[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
LIVES WORTH LIVING: ADDRESSING THE
FENTANYL CRISIS, PROTECTING CRITICAL LIFE-
LINES, AND COMBATING DISCRIMINATION
AGAINST THOSE WITH DISABILITIES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
FEBRUARY 1, 2023
__________
Serial No. 118-2
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Published for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
51-563 PDF WASHINGTON : 2023
-----------------------------------------------------------------------------------
COMMITTEE ON ENERGY AND COMMERCE
CATHY McMORRIS RODGERS, Washington
Chair
MICHAEL C. BURGESS, Texas FRANK PALLONE, Jr., New Jersey
ROBERT E. LATTA, Ohio Ranking Member
BRETT GUTHRIE, Kentucky ANNA G. ESHOO, California
H. MORGAN GRIFFITH, Virginia DIANA DeGETTE, Colorado
GUS M. BILIRAKIS, Florida JAN SCHAKOWSKY, Illinois
BILL JOHNSON, Ohio DORIS O. MATSUI, California
LARRY BUCSHON, Indiana KATHY CASTOR, Florida
RICHARD HUDSON, North Carolina JOHN P. SARBANES, Maryland
TIM WALBERG, Michigan PAUL TONKO, New York
EARL L. ``BUDDY'' CARTER, Georgia YVETTE D. CLARKE, New York
JEFF DUNCAN, South Carolina TONY CARDENAS, California
GARY J. PALMER, Alabama RAUL RUIZ, California
NEAL P. DUNN, Florida SCOTT H. PETERS, California
JOHN R. CURTIS, Utah DEBBIE DINGELL, Michigan
DEBBBIE LESKO, Arizona MARC A. VEASEY, Texas
GREG PENCE, Indiana ANN M. KUSTER, New Hampshire
DAN CRENSHAW, Texas ROBIN L. KELLY, Illinois
JOHN JOYCE, Pennsylvania NANETTE DIAZ BARRAGAN, California
KELLY ARMSTRONG, North Dakota, Vice LISA BLUNT ROCHESTER, Delaware
Chair DARREN SOTO, Florida
RANDY K. WEBER, Sr., Texas ANGIE CRAIG, Minnesota
RICK W. ALLEN, Georgia KIM SCHRIER, Washington
TROY BALDERSON, Ohio LORI TRAHAN, Massachusetts
RUSS FULCHER, Idaho LIZZIE FLETCHER, Texas
AUGUST PFLUGER, Texas
DIANA HARSHBARGER, Tennessee
MARIANNETTE MILLER-MEEKS, Iowa
KAT CAMMACK, Florida
JAY OBERNOLTE, California
------
Professional Staff
NATE HODSON, Staff Director
SARAH BURKE, Deputy Staff Director
TIFFANY GUARASCIO, Minority Staff Director
Subcommittee on Health
BRETT GUTHRIE, Kentucky
Chairman
MICHAEL C. BURGESS, Texas ANNA G. ESHOO, California
ROBERT E. LATTA, Ohio Ranking Member
H. MORGAN GRIFFITH, Virginia JOHN P. SARBANES, Maryland
GUS M. BILIRAKIS, Florida TONY CARDENAS, California
BILL JOHNSON, Ohio RAUL RUIZ, California
LARRY BUCSHON, Indiana, Vice Chair DEBBIE DINGELL, Michigan
RICHARD HUDSON, North Carolina ANN M. KUSTER, New Hampshire
EARL L. ``BUDDY'' CARTER, Georgia ROBIN L. KELLY, Illinois
NEAL P. DUNN, Florida NANETTE DIAZ BARRAGAN, California
GREG PENCE, Indiana LISA BLUNT ROCHESTER, Delaware
DAN CRENSHAW, Texas ANGIE CRAIG, Minnesota
JOHN JOYCE, Pennsylvania KIM SCHRIER, Washington
DIANA HARSHBARGER, Tennessee LORI TRAHAN, Massachusetts
MARIANNETTE MILLER-MEEKS, Iowa FRANK PALLONE, Jr., New Jersey (ex
JAY OBERNOLTE, California officio)
CATHY McMORRIS RODGERS, Washington
(ex officio)
C O N T E N T S
----------
Page
Hon. Brett Guthrie, a Representative in Congress from the
Commonwealth of Kentucky, opening statement.................... 2
Prepared statement........................................... 4
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 9
Prepared statement........................................... 11
Hon. Cathy McMorris Rodgers, a Representative in Congress from
the State of Washington, opening statement..................... 13
Prepared statement........................................... 15
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 19
Prepared statement........................................... 21
Hon. Robert E. Latta, a Representative in Congress from the State
of Ohio, prepared statement.................................... 179
Hon. Richard Hudson, a Representative in Congress from the State
of North Carolina, prepared statement.......................... 184
Witnesses
Kemp Chester, Senior Advisor, Office of National Drug Control
Policy......................................................... 23
Prepared statement........................................... 26
Submitted questions for the record \1\....................... 283
Neeraj Gandotra, M.D., Chief Medical Officer, Substance Abuse and
Mental Health Services Administration, Department of Health and
Human Services................................................. 37
Prepared statement........................................... 39
Answers to submitted questions............................... 287
John DeLena, Associate Administrator, Drug Enforcement
Administration, Department of Justice.......................... 51
Prepared statement........................................... 53
Submitted questions for the record \1\....................... 299
Kandi Pickard, President and Chief Executive Officer, National
Down Syndrome Society.......................................... 102
Prepared statement........................................... 104
Answers to submitted questions............................... 303
Frederick Isasi, Executive Director, Families USA................ 110
Prepared statement........................................... 112
Additional material submitted for the record................. 120
Answers to submitted questions............................... 307
Molly A. Cain, Parent Advocate................................... 128
Prepared statement........................................... 130
Stephen Loyd, M.D., Chief Medical Officer, Cedar Recovery........ 135
Prepared statement........................................... 137
Answers to submitted questions............................... 309
Timothy W. Westlake, M.D., Emergency Medicine Physician.......... 141
Prepared statement........................................... 143
Answers to submitted questions............................... 313
----------
\1\ Mr. Chester and Mr. DeLena did not answer submitted questions for
the record by the time of publication. Replies received after
publication will be retained in committee files and made available at
https://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=115361.
Legislation
H.R. ___, the Halt All Lethal Trafficking of Fentanyl Act........ 186
H.R. ___, the Protecting Health Care for All Patients Act........ 205
H.R. ___, the 9-8-8 Lifeline Cybersecurity Responsibility Act.... 208
H.R. ___, the Block, Report, and Suspend Suspicious Shipments Act 212
Submitted Material
Inclusion of the following was approved by unanimous consent.
Letter of January 31, 2023, from Christopher Banks, President/
Chief Executive Officer, Autism Society of America, to Mrs.
Rodgers and Mr. Pallone........................................ 216
Letter of January 30, 2023, from Nicole Jorwic, Chief of Advocacy
and Campaigns, Caring Across Generations, to Mrs. Rodgers and
Mr. Pallone.................................................... 218
Letter of January 31, 2023, from Silvia Yee, Senior Staff
Attorney, Disability Rights Education & Defense Fund, to Mrs.
Rodgers and Mr. Pallone........................................ 220
Letter of January 27, 2023, from Allison Zetterquist, Acting
Chief Executive Officer, Epilepsy Foundation, to Mrs. Rodgers
and Mr. Pallone................................................ 222
Letter of January 31, 2023, from Michael Lewis, Director,
Disability Policy, Muscular Dystrophy Association, to Mrs.
Rodgers, et al................................................. 224
Letter of January 31, 2023, from Paul C. Langley, Adjunct
Professor, College of Pharmacy, University of Minnesota, to Mr.
Guthrie, et al................................................. 226
Letter of October 3, 2022, from ACMCRN, et al., to Xavier
Becerra, Secretary, Department of Health and Human Services.... 229
Letter of January 31, 2023, from Mary Sowers, Executive Director,
National Association of State Directors of Developmental
Disabilities Services, to Mrs. Rodgers and Mr. Pallone......... 240
Statement of the Partnership to Improve Patient Care, January 30,
2023........................................................... 242
Letter of February 1, 2023, from Terry Wilcox, Chief Executive
Officer and Founder, Patients Rising Now, to Mr. Guthrie, et
al............................................................. 243
Letter of January 31, 2023, from Julie Ward, Senior Executive
Officer, Public Policy, The Arc, to Mrs. Rodgers and Mr.
Pallone........................................................ 248
Letter of January 31, 2023, from Kenneth Hobby, President, Cure
SMA, to Mrs. Rodgers........................................... 250
Letter of January 31, 2023, from Marlene Sallo, Executive
Director, National Disability Rights Network, to Mrs. Rodgers
and Mr. Pallone................................................ 252
Report of the National Council on Disability, ``Quality-Adjusted
Life Years and the Devaluation of Life with Disability,''
November 6, 2019 \2\
Letter of December 14, 2021, from Brian R. Marvel, President,
Peace Officers Research Association of California, to Senator
Bill Cassidy, et al............................................ 255
Policy Brief of the National Council on Disability,
``Alternatives to QALY-Based Cost-Effectiveness Analysis for
Determining the Value of Prescription Drugs and Other Health
Interventions,'' November 28, 2022 \2\
Article of January 31, 2009, ``Principles for allocation of
scarce medical interventions,'' by Govind Persad, Alan
Wertheimer, and Ezekiel J Emanuel, The Lancet.................. 256
Article of March 27, 2020, ``People With Intellectual
Disabilities May Be Denied Lifesaving Care Under These Plans as
Coronavirus Spreads,'' by Amy Silverman, Arizona Daily Star.... 265
Statement of Regina M. LaBelle, Director, Addiction and Public
Policy Initiative, O'Neill Institute for National and Global
Health Law, Georgetown University Law Center................... 270
Letter of March 8, 2017, from Sara Hart Weir, President, National
Down Syndrome Society, to Members of the Senate and House of
Representatives................................................ 275
Fact sheet, ``Illicitly Manufactured Fentanyl as a Weapon of Mass
Destruction: Rhetoric and Reality,'' Addiction and Public
Policy Initiative, O'Neill Institute for National and Global
Health Law, November 2022...................................... 279
Report of the National Institute on Drug Abuse, ``Medications to
Treat Opioid Use Disorder Research Report,'' December 2021\2\
----------
\2\ The information has been retained in committee files and is
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=115361.
LIVES WORTH LIVING: ADDRESSING THE FENTANYL CRISIS, PROTECTING CRITICAL
LIFELINES, AND COMBATING DISCRIMINATION AGAINST THOSE WITH DISABILITIES
----------
WEDNESDAY, FEBRUARY 1, 2023
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:01 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
Hon. Brett Guthrie (chairman of the subcommittee) presiding.
Members present: Representatives Guthrie, Bucshon, Burgess,
Latta, Griffith, Bilirakis, Johnson, Hudson, Carter, Dunn,
Crenshaw, Joyce, Harshbarger, Miller-Meeks, Obernolte, Rodgers
(ex officio), Eshoo (subcommittee ranking member), Sarbanes,
Cardenas, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt
Rochester, Craig, Schrier, Trahan, and Pallone (ex officio).
