[Senate Hearing 115-383]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-383

 OPIOIDS IN INDIAN COUNTRY: BEYOND THE CRISIS TO HEALING THE COMMUNITY

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

                                 HEARING

                               BEFORE THE

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 14, 2018

                               __________

         Printed for the use of the Committee on Indian Affairs
         
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]



                        U.S. GOVERNMENT PUBLISHING OFFICE                    
32-784 PDF                      WASHINGTON : 2018                     
          
-----------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, 
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected]. 



                      COMMITTEE ON INDIAN AFFAIRS

                  JOHN HOEVEN, North Dakota, Chairman
                  TOM UDALL, New Mexico, Vice Chairman
JOHN BARRASSO, Wyoming               MARIA CANTWELL, Washington
JOHN McCAIN, Arizona                 JON TESTER, Montana,
LISA MURKOWSKI, Alaska               BRIAN SCHATZ, Hawaii
JAMES LANKFORD, Oklahoma             HEIDI HEITKAMP, North Dakota
STEVE DAINES, Montana                CATHERINE CORTEZ MASTO, Nevada
MIKE CRAPO, Idaho                    TINA SMITH, Minnesota
JERRY MORAN, Kansas
     T. Michael Andrews, Majority Staff Director and Chief Counsel
       Jennifer Romero, Minority Staff Director and Chief Counsel
                            
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on March 14, 2018...................................     1
Statement of Senator Barrasso....................................     4
Statement of Senator Cantwell....................................    35
Statement of Senator Cortez Masto................................    27
Statement of Senator Daines......................................    56
Statement of Senator Heitkamp....................................    33
Statement of Senator Hoeven......................................     1
Statement of Senator Lankford....................................    23
Statement of Senator Murkowski...................................     4
    Prepared statement...........................................     5
Statement of Senator Smith.......................................    25
Statement of Senator Tester......................................    31
Statement of Senator Udall.......................................     2

                               Witnesses

Anderson, Hon. John C., U.S. Attorney, District of New Mexico, 
  U.S. Department of Justice.....................................     6
    Prepared statement...........................................     8
George, Jolene, Behavioral Health Director, Port Gamble S'klallam 
  Tribe..........................................................    35
    Prepared statement...........................................    37
Jones, Captain Christopher, Pharm.D., M.P.H., Director, National 
  Mental Health and Substance Use Policy Laboratory, Substance 
  Abuse and Mental Health Services Administration, U.S. 
  Department of Health and Human Services........................    10
    Prepared statement...........................................    12
Moose, Samuel, Treasurer and Bemidji Area Representative, 
  National Indian Health Board...................................    47
    Prepared statement...........................................    48
Toedt, Rear Admiral Michael, M.D., Chief Medical Officer, Indian 
  Health Service, U.S. Department of Health and Human Services...    15
    Prepared statement...........................................    17

                                Appendix

Lucero, Esther, CEO, Seattle Indian Health Board, prepared 
  statement......................................................    63
National Congress of American Indians (NCAI), prepared statement.    64
Response to written questions submitted by Hon. Heidi Heitkamp 
  to:
    Stacy A. Bohlen..............................................    93
    Captain Christopher Jones....................................    89
    RADM Michael Toedt...........................................    92
Response to written questions submitted by Hon. Tom Udall to:
    Stacy A. Bohlen..............................................    82
    Jolene George................................................    80
    Captain Christopher Jones....................................    84
    RADM Michael Toedt...........................................    90
Southcentral Foundation (SCF), prepared statement................    69
Sullivan Hon. Jeromy, Chairman, Port Gamble S'Klallam Tribe, 
  prepared statement.............................................    67
Tanana Chiefs Conference (TCC), prepared statement...............    72
United South and Eastern Tribes Sovereignty Protection Fund (USET 
  SPF), prepared statement.......................................    75
Written questions submitted to Hon. John C. Anderson by:
    Hon. Heidi Heitkamp..........................................    95
    Hon. Lisa Murkowski..........................................    95
    Hon. Tom Udall...............................................    94

 
 OPIOIDS IN INDIAN COUNTRY: BEYOND THE CRISIS TO HEALING THE COMMUNITY

                              ----------                              


                       WEDNESDAY, MARCH 14, 2018


                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m. in room 
628, Dirksen Senate Office Building, Hon. John Hoeven, 
Chairman of the Committee, presiding.

            OPENING STATEMENT OF HON. JOHN HOEVEN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    The Chairman. I call this oversight hearing to order.
    Today we will examine the opioid abuse crisis and its 
effect on Indian Country.
    On November 9, 2017, this Committee held a roundtable on 
the opioid abuse epidemic in Indian Country. The roundtable 
highlighted how the opioid abuse epidemic is particularly 
complex in tribal communities given the lack of access to 
medical care, shortage of law enforcement and insufficient data 
on substance abuse. This hearing will build on that discussion 
and examine how Congress, the Administration, tribes and tribal 
organizations can work together to combat the crisis and heal 
Indian communities.
    The facts of the opioid abuse epidemic are tragic. Our 
Country has witnessed an 18-year increase in deaths from 
prescription opioid overdoses and a recent surge in illicit 
opioid overdoses. According to the U.S. Centers for Disease 
Control and Prevention, CDC, drugs now kill more Americans, 
nearly 40 percent more, than car accidents.
    Native American communities have been among those hit 
hardest by the opioid abuse crisis. The Substance Abuse and 
Mental Health Services Administration reports that the rates of 
opioid abuse are consistently the highest among Caucasian and 
Native peoples.
    According to the CDC, in 2016, 4.1 percent of American 
Indian and Alaska Natives age 12 and older reported opioid 
misuse in the past year, similar to whites at 4.4 percent. 
These statistics are serious, but they may not represent the 
magnitude of the crisis in Indian Country, as the epidemic may 
be underreported.
    Many witnesses at the roundtable highlighted that Native 
Americans are sometimes incorrectly classified as another race. 
Without accurate data, Congress, the Administration and tribes 
are limited in their ability to allocate resources to the area 
of greatest need. The Committee is dedicated to engaging with 
tribes and finding ways to advance the Federal Government's 
role in combating the dangers that opioids and other substances 
present to tribal communities.
    The Indian Health Service has established the National 
Committee on Heroin, Opioids, and Pain Efforts, the HOPE 
Committee. The HOPE Committee has been tasked with promoting 
appropriate and effective pain management, reducing overdose 
deaths from heroin and prescription opioids and improving 
access to culturally appropriate treatment. The IHS also now 
requires all IHS Federal prescribers, contractors, clinical 
residents and trainees to complete a course on treating pain 
and addiction.
    On March 29, 2017, President Trump signed an Executive 
Order establishing the President's Commission on Combating Drug 
Addiction and the Opioid Crisis. On October 26, 2017, the 
President declared the opioid abuse crisis a national public 
health emergency and one week later, the President's Commission 
released its comprehensive final report.
    The final report contains more than 50 recommendations to 
agencies and to Congress. The Commission recommended that the 
IHS remove reimbursement and policy barriers to substance abuse 
treatment. Removing these barriers would help Native American 
communities access much needed treatment. It is important to 
begin implementing these recommendations. I look forward to 
hearing from our witnesses on these and other efforts to find a 
path toward healing for Indian communities.
    Finally, I am also mindful that when Congress does 
appropriate funding to combat this epidemic, it is important 
that Indian Country receives an adequate share of the funding 
and receives this funding in a manner that will ensure 
maximized impact to their communities.
    With that, I would like to welcome our witnesses. Thank you 
for testifying today. I will now turn to our Vice Chairman, 
Senator Udall, for his opening comments.

                 STATEMENT OF HON. TOM UDALL, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Udall. Thank you, Chairman Hoeven, for calling this 
oversight hearing and continuing this Committee's work to 
address the opioid crisis in Indian Country.
    Before I begin my formal remarks, I would like to welcome 
New Mexico's newest U.S. Attorney, John Anderson. Thank you, 
John, for your testimony and hard work on behalf of DOJ and New 
Mexicans. I look forward to working with you on some of these 
important Indian Country issues.
    Last November, we held a roundtable on this very same 
issue. Tribal leaders and Native organizations joined us to 
engage in a dialogue with agency officials from the Indian 
Health Service, Department of the Interior, Department of 
Justice, and the White House.
    These participants brought with them a lot of good 
information on the need for more treatment and prevention 
resources, especially culturally-based services. We were 
reminded that Congress must build in flexibility when making 
these resources available.
    Native communities require and deserve the right to design 
behavioral health programs that suit local needs. Any 
successful response to the opioid and substance abuse crisis in 
Indian Country must be driven by the tribes. Congress must 
support tribal efforts by holding Federal agencies accountable 
and providing sufficient resources.
    We are also working with our colleagues over at the Health 
Education Labor and Pensions Committee. Just last week, at the 
HELP hearing on State responses to the opioid crisis, three 
Senators, Ranking Member Murray, Senator Warren and Senator 
Smith, spoke about tribal opioid challenges and the need for 
better State-tribal coordination.
    As members of the Indian Affairs Committee, we are 
obligated to educate our Senate colleagues about what is 
happening on this Committee so that Indian Country's priorities 
and the voices of tribal leaders are heard beyond these four 
walls. When members work across committees to amplify tribal 
needs, good things happen. The ideas we heard on addressing 
Native substance abuse disorders at the roundtable resulted in 
the introduction of S. 2437, the Opioid Response Enhancement 
Act, a bill led by Senator Baldwin and joined by 15 Senate 
colleagues, including myself and three other Indian Affairs 
Committee members.
    The legislation refines the 21st Century Cures Grant 
Program to make tribes eligible to receive funds, provide 
tribes with programmatic flexibility and includes a 10 percent 
tribal setaside to further ensure that these funds actually 
make it out to Indian Country. Last week, I joined a group of 
ten Senators, led by Senator Heitkamp, on a letter to the 
Appropriations Committee leadership outlining the dire need for 
tribal-specific funding streams within the $6 billion in opioid 
funding put in place as part of the recent budget cap 
agreement.
    Finally, just this morning, I joined Senator Smith and four 
other colleagues to introduce the Native Behavioral Health 
Access Improvement Act. Modeled after the Special Diabetes 
Program for Indians, this legislation would create a special 
behavioral health program for Indians, a mandatory program 
funded at $150 million annually.
    I am heartened by this robust response to Indian Country's 
call for action but as we will learn from our witnesses today, 
there is much left to do. The substance abuse crisis has sent 
ripple effects through Native communities, straining already 
overtaxed tribal systems. Tribal schools, housing departments, 
social services, law enforcement and the courts are all being 
asked to address the broader community disruptions caused by 
this public health emergency.
    I look forward to hearing from all of our witnesses today 
about how Congress can work to address the full impact of the 
opioid crisis in Indian Country. I look forward to continuing 
those efforts at next week's oversight hearing on the 
President's fiscal year 2019 budget proposal.
    Thank you again, Mr. Chairman, for getting this here today.
    The Chairman. Senator Barrasso.

               STATEMENT OF HON. JOHN BARRASSO, 
                   U.S. SENATOR FROM WYOMING

    Senator Barrasso. Thank you very much, Mr. Chairman.
    I just want to take a moment to thank you personally, Mr. 
Chairman, for holding this important hearing today. As a 
doctor, I have given a great deal of attention during my time 
as a member of this Committee to the delivery of health care in 
Indian Country, especially in rural areas.
    I have long been concerned about the serious drug addiction 
crisis facing our Nation. Nowhere is the challenge more 
apparent than it is in tribal communities. I have been working 
hard with my colleagues on this Committee to finalize my bill 
to restore accountability in the Indian Health Service, which I 
believe is a step in the right direction but specific action 
for opioid addiction is critical.
    Just yesterday before the Senate Energy and Natural 
Resources, we are joined now by the Chairman of that committee, 
Secretary Zinke shared his concerns and his commitment to 
addressing the opioid crisis. Successful implementation of 
programs requires cooperation and coordination from all sides, 
Interior, Justice, Health and Human Services and the tribes 
themselves.
    Last year, the Northern Arapaho and Eastern Shoshone Tribes 
joined several Montana tribes to hold the Wind River War Staff 
Symposium in an effort combat drug and alcohol abuse. The 
symposium was held in conjunction with their youth winter 
retreat. While symposiums are not specific to opioid addiction, 
it is the prime example of the need to educate and engage youth 
if we are going to be successful in the fight to end opioid 
addiction.
    I thank you, Mr. Chairman, for your continued leadership.
    The Chairman. Are there other Committee members who would 
like to make an opening statement? Senator Murkowski.

               STATEMENT OF HON. LISA MURKOWSKI, 
                    U.S. SENATOR FROM ALASKA

    Senator Murkowski. Thank you, Mr. Chairman. I too 
appreciate that you have brought this very important issue 
before the Committee and thank you to the Ranking Member.
    In the State of Alaska, we joined six other States in the 
Country in declaring a public health crisis in response to the 
opioid epidemic. We have joined Arizona, Florida, Virginia, 
Maryland, Massachusetts and now Alaska has issued a State 
disaster declaration.
    As many in this Committee know and have heard from me, our 
very rural communities are predominantly Alaska Native 
communities that are being devastated by substance abuse and 
now opioids. The rate of overdose deaths attributed to opioids 
has increased and, in many cases, has greatly exceeded the 
national average.
    In 2012, our prescription opioid pain reliever overdose 
death was more than double the national average. Our heroin-
associated overdose deaths were over 50 percent higher than the 
national rate. The overdose death rate by race was the highest 
amongst Alaska Native people. Our statistics are troubling to 
the core.
    There is a much reported story of four people who overdosed 
in the Native Village of Quinhagak a couple years ago. 
Quinhagak has a population of 700. One of these individuals did 
die as a consequence of that overdose. It was determined that 
it was Fentanyl, more Fentanyl than heroin. We are seeing this 
in a remote, tiny, tiny community.
    We clearly have an opioid epidemic, Mr. Chairman. We must 
deal with it but I must say that we must not lose sight of the 
other killer we are facing in our Native communities, not only 
in Alaska but around the Country. That killer is alcohol and 
how alcohol has wrought devastation.
    The Napaskiak Tribal Council passed a resolution on March 5 
asking that the governor declare a disaster of emergency to 
close the liquor store in Bethel due to high rates of alcohol-
related deaths, accidents and injuries in the surrounding area. 
It is one more reminder to me that when we think about those we 
serve and their cries for help, we have so very much to do.
    I thank you for bringing opioids to the attention of the 
Committee this afternoon. Whether it is opioids, alcohol or 
anything in between, know that I am committed to working with 
you.
    I do ask that my full statement be included as part of the 
record. Thank you, Mr. Chairman.
    [The prepared statement of Senator Murkowski follows:]

  Prepared Statement of Hon. Lisa Murkowski, U.S. Senator From Alaska
    Chairman Hoeven, Vice Chairman Udall, I appreciate this oversight 
hearing to discuss the impacts of the opioid epidemic in Native 
American and Alaska Native communities. Alaska may be a very rural 
state, but we are not shielded from this epidemic and in fact opioid 
abuse in Alaska has rapidly become one of our most pressing issues.
    Last year, Alaska Governor Bill Walker issued a State Disaster 
Declaration to address the growing opioid epidemic in Alaska. This 
meant that Alaska became one of the six states in the Nation to declare 
a public health crisis in response to the opioid epidemic. (Others: 
Arizona, Florida, Virginia, Maryland, Massachusetts)
    Many of our communities, including our very rural ones who are 
predominantly Alaska Native, are being devastated by opioids. The rate 
of overdose deaths attributed to opioids have steadily increased in 
Alaska, and in many cases has greatly exceeded the national average. 
For example, in 2012, Alaska's prescription opioid pain reliever 
overdose death rate was more than double the national average (10.5 vs. 
5.1 per 100,000 persons, respectively), and Alaska's heroin-associated 
overdose death rate was over 50 percent higher than the national rate 
(3.0 vs. 1.9 per 100,000 persons, respectively). Furthermore, the 
overdose death rate by race was the highest among the Alaska Native 
people (20.2 per 100,000).
    The opioid epidemic has been increasingly more prevalent in the 
Alaska Native communities. For instance, the Native Village of 
Quinhagak, with a population of about 700, saw four people overdose 
(one fatally) in the span of one week in August 2016. The heroin used 
in Quinhagak was tested at the Alaska State Crime Lab and it was 
discovered that the heroin used in Quinhagak contained more fentanyl 
than heroin. That was only the second time in Alaska's history that a 
drug submitted to the state crime lab had been confirmed as mixture of 
heroin and fentanyl and it wasn't heroin from the streets of Anchorage 
or Fairbanks. But in a rural village in remote Southwest Alaska.
    Alaska certainly has an opioid epidemic. But, I think this is 
indicative of a much larger substance abuse problem in Alaska and other 
areas across the country. According to the Alaska State Troopers 2016 
Annual Drug Report, the single most abused substance in Alaska is 
alcohol. Not heroin, not cocaine, but alcohol. To date, there are 109 
villages in rural Alaska that have prohibited the sale, importation, 
and possession of alcoholic beverages. I do understand wholeheartedly 
the seriousness of the growing issue of opioids, but I do not want to 
lose focus of some of the other issues we have that have gut-wrenching 
statistics as well. I have said this before, but we must have an all 
hands on deck, and an all-of-the-above strategy for solutions to make 
it through these complex substance abuse issues.
    Just recently, the Native Village of Napaskiak voted on and passed 
a resolution that formally asked the Governor to declare a disaster of 
emergency to close down a liquor store in Bethel, Alaska. One of the 
many reasons that Napaskiak voted on this resolution was because they 
saw an increase in the number of preventable deaths in their community 
related to alcohol abuse. In addition to that, the tribe saw an 
increase in the number of cases brought before their ICWA program, a 
decrease in the attendance rate at the local school because kids 
weren't getting enough sleep due to alcohol disturbances, and an 
increased caseload for law enforcement officials in the region.
    The Tribal Council specifically asked to close the liquor in 
Bethel, Alaska, because that was the primary means for their members to 
obtain alcohol. Napaskiak is one of the 109 villages that has banned 
alcohol and there was still alcohol in the village because the alcohol 
was imported illegally from the liquor store in Bethel.
    Despite the prevalence of opioids in rural Alaska, bootlegging 
alcohol continues to be the most lucrative and profitable criminal 
enterprise in Alaska. In 2016 alone, the Alaska State Troopers arrested 
225 people for the possession or sale of alcohol in dry villages. This 
was more than any other drugs, including cocaine, heroin, and 
prescription medication.
    Alaska Native communities don't just have an opioid epidemic, many 
have a substance abuse epidemic. There are tribes who are standing up 
against this. There are community members who are going out on a limb 
in their own communities to be the one to stand up against it. We must 
stand with them. I look forward to working with my colleagues in this 
committee to find a solution to this epidemic and thank you to all of 
the witnesses that came here today to address this issue.

    The Chairman. Without objection.
    Are there other opening statements?
    [No audible response.]
    The Chairman. Hearing none, our witnesses today are: The 
Honorable John C. Anderson, United States Attorney for the 
District of New Mexico, U.S. Department of Justice, 
Albuquerque, New Mexico; Captain Christopher Jones, Director, 
National Mental Health and Substance Use Policy Laboratory, 
Substance Abuse and Mental Health Services Administration, U.S. 
Department of Health and Human Services, Rockville, MD; and 
Rear Admiral Michael Toedt, MD, Chief Medical Officer, Indian 
Health Service, U.S. Department of Health and Human Services, 
Rockville, MD.
    I want to remind the witnesses that your full written 
testimony will be made a part of the official record and to 
please keep your statements to five minutes.
    With that, we will begin with you, Mr. Anderson.

STATEMENT OF HON. JOHN C. ANDERSON, U.S. ATTORNEY, DISTRICT OF 
             NEW MEXICO, U.S. DEPARTMENT OF JUSTICE

    Mr. Anderson. Chairman Hoeven, Vice Chairman Udall and 
members of the Committee, thank you for inviting us today to 
discuss this critical issue and the Department of Justice's 
efforts to support Native communities dealing with the 
devastating aftermath of the opioid epidemic.
    The Department has been uncompromising in our commitment to 
combating drug abuse and drug crimes, particularly opioids, in 
Indian Country and across the Nation. In my district, New 
Mexico, the opioid crisis in Indian Country is particularly 
acute.
    Despite its staggering natural beauty, northern New Mexico 
and Espanola, New Mexico in particular, has one of the highest 
opioid death rates in the Country. For decades, Espanola has 
had a severe heroin problem. As you may know, Espanola is 
surrounded by Indian reservations. Many New Mexico Indian 
pueblos, including the pueblos of Santa Clara, Okawingay, San 
Ildefonso, Pecurist, Owakay, Nambe, and Tuzukay are all within 
a short distance of the Espanola area.
    The opioid epidemic knows no boundaries, so our Pueblos are 
equally affected by heroin and prescription opioids. 
Individuals and communities alike continue to be plagued by the 
opioid scourge and its secondary effects.
    At a recent consultation in New Mexico, one Pueblo governor 
shared photographs of the parking lot of their casino. The 
photos were of the discarded needles, syringes and other drug 
paraphernalia scattered about the parking lot.
    At the same consultation, a Pueblo chief of police 
emotionally described losing a brother to a heroin overdose and 
a sister to a prescription opioid overdose. The chief of police 
explained that the drug epidemic is dire in northern New Mexico 
and that something needs to be done to address the problem.
    The catastrophic impact opioid abuse can have at every 
level of a community, from family units to infrastructure and 
economic stability, demands our best efforts to offer effective 
and sustainable support to communities in crisis. The 
Department has developed a multifaceted approach to addressing 
the threat and the impact of opioid abuse. Our approach in 
Indian Country is based on the belief that the tribes are in 
the best position to identify solutions to the problems in 
their communities.
    An important element of the Department's support is in 
providing opportunities for funding. In fiscal year 2017, the 
Department awarded nearly $59 million to strengthen drug 
programs and combat the opioid epidemic.
    The Office of Justice Programs administers the Department's 
Comprehensive Opioid Abuse Program. The goals of the 
Comprehensive Opioid Abuse Program are twofold. First is to 
reduce opioid misuse and the number of overdose fatalities. 
Second is to support the implementation of prescription drug 
monitoring programs to prevent the diversion of controlled 
substances.
    The Department understands that effective coordination 
among Federal agencies is crucial to ensuring the success of 
our efforts. We have participated in the High Intensity Drug 
Trafficking Areas Program, the HIDTA Program, which increases 
collaboration and information sharing between tribal law 
enforcement and Federal, State and local agencies to improve 
investigation and interdiction in Indian Country.
    The Indian Country Law Enforcement Coordination Working 
Group, co-chaired by the Department of Justice and the Bureau 
of Indian Affairs, includes representatives from 13 Federal law 
enforcement agencies. This group is an important tool for 
enhancing interagency Federal law enforcement coordination in 
tribal communities.
    We recognize that the crisis requires more than a law 
enforcement response. The Department is working closely with 
Indian Health Service to ensure that other Federal agencies are 
aware of the updated prescription drug monitoring protocols in 
IHS facilities.
    We have also developed a number of training opportunities 
to better equip law enforcement and secondary providers working 
in Indian Country in addressing drug crimes and the secondary 
effects of opioid abuse.
    The DEA has conducted a prolonged community outreach in 
Indian Country to educate tribal leaders and citizens on 
opioids and other drugs. On October 28, 2017, the Department 
and the BIA collaborated on the most recent prescription drug 
takeback day.
    This initiative provided a safe and convenient means of 
disposing of prescription drugs while also educating Native 
communities on the potential for opioid abuse. Over 115 tribal 
communities participated and we intend to repeat this 
initiative in the near future.
    Our goal is clear. We must continue working in partnership 
with tribal, Federal, State and local partners to respond to 
the opioid epidemic and to support communities affected by the 
crisis. We appreciate this Committee's focus on the issue and 
look forward to working with you in combating this threat to 
the health and well-being of our Native communities.
    Thank you again for the opportunity to participate today.
    [The prepared statement of Mr. Anderson follows:]

Prepared Statement of Hon. John C. Anderson, U.S. Attorney, District of 
                 New Mexico, U.S. Department of Justice
    Chairman Hoeven, Vice-Chairman Udall, and Members of the Committee:
    Thank you for inviting us today to discuss this critical issue and 
the Department of Justice's (the Department) efforts to support Native 
communities dealing with the devastating aftermath of the opioid 
epidemic. The Department has been uncompromising in our commitment to 
combatting drug abuse and drug crimes, particularly opioids, in Indian 
country and across the nation.
    In my district, New Mexico, the opioid crisis in Indian Country is 
particularly acute. Despite its staggering natural beauty, northern New 
Mexico, and Espanola, New Mexico in particular, has one of the highest 
opioid overdose death rates in the country. For decades, Espanola has 
had a severe heroin problem. And as you may know, Espanola is 
surrounded by Indian reservations. Many New Mexico Indian Pueblos, 
including the Pueblos of Santa Clara, Ohkay Owingeh, San Ildefonso, 
Picuris, Pojoaque, Nambe and Tesuque are all within a short distance of 
the Espanola area. The opioid epidemic knows no boundaries, and so our 
Pueblos are equally affected by heroin and prescription opioids; 
individuals and communities alike continue to be plagued by the opioid 
scourge and its secondary effects.
    At a recent consultation in New Mexico, one Pueblo Governor shared 
photographs of the parking lot of their casino. The photos revealed 
discarded needles, syringes and other drug paraphernalia scattered 
about the casino parking lot.
    At the same consultation, a Pueblo Chief of Police emotionally 
described losing a brother to a heroin overdose and a sister to a 
prescription opioid overdose. The Chief of Police explained that the 
drug epidemic is dire in Northern New Mexico and that something needs 
to be done to address the problem.
    The catastrophic impact that opioid abuse can have at every level 
of a community, from family units to infrastructure and economic 
stability, demands our best efforts to put forth effective and 
sustainable support to communities in crisis. The Department has 
developed a multi-faceted response to addressing the threat and the 
impact of opioid abuse. Our approach in Indian country is based on the 
belief that the Tribes are in the best position to identify solutions 
to problems in their communities. We have sought to develop resources 
and initiatives that rely on partnership with the Tribes and are 
continually interested in hearing from our Tribal and federal partners 
as we adjust our efforts to better meet the needs of Native 
communities.
    An important element of the Department's support is in providing 
opportunities for funding. In fiscal year 2017, the Department awarded 
nearly $59 million to strengthen drug court programs and combat the 
opioid epidemic. The Office of Justice Programs (OJP) administers the 
Department's ``Comprehensive Opioid Abuse Program.'' The goals of the 
Comprehensive Opioid Abuse Program are twofold: First, the program aims 
to reduce opioid misuse and the number of overdose fatalities. Second, 
the program supports the implementation, enhancement, and proactive use 
of prescription drug monitoring programs (PDMPs) to support clinical 
decisionmaking and prevent the misuse and diversion of controlled 
substances. Tribes are eligible to apply for a variety of funding 
opportunities under this program. As an example of recent awards under 
this program, in Fiscal Year 2017, the Seneca Nation Peacemakers Court 
was awarded funds to create a community-driven, culturally competent 
diversion project aimed at helping Native American opioid users. The 
Port Gamble S'Klallam Tribe was awarded funds in Fiscal Year 2017 to 
support drug courts and programs that support veterans. The Department 
will continue to offer these opportunities to Tribes going forward.
    The Department understands that effective coordination among 
federal agencies is crucial to ensuring our efforts are successful. We 
have participated in the High-Intensity Drug Trafficking Areas (HIDTA) 
program, funded through the Office of National Drug Control Policy, for 
many years now. The HIDTA program increases collaboration and 
information sharing between Tribal law enforcement and federal, state, 
and local agencies to improve investigation and interdiction in Indian 
country. As the Department continues to participate in the HIDTA 
program, our law enforcement agencies, particularly the Drug 
Enforcement Administration (DEA), have been working to build stronger 
relationships with other law enforcement agencies and service providers 
active in Indian country so that we are able to adjust our Task Force 
presence in Indian country most effectively.
    The Indian Country Law Enforcement Coordination Working Group, 
cochaired by the Department of Justice and the Bureau of Indian Affairs 
(BIA) at the Department of the Interior, has become important to 
enhancing inter-agency federal law enforcement coordination in tribal 
communities. The group includes representatives from 13 federal law 
enforcement agencies and has focused heavily on several aspects of the 
opioid epidemic including proliferation, identifying top challenges to 
law enforcement, and coordinating responses. We will continue to use 
this working group to strengthen our coordinated efforts. For example, 
trafficking through the mail is a significant concern and we intend to 
use this working group as a forum to develop better ways to stop the 
movement of opioids through the postal service.
    We recognize that the crisis requires more than a law enforcement 
response, so our efforts to coordinate go beyond law enforcement. For 
example, the Department is working closely with the Indian Health 
Service (IHS) of the Department of Health and Human Services to ensure 
that other federal agencies are aware of updated Prescription Drug 
Monitoring Program (PDMP) protocols in IHS facilities. The updated 
protocols have an impact on how some drug crimes are investigated and 
prosecuted, and on efforts to introduce safeguards against opioid 
abuse. Additionally, we have developed a number of training 
opportunities to better equip law enforcement and service providers 
working in Indian country to address the drug crimes and the familial 
and community impacts of opioid abuse. The Department has presented 
recent trainings, often in coordination with BIA, on opioid trends, 
investigative techniques, drug handling precautions regarding opioids, 
naloxone use, and indicators that opioids are present in a community. 
Other training is available on violent crime associated with opioids, 
prescription drug diversion, and investigating and prosecuting medical 
professionals and others involved in distributing prescription 
medications outside the scope of legitimate medical practice. These 
training opportunities are available to Tribal law enforcement and, in 
some cases, entirely geared for a Tribal audience. The Department is 
currently working with BIA on a new opportunity tentatively slated for 
this summer that will bring Tribal law enforcement representatives 
together with a number of federal law enforcement agencies to train on 
a wide range of drug-related topics.
    Community outreach is another important aspect of our approach to 
this issue. The DEA has conducted a prolonged community outreach effort 
in Indian country to educate Tribal leaders and citizens on opioids and 
other drugs. Additionally, on October 28, 2017, the Department and BIA 
collaborated on the most recent Prescription Drug Take Back Day, which 
is a nationwide program that has also allowed the successful 
collaboration between BIA and DEA. This initiative provided a safe, 
convenient, and responsible means of disposing prescription drugs, 
while also educating Native communities on the potential for opioid 
abuse. Over 115 Tribal communities participated; we intend to repeat 
this initiative and expand participation in the future.
    Improved information sharing plays a crucial role in any law 
enforcement effort, even more so in the context of opioids as we all 
work to get ahead of this terrible epidemic. The Tribal Access Program 
for National Crime Information (TAP) is an effective tool for 
participating Tribes to track and contribute data on opioid-related 
crimes and to perform required background checks. TAP assists Tribes by 
providing a means of access to national crime databases maintained by 
the FBI Criminal Justice Information Services (CJIS) Division for both 
criminal justice and civil background check purposes. This has been an 
especially important tool for performing checks on those who have 
regular contact with children in Indian country, including schools and 
foster care. Service providers in Indian country carry much of the 
burden of healing communities in the wake of opioid abuse, so we 
believe TAP plays an equally necessary role in ensuring safe providers 
as it does in sharing important law enforcement information.
    The use of data analytics to combat the opioid crisis is among the 
new tactics that are under development Department-wide. Attorney 
General Sessions formed the Opioid Fraud and Abuse Detection Unit to 
utilize data analytics, such as distribution and inventory figures, to 
identify patterns, trends, and statistical outliers that can be 
developed into targeted law enforcement operations. As we better 
understand the data across the country we will be able to better 
understand patterns and trends in Indian country.
    Our goal is clear: we must continue working in partnership with 
Tribal, federal, state, and local partners to respond to the opioid 
epidemic and to support communities that are affected by the crisis. We 
are committed to putting forth our best efforts in this joint 
undertaking. We appreciate this committee's focus on this issue and 
look forward to working with you going forward. Thank you again for the 
opportunity to participate today.

    The Chairman. Thank you.
    Captain Jones.

   STATEMENT OF CAPTAIN CHRISTOPHER JONES, PHARM.D., M.P.H., 
             DIRECTOR, NATIONAL MENTAL HEALTH AND 
  SUBSTANCE USE POLICY LABORATORY, SUBSTANCE ABUSE AND MENTAL 
             HEALTH SERVICES ADMINISTRATION, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Jones. Thank you, Chairman Hoeven, Vice Chairman Udall 
and members of the Committee. Thank you for the opportunity to 
testify at this important hearing focusing on tribes and tribal 
entities.
    From the start of his Administration, President Trump has 
been addressing the opioid epidemic as a top priority. At 
SAMHSA, we share the President's commitment to ending the 
crisis in the U.S.
    The American Indian and Alaskan Native population has been 
significantly impacted by the opioid epidemic. Among this 
population, 4 percent of people 12 and older reported 
prescription opioid misuse in 2016. More than 1 percent had an 
opioid use disorder.
    Most concerning are the continued increases in overdose 
deaths. In 2016, American Indians and Alaska Natives had the 
second highest overdose death rate in the United States, 13.9 
deaths per 100,000 people, which represents a 400 percent 
increase since 2000.
    To combat the opioid crisis, HHS launched a five-point 
opioid strategy in April 2017. The strategy aims to improve 
access to prevention, treatment and recovery support services; 
target the availability and distribution of overdose-reversing 
drugs; strengthen public health data reporting and collection; 
support cutting-edge research that advances our understanding 
of pain and addiction; and advance the practice of pain 
management.
    As the Department's lead agency for behavioral health, 
SAMHSA has been at the forefront of the HHS response to the 
opioid crisis. Today, I want to focus on how SAMHSA is working 
with tribal communities under the HHS opioid strategy.
    Since joining SAMHSA, Assistant Secretary McCance-Katz has 
prioritized efforts to support the behavioral health needs of 
the American Indian and Alaska Native population. She has 
charged SAMHSA leadership with identifying every possible 
opportunity for tribal entities to engage with SAMHSA. This 
includes making tribal entities eligible for discretionary 
grant programs wherever possible; ensuring flexibility in how 
tribal entities incorporate cultural practices into their 
programs; and providing assistance to ensure that tribal 
entities are set up for success.
    Under the HHS strategy, SAMHSA focuses its work in three 
areas: building prevention, treatment and recovery capacity 
through funding; providing technical assistance and training; 
and leveraging key stakeholders to support incorporation of 
tribes and tribal populations into the opioid response.
    In the area of funding, SAMHSA administers the State 
Targeted Response to the Opioid Crisis Grants, a two-year 
program authorized under the 21st Century Cures Act. Although 
tribal entities were not eligible for funding under the 
statutory structure of the STR Program, SAMHSA has taken a 
number of steps to support inclusion engagement of tribes in 
State plans.
    Specifically, we required States to assess the needs of 
tribal communities and include them in their strategic plans 
and reviewed each State plan for tribal engagement. We held a 
webinar with States to clarify our expectation that American 
Indians and Alaska Natives be incorporated as a population of 
focus and provided examples of how States are working with 
tribes on the STR Program.
    Most recently, Dr. McCance-Katz sent a letter to governors 
calling on them to work with tribes and allocate funds directly 
to them so they can offer the essential and life-saving 
services their communities need to respond to the opioid 
crisis. Our assessment of the State STR plans indicates that of 
the 35 States with federally-recognized tribes within their 
borders, at least 12 have specifically identified tribes as a 
population of focus or specified actions that are working to 
combat opioids in tribal communities.
    Tribes have also received funding from a number of SAMHSA's 
other discretionary programs. Under the Strategic Prevention 
Framework Partnerships for Success Program, First Nations 
Community Healthsource of New Mexico is using funding to 
develop prevention strategies for tribal communities.
    Under the Strategic Prevention Framework for Prescription 
Drugs Program, four tribes are working with their States to 
incorporate tribal data into State prescription drug monitoring 
programs to better target prevention efforts and reduce 
prescription drug misuse. Last September, SAMHSA awarded 
funding to four tribes under our First Responders Naloxone 
Grant Program. We also recently released a funding announcement 
for Treatment and Recovery Services for Adolescents, 
Transitional Aged Youth and Their Families that actually, for 
the first time, includes a $5 million setaside for tribal 
entities.
    In the area of technical assistance, Assistant Secretary 
McCance-Katz recently reinstated SAMHSA's American Indian and 
Alaska Native Support Center which is part of our Addiction 
Technology Transfer Center Network. This center provides 
critical support to develop and strengthen the specialized 
behavioral and primary healthcare workforce that provides 
treatment and recovery services to tribal communities.
    We also fund a Tribal Training and Technical Assistance 
Center which actively engages and serves tribes across the 
Country. In fact, today, this center is conducting the first of 
two webinars on opioids in Indian Country.
    Finally, SAMHSA is committed to leveraging a broad range of 
stakeholders to ensure that the behavioral health needs of 
tribal populations are a part of our Nation's response to the 
opioid crisis. To support this commitment, SAMHSA is currently 
planning a tribal-State Policy Academy for August 2018 that 
will bring States and tribes together to develop specific, 
actionable plans for how they can collaborate to address the 
opioid crisis and substance use issues in their community.
    Thank you for inviting me to testify. I look forward to 
your questions.
    [The prepared statement of Dr. Jones follows:]

  Prepared Statement of Captain Christopher Jones, Pharm.D., M.P.H., 
 Director, National Mental Health and Substance Use Policy Laboratory, 
    Substance Abuse and Mental Health Services Administration, U.S. 
                Department of Health and Human Services
    Chairman Hoeven, Vice Chairman Udall, and members of the Senate 
Committee on Indian Affairs, thank you for inviting me to testify at 
this important hearing. The Substance Abuse and Mental Health Services 
Administration (SAMHSA) has been actively engaged in the 
Administration's effort to combat the opioid epidemic. SAMHSA works 
with our colleagues at the Department of Health and Human Services 
(HHS), state and local governments, tribal entities, and other key 
stakeholders.
    Thank you for the opportunity to discuss the opioid crisis in the 
United States and the Federal response, particularly in relation to 
tribes and tribal entities. From the start of his Administration, 
President Trump has made addressing the opioid epidemic a top priority, 
and at SAMHSA we share the President's commitment to bringing an end to 
this crisis, which is exacting a toll on individuals, families, and 
communities across the country. The Department, including SAMHSA, has 
made the crisis a top priority and is committed to using our full 
expertise and resources to combat the epidemic.
    Over the past 15 years, communities across our Nation have been 
devastated by increasing prescription and illicit opioid abuse, 
addiction, and overdose. According to SAMHSA's National Survey on Drug 
Use and Health (NSDUH), in 2016, over 11 million Americans misused 
prescription opioids, nearly 1 million used heroin, and 2.1 million had 
an opioid use disorder due to prescription opioids or heroin. The 
American Indian/Alaska Native (AI/AN) population is likewise affected 
by the opioid crisis. According to NSDUH, 5.2 percent (72,000) of AI/AN 
aged 18 and older reported misusing a prescription drug in the past 
year and 4.0 percent (56,000) of AI/ANs aged 18 and older reported 
misusing a prescription pain reliever in the past year. Over the past 
decade, the United States has experienced significant increases in 
rates of neonatal abstinence syndrome (NAS), hepatitis C infections, 
and opioid-related emergency department visits and hospitalizations. 
Most alarming are the continued increases in overdose deaths, 
especially the rapid increase since 2013 in deaths involving illicit 
fentanyl and other highly potent synthetic opioids. Since 2000, more 
than 300,000 Americans have died of an opioid overdose. Opioids were 
involved in 42,249 deaths in 2016, and opioid overdose deaths were five 
times higher in 2016 than 1999.
    The opioid epidemic in the United States can be attributed to a 
variety of factors. For example, there was a significant rise in opioid 
analgesic prescriptions that began in the mid-to-late 1990s. Not only 
did the volume of opioids prescribed increase, but also well-
intentioned healthcare providers began to prescribe opioids to treat 
pain in ways that we now know are high-risk and have been associated 
with opioid abuse, addiction, and overdose, such as prescribing at high 
doses and for longer durations. One additional factor is a lack of 
health system and healthcare provider capacity to identify and engage 
individuals, and provide them with high-quality, evidence-based opioid 
addiction treatment, in particular the full spectrum of medication-
assisted treatment (MAT). It is well-documented that the majority of 
people with opioid addiction in the United States do not receive 
treatment, and even among those who do, many do not receive evidence-
based care. Accounting for these factors is paramount to the 
development of a successful strategy to combat the opioid crisis. 
Further, there is a need for more rigorous research to better 
understand how existing programs or policies might be contributing to 
or mitigating the opioid epidemic.
HHS Five Point Strategy
    In April 2017, HHS outlined its five-point Opioid Strategy, which 
provides the overarching framework to leverage the expertise and 
resources of HHS agencies in a strategic and coordinated manner. The 
comprehensive, evidence-based Opioid Strategy aims to:

   Improve access to prevention, treatment, and recovery 
        support services to prevent the health, social, and economic 
        consequences associated with opioid addiction and to enable 
        individuals to achieve long-term recovery;

   Target the availability and distribution of overdose-
        reversing drugs to ensure the broad provision of these drugs to 
        people likely to experience or respond to an overdose, with a 
        particular focus on targeting high-risk populations;

   Strengthen public health data reporting and collection to 
        improve the timeliness and specificity of data and to inform a 
        real-time public health response as the epidemic evolves;

   Support cutting-edge research that advances our 
        understanding of pain and addiction, leads to the development 
        of new treatments, and identifies effective public health 
        interventions to reduce opioid-related health harms; and

   Advance the practice of pain management to enable access to 
        high-quality, evidence-based pain care that reduces the burden 
        of pain for individuals, families, and society while also 
        reducing the inappropriate use of opioids and opioid-related 
        harms.

