[Senate Hearing 117-404]
[From the U.S. Government Publishing Office]






                                                        S. Hrg. 117-404 

                     FIGHTING FENTANYL: THE FEDERAL 
                      RESPONSE TO A GROWING CRISIS 

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                                   ON

  EXAMINING FIGHTING FENTANYL, FOCUSING ON THE FEDERAL RESPONSE TO A 
                             GROWING CRISIS

                               __________

                             JULY 26, 2022

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]





        Available via the World Wide Web: http://www.govinfo.gov   
        
                             _________
                              
                 U.S. GOVERNMENT PUBLISHING OFFICE
                 
48-915 PDF               WASHINGTON : 2024 
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                    PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                     TOMMY TUBERVILLE, Alabama
                                     JERRY MORAN, Kansas

                     Evan T. Schatz, Staff Director
               David P. Cleary, Republican Staff Director
                  John Righter, Deputy Staff Director  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         TUESDAY, JULY 26, 2022

                                                                   Page

                           Committee Members

Murray, Hon. Patty, Chair, Committee on Health, Education, Labor, 
  and Pensions, Opening statement................................     1
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana, 
  Opening statement..............................................     4

                               Witnesses

Chester, Kemp, Senior Policy Advisor for Supply Reduction and 
  International Relations, Office of National Drug Control 
  Policy, The White House, Washington, DC........................     6
    Prepared statement...........................................     8
    Summary statement............................................    14
Delphin-Rittmon, Miriam, E., Ph.D., Assistant Secretary for 
  Mental Health and Substance Use, Substance Abuse and Mental 
  Health Services Administration, Rockville, MD..................    14
    Prepared statement...........................................    16
Johnson, Carole, Administrator, Health Resources and Services 
  Administration, Rockville, MD..................................    21
    Prepared statement...........................................    23
Jones, Christopher, Pharm.D, Dr.PH, MPH, Acting Director, 
  National Center for Injury Prevention and Control, United 
  States Centers for Disease Control and Prevention, Atlanta, GA.    28
    Prepared statement...........................................    30

                          ADDITIONAL MATERIAL

Burr, Hon. Richard:
    Statement for the Record.....................................    63

                         QUESTIONS AND ANSWERS

Response by Kemp Chester to questions of:
    Senator Baldwin..............................................    64
    Senator Rosen................................................    65
    Senator Burr.................................................    65
    Senator Collins..............................................    66
    Senator Murkowski............................................    66
    Senator Scott................................................    68
Response by Miriam E. Delphin-Rittmon, to questions of:
    Senator Baldwin..............................................    69
    Senator Lujan................................................    70
    Senator Burr.................................................    72
    Senator Cassidy..............................................    73
    Senator Collins..............................................    74
    Senator Murkowski............................................    74
    Senator Scott................................................    76
Response by Carole Johnson to questions of:
    Senator Rosen................................................    76
    Senator Lujan................................................    77
    Senator Burr.................................................    78
Response by Christopher Jones to questions of:
    Senator Casey................................................    78
    Senator Collins..............................................    81
    Senator Murkowski............................................    81

 
                     FIGHTING FENTANYL: THE FEDERAL 
                      RESPONSE TO A GROWING CRISIS 

                              ----------                              


                         Tuesday, July 26, 2022

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in room 
216, Hart Senate Office Building, Hon. Patty Murray, Chair of 
the Committee, presiding.

    Present: Senators Murray [presiding], Casey, Baldwin, 
Murphy, Kaine, Hassan, Lujan, Hickenlooper, Collins, Cassidy, 
Braun, Marshall, Scott, and Moran.

                  OPENING STATEMENT OF SENATOR MURRAY

    The Chair. Good morning. The Senate Health, Education, 
Labor, and Pensions Committee will please come to order. Today 
we are having a hearing on the fentanyl crisis that is 
devastating our communities. I will have an opening statement 
followed by Senator Cassidy. He will--and then we will 
introduce our witnesses.

    After they give their testimony, Senators will each have 5 
minutes for a round of questions. And again, while we are 
unable to have this hearing fully open to the public or media 
for in-person attendance, live video is available on the 
Committee website at help.senate.gov.

    If you are in need of accommodations including closed 
captioning, please reach out to the Committee or the Office of 
Congressional Accessibility Services. Last week, back in 
Washington State, King County declared fentanyl a public health 
crisis and it is painfully obvious why. This year King County 
alone has lost over 270 people to fentanyl overdoses. That is 
an increase of nearly 50 percent from last year.

    That is more than one fentanyl death every day, and that is 
just one county in my state, one corner of our Country, which 
lost over 100,000 people to drug overdoses last year. That is 
an all-time high. And that number doesn't just represent a grim 
record, it represents so many personal tragedies, so many 
families that are shattered by the loss of a loved one, 
parents, caregivers, and increasingly teenagers.

    Now, there is no question we had a mental health and 
substance use disorder crisis on our hands before the COVID 
pandemic. But there is also no doubt things have gotten so much 
worse due to the trauma of this pandemic and so much more 
deadly with the sharp rise of illicit fentanyl in recent years.

    That is because fentanyl is up to 50 times stronger than 
heroin and 100 times stronger than morphine. Two milligrams can 
be a lethal dose. From April 2020 to 2021, synthetic opioids, 
mostly illicit fentanyl, were responsible for nearly two-thirds 
of all overdose deaths. And the recent rise in fentanyl 
overdose deaths has also reflected the painful, systemic health 
inequities we still need to do so much to address.

    Black communities as well as American Indian and Alaskan 
Native communities have suffered a higher increase in overdose 
deaths than other demographics. There has also been a deeply 
alarming rise in young people dying from overdoses. In 2019, 
over 250 teens died from illicit fentanyl. Last year, we lost 
almost 900. Think about that. Fentanyl deaths for teenagers 
more than tripled in 2 years.

    My heart goes out to every family touched by this crisis, 
and I have heard from many of them, people who lost a loved one 
after a long, hard struggle with addiction and those who lost a 
loved one suddenly to a counterfeit pill laced with a lethal 
dose of fentanyl.

    Our communities are doing everything they can to fight 
this, but they need help from the Federal Government to stop 
these dangerous drugs at the source, cutoff supply lines, and 
importantly, get these kids and their families the help they 
need. And the way we do that is to support families on the 
ground through robust public health efforts and better access 
to mental health and substance use disorder care.

    When it comes to cutting off the supply of fentanyl, FDA 
has been working to crack down on counterfeit drugs being sold 
online. Something I want to see them continue making progress 
on to protect our youth. And the DEA is working to seize 
fentanyl laced pills before they can end up in our kids hands.

    I have been pressing President Biden on this the same way I 
pressed the Trump administration. And we are seizing more 
fentanyl laced pills than ever before, and I appreciate the 
hard work that is going into that.

    Our law enforcement and first responders on the ground are 
really working to rise to this challenge, to stop these deadly 
pills and save lives, and ensure people can get the care they 
need.

    But when I talk to police officers or fire chiefs and first 
responders back in Washington State, it is clear we have a lot 
more to do to build on the progress that we are making, cutoff 
the supply lines that produce these dangerous drugs, and 
prevent them from ever reaching our communities.

    Drug trafficking is a serious problem, and that is why 
Democrats continue to work with Republicans to provide 
significant funding for border security and drug interdiction.

    But let's get one thing clear, we need to be taking this 
seriously and having real conversations about how we address 
the national threat of fentanyl use and supply, not playing 
politics, not scapegoating, not fear mongering, not attacking 
refugees and immigrants with proposals that are based more on 
xenophobia than on what will actually work to keep people safe.

    That is not to say we cannot talk about accountability, 
especially for opioid manufacturers who fueled this crisis to 
line their pockets.

    There are enormous corporations that knew just how 
dangerous and addictive these products were and yet decided to 
ignore the risk for patients, market these pills aggressively, 
and flood our communities with opioids. We absolutely must hold 
these companies accountable for padding their profits at the 
expense of countless lives.

    Of course, stopping the supply of illicit fentanyl and 
holding companies accountable, which fueled the opioid crisis, 
is critical. But we really have to tackle this challenge from 
every angle possible. And with that in mind, we have a lot more 
work to do to help our communities get people the mental health 
and substance use disorder care they need.

    Right now, less than 10 percent of people who need 
substance use disorder treatment can get it, and care is even 
harder if you are Black, or Hispanic, or American Indian, or 
Alaskan Native.

    The painful reality is that most people who die by overdose 
didn't get any substance use disorder treatment before they 
passed away. That is unacceptable. We need to do better. A big 
part of the problem is our mental health and substance use 
disorder workforce has been woefully overstretched and 
understaffed.

    I said this before, but it is so important to understand if 
we are going to get our arms around this. Almost 130 million 
Americans live in areas with a mental health care provider 
shortage. Essentially, they don't even have one mental health 
care provider per thousand people--per 30,000 people.

    In Washington, our mental health care workforce is only 
able to meet 17 percent of our state's needs. If we are going 
to turn the tide in the fight against fentanyl, that is going 
to have to change. We cannot lose sight of the fact that a 
strong public health system and easy access to treatment for 
everyone are some of the most powerful tools in our arsenal.

    We need to make sure every community has a robust public 
health department with the data needed to track overdoses, stop 
spikes, and the ability to raise public awareness about rising 
threats like counterfeit drugs laced with fentanyl. And we need 
to support programs on the front lines in our communities that 
are focused on prevention, treatment, and recovery support.

    I have fought hard to invest in our communities to expand 
mental health and substance use disorder care through HRSA, 
which is helping build our mental health and substance use 
disorder workforce in our rural communities, through Federal 
grants, which have helped set up dozens of new treatment 
centers across our states, and in the American Rescue Plan, 
which included critical funds for this work.

    But to talk to anyone on the front lines of this for 2 
seconds and you will understand we have a lot more to do. I 
talked to the fire chief in Seattle who told me a few months 
ago they respond to four overdoses every day.

    I talked with a University of Washington researcher who 
told me how 80 percent of people who could benefit from 
services to keep them alive can't access them. Talked with a 
nurse in Everett who told Secretary Becerra about how there are 
just not enough beds to get people treatment.

    The mom who told him about how she lost her job, her house, 
and her child while she was struggling with fentanyl addiction. 
Talked to Jason Cockburn at the Second Chance Foundation in 
Everett, who is spoken about the challenge of trying to get 
kids the treatment they need, or the many people who 
desperately tried to help him find an open treatment bed for a 
15 year old earlier this year, calling contacts, posting to 
Facebook, no--all, to no avail.

    It is so clear that leaders like Jason, who are on the 
front lines of this crisis, need so much more from our Federal 
agencies and from this Congress. More when it comes to getting 
fentanyl off the streets and more when it comes to getting 
people the health care they need.

    Which is why I am as determined as ever to continue the 
progress Senator Burr and I are making on a bipartisan package 
on mental health and substance use disorder. We need to support 
the programs on the ground in our communities that are already 
doing lifesaving work to identify people who are at risk and 
prevent substance use disorders in the first place, to get 
people treatment, and to support people in recovery.

    We need new programs, especially when it comes to 
addressing the new challenges we are seeing with fentanyl and 
with heart breaking increases in overdoses among young people. 
So I am going to continue to press for us to advance as 
expansive a package as possible, as quickly as possible.

    I believe that we can do it because we have done it before. 
In 2016 and again in 2018, Democrats and Republicans worked 
together to pass some of the most comprehensive legislation to 
respond to the opioid crisis in our Country's history. That has 
made a big difference.

    That legislation has undoubtedly saved lives. But I have 
traveled to just about every part of Washington State to talk 
about this crisis. From Everett, to Seattle, to Longview, to 
the Tri-Cities, to Spokane, and more.

    The challenges that we are dealing with today are not the 
same challenges we faced in 2018. So now it is on all of us to 
build on the bipartisan progress we have made. And it is 
painfully clear our communities cannot wait.

    They need us to meet this moment with serious action and 
lifesaving support for families. With that, I will turn it over 
to Senator Cassidy for his opening remarks.

                  OPENING STATEMENT OF SENATOR CASSIDY

    Senator Cassidy. Thank you, Madam Chair. And I thank 
Ranking Member Burr who allows me to lead this meeting. As a 
physician, I took care of patients with addiction. But it 
doesn't take a physician taking care of those with addiction to 
know that we have a fentanyl crisis. Everyone here and everyone 
watching knows of someone who has died or who has suffered from 
addiction related to opioids.

    If you read of the young person who dies, the teenager or 
in college, most often it is related to a drug overdose. And 
you think about the tragedy of that child whose whole future 
was before she or he, and now it has ended, affecting not just 
their life, but all those generations that would come after 
them from that wonderful person. It is incumbent upon us to 
address this issue.

    Now the statistics. Fentanyl is killing over 200 Americans 
a day. In 2021, we saw the largest annual increase in opioid 
deaths in 50 years. In the 35 years between 1979 and 2016, 
600,000 Americans died to overdose and a 100,000 died last 
year.

    I will speak of my own state. Louisiana's drug overdose 
deaths hit a record high of 2,100 in the 12 months leading up 
to March of 2021. Overdose mortality increased statewide by 
over 56 percent through 2020 to 2021.

    New Orleans was up 51 percent in 2020, with 365 overdose 
deaths. Jefferson Parish up 69 percent. Saint Tammany up 35. 
And Saint Bernard up 64 percent. And we know the cause of this, 
it is fentanyl.

    Illegal fentanyl and fentanyl related substances are 
flooding into our market from our Southern border in 
unprecedented amounts, with the bulk of this ultimately 
originating from a handful of manufacturers in Wuhan, China.

    Fentanyl accounted for 64 percent of the 100,000 overdose 
deaths last year. Two out of every three people who die from 
opioids it is from fentanyl or fentanyl like drugs. Now, 
Congress has to continue to pass tools to fight this from 
multiple fronts.

    First, we need to make the classification of fentanyl 
analogs as Schedule 1 drugs permanent. Several of my colleagues 
and I introduced to Halt Lethal Traffic of Fentanyl Act last 
year to do just that. Second, we need to educate Americans just 
how deadly fentanyl is. Two milligrams is enough to kill 
someone.

    I was proud to join Senator Marshall and other doctors in 
the Congress to record a PSA informing Americans about the risk 
of fentanyl. Health experts and public officials need to 
continue such efforts.

    Third, the border. Last year, the DEA seized 20 million 
fake pills and 50,000 pounds of fentanyl, enough for 440 
million lethal doses. When I went to the border, I saw this big 
cage of illegal drugs. I said, how much do you think you are 
getting? They think, we probably think we are getting about a 
third of it.

    If we seize this much, that much more went through. We have 
to recognize that a policy at the border which has been 
feckless and ineffective as this Administration has had, not 
just allows people to come here who are not--who are illegal, 
illegal immigrants, it allows drugs to come across as well.

    We have got to control that border. If there is a message I 
wish the Administration to get, use your tools to control. 
Fourth, we need to combat the drug cartels' ability to finance 
the production and smuggling of illicit fentanyl into the 
United States. Selling synthetic opioids laced with fentanyl is 
a major source of revenue for cartels, drugs--excuse me, gangs, 
criminal organizations, and for organizations such as 
Hezbollah.

    They use a financial process, including one known as trade 
based money laundering, to disguise their activities and 
illegally move in and out of the country. It is the use of 
financial exchanges that look like legitimate trade to serve as 
cover for illicit flows of money. If we can stop the financing 
of the drug trade, we can stop the trade of drugs.

    Finally, we need to look at loopholes in our customs 
system. For example, cartels will ship Chinese made fentanyl 
into our Country by mail, claiming the contents of the packages 
worth less than $800, which is the threshold for paying 
tariffs. Because it is declared as less than $800, Customs and 
Border Protection does not inspect the package and it passes 
through. It is a glaring loophole in our customs system.

    I look forward to discussing these solutions and more in 
todays hearing. Congress failing to address this crisis 
threatens our national security and risks the safety of the 
individual who does not know that one pill laced with fentanyl 
can kill, which means that there will be one more obituary of 
an 18 year old child whose life is gone forever. With that, I 
yield.

    The Chair. Thank you, Senator Cassidy. I will now introduce 
today's witnesses. Mr. Kemp Chester is the Senior Policy 
Adviser for Supply Reduction and International Relations at the 
Office of National Drug Control Policy, ONDCP.

    Dr. Miriam Dephin-Rittmon is the Assistant Secretary for 
Mental Health and Substance Use and Head of the Substance Abuse 
and Mental Health Service Administration, known as SAMHSA. Ms. 
Carole Johnson is the Administrator of the Health Resources and 
Services Administrator, HRSA.

    Dr. Christopher Jones is Acting Director of the National 
Center for Injury Prevention and Control at Centers for Disease 
Control and Prevention. Thank you to all of you for joining us 
today for this really urgent crisis--discussion on this really 
urgent crisis.

    I really do appreciate all of your sharing your time and 
your expertise. We look forward to your testimony. And Mr. 
Chester, we will begin with you.

  STATEMENT OF KEMP CHESTER, SENIOR POLICY ADVISOR FOR SUPPLY 
REDUCTION AND INTERNATIONAL RELATIONS, OFFICE OF NATIONAL DRUG 
        CONTROL POLICY, THE WHITE HOUSE, WASHINGTON, DC

    Mr. Chester. Thank you, Chair Murray, Ranking Member 
Cassidy, and Members of the Committee. Thank you for inviting 
me to testify today on the dynamic, illicit drug environment we 
face in the United States and the Administration's approach to 
addressing it. Drug poisonings and overdoses claimed 108,809 
lives in 2021 alone, which represents in American life lost 
every 5 minutes around the clock.

    Behind these fatal overdoses or millions of individuals 
experiencing non-fatal overdoses that are overwhelming our 
first responders and taxing our health care system. And while 
these fatalities and non-fatal overdoses are the most visible 
manifestations of our crisis, along with them are tens of 
millions of Americans suffering from a substance use disorder.

    Underlying these heartbreaking numbers is the impact on our 
economic prosperity. The cost of this epidemic is estimated to 
be $1 trillion a year, and up to 26 percent of the loss in our 
labor force participation can be attributed to people suffering 
from addiction.

    The Administration is approaching this crisis with a keen 
sense of urgency and with action that is bold, far reaching, 
and innovative. The President's National Drug Control Strategy 
is an evidence based blueprint designed to save as many lives 
as possible in the near term, while building our capacity to 
deal with untreated addiction and the profit driven trafficking 
of illicit drugs in the long term.

    The Director of National Drug Control Policy has further 
identified four immediate priorities that cut across the 
strategy's goals to achieve these outcomes. First is to have 
naloxone, the opioid reversal medication, in the hands of 
everyone who needs it, especially now when three out of every 
four overdose deaths involve an opioid like fentanyl.

    Second is tackling the enduring issue of Americans with 
substance use disorder not getting the treatment they need. 
Fewer than 1 out of 10 people in the United States who need 
treatment are able to get it. We simply cannot accept that, and 
we are committed to ensuring universal access to medication for 
opioid use disorder by 2025.

    Third, we must disrupt and dismantle the transnational 
criminal organizations who produce and traffic illicit drugs 
like fentanyl, by commercially disrupting the entire global 
illicit business of drug production and trafficking, including 
its illicit financial networks, supply chains, and a holistic 
and coordinated fashion.

    Finally, we need to close our existing gaps in data 
collection and analysis we need to drive and evaluate drug 
policy decisions, especially for non-fatal overdoses, which are 
the most accurate predictors of a fatal overdose in the future. 
Taken together, this represents a new era of drug policy that 
is precisely what we need now to address an environment of drug 
trafficking and use that is more dynamic than at any time in 
history.

    This is the first time the Federal Government is embracing 
high impact harm reduction to reduce overdoses and deaths. 
Commercial disruption is a new approach that brings together 
our efforts in illicit finance, supply chain targeting, and 
international engagement to target drug traffickers, their 
operating capital, and their profits.

    This strategy is the first in which we focused on improving 
data to deliver lifesaving resources to the people who need it, 
particularly those who interact with the criminal justice 
system and those who are incarcerated. This is the first time 
we have emphasized adverse childhood experiences and social 
determinants of health as key elements of our prevention 
efforts.

    This is the first time we have called for making access to 
substance use disorder treatment universal, removing outdated 
barriers to prescribing medications for opioid use disorder, 
and providing workforce opportunities for people in recovery.

    In today's environment, dominated by opioids like illicit 
fentanyl, we must reduce overdose deaths, ensure people can get 
access to the help they need, and disrupt the flow of illicit 
drugs across our borders and into our communities.

    On behalf of Dr. Gupta and the men and women of the Office 
of National Drug Control Policy, I want to thank this Committee 
and your colleagues in Congress for your leadership on this 
critical issue.

    We look forward to working with you to address this complex 
national security, law enforcement, and public health challenge 
with the urgency that it so desperately demands. Thank you, and 
I look forward to your questions.

    [The prepared statement of Mr. Chester follows:]
                   prepared statement of kemp chester
    Chair Murray, Ranking Member Burr, and Members of the Committee, 
thank you for inviting me to testify today on the dynamic illicit drug 
trafficking and use environment we face in the United States, and the 
Administration's approach to addressing it with the urgency it demands.
                              Introduction
    Since 2015, provisional data shows that annual overdose deaths in 
America have more than doubled. \1\ Additionally, the COVID-19 pandemic 
has increased the strain on our health care system and amplified the 
existing difficulties in accessing treatment for substance use 
disorder, which has exacerbated an overdose epidemic that was already 
getting worse prior to the pandemic.
---------------------------------------------------------------------------
    \1\  Centers for Disease Control and Prevention, National Center 
for Health Statistics. Multiple Cause of Death 1999-2020 on CDC WONDER 
Online Data base, released in 2021. Available at http://wonder.cdc.gov/
mcd-icd10.html. Extracted by ONDCP on December 22, 2021.

    The Centers for Disease Control and Prevention (CDC) estimates that 
drug poisoning and overdoses claimed 108,809 lives in 2021 alone, which 
represents an American life lost every 5 minutes around the clock. 
These are our family members, co-workers, neighbors, and friends. Over 
the past two decades, nearly a million Americans have lost their lives 
to drug poisonings and overdoses, devastating their families, our 
communities, and our Nation as a whole. Beyond these fatal overdoses 
over the past two decades are millions of individuals experiencing 
nonfatal overdoses that are overwhelming our first responders and 
taxing our healthcare system. And while these fatalities and nonfatal 
overdoses are the most visible manifestation of our crisis, underneath 
them are tens of millions of Americans suffering from addiction to 
---------------------------------------------------------------------------
opioids.

    While this crisis has been accelerating at an unprecedented rate 
over the years, the impact on our economic prosperity goes even 
further. Research estimates the economic costs of this epidemic to be a 
staggering $1 trillion a year, \2\ and up to 26 percent of the loss in 
U.S. labor force participation can be attributed to people suffering 
from addiction. \3\
---------------------------------------------------------------------------
    \2\  Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug 
overdose death counts. National Center for Health Statistics. 2022.
    \3\  Federal Reserve Bank of Atlanta researcher Karen Kopecky, 
Jeremy Greenwood of the University of Pennsylvania and Nezih Guner of 
the Universitat Autonoma de Barcelona. National Bureau of Economic 
Research Working Paper. https://www.nber.org/system/files/working--
papers/w29932/w29932.pdf.

    This is a nonpartisan issue that touches everyone, regardless of 
where they live or how they vote, and it is why ending the opioid 
epidemic is a key part of President Biden's Unity Agenda for the 
Nation, which he announced during his State of the Union address. The 
strong support we see across our country, and across political parties, 
for comprehensive and meaningful solutions to the overdose crisis 
underscores the nonpartisan nature of this issue and the need for 
immediate action.
          The Administration's National Drug Control Strategy
    The Administration is approaching this crisis with a keen sense of 
urgency, prioritizing saving lives as our fundamental task. Our actions 
must be bold, far-reaching, and innovative while also being evidence-
based, compassionate, equitable, safe, and effective. The President's 
inaugural National Drug Control Strategy is an evidence-based blueprint 
designed to save lives immediately, build the infrastructure our Nation 
desperately needs to treat the enduring problem of addiction, and 
disrupt drug trafficking and the illicit profits that fuel it, 
enhancing public safety for us all. The implementation of President 
Biden's Strategy will save as many lives as possible in the near term 
while building our capacity to deal with untreated addiction and the 
global production of illicit drugs in a long-term and sustainable 
fashion.

    As the Office of National Drug Control Policy developed this 
Strategy, the Director focused on the two fundamental drivers of this 
epidemic: untreated addiction, and the profit-driven production and 
trafficking of illicit drugs.

    In the SUPPORT Act of 2018, Congress laid out key requirements for 
the President's National Drug Control Strategy that includes issuing a 
comprehensive, evidence-based plan to reduce both the supply of, and 
demand for, illicit drugs, and for illicit synthetic opioids more 
specifically.

    The Strategy does precisely this while outlining a bold and 
innovative approach to reduce overdoses that includes measures at both 
the strategic and program levels to hold government accountable under 
the requirements of the SUPPORT Act.

    The Director has identified four immediate priorities that cut 
across the Strategy's goals, which if advanced will help us save lives 
both in the short term while building our capacity to address this 
challenge in the long term:

    First, the most important action we can take right now is to have 
naloxone, the opioid overdose reversal medication, in the hands of all 
those who need it without fear or judgment--especially now when three 
out of every four overdose deaths involve opioids. \4\ Harm reduction 
interventions like fentanyl test strips, naloxone, and syringe services 
programs that enable us to work with people who use drugs to build 
trust, engagement, and, most importantly, keep them alive, are proven 
to work and enjoy broad bipartisan support.
---------------------------------------------------------------------------
    \4\  Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug 
overdose death counts. National Center for Health Statistics. 2022.

    Expanding access to naloxone is a simple and cost-effective tool 
supported by strong evidence: in addition to saving lives, every dollar 
we spend on naloxone provides $2,769 in benefits according to one cost-
benefit analysis. \5\
---------------------------------------------------------------------------
    \5\  Naumann et al. Drug Alcohol Depend 2019;204:107536.

    Second, the President's Strategy lays out actions to tackle a long-
standing issue: the majority of people with a substance use disorder 
are not getting the treatment they need. Fewer than one out of ten 
people in the United States who need treatment get it \6\ and we cannot 
accept that.
---------------------------------------------------------------------------
    \6\  Substance Abuse and Mental Health Services Administration 
(2021). Key substance use and mental health indicators in the United 
States: Results from the 2020 National Survey on Drug Use and Health 
Rockville, MD: Center for Behavioral Health Statistics and Quality.

    When people lack the coverage and support they need for treating 
and managing their substance use disorders they lose their jobs, their 
families, they disengage from their communities, and far too often, 
they lose their lives. Treatment saves lives, and everyone who needs 
treatment should be able to access it. Through the President's 
Strategy, we will ensure universal access to medications for opioid use 
---------------------------------------------------------------------------
disorder by 2025.

    Third, the Director believes we must disrupt and dismantle the 
Transnational Criminal Organizations (TCOs) who produce and traffic 
illicit drugs by targeting their operations, illicit financial 
networks, and supply chains in a comprehensive and sophisticated way.

    The drug production and trafficking environment we see today is 
vastly different than it was just a few years ago. The TCOs that 
sustain and perpetuate the multi-billion-dollar illicit drug business 
operate seamlessly across borders and cooperate with remarkable 
efficiency to obtain raw materials, move and launder their proceeds, 
and to ship their illicit products to the United States and 
destinations around the world. Therefore, we must commercially disrupt 
\7\ the global drug trafficking enterprise, first by raising a 
sophisticated awareness of this environment, especially among private 
sector entities, so we can focus our resources on the malign actors in 
a more precise way. Moreover, we must expand the number of tools we 
apply to include not only financial sanctions, but also a range of 
other actions to disrupt and degrade drug production and trafficking 
operations at best, or at the very least make it incredibly difficult 
and much more costly.
---------------------------------------------------------------------------
    \7\  The 21st century global economy depends upon the constant 
movement of money, ideas, people, and goods across international 
borders with incredible speed and efficiency. Drug producers and 
traffickers exploit this to sustain and enhance their illicit business: 
the provision of precursor chemicals, some of which are unregulated 
chemicals that can be shipped in plain sight; physically dislocated 
payments that include the movement of funds across borders; the 
internet-based sales of raw materials and finished drugs using both 
fiat and cryptocurrency; and the physical movement of chemicals and 
their finished products around the world. The vast majority of the 
physical and virtual terrain on which drug producers and traffickers 
operate such as the dark web, open social media platforms, eCommerce 
sites, express consignment shippers and freight forwarders, banks, 
cryptocurrency vendors, legitimate chemical suppliers, and pill press 
and die mold manufacturers, are private sector entities who likely have 
little to no idea they are a constituent part of an illicit business 
enterprise. We must commercially disrupt what has become a global 
illicit business enterprise that enjoys huge capital resources, routine 
collaboration with raw material suppliers across international borders, 
advanced technology to fund and conduct business, product innovation 
and strategies to expand markets, and in many cases centralized control 
and decision-making. Actions include: Raising a sophisticated awareness 
of this environment with government and commercial sector partners 
around the world, so we can sift out the unwitting from the 
deliberately malignant; increasing the visibility of the legal goods 
such as unregulated chemicals, high capacity pill presses, die molds, 
and pill press replacement parts, that can be diverted for illicit use; 
using financial tools such as sanctions to disrupt the flow of illicit 
proceeds to drug producers and traffickers, and deny them the operating 
capital they need to sustain their business; disrupt illicit drug 
production capacity by focusing on the chemical precursors used to make 
them; and expanding the tools we apply to the entire complex of drug 
production and trafficking, to disrupt drug production and trafficking 
or, at the very least, make it incredibly difficult and more costly. We 
must also apply those tools in a sophisticated and surgical manner, and 
make deliberate government-wide decisions about the long-term 
consequences of our short-term actions, better synchronizing the full 
range of tools to gain strategic results and avoid potentially negative 
downstream effects.

    It is also vitally important that we maintain close and cooperative 
relationships with other countries where these illicit drugs and their 
precursors are manufactured, and do so from a perspective of common and 
shared responsibility. While the people of the United States see the 
effects of global drug trafficking in the heartbreaking realities of 
fatal and non-fatal overdoses, shattered families, and broken 
communities, we must also bear in mind that many of the dollars used to 
purchase those drugs--in addition from seeking to profit from harmful 
and addictive psychoactive substances--often plays a role in 
destabilizing that country, corrupting its officials, and victimizing 
---------------------------------------------------------------------------
its most vulnerable citizens.

    Mexico has become the locus of illicit fentanyl production since 
late 2019 and remains the country of origin for the majority of heroin 
and methamphetamine found in the United States.

    In September 2021, the United States marked a new era in security 
cooperation with Mexico by establishing the U.S.-Mexico Bicentennial 
Framework for Security, Public Health, and Safe Communities. This 
comprehensive, long-term, and holistic approach to improve the safety 
and security of both nations has three overarching goals: Protecting 
Our People, Preventing Transborder Crime, and Pursuing the Criminal 
Networks who threaten both countries. \8\ Earlier this month, the 
Office of National Drug Control Policy and its partners from the 
Department of State traveled to Mexico, where the United States and 
Mexico formally committed to strengthening our work against the 
manufacture, trafficking, distribution, and consumption of illicit 
fentanyl and other synthetic drugs. Further, President Biden and 
Mexican President Lopez Obrador met recently and the two heads of state 
reemphasized the importance of our two nations working together to 
address these challenges.
---------------------------------------------------------------------------
    \8\  https://www.whitehouse.gov/briefing-room/statements-releases/
2021/10/08/fact-sheet-u-s-mexico-high-level-security-dialog/.

    The United States routinely engages with the People's Republic of 
China to address shipments of PRC-origin precursor chemicals bound for 
North America, as well as to cooperatively address the numerous money 
laundering and illicit finance facilitators with ties to Chinese 
---------------------------------------------------------------------------
criminal organizations that enable drug trafficking.

    In the past, the PRC government has been responsive to the United 
States' concerns about the shipment of fentanyl and its analogues 
directly to the United States, and PRC's actions in that regard have 
had a direct and positive impact. We must buildupon those actions, and 
addressing illicit drugs precursor chemicals and associated money 
laundering are areas where U.S. and PRC interests align. We look 
forward to continuing our cooperation with the PRC government in 
holding responsible those individuals, anywhere in the world, who 
engage in this criminal enterprise.

    India, another global producer and exporter of chemicals and 
pharmaceuticals, similarly suffers from the presence of criminal 
elements who traffic precursor chemicals for the manufacture of 
synthetic opioids and other drugs, as well as finished opioids such as 
tramadol and tapentadol. The United States has been working closely 
with India over the last several years to develop a long-term 
counternarcotics relationship, and earlier this month the Office of 
National Drug Control Policy, along with the Departments of State and 
Justice, headed the third, and first in-person, United States-India 
Counternarcotics Working Group (CNWG) in New Delhi. The United States 
made it clear it is in both countries' interest to establish and 
maintain a relationship based upon mutual respect, shared interests, 
and a common desire to partner as leaders on the global issue of 
illicit drug production, trafficking, and use. During 2 days of 
meetings both parties reached agreement on major issues to address 
together and adopted a written framework to guide their collective work 
going forward.

    The Director firmly believes we must bring the international 
community together to control fentanyl precursor chemicals. Earlier 
this year, in response to a request by the United States, the United 
Nations Commission on Narcotic Drugs (CND) voted to take international 
action and internationally control the acquisition, production, and 
export of three precursors used to illicitly manufacture illicit 
fentanyl and its analogues: 4-anilinopiperidine (4-AP), 1-(tert-butoxy 
carbonyl)-4-phenylaminopiperidine (boc-4-AP), and N-phenyl-N-
(piperidin-4-yl) propionamide (norfentanyl). The CND also voted to 
schedule brorphine and metonitazene, two synthetic opioids, under 
Schedule I of the 1961 Convention on Narcotic Drugs, and eutylone, a 
synthetic stimulant, under Schedule II of the 1971 Convention on 
Psychotropic Substances. This action obligates the signatories to these 
conventions to establish national laws to control these substances. At 
the same meeting, the CND also adopted a U.S.-sponsored resolution that 
calls for greater cooperation among member states to prevent the 
diversion of chemicals not subject to international control that are 
diverted to illicit drug production, including so-called designer 
precursor chemicals.