Staff present: Alec Aramanda, Professional Staff Member,
Health; Kate Arey, Content Manager and Digital Assistant; Jolie
Brochin, Clerk, Health; Sarah Burke, Deputy Staff Director;
Kristin Flukey, Professional Staff Member, Health; Theresa
Gambo, Financial and Office Administrator; Seth Gold,
Professional Staff Member, Health; Grace Graham, Chief Counsel,
Health; Nate Hodson, Staff Director; Peter Kielty, General
Counsel; Emily King, Member Services Director; Chris Krepich,
Press Secretary; Clare Paoletta, Professional Staff Member,
Health; Carla Rafael, Staff Assistant; Michael Taggart, Policy
Director; Lydia Abma, Minority Policy Analyst; Jacquelyn Bolen,
Minority Health Counsel; Waverly Gordon, Minority Deputy Staff
Director and General Counsel; Tiffany Guarascio, Staff
Director; Perry Hamilton, Minority Member Services and Outreach
Manager; Saha Khaterzai, Minority Professional Staff Member;
Una Lee, Minority Chief Health Counsel; Juan Negrete, Minority
Professional Staff Member; Greg Pugh, Minority Staff Assistant;
Andrew Rosario, Minority Health Fellow; Andrew Souvall,
Minority Director of Communications, Outreach, and Member
Services; Tristen Tellman, Minority Health Fellow; Rick Van
Buren, Minority Senior Health Counsel; and C.J. Young, Minority
Deputy Communications Director.
Mr. Guthrie. The Subcommittee on Health will now come to
order.
The microphone is not on? It should be on. Yes, it is. Wow.
I hit the button.
Anyway, things you have to learn, right?
Well, thanks a lot. I appreciate everybody being here
today. And I appreciate working with Democrat Leader Eshoo. We
enjoyed working together last Congress, and we will continue to
do so. We have a lot of things before us.
But the subcommittee will come to order. And the Chair now
recognizes himself for 5 minutes for an opening statement.
OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF KENTUCKY
As we turn the page on both 2022 and the 117th Congress,
thousands of Americans and their families are still reeling
from failures by this administration and the last Congress to
meaningfully address one of the greatest public health threats
of our lifetimes, the fentanyl crisis.
Over the past several years, the United States has seen a
historic rise of drug overdoses, driven by an increased supply
of synthetic opioids such as illicit fentanyl analogs. In 2021
alone, there were over 107,000 drug overdoses reported,
according to the Centers for Disease Control and Prevention,
and over 60,000 of these were caused by synthetic opioids. My
home State of Kentucky experienced a 14 percent jump in drug
overdose deaths between 2020 and 2021, with over 70 percent of
these deaths being caused by fentanyl alone.
Sadly, you cannot go a week without reading or hearing
about the stories of mothers, sons, sisters, brothers, and
cherished friends and even babies losing their lives to
fentanyl overdoses.
How could this be possible? We don't have to look farther
than the crisis right now at our southern border. Since last
October, October of last year, our Border Patrol authorities
have seized over 7,000 pounds of illicit fentanyl at our
southwest border. This is on top of the over 14,000 pounds of
illicit fentanyl seized the prior year. The dual crises, both
the fentanyl and border crises, have effectively turned every
community across the United States into a border community.
Fortunately, this very subcommittee has the ability to take
action and do what we know will work to help keep illicit
fentanyl out of our communities and save lives.
One of the bills before us today, H.R. 467, the Halt All
Lethal Trafficking of Fentanyl Act, also known as the HALT
Fentanyl Act, would take the critical step of permanently
scheduling all fentanyl-related substances as Schedule I drugs
under the Controlled Substances Act.
Congress has enacted temporary extensions several times
over the last few years. These continued temporary solutions
are not sustainable. We need a permanent solution and must pass
the HALT Fentanyl Act now. Doing so will be my top priority as
long as I am chairman of this Health Subcommittee.
I want to address the demand for illegal and dangerous
drugs here in the United States while simultaneously focusing
on support for recovery services for those who want help. We
will have an opportunity later this year to reauthorize key
parts of the SUPPORT Act, and we will be able to examine how to
get people into recovery and keep them safe.
But if we have learned anything over the past few years, it
is that these illicit fentanyl analogs are an entirely
different class of drugs than any other deadly substance that
our country has faced thus far and has the ability to make
other illegal drugs that much more lethal.
Further, the Block, Report, and Suspend Suspicious
Shipments Act, introduced by one of our newest subcommittee
members, Representative Harshbarger, would also address the
overdose crisis. This bill would require drug manufacturers and
distributors to report all suspicious shipments of controlled
substances to the Drug Enforcement Agency and require these
entities to decline to fill such orders.
Fighting the overdose epidemic necessitates a multipronged
approach and a strong partnership between the public and
private sectors, which this legislation accomplishes. I thank
Representative Harshbarger for leading on this issue.
The other important pieces of legislation before us today
are equally as focused on protecting the sanctity of life. The
988 Lifeline Cybersecurity Act would ensure that the lifesaving
988 Suicide and Crisis Hotline is protected from cyber
vulnerabilities.
This comes after the lifeline suffered a cyber attack in
early December which resulted in an hours-long outage of the
lifeline. This cannot happen again, and I look forward to
moving this bill through committee.
Finally, we are examining legislation to permanently ban
the use of quality-adjusted life years in all publicly funded
healthcare programs like Medicare and Medicaid. It is long
overdue for Congress to take the necessary step of banning
QALYs. With the Protecting Health Care for All Patients Act
before us today, this would be finally achieved.
Such policies arbitrarily put a value on someone's life and
are especially discriminatory towards those living with
disabilities. A life worth living is always a life worth
saving, regardless of someone's health status. I know this bill
is personal and very important to our chair of the full
committee, Chair McMorris Rodgers.
I urge all of my colleagues on this subcommittee to support
these four bills before us today.
Thank you, and I yield back.
[The prepared statement of Mr. Guthrie follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. The Chair now recognizes the subcommittee
ranking member, Ms. Eshoo, for 5 minutes for an opening
statement.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Eshoo. Well, good morning, everyone.
And thank you, Mr. Chairman. And, first of all, my warmest
congratulations to you on becoming the chairman of this, what I
think is an extraordinary Health Subcommittee.
And welcome to the new members of this subcommittee. You
are going to love serving here. And I know, from this side of
the aisle, that we look forward to working with you for the
benefit of the American people.
Our first hearing today focuses on an issue this
subcommittee has been struggling with for nearly 25 years, the
opioid crisis.
Over 900,000 Americans have died from opioids since 1999,
including more than 107,000 deaths in just the last year. The
country has had three waves of opioid deaths: prescription
opioids, heroin opioids, and now fentanyl.
Fentanyl is a synthetic opioid that is up to 50 times
stronger than heroin and 100 times stronger than morphine.
According to the CDC, over 66 percent of the overdose deaths in
2021 were caused by fentanyl.
Today, our subcommittee considers H.R. 467, the HALT
Fentanyl Act, to address this epidemic.
What is unfortunate is that the HALT Fentanyl Act does
nothing to change the status quo. For the past 5 years, all
fentanyl-related substances have been considered Schedule I
drugs. The HALT Fentanyl Act would continue that scheduling.
Scheduling doesn't stop deaths. Since 2018, when fentanyl-
related substances first became Schedule I, fentanyl deaths
have risen by over 50 percent. So we have to do much more to
save lives.
First, I think we need to stop the supply of illicit
fentanyl. We are making progress through record-breaking DEA
seizures. For example, last year the DEA seized 10,000 pounds
of illicit fentanyl powder--10,000 pounds. I mean, it is so
difficult to get your head wrapped around these figures.
There is another part of this, though, and it isn't really
very often spoken about. I believe that we have broken gun
laws. In this case, Mexican cartels are trading--they are
trading illicit fentanyl for readily available American guns.
We need to stop this so-called ``iron river'' of death between
our two countries.
Another major contributing factor to overdoses is the
difficulty finding treatment. According to SAMHSA, only 11
percent of people--only 11 percent, so 89 percent of people
with opioid addiction do not receive medication-assisted
treatment.
Importantly, in December, Congressman Tonko's MAT Act
became law. The new law eliminates bureaucratic guardrails that
limit the availability of medication-assisted treatment.
Medication-assisted treatment is proven to reduce overdose
deaths and curb illicit drug use.
Naloxone is another miracle medicine that saves lives.
Anyone can use it to rapidly reverse opioid overdose. And I
commend the FDA's recent work to make naloxone available over
the counter. And I urge all the makers of this drug, including
Emergent and Kaleo, to begin switching their product labels
from prescription to over-the-counter.
I look forward to hearing from ONDCP, SAMHSA, and the DEA
today about what else Congress should do to change the status
quo and save lives.
We will also hear two other bills unrelated to fentanyl.
H.R. 498, the 988 Lifeline Cybersecurity Responsibility Act, is
a commonsense bill that requires the 988 network administrator
to report potential cybersecurity threats to SAMHSA immediately
upon discovery. I support that bill.
H.R. 485 is focused on ending the Federal Government's use
of quality-adjusted life years metrics, also known as QALYs. I
support ending the use of discriminatory QALYs, because the
metric devalues the lives of people with disabilities.
So I look forward to learning more about the bill and its
impact, Mr. Chairman, during today's hearing.
So congratulations once again. It is your opening day. And,
again, look forward to working with you.
And I yield back.
[The prepared statement of Ms. Eshoo follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you very--I thank the gentlelady for
yielding back.
And the Chair will now recognize the chair of the full
committee, Mrs. McMorris Rodgers, for 5 minutes for an opening
statement.
OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON
Mrs. Rodgers. Thank you, Mr. Chair.
Welcome, everyone, to the legislative hearing titled
``Lives Worth Living: Addressing the Fentanyl Crisis,
Protecting Critical Lifelines, and Combating Discrimination
Against Those with Disabilities.'' We will hear from a diverse
panel on how we can advance solutions that will help people in
need of hope and healing in our communities.
Last month, the Energy and Commerce Republicans held a
roundtable on the fentanyl crisis, and we heard from Deb and
Ray Cullen, who had lost their son, Zach. They told us they
will never forget the moment that the police showed up at their
door asking if they were Zach's parents. He was just 9 days
past his 23rd birthday, and he was targeted and poisoned by a
drug dealer.
Today, we will hear from Molly Cain from my hometown of
Spokane, Washington. She lost her son, Carson, to fentanyl
poisoning when he was also 23 years old.
Deb, Ray, and Molly have experienced immeasurable pain from
losing their children, and they deserve justice. That is why
Reps Griffith and Latta are working on the HALT Fentanyl Act.
This bill would permanently place fentanyl-related substances
into Schedule I of the Controlled Substances Act and make sure
that our law enforcement can keep these weapons-grade poisons
off the streets.
Unfortunately, the administration is proposing to treat
these deadly poisons differently from fentanyl and other
currently scheduled fentanyl-related substances. The
administration supports exempting the entire class from
mandatory minimums that are typically imposed upon drug
dealers, drug traffickers, preventing law enforcement from
stopping those who would bring deadly substances into our
communities.
If the temporary legislation were to expire, it would mean
the criminals who kill people like Zach and Carson could keep
trafficking these lethal substances with little consequences.
So let's make it permanent.
And I am hopeful that we can work together, both sides of
the aisle, to make sure that we take action that will punish
those who make and import and distribute these poisons to our
children.
