    [House Hearing, 117 Congress]
    [From the U.S. Government Publishing Office]

      AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND
                         MISUSE IN AMERICA

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

                                VIRTUAL HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 FIRST SESSION

                                   ----------

                                 APRIL 14, 2021

                                   ----------

                               Serial No. 117-20

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

         Published for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

     AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND MISUSE
                                   IN AMERICA

     AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND MISUSE
                                   IN AMERICA

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

                                VIRTUAL HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 APRIL 14, 2021

                                   __________

                               Serial No. 117-20

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

         Published for the use of the Committee on Energy and Commerce

                       govinfo.gov/committee/house-energy
                            energycommerce.house.gov

                               ______

                  U.S. GOVERNMENT PUBLISHING OFFICE
    47-023 PDF              WASHINGTON : 2022

                        COMMITTEE ON ENERGY AND COMMERCE

                         FRANK PALLONE, Jr., New Jersey
                                     Chairman
    BOBBY L. RUSH, Illinois              CATHY McMORRIS RODGERS, Washington
    ANNA G. ESHOO, California              Ranking Member
    DIANA DeGETTE, Colorado              FRED UPTON, Michigan
    MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
    JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
    G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
    DORIS O. MATSUI, California          BRETT GUTHRIE, Kentucky
    KATHY CASTOR, Florida                DAVID B. McKINLEY, West Virginia
    JOHN P. SARBANES, Maryland           ADAM KINZINGER, Illinois
    JERRY McNERNEY, California           H. MORGAN GRIFFITH, Virginia
    PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
    PAUL TONKO, New York                 BILL JOHNSON, Ohio
    YVETTE D. CLARKE, New York           BILLY LONG, Missouri
    KURT SCHRADER, Oregon                LARRY BUCSHON, Indiana
    TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
    RAUL RUIZ, California                RICHARD HUDSON, North Carolina
    SCOTT H. PETERS, California          TIM WALBERG, Michigan
    DEBBIE DINGELL, Michigan             EARL L. ``BUDDY'' CARTER, Georgia
    MARC A. VEASEY, Texas                JEFF DUNCAN, South Carolina
    ANN M. KUSTER, New Hampshire         GARY J. PALMER, Alabama
    ROBIN L. KELLY, Illinois, Vice       NEAL P. DUNN, Florida
        Chair                            JOHN R. CURTIS, Utah
    NANETTE DIAZ BARRAGAN, California    DEBBBIE LESKO, Arizona
    A. DONALD McEACHIN, Virginia         GREG PENCE, Indiana
    LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
    DARREN SOTO, Florida                 JOHN JOYCE, Pennsylvania
    TOM O'HALLERAN, Arizona              KELLY ARMSTRONG, North Dakota
    KATHLEEN M. RICE, New York
    ANGIE CRAIG, Minnesota
    KIM SCHRIER, Washington
    LORI TRAHAN, Massachusetts
    LIZZIE FLETCHER, Texas
                                     ------

                               Professional Staff

                       JEFFREY C. CARROLL, Staff Director
                    TIFFANY GUARASCIO, Deputy Staff Director
                      NATE HODSON, Minority Staff Director
                             Subcommittee on Health

                           ANNA G. ESHOO, California
                                    Chairwoman
    G. K. BUTTERFIELD, North Carolina    BRETT GUTHRIE, Kentucky
    DORIS O. MATSUI, California            Ranking Member
    KATHY CASTOR, Florida                FRED UPTON, Michigan
    JOHN P. SARBANES, Maryland, Vice     MICHAEL C. BURGESS, Texas
        Chair                            H. MORGAN GRIFFITH, Virginia
    PETER WELCH, Vermont                 GUS M. BILIRAKIS, Florida
    KURT SCHRADER, Oregon                BILLY LONG, Missouri
    TONY CARDENAS, California            LARRY BUCSHON, Indiana
    RAUL RUIZ, California                MARKWAYNE MULLIN, Oklahoma
    DEBBIE DINGELL, Michigan             RICHARD HUDSON, North Carolina
    ANN M. KUSTER, New Hampshire         EARL L. ``BUDDY'' CARTER, Georgia
    ROBIN L. KELLY, Illinois             NEAL P. DUNN, Florida
    NANETTE DIAZ BARRAGAN, California    JOHN R. CURTIS, Utah
    LISA BLUNT ROCHESTER, Delaware       DAN CRENSHAW, Texas
    ANGIE CRAIG, Minnesota               JOHN JOYCE, Pennsylvania
    KIM SCHRIER, Washington              CATHY McMORRIS RODGERS, Washington
    LORI TRAHAN, Massachusetts               (ex officio)
    LIZZIE FLETCHER, Texas
    FRANK PALLONE, Jr., New Jersey (ex
        officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Anna G. Eshoo, a Representative in Congress from the State
      of California, opening statement...............................     2
        Prepared statement...........................................     2
    Hon. Ann M. Kuster, a Representative in Congress from the State
      of New Hampshire, prepared statement...........................     3
    Hon. Brett Guthrie, a Representative in Congress from the
      Commonwealth of Kentucky, opening statement....................     4
        Prepared statement...........................................     5
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     6
        Prepared statement...........................................     8
    Hon. Cathy McMorris Rodgers, a Representative in Congress from
      the State of Washington, opening statement.....................     9
        Prepared statement...........................................    10

                                   Witnesses

    Regina M. LaBelle, Acting Director, White House Office of
      National Drug Control Policy...................................    12
        Prepared statement...........................................    14
        Answers to submitted questions...............................   308
    Geoffrey Laredo, Principal, Santa Cruz Strategies, LLC...........    78
        Prepared statement...........................................    81
        Answers to submitted questions...............................   312
    Patricia L. Richman, National Sentencing Resource Counsel,
      Federal Public and Community Defenders.........................    88
        Prepared statement...........................................    90
    Mark Vargo, Pennington County, S.D., State's Attorney, and Chair,
      Legislative Committee, National District Attorneys Association.    96
        Prepared statement...........................................    98
    Timothy Westlake, M.D., Emergency Department Medical Director,
      ProHealth Care Oconomowoc Memorial Hospital....................   115
        Prepared statement...........................................   118
    Deanna Wilson, M.D., Assistant Professor of Medicine and
      Pediatrics, University of Pittsburgh School of Medicine........   132
        Prepared statement...........................................   134
        Answers to submitted questions...............................   315

                               Submitted Material

    H.R. 654, the Drug-Free Communities Pandemic Relief Act,
      submitted by Ms. Eshoo\1\
    H.R. 955, the Medicaid Reentry Act of 2021, submitted by Ms.
      Eshoo\1\
    H.R. 1384, the Mainstreaming Addiction Treatment Act of 2021,
      submitted by Ms. Esho\1\
    H.R. 1910, the Federal Initiative to Guarantee Health by
      Targeting Fentanyl Act, submitted by Ms. Eshoo\1\
    H.R. 2051, the Methamphetamine Response Act, submitted by Ms.
      Eshoo\1\
    H.R. 2067, the Medication Access and Training Expansion Act,
      submitted by Ms. Eshoo\1\
    H.R. 2355, the Opioid Prescription Verification Act, submitted by
      Ms. Eshoo\1\

    ----------

    \1\ The proposed legislation has been retained in committee files and
    is available at https://docs.house.gov/Committee/Calendar/
    ByEvent.aspx?EventID=111439.
    H.R. 2364, the Synthetic Opioid Danger Awareness Act, submitted
      by Ms. Eshoo\1\
    H.R. 2366, the Support, Treatment, and Overdose Prevention of
      Fentanyl Act of 2021, submitted by Ms. Eshoo\1\
    H.R. ___, the State Opioid Response Grant Reauthorization Act,
      submitted by Ms. Eshoo\1\
    H.R. ___, the Streamlining Research on Controlled Substances Act,
      submitted by Ms. Eshoo\1\
    Letter of April 13, 2021, from Ellen Glover, Drug Policy, Harm
      Reduction and Criminal Justice Campaign Director, People's
      Action, to Ms. Eshoo, submitted by Ms. Eshoo...................   171
    Letter of April 13, 2021, from Senator Cory A. Booker, et al., to
      President Biden, submitted by Ms. Eshoo........................   174
    Statement of the American Property Casualty Insurance
      Association, April 14, 2021, submitted by Ms. Eshoo............   177
    Letter of March 2, 2021, from David Patton and Jon Sands, Co-
      Chairs, Federal Defenders Legislative Committee, to Alyssa M.
      Hundrup, Acting Director, Health Care, Government
      Accountability Office, submitted by Ms. Eshoo..................   178
    Letter of April 14, 2021, from Dave Yost, Ohio Attorney General,
      to Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo...........   186
    Statement of the American Academy of PAs, April 14, 2021,
      submitted by Ms. Eshoo.........................................   188
    Letter of April 14, 2021, from Katherine McGuire, Chief Advocacy
      Officer, American Psychological Associationm to Ms. Eshoo and
      Mr. Guthrie, submitted by Ms. Eshoo............................   191
    Statement of Bill Greer, President, SMART Recovery USA, April 14,
      2021, submitted by Ms. Eshoo...................................   193
    Letter from Brenda Siegel to Subcommittee on Health, submitted by
      Ms. Eshoo......................................................   197
    Letter of April 14, 2021, from Jeffrey A. Singer, Senior Fellow,
      Department of Health Policy Studies, Cato Institute, to Ms.
      Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..................   200
    Letter of April 8, 2021, from A Little Piece of Light (NY), et
      al., to Chairman Richard Durbin, Senate Judiciary Committee, et
      al., submitted by Ms. Eshoo....................................   207
    Statement of Sandra D. Comer, Professor of Neurobiology (in
      Psychiatry), Columbia University Irving Medical Center, New
      York State Psychiatric Institute, April 14, 2021, submitted by
      Ms. Eshoo......................................................   216
    Letter of April 14, 2021, from Grant Smith, Deputy Director,
      National Affairs, Drug Policy Alliance, to Ms. Eshoo and Mr.
      Guthrie, submitted by Ms. Eshoo................................   227
    Statement of the American Nurses Association, April 14, 2021,
      submitted by Ms. Eshoo.........................................   232
    Report of the National Association of Assistant United States
      Attorneys, ``Fentanyl Scheduling Charge and Response,''
      submitted by Ms. Eshoo.........................................   234
    Letter of April 14, 2021, from Lawrence J. Leiser, President,
      National Association of Assistant United States Attorneys, to
      Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo..............   238
    Letter of April 14, 2021, from Elizabeth Connolly, Director,
      Substance Use Prevention and Treatment Initiative, Pew
      Charitable Trusts, to Ms. Eshoo and Mr. Guthrie, submitted by
      Ms. Eshoo......................................................   240
    Letter of December 11, 2019, from the National Association of
      Attorneys General to Senators Lindsey Graham and Diane
      Feinstein, submitted by Ms. Eshoo..............................   244
    Letter of August 5, 2019, from the National Association of
      Attorneys General to Rep. Nancy Pelosi, et al., submitted by
      Ms. Eshoo......................................................   249
    Letter of April 13, 2021, from Mary R. Grealy, President,
      Healthcare Leadership Council, to Ms. Eshoo and Mr. Guthrie,
      submitted by Ms. Eshoo.........................................   255
    Statement of Margaret Rizzo, Executive Director/Chief Executive
      Officer, JSAS HealthCare, April 12, 2021, submitted by Ms.
      Eshoo..........................................................   257

    ----------

    \1\ The proposed legislation has been retained in committee files and
    is available at https://docs.house.gov/Committee/Calendar/
    ByEvent.aspx?EventID=111439.
    Letter of April 13, 2021, from Erin Schanning, President, End
      Substance Use Disorder, to Mr. Pallone and Mrs. Rodgers,
      submitted by Ms. Eshoo.........................................   259
    Letter of April 14, 2021, from Senator Telena Cruz Nelson to Mr.
      Pallone re: H.R. 955, submitted by Ms. Eshoo...................   266
    Letter of April 14, 2021, from Senator Telena Cruz Nelson to Mr.
      Pallone re: H.R. 2355, et al., submitted by Ms. Eshoo..........   267
    Letter of April 13, 2021, from Association for Behavioral Health
      and Wellness, et al., to Xavier Becerra, Secretary, Department
      of Health and Human Services, submitted by Ms. Eshoo...........   268
    Letter of April 13, 2021, from Ryan Marino, Assistant Professor,
      Departments of Emergency Medicine & Psychiatry, Case Western
      Reserve University School of Medicine, to Congressional
      Policymakers, submitted by Ms. Eshoo...........................   272
    Statement of the Medication Assisted Treatment Leadership
      Council, April 14, 2021, submitted by Ms. Eshoo................   274
    Statement of the National Safety Council, April 14, 2021,
      submitted by Ms. Eshoo.........................................   279
    Letter of April 13, 2021, from Daniel Raymond, Director of
      Policy, National Viral Hepatitis Roundtable, to the
      Subcommittee on Health, submitted by Ms. Eshoo.................   285
    Letter of April 13, 2021, from Marcia Lee Taylor, Chief External
      and Government Relations Officer, Partnership to End Addiction,
      to Ms. Eshoo and Mr. Guthrie, submitted by Ms. Eshoo...........   287
    Statement of Shatterproof, April 14, 2021, submitted by Ms. Eshoo   290
    Statement of Charles Ingoglia, President and Chief Executive
      Officer, National Council for Behavioral Health, April 14,
      2021, submitted by Ms. Eshoo...................................   292
    Article of April 12, 2021, ``Biden Looks to Extend Trump's
      Bolstered Mandatory Minimum Drug Sentencing,'' by Akela Lacy,
      The Intercept, submitted by Ms. Eshoo..........................   293
    Commentary of February 25, 2021, ``X the X-Waiver: How Congress
      can facilitate treatment for opioid abuse,'' by Mike Hunter and
      Josh Stein, The Hill, submitted by Ms. Eshoo...................   297
    Statement of Timothy B. Conley and Dr. Debbie Akerman, Wurzweiler
      School of Social Work, Yeshiva University, April 14, 2021,
      submitted by Ms. Eshoo.........................................   300
    Report of the Government Accounting Office, ``Synthetic Opioids:
      Considerations for the Class-Wide Scheduling of Fentanyl-
      Related Substances,'' April 2021, submitted by Ms. Eshoo 1A\2\
    Letter of February 9, 2021, from Lemrey ``Al'' Carter, Executive
      Director/Secretary, National Association of Boards of Pharmacy,
      to Mr.Tonko, submitted by Ms. Eshoo............................   306

    ----------

    \2\ The report has been retained in committee files and is available at
    https://docs.house.gov/meetings/IF/IF14/20210414/111439/HHRG-117-IF14-
    20210414-SD021.pdf.

     AN EPIDEMIC WITHIN A PANDEMIC: UNDERSTANDING SUBSTANCE USE AND MISUSE
                                   IN AMERICA

                                  ----------

                           WEDNESDAY, APRIL 14, 2021

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:29 a.m., via
    Cisco Webex online video conferencing, Hon. Anna G. Eshoo
    (chairwoman of the subcommittee) presiding.
        Members present: Representatives Eshoo, Butterfield,
    Matsui, Castor, Sarbanes, Welch, Schrader, Cardenas, Ruiz,
    Dingell, Kuster, Kelly, Barragan, Blunt Rochester, Craig,
    Schrier, Trahan, Fletcher, Pallone (ex officio), Guthrie
    (subcommittee ranking member), Upton, Burgess, Griffith,
    Bilirakis, Long, Bucshon, Mullin, Hudson, Carter, Dunn, Curtis,
    Joyce, and Rodgers (ex officio).
        Also present: Representatives Tonko, O'Halleran, and Latta.
        Staff present: Joe Banez, Professional Staff Member;
    Jeffrey C. Carroll, Staff Director; Waverly Gordon, General
    Counsel; Tiffany Guarascio, Deputy Staff Director; Perry
    Hamilton, Clerk; Mackenzie Kuhl, Digital Assistant; Aisling
    McDonough, Policy Coordinator; Meghan Mullon, Policy Analyst;
    Kaitlyn Peel, Digital Director; Tim Robinson, Chief Counsel;
    Chloe Rodriguez, Clerk; Kimberlee Trzeciak, Chief Health
    Advisor; Caroline Wood, Staff Assistant; C.J. Young, Deputy
    Communications Director; Sarah Burke, Minority Deputy Staff
    Director; Theresa Gambo, Minority Financial and Office
    Administrator; Grace Graham, Minority Chief Counsel, Health;
    Caleb Graff, Minority Deputy Chief Counsel, Health; Nate
    Hodson, Minority Staff Director; Peter Kielty, Minority General
    Counsel; Emily King, Minority Member Services Director; Clare
    Paoletta, Minority Policy Analyst, Health; Kristin Seum,
    Minority Counsel, Health; Kristen Shatynski, Minority
    Professional Staff Member, Health; Olivia Shields, Minority
    Communications Director; Michael Taggart, Minority Policy
    Director; and Everett Winnick, Minority Director of Information
    Technology.
        Ms. Eshoo. The Subcommittee on Health will now come to
    order. And due to the COVID-19, today's hearing is being held
    remotely. All Members and witnesses will be participating via
    video conferencing.
        As part of our hearing, microphones will be set on mute to
    eliminate background noise. Members and witnesses need to
    remember to unmute your microphone each time you wish to speak.
    Documents for the record should be sent to Meghan Mullon at the
    email address that we provided to your staff, and all documents
    will be entered into the record at the conclusion of the
    hearing.
        The Chair now recognizes herself for 5 minutes for an
    opening statement.

     OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF CALIFORNIA

        According to recently reported data from the CDC, overdose
    deaths spiked after the start of the pandemic. From September
    2019 through August 2020, there were over 88,000 overdose
    deaths, with 2020 being the deadliest year for overdoses on
    record. These are really stunning numbers. So we are in an
    addiction crisis during a COVID crisis.
        In 2016 Congress passed the 21st Century Act and CARA, C-A-
    R-A, and the SUPPORT Act in 2018 to stem the tide of addiction
    and the devastation that the opioid crisis has created.
    Congress also provided over $8 billion--with a B--to address
    opioid use and mental and behavioral healthcare through the
    American Rescue Plan in the fiscal year 2021 Appropriations
    Act.
        Yet despite our legislative efforts to increase access to
    evidence-based treatment, according to a National Academies of
    Science report, more than 80 percent of the 2 million people
    with opioid use disorder are not receiving medication-assisted
    treatment.
        Today we are going to hear from the Acting Director of the
    Office of National Drug Control Policy about where and why
    previous efforts have fallen short and what the Biden-Harris
    administration believes we need to do to save lives.
        We will also consider 11 bills, many bipartisan, to address
    the opioid crisis. According to the CDC, three in five people
    who died from overdose had an identified opportunity for care
    or other lifesaving actions.
        And we know that Representative Tonko and Trahan's
    bipartisan bills will ensure more doctors are trained and able
    to prescribe the medication-assisted treatment that we know
    saves lives.
        Those who are released from prisons and jails are 12 times
    more likely to die of an overdose than the general public,
    because they often have no access to treatment upon release.
    The bipartisan Medicaid Reentry Act addresses these inequities
    by extending Medicaid eligibility to incarcerated individuals
    30 days before release.
        And lastly, we are considering bills to address the
    upcoming expiration of the temporary placement of all fentanyl-
    related substances in schedule I. Despite the temporary
    scheduling, deaths from fentanyl analogues rose by 10 percent.
    So clearly, scheduling is not the silver bullet and Congress
    has to consider alternatives to stop synthetic opioids.
        [The prepared statement of Ms. Eshoo follows:]

                    Prepared Statement of Hon. Anna G. Eshoo

        According to recently reported data from the CDC, overdose
    deaths spiked after the start of the pandemic. From September
    2019 through August 2020, there were over 88,000 overdose
    deaths, with 2020 being the deadliest year for overdoses on
    record. We're in an addiction crisis amid the COVID-19 crisis.
        In 2016 Congress passed the 21st Century Cures Act and
    CARA, and the SUPPORT Act in 2018 to stem the tide of addiction
    and devastation that the opioid crisis has created. Congress
    also provided over $8 billion to address opioid use and mental
    and behavioral healthcare through the American Rescue Plan and
    the FY 2021 Appropriations Act.
        Yet, despite our legislative efforts to increase access to
    evidence-based treatment, according to a National Academies of
    Science report, more than 80 percent of the 2 million people
    with opioid use disorder are not receiving medication-assisted
    treatment.
        Today we will hear from Acting Director of the Office of
    National Drug Control Policy (ONDCP) about where and why
    previous efforts have fallen short, and what the Biden-Harris
    administration believes we need to do to save lives.
        We'll also consider 11 bills, many bipartisan, to address
    the opioid crisis. According to the CDC, 3 in 5 people who died
    from overdose had an identified opportunity for care or other
    life-saving actions.
        Representative Tonko and Trahan's bipartisan bills will
    ensure more doctors are trained and able to prescribe the
    medication-assisted treatment that we know saves lives.
        Those who are released from prisons and jail are 12 times
    more likely to die of an overdose than the general public
    because they often have no access to treatment upon release.
    The bipartisan Medicaid Reentry Act addresses these inequities
    by extending Medicaid eligibility to incarcerated individuals
    30 days before release.
        And lastly, we're considering bills to address the upcoming
    expiration of the temporary placement of all fentanyl-related
    substances in schedule I. Despite the temporary scheduling,
    deaths from fentanyl analogues rose by 10%, so clearly
    scheduling is not the silver bullet and Congress has to
    consider alternatives to stop synthetic opioids.
        I yield the rest of my time to the sponsor of the STOP
    Fentanyl Act of 2021, Representative Annie Kuster.

        Ms. Eshoo. I now yield the rest of my time--I don't know
    how much is left--to the sponsor of the STOP Fentanyl Act of
    2021, Representative Annie Kuster.
        Ms. Kuster. Thank you so much, Chairwoman Eshoo. As we are
    all too well aware, the pandemic has exacerbated the already
    dire addiction and mental health crises in our country. From
    August 2019 to August 2020, 88,000 Americans died of an
    overdose, the highest number ever recorded over a 12-month
    period.
        But we also know the addiction and overdose crisis in this
    country did not occur overnight. It has devastated communities
    in my State of New Hampshire and across the U.S. for decades.
    What began as an opioid crisis has evolved to an epidemic that
    knows no bounds. It impacts every community, no matter the
    race. It is cross-regional and intergenerational.
        The complexity of this epidemic is urgent. Overdose deaths
    due to synthetic opioids such as fentanyl and fentanyl
    analogues have continued to rise. And what we have learned in
    New Hampshire is there is no silver bullet. It is an all-hands-
    on-deck approach, and any serious solution must look at
    comprehensive reforms to both public health and our criminal
    justice system.
        And that is why I am so pleased to see my bill, the
    Support, Treatment, and Overdose Prevention of Fentanyl Act,
    included in today's hearing. I look forward to discussing it
    more, and thank you, Chairwoman Eshoo, for this time and I--
    including my bill to support public health and public safety
    efforts into responding to fentanyl. It will be a real game
    changer.
        [The prepared statement of Ms. Kuster follows:]

                    Prepared Statement of Hon. Ann M. Kuster

        Thank you, Chairwoman Eshoo.
        As we are all too well aware, the pandemic has exacerbated
    the already dire addiction and mental health crises in our
    country.
        From August 2019 to August 2020, 88,000 Americans died of
    an overdose. This is the highest number ever recorded over 12
    months.
        But we also know the addiction and overdose crisis in this
    country did not occur overnight: It has devastated communities
    in New Hampshire and across the US for over a decade.
        What began as an opioid crisis has evolved to an epidemic
    that knows no bounds: It impacts every community, no matter the
    race. It is cross-regional, and it is intergenerational.
        The complexity of this epidemic is urgent: overdose deaths
    due to synthetic opioids such as fentanyl and fentanyl
    analogues have continued to rise, and what we have learned in
    New Hampshire is that there is no silver bullet--it's an all
    hands on deck approach, and any serious solution must also look
    at comprehensive reforms to both our public health and criminal
    justice system.
        That is why I am pleased to see my bill, the Support,
    Treatment, and Overdose Prevention of Fentanyl Act, included in
    today's hearing.
        I look forward to discussing it more, and hope that all of
    my colleagues recognize the urgency of this crisis.
        Thank you, Chairwoman Eshoo, for the time, and including my
    bill to support both public health and public safety efforts in
    responding to fentanyl. This can be a real game changer, and I
    am grateful for the opportunity to discuss this legislation
    today.

        Ms. Kuster. And I yield back.
        Ms. Eshoo. Well, thank you, Annie. You have been and
    continue to be an important leader on the whole issue of
    opioids, and we are all very grateful to you.
        The Chair is now pleased to recognize Mr. Guthrie, the
    ranking member of the Subcommittee on Health, for 5 minutes for
    his opening statement.
        Good morning to you.

     OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN
               CONGRESS FROM THE COMMONWEALTH OF KENTUCKY

        Mr. Guthrie. Good morning. Good morning, Chair Eshoo, and
    thank you for holding this important hearing today.
        It is devastating that we have lost more than 550,000
    Americans due to COVID-19. Sadly, we have another epidemic that
    has claimed around the same number of lives over the past two
    decades: the opioid crisis. We are hearing from public health
    providers that the COVID-19 pandemic has exacerbated this
    crisis. The CDC recently reported that--over 88,000 overdose
    deaths over the past year, ending in May of 2020, which is the
    highest number of overdose deaths in a 12-month time.
        In 2019 addiction and substance use disorders affected over
    20 million Americans, 10 million of which experienced opioid
    misuse. Last year we sadly saw that number increase even more.
    According to the CDC, we have had three waves of the opioid
    epidemic. First we saw the rise in prescription opioids. Then
    in 2010 we began to see the rise in heroin. And currently we
    are in the third wave, which includes the rise of synthetic
    opioids, which often includes deadly forms of fentanyl.
        My home State of Kentucky has seen some of the highest
    numbers of substance use disorder deaths. One Kentucky
    substance abuse provider group that my office spoke to shared
    that they have lost more patients to overdose during the
    pandemic than they had in the last 5 years. CDC compared the
    death by drug overdose rates over a 12-month period between
    August 2019 and August 2020. In August 2019, Kentucky and 1,307
    overdose deaths; one year later, that number was 1,874.
    Unfortunately, Kentucky is not alone with these increases.
        This committee has worked in a bipartisan way to authorize
    many programs to decrease overdose deaths. But more work needs
    to be done. Specifically, the Energy and Commerce Committee
    authorized the 21st Century Cures Act, the Comprehensive
    Addiction Recovery Act, and the SUPPORT Act for Patients and
    Communities--Communities Act to combat the opioid epidemic.
    Included in the final SUPPORT Act was my bill, the
    Comprehensive Opioid Recovery Act Centers of 2018, which
    authorized the creation of comprehensive opioid recovery
    centers throughout the Nation. This program is currently being
    implemented and provides evidence-based comprehensive care for
    those with substance use disorders.
        Overall, these laws continue to provide critical funding
    and authorizations to help address substance use disorder
    treatment, recovery, and prevention.
        I think it is important for us to look back and fully
    examine these laws and evaluate where we are and where we are
    headed. And while we have 11 new bills before us today, we must
    also examine current authorizations.
        One of these current authorizations is the extension of the
    temporary emergency scheduling of fentanyl analogues. Synthetic
    opioids, which includes fentanyl analogues, were involved in
    744 deaths in Kentucky in 2018. Fentanyl analogues are very
    dangerous, due to their potency, and often come across our
    borders illegally only to harm Americans. Just last month a 2-
    year-old in Kentucky died from exposure to fentanyl. One
    healthcare provider group who treats patients with substance
    use disorders told my office that almost all of their patients
    have some sort of fentanyl in their system. Many of the
    patients are not aware of it themselves. I recently heard from
    another local healthcare provider in Kentucky who said it is
    almost rare to have an overdose that does not have some traces
    of synthetic opioids, such as fentanyl.
        This provider also shared that they have certain
    individuals using substances in their own parking lot in case
    they overdose or anything were to happen, because they know the
    provider is equipped with Narcan.
        We must protect Americans from these harmful drugs that
    ruin lives and families. I look forward to continuing the
    bipartisan work to combat the substance abuse disorder crisis
    in America. I appreciate this hearing, and the witnesses before
    us, and the Members present.
        [The prepared statement of Mr. Guthrie follows:]

                    Prepared Statement of Hon. Brett Guthrie

        Chair Eshoo, thank you for holding this important hearing
    today.
        It is devastating that we have lost more than 550,000
    Americans due to COVID-19. Sadly, we have another epidemic that
    has claimed around the same number of American lives over the
    past two decades: the opioid crisis. We're hearing from public
    health providers that the COVID-19 pandemic has exacerbated
    this crisis. The CDC recently reported over 81,000 overdose
    deaths over the past year ending in May 2020, which is the
    highest number of overdose deaths in a 12-month time. In 2019,
    addiction and substance use disorders affected over 20 million
    Americans, 10 million of which experienced opioid misuse. Last
    year, we sadly saw that number increase even more. According to
    the CDC, we have had three waves of the opioid epidemic. First,
    we saw the rise in prescription opioids, then in 2010 we began
    to see a rise in heroin, and currently we are in the third
    wave, which includes the rise in synthetic opioids, which often
    includes deadly forms of fentanyl.
        My home State of Kentucky has seen some of the highest
    numbers of substance use disorder deaths. One Kentucky
    substance use provider group that my office spoke to shared
    that they have lost more patients to overdose during the
    pandemic than they have in the last 5 years. CDC compared the
    death by drug overdose rates over a 12-month period between
    August 2019 and August 2020. In August 2019, Kentucky had 1,307
    overdose deaths. One year later that number was up to 1,874.
    Unfortunately, Kentucky is not alone with these increases.
        This committee has worked in a bipartisan way to authorize
    many programs to decrease overdose deaths, but more work needs
    to be done. Specifically, the Energy and Commerce Committee
    authorized: the 21st Century Cures Act, the Comprehensive
    Addiction and Recovery Act, and the SUPPORT for Patients and
    Communities Act to combat the opioid epidemic. Included in the
    final SUPPORT Act was my bill, the Comprehensive Opioid
    Recovery Centers Act of 2018, which authorized the creation of
    comprehensive opioid recovery centers throughout the Nation.
    This program is currently being implemented and provides
    evidence-based comprehensive care for those with substance use
    disorders. Overall, these laws continue to provide critical
    funding and authorizations to help address substance use
    disorder treatment, recovery, and prevention. I think it is
    important for us to look back and fully examine these laws and
    evaluate where we are and where we are headed. And while we
    have 11 new bills before us today, we must also examine current
    authorizations.
        One of these current authorizations is the extension of the
    temporary emergency scheduling of fentanyl analogues. Synthetic
    opioids, which includes fentanyl analogues, were involved in
    744 deaths in Kentucky in 2018. Fentanyl analogues are very
    dangerous due to their potency and often come across our
    borders illegally only to harm Americans. Just last month, a 2-
    year-old in Kentucky died from exposure of fentanyl. One
    healthcare provider group who treats patients with substance
    use disorders told my office that almost all their patients
    have some sort of fentanyl in their system; many of the
    patients are not aware themselves. I recently heard from
    another local healthcare provider in Kentucky who said it is
    almost rare to have an overdose case with a substance that is
    pure and does not also have traces of synthetic opioids such as
    fentanyl. This provider also shared that they have had certain
    individuals using substances in their own parking lot in case
    they overdose or anything were to happen, because they know the
    provider is equipped with Narcan. We must protect Americans
    from these harmful drugs that ruin lives and families.
        I look forward to continuing the bipartisan work to combat
    the substance use disorder crisis in America. I yield back.

        Mr. Guthrie. And, Madam Chair, I will yield back.
        Ms. Eshoo. The gentleman yields back, and I thank him for
    his opening statement.
        The Chair is now pleased to recognize Mr. Pallone, the
    chairman of the full committee, for his 5 minutes for an
    opening statement.

    OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
                IN CONGRESS FROM THE STATE OF NEW JERSEY

        Mr. Pallone. Thank you, Chairwoman, and thanks to the
    ranking member, as well.
        This committee has a long history of working on a
    bipartisan basis to combat the threat of opioids and substance
    use and misuse. And together we are making significant
    progress.
        But, unfortunately, the COVID-19 pandemic and the resulting
    economic downturn over the last year has weighed heavily on the
    American people and has only exacerbated substance use and
    misuse. And so today we are continuing our work to address the
    epidemic within the pandemic, essentially.
        The statistics are alarming. In 2019, prior to the
    pandemic, more than 20 million Americans experienced a
    substance use disorder, and half of those involved opioids.
    Tragically, there were nearly 71,000 drug overdose deaths. And
    recent data shows that the pandemic has accelerated overdose
    deaths. From August 2019 to August 2020, 88,000 overdose deaths
    were reported, the highest ever recorded in a 12-month period.
        The primary driver of these deaths was a dramatic increase
    in the availability of synthetic opioids derived from fentanyl.
    These low-cost substances can be 50 to 100 times more potent
    than morphine and are frequently mixed into other drugs like
    cocaine and methamphetamine.
        To combat the opioid epidemic the committee advanced major
    pieces of legislation that became law. These laws expanded
    critical substance use disorder services and supports for
    communities around the country. But our efforts have not ended
    there. And since the beginning of the pandemic we pushed for
    the inclusion of funding aimed at the dual public health
    threats of the virus and rising rates of overdose deaths,
    substance use and misuse, anxiety, and depression. And I look
    forward to hearing from our panelists about the implementation
    of these laws, how the pandemic is impacting people suffering
    from substance use, and what more can be done to help aid in
    response to these threats.
        Now, on our first panel we will hear from the Acting
    Director of the White House Office of National Drug Control
    Policy, or ONDCP, who recently released the Biden
    administration's first-year drug policy priorities. And I
    commend the administration for taking an evidence-based public
    health approach to the drug epidemic. I also applaud them for
    their plans to expand evidence-based treatment, reduce youth
    substance use, enhance recovery services, and advance racial
    equity. Their work falls squarely within the jurisdiction of
    this committee. I look forward to hearing more from ONDCP about
    how we can work together.
        And our second panel is composed of experienced providers,
    public health experts, advocates for justice, and Federal law
    enforcement professionals. This group is on the front lines of
    the epidemic, and their insight on the impact of Federal policy
    is invaluable. And I thank all the witnesses for their selfless
    dedication to this cause.
        Now, throughout our discussion it is important to remember
    that substance use disorder is complex but treatable.
    Regardless of a patient's personal history or healthcare
    coverage, they deserve compassion and help, just like any other
    patient with a diagnosable disease. And we have to approach
    this substance use epidemic as a public health crisis and take
    the lead on destigmatizing effective treatments.
        The 11 pieces of legislation we are considering today
    tackle the epidemic in multiple ways, and many of them take a
    public health approach. And we have considered some of these
    policies before, and they remain a critical component of a
    comprehensive response to the crisis. So we have to continue
    our work in a bipartisan fashion to combat the epidemic.
    Millions of lives depend on it.
        And I commend the sponsors of these bills for their
    leadership and look forward to our continued work to address
    this devastating epidemic in the months ahead.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared Statement of Hon. Frank Pallone, Jr.