    As HHS lead agency for behavioral health, SAMHSA's core mission is 
to reduce the impact of substance abuse and mental illness on America's 
communities. SAMHSA supports a portfolio of activities that address the 
HHS Opioid Strategy.
    Today, I will address how SAMHSA is working with tribes and tribal 
organizations as that work relates to this strategy.
Improving Access to Prevention, Treatment, and Recovery Support 
        Services
    SAMHSA administers the State Targeted Response to the Opioid Crisis 
Grants, a two-year program authorized by the 21st Century Cures Act 
(P.L. 114-255). By providing $485 million to states and U.S. 
territories in Fiscal Year (FY) 2017, this program allows states to 
focus on areas of greatest need, including increasing access to 
treatment, and reducing opioid overdose related deaths through the 
provision of the full range of prevention, treatment, and recovery 
services for opioid use disorder. Specific areas in which states and 
tribes collaborate on prevention activities include: Prescription Drug 
Monitoring Program (PDMP) data-sharing; State Epidemiological Outcome 
Workgroups; overdose education on naloxone distribution; and media 
campaigns. In Minnesota, the state is supporting five Native American 
communities to service high-risk pregnant women with opioid use 
disorder (OUD) in order to strengthen and enhance peer recovery support 
services. In Montana, the state is working with the Rocky Mountain 
Tribal Leaders Council to develop culturally tailored versions of the 
current peer monitoring trainings and peer supervisor trainings.
    Tribes receive SAMHSA prevention grant funds to address opioid 
misuse and abuse. Prevention programs include a focus on change at the 
community level that will, over time, lead to measurable changes at the 
state and tribal levels. Under the Strategic Prevention Framework-
Partnerships for Success (SPF-PFS) grant program, First Nations 
Community HealthSource in New Mexico serves four tribes: Pueblo de 
Cochiti; Pueblo of Laguna; Native American Community Academy; and Zuni 
Pueblo. First Nations Community HealthSource has developed prevention 
strategies based on research and tribal traditions, culture, language, 
and values that reduce prescription drug abuse and misuse; improve the 
capacity of tribal leadership to understand and support prevention 
strategies designed to decrease prescription drug abuse and misuse; and 
develops a tribal strengths based method to decrease prescription drug 
abuse and misuse.
    Other tribes are developing capacity and expertise in the use of 
data from state-run PDMPs. Under the Strategic Prevention Framework for 
Prescription Drugs (SPF Rx) grant program, four tribes (Cherokee 
Nation, Southern Plains inter-tribal, Nooksack, and Little Traverse Bay 
Band of Odawa Indians) currently work with their states to bring tribal 
data into the system and decrease prescription drug misuse in their 
communities. For example, in Oklahoma, the Cherokee Nation has used the 
PDMP data to develop a tribal-wide media campaign, ``Think SMART,'' 
that is educating community members on the responsible use of opioids 
and the risks associated with overprescribing.
    Since coming to SAMHSA, the Assistant Secretary for Mental Health 
and Substance Use, Dr. Elinore McCance-Katz, has reviewed all of our 
discretionary funding announcements and has looked for opportunities to 
improve tribal access to SAMHSA's discretionary grant funds. For 
example, tribal leaders informed her they have a great concern about 
the vulnerability of tribal youth to developing mental and substance 
use disorders. With clarity that tribal youth are a priority, Assistant 
Secretary McCance-Katz was able to ensure that a funding opportunity 
announcement (FOA) that SAMHSA recently released entitled ``Enhancement 
and Expansion of Treatment and Recovery Services for Adolescents, 
Transitional Aged Youth, and their Families'' included at least a $5 
million set-aside for tribes, tribal organizations, urban Indian health 
programs, and consortia of tribes or tribal organizations. This amount 
is approximately 34 percent of the total anticipated $14.6 million 
available for this program.
    Targeting Overdose-Reversing Drugs SAMHSA has been a leader in 
efforts to reduce overdose deaths by increasing, through funding and 
technical assistance, the availability and use of naloxone to reverse 
overdose. SAMHSA's ``Opioid Overdose Prevention Toolkit,'' first 
released in 2013, is one of SAMHSA's most downloaded resources. The 
Toolkit provides information on risks for opioid overdose, recognition 
of overdose, and how to provide emergency care in an overdose 
situation. The Toolkit is intended for community members, first 
responders, prescribers, people who have recovered from an opioid 
overdose, and family members, as well as communities and local 
governments.
    SAMHSA provides a number of funding streams that can be used to 
expand access to naloxone. In September 2017, SAMHSA awarded funding 
for the First Responders-Comprehensive Addiction and Recovery Act (FR-
CARA) grant program, which includes grants to four tribes: White Earth 
Band of Chippewa Indians; Cherokee Nation; Choctaw Nation of Oklahoma; 
and Lac Du Flambeau Band of Lake Superior Chippewa Indians. The First 
Responders grant program provides resources to first responders and 
treatment providers who work directly with the populations at highest 
risk for opioid overdose. For the White Earth Band of Chippewa Indians 
in Minnesota, prescription opiate and heroin admissions for American 
Indians on the Reservation totaled almost 30 percent of the treatment 
admissions. SAMHSA's grant helps support the tribe's collaborative 
approach to addressing the crisis throughout its community, including 
partnerships with public health, law enforcement, behavioral health, 
first responders, public relations, and cultural representatives.
Strengthening Public Health Data and Reporting
    NSDUH provides key national and state level data on a variety of 
substance use and mental health topics, including opioid misuse. NSDUH 
is a vital part of the surveillance effort related to opioids, and the 
data from NSDUH has been used to track historical and emerging trends 
in opioid misuse, including geographic and demographic variability.
    According to the 2016 NSDUH, 5.2 percent (72,000) of AI/AN aged 18 
and older reported misusing a prescription drug in the past year and 
4.0 percent (56,000) of AI/ANs aged 18 and older reported misusing a 
prescription pain reliever in the past year, compared to national 
averages of 7.1 percent and 4.3 percent respectively. The 2016 NSDUH 
also found that 4.1 percent (63,000) of AI/ANs aged 12 and older 
reported opioid misuse in the past year, in line with the national 
average of 4.4 percent. The 2016 NSDUH found that 1.1 percent (16,000) 
of AI/ANs aged 12 and older reported having an opioid use disorder in 
the past year.
Working with Tribes and Tribal Organizations to Reduce Opioid Misuse 
        and Abuse
    Assistant Secretary McCance-Katz reinstated SAMHSA's Addiction 
Technology Transfer Center (ATTC): American Indian and Alaska Native 
Support Center Cooperative Agreement (AI/AN ATTC). The purpose of this 
program is to provide support for the ATTC Network, AI/AN, tribal 
organizations, urban Indian programs, state and local governments, and 
other organizations to develop and strengthen the specialized 
behavioral healthcare and primary healthcare workforce that provides 
substance use disorder (SUD) treatment and recovery support services to 
tribal communities. The University of Iowa, the grantee, works directly 
with SAMHSA and in collaboration with the FY 2017 ATTC National 
Coordinating Center and the 10 Regional ATTC Centers. The Centers focus 
on activities aimed at improving the quality and effectiveness of 
treatment and recovery, as well as working directly with providers of 
clinical and recovery support services, and others that influence the 
delivery of services, to improve the quality of workforce training and 
service delivery to tribal communities.
    SAMHSA also funds the Tribal Training and Technical Assistance 
Center, which actively engages and serves tribes across the Nation. 
Through onsite and virtual training, targeted resources, learning 
communities, assistance with Tribal Action Plans, and intensive 
community engagement, our technical assistance guides tribal 
communities and organizations in using cultural knowledge and strengths 
to support wellness, including addressing the opioid crisis. For 
example, today, this Center is conducting the first of two webinars 
targeting opioids in Indian Country. SAMHSA is in the process of 
assessing the technical assistance provided to assure that the funding 
is appropriate to the need and that the tribal entities get the support 
they need while maximizing grant funds to communities.
    SAMHSA received input from our Tribal Technical Advisory Committee 
(TTAC) and shared TTAC's recommendations with the Secretary's Tribal 
Advisory Committee. Based on input from these tribal leaders, SAMHSA is 
partnering with the Centers for Disease Control and Prevention, Indian 
Health Service, Centers for Medicare & Medicaid Services, and National 
Institutes of Health to host a Joint Tribal Advisory Committee (JTAC) 
meeting. The JTAC will bring together tribal leaders from the tribal 
advisory committees for these operating divisions to discuss related 
priorities. Our plan is to host the joint meeting immediately preceding 
the National American Indian and Alaska Native Behavioral Health 
Conference this summer.
    We have heard from tribal leaders that SAMHSA also has a 
responsibility to improve tribal-state relationships. In response, the 
Agency is hosting a Tribal-State Policy Academy (TSPA) to advance 
tribal behavioral health planning. The TSPA will have a particular 
emphasis on improving current efforts to address the impact of the 
opioid epidemic in Indian Country but will also include an opportunity 
for tribes and states to work together on other primary substances of 
abuse affecting local tribal communities. Beyond supporting improved 
working relationships and planning, proposed outcomes include joint 
tribal-state plans for combating drug use in tribal communities and 
collaborative models that may be replicated by other states and tribes. 
Up to ten tribal-state teams will be able to participate in the Academy 
that is targeted for this summer. Additionally, Assistant Secretary 
McCance-Katz recently sent a letter to governors urging them to assess 
the behavioral health needs of AI/ANs in their states and to equitably 
distribute federal funds directed to states to address the opioid 
crisis and mental health needs.
    Finally, SAMHSA has had discussions with tribal leaders about the 
importance of recognizing and elevating tribal behavioral health as a 
critical step toward collaborative improvements. SAMHSA is in the 
process of engaging Federal and tribal organization partners to host a 
national town hall on combatting substance use in tribal communities. 
The town hall will bring together senior government officials and 
tribal leaders to explicitly address opportunities, and identify a 
clearer path forward, for combatting substance use in AI/AN 
communities.
    Thank you again for inviting me to testify today. I look forward to 
answering your questions.

    The Chairman. Rear Admiral Toedt.

 STATEMENT OF REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF MEDICAL 
             OFFICER, INDIAN HEALTH SERVICE, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Toedt. Good afternoon, Chairman Hoeven, Vice Chairman 
Udall, and members of the Committee.
    I am Dr. Michael Toedt, Chief Medical Officer for the 
Indian Health Service. Today, I appreciate the opportunity to 
provide information on the work that IHS has been doing to 
address the opioid crisis, which is a top priority for the 
agency and the Department of Health and Human Services.
    The impact of the opioid crisis on American Indians and 
Alaska Natives is immense. American Indians and Alaska Natives 
have had the highest drug overdose death rates in 2015 
according to the CDC, and the largest percentage increase in 
the number of deaths over time from 1999 to 2015 compared to 
other racial and ethnic groups.
    During that time, deaths rose more than 500 percent among 
American Indians and Alaska Natives. Collaborating and 
consulting with tribes to address the opioid crisis in Indian 
Country is important. We work with our tribal advisory 
committees to gather input on critical next steps. The opioid 
crisis has been and will continue to be a priority for the 
advisory committees.
    IHS strengthened and prioritized efforts to address the 
opioid crisis in 2012 and developed a number of recommendations 
focused on six areas: patient care; policy development and 
implementation; education; monitoring; medication storage and 
disposal; and law enforcement.
    To address these areas, in March 2016, IHS chartered the 
National Committee on Heroin, Opioids and Pain Efforts referred 
to as the HOPE Committee. The Committee works to advance the 
Department's multifaceted plan to combat opioid abuse 
including: better prevention; treatment, and recovery services; 
better targeting of overdose reversing drugs; better data on 
the epidemic; better pain management; and better research.
    Our Prescription Drug Monitoring Program policy strengthens 
the monitoring and deterrence of prescription misuse and 
diversion. It requires IHS providers to check State PDMP 
databases prior to prescribing opioids for longer than seven 
days. IHS has partnered with all States where IHS Federal 
facilities are located and successfully connected so far with 
17 out of 18 State PDMP databases. As a result, 99 percent of 
IHS facilities offering pharmaceutical services have access. 
IHS pharmacies must report opioid-prescribing data to State 
PDMPs, a proactive requirement not currently required by law.
    We are not working alone. IHS partners with SAMHSA to train 
nearly 70 physicians to treat opioid use disorders, increasing 
access to treatment services in tribal communities. In 2008, 
IHS established a Telebehavioral Health Center of Excellence to 
provide clinical services, provider education and technical 
assistance through the Indian Health system. This center 
supports remote, isolated Native communities with limited 
access to behavioral health services.
    We partner with the Bureau of Indian Affairs to train and 
equip law enforcement officers to recognize symptoms of 
overdose and intervene when necessary. As of December 2017, we 
have trained and provided naloxone at no cost to BIA for more 
than 300 law enforcement officers. We also certified 47 BIA law 
enforcement officers as naloxone trainers.
    Addiction is complex but treatable. There is no single 
treatment that is right for everyone. The IHS Alcohol and 
Substance Abuse Program provides funding, training and 
technical assistance to IHS tribal and urban Indian programs. 
This ensures a variety of treatment options exist. 
Approximately 90 percent of the fiscal year 2017 Alcohol and 
Substance Abuse Program budget of $205 million is administered 
by tribes.
    IHS also supports prevention efforts through the Substance 
Abuse and Suicide Prevention Program. As of fiscal year 2017, 
program funds are approximately $30 million for 175 IHS tribal 
and urban Indian Health organizations. The funds are used to 
develop and implement culturally-appropriate, evidence-based 
and community-driven models. We fund 19 projects that focus 
specifically on methamphetamine and substance abuse prevention 
treatment and recovery programming.
    The majority of substance abuse and suicide prevention 
projects focus on reducing risk factors for suicidal behavior 
and substance use among Native youth. Furthermore, we work with 
tribes to develop and implement models of care that are 
sustainable to combat the opioid crisis. We focus on treatments 
that are evidence-based and culturally-appropriate that will 
have significant impacts on the prevention, treatment and 
recovery efforts.
    IHS collaborates with key stakeholders to develop viable 
reimbursement models for services provided. This comprehensive 
strategy will allow for a more unified approach with tribal 
communities.
    We will continue to work with tribes to develop coordinated 
responses using every available resource possible to battle the 
opioid crisis in tribal communities. Thank you for your 
commitment to improving healthcare for American Indians and 
Alaska Natives by addressing the opioid crisis as a top 
priority.
    I will be happy to answer any questions the Committee may 
have.
    [The prepared statement of Admiral Toedt follows:]

 Prepared Statement of Rear Admiral Michael Toedt, M.D., Chief Medical 
  Officer, Indian Health Service, U.S. Department of Health and Human 
                                Services
    Chairman and Members of the Committee:
    Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members 
of the Committee. I am Dr. Michael Toedt, Chief Medical Officer, Indian 
Health Service (IHS). I earned my Doctorate of Medicine from the 
Uniformed Services University of the Health Sciences in Bethesda, 
Maryland. I am board certified in family medicine and I am a fellow of 
the American Academy of Family Physicians. I have served as a 
Commissioned Officer for 26 years in both the National Health Service 
Corps and the Indian Health Service. Today, I appreciate the 
opportunity to provide information on the work that IHS has been doing 
to address the opioid crisis, which is a top priority for the 
Department of Health and Human Services (HHS).
    IHS is a distinct agency in HHS, established to carry out the 
responsibilities, authorities, and functions of the United States to 
provide health care services to American Indians and Alaska Natives. It 
is the only HHS agency whose primary function is direct delivery of 
health care. The mission of IHS, in partnership with American Indian 
and Alaska Native people, is to raise the physical, mental, social, and 
spiritual health of American Indians and Alaska Natives to the highest 
level. The IHS system consists of 12 Area offices, which oversee 170 
Service Units that provide care at the local level. Health services are 
provided through facilities managed by the IHS, by Tribes and tribal 
organizations under authorities of the Indian Self-Determination and 
Education Assistance Act (ISDEAA), and through contracts and grants 
awarded to urban Indian organizations authorized by the Indian Health 
Care Improvement Act.
    The impact of the opioid crisis on American Indians and Alaska 
Natives is immense. The Centers for Disease Control and Prevention 
(CDC) reported that American Indians and Alaska Natives had the highest 
drug overdose death rates in 2015 and the largest percentage increase 
in the number of deaths over time from 1999-2015 compared to other 
racial and ethnic groups.1 During that time, deaths rose more than 500 
percent among American Indians and Alaska Natives. In addition, because 
of misclassification of race and ethnicity on death certificates, the 
actual number of deaths for American Indians and Alaska Natives may be 
underestimated by up to 35 percent. \1\
---------------------------------------------------------------------------
    \1\ https://www.cdc.gov/mmwr/volumes/66/ss/pdfs/ss6619.pdf
---------------------------------------------------------------------------
Addressing the Opioid Crisis in Indian Country
    IHS recognizes the importance of collaborating and consulting with 
tribes to develop a comprehensive plan for addressing the opioid crisis 
in Indian country. IHS partners with its tribal advisory committees, 
including the Tribal Self-Governance Advisory Committee, the Direct 
Service Tribes Advisory Committee, and the National Tribal Advisory 
Committee on Behavioral Health to gather input on critical next steps 
to address the opioid crisis. The opioid crisis has been a priority on 
recent meeting agendas for the advisory committees and will be a topic 
for future meetings as well.
    IHS strengthened and prioritized efforts to address the opioid 
crisis in 2012 and developed a number of recommendations focused on six 
areas: patient care, policy development/implementation, education, 
monitoring, medication storage/disposal, and law enforcement. In March 
2017, IHS chartered the National Committee on Heroin, Opioids and Pain 
Efforts (HOPE). The HOPE committee, which consists of multidisciplinary 
health care professionals across IHS, works to advance the Department's 
multifaceted plan to combat opioid abuse: (1) better prevention, 
treatment, and recovery services; (2) better targeting of overdose 
reversing drugs; (3) better data on the epidemic; (4) better pain 
management; and (5) better research. To address better research, IHS 
partners with the National Institutes of Health on research addressing 
health disparities and health priorities within Indian communities.
    The HOPE committee is reviewing and updating IHS policies to ensure 
they are aligned with the most current national guidelines and 
addressing the most urgent needs. For example, the IHS ``Chronic Non-
Cancer Pain Management'' policy, originally published in 2014, was re-
released earlier this year to align with the 2016 CDC Guidelines for 
Prescribing Opioids for Chronic Pain. This policy also requires 
mandatory opioid training for all Federal controlled substance 
prescribers with required refresher training every three years.
    The IHS Prescription Drug Monitoring Programs (PDMP) policy 
strengthens the monitoring and deterrence of prescription misuse and 
diversion by requiring IHS providers to check state PDMP databases 
prior to prescribing opioids for longer than seven days. IHS has 
partnered with all states where IHS federal facilities are located and 
has successfully connected with 17 out of the 18 state PDMP databases, 
allowing access for 82 of the 83 IHS facilities offering pharmaceutical 
services. The IHS PDMP policy also requires IHS practitioners to 
conduct peer reviews of prescriber activity. Additionally, under the 
IHS policy, pharmacies must report opioid prescribing data to state 
PDMPs--a proactive requirement not currently required by law. IHS is 
also working to establish two additional policies to expand access to 
medication assisted treatment (MAT), and to standardize how first 
responders in American Indian and Alaska Native communities are 
provided naloxone, a medication for reversing opioid overdoses.
    To address the shortage of specialists who can provide MAT in rural 
tribal communities, IHS is training its current workforce to provide 
these specialty services. Over the last two years, IHS partnered with 
the Substance Abuse and Mental Health Services Administration (SAMHSA) 
to train nearly 70 physicians to obtain their Drug Addiction Treatment 
Act waivers to treat opioid use disorders, which increases access to 
treatment services in American Indian and Alaska Native communities. In 
2008, IHS established the Telebehavioral Health Center of Excellence 
(TBHCE) which provides, clinical services, provider education and 
technical assistance throughout the Indian health system. The TBHCE was 
developed to support remote and isolated American Indian and Alaska 
Native communities and areas with limited access to behavioral health 
services. These services directly equip IHS staff to reduce morbidity 
and mortality surrounding the opioid epidemic. Currently, the TBHCE is 
providing training on MAT for opioid use disorder, which uses Food and 
Drug Administration approved pharmacological treatments, in combination 
with psychosocial treatments and social supports.
    Additionally, IHS offers weekly continuing education on pain and 
addiction as well as consultation on complex cases to further train 
primary care clinicians to provide these specialty MAT services. 
Consultation is offered through virtual clinics hosted by the 
University of New Mexico to connect primary care clinicians with expert 
teams to share knowledge and elevate the level of specialty care 
available to patients. There are some promising signs of the positive 
outcomes as a result of these efforts. For example, a preliminary 
analysis of available IHS data indicates a 13 percent decrease in the 
average number of opioid prescriptions per 100 of all IHS users from FY 
2013-2016. \2\
---------------------------------------------------------------------------
    \2\ IHS--National Data Warehouse
---------------------------------------------------------------------------
    The Tribal Law and Order Act requires HHS, the Department of 
Justice, and the Department of Interior to coordinate efforts on 
alcohol and substance use issues in Indian country. IHS is actively 
involved in interagency coordination and collaboration on tribal 
alcohol and substance use programs. As part of this effort, tribes are 
encouraged to develop Tribal Action Plans (TAP) to address substance 
use and opioid use in their communities. IHS is an integral part of the 
TAP workgroup that works with tribes to help them gain access to 
government resources and coordinate efforts in order to achieve our 
shared goals of preventing and treating substance use disorders.
    IHS partners with the Bureau of Indian Affairs (BIA) to train and 
equip law enforcement officers (LEOs) to recognize signs and symptoms 
of overdoses and intervene when the overdose is occurring. As of 
December 2017, the IHS trained and provided naloxone at no cost to BIA 
for more than 300 LEOs and certified 47 BIA LEOs as naloxone trainers. 
In direct care facilities, IHS has also been providing naloxone 
supplies, training and tool kits to tribal law enforcement. IHS 
encourages its pharmacists to co-prescribe naloxone to patients who are 
at higher risk for opioid overdose based on criteria developed with 
primary care clinicians, and as a result the number of naloxone 
prescriptions has increased by 518 percent from FY 2013 to FY 2017.
    IHS has developed a data reporting system that will provide 
prescribing data on national, regional, and local levels. We will track 
data focusing on the overall improvements and monitoring of prescribing 
practices and procurement. Regional data will be used for comparison 
with state-level data from the CDC and among other facilities in their 
region, as well as nationally. We will use the information to identify 
areas of improvement, monitor trends, intervene early and effectively, 
and enhance efforts to train medical providers.
IHS Behavioral Health and the Alcohol and Substance Abuse Program
    Addiction is complex, but treatable. Unfortunately, there is no 
single treatment that is right for everyone. The IHS Alcohol and 
Substance Abuse Program (ASAP) provides funding, policy, training, and 
technical assistance to local IHS, tribal, and urban Indian programs to 
ensure a variety of treatment options exist. Approximately 90 percent 
of the FY 2017 ASAP budget of $205 million is contracted or compacted 
by Tribes enabling those programs to deliver treatment services 
tailored to meet their local needs. These programs provide services at 
all stages of recovery from detoxification, behavioral counseling, 
outpatient and residential treatment, and long-term follow up to 
prevent relapse.
    IHS also targets suicide and substance use and misuse prevention 
through the Substance Abuse and Suicide Prevention (SASP) program. As 
of FY 2017, SASP funds approximately $30 million to 175 IHS, Tribal, 
and Urban Indian Health organizations to develop and implement 
culturally appropriate, evidence-based and/or practice-based, community 
driven models. We fund 19 projects that focus specifically on 
methamphetamine and substance abuse prevention, treatment, and recovery 
programming. The majority of the SASP projects focus on prevention and 
early intervention strategies to reduce risk factors for suicidal 
behavior and substance use among American Indian and Alaska Native 
youth. A total of 108 funded projects work with Native youth to 
increase resiliency, teach coping skills, promote family engagement, 
and hire behavioral health providers who specialize in treating 
children, youth, and families. The SASP program is currently in its 
third year and IHS will evaluate SASP data to better understand the 
full impact of the program, what is working in tribal communities, 
disseminate best practices, and share lessons learned.
    IHS is addressing the need to assist youth with substance use 
disorders including opioid dependency through twelve Youth Regional 
Treatment Centers (YRTCs). The YRTCs provide a range of clinical 
services to provide treatment rooted in culturally relevant, holistic 
models of care.
    IHS actively solicits feedback and works with the tribes to develop 
and implement models of care that are sustainable to combat the opioid 
crisis. We focus on treatments that are evidence-based and culturally 
effective that will have a significant impact on the prevention, 
treatment and recovery efforts. To sustain this strategy, IHS is 
collaborating with key stakeholders to develop viable reimbursement 
models for services provided, while advocating for reimbursement for 
traditional and culturally based practices, a critical approach to 
opioid recovery in tribal communities. This comprehensive strategy will 
allow for a more unified approach with tribal communities and also 
afford IHS the time to evaluate the impact of these interventions. IHS 
will continue to work with Tribes to develop coordinated responses 
using every available resource possible to battle the opioid crisis in 
tribal communities.
    Thank you for your commitment to improving health care for American 
Indians and Alaska Natives by addressing the opioid crisis as a top 
priority. I will be happy to answer any questions the Committee may 
have.

    The Chairman. Thank you.
    We will now start five minute rounds of questioning.
    Captain Jones, your written testimony outlined the 
Department of Health and Human Services' five point strategy 
which establishes a framework for substance abuse and mental 
health services and SAMHSA's efforts to combat the opioid 
addiction epidemic.
    I would like to hear about benchmarks for success and how 
you gauge the effectiveness of these kinds of programs? What 
are your metrics?
    Dr. Jones. Thank you for the question.
    Through the Department, we are currently working through a 
process to finalize what are the exact measures we want to have 
over time, looking at shorter term behavioral changes, such as 
changes in opioid prescribing, increases in the number of 
people who are receiving addiction treatment, morbidity and 
mortality measures and reductions in emergency department 
visits and overdose deaths. Through that process of the five 
point strategy, we are working to do that.
    We have not specified exactly what our points of success 
are but we have learned from prior experience that oftentimes, 
as in the case of naloxone, we previously had a goal of 
increasing by 25 percent the prescriptions dispensed for 
naloxone. We actually found that there was such a tremendous 
movement at the State level on standing orders and other things 
for naloxone that we saw about a 1,000 percent increase. We 
want to make sure we are calibrating this with the facts 
happening on the ground. It is a process we are working through 
and have not finalized yet.
    The Chairman. You are setting metrics but are working 
through a process?
    Dr. Jones. Yes.
    The Chairman. Rear Admiral Toedt, the same question?
    Dr. Toedt. Thank you, Mr. Chairman.
    IHS has committed to addressing the opioid crisis in 
American Indians and Alaska Native communities. The key to this 
approach is partnering with tribal communities, listening to 
them and being responsive to their concerns.
    Some of the examples IHS is looking at for metrics and is 
measuring at the national level include pain management and 
opioid-related policy implementation. This is evidenced on our 
National Accountability Dashboard which is on our website.
    We are looking at opioid prescribing trends, access to 
medication-assisted treatment, use of telebehavioral health and 
naloxone. There will be many more metrics that we need to 
develop. We want to partner with tribes to do that.
    The Chairman. Mr. Anderson, could you talk a bit more about 
the HOPE Initiative? Also, could you touch on why right now the 
High Intensity Drug Trafficking Program is under the control of 
the Office of the National Drug Control Policy and why the 
Administration wants to move that?
    Mr. Anderson. Chairman Hoeven, the HOPE Initiative, as it 
has been coordinated and implemented in my District of New 
Mexico, is a partnership between the U.S. Attorney's Office in 
New Mexico and the University of New Mexico Health Sciences 
Center. It has a number of prongs including prevention, 
education, public outreach, law enforcement, as well as 
rehabilitation and reentry components to it.
    The principal efforts of the HOPE Initiative at this point 
have been public outreach to educate the public, in particular, 
the youth, on the dangers of opioid abuse. In connection with 
the U.S. Attorney's Office, the HOPE Initiative has developed 
an educational program called Roll the Dice that is directed at 
educating youth on the dangers of opioid misuse. That program 
is culturally tailored for presentation in our Native 
communities.
    The other aspect of this is the Naloxone Initiative. We 
have been at the forefront of educating first responders about 
the benefits of naloxone and educating them about how to 
properly use that in the hope that it is more widely deployed 
for its live-saving potential.
    The Chairman. Thank you.
    Rear Admiral Toedt, could you talk a bit about how IHS is 
doing in terms of partnering with State-based prescription drug 
monitoring programs?
    Dr. Toedt. Yes, Mr. Chairman.
    Our partnership includes linking the ability for the 
electronic medical record to upload that prescription data to 
the prescription drug monitoring programs. In sites where the 
Indian Health Service Federal pharmacies exist, we have been 
able to successfully partner with 17 out of the 18 States so 
far. We are working with the final State to connect the 
prescription drug monitoring programs to the electronic medical 
record.
    We also work with tribes in their States as well at their 
request if they are using the IHS electronic medical record to 
link to the prescription drug monitoring programs.
    The Chairman. Are you seeing that making a real difference?
    Dr. Toedt. Absolutely. Prescribers are able to see which of 
their patients are getting prescriptions perhaps from other 
providers. One of the things patients will do is sometimes they 
will have to seek medications from different providers both 
inside and outside our system. Using the State Prescription 
Drug Monitoring Database ensures we get the broadest input as 
to where they may be getting prescriptions.
    The Chairman. Vice Chairman Udall.
    Senator Udall. Thank you, Mr. Chairman.
    Mr. Anderson, as the new U.S. Attorney for New Mexico, you 
will be directly responsible for upholding the Federal 
government-to-government relationship with each of the 23 
tribes in New Mexico, several of whom you mentioned in your 
testimony.
    What are your plans to engage with tribes in New Mexico to 
address public safety issues like the opioid epidemic in Indian 
Country?
    Mr. Anderson. Senator, the United States Attorney's Office 
in New Mexico has an active outreach program, some of which is 
mandated by statute through the Tribal Law and Order Act. We do 
an annual consultation with all the tribes to address matters 
of concern.
    We also host regular educational outreach and communication 
opportunities. Just last week, prosecutors from my office were 
presenting to both the Navajo Nation and in the Espanola area 
on this very topic, heroin and opioid awareness. The thrust of 
that presentation was to educate in particular tribal law 
enforcement on this opioid crisis we are discussing today.
    In addition, my office has a dedicated tribal liaison 
tasked with ensuring open and prompt communication between the 
U.S. Attorney's Office and the tribes and ensuring that any 
issues they raise in the course of those communications are 
properly addressed.
    On a more basic level, line prosecutors in my office 
routinely communicate with their tribal counterparts in tribal 
law enforcement, in particular, on a case basis. In that 
context, they address any concerns the tribes may have.
    Senator Udall. Thank you. Can I get your commitment that 
you will meet regularly with New Mexico's tribal leaders to 
develop your office's Indian Country public safety priorities?
    Mr. Anderson. That is certainly something we are committed 
to doing, Senator. Again, I believe we have an active and 
robust communication process and will maintain that in the U.S. 
Attorney's Office.
    Senator Udall. Just last December, DOJ's OIG released a 
report confirming what tribes have told us. According to this 
report, nationally, Indian Country case declinations increased 
by 20 percent between 2013 and 2015. Even more of a concern, 
the report showed the number of referrals from DEA for crimes 
in Indian Country decreased by 81 percent.
    Based on this OIG report, Mr. Anderson, should DOJ law 
enforcement and the U.S. Attorney's Office be doing more to 
investigate and prosecute drug crimes in Indian Country?
    Mr. Anderson. Senator, the U.S. Attorney's Office and the 
Department, in general, are committed to robust enforcement of 
drug laws in Indian Country. The DEA is actively involved in 
that in coordination with the BIA and the Department of Justice 
and my office will continue to focus on robust enforcement of 
those laws in our tribal communities.
    Senator Udall. Do you know how many current Indian Country 
cases are pending before your office and how many of those 
cases are drug-related?
    Mr. Anderson. Senator, in preparation for today's remarks, 
I looked into that. I can tell you in fiscal year 2017, we 
prosecuted 49 violent crimes in Indian Country cases. That is a 
subset of the total number of cases we addressed in Indian 
Country. It does not include drug crimes, assaults on law 
enforcement officers or sexual assaults in Indian Country which 
would vastly increase that number.
    We do not track at this point for drug cases, which ones 
arise in Indian Country and which ones do not because it is a 
statute of general applicability but again, I can tell you that 
in New Mexico, enforcement is robust.
    Just last year, we recently did the first Title III wiretap 
case in Indian Country. We also had a substantial seizure of 
methamphetamine on a case developed and worked on the Navajo 
Nation. Those efforts are ongoing and are certainly a priority 
for us in the Department.
    Senator Udall. Can I get your commitment that you will 
speak to your Federal law enforcement counterparts about 
increasing their investigation efforts in Indian Country?
    Mr. Anderson. Certainly, Senator. We will continue to 
promote those communications. Again, Federal law enforcement is 
quite active in Indian Country in partnership with the BIA and 
our tribal law enforcement.
    Senator Udall. Will you also commit to reviewing your 
office's Indian Country declination rates and working with 
tribal leaders to identify and resolve any barriers to 
prosecution?
    Mr. Anderson. We will certainly do that, Senator. We 
constantly reevaluate the process by which we decline cases. We 
carefully scrutinize those brought to us. We do our very best 
in that area, Senator, and will continue to make that a 
priority.
    Senator Udall. Great. Thank you very much. I appreciate it.
    The Chairman. Senator Lankford.

               STATEMENT OF HON. JAMES LANKFORD, 
                   U.S. SENATOR FROM OKLAHOMA

    Senator Lankford. Gentlemen, thank you for being here and 
for the conversation. You all know this is exceptionally 
important, not only to the Nation, but obviously to Indian 
Country and all of us as well. This is a big issue and affects 
a lot of families and our communities.
    Let me start where I typically like to start. We have not 
had an opportunity to talk about it. In Indian Country, can you 
tell me a good example in a tribal area either in interdiction, 
recovery or prevention, any of those three, that you would say 
this particular tribe or this particular location or State is 
doing an exceptional job in one of those three that you can 
pull out and say what they are doing is working? Mr. Anderson.
    Mr. Anderson. Thank you, Senator.
    There is always room for improvement in our efforts to 
combat the opioid epidemic. I think we have had successes along 
the way in both the prevention and enforcement areas, 
recognizing there is continued room for improvement in terms of 
our collaborative efforts with State, local and tribal 
authorities.
    In New Mexico, we have had some successes to include a 
prosecution that centered on the Navajo Nation that happened to 
be a methamphetamine case. My office viewed it as a substantial 
victory on the enforcement front against trafficking in Native 
communities.
    Again, we are tribal partners and are working to improve, 
recognizing that certainly given the state of affairs, there is 
room for improvement.
    Senator Lankford. Can you give me a good example of any one 
location that really stands out to you more than others at this 
point?
    Mr. Anderson. Senator, the case we had on the Navajo 
Nation, I think, was a real victory.
    Senator Lankford. I will take that. Any others?
    Dr. Toedt. Thank you, Senator Lankford. I appreciate the 
opportunity to highlight a program.
    The Indian Health Service has 12 Federal and tribal youth 
regional treatment centers. One of those youth regional 
treatment centers, Desert Visions Youth Wellness Center, has 
made tremendous efforts on incorporating traditional practice 
into the evidence-based care. It was highlighted in the Surgeon 
General's report, Facing Addiction in America, as a best 
practice. Desert Visions used dialectical behavior therapy, an 
evidence-based approach for the treatment of substances, while 
incorporating sweat lodge ceremonies, talking circles and 
smudging ceremonies.
    Senator Lankford. Thank you.
    Captain Jones.
    Dr. Jones. I will just identify Project HOPE which is in 
Alaska. It is not tribal specific but has had a large tribal 
component that uses SAMHSA's funding for naloxone training. 
When you look at some of the metrics, there were 1,300 people 
trained, 8,900 naloxone kits distributed, and 45 overdose 
reversals.
    In particular, in a very disparate, rural State like 
Alaska, I think this is an example, in particular, of where 
tribes can engage with States. I would highlight that as an 
example.
    Senator Lankford. Captain Jones, we have been able to 
identify exactly the makeup of what is the typical overdose and 
that individual in Indian Country, male, female, a certain age, 
and marital status. What is the normal on that?
    Again, I know it will be all over the map. Opioid addiction 
is no respecter of persons, but is there something we have 
identified to say is more typical?
    Dr. Jones. I would say the typical makeup of an overdose 
case is not necessarily different among American Indians and 
Alaska Natives than it is for say, non-Hispanic Whites, which 
the group that looks most similar as far as overdose death 
rates. You tend to see higher overdose death rates among males 
and more than one drug involved. Although we often label them 
as opioid overdose deaths, they often involve alcohol or 
benzodiazepines, and other substances of abuse.
    When you look at age groups, it is very interesting because 
of the rise in heroin use and the proliferation of illicit 
fentanyl and fentanyl analogs. We actually now see two age 
groups that are most impacted.
    The highest overdose death rates for fentanyl, synthentic 
opioids and heroin are among 25 to 34 year-olds. For 
prescription opioids, it is 45 to 54 year-olds. For many years, 
we just sort of saw the top point at 45 to 54 but now we see 
the distribution that is quite different depending on the drug. 
We know those things about individuals. We tend to see 
variations for more heroin or synthetic opioids in more urban 
areas and rural areas still tend to be heavily influenced by 
prescription opioids.
    Senator Lankford. Tell me about the cooperation with the 
Office of National Drug Control Policy and how that is working 
specifically in coordination with Indian Country because when I 
see the total budget, I have gone through it, for the Bureau of 
Indian Affairs and drug control funding, it is about $9.7 
million.
    Obviously, brings out other areas. What is the cooperation 
like? Obviously that is not going to be enough to be able to 
cover it.
    Dr. Jones. I will speak from my perspective at SAMHSA. We 
work very closely with ONDCP and other components at the White 
House to plan out the national drug control strategy and the 
broader framework for addressing substance abuse issues in the 
U.S.
    From the SAMHSA perspective, in fiscal year 2017, we issued 
$36 million in substance use funding to tribes. There is about 
$83 million currently eligible for tribes in fiscal year 2018 
as part of the larger pot of grant funding that is available.
    I cannot comment specifically on BIA but we do work 
closely.
    Senator Lankford. You have funding that is separate, BIA 
has funding, and others have funding. I am trying to figure out 
how the coordination between all of those is going as far as 
planning out how it is going to go and where it is going?
    Dr. Jones. ONDCP has responsibility for the drug control 
budget. They issue letters to departments each year as the 
budget process is in the works. We respond to those requests 
from the Department's perspective.
    We say what is ONDCP asking of SAMHSA in their coordination 
role, we would respond that these are the President's 
priorities, here is where we think our budget lines up with 
this or we can add money here or there in the budget's request 
and then ONDCP, OMB and others work out those things.
    Senator Lankford. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Senator Smith.