I also want to recognize Mrs. Harshbarger's bill in
introducing the Block, Report, and Suspend Suspicious Shipments
Act.
The opioid epidemic is fueled in part by suspiciously large
shipments of pain medication being delivered across the
country, especially in places like Tennessee and West Virginia.
This bill would stop this practice and save lives by requiring
drug manufacturers and distributors that discover a suspicious
order for controlled substances to halt the order and report
the information to DEA.
Additionally, just last month we learned about a cyber
attack on the 988 Suicide and Crisis Lifeline. This lifeline is
a network of local crisis centers that promotes emotional
support to people in suicidal crisis or emotional distress. It
is a critical tool that was established by the bipartisan work
of this committee, and we must ensure that it is protected from
future cyber threats.
Representative Obernolte's 988 Lifeline Cybersecurity
Responsibility Act would do just that. It requires coordination
and reporting to improve cybersecurity protections for the 988
Lifeline.
Finally, we will discuss why it is important to take action
to protect people with disabilities with the Protecting Health
Care for All Patients Act. It would ban quality-adjusted life
years, or QALYs, that discriminate against people with
disabilities and patients with debilitating or life-threatening
health conditions.
QALYs undervalue treatments for patients who have shorter
lifespans than others. In countries with QALYs, the most
vulnerable get pushed to the back of the line for treatment.
People like those with cystic fibrosis, ALS, or people like my
son with Down syndrome, the government says that their lives
don't matter as much. They are not valuable enough.
In America, where we have led the world in amazing medical
breakthroughs and innovation, we must ban QALYs and strongly
affirm that every life is worth living. It is my sincere hope
that we can move forward on this bill with bipartisan support.
Families need hope. And there is inherent dignity in every
human life. And that is why we are coming together today in our
first legislative hearing this Congress, and I look forward to
hearing more.
I appreciate everyone being here to testify as we work
together to promote life, liberty, and the pursuit of happiness
for all.
Thank you, and I yield back.
[The prepared statement of Mrs. Rodgers follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. I thank the chair for yielding back.
The Chair recognizes the ranking member of the full
committee, Mr. Pallone, for 5 minutes.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairman Guthrie.
And I believe the top priority of this subcommittee is
ensuring all Americans have access to quality and affordable
health coverage so they can live long and healthy lives.
And I am also proud of this subcommittee's work in the last
Congress, which is a testament to the life-changing and
lifesaving policies we can achieve if we work together.
Last Congress, we passed landmark laws that make healthcare
and prescription drugs more affordable; we expanded access to
healthcare, including to children and mothers, through CHIP and
Medicaid; we equipped the Food and Drug Administration and the
Centers for Disease Control and Prevention with critical tools
and resources to maintain and enhance our Nation's public
health; and we made significant investments to address the
mental health and substance use disorder crisis, including
implementing historic policy reforms to address the overdose
crisis. Specifically, we included the MAT Act, which will
increase access to lifesaving treatments for those experiencing
substance use disorders.
We accomplished a tremendous amount, and I commend every
member of the subcommittee for their dedication and hard work.
Now, today, we will discuss the scourge that is illicit
fentanyl and fentanyl-related substances, which have caused so
much harm and death to our families, friends, and constituents.
The policies passed in the fiscal year 2023 omnibus in
December, some of which I just mentioned, are concrete examples
of the work we are doing to save lives.
I am disappointed that our first hearing in the Health
Subcommittee does not build on the successes of last Congress
but, rather, that my Republican colleagues have chosen to take
a different route with the partisan HALT Fentanyl Act.
We have learned time and time again that we cannot
incarcerate our way out of a public health crisis and that a
broader public health approach is needed to address what is at
its root a health problem.
Moreover, my Republican colleagues were unwilling to
consider any Democratic bills to address the overdose crisis
for inclusion in this hearing, and that is disappointing. If
Republicans are serious about finding a long-term solution,
then they should be willing to discuss bipartisan, evidence-
based policies to address the substance use and overdose
crisis.
One such bill is the bipartisan Save Americans from the
Fentanyl Emergency Act, which was introduced by Representatives
Pappas, Newhouse, and Gonzales. This legislation reflects the
administration's comprehensive approach to address the fentanyl
crisis. Our Nation's law enforcement and public health agencies
both agreed to this approach.
I am disappointed that this bill was not included in the
hearing, as well as many other bipartisan bills that would help
us address the overdose crisis. Representative Tonko's
bipartisan Reentry Act would ensure that individuals
transitioning out of the justice system and into our
communities have access to treatment for substance use
disorders.
We are also considering a bill today to ban the use of
quality-adjusted life years, often referred to as QALYs, in
value measurements and price determinations set by Federal
agencies and States.
While I appreciate and respect the perspective of those in
the disability community about any economic metrics that value
certain lives differently, I fear this bill is a solution in
search of a problem. Federal law already prohibits the use of
QALYs in Medicare, and Medicaid is required to cover, with
limited exceptions, every outpatient drug covered by the
program if a manufacturer has a rebate agreement in place.
As I mentioned earlier, Democrats delivered on our promise
to lower drug prices last year with the enactment of the
Inflation Reduction Act. That new landmark law provides the
Secretary of Health and Human Services with the authority to
negotiate lower drug prices for Medicare beneficiaries for the
first time, while also explicitly prohibiting the use of QALYs
in this process.
I fear this bill would be a Trojan horse that goes far
beyond just banning QALYs by potentially banning all other
kinds of ways of measuring a drug's value. This would result in
artificially keeping drug prices and healthcare costs high
while also tying the hands of the Federal Government in
determining the value of healthcare services and treatments.
So, again, if my Republican colleagues want to discuss how
to best protect the disability community, we should consider
the impacts of proposed cuts that the Republican majority wants
to make in exchange for a debt ceiling increase.
The Republican Study Committee's budget for fiscal year
2023 calls for cutting Medicaid and CHIP by $3.6 trillion and
cutting Medicare by $2.8 trillion. These drastic cuts will be
devastating for the millions of people with disabilities who
rely on Medicaid for their health and well-being.
The Republican plan to slash and burn Medicaid is an
existential threat to a major source of health insurance for
individuals with disabilities, and Democrats will aggressively
oppose these cuts.
As for today's hearing, I welcome the discussion on how we
move forward to address the fentanyl crisis, and I hope that in
the coming weeks the subcommittee can discuss bipartisan
solutions that were unfortunately not included in this hearing
today.
And, with that, I yield back, Mr. Chairman.
[The prepared statement of Mr. Pallone follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. The gentleman yields back. And I do look
forward to working together as we move forward on reauthorizing
the SUPPORT Act this year.
We now conclude with Member opening statements. The Chair
would like to remind Members that, pursuant to the committee
rules, all Members' opening statements will be made part of the
record.
We will now move to our witnesses. We want to thank all of
our witnesses for being here today and taking the time to
testify before the subcommittee.
Each witness will have the opportunity to give an opening
statement, followed by a round of questions from Members.
Our witnesses today are Mr. Kemp Chester, a senior advisor
at the Office of National Drug Control Policy with expertise in
international relations and supply reduction. Then we will have
Dr. Neeraj Gandotra, the Chief Medical Officer for the
Substance Abuse and Mental Health Services Administration. And,
finally, we will be joined Mr. Jon DeLena, the Associate
Administrator at the Drug Enforcement Administration.
We appreciate you being here today. We will recognize each
for 5 minutes. I think you have all testified before and know
the lighting system. You will have a yellow light just to give
you a warning, and then a red light means to wrap up.
So we appreciate that, and we appreciate you being here.
I will now recognize our first witness to give 5 minutes
for an opening statement. Mr. Chester, you are recognized for 5
minutes.
STATEMENTS OF KEMP CHESTER, SENIOR ADVISOR, OFFICE OF NATIONAL
DRUG CONTROL POLICY; NEERAJ GANDOTRA, M.D., CHIEF MEDICAL
OFFICER, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND
JON DeLENA, ASSOCIATE ADMINISTRATOR, DRUG ENFORCEMENT
ADMINISTRATION, DEPARTMENT OF JUSTICE
STATEMENT OF KEMP CHESTER
Mr. Chester. Chairman Guthrie, Ranking Member Eshoo,
members of the subcommittee, thank you for inviting me to
testify today on the illicit drug environment we face in the
United States and our efforts to address it.
The administration is taking a number of tangible steps to
reduce drug-related deaths, expand access to treatment for
substance use disorder, and target the global production and
trafficking of synthetic opioids like illicit fentanyl which
currently kill more than 107,000 Americans every year.
The administration's National Drug Control Strategy focuses
on attacking the two drivers of the opioid epidemic: untreated
addiction and the drug-trafficking profits that fuel this
crisis.
In terms of public health, we are expanding access to
substance use prevention, harm reduction in addiction
treatment, and recovery support services.
And I want to thank the Congress for including key
provisions of the MAT Act in the bipartisan omnibus government
funding bill, which will allow prescribers across the country
to treat their patients who have opioid use disorder with
buprenorphine without additional Federal licensing.
We are also working to remove barriers to naloxone, make
permanent the COVID-19 flexibilities that expanded access to
treatment, address emerging threats like xylazine being added
into illicit fentanyl. And we look forward to working with the
Congress to make permanent the 2-year extension of the
scheduling of all fentanyl-related substances as a class.
But while the opioid epidemic is a daunting public health
issue, it presents a serious national security and economic
prosperity challenge for the United States as well. The vast
majority of the substances harming Americans are produced
outside the United States and brought across our borders
through a variety of means.
To address this very real threat, we have taken a new and
more comprehensive approach to this problem: to commercially
disrupt the global business of illicit synthetic drug
production and trafficking.
We will target not only the finished drugs themselves and
those who sell them but also the raw materials and machinery
used to produce them, the commercial shipping that moves these
items around the world, and the illicit financial structure
that allows this global business to operate and allows drug
traffickers to profit from the suffering of others.
Using new authorities provided by Executive order, the
Department of the Treasury has imposed sanctions against dozens
of individuals and entities involved in the illicit drug trade,
including illicitly manufactured fentanyl.
In 2022 alone, Customs and Border Protection seized nearly
262,000 pounds of illicit narcotics, including 15,000 pounds of
fentanyl. And our HIDTA task forces seized more than 737,000
pounds of drugs, including 26,000 pounds of illicit fentanyl in
the United States.
These are drugs permanently removed from the illicit supply
chain, not killing our citizens. And domestic seizures alone
denied $9 billion in profits and critical operating capital to
drug traffickers.
And the President has asked for increased funding for both
Customs and Border Protection and the Drug Enforcement
Administration to enable their vital work in keeping our Nation
safe from these dangerous drugs.
However, this problem does not begin or end at the United
States border. This is a global problem that has negative
effects not only in the United States but also the rest of the
world. And American leadership at the global level is
absolutely essential.
These deadly drugs are manufactured using precursor
chemicals made available by criminal elements, often in the
People's Republic of China, that are shipped to Mexico, where
they are used to produce illicit fentanyl or one of its analogs
and often pressed into the counterfeit pills that have poisoned
so many Americans.
The administration is working bilaterally with our
international partners, particularly Mexico, the People's
Republic of China, India, and others, and multilaterally to
address the global threat of illicit synthetic opioid
production and trafficking.
I am pleased to say that, as a result of our work in the
public health and law enforcement domains, we are beginning to
see some progress, with 5 straight months of decreased drug-
involved deaths.
