Members of the Subcommittee. Thank 
you for the opportunity to appear today to discuss the role of 
U.S. Customs and Border Protection in combating the flow of 
dangerous synthetic opioids, particularly fentanyl, into the 
United States.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Perez appears in the Appendix on 
page 92.
---------------------------------------------------------------------------
    The majority of fentanyl smuggled into the United States is 
done so through international mail facilities, express 
consignment carrier facilities, or through our ports of entry 
along the Southern land border.
    In fiscal year 2016, CBP officers and agents seized or 
disrupted more than 3.3 million pounds of narcotics. CBP 
seizures of fentanyl remain relatively small, but have 
significantly increased over the past few years, from two 
pounds seized in 2013 to over 400 pounds seized in 2016. 
Fentanyl is the most frequently seized illicit synthetic 
opioid.
    Along the Southern border, heroin is often spiked with 
fentanyl. Fentanyl is also sometimes spiked with other 
substances and sold as synthetic heroin. Drug-trafficking 
organizations continually adapt to evade detection and 
interdiction by law enforcement.
    CBP uses the same drug interdiction methods to seize 
fentanyl as it uses to detect other drugs coming across the 
border. However, the detection of fentanyl remains challenging 
due to the limited field testing capabilities and the variety 
of fentanyl analogs on the market.
    In the express consignment environment, CBP can place an 
electronic hold and notify carriers that a parcel needs to be 
presented to CBP for inspection. CBP is working to implement 
the same system in the international mail environment. Together 
with the United States Postal Service, we have been conducting 
an advance data pilot on express mail and e-packets from some 
countries. We continue to work with the U.S. Postal Service to 
address the issue of electronic advance data.
    Thanks to the support of Congress, CBP has made significant 
investments and improvements in our drug detection technology 
and targeting capabilities. For example, at the National 
Targeting Center, CBP leverages advance information alongside 
law enforcement and intelligence records to identify smuggling 
trends and target shipments that may contain illicit substances 
or related equipment being diverted for illicit use, such as 
pill presses, tablet machines, or precursor chemicals.
    In addition to their experience, training, and intuition, 
CBP officers and agents use various forms of technology and 
equipment to detect synthetic drugs hidden on people, in cargo 
containers, and in other conveyances. Data from substances 
believed to be or to contain fentanyl and found in the mail or 
in express courier packages is transmitted to CBP's 
Laboratories and Scientific Services for interpretation.
    At land ports of entry, instruments provide a readout 
directly to officers and agents. The low purities of fentanyl 
found along the southern border, usually only about seven 
percent of controlled substance content, make the detection of 
fentanyl particularly difficult.
    Canine operations are another invaluable component of CBP's 
counternarcotic efforts. CBP is currently working to safely and 
effectively add fentanyl as a trained odor to deployed narcotic 
detection canine teams.
    CBP has also implemented a program to provide training and 
equipment to keep our front-line employees safe from accidental 
opioid exposure. Through our ongoing pilot program, CBP 
officers are trained to recognize the signs and symptoms of an 
opioid overdose and administer naloxone, a potentially life-
saving drug for the treatment of opioid overdoses.
    CBP will continue to do all we can to refine and enhance 
the effectiveness of our detection and interdiction of fentanyl 
and other dangerous synthetic opioids through the mail and 
across our Nation's borders.
    Chairman Portman, Ranking Member Carper, and distinguished 
Members of the Subcommittee, thank you for the opportunity to 
testify today and I look forward to your questions.
    Senator Portman. Thank you, Mr. Perez. Ms. Whitcomb.

 TESTIMONY OF TAMMY L. WHITCOMB,\1\ ACTING INSPECTOR GENERAL, 
                  UNITED STATES POSTAL SERVICE

    Ms. Whitcomb. Good morning, Chairman Portman, Ranking 
Member Carper, and Members of the Subcommittee. Thank you for 
inviting me to discuss our work on inbound international mail.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Whitcomb appears in the Appendix 
on page 101.
---------------------------------------------------------------------------
    First, let me provide some context. We started examining 
this area two years ago after we received complaints that the 
Postal Service was not presenting mail to Customs and Border 
Protection for screening as required. After looking into it, we 
determined audit work was needed. Given our role as the Office 
of Inspector General (OIG) for the Postal Service, we focused 
on the Postal Service's procedures and its coordination with 
CBP. We did not review CBP's operations, although we did talk 
to their staff to gather information.
    Also, both CBP and the Postal Service provided information 
used in our reports. They considered some details sensitive and 
requested redactions in the public versions of the reports 
posted on our website.
    Inbound international mail primarily enters the postal 
system at five International Service Centers around the 
country. Generally, all inbound international mail is subject 
to inspection by the CBP and the Postal Service must present 
for inspection all the mail that CBP requests.
    The Postal Service received 621 million pieces of inbound 
international mail in fiscal year 2016. Almost half were 
packages. The growth of e-commerce has caused inbound package 
volumes to nearly double in the last three years, causing 
challenges for managing this flow of traffic. More than half of 
the package volume is from ePackets, which are small tracked 
packages under 4.4 pounds.
    Given the growth of international package flows to the 
Postal Service, there is a need to find more effective ways to 
manage inbound traffic. Some foreign posts send the Postal 
Service advance electronic customs data, which includes 
information on the sender, addressee, and contents of the mail 
piece. This data helps both with processing and inspecting 
inbound mail.
    International postal regulations are beginning to change in 
recognition of the importance of posts providing advance 
electronic customs data. The Postal Service can also require 
this data through bilateral agreements it makes with foreign 
postal operators. However, our audit work found instances of 
bilateral agreements where the Postal Service had not requested 
this advance customs data.
    Since November 2015, the Postal Service has been piloting a 
joint initiative with CBP in New York. CBP is integrating its 
data systems with the Postal Service's systems to use advance 
data to target packages for inspection. The Postal Service and 
CBP intend to expand this pilot to new locations before the end 
of the fiscal year.
    We have issued five reports on inbound international mail 
operations since September 2015 and found several problems with 
the presentation of inbound packages to CBP:
    First, Postal Service employees sometimes began processing 
packages before arrival scans had been input into the system. 
This could result in pieces missing customs screening or in the 
acceptance of inappropriate or unknown shipments.
    Second, problems with scanning during processing into and 
out of customs meant that the Postal Service could not always 
determine whether a package was in CBP's custody or its own.
    Third, and most significant, at times the Postal Service 
just did not present packages to CBP for inspection when 
requested. Instead, the packages were processed directly into 
the mail stream.
    These failures occurred for several reasons including human 
error and electronic system problems. An additional factor is 
that the Postal Service and CBP do not have a formal written 
agreement regarding the appropriate procedures.
    To address our findings, we have made 11 recommendations in 
areas such as enhancing systems, providing employee training 
and oversight, improving scanning data, ensuring items are 
presented to CBP, requesting advance electronic customs data 
from foreign posts, and coordinating with CBP to establish a 
formal agreement regarding presentation requirements. The 
Postal Service agreed with these recommendations and has taken 
sufficient action to close five of them. Six recommendations 
are still outstanding--including establishing a formal 
agreement with CBP.
    Ensuring the safety and security of inbound international 
mail is a critical challenge for the Postal Service and CBP. 
More effort is needed to quickly fix problems in the current 
process and to make sure CBP receives as much electronic 
customs data as possible. My office will continue to monitor 
this issue, and we will work with our colleagues at the 
Department of Homeland Security Office of Inspector General on 
any related work that they conduct.
    Thank you.
    Senator Portman. Thank you, Ms. Whitcomb. Mr. Schenk.

TESTIMONY OF NORM T. SCHENK,\1\ VICE PRESIDENT, GLOBAL CUSTOMS 
        POLICY AND PUBLIC AFFAIRS, UNITED PARCEL SERVICE

    Mr. Schenk. Thank you, Chairman Portman, Ranking Member 
Carper, and distinguished Members of the Committee. I 
appreciate the opportunity to appear before you today to 
discuss how providing the necessary data to Customs and Border 
Protection and other government agencies can help target 
contraband and weed out bad actors seeking to import dangerous 
goods and counterfeit items into the United States.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Schenk appears in the Appendix on 
page 106.
---------------------------------------------------------------------------
    Mr. Chairman, my presence here today, the Thursday before 
Memorial Day weekend, is quite literally deja-vu. I provided 
similar testimony on this very same day 17 years ago, in the 
year 2000, to the House Subcommittee on Criminal Justice, Drug 
Policy, and Human Resources. The hearing then was titled 
``Drugs in the Mail: How Can It Be Stopped? '' For that 
hearing, I was asked to do the same thing--walk through the 
processes that UPS follows to supply advanced data to CBP that 
will enable them to screen for high-risk packages being 
imported into the United States.
    Unfortunately, since 2000, the problem of importing illicit 
goods into the United States has only grown worse. Enabled by 
the Internet, bad actors are getting smarter and smarter, using 
every avenue available to send illicit goods into the United 
States. Back in 2000, the issue of illicit drugs in the mail 
was centered on amphetamines and ecstasy. Today the threat is 
fentanyl and high-tech opioids. The volume of parcels coming 
into the United States has increased substantially, 
particularly from foreign posts, which now send almost 90 
percent of packages into this country.
    UPS delivers more than 19 million packages and documents 
every day in over 220 countries and territories around the 
world. We work hard to be United Problem Solvers. Our business 
processes are complex and our technology advanced. We also work 
closely with CBP, at our own expense, to comply with and even 
exceed existing legal requirements. The key to making this work 
is the advance electronic data we provide which enables CBP and 
47 other government agencies to target high-risk inbound 
shipments and screen them out of the network, and sometimes 
that is as much as 36 hours in advance. This data can also be 
used to screen for counterfeit products and contraband, another 
growing problem. We also apply technologically advanced network 
capabilities that enable us to locate any suspect package in 
our system at any given time so it can be retrieved and 
tendered to legal authorities for additional screening.
    In 2000, when I testified before the House Government 
Oversight Committee, there were about 21 million package 
shipments entering the United States annually--about 10 million 
through the private sector which were accompanied by advance 
electronic data, and 11 million through the international mail 
system which did not have any electronic data. Even 17 years 
ago, it was clear that CBP and other Federal agencies could not 
manually screen packages--purely because of volume--and that 
the most effective way of interdicting bad shipments was 
through the use of advance electronic data.
    The volume of packages entering the United States has 
increased many times over. In 2016, foreign posts likely sent 
over 400 million packages to the United States, and the volume 
is rapidly growing. We have been using advance data for years, 
even before it was required by the Trade Act--Bob and I have 
worked together for probably over 20 years on some of these 
things--to provide CBP with item-level detail about each and 
every shipment entering the country. This helps us reduce the 
potential for dangerous goods entering the United States. It is 
also important to note that UPS and other express carriers 
obtain and submit data for all foreign countries, both 
developed and developing, and I could take out my smartphone 
because even in the most remote places, just take a picture of 
it and transfer it on with that.
    In conclusion, if I could take off my UPS hat for 30 
seconds. I do a lot of international travel and work with 
customs agencies around the world on this very same issue. When 
I board a flight back to the United States, I do not look 
around at the passengers looking for suspected terrorists. I 
think about the bags and bags of foreign post packages that are 
loaded in the belly of the aircraft. No one has any idea what 
is in those packages, none whatsoever. The government does not 
allow passengers on a plane without personal information or 
back into our country without a passport or a screening. Why do 
we allow over a million and potentially more dangerous packages 
a day into this country with no requirements for information 
that will allow CBP to do its job more effectively? I urge you 
to take action on this important issue.
    Thank you.
    Senator Portman. Thank you, Mr. Schenk, and I thank all the 
witnesses.
    Senator Carper has generously agreed to delay his questions 
so that we have an opportunity for the two Members who are here 
to ask their questions. I know everybody have other committees 
to go to. I will do the same.
    I would like to start with Senator Lankford.