    President Biden's budget proposal includes substantial increased 
investments for border security and supply reduction approaches. The 
women and men who work every day to stop illicit drugs from coming into 
our country perform extraordinary work protecting our public safety and 
public health in challenging circumstances, and President Biden is 
committed to ensuring they have the tools and technology they need to 
get the job done.

    This National Drug Control Strategy directs agencies to uncover 
financial networks and obstruct and disrupt the illicit financial 
activities that fund the TCOs that produce and traffic illicit drugs 
into the United States by strengthening every available tool, seeking 
new ones that will provide tangible results, and better synchronizing 
our efforts across the Federal Government to commercially disrupt this 
global illicit enterprise.

    In support of this effort, this past December President Biden 
issued two Executive Orders that provide the executive branch enhanced 
architecture to better counter TCOs in this dynamic environment, and to 
increase our ability to negatively impact foreign persons involved in 
the global illicit drug trade from a financial perspective. When 
issuing those executive orders, the President declared that 
``international drug trafficking, including the illicit production, 
global sale, and widespread distribution of illegal drugs; the rise of 
extremely potent drugs such as fentanyl and other synthetic opioids; as 
well as the growing role of Internet-based drug sales, constitutes an 
unusual and extraordinary threat to the national security, foreign 
policy, and economy of the United States.'' \9\ These carefully chosen 
words not only speak to the high priority the President places upon 
this issue, but also open doors to new authorities and capabilities for 
the United States to address this threat in a comprehensive and 
sustainable fashion.
---------------------------------------------------------------------------
    \9\  https://www.whitehouse.gov/briefing-room/Presidential-actions/
2021/12/15/executive-order-on-imposing-sanctions-on-foreign-persons-
involved-in-the-global-illicit-drug-trade/.

    Additionally, law enforcement task forces such as Organized Crime 
Drug Enforcement Task Forces (OCDETF) and High Intensity Drug 
Trafficking Areas programs (HIDTAs) work diligently with the Nation's 
94 U.S. Attorney's Offices to disrupt and dismantle transnational 
organized crime by prosecuting those individuals responsible for 
manufacturing and distributing these deadly substances in our 
---------------------------------------------------------------------------
communities.

    Through this Strategy, the Director and ONDCP will continue to 
work, both unilaterally and with other nations, to make it more 
difficult and more costly, in every way, for drug trafficking 
organizations to continue their business. This work is critical because 
if it is easier to get illicit drugs in America than it is to get 
treatment, we will never bend the curve on overdoses.

    Finally, the Strategy ramps up our work on data and research at a 
time when the Federal Government faces important gaps in data 
collection and analysis related to drug policy.

    We know that a past non-fatal overdose is one of the most accurate 
predictors of whether someone will experience a fatal overdose in the 
future. \10\ However, we currently lack consistent and timely measures 
of non-fatal overdoses in all jurisdictions in the United States, and 
this constrains our ability to identify emerging trends and act before 
it is too late. Building on gains already made in the timeliness and 
accuracy of our data will greatly increase our ability to drive and 
evaluate policy decisions. With this Strategy, the Administration is 
working to develop a near real-time national estimate for non-fatal 
overdose occurrences, along with a system to rapidly surge substance 
use prevention and treatment resources to those communities 
experiencing the greatest burdens.
---------------------------------------------------------------------------
    \10\  Krawczyk N, Eisenberg M, Schneider KE, et al. Predictors of 
overdose death among high-risk emergency department patients with 
substance-related encounters: A data linkage cohort study. Annal of 
Emergency Medicine 2020;75(1):1-12.

    In addition to these four areas, the President's Strategy also 
directs Federal agencies to take actions to prevent youth substance 
use, support people in recovery, and advance racial equity in our drug 
policies across the board. The Strategy also expands the scope of our 
work to address many of the factors that affect substance use disorder 
including child poverty, employment, and economic opportunity, so 
people can reach their full potential.
                       A New Era for Drug Policy
    Taken together, these goals, priorities, and objectives usher in a 
new era of drug policy that is evidence-based comprehensive, holistic, 
and targeted at saving lives.

    This is the first time the Federal Government is embracing high-
impact harm reduction as a tool to reduce overdoses and overdose 
deaths, an effort that has broad bipartisan congressional support.

    Commercial disruption is a new approach that brings together our 
efforts in illicit finance, supply chain targeting, and international 
engagement as a comprehensive and sophisticated means to target TCOs, 
their operating capital, and their profits.

    This Strategy is the first in which we have delivered extensive 
chapters dedicated to data and criminal justice that will help us 
better understand our environment and deliver life-saving resources to 
people who interact with the criminal justice system, including 
evidence-based treatment for people who are incarcerated, so we can 
improve public health and public safety outcomes.

    This is the first time we have emphasized Adverse Childhood 
Experiences (ACEs) and the Social Determinants of Health (SDOH) as key 
elements of our prevention efforts.

    This is the first time we have called for making access to 
substance use disorder treatment universal.

    Finally, we are placing a new emphasis on getting naloxone to 
everyone who needs it, removing outdated barriers to prescribing 
medications for opioid use disorder, and providing workforce 
opportunities for people in recovery.

    This Strategy represents exactly what we need to do to reduce 
overdose deaths, ensure people can access the help they need, and 
disrupt the flow of illicit drugs across our borders and into our 
communities.
                               Action Now
    While we are taking action now to implement the President's 
inaugural Strategy, since the beginning of this Administration, our 
office has led a number of efforts designed to advance administration 
priorities and deal with America's opioid and overdose epidemic head 
on:

          CDC and SAMHSA established a $3 million partnership 
        to leverage CDC's National Harm Reduction Technical Assistance 
        Center to support implementation of effective, evidence-based 
        harm reduction programs, practices, and policies in diverse 
        settings and decrease health disparities.

          ONDCP announced the release of the Model Law 
        Enforcement and Other First Responders Deflection Act, a 
        resource for states that encourages the development and use of 
        deflection programs across the country. First responders, 
        including law enforcement, often do not have good options when 
        encountering people with substance use and mental health 
        disorders, and this Model Law deflects people with these 
        disorders away from traditional criminal justice programs when 
        appropriate and connects them to evidence-based treatment, harm 
        reduction, and recovery and prevention services, changing lives 
        and reducing a burden on first responders.

          SAMHSA announced the extension of the methadone take-
        home flexibilities for 1 year, effective upon the eventual 
        expiration of the COVID-19 Public Health Emergency. The 
        flexibility promotes individualized, recovery-oriented care by 
        allowing greater access for people who reside farther away from 
        an Opioid Treatment Program or who lack reliable 
        transportation, such as those in rural and tribal communities.

          CDC has provided $300M+ per year through Overdose 
        Data to Action to support 47 states, Washington, DC, two 
        territories and 16 high burden cities and counties in 
        collecting high quality, comprehensive, and timely data on 
        nonfatal and fatal overdoses and in using those data to inform 
        prevention and response efforts, such as ensuring people are 
        connected with the care they need, supporting health care 
        providers and systems with overdose response efforts, and 
        developing partnerships with public safety and first responders 
        to improve data sharing and response.

          CDC expanded its investment in Public Health Analysts 
        participating in the High Intensity Drug Trafficking Areas 
        (HIDTA) program's Overdose Response Strategy. This 
        collaboration is helping communities reduce fatal and non-fatal 
        drug overdoses by connecting public health and public safety 
        agencies, sharing information, and supporting evidence-based 
        interventions. CDC is funding public health analysts in all 50 
        states, the District of Columbia, the U.S. Virgin Islands, and 
        Puerto Rico.

          The Department of Justice's Office of Justice 
        Programs (OJP) has provided more than $110.7 million to reduce 
        recidivism and support adults and youth returning to their 
        communities after confinement. OJP also awarded more than $300 
        million to help address the needs of individuals with substance 
        use disorders, including treatment and recovery services.

          CDC and ONDCP invested in communities by expanding 
        our investment in the Combating Opioid Overdoses through 
        Community Level Intervention (COCLI) initiative to fund eight 
        new projects to implement innovative, evidence-based, and 
        scalable solutions--like the Merrimack Valley, Massachusetts 
        ``Wheels of Hope'' program for persons with substance use 
        disorder to receive rides to treatment appointments.

          Earlier this month ONDCP announced fiscal year 2022 
        Drug Free Communities (DFC) Continuation funds to 646 
        coalitions, representing an investment by the Biden-Harris 
        administration of approximately $81 million in youth substance 
        use prevention in communities across the country. Later this 
        summer, ONDCP anticipates awarding fiscal year 2022 DFC new 
        grant awards.

                               CONCLUSION
    There is no doubt that the environment of illicit drug production, 
trafficking, and use, particularly as it relates to synthetic opioids, 
presents a daunting challenge. However, as difficult as it may be, it 
is not insurmountable. The Biden-Harris administration is focused on 
meeting this complex national security, public safety, and public 
health challenge head on in a comprehensive and sophisticated way. This 
will not only reduce the number of drug deaths and save American lives 
in the short term, but also shape our approach to addressing the 
broader and more enduring challenge of illicit drug use and its 
consequences in the years to come.

    The Administration's leadership on this critical issue, the close 
collaboration among Federal departments and agencies, and the work the 
members of this Committee and your colleagues in Congress have done to 
keep this issue at the forefront of our national consciousness are 
changing the trajectory of the challenge we face.

    On behalf of Dr. Gupta and the men and women of the Office of 
National Drug Control policy, I would like to thank the subcommittee 
for your foresight and leadership on this critical issue, and on behalf 
of the Administration, ONDCP looks forward to continuing to work with 
you to reduce illicit drug availability, use, and the many harms they 
bring to American families and their communities.
                                 ______
                                 
                  [summary statement of kemp chester]
          The Centers for Disease Control and Prevention (CDC) 
        estimates that drug poisoning and overdoses claimed 108,809 
        lives in 2021, and research estimates the economic costs of 
        this epidemic to be $1 trillion a year. Up to 26 percent of the 
        loss in U.S. labor force participation can be attributed to 
        people suffering from addiction.

          The National Drug Control Strategy's approach is 
        saving lives now while prioritizing innovative, evidence-based, 
        compassionate, and equitable actions. The Strategy focuses on 
        the two fundamental drivers of this epidemic: untreated 
        addiction and the profit-driven production and trafficking of 
        illicit drugs.

          The Director identified four key priorities as 
        crucial components of the Strategy's goals:

                Y  Ensuring everyone can access naloxone. With 3 out of 
                4 overdose deaths involving opioids, access to this 
                overdose reversal medication will save lives 
                immediately.

                Y  Expanding access to substance use disorder treatment 
                and provide universal access to medication for opioid 
                use disorder by 2025.

                Y  Dismantling Transnational Criminal Organizations 
                (TCOs) by targeting their operations, illicit financial 
                networks, and supply chains.

                Y  Improving research and near-real time data, 
                particularly in tracking non-fatal overdoses, one of 
                the most accurate predictors of whether someone will 
                experience a fatal overdose in the future.

          We maintain close and cooperative relationships with 
        countries where these illicit drugs are produced and 
        trafficked, and do so from this principal of shared 
        responsibility.

                Y  The 2021 the U.S.-Mexico Bicentennial Framework for 
                Security, Public Health, and Safe Communities is 
                designed to improve the safety and security of both 
                nations.

                Y  The United States routinely engages with the 
                People's Republic of China to address the ever-
                increasing number of precursor chemical shipments 
                originating in China.

                Y  The United States is now working with India in a 
                long-term counternarcotics relationship to address the 
                shipment of precursor chemicals and drugs such as 
                tramadol and tapentadol.

          The Administration's leadership on this critical 
        issue, the close collaboration among Federal departments and 
        agencies, and the work the Members of this Committee and your 
        colleagues in Congress have done to keep this issue at the 
        forefront of our national consciousness are changing the 
        trajectory of the challenge we face.
                                 ______
                                 
    The Chair. Thank you.

    Dr. Delphin-Rittmon.

   STATEMENT OF MIRIAM E. DELPHIN-RITTMON, PH.D., ASSISTANT 
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE 
    AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD

    Ms. Delphin-Rittmon. Good morning and thank you, Chair 
Murray, Ranking Member Cassidy, and Members of the Committee 
for inviting me to testify during this hearing focused on 
fentanyl and its impact on the overdoses across the Nation.

    I am pleased to be here, along with my colleagues from the 
White House Office of Drug Control Policy, the Health Resources 
and Services Administration, and the Center for Disease Control 
and Prevention to discuss SAMHSA's efforts.

    The overdose crisis continues to be a challenge across the 
country. Synthetic opioids, like illicitly manufactured 
fentanyl, and the use of other substances, particularly 
stimulants such as cocaine and methamphetamines, have led to 
significant increases in overdose deaths.

    The COVID-19 pandemic exacerbated an already tragic 
situation, with drug overdose deaths reaching a historic high, 
devastating families and communities. Provisional data from CDC 
reported that more than 107,000 Americans died due to drug 
overdose in the 12 month period ending January 2022.

    Moreover, preliminary findings from SAMHSA's analysis of 
2021 data from the Drug Related Emergency Department visits 
show that fentanyl related emergency department visits rose 
throughout 2021. That is why addressing addiction and the 
overdose epidemic is one of the four pillars of the unity 
agenda the President outlined in the State of the Union 
address.

    Additionally, last year, Secretary Becerra released a 
comprehensive HHS overdose prevention strategy, which is 
designed to increase access to a full range of care and 
services for individuals who use substances that cause 
overdoses and their families. The strategy prioritizes four key 
areas, primary prevention, harm reduction, evidence based 
treatment, and recovery support.

    SAMHSA has several efforts underway across this continuum. 
For example, SAMHSA's First Responder Comprehensive Addiction 
Recovery Act Program trains and equips first responders and 
other volunteer organizations on how to respond to overdose 
related incidents, including how to administer overdose 
reversal medication, naloxone.

    During the program's recent project period, each state 
developed a strategic action plan for combating opioid misuse 
and deaths related to heroin and illicit fentanyl. This year, 
SAMHSA launched the first ever harm reduction grant program and 
issued $30 million in grant awards.

    This opportunity, authorized and funded by the American 
Rescue Plan Act, is increasing access to a range of community 
harm reduction services and supports harm reduction service 
providers as they work to help to prevent overdose deaths and 
reduce the health risks associated with drug use.

    We are increasing access to evidence based treatments to 
more Americans by allowing practitioners to treat more patients 
with buprenorphine through the revised buprenorphine practice 
guidelines. This policy has given over 17,000 more providers 
the ability to provide this lifesaving treatment.

    SAMHSA's programs like the Substance Abuse Prevention 
Treatment Block Grant and the State Opioid Response Grant 
Programs are critical resources for states to fight this 
epidemic. States can use these funds to purchase fentanyl test 
strips, which are disposable, single use tests to detect the 
presence of fentanyl in a substance.

    Finally, SAMHSA's Office of Recovery is promoting the 
involvement of people with lived experience throughout the 
agency and stakeholder activities and fostering relationships 
with internal and external organizations with mental health and 
addiction recovery field. On behalf of my colleagues at SAMHSA, 
I want to thank you for your interest and support of our 
programs and for supporting the Nation's behavioral health.

    I would be pleased to answer any questions and look forward 
to our discussion. Thank you.

    [The prepared statement of Ms. Delphin-Rittmon follows:]
            prepared statement of miriam e. delphin-rittmon
    Good morning. Thank you, Chair Murray, Ranking Member Burr, and 
Members of the Committee for inviting me to testify during this hearing 
focused on fentanyl and its impact on overdoses across the Nation.

    My name is Miriam Delphin-Rittmon, and I am the Assistant Secretary 
for Mental Health and Substance Use at the U.S. Department of Health 
and Human Services (HHS). In this role, I lead the Substance Abuse and 
Mental Health Services Administration, also known as SAMHSA. SAMHSA 
leads public health efforts to advance the behavioral health of the 
Nation and improve the lives of individuals living with mental and 
substance use disorders, as well as their families.

    I am pleased to be here, along with my colleagues from the White 
House Office of National Drug Control Policy, Health Resources and 
Services Administration, and the Centers for Disease Control and 
Prevention (CDC) to discuss SAMHSA's response to the overdose crisis.

    The overdose crisis continues to be a challenge for this country. 
Synthetic opioids like illicitly manufactured fentanyl and the use of 
other substances, particularly stimulants such as cocaine and 
methamphetamine, have led to significant increases in overdose deaths. 
\1\
---------------------------------------------------------------------------
    \1\  O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends 
in and Characteristics of Drug Overdose Deaths Involving Illicitly 
Manufactured Fentanyls--United States, 2019-2020. MMWR Morb Mortal Wkly 
Rep 2021;70:1740-1746. DOI: http://dx.doi.org/10.15585/mmwr.mm7050e3.

    As President Biden has noted, our Country faces an unprecedented 
crisis among people of all ages and backgrounds. The COVID-19 pandemic 
exacerbated an already tragic situation, with drug overdose deaths 
reaching a historic high, devastating families and communities. \2\ 
Provisional data from the CDC reported that more than 107,000 Americans 
died due to a drug overdose in the 12-month period ending in January 
2022. Moreover, preliminary findings from SAMHSA's analysis of 2021 
data from drug-related emergency department visits show that fentanyl-
related emergency department visits rose throughout 2021. \3\
---------------------------------------------------------------------------
    \2\  Substance Abuse and Mental Health Services Administration. 
(2021). Key substance use and mental health indicators in the United 
States: Results from the 2020 National Survey on Drug Use and Health 
(HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville, 
MD: Center for Behavioral Health Statistics and Quality, Substance 
Abuse and Mental Health Services Administration. Retrieved from https:/
/www.samhsa.gov/data.
    \3\  Substance Abuse and Mental Health Services Administration. 
(2022). Preliminary Findings from Drug-Related. Emergency Department 
Visits, 2021; Drug Abuse Warning Network (HHS Publication No. PEP22-07-
03-001). Rockville, MD: Center for Behavioral Health Statistics and 
Quality, Substance Abuse and Mental Health Services Administration. 
Retrieved from https://www.samhsa.gov/data/.

    That is why addressing addiction and the overdose epidemic is one 
of the four pillars of the unity agenda the President outlined in the 
---------------------------------------------------------------------------
State of the Union Address.

    Last year Secretary Becerra released the comprehensive the HHS 
Overdose Prevention Strategy (Strategy), which is designed to increase 
access to the full range of care and services for individuals who use 
substances that cause overdose, and their families. The Strategy 
prioritizes four key areas: primary prevention, harm reduction, 
evidence-based treatment, and recovery support.

    Though this testimony, I will expand on how SAMHSA is working to 
implement the Strategy and advancing the goals of the President.
              SUPPORTING THE SUBSTANCE USE CARE CONTINUUM
                           Primary Prevention
    Prevention is critical to reducing overdoses and overdose deaths. 
SAMHSA's activities in this area are designed to invest in community 
infrastructure necessary to prevent harms related to substance use. 
Examples of SAMHSA's activities in support of the Strategy's primary 
prevention goal are below.
       First Responder Training for Opioid Overdose-Related Drugs
    SAMHSA's First Responders--Comprehensive Addiction and Recovery Act 
(FR-CARA) program is an important part of our response to the overdose 
crisis. The FR-CARA program trains and equips firefighters, law 
enforcement officers, paramedics, emergency medical technicians, and 
volunteers in other organizations to respond to adverse overdose-
related incidents, including to administer naloxone. This program also 
establishes processes, protocols, and mechanisms for referral to 
appropriate treatment and recovery communities. FR-CARA's broader 
eligibility and rural-set asides ensure that much needed services reach 
rural and tribal areas. During the program's recent project period, 
each state developed a strategic action plan for combating opioid 
misuse and deaths related to heroin and illicit fentanyl.
  Strategic Prevention Framework for Prescription Drugs Grant Program
    The Strategic Prevention Framework for Prescription Drugs (SPF-Rx) 
assists grantees in developing capacity and expertise in the use of 
data from state run prescription drug monitoring programs (PDMP). 
Grantees have also raised awareness about the dangers of sharing 
medications and worked with pharmaceutical and medical communities on 
the risks of overprescribing to young adults. SAMHSA's program focuses 
on bringing prescription drug use prevention activities and education 
to schools, communities, parents, prescribers, and their patients. 
SAMHSA tracks reductions in opioid overdoses and the incorporation of 
prescription drug monitoring data into needs assessments and strategic 
plans as indicators of program success.
                             Harm Reduction
    Evidence-based harm reduction strategies minimize the negative 
consequences of drug use to both the individual and the community. 
Therefore, providing funding and support for innovative harm reduction 
services is a key pillar of the Strategy. The activities below 
highlight the substantial strides that SAMHSA has made to advance the 
adoption and use of evidence-based harm reduction approaches.
                     Harm Reduction Grant Programs
    This year, SAMHSA launched its first-ever Harm Reduction grant 
program and issued $30 million in grant awards. This opportunity, 
authorized and funded by the American Rescue Plan Act, will help 
increase access to a range of community harm reduction services and 
support harm reduction service providers as they work to help prevent 
overdose deaths and reduce health risks often associated with drug use. 
This funding is allowing organizations to expand their distribution of 
overdose-reversal medications and fentanyl test strips, provide 
overdose education and counseling, and manage or expand syringe 
services programs (SSP), which help control the spread of infectious 
diseases like HIV and hepatitis C. For example, in Maine, ``Project 
DHARMA (Distribution of Harm Reduction Access in Rural Maine Areas)'' 
will involve the delivery of evidence-based harm reduction strategies 
across the state, with a focus on utilizing Peer Support Workers 
embedded in SSPs to facilitate the distribution of harm reduction 
supplies, such as naloxone and fentanyl test strips, and linkage to 
care for infectious disease prevention and treatment, wound care, and 
substance use.
                          Fentanyl Test Strips
    HHS announced in April 2021 that grantees in certain programs, such 
as State Opioid Response (SOR) grants and the Substance Abuse 
Prevention and Treatment Block Grant program, may use grant funds to 
purchase rapid fentanyl test strips to help curb the dramatic spike in 
drug overdose deaths largely driven by strong synthetic opioids, 
including illicitly manufactured fentanyl. \4\, \5\
---------------------------------------------------------------------------
    \4\  Centers for Disease Control and Prevention, ``Federal Grantees 
May Now Use Funds to Purchase Fentanyl Test Strips'', (April 7, 2021).
    \5\  SAMHSA 2021 Report to Congress on the State Opioid Response 
Grants (SOR). https://www.samhsa.gov/sites/default/files/2021-state-
opioid-response-grants-report.pdf.

    Reports from states such as California, Arizona, Nevada, and Alaska 
note that fentanyl test strips funded through SOR have become an 
important component of syringe service programs; education and 
awareness building toolkits; and innovative, low-threshold, on-demand 
treatment programs. These 4 states report distributing approximately 
15,000 fentanyl test strips collectively since April 2021.
                        Evidence-based Treatment
    Evidence-based treatments for substance use disorder can reduce 
substance use, related health harms, and overdose deaths, and increase 
odds for long-term recovery. Below are examples of SAMHSA efforts and 
programs that support evidence-based treatment.
Flexibilities to Increase Access to Medications for Opioid Use Disorder
    In an effort to get evidenced-based treatment to more Americans 
with opioid use disorder (OUD), in April 2021 SAMHSA and HHS announced 
buprenorphine practice guidelines that remove certain training and 
certification requirements which some practitioners have cited as a 
barrier to treating more people. \6\ We know that treatment with 
buprenorphine decreases opioid-related overdose mortality by over 50 
percent. \7\, \8\ The Practice Guidelines for the Administration of 
Buprenorphine for Treating Opioid Use Disorder (Practice Guidelines) 
provides an exemption from certain statutory certification requirements 
for eligible physicians, physician assistants, nurse practitioners, 
clinical nurse specialists, certified registered nurse anesthetists, 
and certified nurse midwives who are state licensed and registered by 
the Drug Enforcement Administration to prescribe controlled substances. 
Specifically, the exemption allows these practitioners to treat up to 
30 patients with OUD using buprenorphine without taking the previously 
required training so long as a practitioner submits a Notice of Intent. 
This exemption also allows practitioners to treat patients with 
buprenorphine without certifying to their capacity to provide 
counseling and ancillary services. As of July 1, 2022, a total of 
126,286 providers have obtained a waiver; of these, 17,633 were 
specifically related to the revised Practice Guidelines.
---------------------------------------------------------------------------
    \6\  Substance Abuse and Mental Health Services Administration, 
``HHS Releases New Buprenorphine Practice Guidelines, Expanding Access 
to Treatment for Opioid Use Disorder'' (April 27, 2021). https://
www.samhsa.gov/newsroom/press-announcements/202104270930.
    \7\  Substance Abuse and Mental Health Services Administration 
Results From the 2018 National Survey on Drug Use and Health (2019) 
https://www.samhsa.gov/data/.
    \8\  Sordo, Barrio, Bravo, Indave, Degenhardt, Wiessing, Ferri, 
Pastor-Barriuso, Mortality Risk During and After Opioid Substitution 
Treatment: Systematic Review and Meta-analysis of Cohort Studies (Apr. 
2017), available at: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC5421454/.

    During the COVID-19 pandemic, we have seen how telehealth can 
expand access to care, overcome geographic inequality in the provision 
of services, and reduce stigma associated with accessing life-saving 
medications such as buprenorphine. \9\ Providers and patients have 
overwhelmingly supported integration of telehealth into the care of 
those with OUD, since it offers: flexibility in delivery and receipt of 
treatment; a means for those living in rural or remote areas to better 
engage in care; improvement in the provider-client relationship through 
flexible scheduling; greater care coordination activities; maximization 
of workforce productivity; reduction in burnout; and a reduction in 
service delivery costs by allowing remote work and care provision. \10\
---------------------------------------------------------------------------
    \9\  Guille, C., Simpson, A. N., Douglas, E., Boyars, L., 
Cristaldi, K., McElligott, J., Johnson, D., & Brady, K. (2020). 
Treatment of opioid use disorder in pregnant women via telemedicine: A 
nonrandomized controlled trial. JAMA Network Open, 3(1), e1920177-
e1920177.
    \10\  King, V. L., Brooner, R. K., Peirce, J. M., Kolodner, K., & 
Kidorf, M. S. (2014). A randomized trial of web-based videoconferencing 
for substance abuse counseling. Journal of Substance Abuse Treatment, 
46(1), 36-42.

    The COVID pandemic also necessitated flexibilities in how patients 
accessed methadone for unsupervised administration. SAMHSA's relaxation 
of the strict regulations related to methadone take home medication has 
been met with positive feedback and reports from patients, providers, 
and researchers. Allowing patients to take home 14-28 days of methadone 
medication as long as this has been deemed safe and appropriate by the 
treating practitioner at the Opioid Treatment Program has proven safe 
and effective. It has allowed patients to work, go to school, and take 
care of their families without the restrictions previously imposed by 
SAMHSA's regulations--many of which have been criticized for years as 
being overly restrictive. Recent research has found that these 
increases in methadone take home doses have not been associated with 
increases in overdoses or other negative impacts. For these reasons, 
SAMHSA has announced that it intends to propose making these 
---------------------------------------------------------------------------
flexibilities permanent through rulemaking.

    In 2021, SAMHSA certified 113 new opioid treatment programs, new 
brick and mortar medication units, as well as new mobile units to 
expand treatment across the Nation. As of July 2021, there are 1,950 
active opioid treatment programs (OTPs) with 65 brick and mortar 
medication units, and 19 mobile locations. Additionally, SAMHSA 
assisted the Federal Bureau of Prisons (BOP) with establishing OTPs for 
its hub and spoke model for providing treatment across their system.
                State and Tribal Opioid Response Grants
    To assist states, territories, Tribes and Tribal Nations in 
addressing the Nation's overdose crisis, SAMHSA manages the State 
Opioid Response (SOR) and Tribal Opioid Response (TOR) grant programs. 
Recognizing that illicitly manufactured fentanyl is driving overdose 
deaths across much of the country, often in combination with 
stimulants, both programs focus on opioids and as selected by grantees, 
stimulants. As such, the core aims of SOR and TOR continue to involve 
increasing access to the three FDA-approved medications for the 
treatment of opioid use disorder, reducing unmet treatment need, and 
reducing opioid-related overdose deaths by supporting the full 
continuum of prevention, harm reduction, treatment, and recovery 
support services. These programs also support the continuum of care for 
those states and communities across the country who are dealing with 
rising rates of stimulant use in addition to opioids and the associated 
negative health, social, and economic consequences. Like the SOR 
program, the Tribal Opioid Response TOR grants program provides 
dedicated resources for these activities to Tribes and Tribal Nations.

    As an example, in partnership with the Seattle Indian Health Board, 
Washington State provided low barrier treatment with medications for 
opioid use disorder and related services to urban American Indian and 
Alaskan Native individuals who are experiencing homelessness with OUD. 
In Alaska, in collaboration with the University of Alaska and with the 
assistance of SAMHSA-funded opioid technical assistance and training 
resources (i.e. Addiction Technology Transfer Center and the Opioid 
Response Network), Alaska has provided co-occurring behavioral health, 
opioid and stimulant use disorder trainings with SOR grant resources.
          Substance Abuse Prevention and Treatment Block Grant
    The Substance Abuse Prevention and Treatment Block Grant (SABG) 
helps all 50 states, the District of Columbia, Puerto Rico, the U.S. 
Virgin Islands, 6 Pacific jurisdictions, and 1 tribal entity in 
addressing substance use disorder treatment and prevention needs 
through support of prevention, treatment, and other services not 
covered by public or private insurance and non-clinical activities and 
services that address the critical needs of state substance use service 
systems. The SABG supports state prevention, treatment, and recovery 
systems' infrastructure and capacity, thereby increasing availability 
of services and development and implementation of evidence-based 
practices.
    Medication-Assisted Treatment for Prescription Drug and Opioid 
                               Addiction
    The Medication-Assisted Treatment for Prescription Drug and Opioid 
Addiction (MAT-PDOA) program addresses treatment needs of individuals 
who have an OUD by expanding/enhancing treatment system capacity to 
provide accessible, effective, comprehensive, coordinated/integrated, 
and evidence-based Medications for Opioid Use Disorder (MOUD) and 
recovery support services.
                 Comprehensive Opioid Recovery Centers
    The Comprehensive Opioid Recovery Center (CORC) program provides 
grants to nonprofit substance use disorder treatment organizations to 
operate comprehensive centers which provide a full spectrum of 
treatment and recovery support services for opioid use disorders. 
Grantees are required to provide outreach and the full continuum of 
treatment services including MOUD; counseling; treatment for mental 
disorders; testing for infectious diseases, residential treatment, and 
intensive outpatient services; recovery housing; peer recovery support 
services; job training, job placement assistance, and continuing 
education; and family support services such as childcare, family 
counseling, and parenting interventions. The CORC Grantees have been 
utilizing funding to expand access to comprehensive services in a 
variety of ways, from improving the system of comprehensive MOUD care 
at the county level; improving follow-up with clients who have 
experienced overdose reversals; and removing barriers to MOUD in 
residential treatment to engaging special populations, such as homeless 
persons, people on probation, and LGBTQ+persons , and meeting the needs 
of underserved areas.
     Certified Community Behavioral Health Clinics Expansion Grants
    The Certified Community Behavioral Health Clinics (CCBHC) Expansion 
program is designed to increase access to and improve the quality of 
community mental and substance use disorder treatment services. CCBHCs 
funded under this program must provide access to services for 
individuals with serious mental illness or SUD, including OUD; children 
and adolescents with serious emotional disturbance; and individuals 
with co-occurring mental and substance use disorders. This program 
improves the mental health of individuals by providing comprehensive 
community-based mental and substance use disorder services; improving 
treatment of co-occurring disorders; advancing the integration of 
mental/substance use disorder treatment with physical health care; 
utilizing evidence-based practices on a more consistent basis; and 
promoting improved access to high quality care.

    Data from intake to most recent reassessment for individuals served 
in the CCBHC program demonstrate that as of March 2022, enrollees have 
achieved a 72 percent reduction in hospitalization and a 69 percent 
reduction in Emergency Department visits, as well as a 25 percent 
increase in mental health functioning in everyday life. Additionally, 
the data demonstrated a 12 percent increase in employment or school 
enrollment. SAMHSA appreciates Congress including support for CCBHC 
planning grants and technical assistance in the Bipartisan Safer 
Communities Act.
                 Pregnant and Postpartum Women Program
    The Pregnant and Postpartum Women program (PPW) uses a family 
centered approach to provide comprehensive residential substance use 
disorder treatment, prevention, and recovery support services for 
pregnant and postpartum individuals, their minor children, and for 
other family members. The family centered approach includes partnering 
with others to leverage diverse funding streams, encouraging the use of 
evidence-based practices, supporting innovation, and developing 
workforce capacity to meet the needs of these families. The PPW program 
provides services not covered under most public and private insurance. 
SAMHSA continues to prioritize states that support best-practice 
collaborative models for treatment, as well as provide support to 
pregnant individuals with OUD. The Comprehensive Addiction and Recovery 
Act increased accessibility and availability of services for pregnant 
individuals by expanding the authorized purposes of the program to 
include the provision of outpatient and intensive outpatient services.
                                Recovery
    SAMHSA has a long history of advancing recovery supports dating 
back to the 1980's with the Community Support Program and the 1990's, 
when the first Recovery Community Support Programs were funded. SAMHSA 
defines recovery as a process of change through which individuals 
improve their health and wellness, live self-directed lives, and strive 
to reach their full potential.
     Establishing an Office of Recovery and Advancing Peer Supports
    Recovery is a key pillar of the HHS Overdose Prevention Strategy. 
That is why during Recovery Month last fall, SAMHSA announced it would 
be establishing a new Office of Recovery. This office promotes the 
involvement of people with lived experience throughout agency and 
stakeholder activities, fosters relationships with internal and 
external organizations in the mental health and addiction recovery 
fields, and identifies health disparities in high-risk and vulnerable 
populations to ensure equity for support services across the Nation.