Together, the administration and the Congress are changing
the trajectory of a complex national security, criminal
justice, and public health challenge that has vexed the Nation
for the better part of three decades. There are signs of hope,
but we have a very long way to go.
On behalf of Dr. Gupta and the men and women of the Office
of National Drug Control Policy, thank you for your foresight
and leadership on this difficult issue, and we look forward to
continuing our work with you in the months and the years ahead.
Thank you, and I look forward to your questions.
[The prepared statement of Mr. Chester follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you.
The gentleman yields back.
And I will now recognize Dr. Gandotra for 5 minutes for
your opening statement.
STATEMENT OF NEERAJ GANDOTRA, M.D.
Dr. Gandotra. Good morning. Thank you, Chair Guthrie,
Ranking Member Eshoo, Chair McMorris Rodgers, Ranking Member
Pallone, and members of the subcommittee, for inviting me to
testify at this hearing covering fentanyl and the 988 Suicide
and Crisis Lifeline, among other topics.
My name is Dr. Neeraj Gandotra, and I am Chief Medical
Officer for the Substance Abuse and Mental Health Services
Administration, also known as SAMHSA. SAMHSA leads public
health efforts to improve behavioral health of our Nation.
I am pleased to be here along with my colleagues from the
White House Office of National Drug Control Policy and the Drug
Enforcement Administration.
I look forward to discussing our work at SAMHSA, which aims
to support all aspects of the care continuum, from prevention
and harm reduction to treatment, crisis care, and sustained
recovery services.
Ultimately, SAMHSA envisions people with, affected by, or
at risk for mental health and substance use conditions receive
care, thrive, and achieve well-being.
Over the past few years, we have seen the opioid overdose
epidemic evolve. We are now faced with the reality that
fentanyl and substances laced with fentanyl are far more deadly
than other opioids or stimulants alone.
That is why addressing addiction and the overdose epidemic
are one of the four pillars of the Unity Agenda that the
President outlined in last year's State of the Union Address.
Additionally, at the beginning of the Biden-Harris
administration, Secretary Becerra released the comprehensive
HHS Overdose Prevention Strategy, which is designed to increase
both access to primary substance use prevention activities and
access to the full range of services for individuals at risk
for overdose as well as services for their families. This
strategy prioritizes four key areas: primary prevention, harm
reduction, evidence-based treatment, and recovery support.
SAMHSA's substance abuse prevention programs target at-risk
populations and specific age groups to stop substance use
before it starts. We work with State and local partners to
reach people where they are and to reduce the impacts of
substance misuse. For example, SAMHSA's First Responders-CARA
program trains first responders on how to respond to overdose-
related incidents and provides training on naloxone
administration.
SAMHSA also provides funding and support for evidence-based
harm-reduction services. Our harm-reduction grants support
activities such as expanded distribution of overdose-reversal
medications and fentanyl test strips. It also provides overdose
education and counseling and works to stop the spread of
infectious diseases.
Fentanyl test strips are an important component of harm-
reduction programs, education and awareness-building toolkits,
and low-threshold, on-demand treatment programs. All of these
are efforts that help save lives.
Because of Congress' commitment to treatment programs and
thanks to December's omnibus, SAMHSA is actively working with
Federal partners to implement the removal of the DATA 2000
waiver and related policies so that more Americans can access
this lifesaving medication.
In addition to preventing and treating substance use, we
also ensure that patients in mental health and substance use
crisis are quickly directed to the appropriate level of care.
This work includes helping States and localities coordinate
crisis services through the 988 Suicide and Crisis Lifeline.
The lifeline helps connect individuals with trained counselors
and, if needed, crisis intervention and stabilization services.
It may also include warm handoffs to treatment providers.
Thanks to the support from Congress, the lifeline is
serving more Americans in crisis. For example, when comparing
December 2021 with December 2022, the 988 Lifeline answered
434,000 contacts, which is 172,000 more calls, chats, and texts
versus 2021, and it has also significantly improved how quickly
these contacts were answered. Additionally, when comparing
December 2022 to December 2021, calls, chats, and texts
answered all increased--48 percent, 263 percent, and 1,443
percent, respectively.
In closing, on behalf of my colleagues at SAMHSA, thank you
for supporting our programs and for working to improve our
Nation's behavioral health. I would be pleased to answer any
questions that you might have.
[The prepared statement of Dr. Gandotra follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. I appreciate your testimony.
The gentleman yields back.
And I will recognize Mr. DeLena for 5 minutes for an
opening statement.
STATEMENT OF JON DeLENA
Mr. DeLena. Good morning, Subcommittee Chairman Guthrie,
Ranking Member Eshoo, Committee Chair McMorris Rodgers, Ranking
Member Pallone, and distinguished members of this subcommittee.
On behalf of the Department of Justice and, in particular,
the approximately 10,000 employees of the Drug Enforcement
Administration, it is my honor to appear before you today. I
thank the committee for bringing attention to this important
topic.
Today's hearing comes at a critical moment in our country's
history. Our Nation is in the midst of a devastating drug
poisoning epidemic that claimed the lives of over 107,000
people this past year. An estimated 294 people die every day
from drug poisoning, and countless more overdose and survive.
I have had the privilege of being a DEA special agent for
nearly 27 years. I have worked in Colorado, Florida, Virginia,
and my home region, New England. The current drug poisoning
epidemic is like nothing I have ever experienced in my career.
In 2022, DEA seized more than 50 million fake pills and
10,000 pounds of fentanyl powder. That is approximately 379
million deadly doses of fentanyl taken off of American streets.
That is enough fentanyl to supply a potentially lethal dose to
every member of the U.S. population.
As a country, we must do everything we can to stop this
national crisis. For our part, the men and women of the DEA are
relentlessly focused, day in and day out, on combating the
deadly drug poisoning epidemic and on saving lives.
DEA leads and coordinates the whole-of-government response
to defeat the two Mexican drug cartels, the Sinaloa Cartel and
the Jalisco Cartel, that are responsible for driving the drug
poisoning epidemic in all of our communities.
A unified response, with DEA in the lead, ensures that the
whole of government is moving in one direction. Through this
unified response, we can protect the safety and health of
Americans.
The Sinaloa and Jalisco cartels pose the greatest criminal
drug threat the United States has ever faced. These ruthless,
violent criminal organizations have associates, facilitators,
and brokers in all 50 States as well as in more than 40
countries around the world.
The Sinaloa and Jalisco cartels control the supply chain
for illicit fentanyl. They obtain precursors from China and use
these precursor chemicals to manufacture fentanyl and other
synthetic drugs in clandestine laboratories in Mexico. The
cartels take that fentanyl and press it into fake prescription
pills and other drugs. The cartels then transport fentanyl in
pill and powder form, as well as other drugs like
methamphetamine, heroin, and cocaine, into the United States.
I have seen firsthand what the Mexican cartels have done to
our great country. The cartels are destroying families and
communities with callous indifference and greed.
The DEA is working across its global operations to defeat
these two cartels and protect our communities. I would like to
briefly highlight three initiatives in particular.
First are the counter-threat teams. DEA launched two cross-
agency counterthreat teams that focus exclusively on defeating
the Sinaloa Cartel and Jalisco Cartel. The teams use a network-
focused approach. They are mapping, analyzing, and targeting
the cartels' entire operations. The teams will use all of the
resources at their disposal to defeat these two cartels.
The second initiative is Operation Overdrive, which targets
drug-trafficking organizations and gangs that are responsible
for the greatest number of deaths and violence. Operation
Overdrive is a data-driven approach that is currently in 57
locations across the country, and we will expand.
The final initiative I would like to highlight are DEA's
family summits. In June and November of 2022, DEA brought
together families from across the country who have lost loved
ones to drug poisoning. The summits were incredibly impactful.
They were an opportunity for DEA to explain what we are doing
to combat the drug poisoning epidemic, but, more importantly,
it was an opportunity for families to share their stories with
one another and with us.
Throughout my career, I have partnered with families, local
groups, prevention specialists, and community outreach
organizations for events big and small, and I appreciate the
great work that they do and feel very strongly that the
connections we have made with these people and these families
will help educate, spread awareness, and save lives.
Congress, of course, has an important role to play. I
personally want to thank and extend my sincere thanks to the
Members of Congress who have worked so hard to ensure the
temporary classwide scheduling of fentanyl-related substances
does not expire. Classwide scheduling is critical to DEA's
ability to seize FRS when they are encountered and to
investigate and prosecute those that manufacture and traffic in
these deadly drugs. I urge Congress to make the temporary
scheduling permanent. This is critical to the safety and health
of Americans.
Thank you for the opportunity to testify before your
subcommittee on this important issue, and I look forward to
your questions.
[The prepared statement of Mr. DeLena follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you.
The gentleman yields back.
I thank the witnesses for their testimony.
And we will begin--we will now move into the Q&A portion of
the hearing. I will begin the questioning and recognize myself
for 5 minutes.
So, Mr. Chester, first, we had Dr. Gupta in Bowling Green,
Kentucky, my hometown, with Leader McConnell. And a lot of my
law enforcement guys were real concerned. And it goes back to a
comment that you made in a hearing in December 2021. And you
were defending the context of--what they were upset about is
that--and a lot of us are concerned about--is the
administration's position to schedule fentanyl-related
substances as a Schedule I but exempt it from the mandatory
minimums.
And in defending that policy before, you made this
statement, and I will quote it to you. It says: The
administration, quote, ``has gathered up an entire class of
substances uncreated that, within the class of substance, there
may be substances that either have medical merit or are not the
least bit harmful. They are not any more harmful than water,''
unquote. That was a direct quote.
I just can't imagine anywhere that a cartel would smuggle
fentanyl analogs into our country that is not as harmful as
water. Would you clarify that statement?
Mr. Chester. Thank you for your question, Congressman. Yes.
And I remember that. I remember that very clearly----
Mr. Guthrie. I do, too.
Mr. Chester [continuing]. When we were talking about two
sides of the same coin, with gathering up an entire class of
substances that have not been subjected to testing. And so it
is chemically possible that there are alterations to the
fentanyl molecule that have no effect on the body.
The question is, we don't know that. And so, not until they
are subjected to the three- and the eight-factor analysis that
the FDA does that the effect on the body of these substances
can be determined.
Traffickers often create new substances based upon their
chemical structure and then move them in and then ask for
customer feedback afterwards. And this is something that we see
quite often. They experiment with substances by sending them
out and then hear what the users provide in terms of feedback.
So there is a possibility that a trafficker creates a
substance based upon the fentanyl molecule, maybe a deletion of
the fentanyl molecule, sends it out, and it winds up having no
effect on the body at all.
Mr. Guthrie. That just seems--maybe that--I just can't
imagine a cartel--maybe they do send some of this.
But, anyway, you have illegal cartels smuggling drugs into
our country. Say they have no effect, somebody takes them and
complains, ``I took this pill. It has no effect.'' That is
still an illegal cartel moving drugs into this country.
The other one you said may have medical merit. You know,
fentanyl in itself has medical merit, except it is illegal and
is subject to mandatory minimums if you illegally traffic
fentanyl.
So I just--it is concerning the administration has that
position and--it is concerning to me.