                 STATEMENT OF HON. TINA SMITH, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Smith. Thank you very much, Chairman Hoeven and 
Ranking Member Udall. Thank you very much to all of you 
gentlemen for being here today.
    I would like to talk with you a little bit and get your 
thoughts on the question of culturally-based treatment and dive 
into that a little more.
    We often talk a lot about the immediate impacts of the 
opioid addiction on people but also we know we need to think 
about this in terms of two generations or multiple generations. 
Children of mothers who are addicted to opioids are at risk of 
being born of course with Neonatal Abstinence Syndrome which is 
a particularly terrible problem.
    The Leech Lake Band in Minnesota has actually declared a 
public health emergency related to the opioid epidemic in 
maternal and child health because so many babies are being born 
with Neonatal Abstinence Syndrome.
    I would like to hear from Captain Jones or Rear Admiral 
Toedt if you could tell us a little bit about what you are 
doing to expand access to treatment for pregnant women?
    Dr. Jones. Thank you for the question.
    I think this is an important area and certainly an area 
that has received increased attention over the last several 
years. Our perspective at SAMHSA is that we need to look at 
this comprehensively, not neonates who are born physically 
dependent and siloed from the mother who was addicted during 
the pregnancy.
    A couple of programs we have in place are trying to build a 
comprehensive suite of services to address the needs of mother 
and baby and even family, and include our pregnant and 
postpartum women grant programs.
    We have two different programs. One is a residential-based 
program. We funded 19 grantees last year. Under CARA 
legislation, we have a new pilot program at the State level for 
essentially outpatients, trying to move that comprehensive 
suite of services to the outpatient setting.
    We know sometimes going in-patient is very much needed for 
post-partum women or someone who is pregnant. Also that brings 
its own constraints of, how do you manage your responsibilities 
as a parent if you have older kids and trying to make sure 
those systems are in place to support residential care when 
needed. Also looking at, if we provide high quality evidence-
based treatment in the outpatient setting, how does that help 
connect them to the regular part of their day, to other kids or 
other family responsibilities? We are looking at both of those.
    We also have family treatment drug courts which use the 
drug court model but try to address the family aspect of this 
issue. I think across all three of those programs, it is very 
important that it is not just about providing the medication or 
addiction treatment, it is what are the recovery supports, the 
housing, employment and what are the other supports that really 
set a family as well as the individual who is addicted up for 
success as they are leaving?
    We have also issued a variety of different guidance 
documents and communications around how to do this in practice. 
If you are not one of our grantees, how do you go about doing 
it because many communities are affected by this?
    Most recently, we issued a clinical guidance for treating 
pregnant and parenting women who have opioid use disorder and 
treating of the infants. It is really the playbook of how the 
clinicians go about doing this in a comprehensive manner. We 
are trying to address both through our funding streams as well 
as training and technical assistance that system that needs to 
be built to address the needs of those individuals.
    Senator Smith. Thank you very much. I think what you said 
is very important because the old way of thinking about this is 
to separate moms from their babies. Oftentimes, that is exactly 
the wrong thing to do if you want everyone to recover.
    Dr. Jones. We know people often do much better if they are 
there. Certainly, if you are a mom and preoccupied with 
thinking about what is going on with your kids, it is really 
hard to pay attention to treatment and address the things right 
in front of you.
    Senator Smith. Thank you very much.
    Admiral Toedt, would you like to add anything?
    Dr. Toedt. Yes, Senator Smith. Thank you.
    I agree entirely with your comment about the importance of 
bonding between mothers and infants. All of our hospitals in 
the Indian Health Service which deliver babies are baby 
friendly hospitals in support of the mother-baby dyad of 
keeping them together.
    The Indian Health Service is partnering with professional 
organizations such as the American College of OB-GYN and the 
American Academy of Pediatrics to create culturally appropriate 
guidelines for care such as the Neonatal Withdrawal Syndrome 
guideline.
    We also are increasing screening to mothers identified as 
at risk who may benefit from early referral to medication-
assisted treatment programs. We are increasing the number of 
treating providers by training nurse practitioners and midwives 
through increased authority through the Comprehensive Addiction 
and Recovery Act.
    Senator Smith. Thank you very much.
    Mr. Chairman, I see I am almost out of time but I want to 
thank Senator Lankford for his question about giving us 
examples of what works.
    The Chairman. I am sorry, Senator Smith. We do not have 
time for thanking Senators.
    Senator Smith. I am still learning all the rules, Chairman 
Hoeven.
    The Chairman. Please go ahead.
    Senator Smith. I appreciated that question. I wanted to 
mention that on the White Earth Reservation in Minnesota, we 
have a program called the MOMS Program which specifically 
focuses on what we have just discussed, how to help support 
pregnant women and then moms and babies. I think it is a good 
example of something that could be applied in lots of different 
places.
    Thank you.
    The Chairman. Thank you, Senator.
    Senator Cortez Masto.

           STATEMENT OF HON. CATHERINE CORTEZ MASTO, 
                    U.S. SENATOR FROM NEVADA

    Senator Cortez Masto. Thank you.
    Thank you, gentlemen, for being here today. Let me start 
with Captain Jones and Rear Admiral Toedt.
    After talking with our Washoe Tribes of Nevada and 
California, what I am hearing from many of our tribes is that 
tribal-specific funding streams to address the opioid epidemic 
in our tribal communities was not included in the 2017 State-
targeted response to the opioid epidemic grants. Is that true?
    Dr. Jones. Correct. The statute basically limits 
eligibility to States.
    Senator Cortez Masto. Don't you think there should be 
targeted grant funding to address these issues in tribal 
communities?
    Dr. Jones. We certainly would be willing to carry forward 
however Congress appropriates or authorizes those dollars.
    Senator Cortez Masto. Are they needed?
    Dr. Jones. I think we have described today that there is a 
substantial problem in Indian Country. We have taken as many 
flexibilities as we can.
    Senator Cortez Masto. I will take that as a yes.
    My colleague talked to you about culturally-appropriate 
treatment. I believe in it. I think not only do we need 
culturally-appropriate but we need trauma-informed treatment as 
well. Can both of you talk a bit about that? Do you provide 
trauma-informed treatment as well when we talk about substance 
abuse needs and treatment in the tribal communities?
    Dr. Toedt. Yes, ma'am.
    We entirely support trauma-informed care. It is very 
important to get to the root of the problem. So many patients 
that are seeking relief from opioids may actually be suffering 
from untreated mental illness. They may also be suffering from 
economic disparity, historical trauma, or a lot of issues that 
came up through childhood as well.
    Having an understanding of a person's background and 
culture, where a person is coming from, is very important to 
being able to effectively bond with them, make a connection and 
deliver effective treatment.
    Senator Cortez Masto. Thank you.
    Dr. Jones. I think trauma-informed care and the importance 
of addressing co-occurring substance use and mental disorders 
are infused throughout our grant programs.
    Senator Cortez Masto. Fantastic.
    Rear Admiral, do you have the resources you need to provide 
that level of care?
    Dr. Toedt. I appreciate the question.
    The IHS wants to be responsive to tribal concerns. I have 
heard from tribes that there are not enough resources out 
there. Certainly any funding that Congress can provide will 
definitely be appreciated.
    Senator Cortez Masto. I also hear from our tribes that it 
is difficult to get that treatment. I have heard a lot of 
conversation about working with our States but the States 
already have tapped out trying to find the treatment they need 
for substance abuse within their States.
    Requiring our tribes to work with the States to fight for 
that money is difficult and makes it much harder to get the 
resources to our tribal communities. Wouldn't you agree with 
that?
    Dr. Jones. I think building the capacity is really the 
importance of the STR funding and other training and technical 
assistance we are applying broadly across the U.S., even 
specific to tribes around training and technical assistance.
    We could have multiple billions of dollars that could be 
spent on treatment but if we do not have providers who can 
provide that care, whether you are in Indian Country or not, 
you are not going to be able to get access to evidence-based 
care. Really a core part of the work we are doing is to build 
that foundational capacity.
    Senator Cortez Masto. Would you agree that a special 
behavioral health program for Indians that parallels the 
structure of the existing Special Diabetes Program for Indians 
to provide substance abuse prevention, intervention and other 
needed behavioral health services might be an answer to 
addressing these substance abuse needs in tribal communities?
    Do you think the Diabetes Program is a good model to 
emulate?
    Dr. Toedt. Thank you, Senator.
    We absolutely think that the Diabetes Program has been an 
excellent model. Emulation of that funding model is something 
we have heard from tribes. Yes, it is an excellent idea.
    Senator Cortez Masto. Thank you.
    I have one final question for Mr. Anderson. Thank you for 
everything you do.
    First of all, I do know U.S. Attorneys and AUSAs across the 
Country are working very hard in our tribal communities. You 
are tapped for resources. I know that. I will say that as 
somebody who worked in my State in law enforcement.
    Chairman Hoeven asked you about the impact of moving HIDTA 
out of the Office of National Drug Control Policy. Can you talk 
a bit about HIDTA and how important those grants are and how 
effective HIDTA is in our communities?
    Mr. Anderson. Senator, HIDTA certainly is an important part 
of what we do with the Federal partnership focusing on those 
high intensity drug corridors throughout the Country.
    In terms of the structure of HIDTA or its funding, that is 
not something I can discuss today but I can tell you that they 
are, from the Federal law enforcement perspective, a critical 
aspect of our efforts to interdict the flow of illegal drugs, 
including opioids, heading to and that end up in our tribal 
communities.
    Senator Cortez Masto. Thank you. Critical and effective, 
right?
    Mr. Anderson. Yes.
    Senator Cortez Masto. Let me just say this. We are 
combating opioids now and it is a crisis across the Country. 
Ten years ago, it was methamphetamines. It is black tar heroin. 
I can promise you that unless we address this through 
treatment, dollars and fighting, not just assuming law 
enforcement will do it all, we are going to constantly see this 
shifting from methamphetamines to black tar heroin to the 
opioids in our communities.
    It is a scourge that we need to address. We have to come 
together on the treatment and law enforcement sides and 
adequately fund in all of our communities, including our tribal 
communities to really combat the crisis we have across this 
Country.
    Thank you.
    The Chairman. Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Gentlemen, thank you all for what you do respectively. I 
apologize that I was not able to hear some of the colleagues' 
questions. Again, these are issues that are so key and 
important.
    Captain Jones, I appreciate you mentioning the Project HOPE 
Program and how it is working or helping in Alaska.
    I mentioned in my opening not just the opioids and how that 
has ravaged us but also alcohol. I will just cite our annual 
drug report which acknowledges the multifaceted drug abuse 
problem in the State. Drug abusers in Alaska tend to abuse more 
than one substance, oftentimes multiple substances. The drug of 
choice is alcohol, heroin, meth, cocaine, prescriptions and 
marijuana. They emphasize that alcohol was the single-most 
abused substance.
    As we have been focusing our efforts here in Congress on 
opioid, opioid, opioid, I don't want us to lose sight of the 
fact that underlying so much of this is alcohol and fail to 
provide the support for programs and grants in that alcohol 
space as well. When we talk about substance and substance 
abuse, we need to make sure that it is alcohol and substance 
programs. Everyone is shaking their heads like you agree with 
me. We do not need to bifurcate these. These are all one big, 
ugly, horrible problem with which we are dealing.
    Let me ask about what I will call a workforce issue. Our 
reality is that we have identified the problem and some of the 
solutions. However, we know so much of this comes back to 
making sure we have mental professionals able to be there, to 
be that support.
    I have been working with my colleague from Indiana, Senator 
Donnelly, on an effort that would incentivize those to go into 
substance use disorder treatment work. Basically, it is a loan 
forgiveness program we think will be helpful in incentivizing 
more.
    I have to assume part of the challenge we are facing is we 
simply do not have enough mental professionals to help us. Is 
that so? I am getting head nods. We need to work on that as 
well.
    Here is my question to you. This is intended to help at 
least three individuals in the audience. I met with the Mayor 
of Utqiagvik who is with us today and two others who are part 
of her council. They mentioned that in Utqiagvik, formerly 
Barrow, the issue relating to opioids and drugs, again the 
intensity we cannot single out enough.
    From an enforcement perspective, I will look to you, Mr. 
Anderson. They say they do not have a district attorney there 
and that prosecution for these drug offenses is not moving 
forward.
    The drugs come in by mail and plane. We know how they get 
in but we cannot get attention on anything unless it is at the 
full felony level. People know that they can sell, deal, and 
use. There is no follow up, consequence and no enforcement.
    What would you tell the Mayor of Utqiagvik?
    Mr. Anderson. Senator, I would urge the Mayor to work to 
seek Federal grants to develop that type of thing. There are 
Federal grants available through the Department of Justice's 
Comprehensive Opioid Abuse Program. I would hope those could be 
used to develop that type of legal infrastructure described in 
your question in posing that issue.
    Certainly it is an important component of addressing this 
crisis, that we have that law enforcement infrastructure in 
place. I understand that in your State and many of our tribal 
communities, there is a shortage of access to courts and 
related resources.
    I would urge those communities to apply to the Department's 
grant program to be able to fund that type of infrastructure. I 
think that is critical to proper enforcement in combating the 
opioid epidemic.
    Senator Murkowski. I appreciate that.
    Mr. Chairman, I also recognize we hear from a lot of our 
constituents that we are basically setting tribes up to compete 
with other tribes when they all have significant need. You have 
some tribes that perhaps might not have the band width to 
submit. I think a community like Utqiagvik is probably 
positioned a bit differently.
    It is something I recognize. We have some gaps. We have 
been talking about tribal courts and the opportunities they may 
present to help address some of these issues on the enforcement 
side. We know we have a lot of work to do.
    I am over my time. I could spend all afternoon with you. 
Thank you again and thank you for your work.
    The Chairman. Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman.
    I want to thank you all for being here. I want to follow up 
a bit on the Ranking Member's line of questioning on 
declinations.
    Ten years ago, if my memory serves me correctly, when Byron 
Dorgan was chairman of this Committee, we talked about how 
declinations were way, way too high in Indian Country. From 
2013 to 2015, the U.S. Attorney's Office declinations increased 
by another 20 percent, according to the Ranking Member's 
information.
    In this case, increase is not a good thing. Declinations 
increased by 20 percent. Can you tell me why?
    Mr. Anderson. Senator Tester, we are committed, obviously, 
to constantly look at why the declination rate in Indian 
Country moves the way it does. It is an important figure for us 
to follow and to work to reduce that declination figure.
    Senator Tester. I got you. But that does not answer my 
question. It does not make any sense to me. Is it that we do 
not have enough FBI agents or you do not have enough people on 
your staff? What is going on?
    As I said, it has been fully 10 years, probably 11, and was 
probably a problem 10 years before that. I am not blaming you. 
I just need to know why because it is unacceptable. What can 
this Committee do to make it work so there aren't these kinds 
of declinations in Indian Country? In Montana, that is what the 
highest crime rate is.
    Mr. Anderson. Senator, I am not sure I can give you an 
answer for why over a period that long, for example, 10 years, 
the declination rate has gone the way it did. I can hypothesize 
and am hopeful that it may be an increasing number of reported 
crimes. Obviously, every case that is opened by my office in 
New Mexico is carefully examined by an Assistant U.S. Attorney 
and worked by an FBI agent.
    Senator Tester. I will use the Ranking Member's numbers 
again. Between 2011 and 2014, the numbers referred to the U.S. 
Attorney's Office decreased by 81 percent.
    Here is the problem and what I would love to have you do. I 
know you are fairly new to this position. Could you take it 
back to your group and tell us why? That is all I want. Is it 
because of the sovereignty issue and there is no cross work 
being done as far as law enforcement or is it because the FBI 
has not put enough people in this Country? As I said, is it 
your staff?
    We are not getting it done. I think it is a big issue in 
Indian Country because of violence against women, which could 
have to do with drugs, poverty or something else but it is 
crimes and is serious stuff.
    I think it is something we have always talked about. People 
have come before committees like this and answered and it 
continues to get worse. This position is not forever for you 
but maybe it is. Udall says you are a good guy, by the way.
    The truth is, in fact, if you can do something about this 
and give us some instruction, put it back on us. Say, Indian 
Affairs Committee, here is what you need to do and we can get 
this fixed. We would be more than happy to work with you.
    I want to talk to you, Captain Jones. You discussed the 
budget request for fiscal year 2019 being $10 billion in new 
resources across the Department of Health and Human Services. 
This follows a question maybe Senator Smith asked.
    Would you be opposed, when the Appropriations Committee 
gets done with massaging these numbers, if they carve out a 
certain percentage of that $10 billion for Indian Country?
    Dr. Jones. Again, we are absolutely ready to carry forward 
what direction we get from Congress.
    Senator Tester. The question is if you oppose it, we will 
never get it done. If you do not oppose it, then we would 
probably do it and get it done.
    Dr. Jones. I will say our posture has been where we have 
been able to be flexible in putting setasides in place, when 
there is not a statutory prohibition that funds can go to 
different groups, we have tried to include tribe in setasides 
or other means.
    Senator Tester. I will try, and I think Senator Murkowski 
would probably maybe do the same thing, to peel some of this 
money off and dedicate it to Indian Country. I would hope you 
would not oppose that when it comes through, okay? That is just 
a little heads up.
    I will make the last thing quick because I know Heidi has 
some important questions to ask you guys. Can the money only be 
used for opioids? Can it be used for meth also?
    Dr. Jones. The STR dollars are an opioid-specific grant but 
certainly we recognize that individuals have co-occurring 
disorders using other substances.
    Senator Tester. Are the STR dollars the $10 billion in 
resources? Is STR what that is called?
    Dr. Jones. The STR Program is the program created under the 
21st Century Cures Act in the 2019 budget.
    Senator Tester. That is fine, that is different. I am 
talking about the $10 billion of new resources across the 
Department of Health and Human Services. Can that be used for 
opioids, meth and heroin, as far as that goes?
    Dr. Jones. STR would be a component of that. Under the 2019 
budget, that is an increase of $1 billion for the STR Program, 
which is specific to prescriptions or illicit opioid. Heroin 
would be in that group. The specifics of the remainder of the 
dollars are still being worked out.
    Senator Tester. Would meth be a part of it?
    Dr. Jones. Again, to the extent they are co-occurring and 
co-use of other substances.
    Senator Tester. But it would not be in and of itself. That 
is good. I would just ask you go back to your people.
    Dr. Jones. I just want to say in the budget, we also have 
requested $30 million for the Tribal Behavioral Health Grant 
which is much broader.
    Senator Tester. Did you say $30 million?
    Dr. Jones. Yes, $30 million. Again, we try to be very 
flexible.
    Senator Tester. I am way, way over. I would just say we 
need your help on this stuff. This is your budget and not mine. 
I need to know what you had in mind when you crafted your 
budget for this.
    With that, I appreciate you being here.
    Thank you, Mr. Chairman.
    The Chairman. Senator Heitkamp.

               STATEMENT OF HON. HEIDI HEITKAMP, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Heitkamp. Mr. Anderson, I want you to know that I 
have asked all these questions of FBI Director Wray as well, so 
I am not just picking on you. Do you think we need more FBI and 
DEA agents in Indian Country, yes or no?
    Mr. Anderson. Senator, I would have to figure it out. I 
think it depends on each specific reservation.
    Senator Heitkamp. No. I will tell you this. We need more 
DEA and FBI agents in Indian Country. It does not depend on 
anything.
    The reason why you have declinations is you do not have 
quality investigations. I will tell you that. The other reason 
why you have declinations is because your limit in FBI and DOJ 
is too high. It is too high because you guys treat it the way 
you would if you worked in Indian Country.
    You are the only jurisdiction in Indian Country. When you 
do not show up, we do not have law enforcement. When there is 
no law enforcement, we have mayhem and give out jail free zones 
for drug dealers.
    We have to have protection for people in Indian Country. I 
can tell you it frustrates me to no end to hear a discussion, 
Captain Jones, about well, you know, if you use opioids but 
maybe you have a co-utilization. That is nonsense. Our problem 
in North Dakota is not opioids. It is methamphetamine. It is 
methamphetamine. It is killing whole generations of people in 
my State. It has to end.
    It has to end first from a law enforcement standpoint. We 
can do all the treatment in the world but if these drugs flow 
freely into Indian Country with no opportunity for change, we 
will not change anything. We have to get law enforcement.
    Mr. Anderson, you are just the brunt of my frustration 
today. I have had this conversation with Directory Wray, the 
then-nominee for the Attorney General and with DOJ officials 
who deal with Indian Country, on drugs and trafficking in 
Indian Country. We are screaming for help. We are screaming for 
help. There is no one who lives in Indian Country who does not 
recognize this. I just want to read the comments from Vice 
Chairman Headdress from the Ft. Peck Assiniboine and Sioux 
Tribes who attended our roundtable on this issue.
    He asked ``Why service units or tribes cannot funnel some 
of their purchase and referred care dollars for prevention and 
treatment of opioid misuse?'' I will tell you in our neck of 
the woods, there does not seem to be a coordinated response to 
this problem in Indian Country. I mean across the board. You 
see it right there.
    I am telling you we are an endangered species in many 
tribal organizations. It is because we are losing generations 
to addiction whether it is alcohol, opioids or 
methamphetamines. I cannot state it more clearly.
    We need to do better. Hearings like this give us a chance 
to vent but I hope a unified plan comes out of this. We are all 
going to support setasides. I do not think there is any doubt 
about it. Maria has been working on setasides for tribal 
organizations.
    To give you just a little example, in my State, the first 
grants that went out, the opioid grants, there were I think 
seven or eight applications. Two were denied; both were in 
Indian Country. We eventually complained and the Governor found 
some additional money to send to Indian Country.
    It has to be culturally significant in the way Senators 
Cortez Masto and Smith discussed. We need a plan. It cannot 
just be about treating the addiction. It has to be a plan about 
getting law enforcement on the ground. I hope you guys will 
take from this an opportunity to sit down and actually come up 
with a plan in consultation with the tribes because they are 
screaming for help.
    I ask to tell one story. A friend of mine, Paul Iron Cloud, 
who was Chairman and head of housing for Pine Ridge, came to me 
in one of his last visits. Unfortunately, he died of cancer 
after his visit with me.
    He was very frustrated. He said, ``Senator Heitkamp, we 
need help. We need law enforcement. We need the FBI. We need 
people to come help us.'' I said, ``Paul, where are the tribal 
elders and where are the tribal communities?'' He looked at me 
incredulously and said, ``We are afraid. All the good people 
are hiding. They are afraid of what is happening in their 
homes.''
    This cannot continue, not in the United States of America. 
We have murder rates that are unsurpassed in any other part of 
the Country. This is driven by drugs and addiction and we need 
to get to the bottom of this.
    I am pleading with you, on behalf of all the people that I 
represent who are pleading with me, please, please, please, 
make this a top priority. If you care about law and order, this 
has to be a top priority. If you care about Indian healthcare, 
this has to be a top priority. If you care about changing the 
dynamic for children in the future, this has to be a priority 
or we will be nowhere.
    I want to thank the Chairman for having the hearing. I want 
to thank this Committee for being so engaged and involved. And 
I want to pledge to you, as Senator Tester did, tell us what 
you need and what will change the outcome. We will work with 
you to make it happen. Tell Director Wray I had some strong 
words.
    The Chairman. I would like to thank our witnesses. Members 
may also submit follow-up questions for the record. The record 
will be open for two weeks. I want to thank the witnesses for 
being here and for your testimony today. Panel One is 
adjourned.
    We will now set up our second panel. We will now hear from 
our second panel. Our witnesses today are: Ms. Jolene George, 
Behavioral Health Director, Port Gamble S'Klallam Tribe of 
Kingston, Washington and Mr. Samuel Moose, Treasurer and 
Bemidji Area Representative, National Indian Health Board, 
Bemidji, Minnesota.
    Ms. George.
    Ms. George. Thank you, members of the Committee, on behalf 
of the Port Gamble S'Klallam Tribe.
    The Chairman. Ms. George, I am sorry to interrupt. I 
understand Senator Cantwell wanted to give you a glowing 
introduction and I do not want to get in the way of that. I 
apologize.
    Senator Cantwell.

               STATEMENT OF HON. MARIA CANTWELL, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Cantwell. Thank you, Mr. Chairman. I know we are 
tight on time because there is a vote.
    I did want to point out that Ms. George is Behavioral 
Health Director for the Port Gamble S'Klallam Tribe in 
Kingston. S'Klallam means ``strong people,'' by the way.
    I am really happy she is here because she has been on the 
front lines of the opioid crisis with her tribe and the 
surrounding community. They have had numerous overdoses and 
deaths stem from the opioid epidemic. Many of these deaths stem 
from the fact that the drugs were prescribed by medical 
professionals.
    I believe Ms. George will talk about this crisis, how it 
has impacted families and put a strain on law enforcement and 
tribal services. She is also going to talk about the 
collaborative approach that the Port Gamble S'Klallam Tribe has 
used to address this abuse.
    I think the Federal Government can learn something from her 
and the Port Gamble S'Klallam Tribe in tackling this epidemic. 
Thank you for being here today and thank you for the good work 
in this area.

 STATEMENT OF JOLENE GEORGE, BEHAVIORAL HEALTH DIRECTOR, PORT 
                     GAMBLE S'KLALLAM TRIBE

    Ms. George. Thank you again, members of the Committee, on 
behalf of the Port Gamble S'Klallam Tribe, for this opportunity 
to present the impacts of the opioid epidemic on our tribe and 
what we need from Congress to effectively confront this issue.
    I ask that my written statement also be included in the 
record.
    My name is Jolene George. I am a tribal member and the 
Behavioral Health Director. We are a federally-recognized, 
self-governing tribe, owning 100 percent of our reservation 
lands with over 1,200 enrolled members.
    As this Committee knows, we are disproportionately impacted 
by opioids. The statistics you hear reflect our heartbreaking 
reality as we struggle to confront the drug epidemic caused by 
opioids flooding our community. Every family on our reservation 
has been impacted by this epidemic. Many are grieving the loss 
of loved ones because of it.
    At a government level, these impacts cut across all 
departments, complicating funding priorities and creating 
competition for already scarce resources. I shared statistics 
from our department to highlight the strain on staff and 
resources.
    At least 75 percent of our substance abuse patients are 
opioid-dependent. These complex patients often utilize 
behavioral health resources at a higher rate than other 
patients. In our health clinic, pain management patients 
overwhelm the schedule. Our family medicine physician has 
become a pain management specialist.
    In social services, 98 percent of our dependency cases are 
due to drug use. In one year, 100 percent of our housing 
program evictions were drug-related. Creating homeless drug 
addicts does nothing but perpetuate the vicious cycle.
    Opioids have increased crime and police focus on drug 
interdiction means less time for other police priorities. Our 
court system has had a 90 percent increase in drug and alcohol-
related cases over the past four years. Again, the impacts of 
the opioid crisis cut across all aspects of our community and 
our government.
    The opioid epidemic is a complex issue and there is no 
quick and easy fix for resolving it. We need a multi-faceted, 
comprehensive approach with tactics that work.
    We took note of the November 2016 Surgeon General's report 
on Alcohol, Drugs and Health, which identified prevention as 
key to the fight against abuse and addiction. Our tribe has 
been working to implement just such an approach but we need 
your help.
    We have shown leadership and are aggressive in our 
comprehensive response to the opioid epidemic with the 
following. We have developed THOR which stands for Tribal 
Healing Opioid Response. Unique about THOR is the coordination 
among all departments, community engagement and the custom 
strategies. THOR has three main goals: preventing opioid misuse 
and abuse; expanding access to opioid use and disorder 
treatment; and preventing deaths from overdose. We have self-
funded the opioid response.
    While we have made a thoughtful and deliberate attempt to 
combat this epidemic, we still experience many barriers. 
Adequate and direct funding is necessary to continue our 
coordinate efforts.
    We support Senator Daines' bill which reflects the 
government-to-government relationship and would make the tribes 
eligible for direct funding. Our tribe participated in the 
Indian Health Service Tribal Budget Formulation Work Group and 
we support that request, including full funding of contract 
support costs.
    Forty-two CFR Part 2 is our biggest regulatory hurdle 
towards behavioral health integration. Segmented care does not 
work. Health care providers need to see a patient's complete 
health record, including CD records to provide whole person 
care. Congress can eliminate this hurdle by aligning the status 
of chemical dependency records with medical and mental health 
records under HIPPA.
    The lack of co-location of primary care and behavioral 
health services on our reservation only adds to our struggle. 
We look to Congress for innovative ideas, perhaps through its 
infrastructure package, for facilitating construction of co-
located health care facilities on tribal lands.
    We support Senator Cantwell's bill, the CARES Act. This is 
a good bill that would increase opioid prevention and treatment 
funding, limit opioid prescriptions and enhance prescription 
drug monitoring programs. We appreciate her work on behalf of 
Indian Country and her early consultation with us on the bill.
    As our chairman said, ``Our tribe has been devastated by 
this epidemic. Opioids keep taking from our community. They 
have torn apart our families and taken away loved ones.'' It is 
my hope that, with your help and the agencies here, we can put 
an end to the opioid crisis. The Port Gamble S'Klallam Tribe is 
happy to share any of the resources we have developed with 
other tribes. We formally invite the Committee members to visit 
our tribe to learn more about our ongoing work and continue 
this discussion.
    I am going to leave with you a postcard with our THOR logo 
designed by our tribal member and comic book artist, Jeffrey 
Veregge, with our three main goals on the back.
    I thank you for this opportunity to testify and I am happy 
to answer any questions.
    [The prepared statement of Ms. George follows:]

 Prepared Statement of Jolene George, Behavioral Health Director, Port 
                         Gamble S'klallam Tribe
    Thank you, members of the Committee, on behalf of the Port Gamble 
S'Klallam Tribe, for the opportunity to present the impacts of the 
opioid epidemic on our Tribe, our response, and what we need from 
Congress in order to effectively confront this issue.
I. About the Tribe, our Health Care System and Relevant Programs
    The Port Gamble S'Klallam Tribe is a federally recognized, self-
governing tribe owning 100 percent of its reservation lands. We are 
located on the northern tip of the Kitsap Peninsula in Kitsap County 
Washington. The Tribe's Reservation is home to about two-thirds of the 
Tribe's 1,200 enrolled members. The Tribe is the only Indian health 
care provider of both primary and behavioral health services in Kitsap 
County, and proudly provides culturally appropriate health care to our 
members and approximately 800 other American Indians and Alaska Natives 
(AI/AN) and community members living on our Reservation.
    The Tribe joined the Tribal Self-Governance Project, a consortium 
of self-governing Indian Tribes, in 1990 and has directly provided 
health services to its members for over 20 years. We fund our health 
services though a compact with the Indian Health Service under the 
Indian Self-Determination and Education Assistance Act, and operate and 
manage our entire health system on our Reservation.
    Our health system includes primary care, dental, mental health and 
substance abuse services. We provide our primary care services out of 
our outpatient primary care health clinic, which is staffed with 2 
physicians, a physician assistant, and 4 registered nurses. Our dental 
building is next door and includes 2 dentists, 1 dental health aide 
therapist, and a dental hygienist. Our behavioral health clinic is 
approximately two miles away. It includes 1 physician, 1 Advanced 
Registered Nurse Practitioner (ARNP), 4 substance abuse counselors, 5 
mental health counselors and 2 prevention specialists. It provides 
outpatient substance abuse treatment, relapse prevention, group, 
individual and family mental health counseling, psychiatric evaluation 
and medication management, and Medication Assisted Treatment (MAT). 
Over 98 percent of our behavioral health clients are also served by our 
primary care clinic. Community Health Representatives and transporters 
fill an essential role for both clinics, providing clinical linkages to 
the community and transportation services.
    In addition, relevant to the opioid issue, our Tribe operates a 
police department, which consists of nine officers and places a strong 
emphasis on community-oriented policing for all residents and visitors. 
We also operate a Tribal Court with jurisdiction over criminal, civil 
and juvenile matters. Appeals are heard by our three-judge Court of 
Appeals.
    Our Children & Family Services Department includes our Behavioral 
Health Division and the Community Services Division and works to 
enhance the quality of life of our Tribal members and their families 
through a culturally sensitive approach that encourages living a 
healthy lifestyle and promotes self-sufficiency. The Port Gamble 
S'Klallam Tribe operates all eligible programs under Title IV of the 
Social Security Act; Temporary Assistance to Needy Families (TANF) Part 
A, Child and Family Services (Part B), Child Support (Part D), and 
lastly, Foster Care and Adoption Assistance (Part E).
II. Impacts of the Opioid Crisis on the Tribe
    In Washington State, the Native American overdose rate is more than 
twice as high as that of white Washingtonians. \1\ The data shows that 
AI/AN in Washington State die of drug overdoses at a rate of 34.4 per 
100,000 people, more than twice the rate of the next highest group 
(15.1 for Pacific Islanders), and almost three times that of whites at 
12.4 and African Americans at 12.3. Other rates are 1.1 per 100,000 for 
Latinos, and 1.2 for Asian Americans. \2\ For every opioid overdose 
death, there are 10 treatment admissions for abuse, 32 emergency room 
visits, 130 people who are addicted to opioids, and 825 nonmedical 
users of opioids. \3\
---------------------------------------------------------------------------
    \1\ Austin Jenkins, Inslee Wants Washington State to Declare Opioid 
``Public Health Crisis,'' KUOW.org (Jan 12, 2018), available at http://
kuow.org/post/inslee-wants-washington-state-declare-opioid-public-
health-crisis.
    \2\ Washington Department of Health Death Certificate Data.
    \3\ National Institute on Drug Abuse. Opioid Abuse Crisis. 
Available at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-
overdose-crisis (last accessed March 8, 2018).
---------------------------------------------------------------------------
    Misuse of prescribed opioids frequently leads to other drugs such 
as heroin. According to the National Institute of Drug Abuse, 21 to 29 
percent of patients prescribed opioids for chronic pain misuse them, 
and 4 to 6 percent who misuse prescription opioids transition to 
heroin. About 80 percent of people who use heroin first misused 
prescription opioids. The death rate for heroin overdoses among Native 
Americans has also skyrocketed, rising 236 percent from 2010 to 2014. 
\4\
---------------------------------------------------------------------------
    \4\ Dan Nolan and Chris Amico, How Bad is the Opioid Epidemic?, 
PBS.org (Feb. 23, 2016), available at https://www.pbs.org/wgbh/
frontline/article/how-bad-is-the-opioid-epidemic/ (last accessed Feb. 
27, 2018).
---------------------------------------------------------------------------
    The CDC reports that American Indians/Alaska Natives had the 
highest national drug overdose death rates of any race in 2015, and a 
519 percent increase in the number of non-metropolitan overdose deaths 
from 1999-2015. \5\ Alarmingly, approximately 1 in 10 American Indian 
youths ages 12 or older used prescription opioids for nonmedical 
purposes in 2012, double the rate for white youth. \6\
---------------------------------------------------------------------------
    \5\ CDC Morbidity and Mortality Weekly Report (MMWR), available at 
https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm?s_cid=ss6619a1_w 
(last accessed March 8, 2018).
    \6\ National Congress of American Indians, Reflecting on a Crisis 
Curbing Opioid Abuse in Communities (Oct. 2016), available at http://
www.ncai.org/policy-research-center/research-data/prc-publications/
Opioid_Brief.pdf (last accessed Feb. 27, 2018).
---------------------------------------------------------------------------
    These statistics reflect the heartbreaking reality on the Port 
Gamble S'Klallam Reservation as we struggle to confront the drug 
epidemic caused by opioids flooding our community. We have had numerous 
overdoses and deaths in our community as a result of the opioid crisis, 
and not only from the vast supply of drugs available on the black 
market. It has been estimated that approximately 60 percent of the 
opioids that are abused come, directly or indirectly, through doctors' 
prescriptions.
    On our Reservation, the deaths include members who were prescribed 
opioids as pain medication and accidentally overdosed. In the recent 
past, the Tribe experienced an overdose by a young mother and the death 
of a toddler, just two years old, who got into his parents' opioid 
medication. We have grieving children, parents, grandparents, and 
great-grandparents who have lost family due to this scourge. Every 
family on our Reservation has been impacted by this epidemic.
    At a government level, these impacts cut across all departments, 
complicating funding priorities and creating competition for scarce 
resources. Our Health, Behavioral Health, Children & Family Services, 
and Housing Departments, as well as our courts, law enforcement, and 
administration, all have a role to play in responding to this crisis.
    Our Children & Family Services Department feels the effects of the 
opioid crisis acutely. One of its roles is to keep children with their 
families. When children are removed, we have both relative placements 
and 20 Tribal licensed foster homes, but the increased number of 
dependency cases due to opioid abuse or overdose has challenged our 
capacity. Opioid abuse impacts the whole family. Our Tribal member 
grandparents are often raising their grandchildren. In addition to this 
role, they often struggle to help their own child who is suffering from 
addiction.
    One specific example of the impacts we face involves dependency 
cases that the Tribe files to ensure a child's safety and well-being. 
Ninety-eight percent of all dependency cases are due to drug use. In 
the first eight weeks of 2018, the Tribe filed four new dependency 
cases, three of which were related to parent(s) opioid abuse. This 
already surpasses the total new cases filed in 2017. These new cases 
are in addition to the open dependency cases that the Tribe has already 
filed.
    The increased number of dependency proceedings burden existing 
child welfare services staff and resources, and require additional 
hires. Every child who comes into the Tribe's care and custody needs an 
array of intervention and services, including mental health counseling, 
medical services, substitute care, and housing. The parents who survive 
need treatment and counseling as well. Children who are exposed to 
opioids in utero suffer from opioid withdrawal and Neonatal Abstinence 
Syndrome, and often bear scars that will last a lifetime. These infants 
are immediately transferred to a neonatal intensive care unit for a 
period of days, weeks, or even months, frequently requiring emergency 
evacuation for care to save the infant's life. Such emergency 
transportation costs the Tribe thousands of dollars for each 
occurrence.
    The crisis has forced the Tribe to staff new positions at great 
expense, including additional substance abuse counselors to deal with 
the substantial increase in opioid addiction, a nurse specializing in 
substance abuse disorders for case management related to the opioid 
epidemic, and physicians to provide Medication Assisted Treatment with 
drugs such as naltrexone for opioid addiction and abuse.
    The Tribe has provided naloxone HCl, also known as ``Narcan'', a 
nasally administered overdose reversal drug, and the training to use 
it, to all law enforcement personnel and natural resource officers. Due 
to their work in the field in our Tribal community, those officers and 
personnel regularly encounter individuals suffering from opioid 
overdose symptoms who can only be assisted and saved from death by 
timely administration of Narcan. The Tribe provides Narcan and training 
in its use to other members of our community, because the need for such 
emergency treatment is severe. Approximately 120 Tribal members have 
been provided with Narcan and trained on how to administer the drug. 
These steps are necessary, but they also cost money, which affects our 
Tribe's budget and priorities for budget spending.
    In terms of housing, the Tribe receives federal funding under the 
Native American Housing Assistance and Self-Determination Act (NAHASDA) 
to develop and operate affordable housing for low-income Indian 
families. Due to the substantial increase in opioid abuse, the Tribe 
has seen a parallel increase in evictions of Tribal members and other 
Indian families (since NAHASDA requires all leases to have language 
authorizing eviction for ``drug-related criminal activity''). When 
those families are evicted from the Tribe's housing they generally 
become homeless, and as a result they are then in even greater need of 
social, medical, and child welfare services from the Tribe.
    The opioid crisis is overwhelming to our law enforcement and social 
services programs as they are not presently resourced sufficiently to 
meet the needs arising from the opioid epidemic. We are working as hard 
and as efficiently as we can with the resources we have, but additional 
resources in terms of funding, personnel and authorities are needed to 
combat the myriad problems the opioid crisis causes.
    This epidemic is a complex issue, and there is no quick and easy 
fix for resolving the problem. Rather, we need a multifaceted, 
comprehensive approach with tactics that work. Our Tribe has been 
working to implement just such an approach, but we need your help.
III. What Port Gamble S'Klallam Tribe is Doing to Combat the Crisis
    The Tribe has shown leadership in its aggressive and comprehensive 
response to the opioid epidemic through our cross-governmental Tribal 
Healing Opioid Response (THOR) program, collaboration with Washington 
State, through participation in the Three County Coordinated Opioid 
Response Project (3CCORPS), and, most recently, like many other state 
and tribal governments, by seeking to cut the flow of opioids into our 
community by filing a lawsuit against the manufacturers and 
distributors of these drugs.
A. THOR--Tribal Healing Opioid Response
    The Tribe convened two Tribal town hall meetings last year to share 
the local impacts of the opioid crisis and determine a path forward. 
The extraordinary attendance at these community events demonstrated the 
intense and widespread impact of the crisis. Our Tribal Council then 
met with Kitsap County officials to discuss a response to the opioid 
crisis. The Tribe recognized that the crisis affects all our members 
and Tribal agencies and requires a cross-government response. These 
efforts led to the creation of our Tribal Healing Opioid Response, a 
project led by the Tribe's Behavioral Health and Health Services 
Departments. THOR is now the heart of our opioid response on our 
Reservation.
    THOR has three main goals, and Departments across the Tribe--not 
just health-related entities--are responsible for achieving them. These 
three main goals and the associated strategies are:

        (1)  preventing opioid misuse and abuse by changing 
        prescription practices, raising awareness of the danger of 
        overdose, youth prevention programs, safe storage and disposal 
        education, and drug supply reduction;

        (2)  expanding access to opioid use disorder treatment by 
        training health providers to recognize disorder symptoms, 
        increasing access to treatment, applying treatment practices in 
        the criminal justice system, implementing syringe exchange and 
        overdose prevention/treatment training, and reducing instances 
        of opioid withdrawal in newborns; and

        (3)  preventing deaths from overdose by educating the Tribal 
        community in how to recognize and respond to an overdose, and 
        expanding access to overdose reversal medication.