    We know that recovery is enhanced by peer-delivered support 
services. These services have proven to be effective in sustaining 
recovery over the long term. Investing in peer services is critical, 
given the significant workforce shortages in behavioral health. That is 
why, as part of the President's Strategy to Address Our National Mental 
Health Crisis, SAMHSA is updating and expanding existing compendia \11\ 
of state-by-state peer specialist certifications and is convening 
stakeholders to create a new set of model national standards for peer 
specialist certification.
---------------------------------------------------------------------------
    \11\  Peer Recovery Center of Excellence, Comparative Analysis of 
State Requirements for Peer Support Specialist Training and 
Certification in the United States, January 2022 https://
www.peerrecoverynow.org/documents/Comparative%20Analysis-
Jan.31.2022520(003).pdf.
---------------------------------------------------------------------------
                        SABG Recovery Set-Aside
    The Administration supports the addition of a 10 percent set-aside 
within the SABG for recovery support services aimed at significantly 
expanding the continuum of care both upstream and downstream. This 
proposed set-aside would support the development of local recovery 
community support institutions (i.e., recovery community centers, 
recovery homes, recovery schools); develop strategies and educational 
campaigns, trainings, and events to reduce addiction/recovery-related 
stigma and discrimination at the local level; provide addiction 
recovery resources and support system navigation; make accessible peer 
recovery support services that support diverse populations and are 
inclusive of all pathways to recovery; and collaborate and coordinate 
with local private and non-profit clinical health care providers, the 
faith community, city, county, state, and Federal public health 
agencies, and criminal justice response efforts.
                               CONCLUSION
    On behalf of my colleagues at SAMHSA, thank you for your interest 
in, and support for, our programs, and for supporting the Nation's 
behavioral health. I would be pleased to answer any questions you may 
have.
                                 ______
                                 
    The Chair. Thank you.

    Ms. Johnson.

 STATEMENT OF CAROLE JOHNSON, ADMINISTRATOR, HEALTH RESOURCES 
           AND SERVICES ADMINISTRATION, ROCKVILLE, MD

    Ms. Johnson. Chair Murray, Senator Cassidy, and Members of 
the Committee, thank you for the opportunity to speak with you 
today about the work of the Health Resources and Services 
Administration to address the opioid crisis, which, as this 
hearing demonstrates, is increasingly a fentanyl crisis.

    I am Carole Johnson, Administrator of the Health Resources 
and Services Administration, the agency in the Department of 
Health and Human Services that is home to the Federal Office of 
Rural Health Policy, community health centers, the Ryan White 
HIV AIDS Program, Federal behavioral health workforce training 
programs, and our Federal investments in maternal and child 
health.

    Across our work, we are seeing the impact of fentanyl use 
in the historically underserved communities that we serve, 
including urban, rural, and tribal communities. And we are 
committed to improving access to mental health and substance 
use disorder treatment and growing the behavioral health 
workforce.

    I want to focus my remarks today on three key issues 
related to the crisis that HRSA's work aims to respond to. 
First, as the Chair mentioned, our investments in training and 
growing the mental health and substance use disorder workforce.

    This includes psychiatrists and psychiatric nurses, social 
workers, substance use disorder counselors, psychologists, and 
peer support specialists with lived experience who are trained 
and funded through programs like our Behavioral Health 
Workforce Training Program that supports direct training and 
stipends to build the next generation of mental health and 
substance use disorder providers.

    The National Health Service Corps, where we offer loan 
repayment and scholarships to behavioral health students and 
providers in return for practicing in high need areas. And our 
other dedicated substance use disorder workforce programs like 
the Substance Use Disorder Treatment and Recovery Loan 
Repayment Program, our Addiction Medicine Fellowship Program, 
and our Opioid Impacted Families Support Program.

    We believe that is critical to expand our investment in 
this training and deployment of a mental health and substance 
use disorder workforce that can respond to the prevention, 
treatment, and recovery needs of individuals struggling with 
fentanyl use.

    That is why the President's budget includes a nearly $400 
million investment in growing the number of mental health and 
substance use disorder providers. It is also why the American 
Rescue Plan's unprecedented investment in the National Health 
Service Corps has allowed us to see the largest cohort in the 
program's 50 year history, including thousands of behavioral 
health providers.

    Second, I want to speak to our work to expand access to 
substance use disorder services in rural communities across the 
country. HRSA's Rural Communities Opioid Response Program 
reaches over 1,500 rural communities in 47 states. And we are 
funding what rural communities tell us they need, including 
more access to treatment for individuals using fentanyl.

    In fact, in June, we announced a new $10 million rural 
investment to tackle synthetic opioid overdoses, including 
fentanyl and fentanyl laced drug overdoses, with the goal of 
creating new treatment access points in rural communities.

    In June, we also announced a new $50 million rural 
investment focused on stimulants like methamphetamine, 
particularly as rural communities have reached out to us for 
help with their critical needs as they see drugs like meth and 
cocaine becoming even more dangerous due to contamination with 
highly potent fentanyl.

    We also fund other tailored support programs in rural 
communities, such as grants to reduce the incidence and impact 
of neonatal abstinence syndrome and our Rural Centers of 
Excellence on Substance Use Disorder. And we are continuing, 
and we are committed to continuing to help rural communities 
respond to this crisis.

    For a third and final point I want to emphasize HRSA's work 
to help ensure that there is no wrong door for getting mental 
health and substance use disorder help. And we want to do that 
by integrating behavioral health into primary care. And with 
this Committee's leadership, two important steps on that path 
were included in the bipartisan Safer Communities Act.

    The bill gave us new tools and resources to expand mental 
health training of primary care providers, and the funding 
needed to grow our pediatric mental health access program to 
expand our work with pediatricians, as well as reach beyond 
pediatricians' offices and into schools in emergency 
departments.

    We want there to be no wrong door for those seeking mental 
health and substance use disorder care, which is why we aim to 
expand the capacity of the primary care workforce to respond to 
the mental health and substance use disorder needs of the 
community, including family medicine, pediatrics, maternal 
care, internal medicine, and others.

    We are committed to building on the primary care footprint 
of the 1,400 community health centers we fund in communities 
across the country to help reach this goal. We know there is 
much more work to do and are grateful to the Committee for the 
opportunity to work with you on the next steps.

    Thank you for the opportunity to discuss HRSA's work, and I 
look forward to your questions.

    [The prepared statement of Ms. Johnson follows:]
                  prepared statement of carole johnson
    Chair Murray, Ranking Member Burr, and Members of the Committee:

    Thank you for the opportunity to speak with you today about the 
work of the Health Resources and Services Administration (HRSA) to 
address the opioid crisis, which is increasingly a fentanyl crisis, in 
communities across the country. I am Carole Johnson, Administrator of 
HRSA, the agency of the Department of Health and Human Services that is 
home to the Federal Office of Rural Health Policy, community health 
centers, the Ryan White HIV/AIDS Program, Federal behavioral health 
workforce training programs, and our Federal investments in maternal 
and child health programs. Across our work, we are seeing the impact of 
fentanyl use in the historically underserved and rural communities that 
we serve, and are committed to improving access to services and growing 
the behavioral health workforce to address these critical needs.

    In October 2021, the Department of Health and Human Services 
released the HHS Overdose Prevention Strategy (Strategy), which is 
focused on saving lives, reducing risk, and removing barriers to 
effective interventions. As the Strategy notes, the epidemiology of 
drug overdose deaths has shifted from primarily involving prescription 
opioids in the late 1990's and early 2000's to the current poly drug 
landscape, where synthetic opioids like fentanyl and stimulants like 
methamphetamine are the major drivers of overdose.

    Also, in recent years, there have been marked increases in overdose 
deaths among racial and ethnic minority populations, who are more 
likely to face barriers in accessing equitable treatment and recovery 
services. The rate of overdose deaths among non-Hispanic Black 
Americans more than tripled between 2010 and 2019, but Black Americans 
are still less likely to receive substance use disorder treatment than 
White Americans. At the same time, research also has shown regional 
variation in the types of drugs most commonly consumed and in access to 
services, with rural areas experiencing more challenges in treatment 
access compared to urban areas.

    Today's testimony will review our work in rural and underserved 
communities to expand access to services as well as our focus on 
training and building the behavioral health workforce.
         Overdose Prevention and Treatment in Rural Communities
    Rural communities are on the frontline of the surge in synthetic 
opioid overdoses, including fentanyl and fentanyl-laced drug overdoses. 
HRSA funds the Rural Communities Opioid Response Program (RCORP), a 
multi-year initiative aimed at reducing opioid use in rural communities 
that reaches over 1,500 rural communities in 47 states and has 
supported the provision of direct services to over two million rural 
residents. The RCORP initiative is aimed at meeting community needs and 
programs are designed through feedback received directly from rural 
stakeholders. Through RCORP, HRSA funds five major lines of work in 
rural communities addressing opioid use disorder, including:

          Planning grants to help rural communities conduct 
        needs assessments, build partnerships, and develop workforce 
        plans and otherwise build their community framework for 
        prevention, treatment and recovery;

          Implementation grants to support rural communities in 
        strengthening and expanding opioid use disorder prevention, 
        treatment, and recovery services in rural areas;

          Medication-Assisted Treatment expansion grants to 
        support the establishment and/or expansion of medication-
        assisted treatment in eligible rural hospitals, clinics, and 
        tribal organizations;

          Neonatal Abstinence Syndrome grants to reduce the 
        incidence and impact of Neonatal Abstinence Syndrome in rural 
        communities by improving systems of care, family supports, and 
        social determinants of health; and

          Psychostimulant Program grants to strengthen and 
        expand prevention, treatment, and recovery services for 
        individuals in rural areas who misuse psychostimulants and 
        enhance their ability to access treatment and move toward 
        recovery.

    HRSA also supports three Rural Centers of Excellence on Substance 
Use Disorders to identify and share evidence-based programs and best 
practices for substance use disorder treatment, including as it relates 
to fentanyl and prevention in rural communities. They are: (1) the 
University of Rochester in New York, which focuses on addressing 
synthetic opioid-related overdose mortality in the Appalachian region, 
particularly high-need rural Appalachian counties in Kentucky, New 
York, Ohio, and West Virginia; (2) the Center on Rural Addiction at the 
University of Vermont, which focuses on treatment interventions and 
supports in rural communities in Maine, New Hampshire, and Vermont; and 
(3) the Fletcher Group in Stockbridge, Georgia in partnership with the 
University of Kentucky, which focuses on recovery housing in rural 
counties in Kentucky, Georgia, West Virginia, Ohio, Idaho, Montana, 
Oregon, and Washington. In addition, in partnership with the Northern 
Border Regional Commission, a Federal-state partnership to assist the 
most distressed counties of Maine, New Hampshire, Vermont, and New 
York, HRSA supports Rural Behavioral Health Workforce Centers to train 
health workers and community members to support individuals with 
substance use disorders. HRSA also supports an online technical 
assistance portal to help our rural behavioral health grantees request 
technical assistance, find nearby grantees or grantees with a similar 
focus, and access a repository of resources tailored to support RCORP 
grantees.
    In fiscal year 2020, HRSA rural grantees trained over 44,000 
providers, paraprofessional staff, and community members to administer 
naloxone and between September 1, 2021 and February 28, 2022, over 60 
percent of award recipients reported actively distributing fentanyl 
test strips in their rural service area. \1\ Yet, with almost 30 
percent of rural Americans compared to 2.2 percent of urban Americans 
living in a county without a buprenorphine provider, HRSA believes it 
is critical to continually focus on expanding access to the evidence-
based tools that we know work, including medication to treat opioid use 
disorder. To that end, HRSA recently announced the availability of $10 
million in grant funding through a new RCORP program called Medication-
Assisted Treatment Access. This funding will help rural communities 
establish new treatment access points to connect individuals to 
medication, counseling, and behavioral therapies to treat opioid use 
disorder, with a particular emphasis on supporting new buprenorphine 
providers to help reach more individuals in need.
---------------------------------------------------------------------------
    \1\  RCORP-awardee performance data.

    Last month, HRSA announced nearly $15 million in funding to address 
psychostimulant misuse and related overdose deaths in rural 
communities. Psychostimulants include methamphetamine and other illegal 
drugs, such as cocaine and ecstasy. The overdose crisis has evolved 
over time and is now largely characterized by deaths involving 
illicitly manufactured synthetic opioids, including fentanyl, and, 
increasingly, psychostimulants. Overdose deaths involving 
methamphetamine nearly tripled from 2015 to 2019 among people ages 18-
64 in the United States, according to a study by the National 
Institutes of Health, which also noted that methamphetamine and cocaine 
are becoming more dangerous due to contamination with highly potent 
fentanyl, and increases in higher risk use patterns such as multiple 
substance use and regular use. Rural communities have made their 
concerns about what they are seeing with stimulant use known to us, and 
given the flexibility of the RCORP program, we were able to respond 
---------------------------------------------------------------------------
with these timely investments.

    Looking ahead, HRSA will continues to provide critical resources to 
address the drug overdose crisis and remain responsive to rural 
community needs. We anticipate awarding more than $90 million in 
additional community-based funding to help rural communities address 
substance use disorder and broader behavioral health care needs before 
the end of this fiscal year. \2\ In fiscal year 2023, our proposed 
budget focuses on expanding access to substance use prevention and 
treatment across rural communities.
---------------------------------------------------------------------------
    \2\  RCORP-Implementation (HRSA-22-057); RCORP-Behavioral Health 
Care Support (HRSA-22-061).
---------------------------------------------------------------------------
                 Health Centers and Opioid Use Disorder
    As you know, HRSA supports 1,400 community health centers in high 
need, underserved communities across the country, where services are 
available regardless of an individual's ability to pay. The Health 
Center Program supports health centers that provide primary care in 
underserved communities across the country and health centers are 
increasingly focused on integrating behavioral health into primary care 
services. We also fund the Health Care for the Homeless Program, which 
supports coordinated, comprehensive, integrated primary care including 
substance use and mental health services for individuals experiencing 
homelessness. While many health centers offer a range of integrated 
primary care services, HRSA is committed to increasing the capacity of 
health centers to deliver mental health and substance use disorder 
services. HRSA also provides all health centers with access to 
technical assistance resources to promote the integration of behavioral 
health and substance use disorder services in primary care.

    To further improve access and raise the quality of substance use 
disorder services, the availability of services onsite is essential. 
HRSA is supporting this goal by training health center clinicians to 
provide high quality and expanded services for those with substance use 
disorders. Because many communities served by health centers have a 
high need for substance use disorder treatment and services, many 
health centers have chosen to co-locate and integrate substance use 
disorder services reflecting efficient and effective approaches in 
meeting patient needs. The integration of these services can include 
the provision of enhanced services, such as medication-assisted 
treatment by primary care clinicians. Going forward, HRSA is committed 
to continuing to grow this footprint and expand access to opioid use 
disorder treatment in high need communities across the country. Further 
support is provided to clinicians through the Substance Use Warmline, 
which provides free, real-time clinician-to-clinician telephone 
consultation to health centers, focusing on substance use evaluation 
and management for integrated primary care and behavioral health 
clinicians.

    HRSA also supports health centers to improve their care and 
delivery of services by making a variety of technical assistance 
available. The Health Center Program Care Integration of Behavioral 
Health and Substance Use Disorder Services Technical Assistance focuses 
on integrating behavioral health services through the dissemination of 
evidence-based practices for health care delivery, as well as quality 
improvement recommendations to improve access to health care for 
medically underserved and vulnerable populations. Health centers 
receive one-on-one support, directed to the health center's specific 
needs and goals. Additionally, the National Training and Technical 
Assistance Partners provides training and technical assistance to 
existing and potential health center grantees and look-alikes.
          Ryan White HIV/AIDS Program and Opioid Use Disorder
    The Ryan White HIV/AIDS Program provides critical health care and 
support services for people with HIV to help them get into and stay in 
HIV care. This includes a range of behavioral health-focused services, 
including mental health services, case management, inpatient and 
outpatient substance use disorder treatment, and psychosocial support 
services. The program plays a critical role in addressing the public 
health crisis of opioid use disorder, including fentanyl, for people 
with HIV, especially within rural communities. In consideration of the 
opioid crisis, Ryan White HIV/AIDS Program grantees are facing the need 
to redouble their efforts to provide a range of needed services to the 
most vulnerable populations, including those who are uninsured or 
underinsured, meeting clients where they are and working to improve 
individual-level and overall public health.

    HRSA supports Ryan White HIV/AIDS Program providers in addressing 
opioid use disorder through training, technical assistance, and funding 
innovative projects, including targeted projects to strengthen networks 
of care to respond to the opioid epidemic and ensure people with HIV 
and an opioid use disorder have access to behavioral health care, 
treatment, and recovery services. Further, HRSA also funds an 
initiative focused on implementing effective and culturally appropriate 
evidence-informed interventions for integrating behavioral health in 
primary care settings and identifying and addressing trauma among 
people with HIV. Services include recently diagnosed patients being 
screened for referrals to substance use treatment, mental health 
supports, and other services, as well as facilitating rapid institution 
of prophylactic medications when necessary; taking action to ensure 
that mental health conditions, substance use, history of trauma, low 
health literacy, and lack of support services among individuals living 
with HIV can be addressed; and cognitive-behavioral group therapy 
program designed to address co-occurring substance use and PTSD.
                 Health Workforce and Behavioral Health
    HRSA programs play a critical role in growing and training the 
behavioral health workforce, which are integral to building the 
capacity to improve access to mental health and substance use disorder 
treatment. HRSA funds:

          Scholarships and loan repayment through the National 
        Health Services Corps where behavioral health providers receive 
        support for committing to practice in a high need community;

          Training programs focused on recruiting and training 
        mental health and substance use disorder clinicians such as 
        psychiatrists, psychologists, psychiatric nurses, social 
        workers, and marriage and family therapists;

          Training programs that help engage and retain people 
        in mental health and substance use disorder treatment, 
        including community health workers and peer support 
        specialists;

          The Addiction Medicine Fellowship Program that 
        focuses on increasing the number of board certified addiction 
        medicine and addiction psychiatry specialists trained in 
        providing behavioral health services, including prevention, 
        treatment, and recovery services;

          Graduate Medical Education, including the Children's 
        Hospitals Graduate Medical Education Program, which supports 
        the training of pediatric residents, including pediatric 
        psychiatry residents, in freestanding children's teaching 
        hospitals, and the Teaching Health Center Graduate Medical 
        Education Program, which supports primary care residency 
        training, including for psychiatry, in community-based 
        ambulatory patient care centers.

    Thanks to the Bipartisan Safer Communities Act, HRSA is also 
working to implement new funding to support integrating behavioral 
health training in pediatric primary care training.

    To strengthen the mental health and substance use disorder 
workforce, the fiscal year 2023 budget proposes an investment of $397 
million for HRSA's Behavioral Health Workforce Development Programs, 
which is $235 million above fiscal year 2022 enacted level. This 
funding will increase training of new behavioral health providers, 
including a track for health support workers like peers and community 
health workers, and place an emphasis on team-based care. To promote 
inclusive and equitable behavioral health care for youth, this 
investment will support a special focus on the knowledge and 
understanding of children, adolescents, and youth at risk for a mental 
health disorder, serious emotional disturbance, or substance use 
disorder.

                     National Health Service Corps:
    HRSA's largest workforce program is the National Health Service 
Corps, which has also played a significant role in combatting the 
overdose epidemic by growing and retaining a skilled workforce of 
behavioral health professionals and increasing access to opioid and SUD 
treatment and mental and behavioral health services in underserved 
communities. Thousands of behavioral health clinicians have and are 
serving in underserved communities through the support of the NHSC. The 
NHSC provides scholarships and loan repayment for clinicians, including 
mental health and substance use disorder providers, who commit to 
practice in underserved communities. In 2021, thanks to the American 
Rescue Plan Act of 2021, nearly 20,000 clinicians were practicing in 
underserved communities through the National Health Service Corps, the 
largest number in the 50-year history of the program.

    The National Health Service Corps also received a dedicated 
appropriation to expand and improve access to quality opioid and 
substance use disorder treatment in rural and underserved areas in 
settings such as opioid treatment programs, office-based opioid 
treatment facilities, and non-opioid outpatient SUD facilities. Funding 
for this National Health Service Corps Substance Use Disorder Workforce 
Loan Repayment Program supports the recruitment and retention of health 
professionals needed in underserved areas to provide evidence-based 
substance use disorder treatment and to help prevent overdose deaths. 
Providers receive loan repayment assistance to reduce their educational 
financial debt in exchange for service at substance use disorder 
treatment facilities. More than 3,000 clinicians are practicing in the 
field thanks to the National Health Service Corps Substance Use 
Disorder Workforce Loan Repayment Program.

    HRSA also support the National Health Service Corps Rural Community 
Loan Repayment Program, a program for providers working to combat the 
opioid epidemic in the Nation's rural communities. This program has 
made loan repayment awards in coordination with the Rural Communities 
Opioid Response Program initiative to provide evidence-based substance 
use treatment, assist in recovery, and to prevent overdose deaths in 
rural communities. More than 1,200 clinicians are practicing in rural 
communities thanks to the National Health Service Corps' Rural 
Community Loan Repayment Program.

    The Substance Use Disorder Treatment and Recovery (STAR) Loan 
Repayment Program focuses on recruiting and retaining medical, nursing, 
and behavioral health clinicians and paraprofessionals who provide 
direct treatment or recovery support of patients with or in recovery 
from a substance use disorder through loan repayment in return for 
providing services in high need areas. Participation in this new 
program is open to a number of provider disciplines and specialties, 
including bachelor's-level SUD counselors, behavioral health 
paraprofessionals, and clinical support staff, that previously have not 
been eligible to participate in other HRSA-administered opioid-related 
loan repayment programs. The STAR Loan Repayment Program's first 
application cycle in fiscal year 2021 made 255 awards.
             Behavioral Health Workforce Training Programs:
    The Behavioral Health Workforce Education and Training Programs 
(BHWET) for Professionals and Paraprofessionals are HRSA's primary 
grant program to support the training of social workers, psychologists, 
school and clinical counselors, psychiatric nurse practitioners, 
marriage and family therapists, community health workers, outreach 
workers, social services aides, mental health workers, substance use 
disorder workers, youth workers, and peers. In Academic Year 2020-2021, 
the BHWET Program supported training for nearly 6,500 individuals. The 
program aims to increase the supply of behavioral health professionals 
and paraprofessionals while also improving distribution of a quality 
behavioral health workforce and thereby increasing access to behavioral 
health services. The President's Budget for Fiscal Year 2023 would 
significantly expand investment in this critical training program.
    The HRSA Addiction Medicine Fellowship Program focuses on 
increasing the number of board certified addiction medicine and 
addiction psychiatry specialists trained in providing behavioral health 
services, including prevention, treatment, and recovery services in 
underserved, community-based settings. In Academic Year 2020-2021, 
awardees trained 98 fellows in addiction medicine, including 63 
graduates. Throughout the year, the fellows recorded over 61,000 hours 
of training and nearly 80,000 patient encounters in medically 
underserved communities. The HRSA Integrated Substance Use Disorder 
Training Program supports training and expansion of the number of nurse 
practitioners, physician assistants, health service psychologists, and 
social workers trained to provide mental health and substance use 
disorder services in underserved community-based settings that 
integrate primary care and mental health and substance use disorder 
services, and the HRSA Opioid-Impacted Family Support Program trains 
paraprofessionals to support children and families living in 
underserved areas who are impacted by opioid use disorder and other 
substance use disorders. The HRSA Graduate Psychology Education Program 
supports innovative doctoral level health psychology programs that 
foster a collaborative approach to providing mental health and 
substance use disorder prevention and treatment services in high need 
and high demand areas through academic and community partnerships. In 
addition, HRSA recently issued a funding opportunity announcement for 
community health worker and other health support worker training, 
including peer specialists, which aims to build the workforce 
supporting community connections to care.

    Additionally, HRSA supports the Children's Hospitals Graduate 
Medical Education Program which supports the training of pediatric 
residents, including pediatric psychiatry residents, in freestanding 
children's teaching hospitals, and the Teaching Health Center Graduate 
Medical Education Program, which supports primary care residency 
training, including for psychiatry, in community-based ambulatory 
patient care centers.

    HRSA continues to take innovative steps to grow the behavioral 
health workforce and support the recruitment and retention of health 
professionals needed in underserved areas to expand access to substance 
use disorder treatment and prevent overdose deaths, particularly given 
the increasing challenges communities are facing as a result of 
fentanyl.
                               Conclusion
    Thank you for the opportunity to discuss HRSA's work on this 
critical public health issue and our commitment to continuing to take 
all steps that we can to combat is epidemic. We look forward to 
continuing to work with the Committee on solutions to the Nation's 
overdose crisis.
                                 ______
                                 
    The Chair. Thank you.

    Dr. Jones.

  STATEMENT OF CHRISTOPHER JONES, PHARM.D, DR.PH, MPH, ACTING 
 DIRECTOR, NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL, 
   UNITED STATES CENTERS FOR DISEASE CONTROL AND PREVENTION 
                          ATLANTA, GA

    Dr. Jones. Chair Murray, Senator Cassidy, and distinguished 
Members of the Committee, it is an honor to appear before you 
today to discuss the Centers for Disease Control and 
Prevention's efforts to address the overdose crisis. Thank you 
to the Committee for your attention to this important public 
health challenge.

    This is a complex issue that requires a coordinated 
approach, and I am pleased to be here with my colleagues from 
SAMHSA, HRSA, and ONDCP. The overdose crisis continues to 
escalate due to the proliferation of highly potent synthetic 
opioids like illicit fentanyl and the resurgence of stimulants 
like methamphetamine.

    In fact, we have never seen an illicit drug supply that is 
so potent, unpredictable, or lethal. According to the latest 
CDC provisional data, of the more than 100,000 overdose deaths 
in 2021, 75 percent involved at least one opioid, with 66 
percent specifically involving synthetic opioids and 50 percent 
involving stimulants, often in combination with synthetic 
opioids.

    These statistics reflect the urgent need for action, and 
CDC is confronting this crisis through five key strategies that 
complement the work of our sister agencies in HHS and across 
the Federal Government. Our first strategy focuses on data 
which are foundational to prevention efforts.

    CDC uses data to stay on the leading edge of overdose 
trends to ensure that communities have the information they 
need to respond to the evolving crisis. Through our Overdose 
Data to Action or OD2A program, CDC administers two key data 
systems to improve the timeliness and comprehensiveness of both 
nonfatal and fatal overdose data.

    The drug overdose surveillance and epidemiology or DOSE 
system collects near real time data on non-fatal overdoses in 
emergency departments. States participating in DOSE have 
immediate access to their data and can quickly mobilize a 
community response to surges in overdose.

    The State Unintentional Drug Overdose Reporting System, or 
SUDORS, provides detailed contextual information on the 
circumstances of overdose deaths and the specific substances 
involved in deaths to inform prevention strategies. To make 
these data more readily available for decision-making, we 
recently launched public facing dashboards for both DOSE and 
SUDORS.

    Our second strategy is building state, tribal, local, and 
territorial capacity. In addition to 47 states and DC, CDC's 
OD2A program funds in 19 cities, counties, and territories, and 
we fund 26 tribal entities through other cooperative 
agreements.

    Under these programs, funding is used to build public 
health capacity, leverage data to drive action, and support the 
implementation of evidence based strategies to reduce overdose. 
Our third strategy is supporting providers, health systems, 
payers, and employers.

    Under this strategy, CDC supports efforts to increase safer 
prescribing and improve pain care, maximize the use of 
prescription drug monitoring programs, advance insurer and 
health system interventions, and link people to care and 
services across health care, community, and criminal justice 
settings.

    Our fourth strategy focuses on partnering with public 
safety and community organizations. For example, the Overdose 
Response Strategy, a unique collaboration between CDC and 
ONDCP's HIDTA program helps communities reduce overdose by 
connecting public health and public safety agencies in all 50 
states.

    CDC also partners with ONDCP on the Drug-Free Communities 
Program to provide grants and supports to hundreds of community 
coalitions across the country to advance youth substance use 
prevention. Our fifth strategy is raising public awareness and 
reducing stigma.

    To advance this strategy, we recently launched a campaign 
called Stop Overdose, which focuses on raising awareness about 
fentanyl, naloxone, polysubstance use, and decreasing stigma. 
To date, Stop Overdose has reached over 1 billion views.

    Finally, CDC recognizes the importance of preventing 
adverse childhood experiences or ACEs as a key part of the 
prevention strategy. ACEs are potentially traumatic events that 
happen during childhood, and decades of research show ACEs are 
strongly linked to risk for substance use addiction and 
overdose, as well as risk for mental health challenges and 
suicide, among other leading causes of death.

    By focusing on upstream ACEs prevention, we can make 
substantial progress in preventing substance use and overdose 
and addressing the behavioral health challenges facing our 
Nation. As a person in long term recovery, I know firsthand the 
pain and devastation that addiction can inflict on individuals, 
families, and communities. But I have also seen the 
transformative power of recovery.

    I am grateful to be one of the millions of Americans in 
recovery that can serve as a beacon of hope to others 
struggling with substance use. This work is very personal to 
me, and at CDC, we are committed to advancing a comprehensive, 
community driven approach to save lives today, get ahead of the 
crisis by identifying emerging threats, and supporting upstream 
prevention so the next generation doesn't have to experience 
this overdose crisis.

    Thank you for the opportunity to be here. I look forward to 
your questions.

    [The prepared statement of Dr. Jones follows:]
                prepared statement of christopher jones
                              Introduction
    Chair Murray, Ranking Member Burr, and distinguished Members of the 
Committee, thank you for the opportunity to be here today to discuss 
the Centers for Disease Control and Prevention's efforts to address of 
our Nation's drug overdose crisis. I appreciate the Committee's 
dedicated support and attention to this pressing public health issue 
and we at CDC are committed to continuing our work to tackle the 
growing crisis.
    Over the past two decades, drug overdose deaths have claimed far 
too many lives, with more than 250 Americans now dying each day from an 
overdose. \1\ These sobering statistics represent individuals, 
families, and communities that have been deeply and forever impacted by 
this crisis. However, there is hope in knowing that we can alter this 
trajectory. Drug overdoses can be prevented and people with substance 
use disorders can recover. At CDC, we are working tirelessly to prevent 
overdose and substance-use related harms so that we can save lives and 
all people can achieve optimal health and well-being.
---------------------------------------------------------------------------
    \1\  Wide-ranging online data for epidemiologic research (WONDER). 
Atlanta, GA: CDC, National Center for Health Statistics; 2021. 
Available at http://wonder.cdc.gov.

    The drug overdose crisis is complex and requires a multi-sector, 
multi-pronged response. That is why I am pleased and privileged to be 
joined by colleagues from the Office of National Drug Control Policy 
(ONDCP), the Substance Abuse and Mental Health Services Administration 
(SAMHSA), and the Health Resources and Services Administration (HRSA) 
to discuss the Federal Government's comprehensive response to curtail 
substance use and overdose, particularly from illicitly made fentanyl. 
---------------------------------------------------------------------------
Together we can stop drug overdoses and save lives.

    The latest provisional mortality data from CDC indicate that more 
than 107,000 Americans died from a drug overdose in the 12-months 
ending in January 2022. Of these deaths, it is estimated that 80,590 of 
these deaths, or 75 percent, involved at least one opioid, with 71,450 
(66.5 percent) involving synthetic opioids, primarily illicitly 
manufactured fentanyl or fentanyl analogs. \2\ Stimulant overdose 
deaths are also on the rise, with approximately 33,128 (30.8 percent) 
deaths involving methamphetamine and 24,751 (23 percent) involving 
cocaine. \3\ The increases in overdose deaths have been experienced 
across the nation. The overdose crisis cuts across socioeconomics, 
demographics, political and religious affiliation, and geography. This 
is a crisis that impacts both large cities and rural communities. 
Particularly noteworthy are the recent unprecedented increases in 
overdoses among communities of color, including Black persons and 
American Indian and Alaska Native persons, with disparities in overdose 
deaths among these populations compared to White persons worsening 
during the COVID-19 pandemic. \4\
---------------------------------------------------------------------------
    \2\  Centers for Disease Control and Prevention. State 
Unintentional Drug Overdose Reporting System (SUDORS). Atlanta, GA: US 
Department of Health and Human Services, CDC; [2022, July, 11]. Access 
at: https://www.cdc.gov/drugoverdose/fatal/dashboard.
    \3\ Centers for Disease Control and Prevention. State Unintentional 
Drug Overdose Reporting System (SUDORS). Atlanta, GA: US Department of 
Health and Human Services, CDC; [2022, July, 11]. Access at: https://
www.cdc.gov/drugoverdose/fatal/dashboard.
    \4\ Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic 
and Social Determinants of Health Characteristics--25 States and the 
District of Columbia, 2019--20Mbabazi Kariisa, PhD1; Nicole L. Davis, 
PhD1; Sagar Kumar, MPH1; Puja Seth, PhD1; Christine L. Mattson, PhD1; 
Farnaz Chowdhury; Christopher M. Jones, PharmD, DrPH3 Vital Signs: Drug 
Overdose Deaths, by Selected Sociodemographic and Social Determinants 
of Health Characteristics--25 States and the District of Columbia, 
2019-2020 MMWR (cdc.gov).