             OPENING STATEMENT OF SENATOR LANKFORD

    Senator Lankford. Thank you, Mr. Chairman and Ranking 
Member. I appreciate that very much.
    Mr. Thome, tell me about where we are as far as moving on 
advance electronic data and why for developing countries this 
has taken so long when there are some straightforward 
solutions. If they can get the mail to the spot to be able to 
get it out, why they cannot get the data?
    Mr. Thome. Thank you, Senator, for your question. We have 
been working very closely with the UPU to try to move this 
process along more quickly, but the issues that we face in 
developing countries, I would say previously there was a lack 
of will and a lack of understanding that for them to catch up 
with their business models and take part in the e-commerce boom 
that is occurring worldwide, there was not an understanding 
that AED was the key to that. I think the major advance we have 
made--and it is not a statistic, but it is a change of mind-set 
within the UPU--is that countries now understand, regardless of 
their level of development, they have a lot to earn and a lot 
to gain and they can even enhance their economies by taking 
part in this global----
    Senator Lankford. All right. So the encouragement from this 
Congress would be at some point to say packages do not come in 
without it. Obviously, that isolates a lot of countries, and it 
isolates a lot of people who may be able to get materials in. 
But the most straightforward way that we could deal with that 
is just to be able to put a clear deadline out there and say we 
do not allow packages to be able to come into our country 
unless there is some electronic data collection of that in 
advance.
    Mr. Thome. Thank you. Well, as I described in my testimony, 
the global postal system simply is not able to exchange AED 
comprehensively at this time, and a requirement that it do so 
immediately as a precondition to our accepting its mail, it 
would severely restrict the inflows of mail into our country 
and then probably preclude the acceptance of mail not covered 
by a bilateral agreement. And if we stop accepting, cold, other 
countries' mail immediately or on very short notice, we would 
have to anticipate that many would stop accepting ours as well.
    Senator Lankford. Well, I would assume, by the way--I would 
be surprised of anything that Congress could do on short 
notice. However, I would assume that we would set a firm 
deadline to say by this certain date, so that this is not being 
negotiated in the days ahead--this seems to slip year after 
year. My concern is, how do we actually get a certain date that 
is sitting out there on the horizon that we know this will be 
resolved? Because this is only one element of trying to be able 
to stop the illicit movement of drugs in. Clearly, most 
individuals that are shipping fentanyl are not going to label 
their package as containing fentanyl. We are very aware of 
that. So this is only one element of being able to help deal 
with this, but this should be a pretty straightforward element.
    Mr. Thome. I agree that it should be straightforward. I 
think the challenge we face is that other countries just are 
working on other timetables. I think we have made good 
progress, and, again, I think that the question of their own 
needs they now understand.
    Again, the UPU is putting forward half of its cooperation 
budget to helping these countries install the capabilities they 
need. But electricity and the Internet are not available 
everywhere.
    Senator Lankford. Right. But in countries that they are--we 
are still dealing with Germany and France, and the last I heard 
they do have electricity. The United Kingdom does. So we can go 
on and on and on through places that this should be pretty 
straightforward. So we have to be able to get this resolved.
    Let me ask a separate question. Customs and Border Patrol 
and USPS have worked on a memorandum of understanding (MOU) 
relationship for quite a while to try to establish consistent 
methods of how they are going to exchange data. How is that 
working right now? And where are we in the process of getting a 
clear MOU of exchanging information?
    Mr. Perez. The MOU regarding the general operations, 
Senator, and how that functions at our international mail 
facilities and how that mail is delivered is with CBP. We 
expect to give that back with our comments to the U.S. Postal 
Service within the next two to three weeks.
    Senator Lankford. Good.
    Mr. Perez. I checked on that just before I got here.
    Senator Lankford. I appreciate that. That has been 
outstanding for about a year.
    Mr. Perez. Indeed, Senator. The MOU really puts into place 
best practices that have already been in place in a lot of the 
field locations, including JFK back in New York, on how the 
mail is handled, that is, the ones that are coming from 
countries of interest for CBP. I am not aware that it 
specifically gets into the detail of the electronic data. That 
is really more so under the confines of the pilot itself that 
is being run.
    Senator Lankford. Do you have a comment on that, Mr. 
Cintron?
    Mr. Cintron. I just wanted to add to exactly what was said 
here. It has been a year and certainly we have been working at 
each one of our ISCs very closely with Customs and Border 
Protection to make sure that the processes and procedures are 
in place. We have been working through those issues. So it is 
not like we have been waiting for the MOU to get that 
finalized. So we are certainly working. Glad to hear we will 
have it back in a few weeks and get it finalized.
    Senator Lankford. Assuming that gets finalized fairly 
rapidly after it comes back in?
    Mr. Cintron. Yes, you can assume that to be accurate.
    Senator Lankford. That would be terrific, obviously. Again, 
that is just basic operation to be able to help increase 
efficiency in the process on this.
    On the Inspector General side of things, tell me where we 
are as far as the things that we can provide the greatest 
oversight on to make sure they get checked off from USPS. I 
know you gave us a very good list of some items that are 
already being worked through, top items for Congressional 
oversight. What would you list?
    Ms. Whitcomb. I think the MOU is critical, and I also think 
encouraging the Postal Service to work on these bilateral 
agreements with these countries to receive the data. I think 
they are making some really good progress.
    When we first started our work in 2015--and Mr. Cintron 
mentioned it--there was not much data at all available. 
Significant progress is being made and has been made in the 
last two or three years. But it is one of those things that you 
have to continually work on and ensure every bilateral 
agreement has that requirement in it. So those are two things 
that I would encourage.
    Senator Lankford. I would only say to this group I 
appreciate the diligence and the focus on this. As it has been 
seen and been noted already for commercial entities, this has 
been something they have been very persistent on for a while. 
Obviously, they have a more seamless network. They are not 
receiving every single package that comes from every single 
country. They are able to monitor that through their system. 
But it is a system that is achievable in the process.
    I would also note for Customs and Border Patrol we 
appreciate very much the work that you are doing. This is 
incredibly dangerous work. As has already been noted by the 
Chairman in the opening statement, even the smallest amount 
that gets on an individual as they are doing an inspection is a 
life-or-death issue. So from our Committee to all of your team, 
we express our gratitude for what you are protecting the 
American citizens from.
    So thank you. I yield back.
    Senator Portman. Thank you. Senator Carper.
    Senator Carper. Thanks. Thank you so much.
    Sometimes when we have a diverse panel like this but people 
that are highly knowledgeable about a particular issue that we 
are trying to address, I ask them to help us solve the problem. 
I am going to ask you today to help us solve the problem. I am 
going to ask each of you to say: ``If you do not do anything 
else, do at least this,'' ``you,'' Congress, this Committee. 
What is one thing we ought to do like right away?
    All right. Mr. Thome, give us one, ``For God's sakes, do 
this'' idea.
    Mr. Thome. Thank you, Senator Carper.
    Senator Carper. I said earlier this is all hands on deck. I 
am an old Navy guy. It is all hands on deck. We are trying to 
convey a sense of urgency. God knows when we go home, the folks 
that we represent convey a sense of urgency to us, so we are 
trying to convey that as well. Go ahead.
    Mr. Thome. Thank you very much, Senator. I think as we have 
talked about, this is a difficult problem that needs a lot of 
solutions, but in terms of the remit of the State Department 
and our interactions with the UPU, as I said before, we have 
turned the corner, and the countries want AED. I think we have 
to all work together to give a realistic timeframe to it. There 
is urgency to this in our country. I am the first to admit 
that. And as has been discussed, we have an epidemic here that 
cannot wait years and years.
    But with the momentum we have had, I would say, since the 
2012 UPU Congress, it has really accelerated, and countries 
want this. But if they find themselves in a situation where 
they have a Sword of Damocles over their head with a date 
certain, which is why I hesitated to put one on in response to 
the Senator's question previously, we run the risk of losing 
that momentum in that if the mail shipments are stopped or 
threatened to stop to the United States, that could have 
devastating effects on their economy.
    Senator Carper. That is not my question.
    Mr. Thome. Sorry.
    Senator Carper. I was asking you to give me one takeaway, 
one thing that we ought to be doing to expedite this, to move 
it. Give me one.
    Mr. Thome. I think if we put our efforts behind what the 
UPU is doing and keep that moving, along with the efforts 
bilaterally that are happening, we can make this happen.
    Senator Carper. All right. And ``we'' is ``us.'' Give us 
some advice. All right. Give us some advice. What can we do to 
get this moving?
    Mr. Thome. I think in my personal opinion the act that you 
have put forward is on the right track, and it will certainly 
contribute to this. We just need to craft it in a way that is 
realistic to get it done with countries that we cannot order to 
do things, but we need to negotiate and help them see the 
benefit of doing it.
    Senator Carper. All right. Mr. Cintron?
    Mr. Cintron. Yes, I guess for us----
    Senator Carper. There must be some way we can incentivize 
these folks, particularly some of the nations--and Senator 
Lankford mentioned some of the nations that still are not doing 
their share. And they are not Third World nations. There must 
be some way we can incentivize them. Go ahead, please.
    Mr. Cintron. I think one thing we would certainly ask 
support around our strategy to target--focus in on targeted 
countries. We understand that that part, when we look at the 
whole picture for us, our strategy has been to really stay 
focused on where we see the largest volume coming in, and I 
think that is where--we are looking for that cooperation 
certainly, to take that step. As noted here, one of the 
concerns is some of the conditions that we might find in some 
of these other developing countries. But for us, our strategy 
really is going to be to stay very focused and prioritize, and 
we believe through that and through our efforts and what we are 
doing with the AED and the pilot at JFK, we could really push 
this along in order to help Customs and Border----
    Senator Carper. You have not answered my question. I asked 
both of you the same question. What does the Congress need to 
do to help move this along, to expedite this? What do we need 
to do?
    Mr. Cintron. Well, one other thing, Senator, I might ask is 
certainly around the passage of comprehensive postal reform for 
us. There are a lot of things that are tied up in that, and 
anything you can do to help us with that regard certainly helps 
our overall initiatives with everything we are doing.
    Senator Carper. One of the things--and a number of us have 
been working on this for a while, as you know--is we want to 
have additional postal revenues in order that they can, among 
other things, modernize their mail processing centers. There 
are 300 that need to be modernized. They can buy new equipment, 
new vehicles for delivery. They can modernize the post offices. 
It sounds like this might be another use for some additional 
revenues at the Postal Service, and that might be helpful as 
well. Good. Thank you. That is a good takeaway.
    Mr. Perez, good advice for us.
    Mr. Perez. Yes, well, first let me say thank you, Senator, 
for the ongoing support, not just of this Committee but the 
entirety of the Congress, for everything that CBP does and the 
entirety of the effort that we put forth to combat illegal 
narcotic trafficking, and that is where I would specifically 
ask ever so respectfully that that support continue for all 
things narcotic trafficking, because CBP, frankly, we are not 
waiting and do not wait for the evolution of the different 
types of threats and the enhancements that we absolutely need 
to lean forward and do everything we possibly can to interdict, 
to detect, to deter, and dismantle those who would do us harm 
in this fashion.
    And so, whether we are talking about that or whether we are 
talking about tools and technology that we are trying to 
deploy, and even the personnel, that ongoing support that this 
body continues to provide CBP on the overall drug mission is 
absolutely critical, and we appreciate that.
    Senator Carper. Thank you.
    Ms. Whitcomb, same question.
    Ms. Whitcomb. Yes, I think focusing oversight on ensuring 
that the MOU moves forward quickly--and also I just heard a 
minute ago that the MOU does not necessarily cover the pilot 
program. I think that pilot is critical--there are lots of 
lessons learned through that pilot, but expanding that pilot 
quickly across the country to the other International Service 
Centers so that the data that is being received from these 
countries can be used to target specific and dangerous 
packages. So oversight on that.
    Senator Carper. OK. If we have a second round, I want to 
come back and talk about the pilot and those lessons learned.
    The last witness, please. Norm? Seventeen years ago today.
    Mr. Schenk. Pass the STOP Act, and the reason I say that 
is, we discussed it here 17 years ago, and nothing tangible has 
changed, and it is just moving at a snail's pace. And we think 
the right way is to pass the legislation, and we appreciate all 
the fine work that has been done on that.
    We have worked with CBP for years before the Trade Act, and 
I do not know how they do the job that they do on the mail 
because we have our own challenges with all the data, but we 
are talking about the minimum. So pass the STOP Act.
    Senator Carper. All right. Thanks so much.
    Thank you, Mr. Chairman.
    Senator Portman. Senator McCaskill.

             OPENING STATEMENT OF SENATOR MCCASKILL

    Senator McCaskill. So I understand that--first of all, I 
thank all of you. We are all hands on deck, as Senator Carper 
said, on this, and this Committee is busy doing an 
investigation into another piece of this, which is the sales 
and marketing techniques that have been employed by the opioid 
manufacturers. And we are also going to be looking at the 
distributors in terms of that issue internally in our country.
    But I want to focus my time here on the fact that we have 
some of this fentanyl produced in China, sent to the United 
States, where then it is sent to Mexico. Are you all aware that 
this is commonly occurring, that we have a large amount of 
opioids that are moving through our country in that regard? 
Does anybody disagree with that analysis?
    Mr. Perez. Senator, if I can comment, I would share that my 
understanding is that much of the fentanyl coming out of China, 
when in its actual form will come directly into the United 
States. What we have seen that moves from China typically into 
the labs in Mexico that are diluting, creating analogs, and 
then lacing heroin shipments with the fentanyl as well is 
precursors, and moving directly from China into Mexico. I am 
not aware, at least at this current time, of the movement 
southbound from the United States into Mexico, but I will 
gladly take that back.
    Senator McCaskill. My staff has looked into this and 
believes that there is a significant amount of this that is 
moving from China to the United States, the precursors, and 
then going from the United States to Mexico for them to process 
in their labs. If we are getting wrong information, I can live 
with that. If you do not have the information that is accurate, 
I am worried because I think it is really important that we 
understand where this is flowing.
    Mr. Cintron, would you agree that you all believe that some 
of this is coming to the United States and then being shipped 
to Mexico as a precursor to be used in the labs to cut heroin?
    Mr. Cintron. Yes, Senator, I could not specifically respond 
to that, but certainly the Inspection Service part of the 
organization, we could provide you after this hearing,\1\ I 
could provide you information on that.
---------------------------------------------------------------------------
    \1\ The information from Mr. Cintron appears in the Appendix on 
page 176.
---------------------------------------------------------------------------
    Senator McCaskill. So I understand that mail from China is 
not covering the costs to the United States Postal Service to 
handle this mail. Is that correct?
    Mr. Cintron. Again, Senator, I apologize, but I would 
certainly ask your permission to provide any of that 
information post the hearing.\2\
---------------------------------------------------------------------------
    \2\ The information from Mr. Cintron appears in the Appendix on 
page 176.
---------------------------------------------------------------------------
    Senator McCaskill. Well, once again, my staff tells me 
that--the United States Postal Service is underwriting the 
costs of mail coming to here from China, and that just seems 
crazy to me. How in the world does that happen?
    Mr. Cintron. Well, again, unfortunately, I am not able to 
answer that specific question, but I certainly can provide the 
information after the hearing,\1\ Senator.
---------------------------------------------------------------------------
    \1\ The information from Mr. Cintron appears in the Appendix on 
page 176.
---------------------------------------------------------------------------
    Senator McCaskill. Yes, I mean, we are obviously struggling 
to keep the U.S. Postal Service out of bankruptcy. It is one 
thing to be giving Federal Express (FedEx) and UPS a deal on 
the last mile of package delivery, which I have been railing 
about in this Committee for many years. But if we are actually 
making it cheaper for China to use the United States Postal 
Service because we are underwriting our costs there, that is 
really outrageous, and I am anxious to get to the bottom of it. 
So if you would followup as quickly as possible, we would 
really appreciate it.
    Mr. Cintron. Absolutely.
    Senator McCaskill. OK. So for the Trade Act, it is my 
understanding in terms of the private deliveries that they are 
supposed to be having the information on the packages they send 
the name and the address of the recipient coming into this 
country from other countries. But I understand that many times 
all CBP gets is the address of the processing facility where it 
is coming to and not the address of who the actual recipient 
is. Is that accurate, Mr. Perez?
    Mr. Perez. In the context of the U.S. Postal Service, the 
general mail, that is true. That is the type of data that we 
are pursuing through the pilot to begin to get more of that 
Senator.
    Senator McCaskill. I am talking about Phase 2 of the Trade 
Act requiring the name and address of the recipient from the 
private carriers. Has that been fully implemented? Are we 
getting the address and recipient not from the Postal Service, 
but from FedEx and the other private carriers?
    Mr. Perez. From the express consignment carriers? To my 
knowledge, yes, Senator, but I would take that back to make 
sure we can confirm that for you. But from those other 
commercial entities and carriers, we typically do get a pretty 
comprehensive list of information in advance with respect to 
those particular shipments.
    Senator McCaskill. Well, once again, my information based 
on staff's preparation for this and the preparation I have done 
for this hearing is that, in fact, they are not providing the 
name and address of the recipient and that many times all you 
get is the address of the UPS or FedEx processing facility 
where that package is coming. I really would like to know why 
my information is different than yours.
    The other information that I have is that we are not even 
imposing the fines that need to be imposed on the carriers who 
are not following the law. By the way, this is the Trade Act 
that was imposed after 9/11, when we were trying to get after 
the security of our ports and the security of the entry ports 
in terms of our country in terms of goods, people, and 
services. So I will be anxious to hear you follow up about 
that.
    Phase 3 of trade implementation was supposed to be 
penalties for the bad description, and it is my understanding 
that Phase 3 has not been implemented. Does anybody know the 
answer to that question?
    Mr. Perez. I do not have the details on Phase 3 of the 
Trade Act implementation, Senator, at this time. I would gladly 
take that back and get it back to you and your staff.
    Senator McCaskill. OK. If we are not getting the address of 
where the package is going and we are not fining the carriers 
ahead of time so we can actually look to see if this was an 
address that has popped up before--I mean, law enforcement 
needs to be all hands on deck here. If we are not getting that 
and we are not even knowledgeable about whether or not we have 
implemented the part of the law where penalties are enacted, 
our research indicates that sometimes penalties have been 
imposed, but they have been negotiated down by the carrier's 
lawyers from thousands of dollars to $50. If that is occurring, 
that is a huge problem. I am a little worried that folks do not 
have the answers to these questions at this hearing, 
understanding the subject matter of this hearing, and I will 
look forward to getting the answers to them as quickly as 
possible.
    Yes, Mr. Schenk?
    Mr. Schenk. Senator, if I may respond to that, certainly 
from a UPS perspective, we have been providing that 
information, full information of the shipper, the consignee, 
description, value, country of origin, since we started 
bringing international imports into the United States in 1985, 
and the program was developed with CBP.
    I would also say that we have gone well beyond the Trade 
Act, working with CBP with the Air Cargo Advance Screening 
process, which is a voluntary program that was implemented 
after the Yemen bomb attempt on that, where we not only 
transmit the shipper and the consignee, we go the extra mile 
and transmit the multiple consignees when it is e-commerce 
shipments.
    So speaking for UPS, we do not only the required, but we go 
beyond the required.
    Senator McCaskill. So in your opinion, has Phase 3 been 
implemented? Do you believe there are penalties that would 
apply to you if somehow a package came to the United States 
through your company that did not have the address of the 
recipient on it?
    Mr. Schenk. The answer to that one is I do not know how we 
could, because our processes and systems are developed a 
package cannot enter our system unless that information has 
been entered in there, and then it cannot move through--because 
our systems interconnect between UPS and CBP. Practically 
speaking, it could not happen.
    Senator McCaskill. OK. Well, we will follow up on the 
information we have and get information from all of you and go 
forward from there. Thank you very much.
    Senator Portman. Thank you, Senator McCaskill.
    I am going to ask my questions now, and we will have 
another round as well. I know Senator Hassan has agreed to 
stick around, and I appreciate that. And we have another 
colleague who has joined us.
    First of all, I think we need to back up and talk about 
what this hearing is all about, and, Mr. Perez, I expect your 
answer on this, and all of you. Is it helpful to have advance 
electronic data to be able to identify these packages that have 
this poison in them, which is what we are focused on today, 
which is synthetic opiates that are coming into our country, 
killing more and more of our citizens every day? Do you want to 
have that advance electronic data? And is that helpful for you 
to be able to stop some of this poison from coming into our 
communities? Yes or no.
    Mr. Perez. Unquestionably, Mr. Chairman, having the advance 
electronic data, as we do receive for all of the types of 
cargos, is a key tool in our ability to manage and assess risk, 
to focus and target those threats that may warrant a greater 
inspection, potential threats that may warrant greater 
inspection cargos, people, conveyances of all types. And so, 
unquestionably, having that data and working toward or getting 
that advance data and making sure that it is of high quality 
and reliable for us to do that work is a high priority and the 
reason why we are working so closely with our colleagues to get 
to that point.
    Senator Portman. Otherwise, it is like the needle in the 
haystack I talked about earlier, and, I meet with your folks 
back home, and they use the exact word you just used, ``This is 
a tool we desperately need.'' Otherwise, we are just not 
effective at stopping this stuff. And it is other contraband as 
well, but we are focused here on a crisis. I appreciate the 
State Department perspective on diplomacy and trying to work 
with other countries, and I really appreciate you, Mr. Thome, 
saying that you think the STOP Act is on the right track. But 
the notion that other countries are working on their own 
timetables and some countries do not have electricity, China 
has electricity, and we know where this stuff is coming from. 
Some of it is coming from India as well. They have electricity, 
too. Mr. Cintron, I understand your concern about having to 
apply this to all countries, and you noted in your comments you 
prefer it to be targeted to countries that are known to be 
sending us this poison. Let me just follow up on that a little 
bit. Senator Carper and I talked about this yesterday. We are 
working also on this issue of countries that circumvent our 
trade laws because they have a tariff attached to them, because 
of a dumping order, let us say, and they just simply ship the 
product to another country. Why would that not happen here? If 
you said we are only going to target, a couple countries where 
we know they are countries of interest, why would they not just 
ship it through another country, say Vietnam, Malaysia, or 
Indonesia, and still have these poisons come into our country? 
Can you answer that question?
    Mr. Cintron. What I would say is this: Our focus, our 
strategy, as I spoke, is to prioritize the list, right? So take 
a look at it, make a risk assessment, and target those 
particular countries. Certainly the Inspection Service working 
in collaboration with the other law enforcement agencies I 
think is probably the other key, right? So as you collaborate, 
we share information, if those events occur, I think then we 
refocus and do that.
    I guess our point is there is a starting point, and our 
piece was around where is the highest risk, where do we see the 
highest volume, and how do we go to your point on capacities? 
Those particular countries that have it, we should really be 
focused on those and get that information.
    Senator Portman. No question it is a crisis and we want you 
to prioritize, but, unfortunately, what we have seen is there 
is transshipment of this stuff, and it is going to simply be 
shipped to other countries from the evidence that we have. You 
noted earlier that it is voluntary now. I would ask you, do you 
have enough data? Your answer is going to be no, because you 
would like more advance electronic data from these other 
foreign posts.
    So, again, what our legislation says is, it is time to 
follow up on what Congress passed 15 years ago, which was 
asking the then-Cabinet Secretary in charge, now Homeland 
Security and the Postal Service and the Commissioner to come up 
with a plan. Norm said he testified 20 years ago, even before 
that, I assume that was in the context of preparing for the 
2002 Trade Act.
    So I would just make the point broadly that we do have a 
crisis. We have all acknowledged that. This is not business as 
usual, and if other countries are working on their own 
timetable, that does not work. That dog does not hunt because 
it is an epidemic. You noted, Mr. Thome, which I thought was 
interesting, that advance electronic data is in their interest, 
too, and there is a consensus now, you said, among countries 
around the world that they need to provide it. Well, let us get 
moving on it.
    Another question I would have is for you, Mr. Perez. You 
talked about canines. I just have to ask you this question, 
because I asked this same question of one of your colleagues at 
a roundtable discussion at this very spot about a year ago, and 
I was told that sniffing dogs do not work because the dogs 
could die from sniffing a package or a letter with fentanyl in 
it. What is the situation with regard to monitoring generally 
and screening? Many of us support legislation to provide more 
funding for more inspection. But specifically with regard to 
canines, does that work or is it too dangerous?
    Mr. Perez. Thank you, Mr. Chairman. On the canine front, we 
are currently in a test phase to train the canines for the 
specific odor. As you probably know, they are trained for a 
variety of narcotic odors, and so depending on the actual form 
and nature of the narcotic, they may detect and/or be able to 
alert to some of the opioids. But we are specifically training 
them in a very safe way with the types of odors that are 
generally emitted from fentanyl and such, not with actual 
fentanyl but with our Laboratory and Scientific Services folks 
to make sure that we are doing so in a safe way. Nevertheless, 
we are enabling that tool, along with the other technical and/
or electronic tools that are at our disposal, and are actually 
taking readings from the suspect packages and sending the 
spectra back to our labs to determine whether or not there is a 
presence of fentanyl and other opioids.
    Senator Portman. I would like to think it could be done 
safely. The dogs do not have the masks we talked about earlier, 
and gloves that they can put on, so I would suspect it is still 
a huge danger to them. Much better to have targeted packages 
where you have reason to suspect a package by having this 
advance electronic data. I assume you would agree with that.
    Mr. Perez. Absolutely, Mr. Chairman.
    Senator Portman. Ms. Whitcomb, you talked about the pilot 
program, about the lack of coordination between the Postal 
Service and CBP and the need for a memorandum of understanding 
(MOU), and a written agreement you said is necessary. You said 
you had 11 recommendations, six of which are still outstanding. 
You said we ought to expand this pilot quickly. Have you looked 
at our legislation? Do you think our legislation, the STOP Act, 
would help to expand that pilot quickly?
    Ms. Whitcomb. We did look at the legislation. We did not do 
a detailed analysis of the impact of the legislation on the 
Postal Service. We are supportive of the general idea in the 
legislation about increasing the amounts of advance electronic 
data. However, the impact of that on the Postal Service is 
something that we have not done a detailed analysis of. We do 
believe, as we said in our statement, that additional data 
would be really helpful, and I think the pilot is moving in 
that direction as well.
    Senator Portman. Well, that is what the STOP Act is about, 
is making that mandatory and moving away from just making it a 
pilot, but making it a requirement.
    Mr. Schenk, just quickly for you, and then I will turn to 
my colleagues. You talked about testifying in 2000 on this, 17 
years ago, and the fact that you get your data to CBP sometimes 
36 hours in advance. Thirty-six hours in advance gives them 
time to be able to respond to it.
    Tell us how you do that. How do you do what the Post Office 
has not been able to do over the last 15 years since the Trade 
Act.
    Mr. Schenk. Thank you, Chairman. It really starts with the 
collection of the data, and it depends on the size of the 
customer, but the bottom line is for the large multinationals 
we have software and direct interfaces with them. But even in 
the individuals that walk into one of our UPS stores, it can be 
input. So we get the information into the system immediately.
    As soon as the package is picked up, that is what actually 
is the indicator, and every 15 minutes our system automatically 
transmits to CBP so that we can get the information to them as 
early as possible. That was part of the collaborative effort 
that I think from the business side we have a shared 
responsibility to do that. Then depending on what is going on 
with the shipments, they communicate back with what is going 
on, but the principle and foundation of what we do for CBP is 
let us get the data and let us get it to you as soon as 
possible so that you can begin that.
    Now, there is a couple of transmissions--it gets a little 
technical, but it is very, I think, good----
    Senator Portman. When the package is picked up, the data 
goes and the law enforcement folks of 47 agencies we talked 
about have access to it. Senator Hassan.
    Mr. Cintron. Chairman, can I clarify?
    Senator Portman. Yes. I want to get to Senator Hassan. She 
has been very patient. If you do not mind, we will do a second 
round, and I will have the opportunity to speak with you as 
much as you would like. Senator Hassan.