        This committee has a long history of working on a
    bipartisan basis to combat the threat of opioids and substance
    use and misuse. Together, we were making significant progress,
    but unfortunately the COVID-19 pandemic and the resulting
    economic downturn over the last year has weighed heavily on the
    American people and has only exacerbated substance use and
    misuse. Today, we are continuing our work to address the
    epidemic within the pandemic.
        The statistics are alarming. In 2019--prior to the
    pandemic--more than 20 million Americans experienced a
    substance use disorder, and half of those involved opioids.
    Tragically, there were nearly 71,000 drug overdose deaths.
        Recent data shows that the pandemic has accelerated
    overdose deaths. From August 2019 to August 2020, 88,000
    overdose deaths were reported, the highest ever recorded in a
    12-month period. The primary driver of these deaths was a
    dramatic increase in the availability of synthetic opioids
    derived from fentanyl. These low-cost substances can be 50 to
    100 times more potent than morphine and are frequently mixed
    into other drugs like cocaine and methamphetamine.
        To combat the opioid epidemic, the committee advanced major
    pieces of legislation that became law, including the
    Comprehensive Addiction and Recovery Act, the 21st Century
    Cures Act, and the SUPPORT for Patients and Communities Act.
    These laws expanded critical substance use disorder services
    and supports for communities across the Nation. But our efforts
    have not ended there.
        And since the beginning of the pandemic, we pushed for the
    inclusion of funding aimed at the dual public health threats of
    the virus and rising rates of overdose deaths, substance use
    and misuse, anxiety, and depression. I look forward to hearing
    from our panelists about the implementation of these laws, how
    the pandemic is impacting people suffering from substance use
    and misuse, and what more can be done to help aid in response
    to these threats.
        On our first panel, we will hear from the Acting Director
    of the White House Office of National Drug Control Policy
    (ONDCP), who recently released the Biden administration's
    first-year drug policy priorities. I commend the administration
    for taking an evidence-based public health approach to the drug
    epidemic. I also applaud them for their plans to expand
    evidence-based treatment, reduce youth substance use, enhance
    recovery services, and advance racial equity. Their work falls
    squarely within the jurisdiction of this subcommittee. I look
    forward to hearing more from ONDCP about how we can work
    together to eradicate the threat of illicit fentanyl-derived
    substances.
        Our second panel is composed of experienced providers,
    public health experts, advocates for justice, and Federal law
    enforcement professionals. This group is on the frontlines of
    the opioid epidemic, and their insight on the impact of Federal
    policy is invaluable to our work here. I thank all the
    witnesses for their selfless dedication to this cause.
        Throughout our discussion, it is important to remember that
    substance use disorder is a complex, but treatable disease.
    Regardless of a patient's personal history or healthcare
    coverage, they deserve compassion and help just like any other
    patient with a diagnosable disease. We must approach the
    substance use epidemic as a public health crisis and take the
    lead on destigmatizing effective treatments.
        The 11 pieces of legislation we are considering today
    tackle the epidemic in multiple ways and many of them take a
    public health approach. This includes proposals to address the
    need for first responder training and prescriber education, to
    dismantle barriers to treatment, and to bolster public health
    and recovery programs in the States.
        We have considered some of these policies before and they
    remain a critical component of a comprehensive response to the
    crisis. Other policies are a result of the emerging data and
    rising threat of illicit fentanyl.
        We must continue to work in a bipartisan fashion to combat
    this epidemic as millions of lives depend on it. I commend the
    sponsors of these bills for their leadership and look forward
    to our continued work in addressing this devastating epidemic
    in the months ahead.
        Thank you, I yield the remainder of my time.

        Mr. Pallone. Thank you again, Madam Chair. I think this is
    a very important hearing, and I yield back.
        Ms. Eshoo. Thank you, Mr. Chairman.
        The Chair now is pleased to recognize the ranking member of
    the full committee, Representative Cathy McMorris Rodgers, for
    her 5 minutes for an opening statement.

          OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A
        REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON

        Mrs. Rodgers. Good morning, everyone. Thank you, Chair
    Eshoo, and thank you to our witnesses.
        America remains in the midst of two national emergencies,
    COVID-19 and the substance use disorder crisis. Experts,
    including law enforcement, the DEA, and local leaders in my
    community, are raising the alarm.
        We are losing more people to the death of despair. The
    social isolation, economic shutdowns, stress, fear, loneliness
    has taken a severe toll. According to the CDC, 88,000 people
    died of overdose in the last 12 months leading up to August
    2020. That is a 26.8 percent increase. And that comes after the
    CDC released May data that we had the highest number of
    overdose deaths in the history of our country. This is how one
    mental health expert in eastern Washington put it to me: ``A
    situation such as 2020 that really stressed even the strongest-
    willed among us, it can really impact how they are feeling, and
    it can increase their need for a substance use as a way to
    protect themselves, as a way to find the comfort they are used
    to having.''
        People need hope, hope to overcome fear, change their
    lives, provide for their families, and thrive, and that is what
    is on the line as we work to address this epidemic within the
    pandemic, head on.
        While I have some concerns with some of the bills, I am
    pleased that we are coming together to improve prevention,
    increase access to treatment, and offer support to those in
    recovery. All of this will build on our historic bipartisan
    work on the comprehensive Addiction and Recovery Act, CURES,
    and the Support for Patients and Communities Act.
        Energy and Commerce has a rich history of leading on the
    most significant efforts against addiction crisis, and today I
    am hopeful that we can move more of those solutions across the
    finish line. That includes stopping the scourge of fentanyl
    coming across our southern border from Mexico and also China.
    Nearly all States are seeing a spike in synthetic opioid
    deaths, with 10 western states reporting more than a 98 percent
    increase.
        In Washington State, it is even worse. The fentanyl
    positivity rate increased by 236 percent. Washington State is
    the highest in the Nation. Last fall we lost two teenagers in
    eastern Washington to potential fentanyl exposure. We have had
    close calls with police officers who barely came in contact
    with fentanyl, just a few milligrams. What can fit on Lincoln's
    ear on a penny is lethal. The analogues are oftentimes more
    potent. If it is reaching our streets in Washington State in
    deadly quantities from Mexico, I can assure you that the
    scourge is everywhere.
        That is why DEA created a temporary scheduling order for
    fentanyl analogues, placing these dangerous substances in the
    schedule I. Previously, drug traffickers could slightly change
    the chemical structure of fentanyl, so the novel formula was
    not considered prohibited. The DEA would then have to
    individually schedule each variant. Once one analogue was
    scheduled, a new one would emerge, creating this game of Whac-
    a-mole for drug control efforts.
        With wide class scheduling, any dangerous variant of
    fentanyl is controlled under schedule I. This allows law
    enforcement to combat all fentanyl-related substances and
    protect the public. For example, one recently encountered
    substance was approximately 8 times more potent than fentanyl.
    A scheduling order is set to schedule in less than a month.
        Given the House schedule, Speaker Pelosi must make this a
    priority for this week or next. I fear that, like last year,
    the majority may wait until the last minute. We should work
    with DEA and other agencies to make this scheduling permanent,
    like with Mr. Latta's FIGHT Fentanyl Act.
        We should also look for reforms that encourage the
    scientific research. If the majority will not act on a
    permanent solution, then we must temporarily extend it.
    Judiciary Republican Leader Jordan and I are leading a one-year
    extension to buy us time. The clock is ticking. If this is
    allowed to expire, Customs and Border Protection will lose
    their authority to seize these substances at ports of entry,
    and drug traffickers regain the incentive to push deadlier and
    deadlier drugs on our streets.
        There is no excuse to let May 6th come and go without us
    doing our job to keep people safe, break the cycle of despair,
    and build a more prosperous future for America.
        [The prepared statement of Mrs. Rodgers follows:]

               Prepared Statement of Hon. Cathy McMorris Rodgers

    INTRO
        Thank you, Chair Eshoo.
        And, thank you to the witnesses.
        America remains in the midst of two national emergencies--
    COVID-19 and the substance use disorder crisis.
        Experts--including law enforcement, the DEA, and local
    leaders in my community--are raising the alarm.
        We are losing more people to the deaths of despair.
        The social isolation ... economic shutdowns ... stress ...
    fear ... loneliness have taken a severe toll.
        According to the CDC, 88,000 people died of an overdose in
    the 12 months leading up to August 2020.
        That's 26.8 precent increase ...
        ... and comes after the CDC released May data that we had
    the highest number of overdose deaths in our recorded history.
        This is how one mental health expert in Eastern Washington
    put it:
        ``A situation such as 2020--that really stressed even the
    strongest-willed of us--it can really impact how they're
    feeling, and it can increase their need for a substance use as
    a way to protect themselves, as a way to find that comfort
    they're used to having.''
        People need hope--hope to overcome fear ... change their
    lives ... provide for their families, and thrive.
        That's what is on the line as we work to address this
    epidemic within the pandemic head on.
    SOLUTIONS
        While I have some concerns with some of these bills ...
        ... I'm pleased that we are coming together to improve
    prevention, increase access to treatment, and offer support to
    those in recovery.
        All of this will build on our historic bipartisan work on
    the Comprehensive Addiction and Recovery Act ... CURES ... and
    the SUPPORT for Patients and Communities Act.
        Energy and Commerce has a rich history on leading the most
    significant efforts against the addiction crisis.
        Today, I'm hopeful we can move more solutions across the
    finish line.
    FENTANYL AND FENTANYL-RELATED SUBSTANCES
        That includes stopping the scourge of fentanyl coming
    across our southern border from Mexico and also from China.
        Nearly all States are seeing a spike in synthetic opioid
    deaths--with 10 western states reporting a more than 98 percent
    increase.
        In Washington State, it's even worse. The fentanyl
    positivity rate increased by 236 percent. That's the highest
    nationwide.
        Last fall, we lost two teenagers in Eastern Washington to
    potential fentanyl exposure.
        We've also had close calls with police officers who barely
    came in contact with fentanyl.
        Just a few milligrams--what can fit on Lincoln's ear on a
    penny--is lethal.
        The analogues are oftentimes more potent.
    STOPPING ANALOGUES
        If it's reaching our streets in Washington State in deadly
    quantities from Mexico--I can assure you this scourge is
    everywhere.
        That's why the Drug Enforcement Agency created a temporary
    scheduling order for fentanyl analogues, placing these
    dangerous substances in schedule I.
        Previously, drug traffickers could slightly change the
    chemical structure of fentanyl, so the novel formula was not
    considered prohibited.
        The DEA would then have to individually schedule each
    variant.
        Once one analogue was scheduled, a new one would emerge,
    creating a game of ``Whac-a-mole'' for drug control efforts.
        With class-wide scheduling, any dangerous variant of
    fentanyl is controlled under schedule I.
        This allows law enforcement to combat all ``fentanyl-
    related substances,'' and protect the public.
        For example, one recently encountered substance was
    approximately 8-times more potent than fentanyl.
        The scheduling order is set to expire in less than a month.
        Given the House schedule, Speaker Pelosi must make this a
    priority for this week or next.
        I fear that like last year, the majority is waiting until
    the last minute.
        We should work with the DEA and other agencies to make this
    scheduling permanent--like with Mr. Latta's FIGHT Fentanyl Act.
        We should also look for reforms that encourage scientific
    research.
        If the majority won't act on a permanent solution, then we
    must temporarily extend it immediately.
        Judiciary Republican Leader Jordan and I are leading for a
    one-year extension to buy us time.
        The clock is ticking.
        If Speaker Pelosi allows this to expire.
        Customs and Border Protection will lose the authority to
    seize these substances at Ports of Entry.
        ... and drug traffickers regain the incentive to push
    deadlier and deadlier drugs on our streets.
        There is no excuse to let May 6 come and go without us
    doing our jobs to keep people safe, break this cycle of
    despair, and build a more prosperous future for America.

        Mrs. Rodgers. With that, I yield back.
        Ms. Eshoo. The gentlewoman yields back. The Chair would
    like to remind Members that, pursuant to committee rules, all
    Members' written opening statements will be made part of the
    record.
        I would now like to introduce our witnesses for our first
    panel. Regina LaBelle is the Deputy Director of the White House
    Office of National Drug Control Policy and is currently the
    Acting Director of the agency, serving as the principal adviser
    to the Biden-Harris administration on drug policy matters
    ranging from substance use, prevention, treatment, and recovery
    to drug interdiction.
        Acting Director LaBelle previously served as the Chief of
    Staff of the ONDCP during the Obama administration, where she
    oversaw the Federal Government's initial efforts to address the
    opioid epidemic. And before returning to the agency, she served
    as a distinguished scholar and program director of the
    Addiction and Public Policy Initiative at Georgetown
    University's O'Neill Institute for National and Global Health
    Law, and was also a director of the graduate school's master of
    science program in addiction policy and practice.
        So we have a seasoned professional representing the agency.
        And Acting Director LaBelle, you are recognized for 5
    minutes. Please remember to unmute, and I recognize my--I will
    recognize myself for questions after your testimony.

     STATEMENT OF REGINA M. LaBELLE, ACTING DIRECTOR, WHITE HOUSE
                 OFFICE OF NATIONAL DRUG CONTROL POLICY

        Ms. LaBelle. Thank you, Chairwoman Eshoo, Ranking Member
    Guthrie, Chairman Pallone, Ranking Member McMorris Rodgers,
    members of the subcommittee. Thank you for inviting me to
    testify today. It is my pleasure to discuss the Biden-Harris
    administration's drug policy priorities for our first year and
    the activities of the Office of National Drug Control Policy.
    Thank you for holding this hearing so early in the 117th
    Congress. It reflects the urgency of addressing the overdose
    and addiction epidemic.
        ONDCP coordinates Federal drug policy by developing and
    overseeing the national drug control strategy and the national
    drug control budget. We develop, evaluate, coordinate, measure,
    and oversee the international and domestic drug-related efforts
    of executive branch agencies and work to ensure those efforts
    complement State, local, and Tribal drug policy activities.
        In this role I advocate for people with substance use
    disorder and their families, for a balanced approach to drug
    policy that includes public health and public safety, and for
    greater inclusion and equity in our efforts to tackle the
    addiction and overdose epidemic. These responsibilities are
    evident in the work ONDCP has undertaken since President Biden
    took office.
        On April 1st, ONDCP delivered the Biden-Harris
    administration's Statement of Drug Policy Priorities for the
    first year to Congress. These seven priorities have two
    overarching themes: first, immediately getting services to
    people most at risk for overdose; and second, building the
    addiction infrastructure necessary to meet the needs of the
    more than 20 million people in this country who have a
    substance use disorder.
        Our policy priorities include a focus on preventing
    substance use initiation, including through our Drug-Free
    Communities Support Program, and expanding access to quality
    treatment and recovery support services. It also includes
    supporting harm reduction services. This is especially
    important during this time when illicitly manufactured fentanyl
    is present in so many drugs. Harm reduction services include
    distributing the lock zone and fentanyl test strips, and
    expanding syringe services programs. These programs build
    connections, reduce people's chance of overdose, and give them
    the opportunity to receive services and engage them in
    healthcare, including treatment.
        As the epidemic continues, the shifting dynamics require us
    to adapt and meet people where they are. I have an example. I
    recently read about a 60-year-old woman in Miami who had
    untreated opioid use disorder. After many years she received
    services finally through a mobile service provider. She engaged
    in treatment, now has an apartment, and is able to spend time
    with her children and grandchildren.
        Also included in our policy priorities is racial equity in
    drug policy, both in criminal justice and healthcare. Our
    priorities include the entire continuum of care and seek to
    reduce the stigma of addiction.
        We also recognize the need to reduce the supply of illicit
    drugs in the United States. Illicitly manufactured fentanyl,
    fentanyl analogues, cocaine, methamphetamine, and other drugs
    enter our country through our ports of entry or through the
    mail, including express couriers. Our efforts to disrupt drug
    trafficking networks include working with domestic law
    enforcement through ONDCP's High Intensity Drug Trafficking
    Areas Program, and we appreciate Congress's strong support for
    this program.
        We are also working closely with countries such as
    Colombia, Mexico, and China to disrupt drug-trafficking
    networks and stem the flow of drugs coming into this country.
    On this issue Congress is facing a deadline of May 6 to extend
    the temporary fentanyl class scheduling bill. The
    administration is asking Congress to extend this law while we
    work with the Departments of Justice and Health and Human
    Services to address legitimate concerns regarding mandatory
    minimums and research provisions involved in class scheduling.
        Beyond extending temporary class scheduling, Congress has
    an important role to play in addressing the overdose and
    addiction epidemic. Already, Congress has provided needed
    resources through the American Rescue Plan, and the President's
    budget request calls for a substantial investment of $10
    billion. This funding will help build the type of
    infrastructure the Nation needs to reduce overdose deaths in
    the short term while laying the groundwork for a system of care
    that is long overdue. These funds will be guided by science and
    evidence, and we hope this budget request informs your work.
        Addressing the addiction and epidemic is an urgent issue,
    and the Biden-Harris administration's drug policy priorities
    are intended to bend the curve and save lives. And working with
    our Members--with Members of Congress, ONDCP will take quick
    action to implement them.
        Thank you for your time, and I look forward to your
    questions.
        [The prepared statement of Ms. LaBelle follows:]