    Since January 2017, the Tribe has convened monthly THOR workgroup 
meetings composed of Tribal Council Members, Department Directors, 
staff, and other community members to implement the THOR goals. The 
workgroup is responsible for developing, reviewing and updating the 
Tribe's local response plan. It reviews the statewide opioid response 
plan and other best practices, identifies appropriate strategies, and 
assigns tasks and responsibilities to workgroup members.
    Significantly, our Tribe took note of the November 2016 Surgeon 
General's Report on Alcohol, Drugs and Health which identified 
prevention as key to the fight against abuse and addiction. We pulled 
strategies from this report and put them into practice in our effort to 
get ahead of potential addictions by creating a Prevention Team. Our 
Prevention Team is responsible for numerous programs that focus on 
youth and using evidenced-based approaches to keep youth active in the 
community. The youth services program offers extended hours, a safe 
space, and education about substance abuse and suicide prevention 6 
days a week. Through our Chi-e-chee Tribal Coalition, we collaborate 
with adults in the community and provide substance abuse education and 
prevention activities to adults and families. Chi-e-chee can be 
translated to ``the workers or the do-ers.'' The coalition has been 
active for over 20 years and is identifying and implementing events and 
activities around issues that are significant to our community.
    The Tribe provides education to the community, focusing on pain 
treatment with exercise, mental health and non-opioid medications. Our 
ultimate goal through this effort is to significantly reduce the number 
of opioid prescriptions. Town hall meetings are held quarterly to help 
educate the community on current issues/topics that are significant to 
the community and are well attended.
    THOR assigns specific responsibilities to each of the Tribe's 
departments to reach the THOR goals. \7\ For prevention, the Health 
Department is responsible for promoting best practices in prescribing 
and promoting safe storage and disposal of prescriptions; the 
Behavioral Health Department is responsible for awareness programs; 
Chi-e-chee is responsible for preventing misuse in youth; and the 
Police Department is responsible for attempting to interdict and 
decrease the supply of illegal opioids. For treatment, the Health and 
Behavioral Health Departments, along with the Police Department, train 
providers to recognize abuse, and the Behavioral Health Department, 
Health Department and Re-Entry Program work together to increase access 
to treatment and offer syringe and needle exchange. To prevent overdose 
deaths, Chi-e-chee, Human Resources, Behavioral Health and Health work 
together to educate the entire community to recognize and respond to 
overdoses, including through the administration of naloxone.
---------------------------------------------------------------------------
    \7\ Tribal Healing Opioid Response Program, https://www.nihb.org/
docs/12032017/Tuesday%20Sessions/THOR%20Presentation.pdf (last accessed 
March 11, 2018).
---------------------------------------------------------------------------
    As a tribal government, we are focused on providing culturally 
appropriate treatment to our members suffering from opioid addiction 
and the host of health and mental health issues that come with it. 
These include programs such as our wellness activities, talking 
circles, and group therapy. The Healing of the Canoe Project is a 
collaborative project among the Port Gamble S'Klallam Tribe, the 
Suquamish Tribe, and the Alcohol and Drug Abuse Institute at the 
University of Washington. Its central mission is to develop a life 
skills curriculum for tribal youth that includes drug abuse materials. 
The Project has made its curriculum available and has trained a total 
of 350 attendees from 46 Tribes and 14 tribal organizations in how to 
adapt and implement the curriculum.
    One of central reasons why our THOR program is so effective is 
because the Tribe is not only a health care provider for our community, 
we are also a government with the ability to coordinate with State, 
County, and regional groups. Our clinics, Police Department and social 
services departments have the ability to quickly work through 
bureaucracy for cross departmental collaboration, providing better 
services to both Tribal members and the community as a whole.
B. Collaboration with Washington State and Accountable Communities of 
        Health (ACH)
    Washington State has a Section 1115 waiver under the Social 
Security Act which funds experimental, pilot, or demonstration projects 
that are found by the United States Secretary of Health and Human 
Services to be likely to assist in promoting the objectives of the 
Medicaid program. These demonstration projects provide states 
additional flexibility to design and improve their programs with an eye 
toward evaluating state-specific policy approaches to better serve 
Medicaid populations. Through its Section 1115 waiver authority, 
Washington State has created Accountable Communities of Health, which 
bring together leaders from multiple health sectors around the state 
with a common interest in improving health and health equity. ACHs seek 
to align resources and activities to support wellness and a system that 
delivers care for the whole person. ACHs are also working to shift 
health care reimbursement strategies away from a system that pays for 
volume of service to one that rewards quality and outcomes.
    Through the Section 1115 waiver and the creation of these ACHs, the 
Tribe has been able to form partnerships that were not otherwise easily 
accessible or workable. Now, on the opioid issue, specifically, the 
Tribe has multiple partners at different levels with whom it can and 
has been coordinating to develop and implement a variety of tactics to 
address the many issues arising from the epidemic. The Tribe 
collaborates with Washington State on the Washington State Opioid 
Response Plan and, on the regional level, the Olympic Community of 
Health (OCH) which is implementing the Three County Coordinated Opioid 
Response Project (3CCORPS).
C. Olympic Community of Health and 3CCORPS
    OCH is an Accountable Community of Health whose objectives are to 
improve patient care, reduce the cost of health care and improve the 
health of the population in Clallam, Jefferson and Kitsap Counties. 
Each of the seven Tribal Nations within the three county region, 
including our Tribe, is represented on the OCH Board of Directors.
    3CCORPS, OCH's specific opioid response, was launched in September 
of 2016 and convened an opioid summit in January 2017. It was not long 
before this summit that one of our Tribal members died due to missing a 
dose of naltrexone. This tragedy spurred momentum for our Tribe's 
active opioid response.
    3CCORPS is currently in the implementation phase of its opioid 
response plan. Addressing the opioid epidemic is a required project in 
the Medicaid Transformation Project (MTP) of the OCH. 3CCORPS' 
foundations are the same 3 goals and strategies that the Tribe has 
adopted and adapted as our own opioid response plan. They also align 
with the statewide plan. The alignment of goals and strategies allows 
for quick duplication of evidence-based strategies and the ability to 
coordinate within the broader regional and state level, and also 
facilitates evaluation and data collection efforts.
    3CCORPS is our work on the regional level with the OCH. Other 
groups that participate in 3CCORPS are independent clinics, police 
departments, and social service agencies that serve many different 
communities.
D. Litigation to Curtail Oversupply of Opioids
    On March 5, 2018, the Port Gamble S'Klallam Tribe, along with the 
Suquamish Tribe and the Jamestown S'Klallam Tribe, filed a complaint in 
federal district court naming various opioid manufacturers and 
distributors, including Purdue Pharma LP, McKesson Corp., Cardinal 
Health Inc., AmerisourceBergen Corp. and others. Our complaint alleges 
that these companies spread false and misleading information about the 
safety of opioids, negligently created an illicit market for opioids, 
and failed to control the flow of opioids to our Tribal members. The 
complaint details the same devastating impacts that we report to you 
today, and asks the court to find that the defendants broke the law 
though fraud, negligence, public nuisance, violation of Washington 
State consumer protection laws, other laws, and racketeering. Through 
the lawsuit, we seek compensation for the cost of responding to and 
treating opioid-related addiction and punitive damages. In filing this 
lawsuit, we join over 400 other plaintiffs across the country, \8\ 
including state and tribal governments, in seeking to hold these 
companies accountable for the destruction caused by the opioid crisis.
---------------------------------------------------------------------------
    \8\ ``Can This Judge Solve the Opioid Crisis?'', New York Times, 
March 5, 2018, available online at https://www.nytimes.com/2018/03/05/
health/opioid-crisis-judge-lawsuits.html, (last accessed March 8, 
2018).
---------------------------------------------------------------------------
IV. Lessons Learned and Strategies All Tribes Can Choose to Put in 
        Place
A. Cross-Government Coordination
    Through THOR and our 3CCORPS program with the OCH, we have learned 
many lessons in the fight against opioid addiction and efforts to treat 
those affected. At the forefront, we learned that coordination and 
communication across our government is key as well as ensuring that all 
of our Departments pitch in to the effort however they can. As the 
opioid epidemic affects all facets of our community, we have taken an 
``all-hands-on-deck'' approach as a government. As explained above, we 
draw on any and all of our Departments that can help so that we can 
attack the crisis from many angles. Our monthly THOR workgroup meetings 
have been key to synchronizing our programs and generating action items 
to address the opioid problems in our community.
B. Culturally Appropriate Care
    Recognizing that traditional healing practices, cultural beliefs 
regarding approaches to treatment, and differences in interpersonal 
communication contribute to significant variances in effectively 
meeting the healthcare needs of AI/AN, cultural competency is an 
inherent part of who we are, who we serve and what we do.
C. Abuse Prevention
    Prevention is the cornerstone for any opioid response, as the 
Surgeon General's Report on Alcohol, Drugs and Health (November 2016) 
states. We realize that availability of resources is different in 
different parts of Indian Country. Yet, there are strategies that any 
Tribe can put into place in its fight against the opioid epidemic. Our 
Tribe has a ``toolkit'' which we share with other Tribes in their 
opioid fight. We are happy to share our ``toolkit'' with any Tribe who 
would like access to it. Our ``toolkit'' includes:

        (1)  Our Pain Agreement--used in the clinic for clients with 
        opioid prescriptions for chronic pain;

        (2)  Our Narcan Standing Orders & Policy--provides Narcan to 
        any Tribal member or household that requests it, and to any 
        patient with an active opioid prescription; and

        (3)  Our Good Samaritan Tribal Code--provides liability 
        protection for those who act in good faith and seek medical 
        assistance for any person who is experiencing a drug-related 
        overdose.

    Collaborating with federal agencies has been very helpful in our 
Tribe's fight against the epidemic. We suggest that Tribes regularly 
call upon their regional federal agency officials from IHS, SAMHSA, 
HRSA, BIA, DOJ, and others. These agencies have resources, technical 
assistance and connections that they can share. Further, Tribes may 
find that partnering with their neighboring governments on this 
particular issue yields a variety of benefits. Accessing additional 
resources is always a benefit, whether they are financial resources or 
non-financial resources such as experience, expertise and technical 
assistance. Brainstorming and sharing ideas with federal agencies and 
neighboring governments with mutual interest in stemming the opioid 
crisis can lead to innovation and cooperation.
    The Tribe has benefited from having close collaboration with 
federal agencies at the regional level. The Acting Regional Director of 
the Department of Health and Human Services (HHS), and the Regional 
Director of the Substance Abuse and Mental Health Services 
Administration (SAMHSA), have both visited the Tribe recently, 
participating in robust discussions on opioid prevention. As a specific 
example, our SAMHSA discussion helped clarify 42 CFR Part 2 updates and 
requirements.
V. Barriers and Needs to More Effectively Fight the Opioid Crisis
A. Funding Needs
    There are several barriers that Tribes face in their efforts to 
overcome the opioid epidemic. We have run into several.
1. Adequate Funding and Direct Funding
    Adequate funding to combat this behemoth opioid crisis is, of 
course, a major barrier. Getting funding out to Tribes for their on-
the-ground work is an issue not only in the amounts, but also in the 
manner in which such monies flow to Tribes. We strongly encourage 
Congress to not only work on increasing available funding, but to also 
provide direct funding to Tribes and ensure that any additional funds 
for opioid crisis response do not decrease services in other areas.
    We truly appreciate Congress's inclusion of authorization for $6 
billion over 2 years for opioid efforts in the recently passed 
Bipartisan Budget Act of 2018. We ask the Committee to advocate for 
full funding of the authorization and ensure that these funds go 
directly to tribal governments for them to spend in their own 
communities. Such funds should not be passed through the States. Direct 
funding of tribal programs is important as it ensures that funds are 
available to tribal governments like ours that have culturally 
appropriate programs and mechanisms in place for fighting the opioid 
epidemic.
    An important bill that includes the requested direct funding 
mechanism is S. 2270, the Mitigating the Methamphetamine Epidemic and 
Promoting Tribal Health Act. This bill, introduced by Senator Daines, a 
member of this Committee, would make Tribes and tribal organizations 
eligible for direct funding under the 21st Century Cures Act, which 
provides an allocation to states for opioid prevention and response. S. 
2270 would allow such allocation to also be used for prevention and 
response for other substances, such as methamphetamines, if they are 
having a substantial impact on the state or Tribe.
2. Full Funding of IHS Budget
    Additionally, we ask you to work toward providing sufficient 
funding to the Indian Health Service (IHS) for opioid treatment and 
prevention. The FY2019 Budget Request provides $10 billion in new 
resources across HHS to combat the opioid epidemic and address serious 
mental illness. As part of this effort, the Budget Request includes an 
initial allocation of $150 million to IHS to provide multi-year 
competitive grants based on need for opioid abuse prevention, 
treatment, and recovery support in Indian Country. \9\
---------------------------------------------------------------------------
    \9\ 2019 Budget in Brief https://www.hhs.gov/sites/default/files/
fy-2019-budget-in-brief.pdf. As of the preparation of this testimony, 
HHS has not released its detailed FY 2019 Budget Justification, 
including for IHS.
---------------------------------------------------------------------------
    The Public Health Service Commissioned Corps plays a vital role in 
providing direct patient care throughout the Indian Health Service, and 
also has a direct role in the work of Tribes combating the opioid 
crisis. Any restructuring of the Corps should be done in close 
collaboration and consultation with Tribes.
    The FY 2019 Budget Request eliminated both Community Health 
Representatives and Health Education from the IHS budget. These two 
line items support the front line work of Tribes and the IHS on both 
the opioid crisis and daily operations and patient care.
    They need to be restored.
3. Full Funding of Contract Support Costs
    The FY 2019 Budget Request fully funds Contract Support Costs at an 
estimated $822 million and continues the use of an indefinite 
appropriation, which allows IHS to guarantee full funding of this 
program. Funding for Contract Support Costs supports the costs incurred 
by Tribes for activities that are necessary for administering health 
care service programs under self-determination contracts and self-
governance compacts. \10\ This is an important funding mechanism for 
self-governing Tribes like ours to administer our opioid prevention and 
treatment programs.
---------------------------------------------------------------------------
    \10\ Id.
---------------------------------------------------------------------------
B. Barriers Beyond Funding
1. Regulatory Hurdles
    There are several barriers in the fight against the opioid crisis 
that are beyond funding. One such barrier relates to funding, but is an 
administrative limit on accessing already available funding. The Health 
Resources and Services Administration (HRSA) has behavioral health 
integration funding available, but it is restricted to rural locations. 
Kitsap County does not qualify as ``rural'' and so the Tribe is 
ineligible for these grants. We recently raised this issue to HRSA, and 
received assurances that this issue would be addressed. However, it 
would be helpful for members of Congress to encourage HRSA to 
reconsider the rural restriction and develop a mechanism for channeling 
such monies to Tribes. This could be through revising the definition of 
``rural'' to include Tribes regardless of location or ``geographic 
trait'' of its reservation.
2. Barriers to Medication Assisted Treatment
    We also want to point out certain other barriers to our efforts to 
combat the opioid crisis. Current regulations impose onerous training 
and waiver requirements for providers of Medication Assisted Treatment 
(MAT) prescribing drugs such as buprenorphine, even though no such 
limitation exists on providers prescribing opioids. This creates 
barriers to accessing MAT. Medicaid dollars used to fund transportation 
to opioid services could be reduced significantly if buprenorphine, an 
opioid addiction treatment drug also known as Suboxone, was easier to 
access at primary care facilities. Those saved funds could be used for 
prevention or treatment. In addition, nurse care management as an 
adjunct to MAT has been shown to be successful and is an evidence-based 
practice in treating opioid addiction. We need to expand Tribes' access 
to this treatment.
3. Physician Access to Medical Records
    Federal regulations at 42 CFR Part 2, related to the privacy of 
substance abuse treatment records, currently prevent the Tribe's 
primary care and mental health providers from accessing patient records 
from dependency providers so the whole person can be treated.
    This lack of access is a barrier to coordinated, safe, and high-
quality medical care and can cause significant harm. Part 2 regulations 
may lead to a doctor treating a patient and writing prescriptions for 
opioid pain medication for that individual without knowing the person 
has a substance use disorder.
    In August 2017, Congressmen Tim Murphy and Earl Blumenauer 
introduced bipartisan legislation that would help align 42 CFR Part 2 
with HIPAA rules, ensuring that substance use disorder patients can 
receive proper care while their data remains secure. The Overdose 
Prevention and Patient Safety (OPPS) Act (HR 3545) allows access by 
doctors to patients' full medical records with all the safeguards of 
HIPAA, but also makes use of such information in criminal 
investigations unlawful. The Tribe joins others such as the Partnership 
to Amend 42 CFR Part 2, a coalition of over 20 healthcare stakeholders 
including the American Hospital Association, in support of HR 3545.
4. The Lack of Co-location of Health Services on Our Reservation
    The Tribe is actively working to align substance use disorder 
treatment with primary care to address a person's overall health, 
rather than treating it as a substance misuse or a physical health 
condition alone or in isolation. As stated, our Health Facility and 
Dental Facility are nearby each other, but our Mental Health Facility 
and Rehabilitation Facility are some distance away. This causes extra 
administrative burden and expense of resources. Co-locating these 
services would improve behavioral health integration, but a new 
integrated facility for all health services would cost over $8 million 
dollars. We suspect other Tribes face similar problems with respect to 
the lack of co-location of services. We look to Congress for innovative 
ideas, perhaps through its infrastructure package, for facilitating the 
construction of co-located health care facilities on tribal lands.
5. The Need to Modernize the IHS's Health Information System
    This issue impacts the ability of Tribes to confront the opioid 
epidemic. Barriers to integration within the health information system 
are being addressed at significant cost to the Tribe as we left the 
Indian Health Service RPMS system for direct patient care documentation 
years ago, although we continued to utilize that system for Purchased & 
Referred Care (PRC). The system we use, NextGen, is adequate for 
primary care, but has limitations for mental health and substance 
abuse. This has impacted our behavioral health integration work.
    The Veteran's Administration announcement that it will pursue a 
contract with Cerner as a replacement for the RPMS Parent system may 
provide an opportunity for both IHS and Tribes. IHS needs to ensure 
that the replacement of RPMS will include options for non-RPMS tribes 
and pathways for cost saving programs such as the VA Consolidated Mail 
Outpatient Pharmacy Service (CMOPS).
6. The Need for Pilot Projects for Residential Post-Treatment 
        Facilities on Tribal Lands
    Our Tribe is particularly interested in initiating a pilot program 
for residential post-treatment facilities. The Tribe would like to 
provide treatment and support past the prevailing 28-day model, 
utilizing evidenced-based practices with a robust evaluation component. 
The Tribe has partnerships with Oxford House and Habitat for Humanity 
to construct and operate such facilities, and is well positioned to 
start such a pilot program. We ask Congress to support the 
establishment of a pilot program by an agency such as SAMHSA, HUD, or 
IHS to fund residential post-treatment facilities on reservations to be 
operated by Tribes for their members and families.
7. Lack of Easy Access to Methadone Clinics
    Our Tribal Members must travel to Tacoma or the greater Seattle 
area to a methadone facility to receive such treatment. We are working 
with OCH to obtain a methadone facility in Kitsap County to save our 
Members the burden and cost of traveling so far for that treatment. We 
ask Congress to consider ways it can facilitate the construction and 
operation of these facilities in locations accessible to tribal and 
rural communities like ours. Kitsap County, where we are located, has a 
restriction limiting service to one methadone clinic in the county. 
This limitation hampers our ability to provide expanded services in the 
future.
C. Beneficial Legislation: Senator Cantwell's Bill, S. 2440
    In addition to S.2270 (Senator Daines' bill), we ask this Committee 
to support S.2440, introduced by our Senator and Committee Member, 
Senator Cantwell. We appreciate Senator Cantwell's work on behalf of 
Indian Country and, specifically, on the opioid issue. We also note 
that the Senator's consultation with our Tribe for receiving early 
input about this bill could serve as a model for tribal consultation 
when developing legislation. Our Tribe supports S. 2440.
    S. 2440, known as the Comprehensive Addiction, Recovery, Education 
and Safety (CARES) Act, would, among other things, hold opioid 
manufacturers accountable for failure to report suspicious drug orders. 
The intent of the CARES Act is to increase opioid prevention and 
treatment funding, limit opioid prescriptions and enhance prescription 
drug monitoring programs. The Act would increase civil and criminal 
penalties on companies that fail to reasonably curtail their drugs from 
entering the illicit drug market. The legislation increases civil 
penalties from $10,000 to $100,000 per violation for negligence in 
reporting suspicious transaction activity, and doubles the maximum 
criminal penalty from $250,000 to $500,000 for willful violations. The 
Act increases funding for the DEA's Tactical Diversion Squad which 
investigates drug manufacturers that fail to prevent their drugs from 
entering the illicit drug market. The legislation also authorizes $50 
million for the DEA's heroin enforcement groups.
    This important bill aligns with the Tribe's goals in our federal 
lawsuit to hold drug companies responsible for failing to track orders 
and for creating an illicit market for their drugs, and will be an 
enormous boost in the fight against opioid addiction. We applaud 
Senator Cantwell and ask all on this Committee to cosponsor and support 
this bill. Increased response funding and manufacturer accountability 
could drastically curtail shipments of the prescription pills that 
result in crippling addiction for our Tribal members.
VI. Conclusion
    The crisis has ripped the fabric of our community. The loss 
(through death or addiction) of parents, children, brothers and 
sisters, uncles and aunts, nieces and nephews, and cousins to this 
crisis has been devastating, and will impact the Port Gamble S'Klallam 
Tribe for generations. We are doing what we can to fight it, and we 
want to work with you to eradicate this crisis once and for all.
    Thank you for the opportunity to provide this testimony. We invite 
you to visit our Tribe to learn more about our ongoing work.

    The Chairman. Senator Smith, I believe you wanted to give 
an introduction of Mr. Moose.
    Senator Smith. Very briefly, Mr. Chair, because I know we 
are rushed for time.
    I want to welcome you to this Committee. It is wonderful to 
see you.
    Mr. Moose is a member of the Mille Lacs Band of Ojibwe from 
Minnesota and is an important leader on Native health issues 
broadly, not just issues related to the opioid epidemic. As 
Chairman Hoeven said, he serves as Treasurer and the Beidji 
Area representative to the National Indian Health Board. Thank 
you so much for being here.
    I am going to have to run to go vote but I have read your 
testimony and look forward to hurrying back so that I can ask 
you a question or two.
    Senator Cantwell. [Presiding] I thank the witnesses for 
their testimony. Did you want to ask a question at this moment? 
If you want, go ahead, Senator Smith.
    Senator Smith. I will do that. That way I don't have to run 
back. Thank you.
    Mr. Moose, I am very interested in talking to you about the 
opportunities we have with the special behavioral health 
program modeled on the Diabetes Program. Earlier today, I was 
able to introduce legislation that several Committee members, 
including Senators Udall, Tester, Cortez Masto and Heitkamp, 
also introduced.
    This bill would provide Native communities with flexible 
funding, as we have discussed so much today, to create programs 
that can really build on the work you are already doing. Could 
you talk a bit from your perspective on what we could do at the 
Federal level to make sure we are not just reacting to current 
events but are really giving tribes the flexibility they need 
to take action?
    Mr. Moose. One of the things that is really good about the 
bill you are looking at introducing is the fact that it does 
look at long range infrastructure funding for Indian Country. 
One area we often struggle with is grants, from time to time, 
are kind of dropped into Indian Country and then go away.
    One of the issues we have in Indian Country is 
infrastructure development, ongoing support and flexibility to 
utilize funding that meets our specific needs. Unfortunately, 
at times, States, under good pretenses, provide funding large 
areas of tribes within their State systems.
    Oftentimes that funding gets so specific that it does not 
meet the needs of every tribe within the State. Some States may 
need that specific direct funding, whether it is recovery, case 
manager support or other specific support. However, other 
tribes may have moved on from that funding and have a hard time 
utilizing that funding or using that funding to leverage other 
funding. I think it is really good to see that the bill 
supports ongoing funding for Indian Country, specifically what 
we have seen with the Special Diabetes for Indians.
    Senator Smith. Thank very much. I will leave it at that but 
I thank you and look forward to working with you on the bill. 
Also, thank you very much, Ms. George, for being with us.
    Senator Cantwell. Thank you, Senator Smith.
    Ms. George, you mentioned the CARES Act, which we have 
introduced. One key focus of that legislation is putting 
stiffer penalties on manufacturers who fail to meet the 
standard DEA has set up for some drugs as addictive as opioids.
    The DEA really wants to follow the distribution of that 
product and make sure the failure to report distribution of 
something as highly addictive as opioids is penalized if 
manufacturers fail to do that. That is what I and Senator 
Harris of California have introduced.
    In our State, we have had over 10,000 fatal overdoses in 
basically a 17-year period of time. I know the rate in Indian 
Country is more than twice as high as the rest of the 
population. What do you think this kind of partnership with law 
enforcement in tracking and distribution of drugs would do to 
help the problem in Indian Country?
    Ms. George. I really believe that collaboration between law 
enforcement and all sectors needs to be represented in this 
process to really combat this crisis as a whole. Law 
enforcement is definitely key.
    In our community, although we are a small community, our 
law enforcement sometimes is the only people that have 
interactions with some of our folks having overdose incidents. 
Not only are they able to keep them alive in that instance they 
experience, but also bring them directly to our programs that 
service them. They play a very integral part in fighting this. 
At least in our community, I think our law enforcement 
recognizes that and is willing to take the steps necessary to 
move forward.
    Senator Cantwell. Thank you for that answer.
    Unfortunately, we are going to have to take a short recess 
and will resume shortly. The Committee will be in recess.
    [Recess.]
    Senator Udall. [Presiding.] The Committee is reconvened.
    We apologize for the inconvenience. These votes are an 
occupational hazard and if we do not vote, we get in a lot of 
trouble. Thank you for your patience.
    I believe we were at the point in the proceeding where next 
to testify was Mr. Samuel Moose, the Treasurer and Bemidji Area 
Representative of the National Indian Health Board.
    Before you start, Sam, both of you obviously have real 
admirers in Senators Cantwell and Smith who really appreciate 
all the good work you are doing.
    Thank you.

     STATEMENT OF SAMUEL MOOSE, TREASURER AND BEMIDJI AREA 
          REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD

    Mr. Moose. Chairman Hoeven, Vice Chairman Udall and members 
of the Committee, on behalf of the National Indian Health Board 
and the 573 tribal Nations we serve, I thank you for holding 
this important hearing.
    My name is Samuel Moose. I am the Human Services Director 
for the Fond du Lac Band of Lake Superior Chippewa and an 
enrolled member of the Mille Lacs Band of Ojibwe.
    The current opioid epidemic represents one of the most 
pressing public health crises affecting tribal communities. 
While this epidemic is affecting many communities throughout 
America, it has disproportionately impacted tribes and has 
strained the limited public health and health care resources 
available to tribes.
    American Indians and Alaska Natives have had the highest 
rate of drug overdose deaths every year since 2008 to 2015. In 
my home State of Minnesota, the age adjusted death rate due to 
drug poisoning is five times higher among the American Indian 
population compared to Whites.
    American Indians accounted for 15.8 percent of those who 
entered drug treatment for opioid use despite only being 1.1 
percent of tribal or the State population. These statistics 
demonstrate the critical need for more comprehensive 
intervention in tribal communities to improve prevention and 
treatment services.
    This epidemic is so bad that several tribes throughout the 
Country, including three within Minnesota, declared a state of 
emergency to tackle this crisis. Historic and intergenerational 
trauma along with current trauma that spans a lifetime for 
American Indians, a lack of funding for IHS, and the failure to 
include tribes in State level prevention and public health 
programs all contribute to the current crisis in tribal 
communities.
    In Minnesota, pregnant American Indian women were 8.7 times 
more likely to be diagnosed with maternal opioid dependence. 
American Indian infants were 7.4 times more likely to be born 
with Neonatal Abstinence Syndrome, meaning that the 
repercussions and trauma of this crisis are intergenerational.
    The deferral of healthcare in the Indian health care system 
due to funding and workforce shortages has created greater 
dependency on opiates. Limited funding resulted in nearly 
80,000 Purchased/Referred Care service denials in fiscal year 
2016 alone. Instead of being referred for surgeries and support 
treatment, patients are simply placed on prescription opiate 
medication as they wait for access to additional care. This 
endless cycle of deferral and opiate dependency is a direct 
result of underfunding in the IHS system contributes to the 
issue.
    Solutions should focus on allowing tribes to access long 
term, sustainable resources, improve data and disease 
surveillance and enhance tribal practice of traditional healing 
and culturally-based treatment. Congress should allow tribes 
access to the State Targeted Response to Opiate Epidemic 
Grants. NIHB supports the provisions in S. 2270, the Mitigating 
METH Act, and S. 2437, the Opioid Response Enhancement Act.
    Congress should: establish tribally-specific funding 
streams such as a Special Behavioral Health Program for 
Indians, modeled after the very successful Special Diabetes 
Program for Indians; ensure parity between States and Tribes in 
any new opioid-related legislation advanced in Congress, not 
only including tribes as eligible entities, but also requiring 
tribal consultation, information and data sharing, and funding 
set asides; establish trauma-informed interventions in 
coordination with tribes to reduce the burden of substance use 
disorders including those involving opioids; and include set 
asides for tribes within the $6 billion in opioid program 
funding for fiscal years 2018 and 2019.
    In addition, health IT and data issues represent a serious 
challenge when it comes to the opiate crisis. IHS' current 
Electronic Health Record system has difficulty tracking data 
across various systems, including those tribes who operate 
different EHRs. RPMS is often not compatible with State-based 
prescription drug monitoring programs which makes tracking 
access to opiates a severe challenge.
    Congress should make investments in the health IT resources 
at IHS, especially as the VA system begins to transition from 
Vista. It should require that States consult with tribes on use 
of prescription drug monitoring programs and incentivize 
providers to adopt E-Prescribe as a way of reducing the 
needless and harmful spread of opiates.
    I would also like to highlight the importance of 
integrating traditional healing practices with conventional 
strategies in Indian Country and tribal communities that have 
been healing their people for thousands of years. Although 
Federal grants and Medicare do not reimburse for traditional 
healing services, it is critical that Congress support these 
traditional practices by providing funding and including them 
in the Medicaid reimbursement.
    Again, thank you for allowing this time for me to be here 
with you today and holding this hearing.
    [The prepared statement of Mr. Moose follows:]

    Prepared Statement of Samuel Moose, Treasurer and Bemidji Area 
              Representative, National Indian Health Board
Introduction
    Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, 
the National Indian Health Board (NIHB) thanks you for holding the 
hearing, ``Opioids in Indian Country: Beyond the Crisis to Healing the 
Community.'' On behalf of NIHB and the 573 federally-recognized Tribes 
we serve, I, Sam Moose, Director of Human Services at Fond du Lac Band 
of Lake Superior Chippewa submit this testimony.
    NIHB is a 501(c)3, not for profit, national Tribal organization 
founded by the Tribes in 1972 to serve as the unified, national voice 
for American Indian and Alaska Native (AI/AN) health in the policy-
making arena. Our Board of Directors is comprised of distinguished and 
highly respected Tribal leaders in AI/AN health. They are elected by 
the Tribes in each region to be the voice of all 573 Tribes at the 
national level.
    Since 1972, NIHB has advised the U.S. Congress, Indian Health 
Service (IHS), and other federal agencies about health disparities and 
service issues experienced in Indian Country. The current opioid 
epidemic represents one of the most pressing public health crises 
affecting Tribal communities. While this epidemic is affecting many 
communities throughout America, it has disproportionately impacted 
Tribes and has further strained the limited public health and 
healthcare resources available to Tribes. The Federal Government must 
take concrete action to ensure Indian Country has the tools it needs to 
address opioid abuse and heal Tribal communities.
Trust Responsibility
    The federal promise to provide Indian health services was made long 
ago. Since the earliest days of the Republic, all branches of the 
Federal Government have acknowledged the nation's obligations to the 
Tribes and the unique trust relationship between the United States and 
Tribes.
    The Indian Health Service is the primary agency by which the 
Federal Government meets the trust responsibility for direct health 
services. IHS provides services in a variety of ways: directly, through 
agency-operated programs and through Tribally-contracted and operated 
health programs; and indirectly through services purchased from private 
providers. IHS also provides limited funding for urban Indian health 
programs that serve AI/ANs living outside of reservations. Tribes may 
choose to receive services directly from IHS, run their own programs 
through contracting or compacting agreements, or they may combine these 
options based on their needs and preferences.
    Today the Indian healthcare system includes 46 Indian hospitals (1/
3 of which are Tribally operated) and nearly 630 Indian health centers, 
clinics, and health stations (80 percent of which are Tribally 
operated). When specialized services are not available at these sites, 
health services are purchased from public and private providers through 
the IHS-funded purchased/referred care (PRC) program. Additionally, 34 
urban programs offer services ranging from community health to 
comprehensive primary care. To ensure accountability and provide 
greater access for Tribal input, IHS is divided into 12 geographic 
Service Areas, each serving the Tribes within the Area. It is important 
to note that Congress has funded IHS at a level far below patient need 
since the agency's creation in 1955. In FY 2017, national health 
spending was $9,207 per capita while IHS spending was only $3,332 per 
patient.
Overview of the Opioid Epidemic in Indian Country
    The national opioid epidemic represents one of the great public 
health challenges of the modern era. The Centers for Disease Control 
and Prevention (CDC) noted over 64,000 drug overdose deaths in 2016 
alone, largely driven by prescription and illicit opioids. \1\ Among 
AI/ANs, the rate of drug overdose deaths is twice that of the general 
population, according to the IHS. Deaths from prescription opioid 
overdoses increased four-fold from 1999 to 2013 among AI/ANs. \2\ The 
CDC reported that AI/ANs consistently had the highest drug overdose 
death rate by race every year from 2008-2015, and the highest 
percentage increase in drug overdose deaths from 1999-2015 at 519 
percent. \3\ Deaths from prescription opioid overdoses increased four-
fold from 1999 to 2013 among AI/ANs, with an opioid overdose death rate 
of 9.6 per 100,000 in 2015--second only to whites.
---------------------------------------------------------------------------
    \1\ National Institute on Drug Abuse. 2017. Overdose Death Rates. 
Retrieved from https://www.drugabuse.gov/related-topics/trends-
statistics/overdose-death-rates
    \2\ Indian Health Service. New effort targets drug overdoses in 
Indian Country. Retrieved from https://www.ihs.gov/newsroom/
pressreleases/2015pressreleases/new-effort-targets-drug-overdoses-in-
indian-country/
    \3\ Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit 
Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and 
Nonmetropolitan Areas--United States. MMWR Surveill Summ 2017;66(No. 
SS-19):1-12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1
---------------------------------------------------------------------------
    Regional data trends further demonstrate the high burden of the 
opioid epidemic within Tribal communities. According to the State of 
Alaska Epidemiology Center, AI/ANs had the highest overdose death rate 
by race from 2009-2014 at 20.2 deaths per 100,000 population. 
Similarly, the Washington State Department of Health reported that from 
2011-2015, the opioid overdose death rate was highest among AI/ANs at a 
rate of 29 deaths per 100,000 compared to 12 deaths per 100,000 for 
Whites.
    In my home state of Minnesota, the Department of Human Services 
reported that the age-adjusted death rate due to drug poisoning is four 
times higher among AI/ANs compared to whites. Further, despite 
representing roughly 1.1 percent of the population for the state, AI/
ANs accounted for 15.8 percent of those who entered treatment for 
opioid use disorder. These statistics illuminate the critical need for 
more comprehensive interventions in Tribal communities to improve 
prevention and treatment measures.
    The Indian Health system is chronically underfunded, understaffed 
and overextended. Limited Tribal and IHS public health and healthcare 
resources have been further inundated by this highly deadly and 
superbly costly epidemic. While the treatment and recovery costs are 
certainly great, the human toll of the epidemic on our Tribal 
communities is even greater. The state of Minnesota reported that 
pregnant AI/AN women were 8.7 times more likely to be diagnosed with 
maternal opioid dependency, and that AI/AN infants were 7.4 times more 
likely to be born with neonatal abstinence syndrome (NAS)--meaning that 
the repercussions and trauma of this crisis are intergenerational. 
Other secondary impacts include the undue burdens imposed on many AI/AN 
families struggling with opioid and substance use disorders, the 
children forced into foster care, and the kinship care networks that 
are strained beyond their ability.
    While Tribal communities are certainly in need of expanded 
treatment resources, public health prevention must not be forgotten. 
This includes upstream prevention activities such as comprehensive 
substance use education in youth, expanded substance and alcohol use 
education and training for our providers, prevention of adverse 
childhood experiences, healing from historical and intergenerational 
trauma, and investment in culturally appropriate and Tribally-driven 
programming.
    Bolstering Tribal public health surveillance infrastructure is also 
a major need. The CDC noted in 2017 that the actual drug overdose death 
count among AI/ANs may be underestimated by as much as 35 percent due 
to racial misclassification on death certificate data. That is truly 
unacceptable. Data is the backbone of any public health system, and 
without it the Tribes and IHS are unable to maintain accurate records 
of vital statistics, to quantify disparities in health outcomes between 
AI/ANs and other populations, and to ultimately make true assessments 
of need. More importantly, Tribal leaders must have this information to 
make informed policy decisions and implement targeted programs.
    Tribes also remain behind many other communities in their public 
health infrastructure, capacity, and workforce capabilities as a result 
of being largely left behind when the United States was modernizing its 
public health infrastructure. These obstacles have made it particularly 
difficult for Tribal communities to assemble a coordinated and 
comprehensive defense against major health emergencies, including the 
opioid epidemic.
    At IHS, and indeed even at many Tribal facilities, deferral of care 
due to funding and workforce shortages has pushed more and more Tribal 
members towards prescription opioids to treat health conditions that 
would otherwise successfully be treated with non-opioid therapies. For 
instance, limited funding resulted in nearly 80,000 Purchased/Referred 
Care (PRC) services (an estimated total of $371 million) being denied 
in FY 2016 alone. This endless cycle of deferral and opioid dependency 
is a direct result of the underfunding of the IHS system, and must be 
stopped.
    The CDC Guideline for Prescribing Opioids for Chronic Pain 
describes how opioid therapy should not be the first line of treatment 
for acute or chronic non-cancer related pain management, and should 
rarely, if ever, be prescribed with other medications such as 
benzodiazepines. Nevertheless, many Tribal members still report that 
opioids are some of the only options available to them to address their 
pain symptoms. Lack of reimbursement and access to non-opioid 
therapies, traditional medicine and other alternatives leaves both 
providers and patients in a catch-22 that ultimately leads to more 
harm.
    Tribes throughout the country are finding that the systemic 
problems with the current Indian health system are impacting their 
ability to confront the opioid crisis. Bay Mills, a Tribe located on 
the Upper Peninsula in Michigan, has capacity issues so severe that, 
even if that Tribe received federal funds to operate an opioids 
treatment outpatient program, the Tribe reports that their facilities 
are too small and outdated to be able to operate such a program on-
site. NIHB has noted in previous testimony to Congress that IHS's 
facilities construction budget is so underfunded that a facility built 
today would not be able to be replaced for 400 years. These chronic 
funding issues have limited the ability of Tribes to confront the 
opioid crisis without additional, sustained Congressional support.
    The Red Cliff Tribe of Chippewa Indians in Wisconsin lacks 
resources to keep up with the latest training practices available to 
healthcare providers. While the Tribe has started a Harm Reduction 
Program to provide access to Naxolone, lack of substance abuse and 
addiction training among Tribal providers limits the program's reach 
and uptake in the community. The Red Cliff Police Department reported 
346 investigations on drug use in 2016, an increase of almost 100 from 
the year prior. The total population of the reservation is under 1,000.
Tribal Response to Opioids
    Despite these challenges and setbacks, Tribes across Indian Country 
have engaged in multifaceted response efforts that traverse the 
prevention, treatment and interdiction landscape. For instance, after 
declaring a state of emergency on the opioid epidemic in March 2016, 
the Mashpee Wampanoag Tribe in Massachusetts partnered with the IHS to 
assemble more resources to address the growing number of overdose 
deaths in their community. The Tribe worked towards establishing an 
integrated community intervention model, implementing the CDC Guideline 
for Prescribing Opioids for Chronic Pain, and developing an opioid 
response grounded in the social determinants of health. The Tribe 
worked with Tribal Police and Homeland Security to create prescription 
drug drop boxes, developed a 24-hour call line for crisis intervention, 
and established a Tribal Coordinating Committee to create a 5 year 
Tribal Action Plan to address alcoholism and substance abuse issues.
    In Washington State, the Muckleshoot Tribe has been operating a 
successful behavioral health program for the past few years. The 
initiative includes a medication-assisted treatment program where 
Tribal members are able to receive Suboxone or Vivitrol for treatment 
of opioid use disorder. The program has proven successful, as 
compliance with the program reached 94 percent in July, 2017. 
Muckleshoot has distributed close to 4,000 kits of Naloxone as of 
August 2017, and also operates a syringe service program to help reduce 
the risk of co-occurring health conditions such as HIV and Hepatitis C.
    In Oklahoma, the Chickasaw Nation launched the ``Define Your 
Direction'' campaign, which is an education initiative encouraging 
Tribal youth to make healthy choices and be positive role models when 
it comes to resisting prescription drug misuse and underage drinking in 
their communities. Some outcomes of the program thus far include 
equipping all Chickasaw Nation Lighthorse officers with Naloxone; 
distributing more than 400 medication lockboxes to Elders; recording 
significant reductions in prescription drug misuse within the past 30 
days among 6th, 8th, 10th and 12th graders; and reductions in risk 
factors such as early drug use initiation and low neighborhood 
attachment among Tribal youth.
    NIHB encourages the Committee Members to connect with the Tribes in 
your home states to learn more about current initiatives and gain 
further insight into technical assistance and funding needs, so that 
programs such as these are replicated in more and more Tribal 
communities.
Policy Solutions
A) Access to Federal Opioid Resources
    Addressing the opioid epidemic is a nationwide priority; however, 
access to critical opioid prevention and treatment dollars are not 
reaching many of the Tribal communities that are in serious need of 
these funds. As sovereigns, Tribes are not systematically included 
within statewide public health initiatives such as the recent 
prevention and intervention efforts created through the new opioid 
crisis grants found in the 21st Century CURES Act, passed by Congress 
in 2016.
    The CURES Act provided $1 billion in funding over a two-year period 
to states and territories to combat the opioid crisis. Tribes were not 
eligible entities for this critically important funding. Although a 
small number of states subsequently allocated CURES funds to Tribes, 
access was not at the level of need, nor was it equitably distributed. 
Furthermore, as the trust responsibility is exclusive to Tribal Nations 
and the Federal Government, Congress must not circumvent this sacred 
duty by forcing Tribes to go through state agencies for these funds. In 
addition, many Tribes have historically had complicated relationships 
with state governments as a result of having to compete for limited 
dollars. Providing direct funding to Tribes would solve this issue.
    An example of this can be seen in Ho-Chunk Nation in Wisconsin. 
Like many Tribes, Ho-Chunk has seen an increased number of infants born 
with substance addiction and NAS, as well as an increase in opioid-
related overdose deaths in the community. The Tribal government 
declared a State of Emergency regarding the opioid crisis and is in the 
process of developing a Tribal Action Plan within their departments. A 
major problem for the Tribe is that the grant money the state receives 
and distributes to the Tribes is not sufficient to meet the added 
burden the Tribe's behavioral health facility is experiencing.
    To correct this dynamic and ensure that needed opioids funding is 
reaching the Tribes, Congress should:

   Amend the CURES Act, specifically the State Targeted 
        Response to Opioid Epidemic grants, to ensure Tribes can 
        receive funding directly from the Federal Government to address 
        the opioids crisis. NIHB supports the provisions in S. 2270, 
        the Mitigating METH Act, and S. 2437, the Opioid Response 
        Enhancement Act, that address this.