              OPENING STATEMENT OF SENATOR HASSAN

    Senator Hassan. Thank you, Senator Portman and Ranking 
Member Carper, for allowing me to participate in this 
Subcommittee and for your leadership on the STOP Act.
    I do want to just take a minute also to echo Senator 
Carper's reminder that while we are focused today on the supply 
of illicit drugs and especially the precursors to these 
synthetics like fentanyl and carfentanil, we have to continue 
to also focus on the demand side here at home, which is why 
Medicaid expansion and continuing work to make sure people can 
get treatment--and we are working on prevention as well--is so 
important.
    As you all probably know, New Hampshire is one of the 
States that has been hit hardest by the opioid epidemic. Last 
year, 70 percent of our overdose deaths involved fentanyl; 80 
percent so far this year involved fentanyl. We are seeing 
acetyl fentanyl, so an analog of fentanyl, and just in the last 
six weeks or so, we have seen now six deaths for carfentanil. 
So to echo what my colleagues are saying, everywhere we go we 
are talking to people from all walks of life whose lives have 
been taken or ruined or impacted, and it is a drain on not only 
our lives and our communities, but our economy as well.
    I wanted to focus just a minute, because in my last 
briefing with the DEA at home, they recounted to me in very 
graphic and vivid details how dangerous fentanyl and 
carfentanil is for our law enforcement and first responder 
personnel, and that obviously extends to people who may be 
handling these substances through the postal system.
    We know you can overdose by touching this stuff with a bare 
finger or breathing it in. Carfentanil in particular is 
changing the way our law enforcement is dealing with everything 
about the way they enter a suspect's home to a crime scene 
afterwards.
    We also know we do not want to put third parties like USPS 
personnel at risk, so let me just start, Mr. Cintron, with you. 
What has the Postal Service done to help address these risks to 
USPS employees? And can we both protect our workers but make 
sure that law enforcement has the tools that they need to 
investigate and crack down on the supply of these synthetics?
    Mr. Cintron. Yes, Senator. The USPS has over 600,000 
employees, so from processing to delivering the mail, 
transporting the mail, all of our employees are involved in 
that supply chain of doing so. And on a regular basis, whether 
it is at International Service Centers or other processing 
centers around the country, delivery operations, we do a lot of 
training with our folks around hazardous-type conditions. We 
have seen tragedy in the past in this organization, so we are 
very well aware of effects of what that can do.
    Our focus really is to constantly and consistently train 
employees, and we do the same with our Inspection Service, 
which does a lot with our processing facilities as well for 
oversight and investigating and addressing issues that we find 
in the mail.
    Senator Hassan. Thank you, and I will ask Mr. Perez to 
comment. You discussed steps CBP has taken to protect its 
personnel, and I would love it if you could expand and again 
talk about the balance here. I know of an agent in New 
Hampshire who was doing everything right. She was all masked 
and gloved, and then she took off a glove to handle the 
suspect's cell phone, and she OD's, brought back by multiple 
doses of Narcan. So I was very concerned about it.
    Mr. Perez. Well, thank goodness, Senator, and thank you. 
Beginning in 2015, in fact, we began a very comprehensive 
training and instruction that was deployed to all our front-
line officers and agents, the people who would typically 
potentially come in contact with these substances that went 
into great depth on the proper handling, the personal 
protective equipment (PPE) that they need to don and wear if 
and when they encounter a parcel of any type, or a person for 
that matter, that may be carrying--a vehicle as well, where 
they believe the presence of these dangerous opioids may be.
    So in addition to that, we began our naloxone program as 
well so that we have those countermeasures deployed in over 34 
locations now over the past two years. Those locations include 
all the busiest express consignment facilities, all the busiest 
international mail facilities, and the locations along the 
southwest border where we see the most trafficking in these 
types of opioids.
    The last point I will make in addition to all that is that 
we have also deployed over 600 doses of Narcan in addition to 
the naloxone throughout the country. As a side note, the 
officers and agents that are typically trained in actually 
utilizing these are EMS-certified CBP officers and/or agents. 
So that is pretty much what we are doing, and we continue to 
make sure that that training, that awareness is ongoing, and 
that we do absolutely everything we can, particularly with the 
uptick in our encounters with these drugs.
    Senator Hassan. OK. And, Mr. Schenk, I am going to ask you 
to answer the same thing. Obviously, the concern here is if, 
for instance, law enforcement thinks that they are putting 
third parties at risk through certain kinds of undercover 
operations, then they are going to stop doing it. We obviously 
need to be able to continue investigations. So it is helpful to 
hear that training is ongoing. But how does UPS address this 
issue?
    Mr. Schenk. I will be honest with you, I really do not know 
the answer, but I will get back to you on that.
    Senator Hassan. There used to be certain kinds of 
undercover operations that, I think law enforcement is taking a 
look at because of the risk to people handling a package that 
they may not know has an illicit and deadly substance. So it 
would be great if you would look at it.
    Mr. Schenk. I will get back to you.
    Senator Hassan. The one other thing I wanted to ask Mr. 
Thome, you discussed in your testimony that fentanyl and other 
synthetics are bought online, bought both on the open web and 
the dark web. So what efforts are being made internationally to 
crack down on illegal purchases of these synthetic drugs and 
the precursor chemicals that are used in them? I know a lot of 
what we are doing here, but what is happening internationally?
    Mr. Thome. The State Department is engaged in extensive 
negotiations with countries that we feel are sources for these 
kind of things. I cannot give you a comprehensive answer across 
the board, but I did talk with our Bureau of Narcotics and Law 
Enforcement, and they did give me some information on what has 
happened with China, which is of great concern and has been 
brought up, so I could share that with you.
    So in response to repeated U.S. requests made through the 
bilateral joint liaison group that we have with China on law 
enforcement, China has, in fact, domestically controlled now 
more than 134 synthetic drugs, including carfentanil. So this 
is an advance that we have made in getting them to see this.
    China's decision to domestically control, for example, 
carfentanil, which has caused the deaths in the United States 
that you mentioned, is a welcome measure, and we hope we can 
continue working with the Chinese. In many cases, the Chinese 
argue to us that these are not causing problems in their 
country, and we have succeeded in convincing them that even if 
that may be something they claim, they are causing problems in 
our country, and we want them to take measures.
    So, again, we continue that process. There is a lot of work 
left to do, but we have had that success.
    Senator Hassan. Thank you very much, and thank you, Mr. 
Chairman.
    Senator Portman. Thank you. Senator Tester.