    Driving the historic increases in overdose deaths, particularly 
since 2013, is the continued proliferation of a highly potent and 
unpredictable illicit drug market saturated with synthetic opioids, 
especially illicitly manufactured fentanyl and fentanyl analogs (IMFs), 
which are easier and less costly to make, distribute, and sell. 
Introduced primarily as adulterants in, or replacements for white 
powder heroin in drug markets east of the Mississippi River, IMFs are 
now widespread in these white powder heroin markets, increasingly 
expanding into drug markets in the western United States, and readily 
available as pressed counterfeit pills that resemble commonly misused 
prescription drugs such as oxycodone and alprazolam throughout the U.S. 
\5\ Data from the Drug Enforcement Administration and other law 
enforcement partners also indicate that IMFs are found in some illicit 
supplies of other drugs such as methamphetamine and cocaine, adding an 
additional concern about unintentional exposure to these highly potent 
drugs among individuals who may have little prior exposure to opioids--
exponentially raising their risk for overdose. Illicitly manufactured 
fentanyl is highly potent, and CDC data shows that over half of 
decedents with an IMF-related overdose had no pulse when first 
responders arrived at the scene. \6\, \7\
---------------------------------------------------------------------------
    \5\  Shover CL, Falasinnu TO, Dwyer CL, et al. Steep increases in 
fentanyl-related mortality west of the Mississippi River: recent 
evidence from county and state surveillance. Drug Alcohol Depend 
2020;216:108314. https://doi.org/10.1016/j.drugalcdep.2020.108314.

    \6\  O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends 
in and Characteristics of Drug Overdose Deaths Involving Illicitly 
Manufactured Fentanyls--United States, 2019-2020. MMWR Morb Mortal Wkly 
Rep 2021;70:1740-1746. DOI: http://dx.doi.org/10.15585/mmwr.mm7050e3.

    \7\  Gill H, Kelly E, Henderson G. How the complex pharmacology of 
the fentanyls contributes to their lethality. Addiction 2019;114:1524-
5. https://doi.org/10.1111/add.14614.

    The recent increases in overdose deaths highlight the need to 
ensure people most at risk of overdose can access care, as well as the 
urgent need to expand prevention and response activities with a focus 
on health equity. As the nation's public health and prevention agency, 
CDC is leading the public health approach in collaboration with our 
state, local, territorial, and tribal partners. Our top priority is to 
address the overdose crisis by rapidly tracking the evolving epidemic 
and using this information to equip people on the ground to save lives 
in their community. We work to ensure that data is driving decision 
making and planning so that the response to the overdose crisis meets 
local needs, particularly in communities hardest hit by IMFs. 
Communities use this information to inform where they should focus 
their efforts including activities such as providing naloxone, 
decreasing stigma, increasing linkage to care, and improving bystander 
---------------------------------------------------------------------------
education and response.

    CDC prioritizes five key strategies that align with the HHS-wide 
Overdose Prevention Strategy to address the evolving drug overdose 
crisis and reduce substance use related harms: (1) monitoring, 
analyzing, and communicating trends; (2) building state, tribal, local, 
and territorial capacity; (3) supporting providers, health systems, 
payors, and employers; (4) partnering with public safety and community 
organizations; and (5) raising public awareness and reducing stigma. 
CDC's mission is to end this crisis by using data to drive innovation, 
tailoring prevention in local communities, partnering broadly, and 
addressing underlying factors, including a central focus on health 
inequities, and preventing or reducing adverse childhood experiences, 
which are key risk factors for substance use and overdose.
           CDC's Efforts to Use Data for Overdose Prevention
    Data are essential for informing a public health response to the 
overdose crisis. CDC uses data to understand drivers of both nonfatal 
and fatal overdose, including its scope and magnitude, who is most 
impacted, and to track trends over time to inform prevention and 
response efforts. CDC's National Center for Health Statistics (NCHS) 
maintains strong working relationships with state vital records offices 
and has made great strides in improving the timeliness and completeness 
of drug overdose death certificates in recent years. In fact, the 
improvements in the timeliness of these data have now made it possible 
to provide provisional drug overdose death data on a monthly basis, 
allowing for the identification of trends in overdose counts by drug 
class within 4-5 months as opposed to within 2 years. NCHS has also now 
released provisional drug overdose death data on CDC's online analysis 
system WONDER, enabling for the first time, detailed analyses of 
overdose death counts and rates by demographic and geographic 
characteristics. These improvements allow us to assess overdose death 
trends at a national level and adjust our use of resources in a 
timelier manner. In addition, the completeness of drug overdose death 
certificates has greatly improved in recent years, with approximately 
95 percent of drug overdose death certificates listing specific drugs 
contributing to the overdose, up from approximately 75 percent a decade 
ago. To continue to advance improvements in the death certification 
process, CDC has recently established a Coordinating Office for Medical 
Examiners and Coroners that will continue to seek improvements in the 
speed, accuracy, and completeness of data received.

    CDC's National Center for Injury Prevention and Control has 
developed two key data systems to improve the timeliness and 
comprehensiveness of both nonfatal and fatal overdose data as part of 
the Overdose Data to Action (OD2A) cooperative agreement. These two 
systems provide more information about substances contributing to 
nonfatal overdoses and contextual information about what led to an 
overdose death. CDC's Drug Overdose Surveillance and Epidemiology 
(DOSE) System was developed to analyze data from electronic health 
records to rapidly identify outbreaks and provide situational awareness 
of changes in suspected drug overdose-related emergency department 
visits at the local, state, and regional levels ensuring consistent and 
accurate reporting across all entities that make it easier to compare 
data across states. DOSE captures timely data on emergency department 
visits involving all suspected drug overdoses, including demographic 
characteristics of those who overdose such as sex, age, and county of 
patient residence. Since 2019, forty-one states and the District of 
Columbia have provided data to CDC on a monthly basis which is publicly 
accessible through an Interactive dashboard. This data improves 
coordination and strategic planning for intervention and response 
efforts among health departments, community members, healthcare 
providers, public health, law enforcement, and government agencies.

    CDC's State Unintentional Drug Overdose Reporting System (SUDORS) 
collects comprehensive information on drug overdose deaths in 47 states 
and the District of Columbia. The data are collected from death 
certificates and medical examiner/coroner reports (including scene 
findings, autopsy reports, and full postmortem toxicology findings) to 
help inform overdose prevention and response efforts by (1) lending a 
better understanding of the circumstances that surround overdose 
deaths, (2) identifying specific substances causing or contributing to 
overdose deaths as well as emerging and polysubstance overdose trends, 
and (3) improving the timeliness and accuracy of overdose data. In 
2016, SUDORS began as part of CDC's Enhanced State Opioid Overdose 
Surveillance (ESOOS) program, to provide comprehensive data on opioid-
involved overdose deaths. In 2019, SUDORS expanded to collect data on 
all unintentional and undetermined intent drug overdose deaths. Through 
this data, we have gleaned integral information that can help inform 
prevention in communities. For example, recent SUDORS data indicated 
that more than 3 in 5 people who died from a drug overdose had an 
identified opportunity for linkage to care or life-saving actions. \8\ 
In addition, 40 percent of overdose deaths occurred while a bystander 
was present. \9\ CDC disseminates both DOSE and SUDORS data through 
interactive data dashboards accessible via CDC's website.
---------------------------------------------------------------------------
    \8\  O'Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL. 
Vital Signs: Characteristics of Drug Overdose Deaths Involving Opioids 
and Stimulants--24 States and the District of Columbia, January--June 
2019. MMWR Morb Mortal Wkly Rep 2020;69:1189-1197. DOI: http://
dx.doi.org/10.15585/mmwr.mm6935a1.
    \9\  O'Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL. 
Vital Signs: Characteristics of Drug Overdose Deaths Involving Opioids 
and Stimulants--24 States and the District of Columbia, January--June 
2019. MMWR Morb Mortal Wkly Rep 2020;69:1189-1197. DOI: http://
dx.doi.org/10.15585/mmwr.mm6935a1.

    In addition to DOSE and SUDORS investments in states, localities, 
and territories, CDC continues to use other proprietary data sets to 
gain a holistic understanding of the factors that contribute to drug 
overdose and substance use related harms so communities know what 
interventions to choose and when to make adjustments based on the 
evolving crisis. This includes leveraging data sets within CDC and from 
our Federal partners, including data related to substance use disorder 
and treatment, prescribing data, and using innovative data science 
tools, methods, and techniques, and advance modeling efforts to help 
communities allocate resources and interventions. CDC is also 
supporting medical examiners and coroners with increased toxicology 
testing as well as supporting labs to identify synthetic opioids 
through the provision of Traceable Opioid Material Kits that provide 
reference materials for fentanyl compounds and other synthetic opioids. 
In coming months, CDC will expand this portfolio to include stimulant 
reference materials. Finally, CDC works collaboratively with other 
Federal partners to conduct research and leverage available data 
sources that help identify key information about emerging substance use 
patterns, prevalence, treatment availability, and the changing drug 
supply.
 CDC's Comprehensive Public Health Approach to Preventing Overdose and 
                      Substance Use Related Harms
    CDC's National Center for Injury Prevention and Control has funded 
state health departments for overdose prevention activities since 2015, 
beginning with a small subset of high-burden states. This program has 
since scaled to a national program that has not only provided support 
to every state that applies for funding but adapted as the overdose 
crisis evolved. Under the Overdose Data to Action (OD2A) program, CDC 
now funds 47 states, Washington DC, and 16 city and county health 
departments to advance surveillance efforts, which allows the 
departments to tailor the implementation of prevention efforts with a 
menu of strategies that support jurisdictions in addressing the primary 
drivers of overdose in their states and communities.

    As the overdose crisis has broadened, CDC has expanded the initial 
scope of its overdose prevention activities to address new challenges 
along with opioids misuse and overdose. This flexibility allows funded 
jurisdictions to meet the needs of today's crisis, including investing 
in populations with a high percentage of individuals using stimulants 
like methamphetamine and cocaine, which we know are increasingly 
intertwined with illicit fentanyl and opioid overdose. CDC has also 
scaled investments in activities to link people to care and treatment 
across health care, community, and criminal justice settings. These 
activities include peer navigation, quick response teams, and harm 
reduction and represent an important compliment to the work of other 
agencies focused on funding substance use treatment and service 
delivery. The insights we have gained from OD2A have informed two new 
funding opportunities that were recently announced, including an 
announcement specifically to support state and territorial health 
departments (OD2A-S) and another to support local health departments 
(OD2A-Local). CDC is also partnering with other Federal agencies to 
coordinate and leverage all resources to increase uptake of these 
important strategies. For example, The National Harm Reduction 
Technical Assistance Center (NHRTAC) is a joint project funded by CDC 
and SAMHSA. This program provides critical technical assistance to harm 
reduction programs, including syringe services programs (SSPs) to 
prevent the spread of infectious diseases, and other community-based 
programs and organizations that provide treatment, prevention, 
recovery, and harm reduction services including increasing access to 
fentanyl test strips (FTS) by allowing Federal funds to be used to 
purchase FTS in an effort to curb the spike in drug overdose deaths.

    In addition to the Overdose Data to Action program, CDC, in 
partnership with the National Association of City and County Health 
Officials, supports local county health departments through the 
Implementing Overdose Prevention Strategies at the Local Level (IOPSLL) 
program. This program focuses on establishing linkages to care; 
supporting providers and health systems; enhancing surveillance and 
data sharing capabilities; improving partnerships with public safety 
and first responders; implementing harm reduction activities such as 
providing fentanyl test strips and educating about the use of naloxone; 
developing communications campaigns; and implementing innovative 
prevention projects. This program enables the implementation of 
innovations and promising strategies at the local level and is an 
essential source of funding for capacity-building that can increase 
readiness to participate in future funding opportunities aimed at local 
health departments.

    CDC also funds 11 Tribal Epidemiology Centers and 15 tribes or 
tribal-serving organizations for overdose prevention activities. These 
collaborations support efforts to improve data quality, completeness, 
accuracy, and timeliness among a high-risk population. Funding also 
supports regional strategic planning to address opioid overdose 
prevention so that strategies appropriate to tribal communities are 
developed by the communities impacted and the strengths inherent to 
tribal organizations are built upon and scaled across the country.

    In addition to supporting states, localities, territories, and 
tribes, CDC continues to advance partnerships through multiple public 
health and public safety collaborations that aim to strengthen and 
improve efforts to reduce drug overdoses. These partnerships allow for 
effective implementation of programs and help advance promising 
strategies that address rising overdoses in communities. The Overdose 
Response Strategy (ORS) is a unique collaboration between CDC and the 
High Intensity Drug Trafficking Areas (HIDTA) program at ONDCP designed 
to enhance public health and public safety partnerships. The mission of 
the ORS is to help communities reduce fatal and non-fatal drug 
overdoses by connecting public health and public safety agencies, 
sharing information, and supporting evidence-based interventions. More 
specifically, under the program, drug intelligence officers and public 
health analysts collaborate and leverage supply and overdose data to 
problem-solve and address local and regional issues, including spikes 
in overdoses related to illicit fentanyl. Given the potential impact of 
this program, CDC has expanded its investment in this partnership to 
support the public health component in all 50 states, Puerto Rico and 
the U.S. Virgin Islands.

    The ORS also supports the Combatting Overdose through Community-
level Intervention program, to implement innovative strategies within a 
targeted geographic area to build the evidence base for response 
activities that other communities can employ. Projects include efforts 
on post-overdose strategies to link people to care using patient 
navigators and recovery coaches; justice-involved populations and 
access to medications for opioid use disorder (MOUD); buprenorphine 
induction in emergency departments; and training and provision of 
trauma-informed care.

    One example from the program is the Martinsburg Initiative in West 
Virginia. The Initiative is an innovative, police-school-community 
partnership focused on opioid overdose prevention that can act as a 
model for other communities. Through a partnership between the 
Martinsburg Police Department, Berkeley County Schools, and Shepherd 
University, this project expands community resources and links law 
enforcement, schools, communities, and families in a dynamic 
partnership that assesses participants' ACE scores and subsequently 
links them to necessary resources and supports. Through a strategic 
focus that targets at-risk children and families experiencing 
challenges, this initiative aims to assess, identify, and reduce the 
root cause families experiencing challenges, this initiative aims to 
assess, identify, and reduce the root cause of substance use through a 
trauma-informed and collaborative approach.

    CDC also partners with the Office of Justice Programs, Bureau of 
Justice Assistance's Comprehensive Opioid, Stimulant, and Substance 
Abuse Program (COSSAP) to support effective state, local, and tribal 
responses to illicit substance use. These demonstration projects 
promote public safety, and support access to treatment and recovery 
services in the criminal justice system in order to reduce overdose 
deaths. This partnership has focused on rural responses, expanding use 
of the Overdose Detection Mapping Application Program (ODMAP) in states 
and tribes, harm reduction education and training for law enforcement, 
building bridges between jail and community-based treatment, and 
overdose fatality review (OFR) implementation.

    In an epidemic of this scale, public education and empowerment to 
combat stigma has never been more important. This is true not only for 
individuals who use drugs, but also anyone--friend, parent, caregiver, 
or community member--who may encounter someone experiencing an 
overdose. CDC's public messages and campaigns have evolved along with 
the epidemic. For example, CDC's Rx Awareness campaign initially 
focused on increasing awareness of the risks associated with 
prescription opioids when prescription opioids were the primary driver 
of overdose deaths. As the crisis evolved, the campaign shifted to 
focus on messages of hope in recovery with a focus on equity and 
inclusion. Most recently, CDC's latest messaging includes four mini-
campaigns, entitled ``Stop Overdose,'' and focuses on raising awareness 
of fentanyl, naloxone, polysubstance use, and decreasing stigma with a 
particular focus on 18-34 year olds--a group experiencing some of the 
highest rates of overdose in recent years. Launched in late 2021, these 
new mini campaigns have reached over 1 billion views, showing not only 
the importance of these messages, but the need for messages in reaching 
all populations, especially young adults.

    We cannot reverse current trends without a holistic effort that 
fully leverages the health system and health care providers to address 
substance use disorder and overdose. Recent research shows that touch 
points with the health system present an important opportunity to 
engage at-risk patients in care for substance use-related challenges 
and overdose prevention. This includes advancing efforts for 
prevention, screening, linkage to care, and retention in treatment 
toward long-term recovery. In particular, CDC's work in health systems 
and funding to jurisdictions a focus on improving upstream prescribing 
and pain care, enhancing linkage to care and treatment across various 
health care settings, from primary care to emergency departments, 
utilizing peer navigators to help individuals seek and connect to 
recovery options, and reducing stigma among clinicians and providers so 
that people feel safe seeking the care they need. Pain, particularly 
chronic pain, can lead to impaired physical functioning, poor mental 
health, and a reduced quality of life. A key aim of pain management is 
the provision of individualized, patient-centered care that focuses on 
optimizing function and supporting activities of daily living. CDC 
provides guidance to clinicians, as well as tools and resources for 
patients and clinicians, to help advance comprehensive pain care. One 
important way CDC promotes patient-centered pain care is through 
recommendations in its 2016 CDC Guideline for Prescribing Opioids for 
Chronic Pain and accompanying training and ancillary resources.

    Since release of the Guideline in 2016, CDC has stayed at the 
forefront of new research and collaborated with the Agency for 
Healthcare Research and Quality to conduct five formal systematic 
reviews of new available evidence on noninvasive, nonpharmacological 
treatment and nonopioid pharmacological treatment of chronic pain. As a 
result of these reviews and the new scientific evidence that has 
accrued since 2016, CDC determined that an update of the Guideline, and 
an expansion to certain acute conditions, was warranted. The draft 2022 
CDC Clinical Practice Guideline for Prescribing Opioids was posted for 
a 60-day public comment period from February 10, 2022, to April 11, 
2022. Release of a final updated Guideline is anticipated in late 2022, 
along with a suite of translation and communication resources to 
facilitate effective implementation.

    Finally, focusing on preventing substance use in the first place is 
a core component of CDC's work and the long-term solution to reversing 
the decades-long overdose crisis. A key element of this work is 
advancing upstream prevention strategies to prevent Adverse Childhood 
Experiences, or ACEs--potential traumatic events like experiencing 
abuse or neglect, witnessing violence in the home or community, and 
growing up in a household with mental health or substance use problems. 
Research shows that ACEs are strongly linked to increased risk for 
substance use, including increased risk for prescription opioid misuse, 
opioid injection, cocaine and amphetamine use and use disorder, and 
earlier age of initiation for these substances. Additionally, losing a 
loved one to overdose or suicide are themselves ACEs that can increase 
the risk of overdose or suicide in the future. Thus, preventing 
exposure to these early adversities is an important step in reducing 
the risk for overdose and suicide, and many other health risk behaviors 
and health outcomes throughout the lifespan. Focusing on shared risk 
and protective factors at the individual, family, and community levels 
helps to create safe, supportive, and nurturing relationships and 
environments and reduces these risks. Upstream prevention of ACEs and 
other violence and adversity among children and youth can have a 
profound impact on the trajectory of substance use, overdose, and 
mental health in the United States. CDC appreciates the support of 
Congress to address these intertwined crises through an integrated 
public health approach.

    CDC also partners with ONDCP on youth prevention efforts through 
the Drug Free Communities (DFC) Support Program. DFC, the Nation's 
leading effort to mobilize communities to prevent and reduce substance 
use among youth is administered by ONDCP and managed by CDC. The DFC 
Program funds community-based coalitions to strengthen the 
infrastructure among local partners to create and sustain a reduction 
in local youth substance use. The DFC coalitions focus efforts on youth 
and in many instances, promote health equity and aim to reduce 
disparities that impact youth substance use, and address the risk and 
protective factors that negatively impact health outcomes in 
communities. More than 700 community coalitions across the country 
receive funding of up to $125,000 per year to strengthen collaboration 
among local partners and create an infrastructure that reduces youth 
substance use.
                                Closing
    The drug overdose crisis continues to evolve, and our response must 
be nimble and flexible to the changing situations in communities 
throughout our country. We know that public health thrives when the 
approach is comprehensive, coordinated, and can quickly adapt and 
respond to current and emerging needs. Data are foundational to this 
effort. This is especially true with an overdose crisis driven by an 
extremely potent illicit substance, like fentanyl. CDC is continuously 
using data to drive prevention action in states, territories, tribes, 
and local communities. We are continuing to make vital strides in 
accelerating data collection, analysis, and dissemination of nonfatal 
and fatal overdoses and increasing the use of innovative data science 
and modeling efforts to fight the current crisis and predict where it 
will go next.

    For far too long the tragic consequences of overdose have devasted 
families and communities across the country, and the continued 
proliferation of illicitly made fentanyl has only exacerbated the 
challenges we face. CDC is committed to using data, science, 
innovation, and collaboration as part of a whole-of-government approach 
to save lives and bring an end to our Nation's overdose crisis.
                                 ______
                                 
    The Chair. Thank you very much to all of our witnesses 
today and for sharing your expertise. We will now have opening 
rounds of questions from Senators. Please again, if you can 
keep your remarks to, or your questioning to 5 minutes.

    Mr. Chester, let me start with you. As you know, fentanyl 
has been devastating for all of our communities, including in 
my home State of Washington. Over 2,000 people died from a drug 
overdose in Washington State in 2021.

    That is an increase of nearly 70 percent over 2019. And 
half of those deaths involve fentanyl. So those numbers are 
really heartbreaking. And in King County, we saw record high 
fentanyl deaths in 2021.

    Spokane County reported out 186 percent increase in 
fentanyl overdose. That is devastating. And because of the 
transnational criminal networks that traffic fentanyl, it is 
only becoming more prevalent. The Drug Enforcement 
Administration recently reported a 264 percent increase in 
counterfeit pill seizures in Washington State alone.

    Law enforcement officials and first responders are working 
hard to intercept and seize fentanyl before it reaches our 
communities and respond to the increased use, but the Federal 
Government really has to do more.

    Mr. Chester, share with us what steps ONDCP is taking to 
coordinate the activities of the Federal law enforcement 
agencies, Department of Justice, DEA to make sure that our 
efforts to disrupt fentanyl trafficking is as effective as 
possible.

    Mr. Chester. Thank you for the question, Senator. And in 
your question was a great deal of the answer, and that is going 
after the transnational criminal organizations before the drugs 
can even get across our borders and into our communities. And 
it is what we refer to as commercial disruption.

    What we are dealing with is a global illicit business that 
has all of the hallmarks of a transnational business 
organization. They have access to resources. They do product 
development. They have the ability to move money, products, raw 
materials across borders with incredible efficiency. They are 
free riders on the back of the legitimate commercial network 
that keeps the international economy alive.

    But it has critical vulnerabilities. And so what we are 
focused on, and this is across the interagency and across the 
Federal Government, is focusing our efforts on those critical 
vulnerabilities where we can get the greatest amount of effect. 
And one of them, obviously, as was discussed before, is illicit 
finance.

    That is their operating capital and that is their profits. 
And another one is the precursor chemicals that are used in 
order to manufacture these drugs. And in many cases now, the 
technology is at the point where precursor chemicals are no 
longer regulated and some of them are so legitimate that they 
can't be regulated. The third one is going after the commercial 
shipping that moves these things around the country.

    Then the fourth thing is the pill presses and the dye molds 
that are used to make them. And so what we are doing at the 
Office of National Drug Control Policy is not only working 
across the Federal Government, but working bilaterally with key 
countries like China, like Mexico, and like India in order to 
be able to disrupt the production of these drugs at their 
source and to prevent them from getting to our borders and into 
our communities in the first place.

    That is truly an interagency effort, and it is where the 
bulk of our efforts lie right now.

    The Chair. Okay. Thank you. Thank you very much. Let me 
turn to Dr. Delphin-Rittmon. For a lot of parents, it is really 
hard to help their kids navigate teenage years anyway, 
especially when it comes to drug and alcohol. And the fentanyl 
crisis has made keeping our kids safer a lot harder.

    I am a mom. I am a grandma. I understand exactly how scary 
this is for parents today. Counterfeit pills with fentanyl are 
extremely dangerous and extremely easy for teens to find, often 
accidentally, on social media platforms. The stories from 
parents and family members and loved ones are heartbreaking.

    Kids buy what they think are prescription opioids online, 
only to get lethal fentanyl laced pills instead. And in fact, 
the problem is so widespread that the Drug Enforcement 
Administration issued its first public safety alert in 6 years, 
warning about the dangers of those pills.

    We have got to protect our communities, especially our 
kids, from fentanyl. It is vital that we invest in substance 
use disorder prevention, treatment, and recovery for youth. 
Talk to us about how this Committee can support the efforts, 
especially in our upcoming reauthorization package.

    Ms. Delphin-Rittmon. Yes. So, thank you, Chair Murray, for 
that question. And you are right. I mean, this is such a 
challenging area. And I also want to thank you for your 
bipartisan work to reauthorize our programs.

    We do have a specific program, the Strategic Prevention 
Framework for Prescription Drugs, that is geared toward helping 
to increase awareness of the dangers of sharing substances or 
substance use. It is geared toward raising awareness among 
youth and families and communities.

    This program also does include information and training in 
technical assistance related to the dangers of buying 
substances, period, but also through the web, and particularly 
focuses on youth. So some of the goal is to raise awareness and 
to change youth behaviors through that awareness raising.

    The Chair. Well, thank you. I am out of time. Dr. Jones, I 
wanted to ask you, your--what efforts CDC is doing and how we 
can support that. If you can give that to me in writing or if I 
can get a back around for a second round of questions, I will 
ask you that question.

    Senator Cassidy.

    Senator Cassidy. Thank you, Madam Chair. Mr. Chester, you.

    [Technical problems]--thank you. I am still getting 
feedback. Still getting feedback. Oh, well. It is irritating 
me, so it is probably--let's try that.

    Mr. Chester, I am struck that I can speak about chemical 
providers in Wuhan sending chemicals here that are precursors 
for fentanyl that are used by Mexican cartels that are all 
shipped directly--you can acknowledge it in your testimony.

    Now, we think of China as an area where they have 
surveillance cameras on every corner in which at any point 
someone may be arbitrarily imprisoned. I could go on, but we 
know what the go on would be.

    How much collaboration are we getting from the Chinese in 
terms of this? Because some have suggested this is a form of 
bioterrorism.

    Mr. Chester. Yes, Senator. No, thank you very much for the 
question. I can tell you that we engage regularly with the 
People's Republic of China on this specific issue.

    Although, as you know, we have a very complicated 
relationship with China, this is an area where U.S. and PRC 
interests align, and we have made progress in the past. The 
most notable was our work up until May 2009----

    Senator Cassidy. Let me stop you though. I am sorry.

    Mr. Chester. Yes, sir.

    Senator Cassidy. But if we know who those chemical 
manufacturers are, the Chinese know who they are. So, yes, 
there may be collaboration----

    Mr. Chester. Right.

    Senator Cassidy [continuing]. But there is a fundamental 
breakdown there, right?

    Mr. Chester. Yes, sir. And the first thing is ensuring we 
have open lines of communication so the information that we 
have, that we understand about seizures in the Western 
Hemisphere can be sent to the Chinese so that they can take 
action on it.

    The second part of that is, and something that we have 
clearly communicated to the Chinese--and you mentioned it in 
your opening statement. I think you brought up a very good 
point when you talk about the mislabeling. We have asked the 
Chinese Government to do three very simple things.

    The first one is agree with us on the list of unregulated 
chemicals that are used to create precursor chemicals that bear 
increased scrutiny. That is the first thing. The second thing 
is to properly label their chemical and equipment shipments in 
accordance with the World Trade Organization. And the third one 
is that they know their customer and put--know your customer 
procedures into place.

    Those are the things we should expect of any responsible 
country. We have asked other countries to do this as well, and 
we look forward to working with the Chinese for them to 
implement these procedures to reduce the flow of these 
precursor chemicals into the Western Hemisphere.

    Senator Cassidy. Now, we have been raising this issue of 
the Chinese for several years now. So I guess what I am after, 
which I am not sure I am getting, is a level of collaboration 
and true collaboration as opposed to, hey, we are with you, as 
opposed to no, we are knocking on doors, and we are shutting 
down people and we are throwing them in jail.

    Mr. Chester. Right. I would tell you that in--the 
relationship that we have with Chinese, with the PRC, has given 
us uneven progress. I wouldn't disagree with you on that. I 
think that there are areas where the Chinese Government has 
taken quick and decisive action at a request of the United 
States and has had good results.

    I think there are other times that we have differences with 
the Government of China procedurally on certain things that we 
ask them to do, and we have to ensure that we continue to 
communicate with them and impress to them how incredibly 
important this is, not just to the United States, but to the 
rest of the world.

    Other countries, and Secretary Blinken brought this up in 
his speech about China, other countries should expect two great 
countries like the United States in the PRC to work together on 
this global issue and they understand that.

    Senator Cassidy. Now, looking at Mexico, I know you have a 
sense that Mexico is always teetering on whether or not it is 
in control or not, and several states apparently are not in 
control of the central Government.

    But to what degree has the Mexican Government collaborated 
with us if these cartels are bringing these drugs from China to 
then bring across our border? To what degree are we getting 
collaboration there?

    Mr. Chester. We have a good and long standing relationship 
with the Government of Mexico, which was solidified in the 
bicentennial framework for security that was signed just a few 
months ago that replaces the previous Merida Initiative that is 
a little bit more holistic and takes in more of the 
contributing factors within Mexico, not just the security side 
of the house.

    We have, on the ground, we have a large embassy down there. 
We have deep law enforcement relationships with the Government 
of Mexico. And we have had cooperation in the past. And most 
recently, obviously, the apprehension of Rafael Caro Quintero 
is a good example of cooperation with the Government of Mexico 
that actually bears--that bears fruit.

    Senator Cassidy. Now, but I had a sense that recently there 
were some--a back, like increased liability for some of our 
agents who might be down there if something goes wrong. And 
also had a sense that President, or I will just call him AMLO, 
the President of Mexico, has less affection for the U.S. than 
perhaps some of his predecessors. Any comment on that?

    Mr. Chester. What you are referring to is the national 
security law that was put in place in January of last year, 
that created a bunch of increased procedures for collaboration 
between Mexican and U.S. law enforcement agencies.

    I think on the ground, that has been worked out in 
practical terms, that it has not had a devastating effect on 
law enforcement cooperation in Mexico. That is not uniform 
across all agencies, but I think in general terms, the national 
security law isn't a barrier from us working with Mexico, but I 
think it is clear that President Lopez Obrador sees really two 
things.

    The first one is he wants to go after the root causes of 
criminality. And the second thing is he continually looks at 
the U.S., Mexico relationship in terms of Mexico's interests as 
much as United States' interests.

    This has caused a recasting of our relationship with 
Mexico. But we have made some progress on this particular 
problem when working with the Government of Mexico.

    Senator Cassidy. I yield.

    The Chair. Thank you.

    Senator Murphy.

    Senator Murphy. Thank you very much, Madam Chair. Thanks 
for this hearing. You are all doing super important work. We 
appreciate the testimony. Dr. Delphin-Rittmon, I wanted to talk 
to you about the genesis of the opioid crisis, which, of 
course, at first is rooted in America's penchant to prescribe 
opioids and addictive pain medication at a rate that is 
unparalleled in the rest of the world.

    We have made a lot of progress when it comes to the overall 
number of opioids that are prescribed in this country. And 
there is a direct line between individuals who become addicted 
to these pain medications and then those that end up seeking 
illicit drugs in black markets that often end up having 
fentanyl attached to them.

    We have seen this drop in the number of opioids that have 
been prescribed, and we have sort of pat ourselves on the back. 
And yet when you look at our numbers, even with this drop 
compared to the rest of the world, we are still a crazy 
outlier, right.

    We are still 5 percent of the world's population and 
somewhere between 70 and 80 percent of the world is opioid 
prescriptions, even with a 40 percent drop in the overall 
number of prescriptions that are being made.

    Just talk for a second about, as we are as we are talking 
about the fentanyl crisis here, the work that we still have to 
do to alter prescribing patterns as a means to stop people from 
getting on this pathway to fentanyl.

    Ms. Delphin-Rittmon. Yes. Thank you for that question, 
Senator. And, the prescribing patterns and, ultimately ensuring 
that people have access to evidence based services and supports 
is so critical.

    We have seen that over time, and we know that the evidence 
based practices and treatment such as medication assisted 
treatment, whether it be buprenorphine or methadone, can help 
people who are struggling with opioid related substance 
challenges.

    In terms of prescribing patterns, I mean, one thing that we 
are working on is to increase that access for individuals that 
may be struggling, is to allow individual prescribers that is, 
prescribers to treat up to 30 individuals with buprenorphine.

    We have revised the buprenorphine practice guidelines such 
that those individuals can control individuals struggling with 
opioid addiction with buprenorphine.

    Senator Murphy. But I guess what I am talking about, right, 
pain management. I am talking about the fact that we still are 
prescribing far more pain medication, addictive pain medication 
than the rest of the world.

    That we have got to--from your perspective, right, you have 
got to focus on trying to find alternative ways to manage pain 
so that people never get in the position of being addicted to 
pain medication that then becomes an addiction to heroin, 
fentanyl, etcetera.

    Ms. Delphin-Rittmon. Yes. And we do have grants actually 
that do that type of training. So for example, our state opioid 
response grant does train providers on alternatives to pain 
management such that prescription medications aren't the first 
course. And so other strategies to manage pain and that can 
help to alter and change some of the prescribing practices that 
we are seeing.

    Senator Murphy. Mr. Chester, I want to talk to you a little 
bit about how fentanyl and other illicit substances come into 
the United States through the Southern border. It is still 
true, correct, that the lions share, the vast majority, not 
all, but almost all of the products coming into the United 
States comes through our ports of entry.

    We have made through the Appropriations Committee, I chair 
the subcommittee that writes the budget for DHS, some 
significant investments in technology at those ports of entry. 
But there is sometimes there is an impression here that a lot 
of this product is being, moved across in the dead of the night 
through the desert.

    But the reality is we still don't catch as much as we 
should that is walking straight through public ports of entry. 
And there is additional investments that we can make to try to 
catch more of it and ultimately deter more of that activity.

    Mr. Chester. Yes, Senator. No, you are correct. So the 
preponderance of the drugs do come through the existing ports 
of entry. The technology that they have available is very 
impressive. And the men and women of Customs and Border 
Protection, those are our most experienced folks on the ground.