   Establish Tribally-specific funding streams such as a 
        Special Behavioral Health Program for Indians, modeled off the 
        very successful Special Diabetes Program for Indians, so that 
        Tribes can develop their own programs to address substance 
        misuse and dependence in their communities. NIHB supports House 
        legislation that has been introduced for this purpose, H.R. 
        3704 the Native Health Access Improvement Act.

   Ensure parity between states and Tribes in any new opioid-
        related legislation advanced in Congress. This means not only 
        including Tribes as eligible entities, but also requiring 
        Tribal consultation, information and data sharing, and funding 
        set asides, where applicable. For example, the newly introduced 
        ``Comprehensive Addiction and Recovery Act (CARA) 2.0'' (S. 
        2456) legislation should include Tribes and Tribal 
        organizations in several sections of the bill. This includes 
        Section 6 which establishes funding for regional technical 
        assistance centers to focus on addiction recovery and naloxone 
        training/dissemination; Section 7 which allows states to 
        increase the 3-day limit on first time opioid prescriptions 
        found in Section 3 if the state passes a law or implements a 
        statewide regulation should include Tribal law as well; and 
        Section 10 which provides funding to states for addiction 
        treatment programs targeted toward pregnant and post-partum 
        women. Finally, we recommend adding language to Section 13 that 
        would require states to consult with Tribes on the 
        implementation of prescription drug monitoring programs.

   Establish trauma-informed interventions in coordination with 
        Tribes to reduce the burden of substance use disorders 
        including those involving opioids.

   Include set asides for Tribes within the $6 billion in 
        opioid program funding for Fiscal Years 2018 and 2019 
        appropriated in the February 2018 Continuing Resolution.

FY 2019 Budget Proposal
    NIHB and Tribes were glad to see that the FY 2019 President's 
budget request proposed $150 million in funding to ``provide multi-year 
competitive grants based on need for opioid abuse prevention, 
treatment, and recovery support in Indian Country.'' \4\ Tribes are 
supportive of this additional funding, but many Tribes have expressed 
concerns that competitive grant programs are not the solution to long-
term, broad-based funding. Competitive grants erode Tribal sovereignty 
and do not honor the federal trust responsibility. Furthermore, when 
Tribes are forced to apply for grants it takes away scarce staff and 
resources from other program-oriented work leading to diminished 
program effectiveness across the board. We look forward to working with 
you as this policy is developed to ensure that the proposed funds truly 
reach the areas with greatest need and fully honor the promises made to 
our ancestors. In addition, we note that other federal agencies--such 
as the Substance Abuse and Mental Health Services Administration and 
the Centers for Disease Control and Prevention--should have funding 
made directly available to Tribes.
---------------------------------------------------------------------------
    \4\ U.S. Department of Health and Human Services. ``FY 2019 Budget 
in Brief.'' February 12, 2018. Pg. 28.
---------------------------------------------------------------------------
B) Health Information Technology (IT) within the Indian Health System
    The Federal Government has not met its trust responsibility as it 
relates to updating and modernizing the physical and technological 
infrastructure within IHS and Tribal health facilities and health IT 
systems. The current primary Electronic Health Record (EHR) system IHS 
uses is the Resource and Patient Management System (RPMS), an 
integrated public health information system based on the U.S. 
Department of Veteran's Affairs (VA) VistA system. It is a 
comprehensive suite of applications that supports virtually all 
clinical and business operations at IHS and most tribal facilities, 
from patient registration to billing. RPMS is comprised of over 80 
software applications and is designed to track patient and population 
based clinical and practice management applications. However, various 
concerns and challenges have been cited regarding RPMS. Some notable 
issues are:

   Many Tribes utilize different EHR systems instead of RPMS;

   Smaller Tribal health facilities do not have the bandwidth 
        to fully operationalize RPMS, and would benefit from the 
        ability to share new components such as files that contain all 
        available drugs instead of just some;

   Some smaller Tribal health clinics are in need of greater 
        training and technical assistance on how to utilize the system 
        most efficiently;

   There is a need to further streamline the system and align 
        it with other EHRs utilized by Tribes;

   Robust and timely IT support is not routinely available;

   Interoperability is incomplete, meaning that if a patient is 
        referred to another clinic that utilizes a different system, 
        the patient records are more than likely not cross-referenced 
        which leads to inconsistencies in patient records.

    Issues also exist in terms of RPMS interactions with Prescription 
Drug Monitoring Programs (PDMPs). PDMPs are state-run electronic 
databases that track controlled substance prescriptions. Across the 
board, utilization of PDMPs is inadequate. A national survey of primary 
care physicians found that 86 percent of the time, physicians did not 
check their statewide PDMP prior to prescribing an opioid, despite the 
fact that 72 percent of primary care physicians are aware of their 
state's PDMP. \5\
---------------------------------------------------------------------------
    \5\ Office of Management and Budget. Circular A-130. Appendix III. 
Security of Federal Automated Information Resources.
---------------------------------------------------------------------------
    It is important to note the limitations of the PDMP system, both 
generally and in its usefulness for IHS and Tribal providers, 
pharmacists and public health practitioners. One, PDMP laws and 
regulations differ by state. In other words, whereas one state may 
require providers to update the system within a 24 hour period, other 
states only require updating the system every few days, or even over a 
longer period of time. Further, interstate sharing of PDMP data is not 
streamlined, which creates gaps in monitoring especially for 
individuals living in border towns, or for reservations that traverse 
multiple state boundaries. Additionally, to NIHB's knowledge, only the 
state of Alaska decreed a special consideration for IHS providers to 
access the PDMP system, which may explain why IHS established 
memorandums of understanding (MOU) with state agencies to permit IHS 
access and reporting. Also, there is currently no Tribally-specific 
PDMP system. The FY2017 House Appropriations Bill authorized $1 million 
to IHS to establish such a system; however, to NIHB's knowledge, this 
system has not yet been implemented.
    Finally, no PDMP system collects racial demographics, limiting its 
value as a tool for public health monitoring for Tribes and Tribal 
Epidemiology Centers.
    Due to budgetary constraints, IHS has not been able to support 
operations and maintenance for the certified RPMS site. Other federal 
agencies, like the Veterans' Administration, are in the process of 
moving away from RPMS-like systems toward more integrated software 
platforms, where EHRs and PDMPs can communicate under an interoperable 
platform. Unless Congress intervenes, this will create a disconnect 
between IHS and other agencies.
    NIHB supports E-prescribing, especially given its potential to 
reduce the spread of prescription opioid abuse, and encourages IHS to 
utilize it where practicable. However, most IHS and Tribally run health 
facilities are in rural areas where limited broadband make widespread 
adoption of E-prescribing unrealistic without Congressional 
intervention. To ensure that E-prescribing is a viable tool in the 
Indian health system, Congress must first continue, and expand, its 
investment in rural broadband to incorporate rural Tribal communities.
    Telehealth is a much-needed and successful innovation in rural 
areas. For example, the Eastern Aleutian Tribes, a healthcare provision 
organization serving 8 Alaska Native communities, has begun using 
telemedicine to diagnose conditions, prescribe treatment, and conduct 
follow up examinations. Many Tribes in remote Alaska communities, often 
disconnected by the road system and only accessible by plane or boat, 
do not have access to medical providers regularly and have come to rely 
on telemedicine to fill a gap in healthcare provision. However, this 
was only accomplished through sustained investment in rural broadband.
    Greater network bandwidth and broadband access is a critical need, 
demonstrated by a 2018 FCC report that found as many as 35 percent of 
individuals living in Tribal lands lack broadband access, while in some 
Tribal communities as much as 80 percent lack broadband access.
    To ensure Tribes are able to utilize Health IT to the greatest 
extent possible in confronting Indian Country's opioid epidemic, 
Congress should:

   Provide adequate support, funding, and oversight as IHS 
        moves away from the RPMS system toward a more integrated 
        platform that can better interact with E-prescriptions and 
        EHRs.

   Provide oversite to IHS to implement a Tribally-specific 
        PDMP system than can interact with state PDMPs.

   Review and support IHS's list of Tribal broadband projects, 
        and also include direct funding to Tribes to improve their 
        broadband and telehealth infrastructure.

   Mandate State-Tribal consultation on changes to state PDMPs.

   Incentivize providers to adopt E-prescription as a way to 
        reduce the needless and harmful spread of opioids. Should 
        Congress provide a grant program to that end, a set aside of 3-
        5 percent would be appropriate to ensure Tribes are not at a 
        disadvantage in tapping into those funds.

   Eliminate the requirement for Tribal providers to obtain the 
        Secretary's authorization to be designated as an Internet 
        Eligible Controlled Substances Provider, as it imposes an undue 
        burden that delays the delivery of much-needed treatment 
        resources, especially given that no other providers are subject 
        to this requirement. \6\
---------------------------------------------------------------------------
    \6\ (21. U.S.C. 829) Section 311(g)(2)
---------------------------------------------------------------------------
Conclusion
    Again, NIHB would like to thank the Committee for holding this 
hearing and soliciting input from a variety of stakeholders. Indian 
Country has seen over the past several years that opioids do not face 
barriers in entering Tribal communities. To truly address this problem, 
Congress must ensure that Tribes receive direct funding, and are 
included any type of national-level opioid legislation moving forward.
                                 ______
                                 
                   Supplemental Testimony of the NIHB
    Chairman Hoeven, Vice Chairman Udall, on behalf of the National 
Indian Health Board (NIHB) and the 573 American Indian and Alaska 
Native (AI/AN) Tribes we serve, I would like to thank you for holding 
the hearing, ``Opioids in Indian Country: Beyond the Crisis to Healing 
the Community,'' and for NIHB to offer testimony at the hearing.
    NIHB is a 501(c)3, not for profit, national Tribal organization 
founded by the Tribes in 1972 to serve as the unified, national voice 
for American Indian and Alaska Native health in the policy-making 
arena. Since 1972, NIHB has advised the U.S. Congress, Indian Health 
Service (IHS), and other federal agencies about health disparities and 
service issues experienced in Indian Country.
    The current opioid epidemic represents one of the most pressing 
public health crises affecting Tribal communities. While this epidemic 
is affecting many communities throughout America, it has 
disproportionately impacted Tribes and has further strained the limited 
public health and healthcare resources available to Tribes. The Federal 
Government must take concrete action to ensure Indian Country has the 
tools it needs to address opioid abuse and heal Tribal communities.
    While each witness brought a wealth of knowledge and experience to 
the committee, NIHB wishes to ensure the Senators on the committee have 
all of the information they need to make informed decisions on how best 
to support Tribes and Tribal health programs in confronting the opioid 
crisis.
    The 21st Century CURES Act included two years of funding to states 
to develop State Targeted Responses. As CAPT Jones from the Substance 
Abuse and Mental Health Services Administration (SAMHSA) mentioned in 
his testimony, of the 36 states with Tribes, only 12 have incorporated 
Tribes into their State Targeted Responses or identified American 
Indians/Alaska Natives (AI/ANs) as a specific population under the 
state plan. The funding is not reaching Tribal communities. NIHB is 
supportive of the provisions in S. 2270, the Mitigating METH Act, and 
S. 2437, the Opioid Response and Enhancement Act, which would open 
CURES Act funding to Tribes directly. These needed revenue streams 
would allow all Tribes to replicate success seen in several Tribal 
programs across America. In her questioning at the hearing, Senator 
Cortez Masto asked witnesses from federal agencies if direct Tribal-
specific funding streams were needed to combat the opioids crisis. Had 
that question been asked of the Tribal witnesses, the committee would 
have heard an unambiguous ``Yes.''
    There is an inherent structural problem with the system of Tribes 
through states to access federal funding. There is no established legal 
relationship between the states Tribes. States are not compelled to 
have consultation with the Tribes, or even listen to their needs. There 
is no treaty, constitutional relationship or law that sets forth 
Tribal-state collaboration. Using this type of construct essentially 
just cuts Tribes out of the system all together. Forcing Tribes to go 
to states diminishes the federal trust Tribes are not subservient to 
the state governments, but are recognized as sovereign nations within 
the federal system. In practice, this means, that few tribes actually 
see this funding, and if they do it is usually insufficient to meet 
need.
    Senator Tester similarly asked federal agency witnesses if some of 
the $10 billion for opioids included in the President's Fiscal Year 
2019 Budget Request should be set aside for Tribes. Again, the answer 
from Tribal witnesses would have been, ``Yes.''
    We were also pleased to see that the Consolidated Appropriations 
Act of 2018 contained a $50 million set-aside for Tribes in the State 
Targeted Response (STR) to opioid grants as well as a $5 million set 
aside for medication assisted treatment for Tribal communities. This 
funding is a critical first step in ensuring that Indian Country has 
access to the resources it needs to combat this deadly epidemic. Thank 
you for the advocacy that you and other committee members undertook to 
make this possible. We look forward to working with you to build on 
these gains in the coming year so that there is long-term sustained 
funding going to fight substance abuse among Tribal Nations.
    Senator Smith asked CAPT Jones how SAMHSA and other agencies were 
looking at intergenerational addiction, especially as relates to 
addicted mothers and newborns. He answered correctly that the agency is 
looking at the issue holistically and trying to break down siloes. 
However, it is crucial to note that neither program he cited, the 
residential program with 19 grantees, nor the outpatient program 
authorized by the Comprehensive Addiction and Recovery Act (P.L. 114-
198), are open to Tribes. Because Congress did not list Tribes, Tribal 
organizations, and Urban Indian Health Centers as eligible entities, 
the funding for the grant programs does not reach Tribal communities 
and should not be cited as a success story in Indian Country.
    Furthermore, even if Congress authorized funding from those 
programs to go directly to Tribes, the competitive grant program is 
unfair to smaller Tribes which may lack capacity but which do not lack 
need. As Senator Murkowski said, the current competitive grant program 
``sets Tribes up to compete with other Tribes.'' We could not agree 
more. Instead, Congress should work to empower IHS and Tribal health 
programs to implement successful, community-based, culturally competent 
care geared toward helping Tribal communities confront and heal from 
the opioid epidemic.
    While evidence-based care has many advantages in opioids treatment, 
Congress dictating a one-size-fits-all approach to this challenge will 
not work in Indian Country. Tribes often utilize traditional, 
culturally-based and promising practices as well as evidence-based 
practices. Culturally-based programming helps Tribes tailor initiatives 
to the specific needs of their community, while also honoring Tribal 
sovereignty and the right to self-determination. Evidence-based 
practices that do not integrate traditional Tribal practices are not 
always as effective at improving health outcomes as programs that do. 
Many Tribal public health programs--including the well-known and highly 
successful Special Diabetes Program for Indians (SDPI)--combine Tribal 
best practices with evidence-based practices. This model has worked and 
should be replicated to confront opioid addiction, with support and 
oversight from Congress.
    We hope this information clarifies some of the questions raised at 
the hearing. NIHB thanks you and the Senate Committee on Indian Affairs 
for holding the hearing and using Congress's authority to support 
Indian Country as our communities confront and heal from the opioid 
epidemic.

    Senator Udall. Thank you, Mr. Moose. Thank you, Ms. George 
for your testimony. Please be assured there will be a lot of 
questions. The staffs of all the Senators who are here and will 
be following very closely your testimony. We are really happy 
to have you here.
    Senator Daines, we are happy to see you back. Please 
proceed with your questions.

                STATEMENT OF HON. STEVE DAINES, 
                   U.S. SENATOR FROM MONTANA

    Senator Daines. Thank you, Ranking Member Udall. We have 
votes going on right now, as you understand. There is a lot of 
interest and they will be coming back from the Floor soon.
    I hail from the State of Montana. Opioid abuse is an issue 
in my home State. Meth use is increasingly a crisis. We know it 
is even more concentrated among Montana's Indian tribes. That 
is why I have introduced the Mitigating METH Epidemic and 
Promoting Tribal Health Act also known as the Mitigating METH 
Act.
    As a matter of this government-to-government relationship 
between the United States and tribes, this legislation would 
make tribes, like States, directly eligible for funding that is 
authorized in the 21st Century CURES Act to combat the opioid 
crisis. Additionally, it would give States and tribes the 
flexibility to address the substance abuse and disorders most 
prevalent among their constituencies, which in Montana, would 
include meth. This legislation enjoys the support of eight co-
sponsors from both sides of the aisle, including members of 
this Committee and is the only bipartisan legislation in the 
U.S. Senate that makes tribes directly eligible for this 
funding.
    Mr. Moose, I know you and Ms. George both discussed the 
benefits of my bill in your testimony. Could you expand on why 
you see it as important that the bill make tribes directly 
eligible for Federal funds to combat substance abuse?
    Mr. Moose. Thank you for the question.
    I think probably the most important thing we talk about 
among tribal program administrators and tribal providers is 
getting direct funding. Tribal leaders throughout Minnesota, 
Wisconsin and Michigan are always looking at direct funding for 
their tribal programs. It helps us enhance the things we 
currently do well and helps us target the things we need 
funding to expand or create access for. Anything that will 
provide sustainable funding for our tribal programs, something 
we can change or redirect based on how we see the need in our 
communities is critical to our addressing this issue.
    Senator Daines. Thank you, Mr. Moose.
    Ms. George, I have the same question to you. Why do you see 
my bill, the Mitigating METH Act, as so important and 
beneficial?
    Ms. George. I think there are a couple areas where we saw 
significant support for us. Really, it reflects the government-
to-government relationship with the tribe, allowing direct 
access and also recognizing grant funding limits creates 
competition for resources not just between tribes but even 
other local agencies we work with.
    We are often forced to choose between two or more very 
important issues. We sometimes do not get where we need to get.
    Senator Daines. I think one of the underlying foundational 
principles is really tribal sovereignty and this government-to-
government relationship and how the U.S. Government should be 
viewing the direct access for these funds to address the crisis 
we are seeing right now with meth and opioid abuse.
    I agree with both of you and I appreciate your support. 
These are the very reasons why I have authored this crucial, I 
think very timely, piece of legislation.
    I would like to turn to a discussion of CARA 2.0. I applaud 
Senator Portman for continuing to lead the charge on this 
legislation to combat the drug overdose crisis and would like 
to explore ways to ensure tribes are appropriately included in 
this effort.
    Mr. Moose, what change would you like to see in CARA 2.0 to 
help address the drug abuse crisis in your community? I would 
be especially interested in your perspective on needed changes 
to the section which provides funding to States for addiction 
treatment targeted toward pregnant and post partum moms.
    Mr. Moose. We recommend allowing tribes to access the 
program outlined in Section 6 which establishes funding for 
regional technical assistance centers to focus on addiction 
recovery and naloxone training and dissemination. We recommend 
in Section 7 allowing States to increase the three-day limit on 
first-time opiate prescriptions found in Section 3 of the bill, 
if the State passes a law or implements statewide regulations, 
tribal law should have the same authority.
    Tribes should also have access to Section 10 which provides 
funding to States for addiction treatment programs targeted 
towards pregnant or postpartum women. Finally, we recommend 
adding language to Section 13 that would require States to 
consult with tribes on implementation of their prescription 
drug monitoring program.
    Senator Daines. Thank you. That input will be relayed to 
Senator Portman who is a great colleague and leader here in the 
Senate. I appreciate that testimony.
    I want to thank you for the input. I want to continue to 
work with you, the NIHB and my colleagues to see how we might 
be able to work some of these changes into that legislation. 
Indian tribes cannot afford to be left out. They cannot be left 
out of these discussions. I remain committed to seeing that 
their needs are addressed.
    Thank you.
    Senator Udall. Thank you so much, Senator Daines. I really 
appreciate your questions.
    Early on, I think this is mentioned in your testimony, 
there were issues about the cuts that were going to take place. 
I think you all are familiar with those. These are program 
areas, many of them when you talk about programs and needing 
services, these are the same program areas where President 
Trump has Indian line items where he has proposed cutting in 
the 2019 budget request.
    I want to ask you both what impact would cuts to Federal 
funding for tribal housing, human services and public safety 
programs have on your tribe's ability to continue its efforts 
to combat the opioid crisis?
    Mr. Moose. Thank you for the question, Senator.
    Funding for social safety net programs is very much linked 
with healthcare programs. When individuals do not have access 
to social safety net services, the effect of substance abuse 
disorder will be exacerbated because patients will not have the 
comprehensive services to support them in recovery. This 
includes protections of SNAP, Medicaid, TANF, and the Indian 
Housing Block Grant.
    For instance, if the proposed cuts to the Medicaid Program 
were to be enacted, it would place additional burden because 
there would be less resources available for medical treatment. 
Further, many of these programs are effective in preventing 
substance use altogether.
    Research has shown access to healthy and traditional foods, 
stable housing and other social programs reduces substance use 
later in life. This is a very important aspect of the public 
health approach. Comprehensive care, the kind that promotes the 
whole health of a person, is the most effective in improving 
the health outcomes related to substance use and opioid abuse 
disorder.
    Senator Udall. Ms. George?
    Ms. George. I fully support the comments Mr. Moose just 
made. In addition to that, any cuts to tribal programs hamper 
the tribe's ability to sufficiently provide services to its 
members, run our governmental programs and initiate new 
projects.
    Senator Udall. Aside from more direct tribal funding for 
behavioral health programs at HHS, for what other departments 
should we request more dedicated resources for tribal opioid 
and substance abuse efforts?
    Mr. Moose. Would you repeat the question?
    Senator Udall. Aside from more direct tribal funding for 
behavioral health programs at HHS, for what other departments 
should we, the Committee looking into this, request more 
dedicated resources for tribal opioid and substance abuse 
efforts?
    Mr. Moose. One of the areas we have talked about within our 
system of care at Fond du Lac is prevention funding such as 
public health, infrastructure support and support for youth 
programs and youth prevention programs. One of the initiatives 
we are looking at starting is a children's initiative. Having 
support with regard to these types of prevention programs is 
critical in our heading off the issue of opioid and substance 
abuse and healthcare disparities in general. I think anything 
that would fund prevention, public health infrastructure, 
surveillance and those types of issues would be important for 
us.
    Senator Udall. Ms. George, do you want to add to that?
    Ms. George. For us, increased funding for tribal courts and 
law enforcement is important. Our tribal court also operates a 
reentry program because once we get help for these people, they 
also need to be reentered to their community, gain skills to 
maintain employment and be successful, thriving members again 
in our community. Those are areas I think we would identify as 
well.
    Senator Udall. Thank you very much.
    One issue I have focused on throughout my entire time in 
Congress is Federal information technology reform. Just last 
year, I worked with another member of this Committee, Senator 
Moran, to get our bill, the Modernizing Government Technology 
Act, passed as part of another bill. The opioid crisis is just 
one more example of how outdated information technology can 
slowdown efforts to gather real-time data, in this case, 
prescription monitoring, people getting prescriptions from 
multiple areas.
    You both testified about the inadequacy of RPMS and PDMP 
systems coordination putting limitations on tribes' trying to 
look at opioid prescription patterns. Do you believe that 
information technology challenges at the Indian Health Service 
led to shortcomings in implementation of a robust PDMP system?
    Mr. Moose. Yes, I do. I was the Commissioner of Health and 
Human Services for the Mille Lacs Band. We utilized the RPMS 
system. Unfortunately, the RPMS system had challenges with 
regards to its being robust. I know that within our behavioral 
health program, in 2014, we started looking at implementing the 
Behavioral Health Electronic Health Record. That was in 2014, 
mind you.
    We have many programs concerning the program that I am at 
right now. The Fond du Lac Band of Lake Superior Chippewa 
purchased an off-the-shelf electronic health record system. We 
were far more advanced than we are at Mille Lacs. I definitely 
would support that.
    Senator Udall. Thank you, Mr. Moose.
    Ms. George, did you have anything else to add? I have 
another question focusing on you, but go ahead, please.
    Ms. George. I just wanted to add that our tribe has had to 
spend an enormous amount of money creating custom templates for 
our information system. It is still not as adequate as we would 
like. That was a big burden to us.
    Senator Udall. Ms. George, has the IHS, or any other 
Federal agency, offered support to help your tribe, or any 
other tribe that operates its own health facilities, coordinate 
with State-run PDMPs?
    Ms. George. No, they have not.
    Senator Udall. Ms. George and Mr. Moose, what advice would 
you give the Administration and this Committee when evaluating 
replacements for RPMS systems, especially in light of the need 
to improve opioid prescription monitoring?
    Mr. Moose. We would suggest tribal consultation, working 
with tribes to identify the systems, creating a work group that 
looks and combs the landscape for what is best for Indian 
Country, along with hearing that input from specific Indian 
Country practitioners, tribes and tribal units for health 
service systems.
    Senator Udall. Do you have anything else to add to that?
    Ms. George. I would just like to add that interoperability, 
reporting and population health are also important aspects.
    Senator Udall. Thank you very much.
    Ms. George, I am impressed by your testimony describing 
Port Gamble's experience combating the opioid crisis through 
State and local partnerships. These partnerships seem to be 
working and could be a model for other tribes across the 
Country.
    What advice would you give to other tribes considering 
partnering with their State and local counterparts? Do you have 
any advice for those whose State or local governments are not 
as willing as that of Washington to engage in similar 
partnerships?
    Ms. George. I am not sure that I have any advice to other. 
I would like to add that I do not believe there is a community, 
county or State that this epidemic is not touching right now. I 
think tribes would be surprised how quickly our local and State 
governments come to the table because none of us know how to 
handle this epidemic.
    Senator Udall. Mr. Moose, based on your experience in 
developing cross-governmental partnerships, could Congress help 
encourage more fruitful partnerships by providing tribes with 
their own direct funding to leverage and bring to the table 
these other partners?
    Mr. Moose. Yes, Senator. I believe it would be important to 
have tribes. One thing I keep thinking about is the discussion 
in our region with regards to some of the State-targeted 
response funding that a few of us put together specifically to 
address the opioid issue.
    We were trying to change our services to fit those grants. 
When I say services, I look at our traditional and cultural 
practices. Oftentimes when we have to go with that approach, it 
really takes us away from some of the internal infrastructure 
or development we have to deal with in some of our cultural 
practices or traditional approaches. Oftentimes, it takes up 
time and space when we should be concentrating on those issues, 
trying to fit our programs to the grant funding or other 
funding that is competitive, along with administrative time of 
managing those grants.
    Senator Udall. I know I have asked a number of questions 
and you also heard from a number of Committee members with 
questions. Is there anything off the top of your head right now 
that you wanted to say in conclusion?
    Mr. Moose. One of the areas we were looking at as part of 
the information I just provided is we have a young practitioner 
in our tribal clinic. She is looking at doing her dissertation. 
In that dissertation, she came across something that was really 
interesting to her as a non-Indian practitioner.
    Several months ago, we started traditional healing services 
within our clinic. We gave access to a traditional healer we 
had hired within our clinic system to patients. This mental 
health practitioner was able to send her clients to this 
traditional healer. She looked at the clients going through our 
Core 12 program, our comprehensive opioid response program that 
utilizes suboxone as part of its treatment modality along with 
traditional healer services.
    One of the things she recognized, which became part of a 
passion that she wanted to do her dissertation on, was the 
impact those traditional healer services had on those clients. 
She saw incredible improvement in their depression rates, their 
anxiety and the overall treatment outcome for these clients 
which were incredibly important to us.
    Our course our tribe is definitely supporting her in 
identifying this as a piece within her research and her 
dissertation. I think it really came to us, and my comments 
before, that these are the services tribes in Indian Country 
need to reinvest in, our traditional and cultural practices as 
part of our treatment modalities.
    When we are trying to fit our services into a square peg, 
oftentimes we lose the ability to make that type of impact. If 
we could concentrate on those things within our communities 
that really enhance treatment services or gets a patient to 
accept that type of modality, I think it is really good for 
Indian Country.
    Senator Udall. Thank you.
    Ms. George. I would just like to again extend the 
invitation to the Committee members and the agency directors to 
come and visit the tribes, see what we are doing and see what 
is working for us to get a better understanding of where our 
needs really lie.
    Senator Udall. Thank you for that invitation. You have the 
Rear Admiral in the audience, so he certainly heard that. I 
will convey that information to all the members of the 
Committee. I would love to visit you both in your respective 
States.
    Today, you have given very enlightening testimony and 
answers for the Committee. We really look forward to digesting 
all of this and trying to work on getting the legislation just 
right so we can get resources into Indian Country. As I 
mentioned earlier, you may get additional questions from 
Committee members that will be submitted to you in writing 
after today's hearing.
    If there are no more questions today, which looking around, 
I do not think there are, members may also submit follow-up 
written questions for the record. The hearing record will be 
open for two weeks.
    Once again, I want to thank these witnesses for their 
testimony here today.
    The hearing is adjourned.
    [Whereupon, at 4:55 p.m., the Committee was adjourned.]