              OPENING STATEMENT OF SENATOR TESTER

    Senator Tester. Thank you, Mr. Chairman.
    So for you, Mr. Schenk, the packages are dropped off at a 
UPS facility, whether it is here or in some other foreign 
country. You are able to track those with a code, to 
electronically track them, share information with the Customs 
and Border Protection, and that is pretty much your system, 
correct?
    Mr. Schenk. That is correct.
    Senator Tester. OK. And the Postal Service, tell me why you 
cannot do the same thing.
    Mr. Cintron. For inbound packages coming in, foreign 
shippers ship to a foreign post, and then they tender into the 
USPS, so we do not have that direct connection at a point of 
origin.
    Senator Tester. OK. So, State Department, why we cannot 
require that from the shippers in foreign countries, their 
equivalent of their post office?
    Mr. Thome. Well, as my colleague from the Postal Service 
says, unlike the express shippers that control both ends of the 
transaction, we do not control both ends.
    Senator Tester. But why we cannot tell them that they 
cannot utilize our post office unless they have an electronic 
tracking number on it that we can track and share with CBP to 
cut down on this baloney?
    Mr. Thome. Our treaty obligations at the UPU, which is an 
organization based on reciprocity for the exchange of 
international mail----
    Senator Tester. Right. Would we do that for them, by the 
way? Would we give them an electronic tracking if they 
requested?
    Mr. Thome. We have offered, and we certainly would like to 
be able to share data with them if they have the capacity to 
use it. We would.
    Senator Tester. So here is the problem. The Ranking Member 
and the Chairman talked about the fact that we have a problem 
in this country. And we have a problem in this country. So I 
get it, they do not want to do it. I do not want to do a lot of 
things that I am told to do. So why we do not hold their feet 
to the fire? I mean, the truth is, would it have some impacts 
on our country? Yes, it would probably have some economic 
impacts. But I am here to tell you not doing is having economic 
impacts.
    And so, is there any way people could roll up their sleeves 
and say, hey, look, we have people dying every day in every 
State in the Union from this crap, and it is time to say, 
``Enough''?
    Mr. Thome. Mr. Senator, I would definitely argue that we 
are doing our level best to hold their feet to the fire and to 
demonstrate to them----
    Senator Tester. Has the threat been made that you are not 
going to be able to ship it via the Postal Service if you do 
not do this?
    Mr. Thome. We have not made that explicit threat. That, 
again, would be outside of our treaty obligations.
    Senator Tester. It is actually not a threat. It is a real-
life situation. I mean, look, we can pat people on the back and 
say, ``Please,'' but that has not worked. So, I am not in the 
negotiation, so I do not know what you guys are faced with. But 
I do know what we are faced with in this country, and this is 
costing a pile of money and ruining a lot of lives. I would 
just encourage you the next time the UPU meets to buckle down 
and do it. Otherwise, we might have to do something pretty 
draconian at this end, and I am not sure that we want to go 
that direction. OK?
    Mr. Thome. I take your message, Senator, and I want to 
assure you that we are working very hard to demonstrate the 
urgency on this.
    Senator Tester. Thank you. And I appreciate that. And it is 
not you, by the way. It is just the general overall thing. I 
appreciate you all being here, by the way.
    The Inspector General, that might be you, Ms. Whitcomb, 
came up with some audit reports on inbound international mail 
to the Postal Service, and this question is for you, Mr. 
Cintron or Mr. Perez, or both. There were 11 recommendations. 
Five of those have been closed. If my math is correct, six are 
still open. One of the recommendations was that the Postal 
Service establish an MOU with the CBP to better clarify 
inspection requirements on packages and sit down to establish 
that process. Why are we not doing this?
    Mr. Cintron. Yes, earlier today we did speak; my colleague 
Mr. Perez indicated that within the next three weeks we will 
have the MOU that is sitting up right now with Customs and 
Border Protection. It will be tendered back to the Postal 
Service. Collectively in collaboration, we will then get that 
hammered out and get it in place as soon as possible.
    Senator Tester. OK.
    Mr. Cintron. Just to reiterate for the record, we have not 
waited for the MOU. A lot of these things we work collectively 
or collaboratively with customs locally to get these things in 
place.
    Senator Tester. Good. Appreciate that.
    Mr. Cintron. It is going to happen.
    Senator Tester. Do you agree with that assessment, Mr. 
Perez?
    Mr. Perez. In fact, Senator, yes. I mentioned earlier the 
timeline of getting that delivered and that it is in effect 
codifying, if you will, many of the best practices and 
procedures that are already in place in the international mail 
facilities around the country.
    Senator Tester. So if I might, Mr. Chairman, when you get 
that MOU signed three weeks from now, would you rifle a copy 
off to the leadership of this Committee so we know it is done?
    Mr. Cintron. We can provide it.
    Senator Tester. OK. Thank you.
    One more thing, and this goes to Mr. Cintron, Mr. Perez, or 
Ms. Whitcomb, whoever would like to respond, if not all of you. 
And, that is, is there legislation that is required in order 
for you to take swifter or stricter actions to prevent these 
poisons from coming into this country? Or do you think you have 
the ability to do it with what is on the books now? Anybody can 
go. Mr. Cintron.
    Mr. Cintron. Yes, could you repeat one more time, Senator?
    Senator Tester. The question is: Do you require further 
legislation to be able to take swifter and stricter action to 
prevent these poisons from coming into the country? Or do you 
have enough latitude with the rules that are on the books now?
    Mr. Cintron. Yes, I----
    Senator Tester. Is there legislation that is needed for you 
to be able to stop these drugs from coming in? That is the 
question. Or do you have the latitude to do it today?
    Mr. Cintron. I would defer to the State Department, maybe, 
or Customs to maybe answer.
    Senator Tester. Mr. Perez.
    Mr. Perez. Yes, Senator, we are very comfortable with our 
authorities.
    Senator Tester. Good.
    Mr. Perez. Nevertheless, again, I just would continue to 
emphasize the unquestionable need to further the efforts to get 
the advance information.
    Senator Tester. All right. Ms. Whitcomb, do you have 
anything you would like to add?
    Ms. Whitcomb. I would just piggyback on what Mr. Perez 
said, that the timing of rolling out this pilot I think is 
critical to this legislation does not go into----
    Senator Tester. I would just ask that if you have any 
recommendations that need to be changed within the code, do not 
be afraid to tell us. That would be helpful. All right?
    Thank you all for being here today. I very much appreciate 
it.
    Senator Portman. Thank you, Senator Tester. Senator Daines.

              OPENING STATEMENT OF SENATOR DAINES

    Senator Daines. Thank you, Mr. Chairman.
    Mr. Chairman, I want to thank you for your personal 
leadership on this issue. The people of Ohio and the people of 
this country would have been very proud, what I saw six weeks 
ago. I was with the Chairman in Beijing. We had meetings with 
the chairman in China, the Chairman of the NPC, Zhang Dejiang, 
number three in charge of all of China, followed by a meeting 
with the premier, Li Keqiang. Mr. Chairman, you were very 
direct in asking for help from the Chinese Government at the 
very highest levels to deal with issue of the source of 
fentanyl and carfentanil, and thank you. I saw that behind 
closed doors, and thank you for your leadership that extends 
and influences beyond this country and around the world to stop 
this scourge.
    Senator Portman. Thank you, Senator.
    Senator Daines. Thank you for testifying today before our 
Committee. In recent years, in my home State of Montana, we 
have been facing a meth epidemic. I realize it is something 
that started with the opioids and meth in the Northeast, 
working its way across the country. It is in Big Sky country as 
we speak.
    Largely, the import of meth is coming from Mexico. It has 
gripped my State, and it has shown the somber and sad signs of 
the drug's widespread presence. In fact, in December 2016, the 
Montana Department of Justice (DOJ) issued a report that there 
were 14 children that died in our foster care system; 11 of 
those 14 children died as a result of household drug use, and 
four of those were specifically linked to meth. That is not the 
way you are supposed to grow up with a child in our great 
State.
    In addition, the Montana Department of Justice Division of 
Criminal Investigation has seen since 2010 to 2015 a tripling 
of the number of cases they are addressing as it relates to 
meth. Meth has left its mark on Montana through increased 
incarcerations, increased death, heartbreak, and in straining 
our community resources to keep up. To stop the importation of 
meth at its source would go far to begin the healing process in 
States like Montana.
    Mr. Cintron, in your written testimony, you mention that 
from fiscal year 2015 to the present, the use of advance 
electronic data for inbound international mail increased from 
approximately one percent to somewhere in the 40-to 50-percent 
range. And I know in Montana, Mexico has specifically been 
identified as an overwhelming source of meth.
    My question is: What countries have been either 
collaborative or particularly unresponsive in sharing advance 
electronic data? And the second part of that, has Mexico been 
at all helpful in providing the necessary data?
    Mr. Cintron. Yes, I could provide that information after 
the hearing. We have many countries that we have agreements 
with, like, I called out before that we have bilaterals with 
many other countries that we are receiving advance electronic 
data from that make up that 40 to 50 percent. But I can 
certainly provide you some better information after the hearing 
specific to Mexico.
    Senator Daines. And any zeroing in on a couple of specific 
countries, as you mentioned, Mexico and China are the largest 
sources of illicit drugs. Have they been responsive in working 
toward the Universal Postal Union's 2020 implementation date 
for universally providing advance customs data or are we just 
grasping at the air on this one?
    Mr. Cintron. As it relates to China, certainly, again--and 
I can provide better data--absolutely we are seeing substantial 
data that comes back, the advance electronic data from them, 
and I can certainly provide you that information after the 
hearing.
    Senator Daines. OK. Thank you. I would appreciate that.
    Mr. Schenk, you mentioned in your testimony that the UPS 
delivers more than 19 million packages and documents each day 
while providing the advance customs data. Could you share, Mr. 
Schenk, one, how many packages containing illicit drugs are 
removed from delivery by CBP due to the use of advance customs 
data? And, number two, what percentage might those packages 
represent?
    Mr. Schenk. Thank you, Senator. For that, the reality is we 
are not perfect. We would like to say that no bad people are 
going to use our network, but they certainly attempt to do 
that. Fortunately, with the relationship that we have with 
Customs and Border Protection and sharing information, we do 
find ways to interdict it, and we do get some occasional 
shipments. We have had several shipments of fentanyl over the 
past year that were seized by CBP, and then we also had 
actually a little bit more in terms of numbers of shipments of 
meth that was mentioned earlier that got seized with that, and 
we work with CBP.
    In terms of percentage of it, it is minuscule. One of the 
reasons that we would hope that the bad people do not try and 
use our network is because of all the programs that we do, and 
actually what we are talking about here is kind of 101 border 
level stuff with that, plus our ability to track and trace and 
then work with the local authorities, which we do on 
investigations.
    Senator Daines. Mr. Cintron, do you have an idea of the 
estimate of the percentage of packages under current practices 
that are flagged because of illicit drugs?
    Mr. Cintron. I would have to defer maybe to Mr. Perez to 
answer.
    I can provide you the data after the session. It is a very 
small percentage, but we can certainly provide that information 
after the hearing.
    Senator Daines. And small is, I guess, less than one 
percent? Less than five percent? Any sense of how small is 
small?
    Mr. Cintron. Do not have that exact.
    Senator Daines. OK.
    Mr. Cintron. But I will provide that.
    Senator Daines. OK. Thank you.
    Let me just close by saying I do believe the most effective 
way to end the meth crisis in a State like Montana and allow 
this healing process to begin is going to be by cutting off 
meth at its source. Yes, we have to work on our demand issues, 
but we can work together here on source. We will need the 
collaboration between the USPS, CBP, and our foreign post 
stakeholders. And if our foreign post stakeholders decide not 
to cooperate, I do think we need to take stronger action and do 
put America first in this equation.
    Thank you, Mr. Chairman.
    Senator Portman. Thank you, Mr. Daines. Senator Heitkamp.