    It is the most efficient way to be able to move them across 
and then have access on the other side to an available network 
to get them quickly across the country. So they do come through 
most of the ports of entry, but there is obviously more that we 
can do.

    The President has asked for $300 million in enhancements 
for Customs and Border Protection for that very reason that 
this is an evolving threat. But there are other places, 
obviously, through the mail system, through maritime 
conveyances, that these drugs get into the country as well.

    Senator Murphy. I just make that point, Madam Chair, 
because a lot of our colleagues think that by putting up this 
wall on the border you are going to stop fentanyl from coming 
into the country.

    The reality is that fentanyl is coming in through the 
ports. And so we can make investments, but the idea that it is 
the one wall portions of the border where the fentanyl is 
pouring in is just not what the facts bear out. Thank you, 
Madam Chair.

    The Chair. Thank you.

    Senator Marshall.

    Senator Marshall. Thank you, Madam Chair. Dr. Jones, do you 
consider the fentanyl crisis to be a public health emergency?

    Dr. Jones. Yes. And there is currently a public health 
emergency declared for the opioid crisis.

    Senator Marshall. Okay. Thank you. Like every state, my 
home State of Kansas is now a border state. That is right, as 
you can see from this map behind me, Kansas is literally at the 
crossroads of fentanyl trafficking.

    With three major arteries coming out of Mexico piercing the 
heart of our great state, and all three bisecting the Nation is 
busiest East-West byway, we are now at ground zero. In fact, 
just recently, officers in Kansas City, Kansas, seized nearly 
15,000, 15,000 fake pills laced with fentanyl during a 2-day 
bust. Fentanyl is now killing a Kansan and almost every day is 
killing over 250 Americans every day.

    Sadly, fentanyl is now the No. 1 killer of young adults, 
poisoning deaths. And I mention and I stress these are 
poisoning deaths from synthetic opioids, particularly fentanyl, 
have increased by more than 600 percent. So where does it come 
from and why is it so cheap? As we all know, the fentanyl 
precursors are made in China.

    You could call this China's revenge on the West for the 
opium war. In Mexico, Chinese chemists and their cartels 
convert these precursors into fentanyl, and they lace fake 
pills like Adderall or Xanax or Percocet, they mix them with 
illicit drugs like meth and cocaine, or simply they sell it in 
various pure forms.

    Unfortunately, this is one supply chain from China that is 
not broken. It goes without saying, with an open, porous 
Southern border, the supply is abundant, driving the street 
price down. For where oxycodone tablets maybe cost $60, you can 
pay $2 to $6 for a fentanyl tablet.

    One final point I want to go back to, returning to this 
fake pills concept. Dying from fentanyl is poisoning. It is not 
an overdose. That is poisoning. If a non-suspecting student 
takes a fake Adderall pill they purchased online or wherever 
they purchased and dies, that is poisoning, and the criminals 
should be tried for murder.

    At least that is how I see it. Mr. Chester, would securing 
borders and decreasing smuggling impact the fentanyl crisis?

    Mr. Chester. Yes, Senator. I mean, as I said in response to 
Senator Murphy as well, the men and women that we have at our 
Southern border are the finest we have.

    Senator Marshall. We understand, but you agree it would 
have a significant impact. Dr. Jones, same question. Would 
securing our borders and decreasing the smuggling and the easy 
access to fentanyl impact the crisis?

    Dr. Jones. I would reiterate Mr. Chester's points about the 
efforts in the National Drug Control Strategy to address----

    Senator Marshall. But they are not working. You can rewrite 
the points, but obviously with a 600 percent increase in 
deaths, whatever we are trying to do, reiterating the points, 
forming committees, talking to people, something is not 
working. Dr. Jones, do you believe we should apply Title 42 to 
drug smuggling across the Southern border?

    Dr. Jones. Well, Title 42 is rooted in protecting public 
health from communicable diseases. So while there is a declared 
319 public health emergency for the opioid crisis, it falls 
outside of the scope of Title 42.

    Senator Marshall. Okay. Mr. Chester, you stated that first, 
the most important action we can do right now is to get more 
naloxone out. As a physician, that is like telling me to give 
people with brain tumors, Tylenol, to say that is the most 
important thing. Do you really feel that giving out naloxone 
would have a bigger impact than securing our borders?

    Mr. Chester. Senator, by most important thing, what I meant 
was most important thing in saving lives now because it can 
reduce an opioid overdose. But that is not exclusive of all the 
work that is being done at the Southern border and with other 
countries and with the Postal Inspection Service and all of the 
other means that we do to keep the drugs out of our 
communities. The Naloxone is designed to reduce an overdose 
death and save a life immediately.

    Senator Marshall. What we are doing now is we are putting a 
finger in the dike and the entire dike is giving away. If we 
don't secure our borders, this epidemic is only going to get 
worse. Mr. Chester, you also stated that the U.S. routinely 
engages with the People's Republic of China to address 
shipments.

    You go on to say the PRC actions in that regard have a 
direct and positive impact. How can you objectively, 
quantitatively substantiate your statement when we are seeing a 
600 percent increase in deaths?

    I know you are talking to them. I know there is 
collaboration. But what is your objective evidence that says 
that China is doing anything to slow this machine down?

    Mr. Chester. The best example I can give you is the work 
that we did with China prior to May 2019, when China class 
scheduled all fentanyl related substances, and as a result, the 
direct shipment of fentanyl and fentanyl related substances 
from China to the United States went down to almost zero. Now--
--

    Senator Marshall. That was in 2019?

    Mr. Chester. That was in 2019. Yes, sir. And now, the 
traffickers moved from producing finished fentanyl into 
precursor chemicals, which they supplied to Mexican suppliers 
and that went up, but that speaks to the dynamic and 
interactive nature of a very determined, profit driven----

    Senator Marshall. But quantitatively, what have you done 
that can show me that we have impacted that? What--is there any 
objective evidence that we have impacted China's supply? I 
mean, they are sending it to us like we send wheat to them.

    Mr. Chester. The number of seizures of precursor chemicals 
and pre-precursor chemicals in the Western Hemisphere has been 
consistently high. And in many of those cases, that was due to 
cooperation with Chinese officials, or subsequent to the 
seizure, the information was sent to the Chinese officials so 
that they could take action and hold the individuals 
responsible.

    Senator Marshall. Thank you, Madam Chair. I yield back. But 
the point is, the seizures are going up because objectively, 
China is not doing--is not stopping the supply of these 
precursors. Thank you. I yield back.

    The Chair. Senator Hassan.

    Senator Hassan. Thank you, Madam Chair. And thank you to 
all of our witnesses for being here today. I want to start with 
a question to you, Mr. Chester. Deaths from fentanyl among 
teenagers more than tripled between 2019 and 2021.

    As Chair Murray mentioned, many of these teens were not 
seeking fentanyl. They purchased what they thought was 
Percocet, Oxycodone or Adderall, only to take a fatal dose of 
fentanyl. And the stories are truly heartbreaking. How are 
young people getting exposed to these fentanyl laced drugs?

    Mr. Chester. Thank you for the question, Senator. And I 
think the distinction was made between poisonings and overdose 
deaths. And I think it is an important one because you bring it 
up in your question. Unfortunately, they are being exposed to 
these drugs in a greater variety of means than they ever were 
before.

    In many cases, and Dr. Gupta has said this several times, 
getting access to these drugs is as simple as in the palm of 
your hand, through a social media app. And so when you are 
dealing with global drug traffickers who want to reduce their 
risk and reduce their overhead and increase their customer base 
and increase their profits, it is in their interest to make it 
available through a variety of means.

    The first thing is to have access to them through social 
media apps, through the dark web, sometimes through the clear 
web, sometimes through their own personal interactions. The 
second thing is how those drugs move across our borders and 
into the United States. And in some cases it is the Southwest 
border, but in some cases it is through our mail and express 
consignment.

    The work we have done with the Postal Inspection Service, 
where the number of seizures in the mail has increased, I think 
has been admirable in being able to disrupt that vector coming 
into the country.

    Senator Hassan. Thank you. Another question for you. Last 
year's National Defense Authorization Act included a bipartisan 
bill that Senator Toomey and I authored, the Blocking Deadly 
Fentanyl Imports Act.

    This law requires the Government to publicly identify 
countries that are major producers or traffickers of illicit 
fentanyl and cutoff foreign aid to those countries if they fail 
to increase efforts to fight drug trafficking.

    Mr. Chester, what steps has the Administration taken to 
evaluate whether we should cutoff foreign aid to countries due 
to the production or trafficking of fentanyl and fentanyl 
analogs within their borders?

    Mr. Chester. Thank you for the question. I am sure you 
understand, I can't take a position on pending legislation. 
What I can tell you is that the current process that we have, 
that we apply under the majors list process for plant based 
drug producing countries, has been effective over the years. 
And we welcome any tool that gives us the ability--[technical 
problems]----

    Senator Hassan. Thank you. I appreciate that. How is our 
audio here? Is there--Okay. We are good.

    The Chair. I can hear you. I am not sure we can hear the 
witness. Is it off?

    Senator Hassan. I think we are all right now. I want to 
turn to Ms. Johnson with another question, and I appreciate Mr. 
Chester's response to the last one.

    Ms. Johnson, according to the Department of Health and 
Human Services, the country must add more than 100,000 general 
psychiatrists and 43,000 addiction psychiatrists to meet the 
current need. This shortage impacts States like New Hampshire, 
where patients may have to drive hours to find treatment for a 
substance use disorder.

    As part of funding I helped advocate for, the Department of 
Health and Human Services awarded a $1.4 million grant to 
Dartmouth-Hitchcock in January to train behavioral health 
clinicians, paraprofessionals, and other residents of rural New 
Hampshire communities to address the substance use disorder 
needs of residents.

    Ms. Johnson, how will these grant programs help build the 
behavioral health workforce over the long term? How will they 
help rural areas in particular?

    Ms. Johnson. Thank you, Senator. And thank you for your 
leadership in supporting and developing these critical programs 
that are really part of what it is going to take for us to 
confront this crisis, for us to be able to build critical 
programs that my colleagues across the table have identified.

    We need a workforce to be able to deliver on that. And it 
is the types of programs that you have helped create that give 
us the tools to be able to recruit people into the field, to 
get them the training that they need, and then to deploy them 
into the communities where they are needed most.

    We are looking forward to the work that will happen at 
Dartmouth under the grant program.

    Senator Hassan. Well, thank you for that. Quickly, I have a 
question for Dr. Delphin-Rittmon. While we know that medication 
assisted treatment, like buprenorphine, is the gold standard 
for opioid use disorders, access to treatment is limited by the 
requirement that providers obtain a special DEA waiver known as 
the X-waiver in order to prescribe buprenorphine.

    About 40 percent of counties across the United States in 
2018 lacked even a single waiver practitioner who was able to 
provide this treatment. Dr. Delphin-Rittmon, if the X-waiver 
continues, how will the lack of treatment providers offering 
medication assisted treatment impact fentanyl overdose rates?

    Ms. Delphin-Rittmon. Yes. Thank you for that question, 
Senator, and for all of your work in this critical area. We 
know that it is just vital that people have access to 
medication assisted treatment when they are struggling with 
opioid use disorder.

    Data shows that. It can help people move into long term 
recovery along with other services and supports. In terms of 
increasing the number of providers, we have removed some of the 
barriers and we are in full support of removing barriers to 
such that additional providers can be--can prescribe 
buprenorphine.

    That is why we changed some of the training requirements 
along with the buprenorphine guidelines. And so that did bring 
an additional 17,000 prescribers into the field since we put 
that in place.

    Senator Hassan. Well, that is important, but I think we 
have more to do. So I have introduced the Bipartisan 
Mainstreaming Addiction Treatment Act, which would eliminate 
the X-waiver and expand access to treatments that we know will 
save lives. Thank you so much, Madam Chair.

    The Chair. Thank you. Senators know that a vote has been 
called. I am going to call on Senator Moran and Senator Lujan. 
I will go vote and come back. Senator Casey will hold the gavel 
while I am gone.

    Senator Moran. Chair, thank you. Thank you very much for 
your presence today. Let me start with Administrator Johnson. 
In your testimony, you mentioned that HRSA is working on better 
connecting substance abuse disorder treatment with access to 
mental health care.

    I come from a state, but I also come from a nation in which 
access to mental health care is limited in--for a number of 
reasons, but particularly the rural parts of our state, the 
inability to attract and retain health care professionals is a 
huge issue. I see this in my Veterans Affairs Committee where 
we are trying to take steps necessary to prevent veteran 
suicide.

    The services, if they exist, are a distance away. Senator 
Smith and I recently introduced a bill authorizing a grant 
program under HRSA to help primary care practices integrate 
behavioral health care services into their offices. Designed to 
take those circumstances in which you do have a hometown 
physician, a family practice doctor, and bring mental health 
care services to that practice.

    Do you think better integrating behavioral health services 
into primary care settings for adults and children makes sense? 
And would that help address the substance abuse crisis that our 
Country is facing?

    Ms. Johnson. Thank you, Senator. I thank you so much for 
your leadership on this issue. I think integrating behavioral 
health, mental health and substance use disorder services in 
primary care is essential for us to confront this crisis.

    We are not going to be able to solve this problem unless 
people can get the care and services they need, and that means 
we have to deploy all available assets to the problem. And that 
means there needs to be no wrong door for getting in to get 
mental health and substance use disorder services.

    That is why we are really focused on trying to leverage the 
programs that HRSA and are grateful for the support of this 
Committee to identify ways that we can continue to help the 
primary care workforce understand and treat and identify mental 
health and substance use disorders.

    Senator Moran. Thank you. I intend to use your endorsement 
in our efforts to get the legislation passed. Dr. Delfin-
Rittmon, in addition to serving on this Committee, I am also 
the lead Republican on the Appropriations subcommittee that 
funds the Department of Justice.

    What--in your testimony you touched on the First Responders 
Comprehensive Addiction and Recovery Act grant program, which 
helps to train and equip first responders to respond to 
overdose related incidents. This grant program, as you note--
noted, includes a rural set aside.

    For many rural departments, the loss of man or woman power 
while an officer or deputy is off training is almost as 
prohibitive as the lack of funding. What is your department 
doing to make training and other resources more accessible, 
such as through online training courses to small and 
understaffed departments?

    Ms. Delphin-Rittmon. Thank you for that question, Senator. 
You are right. I mean, it is so important to be able to have 
multiple modalities, to be able to offer training. And so we do 
have a number of training and technical assistance centers.

    We have addiction training and technical assistance center, 
as well as the provider clinical support system that provides a 
range of technical assistance, training, and education for 
prescribers as well as other behavioral health providers in the 
field.

    Those include both in-person as well as remotely through 
webinars and online strategies and means as well.

    Senator Moran. I might suggest to you that, at least in our 
state, we have a number of law enforcement training centers 
across the state geographically. You may want to integrate your 
program or share the opportunity for training in those settings 
and utilize the services that generally the law enforcement 
community has already created for ongoing training for members 
of law enforcement.

    I also appreciate your attention to ensuring that rural 
communities have the resources needed to fight fentanyl and 
substance abuse. There are two issues--these two issues are 
often associated with urban areas. I can assure you, it is not 
a urban, suburban issue. It is, it is not solely that.

    Rural America is battling the epidemic, and we do--are 
doing so with, as I indicated earlier, a more strained health 
care delivery system and limited workforce. One particular 
program, you talk about in your testimony, that Kansas is 
utilizing well is a certified community behavioral health 
clinic programs.

    In 2021, Kansas became the first state to establish the 
model at the state level, and by 2024, we have 26 state 
certified CCBHCs. Would you speak further to the role of 
localized care like these community mental health centers have 
in fighting substance abuse that we are talking about today?

    Ms. Delphin-Rittmon. Yes, absolutely. And I want to commend 
Kansas for having that number of CCBHCs. It is a wonderful 
model. It provides both mental health, substance use services, 
as well as coordination and connection and linkage to primary 
care services as well. It is a model that also provides 
wraparound prevention treatment and recovery services and 
supports.

    It is critical in terms of being able to connect people 
that are struggling with opioid use disorders, as well as other 
substance use disorders to services and supports, to include 
recovery services and supports as well.

    Senator Moran. Thank you both for responding to my 
questions.

    Senator Casey. Senator Lujan.

    Senator Lujan. There we go. Thank you very much, Madam 
Chair, for this important hearing. I do want to start by 
echoing something from my colleague from Connecticut and 
bringing attention to our ports of entry. Somehow this keeps 
getting politicized.

    If, in fact, the United States wants to be serious about 
stopping the flow of illicit substances into the United States, 
we must remember there is a Southern border and a Northern 
border, and there is two water borders, and then you go down 
and you remember the Gulf of Mexico with our water ports.

    Don't forget about our airports. The screening or lack 
thereof that is done at our ports should alarm all of us. 5 or 
6 percent just improve to 10 percent with passenger screening 
into the Southern border is embarrassing.

    The United States must adopt 100 percent screening into the 
United States with commercial goods and with passenger traffic 
at all of our ports of entry. Only then will we start to 
understand how these cartels and other entities are throwing 
product at the problem.

    I hope that we can at least come together there and work 
together to get something done. By the way, one of the last 
pieces of legislation that was signed by President Trump was a 
bipartisan initiative challenging the Department of Homeland 
Security to tell Congress how to get to 100 percent screening 
of our ports.

    Let's find a way to work together. Second, Mr. Chester, I 
appreciate the attention to the illicit financial markets. The 
United States should be embarrassed by the lack there of 
process that we have with prosecuting against illicit financial 
markets. And it is not just Democrat or Republican 
Administrations. It is both.

    When major financial institutions in the United States are 
found to be laundering money for cartels, and the outcome is no 
one goes to jail, someone gets a fine, well that is just a new 
cost of doing business. If someone can make that much money and 
only get fined, it is going to continue.

    If there is one thing that all these bad people have in 
common in what is happening here is that they are making money. 
And until you stop the flow of that money, you are not going to 
stop any of this.

    I am hopeful that these are some areas, I know we are not 
in the committee of jurisdiction, but some areas that we can 
find some common ground to go after these entities that are not 
politicized.

    Now, the questions that I have, I want to echo a statement 
made earlier, pushing on buprenorphine or improving screening 
at ports of entry in America. Dr. Delphin-Rittmon, does the 
United States need to adopt both, access to treatments as well 
as trying to stop these movements of these illicit substances 
from around the world in the United States?

    Ms. Delphin-Rittmon. Thank you for that question, Senator. 
I can certainly speak to the work of SAMHSA. I know Mr. Chester 
has comments in terms of the movement. It does seem that we are 
taking a multi-level approach, and so certainly there are is 
quite a bit of work underway to increase access to medication 
assisted treatment, as well as other vital prevention and 
recovery services and supports as well.

    It does sound like there is quite a bit of work in terms of 
border--work at the border as well. But in terms of SAMHSA's, 
the programs and initiatives that we have in place, both 
through the source of state opioid response grant, as well as 
the substance abuse treatment block grant, there are a range of 
services and supports available across the country to help 
individuals that are struggling with opioids, to include the 
dissemination of fentanyl test strips, which allow for the 
testing of substances and allow for the testing of the presence 
of fentanyl.

    Senator Lujan. Dr. Delphin-Rittmon, would access to 
fentanyl testing strips save more lives?

    Ms. Delphin-Rittmon. What we are seeing is that fentanyl 
test strips do allow for the identification of fentanyl and 
substances. That is helpful for individuals that are not 
interested--that don't want to take fentanyl. Often what we 
find is that harm reduction programs also disseminate 
information about how to access services.

    Often people are connected with a recovery coach or 
recovery programing. So the harm reduction offers an 
opportunity to sort of disseminate the fentanyl test strips, 
but also to disseminate information about how to navigate and 
access services and supports as well.

    Senator Lujan. I believe access to those strips will save 
lives. It alarms me that in some states those strips are 
treated as illegal use or treated in a way where people can't 
use them. I hope that one thing we can do is come together to 
ensure that access to meds, to strips, things of that nature is 
something that can be accessible across the United States.

    I do have other questions for the record that I will 
submit. The one point that I wanted to raise, though, is, 
according to the CDC, only about one in every ten American 
Indian, Alaska Native, and Hispanic people with substance use 
disorder reported receiving treatment.

    The numbers are about 70 percent of the 2 million folks 
across the country that are not getting any treatment, 
predominantly in rural and Native American communities, and in 
Hispanic communities, Black communities, other communities of 
color as well.

    I appreciate that there is more attention being brought to 
these, but again, what has been happening? The data shows where 
this is occurring and there is still no response. Madam Chair, 
I am certainly hopeful that as we have this conversation and we 
are moving to move legislation to encourage more and demand 
more access to meds, but that we understand where the data is 
based on the number of folks that we are losing, while we also 
stop these illicit financial markets, and we improve 
dramatically and require present screening at our borders to 
begin to make the drastic steps necessary to be able to get our 
hands around this. Thank you. I yield back.

    Senator Casey. Senator Collins.

    Senator Collins. Thank you, Chair, Members of the panel, I 
say this with grave respect for each of you. I know that you 
care deeply and that the policy and programs that you are 
implementing are well-intentioned, but I think we have to face 
the very unpleasant truth that what we are doing is not 
working.

    The data overwhelmingly demonstrate that, whether you look 
at national data or data from the State of Maine. Maine's 
leading drug overdose, drug death researcher, Dr. Marci Sorg 
from the University of Maine recently called Maine's overdose 
epidemic, ``the worst it has ever been.''

    Tragically, we lost a record high 627 Mainers in 2021. And 
the data from the first part of this year shows a 9 percent 
increase over a comparable period of last year. The number of 
total overdoses in Maine exceeded 9,500 last year.

    Fentanyl was involved in 77 percent of deadly overdoses in 
Maine. That is a dramatic increase. So I want to talk to you 
about two issues. One is enforcement and interdiction, and the 
second is prevention and education.

    In 2021, the Maine Drug Enforcement Agency seized more than 
10,000 grams of fentanyl. That is a 67 percent increase. But 
they tell me they cannot possibly keep up. They are 
overwhelmed. And that Maine's overdose crisis is primarily 
driven by the increased supply of illicit fentanyl originating 
in China and smuggled through Mexico into our Country.

    I have been to the border with Mexico. I have seen the 
cartels who are smuggling people across the border. I talked 
with the Border Patrol officers out on their midnight shift, 
and they have expressed such frustration that they have had to 
divert their resources to handling the tremendous influx of 
people crossing the border, rather than focusing on illicit 
drug interdiction.

    Like my colleagues, I cannot help but conclude that our 
inability to secure the Southern border has an adverse impact 
and contributes directly to our inability to stop the flow of 
drugs into this country. I have also talked to the Coast Guard 
and their efforts and how frustrated they feel.

    My first question, Mr. Chester, is, do you agree that the 
unprecedented surge of people illegally entering the United 
States has diverted limited Government resources away from drug 
interdiction?

    Mr. Chester. Thank you for your question, Senator. And I 
know Marcy Sorg and I have worked with her for the past several 
years, and she is an incredible professional.

    Senator Collins. She is.

    Mr. Chester. She understands this issue better than just 
about anybody, so I appreciate that. There is no doubt that 
there are a number of challenges at the Southwest border of the 
United States. But what I would ask that we all bear in mind is 
a couple of things.

    The first one is, these are very determined drug 
traffickers who are going to find any means to get these drugs 
into our Country, whether it is the Southwest border, whether 
it is the mail, express consignment, maritime, or air 
conveyances. I think that is the first thing.

    I think the second thing is our focus that we have not only 
in commercial disruption, but going after the illicit finance, 
not only the profits that are the motivation for doing this, 
but the operating capital that allows it to happen, is an 
overarching way to be able to deal with this very frustrating 
problem.

    The last thing I would tell you, ma'am, is this is a very 
dynamic problem in a very dynamic situation. And when you say 
that what we are doing is not working, it would be easy to say, 
well, what we have done is not working.

    What we have to do is very quickly identify when we have 
new vulnerabilities, when the traffickers have changed the ways 
that they do business and close those gaps and vulnerabilities 
as quickly as we possibly can. And that is what we are in the 
process of doing right now.

    Senator Collins. Thank you. I am going to submit my next 
question for the record, because my time has expired. But Dr. 
Delphin-Rittmon, it is for you. I just want to tell you about 
Hannah Flaherty, a 14 year old girl from Portland.

    A straight-A student with no history of drug abuse who died 
from a suspected fentanyl poisoning last month. And my question 
for you is going to be, for the record, given the time, what 
more can we do to reach young people?

    I am not talking just about high school. I am talking about 
middle school students, to educate them about the dangers of 
drug abuse so that they don't think a pill is harmless, it is 
injecting yourself which is dangerous, which I think is 
common--a common misperception.

    I would like to follow-up and talk with you about that, 
because I remember very well when I was growing up in Cariboo 
in Northern Maine, that we had a recovered heroin addict come 
in and talk to us and it was so powerful.

    It was incredibly powerful. So I am wondering what more we 
can do to educate students at a young age about the dangers. 
And I know I am out of time but thank you.

    The Chair. Thank you, Senator Collins. Critical question, 
and I think we all would look forward to your answering that in 
the response.

    Senator Baldwin.

    Senator Baldwin. Thank you, Madam Chair. I am listening to 
my colleagues as well as the responses and there is sort of a 
pattern that I have observed over time.

    When we were talking in this Committee about the opioid 
epidemic just several years ago, it was much more, the 
conversation was much more focused on prescribers and 
overprescribing and, 30 day supply after dental surgery rather 
than something that would be much more appropriate to avoid 
substance abuse.

    Now we are talking a lot about accidental overdose and 
getting--folks who have gotten fentanyl laced pills, etcetera. 
Like my colleagues, I want to share the stories of several 
Wisconsin families that I have gotten to know this year because 
they have gone through this crisis themselves.

    Cade Reddington was a graduate of Waunakee Community High 
School, a student at UW Milwaukee, and a kid who was full of 
life and energy and excitement. On November 4th of last year, 
Cade died in his dorm room after taking what he thought was a 
Percocet pill. That pill contained fentanyl.

    Combating fentanyl is a critical task for this Committee 
and this entire Administration, but I am concerned we are not 
doing enough to warn our Nation's young people about the 
dangers of counterfeit pills.

    But Dr. Jones, I wanted to just draw your attention to the 
work that, and I am sure you know about it, the work that the 
DEA has been doing to spread the word that, ``one pill can 
kill.'' This message, in my mind, has not yet been shared 
widely enough. And so I wonder how the CDC is working with the 
DEA to elevate this particular message and make sure that this 
information is being shared with young people.

    Dr. Jones. Great. Thanks so much for the question. And we 
worked closely with DEA before that campaign was launched 
because we have experience over the last several years multiple 
campaigns that we have done at CDC around prescription opioids, 
transitioning to recovery, and now the illicit fentanyl market.

    We have learned lessons along the way about how to 
communicate and wanted to make sure that we could assist DEA in 
their messages. So we worked with them prior to the launch, and 
we certainly worked across agencies here with DEA to help 
disseminate those messages.

    I think that campaign is an important one because it is 
very catchy. One pill can kill. That makes sense. And that is 
something that is not lost on people. And it does reflect the 
toxicity of the illicit drug market, as many Senators here have 
mentioned today, the issue of poisoning versus overdose.

    I recently participated in a DEA event that brought 
families together who have lost individuals through those exact 
scenarios, taking counterfeit pills that they thought was Xanax 
or Percocet and was actually pressed fentanyl. But I think I 
will highlight two things at CDC that I think complement the 
work of DEA and how we can continue to spread these messages.

    The first is our Stop Overdose campaign, which I mentioned 
in my opening statement, which focuses specifically on fentanyl 
and the toxicity of the illicit drug market, the availability 
of naloxone, possibly substance use, which is also contributing 
to overdose, as well as unintentional exposure, people thinking 
they are using something else and they are actually getting 
fentanyl, and then decreasing stigma, which we know is a 
barrier for people to seek help.

    That campaign was formally tested among young adults, 18 to 
34 year olds. And so that is something that is freely 
available. People can take what we have done and use it and 
apply it in their communities. So that is, I think, a new asset 
that is available to help spread the message about the toxicity 
of the drug market.

    The last thing I will say is that there is a real 
opportunity to focus on upstream primary prevention. We need to 
get messages out about the toxicity of the drug market. But 
fundamentally, as a long run strategy to addressing this issue, 
we need to help instill resilience, life skills, problem 
solving, conflict resolution, focus on root causes like adverse 
childhood experiences that really set the trajectory for 
someone to have risk for substance use.

    We know that people with ACEs initiate substance use 
earlier, which increases your risk of having a substance use 
disorder. So there are really powerful opportunities for public 
health prevention in that space.

    Senator Baldwin. Thank you, Dr. Jones. And I didn't want to 
cut you off because this is very responsive to my question. I 
did--I will do as Senator Collins did and submit some questions 
for the record.

    But I did want to indicate that both Cade, who I just told 
you about, and Nickolas Barrett Graves of Beloit, were--have 
passed away of fentanyl poisoning. Nicholas of Beloit, 
Wisconsin could have been saved by naloxone, as could have 
Cade.

    That is why I have been pressing manufacturers to make 
their products available over the counter and working on 
legislation to reauthorize the opioid overdose reversal 
medication access and education grant programs.

    For Dr. Delphin-Rittmon, again, for the record, I will be 
inquiring what SAMHSA needs to make sure that naloxone is more 
readily available to first responders and in key locations such 
as school dormitories and community centers. And that will be 
submitted for the record.

    The Chair. Thank you.

    Senator Braun.

    Senator Braun. Thank you, Madam Chair. My question is going 
to be for Mr. Chester. Want to cite a few things that I think 
most Americans would be appalled at what is happening. Since 
2021, January, 3.2 million migrants have crossed the border 
illegally. We have intercepted 1.2 million pounds of illegal 
drugs, over 16,000 pounds of fentanyl.

    That is approximately 3.7 billion lethal doses coming into 
the country to kill the population ten times over. Also, we 
have got 100,000 per year overdose deaths nationally and 2,000 
opioid overdose deaths every year in my State of Indiana.

    I don't know that we need to dispute the facts. I think 
mostly what I am interested--and look at your background. It is 
impressive in that it has kind of been your job to figure out 
how to disrupt the supply chain. Of course, now the main 
manufacturer is China. The main distributor is Mexico.

    When I was down there in March, I think of 2021, illegal 
crossings were 40,000, 50,000 going up to 60,000 or 70,000. Now 
they exceed 200,000. We all remember the vivid interception 
recently of I don't know how many pounds of fentanyl.

    Are you confident that what we are doing is aggravating the 
problem, just encouraging more proportionately from what it was 
pre-Biden administration? And are we making any headway?

    Dr. Jones. Thank you very much. It is a very comprehensive 
question and I want to hit all of it. The first thing is, I 
would ask that we all bear in mind that there has absolutely 
been an increase in the number of drugs seized at our Southwest 
border.

    Those are drugs that are not in our communities, and that 
is money that will not go to drug traffickers for their 
benefits. And I think that is the first thing. I think the 
second thing is, and I think I have mentioned this before, what 
you described very accurately is the results of a global 
business enterprise that is driven by profits and is focused on 
finding vulnerabilities in order to expand their customer base 
and make as much money as they can with the decreased amount of 
risk.

    Synthetic drugs like fentanyl and synthetic opioids can be 
produced at much lower overhead and sold for much more money. 
And so that is the second thing. And then the third thing is 
that this is not confined, the problem doesn't begin or end at 
the Southwest border, but rather it is deep in a country where 
those drugs are produced.

    It is the conveyances that move them and their raw 
materials around the world, and they are shipped through 
multiple means into the United States and into our communities. 
And so what we cannot do is take individual pieces of that 
complex and focus our efforts on it and ignore the others.

    We have to look at it in its totality. We have to determine 
when there are changes in that environment and focus our 
efforts against those changes for the ultimate goal, and you 
use the exact right word, I think, in disrupting over time 
their ability to be able to move these drugs into our Country.

    Snapshots in time, I absolutely understand that they give 
certain numbers in certain indicators, but I can tell you is we 
are approaching this in a holistic fashion, which is what it 
deserves, because that is the complex of issues that we are 
dealing with under this particular drug trafficking----

    Senator Braun. Let me follow-up with this, because that 
sounds like a good approach in terms of how you are analyzing 
it. But we had 40,000 to 60,000 illegal crossings about a year 
and a quarter ago. Now it is up to over 200,000.

    Can--and what they told us then was that the wall, which I 
don't think ever was talked about being from sea to shining 
sea, where it was, it was our most important tool along was the 
stay in Mexico policy.

    How do you explain why it is gone from 40,000 to 60,000 
illegal crossings to what could be approaching 300,000 and how 
we could be doing a better job at intercepting all the illicit 
material that comes along with the illegal crossings?

    Dr. Jones. Yes, Senator, thank you. And please understand, 
I am going to limit my comments and my answers to the issue of 
illicit drug trafficking.

    But what I can tell you is, that is precisely why in the 
Presidents Fiscal Year 2023 budget, we have asked for $300 
million to enhance the capability of CBP to be able to deal 
with illicit drug trafficking across our borders, and another 
$300 million for the Drug Enforcement Administration to be able 
to do its work within the United States at being able to seize 
drugs as well.

    As I mentioned before, these are very determined drug 
traffickers that are going to find a way to get the drugs into 
the country. We have the greatest professionals on the face of 
the earth, but we can always do more in order to give them the 
tools that they need in order to be most effective against this 
problem----

    Senator Braun. I think I am out of time, and I won't go for 
another round of questions. But I think carefully about that 
relationship between how many people are coming across and what 
is underlying the fact that you are going to be intercepting a 
lot more illicit materials as well. Thank you.

    The Chair. Thank you.

    Senator Hickenlooper.

    Senator Hickenlooper. Thank you, Madam Chair. Mr. Chester, 
I wanted to ask a question about pyral, because even as 
fentanyl devastates our communities, more is coming and in 
Colorado we are just starting to see pyral, a drug that appears 
to be ten times stronger than fentanyl.