                            A P P E N D I X

 Prepared Statement of Esther Lucero, CEO, Seattle Indian Health Board 

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
 Prepared Statement of the National Congress of American Indians (NCAI)
    On behalf of the National Congress of American Indians (NCAI), the 
oldest, largest, and most representative American Indian and Alaska 
Native organization serving the broad interests of tribal governments 
and communities, we hereby submit the following testimony for the 
record of the Senate Committee on Indian Affairs Oversight Hearing on 
``Opioids in Indian Country: Beyond the Crisis to Healing the 
Community.''
Impact of Opioid Epidemic on Indian Country
    While the opioid crisis is plaguing communities across the country, 
studies indicate that American Indians and Alaska Natives (AI/ANs) are 
impacted at a higher rate than other groups. According to the Centers 
for Disease Control and Prevention (CDC), AI/ANs had the highest drug 
overdose death rates compared to all other races in 2015. Further, the 
same CDC study found that the drug overdose death rates for AI/ANs in 
nonmetropolitan areas increased by more than 500 percent between 1999 
and 2015. Additional studies indicated that pregnant AI/AN women are 
nearly 9 times more likely than others to be diagnosed with opioid 
dependency or abuse, and one in 10 AI/AN youths age 12 or older used 
prescription opioids for nonmedical purposes, which is double the rate 
for Caucasian youth. These statistics illuminate the critical need for 
a comprehensive strategy to curb the opioid epidemic in tribal 
communities.
NCAI's Efforts and Recommendations
    NCAI has been addressing this crisis in various ways, by utilizing 
NCAI's Policy Research Center to conduct related research, convening 
meetings of NCAI's Substance Abuse Prevention Task Force, developing 
policy objectives during its resolution process, collaborating with the 
Substance Abuse and Mental Health Services Administration (SAMHSA) on 
developing the Tribal Behavioral Health Agenda, holding a roundtable 
during Executive Council Winter Session, hosting a webinar series on 
the crisis, and congressional advocacy. Based on the findings and 
feedback from these undertakings, NCAI would like to provide the Senate 
Committee on Indian Affairs with the following recommendations:
Direct Funding to Indian Country
    Tribal governments need parity with state and local governments. 
When Indian tribes have to go through states in order to access federal 
funding, the result is often unfavorable. Instead, direct federal 
funding to address the opioid crisis should be made available to Indian 
tribes. Currently, tribes are forced to petition states for access to 
opioid-related grants stemming from the 21st Century Cures Act (Cures 
Act).
    Several pending bills would amend the Cures Act to include Indian 
tribes and tribal organizations alongside states as eligible entities. 
These include S. 2270, the Mitigating METH Act (Daines, MT); H.R. 5140, 
the Tribal Addiction and Recovery Act (Mullin, OK); and S. 2437, the 
Opioid Response Enhancement Act (Baldwin, WI). NCAI strongly supports 
the goals of these bills.
Tribal Representation on Federal Task Forces
    Tribal representatives need a seat at the table in order to ensure 
the unique challenges facing Indian tribes are considered. While Indian 
Country was disappointed about the lack of tribal representation on the 
President's Commission on Combatting Drug Addiction and the Opioid 
Crisis, going forward it is crucial that tribal representatives have 
the opportunity to serve on federal task forces or commissions that are 
seeking to address the opioid epidemic.
    In September 2017, NCAI, along with the National Indian Health 
Board, sent a letter to former Secretary Tom Price asking him to 
include a tribal representative on the Department of Health and Human 
Services Pain Management Best Practices Inter-Agency Task Force (Task 
Force). NCAI remains hopeful that a tribal representative will be 
selected to serve on the Task Force.
    In addition, NCAI recommends that the Indian Health Service's 
National Committee on Heroin, Opioid, and Pain Efforts (HOPE) include 
tribal representation. While the committee is comprised of IHS subject 
matter experts, it is important to collaborate with tribal leaders in 
order to fulfill the HOPE Committee's purpose--promoting appropriate 
and effective pain management, reducing overdose deaths from heroin and 
prescription opioid misuse, and improving access to culturally 
appropriate treatment.
Collaboration and Coordination among Agencies and Tribes
    In 2016, NCAI passed Resolution #PHX-16-027, which calls upon all 
federal agencies to increase resources in order to advance education, 
prevention, treatment services, and public safety programs designed to 
address heroin and opioid abuse and addiction within Indian Country. As 
Congress makes more resources available, effective collaboration and 
coordination among federal agencies is needed in order to pool together 
the resources that are available to tribal communities. Further, Indian 
tribes needs flexibility in using various funding sources to develop 
culturally appropriate programs to address the crisis.
    NCAI agrees with Senator Barrasso's statement at the hearing: 
``Successful implementation of programs requires cooperation and 
coordination from all sides--Interior, Justice, Health and Human 
Services, and the tribes themselves.'' A memorandum of understanding 
between these agencies may be a valuable tool to help achieve this 
objective. NCAI is equipped to help ensure that Indian Country is made 
aware of the resources available throughout the Federal Government, and 
able to bring agencies together at various NCAI forums.
    There are two other important aspects to federal agency cooperation 
with tribes. First, tribal governments have increasing law enforcement 
and public safety needs as they work to address the crisis with opioids 
and other forms of substance abuse. Interagency Task Forces are a 
proven method of leveraging available resources by increasing 
cooperation among tribal, federal and state law enforcement, and we 
urge further consultation on using the Task Force model to address the 
substance abuse crisis. In addition, tribal courts and correctional 
systems need additional resources for treatment that can serve as 
alternatives to incarceration.
    Second, the conduct of large pharmaceutical companies has been a 
focal point in opioid-related litigation. Numerous state, local and 
tribal governments have filed lawsuits against opioid manufacturers and 
distributors in various state and federal courts, alleging that they 
helped create the crisis by improperly marketing the drugs. Tribes are 
seeking medical costs, social services costs, child welfare costs, and 
public safety costs. More importantly, tribes are seeking injunctive 
relief to reduce the flow of unregulated opioids. U.S. District Judge 
Dan Polster of the Northern District of Ohio is overseeing more than 
200 of the opioid cases filed in federal court, in multidistrict 
litigation under 28 U.S.C. 1407. The Department of Justice has filed a 
statement of interest on behalf of the Federal Government. There is an 
opportunity for the Committee to urge the Department to coordinate and 
consult with tribal governments, and ensure that tribal interests are 
properly considered in the nationwide multi-district litigation.
Culturally Based Solutions
    For Indian Country, factors related to historical and 
intergenerational trauma will have to be taken into account when 
addressing this crisis. The high rates of depression, suicide, and 
substance abuse in Indian Country are often deeply rooted underlying 
issues. The National Tribal Behavioral Health Agenda (TBHA), which is 
the result of a collaborative effort between Indian Country and its 
federal partners, serves as a valuable guide in the efforts to address 
the opioid crisis in Indian Country. A major tenant of the TBHA is the 
recognition and support of ``tribal efforts to incorporate their 
respective culture wisdom and traditional practices [sic] in programs 
and services that contribute to improved well-being.''
    Legislation such as the Native Health Access Improvement Act (H.R. 
3704 (Pallone, NJ) and S. 2545 (Smith, MN)) is a step in the right 
direction. These bills would establish a Special Behavioral Health 
Program for Indians (SBHPI) grant program for the prevention and 
treatment of mental health and substance abuse disorders. The proposed 
SBHPI program is modeled after the Special Diabetes Program for Indians 
(SDPI), which has been highly successful, in part, due to its allowance 
for the incorporation of culture and flexibility in utilizing the 
funding.
Data Collection
    In March 2018, NCAI's Policy Research Center (PRC) published a 
brief titled, ``The Opioid Epidemic: Definitions, Data, Solutions.'' 
The PRC brief highlights the need for more reliable data related to the 
opioid epidemic. It finds that the data on death rates are often 
underestimated in AI/ANs due to misidentification on death certificates 
and that national data does not reveal potential regional/local 
differences in impact. While some tribes indicate that opioids are a 
huge problem in their communities, others point to greater problems 
with other abused substances. This underscores the need to understand 
local and regional trends to inform action. As Chairman Hoeven 
indicated at the hearing, ``[w]ithout accurate data, Congress, the 
Administration and tribes are limited in their ability to allocate 
resources to the area of greatest need.'' In addition, it is important 
for agencies to establish benchmarks for success.
Conclusion
    NCAI applauds the Committee for holding the hearing on this urgent 
matter and appreciates the opportunity to submit this testimony for the 
hearing record. Addressing this epidemic will require a multifaceted, 
collaborative approach across all levels of government.
                                 ______
                                 
   Prepared Statement of Hon. Jeromy Sullivan, Chairman, Port Gamble 
                            S'Klallam Tribe
    Dear Chairman Hoeven:
    On behalf of the Port Gamble S'Klallam Tribe (the ``PGST''), thank 
you for inviting us to testify on March 14, 2018 at the Senate 
Committee on Indian Affairs (the ``Committee'') hearing titled 
``Opioids in Indian Country: Beyond the Crisis to Healing the 
Community.'' We would also like to thank Senator Cantwell for her very 
kind introduction of our witness, Jolene George, a member of the PGST 
and our Behavioral Health Director.
    We were pleased to share our experiences with the Committee and are 
proud of the steps we have taken towards formulating and implementing a 
multi-faceted, comprehensive approach to respond to the opioid epidemic 
in our community. It is encouraging to hear the Committee member's 
commitment to bipartisan and cross-committee efforts. We are hopeful 
that this dedication will result in the adoption of legislation 
specifically targeting the opioid crisis devastating Indian Country. As 
the Committee continues its endeavors. the PGST is delighted to 
continue assisting it in whatever way we can.
    One lesson that we have learned is that incorporation of 
traditional healing practices, cultural beliefs regarding approaches to 
treatment, and differences in interpersonal communication contributes 
significantly to the quality of care Native people need. It is also key 
for helping our members escape the destructive cycle of substance 
abuse. For over 20 years, the PGST has been actively involved in 
directly providing culturally appropriate health care services to our 
tribal members and Native community members living on the Port Gamble 
S'Klallam Reservation. Since joining the Tribal Self-Governance 
Project. a consortium of self-governing tribes, in 1990, we have funded 
our health care services through a compact with the Indian Health 
Service under the Indian Self-Determination and Education Assistance 
Act. We operate and manage our entire health system on our Reservation, 
which includes primary care, dental, mental health, and substance abuse 
services.
    As Ms. George testified, the heart of our opioid response is THOR: 
Tribal Healing Opioid Response. The Tribe convened THOR out of 
necessity to address the intense and widespread impact of the crisis on 
our community. The main goals of THOR are: (1) preventing opioid misuse 
and abuse; (2) expanding access to opioid use disorder treatment; and 
(3) preventing deaths from overdose. Every department across the PGST 
is responsible for implementing strategies to achieve these goals. \1\ 
Additionally, we coordinate with the State of Washington, Jefferson and 
Kitsap Counties, and other nearby tribes to fight opioid addiction and 
treat those affected.
---------------------------------------------------------------------------
    \1\ Through THOR, each of the Tribe's departments have specific 
responsibilities for reaching the THOR goals. See Tribal Healing Opioid 
Response Program, https://www.nihb.org/docs/12032017/
Tuesday%20Sessions/THOR%20Presentation.pdf (last accessed March 15, 
2018).
---------------------------------------------------------------------------
Support for Specific Legislation
    We have shown leadership by implementing an aggressive and 
comprehensive approach for responding to the opioid epidemic in our 
community. However, as testified, we still need the help of this 
Committee, Congress, and Federal agencies to continue our effective 
efforts to respond to the opioid crisis. We support several pieces of 
legislation introduced in the Senate with the hope that Congress will 
enact them soon and aid our efforts in combating the crisis.
    S. 2440, the Comprehensive Addiction, Recovery, Education and 
Safety (CARES) Act. This bill introduced by Committee Member Senator 
Cantwell--our Senator--would provide law enforcement with more tools to 
hold drug companies accountable for ensuring that their drugs do not 
enter the illicit drug market. Specifically, the bill increases civil 
and criminal penalties on companies that fail to keep proper records or 
report suspicious opioid distribution practices. Additionally, the bill 
authorizes funding for the Drug Enforcement Agency (DEA) to investigate 
suspect drug companies and drug trafficking organizations. The PGST 
supports S. 2440 because it aligns with our goals in our federal 
lawsuit to hold drug companies accountable for the destruction caused 
by the opioid crisis that stems from their failure to track orders and 
for creating an illicit market for their drugs.
    S. 2270, the Mitigating the Methamphetamine Epidemic and Promoting 
Tribal Health Act (the ``Mitigating METH Act''). This bill, introduced 
by Committee Member Senator Daines, would make tribes and tribal 
organizations eligible for direct funding (no set-aside) under the 21st 
Century Cures Act, which provides funding for prevention and response 
to opioids, or other substances--such as methamphetamines--if they are 
having a substantial impact on the state or tribe. The bill would 
increase the allocation of $500 million to $525 million. The PGST 
supports S. 2270 because it gives us access to direct funding and 
important resources for combatting the crisis, in recognition of the 
government-to-government relationship we have with the Federal 
Government.
    S. 2437, the Opioid Response Enhancement Act. This bill, introduced 
by Senator Baldwin, would also make tribes and tribal organizations 
eligible for funding under the 21st Century Cures Act but through a 10 
percent tribal set-aside. Like S. 2270, tribes and states could use 
this funding for prevention and response to other substances 
threatening public health--such as methamphetamines. Additionally, the 
bill requires the Substance Abuse and Mental Health Services 
Administration (SAMHSA) to provide technical assistance to both states 
and tribes for grant applications, formulating outreach and support 
efforts, and collecting data. The PGST supports S. 2437 because it has 
targeted funding for Indian Country, where Native families and 
communities feel the disparate impacts of the crisis hardest.
    S. 2545, the Native Behavioral Health Access Improvement Act of 
2018. Recently introduced by Committee Member Senator Smith, this bill 
aims to help combat the opioid epidemic by creating the Special 
Behavioral Health Program for Indians (SBHPI): a grant program modeled 
after the Special Diabetes Program for Indians (SDPI) and administered 
by the Indian Health Service (IHS), in coordination with SAMHSA. The 
SBHPI would provide IHS, tribes and tribal organizations, and urban 
Indian health programs with access to much-needed resources for 
addressing mental health needs and substance use disorders, 
specifically providing $150 million in annual mandatory funding from FY 
2018 to FY 2022. The grants would give tribes needed flexibility to 
provide tribally driven, culturally appropriate behavioral health care 
to meet the specific needs of their communities. The bill also provides 
that IHS, in coordination with SAHMSA, would create a technical 
assistance center responsible for developing grant-reporting standards 
in consultation with tribal grantees.
    The PGST has operated a robust SDPI program for many years and is 
confident that its use as a model for the SBHPI will be a success. 
However, we caution against providing tribes resources through another 
program funded in the form of grants because competitive funding pits 
struggling tribes and local governments against each other for access 
to limited resources when we should be working together. One of the 
reasons why our THOR program is so effective is that the PGST has good 
relationships with State, County, and regional groups to coordinate on 
response strategies. The PGST does support S. 2545, but suggests, as an 
alternative to grant funding, that self-governance tribes--such as the 
PGST--be able to receive funding through their self-governance 
compacts.
Additional Information in Response to Committee Member Questions
    During the Committee's March 14 Opioid Hearing, Committee Members 
were actively engaged in questioning the witnesses and we wanted to 
follow-up on several of those questions to make sure the Committee has 
ample information about our specific needs and those of Indian Country.
    In response to Vice-Chairman Udall's questions about the impacts of 
funding cuts on the PGST's ability to respond to the opioid crisis and 
what departments--other than behavioral health--should have direct 
funding, we would answer that any reduction in funding harms our 
ability to respond and every department that the PGST operates needs 
direct funding for its programs and services. At a government level, 
our Health, Behavioral Health, Children & Family Services, and Housing 
Departments, as well as our courts, law enforcement, and 
administration, all have a role to play in responding to this crisis. 
It affects all of our members and Tribal agencies. Adequate direct 
funding means reliable resources and flexibility for the PGST to 
continue implementing our culturally appropriate, multi-faceted, 
comprehensive approach to abating the opioid epidemic sweeping the 
community. Additionally, adequate direct funding allows us to plan long 
term for infrastructure development, program enrichment, and service 
enhancements necessary for the well-being of our members and local 
community.
    Thank you for the opportunity to speak on behalf of the PGST 
regarding the opioid epidemic. We look forward to further opportunities 
for discussion and to actively working with the Committee to tackle the 
opioid epidemic.
    We hope that you and the entire Committee will accept our 
invitation to come visit the Port Gamble SiKlallam Reservation to see 
our work--and significant needs--to respond to the opioid crisis.
                                 ______
                                 
        Prepared Statement of the Southcentral Foundation (SCF)
    Southcentral Foundation (SCF) submits written testimony to the 
Senate Committee on Indian Affairs to supplement its March 14, 2018 
hearing entitled: ``Opioids in Indian Country: Beyond the Crisis to 
Healing the Community.'' SCF is the Alaska Native tribal health 
organization designated by Cook Inlet Region, Inc. (CIRI) and eleven 
Federally-Recognized Tribes--the Aleut Community of St. Paul Island, 
Igiugig, Iliamna, Kokhanok, McGrath, Newhalen, Nikolai, Nondalton, 
Pedro Bay, Telida, and Takotna--to provide healthcare services to 
beneficiaries of the Indian Health Service (IHS) pursuant to a contract 
with United States government under the authority of the Indian Self 
Determination and Education Assistance Act (ISDEAA) P.L. 93-638.
    SCF provides a variety of medical services, including dental, 
optometry, behavioral health and substance abuse treatment to over 
65,000 Alaska Native and American Indian people. This includes 52,000 
people living in the Municipality of Anchorage, the Matanuska-Susitna 
Borough to the north, and 13,000 residents of 55 rural Alaska villages. 
Our services cover an area exceeding 100,000 square miles. SCF employs 
more than 2,300 people to administer and deliver these critical 
healthcare services.
    We appreciate Committee Chairman Hoeven calling the hearing and 
hosting a roundtable discussion last November concerning opioid misuse. 
At the March 14th oversight hearing, Senator Hoeven remarked: ``The 
roundtable highlighted how the opioid abuse epidemic is particularly 
complex in tribal communities given the lack of access to medical care, 
shortage of law enforcement and insufficient data on substance abuse.''
    We applaud the efforts by Committee Vice Chairman Udall, and other 
members of the Committee, who wrote to Senate Appropriations Committee 
leaders earlier this month to urge them to provide ``robust direct 
funding to tribal communities'' in the FY 2018 omnibus measure for 
federal programs that will aid in the prevention, treatment and 
recovery from opioid misuse ``to address the disparate impacts of the 
opioid crisis in Indian Country''.
    We also appreciate the day-to-day work that Committee members 
perform to educate your Senate colleagues about the challenges tribes 
and tribal organizations like SCF face to prevent drug abuse, 
successfully treat individuals with addiction disorders, and save the 
lives of high-risk individuals who would otherwise overdose.
    If Alaska Native healthcare providers are to stop the misuse of 
prescription opioids and illegal drugs like heroin and fentanyl, and 
begin to heal our Alaska Native customer-owners, we, together with the 
Federal Government, must attack the root causes that drive demand for 
such drugs: lack of access to appropriate care for medical conditions 
requiring pain management, trauma (domestic abuse, child abuse, 
historic trauma, etc.), mental health disorders, poverty, unemployment, 
overcrowded housing, and lack of access to prevention, treatment, and 
recovery services.
    We urge the Committee and the Congress to ensure that Alaska Native 
communities receive an appropriate share of federal funds to stop the 
illegal distribution of opioids, reduce overdoses, support educational 
awareness programs, and provide the facilities and medication-assisted 
treatment (MAT) programs that Alaska Native communities require to 
combat the opioid epidemic. It is crucial in the battle against opioid 
misuse that Indian tribes and tribal organizations, like SCF, are 
direct recipients of federally appropriated funds to fight the opioid 
crisis, consistent with the government-to-government relationship.
    We therefore strongly support legislation such as Senator Daines' 
``Mitigating METH Act,'' S. 2270, and Senator Baldwin's ``Opioid 
Response Enhancement Act,'' S. 2437. These measures would amend the 
21st Century Cures Act to include ``Indian tribes and tribal 
organizations'' and ``Tribal entities'' as direct recipients of federal 
appropriations to fight the opioid epidemic; provide tribes greater 
flexibility to prevent and treat other substances, such as 
methamphetamines; establish set-asides for tribes; and increase overall 
federal appropriations. We recommend that federal appropriations for 
tribes and tribal organizations be distributed in a manner similar to 
the Special Diabetes Program for Indians (SDPI) to ensure that every 
tribe receives funds based on well documented need.
    The opioid epidemic did not occur overnight. In April 2017, the 
State of Alaska Epidemiology noted that overdose deaths steadily 
increased in Alaska and throughout the country due to three sequential 
epidemiological phenomena:

         The first episode began in the mid-1990s with changes in 
        standards for pain management, approval of new, extended 
        release prescription opioid pain relievers, and aggressive 
        pharmaceutical marketing to encourage the use of prescription 
        opioids. A four-fold increase in prescribing led to a roughly 
        four-fold increase in prescription opioid deaths and created a 
        widespread increase in opioid dependency and addiction. The 
        second wave emerged over the last 10-15 years as heroin prices 
        decreased, and the purity increased, offering an alternative to 
        prescription opioids for persons who were addicted to or 
        dependent on opioids. The third wave developed over the past 3 
        years as illicit fentanyl began to enter the opioid black 
        market. \1\
---------------------------------------------------------------------------
    \1\ State of Alaska Epidemiology, Bulletin No. 11, April 20, 2017, 
http://www.epi.alaska.gov/bulletins/docs/b201711.pdf

    According to the Centers for Disease Control and Prevention (CDC), 
and confirmed by Rear Admiral Michael E. Toedt, Chief Medical Officer, 
IHS, in his appearance before the Committee on March 14, 2018, Alaska 
Natives and American Indians (AN/AIs) ``had the highest drug overdose 
death rates in 2015 and the largest percentage increase in the number 
of deaths over time from 1999-2015 compared to other racial and ethnic 
groups.'' \2\ During that time, deaths rose more than 500 percent among 
AN/AIs. \3\ According to IHS, among AN/Ais, the rate of drug overdose 
deaths is twice that of the general population. Rear Admiral Toedt 
cautioned that due to misclassification of race and ethnicity on death 
certificates, the actual number of deaths for AN/AIs may be 
underestimated by up to 35 percent.
---------------------------------------------------------------------------
    \2\ Testimony of RADM Michael E. Toedt, MD, FAAFP, Chief Medical 
Officer, IHS, March 14, 2018.
    \3\ Id., p. 3.
---------------------------------------------------------------------------
    According to the State of Alaska Epidemiology, from 2009-2015, 
there were 774 drug overdose deaths in the State and AN/AIs had the 
highest overdose death rate by race from 2009-2014, at 20.2 deaths per 
100,000. \4\ In February 2017, Alaska Governor Bill Walker declared the 
opioid epidemic a public health disaster. According to the CDC, in 
2016, there were 64,000 drug overdose deaths in the United States, 
largely driven by prescription and illicit opioids. In a March 2017 
study prepared for the Alaska Mental Health Trust Authority, the 
McDowell Group estimated the economic cost of the opioid crisis in 
Alaska alone was $1.2 billion in 2015 when measured in terms of lost 
productivity, motor vehicle crashes, health care, criminal justice and 
protective services and public assistance. \5\
---------------------------------------------------------------------------
    \4\ State of Alaska Epidemiology Bulletin, No. 6, March 24, 2016, 
http://www.epi.alaska.gov/bulletins/docs/b2016_06.pdf.
    \5\ See https://www.mcdowellgroup.net/wp-content/uploads/2017/03/
mcdowell-group-economicimpacts-of-drug-abuse-final-3.10.17.pdf.
---------------------------------------------------------------------------
    Senator Lisa Murkowski has remarked: ``Alaska may be a rural state, 
but we are not shielded from this epidemic. . . . Opioid abuse in 
Alaska is devastating our communities throughout the state and has 
rapidly become one of our most pressing issues.'' Senator Dan Sullivan 
also knows the great harm that the epidemic is causing to Alaska 
families. In August 2016, he convened a summit in Palmer, Alaska. He 
recognized that the communities hit hardest by opioid misuse are often 
those in economic distress. The opioid epidemic places a tremendous 
strain on Native communities already stretched too thin. SCF and other 
tribal healthcare providers need more federal resources if we are to 
stop the epidemic and reverse its harmful effects on Alaska Native 
families and our State. At that summit, SCF President and CEO, 
Katherine Gottlieb stated that SCF wants to expand our capacity to 
provide treatment for individuals struggling with addiction disorders 
but recurring federal resources to sustain and expand such programs 
remains our greatest obstacle.
    President Trump declared a nationwide public health emergency 
concerning the opioid crisis on October 26, 2017. In February 2018, 
Congress passed the ``Bipartisan Budget Act of 2018,'' Pub. L. 115-123, 
which includes $6 billion over two years (FY 2018 and FY 2019) to 
supplement federal appropriations for opioid addiction by funding 
grants, prevention programs, and law enforcement services. That 
legislation, however, did not make tribes and tribal organizations 
direct recipients of federal funding. As noted above, dedicating 
funding for Alaska Natives and American Indians is the best means to 
ensure that federal funds reach Indian Country and the tribal 
organizations that can make a difference in fighting the opioid 
epidemic. Give us the resources and we will expand our demonstrated 
ability to successfully treat patients with opioid addiction by using 
evidence-based treatment protocols performed in culturally appropriate 
and familiar settings.
    Sam Moose, the Treasurer of the National Indian Health Board 
(NIHB), testified at the March 14 hearing that the opioid epidemic is 
``one of the most pressing public health crises affecting tribal 
communities,'' and has ``further strained the limited public health and 
healthcare resources available to tribes.'' NIHB noted that Congress 
has historically funded IHS at a level below patient need. In FY 2017, 
Moose testified that national health spending was $9,207 per capita 
while IHS spending was only $3,332 per patient, nearly one-third less 
for Alaska Native/American Indian individuals.
    In April 2017, the U.S. Department of Health and Human Services 
(DHHS) outlined a five-point, evidence-based Opioid strategy:

        1.  Improve access to prevention, treatment, and recovery 
        support services to prevent the health, social, and economic 
        consequences associated with opioid addiction and to enable 
        individuals to achieve long-term recovery;

        2.  Target the availability and distribution of overdose-
        reversing drugs to ensurethe broad provision of these drugs to 
        people likely to experience or respond to an overdose, with a 
        particular lbcus on targeting high-risk populations;

        3.  Strengthen public health data reporting and collection to 
        improve the timeliness and specificity of data and to inform a 
        real-time public health response as the epidemic evolves;

        4.  Support cutting-edge research that advances our 
        understanding of pain and addiction, leads to the development 
        of new treatments, and identifies effective public health 
        interventions to reduce opioid-related health harms; and

        5.  Advance the practice of pain management to enable access to 
        high-quality, evidence-based pain care that reduces the burden 
        of pain for individuals, families, and society while also 
        reducing the inappropriate use of opioids and opioid-related 
        harms.

    Last year, IHS chartered the National Committee on Heroin, Opioids 
and Pain Efforts (HOPE) to help implement the Department's five-part 
strategy to combat the opioid epidemic. Alaska Governor Walker also 
established a similar Program HOPE (Harm reduction, Overdose 
Prevention, and Education) which is providing overdose reversal kits 
with naloxone and launching a public information campaign. We 
wholeheartedly agree with these approaches.
    Last December, the heads of three federal agencies; the Substance 
Abuse and Mental Health Services Administration (SAMHSA), the National 
Center for Injury Prevention and Control, Centers for Disease Control 
and Prevention (CDC), and the National Institutes of Health (NIH), 
presented joint testimony to Congress concerning the opioid epidemic. 
The agency officials confirmed the first cause of the epidemic noted by 
the State of Alaska Epidemiology; the significant rise in the 
prescription of highly addictive opioid drugs. In addition, the agency 
officials stated that delays by the U.S. healthcare system in providing 
effective treatment programs, especially medication-assisted treatment 
(MAT) programs, exacerbated the problem of opioid addiction brought 
about by the over-prescription of highly addictive opioids. They noted 
that:

         It is well-documented that the majority ofp eople with opioid 
        addiction in the U.S. do not receive treatment, and even among 
        those who do, many do not receive evidence-based care. 
        Accounting for these factors is paramount to the development of 
        a successful strategy to combat the opioid crisis. \6\
---------------------------------------------------------------------------
    \6\ Testimony of Elinore McCance-Katz, M.D., Ph.D., Assistant 
Secretary for Mental Health and Substance Use, Substance Abuse and 
Mental Health Services Administration (SAMHSA), Debra Houry, M.D., 
M.P.H, Director, National Center for Injury Prevention and Control, 
Centers for Disease Control and Prevention (CDC), and Francis Collins, 
M.D., Ph.D., Director, National Institutes of Health (NIH), on 
``Addressing the Opioid Crisis in America: Prevention, Treatment, and 
Recovery,'' December 5, 2017, before the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education and Related 
Agencies; https://www.nih.gov/aboutnih/who-we-are/nih-director/
testimony-addressing-opioid-crisis-america-prevention-
treatmentrecovery-before-senate-subcommittee. Emphasis added.

    Each year, SCF and other tribal organizations have urged IHS to 
request, and Congress to appropriate, increased funding for behavioral 
health, including funding for the Substance Abuse and Suicide 
Prevention (SASP) programs as well as increased funding for the 
Purchased Referred Care (PRC) program to address substance abuse, 
treatment and recovery programs.
    In FY 2017, IHS allocated $30 million in Substance Abuse and 
Suicide Prevention (SASP) funds to 175 IHS, tribal and urban Indian 
health organizations to develop and implement culturally appropriate, 
evidence-based, community driven programs. The average funding level 
was only $171,000 for the service providers. The Federal Government 
must do better and appropriate greater resources for this important 
work so that many more at-risk Alaska Natives and American Indians can 
recover from opioid addiction and lead a productive life.
    With available federal funding, SCF established The Pathway Home, a 
voluntary, comprehensive, and individualized mental health program for 
adolescents from 13 to 18 years old. The Pathway Home teaches 
invaluable life skills to Alaska Native youth so that they turn away 
from harmful behaviors. Many of these youth have already experienced 
trauma or have seen family members struggle with drug and alcohol 
dependencies, which puts them at greater risk of turning to drugs and 
alcohol later. The mission of the Pathway Home is to create a loving 
and supportive community environment where Alaska Native children can 
develop into independent, serviceminded and productive leaders. 
Increased funding to address root causes of substance abuse is crucial 
to combating the opioid crisis.
    SCF also operates Dena A Coy (DAC), a residential treatment program 
that serves pregnant, parenting and non-parenting women who are 
experiencing problems related to alcohol and other drugs and 
experiencing emotional and psychological issues. This program is open 
to all women in Alaska, regardless of ethnicity, and allows some women 
to participate in the program with their children under the age of 3. 
Our overall philosophy is to treat the person as a whole, let our 
customer-owners drive their healthcare decisions, and give them the 
tools and skills to make healthy decisions. DAC matches national 
standards for successful program completion. The success rate of this 
program shows that our approach is working, and with more resources we 
could expand this program and treat more people who need these 
services.
    If tribal organizations such as SCF are to stop the misuse of 
opioids, alcohol and other harmful substances and begin the process of 
helping individuals and families recover, we must have more resources, 
personnel and, equally important, the facilities to house these 
programs. With a service population of 65,000 our resources are wholly 
insufficient in comparison to the crisis. Timely treatment for opioid 
addiction can mean the difference between recovery or death.
    Prevention, education and timely medication-assisted treatment 
programs remain our most potent tools to raise a new generation of 
Alaska Native people who practice positive, life-affirming behavioral 
traits and who will, in turn, pass on these life lessons to their 
children and grandchildren. Only then will the cycle of trauma and 
opioid addiction be broken.
    Thank you for convening the March 14, 2018 hearing and for allowing 
us the opportunity to provide testimony.
                                 ______
                                 
        Prepared Statement of the Tanana Chiefs Conference (TCC)
    Tanana Chiefs Conference (TCC) submits written testimony to the 
Senate Committee on Indian Affairs to supplement its March 14, 2018 
hearing entitled: ``Opioids in Indian Country: Beyond the Crisis to 
Healing the Community.'' TCC is a non-profit intertribal consortium of 
37 Federally-recognized Indian tribes and 41 Alaska Native communities 
located across Interior Alaska. TCC serves 18,000 Alaska Natives living 
in Fairbanks and in the rural villages located along the 1,400 mile 
Yukon River and its tributaries. TCC's service area encompasses 235,000 
square miles, about the size of Texas.
    To help remote, Interior Alaska Native villages combat the opioid 
epidemic, Congress must make federal appropriations directly available 
to tribes and tribal organizations, and give us the flexibility we 
require to use such funds to prevent, treat and help individuals 
recover who are already addicted to prescription and illicit opioids 
and other illegal drugs.
    We applaud the efforts that Committee Chairman Hoeven has taken to 
highlight the destructive effect that the opioid epidemic is causing to 
American Indian and Alaska Native communities. The March 14, 2018 
hearing followed a roundtable discussion Chairman Hoeven convened last 
November concerning the opioid misuse in Indian Country. Senator Hoeven 
remarked: ``The roundtable highlighted how the opioid abuse epidemic is 
particularly complex in tribal communities given the lack of access to 
medical care, shortage of law enforcement and insufficient data on 
substance abuse.'' At the March 14 hearing, Chairman Hoeven stated 
that: ``I am also mindful that when Congress does appropriate funding 
to combat this epidemic, it is important that Indian Country receives 
an adequate share of the funding and receives this funding in a manner 
that will ensure maximized impact to their communities.''
    TCC fully supports the Chairman's remarks. If tribes are to stop 
the misuse of prescription opioids and illegal drugs, Congress must 
help tribes and tribal organizations attack the root causes: deferred 
medical treatment of conditions that require pain management, domestic 
and child abuse, homelessness, poverty, unemployment, and lack of 
prevention, substance abuse treatment, recovery services, and adequate 
law enforcement.
    In addition to ensuring that tribes and tribal organizations have 
access to federal appropriations to educate, prevent, and treat opioid 
addiction, Congress must also recognize the challenges tribes and 
tribal organizations face to adequately finance essential government 
services such as healthcare, education and job training, public safety, 
and the facilities to house these programs. This is especially true in 
remote, rural areas, such as Interior Alaska where TCC operates. Too 
often, federal appropriations make the difference between the success 
and failure of tribal initiatives, which in turn, determine whether 
economic and social conditions in Alaska Native communities improve or 
deteriorate. Promoting and funding Federal programs that keep Alaska 
Native families together, and help them prosper, is one of the best 
means of combating the opioid epidemic in tribal communities.
    To better inform Congress of the magnitude of the problem remote 
Alaska Native communities face to fight the opioid epidemic that 
threatens our way of life, Congress must better appreciate the degree 
of isolation that exists in rural Alaska. We share below excerpts from 
the Indian Law & Order Commission's 2013 report: ``A Roadmap for Making 
Native America Safer,'' relevant to Alaska:

         Forty percent (229 of 566) of the federally recognized Tribes 
        in the United States are in Alaska, and Alaska Natives 
        represent one-fifth of the total State population. Yet, these 
        simple statements cannot capture the vastness or the Nativeness 
        of Alaska. The State covers 586,412 square miles, an area 
        greater than the next three largest states combined (Texas, 
        California, and Montana). There are only 1.26 inhabitants per 
        square mile-as compared to 5.85 for Wyoming, which is the next 
        least populous state.

         Many of the 229 federally recognized tribes are villages 
        located off the road system and ``more closely resemble 
        villages in developing countries'' than small towns in the 
        lower 48. Frequently, Native villages are accessible only by 
        plane, or during the winter when rivers are frozen, by snow-
        machine. Food, gasoline, and other necessities are expensive 
        and often in short supply. . . . While Alaska Natives 
        constitute a majority of the rural population, each community 
        is nonetheless quite small; typical populations are in the 
        range of 250-300 residents, many of whom share family or clan 
        affiliations. Villages are politically independent from one 
        another. . .  .

         Problems with safety in Tribal communities are severe across 
        the United States-but they are systematically the worst in 
        Alaska. This is evident in an array of data concerning the 
        available services, crime, and community distress.

         Most Alaska Native communities lack regular access to police, 
        courts, and related services:

      Alaska Department of Public Safety (ADPS) officers have 
        primary responsibility for law enforcement in rural Alaska, but 
        ADPS provides for only 1.0-1.4 field officers per million 
        acres. . . . According to ADPS, troopers' efforts ``are often 
        hampered by delayed notification, long response distance[s], 
        and the uncertainties of weather and transportation.

         Social distress, which can be a cause of crime or other 
        threats to public safety, is also high among Alaska Natives and 
        in Alaska's Tribal communities:

      The suicide rate among Alaska Natives is almost four 
        times the U.S. general population rate, and is at least six 
        times the national average in some parts of the State.

      In 2011, over 50 percent of the 4,499 reports of 
        maltreatment substantiated by Alaska's child protective 
        services and over 60 percent of the 769 children removed from 
        their homes were Alaska Native children. \1\
---------------------------------------------------------------------------
    \1\ Indian Law & Order Commission, November 2013, A Roadmap for 
Making Native America Safer, Report to the President & Congress of the 
United States, Chapter Two, Reforming Justice for Alaska Natives: The 
Time is Now, pp. 35-43. See https://www.aisc.ucla.edu/iloc/report/
files/Chapter_2_Alaska.pdf.

    The opioid crisis came as Alaska Native communities were already 
confronting daunting public safety and public health challenges. Public 
safety services remain one of the biggest challenges for our Alaska 
Native communities. Alaska is one of six P.L. 280 States in which 
jurisdiction over crimes in tribal communities rests mainly with the 
States. The Bureau of Indian Affairs (BIA) simply does not have 
sufficient funding for law enforcement services, so it prioritizes its 
public safety efforts in non-P.L. 280 States on the false assumption 
that P.L. 280 States like Alaska are investing sufficiently in public 
safety and law enforcement services in tribal communities. This is not 
the case. Without basic law enforcement services for our tribal 
governments, and without sufficient funds for tribal governments to 
fight opioid addiction, our communities are at much greater risk. The 
statistics bear this out. TCC has been using what little resources it 
has to build partnerships with State and local law enforcement to curb 
the influx of drugs in to our off-road communities. A tribally led, 
grassroots effort raised several thousands of dollars to hire and train 
a canine unit for the Alaska State Troopers in our hub community. TCC 
supports this type of ownership of issues at a local level, but is all 
too aware of the limitations of these efforts without continued and 
dedicated funding.
    According to the Centers for Disease Control and Prevention (CDC), 
American Indians and Alaska Natives ``had the highest drug overdose 
death rates in 2015 and the largest percentage increase in the number 
of deaths over time from 1999-2015 compared to other racial and ethnic 
groups.'' \2\ During that time, deaths rose more than 500 percent among 
AIANs. \3\
---------------------------------------------------------------------------
    \2\ Testimony of RADM Michael E. Toedt, MD, FAAFP, Chief Medical 
Officer, Indian Health Service (IHS), U.S. Department of Health and 
Human Services, before the Senate Committee on Indian Affairs, Hearing 
on Opioids in Indian Country: Beyond the Crisis to Healing the 
Community, March 14, 2018.
    \3\ Id., p. 3.
---------------------------------------------------------------------------
    The Indian Health Service (IHS) notes that among American Indians 
and Alaska Natives, the rate of drug overdose deaths is twice that of 
the general population. The actual number of deaths for AIANs may be 
underestimated by up to 35 percent. \4\
---------------------------------------------------------------------------
    \4\ Id.
---------------------------------------------------------------------------
    According to the State of Alaska Epidemiology, from 2009-2015, 
there were 774 drug overdose deaths in the State and AIANs had the 
highest overdose death rate by race from 2009-2014, at 20.2 deaths per 
100,000. \5\ In February 2017, Alaska Governor Bill Walker declared the 
opioid epidemic a public health disaster. According to the CDC, in 
2016, there were 64,000 drug overdose deaths in the United States, 
largely driven by prescription and illicit opioids.
---------------------------------------------------------------------------
    \5\ State of Alaska Epidemiology Bulletin, No. 6, March 24, 2016, 
http://www.epi.alaska.gov/bulletins/docs/b2016_06.pdf.
---------------------------------------------------------------------------
    The Substance Abuse and Mental Health Services Administration's 
National Survey on Drug Use and Health (NSDUH) found that in 2016, 5.2 
percent or 72,000 American Indian and Alaska Native persons aged 18 and 
older reported misusing a prescription drug in the past year and 4.0 
percent of AIANs, or 56,000 individuals aged 18 and older, reported 
misusing a prescription pain reliever in the past year. SAMHSA Director 
Jones also noted that over the last decade, the U.S. has experienced a 
significant increase in the rates of neonatal abstinence syndrome 
(NAS), hepatitis C infections, and opioid-related emergency department 
visits and hospitalizations. \6\
---------------------------------------------------------------------------
    \6\ Testimony of Christopher M. Jones, PharmD., M.P.H., Director, 
National Mental Health and Substance Use Policy Laboratory, Substance 
Abuse and Mental Health Services Administration (SAMHSA), U.S. 
Department of Health and Human Services before the Senate Committee on 
Indian Affairs, Hearing on Opioids in Indian Country: Beyond the Crisis 
to Healing the Community, March 14, 2018.
---------------------------------------------------------------------------
    Alaska Governor Walker declared the opioid epidemic in Alaska a 
public health disaster in February 2017 and created project HOPE (Harm 
Reduction, Overdose Prevention and Education). Later that year, 
President Trump declared a nationwide public health emergency 
concerning the opioid crisis. In February 2018, Congress passed the 
``Bipartisan Budget Act of 2018,'' Pub. L. 115-123, which includes $6 
billion over two years (FY 2018 and FY 2019) to supplement federal 
appropriations for opioid addiction by funding grants, prevention 
programs, and law enforcement services. Congress has included billions 
of additional funding in the Consolidated Appropriations Act, 2018 
omnibus measure, making final appropriations for FY 2018, to combat the 
opioid epidemic.
    Federal legislation, however, has not made tribes and tribal 
organizations direct recipients of funding to address the opioid 
crisis. Direct appropriations and set-asides in federal legislation for 
Alaska Native and American Indian tribes and tribal organizations is 
the best means to ensure that federal funds reach Indian Country and 
the tribal organizations that can make a difference in fighting the 
opioid epidemic.
    We therefore respectfully urge Congress and the Administration to 
ensure that Alaska Native communities receive an appropriate share of 
federal funds to stop the illegal distribution of opioids, reduce 
overdoses, support educational awareness programs, and provide the 
facilities and medication-assisted treatment (MAT) programs that Alaska 
Native communities require to combat the opioid epidemic. Direct 
funding for tribes and tribal organizations honors the Federal 
Government's trust obligation to tribal nations and the special 
government-to-government relationship between the Federal Government 
and Indian tribes and Alaska Native Villages.
    We strongly support Senator Daines' ``Mitigating METH Act,'' S. 
2270, and Senator Baldwin's ``Opioid Response Enhancement Act,'' S. 
2437. These measures would amend the 21st Century Cures Act to include 
``Indian tribes and tribal organizations'' and ``Tribal entities'' as 
direct recipients of federal appropriations to fight the opioid 
epidemic, provide tribes greater flexibility to prevent and treat other 
substances, such as methamphetamines, establish set-asides for tribes, 
and increase overall federal appropriations. We recommend that federal 
appropriations for tribes and tribal organizations be distributed in a 
manner similar to the Special Diabetes Program for Indians (SDPI) so 
that every tribe receives funding.
    At TCC we use our available funding to promote substance abuse 
recovery, but our resources are limited. We operate the Old Minto 
Family Recovery Camp, an Athabascan alternative to substance abuse 
treatment where healing is provided in a traditional setting. It is our 
belief that for Alaska Native people today, alcohol and drug use/abuse 
became a toxic way of coping with a loss of traditional Native values, 
cultural patterns identities, relationships, and unresolved trauma. 
Using Native cultural and traditional values as a foundation, our goal 
is to help people help themselves as they heal from trauma, choose 
healthy lifestyles and overcome substance use.
    TCC has been working with other stakeholders in the Fairbanks, 
Alaska area to address the homeless situation among individuals 
suffering from alcohol and opioid addictions. TCC also held a three-day 
training session in January on methamphetamine and its impact on brain 
and behavior. The program was facilitated by faculty from the 
University of California Los Angeles (UCLA), and provided a skill-
building workshop for behavioral health staff and treatment providers 
to address the unique challenges meth users bring to health service 
providers. We have advocated tirelessly, and will continue to do so, 
for equal access to law enforcement and improvement of public safety 
services that partially due to extremely limited state funding are 
scarce. We can do so much more to reduce harmful and destructive 
behavior such as opioid prescription misuse if Congress would only 
appropriate more funds for tribes and tribal organizations. If we are 
to stop the misuse of opioids and other harmful substances and begin 
healing in tribal communities, we must have adequate and recurring 
federal resources to attract and retain qualified health professionals 
to come to our remote communities and fight this epidemic. We also 
require the facilities to house substance abuse programs and services.
    TCC and other tribal organizations have successfully demonstrated 
what we can accomplish in remote Alaska Native communities when given 
the resources. We cannot afford to lose a generation of Alaskans to the 
opioid epidemic.
    Thank you for allowing us the opportunity to provide testimony.
                                 ______
                                 
 Prepared Statement of the United South and Eastern Tribes Sovereignty 
                       Protection Fund (USET SPF)
    On behalf of the United South and Eastern Tribes Sovereignty 
Protection Fund (USET SPF), we are pleased to provide the Senate 
Committee on Indian Affairs with the following testimony for the record 
of the Committee's oversight hearing, ``Opioids in Indian Country: 
Beyond the Crisis to Healing the Community,'' held on March 14, 2018.
    USET SPF is a non-profit, inter-tribal organization representing 27 
federally recognized Tribal Nations from Texas across to Florida and up 
to Maine. \1\ Both individually, as well as collectively through USET 
SPF, our member Tribal Nations work to improve health care services for 
American Indians. Our member Tribal Nations operate in the Nashville 
Area of the Indian Health Service (IHS), which contains 36 IHS and 
Tribal health care facilities. Our citizens receive health care 
services both directly at IHS facilities, as well as in Tribally-
operated facilities under contracts with IHS pursuant to the Indian 
Self-Determination and Education Assistance Act (ISDEAA), P.L. 93-638.
---------------------------------------------------------------------------
    \1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe 
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian 
Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA), 
Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians 
(NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw 
Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag 
Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi 
Band of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut 
(CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY), 
Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian Township 
(ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot Indian 
Nation (ME), Poarch Band of Creek Indians (AL), Saint Regis Mohawk 
Tribe (NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians 
(NY), Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of Louisiana 
(LA), and the Wampanoag Tribe of Gay Head (Aquinnah) (MA).
---------------------------------------------------------------------------
    The opioid epidemic has had a devastating effect on USET SPF Tribal 
Nations and Tribal Nations across the country, who continue to 
experience the destructive effects of opioid addiction--often at higher 
rates than non-Indian communities. According to data from IHS, American 
Indians and Alaska Natives (AI/ANs) are more likely than any other 
race/ethnicity to have an illicit drug use disorder in the past year. 
In addition, according to the Centers for Disease Control and 
Prevention (CDC), AI/ANs are at the greatest risk for prescription 
opioid overdose, confronting an opioid overdose rate of 8.4 per 
100,000. Though USET SPF is encouraged to see Congress move in an 
expeditious manner to identify solutions to the opioid epidemic 
nationwide, USET SPF is concerned that Tribal Nations are frequently 
left out of the conversation, despite the disproportionate impact the 
opioid epidemic has had within Tribal communities. USET SPF reminds the 
Committee of the unique federal trust responsibility to Tribal Nations, 
and urges the Committee to use its authority to ensure Tribal Nations 
are fully included in any subsequent legislation or other Congressional 
efforts to address the opioid crisis.
Direct Opioid Funding for Tribal Nations
    The Federal Government has a trust responsibility to ensure Tribal 
Nations have access to resources, financial and otherwise, to combat 
the opioid epidemic. Among these vital resources is access to direct 
federal funding for Tribal Nations. While USET SPF is appreciative of 
the recent $50 million Tribal set-aside for this purpose within the 
Fiscal Year (FY) 2018 Omnibus, more resources are required to fully 
address the opioid crisis at the Tribal level. Though our data on this 
issue is incomplete, that which is available shows Indian Country, 
including USET SPF Tribal Nations, is among the communities affected 
most by this crisis. Yet, no direct funding stream currently exists to 
combat this epidemic in Tribal communities. Currently, Tribal Nations 
are ineligible for a majority of funding available under the 21st 
Century Cures Act. Where Tribal Nations are eligible for funding, they 
are forced to compete with state and other entities for limited 
dollars. Tribal Nations should not have to compete to provide their 
citizens with the treatment they critically need. This is contrary to 
the federal trust responsibility to provide healthcare to Tribal 
Nations, and results in few resources delivered to Tribal citizens. In 
addition, the Indian Health System remains chronically underfunded, 
leaving many Tribal communities without the critical resources and 
funding to address opioid addiction and treatment. During the hearing, 
Tribal witnesses testified on the need for direct funding to Tribal 
Nations for Tribal opioid treatment and prevention programs due to the 
increasing levels of opioid abuse, deaths, and trafficking within 
Tribal communities. USET SPF echoes these concerns and urges the 
Committee to prioritize addressing this shortfall by working to ensure 
Tribal governments have access to direct funding.
    Despite the government-to-government relationship between Tribal 
Nations and the United States, many federal grant programs, including 
those available as part of the 21st Century Cures Act, require funding 
to pass through the states before it can be delivered to Tribal 
governments. Because of this, a majority of Tribal communities have 
difficulty accessing federal funds, with many completely unable to 
access them in this manner. Further, when applying for these grants, 
states will often include Tribal population numbers in the overall 
state population used to determine each state's award. Yet, Tribal 
Nations are not provided with outreach for these programs and are left 
with minimal resources to address the opioid crisis in their 
communities. In order to ensure Tribal Nations are fully accessing 
these federal funds in the future, USET SPF recommends the Committee 
and Congress:

        1.  Consider implementing a funding model utilized by the CDC's 
        Good Health and Wellness in Indian Country initiative, which 
        allows for a direct, separate funding mechanism specifically 
        for both Tribal Nations and TECs. This model has proven to be 
        successful.