So, Mr. DeLena, you are in the DEA. Do you believe that we
should permanently--you said in your testimony that permanently
scheduling illicit fentanyl analogs has an effect and you have
the ability to--it gives you more authority. Would you care to
just talk about how important it is for your administration to
have this bill in place?
Mr. DeLena. Thank you for the question, Congressman.
It is the top legislative priority for DEA to permanently
schedule fentanyl as a classwide substance. We have never seen
a deadlier drug, and we have seen the impact throughout the
entire United States.
Mr. Guthrie. Have you ever seen a cartel smuggle a harmless
drug into the country?
Mr. DeLena. I can't speak to every single thing that has
ever been smuggled, but what I can tell you----
Mr. Guthrie. But have you ever seen a harmless drug
smuggled into the country?
Mr. DeLena [continuing]. The two cartels that we are laser
focused on, the Sinaloa Cartel and the Jalisco Cartel, are
producing fentanyl and methamphetamine at epic rates. And it is
fentanyl and methamphetamine that is ending up in our
communities and causing the devastation and harm that we have
seen play out: 107,735 Americans died between August 2021 and
August 2022. It has to stop.
Mr. Guthrie. You do see drugs that have medical merit, that
are prescription drugs that have been diverted, that are
smuggled into our country. That should be a crime and subject
to the same as well.
I mean, the administration says, ``It could have medical
merit. We need to test it first.'' But if a cartel is smuggling
even prescription drugs that have been diverted, it still
should be punished and subject to mandatory minimums. Do you
agree?
Mr. DeLena. Thank you for the question, Congressman.
DEA is a law enforcement agency. We conduct investigations,
and we bring these cases forward to prosecutors. It is the
prosecutors and the judges who ultimately make those decisions.
Mr. Guthrie. So, if we permanently schedule fentanyl
analogs subject to Schedule I and some do come in that have
medical merit, they will be treated just like any other drug
that has medical merit? And if for some reason a cartel decides
to send some that are harmless, you still want to have the
ability to disrupt those cartels, correct?
Mr. DeLena. Thank you for the question, Congressman.
We are laser focused on disrupting and defeating the two
cartels, Sinaloa and Jalisco, that are causing the damage and
destruction throughout all of our communities.
Mr. Guthrie. Thank you.
My time has expired, and I recognize Ms. Eshoo from
California for 5 minutes to ask questions.
Ms. Eshoo. Thank you, Mr. Chairman.
And thank you to the witnesses for your testimony.
First, I want to go to Mr. DeLena.
Thank you for being here. A lot of passion in your voice
and in your testimony. A career that spans decades.
I think you have answered my first question: Do Mexican
cartels fuel the supply of illicit fentanyl in the United
States? That is a definite ``yes.''
So just ``yes'' or ``no'' to the following: Do the Mexican
cartels benefit from the availability of American guns?
Mr. DeLena. Thank you for the question, Congresswoman.
As I stated, the two cartels, Sinaloa and Jalisco Cartel,
are driven by greed. They are producing methamphetamine and
fentanyl at catastrophic rates and bringing those drugs into
all of our communities----
Ms. Eshoo. So it is ``yes''?
Mr. DeLena. They are fueled by any type of greed, and they
are paid and repatriated in any way possible.
Ms. Eshoo. Do they benefit from the guns, though, the
trafficking of them?
Mr. DeLena. Thank you for the question.
These are ruthless, violent criminal organizations----
Ms. Eshoo. But is it ``yes''----
Mr. DeLena [continuing]. That are involved in----
Ms. Eshoo. We know they are ruthless. I mean, my God. But
is it ``yes'' or ``no''?
Mr. DeLena. They use violence, guns of all----
Ms. Eshoo. So it is ``yes''?
Mr. DeLena. Yes.
Ms. Eshoo. OK.
If the cartels had less access to American guns, would that
diminish their strength and their firepower?
Mr. DeLena. Anything that we provide them----
Ms. Eshoo. I think it is obvious, but I want to hear what
you think.
Mr. DeLena [continuing]. Less access to--exactly. Thank
you.
Ms. Eshoo. Uh-huh.
If the cartels were weakened, would that reduce the amount
of illicit fentanyl coming into the United States from Mexico?
Mr. DeLena. Our focus is to defeat them, not just weaken
them, but----
Ms. Eshoo. But is it ``yes''----
Mr. DeLena [continuing]. Defeat those two cartels.
Ms. Eshoo [continuing]. Or ``no''?
Mr. DeLena. Yes. Yes.
Ms. Eshoo. OK.
To Dr. Gandotra, as I said in my opening statement, only 11
percent of people who need substance use treatment receive it.
So that is a very small number of people in our country.
Hopefully the number is going to grow soon, given the MAT
Act that we passed that was signed into law. It is going to
allow more doctors to prescribe medication-assisted treatment.
As quickly as you can, what are both SAMHSA and ONDCP doing
to educate the providers about the MAT Act so that we can
expand the access to medication-assisted treatment?
And if you can give us a specific, so that we have a
clearer handle on what you are doing.
Dr. Gandotra. Thank you for the question.
Certainly SAMHSA, HHS, and our Federal partners at ONDCP
and DEA are working together quickly to provide providers with
education and direction.
Ms. Eshoo. Yes, but what are you doing? Give us an example.
When you say we are working to provide, what does that mean?
Dr. Gandotra. Well, we are having regular meetings to
coordinate frequently asked questions. There has been a letter
that has been sent out to DEA registrants. Certainly we are
working with the professional societies to perform a framework
of educational priorities and competencies for providers.
We have been reaching out to all of our stakeholders--
States, the State opioid treatment authorities, as well as
providers themselves--so that they can have the education.
There are updates on our web pages, both for ourselves as well
as for our colleagues at the DEA.
Mr. Chester. Ma'am, I think my colleague from SAMHSA has
summed it up well in terms of implementation, but let me just
add that it is critically important that the elimination of the
X waiver created the opportunity for physicians to be able to
do this. Through greater education through SAMHSA and others,
they are creating the willingness of physicians to be able to
prescribe this very necessary drug as well. And SAMHSA is doing
great work in that regard.
Ms. Eshoo. I think it is important to note here, as we talk
about the need for medication-assisted treatment, how few in
our country receive it today; what our goal is, certainly, with
the new law; that Medicare currently covers an estimated 1.7
million beneficiaries with substance use disorder. That is
Medicare, which may be surprising to some people. You think of
older people, there is addiction there that--it is a
disappointment and a surprise. And Medicaid--Medicaid covers
about 6 million people with substance use disorder.
So I would say to my Republican friends that, as there is a
nexus between debt ceiling and cutting Medicare, watch it.
Because these are people that need, absolutely have to have
this coverage.
With that, I yield back, Mr. Chairman.
Mr. Guthrie. The gentlelady yields back.
Mr. Burgess from Texas is recognized for 5 minutes for
questions.
Mr. Burgess. Thank you, Mr. Chairman.
I wasn't going to bring this up, but the ranking member and
the ranking member of the full committee have provoked me on
this.
Look, cuts to Medicare over the past 2 years have been
staggering. And you talk to any practicing physician out in the
country and ask them, ``Have you felt the effect of Medicare
cuts in the last 2 years?'' and the answer will be,
``Absolutely, yes.''
Now, the American Rescue Plan--actually, one of the pay-
fors of the American Rescue Plan was a sequester on Medicare.
Yes, Congress has put a stay on that sequester, but that looms
out there as a budget item in the future. The Inflation
Reduction Act--$300 billion of Medicare cuts to pay for money
to go to insurance companies.
So, please, let's be careful about our language here,
because it does matter.
But we have a very important issue at hand.
And, Mr. DeLena, thank you so much. Your testimony was very
powerful. Your written testimony is some of the most disturbing
that I have read since I have been on this committee, and that
goes back to 2005.
I am grateful that you are working with the State
Department. You referenced the State Department's International
Narcotics Control Strategy Report. So I am encouraged by that.
What is concerning to me is the next paragraph. You say,
``DEA has been willing to engage the People's Republic on
fentanyl-related substances and precursors. However, due to
diplomatic tensions between the United States, the People's
Republic of China, the government''--I assume that is the PRC
Government--``has suspended all counter-narcotics cooperation
with the United States.''
Is that an accurate statement?
Mr. DeLena. Congressman, thank you for your question.
DEA is working in China to stop the illicit flow of those
precursor chemicals that are ending up in the hands of the two
cartels, the Sinaloa Cartel and the Jalisco Cartel. We know
that, every day, chemicals, precursor chemicals, are leaving
China. China doesn't have a know-your-customer rule, or there
is no oversight of any of that stuff that is ending up in
Mexico.
And we also know that in China and throughout China there
has been a dramatic increase in money-laundering activities as
another way to get back involved with those two cartels,
essentially undercutting all the other traditional forms of
money laundering that had occurred up until now.
But the relationship right now, we know that China needs to
do more to get more engaged.
Mr. Burgess. Yes. There is the understatement of the year:
``China needs to do more.''
I mean, these are chemical weapons that are being
dispatched into our country to kill our young people at a rate
greater than 100,000 a year. Is that a fair statement that I
have just made?
Mr. DeLena. Thank you for the question.
The chemicals, the precursor chemicals, that are
essentially leaving China are ending up in Mexico, where those
two cartels are mixing them in these clandestine laboratories
into the synthetic drugs. And it has become a limitless supply
now that we have, you know, switched to synthetics versus
plant-based drugs.
Mr. Burgess. So a terrorist organization producing weapons
of mass destruction that are coming into our country, it seems
like we would do everything within our power to disrupt them
financially under tools that are already in existence probably
dating back to the PATRIOT Act after 2001.
So are we disrupting the financial instruments that are
available to chemical precursors in China and the cartels in
Mexico?
Mr. DeLena. Thank you for the question.
As a law enforcement agency, DEA has taken a network
approach to try to fully map and analyze and identify where
these cartels are operating. They are operating throughout the
entire United States, obviously, and throughout Mexico but also
in 40 countries around the world.
It is our goal to absolutely infiltrate and defeat those
cartels as they exist.
Mr. Burgess. Well, let me give you a mission statement,
then: Follow the money. Because I think, in this case, it is
extremely important. And, further, disrupt the ability to
continue to fund this operation.
I mean, it is great we are doing harm reduction. And I
would go back to Nancy Reagan's ``Just say no.'' I think that
was the greatest harm reduction that was made available to the
country, back in the 1980s. But if we do not disrupt the
financial instruments that allow this warfare to continue, we
can't win. You can't--you can't harm reduction your way out of
this problem.
And let me just ask you this as one last thing. We hear
over and over again, ``Well, it is not--you know, people coming
over the border is really not the problem. It is points of
entry.'' But it is the removal of Customs and Border Protection
and even some of your agents, having to handle these vast
numbers of people that are coming across the border illegally,
and deflecting them from other activities that might be used to
interdict fentanyl and even agricultural products that
shouldn't be coming into this country. Is that something that
concerns you?
Mr. DeLena. Thank you, Congressman.
I think, specific to your question, it is probably best
served for the Department of Homeland Security and their
components who actually control the border and those points of
entry.
Mr. Burgess. They don't control the border is precisely the
point.
Thank you, Mr. Chairman. I will yield back.
Mr. Guthrie. Thank you.
The gentleman yields back.
We are going to try to stick to 5 minutes. We have two
panels today. So I know we had a couple run over. I want to try
to get on to sticking to the 5 minutes.