             OPENING STATEMENT OF SENATOR HEITKAMP

    Senator Heitkamp. Thank you so much, Mr. Chairman, for 
taking on this issue. It is critically important. I remember a 
conversation we had last Congress. DEA was in the room, and 
when I suggested that they may want to use drug dogs to detect 
fentanyl packages, the DEA agent told me that would not be wise 
given that if they actually could smell it, they would die. The 
dogs would die. So we are dealing with an incredibly dangerous 
material. And this is moving through the Postal Service, and 
every postal worker who touches a package is at risk.
    And so, for the Postal Service, it is not just about 
processing and getting things through, but it really is an 
issue of care for your employees. So I just wanted to raise 
that.
    Ms. Whitcomb, we noted in your testimony that the Postal 
Service OIG report, your audit work, found that the Postal 
Service had the ability to request advance custom data under 
several bilateral agreements, but opted not to do that in 
certain circumstances. Why did the Postal Service make that 
determination? What would you recommend in response?
    Ms. Whitcomb. Yes, I think most of the bilaterals that did 
not have these requirements in them were older bilateral 
agreements. More recently, the negotiations on bilaterals have 
included this requirement, so I believe it is more of a timing 
issue and recognizing the importance of this. I think it has 
improved over time, I should say. But some of the ones that we 
had reviewed that did not have this requirement were older 
bilateral agreements.
    And Mr. Cintron may know a little bit more about the 
direction the Postal Service is taking to include this more 
consistently in the bilateral agreements than I do at this 
point.
    Senator Heitkamp. Mr. Cintron.
    Mr. Cintron. Yes, Senator, all new bilateral agreements 
require advance electronic data.
    Senator Heitkamp. OK. And this is for anyone on the panel. 
It appears that one of the arguments being made regarding the 
Postal Service being unable to utilize a system similar to the 
system that has been outlined by private shippers and carriers 
is a cost issue. I understand that other issues also complicate 
equalizing the shipping requirements, but cost, processes, and 
technology seem to be a factor in the Postal Service claims 
which are inhibiting their efforts. Is this an accurate 
statement? If so, how do we bring down the cost of compliance 
and technology? Is it possible to look at prioritizing the 
advance electronic data upgrades through a tiered system with 
foreign shippers? And under the current method you are using to 
try and address this situation, how long do you think it would 
take to get foreign countries utilizing AED at higher rates? Do 
you have any plans to have that discussion? I guess maybe we 
could start with you, Mr. Perez.
    Mr. Perez. Through the pilot program that we have, Senator, 
with the U.S. Postal Service, we are currently getting advance 
electronic data from several different countries. Specifically, 
the pilot in JFK has to do with both China and France, and so 
we are going to continue to focus on that and work alongside 
our Postal Service partners to see what else we can do to make 
sure that we are being able to not only utilize and get that 
advance electronic data, but then focus our efforts to expand 
not only the volume that we are able to apply, but, again, the 
quality itself so that we can make better and more informed 
decisions on where it is we need to focus our efforts.
    Senator Heitkamp. Mr. Cintron?
    Mr. Cintron. Yes, I certainly wanted to--and I can clarify 
more on the point earlier, is that for us with the AED and the 
pilot in JFK, certainly one of the things that we are going to 
be looking to do, expand that part of it to the other ISCs that 
we have, and certainly get better with the amount that we are 
generating that is going to--and I can speak more about that 
later.
    In regard to the costs, the cost really are going to be 
incurred at the foreign post where, they really have the 
technological upgrades and challenges that will really need to 
be--that is where those costs are going to come in, and 
certainly that is the difference, I think. The technology part 
of what we can do on our side is a little bit different in 
regard to AED once we actually get the data itself.
    Senator Heitkamp. I do not want to prolong this, but I will 
tell you, if we were happy with the speed to which the U.S. 
Postal Service were dealing with this issue, you all would not 
be here. This is not moving fast enough. We see these drugs 
coming in. We have had numerous deaths in my State because of 
fentanyl abuse. And we know that the delivery point is the 
United States Postal Service, either point to point in this 
country--my recent investigation and prosecution regarding 
fentanyl moving in the mail from Portland, Oregon, but it 
originally came in from Canada. This is serious stuff, and it 
needs to be addressed. And we need to have a plan, it seems to 
me, with detailed timelines. And if resources are a problem, we 
need to know that. If there is a legal problem with the 
bilaterals or with the agreements, we need to know that. If 
there is a resource problem, we need to know that. But we have 
to stop jeopardizing the lives of people who move this stuff, 
whether it is at the post office or people who come in contact 
with a package unwittingly. But we have to have a plan, and it 
is frustrating because we addressed this in a roundtable last 
year or the year before, and I am hearing the same things over 
and over again. And pilots are good, but they do not give us a 
plan.
    And so, I applaud the Chairman and the Ranking Member for 
bringing this issue to the Committee. This is something we are 
going to be serious about in terms of oversight and moving 
forward.
    So with that, Mr. Chairman, I will yield back the rest of 
my time.
    Senator Portman. Thank you, Senator Heitkamp.
    We are now going to do a very quick second round, a 
lightning round, and let me just say I agree with what my 
colleagues were saying that we are not moving fast enough. Let 
me give you a specific example of this.
    There was a letter sent in April 2016, more than year ago, 
to this Committee. In that letter it said, and I quote, ``The 
plan to expand the John F. Kennedy (JFK) pilot program with 
China to Los Angeles International Airport is currently 
scheduled for the summer of 2016.'' We are now in the summer of 
2017. Has it expanded?
    Mr. Cintron. It has not expanded beyond----
    Senator Portman. No. OK, it has not. The UPU, we have heard 
today about what is going to happen with regard to the 
Universal Postal Union, and with all due respect to our 
international partners and the UPU, will it get done by 2018, 
2020, or even 2022? They keep pushing it back with respect to 
advance electronic data.
    So, look, if we did not have a crisis in this country, we 
could kind of go along with the normal routine, which is, as 
was said earlier, and I quote, ``other countries are working on 
their own timetables.'' We cannot afford to have them work on 
their own timetables because our people are dying. I guess the 
question I would ask this morning is: How many more Americans 
have to die before our government gets its act together and 
makes sure that the pilot is working, makes sure that it is 
expanding as it was promised, which has not occurred, and makes 
sure that we are actually doing everything we can to keep this 
poison out of our communities?
    Admittedly, this is not the silver bullet. There is not one 
silver bullet. I am going to steal a line from my Ranking 
Member, who said there is a lot of silver BBs, but this is one 
of them. Every one of you have acknowledged that today.
    My hope is that because of this hearing we will be able to 
move more quickly on this issue, we can get this legislation 
passed to give you the additional authority I think you need to 
have. As Mr. Perez said, rightly, you need the tools to be able 
to identify the right packages, to go after them, to stop some 
of this poison, and also to increase the cost on the street, 
because right now this stuff is so cheap and so deadly that it 
is killing more and more people.
    We are going to hear from the next panel about what is 
happening in our communities and what is likely to happen this 
year as compared to last year. The summary is more people 
dying, getting worse and worse.
    So thank you all very much for being here, and I now turn 
to my Ranking Member, Mr. Carper.
    Senator Carper. Thank you. Thank you, Mr. Chairman.
    When Senator Heitkamp was speaking just a moment ago, I am 
reminded of the work that we have done, a lot of on this panel 
have done on postal reform legislation over the years. And one 
of the things we focused on is how do we increase the revenue 
flow to the Postal Service so that they can replace vehicles 
that are 25 years old, a 25-year-old fleet, so they can 
modernize mail processing centers, which really are not 
designed to handle large packages or parcels. And, number 
three, how do we modernize post offices, provide better service 
from post offices, and with rural letter carriers that are sort 
of mobile post offices? How do we provide those revenues?
    There is another reason why the Postal Service needs 
revenue, and it is to be able to do their job, a better job 
with respect to intercepting and stopping the movement of these 
highly toxic chemicals. And we are going to use that. We are 
going to use that in reminding our colleagues why it is 
important to move on postal legislation and sooner rather than 
later. That is one of the reasons why we need to do that.
    The other thing I want to come back to is the pilot. Take 
me to the pilot, if you will. It is JFK, right?
    Mr. Cintron. Yes.
    Senator Carper. And, again, why the delay in spreading and 
extending the pilot to the other four destinations? Why?
    Mr. Cintron. Yes, well, a couple things. Let me just kind 
of explain the pilot itself as we have gone through it, mid-
2015 when they started, and the recent probably two months we 
have made some pretty significant improvements. Part of what we 
try to eliminate is the manual handling of the product itself. 
So we get the advance electronic data. We provide it to Customs 
and Border Protection. They provide us a list of what they want 
us to extract. We were doing that in a manual fashion in terms 
of identifying the sacks and then identifying what we needed to 
do to extract those pieces.
    In today's environment, when there has not been any 
experience and there has been improvements significantly to 
take that and now put it on the processing equipment, we have 
worked very closely with the Inspection Service and our 
engineering systems now to be able to do this on our processing 
equipment.
    So one of the key things that will happen with this is it 
will be on equipment at JFK ISC. We also have connected the 
down-flow facilities that are connected to JFK where we are 
actually able to trap those pieces now. So much the same way 
that you heard from the UPS testimony, pretty much everything, 
and we do this very well on the domestic side of the network 
today. We are very good at this part of it, tracking bar codes. 
So we have the ability now to do that. The expansion is and our 
full commitment is to get those other sites up and running now 
that we have flushed through this as quickly as we can get them 
up. We need to do it in collaboration with Customs and Border 
Protection and, Mr. Perez may want to chime in a little bit. 
But we are very focused to get moving. It is ready to move 
forward and get expanded to the other four sites. We are very 
committed to getting that done.
    Senator Carper. All right. Thanks.
    Mr. Schenk, give us a final 30 seconds, just a great 
takeaway. You were here 17 years ago. I want to make sure you 
are not here 17 years from now. We probably will not be either. 
But give us just a great takeaway in terms of our to-do list 
here on our end, on the Congressional end.
    Mr. Schenk. Well, I think, again, the key thing is passage 
of the STOP Act. Not only will it help with the problem, we 
also think it will actually help the postal operators in their 
negotiations with the UPU, that they will have legislative 
language that says we have a mandate, we have to do it.
    The other thing is if there was a way to maybe increase the 
amount of information that is shared. We have a great working 
relationship with CBP, but there are limitations in terms of if 
we knew more about maybe who some of the bad people were, we 
could build that into our systems, and we can shrink the 
haystack from both sides.
    Those would be the two things.
    Senator Carper. All right. That is great. Thank you. I am 
going to be asking for the record if there are any amendments, 
any changes that should be made to the STOP Act, what is the 
rationale? What changes, if any, should we consider? And sort 
of prioritize those for us. That will be a question for the 
record for each of you. If you could do it, that would be 
great.
    Mr. Chairman, so far, we are halfway home, and this has 
been a great first half. Thank you.
    Senator Portman. Thank you. Senator Hassan.
    Senator Hassan. I will pass. Thank you.
    Senator Portman. Well, let me just conclude by thanking our 
witnesses again, and I thank every one of you for what you are 
doing in your own way to try to push back on this epidemic, 
because each of you in your capacities are working on this 
issue. As I said, we have to figure out how to do it more 
effectively and faster.
    Let me end with a story. Yesterday we had our weekly 
Buckeye coffee, and we have Ohioans come in. A couple hundred 
come in sometimes, as was the case yesterday. Four rural letter 
carriers were there, and they were there from the union to talk 
to me about postal issues. They talked about the STOP Act and 
talked about the need for more resources for Senator Carper's 
efforts. He has been a leader on this over the years.
    Then two of the four took me aside privately. This is 50 
percent of your rural letter carriers who came to see me 
yesterday and said, ``You know what? I have a family member''--
one was a nephew, one was a son--``who were addicts.'' 
Recovering addicts now. In both cases, they had the opioid 
addiction. They are now in and out of recovery, which is not 
unusual. They both said to me, ``You have to move forward with 
this. You have to continue your efforts.''
    So I would just tell you this is affecting everybody, 
including our families and our friends and our neighbors in 
every zip code, including the rural letter carriers who came to 
talk to me about another topic but ended up focusing on a 
personal topic, which is their deep concern about this issue.
    Thank you all for being here, and I appreciate continuing 
to work with you on this legislative initiative and stopping 
this poison from coming into our communities. Thank you.
    [Pause.]
    All right. The second panel has now joined us. We are going 
to move quickly here through the introductions. Each of you 
deserve a 20-minute introduction, but I am going to give you a 
shorter one today, with the hopes that we can get to questions 
quickly.
    First is Michael Botticelli, executive director of the 
Grayken Center for Addiction Medicine at Boston Medical Center. 
As some of you know, Mr. Botticelli has been at this a long 
time and is a real expert. He actually was the Drug Czar. He 
was the head of the Office of National Drug Control Policy 
(ONDCP) until just a few months ago. We are delighted to have 
you here, Mr. Botticelli.
    Second, we have Chief Thomas Synan. He is Police Chief for 
the city of Newtown in Hamilton County, Ohio. He has also been 
very involved in the Hamilton County Heroin Coalition Task 
Force. He is chair of the law enforcement sector of that task 
force. Everywhere in southwest Ohio people look to him for his 
advice on this, and he is going to be able to talk to us a 
little bit about what is happening on the street.
    We have Dr. Thomas Gilson, who is the Medical Examiner of 
Cuyahoga County. Previously, he was Chief Medical Examiner for 
the State of Rhode Island. He has a lot of experience. I told 
him today he provides us the best information because every 
month he gives us the data on what is happening in Cuyahoga 
County, broken down by area of the county, rural, suburban, 
inner city, ethnicity, age, and it is very helpful data. The 
bottom line is it affects everybody. It knows no zip code.
    Dr. Terry Horton is also here with us. He is the chief of 
the Division of Addiction Medicine at Christiana Care Health 
Services in Wilmington, Delaware. Previously, Dr. Horton served 
as Medical Director and Vice President of the Phoenix House 
Foundation in New York, well known. Most recently, he helped 
develop and launch the Opioid Withdrawal Pathway, a program 
designed to help screen, identify, and treat opioid-addicted 
patients who are admitted to the hospital. He also founded 
Project Engage and has been very involved in Delaware as the 
Chair of the Drug Overdose Fatality Review Commission.
    We really appreciate all four of you being here today as 
experts, and we would now ask you to stand so we can swear you 
in quickly. It is the custom of the Subcommittee to swear in 
all witnesses. I would ask you to raise your right hand and 
repeat after me. Do you swear the testimony you will give 
before this Committee will be the truth, the whole truth, and 
nothing but the truth, so help you, God?
    Mr. Botticelli. I do.
    Chief Synan. I do.
    Dr. Gilson. I do.
    Dr. Horton. I do.
    Senator Portman. Thank you, gentlemen. Please be seated.
    Senator Carper. Mr. Chairman.
    Senator Portman. Yes?
    Senator Carper. Could I just make a quick comment? Terry 
Horton is here representing Christiana Care, a large regional 
health care provider, and great work in this area. Terry is a 
leader. Sitting right behind him is Bettina Riveros, who at one 
time when I was Governor, she was my Deputy Legal Counsel, and 
she has gone on just to be a wonderful leader at Christiana in 
our State on a wide range of health care issues.
    And I think there is a young guy back there named 
Sebastian. We all rode down on the train together. Sebastian is 
15 years old. He is Terry's son, and we welcome him as well. We 
will be watching carefully to see if Sebastian's lips are 
moving when his father speaks.
    Senator Portman. Yes, thank you, and I am sure you 
attribute all of your success in life since then to Governor, 
now Senator Carper.
    Senator Carper. She succeeded in spite of my mentoring.
    Senator Portman. Let the record reflect the witnesses all 
answered in the affirmative with regard to the oath.
    Gentlemen, your written testimony, of course, will be 
printed in the record in its whole. We would ask you to keep 
the oral comments to five minutes so we have time for questions 
and a good dialogue.
    Let us start with Tom Gilson, if that is OK. Dr. Gilson, 
let us hear from you first.

   TESTIMONY OF THOMAS P. GILSON, M.D.,\1\ MEDICAL EXAMINER, 
       CUYAHOGA COUNTY MEDICAL EXAMINER, CLEVELAND, OHIO

    Dr. Gilson. Thank you. Good morning, Chairman Portman, 
Ranking Member Carper, and other Subcommittee Members. My name 
is Thomas P. Gilson. I am the medical examiner from Cuyahoga 
County as well as the crime laboratory director, and I thank 
you for allowing me to be here to speak on this critical 
subject.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Gilson appears in the Appendix on 
page 113.
---------------------------------------------------------------------------
    If I were to tell you that a major catastrophe that would 
kill tens of thousands of people in the United States this year 
were to occur, how would the Federal Emergency Management 
Agency (FEMA) respond? How much money, how many people, how 
many resources would be put into action in this response? If 
this catastrophe was allowed to happen again, with even more 
fatalities, how many more hearings would be called to determine 
what went wrong in the response?
    The opiate crisis should be thought of as a slow-moving 
mass fatality event that occurred last year, is occurring again 
this year, and will continue to occur next year. Each year is 
getting worse than the previous. In my home of Cuyahoga County, 
we will see approximately 800 drug-related deaths in 2017, 
which is an increase from our most devastating year, last year, 
2016, when we saw approximately 660 people die from drug-
related deaths, up from 370 the year before.
    Nearly 90 percent of these deaths will be due to opiates or 
opioids of some kind--prescribed pills from which the crisis 
originated and grew from, heroin, fentanyl, and now the newer 
analogs of fentanyl. It is a nationwide public health emergency 
which is simply out of control. Ohio was one of the hardest-hit 
States, but Appalachia, the Middle Atlantic States, and the New 
England States are also particularly hard hit.
    In the fall of 2011, my office alerted our county executive 
to an alarming trend of rising heroin-associated deaths. In the 
subsequent months and now years, we partnered with our county 
sheriff, Cleveland Police Department, U.S. Attorney's Office, 
the county prosecutor, Addiction and Mental Health Services 
(ADAMS) Board, and our Board of Health to launch a community 
initiative which I am proud to say has attempted to combat this 
public health crisis. Partners were quickly added from the 
major medical institutions, including the Cleveland Clinic, 
Case Western Reserve University Hospitals, and our county 
hospital, MetroHealth Medical Center, as well as the Free 
Clinic, a free public health service provider, and set in 
motion some important pieces of response. We have drug dropoff 
boxes now to take back overprescribed prescription pain 
medication in over 50 police departments. Our naloxone 
distribution program is run out of the county hospital as well 
as the Free Clinic and the Board of Health. We also issue 
warning letters to released inmates who are at greater risk of 
overdose due to their abstinence while incarcerated, as well as 
patients leaving treatment centers. These folks are at risk 
because of decreased tolerance. The creation of our Heroin 
Death Review Committee allowed us to look at data from the 
overdose fatalities in an attempt to plan intervention 
strategies.
    We also held a Heroin Summit hosted by the Cleveland Clinic 
in November 2013. As a result, Law enforcement created 
specialized task forces that work with our medical scene 
investigators to begin investigations earlier and our Regional 
Forensic Laboratory provides highly accredited, timely, and 
efficient scientific testing. Prosecutors at the county and 
Federal level are now levying much stiffer charges against drug 
dealers. All of this work continues to implement a community-
wide and community-based strategy that was created at the 
Cleveland Clinic Heroin Summit.
    When a heroin overdose occurs, individuals typically fall 
asleep and breathe more slowly and shallowly until, at last 
they stop altogether. During this progression, the dying 
sequence can be relieved by the heroin antidote Naloxone, which 
was made more readily available in Ohio and is an immediate 
first step in saving lives and should be applauded. Cuyahoga 
County and the MetroHealth Medical Center partnered in 2013 to 
distribute Naloxone by prescription as was then allowed by law, 
and we have currently documented over 1,000 overdose reversals 
with Naloxone. Police departments, in a pilot program started 
in 2014 but ramped up in earnest last year, have documented 
another 300 reversals. These 1,300 individuals did not have to 
make a final trip to my office. The introduction of fentanyl 
and even more potent analogs like carfentanil (a large-animal 
tranquilizer) was initially seen in Akron and subsequently in 
our jurisdiction, have diminished the efficacy of Naloxone. 
Several doses may now be required, and the time window for 
administration is greatly shortened. This is a fundamental 
reason for the catastrophic mortality rise in 2016.
    Research conducted at the medical examiner's office in my 
county, in collaboration with medical, law enforcement, and 
forensic partners, indicates that nearly 600 people died of 
heroin overdoses between 2012 and 2014. Some promising 
intervention points should be considered. At least 72 percent 
of all of these overdoses had been prescribed a controlled 
substance within two years of their death, and over 50 percent 
for opioids.
    Several of these people were ``doctor shopping,''; however, 
with the mandatory implementation of a prescription drug 
monitoring program (PDMP), Ohio Autormated RX Reporting System 
(OARRS) in our State, we are now moving in a positive direction 
to reduce this as an entryway for people to go into the illicit 
drug market.
    As a final example of how valuable information can be 
gleaned from death certificate and death review data is the 
fact that many of the individuals who came to my office had 
been in contact with the legal system and/or drug and alcohol 
treatment programs. There is a tremendous need for education 
and these opportunities are needed to maximize this for 
messaging. But it is naive to think that education and 
messaging would be effective if we do not adequately address 
the need for treatment options once the message has been 
delivered. People can recover from drug addiction with adequate 
support.
    While data and information are critical in helping to 
determine effective strategies, it has been particularly 
inspiring to see the sense of community in Cuyahoga County that 
has brought treatment prevention, law enforcement, prosecution, 
and medical examiners like myself together for a single 
purpose, which is to save lives.
    At the same time, however, our local resources have been 
stretched to the point of exhaustion. The Death Investigation 
System and local forensic laboratories are facing double-digit 
caseload increases annually, personnel shortages, equipment 
problems, and increasingly complex processes to support the 
fight, especially now with the fentanyl analogs entering our 
country.
    While we have interacted successfully with Federal 
partners, it is clear that the supply and delivery of the drugs 
to our communities continued nearly unabated, and treatment 
options, as I mentioned, are severely limited. Our community 
has added millions of dollars to this effort in the past 
several years. Our estimates are that there are enough people 
in my county to fill our football stadium every year, and that 
approximately a sufficient number of people to fill our 
basketball arena transition over from the use of prescription 
opioids to heroin and fentanyl.
    That used to be a largely Caucasian majority of upwards of 
85 percent of victims. However, this is changing now, and it 
seems almost with purposeful intent. Cocaine is now being mixed 
into the fentanyl distribution and the analogs of fentanyl in 
an effort to introduce these drugs into the African American 
community. Cocaine had been the only drug where victims in our 
community were predominantly African American. That has changed 
since the introduction of cocaine into that supply 
distribution. And it is also of note that we have a rising 
percentage of African American deaths in our drug overdose 
crisis.
    The strategies to combat this crisis are not a matter of 
innovative creation but of sheer will, cooperation, and 
adequate resources. The will and cooperation I feel I see 
already in my county that the resources at a local level are 
depleted and overwhelmed. Treatment beds need to be opened and 
adequately funded. Our county executive, in cooperation with 
our mayor and local Alcohol and Drug Board, has created 
additional funding for treatment.
    The Institution for Mental Disease (IMD) exclusion, which 
limits the number of treatment beds to 16 for a substance abuse 
treatment facility, needs to be lifted, and I salute the bill 
currently offered by you, Chairman Portman, as well as your 
Ohio colleague Senator Brown, that will more than double the 
number of available beds. Interdiction agreements with China, 
Mexico, and Canada need to be strengthened, and delivery of 
these substances through the U.S. Postal Service and other 
delivery services needs to be squeezed off. I appreciate your 
cosponsorship of S. 708 to this purpose.
    I am sorry to go over time, but to add this: There is a 
national crisis in my field in death investigation. My field of 
specialty, forensic pathology, is in dire need. There are less 
than 500 board-certified, full-time forensic pathologists 
practicing in the United States. Currently, on my professional 
organization's website, 28 offices are seeking to hire 
additional forensic pathologists. I have the privilege of 
heading the oldest forensic pathologists training program in 
the country. There are only 35 such programs in existence and 
they are not funded by Medicare, which is unlike any other 
medical training specialty. Our program graduates one or two 
doctors a year in a system that can only produce a few dozen 
pathologists annually. We rely on accurate data around 
mortality to define this crisis and I think it will serve as a 
significant measure of our success or failure, and that depends 
on a competent death investigation. It is essential that 
additional support be given to these training programs as well 
as to doctors already practicing in the field.
    All of these actions are beyond the ability and authority 
of a local county like mine. We need your continued and renewed 
assistance, resources, and commitment to all phases of this 
fight: prevention, education, treatment, enforcement, and 
recovery.
    As I said, I am sorry to go over time. It is a very 
important topic to me. I thank you for your time and 
consideration. I would be happy to answer any questions. And we 
also provided a packet of information which summarizes even 
more. I could have talked longer.
    Thank you very much.
    Senator Portman. Thank you, Dr. Gilson. Mr. Botticelli.
    Senator Hassan. Mr. Chairman?
    Senator Portman. Yes?
    Senator Hassan. Just because I have to leave and I wish I 
could stay for all of you, but I just also wanted to thank Dr. 
Gilson, who was deputy chief medical examiner for the State of 
New Hampshire for some time. And thank you so much for your 
work, and thank you so much for your continued work, and thank 
you to all of the panelists. And, Mr. Botticelli, I am sorry I 
am going miss you, but we have talked before and we will talk 
again.
    Thank you so much.
    Senator Portman. Thank you, Senator Hassan.
    Mr. Botticelli, and remember, your full statement will be 
made part of the record.