        2.  Expand language within grant funding programs to 
        specifically include Tribal Nations as direct grantees so that 
        states cannot exclude them in grant funding disbursements.

        3.  Recognize that competitive grants are not reflective of the 
        federal trust responsibility and work to provide more funding 
        to Tribal Nations via formula-based distribution methodologies.

        4.  Explore opportunities to deliver opioid funding to Tribal 
        Nations via self-governance contracting and compacting in 
        recognition of Tribal sovereignty and self-determination.

    With these priorities in mind, USET SPF urges the Committee and 
Congress to fully consider the following legislation, as it would 
provide critical opioid response resources to Tribal Nations, including 
direct funding.
Mitigating METH Act
    As discussed above, despite Tribal advocacy, Tribal Nations are 
ineligible for a majority of funding delivered to state and local 
governments under the 21st Century Cures Act. Where Tribal Nations are 
eligible for funding, they are forced to compete with state and other 
entities for limited dollars. On December 21, 2017, Senator Steve 
Daines introduced S. 2270, the Mitigating the Methamphetamine Epidemic 
and Promoting Tribal Health Act, or the Mitigating METH Act. The 
Mitigating METH Act would make Tribal Nations eligible to be direct 
grantees of federal opioid funding under the 21st Century Cures Act to 
combat opioid abuse in our communities. In addition, S. 2270 would 
provide an increase in grant funding of $25 million to states and 
Tribal Nations under the State Targeted Response (STR) grants within 
the 21st Century Cures Act. USET SPF supports this legislation \2\ that 
would bring critical direct funding to Tribal communities for the 
treatment and prevention of opioid addiction.
---------------------------------------------------------------------------
    \2\ USET SPF Board of Directors supporting resolution.
---------------------------------------------------------------------------
Native Health Access Improvement Act
    In addition to the Mitigating METH Act, USET SPF would like to 
convey our support for S. 2545, the Native Health Access Improvement 
Act of 2018, which was introduced by Senator Tina Smith on March 14, 
2018. This legislation would provide critical behavioral health 
resources to Tribal communities by creating a Special Behavioral Health 
Program for Indians (SBHPI). The SBHPI is modeled after the Special 
Diabetes Program for Indians (SDPI), a successful Tribal health program 
that has had a significant impact on diabetes within Tribal 
communities. Like SDPI, SBHPI responds to a public health crisis by 
providing dedicated, formula-based funding to Tribal Nations to address 
behavioral health and substance use disorders, including opioid abuse 
and addiction. In addition, it would support cultural competency by 
promoting the incorporation of both modern and traditional practices 
into Tribal behavioral health programs. Further, this legislation would 
require that funding standards and distribution methodology be 
developed in consultation with Tribal Nations and would provide the 
technical assistance necessary to develop robust programs. USET SPF 
requests that the Senate Committee on Indian Affairs ensure this 
legislation receive an immediate hearing.
Opioid Response Enhancement Act
    USET SPF also conveys our support for the Opioid Response 
Enhancement Act, legislation introduced by Senator Tammy Baldwin, which 
would make significant investments in Indian Country to fight the 
opioid epidemic. The legislation would provide an additional funding of 
$10 billion to states and Tribal Nations over five years for the State 
Targeted Opioid Response (STR) Grant, including $2 billion for a new 
Enhancement Grant for Tribal Nations and states with high morbidity 
rates. The Opioid Response Enhancement Act would also include Tribal 
Nations as eligible entities for STR Grants, funded by a 10 percent set 
aside, which USET SPF feels reflects a commitment to ensuring this 
crisis is addressed in Indian Country. Other components of the 
legislation include:

   Technical assistance delivered from SAMHSA to Tribal Nations 
        through the Tribal Training and Technical Assistance Center; 
        and

   Flexibility to allow Tribal Nations and states to use 
        funding to help address other substance abuse issues in 
        addition to opioid prevention and treatment;

Funding for Comprehensive Opioid Data Collection within the Indian 
        Health System
    As noted by Tribal witnesses during the hearing, the available data 
on opioid abuse and mortality within the Indian Health System is 
inadequate and fails to fully illustrate the impacts opioids are having 
in Tribal communities. . As the Committee moves forward with 
recommendations on how to effectively treat and prevent opioid 
addiction, the Committee must promote the provision of adequate 
resources, including direct funding, to the IHS, Tribal Nations, and 
Tribal Epidemiology Centers in order improve opioid data collection. 
Expanding data collection and analysis would improve the treatment and 
prevention of substance abuse within Indian Country. Though our data on 
opioid abuse is incomplete, data that is available shows Indian 
Country, including USET SPF Tribal Nations, is among the communities 
most impacted by this crisis. Without access to critical data, Tribal 
Nations will continue to feel the impacts of the opioid epidemic for 
generations. USET SPF urges the Committee to prioritize addressing this 
shortfall by working to ensure Tribal Nations have access to resources 
to improve opioid data and provide for the treatment and prevention of 
substance abuse.
Tribal Prescription Drug Monitoring Programs
    During the hearing, witnesses testified on the importance of 
partnering with state Prescription Drug Monitoring Programs (PDMP). IHS 
stated that the agency has been partnering with certain states to 
connect IHS with state PDMP data. USET SPF supports these partnerships 
and recommends the Committee and Congress ensure IHS has the necessary 
resources to expand and update the Indian Health Service's Resource and 
Patient Management System (RPMS) Electronic Health Record (EHR) to 
fully include and collaborate with state PDMPs on a multi-state basis. 
Integrating PDMP functionality into the RPMS EHR will connect Tribal 
Nations to crucial data within state PDMPs and will ensure an efficient 
and unified platform for Indian health providers to allow providers to 
quickly and easily make accurate and appropriate diagnoses (addiction, 
dependence, drug-seeking behavior, etc.) and document those in the RPMS 
EHR.
Culturally Competent Treatment
    The incorporation of traditional healing practices and a holistic 
approach to health care are fundamental to successful opioid treatment 
and aftercare programs in Indian Country. Culturally appropriate care 
has had positive, measurable success within Tribal communities, and the 
incorporation of traditional healing practices and holistic approaches 
to healthcare has become central to many Tribal treatment programs. 
Tribal communities have unique treatment needs when it comes to 
substance abuse disorders, as AI/ANs experience high levels of 
substance abuse disorders, with a strong link to historical trauma. 
Opioid addiction treatment in Indian Country, then, must be cognizant 
of this trauma, respectful of community factors, and utilize 
traditional health care practices. Additionally, opioid addiction 
treatment within Tribal communities must include adequate culturally 
appropriate aftercare programs to help prevent substance abuse relapse. 
These services must be accessible through the Indian Health Care 
Delivery System.
    Even though culturally competent care has had success across Indian 
Country, treatment options that incorporate cultural healing aspects 
are oftentimes not available within or near Tribal communities due to a 
lack of resources. However, some USET SPF member Tribal Nations are 
engaging in innovative practices that have the potential to be 
replicated across Indian Country. For example, one Tribal Nation's 
treatment program incorporates a culturally-based recovery model that 
has had great success, including in preventing early relapse following 
treatment. Other best practices within USET SPF Tribal Nations include:

   Extended, culturally-based recovery support in a sober 
        living environment; and

   Trauma informed care training for health and behavioral 
        health staff.

    Other notable best practices and culturally healing modalities not 
currently being employed by USET SPF Tribal Nations include:

   Rapid entry into an acute care facility (detox/inpatient 
        care); and

   Prevention and control interventions developed utilizing the 
        Community Based Participatory Action model.

    With additional funding and guidance, these best practices have the 
potential provide higher rates of recovery for our people. USET SPF 
encourages the Committee to explore how it might expand and promote 
these models through legislative action.
Tribal Healing to Wellness Courts
    In addition to traditional healing practices, USET SPF urges this 
Committee and Congress to support innovative, culturally-appropriate 
Tribal restorative justice models through sustained funding. USET SPF 
is encouraged that the success of family drug courts, or Healing to 
Wellness Courts (HTWC), was discussed during the hearing. Established 
as alternatives to conventional sentencing for non-violent individual 
offenders, Tribal HTWCs promote long-term recovery through treatment, 
community healing resources, and the Tribal justice process by using a 
multi-disciplinary approach to achieve the physical and spiritual 
healing of participants.
    For example, USET SPF member, the Penobscot Nation, has operated an 
HTWC since 2011. Any individual Penobscot Nation citizen who is charged 
with a non-violent crime can petition to participate in the HTWC 
program. Once accepted into the program, the individual must agree to 
enter a guilty plea for the crime charged against him/her, but his/her 
sentence is ``deferred'' to allow the individual to go through the 
program. Then, a comprehensive, holistic plan is developed in 
collaboration between 10 Tribal government departments to address the 
individual's treatment needs in four phases:

   Phase I: Introduction/Education. This phase is focused on 
        detoxification and beginning treatment and generally lasts 180 
        days.

   Phase II: Personal Responsibility. This phase is focused on 
        stabilization and treatment and generally lasts 120 days.

   Phase III: Cooperation/Accountability. This phase is focused 
        on maintenance and treatment and generally lasts 120 days. ?

   Phase IV: Completion/Continuing Wellness. This phase is 
        focused on graduation and aftercare and generally lasts 120 
        days.

    Successful completion of the program results in a dismissal of the 
participant's guilty plea. Over two dozen individuals have gone into 
the program since 2011. Recidivism is extremely low. Regrettably, the 
biggest challenge that the Penobscot Nation has encountered is that 
they do not have sufficient resources to accommodate all the 
individuals who are interested in participating in the program. While, 
the program is funded mainly through the Bureau of Indian Affairs, with 
supplemental funding from IHS, the Department of Justice, and the 
Department of Housing and Urban Development, this is administratively 
burdensome and unlikely to result in additional resources for the 
Court. Similarly, while some grants offered by the Substance Abuse and 
Mental Health Services Administration (SAMHSA) could possibly be used 
for this purpose, SAMHSA's application requirements and standards often 
serve to preclude smaller, less resourced Tribal Nations from applying. 
The recovery model offered by Tribal HTWCs should be supported by this 
Congress, as it seeks to incentivize long-term sobriety and reduce 
criminal recidivism among drug offenders. In order to accomplish this, 
USET SPF urges this Committee to consider dedicated, sustained funding 
for this infrastructure in Indian Country.
Tribal Engagement at all Levels of Government
    USET SPF reminds the Committee that Tribal Nations are sovereign 
governments to which each member of Congress has a trust 
responsibility. This trust responsibility is carried out not just 
through funding, but through meaningful government-to-government 
consultation and coordination to ensure Tribal Nations are included as 
full partners. When it comes to addressing the gaps in comprehensive 
Tribal programs to prevent, treat, and measure opioid addiction, this 
effort must include collaboration between federal, state, and Tribal 
governments. During the hearing, Tribal witnesses underscored the 
crucial need for collaboration on between Tribal Nations and all levels 
of government, including federal, state and local, in addressing the 
opioid epidemic. However, Tribal Nations are frequently excluded from 
these types of collaborative efforts as other units of government work 
together to ensure a coordinated response.
    As the trustee to Tribal Nations, the Committee and Congress must 
acknowledge the substantial challenges within Indian Country must 
fulfill the trust responsibility by facilitating and requiring 
collaboration between Tribal governments and state and local 
governments in the fight to end the opioid epidemic. Failure to include 
Tribal Nations, including when seeking solutions to the opioid epidemic 
will result in major gaps in the ability of the United States to 
eradicate opioid addiction in this country. These gaps in coordination 
are detrimental not just from a healthcare and treatment perspective, 
but from a law enforcement perspective, as well. Outreach from the 
Committee, as well as future legislation, should promote and require 
this necessary intergovernmental collaboration.
Access to Law Enforcement Resources
    In addition to opioid addiction and treatment resources, USET SPF 
member Tribal Nations report a lack of adequate law enforcement 
infrastructure to combat the opioid epidemic within our region. 
Currently, there are only seven drug enforcement agents assigned to 
serve over one hundred Tribal Nations within our BIA Drug Enforcement 
Region (from ME to FL to NM to the central US). This limited number of 
law enforcement agents is unacceptable considering the persistent and 
growing problem of opioid trafficking within Indian Country, 
particularly the USET SPF region. As mentioned during the hearing, law 
enforcement within Indian Country needs additional resources to in 
order to sufficiently address the growing opioid abuse and trafficking 
within our Tribal Nations, including human capital.
    Though our Tribal patrol officers perform a vital role in 
addressing drug issues within a community, our law enforcement agencies 
face underfunding, understaffing, and other failures due to inadequate 
appropriations. Though USET SPF is pleased that $7.5 million was 
recently appropriated in the FY 2018 Omnibus bill providing funding to 
the Bureau of Indian Affairs law enforcement, additional resources and 
continued investments must be made available to Tribal Nations when it 
comes to critical drug enforcement investigations. These services are 
conducted primarily by specialized units or task forces on 
departmental, statewide and federal levels and involve enhanced 
intelligence gathering, information sharing, controlled buys, 
surveillances and other factors. As the Committee approaches this 
crisis, it must not forget the importance of stopping the supply of 
opioids on Tribal lands through well-equipped law enforcement.
Conclusion
    USET SPF appreciates the Committee's continued attention to the 
opioid epidemic and the destructive effects that it has had within 
Indian Country. We call upon the Committee to take action to ensure 
vital resources are directed to Tribal communities. Failure to include 
Tribal Nations in future legislation is a failure to recognize the 
trust responsibility and will result in an incomplete response to this 
crisis. USET SPF urges the Committee to use the crucial information 
gathered during these events to educate Senate colleagues on the impact 
of the opioid epidemic within Indian Country, and to continue to voice 
these priorities beyond the Committee during the legislative process.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                             Jolene George
Federal Funding Access for Tribes and Native Communities
    Question 1. Legislative proposals that would give tribes access to 
direct access to dedicated funding to address opioid addition and other 
behavioral health challenges. Do you support the correction to the 
State Targeted Response program's state pass-through funding model 
proposed by S. 2270 and S. 2437?
    Answer. Yes, we support direct funding to tribes as authorized in 
both S. 2270 and S. 2437. Adequate direct funding means reliable 
resources and flexibility for the PGST to continue implementing our 
culturally appropriate, multi-faceted, comprehensive approach to 
abating the opioid epidemic sweeping our community. Additionally, 
adequate direct funding allows us to plan long-term for infrastructure 
development, program enrichment, and service enhancements necessary for 
the well-being of our members and local community. We support both 
bills and are encouraged by the Sponsors' recognition of the importance 
of direct tribal funding. However, we note that S. 2437 provides 
significant increases in funding for a longer period of time, and we 
prefer that approach. The opioid crisis has been a long time in 
building, and its impacts are going to be long term. The additional 
funding is needed and could be put to use by Indian Country to carry 
out important opioid response activities in light of the magnitude and 
duration of the crisis.
    Further, while the PGST supports both S. 2270 and S. 2437, we would 
recommend, as an alternative to the grant funding contemplated in both 
bills, that Congress use the self-governance model for this funding for 
tribes like ours that already carry out programs and functions through 
self-governance compacts . Since joining the Tribal Self-Governance 
Project, a consortium of self-governing tribes, in 1990, we have funded 
our health care services through a compact with the Indian Health 
Service (IHS) under the Indian Self-Determination and Education 
Assistance Act. We operate and manage our entire health system on our 
Reservation, which includes primary care, dental, mental health, and 
substance abuse services along with prevention and community health.
    We would much prefer receiving these monies through our self-
governance compact if possible rather than through grants. 
Administering programs by competitive grant funding is inappropriate 
for meeting the critical needs of Indian Country, as it pits tribe 
against tribe to compete for limited funds and fosters uncertainty 
since funding cannot be relied on year-to-year. Moreover, having our 
Program Directors spend time pursuing grants or reporting for grants 
takes their energy away from carrying out the critical program duties. 
Finally, if we are competing with the states that will undermine our 
working together which is what we should be doing to combat the opioid 
epidemic. One of the reasons why our Tribal Healing Opioid Response 
(THOR) program is so effective is that we are working with the State, 
the County, and regional groups to coordinate response strategies.

    Question 1a. Would the authorization of a ``Special Behavioral 
Health Program for Indians'' as proposed by S. 2545 help your Tribe in 
its opioid response efforts?
    Answer. Yes, we support the creation of a Special Behavioral Health 
Program for Indians (SBHPI) under this legislation, as it would provide 
the Indian Health Service (IHS), Tribes, Tribal organizations, and 
urban Indian health programs with access to $150 million in annual 
mandatory grant-based funding from FY 2018 to FY 2022. As mentioned 
above, we operate and manage our entire health system on our 
Reservation, and we have operated a robust Special Diabetes Program for 
Indians (SDPI) program for many years. We are confident that using the 
SDPI program as a model for the SBHPI will be a success.
    The PGST supports S. 2545. However, as with S. 2270 and S. 2437, we 
recommend that self-governance tribes--such as the PGST--be able to 
receive such funding through their self-governance compacts rather than 
through grant funding. As we know from our SDPI experience, grant 
reporting requirements take away from clinical time, and the self-
governance model would allow for more administrative efficiency.
Federal, State, Tribal Intergovernmental Coordination
    Question 2. What else could Congress do to help encourage states 
and local governments to coordinate with tribes on their opioid 
response efforts?
    Answer. The following are some ideas that Congress could encourage 
state and local governments to work with Tribes:

   Establish and set aside funding for demonstration/pilot 
        programs for opioid response activities to show how cooperation 
        leads to results.

        --Congress could base such a program on the PGST's efforts with 
        the Olympic Community of Health, implementing the Three County 
        Coordinated Opioid Response Project. A demonstration/pilot 
        program would provide the framework for bringing tribes and 
        neighboring governments together in areas where states and 
        local governments are reticent to work with tribes. The program 
        could show the successes that are achievable when state, local, 
        and tribal governments work together.

   Create an opioid task force with representatives of state, 
        local, and tribal governments, and include other relevant 
        sectors, e.g. housing, schools, law enforcement, corrections, 
        etc. Doing so would incentivize the governments to come 
        together with each other and the people who are doing the work 
        on the ground to develop coordinated and creative approaches to 
        dealing with the crisis on an ongoing basis. The task force 
        could advise Congress and/or relevant federal agencies about 
        the challenges they face and what they need to effectively 
        fight the opioid crisis.

        --Such a task force could be modeled on what the PGST is doing 
        with Washington State and our neighboring counties. It could be 
        set up on a regional level with multiple regions.

   Encourage the use of Medicaid Demonstration Waivers for 
        experimental, pilot, or demonstration projects found by the 
        Secretary of Health and Human Services to be likely to assist 
        in promoting the objectives of the Medicaid program. Washington 
        State's waiver formed regional Accountable Communities of 
        Health, which have helped form partnerships that were not 
        otherwise easily accessible or workable.

   Include a provision in opioid legislation mandating state 
        and local governments to work together with tribes to respond 
        to the opioid crisis. One potential vehicle isS. 2437, the 
        Opioid Response Enhancement Act, which, in part, amends the 
        21st Century Cures Act of 2017 (the ``Cures Act'') to encourage 
        community and local government engagement.

        --Section 2(a)(2(B)(i)(l) ofS. 2437 would amend Section 
        1003(c)(2) of the Cures Act to read, ``Grants awarded under 
        this subsection shall be used for carrying out activities, 
        including activities supported by community-based organizations 
        and counties, that supplement activities pertaining to opioids 
        undertaken by the State agency responsible for administering 
        [the grant].'' The new language is in italics. Congress could 
        include a statement that directs state and local governments to 
        work coordinate with tribes on opioid response efforts.

        --Another place in S. 2437 for additional language is Section 
        2(a)(4), the Technical Assistance provision. Through this 
        proposed new mandate, Congress could direct the Secretary of 
        Health and Human Services to assist tribes, states, and local 
        governments with coordinating strategies and developing 
        collaborative responses.

   Allow special access to funding for consortium projects that 
        involve tribes together with state agencies or local 
        governments, which would incentivize intergovernmental 
        collaboration. Such a provision could be included in pending 
        opioid legislation.

   Provide monetary incentives for states and local governments 
        to coordinate with tribes.

   Include a requirement for a GAO report examining the hurdles 
        that prevent effective state, local, and tribal government 
        coordination on opioid response efforts.

        --A potential vehicle for this could be H.R. 994, the Examining 
        Opioid Treatment Infrastructure Act of 2017. This is a 
        bipartisan bill specific to Indian Country that currently calls 
        for a GAO report on: (1) inpatient and outpatient treatment 
        capacity, availability, and needs, including detoxification 
        programs, clinical stabilization programs, transitional 
        residential support services, rehabilitation programs, and 
        treatment programs for pregnant women or adolescents; (2) 
        treatment availability and effectiveness through Indian health 
        programs; and (3) the barriers to real-time reporting of drug 
        overdoses at the federal, state, and local level and ways to 
        overcome those barriers. The scope of the GAO report under this 
        bill could be expanded to include an examination of the 
        barriers relating to positive state and local government 
        coordination with tribes.
Additional Issue
    We would like to make one additional point that is consistent with 
our responses above, but which does not neatly fit under any one of the 
specific questions asked. At the local level, a major challenge has 
been integrating behavioral health with primary care in order to 
optimize patient outcomes. This is the work that will reach people 
grappling with the opioid epidemic on the front lines. Federal law and 
regulations complicate the complexities of integrating health systems 
with behavioral health systems. Federal regulations at 42 CFR Part 2, 
related to the privacy of substance abuse treatment records, currently 
prevent the Tribe's primary care and mental health providers from 
accessing patient records from dependency providers so the whole person 
can be treated. This lack of access is a barrier to coordinated, safe, 
and high-quality medical care and can cause significant harm. Part 2 
regulations may lead to a doctor treating a patient and writing 
prescriptions for opioid pain medication for that individual without 
knowing the person has a substance use disorder. There remains a strong 
need for technical assistance and a potential legislative fix to align 
the varying levels of patient privacy under the Health Insurance 
Portability and Accountability Act of 1996 (HIP AA) and 42 CFR Part 2 
that challenge the integration process.
Conclusion
    Thank you for the opportunity to speak on behalf of the PGST 
regarding the opioid epidemic facing this Nation. We look forward to 
further opportunities for discussion and to actively working with the 
Committee to tackle the opioid epidemic. We hope that you and the 
entire Committee will accept our Tribe's invitation to come visit the 
Port Gamble S'Klallam Reservation to see our work and significant needs 
in responding to the opioid crisis.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                            Stacy A. Bohlen
Federal Funding Access for Tribes and Native Communities
    Question 1. Your written testimony states, ``access to critical 
opioid prevention and treatment dollars are not reaching many of the 
Tribal communities that are in serious need of these funds.'' The 
Senate is currently considering three different legislative proposals 
that would give tribes direct access to dedicated funding to address 
opioid addiction and other behavioral health challenges (i.e., S. 2270, 
Mitigating METH Act; S. 2437, the Opioid Response Enhancement Act; and 
S. 2545, the Native Behavioral Health Access Improvement Act of 2018). 
Do you have an estimate of how much funding from the 21st Century CURES 
Act State Targeted Response program is reaching Native communities?
    Answer. No, we do not have an overall estimate, because states are 
not required to report this data. We do know that some states have 
chosen to include Tribes in their funding distribution, but this is not 
guaranteed or required due to the current funding scheme. Of the 36 
states with Tribes, only 13 have included Tribes in their State 
Targeted Response (STR) or somehow identified American Indians and 
Alaska Natives (AI/ANs) as a target population with specific needs.
    California and a few other states have used their funds to create 
Tribal MAT projects to improve the delivery of treatment services in 
AI/AN communities, and that other states like Minnesota, Washington and 
Oregon have outlined AI/ANs as one of their primary target populations 
for the funds. In Washington for example, the state is looking to pilot 
a low-barrier buprenorphine program in Tribal communities, and is 
engaging at least 5 Tribes to develop a Tribal treatment outreach and 
education campaign.
    But this is far less than adequate. At the Ho-Chunk Nation in 
Wisconsin they have seen an increased number of infants born with 
substance addiction and neonatal abstinence syndrome, as well as an 
increase in opioid-related overdose deaths in the community. The Tribal 
government declared a State of Emergency regarding the opioid crisis 
and is in the process of developing a Tribal Action Plan within their 
departments. A major problem for the Tribe is that the grant money the 
state receives and distributes to the Tribes is not sufficient to meet 
the added burden the Tribe's behavioral health facility is 
experiencing.

    Question 1a. Do you support the correction to the State Targeted 
Response program's state pass-through funding model proposed by S. 2270 
and S. 2437?
    Answer. Yes, the inclusion of Tribes in the correction to the STR 
program's model is a very important first step Congress must make to 
address the opioids crisis in Indian Country. NIHB is supportive of the 
provisions in S. 2270, the ``Mitigating METH Act'' from Senator Daines, 
and S. 2437, the ``Opioid Response Enhancement Act'' from Senator 
Baldwin. By ensuring Tribes can receive federal funds directly, 
Congress would ensure that the funds reach Tribal communities 
experiencing desperate need of relief. This change would also uphold 
the federal trust responsibility by ensuring Tribes do not need to go 
through their states' health department or sub-granting process to 
receive the care that is historically promised and legally owed. 
Finally, allowing Tribes to receive these funds authorized by the 21st 
Century CURES Act of 2016 would alleviate the states of the burden of 
having to provide care to Tribes. Not all states have the expertise or 
capacity to provide care to Indian Country. Changing the STR program to 
include direct, formulaic federal funding for Tribes directly would 
uphold the trust responsibility, respect states, and most importantly, 
ensure Tribes have the resources to care for themselves.

    Question 1b. Would the authorization of a ``Special Behavioral 
Health Program for Indians'' (SBHPI) as proposed by S.2545 help your 
Tribe in its opioid response efforts? And, are there any particular 
characteristics of the SDPI model that are important to carry over to 
an SBHPI?
    Answer. Yes, the creation of SBHPI is a priority for the National 
Indian Health Board. American Indian/Alaska Native 12th graders are 
roughly twice as likely to have used heroin or OxyContin as 12th 
graders nationally. Additionally, the chronic underfunding of the 
Indian health system leaves many healthcare facilities unable to offer 
preventative services, instead resorting to distributing painkillers 
when the health issue becomes acute. The opioids crisis is real in 
Indian Country. The proposed SBHPI would provide funding to Tribes to 
develop Substance Use Disorder treatments at the Tribal and community 
level.
    A program like this would provide broad-based funding in Tribal 
communities for addressing behavioral health challenges. If the program 
is designed in a similar way to SDPI, it will be recurring, formula 
based funding that Tribes can count on from year to year. This will 
allow for investment in Tribal communities that focuses on traditional 
healing combined with clinical measures. The flexibility permits Tribes 
to focus on both prevention and treatment, and to create programs that 
are tailored to their communities. We know the SDPI model works.
    The SDPI model offers Tribes the flexibility they need to develop 
culturally competent and tailored programs that have shown enormously 
successful results since SDPI began in 1997. By supporting each Tribe's 
work, SDPI reflects that a one-size fits all approach is inappropriate 
for Indian Country. NIHB is glad to see the same level of flexibility 
in Senator Smith's SBHPI legislation.
    As impactful as SDPI is, NIHB would suggest that the legislative 
model for the program is imperfect. Historically, Congress has renewed 
SDPI on a 2-year cycle. Last year, SDPI renewal was tied to the CHIP 
reauthorization bill and became caught in a larger political battle. 
For several months, Tribal administrators of SDPI-funded programs did 
not have the certainty needed for effective long term planning. Long-
term reauthorization for SDPI, such as found in the Vice Chairman's 
bill, S. 747, would prevent this from happening again. SBHPI should be 
authorized and funded for no fewer than the five years found in S. 
2545. Additionally, SDPI's funding level has plateaued since 2004, with 
about one third of the buying power lost to medical inflation. NIHB 
would recommend that legislation for both SDPI and SBHPI include 
funding adjustments over time to compensate for rising healthcare 
costs.
    As promising as the Native Behavioral Health Access Improvement Act 
is, this is really just one small step. The $150 million outlined in 
this legislation will not be nearly enough to get to Tribal communities 
to generate systems change. What we really need is comprehensive 
investments in IHS funding, improved staffing for medical professionals 
in our rural communities, and access to training for first responders 
and other enforcement activities.
Federal, State, Tribal Intergovernmental Coordination
    Question 2. Port Gamble S'Klallam Tribe's testimony lists ``cross-
government coordination'' as one of the most important components of 
designing an impactful tribal response to public health crises. It goes 
on to cite the Tribe's work with three local county efforts as evidence 
of the effectiveness of this recommendation to prioritize 
crossgovernment coordination. Unfortunately, not all tribes find their 
state and local counterparts willing to partner with them to address 
issues that span across multiple jurisdictions. What else could 
Congress do to help encourage states and local governments to 
coordinate with tribes on their opioid response efforts?
    Answer. Port Gamble S'Klallam Tribe is right to point out the 
potential of a well-coordinated and interconnected collaboration across 
various government entities in creating an effective opioid response 
plan. Some Tribes are in ideal positions to leverage intergovernmental 
relationships to ensure their members receive services; however, this 
cannot be the federal government's fallback strategy to upholding its 
trust responsibility to Tribes. As stated in the question, not all 
state and local governments have the will, capacity, or expertise to 
deliver cross-government coordinated services to Tribal communities 
adequately. The most productive course of action would be for Congress 
to require Tribal consultation in the earliest stages of opioid 
targeted response at the state and local level. Tribes need to be at 
the table, not to evaluate an otherwise-final state proposal, but to 
help states and local governments craft the proposals from the 
beginning, ensuring that the final product respects Tribal needs and 
sovereignty.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                       Captain Christopher Jones
Tribal Access to SAMHSA Grants
    Your testimony cites a number of grant programs operated by SAMHSA 
that allow communities to address opioid and substance abuse issues. In 
your written testimony, you mention several SAMHSA grant programs aimed 
at addressing the opioid crisis (e.g., State Targeted Response grants, 
two separate Strategic Prevention Framework Programs, the First 
Response-Comprehensive Addiction and Recovery Act Program, etc.). In 
your oral testimony and in the course of answering questions at this 
oversight hearing, you noted a residential program with 19 grantees 
that addresses intergenerational addiction and an outpatient program 
authorized by the Comprehensive Addiction and Recovery Act.

    Question 1a. Are tribes, tribal organizations, and urban Indian 
health organizations eligible for all of the SAMHSA grants noted above?
    Answer. By statute, eligibility for the State Targeted Response to 
the Opioids Crisis (section 1003 of the 21st Century Cures Act) and 
State Pilot Grant Program for Treatment for Pregnant and Postpartum 
Women (section 508(r) of the Public Health Service Act) grant programs 
are limited to states. Tribal entities are eligible for the Strategic 
Prevention Framework for Prescription Drugs, Strategic Prevention 
Framework Partnerships for Success, First Responders--Comprehensive 
Addiction and Recovery Act, and Residential Treatment for Pregnant and 
Postpartum Women programs.

    Question 1b. If tribal grantees are eligible for the programs 
mentioned in your written testimony (e.g., State Targeted Response 
grants, two separate Strategic Prevention Framework Programs, the First 
Response-Comprehensive Addiction and Recovery Act Program, etc..),what 
percentage of grant recipients are tribal grantees? And, what 
percentage of total grant funds do those tribal grantees receive from 
each of those grants?
    Answer. By statute, eligibility for the State Targeted Response to 
the Opioids Crisis (section 1003 of the 21st Century Cures Act) and 
State Pilot Grant Program for Treatment for Pregnant and Postpartum 
Women (section 508(r) of the Public Health Service Act) grant programs 
are limited to states.
    In FY 2015, tribal entities represented and received the following 
funds through the Strategic Prevention Framework Partnerships for 
Success Program (awards are for the first year of the grant):

   SAMHSA awarded grants to 7 of the 8 applications received 
        from organizations that self-identified as tribal organizations 
        (88 percent success rate)

   SAMHSA awarded grants to 24 of the 24 applications received 
        from non-tribal organizations (100 percent success rate)

   Tribal entities represented 23 percent of recipients (7 of 
        31)

   Tribal entities received 10 percent of awarded funds 
        ($3,874,777 of $38,687,939)

    In FY 2016, tribal entities represented and received the following 
funds through the Strategic Prevention Framework for Prescription Drugs 
Program (awards are for the first year of the grant):

   SAMHSA awarded grants to all 4 applications received from 
        organizations that self-identified as tribal organizations (100 
        percent success rate)

   SAMHSA awarded grants to 21 of the 24 applications received 
        from non-tribal organizations (88 percent success rate)

   Tribes/tribal organizations represented 16 percent of 
        recipients (4 of 25)

   Tribes/tribal organizations received 19 percent of awarded 
        funds ($1,751,982 of $9,322,676)

    In FY 2017, tribal entities represented and received the following 
funds through the First Responders--Comprehensive Addiction and 
Recovery Act Program (awards are for the first year of the grant):

   SAMHSA awarded grants to all 4 applications received from 
        organizations that self-identified as tribal organizations (100 
        percent success rate)

   SAMHSA awarded grants to 17 of the 48 applications received 
        from non-tribal organizations (35 percent success rate)

   Tribes/tribal organizations represented 19 percent of 
        recipients (4 of 21 awards)

   Tribes/tribal organizations received 8 percent of awarded 
        funds ($936,724 of $11,235,881)

    Question 1c. If tribal grantees are eligible for the programs 
mentioned in your oral testimony and question responses (i.e., a 
residential program with 19 grantees and an outpatient program 
authorized by the Comprehensive Addiction and Recovery Act), what 
percentage of grant recipients are tribal grantees? And, what 
percentage of total grant funds do those tribal grantees receive from 
each of those grants?
    Answer. In FY 2017, there were no tribal recipients of the 
Residential Treatment for Pregnant and Postpartum Women Program and by 
statute only states are eligible for the State Pilot Grant Program for 
Treatment for Pregnant and Postpartum Women (section 508(r) of the 
Public Health Service Act).
    In FY 2016, there were no tribal recipients of the Residential 
Treatment for Pregnant and Postpartum Women Program.

    Your testimony also states that Assistant Secretary for Mental 
Health and Substance Use McCance-Katz is actively looking for ways to 
improve tribal access to SAMHSA's grant programs.

    Question 2a. What metrics, if any, has SAMHSA identified to 
determine if tribal access to SAMHSA grants is improving?
    Answer. Dr. McCance-Katz has provided strong leadership on this 
priority and over the past five months, she has:

   Reestablished the Addiction Technology Transfer Center 
        (ATTC) Program: American Indian and Alaska Native Support 
        Center Cooperative Agreement.

   Will be establishing Tribal TA Centers for Mental Health as 
        well as for Prevention.

   Established a $5 million set-aside as part of the SAMHSA 
        Enhancement and Expansion of Treatment and Recovery Services 
        for Adolescents, Transitional Aged Youth, and their Families 
        Program.

   Will make awards to three tribal entities, out of the nine 
        total projected awards, under the Statewide Consumer Network 
        Program.

   Will ensure that at least one of the four Healthy 
        Transitions grants goes to tribes/tribal organizations.

   Will ensure that at least four awards of Project AWARE 
        grants go to tribes/tribal organizations.