So next up is Mr. Sarbanes from Maryland. You are
recognized for 5 minutes.
Mr. Sarbanes. Thanks very much, Mr. Chairman. And
congratulations on taking up the leadership of this
subcommittee.
I want to thank all of you for your testimony today. You
have responsibility for a broad set of initiatives. And, in
particular, I want to thank your agencies for their work to
combat the mental health and behavioral health crises that we
see. We know that there is an intersection of those crises with
the addiction crisis across this country, so that is a very
important part of our response.
Last Congress, I was proud to work with colleagues on our
committee to enact legislation that provided increased funding
for mental health programs and reauthorize several key mental
health and substance use disorder programs, including
legislation I helped sponsor to bolster two programs that
provide care for children and adolescents.
Both of these programs--the first one, the Comprehensive
Community Mental Health Services for Children with Serious
Emotional Disturbances Program--and let me break that down,
because that is a mouthful. Comprehensive community mental
health services--so the idea that we have to take a holistic
approach to this and make sure that it is a full community
response--with children who have serious emotional
disturbances, so that is the particular audience that it is
being addressed to. The other program, the Youth and Family
TREE Program. These are administered by SAMHSA, which has been
working closely with the Biden administration to implement
evidence-based policies and programs that save lives.
Dr. Gandotra, in your testimony, you note that many of the
recent actions taken by Congress and the Biden administration
have had a measurable impact on mental and behavioral health
outcomes.
For example--and this is pretty remarkable--you note that
the recent expansions in care through Certified Community
Behavioral Health Clinics, which is an important part of the
infrastructure in this area, have achieved a 74 percent
reduction in hospitalizations and a 69 percent reduction in
emergency department visits, not to mention a 31 percent
increase in individuals' mental health functioning in everyday
life.
So there has definitely been a very positive response to
these programs. It is remarkable progress. We have to keep
building on the success.
I do want to say that in Maryland we are working very hard
to combat an acute crisis we face in pediatric mental health
access, which has left far too many families struggling to find
mental health care for their children, many of whom have been
forced to remain in emergency departments or were turned away
from care when they need it most.
Governor Moore, recently inaugurated in Maryland, has
deemed addressing health issues as a core priority of his
administration and proposed an investment of almost $1.5
billion in mental health care services in Maryland this year.
Dr. Gandotra, can you further explain how the recent
investments in mental health through the Bipartisan Safer
Communities Act and the bipartisan mental health package that I
referred to are making a real difference in communities and why
it is so important that we continue to invest in these
programs?
Dr. Gandotra. Thank you, Congressman, for your question.
And, certainly, investing in children's mental health pays
dividends for the community, for services throughout not just
Maryland but throughout the country. We have seen investments
really pay dividends with regard to improved functioning in
school, decreased criminal justice involvement, decreased
hospitalizations, decreased emergency department use.
As far as resources, SAMHSA's resources really do leverage
a number of educational activities in terms of providing
schools, counselors, teachers, as well as community
organizations with the tools they need to help identify mental
illness, prevent conditions before they worsen, and provide
them with resources to link patients to treatment.
Also, we like to enhance the services we already have, by
providing culturally competent workforce educational products
as well as an ensuring individuals who are identified early are
not only linked to the right treatment but the appropriate
level of care. That is also done with crisis management
services as well.
Mr. Sarbanes. Thanks very much.
I am out of time. I was going to ask you about telehealth
also being a means of expanding access. I know that is very
important. We want to continue to explore the opportunities
there.
With that, Mr. Chairman, I yield back. Thank you.
Mr. Guthrie. I thank the gentleman for yielding back.
The Chair now recognizes Chair McMorris Rodgers for 5
minutes.
Mrs. Rodgers. Thank you, Mr. Chairman.
In 2019, China permanently scheduled all fentanyl-related
substances. They were the first country in the world to do so.
So far, the United States has stopped short of doing the same.
A permanent American solution, like passing the HALT Fentanyl
Act, is necessary.
Mr. Chester, can you discuss our working relationship with
China to prevent the entry and sale of fentanyl and its
analogs?
Mr. Chester. Thank you for the question, Congresswoman. Our
relationship with the PRC doesn't move in a straight line, but
as you point out, we have, in the past, had success in dealing
with the PRC, specifically the class scheduling of fentanyl
that we asked them to do that they announced in 2019, and a
couple of things happened when that occurred.
The first one was, shipments of finished fentanyl directly
from the PRC to the United States, principally through mail and
express consignment, dropped to almost zero where they remain
today.
Traffickers moved from the business of finished fentanyl to
the precursor chemicals that they supply to manufacturers
within Mexico, and Mexico became the locus of illicit fentanyl
production.
We have worked with the PRC on a number of issues in terms
of accountability and the prevention of the diversion of
illicit chemicals, pill presses, better oversight over the
shipping companies.
And while it is true that within an environment of
competition, there are some areas of cooperation and that the
PRC stepped back last summer from many of them, we continue to
have contact with the government of the PRC, and we continue to
call upon them to partner with the United States on a global
level because they share a large portion of the task in dealing
with this issue.
Mrs. Rodgers. Would you speak to how they are enforcing
this ban on fentanyl and fentanyl-related substances in China,
and what mechanisms do we have to hold China accountable to its
commitment to ban the export of fentanyl in its analogs?
Mr. Chester. Within the PRC, their Ministry of Public
Security and their law enforcement organizations take the issue
of fentanyl trafficking very, very seriously, and in fact, when
they announced in May 2019 that they were scheduling all
fentanyl-related substances as a class, that September they
invited members of our embassy over to witness the sentencing
of 10 fentanyl traffickers.
And this was remarkable because, not just a year before,
the government of the PRC had told me that no fentanyl was
coming from the PRC. So what that tells us is, they take it
very seriously.
We do have the opportunity to have progress, and when the
government of PRC takes this issue seriously, they can do very,
very good things. What we are asking them to do now is exert
more oversight over their shipping industries and their
chemical industries----
Mrs. Rodgers. Yes.
Mr. Chester [continuing]. That divert these chemicals for
production.
Mrs. Rodgers. Right. It is frightening how many plants in
China are producing the chemicals.
Mr. Chester. Yes, ma'am. There are about, we are told about
160,000 chemical plants, but the issue is that they are
diverted on their way out of the country, destined for unknown
and undeclared customers in Mexico who use them to produce the
fentanyl-related substances.
Mrs. Rodgers. Have any other countries permanently
scheduled all fentanyl-related substances?
Mr. Chester. I believe not, but I will get you that
definite answer, ma'am.
Mrs. Rodgers. OK. Mr. DeLena, offenses prosecuted under
classwide scheduling can trigger a mandatory minimum of 5 years
for 10 grams or 10 years for 100 grams of a drug mixture
containing a detectable amount of fentanyl analogs.
To put it into perspective, how many grams are fentanyl are
lethal?
Mr. DeLena. Congresswoman, thank you for the question. DEA
estimates about 2 milligrams is a potentially lethal dose. That
is about enough to fit on the tip of a pencil.
Mrs. Rodgers. And then what is a lethal dose of
carfentanil, which is a fentanyl analog?
Mr. DeLena. Thank you, Congresswoman. I would have to defer
to some of the scientists and lab folks at DEA, but I can get
you that exact, specific answer.
Mrs. Rodgers. Well, bottom line--bottom line--we know that
there is enough fentanyl now in the United States to kill every
person seven times over, and so it is a huge amount of fentanyl
that has come into the United States.
And it is lethal, and it is impacting those that are
addicted, but it is also impacting people who don't know even
what they are doing or what they are taking, some of these
pills that are laced with fentanyl.
And so I really just appreciate all you being here. We are
committed to taking action to ensure that we are doing
everything we can to keep fentanyl and fentanyl-related
substances off our streets. It is destroying families,
individuals, and communities all across this country, so thank
you. I yield back.
Mr. Guthrie. I thank--the Chair yields back. The ranking
member, Mr. Pallone from New Jersey, is now recognized.
Mr. Pallone. Thank you, Chairman.
One bill that would have been a great addition to this
hearing today is the Medicaid Reentry Act, and this bipartisan
legislation would extend Medicaid eligibility to incarcerated
individuals back to 30 days prior to their release. So let me
start with Dr. Gandotra.
It is my understanding that individuals newly released from
incarceration are at a much higher risk of overdose than
suicide. Can you describe some of the reasons for that?
Dr. Gandotra. Thank you for the question. And as you
accurately describe, individuals who are reentering society
from incarceration are at higher risk for overdose, in
particular, because during their incarceration, their tolerance
levels have changed, and when they reenter society and they use
again, they are much more likely to overdose if they
previously--amounts that they had previously used that they
were tolerant to.
So it is vitally important that these individuals engage in
treatment, both prevention and recovery services as well as
evidence-based treatment, well before they are actually
released.
The most important aspect of that is the transition
planning. There are certainly models that have been successful,
such as the sequential intercept model, which not only
encourages transitional planning by jail and end-reach
providers but also can facilitate other resources that are
necessary for success--social determinants of health, case
management, resources that will be needed.
Sometimes a warm handoff and actual conversations with the
service providers in the communities can really go a long way
towards reducing mortality for those reentering society.
Mr. Pallone. And the problem now, Doctor, is that they are
not eligible for Medicaid under the law now until they leave
prison, and then oftentimes we can't even find them to tell
them to sign up or whatever, correct?
Dr. Gandotra. So certainly there are treatment gaps that
need to be addressed, particular coverage gaps with regard to
remuneration of services, but the prescriptions themselves,
having those before they leave, having a contact, peer recovery
support specialist in the community that can help connect them
and keep them connected to treatment, because we know the
treatment retention yields better outcomes.
Mr. Pallone. All right. Now, I wanted to shift to Mr.
Chester. In order to conduct quality research, investigators
need access to fentanyl analogs as they might be useful in
enhancing current treatments or developing new ones.
A key component of the administration's proposal involves
how FRS are classified, or subsequently reclassified if found
to have a lower risk profile. Can you explain the importance of
the provision for off ramping and FRS?
Mr. Chester. Thank you, Congressman. That was a key
component of the administration's proposal when it comes to
fentanyl-related substances. So the first step is to scoop
these substances up and make sure that Americans don't have
access to them, that they can't be harmed.
But the second one is what you say, to determine two
things: if those substances may have some medical merit, and
what their qualitative effect is on the body. And it is
critically important for researchers to be able to, even though
they are in Schedule I, to have access to them.
And part of the proposal for FRS was not only FRS, but all
Schedule I drugs, actually reworking the process by which
researchers can have access to Schedule I drugs for the
purposes of research.
Mr. Pallone. All right. Now, I am just going to rush
through this because there is only about a minute left. What is
your understanding of how the current administration's proposal
differs from the HALT Fentanyl approach, and is the
administration's approach evidence based? Why is it important
to use evidence-based approaches when it comes to scheduling of
FRS?
Mr. Chester. So on the first part, I apologize, I can't
take a position on a specific piece of legislation, but what I
can say is, the administration's proposal was comprehensive,
and it was a consensus-based proposal that came across the
interagency, and it is evidence based. It is based on what we
know about access to research, what we know about criminal
justice outcomes, and also what we know about the trafficking
of these substances.
Mr. Pallone. All right. I appreciate that. Thank you, Mr.
Chester, for helping us understand some of the differences, if
you will, from what the current administration is proposing.
