[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\]
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\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.
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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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