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much, Acting Director LaBelle,
    for being with us.
        So how many days have you been on the job?
        Ms. LaBelle. So I was sworn in the afternoon of
    Inauguration Day, so it is 85 days, I guess.
        Ms. Eshoo. Well, congratulations to you.
        Ms. LaBelle. Thanks.
        Ms. Eshoo. You have a weighty portfolio. Now, based on the
    early data, 2020 is the deadliest year for overdoses, with
    88,000 deaths counted so far, 88,000 in 2020.
        Now, as Members stated in their opening statements, our
    subcommittee and the full committee have done a lot of work. We
    have passed packages of bills. The first big effort, I think,
    was something like 53 bills. I think every single one of them
    was bipartisan. We have put money to this.
        Something isn't working. Something isn't working. We are
    not putting a dent in this. And I don't know--I know that you
    were part of doing a report before you came to head up the
    agency. What instructions do you have for the subcommittee
    about what we need to change, what we need to do more of, what
    is not working, and also the bills, the 11 bills that we have
    before us? Can you comment on this?
        It is very disturbing to me that we all think we have done
    very important work. And I still think that we have. But 88,000
    deaths? I mean, that--we just--it seems to me that we are not
    making--to put it mildly, I don't think we are making progress.
        Ms. LaBelle. Right. So thank you, Chairwoman.
        I think the issues are very complex, but I think that we
    can't see immediate results over a problem that has evolved for
    decades. You know, we have had overdose deaths increasing since
    the 1970s. They did go down in 2018, but fentanyl, illicit
    fentanyl that is getting into the drug stream, it is getting
    into coke, methamphetamine, heroin, that is really what is
    driving a lot of these overdose deaths.
        So there are things--I mean, there are bright spots. The
    money has not been wasted. We have seen an increase in the
    number of providers who are--provide buprenorphine, one of the
    three forms of medication treatment. We have made efforts. It
    is not enough yet. And that is why our policy priorities stress
    what it does--harm reduction, prevention, recovery supports--
    because this is a chronic disease, and we need the full
    continuum of care.
        Ms. Eshoo. On the soon-to-expire temporary scheduling of
    the fentanyl-related substances, what is your agency's
    suggested policy on this?
        Ms. LaBelle. So we are going to--we have been having
    discussions with HHS and the Department of Justice and DEA. We
    just got the GAO report that had--that was required as part of
    the Federal scheduling extension from 2 years ago. We are going
    to be looking closely at what the results have been of that
    and, you know, come together to make sure we have a whole-of-
    government approach to this issue.
        Ms. Eshoo. And what kind of timeframe are you thinking of
    here, to get the job done?
        Ms. LaBelle. So we are, you know, engaged in continuous
    conversations about this. We understand the urgency. It is not
    going to happen before May 6th, but we are going to work as
    quickly as possible after that.
        Ms. Eshoo. And what is your response to the criticisms that
    classwide scheduling leads to disproportionate incarceration of
    Black and brown people, many of whom--who don't receive the
    treatment they need while they are in jail or prison?
        But of course, we have an excellent bill that--before us
    that addresses that. But can you comment on that, please?
        Ms. LaBelle. Yes. So the mandatory minimum issues are much
    broader than this bill. But when we work with Department of
    Justice, we are going to look exactly at that. What are the
    effects of this legislation on the fentanyl scheduling on
    mandatory minimums?
        But the--you know, but the mandatory minimum issue is a
    much broader issue that involves all forms of drug as well as
    other sentencing.
        Ms. Eshoo. Well, thank you very much for agreeing to
    testify today, and we need to--you know, we need the agency to
    really operate in top gear, because this number of deaths says
    to me that we are not making progress, and we have to change
    that. We have to change that. So thank you very much to you.
        And now I will recognize Mr. Guthrie, the wonderful ranking
    member of our subcommittee, for his 5 minutes of questions.
        Mr. Guthrie. Thank you very much. And thank you, Director,
    for being here. I really appreciate it.
        One of my prepared questions, by not meeting the May 6
    deadline, we have to make, you know, some important decisions--
    or not having information for us--and I know you have a lot of
    the experts. I think you said that fentanyl analogues are
    driving the overdose deaths. And I would--and I said in my
    opening statement that almost all of my providers are saying
    that everybody with an overdose death has some fentanyl
    analogue.
        And I would agree it is not just a criminal justice issue,
    but I think it is a criminal justice issue, but not just. And
    this committee has responded with the CARES Act, SUPPORT Act,
    and hopefully we will have a chance to look at all of that and
    see how it is making a difference. But I think it is both, we
    have to deal with both. And any disparities in the laws being
    enforced absolutely need to be dealt with as well. But I
    would--it would be nice to have information before May 6, or a
    position from the administration. But I appreciate it.
        I know you had--you put out your priorities for the year
    one report, and I really want to work with you to achieve your
    seven goals that you set. And specifically, I would like to
    focus on evidence-based treatment and how you plan to address
    holistic treatment for those with co-occurring substance use
    disorders. Are you willing to work with me and the committee on
    fully evaluating current programs that are authorized or funded
    for substance use disorders?
        Ms. LaBelle. I am sorry, can you repeat the last part of
    your question? I had a hard time hearing.
        Mr. Guthrie. OK. Are you willing to work with me and the
    committee on fully evaluating current programs that are
    authorized or funded for substance use disorders?
        Ms. LaBelle. Yes, absolutely, Congressman Guthrie, thanks
    for your question. That is--you know, we want to make sure that
    it is quality treatment that is evidence-based. And so we
    intend to work across, you know, all the HHS, SAMHSA to make
    sure that the programs that the Federal Government is funding
    are effective. And so we have to put those standards into
    place.
        Mr. Guthrie. OK, thank you for that.
        And then, additionally, I believe we need to ensure that
    the Office of National Drug Control Policy is addressing
    polysubstance abuse, not just opioids, but also stimulants and
    alcohol abuse. Can you please share how you plan to address
    this, and while also taking a wide lens on what programs we are
    already funding and how we can make sure they are best serving
    those with substance use disorders?
        Ms. LaBelle. Yes----
        Mr. Guthrie. So kind of more emphasis on your----
        Ms. LaBelle. Sure----
        Mr. Guthrie. You sort of answered a little bit, but just a
    little broader on what you just answered.
        Ms. LaBelle. Sure, thanks. So polysubstance use is,
    obviously, as you point out, a huge problem. People are not
    just using one substance, they are using multiple substances.
    And we can't kind of have blinders on that we are only going to
    deal with one drug at a time.
        So our policy priorities call for a holistic approach,
    starting with prevention of all substances--as you mentioned,
    youth alcohol use--and then treatment, making sure the quality
    treatment is available where people live, harm reduction, and
    recovery support services. Those don't have--there are
    certainly medications that work for certain drugs, but we need
    to make sure that we are responsive to all forms of substance
    use disorder.
        Mr. Guthrie. Great, thank you. And then I will just say
    again that, when we were looking at all the CARES Act, SUPPORT
    Act, and all the others that we worked on, I know--and I had to
    change some of my attitude. Mine was coming from a pure--not
    pure, but strong emphasis on the criminal justice side, that
    this is illegal, and people use it illegally. And as you really
    delve into this, some people commit crimes because of their
    drug habit. If you could deal with the substance abuse
    disorder, you could solve the criminal problem.
        But some people are criminal, and they are out to--and a
    lot of them aren't users. That is--if you read some of the
    books that you read about, that they avoid using because it
    takes away from their ability to do business. And so my--I
    would be really concerned if we start descheduling, or not
    allowing these types of drugs to go forward, particularly
    that--you have said, and I have witnessed or heard from people
    who practice in this, that fentanyl analogues are a big driver
    in the overdose and overdose deaths.
        We had a--I mentioned in my opening statement--a little--I
    have a couple of--few seconds--but a 2-year-old, we felt--they
    believe touched and handled his mother's fentanyl, and her
    opioid, which had fentanyl in it, and that is why the 2-year-
    old passed away.
        And so this is just something that--we need to really look
    at this as we move forward, and try to work together. So I
    really appreciate your time, and I will yield back to the
    Chair.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. The gentleman yields back. The Chair now
    recognizes the ranking member of the full committee--pardon me?
        Voice. Mr. Pallone.
        Ms. Eshoo. Oh, I am sorry. The chairman of the full
    committee first.
        Mr. Pallone?
        Mr. Pallone. Thank you, thank you, Chairwoman. I wanted to
    ask the Director about this drug policy, first-year drug policy
    report that you just released.
        I know your jurisdiction puts you in a unique position,
    because you collaborate with public health and public safety
    agencies to drive the direction of drug policy, not only in the
    U.S. but around the world. And what we discussed today and what
    we do in the months to come is really an issue of life and
    death, so it is very serious.
        But your office recently released the Biden
    administration's first-year drug policy priorities. I want to
    applaud the bold approach in that to reducing overdose deaths
    and the urgency in which you intend to act. But I wanted to
    focus on the first priority, which is expanding access to
    evidence-based treatment.
        Acting Director LaBelle, the statement of drug policy
    priorities places expanded access to evidence-based treatment
    at the top of the list. So what actions are you going to take
    in year one to achieve that specific goal, if you would?
        Ms. LaBelle. Sure, thanks. So it is important that we look
    at the full continuum of care, but also that we look at the
    types of FDA-approved medications. So it is buprenorphine. We
    will be looking at how we can reduce barriers to buprenorphine
    access.
        We are also looking at how can we modernize our methadone
    treatment that is available to people. So there is--there are
    many steps that we have to take to look for how to update
    today's treatment approaches and not be stuck in approaches
    that we had 15 to 20 years ago.
        Mr. Pallone. Well, you know, only a fraction of the
    patients with substance use disorders have access to these
    evidence-based treatments. And as part of expanding access for
    evidence-based treatment, the statement noted that the Biden
    administration will ``remove unnecessary barriers to
    prescribing BUP, and identify opportunities to expand low-
    barrier treatment services.''
        Just discuss a little further the barriers the
    administration sees currently to prescribe BUP, and the steps
    that the administration plans to take to address those
    barriers, if you will.
        Ms. LaBelle. Sure. So the research shows that some of the
    barriers to people--to prescribers prescribing buprenorphine
    include--so they don't necessarily feel comfortable treating
    patients with addiction, so there is stigma attached to that.
        There is also a lack of training in many medical schools.
    We don't do a good job of building out the addiction workforce.
    That is a second piece we will be working with medical schools
    to talk about that.
        And then lastly, we have an--interagency working groups
    going on that are looking at the X-waiver, specifically, which
    is the eight-hour training for doctors and a 24-hour training
    for nurse practitioners and physician's assistants. So we are
    looking specifically at that issue, as well, at how we can
    remove barriers to the X-waiver, what we can do
    administratively, what requires legislative action.
        Mr. Pallone. Well, that is great. That is very important,
    and I appreciate your answer.
        Last question: Any other steps that Congress or the Biden
    administration can take to ensure that providers are equipped
    with the tools that they need to diagnose or treat patients
    with substance use disorder?
        Ms. LaBelle. Sure. I think--so many of the authors of the
    appropriations have helped to expand our addiction workforce.
    We need to look where there have been things authorized and
    money has not yet been appropriated, because we really need to
    expand the number of physicians and nurse practitioners and
    healthcare providers who feel competent to not only treat
    addiction but to screen for it. Because the earlier we can
    identify someone who might have an emerging substance use
    disorder, the easier it will be to treat those people before
    their condition becomes chronic.
        So Congress can help us, you know, expand awareness about
    the importance of medical training and nurse--nursing training
    on addiction.
        Mr. Pallone. Well, thank you. You know, I heard Chairwoman
    Eshoo, you know, repeatedly point out how, you know, this
    scourge of overdose deaths, and the rising rates, particularly
    now during the pandemic--so we really look forward to working
    with ONDCP and the Biden administration to reduce this.
        I mean, it is just--I think the ranking member, Mrs.
    Rodgers, you know, talked about, you know, this essentially
    double dose of problems between the pandemic and the opioid
    abuse and misuse. And so we really want to get to the bottom of
    it. Thank you for being here.
        Thank you, Madam Chair.
        Ms. LaBelle. Thank you, Congressman.
        Ms. Eshoo. Thank you, Mr. Chairman.
        Now the Chair recognizes the ranking member of the full
    committee for her 5 minutes of questions.
        Mrs. Rodgers. Thank you. Thank you, Madam Chair and Mr.
    Chairman. And I too just want to join in saying that we on the
    Republican side of the aisle look forward to working with you,
    continuing to work with you. This is a huge issue all across
    the country. And I think, without a doubt, the last year has
    been a difficult year, with COVID and everything that it has
    meant as far as lockdowns, and isolation, and fear, and
    uncertainty.
        But there is this other crisis underway, and the depths of
    despair has really been on my heart, and I know it is on a lot
    of people's hearts, with the increased substance abuse,
    increased suicides. And I absolutely believe that this is an
    area that we must take action. We must continue to identify
    what is going to work, what is going to be most successful in
    ensuring that individuals and families get the support and the
    treatment that they need.
        But I also think there is more that Congress needs to be
    doing.
        And I just wanted to start by asking the Acting Director
    LaBelle--and I appreciate you being with us today--just--I
    would like to ask you, do you believe that Congress should
    extend this--the temporary scheduling order for fentanyl-
    related substances before it expires on May 6th?
        Ms. LaBelle. We are asking Congress to give us more time
    to--I mean, it can be extended. We need more time to--before it
    is extended further. So we--as I said, I don't think we--there
    is any way we can come to you with new legislation before May
    6. So we need--we are asking Congress to extend the time so
    that we have time to come together and present you with another
    proposal.
        Mrs. Rodgers. So just so I understand, so would you support
    the temporary extension while we work on a more permanent
    solution?
        Ms. LaBelle. We are looking to Congress to extend this for
    a period of time. We don't have a period of time in mind yet,
    because we have to get our interagency together to talk about
    this. But we support and we are asking Congress to extend
    this--the fentanyl scheduling bill for a short period of time.
        Mrs. Rodgers. OK, great. I wanted just to highlight to the
    committee that, when ONDCP Assistant Director Kemp Chester
    testified before the Senate Judiciary Committee, he stated that
    codifying the scheduling emergency order and making it
    permanent is a ``critical, most important first step that we
    have to take.''
        And to the Acting Director LaBelle, is it still the
    position of ONDCP that the scheduling order be made permanent?
        And would you just speak if the position is changed?
        Ms. LaBelle. Sure. So I think we just got the GAO report.
    We are working with DEA to see what the results of this
    fentanyl scheduling act has been so far.
        One thing that we know about the drug environment is that
    it is ever changing. And sometimes legislation that we put in
    place 2 years ago doesn't address today's issue. But the
    biggest challenges we face are synthetic drugs, and those are
    morphing over time. We want to make sure that the solutions we
    put into place and that we ask Congress to put into place
    address today's problems, not yesterday's problems.
        Mrs. Rodgers. OK. The chairman of--the chair of the
    subcommittee highlighted the 88,000 deaths this last year. I
    would just like to reiterate to the committee that I believe
    Congress must act, either this week or next, to prevent the
    spread of deadly fentanyl variants by making it permanent and
    extending DEA's classwide scheduling order.
        You know, I would just highlight, when you compare the
    first quarter of 2021--so January to March, 2021, the seizure
    of fentanyl at the southwestern border by CBP has increased,
    just in this quarter, by 233 percent from last year, 2020
    quarter 1. And so I think what we are seeing is that we do have
    a crisis on our hands, and we are seeing a huge increase.
        If--so if you compare first quarter of 2020 to this
    quarter, January to March, 2021, seizure of fentanyl at the
    southwestern border has increased by 233 percent. So we need to
    make sure that we are providing the support necessary at the
    border and throughout the country so that people are protected
    and that we do not allow the continued negative impacts and
    destruction of lives and families due to fentanyl in America.
        With that, I will yield back. Thank you, Madam Chair.
        Ms. Eshoo. I thank the gentlewoman. Yes, there has been the
    increase coming in from Mexico, but thank God we--the reason we
    know the figures that you just stated is because it was seized.
    And--but we need, really, a refreshed plan on this, because we
    can't gather a year from now and have statistics saying this is
    what happened in 2021, and it is more lives lost.
        The Chair now recognizes the gentleman from North Carolina,
    Mr. Butterfield, for your 5 minutes of questions.
        Good to see you.
        Mr. Butterfield. Thank you so very much, Madam Chair, for
    convening this hearing----
        Ms. Eshoo. I think you are--I can't hear you.
        Can everyone else hear Mr. Butterfield?
        No, they are shaking their heads no. There is something
    wrong with your microphone. We can't hear you.
        Mr. Butterfield. Does that work?
        Ms. Eshoo. Yes, there you go.
        Mr. Butterfield. OK, I had my earpiece plugged in. That
    messed it up.
        Thank you. Thank you very much, Madam Chair, for convening
    this very, very important hearing this morning. And thank you
    for your leadership. It has been nothing less than stellar.
    Thank you so very much. And thank you for the direction that
    you are taking this subcommittee. And thank you to the
    witnesses, the one witness on this panel and the witnesses on
    the next panel. Thank you for taking the time to join us today.
        Director LaBelle, let me just start here. I am hoping that
    you can help us better understand the ways in which the Federal
    Government benefits from your office. This is simply a
    continuation of what Mr. Malone was--Pallone was talking about
    a few minutes ago.
        I understand that your office leads and it coordinates the
    Nation's drug policy with the goal of improving the health and
    lives of our constituents. So my question is, your priorities
    seem to intersect with both public health and public safety. I
    want to talk about that intersection, if I can. How does your
    office--what is your office's role, and how does it differ from
    that of HHS and DEA?
        Ms. LaBelle. Sure. Thanks, Congressman. So the Office of
    National Drug Control Policy is, obviously, a unique office
    situated in the Executive Office of the President. And the
    purpose--our purpose of our office is to bridge the gap that
    often occurs between public health and public safety.
        So we bring Drug Enforcement Administration in, the
    Department of Justice in, as well as with our colleagues from
    HHS, from all of the various components of HHS, to discuss
    issues like fentanyl scheduling, because there are different--
    the X-waiver is a perfect example. Law enforcement has a
    different perspective and a different goal sometimes. I mean,
    all of our goals is to reduce overdose deaths. But our charges
    are different.
        So the Office of National Drug Control Policy, we have
    about 65 full-time staff, about 35 additional staff detailees,
    and they bring these sides together so we can find solutions
    that serve both needs. So that is really the unique role that
    ONDCP plays.
        Mr. Butterfield. Well, in that light, in what way do you
    coordinate and/or convene the other relevant agencies in your
    work?
        Ms. LaBelle. Sure----
        Mr. Butterfield. Do you coordinate with the other agencies?
        Ms. LaBelle. Yes. So we often have convenings. We have--I
    mean, I think someone gave me data about the number of meetings
    we have had across the interagency just since the end of
    January. It has been about 78 meetings, where we work with
    other White House components. We work with HHS, DOJ, and we
    talk about these issues that we--our goal is to make things
    move quicker, and--so that we don't have to--and build those
    bridges, so that we are not separately talking to Congress, for
    example, so that we can come together with one approach on an
    issue.
        Mr. Butterfield. You know, during the presidential
    campaign, Joe Biden announced a very robust and comprehensive
    drug policy agenda, and I hope that he will continue to pursue
    that agenda. How will the administration leverage your office
    --if you know, how will the administration leverage your office
    to carry out its drug policy agenda?
        Ms. LaBelle. Sure, thanks. So I think the one unique role,
    again, is that we have public health and public safety experts
    together in the same agency. That doesn't occur anywhere else.
        I am very engaged and aware of all the Biden-Harris
    campaign pledges that were made. Those are areas that--we are
    going to take them one by one and look at how we can implement
    those over the next couple of years and, again, by having our
    convening authority, which helps to have one voice on these
    issues.
        Mr. Butterfield. Thank you for those responses, and thank
    you for your incredible work. I realize that you were just
    installed the day after the inauguration, whatever date you
    announced, but it seems like you have hit the ground running.
    And just thank you so much for what you are doing and what you
    are going to do. I look forward to working with you as the
    administration advances its priorities in this space. So thank
    you, thank you, thank you.
        I yield back.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. The gentleman yields back, and I appreciate your
    very kind comments, Mr. Butterfield.
        It is a pleasure to recognize a former chairman of our full
    committee, the gentleman from Michigan, Mr. Upton, for your 5
    minutes of questions.
        Mr. Upton. Well, thank you, Madam Chair. And I just want to
    share, Ms. LaBelle, this is so personal to all of us. I mean,
    every one of us on both sides of the aisle have many personal
    stories on this. We have family members. It is indeed close to
    our heart, as we try to do our very best to resolve this major
    issue that continues to plague virtually every one of our
    communities, families across the country. So I appreciate your
    leadership.
        You and I, of course, both sit as members of the Commission
    on Preventing Synthetic Opioid Trafficking, as appointed by our
    respective leaders. And though we had our first meeting just a
    week or so ago on Zoom, certainly I just want to commit and
    definitely look forward to working with you and other members
    of the Commission on ideas to help curb this terrible scourge
    that plagues our Nation.
        Can you briefly share your thoughts on how the Commission
    could be most impactful on stopping this trafficking?
        Ms. LaBelle. Thank you, Congressman. And the Synthetics
    Commission, we--as you mentioned, we just had our first
    meeting. We are just organizing it. I think it is charged with
    a very--with very specific--it has a very specific charge. I
    think what it--the best part about the Commission is it has
    external experts, it has a bipartisan approach, including
    Congressman Trone, yourself, Senator Markey, and Senator
    Cotton.
        So what I think the Commission will be best able to do is
    to look at these issues, the international synthetics
    landscape, and come up with some--take the time to come up with
    some specific approaches that Congress can take up, that we can
    do by Executive order or administratively. So it is going to be
    a real focused effort that I think is going to help with this
    issue.
        Mr. Upton. So I want to--well, thank you. I want to echo
    our Republican leader, Cathy McMorris Rodgers, in terms of her
    question on why don't we make this permanent, the classwide
    scheduling for fentanyl, rather than an extension. I think that
    makes a lot of sense.
        You sensed, as we get--close in on this deadline, again,
    that perhaps the administration, if Congress fails to act,
    knowing that we are only in session this week and next, that
    they might pursue an Executive order to try and extend that?
        Ms. LaBelle. So, Congressman, I think I would have to check
    to see if we have the authority by Executive order. I am not
    sure that we can do it.
        What DEA can do is, you know, ask for--by--analogue by
    analogue, to schedule it. That they certainly could do. I am
    not sure the Executive order would--could make it--could extend
    it, however.
        Mr. Upton. So we know that much of the fentanyl issue is
    coming from China, right? Tell us what you are doing to try and
    close that door.
        Ms. LaBelle. Sure, thanks. So what we are seeing right now,
    as I said, these issues are very dynamic, and drug traffickers
    are, obviously, very crafty. And so what is happening--what
    Congress did over the last several years is pass several pieces
    of legislation that allowed our Customs and Border Patrol to
    identify this--the drugs that were coming through the mail.
        Now--and China acted to schedule fentanyl as a class. So
    now a lot of the drugs are going in through Mexico. We are
    working with Mexico to make sure that they are working on
    interdiction, so that it never even comes to the border, that
    they are working on identifying labs so they can seize these
    labs. And then lastly, working at their ports of entry to
    identify and seize these substances. So we have a good working
    relationship with Mexico on these types of issues, and our law
    enforcement partners can work together on it.
        Mr. Upton. I don't know--I don't have the clock on my
    screen. Do I have a lot of time left, Anna?
        Wait, I didn't hear you.
        Voice. You have 50 seconds.
        Ms. Eshoo. You have a minute.
        Mr. Upton. OK, one of the things that we discovered in the
    last Congress was that our postal inspectors, frankly, didn't
    have the resources.
        So, as you know, I am from Michigan. Much of our mail in
    west Michigan actually goes through the Grand Rapids postal
    facility. You know, we learned that, at the time, they had one
    postal inspector to really look through all of these different
    packages coming through. I know Dr. Burgess was up to New York
    and saw just a number of these facilities. There has been a lot
    of documentation on that on TV, in terms of the issues there.
        What are we doing on more resources to try and stop this
    from coming in using FedEx, UPS, as well as the Postal Service,
    things that would seem pretty routine to you and me?
        Ms. LaBelle. So I will quickly answer that. So, number one,
    we saw that there was a decided drop in mail coming from China
    that had fentanyl in it. So that was a success over the last
    year.
        However, Congress did provide additional resources to the
    U.S. Postal Service, Inspection Service, to identify these
    drugs. And there were other pieces of legislation passed to
    make it easier to identify something that might be coming from
    a chemical company that could have fentanyl in it.
        Mr. Upton. Thank you, I yield back.
        Ms. Eshoo. We thank the gentleman.
        It is a pleasure to recognize the gentlewoman from
    California--and she is a gentlewoman--Congresswoman Matsui.
        Ms. Matsui. Thank you very much, Madam Chair, and thank you
    for holding this very important hearing.
        And Ms. LaBelle, welcome to the committee and thank you for
    your testimony and the very important work that you are doing.
        Now, we know that the lack of access to timely, high-
    quality behavioral health treatment continues to be a
    significant challenge. And that is why I have long supported
    the expansion of Certified Community Behavioral Health Clinics,
    CCBHCs, which provide a comprehensive range of mental health
    and substance use disorder services to vulnerable individuals,
    including 24/7 crisis response and care coordination.
        Addiction treatment is a core component of CCBHCs' required
    service offerings. And as a result, all 340 clinics across 40
    States, DC, and Guam have either launched new addiction
    treatment services or expanded the scope of their addiction
    care. And well over half of CCBHCs provide same-day access to
    medication-assisted treatment for patients with opioid use
    disorder. This model is really well placed to respond to the
    pandemic's expected long-term impact on behavioral health
    needs, and Congress has recognized its value by extending
    support to the program in recent COVID relief bills.
        Ms. LaBelle, how does the Biden administration plan to
    leverage existing treatment networks like CCBHCs expand access
    to recovery support services?
        Ms. LaBelle. Sure, thank you, Congresswoman. You raise a
    really important point about recovery services.
        As we recognize that addiction is a chronic condition, we
    need to have recovery support so that we can sustain people's
    recovery over a period of time. CCBHCs received about $420
    million in the American Rescue Plan, and that includes--they
    are required to have recovery support services within them.
        Peer support services are incredibly important, as you
    point out. They have to be provided throughout communities. As
    some Member of Congress mentioned, one of our highest rates of
    overdose death are among people--the reentry population, people
    leaving jails and prisons. It is important that recovery
    services reach them to help them sustain their recovery so that
    they don't overdose and that they can go on to live full lives.
        So we look forward to working with you further to determine
    how to integrate recovery services throughout all of our
    treatment programs.
        Ms. Matsui. Well, I look forward to that, thank you very
    much.
        You know, in 2018 Congress included in the SUPPORT Act a
    provision requiring DEA to issue regulations around a special
    registration process to expand remote prescribing of controlled
    substances. While in the past year the public health emergency
    has eased historic barriers to certain telehealth services,
    including allowing providers to initiate treatment for opioid
    use disorder over the phone and via video chat, the DEA has
    still not completed its statutory requirement to stand up the
    special registration process for remote prescribing.
        Ms. LaBelle, can you expand a bit on the framework ONDCP is
    using to evaluate whether to make permanent the emergency
    telehealth provisions related to MAT prescribing?
        Ms. LaBelle. Thanks for asking that. So we--you know, we
    have this included in our policy priorities. There are
    researchers at NIDA who are funded by the National Institute on
    Drug Abuse who are looking at exactly how effective the
    regulatory changes that were made during COVID have been. We
    are going to be looking at that and determining if it is
    administrative changes that need to be made, are there
    legislative changes, and how can we--what we have heard is a
    lot of anecdotal information that is really positive about how
    telehealth has helped people who are already in treatment be
    retained in treatment.
        So we want to be guided by science and evidence, and we are
    working with our colleagues at the National Institute on Drug
    Abuse to inform those policies.
        Ms. Matsui. Well, thank you very much, because I have been
    working with many providers in my community, and--whether it is
    at the hospital or the community health centers, they have had
    an increase in the telehealth with their patients and found
    very much that it was almost immediate, as far as the
    prescriptions and all of this and the sense of being able to,
    in fact, walk people through some of these crises as they have
    occurred.
        So I really do encourage that you really look at this, and
    I would be happy to work with you as we do this too. So thank
    you very much, very much for being here today.
        Ms. LaBelle. Thanks.
        Ms. Matsui. I yield back.
        Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
    recognize the gentleman from Texas, Dr. Burgess, for his 5
    minutes of questions.
        Mr. Burgess. I thank the Chair. I thank our witness for
    being here.
        Ms. LaBelle, it is great to make your acquaintance. I have
    worked with your predecessor, James Carroll, while we--in two
    Congresses ago, when we worked on the SUPPORT Act. So this
    ongoing work is critically important.
        Just to pick up on one of your answers to Ms. Matsui's
    question about telehealth, do you sort of foresee telehealth,
    you know--that was a big deal in getting people to continue
    doing their treatment, because they lost the in-person care
    that they were at one point receiving during the pandemic. So
    how do you see this working, as we come on the other side of
    the pandemic?
        Will telehealth continue to be complementary to the
    treatment available?
        Ms. LaBelle. Yes, thank you, Congressman. I think that
    telehealth will always be an essential piece going forward.
        I don't think it is going to replace in-person care, but it
    certainly makes it a lot easier for people who may be some
    distance from a treatment provider. What we want to do is
    increase interventions at every single point. And so, if we can
    remove the barrier that people face--it might be
    transportation, it might be child care--telehealth can help
    remove those types of barriers to get people to be retained in
    treatment.
        Mr. Burgess. Yes, and I was interested in your testimony,
    because it actually talked a little bit about the methadone
    treatment programs. Obviously, that is--by definition, that is
    in person, because the methadone is administered and has to be
    taken on site, literally.
        I actually worked in a methadone clinic when I was a senior
    medical student on an elective, but this was back in 1975, so
    it has been some time. But methadone--you are right, I don't
    think the methadone availability or methadone clinics have
    quite kept pace with what is available technologically. And I
    do think that is an important part that we need to include.
        Ms. LaBelle. Yes, sure. And that is--I think that is one
    thing we found, again, anecdotally--the research will follow
    soon, hopefully--is that, particularly for patients early in
    their methadone treatment, I mean, that is a long haul for many
    people to get to a methadone clinic, as you know. And so
    allowing them to have take-home doses and be able to have
    telehealth is a really--a great way to remove a barrier for
    someone who might otherwise not be able to continue in
    treatment and might be subject to overdose.
        Mr. Burgess. Right. But the risk for diversion is
    significant with methadone, and that has to be borne in mind.
        Let me just ask you--and I appreciate you providing the
    Biden-Harris administration policy priorities. One of those
    listed is reducing the supply of illicit substances. And
    clearly, that is absolutely critical. And many of us have spent
    some recent time down on the--I represent a district in Texas.
    I am not on the Texas border with Mexico, but there is a lot of
    activity, and a lot of illicit activity, a lot of contraband,
    of course, as well as people that are coming across the border.
        So how do you see what your task in preventing that is, in
    disrupting the supply of illicit substances? How do you see
    that working?
        Ms. LaBelle. Sure. So we have ongoing conversations with
    the Government of Mexico, and with our law enforcement partners
    through something called North American Drug Dialogue. We are
    working with Mexico on interdiction in their own country to
    prevent those drugs from even getting to the border,
    identifying and disrupting their labs, lab production, which is
    how the fentanyl is produced, or heroin, and then also their
    ports, which is where the precursor chemicals come. So that is
    kind of what--you know, some of the steps we are taking to make
    sure that it never even gets to the border. And that is a
    partnership that we have had, a long partnership with Mexico.
        Mr. Burgess. Well, good luck. But, I mean, if you have ever
    been down to the Texas-Mexico border, particularly that sector
    in the lower Rio Grande Valley, it is very, very difficult to
    provide those--that interdiction. And, of course, you couple
    that with the human toll that is coming across the border, and
    our Customs and Border Protection are tied up having to
    administer to them, it creates a diversion where additional
    supply can pretty much come across uninterrupted. So please
    don't take your eye off of that. That is absolutely critical,
    that we bring that under control. And that is certainly part of
    the Biden-Harris agenda that I would support, is interdicting
    that illicit supply coming into the country.
        Ms. LaBelle. Right----
        Mr. Burgess. Thank you, Madam Chair, I will yield back.
        Ms. Eshoo. The gentleman yields back. Those are excellent
    points.
        And now it is a pleasure to yield to the gentleman from
    Maryland, Mr. Sarbanes.
        [Pause.]
        Ms. Eshoo. I saw Mr. Sarbanes.
        There you are. Are you--Mr. Sarbanes? Can you hear us?
        Mr. Sarbanes, you need to unmute.
        Mr. Sarbanes. Sorry, Madam Chair.
        Ms. Eshoo. You looked like you were studying something very
    hard there.
        Mr. Sarbanes. Yes, I appreciate----
        Ms. Eshoo. You are recognized.
        Mr. Sarbanes. Yes, thank you very much for the hearing.
        Many of us, it is clear from our comments already, are
    focused on the impact of this opioid crisis on our particular
    States, the districts that we represent. I am no different from
    my colleagues in that respect.
        In Maryland, since 2017 we have seen over 2,000 opioid-
    related deaths each year, and the numbers have gotten worse, as
    we have been discussing today, during the coronavirus pandemic.
    In the first three quarters of 2020 there were more opioid-
    related deaths in Maryland than in the same time period in
    prior years. So we are seeing that acceleration. I think that
    goes to the heart of your opening comments about what do we
    need to do to really get our arms around this.
        I had the opportunity to serve on Energy and Commerce back
    in 2018, when we were crafting a legislative package to address
    the crisis that resulted, as you will recall, in H.R. 6, the
    SUPPORT for Patients and Communities Act, which included bills
    addressing a wide range of substance use disorder issues.
        Workforce issues are a very important part of the
    conversation, in terms of reversing this opioid epidemic. And
    the package back in 2018 included a bill which I had worked on,
    the Substance Use Disorder Workforce Loan Repayment Act, which
    would help increase the number of healthcare professionals
    working in addiction treatment and substance use disorder
    programs. It would provide loan repayment for individuals who
    provide direct patient care at opioid treatment programs in
    high-need areas.
        Director LaBelle, in your testimony you discuss staffing
    shortages in the behavioral health occupations. Could you
    describe some of the challenges that you are seeing in this
    area in particular and how it relates to our ability to address
    this crisis?
        Ms. LaBelle. Sure. Thank you, Congressman. And the loan
    repayment program is a good example of a solution.
        You know, we know how much colleges--medical school costs
    for people. And it might be--there are many communities around
    this country where they don't have access to any type of
    addiction treatment. Buprenorphine-waived doctors are not
    available. Methadone clinics are not available. Doctors don't
    know how to treat addiction or screen for it.
        So the workforce piece is something we are looking at very
    closely, and actually have had conversations with Johns Hopkins
    about how we work to encourage more medical schools, more
    healthcare providers, healthcare professional schools to
    include addiction in their curriculum, so that when people come
    out they are prepared to screen and identify folks for
    substance use disorder. The workforce issue is so important
    because, as we--Congress has been very generous in giving a lot
    of money to the States, but unless we address those workforce
    shortages, we are not going to be able to put that money to
    good use across the country.
        Mr. Sarbanes. Can you be a little more specific about some
    of the actions you plan to take in this space in the coming
    months?
        I mean, do you have a kind of prioritized list when it
    comes to boosting the workforce?
        And then, how can we help? I mean, how can Congress help
    support those efforts in concrete ways?
        Ms. LaBelle. Sure, thanks. So a couple of things.
        One is that there are fellowships that are available that
    have been funded by--in HRSA by HHS that are not filled yet. So
    we are going--we plan first to just make sure that people know
    that these fellowships, addiction fellowships, are available
    that can help build the addiction treatment workforce.
        Secondly, we plan to talk once again with our colleagues in
    medical school--medical schools, nursing schools--about what
    they can do to make sure that, for example, all of their
    residents are DATA-waived. That is one step they can take.
        So those are two things that we plan to take on right away.
    And again, we are going to work closely with Johns Hopkins on
    several of these issues.
        Mr. Sarbanes. Thank you very much.
        Madam Chair, I yield back my time.
        Ms. Eshoo. The gentleman yields back. It is a pleasure to
    recognize the gentleman from Virginia, Mr. Griffith, for your 5
    minutes of questions.
        Mr. Griffith. Thank you very much, Madam Chair.
        Director LaBelle, I first want to say that I greatly
    appreciate the work that the Office of National Drug Control
    Policy does and the role it plays in combating abuse of
    controlled substances.
        In fact, you mentioned one of the programs that was very
    helpful in my district--in fact, they would like it expanded--
    and that is the HIDA program.
        Former Director Jim Carroll traveled to the district a
    little over a year ago, and we visited with the folks in a far
    southwest corner of Virginia where the opioid epidemic has hit
    particularly hard, although it is spread across the district.
    And prescription opioid abuse has been a major problem, as it
    has been in many districts. But for many years, the Nation's
    highest per-capita prescribing rates for opioid pain pills
    occurred in two of the localities in my district. One, it was
    306 pills per person, and in another it was 242. So obviously,
    we can do better, and we are doing better, and I appreciate
    your work on this as well.
        And we have more than our share of illegal drugs trafficked
    in from China and Mexico.
        But the question is, how does the ONDCP approach to data
    collection and recommendations differ between schedule I and
    schedule II substances?
        Ms. LaBelle. So I think--I am sorry, can you repeat the
    last part of the question?
        Mr. Griffith. Sure. What is--what are the differences
    between schedule I and schedule II when it comes to your data
    collection and then the recommendations you make?
        Ms. LaBelle. So the National Survey on Drug Use and Health
    is one of our tools that the Health and Human Services
    Department uses to collect data on drug use. And it has--it
    asks questions about lifetime drug use, substance use. It
    includes alcohol, it includes schedule I and schedule II drugs.
    And they added a lot about schedule II--I am sorry?
        They added quite a few questions about schedule II drugs in
    the last couple of years because, as you said, we can't keep
    our eye off the ball of other types of substance misuse.
        What we are trying to do in our strategy, in our policy
    priorities, is look at this from a holistic standpoint, that it
    is not just about one drug, it is about all drugs. It is about
    polysubstance use. And that can include alcohol use, as well,
    because we know that that is a substance that young people
    first start with, including alcohol and marijuana.
        So those are our issues. We work closely with HHS through
    their National Survey on Drug Use and Health to inform our
    policies.
        Mr. Griffith. And I appreciate that. And I appreciate
    recognizing that all substances may have a problem. I come from
    a family with some history of substance abuse, and so I have
    chosen throughout my life not to use any of the substances,
    including alcohol and marijuana.
        All right, new subject, Director LaBelle. In 2019 a Federal
    interagency work group led by ONDCP recommended the use of
    permanent classified scheduling for fentanyl-related
    substances, along with legislative modifications to allow for
    easier rescheduling of any fentanyl-related substances with low
    or no abuse potential. This would allow rescheduling to happen
    in a more timely manner, and it would make it easier to conduct
    research on schedule I substances. And I am big on research.
        I understand that ONDCP is reevaluating permanent
    scheduling, but does ONDCP still stand by these recommendations
    to make conducting research for medical purposes easier?
        Ms. LaBelle. So we are talking to HHS about exactly what
    the barriers are to research with the fentanyl scheduling
    legislation as it currently stands. We will be engaging with
    them in the future. We can build off of what was done and have
    that inform our work, but we need to make sure we are talking
    to them about the issues they are facing today.
        Mr. Griffith. Because, I mean, I think this is an important
    issue, and I think we need to do research because, while some
    of this stuff is the nastiest stuff out there and has no
    benefit whatsoever, sometimes things have medical capabilities
    that we are just not aware of. And if we don't allow our
    research facilities and our medical teams to experiment and try
    to figure out how to--how do you solve these problems, then we
    will still be in the dark 20 years from now.
        Ms. LaBelle. Right.
        Mr. Griffith. So I would hope that you all would allow more
    research, even on schedule I, and figure out ways to make it so
    that it is practical and effective and efficient.
        And I have got a little bill that will help you do that,
    but--that Dan Crenshaw and I are carrying. But I am encouraged
    by your comments, and I yield back.
        Thank you, Madam Chair.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. I thank the gentleman, and especially for being
    willing to express what your family and extended family have
    dealt with. That is to your credit. And I think it is important
    for not only Members but the American people hear you express
    that, Mr. Griffith.
        Now I would like to recognize the gentleman from Oregon,
    Mr. Schrader, for your 5 minutes of questions.
        Mr. Schrader. Thank you very much, Madam Chair.
        And Director LaBelle, thanks for being here. I appreciate
    it very, very much. I am encouraged by the interest shown by
    ONDCP in pursuing mental health parity. We try and do that in
    Oregon. It is a huge benefit at minimal cost, and I would argue
    it saves millions of lives and a lot of money in the long run.
        Just like we have been talking about here, access to
    treatment is a huge issue. And while payers can't create more
    providers, ensuring that, you know, they cover the ones that
    exist is one piece of the puzzle.
        And so, in that regard, what policies is ONDCP considering
    to encourage the growth of substance use disorder providers?
        Ms. LaBelle. So what we are doing is making sure,
    obviously, that there is quality treatment. As you mentioned,
    the parity work, we did quite a bit of that when I was here at
    ONDCP last. We need to catch up to see where the barriers still
    exist to parity. We need to work with Department of Labor as
    the agency that administers and enforces the Parity Act. So we
    will be working with them to determine what the gaps--where the
    gaps continue to be.
        Mr. Schrader. Very good, very good, excellent.
        And others have spoken about this too, but, you know, the--
    last March, millions of Americans that were getting treatment
    for alcohol, cocaine, methamphetamine, marijuana, fentanyl,
    heroin addictions basically lost access. There have been some
    creative opportunities through telehealth to help in that
    regard.
        And so, given the constraints that we have encountered with
    the in-person care, has ONDCP given any consideration--the
    field--the FDA cleared and regulated products called
    Prescription Digital Therapeutics that use software to treat
    serious unmet medical health needs? And if so, how so?