  TESTIMONY OF THE HONORABLE MICHAEL BOTTICELLI,\1\ EXECUTIVE 
DIRECTOR, GRAYKEN CENTER FOR ADDICTION MEDICINE, BOSTON MEDICAL 
                             CENTER

    Mr. Botticelli. Thank you. Chairman Portman, Ranking Member 
Carper, Senator Hassan as you leave, thank you for the 
opportunity and the invitation to be here today and for your 
ongoing leadership in this epidemic.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Botticelli appears in the 
Appendix on page 146.
---------------------------------------------------------------------------
    I think we all know the opioid epidemic is the pressing 
public health issue of our time, and in many respects, a public 
safety issue of our time.
    The 2016 National Survey on Drug Use and Health estimates 
that approximately 2.1 million people in the United States have 
an opioid use disorder. In 2015, the last year that we had 
complete national statistics, 91 people a day died from an 
overdose of opioids, including prescription pain medication, 
heroin and/or fentanyl, resulting in over 33,000 deaths in 2015 
alone. In Massachusetts, 1,900 people died of an overdose in 
2016, and that is up from 742 just from 2012.
    In addition to addiction and death, we know injection drug 
use associated with this epidemic has been linked to dramatic 
increases in viral hepatitis across the country along with 
local outbreaks of human immunodeficiency virus (HIV). A recent 
analysis done by the CDC showed that there are at least 220 
counties, mostly in Appalachia, that are at significant risk 
for another outbreak similar to the one that we saw in Scott 
County, Indiana, two years ago.
    Over the past few years, we have seen the emergence of 
synthetic opioids like fentanyl. The CDC estimates that 
overdose deaths attributed to synthetic opioids other than 
methadone increased by over 72 percent from 2014 to 2015. 
Reports from the DEA as well as State law enforcement indicate 
that these deaths have been associated with law enforcement 
seizures testing positive for fentanyl. This increase is not a 
result of prescribing fentanyl, which indicates this is largely 
illicitly manufactured. Domestic law enforcement seizures have 
increased by 426 percent from 2013 to 2014. Analysis was 
limited to those States, like Ohio, that have excellent or very 
good reporting which means that overdose deaths are reported 
with the specific drug involved. Twenty-six States reported 
statistically significant increases from 2014 to 2015 with 
States in the Northeast and Midwest experiencing the highest 
increases.
    A recent analysis of overdose deaths in Massachusetts 
showed that deaths involving fentanyl rose from 32 percent in 
the 
2013-14 period to 72 percent in the first half of 2016.
    Fentanyl is often mixed with heroin and cocaine with or 
without the user's knowledge, usually without. As we have seen 
in some high-profile deaths, it also can be disguised as 
prescription pain medication and again taken without the users 
knowing that it contains fentanyl. The supply, as we have 
discussed, appears to be largely illicitly manufactured in 
China, either directly shipped to the United States, via both 
open and dark web sources, or shipped to Mexico where it gets 
mixed in with heroin before transport to the United States.
    I will not go into detail for lack of time, but I think you 
all know the Administration's response to these efforts, and 
underpinning all of those efforts is ensuring people who need 
treatment have timely access to high-quality care, including 
medication-assisted treatment.
    The Affordable Care Act contributed to perhaps the greatest 
expansion of treatment by ensuring substance use disorder 
treatment was one of the 10 essential benefits that Medicaid 
expansion plans and marketplace plans had to cover. It also 
ensured that those benefits be offered on par with the Federal 
Mental Health Parity and Addiction Equity Act.
    Again, for lack of time, I will not go into detail, but I 
am very proud of the accomplishments that we were able to make 
with Congress in terms of the passage of the Comprehensive 
Addiction Recovery Act (CARA), rescinding the Federal ban on 
the programmatic aspects of syringe service programs. We 
accomplished a lot in our time together here in Washington. But 
we still have a long way to go.
    So I will focus the remainder of my remarks on what I think 
are recommendations as we look on how we deal with fentanyl.
    Continuing to enhance our intelligence and information 
gathering on the manufacturing and distribution of fentanyl is 
critical. And while I was very appreciative of the intelligence 
community's (IC) call for better information, there are still 
many unanswered questions. I was very happy to hear that the 
Director of National Intelligence (DNI) looked at synthetic 
opioids as a major threat. Quite honestly, I was very 
frustrated during my time at ONDCP that I did not know we had 
fentanyl and things like carfentanil until we saw local 
outbreaks in the United States. Our intelligence community is 
too good for us to be caught unaware in terms of what is coming 
at us.
    Since fentanyl is much harder to detect and can present a 
hazard to State, Federal, and local law enforcement, we need to 
promote better ways to expand current drug-testing technology 
and continue to develop detection capabilities.
    We need to continue to provide fact-based handling 
instructions to law enforcement, Border Patrol, and others who 
may come in contact with fentanyl.
    We need to continue our engagement with China and press 
them for additional action to schedule fentanyl analogs and to 
take down illicit manufactures and shippers.
    There is also a significant amount of variability of 
standard testing of fentanyl, with law enforcement, criminal 
justice systems, coroners and medical examiners, and treatment 
programs. They need to incorporate fentanyl into their drug-
testing panels.
    With public health experts, we need to develop and 
distribute informational material on how users can minimize 
their overdose risk in areas where fentanyl might be present.
    We need to expand the use of Naloxone by anyone who is in a 
position to witness or reverse an overdose. Because of the 
potency of fentanyl and what appears to be a pattern of drug 
users injecting alone, the period of time we have to reverse an 
overdose has shortened.
    We also need the Federal Government to deploy rapid 
response teams to our communities like we do with other 
diseases so that communities have the investigatory tools that 
they need to examine some of these outbreaks and the causes 
behind it.
    We need to expand syringe service programs and other 
programs that engage active drug users to promote safer 
injecting, distribute Naloxone, and minimize overdose risk.
    Most importantly, we need to preserve the coverage gains 
made through the Affordable Care Act, particularly Medicaid 
expansion and other Federal grant programs. Even with these 
provisions, timely access to quality care remains an issue for 
many, particularly in rural communities.
    Thank you for your time, and I look forward to your 
questions.
    Senator Portman. Thank you. Dr. Horton.

   TESTIMONY OF TERRY L. HORTON, M.D.,\1\ CHIEF, DIVISION OF 
   ADDICTION MEDICINE, AND MEDICAL DIRECTOR, PROJECT ENGAGE, 
      CHRISTIANA CARE HEALTH SYSTEM, WILMINGTON, DELAWARE

    Dr. Horton. Thank you. Thank you, Chairman and Senator 
Carper.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Horton appears in the Appendix on 
page 152.
---------------------------------------------------------------------------
    First, I would like to say I think this issue of addressing 
fentanyl is important. Fentanyl certainly exacerbates any issue 
I have to attend to at the hospital in trying to help 
individuals get into care. It just creates a rapid spiraling of 
addiction, much more so than we would see otherwise.
    In Delaware, 25 percent of our individuals who die from 
drug overdose have fentanyl in their blood at the time of 
death, so when we look at the potential for damage in our State 
if the presence of fentanyl reaches the levels in 
Massachusetts, I think there is going to be a real catastrophic 
increase in the coming year.
    Having said that, as someone who sits in a hospital, works 
in an inpatient setting and in the emergency room and clinics, 
I want to share some of the lessons I have learned over the 
past 25 years. This is a horrific epidemic. It strikes across 
the board. I take care of young mothers who have given birth, 
high school kids who are pole vaulting champions and wrestling 
champions, grandparents, couples, people of all races, all 
ages. What they share is a horrific addiction. Their brains 
have changed. Their motivational circuits have been distorted. 
And when they stop using the drugs, they have this new onset of 
withdrawal, a withdrawal that is really like primal misery. 
Withdrawal is like a wall that prevents them from moving 
through that wall to go on to care. They will stay outside of 
that care and avoid it at all costs because they cannot manage 
the withdrawal, they cannot go through that wall to the other 
side where there is care.
    That is our reachable moment. That is also what we can 
leverage. And we have done that in the hospitals, and we have 
done that in jails. So when someone is in a hospital and they 
can no longer be on the outside, and they are desperate to 
avoid withdrawal, we can address their withdrawal and we can 
treat it aggressively with medications like Suboxone. We have 
been able to leverage that reachable moment and get them into 
treatment.
    Two-thirds of the people that I see in the hospital are 
very agreeable to go into long-term care. Two-thirds. They do 
not come into the hospital looking for that care. They have an 
infected leg or an infected heart, but they use that 
opportunity to get into drug treatment. It is really 
remarkable. Two-thirds of individuals I see are actively 
looking to go into drug treatment when I offer it and I address 
their withdrawal and begin treatment.
    Of those individuals, remarkably, nearly 80 percent show up 
to their community care provider when I have inducted them on 
to Suboxone or methadone in the hospital. So the hospital is a 
reachable moment. And of those individuals, 70 percent are 
there in treatment a month later. So what I am telling you is 
that when individuals who are addicted to opiates, who come 
into our hospital system, it is a reachable moment to address 
their withdrawal, and we can use that leverage to get them into 
treatment--and they stay there. If you are on drug treatment, 
if you are on medicines like Suboxone, which block opiates, and 
you use opiates, you are not going to overdose. This is really 
about safety. I tell each of my patients every day when I see 
them in the clinic--yesterday I had clinic, and this is what I 
said: ``Take your Suboxone today and tomorrow, and those days 
we do not have to worry about you overdosing.'' It is a pretty 
simple, straightforward safety message.
    Having access to that care and medication is really 
critical to what I am trying to do as a doctor: to help 
individuals get into care and stay in care so they do not 
overdose and they do not die. And we are pretty fortunate. In 
Delaware, we have been able to expand outpatient slots for 
primary care--or for substance abuse care really--by the 
thousands. When I identify an individual in the hospital, I 
have no difficulty getting them into care the next day in a 
community setting. It has to be that contiguous, or I lose them 
and they relapse.
    So it is remarkable that I am able to do that, but I am 
able to do that because that care is available, and that care 
is completely and wholly dependent on Medicaid. Without 
Medicaid, that care would collapse.
    And so, I can tell you what I am really fearful of. I am 
fearful that I know how to address this opiate epidemic, I know 
how to treat the patients that I have who are addicted to 
heroin and to other drugs. I know how to get them into a safe 
place, but I am fearful that I will lose the tools and the 
medicines I need to keep them safe. And I am really fearful 
that some of the cuts that have been proposed will completely 
gut the system that I rely on to treat my patients and keep 
them alive and help them get to a better place.
    So basically I am saying, please, it is critical. Do not 
take away my ability to treat my patients and keep them safe. 
They depend on me, and I am depending on you to really preserve 
the system of care that I have been able to work with and make 
improvements to in order to care for my patients. Without it, I 
think this war is lost.
    Senator Portman. Thank you, Dr. Horton. Chief Synan.