And I just want to say appropriately studying and
categorizing substances is key to addressing the opioid and
fentanyl crisis. So it is important that we understand the
differences between these various approaches.
And with that, I will yield back, Mr. Chairman.
Mr. Guthrie. Thank you. The gentleman yields back. The
Chair recognizes Mr. Latta for 5 minutes for the purpose of
asking questions.
Mr. Latta. Well, thank you, Mr. Chairman, and thanks to our
witnesses for being here. First, I would just like to, once
again, show people--well, this is from the DEA website that I
have used back in our district.
This is the amount of fentanyl that will kill you when you
are looking at it next to a penny, and I think it is really
important to see that because, again, what everyone is up
against in this country and how we are going to have to stop
this, because--and the testimony again being today that 107,477
Americans that lost their lives last year.
And, Mr. DeLena, I really appreciate something you are
saying. You are saying ``poisoning'' now. We are not talking
about overdose deaths, we are talking about poisoning.
And that is something that came up in the roundtable that
we had with family members and law enforcement. It is no longer
overdose. This is poisoning.
And when you think about the--you mentioned 294 people died
from drug poisoning every day in this country, and that, you
know, what was interdicted, that we know of, is 7.5 million
tons of fentanyl that came into this country--7\1/2\ tons, not
millions, excuse me--7\1/2\ tons of fentanyl that came into the
country. So I think it is really important that we keep that in
line.
And something else I think is really important, I think, in
your testimony. It is costing--it says in your testimony, you
say, it costs the cartels as little as 10 cents to produce a
fentanyl-laced fake prescription pill sold in the United
States. That is what we are saying, then, is they can kill us
for 10 cents--10 cents.
So when we talk about do we got a crisis on our hands, we
are past a crisis in this country, and I know my friend from
Texas asked some of the questions especially dealing with the
PRC, but--and the paragraph before because, again, it is where
these chemicals be coming in, when you talk about 160,000
chemical companies in the PRC and those that are distributing
the precursor chemicals for use in fentanyl and meth.
The question, you know, right now is that since they are
faking these labels as they are going from China to Mexico, we
are talking to our Mexican counterparts, is there anything that
they are--being done within Mexico to try to find these fake
labeled shipments as they come through?
Mr. DeLena. Congressman, thank you for your question, and
to address the first part of it with drug poisonings, DEA--and
I have been a part of it--has met with family members that have
lost loved ones. We had 22 family summits, where we met with
families who have lost loved ones, and, you know, we hear from
them every day, you know, the pain and suffering that is caused
by this drug, fentanyl.
And it truly is a poisoning, that is how we look at it now,
that it is Americans that are being poisoned across the
country.
To talk about the chemicals that you ask about, these
Chinese chemical supply companies, there is no oversight or
know-your-customer rule, and as you said, they are shipping
these precursor chemicals into Mexico all the time.
We know, on one side, China needs to do a lot more, and we
know the same has to happen in Mexico. The Mexican Government
needs to do a lot more to enforce what is coming into that
country and work with us to try to defeat these two cartels.
Mr. Latta. Great. Let me follow up on, because, again, when
you look at the, prior to 2018 with fentanyl, and what we want
to do, my good friend from Virginia and I and our legislation
on HALT Fentanyl, again, what will having it permanent because,
again, you know, you always--you talk in your testimony about
the temporary scheduling order 8 times. How will this bill help
you on the crisis that we have with fentanyl?
Mr. DeLena. Thank you again for the question. The permanent
scheduling will allow DEA to arrest and seize when we encounter
fentanyl-related substances wherever that happens.
We also know that with classwide scheduling, there has been
less production of different analogs. It is just not worth the
chemical brokers and chemists in Mexico when they are making
this substance, when they know it is a classwide, you know--it
is illegal classwide, there is no benefit for them to try to
create new substances.
Mr. Latta. Well, again, I appreciate, you know, the work
that you are doing because, again, we need to get this
legislation across the finish line because we want to stop this
horrendous rise in deaths across this country. And it has got
to happen now.
So, Mr. Chairman, I yield back the balance of my time.
Mr. Guthrie. Thank you. The gentleman yields back.
The Chair now recognizes Mr. Cardenas of California for 5
minutes for asking questions.
Mr. Cardenas. Thank you very much, and congratulations,
Chairman Guthrie. I have always enjoyed working with you and
looking forward to working with you as the chairman of this
very important committee.
And also to Ranking Member Eshoo, thank you so much for
your diligent work, and I have enjoyed working with you, and
this committee is going to hopefully do much, much good work
over these next 2 years.
Before I ask my questions, I just want to mention a few
words--Purdue, the Sackler family, and crime pays. Still one of
the richest families in the world. Where did all this start and
who was a big part of where we are today.
Dr. Gandotra, thank you for joining us today and for
sharing your informative and valuable expertise on mental
health policy.
As you are aware, HHS recently implemented the 988 hotline,
a potentially life-saving service for individuals experiencing
mental health crises, spearheaded by my colleague here,
Congressman Sarbanes.
Thank you so much for everything you do in the space of
mental health.
While there is much work to be done, I believe that the
promise of 988 and the momentum--excuse me--the continuum of
crisis care built around it, offers some much-needed hope for
those struggling with their mental health.
However, in December the 988 hotline experienced a service
interruption after a suspected cyber attack on Intrado, a large
telecommunications company that provides services to Vibrant,
the administrator of the 988 hotline.
The bill before us today, which I am co-leading, aims to
prevent this from happening again. In the wake of the December
Intrado service outage, how is SAMHSA mitigating the risk of
similar incidents and hoping to keep that from happening again?
Can you put your microphone just a little closer? Thank you.
Dr. Gandotra. Sure. Thank you, Congressman, for your
question, and also for the ongoing support for the 988 program.
And I would like to first state that our highest priorities are
to develop additional redundancies in the event of any future
outages.
While minimizing the likelihood of such events, we want to
continue to protect personal information and be sure that there
is clear communication protocols among the partners and the
public. We certainly owe the public trust when it comes to
their personal information.
We also want to be able to continue to expand services and
understanding that when these problems arise, we want to
quickly resolve them and provide clear guidance on where and
how to seek help. Certainly, clear communication and protocols
between the partners and public is going to be paramount.
Mr. Cardenas. Are more resources needed, and do you
appreciate Congress actually providing more resources in the
future?
Dr. Gandotra. Well, we thank Congress for the investment
certainly as we recognize that mental health crisis services
are always needed. As there has been a growing need recognized,
not just in the past years, but throughout the past decade, we
would appreciate all the support the Congress has given us.
Mr. Cardenas. Thank you. I look forward to working with you
and SAMHSA on improving 988 and getting it to where it should
be in the future.
I also want to take a moment to discuss our policy around
fentanyl and fentanyl-related substances. Overdose deaths are
skyrocketing in this country, and I share my colleagues' horror
at the devastation we have seen at the hands of the fentanyl
crisis.
But among other things, this is a complex, multifaceted
public health crisis that requires a robust public health
response. And candidly, I am concerned that this class-wide
scheduling approach sets a precedent of guilty until proven
innocent.
The proposal put forth by my Republican colleagues goes all
in on applying harsh Federal penalties, but lays almost no
groundwork to test for the potential harmlessness of these
fentanyl-related substances, or even their potential
therapeutic value.
We could be overlooking the next naloxone, which has saved
countless lives from opioid overdose because our focus is
solely punitive, and I think that is a grave error with immense
consequences. The responses are usually multifaceted, but not
simple.
Mr. DeLena, under the current classification system, what
kind of resources have you allocated toward testing the effects
of Schedule I compounds which may have medicinal purposes?
Mr. DeLena. Congressman, thank you for the question. DEA is
open to the testing of Schedule I substances. It is our
partners at HHS that conduct those type of tests, and as I
said, we are open to Schedule I testing and research for any
scientific need, and for any medical evaluation that could come
out of it.
Mr. Cardenas. OK. Thank you so much. My time having
expired, I yield back.
Mr. Guthrie. Thank you. The gentleman yields back, and now
Mr. Griffith is recognized for 5 minutes for the purpose of
asking questions.
Mr. Griffith. Thank you very much, Mr. Chairman.
There is some confusion about the HALT Fentanyl Act that I
am hearing in some of the questioning and in some of the
statements that have been made. The Act does, in fact, include
the ability to do research and makes it easier to get through
the pathways to get research done.
On some of those--and to our colleagues on the other side
of the aisle, they held a great hearing earlier, last year,
sometime last year. If memory serves me correct, there are
approximately 48,000 potential analogs to fentanyl, of which,
we have looked at somewhere between 30 and 40.
But that is a--you know, if you want more research, this
makes it easier, and we probably need to get the appropriators
to appropriate money to go in that direction, if that is the
intent.
But we are--the bill does allow for more research. I have
been a big advocate for researching substances and their
potential medical use since I came to Congress.
Also, Mr. Chairman, I would request unanimous consent for
the introduction of a letter for the record from the Peace
Officers Research Association of California, representing
75,000 public safety members and 930 public safety associations
which expressed their support for the HALT Fentanyl Act.
Mr. Guthrie. Any objections?
Seeing none, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Griffith. And from that letter, Mr. Chairman, they say,
as the law enforcement community continues working to reverse
these trends, the HALT Fentanyl Act would help to bolster the
efforts by ensuring current Schedule I classification of
fentanyl under the Controlled Substances Act does not expire.
So there is that.
Let me ask a couple other things that I thought was
interesting. Mr. DeLena, you indicated that because of the
temporary ban, it is not worth it to the cartels to work on the
analogs. That implies, and I believe it was happening, is that
when there wasn't--when the analogs were not illegal, they were
looking for analogs that would be legal, that they could get
around the laws and not face criminal punishment in the United
States by importing these poisons into our country. And this
has actually helped stop that.
It may not have stopped the fentanyl deaths, and certainly
this is only one part of a complex answer. But I am I correct
that they were looking for other ways so they could avoid
criminal punishment, yes or no?
Mr. DeLena. Thank you for the question. We have actually
seen that play out before where they can flip one molecule and
keep moving it along. With the class-wide scheduling, it is
just not beneficial for them to do that.
Mr. Griffith. And I appreciate that. I am going to switch
gears for a second, Doctor, and I hope I am saying it right,
Gandota, Gandotta?
Dr. Gandotra. Gandotra.
Mr. Griffith. Gandotra. In a recent study published in the
Journal of the American Medical Association, they said there
was no evidence that telemedicine has actually expanded access
to care for opioid use disorder.
They also found that telemedicine opioid use disorder
patients tended to be more concentrated in higher income metro
areas. And I am a big believer in telemedicine, so what do you
think we can do to expand access to more rural areas like mine?
Dr. Gandotra. Thank you, Congressman, for the question.
Certainly SAMHSA is committed to expanding treatment access for
medications for opioid use disorder. We have heard from
numerous stakeholders, in particular, from rural areas or from
our State opioid treatment authorities.
Mr. Griffith. So you are going to work with us on that?
Dr. Gandotra. Yes, sir.
Mr. Griffith. All right, I appreciate that.
Buprenorphine. Now there is no limit on the number of
doctors prescribing, but even before that--or the number of
patients that a doctor can have to prescribe, but even before
that, it was starting to become used as a street drug in a
couple of my counties.