        Ms. LaBelle. Sure. Thank you for asking that. So clearly,
    there are lots of innovations that have come out across the
    country to address this need.
        I mean, there are--technological innovations kind of
    abound, which is great because, as I said before, our policy
    priority is about increasing interventions at every single
    point and removing barriers. And technological advances such as
    the one you identified, that is something I need to look into a
    little bit further, and I would be happy to talk to you about
    that more.
        Mr. Schrader. Well, that would be great. I would like to
    have you work with the committee on the opportunities that are
    there.
        My understanding is that the products actually have
    accountability and support features built into them, which are
    both very, very important in terms of followthrough. So I want
    to make sure that, while these apps and opportunities are
    there, they are actually doing what we want them to do and can
    register improvement from our patients. So if you will work
    with us, I would appreciate it.
        Ms. LaBelle. Sure, thank you.
        Mr. Schrader. Thank you.
        And Madam Chair, I yield back.
        Ms. Eshoo. Thank you. The gentleman yields back.
        It is a pleasure to recognize the wonderful Mr. Bilirakis--
    --
        Mr. Bilirakis. Thank you very much. I appreciate it, Madam
    Chair----
        Ms. Eshoo [continuing]. Members on our committee.
        Mr. Bilirakis. Thank you so much, it is appreciated.
        Madam Chair, the United States remains in an overdose
    epidemic. I know you know that. Sadly, according to the CDC,
    drug overdose deaths rose from 2018 to 2019; 70,630 lives lost
    in 2019, sadly. And with deaths involving synthetic opioids,
    primarily fentanyl, there was a continued increase with more
    than 36,359 lives lost in 2019. It is just terrible.
        DEA temporarily scheduled fentanyl analogues as controlled
    substances 3 years ago. Last year Congress passed a temporary
    extension that continued to criminalize fentanyl analogues
    until May 6, 2021. Locally, we have seen that fentanyl has been
    a major problem even with the schedule being in place. Madam
    Chair.
        For example, Pasco County in my district has already had 48
    people die from overdoses since January of this year. And Pasco
    is not alone, as you know. Many communities throughout the
    country are experiencing the same overdose increases as the
    pandemic has only exacerbated the mental health and addiction
    crisis in our country. If this scheduling ban expires, we
    expect far more fentanyl to flood our streets and many more
    lives to be tragically lost. We cannot allow that to happen.
        While we have made meaningful bipartisan strides to address
    this scourge, we are certainly far from being out of the woods.
    It is critical that we remain engaged in the fight to save the
    communities we are charged to represent, and the lives of our
    neighbors too often cut short.
        Director LaBelle, thank you for being here. Thank you for
    your testimony. Can you discuss our working relationship with
    China to prevent the entry and sale of fentanyl and its
    analogues?
        And then, given the dynamics of the current U.S.-China
    relationship, what is the level of transparency and information
    sharing with law enforcement agencies, please? Thank you.
        Ms. LaBelle. Sure, thank you, Congressman. I will start
    with your first question first.
        So our office, the Office of National Drug Control Policy,
    has a regular conversation with our embassy in Beijing, where
    we discuss these very issues that you raised. China has a very
    large chemical industry, much of it which is unregulated. So we
    are discussing with them on a regular basis about just the
    issues that we have discussed, how to control the chemical
    industry so the precursor chemicals that are used in the
    manufacturing of fentanyl and fentanyl analogue are more
    controlled.
        And then the second--your second question concerned, you
    know, what--going forward, what we can do. Again, you know, it
    is making sure that--there were several pieces of legislation
    put into place that--so we could have our Customs and Border
    Protection and the U.S. Postal Service make sure they are
    getting the chemicals that are coming in, the fentanyl
    analogues that are coming in through the mail or express
    couriers, so they can seize those.
        And then also, I think it was good in--a couple of years
    ago when China--working with China to make sure they were--they
    scheduled all of their fentanyl. So that did reduce the amount
    of fentanyl coming in directly to the United States from China.
        Unfortunately, a lot of that--the chemicals are now going
    to Mexico, where we are working with Mexico on the problem.
        Mr. Bilirakis. Thank you.
        You know, Madam Chair, while China's step to designate
    fentanyl and all its related analogues as controlled substances
    is certainly helpful, if COVID-19 has taught us anything, it is
    that we ought to remain skeptical and not rely on the goodwill
    of the Chinese Communist Party.
        A permanent American solution is necessary, as you know,
    and I encourage my colleagues to review and consider a
    permanent ban for these deadly analogues under H.R. 1910, the
    FIGHT Fentanyl Act, or continuing the temporary ban under H.R.
    2430, the Temporary Reauthorization of the Emergency Scheduling
    Fentanyl Analogues Act.
        Thank you very much for holding this very important
    hearing, Madam Chair, and I will yield back. Thank you.
        Ms. Eshoo. I thank the gentleman, and he yields back.
        I don't see Dr. Ruiz, so I am going to go to the
    gentlewoman from Michigan, Mrs. Dingell.
        You are recognized.
        [Pause.]
        Ms. Eshoo. Unmute.
        Mrs. Dingell. I know----
        Ms. Eshoo. Now we can hear your voice.
        Mrs. Dingell. I am sorry. Thank you, Chairwoman Eshoo and
    Ranking Member Guthrie, for convening this important hearing on
    the opioid crisis, which, as we have all talked about this
    morning, remains one of the defining public health challenges
    of our time. And thank you, Acting Director LaBelle, for the
    leadership you and your team have already put forward at the
    Office of National Drug Control Policy.
        As we know, substance abuse disorders are complex, but they
    are treatable diseases. And it is good to be part of a
    committee that has recognized that and sees this as a public
    health problem.
        Despite all of our work over the years, the Nation is still
    experiencing a significant treatment gap, and I would like to
    ask you to expand on how we can work together to reduce
    barriers to treatment, particularly for patients who receive
    methadone. By law, only certain treatment programs can dispense
    methadone for the treatment of opioid use disorder. Patients
    who receive methadone as part of their treatment must also
    receive the medication under the supervision of a practitioner.
        Could you--Director LaBelle, could you--the
    administration's drug policy priority states that you plan to
    review policies relating to the methadone treatment and develop
    recommendations to modernize them. When will this review begin,
    and when do you expect to develop recommendations?
        Ms. LaBelle. Thank you for your question. And methadone is,
    obviously, a proven medication for opioid use disorder, as you
    have recognized. We are--we have not yet begun that review. I
    can't give you a timeline. We do know how urgent it is.
        Methadone regulations and rules haven't been reviewed in
    some--for some time. So we need to--you know, our policy
    priorities were issued on April 1st. We are now looking for
    what the best venue is to review that. So as soon as we know
    that, I will make sure our office stays in touch with your
    staff about it.
        Mrs. Dingell. Thank you. During the pandemic SAMHSA and
    other agencies have made exceptions to rules around treatment
    for opioid use disorder. But some restrictions around methadone
    remain in place, such as requiring new patients that are
    treated with methadone to complete an in-person medical exam.
    Does that in-person requirement exist for other forms of opioid
    use disorder treatment?
        Can this requirement be a barrier for patients seeking
    treatment?
        Ms. LaBelle. So the methadone--the way--and again, I am a
    lawyer, not a doctor, so I don't want to step into clinical
    recommendations. But as I understand it, one of the issues with
    methadone is making sure you get the right dose, which is why
    it is so important to have the in-person piece.
        Those are issues that we need to make sure are reviewed and
    that we have clinicians who can discuss that very issue,
    because we know methadone works and we want to remove those
    barriers.
        Mrs. Dingell. One way to--thank you for that. One way to
    reduce barriers to treatment is to find ways to meet patients
    where they are. Your priorities include finalizing a rule
    related to methadone treatment vans. Can you talk to--talk us
    through how these would work and why they might be important
    for both rural and urban communities?
        Ms. LaBelle. Great, thank you. So methadone treatment vans
    have been--we haven't had new ones for almost a decade now, and
    so that is why it is so important to get these methadone rules
    out. The mobile methadone vans can be useful. I feel very
    strongly they can be useful in--across the country in jails
    that may not have their own opioid treatment program. A
    methadone van could provide those services to those
    individuals.
        I also think that it is important--and I talked about the,
    you know, the mobile treatment availability. It is--that is
    important for rural areas, but it is also important in urban
    areas as well, where you might have the same type of--or
    similar issues with transportation. So I am a strong proponent
    of mobile methadone vans, and we are working diligently to make
    sure that those get out as soon as possible.
        Mrs. Dingell. Thank you, Director LaBelle. As we have heard
    today, the trend in drug overdose death statistics is really
    alarming, and we know that increasing the availability of
    treatment will ultimately save lives.
        I lost my sister to this, so it is an issue that remains
    very personal. My father was an addict too. So thank you for
    all the work you are doing, and we also have to remove this
    stigma attached to it so we can get out there and really treat
    the problems. Thank you.
        I yield back, Madam Chair.
        Ms. Eshoo. The gentlewoman yields back. And I would also
    add to Mr. Griffith's personal testimony, I think that it is
    really rather courageous of Members coming forward, as Mrs.
    Dingell has, to let the American people know that we are all
    just as human as the rest of the people in our country and that
    these terrible, terrible drugs have impacted so many Members
    in--obviously, in a very personal way. So thank you to you.
        The Chair now recognizes the gentleman from Missouri, the
    one, the only Congressman Long.
        Mr. Long. Thank you, Madam Chair, and I appreciate it very
    much. And I remember being on a trip to Turkey with you a few
    years ago, right around the start of the Syrian War. And we had
    some refugees from Syria in our roundtable discussion, so we
    were there a week and really trying to drill down. And at one
    point you leaned back and you said, ``What a mess.'' And that,
    I think, is what we are faced with here again today. What a
    mess.
        I never came home growing up and had my parents tell me
    that one of their friend's children had deceased from drugs.
    And just within the last month I have had the fourth child that
    is the same age as my children and grew up with them, that
    deceased from opioid abuse, I guess you would call it. And all
    four of those cases, all four, are personal friends of mine
    that have lost children. They had had them--they were all
    middle--upper- or middle-class and above. They had all done
    everything humanly possible for their children, had them in
    rehab facility, rehab facility, after rehab facility. One died,
    they found him in the bushes of the rehab facility with a
    needle still stuck in his arm.
        So thank you very much, Madam Chair, for holding this very
    important hearing today. It is titled, ``An Epidemic Within a
    Pandemic: Understanding Substance Use and Misuse in America.''
    And I hope we can understand how to break the addiction for
    these kids, because in all four cases in our--you knew what was
    going to happen, you knew how the book was going to end, how
    the story was going to end. And it did. And I don't know what
    the breakthrough will be, with a drug company or with someone
    to come up with something to break this horrendous addiction,
    and--that brings so much death to families across America.
        I was in Kansas City a couple of years ago visiting a drug
    facility where, when the cops pick you up, instead of taking
    you to jail, they take you to this facility. And the first
    thing that they do is they test you for drugs. And they have
    got this guy in there, the cops brought him in, and instead of
    taking him to jail, bringing him to the rehab facility, brought
    him in, and they said, ``What are you on?''
        And he said that he was on opioids, and they tested him and
    they said, ``You don't have one opioid in your system. You have
    fentanyl.''
        He said, ``What is fentanyl?''
        So, again, I, you know, just want to thank you for holding
    the hearing.
        And Ms. LaBelle, for years Missouri had one of the worst
    problems in the country with meth labs. And that trend has,
    thankfully, gone down. But, unfortunately, these bigger
    manufacturing operations are filling the void.
        We tend to think of meth as the small lab's business. And
    when I was an auctioneer, I would go out to book a farm, a real
    estate auction, and there would be a black trash bag on the
    ground with, like, smoke coming up. It wasn't smoke. I don't
    know exactly what it was, but somehow I guess you can put meth
    in a black plastic trash bag. But--so we tend to think of it as
    small labs in basements or out in the fields, I guess. But it
    is clear that the meth production has turned into a highly
    industrialized operation.
        And last week a Missouri State Highway Patrol trooper found
    88 pounds of meth in a car during a traffic stop. And this was
    following a similar traffic stop in Missouri the week before,
    where they discovered 75 pounds in a cooler in the back of a
    car.
        Last year, in March, we had a hearing on substance use
    disorder, and I asked Admiral Brett Giroir, the Assistant
    Secretary of HHS at the time, about methamphetamine. He noted
    the cartels were manufacturing and then distributing hundreds
    of thousand pounds of pure methamphetamine. And he
    characterized methamphetamine as the fourth wave of substance
    abuse.
        Director LaBelle, last year's hearing was right before the
    COVID pandemic and everything that came with it. Fast forward a
    year. What are you now seeing, in terms of availability,
    manufacture, and distribution, and use of methamphetamine?
        Ms. LaBelle. Thank you, Congressman. So I think, as you
    said, it is not yesterday's meth. Meth that is being--now it is
    manufactured in Mexico, and it is coming in to the United
    States across the border. So--and we are seeing it where--I
    grew up in New England, but lived in Washington State for a
    long time. Never heard of it in New England. Washington State
    had a lot of meth labs. Now we are seeing more meth
    availability in the Northeast and across the country.
        And so I think that that is getting much more attention. We
    know there are treatment programs that work, and will be
    working with HHS on making sure that, again, the barrier to
    effective treatment for meth use disorder is something that we
    take up.
        Mr. Long. OK, I only have 47 more questions, but I am out
    of time. So, Madam Chair, I yield back.
        Ms. Eshoo. The gentleman yields back. I think that it is
    worth noting that when--with a sweeping schedule I designation,
    it is very difficult for there to be the development of new
    drugs to be administered to people that would benefit from
    them, because in that sweeping schedule I it eliminates the
    possibility of some of these substances to be used to the--for
    the benefit of individuals. So I think we need to keep that in
    mind.
        Let me recognize the gentleman from California, Dr. Ruiz,
    for his 5 minutes of questions.
        Mr. Ruiz. Thank you, Madam Chair, and thank you, Acting
    Director LaBelle, for providing an update on the
    administration's drug policy priorities.
        One issue I would like to address today is access to
    treatment, and how that is directly related to the amount of
    education and training of providers. In other words, also the
    physician shortage that we see, not only in all aspects and all
    specialties, but specifically with addiction medicine.
        As an emergency physician myself, I have cared for
    countless individuals in the emergency department who were
    actively overdosing and have resuscitated many and intubated
    them, et cetera, given them the appropriate medications when
    appropriate, and saved their lives. And there is an obvious
    opportunity in the emergency department to help an individual
    get help by seeking long-term treatment.
        However, many patients with substance use disorders also
    come to the emergency department for completely different
    reasons. And being able to identify the more subtle signs of
    substance use disorders can be a critical tool to help more
    individuals get access to the treatment they need. In other
    words, identify those at risk, give them the treatment before
    they come in blue and not breathing.
        And this is not just for emergency physicians. The more
    providers in all specialties that can help identify the signs,
    the more opportunity we have to open doors for our patients to
    seek care and improve their lives. A National Academies paper
    issued last April found that, ``despite the impact and
    pervasiveness of the opioid epidemic, most clinicians cannot
    confidently diagnose and treat patients with substance use
    disorder.''
        So Acting Director LaBelle, just talk to me about whether
    or not additional education and training around substance use
    disorders improve provider confidence in diagnosing and
    treating substance use disorders and, therefore, increase
    access to treatments for individuals with substance use
    disorders.
        Ms. LaBelle. Thank you, Doctor. I couldn't agree more about
    the importance of all providers, all healthcare providers,
    being able to identify early stages of a substance use disorder
    before it becomes chronic, when it is much harder to treat, as
    you know.
        So we are working with the National Academies. We will
    continue to work with the National Academies, the American
    Medical Association, pediatricians. These are all important
    parts of the answer to this, is to make sure that they get the
    training that they need in medical school but also, you know,
    during residency, so that they understand how to identify and
    refer people to treatment. That is a key element of our
    strategy.
        Mr. Ruiz. Thank you. And you also note in your testimony
    that the Nation's addiction workforce is experiencing staffing
    shortages. In what way does the Biden-Harris administration
    plan to support, diversify, and expand the addiction workforce?
        Ms. LaBelle. Thank you, an important point about
    diversifying the addiction workforce.
        There are fellowship programs, minority fellowship programs
    in particular, that would help diversify the workforce. I don't
    think we are there yet. And I want to work with your office to
    identify how better to address those issues, because I think
    there have been workforce approaches that have been authorized
    but not appropriated. We need to work with HHS to identify what
    those are and expand them, and particularly in areas where
    there is a high need.
        Mr. Ruiz. Director LaBelle, I helped start a medical school
    in one of the--California's most underresourced areas that
    faced high health disparities, our senior--founding senior
    associate dean at the UC Riverside School of Medicine. And one
    of our missions was to develop a workforce that comes from the
    underserved communities. In other words, it is--diversity was
    very important.
        The best way to do so is to create pipelines from those
    communities into those specific targeted specialties that you
    need for that region. And so I am more--and I developed
    pipelines, not only through my pre-med mentorship programs from
    those underserved communities but also developing residency,
    because the best predictors of where a person will practice is
    where they are from and where they last train. So you need to
    develop pipelines and create residencies in addiction medicine
    in those under-served communities.
        And so with that, I want to thank you. I want to make
    myself available to you as we address this pandemic the right
    way.
        And I yield back my time.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. The gentleman yields back. It is a pleasure
    now----
        Mr. Guthrie. Excuse me, Madam Chair?
        Ms. Eshoo. Yes?
        Mr. Guthrie. Hey, it is Brett Guthrie. Hey, you made a
    comment between the last two questioners about research and
    fentanyl. And I am not speaking for every single Republican, I
    think, but for our side is that we just want to say we want to
    do research, but we don't think they are mutually exclusive,
    that you can have scheduling--and there is a bill that I think
    Mr. Griffith and Mr. Crenshaw have allows for research to go
    forward too.
        So I just wanted to--I know we don't have a chance to
    respond to that comment, I just wanted to respond to what you
    said between the last two.
        Ms. Eshoo. Yes, it is not a hit on anyone. I think there is
    bipartisanship on the--always on the development of new drugs
    to----
        Mr. Guthrie. Absolutely.
        Ms. Eshoo [continuing]. Suppress whatever it is that is
    serious out there.
        Mr. Guthrie. Right.
        Ms. Eshoo. I thought it was, you know, important just to
    mention, and thank you for raising it.
        Mr. Guthrie. Thank you, I appreciate that.
        Ms. Eshoo. We can be for--we can certainly be for both, and
    I believe that we are, and bills address it.
        I now would like to recognize the gentleman from Indiana,
    Dr. Bucshon, for his 5 minutes of questions.
        Great to see you. Look at that big smile. You make me
    happy, just looking at my screen.
        Mr. Bucshon. Yes, well, thank you, Madam Chairwoman. I very
    much appreciate it. And thank you to the panel.
        I was a cardiovascular and thoracic surgeon before, so I
    have been in healthcare for over 30 years, and this is really a
    critical subject.
        But before I get to my questions, I would like to share my
    concerns regarding one of the bills being considered today.
    Buprenorphine can be effectively administered by properly
    educated and trained providers who counsel and educate
    patients. However, the vast majority of individuals currently
    receive little or no counseling.
        I have been working in Congress to implement prescribing
    limits and increased prescriber education for buprenorphine and
    other medication-assisted treatment to mitigate the practice of
    only treating people with medication-assisted treatment but not
    continuing on with a more comprehensive treatment plan.
        However, not everyone agrees with this, and some of my
    friends continue to work on expanding the scope of practice to
    allow almost anyone, regardless of their qualifications and/or
    training, to prescribe buprenorphine. In my opinion, that is
    exactly what H.R. 1384, the Mainstreaming Addiction Treatment
    Act, does. It removes education requirements and limits, making
    it easier to prescribe the medication known to be one of the
    most highly diverted drugs in the country.
        This bill will only expand access to medication, not real
    and effective treatment for individuals with substance use
    disorder. Everyone who is legitimately involved in the
    medication-assisted treatment space to treat people who are
    addicted recognize the importance of a comprehensive treatment
    plan. The last thing Congress should do is relax the
    requirements for prescribing and dispensing narcotic drugs such
    as buprenorphine because, as I mentioned before, expanding the
    use of medication-assisted treatment is not going to be
    effective unless we have a comprehensive treatment plan in
    place. So I would like to voice my opposition to this
    legislation.
        Pivoting now to another topic, pain management is real, and
    people have chronic pain, and we must look--all of us--to
    finding non-opioid alternatives to use to help individuals that
    suffer from pain daily. Director LaBelle, recently eight States
    have passed non-opioid directives that ensure non-opioid
    options are considered for the treatment of pain management.
    These directives are voluntary and are intended to spur
    discussions between patients and providers around alternative
    ways to alleviate pain.
        Does the White House support establishing a Federal--my
    question is, does the White House support establishing a
    Federal non-opioid directive to further empower patients and
    providers across the country to engage in important
    conversations around the need for non-opioid alternatives?
        And are we--also I would request that the White House
    consider reimbursement as an issue, as opioids are cheap and
    new medicines are expensive. And what advice might you have to
    Congress in addressing that particular issue?
        Ms. LaBelle. Thank you, Congressman. So, on the first one,
    I think we could--we would be happy to work with your office to
    get more information on that issue, on the directives.
        On the second issue, the reimbursement rates certainly, you
    know, are something that we would have to speak with CMS about.
    And as we go forward in our national drug control strategy,
    which we will issue next year, we can certainly take a look at
    that.
        Mr. Bucshon. Yes, because that is one of the most important
    barriers for hospital systems or clinics, is, again, opioids
    are very cheap, potentially new non-opioid alternatives are
    expensive. And when you look at, you know, bundled payments
    that--based on diagnostic-related groups and other ways
    providers are reimbursed, it doesn't make a lot of economic
    sense, in many cases, to use non-opioid alternatives, and we
    need to fix that, because, whether we like it or not, in
    healthcare financial incentives drive the ship many times.
        Ms. LaBelle. Right, right.
        Mr. Bucshon. And so we need to address that. So I
    appreciate that.
        You can also not properly combat the opioid misuse epidemic
    without addressing one of its root causes: again, as I just
    mentioned, inadequate pain management. HHS has included
    improving pain management as one of their pillars of the opioid
    strategy. What is ONDCP's position on improving pain
    management, provider education, and patient access to non-
    opioid therapies?
        And that is just an extension of what I just mentioned.
        Ms. LaBelle. Sure. I think it is really important that we
    make sure that people who are--have pain are treated properly,
    whether that is--and what the alternatives are, that is an
    important issue that I know that the National Institutes on
    Drug Abuse have looked at, as well as the rest of HHS and CDC.
    So it is a very important issue that we will look at, going
    forward.
        Mr. Bucshon. Thank you. I can--I had a personal experience
    with my father, who has now passed away, had substantial back
    issues that, really, there was nothing they could do for him--
    he was in his late 70s, early 80s--other than opioids,
    unfortunately. And all of us are fighting the opioid epidemic.
    But what happened to him is--in his home State--is it became
    more and more difficult to acquire his medication, even through
    his primary care provider, because of things put in place at
    the State level.
        So I just want to mention the pain--chronic pain management
    is an issue. We need good opioid alternatives.
        With that, Madam Chairwoman, I yield back. Thank you.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. The gentleman yields back. It is a pleasure to
    recognize the gentlewoman from New Hampshire, certainly not a
    newcomer to this issue, offered really important insights and
    leadership on the whole issue of opioids, Ms. Kuster.
        You are recognized.
        Ms. Kuster. Thank you so much, Chairwoman Eshoo, and thank
    you to Director LaBelle for joining us today. I am pleased to
    see that this administration's priorities focus on evidence-
    based approaches that holistically address prevention, support,
    and treatment for those battling with substance use disorder.
    And I think you can appreciate today, for many of us, this is a
    personal issue in our families as well.
        My legislation, the Emergency Support for Substance Use
    Disorder, was included in the American Rescue Plan to ensure
    smaller organizations on the front lines of the addiction
    crisis would receive support for their harm reduction services
    during COVID-19. I look forward to working with you.
        I want to commend Representative Tonko's bill today about
    treatment at the end of incarceration, and I would like to meet
    with you about treatment during incarceration so that we can
    break this terrible recidivism cycle that we are engaged in.
        This is deeply personal. And New Hampshire has consistently
    had one of the highest rates of overdose deaths in the country.
    In 2019 my State ranked third for the most overdose deaths per
    100,000 people. And we had the highest rate of fentanyl
    overdose deaths per capita in the United States for many years.
    In 2020 about 65 percent of the overdoses in New Hampshire were
    caused by fentanyl, or a combination of fentanyl and other
    drugs, as we have heard today.
        But we know this is not just happening in my State. My
    colleagues all have similar stories about how the opioid crisis
    has evolved into an overdose crisis at the hands of synthetic
    opioids.
        Now, at the same time, the Drug Enforcement Agency has had
    the ability to go after the proliferation of fentanyl-related
    substances through emergency classwide scheduling. Despite this
    tool, we have seen the continued upward trend of overdose
    deaths related to fentanyl and its analogues. And that is why I
    have introduced, with my good friend and colleague
    Congresswoman Blunt Rochester, the STOP Fentanyl Act to provide
    a comprehensive, balanced public health approach.
        Director LaBelle. You have said the administration is
    supportive of this short-term extension, but could you explain,
    as specifically as you can, how another temporary extension is
    necessary to explore a more comprehensive and effective
    approach to fentanyl-related substances?
        Ms. LaBelle. Sure. Thank you, Congresswoman, and thank you
    for your work on this issue.
        I think that we need the extension because we need a little
    bit more time to--you know, we have only been in this position
    for about 85 days. There are many people who aren't even in
    place yet. This is a critically important issue, and we want to
    do it right. So we need the time to look at the mandatory
    minimum implications of this legislation as well as the
    research implications that have come up several times on both
    sides of the aisle. So that is why we need the extension of
    time.
        Ms. Kuster. And if I could press you a bit further, what is
    the plan to use that time effectively, so we won't be back in
    this same situation if we grant a seven-month extension?
        Ms. LaBelle. Sure. I mean, so the plan is that, you know,
    it is a process plan, which is we get our colleagues together
    from the Department of Justice, we get our colleagues together
    from HHS, and we hash this out. We have had a couple of
    meetings already. We are going to have more, and we are going
    to come together and have a resolution of the issues.
        Ms. Kuster. And how can we work with you to make sure that
    we address the issue of racial equality?
        I am very concerned, as many of us are on both sides of the
    aisle, about the disparate impact on race with these mandatory
    minimums. How can we do a better job with a public health
    approach, rather than being so focused on mandatory minimums,
    when we know we are not getting the treatment into the jails
    and prisons across this country?
        Ms. LaBelle. Yes, so we know that incarceration rates are
    higher for poor Black Americans, and the work that has to be
    done in jails across the country, we are getting there.
    Certainly, New Hampshire has medication, most of the New
    England States do. There is a lot more work that needs to be
    done.
        I am encouraged by the Congress's help, though, to provide
    funds through the Department of Justice to expand access to
    treatment in jails.
        Ms. Kuster. Well, we would love to meet with you. I will
    set that up. We have game-changer legislation that would
    eliminate the exclusion of Medicaid during incarceration. And I
    think it would really change the scope. We would be talking
    about treatment, we would be talking about support services,
    and we would help people get back on their feet and lead much
    more productive lives.
        So with that, I yield back, and thank you.
        Ms. Eshoo. The gentlewoman yields back. I would like to
    recognize the gentleman from Georgia, Mr. Carter, our favorite
    pharmacist.
        Mr. Carter. Thank you, Madam Chair. I appreciate that very
    much. And thank you for being here. We appreciate this very
    much, this is extremely important.
        I wanted to mention, first of all, that I understand we
    don't have jurisdiction over the border in this committee. But
    I do want to bring up the border crisis, as it is impacting
    this epidemic. And I know that because I was there last week. I
    was there last Friday.
        The GAO has reported that Customs and Border Patrol data at
    U.S. ports of entry at the southern border show seizures of
    fentanyl and its analogues have gone up more than 200 percent
    in the last couple of years.
        Ms. LaBelle, is it correct the majority of fentanyl and its
    analogues come through the southern border from Mexico?
        Ms. LaBelle. Most--well, much of fentanyl certainly is
    seized at the border. We are getting some that comes through
    couriers. So mail systems, that is much reduced, but much of it
    comes--is seized at the southern border.
        Mr. Carter. Well, from my investigation of it, my studies
    of it, what I have seen is there is enough fentanyl coming
    across the southern border to kill every American several times
    over. So I think it is really a stunning problem.
        Again, I want to allude back to my visit this past Friday
    to the border, and what I witnessed there, because, listen,
    these cartels, they are not dumb. In fact, they are very smart.
    And what they are doing is flooding the border in one area so
    that it takes the attention of Customs and Border Patrol
    agents, and then they are just bringing drugs across at another
    point. It is causing us to have even more of a problem.
        Obviously, we have got a humanitarian crisis down at the
    border with what is going on with the illegal immigrants. But
    we have also got another problem, and that is a national
    security problem with our--with all of these drugs that are
    coming across this border. We have got to get this under
    control.
        You know, it would be easy for all of us just to sit back
    and think, oh, what is happening down there is just a problem
    at the border, and those poor people down there. But it is much
    more than that, because when we talk about fentanyl, when we
    talk about illegal drugs, those drugs that are coming across
    that border, they are going to be in your community next.
    Whether you are in Georgia, whether you are in the northern
    United States, or the northeast, or the northwest, it is going
    to be impacting you.
        And that is why it is such a big problem. It is killing
    people in our communities. Just this past week in Georgia we
    had two incidents of fentanyl overdoses, one in Richmond County
    near Augusta, one in Chatham County near Savannah, where my
    district is. And that is a problem that we have got to deal
    with, and it is a problem that is being exacerbated by the
    fentanyl that is coming across the southern border and coming
    across from Mexico.
        I wanted to ask you, Ms. LaBelle, would you agree that you
    have an obligation to advise the President, as he must get the
    border under control, because the epidemic that we are
    discussing today has gotten much, much worse--have you
    discussed with the Vice President or the President the harm an
    open border is having on the opioid epidemic, specifically the
    trafficking of fentanyl?
        Ms. LaBelle. So we are working very closely with all of our
    White House colleagues on this issue. We are separating the
    migrant issue from the drug issue. And that is where we have
    ongoing conversations on a monthly basis with the Government of
    Mexico and with our law enforcement partners, to make sure that
    they are doing everything they can to interdict the synthetic
    drugs that are coming from China into Mexico. So certainly
    these are ongoing conversations, and particularly with the
    National Security Council.
        Mr. Carter. So I want to make sure I heard you right. You
    said these are monthly conversations, that you only discuss
    them once a month?
        Ms. LaBelle. With Mexico.
        Mr. Carter. With Mexico. But in the administration, with
    the Vice President----
        Ms. LaBelle. Oh, no, we have----
        Mr. Carter. That was----
        Ms. LaBelle. I am sorry, sir. We have ongoing conversations
    with our colleagues throughout the White House on this issue on
    a daily basis.
        Mr. Carter. We were told last week when we were down there
    that over $400 million of illegal drugs crossed that border
    last month, that we know of. That, to me, is substantial. And I
    think to everyone in America it would be substantial. Don't you
    feel like this deserves more immediate attention than what it
    is getting at the White House right now?
        Ms. LaBelle. I think that everyone is paying very close
    attention to the issue. Certainly, the issue of how many drugs
    are coming through can be a matter of enforcement, because that
    is what we are seizing. That is not necessarily--it is hard to
    tell what it is when----
        Mr. Carter. And that is why I mentioned $400 million of
    what we know of, because what is happening is the Customs and
    Border Patrol agents, as you know, are having to be in the
    processing facility, and they are not able to monitor the
    borders. Therefore, we are not catching as much as what is
    coming across. So we don't really know the true number, but we
    know it is more than 400 million.
        OK, well, listen, this deserves immediate attention, Ms.
    LaBelle.
        Ms. LaBelle. Yes, sir.
        Mr. Carter. I hope you will go back to the White House
    immediately. And listen, we have got to get this stopped.
        Thank you, Madam Chair, and I yield back.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. The gentleman yields back. It is a pleasure to
    recognize the gentlewoman from Illinois, Ms. Kelly.
        Ms. Kelly. Thank you, Madam Chair. The Biden-Harris
    administration's statement of drug policy priorities for year
    one published by the Office of National Drug Control Policy
    stated, and I quote, ``Black individuals generally entered
    addiction treatment 4 to 5 years later than White individuals.
    And this effect remains when controlling for socioeconomic
    status.''
        Have plans been identified on how to ensure that Black
    people have more timely access to evidence-based care that
    includes prevention, harm reduction, treatment, and recovery
    services?
        Ms. LaBelle. Thank you, Congresswoman. So we included that
    in there in order to make sure that we can work with HHS to
    look at the data, to look at the research, just what we
    identified in our policy priorities, and then put in place
    specific programs that can handle--that can tackle those
    issues.
        We want to do more than just a program that sounds good or
    looks nice. We want to put in programs and policies that are
    really going to make a difference once and for all on this
    issue. And it is not going to happen overnight.
        I mean, one of the first steps is making sure that we
    acknowledge this is an issue, and then we are going to work
    with HHS to put plans in place that are going to make a
    difference on it.
        Ms. Kelly. Thank you. In the HHS OIG report titled
    ``Geographic Disparities Affect Access to Buprenorphine
    Services for Opioid Use Disorder,'' 40 percent of counties in
    the United States did not have a single waivered provider, and
    waivered providers were not necessarily found in areas where
    the need for the treatment is most critical.
        How can we ensure equity of access for geographic
    locations, and is telehealth a tool that we can use to ensure
    provider equity?
        Ms. LaBelle. Thank you. So this raises the issue that we
    talked about before with methadone clinics, that--you know, so
    you can go to an office and get your buprenorphine, a doctor's
    office. If you are going to a methadone clinic, you are
    probably standing out in the street corner, waiting to get in.
    So much less private, much less personal care.
        Certainly, there are a lot of great opioid treatment
    programs around the country that provide methadone, but it is a
    different form of care.
        So how we tackle this is, number one, removing barriers to
    buprenorphine treatment to expand the number of providers--not
    just physicians, but nurse practitioners and physicians'
    assistants--so that we can reduce those barriers to care that
    occur around the country.
        Ms. Kelly. And can you give more insight on why providers
    must receive a waiver to provide medication to treat opioid use
    disorders but not to prescribe the medications that have gotten
    us to where we are today? This seems counterproductive.
        Ms. LaBelle. Sure, thank you. So I think the issue is that
    we have--as we have spoken about, we really have minimal
    training and education in addiction in the healthcare services.
    And so, in order--and so, you know, people who are prescribing
    buprenorphine are required to go through that training, the
    eight-hour training, because they may not have ever really
    encountered or have a lot of knowledge about the treatment of
    addiction.
        So I think what we really need to do is expand the number
    of people in our healthcare system who understand how to screen
    and treat and help people recover from addiction, as opposed to
    hinging it all on this one medication.
        Ms. Kelly. OK, thank you so much. And Madam Chair, believe
    it or not, I will yield back.
        Ms. Eshoo. The gentlewoman yields back, and now I have the
    pleasure of recognizing the gentleman from Florida, Mr. Dunn,
    for your 5 minutes of questions.
        Mr. Dunn. Thank you very much, Madam Chair. You know, the
    increase in fentanyl throughout the United States, including
    Florida, is deeply troubling. Sadly, this has been a growing
    problem in my district too.
        Just last month the Panama City Police Department arrested
    a man with 90 grams of fentanyl. That is more than 43,000
    lethal doses of this drug. And for perspective, that is enough
    to kill over half of the population of Panama City.
        On the other end of my district, the Ocala Police
    Department seized 177 grams of fentanyl in a single bust just
    last fall, and the police chief there said that that was enough
    fentanyl to kill, with overdose, every person in Polk County,
    man, woman, or child.
        When using fentanyl for medical purposes, a typical dose
    would be 25 micrograms. That is 25 millionths of a gram.
    Doctors always use this drug very, very cautiously, with
    extreme care, because even the medical formulation of fentanyl
    is extremely potent and potentially hazardous.
        Florida law enforcement is doing a heroic job getting it
    off the streets, putting traffickers behind bars. However, they
    need help. Fighting fentanyl requires a team effort among the
    trade and shipping industries, law enforcement, healthcare
    professionals, community leaders, and lawmakers.
        And I want to associate myself with the comments made by my
    colleague Dr. Bucshon regarding the dangers of making access to
    buprenorphine and Suboxone too easy. Because honestly, these
    are drugs that are used--buprenorphine is the single most
    common cause of opioid overdose in northern Europe. So we have
    to be careful. We have to get this in the hands of skilled
    people who know how to use it safely.
        And I do have some questions, but I will be submitting
    those to the second panel of witnesses. So with that, Madam
    Chair, I yield back. Thanks so very much.
        Ms. Eshoo. The gentleman yields back, and I thank him for
    his questioning, and it is a pleasure to recognize the
    gentlewoman from Delaware, Ms. Rochester Blunt--Blunt
    Rochester, I am sorry. You need to unmute.
        [Pause.]
        Ms. Eshoo. You need to unmute. Lisa?
        [Pause.]
        Ms. Eshoo. We will get this one of these days, right?
        Voice. I don't think she can hear you.
        Ms. Eshoo. I don't think she hears us, so I think I will go
    to--Angie Craig?
        Voice. Angie Craig.
        Ms. Eshoo. We will go to the gentlewoman from Minnesota,
    Angie Craig, for her 5 minutes of questions, and then circle
    back with--I hope Ms. Blunt Rochester's staff is listening, but
    we will--Ms. Craig is--Representative Craig is recognized for
    her 5 minutes of questions.
        Are you with us?
        No?
        Voice. Schrier.
        Ms. Eshoo. All right, then we are going to go to another
    doctor, the gentlewoman from Washington, Dr. Schrier.
        It is great to see you.
        Ms. Schrier. Well, great to see you, and I am now unmuted.
    I was just texting Lisa to see if I could let her know. Thank
    you, Madam Chair, and thank you to Ms. LaBelle for sharing how
    the White House is going to be focusing on these issues.
        You have already heard that Washington State has been hit
    hard by this opioid epidemic. For over a decade, our State has
    lost about 700 people per year from overdoses, mostly from
    opioids. And sadly, we saw a 40 percent increase in mortality
    due to opioid use in 2020.
        So we know fentanyl in particular has become an
    increasingly dangerous threat in my State and, as we have
    heard, across the country. In 2019, three students in my
    district died because the oxycodone that they thought they were
    taking, which is bad enough already, was laced with fentanyl.
    And two were students in the high school just down the street
    from my house.
        Then, 2 days ago, in a conversation with another parent, I
    heard about a bring-your-own-pill party, where a group of high
    school seniors in my town all brought whatever pills they had
    to a party: Ritalin, Adderall, oxycodone, Vicodin, whatever.
    They dumped it in a bowl like M&Ms and then helped themselves
    without even knowing what they were taking. And this is barely
    1 year after the two deaths that I just mentioned.
        So, Ms. LaBelle, you mentioned in your testimony that one
    of your strategies to mitigate drug abuse and death is support
    evidence-based prevention efforts to reduce youth substance
    abuse. And as a pediatrician I know how important it is for
    pediatricians to talk with their patients, and parents to talk
    with their children. I wonder if you could just talk briefly
    about the most effective ways to prevent these risky behaviors
    from starting, and then these tragedies.
        Ms. LaBelle. Thank you very much, Congresswoman, for asking
    that important question. I want to raise one issue about the
    pressed pill issue that you raised. I think all of us need to
    be aware that this is a trend. CDC has sent alerts about these
    pressed pills. That is a lot of what we are seeing. This is
    pure fentanyl, and people have no idea what they are getting.
    And this is why the administration has put out the fentanyl
    test strips, so people who--can test what it is that they are
    getting. I am not talking about that for youth use, but that is
    important for--to prevent overdose deaths.
        So for youth use, the National Institute on Drug Abuse has
    some great tools. SAMHSA--I am a parent myself. I probably
    drive my son crazy by talking to him about these issues so
    much, because he has a genetic predisposition to this. So I--
    you know, you have to--there is a--SAMHSA has a ``you talk,
    they listen,'' which is a great tool. And actually, the
    University of Washington has some great prevention programs,
    and one of the preeminent prevention researchers in the country
    is there.
        So there--we can't--we think that kids won't listen.
    Certainly, they are going to roll their eyes, but they will
    listen to you when you talk to them.
        The other piece that we want to do on prevention is
    preventing adverse childhood experiences that lead to risky
    behavior, and that includes substance use. So that is an area
    that we will be working more with the Centers for Disease
    Control and Prevention on, particularly with our drug-free
    community coalitions.
        Ms. Schrier. I really appreciate you bringing all those
    things up. Can I ask just a quick followup question on the
    fentanyl test strips?
        Are those--are the pills--do they contain fentanyl only on
    the outside, or throughout?
        I mean, is this something we have to crush a pill to test
    strip it, or can you just rub it on the outside of a pill?
        Ms. LaBelle. You could--you wet the test strip, and you can
    rub it on the outside of the pill.
        Again, these are--you know, these are--there are various
    forms of this, but in many cases it is pure fentanyl.
        Ms. Schrier. OK. It is devastating. Thank you.
        Also, with the limited time I have left, you know, one of
    the barriers to care that we have all talked about is simply
    not having enough access to providers who are trained and
    confident in treating substance abuse disorder. In particular,
    most pediatricians have no experience with medically assisted
    treatment. And I was wondering what ONDCP's role is in ensuring
    that there is a broad provider network that is adequately
    trained, and where pediatricians might fall in that plan.
        Ms. LaBelle. So the pediatrician association actually
    encourages, as you are probably aware, screening for all of
    their patients. So we want to work with them again on expanding
    that work.
        Ms. Schrier. And screening is standard. Treatment, not so
    much----
        Ms. LaBelle. Right----
        Ms. Schrier [continuing]. Pretty intensive appointments. Do
    pediatricians generally get the special training?
        Ms. LaBelle. No, they don't. So we need to--we will be
    happy to work with you on that issue.
        Ms. Schrier. Thank you, I yield back.
        Ms. Eshoo. The gentle doctor yields back, and it is a
    pleasure to recognize the gentleman from Pennsylvania, Mr.
    Joyce, for your 5 minutes of questions.
        Mr. Joyce. Thank you, Chairman Eshoo, and thank you,