 TESTIMONY OF THOMAS SYNAN, JR.,\1\ CHIEF OF POLICE, NEWTOWN, 
                    OHIO, POLICE DEPARTMENT

    Chief Synan. Thank you, Chairman Portman and Ranking Member 
Carper, along with the Subcommittee, for giving me this 
opportunity to discuss this very important topic of how 
synthetic drugs such as fentanyl and carfentanil are destroying 
the lives of loved ones and our communities. In my 24 years of 
law enforcement, I have never seen a substance cause such 
damage and devastation with its death rates that have risen to 
levels higher than car accidents and homicides combined. I have 
witnessed the power of drugs in my small community watching an 
entire family from the mother to her three sons wiped out. 
Three brothers, an entire generation gone because of drugs, the 
last two brothers due to heroin.
---------------------------------------------------------------------------
    \1\ The prepared statement of Chief Synan appears in the Appendix 
on page 157.
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    Events such as this led us to form the Hamilton County 
Heroin Coalition at a time when we were calling this an 
epidemic, with an average of 20 to 25 overdoses and one to two 
deaths a week, an epidemic. In July 2016, I received a call 
from the Greater Cincinnati Fusion Center, a part of Homeland 
Security, a center that was originally designed after the 9/11 
attacks for law enforcement to share intelligence on potential 
terrorist situations which could be analyzed and shared with 
local, State, and Federal law enforcement along with the 
public. Recognizing the centers ability to analyze data and 
share it quickly among various agencies, we adapted its use for 
heroin, tracking overdoses, locations, and intelligence that 
could track trends on the street.
    At 10 p.m., that call told me, ``Tom, there is a new drug 
on the street called carfentanil.'' I asked, ``What is 
carfentanil?'' The response was, ``We are not sure; it is used 
to knock out large animals.'' I replied, ``Like a pig?'' And he 
responded, ``No. Elephants.''
    We passed this information on to the coroner and the 
Hamilton County health commissioner trying to obtain as much 
information as we could to try to figure out what the 
introduction of carfentanil on our streets would mean. What we 
learned about this drug was frightening: it is at the top of 
the fentanyl/opiate chain, potentially used in some chemical 
weapons, a drug not intended for humans, so powerful that the 
equivalent of two grains of salt had the potential to kill a 
human. This drug, 10,000 times more powerful than heroin, was 
now on our streets leading us to issue a public warning due to 
concerns not only for the user but first responders, hospitals, 
treatment centers, and the public--all who could unknowingly be 
exposed to this extremely dangerous synthetic. We were so 
concerned for the safety of law enforcement that we recommended 
stopping field testing of heroin, which is a process needed to 
develop probable cause to arrest a person for heroin, because 
the officer's safety was the priority over enforcement. This 
warning has reached other States such as Georgia and Florida 
who have also stopped this practice to ensure the safety of 
their officers. With all the dangers already facing law 
enforcement, this danger which could be undetected until it was 
too late was a danger that concerned the most hardened police 
veteran and led police administrators to modify policies to 
protect their officers. We knew this drug was strictly 
controlled and monitored in the United States, and with the 
assistance of the DEA, we determined it was not coming from 
sources within the United States.
    We could have never anticipated that our epidemic would 
reach levels more along the lines of a pandemic and become the 
new normal. In the week of August 19-27, 2016, an event 
occurred that would forever change the heroin epidemic in our 
area when the hardest hit, Cincinnati, experienced nearly 200 
overdoses and three deaths in one week. Seeing and hearing from 
dealers and users alike that there was nothing on the streets 
other than synthetic drugs like fentanyl and carfentanil, we 
experienced the literal shift from the ``organic'' opiate of 
heroin to the synthetic opiate of fentanyl, all its 
derivatives, and carfentanil.
    This shift in synthetics is testing the limits of users, 
first responders, the systems of government, hospitals, and the 
spirit of each person who, no matter drawn in by choice or 
necessity, is to the point of breaking. I not only witness this 
devastation but the determination of those same people who day 
in and day out try to keep up with the new normal, the new 
average of 50 to 70 overdoses and with four to five deaths a 
week. Moments of spikes where 70 overdoses occur in one 
weekend, 11 people die in one weekend, and multiple overdoses 
at the same time in the same location. At times overdoses reach 
nearly 40 in one day, stretching the resources of even large 
police and fire departments such as Cincinnati, who in one 
district with 20 officers had 16 on overdoses and four on 
shootings, causing every officer to be unable to respond to 
other calls. In 2012, our area had seven deaths that were 
fentanyl related. In just three years, that number exploded to 
238 in 2015.
    Heroic efforts made by many who initiated innovative 
programs such as quick response teams that try to connect users 
to treatment, the Coalition issuing Narcan to every first 
responder who in 19 months has used over 7,500 Narcan kits. The 
sheer volume of numbers has lead us to follow the mantra of the 
starfish parable where a young boy was walking down the beach 
where thousands of starfish had washed up. The young boy would 
pick up a starfish and throw it into the sea and go to the next 
one. An old man seeing this stopped the boy and said, ``Young 
man, there are too many to make a difference. You cannot save 
them all.'' The young boy picked up a starfish, throwing it 
back into the sea, replied, ``I saved that one.'' This 
description we follow is beautiful in its nobility and 
heartbreaking in its reality, describing where we are right now 
with this epidemic.
    But no matter how great our efforts, our initiatives, our 
determination, the tremendous influx of such powerful 
synthetics such as fentanyl--which illegal labs have altered 
the molecular structure into even more powerful derivatives 
force us to change oure beliefs in order to keep up with its 
power. Our coroner's office has identified at least 10 
variations of fentanyl--and the current ultimate on the opiate 
scale of carfentanil have rendered each initiative less 
effective. The original two milligram Narcan we issued to over 
1,000 police officers, is now obsolete and replaced with a 
higher concentration of a four milligram dose of Narcan, which 
often due to the strength of the synthetic, requires multiple 
doses. It is more common to hear of unconscious users taken to 
the hospital and placed on a constant Narcan drip in order to 
keep them alive.
    These synthetics are now so ingrained in the user in our 
area that when we think the situation cannot get more difficult 
or cause any more fear, dealers insensitive to the damage they 
are causing to the user and our communities have now begun to 
place these synthetics in other drugs like cocaine. This will 
not only cause more overdoses but deaths due to the cocaine 
user's body not being accustomed to not only general opiates 
but especially ones as strong as carfentanil. Carfentanil is 
now so common in our drug supply, a staple in the heroin 
supply, is now expanding. Just a couple weeks ago, four people 
in Cincinnati who bought what they thought was just cocaine 
overdosed. Two died on the scene; two left in critical 
condition on Narcan drips due to that cocaine containing 
fentanyl and carfentanil.
    Since I submitted this report last week, another person in 
that incident died. So three have died and one is still 
hospitalized at my last check.
    That same week in my small community, a mother drove her 
10-month-old baby into a driveway where she got out and 
collapsed. Neighbors called 911, brought the baby inside where 
the officers arrived, and the mother regained consciousness. 
She believed she had only purchased heroin, but was later found 
that she actually had been given a mixture of cocaine, 
fentanyl, and carfentanil. And since I submitted this report 
last week, two officers and I stood over the body of a 26-year-
old at that same location who died from a suspected fentanyl 
overdose.
    I commend this Committee for taking the time to hear, 
investigate, and look into ways to help reduce these powerful 
synthetics from entering our country, drug supply, and our 
communities. I plead with this panel to do all it can to help 
us by stopping this poison from even getting into the country. 
Although this will not stop addiction or stop every supply, 
each intervention that prohibits these synthetics from reaching 
the streets means first responders can get relief from the 
overwhelming numbers which has caused such stressors on them 
and our system. We have coined a term while working with the 
Ohio Attorney General's office, called ``first responder 
fatigue.''
    Take this deadly ingredient from those who push these drugs 
on our streets so their potions become less powerful. Take this 
tool away from them so that the tools we are using can be given 
the chance to work. Reduction from these powerfully devastating 
synthetics would mean less people would overdose and the number 
of deaths would be reduced. It is never lost on us that each 
one of those numbers is a person who has a mother, father, 
brother, sister, son, or daughter who will forever grieve the 
loss of their loved one.
    Thank you for allowing me to speak on this subject. I 
commend you for your compassion to want to help all of us in 
making the lives of those we serve better.
    Thank you.
    Senator Portman. Thank you, Chief, and thanks to all four 
of your for some very powerful testimony.
    I was struck by your testimony, Chief, about law 
enforcement and, as you said, trying to keep up with the 
changing drug mix and specifically the move to synthetic 
opioids, carfentanil and fentanyl in particular. I am thinking 
about how law enforcement approaches this. Now you have a 
situation where, through the U.S. Mail system, someone can at 
their post office box pick up fentanyl from China, use it as an 
individual, and there is no drug dealer for you to go after.
    Now, some of these individuals also become drug dealers, as 
you said, and yet it is a different situation than being able 
to go after the source because the source is coming in through 
the U.S. Mail. You talked about tools. Earlier, we were talking 
to law enforcement folks, and CBP said they want the tool of 
being able to get advance electronic data so they can identify 
these packages. You also said you want to take this tool away 
from the traffickers, the tool of being able to ship this stuff 
into our communities through the mail system.
    So I would ask you, given your experience and given your 
background in this, and seeing what is going on, would it be 
helpful at a critical choke point like these International 
Service Centers we have talked about here today to be able to 
stop this poison in part to be able to keep the volume down, to 
avoid the first responder fatigue you talked about, but in part 
to raise the cost, the risk to the trafficker of being caught, 
but also the cost of this by reducing the supply?
    Chief Synan. Yes, Senator Portman, it would definitely help 
cutting off that supply. There is very little risk for the 
dealers right now. There is quite a bit of reward. And the 
problem with it coming through the mail is that it is not like 
in the 1980s with crack where you had major gangs that were 
mostly pushing the crack cocaine, and once you identified the 
gang, you cut the head off the snake, and the rest of it 
collapsed.
    Here it is everywhere, with hundreds of dealers, and not 
necessarily in a network or sourced in one area. So it makes it 
very difficult for enforcement.
    I do want to say, however, that I want to caution that we 
do not repeat history. In Ohio, we did a great job of shutting 
down pill mills and doctor shopping. And, inadvertently, that 
created part of this epidemic when we had a segment of society 
that was left out there opiate dependent. And I want to be 
careful that we not just shut off the supply, which is an 
incredibly important part of this; it would give first 
responders that chance to breathe. But I also want to make sure 
that while we are doing that we still have the resources on the 
back end. Part of the problem we are facing with this epidemic 
is if you can get someone who is opiate addicted into 
treatment, often there is not space available. In addition, 
there is discussion of medically assisted treatment and the 
signs show that that is effective. But we also need doctors and 
nurses and we need the facilities. So not only is that choke 
point important, but we also need to work on the issue of 
having those people who are addicted get long-term care in 
order to reduce the demand. In my belief, once we reduce demand 
then we will reduce supply.
    Senator Portman. That is a great point, and I was impressed 
with Dr. Horton's health care system that he has the ability to 
take somebody who is in need of treatment, and within 24 hours 
get them into treatment, which, frankly, is not the case in 
many places in Ohio, particularly in our rural areas. We have a 
real issue with the availability of treatment, and longer-term 
recovery, which, as you know, I have been focused on because I 
think that leads to better results. I think the law enforcement 
system can lead to better results, too, by supporting our drug 
courts more, as we do. I know you are involved with that as 
well.
    Dr. Gilson, you talked about what you are facing, and 
specifically you talked about the forensic pathologists being 
just overwhelmed. You and I talked a little about this prior to 
the hearing as well. One thing you said to me was that at a 
death scene where someone had overdosed from fentanyl, your 
people sometimes find a package, literally a package from China 
at the death scene. Again, I think this is just an 
extraordinary change from what you are used to with cocaine or, 
for that matter, with heroin coming over land and being sold at 
the street corner in Cleveland, Ohio. I was struck by that.
    Can you talk to us for a second about what you see 
happening? I think, as I told you earlier, you have the best 
data, at least in Ohio, and for 2016, unfortunately, you were 
pretty accurate that there would be an increase; the number of 
deaths from fentanyl was 399, as I recall, or 400.
    Dr. Gilson. Yes, that is true.
    Senator Portman. Since you do keep this accurate data on 
overdoses and fentanyl-related deaths, what trends are you 
predicting for 2017 as compared to the 399? What do you project 
for 2017?
    Dr. Gilson. Senator, I think we are already far enough into 
2017 that we can make some predictions. One is that the crisis 
is going to get worse. We are projecting an increase from 660 
total deaths up to close to 800. I think most of that, again, 
is going to be driven by fentanyl, and I think the other thing 
that everybody in the room should be incredibly concerned about 
is what is going to be the impact of the analogs of fentanyl. 
We had 54 deaths in 2016 related to carfentanil just in my 
jurisdiction.
    Since the beginning of 2016, we have identified at least 16 
to 17 different analogs of fentanyl, and many of these, like 
carfentanil and 3-methyl-fentanyl, are far more potent than 
fentanyl. Fentanyl is already a bad drug. What concerns me is 
at some point if these drugs start to replace fentanyl in our 
community, these numbers will take off again.
    To echo kind of what the chief said, we started with 
diverted prescription drug medication. In about 2011, what my 
office saw was a transition away from prescription drugs such 
as oxycodone, which appeared to plateau, then heroin took off 
dramatically. And that was our trend up until 2015. When heroin 
got started, actually it looked like they were going to go down 
because of the Naloxone and education programs. But then we 
caught a tidal wave of fentanyl, another more potent drug, 
making 2016 a uniform disaster in Cuyahoga County. We nearly 
lost twice as many people. These are hundreds of people dying 
of drug overdoses.
    If carfentanil becomes the new fentanyl in 2017, I shudder 
to think how much worse that can be.
    Senator Portman. Dr. Gilson, from your experience, is the 
carfentanil also coming through the mail system?
    Dr. Gilson. I think, this is, again, partly what I can tell 
you from death scenes and partly what I can glean from the 
collaborations we have with particularly the Drug Enforcement 
Agency. Yes, my investigators by happenstance will sometimes 
identify computer records and/or packaging that clearly show 
that these drugs are coming from overseas. And the concept that 
a lot of these drugs are coming from China is something that 
our DEA liaisons completely support. The idea, too, that--and 
one of the Senators mentioned it earlier--maybe the drugs come 
to this country and then get rerouted into Mexico I think is 
also true, because in the heroin epidemic, the Mexican 
production went up dramatically to the point where they became 
the second largest heroin producer in the world. That 
distribution system is definitely in place, and I think 
fentanyl can follow the same distribution system.
    So I do think that these are drugs that are coming from 
overseas, primarily from China, and are being sold in our 
country really almost on a basis that could be considered an 
act of terrorism.
    Senator Portman. That is an interesting comment given what 
we said earlier about what Mr. Botticelli said with regard to 
the DNI, listing it this year for the first time ever last 
month in his World Assessment. He put synthetic opioids into an 
State context. Senator Peters.