    Additionally, in report language on the Consolidated Appropriations 
Act, 2018, Congress directed SAMHSA to ensure that $5.millionin funding 
from the Medication-Assisted Treatment--Prescription Drug and Opioid 
Addiction program goes to tribes/tribal organizations; that act also 
included a $50 million set-aside in the State Opioid Response Program 
for tribal awardees.
    The metrics used for success will be the number and proportion of 
grant awards made to tribes/tribal organizations in these programs.

    Question 2b. Does SAMHSA have any information on the overall number 
of tribal applicants for all SAMHSA grant programs? If so, please 
provide a summary of that information.
    Answer. In FY 2016, SAMHSA received 126 applications from 
organizations that self-identified as tribal organizations. In FY 2017, 
SAMHSA received 82 applications from organizations that self-identified 
as tribal organizations.

    Question 2c. Does SAMIISA have any information on the success rate 
of tribal grant applicants compared to other types of applicants for 
competitive grant programs within the Agency? If so, please provide a 
summary of that information.
    Answer. In FY 2016, SAMHSA awarded grants to 79 of the 126 
applications received from organizations that self-identified as tribal 
organizations (63 percent success rate). In FY 2016, SAMHSA award 
grants to 527 of the 1,410 applications received from non-tribal 
organizations (37 percent success rate).
    In FY 2017, SAMHSA awarded grants to 37 of the 82 applications 
received from organizations that self-identified as tribal 
organizations (45 percent success rate). In FY 2017, SAMHSA awarded 
grants to 412 of the 1,025 applications received from non-tribal 
organizations (40 percent success rate).

    Your testimony notes that Assistant Secretary McCance-Katz included 
a $5 million dollar tribal set-aside in a recent funding opportunity 
announcement for ``Enhancement and Expansion of Treatment and Recovery 
Services.''

    Question 3a. Has SAMHSA included a tribal set-aside within this 
funding opportunity in previous funding application rounds? Or is this 
$5 million set-aside a first time occurrence?
    Answer. This set-aside was done at the direction of Dr. McCance-
Katz. FY 2018 is the first time that SAMHSA included a $5 million set-
aside for tribes and tribal organizations in its Funding Opportunity 
Announcement (FOA) focused on substance use disorder treatment services 
for adolescents, transitional aged youth, and their families.

    Question 3b. Please provide information about the number and 
amounts of tribes awarded to tribal applicants for this grant program 
under any previous grant award rounds.
    Answer. SAMHSA previously awarded grants to tribes and tribal 
organizations under the State Youth Treatment Initiative from FY 2012 
to FY 2017. This Initiative helps to further the use of, and access to, 
effective evidence-based family-centered treatment approaches for 
adolescents (ages 12 to 17) and transitional age youth (ages 18 to 25) 
with substance use disorders and co-occurring substance use and mental 
disorders. Under this Initiative, 62 total grants have been made across 
35 states/tribes/territories. Of the 62 total awards, seven awards 
totaling $13,158,595 have been made to the following tribes and tribal 
organizations (the amounts listed represent the first-year funding 
award):

        --Chickasaw Nation (OK)-one grant award (FY 2013: $555,333)

        --Fallon Paiute Shoshone (NV)-one grant award (FY 2013: 
        $950,000)

        --Pascua Yaqui Tribe (AZ)-one grant award (FY 2015: $800,000)

        --Fairbanks Native Association (AK)-two separate grant awards 
        (FY 2016: $464,173; FY 2015: $249,767)

        --Kickapoo Tribe (OK)-two separate grant awards (FY 2017: 
        $800,000; FY 2015: $250,000)

Fostering Tribal-State Partnerships
    Your testimony discusses how the Cures Act State Targeted Response 
(STR) grant program interacts with Indian Country through state-tribal 
partnerships.

    Question 4a. Please provide a list of the states receiving STR 
funds that used tribal engagement as part of their plans for utilizing 
STR resources.
    Answer. Please see Chart below.

    Question 4b. Please provide a summary of the types of tribal 
engagement states identified as part of those STR plans.
    Answer.

------------------------------------------------------------------------
        State             State Plan Information on Tribal Engagement
------------------------------------------------------------------------
Alaska                Funding to 17 tribal health organizations
Arizona               Arizona's needs assessment included focus on the
                       Hopi Tribe and Navajo Nation in Chochino and
                       Navajo counties. As a result, the STR funds are
                       being used to address prescription drug misuse in
                       these focus areas.
California            American Indian/Native Alaskan (AI/NA) communities
                       have significant challenges in accessing MAT
                       services and their issues with the opioid
                       epidemic are also on the rise. The death rate
                       from unintentional drug poisoning is almost twice
                       as high in the AI/NA population compared to the
                       population nationally. STR project goals for
                       tribal communities include: improve MAT access;
                       increase the total number of tribal waivered
                       prescribers certified; provide expanded MAT
                       services that include tribal values, culture, and
                       treatments; provide innovative telehealth in
                       rural and underserved areas and increase
                       community capacity to support OUD prevention and
                       treatment; and, increase treatment engagement by
                       enhancing clinical decision tools using health
                       information technology.
Colorado              The State will work with the two recognized tribes
                       to help them each identify needs and develop
                       their own strategic plans.
Michigan              The State identified the following objectives: (1)
                       build the capacity of the Inter-Tribal Council
                       (ITC) Tribal OUD Prevention Initiative using
                       train the trainers combined with extensive
                       technical assistance (facilitators will be
                       trained using the Gathering of Native American
                       Model to either initiate the creation of a Tribal
                       Action Plan (TAP) or enhance existing TAP efforts
                       to focus specifically on the opioid epidemic);
                       and, (2) provide assistance with treatment costs
                       for American Indian and Alaskan Native (AI/AN)
                       under and uninsured patients with an OUD (the ITC
                       will implement the Tribal Opioid Treatment and
                       Recovery initiative using the existing Access to
                       Recovery infrastructure, entitled Anishnaabek
                       Healing Circle). 500 uninsured or underinsured AI/
                       AN OUD patients will be served.
Minnesota             A contract to provide treatment to Native
                       Americans and five contracts to provide recovery
                       support services focused on pregnant and
                       parenting women to tribes. Funds have also been
                       distributed to develop a culturally appropriate
                       awareness campaign.
Montana               The State will contract with the Rocky Mountain
                       Tribal Leaders' Council to work with Montana's
                       Peer Network to develop culturally tailored
                       version of the current peer mentoring trainings
                       and peer supervisor trainings. Rocky Mountain
                       Tribal Leader's Council will also be involved in
                       the outreach on reservations and with tribal
                       providers for the implementation of peer
                       mentoring.
Nevada                The STR Director is working with Tribal Health
                       Medical Directors to promote naloxone
                       distribution and overdose education and
                       integration with tribal primary health providers
                       and public health through sharing of data and
                       resource referral.
New Mexico            New Mexican Pueblo communities will receive
                       priority for overdose prevention education and
                       Narcan distribution. Anecdotally, opioid overdose
                       death rates on tribal lands are increasing.
                       Tribal leaders, police, community members, and
                       health and social service providers are all
                       reporting an increase in heroin and prescription
                       opioid use. Indigenous champions and local
                       ambassadors are being identified to build the
                       necessary and complex relationships with tribal
                       leaders to expand STR into those communities. The
                       State is also utilizing its Native American
                       employees to advise and consult on the project.
                       The Eight Northern Pueblos (ENP) currently
                       participate and recently Pojoaque Tribal Police
                       received training to respond to an opioid
                       overdose. The ENP are geographically located in
                       Rio Arriba and Taos Counties--Rio Arriba County
                       is consistently the county with the highest
                       overdose death rate in the United States. From
                       2012 to 2016, the mortality rate in Rio Arriba
                       County is almost 90 per 100,000. Recent
                       discussions with tribal members reinforce the
                       requirement that historical trauma will inform
                       the development of overdose prevention projects
                       with the Pueblos and be led by the community.
                       Intervention and prevention programs will be
                       coordinated with the Indian Health Service. This
                       collaboration is already in place with the
                       central hub through the ECHO project.
                       Incorporation of current trainings and
                       consultation regarding OUD treatment, addiction
                       and Chronic pain, etc. are present in the STR.
                       Finally, the State behavioral health department
                       currently holds a liaison position to ensure
                       incorporation of tribal health agencies and
                       ``638s'' and use of this liaison will occur to
                       disseminate training materials from the STR.
New York              A targeted media campaign is being supported. The
                       objectives are to: (1) conduct listening forums
                       for input in developing targeted media campaigns;
                       (2) deliver statewide media campaigns that
                       include Native American communities; (3) media
                       will focus on radio, television, digital, and
                       social media; and (4) customized messages will
                       focus on opioid overdose prevention to raise
                       awareness of the opioid crisis, educate target
                       populations on the risks and dangers of opioid
                       use; and inform individuals on how to seek and
                       access appropriate treatment and recovery
                       services.
North Dakota          The action items within the strategic plan are
                       inclusive of tribal nations. Proposals have been
                       received from two tribal nations to increase
                       access to MAT through the utilization of
                       telehealth.
Oklahoma              Targeted media campaign
South Dakota          Develop educational materials that are culturally
                       sensitive for Native Americans, and work with
                       providers and service agencies to utilize those
                       materials. Draft and issue a request for
                       proposals for a vendor to develop materials and
                       distribution. Select vendor and execute agreement/
                       implement scope of work. Distribute materials/
                       videos to Native American communities through
                       education and medical services.
Washington            Tribal Entities are part of the strategic planning
                       process and are engaged in all of the strategic
                       goals for both prevention and treatment.
Wisconsin             STR funding has been awarded to tribal entities
                       through application process to provide SUD/MAT.
                       Other STR funding initiatives will focus on
                       working within tribal communities. Areas of
                       interest we are aware of from tribes are recovery
                       coaching, naloxone training/distribution,
                       prevention, and looking to expand OUD treatment.
                       The application process for Wisconsin counties
                       and tribes is complete to apply for STR funds to
                       provide MAT, counseling and recovery support for
                       individuals on their waitlists. Approximately
                       $2.4 million was awarded to 19 counties and
                       tribes who will be able to provide MAT for 841
                       additional Wisconsin residents with OUDs.
Wyoming               Treatment and prevention activities are targeted
                       for the Wind River Reservation. Volunteers of
                       America possesses a working relationship with
                       Indian Health Service and has expressed
                       intentions in their application to enhance that
                       relationship to better serve those populations.
                       VOA is a Wellbriety Certified Treatment Center
                       through White Bison, Inc. VOA's certification
                       further enforces a positive working relationship
                       between the treatment center and regional tribes/
                       tribal entities by utilizing culturally
                       appropriate interventions.
------------------------------------------------------------------------


    Question 4c. Does SAMHSA have an estimate of what percentage of the 
funding awarded to the states identified in response to part (a) is 
being used for those tribal-specific portions of the STR plans? If so, 
please provide that estimate.
    Answer. This level of detail is not required in the STR budgets as 
tribal participation is not a statutory requirement.

    Your written testimony notes, ``We have heard from tribal leaders 
that SAMHSA also has a responsibility to improve tribal-state 
relationships.'' It then describes two efforts undertaken by the Agency 
and Assistant Secretary McCance-Katz in response to this tribal 
feedback--hosting a Tribal-State Policy Academy (TSPA) and a letter to 
state governors.

    Question 5a. Please provide more specific information about the 
TSPA, including any available information on participation, tentative 
dates or locations, and goals for the event.
    Answer. The TSPA is part of SAMHSA's approach for supporting 
improvements in tribal-state relations as well as advancing a more 
comprehensive and collaborative approach to addressing opioids and 
other substances of abuse in tribal communities. This first academy is 
planned for August 2018 and will include approximately 100 participants 
(50 state and 50 tribal representatives). Tribes and states with 
varying levels of engagement have been identified and planning is 
underway.
    On February 28, 2018, Assistant Secretary McCance-Katz sent a 
letter to governors with federally-recognized tribes within their 
borders. The letter shared the disproportionate impact of substance 
abuse on tribal communities and that addressing the behavioral health 
of American Indians and Alaska Natives is a priority. The letter 
further called upon governors to ensure that tribes, tribal 
organizations, and American Indians and Alaska Natives are engaged and 
involved in state programs in a meaningful and beneficial manner. These 
programs include the Substance Abuse Prevention and Treatment Block 
Grant and State Targeted Response to the Opioids Crisis Programs. The 
collaborative plans developed through the TSPA will help advance the 
intent of Assistant Secretary McCance-Katz's letter.

    Question 5b. How will SAMHSA and Assistant Secretary McCance-Katz 
ensure that any TSPA-identified best practices/takeaways are shared 
with states and tribes that are not able to participate directly?
    Answer. Outcomes from the TSPA will be shared with tribes and 
states immediately following the academy and as tribes and states 
complete their plans. Multiple channels will be used to disseminate 
information about the tribal-state plans and all completed plans will 
be posted on SAMHSA's website to facilitate access.

    Question 5c. What other plans or initiatives, if any, does SAMHSA 
or Assistant Secretary McCanceKatz plan to undertake to improve state-
tribal coordination for behavioral health challenges that impact both 
state and tribal communities?
    Answer. Technical assistance for tribal and state collaborators is 
planned following the TSPA to support continued engagement and progress 
on their plans. Two additional TSPAs are proposed to ensure that the 
remaining tribes and states are afforded an opportunity to develop 
collaborative plans. SAMHSA is also identifying opportunities for 
engaging tribes and states such as the State Block Grant Conference and 
other Agency events.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Heidi Heitkamp to 
                       Captain Christopher Jones
Tribal Access to SAMHSA Grants
    It is my understanding tribes must apply through their respective 
states to access State Targeted Response (STR) funds made available in 
the Cures Act. I worked with colleagues to introduce legislation to 
address this barrier for tribes and increase STR resources--the Opioid 
Response Enhancement Act (S. 2437) with Senator Baldwin.
    Question 1a. How can we better ensure tribes have access to these 
funds?
    Answer. By statute, eligibility for the State Targeted Response to 
the Opioids Crisis (Section 1003 of the 21st Century Cures Act) grant 
program is limited to states. However, on February 28, 2018, Assistant 
Secretary McCance-Katz sent a letter to governors of states with 
federally-recognized tribes within their borders. The letter shared the 
disproportionate impact of substance abuse on tribal communities and 
that addressing the behavioral health of American Indians and Alaska 
Natives is a priority. The letter further called upon governors to 
ensure that tribes, tribal organizations, and American Indians and 
Alaska Natives are engaged in state programs in a meaningful and 
beneficial manner. These programs include the Substance Abuse 
Prevention and Treatment Block Grant and State Targeted Response to the 
Opioids Crisis Programs.
    SAMHSA continues to work with states to encourage them to ensure 
tribes have access to these funds and to monitor states' compliance 
with their plans as noted in the following State Plan Information on 
Tribal Engagement. (See Table in Senator Udall's questions)
    Additionally, the Consolidated Appropriations Act, 2018 included a 
$50 million set-aside in the State Opioid Response Program for tribal 
awardees.

    Question 1b. What feedback have you received from tribal 
communities on the types of collaborations, technical assistance, and 
flexibility they need to ensure STR funds are best serving their 
communities?
    Answer. As noted in written testimony, tribal leaders have 
communicated to SAMHSA their desire to see improvements in tribal-state 
relationships. In response, SAMHSA has issued the letters to state 
governors noted above, reestablished the Addiction Technology Transfer 
Center (ATTC) Program: American Indian and Alaska Native Support Center 
Cooperative Agreement and will be hosting a Tribal-State Policy Academy 
(TSPA) to improve collaborative relationships.
    The TSPA is part of SAMHSA's approach for supporting improvements 
in tribal-state relations as well as advancing a more comprehensive and 
collaborative approach to addressing opioids and other substances of 
abuse in tribal communities. This first academy is planned for August 
2018 and will include approximately 100 participants (50 state and 50 
tribal representatives). Tribes and states with varying levels of 
engagement have been identified and planning is underway.
    Outcomes from the TSPA will be shared with tribes and states 
immediately following the academy as tribes and states complete their 
plans resulting from the TSPA. Multiple channels will be used to 
disseminate information about the tribal-state plans and all completed 
plans will be posted on SAMHSA's website to facilitate access. 
Technical assistance for tribal and state collaborators is planned 
following the TSPA to support continued engagement and progress on 
their plans. Two additional TSPAs are proposed to ensure that the 
remaining tribes and states are afforded an opportunity to develop 
collaborative plans. SAMHSA is also identifying opportunities for 
engaging tribes and states such as the State Block Grant Conference and 
other Agency events.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Tom Udall to 
                           RADM Michael Toedt
Opioid Prescription Monitoring
    Question 1. Your written testimony states that IHS has Prescription 
Drug Monitoring Program (PDMP) partnerships with 17 out of 18 states 
where federally-operated IHS facilities are located. Please identify 
the state with which IHS does not have a partnership. When does IHS 
anticipate that it will finalize a partnership with that state?
    Answer. Since August 2016, Indian Health Service (IHS) has worked 
closely with the State of Nebraska to develop a Memorandum of 
Understanding (MOU) for a PDMP partnership. In 2018, Nebraska changed 
its PDMP to a web-based system that will now allow IHS pharmacies to 
access the PDMP. IHS is waiting for the state to sign the MOU and has 
been told it is ``on the roadmap in 2018.'' IHS is eager to start 
reporting dispensing data to the State of Nebraska.

    Question 1a. Does IHS track whether states are working with 
tribally operated facilities and Urban health programs on PDMP database 
access?
    Answer. IHS does not track states' work with tribal or Urban Indian 
Organizations on PDMP access.

    Question 1b. What is IHS doing to help tribally-operated facilities 
and Urban IHS facilities develop similar partnerships with states to 
access their PDMP databases?
    Answer. IHS responds to requests for information from tribal/urban 
IHS facilities that are interested in developing MOUs with state PDMPs. 
Information includes state key contacts, MOU language, and assistance 
explaining requirements, and Health Insurance Portability and 
Accountability Act provisions related to PDMP reporting. Technical 
assistance is provided to tribal facilities that utilize the IHS 
Electronic Health Record (EHR), Resource Patient Management System 
(RPMS).

    Question 2. In FY 2017, Congress gave IHS $1 million to develop its 
own PDMP database. Your testimony mentions the ongoing development of a 
``data reporting system.'' Is the ``data reporting system'' mentioned 
in your testimony the same as the PDMP system for which Congress 
appropriated $1million in FY2017?
    Answer. The data reporting system referred to in the testimony is 
an application developed by IHS called ``Safe Opioid Monitoring.'' It 
differs from a PDMP in that it does not provide individual patient and 
prescriber level data.
    The ``Safe Opioid Monitoring'' software extracts data from the IHS 
National Data Warehouse including opioid prescription rates, naloxone 
utilization, methadone prescriptions, and percentage of opioids 
prescribed compared to all prescriptions. This tool allows IHS to 
compile selected data into user friendly reports used to monitor opioid 
metrics by service unit and area, to determine trends within IHS. These 
reports identify trends and potential areas of concern that require a 
deeper look.

    Question 2a. What is the status of IHS's efforts to launch its own 
PDMP system?
    Answer. IHS is working with the states to report to PDMPs through 
their systems and is in the planning phases for FY 2018 PDMP funding to 
enhance our current interoperability of PDMP reporting.

    Question 3. The National Indian Health Board's testimony states 
that the Board is not aware of any tribally-specific PDMP system. Their 
testimony goes on to state that the organization is not aware of IHS's 
efforts to utilize the FY 2017 funding for development of such a 
system. Is IHS communicating with tribes and urban Indian health 
programs about its efforts to develop a more robust tribal PDMP system? 
If so, how?
    Answer. Yes. In FY 2017, IHS transferred funding as tribal shares 
to support tribal PDMP improvements.
    In addition, tribes that use the IHS EHR/RPMS have access to the 
IHS PDMP platform and have the ability to submit data to state PDMPs. 
As RPMS PDMP improvements are implemented, IHS communicates the 
instructions for installation and related procedures for the software 
updates to all RPMS users, including the tribes.
Secondary Public Health Implications
    Question 4. According to a recent report highlighted by the Centers 
for Disease Control and Prevention, the increase to the growing number 
of intravenous drug users, including intravenous opiates, correlates to 
a simultaneous increase in acute hepatitis C infections. \1\ Does IHS 
have any data on changing numbers of IHS patients presenting with 
opioid or substance abuse-related blood borne infectious diseases like 
hepatitis C or HIV/AIDS? If so, please provide a summary of that data.
---------------------------------------------------------------------------
    \1\ Zibbell, Jon E., et al. ``Increases in Acute Hepatitis C Virus 
Infection Related to a Growing Opioid Epidemic and Associated Injection 
Drug Use, United States, 2004 to 2014.'' American journal of public 
health 0 (2018): e1-e7.
---------------------------------------------------------------------------
    Answer. IHS does not have data on the changing numbers of IHS 
patients presenting with opioid or substance abuse-related blood borne 
infectious diseases like hepatitis C (HCV) or HIV/AIDS. Moreover, IHS 
does not have the ability to monitor this correlation with its existing 
EHR infrastructure or personnel. However, IHS, in collaboration with 
the Centers for Disease Control and Prevention (CDC), is currently 
undertaking a vulnerability study looking at the risk of HIV or HCV 
transmission from injecting drug use.

    Question 4a. Is IHS aware of any other increases in secondary 
health complications related to rising rates of substance abuse (e.g., 
neonatal abstinence syndrome, respiratory illnesses, etc.)? If so, 
please provide a summary and description of any such secondary health 
complications.
    Answer. The IHS is in the process of quantifying the impact of 
secondary health complications related to opioids and developing 
strategies to reduce these health complications, such as Neonatal 
Abstinence Syndrome (NAS), or also known as Neonatal Opioid Withdrawal 
Syndrome (NOWS).

    Question 4b. Does IHS have a plan to address any of the increased 
demand caused by any increase in secondary health complications related 
to rising rates of substance abuse discussed above? If so, please 
provide a description of the plan here.
    Answer. The HHS five point strategy to address the opioid crisis in 
the United States is central to our response to increased demand. This 
includes:

   Improving access to prevention, treatment, and recovery 
        support services, including medication-assisted treatment;

   Targeting the availability and distribution of overdose-
        reversing drugs;

   Strengthening our understanding of the epidemic through 
        better public health data and reporting;

   Supporting cutting edge research on pain and addiction; and

   Advancing better practices for pain management.

    As part of the overall HHS strategy, IHS believes in a holistic 
approach integrating physical, mental, spiritual, and cultural 
components is essential to addressing substance use prevention, 
treatment, and recovery.
    The IHS established the Heroin, Opioids, and Pain Efforts (HOPE) 
Committee to ensure appropriate and effective pain management, reduce 
overdose deaths from heroin and prescription opioid misuse, and expand 
access to culturally appropriate treatment. The HOPE response includes 
creating guidelines, endorsing best and promising practices surrounding 
secondary complication of opioid use, creating training modules for ITU 
providers, as well as developing mechanisms to track impact of these 
interventions. In addition to the HOPE Committee, IHS has involved all 
of the departments within the Agency to be more responsive and 
effective in addressing all needs related to substance use, including 
secondary health complications.
    Specific to HCV, IHS provided all IHS facilities with Guidelines 
for Screening, Management and Pre-Treatment for HCV that can be 
modified as needed for local or regional use. This guideline follows 
national recommendations from established authorities such as the 
United States Preventive Services Task Force, CDC, and the American 
Association for the Study of Liver Diseases. In October 2017, the IHS 
Chief Medical Officer convened the first ever IHS, tribal, and urban 
Hepatitis C Elimination Workgroup, which informs overall federal 
responses and strategies.
    The IHS also actively collaborates with other federal agencies 
through MOAs to leverage resources and provide more coordinated 
approaches to the substance use crisis. For example, IHS is 
collaborating with the American Academy of Pediatrics Committee on 
Native American Child Health to develop guidelines to manage NOWS 
including early identification and referral of mothers with suspected 
opioid use disorders, obstetric care and delivery at IHS facilities, 
and care and treatment of babies born with NOWS.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Heidi Heitkamp to 
                           RADM Michael Toedt
    Rear Admiral Toedt, during the opioid roundtable the Committee held 
in November, there were a couple of points mentioned that you said you 
would look into, and I'd like to follow up on those.
    Question 1. Vice Chairman Headdress of the Fort Peck Assiniboine 
and Sioux Tribes asked why service units or tribes can't funnel some of 
their purchase and referred care (PRC) dollars for prevention and 
treatment of opioid misuse, if they have adequate means from third-
party billing. Is this a matter of flexibility or a matter of resources 
for IHS?
    Answer. The Indian Health Service (IHS) consulted with tribes on 
whether or not there should be a set-aside of Purchased/Referred Care 
(PRC) funds for prevention services. Input from this consultation 
indicated support for funding more prevention services. With this in 
mind, IHS Areas or Service Units, in consultation with the tribes, can 
decide whether they want to set-aside a percentage of their PRC program 
funds for prevention services. This would apply to either individual 
patient referrals at the local IHS Service Unit or for area-wide 
prevention services available to all IHS Service Units. The IHS area 
office and local tribes would have to consult and decide on the best 
approach.

    Question 2. I also asked you what IHS is doing to build resources 
to license practitioners to dispense methadone. You said you would get 
back to me on how many providers of Medication Assisted Treatment (MAT) 
there are within IHS and where they are located. Have you looked into 
this?
    Answer. Medication Assisted Treatment (MAT) with methadone is 
provided through Opioid Treatment Programs (OTPs), which are certified 
by the Substance Abuse and Mental Health Services Administration, 
registered by the Drug Enforcement Administration, and licensed by the 
state. MAT cannot be provided through office-based settings that are 
not OTPs. IHS has focused on buprenorphine containing products for MAT 
that are provided through office-based opioid treatment. This form of 
office-based MAT has been very effective in the treatment of opioid use 
disorders.
    Additionally, IHS is in the process of implementing a robust 
medical staff credentialing platform that will deliver the capability 
to query a national database to determine the number of federally-
credentialed IHS prescribers with Drug Addiction Treatment Act of 2000 
(DATA) waivers.
    IHS has collected information from its federal facilities and 
identified 21 providers who have a DATA waiver and are actively 
prescribing MAT in the following locations: Jicarilla Apache Health 
Care Facility in Dulce, New Mexico; Gallup Indian Medical Center in 
Gallup, New Mexico; Northern Navajo Medical Center in Shiprock, New 
Mexico; Hopi Health Center in Polacca, Arizona; Fort Duchesne Indian 
Health Center in Fort Duchesne, Utah; Southern Bands Health Center in 
Elko, Nevada; and Whiteriver Indian Hospital in Whiteriver, Arizona. In 
addition to these federal locations, it is important to note that MAT 
services are also provided through a combination of tribal, direct, and 
contract health services.
    IHS supports tracking buprenorphine prescriptions and acquisitions 
data for buprenorphine containing products. While IHS is in the final 
stages of implementing its Safe Opioid Monitoring data mart, 
preliminary data reveals that buprenorphine prescriptions have 
increased significantly. With the completion of this data mart, IHS 
will be able to determine the number of facilities providing 
buprenorphine directly to patients from IHS pharmacies.

    Question 3. Can you share the progress in data sharing and two-way 
communication between IHS and state Prescription Drug Monitoring 
Programs (PDMPs)?
    Answer. IHS has initiated a process to report (share data) and 
query (receive data) with Prescription Drug Monitoring Program (PDMP) 
partnerships in 17 out of 18 states where federally-operated IHS 
facilities are located. IHS is actively pursuing partnership with the 
last state to implement PDMP data sharing across all IHS pharmacies and 
state PDMPs.

    Question 4. When do you expect the IHS Strategic Plan will be 
finalized and published?
    Answer. The IHS Strategic Plan FY 2018-2022 is expected in 
September 2018. A final release date is subject to the feedback 
received during a 30-day public comment period, including comments from 
tribes and Urban Indian Organizations.
    On September 15, 2017, IHS consulted and conferred with tribes and 
Urban Indian Organizations on the IHS Strategic Plan. An initial 
framework was developed and IHS requested comments from tribal and 
Urban Indian Organization leaders, and IHS employees, through October 
31, 2017. In November 2017, an IHS-tribal workgroup was formed to 
review the hundreds of submitted comments and recommendations. Over a 
four month period, the workgroup developed recommendations that form 
the basis of the draft IHS Strategic Plan FY 2018-2022. IHS is in the 
process of finalizing a Federal Register Notice (FRN) asking for 
comments on the draft IHS Strategic Plan FY 2018-2022. The FRN is 
expected to be published in July 2018. IHS plans to conduct tribal 
consultation and Urban Confer sessions on the draft IHS Strategic Plan 
in July and August.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Heidi Heitkamp to 
                            Stacy A. Bohlen
    Question 1. Mr. Moose, On Tuesday, March 13th I spoke on the phone 
with Secretary Azar about IHS and what they are doing to support and 
improve services. We talked about things like workforce recruitment and 
patient wait time data. One thing he said to me is that IHS/HHS should 
target a few top priorities from the IHS Quality Framework that was 
published in late 2016 and focus on those. In your opinion, what should 
the top three priorities be to improve patient experience and outcome 
and ensure the delivery of high quality health care?
    Answer. Senator Heitkamp, thank you for the question and for your 
continued dedication to improving the quality of health services for 
all of Indian Country. Ensuring the delivery of the highest quality of 
care is a top priority across all IHS health service delivery areas, 
but is especially key in curbing the national opioid overdose epidemic. 
As you very well know, the excessive and often times indiscriminate 
prescribing of opioid analgesics for both chronic and acute pain 
symptoms were, and continue to be, a pervasive issue fueling the 
crisis. Within the Indian Health System, provider shortages--
particularly behavioral health providers who have the knowledge and 
expertise in the intersection of addiction, mental illness and public 
health--have forced an overextended health workforce to be overly 
reliant on opioid medications to treat pain, as opposed to having 
opioid medications be the last resort. According to the IHS, the 
physician vacancy rate in 2014 was 22 percent nationally, with some 
areas experiencing far higher vacancy rates.
    Access to care remains a critical need, but meeting quality of care 
goals are just as crucial. While we applaud the IHS for imposing new 
rules and procedures such as requiring all federally employed 
prescribers and dispensers to check the state prescription drug 
monitoring program, and updating the Indian Health Manual to align with 
the Centers for Disease Control and Prevention (CDC) Guideline for 
Prescribing Opioids for Chronic Pain, much more needs to be done to 
improve the delivery of high quality health care. Issues include gaps 
in the availability and infrastructure of telemedicine, underfunded and 
understaffed substance use treatment facilities, low numbers of 
providers with waivers to prescribe buprenorphine for treatment of 
opioid use disorder, inconsistent access to naloxone, and low provider 
familiarity with and implementation of the CDC Guideline.
    Undoubtedly, all five of the quality priorities embedded within the 
2016 IHS Quality Framework are essential if we are to stem the tide of 
this epidemic. Within the context of the opioid overdose epidemic, the 
three most critical priorities are to:

        1.) Strengthen Organizational Capacity to Improve Quality of 
        Care and Systems

   Providers need more training and education on the CDC 
        Guideline and on the signs, symptoms and risk factors for 
        substance misuse, addiction and overdose. Given that providers 
        are at the frontlines of this epidemic, it is critical that 
        concerted investments be made towards raising provider capacity 
        to effectively deliver care to patients in need of pain 
        management.

        2.)Align Service Delivery Processes to Improve Patient 
        Experience

   IHS efforts to align their policies with the CDC Guideline 
        are an important step towards ensuring accountability and 
        consistency in care. NIHB is hopeful that these changes will 
        lead to reductions in overprescribing, but much more needs to 
        be done to improve the patient experience overall. For 
        instance, high provider turnover and chronic workforce 
        shortages pose significant barriers and create disparities in 
        the quality of care. In addition, limited attention to 
        wraparound and comprehensive care that includes mental health 
        treatment, case management, job training and housing services 
        mean that patients are encountering gaps across the care 
        continuum.

    3.) Ensure Patient Safety

   The crux of reducing unsafe and ineffective prescribing of 
        opioids is ensuring patient safety. Too often has provider 
        misconduct and malpractice led to tragic and yet largely 
        preventable deaths within the Indian Health System. NIHB 
        encourages Congress to review reports from the United States 
        Department of Health and Human Services Office of Inspector 
        General on deficiencies in system security and physical 
        controls at IHS hospitals and how this impacts patient safety.
                                 ______
                                 

    *Responses to the following questions were not available at the 
time this hearing went to print*

           Written Questions Submitted by Hon. Tom Udall to 
                         Hon. John C. Anderson
Opioid Funding and Utilization in Indian Country
    Question 1. The Department of Justice's FY2019 Budget Request 
summary states, ``[The Department's FY2019 Budget Request] provides the 
needed resources so that Federal, state, local and trial law 
enforcement agencies can fight the opioid epidemic that is destroying 
neighborhoods.'' \1\
---------------------------------------------------------------------------
    \1\ Staff of Dep't of Just., 2019 Budget Summary (2018). Available 
at https://www.justice.gov/jmd/page/file/1033086/download#page=2.

        a. Please summarize how this Budget Request reflects the stated 
---------------------------------------------------------------------------
        goal of addressing the opioid epidemic in tribal communities.

        b. What additional law enforcement and prosecution resources, 
        if any, does this Budget Request propose specifically for 
        tribal communities?

        c. Did the Department consult with tribes about design of the 
        opioid epidemic response proposals included in this Budget 
        Request?

        d. Did the Department, its budget and performance personnel, 
        its law enforcement agencies, or the Executive Office for 
        United States Attorneys coordinate with the Department of the 
        Interior's Bureau of Indian Affairs-Office of Justice Services 
        in the design of proposals for Indian country in this Budget 
        Request?

    Question 2. Your written testimony states, ``An important element 
of the Department's support [for response to the opioid crisis] is 
providing opportunities for funding.'' It goes on to include several 
references to Department programs that grantees can use to address the 
opioid crisis--including Drug Courts funding and Office of Justice 
Programs' Comprehensive Opioid Abuse Program. The testimony highlights 
two tribal grantees under these programs. Please provide detailed 
information on how much funding the Department awards to tribal 
grantees for drug courts and substance abuse prevention, including a 
list of tribes that receive such funds and estimates of the amount of 
funding available to each such tribal grantee.
Investigations and Prosecutions of Crimes on Indian lands
    Question 3. At the hearing, several Members of the Committee 
discussed case referral statistics included in a December 2017 report 
issued by the Department's Office of the Inspector General. \2\ This 
report includes a description of the numbers of investigations referred 
to U.S. Attorney Offices (USAOs) for prosecution by various law 
enforcement agencies.
---------------------------------------------------------------------------
    \2\ Staff of Dep't of Just., Review of the Department's Tribal Law 
Enforcement Efforts Pursuant to the Tribal Law and Order Act of 2010 11 
(2017). Available at https://oig.justice.gov/reports/2017/e1801.pdf.

        a. Please provide an estimate of the number of investigations 
        referred to USAOs by the Bureau of Indian Affairs, the Drug 
        Enforcement Administration, the Federal Bureau of 
        Investigation, and Tribal law enforcement in CY 2015, CY 2016, 
---------------------------------------------------------------------------
        and (if available) CY 2017.

        b. Please provide information on the types of investigations 
        most frequently referred to USAOs by the law enforcement 
        agencies listed in part (a) and, if possible, an estimate of 
        the percentage of referred cases that are related to drug 
        crimes.

    Question 4. The same report notes that the number of declinations 
for prosecution of crimes in Indian country by USAOs increased by 20 
percent from CY 2013 to CY 2015. \3\ Please provide an estimate of the 
number of declinations and the number of defendants against whom 
charges were filed for crimes in Indian country nationally in CY 2016 
and, if available, CY 2017.
---------------------------------------------------------------------------
    \3\ Id. at 10.
---------------------------------------------------------------------------
                                 ______
                                 
          Written Questions Submitted by Hon. Heidi Heitkamp 
                         Hon. John C. Anderson
    Question 1. I hear one consistent from all five tribes in North 
Dakota when it comes to drugs--not just opioids--but drugs in general. 
. . . ``Please help us, we are being overrun''. I know the 
jurisdictional challenges, the lack of law enforcement on the 
reservations, little to no DEA presence, lack of detention and 
treatment facilities, and the tendency for U.S. Attorney's Offices to 
not pursue dealers arrested with small quantities on the reservation.

    (a) When you hear and know all of this--do you think we can 
honestly say that we are upholding our treaty responsibilities to our 
tribes? Do you truly think that the Department of Justice is doing 
everything it can to shut down the drug trafficking problem in Indian 
Country?

    (b) Do you think we need more FBI and DEA agents available to 
assist in these types of crimes and investigations in Indian Country in 
order to stem the flow of illicit drugs? Do you agree that FBI and DEA 
agents should be forming relationships with our tribes and operating on 
the reservation as much as possible as opposed to only responding in a 
crisis or in response to a major crime?

    (c) You mentioned HIDTA Drug Task forces in your testimony--do you 
know how many of these task forces are currently operating within 
Indian Country? My understanding is that right now in North Dakota the 
number is zero--is that acceptable if we all admit that there is a 
problem of illicit drugs flowing freely into and through Indian 
Country?

    (d) DOJ also has Safe Trails Task Forces that are specifically 
focused on combatting in crime in Indian Country--do you know how many 
Safe Trails Task Forces we have in North Dakota? Zero. So why is DOJ 
not doing everything in their power to stand up as many of these Task 
Forces as possible to address the supply side of the illicit drug 
problem in Indian Country?
                                 ______
                                 
          Written Questions Submitted by Hon. Lisa Murkowski 
                         Hon. John C. Anderson
    Thank you Mr. Chairman and gentlemen thank you all for what you do, 
respectively. I apologize I was not able to hear some of the questions 
from my colleagues. But again, these are issues that are so key and so 
important and I appreciate your testimony. Thank you Captain Jones for 
mentioning the Project Hope Program and how it is working or helping in 
Alaska. In my opening statement, I didn't just talk about the opioid 
epidemic and how that's ravaged our communities. I also talked about 
alcohol and how it seems to be an underlying issue in Alaska.
    I will just cite to our annual drug report that says acknowledges 
there is a multi-faceted drug abuse problem in the state and that drug 
abusers in Alaska tend to abuse more than one substance. Often times 
they are abusing multiple drugs at once. The Alaska State Troopers 
emphasized in their report that alcohol was the single most abused 
substance. So as we have been focusing our efforts here in Congress on 
opioids, I don't want us to lose sight of the fact that there is an 
underlying issue and that is alcohol. We have to provide the support 
for programs and grants in that alcohol space as well and so when we're 
talking about substance abuse, we have to make sure that we are talking 
about alcohol and substance abuse programs, too. Everyone in the crowd 
is shaking their heads, like they agree with me.
    We don't need to bifurcate all of these drug issues. We all have 
one big, ugly, horrible problem that we are dealing with. Let me ask 
you this, I'll call it a workforce issue, but our reality is that we 
have identified the problem and some of the solutions. But, we know 
that so much of this comes back to making sure that we have mental 
health professionals that are able to be there to and support those who 
need it. I have been working with my colleague from Indiana, Senator 
Donnelly, on an effort that would incentivize those to go into the 
field and work to find the best treatments for substance use disorders. 
Basically, it's a loan forgiveness program that we think will be 
helpful in incentivizing more people to enter the mental health 
profession. I have to assume that part of the challenges that we're 
facing is we simply don't have enough mental health professionals to 
address the substance abuse epidemic in the United States. I'm also 
getting head nods for this too.
    Question. So, here's my question to you and this is this is 
intended to help at least three individuals that are in the audience. 
One of which I have met with and she is the Mayor of Utqiagvik. She, 
and two others that are part of her council, met with us today and 
they've mentioned that Utqiagvik has an issue with drugs, not just 
opioids. They said that we can't single out a single drug from a law 
enforcement perspective and I'll look to you Mr. Anderson to answer 
this. They are saying that they don't have a district attorney and 
they're (the City of Utqiagvik) is responsible for the prosecution of 
these drug offenses and they are not moving forward as fast as they 
would like because the drugs are coming in by mail the drugs and by 
plane. And that's it. We know how they get in, but because we can't get 
attention on anything unless it's at full federal, full felony level, 
that people think they can get away with selling and dealing. They can 
use and there's no here's no follow up and no consequence. What would 
you tell the Mayor of Utqiagvik?

                                  [all]