    Ranking Member Guthrie. This is an important discussion that we
    have, specifically discussing the epidemic that we face within
    the pandemic.
        In Pennsylvania, where I represent, the availability of
    illicit drugs, and specifically fentanyl, is a crushing blow to
    our local communities. In joining this COVID-19 pandemic, this
    epidemic has spiraled further out of control. In 2020, Blair
    County, my home county, we have seen an 80 percent increase in
    overdose deaths. Eighty percent.
        Coroner Patty Ross, she can rattle off these statistics in
    a breath, and she will tell you that fentanyl can be 100 times
    more potent than morphine. Coroner Patty Ross knows how many
    families have been torn apart, how many children have suffered
    from drug-related circumstances. She has witnesses--she has
    been a witness to tragedies firsthand. She talks about
    addressing families, talking to them as she relays the tragedy
    of the death of a loved one, talking to them about these loved
    ones who have just come out of rehab.
        In Pennsylvania and around the country, Coroner Ross and
    other local leaders, they are desperate for Congress to get
    serious about combating fentanyl and illicit drugs, providing
    support to the brave Americans in recovery, and advocating for
    communities with the widespread ramifications of substance
    abuse and addiction, and addressing what we need to address:
    the stigma of drug abuse. We need to be taking action right now
    to keep our communities safe. But also we need to expand
    lifesaving treatments for those who have substance abuse
    disorders.
        Director LaBelle, shortly before leaving office, the
    previous Director of ONDCP, James Carroll, announced new
    practice guidelines for the administration of buprenorphine for
    treating opioid use disorder. And these guidelines were
    intended to make it easier for practitioners to prescribe
    buprenorphine. As I understand it, on January 14th the Biden
    administration made a statement saying that those guidelines
    were issued prematurely and could not be sustained.
        Director, could you please tell us why these guidelines
    were pulled?
        Ms. LaBelle. Sure, thank you, Dr. Joyce. These are
    important issues that you just raised. We all want to expand
    access to evidence-based care. The practice guideline that was
    rescinded by the administration, or that is being reconsidered,
    and making sure--what we don't want to do is to issue a
    practice guideline that would not be upheld, or would not
    withstand legal scrutiny.
        So we are taking a look at it to make sure that anything
    else that is issued can withstand any kind of legal challenge
    to it. So that is where we are at right now.
        Mr. Joyce. And what is the current status of your
    evaluation for renewing these guidelines?
        Ms. LaBelle. We are taking a look with our lawyers on it to
    make sure that it gets issued. So we are working on it. I can't
    give you a precise timeline right now.
        Mr. Joyce. The previous administration came up with rural
    guidelines addressing substance abuse. In the rural communities
    throughout America, as you pointed out, as well as in the
    metropolitan areas, these substance abuses still exist. And we
    are looking forward to having the answers to when these
    guidelines will be reissued.
        Can you assure us, so I can take back to the coroners, to
    the leaders who are facing these issues, that this is of utmost
    concern to you, as the acting director of the ONDCP, as it was
    to your predecessor?
        Ms. LaBelle. Absolutely, sir.
        Mr. Joyce. Can you provide for us additional guidance of
    what we should be doing from a legislative point of view to aid
    you in making this decision?
        Ms. LaBelle. So I think that what we want to make sure is
    that, when it is released, that it is lifted up.
        But we can't stop there. We have a lot more work to do. Our
    policy priorities lay out our expansive approach to this,
    because it can't--we can't just look at one tool. We have to
    look at all the tools available to address every form of
    addiction, not just opioid use disorder. So we are looking
    forward to working with you on the totality of the addiction
    epidemic.
        Mr. Joyce. I thank you for your hard work, and I look
    forward to seeing the guidelines on the administration of
    buprenorphine for treating opioid disorders. Thank you for
    being here today.
        And again, thank you, Chair Eshoo and Ranking Member
    Guthrie.
        Ms. Eshoo. The gentleman yields back.
        And I apologize to you, Dr. Joyce. I think it is very
    important, when recognizing our physician Members, that it--
    that that always be stated. So apologies to you.
        Mr. Joyce. Not necessary, Chair. Thank you, though. I
    appreciate that.
        Ms. Eshoo. We are very happy to have you as a member of our
    subcommittee.
        Mr. Joyce. It is an honor, thank you.
        Ms. Eshoo. Oh, you are very nice. You are such a gentleman.
        And now I recognize with pleasure, from Delaware,
    Congresswoman Lisa Blunt Rochester.
        I am sorry that you didn't hear us earlier.
        Ms. Blunt Rochester. Thank you so much, Madam Chairwoman.
    And forgive me, I am on two screens at the same time, so
    please----
        Ms. Eshoo. Not to worry, not to worry. We see you and hear
    you now.
        Ms. Blunt Rochester. Thank you so much. And I want to thank
    you, Ms. LaBelle, for joining us as well, and for your work and
    dedication.
        Under the previous administration, the approach towards
    fentanyl-related substances was handled through policies that
    more promoted decriminalization and not public health. And
    evidence shows us that that isn't the most effective approach.
        The U.S. Sentencing Commission's January 2021 report on
    fentanyl and fentanyl analogues found that in fiscal year 2019
    a greater proportion of fentanyl and fentanyl analogue
    offenders were Black, and over half of the total offenders were
    convicted of an offense with a mandatory minimum penalty. But
    less than 10 percent of offenders knowingly sold fentanyl and
    fentanyl analogues as another substance.
        I am seriously concerned that our efforts are targeting
    minimally involved individuals instead of the higher-up
    traffickers and cartels. What is the administration's plan to
    stop illicit fentanyl from coming into the country, so we are
    targeting the drug traffickers that are manufacturing fentanyl
    and placing it into the drug supply?
        Ms. LaBelle. Thank you, Congresswoman, for that important
    question.
        So, you know, when--the Office of National Drug Control
    Policy works a lot on international issues. I would say it is
    probably half of the time in our office. And so we are working
    with China to look at their regulatory controls over their vast
    chemical industry. We are also working closely with Mexico on
    their interdiction efforts inside Mexico, as well as destroying
    and using evidence from their labs, their lab takedowns, and
    then--as well as working with them on how to identify some of
    the precursor chemicals that are coming from China into their
    ports.
        So those are numerous--a number of issues that we are
    dealing with with China and Mexico right now to stop it from
    ever coming into the country.
        Ms. Blunt Rochester. And can you be more specific about the
    length of time that you would need to come up with the
    permanent solution of--because I know a couple of people have
    asked this, and because time is of the essence, it would be
    really good if we could get a clearer picture of the specific
    length of time that you would need.
        Ms. LaBelle. Yes, thank you for asking that. It is urgent.
    We know it is urgent. I can't give a timeline. As I said, you
    know, we have been here about 85 days, and there are plenty of
    people at DOJ who aren't in place yet. So I can't give a
    timeline, but know that we are working diligently on this
    issue.
        Ms. Blunt Rochester. And thank you. I know that you are
    aware that overdose deaths involving synthetic opioids like
    fentanyl continue to rise, and from 2017 to 2018 rose as high
    as 10 percent. If we don't pursue a public health approach as
    part of the solution for addressing fentanyl-related
    substances, as Representative Kuster and I are suggesting, what
    would be the impact on people with substance use disorder, and
    how will their access to evidence-based treatment change?
        Ms. LaBelle. So the public health approach that we have
    laid out in our policy priorities identifies the specific
    actions we can take, as--such as harm reduction programs that
    can prevent people from overdosing.
        I am very concerned that, if we don't expand access to
    evidence-based treatment throughout the country, especially in
    areas of high risk for overdose, that these rates are just
    going to continue to climb. And I have been working on this
    issue since 2009, when it first started. And it is--and the
    steps that we are taking are--every day counts at this point.
        Ms. Blunt Rochester. Yes. Will ONDCP commit to working with
    Congresswoman Kuster and I on a comprehensive public health
    approach to addressing the overdose epidemic?
        Ms. LaBelle. Yes, we look forward to working with you,
    absolutely.
        Ms. Blunt Rochester. Thank you so much, and I yield back my
    time.
        Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
    recognize the gentleman from Utah, Mr. Curtis, for your 5
    minutes of questions.
        Mr. Curtis. Thank you, Madam Chair. I enjoyed the
    interchange between you and Dr. Joyce. I am wondering if there
    is a title that we should use for those of us that have put
    children through medical school. Maybe we could work on that.
    And you are on mute, so I am just going to keep going, Madam
    Chair.
        Director, 4 in 10 adults--and this is as reported by the
    Huntsman Institute of Mental Health--have reported new symptoms
    of anxiety and depression disorder, which is a fourfold
    increase since last year. And so, to state the obvious, this
    hearing couldn't be more important, couldn't be more timely,
    and the work that you do.
        I am grateful for Representative Scott Peters of San Diego.
    He and I recently reintroduced a bill, H.R. 2051, which would
    declare meth an emerging drug threat. And I want to thank
    Congressman Peters for his leadership on this issue. It is an
    important issue to both of us in our districts, and we view it
    as the first of many steps in continuing to fight substance
    abuse.
        The legislation would require the Office of National Drug
    Control Policy--you--to develop a strategy to prevent the sale
    and use of this drug. We have touched on meth a little bit in
    this hearing. Can you just share, from your perspective, where
    this fits in with the larger picture of what you are seeing
    across--with meth across the United States?
        And specifically what can Congress be doing to help you?
        Ms. LaBelle. Sure. Thank you. So our policy priorities
    include contingency management and looking at the barriers to
    expanding access to contingency management therapy, which is an
    effective tool to use for people with meth use disorder.
        Our policy priorities also include an emphasis on
    prevention. So that is another tool that we need to use to
    reduce meth use.
        And then also our policy priorities include disrupting the
    drug supply coming in from Mexico, which is where much of our
    methamphetamine is sourced. So all of that is part of our
    priorities for us that we will be looking at in the first year.
        As far as what Congress can do, I think that we may be
    coming back to on contingency management, to see if there are
    legislative barriers to expanding that. I think the most
    important thing that Congress can do is making sure that we
    have sustainable funding for a lot of these programs,
    particularly for prevention and treatment, so that the States
    are not reliant and local communities are not reliant on one-
    time grants that may not help them address the totality of the
    issue.
        Mr. Curtis. Thank you, a very good answer.
        I have listened as my colleagues have all expressed--many
    have expressed close loved ones and people they know who have
    been impacted by this tragic problem. It came home to me and my
    wife with not only some of our loved ones, but this summer,
    when we purchased a home, we kind of randomly did a meth test
    that--we were purchasing a home from a couple that had passed
    away in old age, and we were surprised to find out the home had
    been used as a meth lab. And I think that is just a small
    indication of what is going on across the United States.
        Quickly, I represent a very rural community with very
    limited resources, particularly for law enforcement, a vast
    geography, very, very difficult for law enforcement to cover
    it, which poses a challenge to crack down on this. Are there
    ways that we can leverage machine learning?
        Have you spent any time on this, by using data collected by
    law enforcement agencies and public health agencies on drug
    overdose in certain communities to help augment the local
    authorities in rural areas?
        Ms. LaBelle. So ONDCP funds ODMAP, which gets information
    from local law enforcement that helps kind of identify trends.
    That is in all 50 States, but it is not universal. That is one
    tool.
        We also should be working with our partners at the Bureau
    of Justice Assistance and the COPS program to look at exactly
    those issues that you just raised, because we know law
    enforcement in rural areas is stretched thin.
        Our High Intensity Drug Trafficking Areas Program works
    with a lot of law enforcement in rural areas, and that is a
    force multiplier for a lot of rural efforts.
        Mr. Curtis. Yes, thank you for appreciating the special
    needs in rural.
        It has been touched on a lot today, so I am only just going
    to mention--not ask the question, but just--I want to
    reemphasize the conversations we have had today about
    telehealth, how important it is in these rural parts of my
    district.
        And with that, Madam Chair, I yield my time.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. I agree with you on telehealth. I think that--
    and I think other Members believe that it should be made
    permanent. So we have our work to do on that.
        I don't think there are any other Republicans that need to
    be recognized. I see Mr. Latta, but I know that you are
    interested in panel two, is that correct?
        OK, so we have two Democrats, and then we are going to go
    to--or we might have another one, I don't know, but I have two
    lined up right now.
        And then, Members, we do have a second panel with five
    witnesses that are waiting in the wings for us. So I will
    recognize the gentlewoman from Minnesota, Ms. Craig, for her 5
    minutes.
        Ms. Craig. Well, thank you so much, Madam Chair.
        Acting Director LaBelle, thank you very much for your
    testimony today. Your experience and your expertise is greatly
    appreciated.
        As many of you are aware, over 20 million Americans
    struggle with substance use disorder. A significant portion of
    them have an opioid use disorder. Moreover, many overdose
    deaths involve opioids such as illicit fentanyl and fentanyl-
    mixed substances. The DEA recently cited fentanyl-mixed cocaine
    and meth as an accelerant of overdose deaths, due to its
    widespread availability. This trend is reflected in my home
    State of Minnesota, where an overwhelming majority of opioid
    overdose deaths involve synthetic opioids. Unfortunately, it is
    likely we are going to see a record increase in those deaths
    from 2020.
        I recently hosted a roundtable in my district that
    addressed veterans' access to mental health services and the
    disproportionate rate of substance use disorder among veterans.
    One of the barriers to care raised by stakeholders is the
    stigma that often surrounds substance use disorders, an issue I
    know is not limited just to this Nation's veterans.
        It is critical to remember that substance use disorder is a
    treatable disease. People with substance use disorder deserve
    compassion and adequate access to affordable, quality care. The
    problem won't be solved in jails and emergency rooms. It will
    take a shift in attitudes by many of the stakeholders involved.
        So Acting Director LaBelle, how does ONDCP hope to reduce
    stigma associated with substance use disorders through its drug
    policy priorities in year one?
        Ms. LaBelle. Thank you for asking that important question,
    Congresswoman.
        So the first step we took, and that happened during the
    transition, was hiring people, bringing people on who are in
    recovery. Our chief policy adviser is a person in long-term
    recovery. Our outreach director is a person in long-term
    recovery.
        And we are expanding a lot of our work on talking about
    recovery and making--because really, when you look at our
    policy priorities, all of these barriers really go back to
    stigma, the stigma that is attached to addiction. Why don't
    people want to treat addiction? There is stigma attached to it.
    Why don't people want to seek out help? Because there is stigma
    attached to it.
        So the first step we can take, as ONDCP, is setting an
    example and involving people who are in recovery in the
    policymaking process.
        Ms. Craig. Thank you so much. And I know stigma is one part
    of this that you are focused on, but also folks face barriers
    due to lack of access to coverage. So what levers is your
    office using, can you use, to address the access to care in the
    long term?
        Ms. LaBelle. So there are lots of pieces to this. One is we
    are going to focus on parity to make sure that coverage,
    insurance coverage, is--that people are complying with parity.
        The other access-to-care pieces are--involve workforce. How
    do we improve the workforce access throughout this country, and
    then also identifying, you know, the barriers to treatment with
    buprenorphine, methadone treatment, and contingency management
    services.
        Ms. Craig. Let me ask you what you think Congress can do to
    build on the previous legislation that we put forward,
    particularly around reduction of stigma. What are the most
    important couple of things that we could be focused on that
    helps you reduce stigma when it comes to this particular
    disease?
        Ms. LaBelle. Thanks. So I think one thing we can do is to
    make sure that Congress, by looking at this as an ongoing
    issue--this is not a--these are chronic conditions, not acute
    conditions, that require sustainable funding over the long
    term. So if we--by having Congress make sure that we are
    recognizing that these are not acute conditions, that people
    don't go into treatment and then 20 days later they are cured,
    that recovery services are part of the continuum of care, and
    continuing to emphasize recovery services is important.
        Ms. Craig. Well, thank you so much, Director LaBelle, and I
    look forward to working with you and the Biden-Harris
    administration.
        Madam Chair, with that I will yield back.
        Ms. Eshoo. The gentlewoman yields back, and we thank her,
    and we now will go to the gentlewoman from Massachusetts, Mrs.
    Trahan, for your 5 minutes.
        And thank you for your patience. You have been with us from
    the very--as most Members--from the very beginning of today's
    hearing.
        Mrs. Trahan. Well, thank you----
        Ms. Eshoo. And it is now afternoon.
        Mrs. Trahan. Yes. But it is such a critically important
    hearing, and I thank you for convening us on this topic.
    Certainly my thanks to Director LaBelle for being here today.
    And we all look forward to working closely with you and ONDCP
    in the months and years ahead to push policies that take a
    multipronged approach to curb overdoses.
        You know, the substance use disorder epidemic has claimed
    too many lives in all of our districts, red and blue alike. And
    over the last 20 years our Nation has lost more than 750,000
    lives due to drug overdoses. The latest CDC data suggests that
    the coronavirus pandemic has triggered an acceleration in lives
    lost to overdoses.
        Now, anyone with a loved one who has suffered from this
    terrible disease knows how powerful addiction can be. It can
    appear to have an unbreakable hold on those in its grip. My
    heart certainly goes out to those suffering from substance use
    disorder. You know, I have met with too many moms who have lost
    a child--the worst thing a parent can even imagine--and they
    and their families deserve our compassion and acceptance, free
    from judgment.
        But we also owe it to all of our constituents, particularly
    our young people, to do more to defeat SUD through greater
    attention to preventative measures and safer, effective
    treatment options. The Medication Access and Training Extension
    Act, legislation I have introduced with Representatives Kuster,
    Carter, Trone, and McKinley, would ensure that most DEA-
    licensed prescribers, at a minimum, have the baseline knowledge
    to treat and manage their patients with substance use disorder.
        So Director LaBelle, in your written testimony you say that
    the origins of the overdose epidemic began with prescription
    opioids. Current CDC data shows that overdose deaths involving
    prescription opioids more than quadrupled from 1999 to 2019.
    How does prescription drug misuse continue to contribute to the
    overdose and overdose death epidemic in our Nation today?
        Ms. LaBelle. Thank you, Congresswoman, for asking that. So
    it continues to be part of the issue. As I said, our policy
    priorities focus on the addiction epidemic. And so there are
    certainly specific prevention tools that we can use for each
    substance. So in that regard, prescription opioids as a driver
    is--of later substance use disorders is important.
        But we are really taking the entirety of the addiction
    epidemic and looking at it from how do we prevent, treat--have
    quality treatment, provide harm reduction services, and help
    people recover. So that is really our--the extent of our
    continuum of care that we are looking at implementing.
        Mrs. Trahan. So many prescribers must take some sort of,
    say, prescribing education, but few take substantial education
    on how to identify, treat, and manage their patients with
    opioid and substance use disorder. You know, Dr. Ruiz said it
    himself, that many patients with SUD enter medical offices and
    emergency rooms for separate medical reasons. And so the
    ability of physicians to identify the more subtle signs of SUD
    is critically important.
        Does the Biden-Harris administration believe that it is the
    responsibility of all prescribers with a DEA license to know
    how to identify, treat, and manage their patients with opioid
    and substance use disorder?
        And would this education increase access to care?
        Ms. LaBelle. Yes, if we recognize that addiction is a
    chronic disease, then it is up to the healthcare community
    providers, healthcare providers, to be able to recognize it,
    screen for it, and treat it, or at least refer people to
    treatment. But if they can't identify it, they are not going to
    screen it or treat it.
        So I think that that is something that we have long
    emphasized, is the importance of addiction training in medical
    schools for DEA-licensed providers. And I think it is something
    we need to look at.
        Mrs. Trahan. And certainly one of the best things that we
    could do to, as Congresswoman Craig said, accelerate the end of
    stigma associated with addiction.
        Thank you, I yield back the remainder of my time.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
    recognize the gentlewoman from Florida, Ms. Castor, for your 5
    minutes of questions.
        Ms. Castor. Well, thank you, Madam Chair, and thank you so
    much for your leadership on this very important issue. I know
    you have seen today that all of the Members, we are really
    interested and concerned about substance use and misuse.
        And thank you, Acting Director LaBelle, for spending some
    very--a lot of quality time with the committee today. And thank
    you for your leadership. I want to--I have two real quick
    questions. One is going back to Dr. Schrier's attention to
    prevention, especially among young people.
        And one of the bills that is on our list today is the Drug-
    Free Communities Pandemic Relief Act. You identified in the--in
    your--the national drug control strategy that this is an
    essential element to prevent and reduce drug addiction misuse
    among young people. That bill would waive the local matching
    requirement during the pandemic, because many of these local
    community groups simply haven't been able to make that local
    match.
        Can you share with me why that is important at this time,
    and what you are hearing from drug-free communities across the
    country?
        Ms. LaBelle. Sure. Thank you, Congresswoman. So the Drug-
    Free Community Coalition is--one of the great things about them
    is that they are community-based, and--but they rely upon in-
    kind contributions. In-kind contributions that we found in the
    last year during COVID have been--there have been shortfalls in
    that. And so helping Drug-Free Community Coalitions in that
    regard is very important. They--we know that Drug-Free
    Community Coalitions reduce youth substance use, and that is an
    important tool that we can use to reduce addiction overall.
        Ms. Castor. Thank you very much. And that is what I hear
    from folks back home, as well. The issues that are so complex
    these days--but there has been a dropoff on community support,
    and I think this would go a long way to helping keep all of
    those coalitions moving forward and focused on youth drug use
    prevention.
        So my second question is a much broader one on the American
    Rescue Plan. We are so proud of the depth and breadth of the
    American Rescue Plan recently signed into law by President
    Biden. It provides, just in this area, $4 billion to SAMHSA and
    HRSA for a lot of the issues that your office will oversee.
        Give us a good thumbnail sketch on what you are working on
    right now, in coordination with those agencies and our local
    partners, to ensure that those dollars get to communities and
    families that need them. Will--we--are you coordinating the
    guidance that will be issued from the agencies, and what can we
    expect?
        Ms. LaBelle. Thank you. So the--HHS, SAMHSA, the Substance
    Abuse Mental Health Services Administration, we are working
    closely with them on what this is going to look like, because,
    I mean, the good thing is that this funding can be spent over a
    period of time so that States aren't going to get this huge
    influx of money that they have to spend in a year. So there
    will be a more sustainable funding source for them.
        So we are talking to SAMHSA about, you know, what are the
    gaps, what is missing, who are the vulnerable groups. That is--
    so because this money is going through the block grant, it will
    be easier to facilitate that funding. So it is a great
    opportunity to really make a difference on this issue.
        Ms. LaBelle. I agree. We are all so proud of what we have
    been able to do in the American Rescue Plan. And a lot of folks
    are focused, of course, on vaccinations and the stimulus
    payments, and kids in school safely. But there are very
    significant dollars for our local communities when it comes to
    behavioral health. So thank you so much, and we will look
    forward to working with you in future months.
        Mrs. Trahan. I yield back.
        Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
    recognize a fellow Californian, Mr. Cardenas, for his 5 minutes
    of questions.
        Mr. Cardenas. Hello, can you hear me?
        Ms. Eshoo. Yes, very well.
        Mr. Cardenas. OK, can you see me?
        Ms. Eshoo. I can see you, and you look very well too.
        Mr. Cardenas. OK, thank you so much, because earlier today
    during gavel I was not recognized as being seen, so I had to
    wait and----
        Ms. Eshoo. Oh, I am sorry.
        Mr. Cardenas [continuing]. My questions, so----
        Ms. Eshoo. Sorry. How does that happen?
        Mr. Cardenas. Sorry about that.
        Ms. Eshoo. Oh, my.
        Mr. Cardenas. We will hopefully get a better system within
    the committee to make sure that that doesn't happen again to
    any of us as we all try to be here at gavel----
        Ms. Eshoo. Is that the technological difficulty with the
    committee's technology, Tony?
        Mr. Cardenas. Well----
        Ms. Eshoo. No?
        Mr. Cardenas. I don't know what happened, because I saw
    myself on the screen, I heard you clearly, I saw you, I saw a
    bunch of my colleagues and the witnesses, or what have you. But
    anyway, that is housekeeping. We can take care of that later.
        Ms. Eshoo. OK, good.
        Mr. Cardenas. But thank you so much----
        Ms. Eshoo. I apologize.
        Mr. Cardenas [continuing]. Madam Chair. No, that is OK.
        Ms. Eshoo. What happened?
        Mr. Cardenas. I want to talk a bit about health
    disparities. And when it comes to pandemics, when it comes to
    addiction, when it comes to incarceration, all of these kinds
    of things are issues. So I would like to know, how does that
    fit into what the dynamic of the administration's efforts are
    on the topic we are talking about today when it comes to
    opioid--the opioid pandemic and--epidemic, excuse me, it is a
    pandemic, sort of--and when it comes to assisting with making
    sure that we treat it more as an illness, not as something that
    is just--we treat it as a punitive matter.
        Ms. LaBelle. Right. Thank you, Congressman. So the
    disparities in treatment, we have identified some of them in
    our policy priorities. They include kind of a two-track system
    that we have seen. Certainly, some people get healthcare,
    treated through the healthcare system, and others are
    incarcerated. And what the President has committed to is
    reducing rates of incarceration, and having--not having it so
    that people are incarcerated for drug possession alone, because
    we know that often people who have low amounts of drugs in
    their possession are--often have a substance use disorder
    themselves. So there is a couple of things that we want to do.
        Number one, we need to make sure that we have better data
    sources on this. And I know that sounds like it is not an
    immediate issue, but it is not something that we have a great
    deal of granularity on, you know, where the disparities exist
    and how exactly are we going to address those disparities. So
    that is one step that we have to take.
        The second thing that we need to do, we talked a little bit
    about before, is make sure that our workforce reflects the
    people that are served. And that is something we will work
    closely with HHS on.
        And then also--so we also will be looking at, you know,
    criminal justice reform, writ large. The drug piece is a part
    of that, so we will be looking at that, as well.
        Mr. Cardenas. Thank you. And you mentioned something that--
    my question is how are the departments going to work together?
        Because when there is this presumption that in poor
    communities--White communities, as well, poor White
    communities, poor Black and brown communities, Native American
    reservations, et cetera, where all of a sudden policing seems
    to be the fortified method of trying to address the issue of
    drug addiction and drug abuse in those communities. I think it
    is important that the departments understand that the amount of
    resources that we allocate at the Federal level, local level,
    et cetera, needs to be proportional to how we are going to--be
    honest with ourselves about how it should be addressed.
        Are you working with other departments to make sure that we
    are all on the same page?
        Ms. LaBelle. Yes, we work closely with our law enforcement
    partners as well as our health department partners.
        And I think what you raised is an important piece. I think
    that some of this is because--that is why we talked about harm
    reduction programs in our policy priorities, because that is--
    provides an alternative intervention point for people who may
    not otherwise be able to get treatment and may end up in law
    enforcement's hands in the criminal justice system. So that
    provides an alternative intervention point.
        Mr. Cardenas. Yes, because I would venture to say--I am in
    Los Angeles, and in my community where I grew up in Pacoima,
    law enforcement seemed to be the answer to treating people with
    addictions or addressing the issue of people with the
    addictions.
        But yet, just a few miles away in Beverly Hills, I would
    contend that there is just as much drug use going on with
    teenagers and adults and seniors in those households as it is
    in households in Pacoima, in a different ZIP code, only the
    difference is, in those other communities like Beverly Hills,
    ``Oh, my gosh,'' you know, ``little Johnny is addicted. We got
    to get Johnny some help. We got to put him in a program,'' et
    cetera, which I believe is the proper, humane way to deal with
    these issues.
        But yet, just a few miles away on the other side of town,
    book him and book him, send the cops in, get the DEA to do a
    crash unit or something, and all of a sudden you have people on
    one side of town who are behind bars, not addressing the issue
    of addiction. But on the other side of town, the other person
    is actually getting support.
        Do you believe that that has been going on in America far
    too much?
        Ms. LaBelle. I think we have two bifurcated systems of how
    we treat addiction. And I think that has been with us for a
    very long time, and we are going to work on that.
        Mr. Cardenas. OK. Well, I look forward to speaking to you
    in the future, and----
        Ms. LaBelle. Yes.
        Mr. Cardenas [continuing]. And also working with you----
        Ms. LaBelle. Yes.
        Mr. Cardenas [continuing]. Both as a legislator and as two
    Americans, to make sure that we get a system that is much more
    appropriate for addressing issues for all of us.
        Thank you so much, I yield back.
        Ms. LaBelle. Thank you, sir.
        Ms. Eshoo. The gentleman yields back. We now have two
    Members that have waived on to our subcommittee, and we welcome
    you. It is always a pleasure to have our colleagues from the
    full committee be a part of our subcommittee.
        So the Chair will recognize the gentleman--and he is a
    gentleman--from New York, Mr. Tonko, for his 5 minutes of
    questions. And he has been very active on the issue of opioids,
    especially, as I recall, fighting for more beds so that
    patients would really get the care that they need.
        You are recognized.
        Mr. Tonko. Thank you, Madam Chair. Can you hear me?
        Ms. Eshoo. I can. Talk a little louder, though.
        Mr. Tonko. OK, thank you, Madam Chair, and thank you for
    allowing me to waive on.
        I am indeed thankful to hear about the leadership already
    put forward by the Biden-Harris administration and want to
    express gratitude to you, Acting Director LaBelle, for agreeing
    to testify today, and thank you for your leadership.
        I am a proud sponsor of two pieces of legislation being
    considered today, including the Medicaid Reentry Act and the
    Mainstreaming Addiction Treatment, or MAT, Act. These two
    bipartisan bills are considered some of the most effective
    policy actions that we can take at reducing opioid overdoses.
        The Medicaid Reentry Act would empower States to restore
    Medicaid eligibility for incarcerated individuals up to 30 days
    before their release to ensure those transitioning will have
    immediate access to critical services, including mental health
    support, addiction treatment, and COVID testing. Granting
    States the ability to jumpstart Medicaid coverage for these
    individuals will mean they are not only able to receive
    lifesaving treatment for mental health, substance use
    disorders, and other conditions; it will also help them stay
    out of our already-overburdened hospitals and on the path to
    recovery and rebuilding their lives.
        As ONDCP identifies ways to reduce the increasing number of
    overdose deaths and to strengthen access to evidence-based
    substance use disorder treatment services and medications,
    would passage into law of the Medicaid Reentry Act help to
    achieve these important goals?
        Ms. LaBelle. Thank you, Congressman, for your leadership on
    these important issues.
        So I am a strong believer that we need to make sure that
    people, regardless of their circumstances, have access to
    evidence-based treatment. And providing incarcerated
    populations access to treatment before they leave is one way to
    do that.
        We also need to make sure that we follow up, that there are
    re-entry tools available to help people with their recovery.
    And actually, upstate New York has a lot of great examples.
    Buffalo MATTERS is one good example.
        So this is a high-risk population that we need to get
    services to.
        Mr. Tonko. Thank you so much. And I heard your earlier
    comments about giving your undivided attention to some of the
    issues concerning the X-waiver. So I also ask for your
    commitment to prioritize the elimination of the X-waiver in
    order to deliver on President Biden's promise to expand access
    to medication-assisted treatment. I ask that you examine all
    actions you can to take on this--support passage of our
    Mainstreaming Addiction Treatment Act, the MAT Act, in order to
    accomplish this goal.
        So a couple of questions. Are you aware that, after France
    took similar action to make buprenorphine available without a
    specialized waiver, opioid overdose deaths declined by some 79
    percent over, I believe it was, a 4-year period?
        Ms. LaBelle. Yes, I am familiar with the research, thanks.
    Yes.
        Mr. Tonko. Yes. And again, I thank you for your attention
    to this matter.
        Are you aware that in 2020 the number of waivered
    physicians accounted for only 5.9 percent of the total active
    physicians?
        Ms. LaBelle. Yes, sir.
        Mr. Tonko. And are you aware that, in 2018, 40 percent of
    counties in the U.S. did not have a single waivered provider?
        Ms. LaBelle. Yes.
        Mr. Tonko. And are you aware that providers can already
    prescribe buprenorphine without additional training, but only
    when treating pain?
        The X-waiver training to prescribe buprenorphine only
    applies to providers treating patients with opioid use
    disorder.
        Ms. LaBelle. Yes.
        Mr. Tonko. OK, so today I would like to submit a letter for
    the record signed by a number of groups, including the
    Association for Behavioral Health and Wellness of the Kennedy
    Forum, Shatterproof, Mental Health America, National
    Association of Attorneys General, the National Alliance on
    Mental Illness, the National Council for Behavioral Health, and
    many other groups.
        And I would indicate that they write--and I quote--``The
    existence of the X-waiver sends a terrible message to
    practitioners and the public alike, that treating OUD with
    buprenorphine requires separate, stigmatizing rules, and that
    buprenorphine is inherently more dangerous than the powerful
    opioids that have fueled this crisis.''
        So I fully agree that the X-waiver reflects a longstanding
    stigma around substance use treatment and sends a message to
    the medical community that they lack the knowledge or ability
    to effectively treat individuals with substance use disorder.
    So do you agree that the X-waiver sends a terrible message to
    practitioners and the public alike, and increases stigma?
        Ms. LaBelle. I think there is a great deal of stigma in
    every aspect of our addiction system, and this--you know, the
    buprenorphine waiver is just one element.
        Mr. Tonko. OK. Well, again, I thank you for your devotion
    to this issue and, again, for your open-mindedness as you
    approach it.
        Ms. LaBelle. Certainly, thank----
        Mr. Tonko. With that, Madam Chair, I yield back, and thank
    you again.
        Ms. Eshoo. The Chair thanks the gentleman, and the letters
    will be placed in the record at the end of the hearing.
        [The information appears at the conclusion of the hearing.]
        Mr. Tonko. Thank you.
        Ms. Eshoo. So thank you for joining us.
        And now we are going to switch back to a member of the
    subcommittee before we go to Mr. O'Halleran, who is waiving on.
        To Mrs. Fletcher from Texas, you are recognized for your 5
    minutes of questions. Great to see you.
        Mrs. Fletcher. Thank you so much, Madam Chairwoman. It is
    great to see you, and I am so grateful that you are holding
    this important hearing today.
        It is clear from the data and the testimony today that
    substance abuse disorders are an epidemic in this country. And
    my hometown of Houston is not immune. The pandemic has also
    exacerbated this crisis. Tragically, first responders in
    Houston reported a 17 percent increase in overdoses in the
    second quarter of 2020 compared to that same time period in
    2019. So I really appreciate that the committee is holding this
    hearing today.
        The alarming drug use overdose statistics are staggering.
    They are deeply concerning. However, I want to acknowledge that
    substance use disorder is a diagnosable and treatable disease.
    We have FDA-approved medications and evidence-based treatment
    that work. Patients with substance use disorder can and do
    recover, and they go on to lead meaningful lives in our
    society.
        In fact, the Biden-Harris Cabinet includes department heads
    like Secretaries Marty Walsh and Deb Haaland, who are both open
    about their long-term recovery from substance use disorders.
    They exemplify the fact that recovery is possible.
        My first question for you, Acting Director LaBelle: In your
    experience talking to communities across the country, what
    benefits do you hear about when it comes to efforts like
    recovery housing, college and high school recovery programs,
    and other peer support services?
        Ms. LaBelle. Thank you, Congresswoman, for asking that
    question. Recovery is something that is a relatively new area
    of research. But we know--I mean, I think all of us know people
    who have benefited from recovery facilities. Recovery high
    schools, I mean, literally, save lives. And so I think recovery
    supports--having people, peer support workers, working with
    folks in early recovery is a really important part. It is in
    our--included in our policy priorities, and something that we
    look forward to working----
        Mrs. Fletcher. Thank you so much. And I just want to follow
    up with that. Can you talk a little bit about the ways the
    Federal Government supports Americans in long-term recovery and
    how your office plans to build on or improve upon those
    efforts?
        Ms. LaBelle. Sure. So in a couple of ways. One is, as I
    mentioned, we have hired people who are in long-term recovery
    in our office. We engage people in recovery in all of our work.
    We will continue to engage people in recovery, and not just to
    tell their stories but to engage them in the policy development
    process and implementation process. Those are two ways.
        Also, we intend to work with the--with HHS on expanding
    recovery support services and--as well as research on what
    works best with different communities, and making sure we have
    culturally competent recovery services across the country.
        Mrs. Fletcher. Well, thank you for that explanation and
    thank you for all the recovery-related efforts that you and the
    administration are working on and plan to put forward. I
    appreciate your testimony here today.
        And again, I appreciate you, Madam Chairwoman, holding this
    hearing. And with that I will yield back the balance of my
    time.
        Ms. Eshoo. The gentlewoman yields back, and now it is a
    pleasure to welcome back to our subcommittee the gentleman from
    Arizona who is waiving on, Mr. O'Halleran.
        You have 5 minutes for your questions, and thank you for--
    --
        Mr. O'Halleran. Thank you, Madam Chair--I appreciate it--
    and Ranking Member, for putting on this meeting in a group that
    historically has been very bipartisan in addressing these types
    of issues. And I am looking forward to that occurring
    throughout this process and these bills.
        You know, I have--this is a different time, different
    place, different drugs, but here we are--all are again, sitting
    here. I was addressing it as a police officer back in the
    1970s: drug overdoses, drug crime. As far as how it was dealt
    with then, a lot of things have changed, but we still have a
    problem that is a continuing problem, day in and day out. And
    our families are being devastated by this, and we need to
    address it. And I know this group feels that way.
        But it is a comprehensive approach. It is not just one
    piece or another piece. It has to be comprehensive, taking into
    account the disparities within our society, taking into account
    the real elements of what causes this, and how do we get the
    therapists necessary to address this issue.
        And that is especially true in areas like rural America. We
    are short of doctors, anyway. We are short of therapists to a
    high degree. We have distances for patients to travel that are
    unreasonable. I know telemedicine is going to be coming around
    at a higher level later on, but not immediately, and we have to
    do something now. Two people die in Arizona every day.
        In August of this year--last year, I should say--507 people
    died from overdoses. And anybody that hasn't been around
    somebody that has died from an overdose, and watched them die,
    I can guarantee you--I am glad the families don't have to see
    it as much as the rest of society sees it when it happens in
    the public arena. But everybody should know that this is a
    tragic example of how America treats people with this type of
    health problem.
        And so, Ms. LaBelle, thank you for being here, obviously,
    but how is the administration planning on addressing the
    opioid--in rural America?
        Now, I want to--I don't see a healthcare issue, whether it
    is the VA or anything else dealing with healthcare, where there
    are specialists, where there are therapists, and our patients
    sometimes have to drive 10 hours round trip to get there. If
    you are calling from--for an overdose, you have to have people
    that--it might take an hour for people to get--even get to the
    house. And that is just something that has to be addressed
    immediately. So I am interested in how to address that.
        And by the way, hospitals are declining in rural America,
    they are not increasing.
        Ms. LaBelle. Thank you, Congressman. So I think in a couple
    of ways. One is you mentioned how long it takes for--it might
    take a first responder to get to a rural area to resuscitate
    someone who has experienced an overdose. So the first thing we
    want to do is make sure that we expand naloxone availability
    across the country, particularly in rural areas, to people who
    are at risk.
        The second piece of what you talk about--and this is going
    to take a little longer--is the workforce issue. As identified
    before, we have shortages. You just said, you know, you have
    healthcare shortages that are already predominant in rural
    areas. So we need to get--and specifically in targeted areas,
    with high rates of overdose, or high rates of substance use
    disorder generally--get the addiction workforce, the trained
    addiction workforce available and encourage them to stay there
    through loan repayment programs. So we will be working with our
    colleagues at HHS on those workforce issues that are important
    in rural America.
        Mr. O'Halleran. And I know that you have just started on
    this, so I appreciate the need for some time to get this going.
    But I think the people of America, and the people of rural
    America especially, would appreciate the ability to see a plan
    of action, not a plan that is going to take 2 years, 3 years to
    get it----
        Ms. LaBelle. Right.
        Mr. O'Halleran [continuing]. Addressed, and then the
    workforce issue is imperative. It is just imperative.
        And the realization, again, that this is not just one
    piece, it is not waking up in the morning and saying, ``I have
    an addiction to opioids.'' It is a process of lifestyle, it is
    a process of being--not being able to get jobs, or--alcoholism
    is part of it. It is a vast issue for this huge country of
    ours, and it hasn't been addressed in the appropriate way for
    decades.
        And I thank you, and I yield back.
        Ms. LaBelle. Thank you.
        Ms. Eshoo. All right. Well, the gentleman yields back.
        And I want to thank you, Doctor. I don't know when you--you
    probably didn't realize, when you signed on and said yes to us
    that you were going--would be willing to come and testify
    today, that you would be with us for, let's see, 10:30, 1:30--3
    hours and 10 minutes.
        What it demonstrates is what a deep and broad interest and
    concern every single member of the subcommittee has. And you
    heard firsthand what they see and have experienced in their
    districts, in their own families and extended families, and
    their knowledge of the various policies that have been
    proposed, legislation that we have put on the books, more--you
    know, bipartisan bills that are being voted on in the House
    today.
        So we look forward to working with you to put more than a
    dent in this. We have a lot of work to do. But you have a
    subcommittee that wants to work hand-in-hand with you.
        Ms. LaBelle. Right.
        Ms. Eshoo. And to the extent that your agency succeeds,
    then the--it will be the betterment of our country from this
    scourge that is taking place in people's lives. So we thank
    you. We thank you for being with us and the time that you gave
    to us. And we will keep working together.
        Now it is a pleasure for me to welcome our second panel of
    witnesses. Let me introduce them to you:
        Mr. Geoffrey Laredo, a principal at Santa Cruz Strategies,
    LLC.
        Ms. Patricia Richman, National Sentencing and Resource
    Counsel for the Federal Public and Community Defenders.
        Mr. Mark Vargo is the Pennington County State's Attorney
    and the legislative committee chairman for the National
    District Attorneys Association.
        Dr. Timothy Westlake is the emergency department medical
    director at the ProHealth Care Oconomowoc--let me do this
    again, Oconomowoc Memorial Hospital. I got it done, I did it.
        And last but not least, Dr. Deanna Wilson, who is the
    assistant professor of medicine and pediatrics at the
    University of Pittsburgh School of Medicine.
        Welcome to each one of you, and thank you for your
    patience, for waiting in the wings. I am sure that you found it
    highly instructive, whenever you joined us in the testimony of
    the new acting director and, very importantly, the excellent
    questions of members of the subcommittee.
        So I am going to go to you, Mr. Laredo, for your 5 minutes
    of testimony.
        And thank you again to each one of you, a panel of just
    superb experts who--you should each know will be highly
    instructive to each one of us.
        So, Mr. Laredo, you are recognized for your 5 minutes of
    testimony. Remember to unmute, please.
        Mr. Laredo. Thank you so much, and I hope that you can see
    and hear me OK this afternoon.
        Ms. Eshoo. I can, thank you.