              OPENING STATEMENT OF SENATOR PETERS

    Senator Peters. Thank you, Mr. Chairman. And thank you for 
calling this very important hearing. Opioid abuse in Michigan 
is growing at an alarming rate, as it is around the country, 
and it is important for us to get to the bottom of this and 
understand how we can deal with it. I appreciate your 
leadership on this issue over the months and years that you 
have been working on this. Certainly thanks to each of the 
panelists for your compelling testimony as well in dealing with 
this.
    My first question really deals with the underlying 
substance abuse and the medical treatment necessary to treat 
this as a medical issue. Certainly, it is a law enforcement 
issue, Chief, but this is a public health issue first and 
foremost that we have to deal with. Whenever we are thinking 
about public health, we must think about our health care 
policies, and in particular the Affordable Care Act with its 
expansion of Medicaid, which has certainly been significant in 
my State. Medicaid expansion has led to over 600,000 
individuals now having health care coverage where they did not 
have it before. And part of the Affordable Care Act is coverage 
for mental health as well as substance abuse, which gets to the 
heart of this problem. Since the ACA's Medicaid expansion went 
into effect, I think more than 1.6 million Americans have now 
gained access to substance abuse treatment.
    So, Mr. Botticelli and Dr. Horton, could you speak to how 
individuals enrolled in Medicaid are using the program and 
whether or not we are seeing an actual impact on folks who are 
suffering from substance abuse problems?
    Mr. Botticelli. Sure. Thank you, Senator. One of the 
longstanding issues with substance use is access to treatment. 
You would think I would know how to do this by now. What we 
have sought for a long time is that when national surveys look 
at why people are not able to access treatment, not having 
adequate access to insurance coverage, and being underinsured 
are some of the biggest reasons. And you are right, the 
Affordable Care Act I think did a number of things as it 
related to increasing access to care and made substance use 
disorder treatment and mental health treatment one of the 
essential health benefits that were required by Medicaid 
expansion and by ensuring that those benefits were on par with 
other medical benefits.
    We have seen some remarkable results as it related to 
increased access to care under the Affordable Care Act, and I 
think your point about particular the Medicaid expansion 
population, which we knew had higher prevalence of substance 
use disorders in the general population. So we have seen 
remarkable results, and quite honestly, remarkable results in 
those States that have been dramatically impacted by this 
epidemic like West Virginia, Kentucky, New Hampshire, and 
Massachusetts. We have seen an incredible increase in people's 
ability to access care to do that.
    I just want to make two quick points. The other important 
point here is that people with substance use disorders often 
have comorbid mental health, and, quite honestly, other health 
conditions. So it is not just accessing care for their 
substance use disorder. They need care for their hepatitis. 
They need mental health coverage.
    And the last thing I will say is I really worry about not 
just people losing coverage, but the stability of our treatment 
infrastructure. Some of these folks can tell you that these 
programs operate on very thin margins, and I worry that we are 
even going to have a treatment infrastructure for those 
remaining people who can access CARA if they are not able to 
bill insurance.
    Thank you.
    Senator Peters. Anybody else? Dr. Horton.
    Dr. Horton. Yes, thank you. As I mentioned, in our system 
we have developed some very unique partnerships with community 
providers. We now screen 30,000 admissions to our medical 
hospital, the largest in Delaware, identify those who are 
opiate dependent quickly around withdrawal, and treat that, and 
they are agreeable and go into care as outpatients in the 
community.
    That care is predominantly Medicaid, so our largest 
community provider program called Connections has the largest 
footprint in the State, and developed that footprint because 
they had a reliable funding stream.
    Now, it is not only a funding stream that cares for 
Medicaid patients. It covers all patients. They are really a 
quality provider. But the bulk of their revenues--what allows 
them to exist--is that they have a reliable revenue stream. And 
because of that, I am able literally--and as I said, my record 
is actually 12 hours--to identify somebody and get them into 
treatment in the community on a medicine like Suboxone. And I 
can do that because the individual is covered. For the most 
part, that coverage is Medicaid. If Medicaid goes away, that 
collapses, and, frankly, the substance abuse infrastructure in 
Delaware collapses. So while I will identify individuals in the 
hospital, I will not have anywhere to send them. They will 
leave the hospital. They will relapse within hours to days, and 
they will be back in the hospital. And actually we will return 
to the days of the revolving door after they have, astronomical 
cost of caring for these individuals at places like my hospital 
and health system and we will never attend to the root cause 
issue.
    The big difference these days is the volume of heroin. It 
used to be once upon a time individuals used one, two, five 
bags a day. Now it is bundles. Each bundle is 13 bags, 50 bags 
a day. And I really think of it as Russian roulette where, 
instead of bullets, it is bags of heroin. If any of those bags 
has fentanyl in it, that person dies. It is amazing.
    So we are in the middle of all this and because I have 
access, ready access to substance abuse treatment on demand, I 
am able to make a difference. And I am clear that those 
individuals who are taking their Suboxone are not overdosing. I 
know because they come in week after week.
    Senator Peters. Thank you. Chief, you are----
    Dr. Gilson. I am sorry, Senator. Can I add a different 
perspective on this, too?
    Senator Peters. Yes, please.
    Dr. Gilson. We do not track it specifically. But we go out 
to respond to death scenes and I think one of the most 
heartbreaking things we see is an individual who has been seen 
in an emergency department within weeks to sometimes days for a 
drug overdose who now is dead of a drug overdose. These are the 
people Dr. Horton does not see. They do not make it back to 
treatment. They die, and we do not have the capacity in my 
county to send these people when we have their captive 
attention--they have just nearly 
died--to treatment. We send them back on the street, like Dr. 
Horton said, to try and see if they can work something out.
    Anything like Medicaid expansion being eliminated that 
limits people's access to health care, I cannot see any good 
coming from that in this crisis, especially with its mortality.
    I am sorry. Thanks for the time.
    Senator Peters. I appreciate those comments. Now, Chief, 
you are at the front lines. Thank you for your service on the 
front lines. I would assume you would concur.
    Chief Synan. Absolutely. Law enforcement, I am very proud 
of my colleagues who have taken the lead on this. But the 
problem is we are taking the lead on something that really is a 
public health issue. You are taking law enforcement, who is 
taking programs like quick response teams, trying to get 
addiction specialists out there. Narcan, we have become 
paramedics. It is not uncommon for officers to take users to 
treatment.
    So it is well outside of our realm to be doing this issue, 
but for us, we have now become somewhat addiction specialists. 
And for law enforcement to talk about that, we should not be 
decreasing Medicaid. That tells you how important this is to 
us, because, again, in order to reduce that demand, which would 
in turn reduce that supply, we have to get people into 
treatment. And one of the programs that our teams are doing out 
there in the Hamilton County area is signing people up for 
Medicaid to try to get them into that treatment.
    These are individuals who are walking with that user to try 
to get them into treatment, and if Medicaid is gone, that would 
have a significant impact. It is already difficult enough. It 
is not uncommon for us to find a user, call numerous treatment 
facilities, be told there is a bed open, drive them up there, 
to find out that bed is gone. So it is difficult enough. Taking 
away Medicaid would make it even more difficult. And like I 
said, we would be spinning our wheels.
    We are already like a mouse on a wheel trap spinning as it 
is. Taking away the tools is just making it more difficult, and 
we will continue to dig ourselves in a hole.
    Senator Peters. Thank you for your testimony, all of you. I 
appreciate it.
    Senator Portman. Thank you, Senator Peters.
    I am going to turn the gavel over to my colleague----
    Senator Carper. Big mistake.
    Senator Portman [continuing]. And ask the Ranking Member to 
conduct his final questions and then close this out. Again, I 
want to thank the four of you for being here and for your work 
every day. All four of you are in the trenches, on the front 
lines. Thank you for helping to reverse this tide, which, 
unfortunately, right now is moving in the wrong direction.
    Thank you, Senator Carper.
    Senator Carper [Presiding.] Mr. Chairman, before you walk 
out, let me just say, I will say this to your face, not behind 
your back. Thank you for your sustained, continued leadership 
on this. Maybe we can use the work, the effort that you have 
led, along with Amy Klobuchar and others last year, and to this 
year on CARA and other initiatives. If we can work that well 
across the aisle on an important issue, maybe we can somehow, 
particularly on the piece of making sure if folks show up at a 
hospital and they are ready to get treatment that they actually 
have access to treatment, how important that is. We have got to 
focus our attention on that as well. But thank you so much.
    I want to come back, Dr. Horton--I know this has been 
mentioned before. Explain to the folks maybe not just here in 
this room but around the country who might be following this, 
how is it in Delaware, when somebody shows up at a hospital, 
they have had an overdose, and they will only be there for a 
brief moment, minutes, hours, when they are ready to go, they 
are ready to start treatment--and the opportunity and reachable 
moment will be lost.
    Dr. Horton. Yes.
    Senator Carper. And within 24 hours or so, we oftentimes 
have the ability to place them in treatment.
    Dr. Horton. Yes.
    Senator Carper. How are we able to do that in Delaware and 
not in other States? Why is that? Does it have anything to do 
with Medicaid expansion?
    Dr. Horton. Yes, because that was the access. In order to 
put someone into treatment, I have to have a treatment to put 
them into, and that treatment is primarily the result of 
Medicaid expansion and programs like our largest program, 
Connections, developing those outpatient slots because they had 
revenue that could be relied upon. Without that revenue, the 
treatment system would not exist.
    We were able to leverage reachable moments. There are many 
more than just the hospital. So we are actually thinking about 
how do we partner with our colleagues or EMS and police to find 
those other reachable moments. The lockup, for example, is 
where an individual is so fearful going into that primal misery 
that they will agree to go into treatment. But you have to have 
those partnerships. You have to have that coordination.
    In the emergency room, when someone is being admitted to 
the hospital, they are there, and it really was more about 
having the institution accept that this was an issue and then 
moving forward to implement standardized care pathways. And, we 
are good at that. We are good at creating electronic health 
record mechanisms to screen and then algorithms to treat, and 
we had the wherewithal. So it was a natural place to do those 
approaches, and they worked, and they can now be replicated. By 
that, I mean identify individuals quickly around this issue of 
withdrawal, address the withdrawal aggressively and use that as 
the lever to move them into care. Most of the patients are very 
interested in it, and as I said, two-thirds of my patients are 
willing to go into treatment, and most of them show up at the 
back end.
    Our question really is, well, what about the lockup? Can we 
have the same sort of results where someone had been arrested, 
usually of petty crimes, breaking into a garage, such as I am 
told by our colleagues in New Castle County, the police 
departments are trying to struggle with this. They have 
actually come up with their own programs on their own called 
Hero Helps.
    Senator Carper. Thank you for that. I would think of what 
Dr. Horton has described, a best practice and the ability to, 
when folks show up at a hospital and they are ready for 
treatment, we get them into treatment. Maybe each of you could 
give us one other quick example of a best practice that the 
rest of us could learn from and implement. Michael, do you want 
to go first?
    Mr. Botticelli. Sure. Actually, this was an area that we 
focused on at the White House by bringing some good best 
practice. I will give you an example at Boston Medical Center. 
We opened what I believe is the first opioid urgent care center 
in the country. So, folks who either came in through the 
emergency department or were identified sometimes coming into 
the community could walk in and we have dedicated staff, some 
peers, and recovery coaches who are able to work with them, to 
get a bed and access to care which is not easy, unfortunately. 
And so they work to make sure that people have the care that 
they need.
    But I have to say, because this is really important, 
Massachusetts I still believe has the lowest uninsured rate in 
the country. So it is not an issue for staff at Boston Medical 
Center in the emergency department or in any other facility. 
And we have a generous Medicaid benefit.
    Senator Carper. OK.
    Mr. Botticelli. So the opioid urgent care center I think is 
something that is worth looking at.
    Senator Carper. Great. Thank you. Chief.
    Chief Synan. I would also have to go along the same track. 
In Hamilton County, we are trying to get the hospitals to work 
with us and allow those people to go in as patients. Again, we 
are looking at this from a law enforcement aspect, which is not 
going to solve the problem, or is not going to be the answer.
    But part of the problem we are also facing from the front-
end line is also those people who do not want to get into 
treatment, which is a significant amount of people. So there is 
a hurdle not just going to jail or to the hospital, but how do 
we get them into those treatment facilities? If we had opiate 
centers, how would we get them there? So that is one of the 
challenges we are facing in Hamilton County that we are trying 
to overcome. If we could take them to a medical system where 
they could go to a hospital, start receiving medically assisted 
treatment, and if we started treating this like a brain injury 
or an illness, like it is defined, as a chronic illness, then I 
think we would have a better solution.
    Senator Carper. Thank you, Chief. Dr. Gilson.
    Dr. Gilson. Thank you, Senator. A lot of ideas come to 
mind, and these guys----
    Senator Carper. Just give me one. Just give me one really 
good one.
    Dr. Gilson. I think one of the things that we have to do is 
use the information that can be gleaned from people who die of 
overdoses to design intervention strategies. We saw 40 percent 
of the people who came to my office during the heroin phase of 
this epidemic had been incarcerated within two years or they 
had been in treatment within two years. I send each of the 
people leaving jail or treatment facilities a letter spelling 
out risk reduction strategies: Do not use by yourself. Do not 
go back to the same dose.
    There is a tremendous amount of public health information 
to be gleaned by medical examiner systems, which, if we can 
take the burden off of the epidemic crushing these systems, 
could be potentially used to design very effective intervention 
strategies.
    Senator Carper. All right. Good. Thank you for each of 
those, and I am going to close, but before I do, let me just 
add another thought or two and then turn it over to Senator 
Peters, and he will close it out.
    We want to thank you again for being here. For those with 
whom you work and represent, we thank them, too. Every now and 
then we have hearings that are illuminating. It is rare that we 
have a hearing that is both illuminating and terrifying, and 
this is really both. And it really is, as I said at the 
beginning an ``all hands on deck'' moment. I am more convinced 
than ever as we wrap this up.
    When Bettina Tweardy Riveros was my deputy legal counsel in 
my last term as Governor, one of the things that I was asked to 
do is be the founding vice chairman of something called the 
American Legacy Foundation. The American Legacy Foundation was 
created out of the 50-State tobacco settlement where the 
tobacco industry provided a lot of money to each of the States 
for a period of 25 years, still does. They also provided about 
$1 billion or $2 billion to create something called the 
American Legacy Foundation, which developed a truth campaign, 
which was probably the most effective campaign we have seen in 
this country's history in terms of convincing young people, if 
they were using tobacco, to stop, and if they had not started, 
not to start.
    I realize it is not an entirely comparable parallel here, 
but we have not talked at all about messaging. I think in the 
back of my mind messaging has got to be a part of all those 
other silver BBs--I talked about earlier. No silver bullet, but 
lot of silver BBs. One that I would not--given what we have 
accomplished with the American Legacy Foundation and the truth 
campaign, messaging is one I would not dismiss.
    Finally, I mentioned to the first panel and will say it to 
you as well. We will be asking questions for the record, and I 
will be asking for, again, a short list of things we ought to 
be doing, a sense of urgency, and ask you to come back with 
those ideas. You can repeat some of the things you said. That 
would be fine. But I think you could feel a real sense of 
urgency on this side of the dais, and I am sure we feel it from 
your side as well. Thank you all for what you are doing. We are 
in this together. Let us go forward together. God bless you. 
Thank you. Senator Peters.
    Senator Peters. First, I want to concur with all your 
comments. Thank you, Senator Carper, for one final question. 
Going back to the root causes--and I appreciated your response 
on how we have to make sure we have health insurance and 
Medicaid available for substance abuse counseling and 
treatment.
    But there is also compelling evidence that prescription 
opioids are really one of the key drivers for what we are 
seeing here. Dr. Gilson, I know in your testimony it struck me 
that you mentioned in your county, of individuals who had been 
prescribed a controlled substance within two years of their 
death, over half of them had prescription opioids that led to 
this.
    And so, just in a final question: are we aware of other 
sorts of treatments that we should be prescribing so that we 
can stop what appears to be perhaps overprescription of opioids 
to patients who then become addicted to them, that we need to 
have different types of treatments, and thinking about how we 
practice medicine, and are there impediments to preventing 
that? What should we be thinking about going forward in trying 
to basically stop the pipeline that starts with some 
prescription drugs?
    Dr. Gilson. Thank you, Senator, for the question. I think 
that you have really hit the genesis of the problem, the nail 
on the head exactly. The culture in medicine tended toward 
overprescribing of opiate pain medications for chronic pain. 
The scientific support for that was minimal, and that, 
unfortunately, became a standard of practice that I think has 
created a large opiate-addicted population.
    If we gave prescription pain medication to everyone in this 
room, they would become addicted to prescription pain 
medication. They would become addicted to opioids. We have 
created a substantial large addicted population through the use 
and abuse of prescription pain medication. That is absolutely, 
inconvertibly true. And how we get back from that I think is 
that we have to start the reeducation of our medical community. 
We have to put much stricter guidelines on people prescribing 
pain medication.
    I am sympathetic to people who have chronic pain, but if it 
is an effective treatment that creates an unnecessary and 
really detrimental consequence, that is not a good treatment, 
and we should hold accountable the people who promoted that 
idea. It was not very well documented, and I am really ashamed 
to say that the part that the medical community played in this 
crisis is not stopping. I still have lots of anecdotal 
information of people getting a month's worth of Vicodin after 
they get teeth pulled, with refills. We have to stop that, turn 
that flow off.
    But I think Dr. Horton and other folks here said we have a 
population of people who already are suffering from that over-
liberal prescription. We cannot turn our back on them. They are 
going to be with us for a while. And treatment does work, and I 
think the ways that we improve treatment will be more effective 
for that.
    Mr. Botticelli. During my time at ONDCP, I think, we worked 
with the CDC on comprehensive guidelines. I think some of the 
issues that we heard in terms of non-opioid therapies, the 
challenges I think are changing the culture of just giving a 
prescription. But I think the other issues that we heard is 
insurance reimbursement for things like physical therapy and 
acupuncture, and often even mental health therapy that can 
really help. So that was an issue that we have really got to 
take a look at in terms of those challenges.
    I will say that we have had some good evidence in States 
that have really robust prescription drug monitoring programs. 
I think we have seen some good data on the reduction in 
prescription drug overdose deaths where physicians had to 
register and they had to check each and every time. And so I 
know many States have moved to mandatory registration and 
mandatory checks because it seems like that works.
    You often get pushback from physicians, and I understand 
that sometimes they are busy. But my response was we are 15 
years into this epidemic and I do not think it is unreasonable 
for a physician to take a modicum of education and to check the 
prescription drug monitoring program. We are losing too many 
people.
    Senator Peters. All right. Thank you. Thank you so much. I 
appreciate your testimony.
    Dr. Horton, I am sorry. Were you going to say something?
    Dr. Horton. Only that in our State I think we have been 
able to implement some of those measures around the 
Prescription Monitoring Program (PMP), use of that, and really 
ratchet up regulations for prescribers. And it is a small 
State, so we are able to make these kind of changes, and we are 
starting to see that cultural change. So there is hope about 
being able to attend to it.
    As far as treatment for prescription drugs, in many ways 
the genie is out of the bottle. Yes, most of the patients I 
attend to were exposed to prescription drugs, but now most of 
them are using heroin. We are actually starting to see--two 
epidemics. The prescription drug epidemic has not gone away, so 
those measures need to continue, reduce the exposure. But now 
we have a heroin epidemic as well.
    Mr. Botticelli. If I could just add one more thing, because 
I think it is important.
    Senator Peters. Please.
    Mr. Botticelli. Because Congress supported this. If you 
talk to Dr. Nora Volkow and the folks at the National 
Institutes of Health (NIH), they will tell you that actually we 
need to do a better job at researching non-opioid pain 
medications. I think one of the barriers is looking at what the 
administration proposed in terms of NIH reductions. I think you 
really put a significant damper on NIH's research capabilities 
and to come up with non-opioid, non-addictive prescriptions for 
pain medication. I think it undercuts what Congress passed as 
part of the 21st Century Cures Act.
    Senator Peters. Thank you so much. I appreciate it.
    Senator Carper. Well, that is a good note to end on. We 
have a lot of good ideas. Some of them we have heard before. My 
preacher at our church likes to say--he knows he is preaching 
to the choir, but he says, ``Even choirs need to be preached 
to.'' So we appreciate you introducing to us a number of good 
practices, best practices, new ideas, but also some, especially 
the last one, that just make a whole lot of sense.
    Again, our thanks to all of you for coming, for the work 
that you and your colleagues are doing. The hearing record will 
remain open for 15 days for any additional comments or 
questions by any of our Subcommittee Members. And, with that, 
this hearing is adjourned. Thank you so much.
    [Whereupon, at 12:47 p.m., the Subcommittee was adjourned.]





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