    I know, Mr. Chester, you have made disrupting the supply of 
illicit drugs a major focus of your career. And how do illicit 
drugs like pyral, where do they come from? How does it end up 
in Colorado, and what is the Administration going to try to 
intercept supply routes?

    Mr. Chester. Yes, thank you for the question, Senator.

    I know in particular, I-75 is a major corridor for you and 
the amount of concerns that are involved with the physical 
movement of drugs throughout your state and really throughout 
the region on that corridor. That particular drug and others 
like it--and I want to be clear kind of in our characterization 
here.

    You have fentanyl itself and then you have fentanyl 
analogs, which are alterations, additions, or substitutions to 
the base fentanyl molecule, an entire class of substances. And 
then you have other non-fentanyl synthetic opioids. And that is 
the nitazenes family and those are others that come up.

    The reason we see them is for two reasons. No. 1, one of 
the best accelerants for the production of a new drug is action 
taken against an existing one. These are profit seeking 
enterprises that have very smart chemists who want to market 
new substances, post them on the internet or on social media 
for availability, and get people to be early adopters to them.

    That is the first time that is the first way that you see 
them. And then the second way that you see them is, it is 
generally product placement. They have the available precursor 
chemicals, they have a chemical formulation they can get on, 
and they advertise it is having a certain qualitative effect on 
the body.

    All of them are illicit. All of them are dangerous. And all 
of them are available on the internet and on the dark web, and 
to be shipped in either physically into the United States or 
across our borders through mail and express consignment. The 
last thing I will tell you is, and I know the Rocky Mountain 
HIDTA did very well.

    We are very proud of the High Intensity Drug Trafficking 
Areas Program that we administer and manage here in ONDCP. It 
is organized--and we have extended the overdose response 
strategy for the HIDTA program to all 50 states, the Virgin 
Islands, Puerto Rico, and DC.

    That brings together drug intelligence officers and public 
health individuals in order to be able to better understand the 
environment, identify those new and emerging threats like the 
one that you just mentioned, to be able to take action on them, 
and they do very good work.

    Senator Hickenlooper. All right. And thank you for this, 
for the HIDTA. It has been very effective and remarkably 
effective. Dr. Delphin-Rittmon, fentanyl has killed 1,600 
Coloradans in the last almost 3 years.

    Just a few months ago, we had a high school sophomore from 
Durango, Colorado, who died from an accidental fentanyl 
overdose. We received $23 million, maybe a little more than 
point $23 million for the substance abuse prevention treatment 
block grants as part of the Rescue Plan, the American Rescue 
Plan.

    As this help goes out across Colorado, do you see, or let 
me be--what specifically do you see as the most effective 
utilizations of that funding? What are the best investments we 
can use to try and go after the fentanyl overdose rates, and 
how is SAMHSA working with states to provide that real time 
information and data and technical assistance to get there.

    Ms. Delphin-Rittmon. Yes. So often what we find is states 
will use the strategic prevention framework approach to be able 
to identify approaches and strategies that will work most 
effectively within their context.

    Many of the community coalitions will do focus groups, meet 
with schools, meet with students to be able to develop 
messaging that is going to resonate with students and resonate 
with schools.

    In some instances, the coalitions will work with schools 
and students to develop some of that messaging so that it is 
really coming from students. So I think that is one thing that 
is helpful, developing messaging that students can take in and 
that raises awareness about the dangers of fentanyl, to include 
social media access of fentanyl, as well as just the dangers of 
fentanyl use.

    I think another strategy that can help is working with 
schools to raise awareness about and being able to identify 
students that may be struggling with substances or that may be 
having trouble. And ultimately being able to connect those 
students to services and supports.

    Senator Hickenlooper. All right. Thank you. And I think 
that--I think we are making progress in actually identifying 
the types of kids that might, would be likely to experiment.

    Often with fentanyl, it seems like so often that it is 
somebody who has almost no experience in drug use. Not always, 
obviously, but too often. Anyway, I am out of time. I have got 
a couple other questions, but I will file them in written form. 
Thank you.

    The Chair. Thank you.

    Senator Casey.

    Senator Casey. Thank you, Chair Murray. And I want to thank 
you for calling this hearing, and I want to thank our witnesses 
for their testimony and for the expertise they bring to bear on 
this awful, awful fentanyl crisis that has consumed the 
country.

    Pennsylvania is third in a category we don't want to be 
third in, third in overdose deaths. Pennsylvania had 5,438 
deaths in 2021 alone. That is around one death every 2 hours. 
And of course, just like in so many other places, fentanyl is 
the dominant, the dominant opioid. So it has consumed so many 
families, so many communities.

    Like Chair Murray, I am very concerned about the rise in 
fentanyl related overdose deaths in adolescents who, because of 
their stage of development, are more vulnerable to opioid use 
disorder.

    This is particularly the case when a young person has a 
mental health condition like ADHD, depression, or anxiety, 
which too often goes undiagnosed and untreated. So I will start 
with Dr. Delphin-Rittmon. Can you speak to two things, No. 1, 
the relationship between opioid use disorder and other mental 
health conditions?

    No. 2, how timely mental health care for young people can 
help prevent opioid misuse.

    Ms. Delphin-Rittmon. Yes. Thank you for that question, 
Senator, and for all your work and advocacy in this area. We 
know that for some youth as well as adults, use of opioids or 
other substances is connected to, for some individuals, mental 
health challenges.

    To the extent that services and supports are, and we talk a 
lot about this, that we are able to take a co-occurring 
approach, that services and supports are able to address both 
mental health and substance use challenges. But that is 
important also in terms of identification.

    We do have a program called, for short it is, the youth 
family tree. And what that program is about is early 
identification of youth that may be struggling, youth, as well 
as transition age individuals, and other members of families.

    It is a grant that takes a community based approach, a 
family based approach, and really uses multi-system approach to 
be able to identify, do early identification, but also early 
connection to services and supports such that the addiction 
doesn't progress.

    I think that is one area that is an important area of work. 
In fact, that grant is up for authorization so certainly 
appreciate this Committee's commitment to that area of work. 
There is also work in terms of being able to ensure access.

    You mentioned the piece around ensuring that there is 
timely access to services and supports. And so I think that is 
an important part of the system of care work as well, ensuring 
that whether it is a school system or whether family members, 
that there is awareness around how to access and connect 
students or families to services and supports.

    Senator Casey. Thank you very much, doctor. And I wanted to 
turn to Carole Johnson, with whom I worked on the Aging 
Committee.

    It is great to see you again, I guess twice in a week. But 
Carole, wanted to make a reference to both the screening and 
access to medications for opioid use disorder, which, of 
course, are not yet meeting demand.

    We know there are wide gaps in the workforce that are 
caring for adolescents. I have a bill with Senator Cassidy to 
support cross training of the pediatric health care workforce 
to address mental health and substance use disorders.

    Given the serious threat of fentanyl to young people, we 
can't afford to miss any opportunity to screen adolescents for 
these disorders. How do we increase opioid use disorder 
competency in the pediatric health care workforce?

    Ms. Johnson. Thank you so much, Senator Casey, and thank 
you for your leadership on this issue. We think this is 
critically important, making sure that we create sort of norms 
and standards in the health care workforce.

    That primary care sites, pediatrics offices, primary care 
physicians, our community health centers are places where our 
clinical workforce is trained to identify mental health and 
substance use disorders and, where appropriate, be able to help 
begin treatment. And so that is why we are committed to this 
work.

    We appreciate the progress that we have made with the 
Pediatric Mental Health Access Program, which has helped us be 
able to bring mental health expertise directly into 
pediatricians' offices. But we want to continue to look for 
ways to grow the capacity of the primary care workforce and 
pediatricians to address substance use disorder directly.

    Senator Casey. Thanks very much. Thanks, Chair Murray.

    The Chair. Senator Rosen.

    Senator Rosen. Thank you, Chair Murray. I really appreciate 
holding this very important hearing today, and of course, the 
witnesses for all of your work in this area. And so, like so 
many of us, we are just so worried about our communities and 
the overdose disparities, especially in Nevada in our Latino 
communities.

    The synthetic fentanyl crisis has gotten worse in recent 
years in Nevada. It has unfortunately disproportionately 
impacted our growing latino population. In fact, between 2019 
and 2020, drug overdose deaths among Latinos in Nevada 
increased 120 percent, and the proportion of those involving 
fentanyl increased 135 percent, the highest among any 
demographic group.

    Compounding this problem is a lack of awareness in our 
Latino community about resources, including harm reduction 
strategies, as well as a shortage of substance abuse disorder 
providers, particularly culturally competent Spanish speaking 
providers.

    Dr. Delphin-Rittmon, what kind of targeted community 
outreach is SAMHSA doing to ensure Latino communities not just 
in Nevada but across the country, have access to evidence based 
substance use disorder resources to help curb addiction, 
including those harm reduction strategies?

    Ms. Delphin-Rittmon. Yes, thank you for that question, 
Senator Rosen. And so this is an area that is a priority for 
SAMHSA. It is certainly a priority as well within the 
Secretary's overdose prevention strategy, or it is one of the 
cross-cutting areas that is equity.

    One of the things that we do is we fund the Hispanic and 
Latino Addiction Technology Transfer Center. What that center 
does is it provides a broad range of training and technical 
assistance to providers across the Country.

    That helps to ensure that those providers are able to 
implement culturally responsive services, services that meet 
the needs of Latino individuals and diverse groups. And so that 
training is available across the Country.

    Another area of work we have through our Office of 
Behavioral Health Equity for our new grantees and actually 
previous grantees as well that we have strengthened this 
program. We now do disparity impact statements. And so grantees 
have to identify disparity populations that may be serving 
within their region or area, and then identify how that grant 
will be used to address disparities among those individuals or 
groups that--where disparities exist.

    Then what we have increased, we have now increased, or will 
be increasing, the technical assistance to grantees to ensure 
that they have the resources and support that they need in 
terms of addressing the needs of diverse groups.

    We are excited about that program. We think that will make 
a real difference in terms of working across our grant programs 
to help them to be able to identify disparity populations, but 
also address those disparities as well to include among Latino 
individuals.

    Senator Rosen. Well, that is great that you are doing that, 
but we know that you need the resources and that means the 
workforce.

    While SAMHSA's minority fellowship program, you have made 
strides in increasing provider diversity and boosting cultural 
competency and behavioral health, data suggests that people of 
color still only constitute a significant minority of the 
substance abuse disorder workforce.

    Again, Dr. Delphin-Rittmon, as the Committee seeks to 
reauthorize and enhance SAMHSA programs this year, I really 
want to see how we can expand and improve on these minority 
fellowship programs to bring people into the workforce to 
ensure we are attracting and retaining these providers, 
mentoring the next gen of them, and they can better serve the 
trust of Latinos, of course, all of our minority populations, 
underserved populations across the Nation.

    Ms. Delphin-Rittmon. Yes. Thank you for that. And that is a 
program, well, for one I can say it is near and dear to my 
heart. I went through the fellowship program 1992 to 1993.

    One thing we are doing to expand that program is to 
increase the number of individuals that can go through at the 
master's level. Either they are doctoral level fellowships that 
are provided.

    I went through the doctoral program, but now we are 
increasing that to the master's level. That will help to 
increase the numbers of individuals that are able to begin 
practicing and begin working in the field sooner.

    We are real excited about that. And we know the programs 
coming up for authorization. That is some of what we will use 
those resources for. Other programs we have are around working 
with HBCUs and Hispanic serving institutions as well around 
attracting individuals to the behavioral health professions who 
may be considering behavioral health or may be interested in 
behavioral health.

    That is an additional program that works to increase the 
numbers of individuals from diverse populations that are 
entering the behavioral health fields or individuals interested 
in working with diverse populations as well.

    Senator Rosen. Thank you. I think my time has expired. 
Thank you, Madam Chair.

    The Chair. Thank you.

    Senator Kaine.

    Senator Kaine. Thank you, Chair Murray. And thank you to 
our witnesses for being here today and for your important 
testimony. So my state is like others, I have heard each 
Senator talk about the tragedy of this in their states.

    There were 2,656 overdose deaths in Virginia in 2021. It 
was a 15 percent increase from 2020, and fentanyl was 
responsible for 77 percent of those fatal overdoses. So we are 
all grappling with this, and I appreciate the testimony, and 
colleagues of mine have asked many questions that I was going 
to.

    I wanted to ask you a question about a strategy to deal 
with this issue, Dr. Delphin-Rittmon, that we have talked about 
before. The last time you were here, I asked a question about 
connecting incarcerated individuals to treatment services and 
in particular about drug courts.

    You shared information from SAMHSA's drug court program, 
and those are programs most of us have in our states. Work to 
divert individuals from further involvement with the justice 
system into behavioral health treatment that is more likely to 
lead to a successful outcome.

    When I meet with sheriffs in Virginia, I always ask them 
this as the opening question, what percentage of people in your 
jail shouldn't be there? I don't have to describe my terms. I 
don't have to define what I mean. They know what I mean.

    They know that I am asking what percentage of people in 
jail aren't really bad people, are not really crooks, they are 
not criminals, but they are people with substance use issues 
that have either been diagnosed and not treated or not 
effectively treated, or in some instances never diagnosed.

    I have never had a sheriff give me a number less than 40 
percent. And often sheriffs give me numbers 50, 60, 65 percent. 
Since 2017, Virginia has received four SAMHSA supported grants 
for drug courts, one in Lynchburg, Harrisonburg, Richmond, and 
Abingdon in far Southwest Virginia.

    I have been to some of the drug courts to talk to them 
about what they do. I have been to some graduations. In fact, I 
have been to two graduations in the last couple of years. In 
one, the drug court program was started by a local circuit 
court judge whose child had died of a drug overdose and that 
led her to spur the effort to start it.

    Then the other one that I went to, one of the probation 
officers who works with the drug court program came up to me 
and said, and this is my second graduation this week, and I 
said, I thought this county only had one program going on at 
any one time. He said, we do, but my first graduation was my 
son graduated from a drug court program in another county and 
here is the one that where I am the probation officer and I am 
here for--because I am proud of my graduates.

    Talk a little bit about the effectiveness of the drug court 
programs in SAMHSA. There is funding issues. Do we have enough 
funding to operate them? I happen to believe the moneys we 
invest in these are some of the best investments we make. But 
if you, Dr. Delphin-Rittmon, talk about drug court programs.

    Ms. Delphin-Rittmon. Yes. Thank you for that question, and 
just for all your work in this area. I mean, what we find and 
what we know is that drug court programs, they make a 
difference. They make a meaningful impact in people is lives.

    That it is an opportunity to reduce further penetration 
into the justice system for individuals that are struggling 
with substance use challenges. It is an opportunity to connect 
people to evidence based services and supports, to include 
medication assisted treatment, and to really change the 
trajectory of an individual's life because they are able to get 
that treatment that is critical.

    As you know, we also do enriched programing. And so the 
enriched programing is for individuals that are connected, are 
further along, and maybe before release, whether it is from 
jail or prison, we work to connect them to services and 
supports to include buprenorphine if necessary.

    In fact, right after this hearing I will be flying to the 
national annual meeting of drug court professionals and will be 
doing a series of meetings with different court groups related 
to their work. This is vital lifesaving work, and this program 
is coming up for reauthorization as well. So, I certainly 
appreciate the Committee's commitment and interest in this 
area.

    Senator Kaine. Please pass on, as you go out and talk to 
drug court professionals, the respect that we have for the work 
that they do. Here is a question dealing with fentanyl coming 
into the United States from abroad.

    What can you tell us, particularly those with the National 
Drug Control Office, what can you tell us if there is a pie 
chart, some come by mail, some people smuggle over the border, 
some maybe come around the borders, but I understand that huge 
percentages of the fentanyl that come in the United States come 
in across our ports of entry in vehicles.

    Because we only inspect one out of every however many 
vehicles, cartels figure they can play the odds and they can 
actually just smuggle it right across the border through ports 
of entry. Can you share what the data is about that?

    Mr. Chester. Yes, Senator. And it is an understandable 
question, but I am afraid it is an unknowable question, because 
the only thing that we can calculate is what we see and what we 
find, right. But your characterization of vehicles is correct, 
but I think for a different reason. Our Customs and Border 
Protection do have the ability to be able to do non-intrusive 
detection that is very impressive.

    I was down last fall in El Paso, and the non-intrusive 
detection capability that they have is very good. But more 
importantly are those ports are manned with incredibly 
experienced agents who can pull a vehicle into secondary just 
based upon, I have seen this before, just based upon intuition.

    They also have heuristic models and algorithms that can 
determine the right time to pull folks into secondary. So there 
are a lot of reasons why someone get pulled in the secondary.

    But your characterization of drug traffickers is absolutely 
correct, because a drug trafficker can send ten vehicles across 
knowing that two may get pulled aside, but that is just built 
into the business model and the amount of profit and knowing 
that the remainder are going to be able to get through.

    That is the challenge that we have. And even if we were 
able to reduce that number to C7 and only three get through, 
drug traffickers in pursuit of profits are going to find other 
ways in order to be able to circumvent that and get the drugs 
into the Country.

    What we do by looking at it really in a more holistic 
fashion is to determine when we see changes in the environment 
and how quickly we can surge in order to address that change as 
well. And that is why we would describe it as a dynamic 
environment. That is what we mean by that.

    Senator Kaine. Well, I am over time. But Madam Chair, to 
me, what that suggests is if any of our efforts on the 
enforcement side just lead creative people who want to make 
profits to figure out another way to do it, then ultimately you 
have got to tackle this on the demand side. And so that is 
prevention, and that is the kind of things you have been 
testifying to. And if we don't talk about--[technical 
problems]----

    The Chair. Thank you. That will conclude our hearing today. 
And I want to thank all of my colleagues, and especially I want 
to thank our witnesses today, Mr. Kemp, Dr. Delphin-Rittmon, 
Ms. Johnson, and Dr. Jones.

    Thank you for a very thoughtful conversation on such an 
urgent crisis for all of our communities. If there is one thing 
we take away from today's conversation, I hope it is that our 
communities can't wait.

    They need urgent action from the Administration and from us 
in Congress to disrupt the supply of dangerous illicit 
fentanyl, to support those on the front lines of this crisis in 
our communities, and especially to connect people with the 
prevention, the treatment, and recovery support services that 
we know saves lives.

    That is why it is really important to me, as--more 
important to me as ever that we can advance a bipartisan 
package that makes meaningful progress on these issues.

    I hope that all of my Republican colleagues agree and that 
we can continue our process negotiating a very robust mental 
health and substance use disorder bill that will support the 
programs we have seen make such a difference and provide 
additional tools and resources to tackle the new threats and 
emerging challenges in this space.

    For any Senators who wish to ask additional questions, 
questions for the record will be due in ten business days, 
August 9th at 5.00 p.m. And the Committee stands adjourned.

                          ADDITIONAL MATERIAL

           prepared statement of ranking member richard burr
    The rise in overdose deaths is being driven by illicit fentanyl and 
has affected every corner of our communities. My home State of North 
Carolina has not been spared, and too many individuals and families in 
my state have dealt with tragedy as a result of fentanyl. In order to 
address the fentanyl problem in the United States, we need strong 
leadership and an effective, multi-sectoral strategy that addresses 
both the source of the drugs and also the substance use disorder 
prevention and treatment needs of the response.

    I had hoped to have Customs and Border Protection here to discuss 
with the Committee what they are seeing, particularly at the border, 
with respect to drug trafficking. Just last week, two men in Washington 
State were charged with smuggling 91,000 fentanyl pills inside potato 
chip containers in connection with a transnational criminal 
organization. Or the Drug Enforcement Administration, which just 
earlier this month, announced the seizure of 100,000 fake oxycodone 
pills containing fentanyl and could provide us with a clear picture of 
the criminal networks that are mass-producing illicit fentanyl and fake 
pills in clandestine laboratories. But Chair Murray did not want to 
invite those agencies to this hearing, despite requests, so that we 
might gain a better understanding of the complexity behind the illicit 
fentanyl and fentanyl analogues problem in the United States and their 
sources.

    Every day, illicit drugs are entering the country from China, 
Mexico, and India. The recent news from Washington State is just one 
example of this problem. And it's driving overdose deaths. According to 
DEA, the agency's lab testing demonstrated that 4 out of every 10 pills 
with fentanyl contain a potentially lethal dose. Permanently scheduling 
fentanyl analogues, which drug traffickers use to skirt trafficking 
laws, as Schedule I under the Controlled Substances Act would play a 
significant role in reducing the supply of illicit fentanyl smuggled 
into the United States. I urge my colleagues to consider the HALT 
Fentanyl Act, a bill that Senator Cassidy and I worked on together that 
would permanently schedule fentanyl analogues as Schedule I under the 
Controlled Substances Act.

    We also need to continue to support and improve public health 
programs charged with responding to the substance use disorder 
prevention, treatment and recovery needs of communities that were hit 
hard by the opioid crisis and now are grappling with high overdose 
rates driven by illicit fentanyl. With the passage of the Comprehensive 
Addiction and Recovery Act of 2016, the 21st Century Cures Act, and the 
SUPPORT for Patients and Communities Act, Congress has demonstrated its 
commitment to supporting substance use disorder needs. We need to make 
sure our programs are effectively utilizing data, leveraging innovative 
medical products for treatment and overdose reversal, and partnering 
with different sectors to promote effective solutions on the ground. I 
am thankful for Senator Bill Cassidy's expertise and willingness to 
serve as Ranking Member for the Senate HELP Committee hearing today, 
and look forward to continuing to work on this issue.
                                 ______
                                 

                         QUESTIONS AND ANSWERS

   Response by Kemp Chester to Questions of Senator Baldwin, Senator 
 Rosen, Senator Burr, Senator Collins, Senator Murkowski, and Senator 
                                 Scott
                            senator baldwin
    Question 1. Steven Welnetz's mother recently shared his story with 
me. She described him as a person with a heart of gold. On November 6, 
2021, he took what he thought was a Xanax. It had been pressed with 
fentanyl, and he died shortly thereafter.

    Fentanyl is being brought in to the United States in large 
quantities, including through International Mail Facilities.

    How is ONDCP working with other agencies to combat the importation 
of fentanyl, including fentanyl that is entering the country through 
the mail?

    Answer 1. Illegal substances enter the United States through a 
variety of means. They can be marketed and sold on the dark web using 
cryptocurrency and delivered to the purchaser through the mail and 
commercial carriers, or can be brought across the Nation's geographic 
borders by multiple conveyances; from body carries, to containers on 
cargo ships, through commercial and private vehicles, or purpose-built 
watercraft. The Biden-Harris administration is committed to exploring 
and using every means available to reduce the supply of illicit 
substances in America's communities. This includes ensuring our law 
enforcement agencies have the resources they need to disrupt the sale 
of these drugs on the internet and the flow of drugs across our borders 
and working with our international partners to halt drug production 
outside the United States. Those international efforts include 
controlling the chemicals used to produce both plant-based and 
synthetic drugs, and ensuring those involved in any aspect of the 
global drug trade, including their illicit proceeds, are held 
accountable.

    There are a number of robust and ongoing interagency efforts 
investigating drug sales on the internet and shipped through the mail 
system. As you can imagine, we do not make a lot of that information 
public so that drug traffickers cannot adapt their tactics based upon 
knowledge the extent of our activities. Discussing law enforcement 
activities in detail could compromise ongoing investigations, but 
successful initiatives are underway, such as the FBI Joint Criminal 
Opioid and Darknet Enforcement (JCODE) program which pursues 
traffickers who exploit the dark web to market and sell opioids, as 
well as other drugs.

    We also know that transnational criminal organizations (TCOs) are 
poly-crime, and that their illicit revenues come from a variety of 
criminal activities in addition to illicit drugs. Organizations like 
Homeland Security Investigations' (HSI) Cyber Crimes Center (C3) is 
dedicated to the criminal investigation of transborder internet-related 
crimes, including the sale and distribution of illicit drugs, as well 
as other criminal activities such as money laundering, illegal arms 
trafficking, child exploitation, and human trafficking.

    The United States Postal Inspection Service is at the forefront of 
both domestic and international efforts to stem the flow of illicit 
drugs through the mail. For example, The United States and Canada 
agreed to a bilateral Joint Action Plan on Opioids to strengthen cross-
border cooperation and develop effective approaches to addressing the 
opioid crisis. Within this bilateral agreement, The U.S.-Canada Postal 
Security Action Plan was created, which directly supports the bilateral 
priorities between the two Governments to address the ongoing opioid 
crisis and the emergence of dangerous synthetic drugs in the supply 
chain within the mail system.

    Over the last 3 years, the Postal Inspection Service has witnessed 
a dramatic decrease in international seizures of opioids, especially 
from China, while domestic seizures are increasing. Since 2019, the 
Inspection Service has not had a direct seizure of fentanyl from China. 
Ninety-nine percent of Postal Inspection Service seizures in fiscal 
year 2021 and fiscal year 2022 were from domestic mail, most originated 
from southwest border states. Overall, the Postal Inspection Service 
has greatly increased seizures of illicit synthetic opioids from the 
mailstream in terms of both the number of seizures and weight. In the 
past few years, the Postal Inspection Service has seen an increase in 
the weight of synthetic opioids per seizure. Nonetheless, China remains 
one of the top global suppliers of precursor chemicals for fentanyl 
production and continues to supply Mexico with these essential 
ingredients to the drug trade.

    The United States will pursue TCOs through all appropriate means, 
whether those are investigations into illicit drug trafficking, or any 
of their numerous other criminal activities.

    If you would like a more in-depth discussion on engagements by 
individual departments and agencies, I refer you to my colleagues in 
the Departments of Justice and Homeland Security, and the U.S. Postal 
Inspection Service.
                             senator rosen
    Question 1. SUPPORTING LAW ENFORCEMENT EFFORTS TO COMBAT FENTANYL 
IN NORTHERN NEVADA: While synthetic fentanyl took hold quickly in other 
parts of the country, it had been slower to reach Northern Nevada, 
which includes many rural communities. However, according to the Washoe 
County Sheriff's Office, as the amount of fentanyl in Northern Nevada 
has spiked in the last year and a half, fentanyl is now the second-
deadliest drug in Washoe County, behind only methamphetamine. Synthetic 
fentanyl is increasingly being pressed into pills to look like 
prescription drugs. As so many of my colleagues have pointed out, this 
is a public health crisis, and we must do more do support both law 
enforcement and the public alike to combat it.

    Mr. Chester, is ONDCP witnessing similar trends among other 
smaller, rural counties across the country, and what more can Congress 
and the Administration do to help support our local law enforcement 
agencies like the Washoe County Sheriff's Office in further disrupting 
fentanyl trafficking and production?

    Answer 1. ONDCP works to coordinate the efforts of Federal, state, 
Tribal, and local law enforcement to reduce the supply of fentanyl and 
other dangerous drugs through multijurisdictional task forces, such as 
those funded through ONDCP's High Intensity Drug Trafficking Areas 
(HIDTA) Program. HIDTA currently augments efforts in Washoe County 
through the Nevada HIDTA. In addition, Congress should pass the Biden-
Harris administration's approach to reduce the supply and availability 
of illicitly manufactured fentanyl-related substances (FRS) by 
permanently scheduling FRS, while safeguarding against racial 
disparities in prosecution and sentencing and reducing barriers to 
scientific research for all Schedule I substances.
                              senator burr
    Question 1. In years' past, and as recently as 2020, the National 
Drug Control Strategy (NDCS) has highlighted the beneficial role that 
Prescription Drug Monitoring Programs (PDMPs) play in combating 
prescription drug abuse and saving lives, going as far as to call for 
an increase in the utilization of PDMPs and their integration into 
Electronic Health Records (EHRs) to increase utilization. However, in 
the recently released 2022 NDCS, there is no mention of PDMPs the role 
they can play in helping to prevent the use and abuse of medications 
and the fact that 47 PDMPs have successfully integrated their PDMP into 
EHRs and Pharmacy Dispensation Systems. Why did the ONDCP decide to no 
longer highlight the positive role that PDMPs are playing in reducing 
access to, and abuse of, controlled prescription medications?

    Answer 1. ONDCP's response to overprescribing and the diversion of 
prescription opioids through prescribing guidelines, PDMPs, and 
provider training has been successful but more can be done to save 
lives. Overprescribing and ``pill mills'' still cause harm but the 
nature of the overdose crisis shifted from prescription opioid 
overprescribing to illicitly manufactured fentanyl, and our strategies 
for responding have shifted to address this new reality. The National 
Drug Control Strategy is a forward-looking document that identifies key 
drug policy priorities for the Federal Government and lays out a plan 
for addressing the most urgent work ahead. It is imperative that we 
focus our supply and demand reduction efforts on the key driver of 
overdose deaths today: illicitly manufactured fentanyl.

    Question 2. As the ONDCP has stated in previous years' National 
Drug Control Strategy that a barrier to the increased utilization of 
Prescription Drug Monitoring Programs (PDMPs) is due to a lack of 
integration into providers' Electronic Health Records (EHRs) and a lack 
of interstate data sharing capabilities. Technology underlying the 
PDMPs has made great strides in recent years to alleviate these issues, 
improving integration into EHRs, providing prescribers with complete 
and interstate data and improving the usability and ease to increase 
uptake and utilization of the PDMP services in all geographies. 
However, there are still impediments to fully realizing the PDMPs 
capabilities due to certain Federal entities discouraging states from 
using their preferred vendor and significantly obstructing progress in 
the market. Will you commit to ensuring that the ONDCP works with PDMP 
service providers and other Federal agencies to ensure that the PDMP 
market is fair and capable of offering the best services available for 
both patients and providers? Will you commit to ONDCP ensuring that 
Federal agencies do not impose any unnecessary conditions that could 
jeopardize the success of these programs by adversely impacting 
patients, providers, states, and/or the public health?

    Answer 2. ONDCP recognizes that PDMPs are a helpful tool for 
monitoring care. ONDCP is supportive of Centers for Disease Control's 
and Prevention and the Bureau of Justice Assistance's work related to 
developing PDMP infrastructure within States and fostering 
bidirectional capacity for data-sharing within and across States that 
enhances and maximizes bidirectional connectivity. ONDCP is embracing a 
combined public health and public safety approach to reduce demand and 
supply which will complement provider use of the PDMPs.
                            senator collins
    Question 1. Actionable Overdose Data (Mr. Chester and Dr. Jones). 
Mr. Chester, I appreciate that the National Drug Control Strategy 
prioritizes the need for more actionable data to track nonfatal 
overdoses, which you recognize in your testimony as ``one of the most 
accurate predictors of whether someone will experience a fatal overdose 
in the future.'' I was also encouraged to hear Director Gupta recently 
met with officials in Maine to see firsthand how Maine collects 
detailed overdose data. This data is critical for law enforcement and 
health care providers to appropriately gauge the scope of the crisis in 
their local communities and target resources where they are needed. I 
understand the Administration has recently created a Drug Data 
Interagency Working Group that will assist with the development of a 
new national plan for obtaining data in near real-time. However, this 
is expected to take 1 year to develop fully.

    Mr. Chester, can you provide an update on the status of this 
overdue data effort, including how the 1-year timeline was determined?

    Answer 1. The SUPPORT Act of 2018 mandated that ONDCP develop a 
``systematic plan for increasing data collection to enable real time 
surveillance of drug control threats, developing analysis and 
monitoring capabilities, and identifying and addressing policy 
questions related to the National Drug Control Strategy and Program.'' 
In order to develop a comprehensive Data Plan that meets these 
statutory requirements, it was critical for ONDCP to obtain and 
incorporate input from Federal agencies engaged in drug-related 
activities, since much of the data collection and analytical activities 
occur within these entities. In order to facilitate discussion and 
obtain feedback from each of the National Drug Control Program 
Agencies, ONDCP reconstituted the Drug Data Interagency Working Group 
in December 2021. The working group has convened four times in total 
with approximately 60 participants from 25 different Federal agencies. 
Through these communications, the working group identified data needs, 
discussed methods, analytical approaches, and challenges to developing 
evidence to support policymaking, and identified steps to be taken to 
implement the plan.

    The 2022 National Drug Control Strategy (pages 123-125) summarized 
the background and process for developing the Data Plan, and proposed 
an approximately 1-year timeline to develop a more comprehensive plan.

    Question 2. Mr. Chester and Dr. Jones, how is ONDCP utilizing 
partners like the CDC who have expertise in data collection and 
partnerships across state and local public health agencies?

    Answer 2. ONDCP routinely meets and collaborates with organizations 
who have expertise in data collection and analysis. We have convened 
the Drug Data Interagency Working Group four times since December 2021 
to discuss data-related topics with the National Drug Control Program 
Agencies. We also meet periodically with CDC and other agencies on a 
regular basis to coordinate and discuss when new data has become 
available (such as the CDC's monthly releases of provisional estimates 
on drug overdose deaths), and to review and provide feedback on new 
data products and deliverables (such as the CDC's State Unintentional 
Drug Overdose Reporting System (SUDORS) and Drug Overdose Surveillance 
and Epidemiology (DOSE) Dashboards). ONDCP also hosts a monthly webinar 
which allows state and local governments to showcase their opioid and 
synthetic drug data. We also engage in stakeholder meetings with non-
profit organizations, private sector companies, and academic 
institutions to learn about innovative data sources and analytic 
approaches (such as wastewater-based epidemiology).
                           senator murkowski
    Question 1. I am concerned about the transportation of illicit 
fentanyl and other substances through the southern border and ports of 
entry. Throughout the U.S., many of the hardest-hit and most at-risk 
communities of the fentanyl and opioid crisis are often remote and 
rural areas. In Alaska, for example, many towns and villages are 
unconnected to major roadways and have limited access to land, air, and 
sea travel, and yet, continue to suffer from the inflow of fentanyl and 
fentanyl analogs into their communities.

    How is illicit fentanyl making inroads into the U.S. and Alaska's 
most rural communities, and what measures are being taken to address 
the trafficking that occurs within our own borders?