         STATEMENTS OF GEOFFREY LAREDO, PRINCIPAL, SANTA CRUZ
       STRATEGIES, LLC; PATRICIA L. RICHMAN, NATIONAL SENTENCING
    RESOURCE COUNSEL, FEDERAL PUBLIC AND COMMUNITY DEFENDERS; MARK
     VARGO, PENNINGTON COUNTY, S.D., STATE'S ATTORNEY, AND CHAIR,
    LEGISLATIVE COMMITTEE, NATIONAL DISTRICT ATTORNEYS ASSOCIATION;
    TIMOTHY WESTLAKE, M.D., EMERGENCY DEPARTMENT MEDICAL DIRECTOR,
    PROHEALTH CARE OCONOMOWOC MEMORIAL HOSPITAL; AND DEANNA WILSON,
         M.D., ASSISTANT PROFESSOR OF MEDICINE AND PEDIATRICS,
              UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE

                      STATEMENT OF GEOFFREY LAREDO

        Mr. Laredo. Chairwoman Eshoo, Ranking Member Guthrie,
    members of the subcommittee, thank you so much for inviting me
    here today. My name is Geoffrey Laredo. I am a substance use
    and addiction policy expert who retired from the Federal civil
    service in 2018 after serving for 30 years in a variety of
    policy positions, mostly within the U.S. Department of Health
    and Human Services. Twenty-two of those years were at the
    National Institutes of Health, where I advocated, as
    appropriate, for science and scientists, research and
    researchers. I continue that work now as a consultant.
        Voice. See, I have never had to do that before.
        Mr. Laredo. Thanks also for continuing your focus on the
    addiction crisis in the United States.
        This committee has for several years written in advance
    legislation aimed at a broad array of addiction research,
    prevention, treatment, and recovery issues. And it was my honor
    to work with you and your staffs on those bills.
        You are considering a range of legislative proposals
    addressing the addiction crisis. One of those is the potential
    classwide scheduling of fentanyl-like compounds. And because of
    that issue's timeliness and my experience working on it as a
    legislative and policy staff at the National Institute on Drug
    Abuse, that is where I have focused my testimony.
        It is absolutely crucial to define what we care about. As a
    public policy professional especially focused on public health,
    what I care about is morbidity and mortality. Every aspect of
    our Nation's drug policy must be laser-focused on decreasing
    disease and death.
        How do we decrease both, and how do we advance evidence-
    based practices to achieve both?
        Classwide scheduling is not the road to success. Despite
    alternative claims, to my knowledge there just isn't any
    credible evidence to show where the classwide scheduling of any
    compound actually reduces morbidity and mortality. Conversely,
    there is ample evidence that properly funded and scaled
    research programs and evidence-based services can dramatically
    reduce morbidity and mortality.
        Further, proposals to increase the use of classwide
    scheduling minimize or eliminate the role of health agencies in
    this process. This is just unacceptable. Health agencies should
    have the primary, if not the sole, responsibility for deciding
    how or whether to schedule compounds. I don't support including
    the Drug Enforcement Administration in this decision process,
    and I would strongly support removing the agency from the
    process as it currently stands. Let health and medical
    authorities do the work of health and medicine, and let's
    provide them appropriate resources to do that work.
        I think you are familiar with the arguments around the
    difficulties of conducting schedule I research. You have talked
    about that a bit today. Since our time here is limited right
    now, I won't delve into those details. We tried hard when I was
    at NIDA to work with the DEA and the FDA to streamline that
    process. We reached some agreement, but it was unclear to me,
    frankly, whether any of those steps have actually really been
    taken. And I have to say this was not a pleasant process, and I
    will come back to that in a moment.
        Researchers have clearly shown that similarities in the
    chemistry of certain compounds do not necessarily equate to
    similar abuse liability. This is really important when
    discussing requirements for a schedule I designation, and I
    refer you to Dr. Sandra Comer and colleagues' work, as I
    mentioned in my written statement.
        So we find ourselves in a situation where placing an entire
    class of compounds into schedule I would clearly delay and
    deter research on exactly what you have been begging for:
    additional and improved solutions for opioid addiction,
    overdose reversal medications, and other medications'
    development results that we perhaps haven't even thought about.
    Why would we take a classwide scheduling action at exactly the
    time that we need to be increasing and accelerating potentially
    lifesaving work?
        In my written statement, I also describe steps we took in
    an effort to improve the overall situation. I hope you will
    read those details. They are pretty unpleasant. Not only did we
    not succeed, but senior DEA staff actually told me that I
    personally--and NIDA as an agency--were ``aiding and abetting
    drug dealers.'' That is pretty outrageous.
        That said, I am not naive, and I do understand the
    difficult position that the subcommittee and the full committee
    is in. I understand the politics. I understand the optics and
    the possible need for compromise. I also understand that you
    might choose to implement classwide scheduling. Such
    implementation without addressing crucial research issues would
    be a setback for our field. If you move in that direction, I
    strongly recommend that you include in your decision provisions
    that, for research purposes, treat all schedule I compounds as
    if they were in schedule II, truly streamline the process for
    obtaining a schedule I license, don't create separate licensing
    and process requirements for different classes of compounds,
    and finally, facilitate the de- or rescheduling of compounds
    when scientists verify that that would be justified.
        Members of the subcommittee, you focused a lot of time and
    effort on these issues over the past several years. So have
    other committees. If we are all really serious about this
    health issue, then I think you deserve to take and have the
    lead on legislation guiding those efforts.
        We should listen to science and scientists, and help them
    do their jobs. We should be thoughtful, especially in the face
    of significant disease and death. We should make the wise
    choice and avoid the knee-jerk reaction of just trying to
    ``ban'' substances that might or might not be helpful.
        And they might or might not--excuse me, they might or might
    not be harmful, and they might or might not be helpful. By
    doing so, we will help find answers that will improve
    conditions in the field.
        Ms. Eshoo. Thank you, Mr.----
        Mr. Laredo. Thank you so much for the honor of sharing my
    views with you, and I will be glad to discuss these issues
    further.
        [The prepared statement of Mr. Laredo follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much, Mr. Laredo. We appreciate
    your being with us, your willingness to testify, and the
    content of your testimony.
        Next the Chair would like to recognize Ms. Richman for 5
    minutes for your testimony.
        And thank you for being a witness, and for your patience,
    and for your willingness to be instructive to us. We are all
    ears, so you may proceed.

                    STATEMENT OF PATRICIA L. RICHMAN

        Ms. Richman. Thank you, Chairwoman Eshoo, Ranking Member
    Guthrie, members of the subcommittee for inviting me to this
    hearing today and the opportunity to share my perspective. I,
    too, will focus my remarks today on why this committee should
    reject the permanent or continued classwide scheduling of
    fentanyl analogues.
        Yesterday Senators Booker, Markey, Hirono, Warren, and
    Whitehouse wrote President Biden to caution against ``adopting
    a policy explicitly designed to expedite drug prosecutions and
    increase penalties.'' I urge you to follow their advice.
        We are in the midst of a national reckoning over police
    officers' use of force against communities of color. Last
    Sunday, Dante Wright was killed just 10 miles from where a
    police officer is on trial for the killing of George Floyd.
    Incidents like these are, in part, the product of a tough-on-
    crime culture focused on punishment instead of preventative
    community and health solutions.
        As a former Federal public defender in Baltimore, Maryland,
    I witnessed the impact of these punitive practices. My clients
    faced harsh sentences for drug offenses. In recent years,
    nearly 80 percent--80 percent--of people who received drug
    mandatory minimums in Maryland's Federal courts are Black, even
    though they make up only 42 percent of the State's population.
        And there is no bright line between user and seller. The
    vast majority of my clients grappled with substance use
    disorder, and many had lost friends and family members to the
    overdose crisis. This crisis is a complicated problem.
        Today I ask this committee not to repeat past mistakes.
    Over the past decade, bipartisan efforts such as the Fair
    Sentencing Act of 2010 and the First Step Act moved in the
    right direction. And President Biden has pledged to end
    mandatory minimums, reduce racial disparities in the criminal
    legal system, and shift drug policy towards public health
    solutions.
        Today fear and misinformation are being used to support
    classwide scheduling of fentanyl analogues, and I ask you to
    look to the evidence. To be clear, harmful fentanyl analogues
    are illegal with or without classwide scheduling. If the
    classwide expires on May 6, no harmful fentanyl analogue will
    become legal.
        During the 3 years that the ban has been in place, many
    experts have examined whether the classwide approach works.
    They have asked two core questions: first, does classwide
    scheduling actually reduce overdose deaths; second, does
    classwide scheduling reduce the supply of harmful substances in
    our country? The answer to both questions is no.
        These are the facts, according to the CDC and the GAO. The
    CDC has reported that, during the 3 years the ban has been in
    place, the number of overdose deaths attributed to fentanyl and
    fentanyl analogues has continued to rise, and fentanyl and
    fentanyl analogues have continued to enter the country in large
    quantities. The recent GAO study found that ``seizures of
    fentanyl and its analogues entering the U.S. ports increased
    substantially from 2017 to 2020.''
        And a chorus of voices, public health experts, scientists,
    and impacted people in the criminal justice community, have
    also identified ways that classwide scheduling is
    counterproductive and unnecessary.
        Public health experts warn that, even if there is a shift
    away from novel fentanyl analogues, it will be to something
    even more potent and harmful.
        Scientists warn that blanket bans of substances impede
    scientific research and may delay or eliminate the discovery of
    badly needed antidotes and treatments. They have identified
    specific substances that have been improperly scheduled by the
    ban and have therapeutic promise.
        And the criminal justice community cautions that classwide
    scheduling would expand mandatory minimums, exacerbate racial
    disparities, and eliminate crucial checks against DEA
    overreach.
        Federal sentences for fentanyl analogues increased nearly
    6,000 percent between 2015 and 2019, and people of color made
    up 68 percent of those cases in 2019. That year, mandatory
    minimums were imposed in more than half of those cases.
    Meanwhile, classwide scheduling has not been used to prosecute
    kingpins but to continue the failed practice of prosecuting
    low-level players. This practice does not disrupt supply or the
    real driver here, demand.
        Classwide scheduling is not regulatory. It is punitive. We
    cannot incarcerate our way out of this problem. It is time to
    do the work to heal our communities and country by finding and
    building evidence-based, science-first solutions that are
    proven to reduce demand and harm associated with these
    substances.
        And in addition to this work, the most important step
    Congress can take to fix America's broken drug policy is to end
    mandatory minimums and to apply those changes retroactively.
        Thank you so much for the opportunity to testify today.
        [The prepared statement of Ms. Richman follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you so much for your testimony. We will
    now go to Mr. Vargo.
        The Chair recognizes you for your 5 minutes of testimony,
    and thank you again for your willingness to be with us and the
    work that you do. You are now--make sure you unmute, please.

                        STATEMENT OF MARK VARGO

        Mr. Vargo. Thank you, Chairwoman Eshoo, Ranking Member
    Guthrie, and to the rest of the committee. I am proud to be
    here to represent the National District Attorneys Association
    and very grateful that you invited us to participate in this
    very important set of hearings on this topic, which we all know
    is extremely dire at this moment.
        I was struck as I prepared to address you today by Director
    LaBelle's characterization in an article she wrote a few years
    ago that addiction is the only disease where we expect people
    to diagnose themselves by hitting rock bottom. But then, you
    know, it dawned on me that perhaps we don't rely on them but
    rather that all of you have been relying on me, because it
    feels like we define rock bottom as arrest, incarceration, and
    criminal prosecution. And it is at that moment that we want to
    mobilize the forces of addiction recovery.
        It is my hope that today we can discuss about ending that
    mentality. And so everything that I tell you I want to put
    through the lens of moving the point of the intercept. Because
    the costs of waiting to intercept drug addiction are
    disastrous, they are disastrous for the addict. And
    Representative Kelly and Representative Cardenas, along with
    Dr. Wilson, in her written testimony, have talked about how
    early treatment is necessary and how our communities of color
    are being deprived that early treatment.
        It is also disastrous for our communities and our families.
    Fentanyl and all other drugs lead to abuse, neglect, and
    poverty. And methamphetamine, which remains a scourge in
    western South Dakota, adds to the problem. It is paranoia,
    hypervigilance, and aggression. People on methamphetamine are
    10 times more likely to be violent if they use every other day
    than a--even a meth addict who is presently in remission. And
    it is the only drug for which the most recent NIDA figures show
    an increase in drug overdose deaths, not just in combination
    with fentanyl or other synthetic opioids but on its own.
        As prosecutors, we do what we can from where we are with
    what we have, and I am very proud of what we are doing from the
    point of intercept that has been assigned to us onward. Our
    diversion programs, which I went into extensively in my written
    testimony, are just one example of how we are trying to change
    the way that we engage with people who have addictions to
    ensure that they have the best chance possible to become
    productive, functioning members of our community. I am very
    proud of my staff, who with very little budget have put
    together a tremendous array of programming to give diversion
    candidates a chance of success.
        Because we have very little funding and because we never
    ask our offenders to pay, we rely on a wide variety of
    community resources, including governments like the Oglala
    Sioux Tribe and cultural and community programs like the Wambli
    Ska Pow-Wow, an indigenous American legacy.
        We tried to change behavior without the criminogenic
    consequences of a conviction. I would like to mention to you
    that NDAA has specifically supported Representative Tonko's MAT
    Act, Representative Curtis and Peters' Methamphetamine Response
    Act, and we support the extension of classwide fentanyl
    analogue scheduling, and we support the EQUAL Act, which would
    reform sentencing.
        But I want to take the little time that I have left to ask
    you three things.
        I am asking you to move the intercept point. The
    descriptions of the needs of our communities, our at-risk
    communities and our communities of color, are very stark. We
    need from Congress money in both the criminal justice system
    and before the criminal justice system. In other words, we need
    you to lead.
        Secondly, we need you to use us in State and Tribal
    government as the laboratories of innovation. Representative
    Tonko, who in the last session talked about Buffalo MATTERS, an
    outstanding program that has been spearheaded by my friend and
    colleague John Flynn in Erie County--programs like that within
    the criminal justice system, and programs like treatment
    programs that are being dealt with by programs like Native
    Healing and Native Women's Health Care, here in South Dakota,
    are very important. In other words, we need you to follow.
        And then finally, I ask you to reduce the Federal
    collateral consequences of State court drug convictions. The
    origins of our diversion were that we recognized that people
    with minor drug convictions had major problems, largely based
    on Federal law. In other words, we need you to get out of the
    way.
        And so, with apologies to both Mr. Paine and to General
    Patton, we need you to lead, we need you to follow, and we need
    you to get out of the way.
        [The prepared statement of Mr. Vargo follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Mr. Vargo, thank you for your excellent
    testimony, really grabbing the attention of every single
    Member. Thank you, and thank you for the superb work you and
    your organization do.
        Now the Chair would like to recognize Dr. Westlake. Welcome
    to the committee. Thank you for being willing to be a witness
    and give testimony today, and for your patience in waiting for
    panel two to begin.
        So please unmute so that everyone can hear you. And
    welcome, again.

                  STATEMENT OF TIMOTHY WESTLAKE, M.D.

        Dr. Westlake. Great, thank you. Thank you, Chair Eshoo,
    Ranking Member Guthrie, and members of the subcommittee. Thank
    you for the opportunity to talk with you and for your
    leadership. My name is Tim Westlake. I am a full-time emergency
    physician and the immediate past chair of the Wisconsin Medical
    Examining Board. I am a licensed provider and prescriber of
    buprenorphine and provide the medical control for the statewide
    peer-to-peer recovery network that provides free Narcan
    education and access. I was also the physician architect of the
    Wisconsin Prescription Opioid Reform Strategy starting in 2014.
        I originated the idea of targeted fentanyl class scheduling
    while serving on the Wisconsin Controlled Substance Board and
    got it enacted first in Wisconsin in 2017. The DEA then
    temporarily put in place the same language federally in 2018.
    Before that point, scheduling of fentanyls was like a lethal
    game of Whac-a-mole, as you have heard before, except for me it
    was literally waiting for kids to die before we could control
    and stop the spread.
        As an emergency physician, I was beyond weary and
    heartbroken having to tell parents, sometimes even friends of
    mine, that their kids were never coming home again after
    overdosing.
        The inspiration for the fentanyl class scheduling reform
    arose out of the tragedy of my friend's son, Archie Badura.
    Archie was an altar server alongside my daughters in church.
    Archie first got hooked on prescription pills and then IV
    opioids. I resuscitated him on his second-to-last overdose. We
    pulled out a body bag and laid it out for him, warning him that
    he would end up in it if he didn't reach out for help. He was
    able to stay clean for 6 months after that, but then fentanyl
    caught up with him and ended his life like it has for hundreds
    of thousands of other kids in our country. His mom, my good
    friend Lauri, remembers seeing me showing him the body bag in
    the emergency department. And the next time she saw that bag,
    Archie was being zipped up into it and taken away to the
    morgue.
        In 2020 Congress enacted a temporary extension of what I
    like to refer to as the ``Archie Badura Memorial Fentanyl Class
    Scheduling Language,'' closing a loophole in Federal drug law
    which cartels have been exploiting for years to create and then
    legally distribute these deadly substances. Now is not the time
    to eliminate a proven harm reduction and overdose prevention
    strategy.
        When looking for policy and legislative solutions to the
    fentanyl devastation that is wreaking havoc in our country, it
    is critical to look at this situation from the proper
    perspective. Unlike marijuana, hallucinogenics, cocaine, or
    even heroin, fentanyls are so toxic and lethal that they can be
    classified and actually can be used as chemical weapons. A
    lethal dose is 2 milligrams, meaning that one teaspoon--which
    is what is in this packet of sugar--can kill 2,000 people.
    Twenty-four pounds is more than enough to kill all 5.4 million
    residents of metropolitan Washington, DC.
        The effects of the 3 years of fentanyl class scheduling are
    clear: the creation and distribution of finished fentanyl and
    fentanyl-related substances from China has ground to a halt.
    Most importantly, according to the National Forensic Laboratory
    Information System, overdose deaths related to fentanyl-related
    substances--newly created fentanyl-related substances--have
    effectively ceased. In Florida, in comparison, between 2016 and
    2017 there were 2,500 deaths attributed to fentanyl-related
    substances themselves. During that same time in New York City,
    there were 900 deaths in the city alone.
        Concerns about potential negative consequences on research
    and increased incarceration simply really have not
    materialized. Most research concerns raised in opposition are
    theoretical and seem to be focused on schedule I research writ
    large and are not specific to fentanyl-class research itself.
    In clarification, there are an exceedingly small number of
    researchers who have studied and--registering to study the
    fentanyls, approximately 30 in total, with many of these being
    DEA and Department of Defense subcontractors focused
    exclusively on the analysis, detection, and attempt to
    understand the harm of these substances. The only dampening or
    restricting of research has been purely theoretical.
        Fentanyl and its derivatives have been extensively
    researched since discovery in 1960, and in that time not one
    fentanyl-based reversal agent or medication-assisted treatment
    has ever been found in the 60 years since.
        Naloxone and Narcan work exceedingly well at reversing
    overdoses from all opioids, including fentanyl and fentanyl-
    related substances. This is something I, unfortunately, see
    sometimes on a daily basis. If it wears off, then more can
    easily be administered. Kids die because they ingest a lethal
    dose of toxic opioids, not because Narcan isn't effective.
        Opposition posits that the Analogue Act is sufficient to
    control any new fentanyl-related substances. But if that were
    the case, all 50 attorney generals, including then-California
    AG Xavier Becerra, wouldn't have crossed the aisle, coming
    together 2 years ago to ask Congress to enact this language,
    and we wouldn't be discussing it here in this hearing right
    now.
        It is important to understand using the Analogue Act is a
    reactive strategy. It often reacts to the deaths of hundreds or
    thousands of our kids. Overincarceration has simply not been
    seen. In fact, in the 3 years since the class scheduling has
    been in place, there have been a total of eight Federal
    prosecutions, half of whom already have known ties to drug
    cartels. It is because this is not a law enforcement bill, this
    is a prevention bill.
        Regarding the mandatory minimums, the amount that triggered
    the minimums are 10 and 100 grams, which at first glance seems
    harsh. But it is critical to remember that that is enough to
    kill 5,000 and 50,000 people, respectively.
        Also setting the record straight, there have been zero
    prosecutions for nonbioactive fentanyl-related substances. This
    is due to the fact that all fentanyl-related substances
    encountered and researched to date have been found to be strong
    and potent opioids. Benzyl fentanyl is not classifiable as a
    fentanyl-related substance.
        I would suggest that so little incarceration is occurring
    as a result of the fentanyl class scheduling because it is,
    first and foremost, an overdose prevention and harm reduction
    tool and strategy originated by me, an emergency physician, who
    was beyond weary having to tell more parents that their
    children would never be coming home.
        Ms. Eshoo. Dr. Westlake, can you just summarize in a
    sentence or two, because your time has expired?
        Dr. Westlake. I am sorry, yes. The solution is not to allow
    the expiration of the fentanyl class scheduling. Congress
    should enact the Archie Badura Memorial Fentanyl Class
    Scheduling language seen in the bipartisan FIGHT Fentanyl Act.
        We need to deploy every----
        Ms. Eshoo. Thank you very much. Thank you, Doctor, we
    appreciate you being with us and for your testimony.
        [The prepared statement of Dr. Westlake follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Last but not least, the Chair recognizes Dr.
    Wilson for 5 minutes for his testimony, and--your testimony.
        And thank you again for your patience in waiting for panel
    two to begin, and we are ready to hear from you. So thank you
    very much. Lovely to see you, and thank you for joining us.
        Dr. Wilson. Chairwoman----
        Ms. Eshoo. And please unmute.

                    STATEMENT OF DEANNA WILSON, M.D.