    Answer 1. The Biden-Harris administration is exploring and using 
every means available to reduce the supply of illicit substances in 
America's communities. This includes working with our international 
partners to halt drug production outside the United States, which 
includes monitoring and controlling the chemicals used to produce both 
plant-based and synthetic drugs; facilitating international law 
enforcement cooperation, ensuring our law enforcement agencies have the 
resources they need to disrupt the sale of these drugs on the internet 
and the flow of drugs across our borders; and ensuring those involved 
in any aspect of the global drug trade, including those that benefit 
from their illicit proceeds, are held accountable.

    The National Drug Control Strategy addresses both domestic and 
international priorities to reduce the supply of illicit substances 
coming into the United States. Domestically, we prioritize improving 
information sharing and cooperation; disrupting domestic production, 
trafficking, and distribution; improving efficiency and effectiveness 
of resource allocation, and protecting individuals and the environment 
from criminal exploitation.

    A key domestic partnership between Federal, state, local and Tribal 
law enforcement which is key to our supply reduction efforts in 
communities across the United States is the High Intensity Drug 
Trafficking Area (HIDTA) Program. HIDTA task forces work to disrupt and 
dismantle drug trafficking organization (DTO) networks that traffic 
Mexican sourced fentanyl into and throughout the United States. The 
HIDTA Program's continued efforts to address fentanyl trafficking 
played a significant role in the response to this threat. In 2021, in 
Alaska, in particular, the Alaska HIDTA has disrupted drug trafficking 
organizations operating in the region, and seized thousands of dosage 
units of fentanyl throughout the state.

    Question 2. According to preliminary data from the CDC, the U.S. 
experienced a 15 percent increase in overdose deaths from 2020 to 2021. 
Meanwhile, in Alaska, that increase was a staggering 75 percent, 
roughly five times the national average. Due to historical trauma other 
inequities, our Alaska Native population have experience high rates of 
substance use and alcoholism. I am concerned about the impact of the 
fentanyl epidemic on our rural Alaska Native communities, who are 
already experiencing significant increases in overdose deaths. How will 
you ensure the Federal efforts to address the rise of fentanyl overdose 
deaths will address the needs of those in rural areas, specifically 
American Indians and Alaska Natives?

    Answer 2. ONDCP continues to work closely with the Health Resources 
and Services Administration to ensure the fentanyl overdose prevention 
and opioid use disorder treatment needs of rural areas are being met. 
This includes expanding access to medication for opioid use disorder, 
naloxone to reverse overdoses, and fentanyl test strips where 
applicable under the law. In addition, ONDCP supports the Alaska HIDTAs 
in their efforts to reduce the supply of illicit fentanyl in the state.
    Question 3. In Alaska and around the country, drug addiction and 
substance use disorders are ending the lives of far too many youths. 
This past June, I, along with my colleagues Senator Feinstein, Senator 
Sullivan, and Senator Hassan, introduced S. 4358, Bruce's Law. This 
bill authorizes funding for the Department of Health and Human Services 
(HHS) to conduct a public awareness campaign targeted toward school-
aged children and youth on the dangers of fentanyl, establish an 
interagency working group on fentanyl contamination, and authorizes an 
expansion of grants for community coalitions to engage school-aged 
children and youth in outreach and prevention efforts.

    What type of outreach and prevention efforts are the CDC and SAMHSA 
currently supporting to educate youth and school-aged children on the 
dangers of counterfeit drugs laced with fentanyl? What inter-agency 
coordination takes place between the CDC, SAMHSA, and ONDCP on these 
efforts?

    Answer 3. ONDCP, CDC, and SAMHSA regularly amplify prevention 
efforts, new resources and training opportunities among the youth 
substance use prevention field. The most recent example of 
collaboration amongst ONDCP, CDC, and SAMHSA Center for Substance Abuse 
Prevention is the sharing of a monthly resource document to ensure 
Federal staff supporting prevention efforts are aware of the resources 
available amongst the three agencies. The sharing of this monthly 
resource will ensure the Federal Government continues to be well 
equipped to support the evolving needs of communities.

    In addition, the Drug-Free Communities (DFC) Support Program is the 
Nation's leading effort to mobilize communities to prevent and reduce 
substance use among youth. Created in 1997 by the Drug-Free Communities 
Act, administered by the White House Office of National Drug Control 
Policy (ONDCP), and managed through a partnership between ONDCP and 
CDC, the DFC program provides grants to community coalitions to 
strengthen the infrastructure among local partners to create and 
sustain a reduction in local youth substance use.

    The Drug Enforcement Administration (DEA) also issued its first 
national public safety alert in 6 years and launched the ``One Pill Can 
Kill'' public awareness campaign to raise awareness of the dangers of 
fake prescription pills laced with fentanyl.

    Question 4. How does ONDCP believe that Bruce's Law, if enacted, 
would enhance their prevention efforts?

    Answer 4. While the Administration has not yet taken a position on 
the legislation, ONDCP supports evidence-based prevention and reduction 
of youth substance use and evidence-based overdose prevention.
                             senator scott
    Question 1. The Drug Enforcement Agency has referred to Mexican 
drug cartels as the ``greatest drug trafficking threat to the United 
States.'' According to the U.S. Customs and Border Patrol Agency, 
fentanyl seizures at our ports of entry increased 1,066 percent in 
2021. This came at a time when the Biden administration was moving to 
end the previous Administration's ``zero tolerance'' border policy.

    Mr. Chester--In your testimony, you describe routine engagements 
between the U.S. and China regarding shipments of precursor chemicals 
and illicit financing schemes with ties to Chinese criminal 
organizations.

    How confident is the Biden administration in its Chinese Communist 
Party counterparts to cutoff the flow and finance of illicit Chinese 
fentanyl into North America, given the lack of cooperation on 
investigations into the origins of COVID-19 and recent provocations by 
the Chinese Communist Party in the Taiwanese region?

    Answer 1. The Chinese government must do more to hold accountable 
the individuals and entities within its borders who supply synthetic 
opioids and drug precursors to drug trafficking organizations. Dr. 
Gupta made this point recently in a Wall Street Journal opinion piece 
urging The People's Republic of China (PRC) to join the United States' 
efforts to stop the flow of illicit precursor chemicals and substances. 
He wrote that ``Unless other countries, including the PRC, join the 
U.S. and act, drugs such as fentanyl and methamphetamine synthesized 
with precursors made in the PRC will continue to flood the world.''

    Question 2. What specific actions has the Biden administration 
taken to not just address the deficit of trust but to also hold the 
Chinese Communist Party accountable in the international fight against 
illicit fentanyl flows and financing?

    Answer 2. There are practical and common-sense steps nations can 
take to disrupt the global trafficking of synthetic opioids and their 
precursors. They include implementing ``know your customer'' standards 
to prevent the diversion of chemicals to illicit drug manufacturing; 
proper labeling of chemical shipments from host countries through 
enforcement of World Customs Organization standards; and monitoring for 
the diversion of uncontrolled chemicals and equipment in international 
flows.

    Dr. Gupta recently expressed the need for the Chinese government to 
reengage in the international arena. Without the Chinese government's 
engagement, shipments of precursor chemicals to illicit drug producers 
in Mexico will continue, and traffickers will keep moving these drugs 
into America. The Chinese government's decision to suspend full 
cooperation on this issue will result in more American deaths and more 
deaths worldwide. The U.S. will continue to work domestically and with 
its partners around the world to disrupt criminal organizations, get 
people the care they need and save lives. The Biden administration is 
turning partnerships it has renewed and strengthened, such as the 
Bicentennial Framework with Mexico and the Opioid Action Plan with 
Canada, into action. The Biden administration will continue to make 
action against the synthetic-drug supply chain a priority in order to 
save lives.

    Question 3. Mr. Chester--Are the relaxed border policies of the 
Biden administration coupled with rouge district attorneys and 
prosecutors who fail to prosecute criminals contributing to, in whole 
or part, America's opioid crisis?

    Answer 3. There are record amounts of illicitly manufactured 
fentanyl being seized at our borders thanks to the brave men and women 
on the front lines. Dr. Gupta has been to the border and seen first-
hand the great work being done there.

    For example, in fiscal year 2022 through July, CBP seized 231,186 
pounds of drugs along the southwest border, 68 percent of which were 
seized at southwest border Ports of Entry (POE). When you look at 
fentanyl and methamphetamine, the percentage of drugs seized at POEs is 
even higher. POE seizures account for 85 percent of the weight of 
fentanyl and 88 percent of the weight of methamphetamine seized along 
the southwest border.

    The good news is that those drugs won't make their ways into our 
communities. But we must also ensure that the men and women on the 
front lines have the resources they need to ramp up their efforts to 
address the immense influx of supply they face at our borders. That's 
why the President called for more than an $18 billion investment to 
reduce the supply of illicit substances in the United States in his 
fiscal year 23 budget. This includes $747.5 million in increases for 
efforts to reduce the availability of drugs, including efforts to 
interdict illicit drugs at ports of entry and disrupt drug trafficking 
networks, support domestic law enforcement efforts to reduce drug-
related violence and property crime, and availability of illicit 
substances and work with international partners to reduce drug 
production.

    However, the challenge of drugs like illicit fentanyl making its 
way into our communities does not begin or end at the border, so we 
must also counter the criminal networks who produce and traffic them; 
disrupt every aspect of their commercial enterprise; target drug 
transportation routes and modalities; and aggressively reduce the 
production of illicit drugs in the countries where they are created. 
Effectively bolstering border security and reducing drug trafficking 
require effort and coordination both domestically and abroad.

    Domestically, our nationwide drug interdiction efforts are focused 
on the most prolific drug trafficking routes and modalities, and we 
seek to fully leverage drug interdictions to help illuminate and 
dismantle the criminal organizations responsible for manufacturing and 
trafficking illicit drugs. Information sharing between agencies is 
vitally important to this end.

    One of the things ONDCP does is provide funds directly to our state 
and local partners through the national HIDTA program to disrupt drug 
trafficking organizations. For fiscal year 2023, ONDCP requested $293.5 
million for the national HIDTA program.

    Abroad, we work with our key partners in the Western Hemisphere, 
like Mexico, to shape collective and comprehensive responses to illicit 
drug production and trafficking. We also engage with nations like the 
PRC and India to disrupt the global flow of synthetic drugs and the 
precursor chemicals used to produce them to nations, like Mexico, where 
illicit synthetic drugs are produced in large quantities.
                                 ______
                                 
   Response by Dr. Miriam E. Delphin-Rittmon to Questions of Senator 
Baldwin, Senator Lujan, Senator Burr, Senator Cassidy, Senator Collins, 
                  Senator Murkowski and Senator Scott
                            senator baldwin
    Question 1. Nikolas Barrett Graves of Beloit, Wisconsin had plans 
to go to culinary school. He was active and outgoing. On December 22, 
2018, he died after trying heroin that contained fentanyl. Cade 
Reddington was a graduate of Waunekee Community High School, a student 
at UW-Milwaukee, and a kid who was full of life, energy and excitement. 
On November 4th, 2021, Cade died in his dorm room after taking what he 
thought was a Percocet pill. That pill contained fentanyl.

    Nikolas and Cade could have been saved by naloxone.

    What does SAMHSA need to make sure that naloxone is more readily 
available to first-responders and in key locations, such as schools and 
community centers?

    Answer 1. The promotion and distribution of naloxone and fentanyl 
test strips represent an opportunity to not only promote life-saving 
interventions, but to also provide education on drug potency and 
mortality. However, some grantees are faced with challenges in the 
distribution of fentanyl test strips due to state laws that classify 
fentanyl test strips as illegal paraphernalia.

    SAMHSA has focused on promoting education about synthetic opioids 
through its grantees and education networks such as the Addiction 
Technology Transfer Centers. We have also produced evidence-based 
guides on addressing polysubstance misuse in order to overcome the 
growing incidence of concurrent substance use disorders.

    Through SAMHSA's State Opioid Response (SOR) program, grantees are 
required to implement prevention and education services including: 
training of peers, first responders, and other key community sectors on 
recognition of opioid overdose and appropriate use of the opioid 
overdose antidote naloxone; developing evidence-based community 
prevention efforts such as strategic messaging on the consequences of 
opioid and stimulant misuse; implementing school-based prevention 
programs and outreach; and distributing the opioid overdose antidote 
reversal naloxone. Naloxone is an important tool in preventing overdose 
deaths and many studies have demonstrated the value of naloxone 
distribution \1\ and that increased saturation in communities reduces 
overdose deaths. \2\ Therefore, SAMHSA has required that all SOR 
grantees submit a naloxone distribution and saturation plan 
particularly focused on areas with high rates of overdose mortality. 
With SAMHSA funds, states have the flexibility to purchase and 
distribute naloxone in areas they deem most appropriate based on the 
needs of the state. SAMHSA will continue working with states on the 
implementation of these plans.
---------------------------------------------------------------------------
    \1\  Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, 
Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and 
implementation of overdose education and nasal naloxone distribution in 
Massachusetts: interrupted time series analysis. BMJ. 2013 Jan 30; 346: 
f174.
    \2\  Irvine MA, Oller D, Boggis J, Bishop B, Coombs D, Wheeler E, 
Doe-Simkins M, Walley AY, Marshall BDL, Bratberg J, Green TC. 
Estimating naloxone need in the USA across fentanyl, heroin, and 
prescription opioid epidemics: a modelling study. Lancet Public Health. 
2022 Feb 10: S2468-2667(21)00304-2. doi: 10.1016/S2468-2667(21)00304-2. 
Epub ahead of print. PMID: 35151372.

    The SOR grant program has supported local educational campaigns on 
naloxone for younger Americans. For example, through an agreement with 
Morgan State University (MSU), MSU created three digital ads on stigma, 
the dangers of fentanyl, and how to use naloxone. These ads were 
displayed on digital advertising boards at three local shopping malls 
over a 90-day period. MSU also created augmented reality spots for the 
social media platform, TikTok, using the Maryland Helpline: Call 211, 
press one campaign. These were all geared for the younger demographic 
as a way to provide lifesaving information through an interactive app 
---------------------------------------------------------------------------
on their cell phones.

    SAMHSA's Substance Abuse Prevention and Treatment Block Grant 
(SABG) program is another resource for states to use to combat the 
overdose crisis. Through the SABG, states are able to promote education 
about naloxone through a wide variety of school, community, and faith-
based organizations. States also have the option to use block grant 
funds for the purchase and distribution of naloxone. A particularly 
critical area of focus is through substance use prevention, harm 
reduction, and treatment programs. These actions through the SABG can 
assure more ready access to and rapid use of naloxone by members of the 
broader community, including prevention, harm reduction, and treatment 
professionals and affiliates, community centers, educational 
institutions, the medical community, clients and potential clients, 
family members, and persons in the larger recovery community.

    SAMHSA's First Responders--Comprehensive Addition and Recovery 
Support Services Act (FR-CARA) grant program provides resources to 
first responders (such as firefighters, law enforcement officers, 
paramedics, emergency medical technicians, mobile crisis providers, 
Tribes or Tribal organizations that respond to adverse opioid related 
incidents) to train, carry and administer naloxone and other drugs and 
devices for emergency reversal of known or suspected opioid overdose. 
The FR-CARA grant program specifically targets populations which are 
especially vulnerable to overdose, including communities with an 
incidence of individuals with opioid use disorder that is above the 
national average and communities with a shortage of prevention and 
treatment services.
                             senator lujan
    Question 1. According to the CDC, only about 1 in every 10 American 
Indian, Alaska Native, and Hispanic people with substance use disorder 
reported receiving treatment. \3\ In fact, more than 70 percent of the 
over 2 million Americans struggling with opioid addiction are not 
getting treatment. \4\ Will improving access to medication assisted 
treatment for opioid use disorder save lives?
---------------------------------------------------------------------------
    \3\  https://www.cdc.gov/media/releases/2022/s0719-overdose-rates-
vs.html.
    \4\  Center for Behavioral Health Statistics and Quality, 2017 
National Survey on Drug Use And Health: Detailed Tables, Rockville, 
Md,: Substance Abuse and Mental Health Services Administration, 2018.

    Question 2. Despite an expansion in access to medication assisted 
treatment for opioid use disorder in some areas, rates of overdose 
remain high for American Indian and Alaska Native communities. \5\ How 
important is the availability of culturally competent treatment for 
historically marginalized communities?
---------------------------------------------------------------------------
    \5\  Higher availability of treatment services does not mean 
improved access to care. Opioid overdose rates in 2020 were higher in 
areas with higher availability of opioid treatment programs compared 
with areas with lower treatment availability, particularly among Black 
(34 vs. 17) and AI/AN (33 vs. 16) people per 100,000. The known 
differences in access, barriers to care, and healthcare mistrust could 
play a role in exacerbating inequities even when treatment is available 
in the community.

    Question 3. Does increasing access and reducing barriers to proven 
---------------------------------------------------------------------------
recovery support services reduce future overdose deaths?

    Question 4. What are the primary barriers for those seeking 
recovery services?

    Question 5.Harm reduction tools are critical to saving lives. New 
Mexico recently passed legislation to decriminalize the possession of 
fentanyl test strips. How have harm reduction measures, like fentanyl 
test strips, impacted people's behavior?

    Answers 1-5. Evidence-based treatments for substance use disorder 
reduce substance use, related health harms, overdose deaths, and 
increase odds for long-term recovery. Medications for opioid use 
disorder (MOUD) in particular have been shown to significantly reduce 
the risk of opioid-related overdose. \6\ However, these medications 
continue to be underutilized, in part due to the stigmatization 
associated to them compounded by other barriers to treatment access.
---------------------------------------------------------------------------
    \6\  Krawczyk, N., Mojtabai, R., Stuart, E. A., Fingerhood, M., 
Agus, D., Lyons, B. C., Weiner, J. P., and Saloner, B. (2020) Opioid 
agonist treatment and fatal overdose risk in a state-wide US population 
receiving opioid use disorder services. Addiction, 115: 1683-1694. 
https://doi.org/10.1111/add.14991.

    Addressing this stigmatization and expanding access to MOUD is a 
significant focus for SAMHSA. Part of this work is ensuring that MOUD 
and other substance use disorder services and policies are culturally 
responsive, evidence-based and in the best interest of those receiving 
services. For instance, SAMHSA's Tribal Opioid Response program is 
specifically focused on providing Tribal Nations resources to address 
opioid use disorder and stimulant use disorder in their communities. 
Another of SAMHSA's grant programs, the Tribal Behavioral Health grant 
program, also known as Native Connections, is intended to prevent 
suicide and substance misuse, reduce the impact of trauma, and promote 
mental health among American Indian/Alaska Native (AI/AN) youth. This 
program fosters culturally responsive models that reduce and respond to 
the impact of trauma and involve AI/AN community members (including 
---------------------------------------------------------------------------
youth, tribal leaders, and spiritual advisors) in all grant activities.

    SAMHSA also has a long history of advancing recovery supports. 
SAMHSA defines recovery as a process of change through which 
individuals improve their health and wellness, live self-directed 
lives, and strive to reach their full potential. Recovery support 
services make up a crucial component of the continuum of care for 
people with substance use disorders given the long-term nature of these 
conditions. With the non-clinical nature of these services, other 
funding sources often do not cover them, even when they are evidence-
based, validated recovery services that are integrated into treatment 
settings. The Administration supports the addition of a 10 percent set-
aside within the Substance Abuse Prevention and Treatment Block Grant 
(SABG) for recovery support services. This 10 percent recovery set-
aside will ensure that each state is supporting:

          the further development of local recovery community 
        organizations and centers, recovery and resiliency focused 
        strategies and educational campaigns, trainings, and events to 
        combat stigma;

           addiction recovery resources and support system 
        navigation;

           the recovery of diverse populations; and

           collaboration and coordination with local private 
        and non-profit clinical health care providers, the faith 
        community, city, county, and Federal public health agencies, 
        and criminal justice response efforts.

    Moreover, the increase in SABG harm reduction and treatment 
activities will help to fortify efforts to reduce drug overdose deaths. 
Additionally, the increased emphasis on the widespread implementation 
of MOUD treatment services can begin to help eliminate community and 
provider barriers to effective engagement in MOUD treatment, and 
encourage clinical, administrative, and fiscal policies and practices 
that incentivize the continued long-term involvement of clients in both 
MOUD treatment and recovery support services.

    Evidence-based harm reduction strategies are also key to minimizing 
the negative consequences of drug use to both the individual and the 
community. That is a key reason why the Department of Health and Human 
Services (HHS) announced in April 2021 that grantees in certain 
programs, such as State Opioid Response (SOR) grants and the SABG 
program, may use grant funds to purchase rapid fentanyl test strips to 
help curb the dramatic spike in drug overdose deaths largely driven by 
strong synthetic opioids, including illicitly manufactured fentanyl. 
Reports from states such as California, Arizona, Nevada, and Alaska 
note that fentanyl test strips funded through SOR have become an 
important component of syringe service programs; education and 
awareness building toolkits; and innovative, low-threshold, on-demand 
treatment programs. From the start of the reporting period on April 1, 
2022 to June 30, 2022, grantees reported distributing 259,025 fentanyl 
test strips.

    Additionally, SAMHSA has awarded 25 grants for the first-ever 
SAMHSA Harm Reduction grant program. The Harm Reduction grant program 
supports community-based overdose prevention programs, syringe services 
programs, and other harm reduction services including test strips for 
fentanyl and other synthetic drugs. In adherence with Federal, state, 
and local laws, regulations, and other requirements, Harm Reduction 
grant recipients enhance overdose and other types of prevention 
activities to help control the spread of infectious diseases, support 
distribution of FDA-approved overdose reversal medication, build 
connections for individuals at risk for, or with, a SUD to overdose 
education, counseling, and health education, and to encourage 
individuals to take steps to reduce the negative personal and public 
health impacts of substance use or misuse.
                              senator burr
    Question 1. In 2018, Congress passed the SUPPORT Act with broad 
bipartisan support, which included Section 6082 directing CMS to review 
its existing packaging policies for the outpatient and Ambulatory 
Surgical Center (ASC) settings, ``with a goal of ensuring that there 
are not financial incentives to use opioids instead of non-opioid 
alternatives.'' Yet, even with this directive from Congress, CMS has 
made no changes to packaging policies in the outpatient setting, and 
only limited changes in the ASC setting.

    For 2022, CMS adopted a policy in the ASC setting that would pay 
for non-opioid pain alternatives separately, but only those costing 
over $130/day separately. Non-opioid pain alternatives with lower 
prices, but still with a meaningful differential compared to less 
costly generic opioids, continue to be bundled in single payment. 
Potentially incentivizing providers to choose opioids over non-opioid 
options that cost under $130. Despite this potential, CMS has proposed 
to keep the $130/day unbundling threshold for 2023 in the Outpatient 
Prospective Payment System proposed rule.

    Though CMS, CDC, HRSA, and SAMHSA are all under HHS, there seems to 
be a lack of comprehensive strategy to combat the opioid epidemic. 
While CDC, HRSA, and SAMHSA are working to put out the fires caused by 
illicit fentanyl, CMS is implementing policy through the Outpatient 
Prospective Payment System that may misalign incentives for the 
prescribing of opioids over non-opioid alternatives.

    Ms. Johnson, Dr. Delphin-Rittmon, and Dr. Jones, can you please 
provide:

        1. The number of times your agencies have reached out to CMS to 
        share information or expertise to inform their rulemaking 
        regarding opioids policies

        2. The number of times CMS has reached out to your agencies for 
        information or expertise to inform their rulemaking regarding 
        opioids policies

        3. The number of times your agency has met with CMS over the 
        past year (by phone, video, or in person) to discuss opioid 
        addiction, abuse, and deaths

        4. The extent to which aggregated data and information 
        collected by your agencies is shared with CMS to inform 
        rulemaking

    Answer 1. SAMHSA and CMS staff coordinate regularly on multiple 
levels. One example of that is through the Behavioral Health 
Coordinating Council (BHCC), a group I co-chair along with the 
Assistant Secretary for Health, that convenes to inform and improve the 
various mental health and substance use-related projects and programs 
that HHS Operating Divisions, like CMS and SAMHSA, are managing an d 
leading. In particular, the BHCC has an Overdose Prevention 
Subcommittee which coordinates programs and policies across HHS in 
terms of implementing the HHS Overdose Prevention Strategy. The BHCC 
also has a Performance Measures, Data and Evaluation Subcommittee at 
which data collected by HHS operating divisions is shared.

    Additionally, since May 2021, CMS, AHRQ, SAMSHA touch base every 
other month on the 1003 project concerning a demonstration grant 
expanding OTP treatment across 11 states. In December 2021 and January, 
SAMHSA engaged with Medicare and Medicaid to confirm SAMHSA's upcoming 
rulemaking to make telehealth flexibilities permanent would be 
compliant with Medicare and Medicaid regulations. Last, SAMHSA met with 
CMS throughout May and June to discuss evidence-based treatment models 
for opioid use disorder, including models for individuals who also have 
other complex medical conditions.
                            senator cassidy
    Question 1. Dr. Delphin-Rittmon, Congress provided the 
Administration discretionary spending of more than $6 billion per year 
from fiscal year 2018 through 2020 for opioid-related programs. This 
was further increased by $2.5 billion via COVID-relief funds. In 2019, 
SAMHSA received $3.7 billion for substance use-related activities. 
Despite these resources, overdose deaths have increased to more than 
100,000 Americans in the 12-month period ending February 2022. What 
metrics does SAMHSA use to determine whether opioid-related funding is 
being used efficiently and effectively?

    Answer 1. Through the Government Performance and Results Act (GPRA) 
of 1993 and the Modernization Act of 2010, SAMHSA's Center for 
Substance Abuse Treatment (CSAT) evaluates program performance and 
effectiveness through six National Outcome Measures, which include:

          Abstinence

          Crime and Criminal Justice

          Employment/Education

          Health/Behavioral/Social Consequences

          Social Connectedness

          Stability in Housing

    In fiscal year 2021, 1,559,592 clients were served by the Substance 
Abuse Prevention and Treatment Block Grant (SABG), State Opioid 
Response (SOR), and Medication-Assisted Treatment for Prescription Drug 
and Opioid Addiction programs. Across the three programs, participating 
clients reported positive rates of change for each outcome measure. The 
fiscal year 2021 performance measures for CSAT's programs are available 
in SAMHSA's Fiscal Year 2023 Justification of Estimates for 
Appropriations. \7\
---------------------------------------------------------------------------
    \7\  https://www.samhsa.gov/sites/default/files/samhsa-fy-2023-
cj.pdf.

    Question 2. Dr. Delphin-Rittmon, the Bipartisan Policy Center has 
estimated that in 2019, mandatory spending on Medicaid beneficiaries 
with opioid use disorder (OUD) exceeded $23 billion. This is a nearly 
150 percent increase in Medicaid spending compared to 2013 when 
spending on OUD was estimated by the Kaiser Family Foundation to be 
about $9.4 billion. From 2013 to 2019, the number of Medicaid 
beneficiaries getting treatment for OUD increased by 150 percent, and 
from 2010 to 2019, the number of Medicaid covered OUD medication 
prescriptions increased by 550 percent. However, overdose deaths kept 
increasing during that timeframe, not decreasing or even plateauing. 
Which SAMHSA-developed or SAMHSA-recommended outcome measures should 
CMS and State Medicaid agencies use to ensure accountability in opioid-
---------------------------------------------------------------------------
related Medicaid spending?

    Answer 2. SAMHSA plans to continue collaboration with CMS and State 
Medicaid agencies to support outcome improvements for individuals with 
Substance Use Disorder (SUD including Opioid Use Disorder (OUD) ). For 
Medicaid 1115(a) demonstrations, CMS continues to develop tools to 
assist states and provide them with CMS's expectations and guidance to 
support rigorous evaluation activities as well as to improve access to 
and quality of treatment to Medicaid beneficiaries as part of a 
Department-wide effort to combat the ongoing opioid crisis. States can 
utilize a flexible, streamlined approach to respond to the national 
opioid crisis while enhancing states' monitoring and reporting of the 
impact of any changes implemented through these demonstrations. \8\
---------------------------------------------------------------------------
    \8\  https://www.Medicaid.gov/sites/default/files/federal-policy-
guidance/downloads/smd17003.pdf.
---------------------------------------------------------------------------

    Additionally, CMS has provided tools and guidance to support state 
approaches to monitoring and evaluation of SUD and tools to meet the 
requirements in special terms and conditions for SUD section 1115 
demonstrations. These tools include templates and guidance for 
implementation, monitoring protocol and reporting, and evaluation 
design. CMS also provides mid-point technical assistance to support 
states with planning and executing the assessment. \9\
---------------------------------------------------------------------------
    \9\  https://www.Medicaid.gov/Medicaid/section-1115-demonstrations/
1115-demonstration-monitoring-evaluation/1115-demonstration-state-
monitoring-evaluation-resources/index.html.
---------------------------------------------------------------------------
                            senator collins
    Question 1. Increase in Teen Overdoses (Dr. Delphin-Rittmon). Last 
month, Hannah Flaherty, a 14-year-old girl from Portland, died from a 
suspected fentanyl overdose 1 day after her middle school graduation. 
According to her friends and family, she was a straight A student with 
no history of drug use. Sadly, Hannah's death is not an outlier. 
According to a new study from UCLA researchers, after staying flat for 
a decade, the overdose death rate among adolescents in the United 
States nearly doubled from 2019 to 2020, and then increased again by 20 
percent in the first 6 months of 2021. This is the first time in 
recorded history that the teen drug death rate has seen an exponential 
rise, which researchers attribute to drug use ``becoming more 
dangerous, not more common.'' Dr. Delphin-Rittmon, we are not 
prioritizing primary prevention enough. What more can be done to 
educate teens and young adults about the dangers of fentanyl and 
counterfeit pills in particular, so we can prevent them from turning to 
drugs in the first place?

    Answer 1. Education is the cornerstone of prevention, however, in 
order to ensure that education works, it must be population specific, 
culturally conscious and easily understood.

    SAMHSA's Substance Abuse Prevention and Treatment Block Grant 
(SABG) program provides funds to all 50 states, the District of 
Columbia, Puerto Rico, the U.S. Virgin Islands, 6 Pacific 
jurisdictions, and 1 tribal entity to prevent and treat substance 
abuse. SAMHSA requires that grantees spend no less than 20 percent of 
their SABG allotment on substance abuse primary prevention strategies. 
These strategies are directed at individuals not identified to be in 
need of treatment. SABG grantees develop a comprehensive primary 
prevention program that targets both the general population and sub-
groups that are at high risk for substance abuse. Grantees use a 
variety of primary prevention strategies, including but not limited to 
education, healthy alternatives, and community-based process, to target 
the populations at greatest risk for substance use in their community. 
The prevention set-aside is one of SAMHSA's main vehicles aimed at 
preventing substance misuse and allows states to develop prevention 
infrastructure and capacity.

    SAMHSA's Strategic Prevention Framework for Prescription Drugs 
(SPF-Rx) grant program provides resources to help prevent and address 
prescription drug misuse within a state or locality. The SPF-Rx program 
is designed to raise awareness about the dangers of sharing medications 
and to highlight the risks of fake or counterfeit pills purchased over 
social media or through other sources.

    Finally, the SABG and State Opioid Response Grant (SOR) programs 
are funds that states can also use to support youth SUD prevention 
efforts. The SOR grant program, for example, funds state strategies 
that focus on the prevention of substance use for at-risk youth. SOR 
grantees also use funds to support interventions through Teen Courts, 
Recovery High Schools, and Peer Mentor Programs.
                           senator murkowski
    Question 1. According to preliminary data from the CDC, the U.S. 
experienced a 15 percent increase in overdose deaths from 2020 to 2021. 
Meanwhile, in Alaska, that increase was a staggering 75 percent, 
roughly five times the national average. Due to historical trauma other 
inequities, our Alaska Native population have experience high rates of 
substance use and alcoholism. I am concerned about the impact of the 
fentanyl epidemic on our rural Alaska Native communities, who are 
already experiencing significant increases in overdose deaths. How will 
you ensure the Federal efforts to address the rise of fentanyl overdose 
deaths will address the needs of those in rural areas, specifically 
American Indians and Alaska Natives?

    In Alaska and around the country, drug addiction and substance use 
disorders are ending the lives of far too many youth. This past June, 
I, along with my colleagues Senator Feinstein, Senator Sullivan, and 
Senator Hassan, introduced S. 4358, Bruce's Law. This bill authorizes 
funding for the Department of Health and Human Services (HHS) to 
conduct a public awareness campaign targeted toward school-aged 
children and youth on the dangers of fentanyl, establish an interagency 
working group on fentanyl contamination, and authorizes an expansion of 
grants for community coalitions to engage school-aged children and 
youth in outreach and prevention efforts.

    Question 2. What type of outreach and prevention efforts are the 
CDC and SAMHSA currently supporting to educate youth and school-aged 
children on the dangers of counterfeit drugs laced with fentanyl? What 
inter-agency coordination takes place between the CDC, SAMHSA, and 
ONDCP on these efforts?

    Question 3. How does ONDCP believe that Bruce's Law, if enacted, 
would enhance their prevention efforts?

    Answer 1-3. One of the key cross-collaboration principles that 
drives SAMHSA's work is promoting greater equity within the behavioral 
health system. This includes addressing the longstanding inequities 
faced by Tribal citizens.

    The Tribal Opioid Response grant (TOR) program assists in 
addressing the public health crisis caused by escalating opioid and 
stimulant misuse and use disorders across tribal communities. The 
purpose of the program is to prevent overdoses in Tribal communities by 
increasing access to FDA approved medications for the treatment of 
opioid use disorder and to support culturally appropriate prevention, 
harm reduction, treatment, and recovery support services.

    SAMHSA's Tribal Behavioral Health grant program, also known as 
Native Connections, is intended to prevent suicide and substance 
misuse, reduce the impact of trauma, and promote mental health among 
American Indian/Alaska Native (AI/AN) youth. This program fosters 
culturally responsive models that reduce and respond to the impact of 
trauma and involve AI/AN community members (including youth, tribal 
leaders, and spiritual advisors) in all grant activities.

    The SAMHSA Tribal Training and Technical Assistance Center and the 
National American Indian and Alaska Native Technology Transfer Centers 
for addiction, prevention and mental health provide training and 
technical assistance specific to working with tribes and tribal 
citizens in the behavioral health arena. These Centers work with 
organizations and treatment practitioners involved in the delivery of 
behavioral health services to American Indian and Alaska Native 
individuals, families, and tribal and urban Indian communities to 
develop and strengthen the specialized behavioral healthcare workforce 
and the primary healthcare workforce that provide these services.

    Furthermore, SAMHSA works closely with the State Opioid Treatment 
Authorities (SOTA) assigned in each state to support MOUD by overseeing 
Opioid Treatment Programs, providing guidance regarding MOUD, and 
facilitating MOUD services within the state. Specific to Alaska, SAMHSA 
has been working with the SOTA to identify ways in which state funds 
and the current Opioid Treatment Programs (OTP) can utilize medication 
unit guidance, issued in November 2021, to establish additional sites 
in Alaska, expanding the reach of current OTPs. Three new OTPs have 
opened in the last year and at least one mobile medication unit is 
planned. In addition, as of July 31, 2022, 792 practitioners in Alaska 
had received a waiver to prescribe buprenorphine.

    The drastic increase in overdoses contributed to fentanyl is of 
pressing concern to Substance Abuse Prevention and Treatment Block 
Grant (SABG) Program and Strategic Prevention Framework--Partnership 
for Success (SPF-PFS) grant recipients. Grant recipients utilize a 
range of evidence-based and culturally informed strategies to educate 
youth and school-aged children on the dangers of counterfeit drugs 
laced with fentanyl. By conducting a local needs assessment, grantees 
are able to target the populations and communities that are most at 
risk for substance use. SAMHSA's Strategic Prevention Framework for 
Prevention Drugs (SPF Rx) grant program provides resources to help 
prevent and address prescription drug misuse within a State or 
locality. The program was established in 2016 to raise awareness about 
the dangers of sharing medications as well as the risks of fake or 
counterfeit pills purchased over social media or other unknown sources, 
and work with pharmaceutical and medical communities on the risks of 
overprescribing. Grant recipients are required to track reductions in 
opioid related overdoses and incorporate relevant prescription and 
overdose data into strategic planning and future programming. 
Recipients are expected to leverage knowledge gained through 
participation in the SPF process to more effectively address targeted 
community needs.

    The HHS Behavioral Health Coordinating Council (BHCC) is tasked 
with coordinating all Federal Government resources to address 
inequities and gaps within the mental health and substance use disorder 
system. The BHCC's chief goals are to share information about the 
various mental health and substance use projects and programs that HHS 
Operating Divisions and Staff Divisions are managing and leading, as 
well as ensure that all behavioral health issues are being handled 
collaboratively and without duplication of effort across the 
department. HHS's BHCC has five areas of focus: Children and Youth 
Behavioral Health, Performance Measures, Data and Evaluation, 
Behavioral and Physical Health Integration, Suicide Prevention and 
Crisis Care, and Overdose Prevention.
                             senator scott
    Question 1. Dr. Delphin-Rittmon--Faith-based organizations provide 
vital community supports and can play a critical role in addressing 
this crisis. Can you discuss how your Agency is currently working with 
faith-based organizations to address this public health emergency and 
your vison for partnership growth?

    Answer 1. SAMHSA engages with faith-based organizations in several 
ways. Through the STOP Act Program and Partnership for Success program, 
we have maintained strong faith-based sector support in the development 
of anti-drug strategies impacting youth. The faith-based community has 
integrated numerous youth programs as a strong addition to community 
coalition efforts in several funded communities over the years. Faith-
based leaders have provided important perspectives which contribute to 
the collaborative sprit of successful anti-drug community level 
campaigns.

    In addition, SAMHSA's Substance Abuse Prevention and Treatment 
Block Grant (SABG) grantees effectively engage with faith-based 
organizations using SABG funds to address the fentanyl overdose crisis. 
These efforts include the active involvement of faith-based communities 
in statewide needs assessments of recovery support services that are 
aimed at addressing specific issues related to the staggering increases 
in fentanyl overdoses. Grantees are expanding recovery support services 
and developing targeted initiatives with faith-based groups, recovery 
community organizations, recovery community centers, and peer advocates 
to support individuals in long-term recovery. Grantees are also 
engaging substance use disorder treatment providers in developing 
culturally appropriate faith-based models to focus on the 
disproportionate overdose rates among African Americans.

    Moreover, through the Medication Assisted Treatment-Prescription 
Drug Opioid and Opioid Addiction (MAT-PDOA) program, some grantees 
provide outreach to faith-based communities through radio programming. 
Utilizing community outreach teams, these grantees connect with faith-
based leaders to ensure that they are supported and that information 
regarding treatment and recovery services are appropriately 
communicated to congregations. They also provide recommendations to 
pastors on effective methods of conveying information to congregants on 
the array of services that are available for persons with an opioid use 
disorder either virtually (during COVID) or through the distribution of 
flyers and pamphlets (provided by the grantee) to their parishioners 
and members of their local communities.

    In addition, SAMHSA's discretionary grants work in collaboration 
with the Health and Human Services (HHS) Partnership Center for Faith-
based and Neighborhood Partnerships to extend the reach and impact all 
of HHS related programs into communities. This includes those related 
to mental well-being and recovery from substance use disorders and 
encourages and supports faith-based community organizations in their 
work to the individuals they serve.
                                 ______
                                 
   Response by Carole Johnson to Questions of Senator Rosen, Senator 
                        Lujan, and Senator Burr
                             senator rosen
    INCREASING ACCESS TO FENTANYL TEST STRIPS: We know that fentanyl 
test strips are relatively easy to use, accurate, and can help prevent 
overdoses. That's why I'm glad the Nevada state legislature recently 
voted--nearly unanimously--to legalize fentanyl test strips in our 
state. I'm also proud of the work that community partners like Northern 
Nevada Hopes--a federally Qualified Health Center (FQHC) in Reno--and 
the Southern Nevada Health District in Las Vegas are doing to 
distribute them to some of our most vulnerable patients.

    Question 1. Ms. Johnson, how is HRSA partnering with federally 
Qualified Health Centers across Nevada and the country to increase 
awareness of and access to fentanyl test strips for those who may need 
them, and how can Congress help you improve this outreach?

    Answer 1. Health Centers that are funded and designated by HRSA 
under section 330 of the Public Health Service Act (which are among the 
types of federally Qualified Health Centers as defined under the Social 
Security Act for purposes of Medicare and Medicaid reimbursement) play 
a key role in providing substance use disorder and mental health 
services. Aligned with the Biden-Harris administration's 2022 National 
Drug Control Strategy, which identified expanding substance use 
disorder services in federally qualified health centers as a strategy 
to increase access to treatment services, HRSA's Health Center Program 
funding supports health centers in implementing and advancing evidence-
based strategies to expand access to quality integrated substance use 
disorder prevention and treatment services, including those addressing 
opioid use disorder and other emerging substance use disorder issues.

    In addition to this health center work, HRSA supports a range of 
prevention, treatment and recovery services and supports through other 
programs, such as the Rural Communities Opioid Response Program 
(RCORP). Between September 1, 2021, and February 28, 2022, 
approximately 40 percent of HRSA's RCORP awardees reported actively 
distributing fentanyl test strips in their rural service area.

    HRSA looks forward to working with you to ensure these important 
programs continue to be successful and reach the populations in need of 
substance use disorder and mental health services.
                             senator lujan
    Question 1. Would incorporating MAT training in primary care and 
emergency department residency programs increase access to this 
lifesaving treatment? What would this additional expertise mean for 
those in rural areas?

    Answer 1. One of HRSA's top priorities is integrating behavioral 
health into primary care, including medications for opioid use disorder 
training, to increase access to evidence-based treatment for opioid use 
disorder. The integration will help to ensure that opioid use disorder 
can be addressed and treated by more providers along the continuum of 
care, including those practicing in rural areas.

    For example, to support these goals, HRSA's Rural Communities 
Opioid Response Program is funding a $10 million in grant awards to 
expand access to MAT in rural communities in fiscal year 2022.

    Additionally, HRSA's Teaching Health Center Graduate Medical 
Education Program also helps support opioid use disorder training in 
primary care settings, many of which are in rural areas. HRSA will 
continue to support strategies to expand access to MAT by training 
additional providers.
    Question 2. How does targeted training for health care providers 
alleviate the stigma associated with treating individuals for opioid 
use disorder?

    Answer 2. HRSA programs aim to increase access to treatment for 
substance use disorder, including opioid use disorder, and educate 
health care providers and the communities they serve on the need for 
providing treatment across patient populations. HRSA's training 
highlights the various touch points at which health care providers may 
encounter individuals with opioid use disorder or substance use 
disorder and provide potentially lifesaving treatments and 
interventions. HRSA programs train health care professionals to provide 
mental health and substance use disorder services, as well as focus on 
training to integrate behavioral health care into primary care. 
Furthermore, these programs focus on training and maintaining workforce 
in rural and underserved communities.

    Question 3. COVID has caused rapid burnout across all health care 
providers. Behavioral health workers face the same challenges. How 
would sustained and coordinated retention efforts help sustain a robust 
behavioral health care workforce?

    Answeer 3. To improve the retention of health care workers, reduce 
burnout and promote mental health and wellness among the health care 
workforce, the American Rescue Plan Act authorized new HRSA grant 
programs to support evidence-informed training on burnout reduction and 
promotion of resilience for providers and help health care 
organizations establish, improve, or expand evidence-informed programs 
and practices to promote mental health and well-being within the health 
care workforce.

    In Fiscal Year 2023, the President's Budget proposes $50 million 
for the Promoting Resilience and Mental Health Among Health 
Professional Workforce program. These funds would support strategies to 
help the health care workforce better prepare for and respond to 
workplace stressors, while fostering healthy workplace environments 
that promote mental health and resilience by improving the quality of 
training and increasing access to care through partnerships and 
linkages. The program is authorized by the Dr. Lorna Breen Health Care 
Provider Protection Act (P.L. 117-105). HRSA looks forward to 
continuing to work with Congress on this important issue.
                              senator burr
    In 2018, Congress passed the SUPPORT Act with broad bipartisan 
support, which included Section 6082 directing CMS to review its 
existing packaging policies for the outpatient and Ambulatory Surgical 
Center (ASC) settings, ``with a goal of ensuring that there are not 
financial incentives to use opioids instead of non-opioid 
alternatives.'' Yet, even with this directive from Congress, CMS has 
made no changes to packaging policies in the outpatient setting, and 
only limited changes in the ASC setting.

    For 2022, CMS adopted a policy in the ASC setting that would pay 
for non-opioid pain alternatives separately, but only those costing 
over $130/day separately. Non-opioid pain alternatives with lower 
prices, but still with a meaningful differential compared to less 
costly generic opioids, continue to be bundled in single payment. 
Potentially incentivizing providers to choose opioids over non-opioid 
options that cost under $130. Despite this potential, CMS has proposed 
to keep the $130/day unbundling threshold for 2023 in the Outpatient 
Prospective Payment System proposed rule.

    Though CMS, CDC, HRSA, and SAMHSA are all under HHS, there seems to 
be a lack of comprehensive strategy to combat the opioid epidemic. 
While CDC, HRSA, and SAMHSA are working to put out the fires caused by 
illicit fentanyl, CMS is implementing policy through the Outpatient 
Prospective Payment System that may misalign incentives for the 
prescribing of opioids over non-opioid alternatives.

    Ms. Johnson, Dr. Delphin-Rittmon, and Dr. Jones, can you please 
provide:

    Question 1. The number of times your agencies have reached out to 
CMS to share information or expertise to inform their rulemaking 
regarding opioids policies

    Question 2. The number of times CMS has reached out to your 
agencies for information or expertise to inform their rulemaking 
regarding opioids policies

    Question 3. The number of times your agency has met with CMS over 
the past year (by phone, video, or in person) to discuss opioid 
addiction, abuse, and deaths

    Question 4. The extent to which aggregated data and information 
collected by your agencies is shared with CMS to inform rulemaking

    Answer 1-4. As a part of interagency clearance on the OPPS/ASC 
rule, HRSA reviews and provides input, as appropriate, on Section 6082 
policies, HRSA works in close collaboration with CMS and other HHS 
operating divisions to combat the opioid epidemic, including through 
Secretary Becerra's Behavioral Health Coordinating Council (BHCC). The 
BHCC is a significant mechanism for HRSA to coordinate existing efforts 
and future initiatives with other HHS operating divisions, including 
CMS, CDC, and SAMHSA. For example, HRSA collaborated with other HHS 
agencies through the BHCC to implement the HHS Overdose Prevention 
Strategy. We will continue to collaborate with our colleagues across 
HHS to combat the opioid epidemic.
                                 ______
                                 
 Response by Christopher Jones to Questions of Senator Casey, Senator 
                     Collins, and Senator Murkowski
                             senator casey
    I hear from Pennsylvanians who have suffered tragic losses from the 
scourge of fentanyl and opioid overdose gripping our Nation. I also 
hear from Pennsylvanians who suffer from debilitating chronic pain and 
depend on medically appropriate use of opioids to lead meaningful 
lives. As our country has taken steps to address the opioid epidemic, 
some of these patients have faced barriers to the care they need.

    In 2016, CDC published its Guideline for Prescribing Opioids for 
Chronic Pain, and subsequently issued a statement in 2019 advising 
against misapplication of the Guideline. In that statement, CDC 
acknowledged that ``some policies and practices that cite the Guideline 
are inconsistent with, and go beyond, its recommendations,'' and noted 
that these issues ``could put patients at risk.'' CDC is now working on 
its successor, the 2022 CDC Clinical Practice Guideline for Prescribing 
Opioids.

    Question 1. As CDC revises the 2022 draft based on feedback and 
prepares to release the updated Guideline, how will CDC work with 
Federal, state, and local agencies, as well as clinicians, to clarify 
acceptable and unacceptable practices for prescribing physicians?

    Question 2. How will CDC ensure that the latest guidelines are not 
misapplied, restricting access for patients with a legitimate medical 
need for opioids, and encourage application consistent with CDC's 
position that ``patients with pain deserve safe and effective pain 
management''?

    Answer 1-2 CDC is working to ensure effective communication about 
the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain. 
CDC is carefully reviewing how recommendations are written to ensure 
they are properly applied and not misinterpreted.

    The 2022 Clinical Practice Guideline addresses these critical 
issues by emphasizing that the 2022 Guideline is a clinical tool to 
improve communication between clinicians and patients and empower them 
to make informed, person-centered decisions related to pain care 
together. The 2022 Clinical Practice Guideline includes call out boxes 
and language throughout the document that clearly states the purpose of 
the Guideline, what it is intended for, and what it is NOT intended 
for. For example:

          The Clinical Practice Guideline IS a clinical tool to 
        improve communication between clinicians and patients and 
        empower them to make informed, person-centered decisions 
        related to pain care together.

          The Clinical Practice Guideline IS NOT intended to be 
        applied as inflexible standards of care across patients, and/or 
        patient populations by healthcare professionals, health 
        systems, pharmacies, third-party payers, or governmental 
        jurisdictions or to lead to the rapid tapering or abrupt 
        discontinuation of opioids for patients.

    CDC will also release a suite of translation and communication 
materials with the 2022 Guideline that will emphasize these critical 
messages and provide resources to clinicians providing pain care to 
patients. These materials will help achieve the goal of providing 
flexible, patient-centered care that is tailored to the needs and 
circumstances of the patient.

    CDC also will work with public and private payers as well as other 
decisionmakers and share evidence that can be used to inform decisions 
regarding coverage for a broader range of pain therapies. To assist in 
uptake and understanding of the 2022 Guideline, CDC will update and 
develop tools and resources for clinicians, health systems, and 
patients. In September 2019, CDC launched the multiyear Overdose Data 
to Action (OD2A) cooperative agreement with 66 recipients (referred to 
as jurisdictions) comprised of state, territorial, county, and city 
health departments in which dissemination and TA on the Guideline will 
also go out through these funded partners. CDC is also working with 
ASTHO to develop tools and resources for state agencies and 
policymakers to support implementation of the Guideline.

    Question 2. In your testimony, you discuss CDC's efforts to use 
data for overdose prevention and the essential role of data in 
informing a public health response to the overdose crisis. I appreciate 
that ``CDC is committed to using data . . . as part of a whole-of-
government approach to save lives and bring an end to our Nation's 
overdose crisis,'' and encouraged by your collection of data which you 
report ``improves coordination and strategic planning for intervention 
and response efforts among health departments, community members, 
healthcare providers, public health, law enforcement, and government 
agencies.''

    In what ways are the CDC data being used to ``improve coordination 
and strategic planning''?

    Question 3. What barriers exist to CDC collaborating and sharing 
data with other government agencies to help ensure the government's 
approach to combatting the crisis is informed by the best available 
clinical evidence and health statistics?

    Answer 2-3. CDC partners across Federal Government agencies to 
leverage data sources to inform prevention, treatment, and harm 
reduction efforts. For example, CDC participates in a number of Federal 
interagency workgroups focused on the improvement of data systems and 
data sharing, including the White House ONDCP Drug Data Interagency 
Workgroup, the HHS Behavioral Health Coordinating Council subcommittee 
on data and metrics, and the Federal Interagency Medicolegal Death 
Investigation Working Group. In addition, CDC regularly partners with 
other HHS agencies, such as SAMHSA, CMS, NIDA, and FDA to collaborate 
and leverage data sources focused on substance use, overdose, and 
prescribing and patient behaviors to help inform translation and 
dissemination of data to the public. Two recent examples of data 
sharing and collaboration from these interagency efforts include 
research papers in JAMA Psychiatry examining COVID-19 related emergency 
policy changes for methadone take-home doses from opioid treatment 
programs opioid treatment programs \1\ and use of telehealth in the 
treatment of opioid use disorder among Medicare beneficiaries. \2\ 
Findings from these papers are informing ongoing discussions related to 
potential permanent adoption of these COVID-19 flexibilities.
---------------------------------------------------------------------------
    \1\  Jones CM, Compton WM, Han B, Baldwin G, Volkow ND. Methadone-
involved overdose deaths in the US before and after Federal policy 
changes expanding take-home methadone doses from opioid treatment 
programs. JAMA Psychiatry. 2022;79(9):932-934.
    \2\  Jones CM, Shoff C, Hodges K, Blanco C, Losby JL, Ling SM, 
Compton WM. Receipt of telehealth services, receipt and retention of 
medications for opioid use disorder, and medically treated overdose 
among Medicare beneficiaries before and during the COVID-19 pandemic. 
JAMA Psychiatry. 2022;Aug 31. Doi:10.1001/jamapsychiatry.2022.2284.

    CDC also partners with Federal agencies, such as the Department of 
Justice and High Intensity Drug Trafficking Programs, to leverage drug 
supply data that can help inform prevention efforts. For example, the 
Overdose Response Strategy is funded by the Centers for Disease Control 
and Prevention (CDC) and the White House Office of National Drug 
Control and Policy (ONDCP). The CDC Foundation and 33 High Intensity 
Drug Trafficking Areas (HIDTAs) are working together to support this 
unique and unprecedented collaboration between public health and public 
safety, which allows agencies to share timely data, pertinent 
intelligence and innovative strategies to address overdoses. Through 
the project, ORS teams made up of drug intelligence officers (DIO) and 
public health analysts (PHA) work together on drug overdose issues 
within and across sectors. In addition to these efforts, CDC's Overdose 
Data to Action (OD2A) program is designed to facilitate data sharing 
and use data to inform prevention efforts at the state and local 
levels, and CDC works closely with funded jurisdictions to optimize 
---------------------------------------------------------------------------
their data to action strategic frameworks.

    Question 3. What more can be done to encourage proactive use of 
CDC-provided resources to develop data-driven approaches to combating 
fentanyl and reducing overdose deaths across public health, law 
enforcement, and other elements of the Federal response?

    Answer 3. CDC's funding to state, local, and territorial entities 
has evolved and expanded with the overdose crisis. CDC data have been 
integral to informing this evolution and the response across 
jurisdictions. CDC's Overdose Data to Action program is forecasted to 
expand support for local communities through a new 5-year funding 
opportunity, Overdose Data to Action: Limiting Overdose through 
Collaborative Actions in Localities (OD2A: LOCAL). Additionally, CDC's 
new forecasted 5-year funding opportunity for states, Overdose Data to 
Action in States (OD2A-S), will build off the work and gains made 
through previous overdose surveillance and prevention investments 
supporting state health departments through the promotion of overdose 
surveillance strategies and evidence-based and promising interventions 
that have an immediate impact on reducing morbidity and mortality 
associated with overdoses, with a primary focus on opioids, stimulants, 
and polysubstance use. OD2A-S will emphasize health equity, and 
strategies will be underpinned by a data-to-action framework that aims 
to expand and strengthen fatal and non-fatal overdose surveillance 
efforts of State Health Departments and their use of these and other 
data to drive prevention strategies and policies. Data-driven 
strategies within each of these funding opportunities aim to enhance 
partnerships and collaborations across public health, public safety, 
law enforcement, and the medical community, among others, and to 
promote evidence-based prevention strategies, interventions, and care.

    CDC also provides extensive technical assistance (TA) to OD2A 
funded recipients. The OD2A TA Hub centralizes and standardizes TA 
provides to recipients across 13 domains using a tech-based portal and 
5 step prioritization process. This portal facilitates access to a 
coordinated network of TA and training services in surveillance and 
prevention activities. It also focuses on:

          systematic amplification and dissemination of CDC 
        scientific and programmatic technical assistance to OD2A funded 
        recipients to better equip them to address the overdose 
        epidemic

          assessment and enhancement of capacity of recipients 
        to successfully implement and evaluate surveillance and 
        prevention activities of OD2A in coordination and collaboration 
        with CDC and as elaborated in the Overdose Prevention Capacity 
        Assessment Tool (OPCAT)

          translation and dissemination of data to inform 
        action as well as best practices and resources; and

          development and maintenance of an electronic resource 
        library.

    In addition, CDC is partnering with SAMHSA to provide technical 
assistance on harm reduction strategies. The Harm Reduction Technical 
Assistance Center is designed to strengthen the capacity and improve 
the performance of Syringe Services Programs (SSPs) throughout the 
United States by supporting enhanced technical assistance (TA) to 
ensure the provision of high-quality, comprehensive harm reduction 
services.
                            senator collins
    Question 1. Actionable Overdose Data (Mr. Chester and Dr. Jones). 
Mr. Chester, I appreciate that the National Drug Control Strategy 
prioritizes the need for more actionable data to track nonfatal 
overdoses, which you recognize in your testimony as ``one of the most 
accurate predictors of whether someone will experience a fatal overdose 
in the future.'' I was also encouraged to hear Director Gupta recently 
met with officials in Maine to see firsthand how Maine collects 
detailed overdose data. This data is critical for law enforcement and 
health care providers to appropriately gauge the scope of the crisis in 
their local communities and target resources where they are needed. I 
understand the Administration has recently created a Drug Data 
Interagency Working Group that will assist with the development of a 
new national plan for obtaining data in near real-time. However, this 
is expected to take 1 year to develop fully. Mr. Chester and Dr. Jones, 
how is ONDCP utilizing partners like the CDC who have expertise in data 
collection and partnerships across state and local public health 
agencies?

    Answer 1. CDC actively participates in the ONDCP Drug Data 
Interagency Working Group, sharing lessons learned from implementing 
our nonfatal and fatal overdose surveillance efforts in funded 
jurisdictions. CDC contributes to the overall development of working 
group outputs related to drug overdose mortality and morbidity efforts, 
focused on improving the timeliness and comprehensiveness of data 
related to drug overdose and related harms, including ongoing 
discussions on how to continue to leverage CDC data systems like the 
Drug Overdose Surveillance and Epidemiology (DOSE) syndromic 
surveillance system to improve awareness about overdoses seen in 
Emergency Departments across the U.S.

    With support from the Office of National Drug Control Policy 
(ONDCP) the Overdose Response Strategy (ORS) is a unique collaboration 
between CDC and the High Intensity Drug Trafficking Areas (HIDTA) 
program designed to enhance public health and public safety 
partnerships. The mission of the ORS is to help communities reduce 
fatal and non-fatal drug overdoses by connecting public health and 
public safety agencies, sharing information, and supporting evidence-
based interventions. This program offers evidence-based intervention 
strategies that can be implemented at the local, regional, and state 
level. CDC has expanded its investment in this partnership to support 
the public health component in all 50 states, Puerto Rico and the U.S. 
Virgin Islands. Drug intelligence officers and public health analysts 
collaborate and leverage supply and overdose data to problem-solve and 
address local and regional issues, including spikes in overdoses 
related to illicit fentanyl.
                           senator murkowski
    In Alaska and around the country, drug addiction and substance use 
disorders are ending the lives of far too many youth. This past June, 
I, along with my colleagues Senator Feinstein, Senator Sullivan, and 
Senator Hassan, introduced S. 4358, Bruce's Law. This bill authorizes 
funding for the Department of Health and Human Services (HHS) to 
conduct a public awareness campaign targeted toward school-aged 
children and youth on the dangers of fentanyl, establish an interagency 
working group on fentanyl contamination, and authorizes an expansion of 
grants for community coalitions to engage school-aged children and 
youth in outreach and prevention efforts.

    Question 1. What type of outreach and prevention efforts are the 
CDC and SAMHSA currently supporting to educate youth and school-aged 
children on the dangers of counterfeit drugs laced with fentanyl? What 
inter-agency coordination takes place between the CDC, SAMHSA, and 
ONDCP on these efforts?

    Answer 1. The Drug Free Communities (DFC) Support Program is the 
Nation's leading effort to mobilize communities to prevent and reduce 
substance use among youth. Administered by ONDCP and managed by CDC, 
the DFC Program funds community-based coalitions to identify and 
respond to the drug problems unique to their community and change local 
community environmental conditions tied to substance use. The DFC 
coalitions focus efforts on youth and in many instances, promote health 
equity and aim to reduce disparities that impact youth substance use, 
and address the risk and protective factors that negatively impact 
health outcomes in communities. As the overdose crisis has evolved to a 
crisis driven by illicit fentanyl and fentanyl analogs, DFC coalitions 
have responded by increasing their focus on this threat to youth. 
Examples of their work include collaboration with CDC's Overdose 
Response Strategy include:

          DFC coalitions in the state of CT collaborate on a 
        fentanyl awareness campaign targeting teens, young adults, and 
        caregivers on the dangers of counterfeit pills. The campaign, 
        which is available through social media, billboards, TV 
        coverage, newspaper ads, banners, and postcards, aims to 
        educate not only how young people are accessing counterfeit 
        medications, but also why they are using them and to provide 
        families with tools and resources that they can use to offer 
        support.

          Westbrook Partners for Prevention (ME): Updated 
        Westbrook School District medication dispensing policy to 
        include naloxone administration. Training will be provided to 
        interested staff, coaches, and others in overdose recognition 
        and response protocols in the 2022/2023 school year. Coalition 
        staff worked to update the Westbrook School District medication 
        dispensing policy to allow for school staff to dispense 
        naloxone if necessary. Staff provided education to school 
        nurses about the policy and new protocols. A plan was made to 
        provide training to teachers, staff, and coaches in the 
        upcoming school year as well.

          Griswold PRIDE (CT): In January, CT had the first 
        youth overdose on fentanyl while at school . . . a middle 
        school. This prompted many discussions, education 
        opportunities, and policy changes among school districts. In 
        April, all 500 high school students watched Natural High's Dead 
        on Arrival documentary, which was followed up with lessons and 
        discussion using their Fentanyl Toolkit. Parents were also 
        provided information on the lessons and a link to the 
        documentary to follow-up at home. Also stemming from that 
        overdose student death, came Narcan/naloxone training for 
        support staff from each of the schools, Griswold Elementary, 
        Middle, High, and Alternative. Before this, only the high 
        school was trained and carried naloxone onsite. Now after a 
        district policy, all of their schools have staff trained, and 
        have naloxone on site.

    CDC recognizes the historical increases in drug overdose deaths 
associated with illicit fentanyl and the risks posed by an increasingly 
changing illicit drug supply. In addition to leveraging data and 
working with public safety to address emerging drug threats and co-
involvement of fentanyl in the illicit drug supply, CDC is also raising 
awareness of the risks of fentanyl and polysubstance use. Our Stop 
Overdose campaign focuses on the risks associated with illicit fentanyl 
and polysubstance use as well as the importance of naloxone as a life-
saving antidote for overdose. The intended audience for these campaigns 
is people who use drugs between the ages of 18-34 and there has been 
widespread pick-up of this campaign, which has received over 2 billion 
impressions over the past year.
    Question 2. How does ONDCP believe that Bruce's Law, if enacted, 
would enhance their prevention efforts?

    Question 3. According to preliminary data from the CDC, the U.S. 
experienced a 15 percent increase in overdose deaths from 2020 to 2021. 
Meanwhile, in Alaska, that increase was a staggering 75 percent, 
roughly five times the national average. Due to historical trauma other 
inequities, our Alaska Native population have experience high rates of 
substance use and alcoholism. I am concerned about the impact of the 
fentanyl epidemic on our rural Alaska Native communities, who are 
already experiencing significant increases in overdose deaths.

    How will you ensure the Federal efforts to address the rise of 
fentanyl overdose deaths will address the needs of those in rural 
areas, specifically American Indians and Alaska Natives?
    Answers 1-3. The increases in overdose deaths among American Indian 
and Alaska Native persons is very concerning, and CDC recently called 
attention to this issue in our July Vital Signs on drug overdose. 
Efforts specific to the needs of the AI/AN population are underway 
across the Federal Government to address this crisis. CDC is working to 
ensure that multiple programmatic efforts are reaching tribal 
populations.
    Targeted AI/AN Funding

    CDC ensures that American Indian and Alaska Native communities are 
reached through many of our national and local programs that are 
represented below, but also provides targeted, tailored funding and 
support that goes directly to tribal and Alaska Native communities and 
tribal serving organizations. AI/AN specific funding includes:

          Capacity building funding to tribal epidemiological 
        centers to provide actionable data on opioid use disorder 
        (OUD), stimulant use disorders (StUD), and polysubstance use.

          Funding to address strategic plan priority areas such 
        as epidemiologic surveillance and public health data 
        infrastructure; implementation of evidence-based health systems 
        interventions; or innovative community-based strategies.

          Funding the National Indian Health Board (NIHB) to 
        produce an opioid conference track at a national conference 
        annually.

          Funding tribal serving organizations to provide 
        training and technical assistance to tribes related to opioid 
        overdose prevention and to develop resources such as a toolkit 
        that translates Indigenous evaluation approaches into 
        actionable guidance for tribal public health & opioid overdose 
        prevention programs.

    Drug Free Communities (DFC)

    During the application process of the DFC program, CDC and ONDCP 
encourage coalitions to pay particular attention to communities or 
populations disproportionately affected by substance use including but 
not limited to those with reduced economic stability; limited 
educational attainment, access or quality, limited healthcare access or 
quality, people from non-English populations, tribal populations, rural 
communities and other geographically underserved areas, racial/ethnic 
minority groups, and sexual and gender minority groups. Currently, the 
DFC program funds the Healing Our People and Environment (HOPE) 
Coalition and the Ketchikan Wellness Coalition in Alaska.

    Partnership with BJA

    CDC partners with the Bureau of Justice Assistance's Comprehensive 
Opioid, Stimulant, and Substance Abuse Program on multiple projects to 
support effective state, local, and tribal responses to illicit 
substance use. These projects promote public safety, and support access 
to treatment and recovery services in the criminal justice system in 
order to reduce overdose deaths. This partnership has focused on rural 
responses, expanding use of the Overdose Detection Mapping Application 
Program (ODMAP) in states and tribes, harm reduction education and 
training for law enforcement, building bridges between jail and 
community-based treatment, and overdose fatality review (OFR) 
implementation. The ODMAP Initiative, co-funded by the Bureau of 
Justice Assistance and the Centers for Disease Control and Prevention, 
supports the implementation of the ODMAP in four tribal communities. 
The project strengthens the ability of the selected tribes to assess 
information gathered from public safety, public health, and behavioral 
health responses. This initiative also strives to enhance the ability 
of the selected tribes to implement tailored prevention and 
intervention activities to reduce overdose deaths and facilitate access 
to treatment and recovery services to survivors of nonfatal overdoses. 
Sites include:

          Eastern Band of Cherokee Indians

          Oneida Nation Behavioral Health

          Tulalip Tribes of Washington

          White Earth Band of Chippewa Indians through its 
        Behavioral Health Division

    Health IT

    In January 2020, CDC and ONC successfully completed an integration 
of the Utah Navajo Health System Electronic Health Records (EHRs) 
through RxCheck, a system that allows healthcare providers within 
clinical settings to access patient prescription history within their 
EHR workflow. CDC and ONC successfully launched a PDMP-EHR pilot with 
the Ponca Health Services in Nebraska and with Blue Mountain Health in 
Utah, which serves both the Ute and Navajo tribes. NCIPC and the Office 
of the National Coordinator for Health Information Technology (ONC) 
have collaborated on this CDC-ONC project to advance and scale 
sustainable pathways to PDMP integration within health IT systems 
(e.g., EHR). CDC and ONC are piloting this work in at least six health 
systems across multiple states. This project also included two 
additional systems that will pilot CDC Guideline-concordant electronic 
clinical decision support.

    CDC also provided funds to the National Indian Health Board to 
support the implementation of evidence-based health interventions to 
prevent substance use disorder and drug overdose in American Indian and 
Alaska Native populations. These interventions include addressing 
challenges in accessing state PDMPs and increasing their use, linking 
people to opioid use disorder treatment services, creating translation 
materials, evaluating the effectiveness of implemented interventions, 
and adapting current CDC factsheets or other materials for clinics that 
serve American Indian and Alaska Native populations.
                                 ______
                                 
    [Whereupon, at 12 p.m., the hearing was adjourned.]

                                   [all]