        Dr. Wilson. Chairwoman Eshoo and Chairman Pallone, Ranking
    Members Guthrie and Rodgers, and members of the committee,
    thank you for the opportunity to speak with you today. My name
    is Dr. Deanna Wilson. I am a pediatrician and internist with
    subspecialty training in addiction medicine. I am an assistant
    professor at the University of Pittsburgh, where I teach
    students and physician trainees about addiction, and I also
    conduct research focused on improving health equity and
    reducing disparities among vulnerable populations with
    substance use disorders.
        The worsening overdose crisis and the setting of the COVID-
    19 pandemic has both unmasked significant health inequities but
    has also created opportunities for us to rethink how we deliver
    care in ways that, one, prioritize equity; two, increase
    treatment access; and three, increase our workforce's capacity
    to treat addiction.
        In cities like Philadelphia, while rates of overdose deaths
    fell by 31 percent among White Americans, there was a
    concurrent increase by more than 50 percent among Black
    Americans. The racial and ethnic disparities and overdose rates
    today reflect our failure to center the needs of Black and
    Latinx communities and address the underlying systemic
    inequities, social inequalities, and structural racism that
    drive differential access and disparate treatment outcomes.
        For example, we know that medications like buprenorphine
    and methadone substantially reduce the risk for both all-cause
    and overdose mortality, making them truly lifesaving. And yet
    your race determines how likely you are to receive them. Black
    patients have 77 percent lower odds of receiving a
    buprenorphine prescription during an office visit compared to
    White patients.
        We must re-imagine how we deliver addiction treatment,
    partnering with community organizations like faith-based groups
    to rebuild trust and reduce stigma, supporting low-threshold
    models of care that minimize barriers, preventing marginalized
    groups from being well-served by traditional health systems.
        We need greater investment in how to support these
    programs, to document their efficacy, and to scale up their
    use.
        Secondly, we need improved treatment access. In response to
    the COVID-19 emergency there has been greater flexibility and
    funding to support telemedicine for the induction and
    maintenance of buprenorphine. Our ability to engage patients
    who are unable to physically make it into clinic allows us to
    see patients who may never have linked to or may have fallen
    out of care. We need legislation that permanently supports our
    ability to use telehealth, but we also need initiatives making
    sure that telehealth is more equitable, such as supporting
    digital literacy and improving access to broadband coverage.
        Similarly, opiate treatment programs were granted
    flexibility to increase take-home doses of methadone.
    Preliminary studies show no increase in fatal overdose. This
    suggests the intense regulation of methadone distribution may
    be unnecessarily restrictive. We urgently need studies to
    further examine outcomes from this period so we can reform
    methadone regulations to become both more evidence based and
    patient centered.
        In light of rising use of stimulants like methamphetamines
    and cocaine, we need to invest in research on effective medical
    therapies. We also need to remove current coverage gaps,
    limiting our ability to offer evidence-based behavioral
    treatments like contingency management.
        Similarly, we need to reform policies that contribute to
    lags in addiction care for incarcerated individuals post-
    release. Incarcerated individuals are 129 times more likely to
    die from an overdose within the first 2 weeks after release
    compared to the general population. Lengthy lag times in
    reactivating insurance post-release contributes to potentially
    fatal return to use.
        In addition, we must recognize that abstinence-only
    approaches to substance use treatment can further stigmatize
    and marginalize patients. Harm reduction services are not only
    effective at reducing harms associated with drug use, but by
    engaging patients who may be ambivalent over time. They provide
    critical access points to link patients to addiction treatment
    when they are ready. We must remove regulatory barriers and
    thoughtfully implement and study promising harm reduction
    interventions.
        Thirdly, we need to increase the capacity of our health
    provider workforce to treat and normalize the care of patients
    with addiction. The regulatory barriers associated with
    prescribing buprenorphine, the X-waiver, have unnecessarily
    restricted access to lifesaving therapies. Removing the X-
    waiver is low-hanging fruit with the potential to drastically
    increase patient access. But at the same time we need to
    support training in addiction medicine for all providers.
        For example, requiring education in addiction, including
    logistics on buprenorphine prescribing as part of DEA
    registration, would empower all providers with a DEA license
    learn how to recognize and treat patients with addiction.
        If I may leave you with these three thoughts: one, we need
    to center equity in our policies and programming; two, we have
    to use evidence-based strategies to expand access to addiction
    treatment; and three, we must remove regulatory barriers and
    normalize the treatment of addiction by all providers.
        Thank you. I am happy to take any questions.
        [The prepared statement of Dr. Wilson follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Ms. Eshoo. Thank you very much, Doctor. The Chair
    recognizes herself for 5 minutes of questioning.
        I would just note that, amongst you, the five witnesses,
    there seems to be a really sharp diversion on the issue of the
    expiration date and how that should be handled. So I am not
    going to go into it, but know that it is clearly noted that
    there are just really sharp differences.
        We have two lawyers, two doctors, a researcher. This is
    really a very fine panel.
        In listening to you, I cannot help but think of FEMA coming
    into New York and other communities, setting up beds, treatment
    being made available to those that were tested positive for
    COVID. Now, I don't want to underestimate what treatment for
    opioid addiction is, but it seems to me that we need to ramp up
    on the urgency of this.
        I mean, to hear the doctor talk about the young person and
    showing him a body bag and saying that if he didn't do such-
    and-such a thing that he would end up being zipped into it, and
    he was. So would each one of you want to comment on this?
        Don't we need more beds, more treatment, that we need to
    ratchet this up so that it matches the urgency that we all know
    this is?
        I just don't think that when we say that it is urgent, that
    we have to stem the tide of the deaths--I think that we need
    strike teams. I think people in every community and every State
    around the country have to see that we are taking this
    seriously and that we are going to do something about it.
        I mean, the number--over 540,000 deaths due to COVID in
    this last year, 88,000 just for opioid. I mean, what, are we
    going to be satisfied with these numbers?
        So I invite any one of you to tell me that I am off track,
    that we need more treatment, we need more beds, we need help
    for people. I think our system is really fragmented.
        So I have used my time to really dump my thinking and my
    frustration and my emotions on you. But you are the experts, so
    I want to hear what you think. You can say yes or no to more
    beds, more treatment, more people trained, more money in the
    effort, if that is what it takes.
        But we need to--I think that we have the capacity in this
    great country to go to near elimination of this.
        And when the district attorneys describe what they are left
    with, because we are not doing everything that we need to do--
    these people are sick. They don't belong in the criminal
    justice system. Then we have to find money to pay for the
    people that are in jail, and in prisons before they leave. I
    mean, what are we doing?
        So who would like to start?
        Dr. Wilson, would you like to take it?
        Dr. Westlake. Sure, I think----
        Dr. Wilson. Yes----
        Dr. Westlake. Oh, sorry.
        Ms. Eshoo. Dr. Wilson?
        Dr. Wilson. Yes. Thank you so much, Chairwoman Eshoo. I
    think that is a critical point. We absolutely need additional
    treatment. We need more access to evidence-based therapies, and
    we need to make sure that we have equitable access to evidence-
    based----
        Ms. Eshoo. Are therapies not the right ones? I mean, have
    we not settled on what works?
        Dr. Wilson. We have wonderful evidence that medications to
    treat opioid use disorder, like buprenorphine and methadone,
    are highly effective at keeping people alive. So I think the
    evidence and science is clear to show that that is the case.
        The problem is we are not getting the medical therapies to
    the patients and communities that need them. And so that is the
    huge treatment gap that we need urgent attention and action to
    address. And that means----
        Ms. Eshoo. So like trying to get the vaccines, enough
    allotments, into the States and into the arms of people.
        Another one of the doctors want to comment? My time is just
    about gone, because I talk too much.
        Yes?
        Dr. Westlake. Yes, Chairwoman, I think you are spot on with
    that.
        In the emergency department I would estimate between 10 and
    30 percent of the patients that I see, there is something to do
    relating to substance use disorder. Usually it is untreated.
    And so this is--I think we are going to look back 30 years from
    now and say, you know, I can't believe that we were doing----
        Ms. Eshoo. You can't--you don't have the ability to refer
    them anywhere?
        Dr. Westlake. Well, it depends on where you are at. So I am
    in a resource-rich community, and so I can. But so much of the
    State, especially the rural parts--and that is where the
    telehealth expansion is really helpful. But there is so much
    that can be done, I think, moving forward.
        Ms. Eshoo. Well, I thank each one of you. My time has
    expired, and I think you clearly know where I am.
        So now I would like to recognize, really, a wonderful,
    important member of our subcommittee, the ranking member, Mr.
    Guthrie, for his 5 minutes of questions.
        Mr. Guthrie. Thanks, Madam Chair. And I want to say I think
    when--somebody said it, they understand the politics and
    optics, and I certainly don't say there is not politics and
    optics in Washington, DC, but I will tell you all of us are
    trying to figure this out, to get it right, because it is
    people's lives that we are dealing with.
        And one that really springs to me, I was touring a lot of
    opioid recovery centers when we were working on the SUPPORT and
    the CARES Act, and one guy--Kentucky has a law that you can
    get--if you are a minor user or so forth--expunged, but you
    can't get expunged if you sell. And that makes sense, when you
    think about it. But I met an individual who said about
    everybody who is addicted had some selling in their background,
    because ``I would buy 30 pills and sell three so I could afford
    the 30.'' But it was--``I was selling to support my habit.''
    And so--but if you read the book ``Dreamland,'' there are
    completely pure criminal enterprises that prey on people like
    him.
        And so I don't think it is all one or the other. I think we
    have to figure out how we punish those who are truly criminal
    and those who are being--who are committing crimes--committing
    to support their habit, if you--and I said in my opening
    statement--if you can help them with their addiction, then you
    help them with--then the crime goes away with that.
        And so--but I am concerned about the truly criminal
    enterprises that we have to deal with. And Dr. Westlake, in
    your testimony you did say that the goal of the fentanyl class
    scheduling is not to--not locking up low-level drug users but
    to stop the development of deadly fentanyl poisons at their
    origin, namely in drug labs overseas. That is the quote. And
    could you explain--expand on this point, and further describe
    how the scheduling order is meant to prevent large-scale
    importation and distribution and not target individuals with
    substance use disorder?
        Mr. Vargo, after, if you would comment on how you use this,
    as well, to focus on the--more the large-scale criminal than
    the low-level user.
        So, Dr. Westlake?
        Dr. Westlake. Sure, thank you. Thank you. The--I think that
    the main point of the whole Act was to--or the whole set of
    languages--is to stop the creation of these substances, so
    that--these substances have been very well--there is very well-
    researched structure activity, pathways that go back 60 years.
    And so it is simply--it is as simple as plugging in a different
    chemical in a formula structure, like a cookbook.
        And so what that--and those are very well laid out. And if
    you look at my testimony, my written testimony, I go through
    this in detail. I don't think I have the time to do that now.
        But the goal was to make those so that those would be
    illegal, so that the--and they wouldn't be created because,
    again, it was this Whac-a-mole game, where they are going
    around what is legal and waiting for the Analogue Act, or
    waiting for the CSA to catch up with it, which would be a year
    or so, or maybe a couple thousand deaths.
        So this--what this does, was this stops the--and it
    disincentivizes them from doing that. I mean, granted, they may
    have switched over to producing illicit fentanyl, you know, but
    what it has done is it shut down the new fentanyl-related
    substance creation machine, the mine of new fentanyl-related
    substances, by--again, by eliminating the incentives for that
    to happen.
        Mr. Guthrie. Mr. Vargo, instead of answering that, can I
    just focus on a specific part of that?
        So--and it was said earlier in testimony that if the
    descheduling goes away, that they still remain illegal. But you
    have to use the Federal Analogue Act for them if they are not
    scheduled. And so could you talk about how that could be
    inconsistent jury findings?
        You have to present to a jury for--that they fall under the
    Federal Analogue Act, and not--that they are not illegal by
    law, they are illegal if you can prove they are illegal to a
    jury. Could you talk about that process and why it would hamper
    your prosecutions of major criminals?
        Mr. Vargo. Certainly, Representative Guthrie, and I will
    tell you that, obviously, I as a State prosecutor don't do a
    great deal of that now. I was, for 15 years, a prosecutor in
    the Federal system, so I have some familiarity.
        I will tell you that it does appear that the--both the goal
    and the effect of the classwide scheduling have been effective.
    If we look at the--what was happening before, we have kind of a
    before-and-after control group, if you will. And, as Dr.
    Westlake pointed out in his written testimony, the number of
    analogues that we are seeing at the border fell significantly
    after the passage of that legislation. In other words, the
    legislation worked in changing the game of Whac-a-mole that we
    were playing with the Chinese laboratories that were creating
    new versions of fentanyl analogues.
        The--as far as prosecution goes, I think it is illustrative
    that the article by the Sentencing Guideline Commission
    recently identified only two cases since the passage of that
    legislation that were actually scheduled--or sentenced under
    the fentanyl analogue classwide scheduling. So it has not led
    to a large-scale incarceration or even large-scale prosecution,
    but it has been effective in reducing the number of new
    analogues that we see.
        The difficulty becomes, if we went under the Analogue Act,
    you have to prove individually that it is an analogue, and then
    you have to prove the person who was distributing it or
    possessed it knew that it was a controlled substance or had a
    controlled nature. Both of those would be very difficult under
    the Analogue Act with every new substance.
        Mr. Guthrie. Thank you. I would--I will yield back my time.
        Thank you for those answers, I appreciate it.
        Ms. Eshoo. The gentleman yields back. The Chair recognizes
    the gentlewoman from California, Ms. Matsui, for your 5 minutes
    of questions.
        Ms. Matsui. Thank you again, Madam Chair, and I do thank
    the witnesses for their testimony today, and I think you feel
    and see the frustration in our voices because all of us are
    troubled by the rise in overdose deaths, especially over the
    past year. And despite the enormity of the COVID-19 pandemic,
    which is, you know--and the overdose deaths and the substance
    uses have been exacerbated. So we can't lose focus on addiction
    crisis in this country.
        Now, over the past several years we have worked in a
    bipartisan way to support targeted efforts that have finally
    begun to reverse some of the overdose trends. But the pandemic
    has robbed us of that progress. So in a way we are talking
    today about what are we going to do moving forward.
        The bills presented today represent an opportunity to take
    a much-needed, broader and bolder approach to address the
    crosscutting facets of the addiction epidemic.
        You know, the task to combat the crisis continues to
    evolve. We know that. And as our witnesses have stated, we are
    now seeing fentanyl increasingly mixed into drugs like cocaine
    or meth, and that is presenting unique challenges to those on
    the front lines. And in some parts of States, including
    California, stimulants are the primary drugs of choice.
        Mr. Vargo, you brought attention to the issue of meth. Can
    you talk more about how Americans who use meth may differ from
    those who use opioids?
        Mr. Vargo. Thank you, Representative Matsui, I would be
    glad to.
        Methamphetamine is one of our most challenging substances
    because every drug that is illegal, every substance that is
    illegal, creates a criminogenic factor because you are dealing
    with it illegally. In the old words of Glenn Frey, you always
    carry weapons because you always carry cash. So we know that we
    create problems any time something is illegal.
        Methamphetamine, though, is, if not unique amongst drugs of
    abuse, certainly the most prominent [inaudible] drugs of abuse.
    It carries with it biological factors that render those people
    more dangerous: the hypervigilance, the paranoia,
    hallucinations, the aggression that comes with it. Even if meth
    were 100 percent legal at every level, it would create
    criminality because it creates violence. It is very much like
    PCP was back in the 1980s. I am that old that I remember that.
        So methamphetamine presents a particularly difficult
    circumstance and, more importantly, presents a very difficult
    treatment because it is one of the most difficult drugs to
    treat. Until recently we didn't believe there was medically
    assisted treatment available. There is some hope in that
    regard, but it is a very difficult drug, both in its use and in
    its treatment.
        Ms. Matsui. OK. Dr. Wilson, you also discussed in your
    testimony the growing number of patients that use stimulants
    either as a primary drug or mixed in with other opioids. How
    does this impact how you care for patients?
        And how are treatment recovery services for these patients
    different from those who--primary for opioid disorders?
        Dr. Wilson. Thank you so much for that question. You know,
    I think it is really important to recognize that, while we have
    really effective medications to help patients with opiate use
    disorder, we do not have effective medical therapies to support
    patients who have stimulant use disorder like methamphetamines
    or cocaine. There are some medications that have very modest
    effects, but the primary treatments that have been shown to be
    effective for patients with stimulant use like methamphetamines
    have been behavioral health treatments.
        The sort of greatest evidence base supports things like
    contingency management, where you reinforce patients who are
    having negative urines and remaining abstinent, for example.
    But it is really hard to operationalize those kind of therapies
    within sort of traditional kind of outpatient treatment
    programs. And so getting access to sort of efficacious
    behavioral therapies for patients with stimulant use disorders
    is more challenging.
        Many of the patients that I see who use stimulants are also
    using other substances. And so I think it becomes really sort
    of challenging to figure out sort of how can you link and
    engage patients in care and get them access to a full
    complement of results. So----
        Ms. Matsui. It seems to me that we don't have as many
    effective treatments for patients that use stimulants.
        Dr. Wilson. That is absolutely true.
        Ms. Matsui. Right, and so we need to have more research in
    order to find some way to deal with this, because meth has been
    around forever, in essence. And I know, in California, people
    don't hear about it as much as they hear about opioids, and yet
    meth is still growing, in essence.
        So I see I am running out of town. Thank you for--time.
    Thank you very much, and I yield back.
        Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
    recognize the ranking member of the full committee, Mrs. Cathy
    McMorris Rodgers.
        Mrs. Rodgers. Thank you, Madam Chair. I want to just thank
    you again for holding this important hearing today. I know it
    has been a long one, but it is really important. And a big
    thank you to all the witnesses for joining us today, sharing
    your perspective, your stories.
        To Dr. Westlake, just thank you for sharing your own
    heartbreaking story. It, unfortunately, is repeated too often
    right now in America. And my heart just breaks for you. I
    wanted to start with a question to you, Dr. Westlake, as well
    as Mr. Vargo.
        GAO's recent analysis found that a number of reports of
    unscheduled fentanyl analogues decreased by 90 percent after
    DEA issued the classwide scheduling order. So they found that
    after DEA issued this classwide scheduling order, the fentanyl
    analogues decreased, the number of reports of it decreased, by
    90 percent. So specifically, in 2016 and 2017 there were over
    7,000 law enforcement reports, 7,058 law enforcement reports of
    encounters with these substances. So that was 2016, 2017. You
    look at 2018, 2019, the encounters were down to 787, so over--
    yes, 7,000 to 787.
        Why did classwide scheduling so significantly reduce the
    encounters?
        And I will start with Dr. Westlake, and then Mr. Vargo.
        Dr. Westlake. Sure. Thank you for the question,
    Congresswoman.
        I have a--there is a phrase that I want to drive home, if
    there is, like, one point that I want to get brought out of
    this hearing. It is that you can't die from something that has
    never been created, and you can't be incarcerated for selling
    something that doesn't exist.
        And so that is what has happened, is, you know, in
    conjunction with our scheduling language--the Chinese actually
    knew about the language coming up. We have been, you know,
    partnering closely with them, trying to get them to control the
    fentanyls, and eventually that happened. And so that just
    stopped. So it is not just that there is no new fentanyl-
    related substances that are being seen, or very few.
        The NFLIS, the National Forensic Lab Information System,
    shows that there is almost no deaths that are occurring from
    new fentanyl-related substances. So you are still seeing deaths
    from the older fentanyl-related substances that are now
    fentanyl analogues, but you are not seeing deaths from the new
    ones. And so that was the goal of this. The whole--this is not
    a law enforcement bill. The vehicle is a law enforcement
    vehicle for scheduling, but the bill is ultimately opioid, you
    know, harm reduction, and opioid reduction of overdoses,
    overdose prevention.
        Mrs. Rodgers. Thank you.
        Mr. Vargo?
        Mr. Vargo. Thank you, Madam Chair. I will tell you that it
    is hardly surprising that criminal enterprises go where the
    money is, and where the criminality is least likely to be
    punished. I think that the response that we have seen from
    these organizations--I wish I could tell you that I don't think
    they are dealing drugs anymore. I doubt that is the case. But
    it means that they haven't tried to go into the area of new
    fentanyl analogues, because that is no longer profitable and it
    is more likely to be punished.
        So I think that that, again, kind of speaks to the question
    of whether or not the original Analogue Act itself was
    sufficient. It was not. And it is the reason that I believe
    that an extension, at least until we get some other format in
    place, is absolutely essential.
        Mrs. Rodgers. Thank you. Thank you. I appreciate that.
        Mr. Vargo, in your testimony you mentioned the work with
    the Sioux Tribe, and the importance of cultural competency. I
    represent several Tribes in eastern Washington. I wanted to ask
    if you would just speak about what you are doing to meet the
    needs of the Tribal communities who have consistently
    experienced larger increases in drug overdose mortality. I know
    that the Colville Confederated Tribe in my district is building
    a new treatment facility, and just--would you speak briefly as
    to what role Congress can play in aiding these efforts?
        Mr. Vargo. Yes, absolutely. Thank you, Representative.
        The Oglala Sioux Tribe is the closest Tribe to us, but we
    also have the Cheyenne River Sioux Tribe and the Rosebud Sioux
    Tribe that are very much part of our geographic area. They face
    extreme poverty, 90 percent unemployment, and they have been
    hit hardest by methamphetamine probably of any group, certainly
    in South Dakota, possibly in the Nation. And they are fighting,
    literally, for their lives in a lot of instances.
        I think that Congress's role here can be to enhance and
    support what they are trying to do, both on the reservations
    and off.
        Native Women's Health Care is an organization that provides
    healthcare to, primarily, pregnant women. We are partnering
    with them as diversion partners. So we send pregnant women with
    criminal offenses to them. If they successfully complete their
    medical program, we dismiss the criminal cases.
        We have also not only partnered with but invested in an
    organization that involves a Tribe called Native Healing. That
    is a residential drug treatment facility. Unfortunately,
    because of COVID, they are not going to be open until June of
    this year. They were supposed to be open April of last year.
    But it is 25 beds. To give you a frame of reference, though, we
    had over 1,200 arrests last year for methamphetamine, so 25
    beds is a great beginning, I believe it gives people hope, but
    it is hardly enough. And I think Congress needs to take a close
    look at those communities to whom the United States has a very
    particular and special relationship.
        Mrs. Rodgers. Thank you. Thank you very much. My time has
    expired. I yield back, thank you.
        Ms. Eshoo. The gentlewoman yields back. The Chair now
    recognizes the gentleman from California, Mr. Cardenas, for
    your 5 minutes of questions, and thank you.
        Mr. Cardenas. Thank you very much, Madam Chairwoman and
    Ranking Member, for us having this incredibly important hearing
    that affects every single person in America. And I would hope
    and pray that we can be an example for the world of how to
    handle drug addiction and how to make sure that we curtail this
    method in the United States that--we have been trying to
    incarcerate our way out of this, which never works. It has
    never worked anywhere on the planet, and it is something that
    we can do better here in the United States.
        And I do appreciate the testimony of every single person on
    this panel. And it appears that you all are, in some fashion,
    in agreement that we need to look at this as treating addiction
    rather than incarcerating our way out of this. So thank you so
    much for all of that.
        And I want to thank all of my colleagues for all the
    legislation that you have done in the many various positions
    that we have all been in. For example, when I was in the State
    legislature we passed the Schiff-Cardenas Act, which is the
    Juvenile Justice Crime Prevention Act, which provided $120
    million per year to local communities to fund prevention and
    intervention programs.
        Also, today in Congress, my colleague Representative
    Griffith and I led the At-Risk Youth Medicaid Protection Act,
    which was signed into law in the SUPPORT Act. This bill allowed
    a young person who is otherwise eligible for Medicaid to
    continue their healthcare coverage immediately following
    release from the juvenile justice system.
        And also we are considering many great bills today. One
    bill I am incredibly supportive of is my colleague
    Representative Tonko's Medicaid Reentry Act. This bill would
    extend Medicaid eligibility to incarcerated individuals 30 days
    prior to their release. Passing this bill is critical to
    improve access to substance use disorder treatment. Ninety-five
    percent of adults who are incarcerated in America will
    transition back into our communities, and data shows that
    individuals released from incarceration are 129 times more
    likely--that is 129 more likely--to die of a drug overdose
    during their first 2 weeks after release.
        Dr. Wilson and Ms. Richman, can you each please share your
    thoughts on this bill, as well as the role Medicaid and access
    to healthcare plays in addressing substance use and misuse in
    America?
        Ms. Richman. Thank you so much for that question. I am
    happy to answer it, and I am very grateful for the work that is
    being done and proposed in both of those bills.
        As a Federal public defender, many of my clients who had
    grown up in Baltimore did not receive the opportunity for
    either mental health or substance use, or sometimes even just
    core healthcare, until they entered the incarceration system,
    whether it be when they were a juvenile or when they were an
    adult. And what I saw in a lot of those clients' lives was a
    cycling in and out and a discontinuity in their treatment
    because of their movements in and out of incarceration and
    because of the lack of resources in the community. So I am very
    glad to see work in this crucial area.
        Mr. Cardenas. Thank you.
        Dr. Wilson. Thank you. I think this is a critical point,
    and an important piece of legislation.
        So we know that access to substance use treatment within
    the correctional system is a critical public health and ethical
    issue. And research shows that, if we start medications like
    methadone or buprenorphine for the treatment of opiate use
    disorder while individuals are incarcerated, that improves the
    likelihood that they will enter treatment and it reduces their
    risk for dying post-release. And so reinstating Medicaid
    coverage before reentry to the community is an important and
    essential way to keep people alive and facilitate their entry
    into evidence-based treatment.
        Mr. Cardenas. Thank you, yes, evidence-based treatment is
    something that, unfortunately, in my opinion is a little too
    new in the United States. We were stuck on just tough on crime
    for far, far too long. And unfortunately, this has affected
    almost every family. We have actually had Members of Congress
    admit to the fact that some of their family members have been
    subjected to addictions, et cetera, and everybody wants to see
    their loved ones treated with respect and dignity, not be
    treated like criminals because they have fallen prey to being
    addicted to some kind of substance. So I really appreciate the
    opportunity for us to bring this to light.
        And also, I would like to point out that this issue of
    addiction has been going on for hundreds and hundreds of years
    across the planet, and certainly has been going on since the
    founding of our country. So, hopefully, during this Congress we
    can actually make substantive changes and have the kind of
    programs funded so that we can treat everybody with dignity and
    respect.
        So my time has expired, and I yield back. Thank you.
        Ms. Eshoo. The gentleman's time--the gentleman yields back.
    I now would like to recognize the gentleman from Virginia, Mr.
    Griffith, for your 5 minutes.
        You need to----
        Mr. Griffith. Thank you, Madam Chair. Yes, ma'am.
        Thank you, Madam Chair. My mask fell down there, so you all
    can hear me.
        Mr. Vargo, as we have discussed, last year Congress
    extended the order temporarily classifying fentanyl analogues
    as schedule I substances. If Congress does not further extend
    that order, what will be the status of fentanyl analogues come
    May 7, 2021?
        [Pause.]
        Mr. Griffith. Mr. Vargo, can you hear me?
        Mr. Vargo. I knew I was going to do it at some point. Sorry
    to do it on your time.
        Mr. Griffith. That is all right.
        Mr. Vargo. Thank you for the question, Representative.
    Those analogues are at least arguably legal. And certainly, if
    Ms. Richman were defending one of those defendants, she would
    say that those analogues had not been scheduled and were not
    illegal or that her client did not know that those analogues
    were illegal and therefore cannot be prosecuted.
        And so it is certainly something that is possible to argue,
    that under the old Analogue Act we can try to stop that
    importation and we can try to bring criminal prosecution, but
    it would be much less likely to be successful.
        And I believe that just the before-and-after has shown us
    that it emboldens folks when they are not specifically
    scheduled.
        Mr. Griffith. Well, and I appreciate that. And I can assure
    you, having been a criminal defense attorney myself for a big
    part of my career, that is exactly what Ms. Richman would
    argue, and properly so. She has got a duty to defend her
    clients. Our job is to make sure the law doesn't create
    loopholes that folks who are trying to do bad things can drive
    a Mack truck through--which, by the way, are made in my
    district, some of them.
        Mr. Laredo, some folks have said keeping fentanyl analogues
    in schedule I inhibits scientific research. Yet DEA has
    approved nearly 800 applications to research schedule I-
    controlled substances, and half of those have been approved in
    just the last 5 years. Do you believe valuable research could
    continue if analogues remained in schedule I?
        Mr. Laredo. Thank you so much for the question. I do
    believe that research can continue. There would be much, much
    less of it if you folks don't provide some exemptions for
    researchers on the research field so that they can really do
    that work.
        There, you know----
        Mr. Griffith. So----
        Mr. Laredo [continuing]. For the time that I was at NIDA,
    it was almost a daily occurrence that I would get a phone call
    from a researcher in the field complaining about something
    about that.
        And even now, I would strongly recommend you reach out to
    the National Institute on Drug Abuse and the College on
    Problems of Drug Dependence, who have been compiling more
    information about this. I personally believe they should be
    compiling even more. But there are some documents that I think
    that they have now that should be shareable with the committee
    that would help you as you talk about this.
        Mr. Griffith. Well, and so, from listening to your
    comments, do you believe that my bill--and I think you do--but
    do you believe my bill, the Streamlining Research on Controlled
    Substances Act, would improve the landscape for conducting this
    research?
        Mr. Laredo. I thought you might be going in that direction.
        Mr. Griffith. Yes.
        Mr. Laredo. I do. I would like to study the bill just one
    more time to look at all the details, but overall I very much
    appreciate your approach.
        Mr. Griffith. Well, and as I have said before, I am a big
    believer in trying to do research. And sometimes we find--out
    of odd and strange things you find a cure or a treatment for
    something that you weren't even necessarily looking for. So I
    want to make sure we----
        Mr. Laredo. Exactly.
        Mr. Griffith [continuing]. The American medical science
    community, because they do amazing things, as we have seen this
    year with the coronavirus. And I want to make sure they have
    all the tools available. I want it to be done legally. I want
    it to be done in a way that--we are looking for a way to use
    these substances, if possible, for medicine. And I think that
    the bill does that.
        However, that being said, if you or any of your colleagues
    has a way that we might improve the bill, I am always happy to
    take a look at that as well.
        Mr. Laredo. Thank you. I would be glad to look at that
    again.
        Mr. Griffith. Thank you. And I invite anybody who wants to
    sponsor it, it is H.R. 2405. If they have concerns in this area
    like I do, please jump on the bill and cosponsor it on both
    sides of the aisle.
        And Director LaBelle said in her testimony, Mr. Vargo, that
    early data suggests a steep rise in overdose deaths during the
    pandemic. When do you expect that we will have a full picture
    on how the pandemic has affected illicit drug use?
        Mr. Vargo. Boy, that depends on when the pandemic ends,
    doesn't it, Representative?
        Part of that is going to be we have to basically get back
    to some kind of normal. We have to readjust for the fact that
    we probably spent a year to maybe 2 years not doing the things
    that we wanted to do. And then we have to guess what things
    might have been.
        I would say that your effect of the pandemic is going to be
    at least as long as the pandemic. So after it is over, it is
    going to take at least as long as that to determine what it
    meant.
        Mr. Griffith. All right. And then you don't think now is
    the time that we should be lightening up on the analogues, do
    you?
        Mr. Vargo. Absolutely not.
        Mr. Griffith. I thank you very much.
        And Madam Chair, I yield back.
        Ms. Eshoo. The gentleman yields back.
        Before I recognize Ms. Kuster, Ms. Richman, your name has
    come up several times. Do you want to just take 1 minute to--
    for any kind of response? I think that it would only be fair to
    do that, but for a limited amount of time, though. You have,
    like, a minute, a minute and a half at the most.
        Ms. Richman. I thank you for the opportunity. A couple
    points I would like to respond to. I think it is tempting to
    draw simple causal connections, but the fact is that the GAO
    report could not analyze a connection between classwide
    scheduling and the decrease in novel substances because of
    multiple confounding factors.
        With respect to the Analogue Act, I do understand there
    have been many complaints about it. But the Department only
    relied on it five times between 2015 and 2019 to prosecute
    fentanyl analogues. In all other cases they have been able to
    make good use of individually scheduled substances, which still
    comprised most substances that are charged.
        In addition, most of these cases are polydrug cases, the
    overwhelming majority, meaning that the presence of the
    fentanyl analogue doesn't make the difference about whether
    something is interdicted or not. It acts, in essence, as a
    sentencing enhancement that triggers mandatory minimums for any
    trace of a fentanyl analogue in a substance weighing 10
    paperclips. It is 5 years. And so that is the source of many of
    our concerns.
        Thank you for the opportunity.
        Ms. Eshoo. Thank you. The Chair now recognizes the
    gentlewoman from New Hampshire, Ms. Kuster.
        You need to unmute, Annie. I have got to hear you.
        Voice. I am sorry, it is Dr. Ruiz.
        Ms. Eshoo. Oh, you know what? I made a mistake, Annie. The
    next one up is a fellow Californian, Dr. Ruiz.
        You are recognized for 5 minutes.
        Mr. Ruiz. Thank you.
        Ms. Eshoo. I am sorry.
        Mr. Ruiz. Thank you. No worries. Thank you to all the
    witnesses for taking the time to be here today. We have heard
    in today's testimony about the increasing rates of substance
    use and overdoses in the United States over the last year.
        However, disparities in prevention, treatment, and recovery
    strategies continue to plague communities of color. A 2020
    issue brief by the Substance Abuse and Mental Health Service
    Administration lists a number of barriers to care for Hispanic
    individuals, including a lack of culturally responsive
    prevention and treatment, less access to medically assisted
    therapy such as buprenorphine and Naltrexone than White
    individuals, and a higher likelihood of relying on detox alone.
        A stigma and misperception within the Hispanic community,
    with only 5 percent of Hispanics with a substance use disorder
    thinking they need treatment, is also an issue. And one of the
    most commonly cited issues regarding prevention, treatment, and
    recovery strategies in the opioid crisis: language barriers for
    substance use disorders, materials, and treatments, and
    culturally relevant treatment from providers who understand the
    communities. In other words, diversifying the workforce, the
    provider workforce.
        So it is clear that we need to examine the policies that we
    consider through a health equity lens and make sure that they
    address prevention and treatment services in high-risk
    communities.
        Dr. Wilson, can you speak more about barriers to prevention
    and treatment services that drive inequalities in outcomes for
    minority communities?
        And in your experience, what are the most common barriers?
        Dr. Wilson. Thank you so much. I think we know that stigma
    related to addiction, to opioid use disorder and other
    substance use disorders exist, and stigma related to that, as
    well as racial bias, really intersect to create overlapping and
    compounding systems of disadvantage. So this contributes to
    lower quality of care and worse treatment outcomes for racial
    and ethnic minorities.
        We have another--a number of physicians who often, due to
    racial bias or structural racism, have inequitable prescribing
    practices and treatment. So we see that, for example, when we
    look at well-known disparities in pain management, for example,
    with lower rates of opioid prescribing or increased oversight
    for Black patients, and we see similar things when we look at
    disparities in the prescription of medications to treat opiate
    use disorder, with much lower rates being prescribed to
    patients with opiate use disorder in communities of color.
        And so, you know, I think, when we think of barriers, it is
    essential that we train our workforce, and we train our
    workforce to provide care to communities of color, and we also
    increase the number of providers of color treating those
    communities.
        Mr. Ruiz. So, Dr. Wilson, I practice medicine, emergency
    medicine, and I do a lot of public health work in underserved,
    medically undeserved areas. And would you say that the driving
    force of the decrease in access to prevention and treatment is
    more the systemic barriers that exist, the lack of providers,
    the lack of clinics, the lack of language, the lack of
    knowledge to empower, the lack of services focused in these
    underserved areas, versus the stigma portion?
        Dr. Wilson. I mean, I think all of those things come
    together, right? I think that patients in these communities,
    families within these communities, are desperate for help. I
    think historically our solutions for those communities have
    been mass incarceration and failed policies.
        And so I think what we really need to do is invest in
    widespread treatment, and I think that means partnering with
    community organizations where patients have had positive
    experiences, increasing culturally competent care, and
    increasing a workforce that is able to provide competent and
    equitable services to those communities.
        Mr. Ruiz. You know, one of the risk factors that have been
    cited in the social studies literature is the lack of social
    capital within communities, or the lack of communities that
    are--so do you think the promotora community health worker
    models by individuals in the communities----
        Dr. Wilson. Yes.
        Mr. Ruiz [continuing]. To keep people together should be
    expounded on in our country?
        Dr. Wilson. Absolutely. I think--I learned a lot of what I
    learned from addiction from amazing peer recovery specialists
    with lived experience in addiction. And I think that there is
    nothing that you can do to sort of help prescribe hope to
    patients other than showing them somebody who has lived through
    addiction and has come out on the other side. And so I think
    supporting and investing in those models is essential to
    increase that sort of treatment access in communities of color.
        Mr. Ruiz. Great. So with your 15 seconds remaining, what
    other recommendations do you have that Congress can do to help
    relieve these disparities?
        Dr. Wilson. I think one essential thing is to support
    training in addiction medicine and to support sort of building
    a more diverse addiction medicine workforce. And so that means
    sort of supporting physicians of color and building and
    supporting the pipeline and incentivizing physicians of color
    to go into addiction medicine.
        Mr. Ruiz. Thank you. I agree. I yield back my time.
        Ms. Eshoo. The gentleman yields back, and it is a pleasure
    to recognize the gentleman, the very patient gentleman, from
    Ohio. He has been with us, I think, since we began at 10:30
    this morning. I kept asking my staff, ``What about Mr. Latta?
    What about Mr. Latta?'' So here he is, and the gentleman has 5
    minutes for his questions.
        And it is great to see you, thank you.
        Mr. Latta. Well, let me thank the Chair, the gentlelady
    from California, for allowing me to waive on today, and I
    really appreciate it. And again, this is such an important
    subcommittee hearing that you are holding today, so I really
    appreciate it. And I also want to thank our witnesses for
    today.
        But, you know, over a year ago the lives of every American
    changed due to the coronavirus. And every day we are getting
    closer to ending the COVID-19 pandemic and returning to
    normalcy. However, long before COVID-19 dominated the
    spotlight, we were dealing with another crisis in this country,
    and that epidemic is still ongoing, which is the opioid crisis
    that has been significantly heightened due to lockdowns and
    immense stress on those already struggling with addiction.
        And before COVID-19 we were beginning to see some light at
    the end of the tunnel, you might say, that--we saw that the
    number of deaths were going down for the first time in decades.
    And however, you know, we already talked about today--is that
    we have seen in the last year, from August of 2020, that over
    88,000 people died from drug overdoses in this country, which
    is the largest ever in a 12-month period.
        So substance use disorder, SUD, and mental health have been
    overshadowed through the pandemic. And those suffering from SUD
    have shown that they are particularly susceptible for
    contracting COVID-19. So we must go back to work in defeating
    this deadly, ongoing crisis, and prepare to meet the needs in a
    post-pandemic world.
        And I have introduced several bills that would help curb
    the opioid pandemic, increase telehealth services, and assist
    those struggling with mental health. One bill that will
    immediately assist in stopping the illegal distribution of
    drugs is H.R. 1910, which is the Fight Fentanyl Act that I
    introduced with my colleague from Ohio, Mr. Chabot.
        In addition, my fellow Ohioan, Senator Rob Portman, and
    Senator Joe Manchin also introduced a Senate companion.
        In February of 2018 the DEA issued a temporary scheduling
    order to schedule fentanyl-related substances to allow our law
    enforcement to crack down on criminals flooding our
    neighborhoods and communities with this deadly drug. However,
    the order is set to expire on May the 6th, 2021. And so the
    Fight Fentanyl Act will simply codify the DEA's precedent to
    approve a schedule fentanyl-related--currently scheduled
    fentanyl-related substances as a schedule I drug.
        So, again, I want to thank our witnesses for being here
    today and, if I could, ask my first question to Dr. Westlake.
        In your written testimony you discussed how the goal of
    fentanyl class scheduling isn't to lock up low-level drug
    users, but to stop the development of deadly fentanyl poisons
    at their origin. Do you believe that the permanent scheduling
    of fentanyl as a schedule I substance, as my bill the Fight
    Fentanyl Act accomplishes, would--will help lower overdose
    death rates and help stop the influx of the illicit fentanyl
    into our communities?
        Dr. Westlake. Thank you, Congressman Latta. Yes,
    absolutely. So I think, to be clear, it will definitely
    decrease the existence and availability of newly created
    fentanyl-related substances. That has already happened. There
    has been a 90 percent decrease coming over from China that--the
    fentanyl-related substances that are new are not being seen in
    overdose deaths. And so that is definitely a part of it.
        So I think it is a huge piece, and I think that, you know,
    the language is very surgically targeted. If you look at my
    testimony, the written testimony, you can see that it is only
    very specific modifications to the molecule that have already
    been proven to have bioactive structure activity chemical
    relationships through the 60 years of research into the class.
    And so the language in your bill exactly, you know, is the
    perfect language to stop the creation of those likely bioactive
    substances.
        So, yes, I think it is a necessary--and from an emergency
    medicine perspective, you know, I am glad that I don't have to
    resuscitate people that are dead from a fentanyl-related
    substance. Unfortunately, we are seeing other, you know,
    illicit fentanyls coming through, and that is a whole
    different--there is only so much you can do at a time, and that
    is one thing we can do.
        Mr. Latta. Great. Well, let me ask--you know, as I
    mentioned, we have seen the largest overdose in our history in
    the last year, with 88,000 deaths. You know, what do you
    believe is the best way to address the crisis as we move
    forward, you know, while also addressing the needs of those who
    are suffering out there?
        Dr. Westlake. Yes, I think it is a huge--the issue for me--
    so I looked at this, and I led the Prescription Opioid Reform
    Strategy in Wisconsin over the past 7 years, since we became
    aware of it.
        And so it is a really, really difficult issue. I mean,
    addiction goes back probably forever in human history. I don't
    think there is any time that we are ever going to get rid of
    addiction. I think that is, you know, like, you can't get rid
    of cancer, you are not--you know, it is a disease. What we have
    to do is, you know, we try to destigmatize it.
        I think the medication-assisted treatment part, and making
    it so that you can prescribe medication-assisted treatments--I
    am running out of--I think you are out of time--is really
    important and critical, because I can prescribe, as a
    physician, without any restrictions other than a DEA license, I
    can prescribe as much Oxycontin as I want, but I have to take 8
    hours to prescribe buprenorphine. And that makes--that has put
    a stigma on the prescribing of buprenorphine. And so that is
    something that is concrete that you guys can do that would make
    a big effect, just like it did in France, as was mentioned
    previously.
        Mr. Latta. Well, thank you very much. Yes, I appreciate the
    witnesses today.
        And Madam Chair, again, thank you very much for allowing me
    to waive on today. I appreciate it.
        Ms. Eshoo. Well, you are always, always welcome, Mr. Latta.
    You enhance our subcommittee any time you are with us.
        Mr. Latta. Thank you.
        Ms. Eshoo. We all feel that way about you.
        The Chair is pleased to recognize the gentlewoman from New
    Hampshire--I think I am correct this time--Ms. Kuster, for your
    5 minutes of questions.
        Ms. Kuster. Thank you so much, Madam Chairwoman. I
    apologize for my technical difficulties, but thanks to all the
    witnesses on the panel, and I appreciate your perspectives on
    the addiction epidemic in this country and your efforts to find
    solutions that will save lives and our communities.
        This is the reason that 7 years ago I founded the
    bipartisan Congressional Opioid Task Force and why this
    Congress we have now expanded it to the Addiction and Mental
    Health Task Force, to include this complex crisis that needs
    comprehensive solutions.
        It also is why I waited 6 years to join the Energy and
    Commerce Committee, and I am so delighted to be on the Health
    Subcommittee at this point. I want to commend you all for the
    incredible work that you do on substance use disorder and
    mental health, most recently working to include $4 billion in
    support for substance abuse and mental health services
    administration as part of our incredible American Rescue Plan.
        But that is not enough. We must do more to address the new
    realities of this epidemic defined by illicit synthetic opioids
    as well as ensure that our policies don't reinforce the
    mistakes of our past that disproportionately have impacted
    communities of color.
        So my legislation with Congresswoman Lisa Blunt Rochester,
    known as the STOP Fentanyl Act, is comprehensive in its public
    health approach to addressing fentanyl. And I want to take the
    time with all of you today to discuss some of those provisions.
        Ms. Richman, thank you for joining us. You stated the STOP
    Fentanyl Act takes a comprehensive health- and evidence-based
    response to fentanyl and fentanyl-related substances. Why do
    you think that this approach is necessary to addressing the
    addiction crisis in our country?
        Ms. Richman. Thank you so much for that question and the
    opportunity to comment on your legislation, Representative
    Kuster.
        I appreciate this putting sort of the work into finding
    what are the evidence-based science solutions that we can turn
    to. If you dive into the history of--the legislative history
    between--behind the draconian War on Drugs laws that were put
    on the books in the 1980s and 1990s, you will see that they
    were passed with the intent to incarcerate manufacturers,
    kingpins, to keep things from ever being brought into our
    country.
        And yet we are seeing substances that have been subject to
    harsh penalties for 30 years--methamphetamine is a case in
    point--proliferate new versions of it that are stronger. We are
    seeing new types of synthetic opioids, not fentanyl analogues,
    proliferate. U-47700 is beginning to see--beginning to be seen
    in more drugs.
        The truth is that most individuals who are incarcerated for
    drugs in our country are low-level dealers, are individuals who
    are minimally involved. And in the case of fentanyl analogues,
    many of them have not made a conscious choice to include that
    substance in whatever they are consuming or selling. So it is
    just acting as a way of bringing these harsh penalties onto
    communities of color that have been disparately impacted for
    far too long.
        Ms. Kuster. Well, thank you. And one provision of our STOP
    Fentanyl Act includes Good Samaritan protections to ensure that
    there are no impediments or fears and judiciary repercussions
    to assisting during an overdose, or reporting an overdose. Can
    you explain why these types of reforms are necessary to save
    lives?
        Ms. Richman. Gosh, I think that these are so very
    important, and I think that the stigmatization and punitive
    approach to drug use in our country really makes people afraid
    to reach out for help when people are in crisis.
        In particular, there is a 20-year mandatory minimum in the
    Federal system for giving or selling drugs to somebody that
    results in death. And we have heard of circumstances where
    people are in a sober house together, one user shares with the
    other one, that person begins to overdose. Their response to
    that may be inhibited by their fear of exposure to criminal
    penalty, and that harms public health.
        Ms. Kuster. Great.
        And Ms. Wilson, the STOP Fentanyl Act includes funding
    directed at community-based organizations that provide harm
    reduction services. Why are these services particularly
    critical for our fentanyl response policies?
        Dr. Wilson. Thank you so much. You know, I take care of a
    lot of patients who are at various points of interest in sort
    of stopping the use of substances, and it is important for us
    to offer sort of treatment and services to everyone, regardless
    of where they are. You know, it is--the harm reduction axiom is
    ``Meet people where they are, but don't leave them there.''
    These services help keep people alive, keep them engaged and
    linked to care, so that when they are ready they are able to
    actually access and get plugged into treatment.
        Ms. Kuster. Great. Well, my time is up. Thank you, Madam
    Chair, for including our bill, the STOP Fentanyl Act. Thank
    you. I yield back.
        Ms. Eshoo. The gentlewoman yields back. I want to--oh, we
    still have two Members, OK.
        The Chair recognizes the gentleman from Florida, Mr.
    Bilirakis, for your 5 minutes of questions.
        Mr. Bilirakis. Thank you, Madam Chair. I appreciate it.
    This question is for Dr. Westlake.
        Higher-dosed pills from improperly mixed batches known as
    hot spots that led to overdose and death in a given area were
    often the way the medical community and law enforcement learned
    that fentanyl or an analogue had been introduced into a local
    drug market, which in turn would beget reactive scheduling in
    States or, as you put it in your testimony, a lethal game of
    Whac-a-mole. This led to work to remove the incentive that
    these international drug traffickers had in modifying the drug
    molecule by targeting likely bioactive fentanyls as a class.
        Can you discuss how fentanyl class scheduling is critical
    not only for law enforcement but for patient and community
    health as well?
        And should this scheduling ban expire, is it realistic to
    expect an increase or even sharp increase in overall deaths?
        Dr. Westlake. Yes. Thank you for the question, Congressman.
        I think, you know, when you look back at what was happening
    with fentanyl-related substances before the scheduling language
    was in place in your State, in Florida alone, in 2016 to 2017
    there were 2,500 deaths from two different fentanyl-related
    substances. We happen to have the similar deaths from similar
    substances in Wisconsin. So we scheduled them, we were the
    first State to schedule them. We are not seeing those any more.
    NFLIS is not reporting those, as I have said before.
        So I think it will definitely decrease the deaths and
    availability of those particular fentanyl-related substances. I
    think there are a lot of other things that need to fall into
    place to start to eliminate deaths, you know, writ large.
        I think also that, again, the important thing to remember
    about the scheduling is that it is surgically specific to only
    target the likely bioactive fentanyl molecules. It is not all
    potential fentanyl modifications. There is one fentanyl
    molecule, benzylfentanyl, a fentanyl analogue, that was found
    to be nonbioactive, and they did not include that in
    rescheduling for fentanyl-related substances. And so it--there
    has never been a nonbioactive fentanyl-related substance found.
        Mr. Bilirakis. Thank you. This question is for Mr. Vargo.
        While patients were not criminals, some career criminals do
    pose as patients or, in some cases, are even providers
    themselves, as recently observed in my district, unfortunately.
    As you alluded to throughout your testimony, prevention is
    worth a pound of cure, and treatment can be more successful
    than incarceration.
        From your conversations with district attorneys across the
    Nation, what law enforcement gaps, if any, exist within the
    current prescription drug monitoring program to detect and
    track?
        So again, yes, again, to detect and track patterns of
    abuse. Can you answer that question for me, please?
        Mr. Vargo. Yes, certainly, Representative, thank you for
    the question.
        Mr. Bilirakis. Of course.
        Mr. Vargo. I would say that we have done a fairly good job
    over recent years of making sure that our data has improved,
    but there is very much still room to take another step.
        Twenty years ago in South Dakota, if I wanted to prosecute
    somebody for doctor shopping, that was almost impossible. I
    would have to go to every doctor that they might have talked
    to, and we didn't have a central clearinghouse. And so our
    ability to say that you were doctor shopping and getting
    multiple prescriptions for the same reason was very, very
    limited. We took care of that clearinghouse now, and that has
    been very effective in making sure that people are only getting
    the prescriptions that they should, and that doctors have all
    the information that they need in making sure they are not
    double-prescribing.
        But I would guarantee you that there are circumstances
    where diversion still takes place. And so the monitoring and
    the tracking that--I believe could still very much be improved.
        Mr. Bilirakis. Thank you. Given the current opioid crisis
    in our Nation, the fact that all opioids are controlled
    substances, and our efforts to curb and eliminate doctor-
    shopping, would you consider it to be a best practice for
    States to require patients to show ID when retrieving an opioid
    prescriptions, similar to purchasing alcohol, Sudafed, or even
    retrieving an MLB ticket from Will Call?
        What do you think about identification?
        Mr. Vargo. I would say that we want to make sure that the
    person receiving the prescription is the person for whom the
    prescription was made. And by whatever means that occurs,
    whether it is because it happens at the doctor's office, where
    the doctor would have direct knowledge, or whether it occurs at
    a linked pharmacy--again, where they would have direct
    knowledge, or whether there is an identification factor that
    guarantees it, that is very important.
        Mr. Bilirakis. Thank you so much.
        Madam Chair, my bill, H.R. 2355, the Opioid Prescription
    Verification Act, would encourage States to adopt systems that
    require pharmacists to check IDs to dispense opioids and
    require CDC to work collaboratively with other Federal agencies
    to provide guidance to pharmacists on ID verification while
    deferring to States on acceptable forms of identification,
    allowable immediate danger exemptions, of course, in addition
    to other State-specific needs that may need to be addressed. I
    encourage my colleagues to review this particular bill and
    consider joining my efforts by cosponsoring the bill.
        So I will yield back, Madam Chair. Thank you so very much.
        Mr. Bilirakis. You are very welcome for the extra 23
    seconds.
        The Chair now recognizes the gentlewoman from Delaware, Ms.
    Blunt Rochester, for your 5 minutes of questions.
        Ms. Blunt Rochester. Thank you, Madam Chair, and thank you
    to the witnesses for joining us for the second panel.
        It is clear our Nation's ongoing overdose crisis isn't
    limited to one community, one region, one race, or one
    socioeconomic class. Previous congressional efforts to reduce
    the number of fatal drug overdoses have helped us make
    progress. But as our chairwoman has said, it is far from
    enough. States like Delaware continue to be in the middle of a
    public health crisis due to the rise in synthetic opioids like
    fentanyl.
        We are anticipating a total of over 500 overdose deaths for
    2020, an all-time high for my State. That is why Congresswoman
    Kuster and I introduced the Support, Treatment, and Overdose
    Prevention of Fentanyl Act, STOP, a comprehensive package of
    public health policies to address the proliferation of
    synthetic opioids without the mainly punitive measures used in
    previous approaches to drug control.
        Dr. Wilson and Ms. Richman, how will a public health
    response to substance use disorder address some of the
    challenges you have seen throughout your careers? And we will
    start with Dr. Wilson.
        Dr. Wilson. Yes, thank you. I mean, I think it--as a
    physician, it is absolutely clear that addiction is a disease,
    and this is a huge public health crisis.
        We cannot schedule our way out of this epidemic, and we
    cannot incarcerate our way out of this epidemic. We absolutely
    need evidence-based and informed public health solutions. So
    expanding access to treatment, we need to get effective
    therapies to communities that need them. We need to partner
    with community organizations that are already embedded within
    communities to strengthen those communities and provide greater
    links from sort of our health care systems to sort of
    organizations already doing the work on the ground in local
    community settings.
        We need to keep people alive, which means we need to expand
    access to harm reduction services to prevent morbidity and
    mortality associated with opiate use, recognizing that not
    everybody is going to be ready to quit today but they may be
    tomorrow, and we have to keep them alive so that they can reach
    that point.
        Ms. Blunt Rochester. Thank you.
        Ms. Richman?
        Ms. Richman. Yes, thank you, Representative Blunt
    Rochester, I appreciate the opportunity to comment.
        I have also been very grateful for Mr. Vargo's response and
    remarks today about shifting the intervention point. And I
    think directing resources away from enforcement and towards
    public health gives the opportunity to bring those
    interventions earlier, and keep individuals from going down a
    path that will be very damaging.
        When I look at the lives of my clients, I see so many
    different intervention points that there could have been: with
    their mother, before she overdosed; when they were a child, to
    be placed in a setting where they would be given holistic,
    educational, medical substance abuse services; all the way into
    the criminal justice system.
        I will never forget working with my social workers and just
    spending hours on the phone for clients who came in suffering
    from substance use disorder to try to find them some sort of
    residential placement where they could go so that the court
    wouldn't send them to jail. A lot of my clients did not have a
    home to go to. They were struggling, and it would be incredibly
    difficult to find that place. And then you just cross your
    fingers and hope it worked.
        Ms. Blunt Rochester. Well, I thank you for sharing all of
    that.
        Included in our STOP Fentanyl Act is dedicated funding and
    support for overdose prevention and treatment programs,
    including grants for harm reduction providers and improving our
    understanding of evidence-based overdose interventions.
        Dr. Wilson, I think you also may have talked about harm
    reduction and the benefits of it. Can you tell us what
    scientific evidence there is that shows that there is a benefit
    for harm reduction efforts?
        Dr. Wilson. Absolutely, I think the evidence is really
    clear that programs, for example, that distribute naloxone
    are--there is a dose response, which is sort of one of the sort
    of strongest relationships in the medicine.
        So the more you integrate overdose prevention within
    communities, the greater the naloxone you distribute within
    communities, the lower the risk of having fatal overdoses, and
    your mortality rate will actually decrease. So there is great
    evidence showing that needle and syringe exchange programs, for
    example, reduce hepatitis C, reduce HIV, and infections related
    to injection drug use.
        And so, again, you know, I think we have to think broadly
    about this. Our goal is not just to reduce overdose, it is also
    to reduce sort of infectious complications, like infective
    endocarditis, associated with injection drug use. You know, we
    have to keep people alive so that we can get them access to
    treatment and harm reduction services. There is really a strong
    evidence base that these things are effective at doing that.
        Ms. Blunt Rochester. Thank you. The STOP Fentanyl Act is
    the long-term solution that our Nation needs to respond to the
    overdose epidemic. And I look forward to working with the
    committee to advance this critical legislation.
        Thank you, Madam Chairwoman, and I yield back.
        Ms. Eshoo. The gentlewoman yields back. The Chair now
    recognizes the gentlewoman from Minnesota, Ms. Craig, for your
    5 minutes of questions.
        Ms. Craig. Well, thank you so much, Madam Chair, and thank
    you to the panelists here today, the witnesses, for your
    incredible expert opinion that helps guide our policymaking.
        Mr. Vargo, you said something in your testimony that I
    would like to highlight. You wrote that, ``Just as we cannot
    incarcerate our way out of an epidemic, neither can we ignore
    it and expect it to go away.'' I completely agree with you, Mr.
    Vargo. And incarceration is not the answer to our current
    substance use epidemic. I would argue that we need additional
    public health support.
        I am proud to represent Minnesota's 2nd congressional
    district, where our county and local law enforcement partners
    have launched programs that focus on intervention, rather than
    incarceration for nonviolent offenders struggling with
    addiction.
        The Shakopee Police Department offers a scholarship program
    to cover the cost of drug or alcohol treatment funded by drug
    and alcohol forfeiture cases. Scott County's drug court
    provides supervision and treatment, an effective alternative to
    incarceration that saves taxpayer dollars and directs
    participants to long-term recovery.
        Mr. Vargo, starting with you, thank you again for your
    testimony here today. As you all know, one of our great
    colleagues, Representative Annie Kuster, put forward H.R. 2366,
    the Support, Treatment, and Overdose Prevention of Fentanyl
    Act. One provision requires HHS to report on how SAMHSA can
    provide and support health services to underserved individuals,
    taking into account drug courts.
        Can you talk a little bit more about how drug courts work,
    and the overall impact they may have in combating drug use and
    abuse, from your experience?
        Mr. Vargo. Thank you, Representative Craig, I would be
    happy to. Drug courts are near and dear to my heart.
        I am an old prosecutor, and I started in Miami in 1988,
    when Ms. Reno was the State attorney down there. And in the
    fall of 1988 into the spring of 1989 she began the Nation's
    first drug court. And so that has always been something that
    has--I have paid attention to. You could not find a county in
    America that doesn't have some access to one of these what we
    call specialty courts.
        The weakness of specialty courts, drug courts, DUI courts,
    even mental health courts, is that they tend to be aimed at
    those who are in the last steps before a penitentiary sentence.
    So they are wonderful. They do divert people from the
    penitentiary. They do not divert people from conviction, and
    they do not divert people at the beginning of their criminal
    justice involvement. That is why we believe that diversion,
    which we unabashedly stole from Manhattan and the Bronx, are
    answers that need to be more widely incorporated with
    prosecutors' offices from here on out.
        So I really am thrilled to hear about what is going on in
    Minnesota. I know some of your wonderful prosecutors--Mr.
    Freeman, Mr. Orput--are good friends of mine, and I am glad to
    hear what they are doing.
        I will tell you that I would love to see in the STOP
    legislation--the numbers are sometimes daunting. When you talk
    about HHS making reports on SAMHSA, we are in the process of
    looking for a grant or a diversion opportunity to test out the
    medical-assisted treatment model for methamphetamine. When
    working with our partners here who already provide opioid MAT
    treatment, they inform me that for half a million dollars a
    year I could probably treat 25 people. In a small county that
    is a daunting number, even on a grant funding.
        And so I am thrilled to hear that we are going to be
    documenting just what happens, because ultimately that 25
    people, that is still cheaper than putting them in the
    penitentiary. So in the end, if we can get that to work, that
    is great. But I do know that it is daunting and that the SAMHSA
    numbers are going to be stretched very thin. And so that is
    part of the hope that I would send to you, which is that you
    would treat this as even more important than the other
    infrastructure projects that you are presently considering.
    Human capital has to be our first goal of infrastructure.
        Ms. Craig. Thank you so much for that thoughtful answer.
        And with that, Madam Chair, I will yield back.
        Ms. Eshoo. The gentlewoman yields back. The Chair now
    recognizes the gentlewoman from Washington State, Dr. Schrier,
    for your 5 minutes of questions.
        Ms. Schrier. Thank you, Madam Chair, and thank you to all
    of our witnesses today for talking in such frank terms about
    how to take away stigma and address the real issues at hand,
    which are, you know, drug addiction and treatment and finding
    the right time, and mitigating mortality. I very much
    appreciate that focus on how to care for our families and our
    communities. I want to turn to Dr. Wilson for my question.
        Doctor, I very much appreciate your candor about how
    physicians in general do not receive sufficient education on
    how to recognize and treat substance abuse disorders. My State
    of Washington has been a leader in working to integrate
    behavioral health into primary care and utilize care
    coordination so people with complex conditions, whether that is
    diabetes and depression, or co-addiction to opioids and
    methamphetamines, can get the care that they need. And yet,
    personally, as a pediatrician, the extent to which I personally
    treated substance use disorder was screening for it and then,
    if I found it, ensuring immediate safety and then referring out
    to specialists.
        And so I was wondering, you know, from a pediatrician's
    perspective, could you just talk about what it looks like to
    treat a patient with substance abuse disorder in the primary
    care setting?
        Dr. Wilson. Absolutely.
        Ms. Schrier. Thanks.
        Dr. Wilson. You know, I often think of addiction as a
    pediatrics disease that we often fail to recognize and treat
    during childhood, which leads to worse outcomes later in life.
    The vast majority of adults who use substances have actually
    started using those substances during their adolescence. And so
    this is a huge missed opportunity to really shift the life
    trajectory of a generation of adolescents and young adults. So
    I think it is essential that we do a much better job, as a
    profession, of recognizing substance use in young people.
        As a pediatrician and adolescent medicine provider, I think
    I am the sort of perfect person to recognize substance use in
    my patients. You know, pediatricians have the ability to build
    deep relationships with patients and their families over time.
    We provide lots of anticipatory guidance and education about
    what to expect as they grow up about puberty, about all sorts
    of things that we know are going to impact the lives of our
    patients. And we know that substance use is a huge potential
    area that would have serious impact on their future. And so I
    think it is natural for us to be the ones to sort of have those
    kind of preventive conversations and start the conversations
    with patients.
        We also see patients regularly for well child visits, and
    that is a perfect opportunity to screen patients as we are
    doing a lot of preventive healthcare.
        And then to sort of offer treatment in the setting, it
    helps sort of remove some of the stigma that both patients and
    their families might have about the disease of addiction,
    right? So I don't say, ``You have an addiction, you have to go
    someplace else.'' I say, ``You have a disease, just like you
    have asthma. And as your doctor, I am going to treat you.'' And
    there is something that is so powerful about sort of flipping
    that narrative for parents. There is nothing shameful about
    dealing with addiction. It is a disease, and we have effective
    treatments, and our job as physicians and pediatricians are to
    get those effective therapies to children and their parents.
        Ms. Schrier. So I really appreciate that perspective. And I
    think it is really nice to destigmatize it like that. I guess--
    here is my next question.
        I am in a generation that did not receive this kind of
    training in medical school or residency. And I understand that,
    you know, that the X-waiver may not be ideal. But then again,
    less than, I think, 1 percent of pediatricians have ever even
    applied for the X-waiver so aren't in a situation to do this
    testing.
        Can you talk about--if it is not--you know, what your
    thoughts are with the X-waiver and, if it is not that, how do
    you catch the more experienced doctors up to speed on treating
    substance use disorders?
        Dr. Wilson. I think----
        Ms. Eshoo. Excuse me, if you could, just summarize your
    answer, because the gentlewoman's time has expired.
        Ms. Schrier. Oh, I missed that.
        Ms. Eshoo. Oh, it hasn't. I am sorry, I am sorry. You have
    37 seconds. I am sorry.
        Dr. Wilson. I think we have to both integrate for sort of
    our learners into health professional education and medical
    residency programs, better education in addiction.
        And I think the X-waiver training is sort of an additional
    regulatory hurdle. I think we should eliminate the X-waiver
    training but integrate basic tenants of addiction medicine as
    sort of linked to, for example, DEA licensure. So as you sort
    of obtain your DEA license, you have to complete a certain
    amount of hours related to--basics related to addiction and
    buprenorphine prescribing, so all prescribers who are able to
    prescribe controlled substances are actually also able to
    recognize, treat, or refer to treat patients with addiction.
        Ms. Schrier. Great, thank you very much.
        Ms. Eshoo. The gentlewoman's time has expired, and excuse
    me for interrupting.
        The Chair now recognizes the gentlewoman from
    Massachusetts, who has been with us all day, and I think that
    is the quality of the hearing, right?
        Mrs. Trahan. Absolutely.
        Ms. Eshoo. Yes. Congresswoman Trahan, you are recognized
    for your 5 minutes, and thank you. You are a wonderful addition
    to our subcommittee.
        Mrs. Trahan. Well, I so appreciate that, Madam Chair, and I
    really do appreciate you convening us on this important issue
    and prioritizing it. Your leadership on substance use disorder
    is unparalleled. And I want to thank all the witnesses today. I
    know it has been a long day, but your contribution to our
    policymaking is so important.
        So in 2016 Max Baker was 23 years old when he died of an
    overdose after suffering from heroin addiction. Prior to his
    passing, Max's father, Dr. James Baker, a hospice care
    physician who works in my district, he sought help for his son
    through his own primary care doctor. But the answer Dr. Baker
    received was not at all encouraging: ``I hope he finds the help
    he needs.'' And this particular primary care doctor didn't have
    the working knowledge to treat Max's addiction or even the
    tools to refer him to someone who could.
        And that isn't a criticism. You know, it is a description
    of an all-too-common problem, as Dr. Schrier just mentioned. In
    fact, even over Dr. Baker's 35 years of practicing medicine, he
    hadn't learned how to treat opioid use disorder, not in his
    coursework at Johns Hopkins or Harvard, not in his medical
    school residency, and not in his public health education.
        So, Dr. Wilson, I am going to stay with you. Why should all
    medical professionals know how to identify and treat SUD?
        And what would you say to your medical colleagues across
    different medical specialties if they questioned why requiring
    education on treating patients with SUD is important to
    improving addiction treatment for all Americans?
        Dr. Wilson. Yes, thank you so much. You know, I think the
    sort of key takeaway point is there should be no wrong door for
    a patient who is seeking help, right?
        And so I think that we historically have had separation--
    have separated addiction treatment from medical treatment. And
    so historically, providers, physicians have not learned about
    addiction medicine as part of routine sort of education or
    curriculum offered in medical school or as part of their
    residency training.
        And so, you know, I would call this out as a failure of our
    profession. And I think part of the treatment gap that we are
    seeing right now is because we haven't recognized that, you
    know, addiction and addiction medicine is part of the care that
    we need to offer all of our patients, right?
        And so you may not provide sort of really in-depth medical
    sort of addiction medicine when you see patients, but you
    should be able to screen, to diagnose, to recognize that a
    patient is struggling with addiction and to know how to refer
    them to treatment, and what treatments exist.
        You know, I take care of patients in the hospital who often
    are admitted with--for many things that have nothing to do with
    their addiction. And that is an opportunity for us to see them,
    offer treatment, and sort of really alter the course of their
    lives.
        Mrs. Trahan. Sure. So let's imagine that the X-waiver
    requirement were eliminated, and so a barrier to treating
    patients with buprenorphine, for example, was no longer an
    issue. That is a powerful drug which many prescribers may not
    be familiar with. And it strikes me that under that scenario it
    would be even more important for our prescribers to understand
    how to use buprenorphine to properly treat SUD.
        So would standardized education on treating addiction lead
    to better treatment for those suffering with SUD, especially if
    some treatment barriers are soon eliminated?
        Dr. Wilson. Yes, so I actually think that we often--and, in
    part, I think this is related to stigma around addiction--we
    prescribe many things which are far more dangerous for patients
    like morphine, like oxycodone, like the medications that
    started this crisis to begin with, that do not have the
    regulatory hurdles like prescribing buprenorphine. It should
    not be easier for us to prescribe pain medicine than it is for
    us to prescribe buprenorphine to treat someone with an opiate
    use disorder.
        So I think part of that is helping providers recognize it
    is actually not that challenging. This is something you can do,
    you are empowered to do it, and with sort of a short sort of
    kind of educational module, an hour or two focused on the
    medication of buprenorphine and how you start it, all providers
    will, I think, realize that they too can recognize and treat
    patients with opiate use disorders.
        Mrs. Trahan. And that is a huge part for us, eliminating
    the stigma.
        I mean, look, had standardized education been the protocol
    a few years ago, perhaps Max Baker would have received the
    early intervention and the support that he needed. And parents
    like--patients like him show up in medical offices across the
    country, and the medical community, frankly, needs to be ready
    to spot problems of this sort, whatever their specialty.
        I mean, this is, after all, a national crisis, and it is
    going to require all of us to do a bit more to keep patients
    healthy and safe, which is what the MATE Act aims to do.
        So I really appreciate your contribution to today's
    conversation, Dr. Wilson, and I yield back the remainder of my
    time.
        Ms. Eshoo. The gentlewoman yields back, and I think the
    final recognition of a wonderful Member is going to be our last
    one, and that is the gentlewoman from Texas, Mrs. Fletcher. Are
    you there?
        Mrs. Fletcher. Thank you----
        Ms. Eshoo. There you are.
        Mrs. Fletcher. Thank you so much, Chairwoman Eshoo. Yes,
    and thank you to all of our witnesses for testifying today
    about this critically important topic, and for being with us
    throughout the day. It really is important. And I want to touch
    on one thing that we haven't, to my knowledge, touched on in
    this panel and get insights from all of you.
        I have the privilege of representing a lot of medical
    professionals in my district in Houston, just outside the Texas
    Medical Center. And I have heard from a lot of the doctors and
    other medical professionals in my district that a lack of
    insurance coverage can significantly impact an individual's
    recovery.
        You know, for example, a person may be on medication-
    assisted treatment and doing very well, but they are laid off
    or get dropped from their partner's coverage. There are a lot
    of scenarios, unfortunately, that we have seen over the last
    year where people have lost their coverage, and then they can
    no longer afford their treatment and they relapse.
        So Medicaid is the largest payer of mental health and
    substance use disorder treatment in the country. Unfortunately,
    in States like mine that have not expanded Medicaid, you know,
    many people who are struggling with substance use disorders are
    unable to get the coverage they need.
        So I want to start with Dr. Wilson. In your testimony you
    discuss the many barriers that can exist to accessing addiction
    treatment. In your opinion, would Medicaid expansion help
    reduce barriers and expand access to critical substance abuse
    disorder treatment?
        Dr. Wilson. Absolutely. It is really a no-brainer. You
    know, I think it is cost-prohibitive for people to pay out of
    pocket for addiction treatment. And I see patients all the time
    who have been doing great, are in sustained recovery, doing
    well, taking medications, engaged in recovery services, and
    they lose insurance coverage through no fault of their own and
    then have withdrawal from the medications that have been
    helping them stay sober and abstinent from illicit opioids and
    really lose access to all the recovery support services that
    have helped them stay in long-term recovery.
        And that can be--we know that any return to use could be a
    potentially fatal return to use. And so this is really a
    conversation about how we keep people alive and keep them
    getting access to medications and treatment that can help save
    lives.
        Mrs. Fletcher. Thank you, Dr. Wilson, and I would love to
    just open that question up to anyone, especially since I am the
    last--last couple of minutes of the hearing, just to see if
    anyone else wants to weigh in on that question about how we can
    keep getting people access to critical services, or--really, if
    somebody else has something to say that we didn't get to and
    you want to use this minute, I would be glad to hear your
    thoughts as we wrap up.
        Mr. Vargo. If I might, Representative?
        Mrs. Fletcher. Go ahead.
        Mr. Vargo. Well, thank you very much for giving me the
    opportunity. I will tell you that it is not just the existence
    of or the lapse of insurance. It is whether they have it in the
    very first place.
        As I said, we have got a 90 percent unemployment rate on
    the Pine Ridge Indian Reservation. So that means that the ACA
    makes no inroads as far as insurance goes.
        And I will also, though, point out one other difficulty,
    which is the ability of Medicaid and Medicare to reimburse for
    off-label uses of proven drugs that would be of assistance. It
    makes it prohibitively expensive for those people to seek
    treatment, and for us, as governments, to then pay for that
    treatment, because we are essentially out of pocket. So even
    before you get to Medicaid expansion, the capacity--I would
    rather that a doctor like Dr. Wilson, who knows what she is
    doing and she makes a decision that this drug is necessary for
    a patient's care, even if it is off label, it strikes me that
    that should be reimbursed by Medicaid.
        Mrs. Fletcher. Thank you, Mr. Vargo, I appreciate that.
        And I think that, Mr. Laredo, you had your hand up.
        Mr. Laredo. Thank you so much. Just following on what Mr.
    Vargo just said, you have a nationwide, systemwide problem of
    complete lack of services compared to the need. So, whether
    there is insurance or not, whether there is Medicaid expansion
    or not, it is another example of needing an all-of-the-above
    approach and, unfortunately, a truly dramatic increase in
    funding across the board to pay for these services.
        The public health system, as we have seen throughout the
    COVID pandemic, is in deep, deep trouble. And that translates
    through the substance use and addiction treatment system. It
    is--frankly, calling it a ``system'' is a little bit of an
    overstatement. So anything at all--you don't always want to
    throw money at a problem. This is a problem that has for
    decades required significantly more funding than it has ever
    received.
        Mrs. Fletcher. Well, thank you so much for that, and I am
    at the end of my time here.
        So, Chairwoman Eshoo, thank you again for holding this
    incredibly informative hearing, and thank you to all of our
    witnesses for your testimony here today. I yield back.
        Ms. Eshoo. The gentlewoman yields back. I don't see any
    other hands for Members, whether they were part of the
    subcommittee or waiving on.
        I want to thank each one of you. You have really given
    superb testimony. What always makes it very interesting in a
    hearing is, you know, the two sides of an issue from two
    professionals. And, you know, none of these issues are--well, I
    think the issue of, you know, the whole--the schedule I issue,
    and that we are going to have to sort out, it is an important
    one, but I can't give you an answer right now of where I am on
    it, because people have made excellent points about it. And
    that is the point of a hearing, is that we get the expert
    testimony. No one can say to any one of you that you don't know
    what you are talking about. You bring decades of professional
    experience to the Congress of the United States.
        And we are not only very deeply grateful to you, we are
    proud of you. When I listen to all the professionals I always
    think to myself, what a country we have, what a country we
    have, individuals that are so committed, so committed to the
    public health system, to research, to the criminal justice
    system. I could go on and on. So you have the collective
    gratitude of our entire committee, and you have been highly
    instructive to us. You have been highly patient for us to take
    up your panel, and we are lastingly grateful to you.
        So thank you, thank you, thank you, and know that we will
    circle back with you with the questions that Members submit. If
    they didn't have the opportunity, they will submit questions,
    and I trust that you will answer them in a timely way.
        So keep doing your extraordinary work. Our country and this
    issue really need you. And hopefully, we will shape policies
    that are going to really put a--really address what--as I said
    earlier, this scourge in our country.
        I mean, it just has wiped out--wrecked lives, wrecked
    families, taken tolls on communities across the country. And it
    doesn't matter what ZIP code people live in. Not a surprise, in
    poorer areas it is even worse. So thank you again.
        Now, I have a request of my wonderful--our wonderful
    ranking member. I have 37 documents to enter into the record.
    They are all wonderful and important, and organizations
    weighing in. And I would like to request a--make a unanimous
    consent request to enter into the record the 37 documents that
    have been submitted to our subcommittee.
        Mr. Guthrie. OK, thanks, and before--I don't object, so I
    won't object. But I just want to say again, to echo what you
    said, to have our witnesses here today, to spend an entire day
    of your time--I know you got to listen to the morning session
    and then spend your entire afternoon with us is--I know your
    time is valuable, but it is helpful. It really is helpful,
    because a lot of us are really trying to sort this out, and not
    coming with preconceived views or optics or anything like that.
    We really want to come up with the right answer. And we
    appreciate your time.
        And I do not object to your unanimous consent request.
        [The information appears at the conclusion of the
    hearing.\1\]
    ---------------------------------------------------------------------------
        \1\ The GAO report has been retained in committee files and is
    available at https://docs.house.gov/meetings/IF/IF14/20210414/111439/
    HHRG-117-IF14-20210414-SD021.pdf.
    ---------------------------------------------------------------------------
        Ms. Eshoo. Well, thank you. Thank you very much. And I
    appreciate it. And yes, 5 hours and 10 minutes total.
        But I think it also--I think that, as you--before you turn
    off your laptops, I am very proud of our subcommittee and the
    Members on both sides of the aisle. You heard so many
    thoughtful, probing questions.
        So while, you know, Congress has always been kind of the--
    at the--well, let's just put it that way, a lot of fingers
    pointed at us, we are made fun of or mocked in different ways.
    Sometimes it is earned. But I think most of the time, frankly,
    it isn't. You saw and heard firsthand the deep concern of
    Members, the knowledge that they have about the subject matter,
    and they are reaching out with deep respect to each one of you
    to probe further and seek your professional advice. So I am
    very grateful, and I am very proud of our subcommittee. It is a
    very important one. And I know that Mr. Guthrie shares that
    view, as well.
        So God bless each one of you. I know you are going to keep
    serving our country well. You have served us so well today.
        And with that, I adjourn the Health Subcommittee hearing of
    today, April 14th, the birthday of my son.
        [Whereupon, at 3:43 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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