Are we monitoring to see if this is going to be a national
trend? Are you all looking at that as a possibility? Because
apparently, it is happening, according to some of my law
enforcement folks.
Dr. Gandotra. Certainly expanding medications for opioid
use disorder including buprenorphine is one of our goals for--
--
Mr. Griffith. Well, I want to know if we are looking to
make sure that we are not creating a new street drug.
Dr. Gandotra. We are certainly--we are certainly educating
providers----
Mr. Griffith. Mr. DeLena, you too? You are all looking at
this?
Mr. DeLena. Thank you, Congressman. Absolutely. Any threat
that is posed to the American public, DEA will continue to
monitor.
Mr. Griffith. And have you seen any uptick in buprenorphine
being used as a street drug?
Mr. DeLena. Again, thank you for the question. I can't
speak to that. I have not seen that in the area that I came
from. My last assignment in New England, we did not see that
trend.
Mr. Griffith. All right. And I am running out of time, so
last question. Got all these cartels in Mexico. Is the Mexican
Government capable of defeating those cartels on their side of
the border?
Mr. DeLena. Thank you for the question. Those two specific
cartels, Jalisco and Sinaloa, that are causing all of this harm
are operating virtually with impunity. We need the Mexican
Government to lean in and do a lot more.
Mr. Griffith. But right now, they can't do it, can they?
I yield back.
Mr. Guthrie. Thank you. The gentleman yields back.
The Chair now recognizes Dr. Ruiz for 5 minutes for
questions.
Mr. Ruiz. Thank you. As an emergency physician, I have seen
time and time again the devastating and often fatal effects of
drug overdose. Fentanyl, in particular, continues to wreak
havoc on our communities.
The most recent data from CDC shows that 67 percent of all
overdose deaths in the U.S. involve synthetic opioids like
fentanyl, and DEA Administrator Ann Milgram called fentanyl,
quote, ``the single deadliest drug threat our Nation has ever
encountered,'' unquote.
Over the past several years, this Congress adopted many
policies to try to stem the tide of the substance use crisis
and increase access to prevention, treatment, and recovery
services.
However, still more needs to be done. I think it is
critical to remind everyone that substance use disorder is a
disease, and it needs to be treated as such. This means we need
to focus on greater access to harm reduction programs and
increase efforts towards prevention.
I approach this disease like I would any other, addressing
how to get someone well after they are sick, but also how to
prevent them from getting sick in the first place.
Our healthcare system is good at healing the sick, but
often too frequently ignores or undervalues prevention so that
people don't get sick in the first place.
So on that note, I would like to talk about the HHS
overdose prevention strategy and what it is accomplishing in
this regard. The strategy involves four priorities: primary
prevention, evidence-based treatment, harm reduction, and
recovery support.
This is especially important among youth as recent data
from the nonprofit group Families Against Fentanyl suggested
children under 14 are dying a faster rate than any other age
group.
So we know you can't incarcerate a public health problem
from ending, and you also got to think through how--that, you
know, the focus is on the drug cartels moving drugs over, but
how about those who have the disease of addiction who are also
fueling that through the enormous demand on our side?
So, Dr. Gandotra, what are the interventions and early
prevention strategies used in the overdose prevention strategy
to address opioid use, particularly among youth.
Dr. Gandotra. Thank you, Congressman, for that question.
Certainly the prevention pillar is important in terms of the
overdose prevention strategy. Our strategic prevention
framework is one of our major grant programs that allows for
community organizations, States themselves, and local
jurisdictions, to identify the problem, also identify then the
resources they have in terms of capacity.
Mr. Ruiz. Well, identifying a problem is not necessarily
prevention because there is already a problem. So how do you
prevent it from becoming a problem?
Let's say a school wants to start a program. Where can they
go to get information or resources and moneys to create
education outreach to prevent this from happening?
Dr. Gandotra. So SAMHSA's Block Grant Program--substance
use Prevention Block Grant, has a 20 percent set-aside where
the local jurisdictions can determine what is best suiting
their needs. That 20 percent set-aside has been incredibly
effective for schools and community organizations.
Mr. Ruiz. Can you explain the concept of harm reduction and
what that means in practice?
Dr. Gandotra. Certainly. Harm reduction is a practice that
utilizes the principle to meet the patient where they are, to
reduce the morbidities, or negative aspects of use.
This may mean that individuals who may not be necessarily
ready to engage in full treatment can still mitigate some of
the effects of their use. In particular, harm reduction can
involve naloxone administration for preventing overdose, as
well as fentanyl test strips for drug testing to allow for
individuals to determine how safe the product is that they have
in their hand.
Those are just two examples, and there is a number of other
harm reduction interventions that can be utilized.
Mr. Ruiz. Thank you. And how does the strategy address
helping people after they receive treatment for SUD? Or how
important is it to facilitate a safe recovery environment?
Dr. Gandotra. So thank you for that question, and for
really highlighting the part that individuals who engage in
harm reduction are much more likely to later engage in
treatment, and be retained in treatment.
You have to reach patients where they are, where they are
willing to actually engage with you. That means that if they
are able to stay alive, you can treat them later. If you can't
keep them alive, then there is no way that they can be engaged
in treatment. So, certainly, the naloxone administration is a
big aspect to that.
Mr. Ruiz. You know, I got to also mention that this illness
of addiction is not just for the individual, but it is for
their family, for their neighborhood as well, and treatment
needs to go toward a family-based, home-based, community-based
treatment programs for prevention and also harm reduction.
Thank you. I yield back my time.
Mr. Guthrie. Thank you. The gentleman yields back.
The Chair now recognizes Mr. Johnson for 5 minutes.
Mr. Johnson. Well, thank you, Mr. Chairman. First I want to
say how excited I am to have been selected to serve on the
Health Subcommittee. Healthcare is such an important issue in
my rural Appalachian district, everything from cost to quality
to availability, and I look forward to working on these
important issues under your leadership, with all of our
colleagues.
For today, however, I want to read some excerpts of a
letter I received from a constituent yesterday right near my
home in Washington County, Ohio. The letter is from a grieving
mother of a young man named Jason who tragically died exactly 2
years ago yesterday, January 31st, 2021.
Jason's mom wrote to me and said, Jason was prescribed
Vicodin by our family doctor after a car accident. Why wouldn't
we trust it? Our doctor prescribed it. Our son had a couple of
relapses after a stint in the Marines and some college, but we
had good insurance and a medication-assisted treatment helped
him pick up the pieces.
His relapse in September 2019 set the stage for a terrible,
15-month battle to save our son's life. By the time we were in
the throes of COVID in March 2020, our son was in the worst of
his disease.
She then went on to say, his drug of choice was heroin, and
now that drug is laced with fentanyl. It was the first time I
realized he was most likely going to die.
Fentanyl is a game-changer, she said. She closed with this.
Jason was so much more than simply addicted. He was loved by so
many, especially his own son, who we are now raising.
My friends and colleagues, this grieving mother is right--
fentanyl is a game-changer. We are in entirely new territory
now compared to when we started confronting what we called at
the time the opioid epidemic, particularly in rural areas, like
where I live.
So, Mr. Chester, let me start with you. Thank you for being
here. The 2021 Drug Free Communities report highlights that
close to 98 percent of Drug Free Communities coalitions address
prescription opioids.
But only just over half address fentanyl, fentanyl analogs,
or other synthetic opioids. And as we know, an increasing
number of overdose deaths are attributed to synthetic opioids
like the situation I highlighted.
The victim started with prescription opioids but moved on
to heroin and then an accidental, extremely potent, and fatal
fentanyl overdose.
Why does this disparity exist within the Drug Free
Communities program? Does ONDCP plan to revisit their efforts
and strengthen its response to synthetic opioids?
Mr. Chester. Thank you very much for the question, and we
all are incredibly sorry for your constituent and the many
others----
Mr. Johnson. I got another question so if you could answer
that one.
Mr. Chester. Yes, sir. The Drug Free Communities program,
the more than 700 grantees, their programs are locally designed
based upon local conditions, and there is not a single Drug
Free Communities overlay over all of them.
Mr. Johnson. Yes, but the fentanyl crisis and synthetic
opioids is a nationwide problem. How can only half of them be
digging into that area?
Mr. Chester. And the Drug Free Communities grantees decide
based upon their local conditions what they want. Now, we do
manage the program in cooperation with others, and we will
absolutely be glad to address that. But the Drug Free
Communities Program is centered at the community level.
Mr. Johnson. OK. I have got one question for you, Mr.
DeLena. Some say the problem with class wide bans is that
potentially thousands of compounds are defined solely by their
chemical structures without regard for their pharmacological
activity.
It is my understanding that the DEA looked at more than
structural similarity when arriving at the definition of
fentanyl-related substances. Can you explain to our committee
what structure activity relationships are?
Mr. DeLena. Congressman, thank you for the question.
Unfortunately, I am focused on the enforcement side. That is my
background and where I come from, but we do have scientists and
experts that handle that. I would be happy to take that
question back.
Mr. Johnson. Are you happy--my time has run out, Mr.
DeLena. Can you get back to your organization and those
scientists and get us some information on that?
Mr. DeLena. We would be happy to. Thank you.
Mr. Johnson. OK. Thank you.
Mr. Chairman, I yield back.
Mr. Guthrie. The gentleman yields back.
The Chair now recognizes Ms. Kuster from New Hampshire for
5 minutes.
Ms. Kuster. Thank you, Mr. Chairman, and thank you to the
witnesses joining us today for your testimony. In particular, I
want to thank Mr. DeLena who has been such a great resource for
us in New England. I really appreciate our work together.
I am cochair of the bipartisan Task Force on Mental Health
and Substance Use Disorder with my Republican colleague, Brian
Fitzpatrick, and David Trone of Maryland.
And we are all grateful for the progress that this
committee made in the 117th Congress, passing important mental
health and substance use disorder legislation and, in
particular, the Restoring Hope for Mental Health and Well-Being
that I might add passed the House with 402 votes. I think it
was probably the most bipartisan bill in the 117th Congress.
But as we all know, there is much more to be done. I am
working closely with my colleague from Delaware, Congresswoman
Blunt Rochester, to reintroduce our legislation, the STOP
Fentanyl Act, and I hope that the Chair will bring that up in a
subcommittee on a future date.
This bipartisan bill was introduced in the 117th to invest
in fentanyl detection and data collection, stem the supply of
fentanyl, and address demand for synthetics through overdose
prevention and substance use disorder treatments.
As Mr. Chester's testimony stated, fentanyl is a complex
national security, criminal justice, and public health
challenge that requires a multifaceted approach, and that is
why the STOP Fentanyl Act devotes resources to enhance fentanyl
surveillance, empowering officials at the State, local, and
Federal level, to support detection and reporting.
We must continue to aggressively pursue the sources of
fentanyl that have been described here today, stopping the flow
of materials for synthetic drugs into this country, and cutting
off the paths that bring these harmful substance into our
communities.
This bill supports efforts to hold bad actors accountable
both at the international governance level and with the social
media companies that our families and friends use every day.
As the experts in this room know, a public health approach
much be complemented by a well-resourced, data-driven plan to
stem the supply of fentanyl. STOP Fentanyl is the path forward
to respond to the challenges before us.
I look forward to hearing from my colleagues on this
committee who are interested in a comprehensive approach to
protect our companies from fentanyl--our communities. I ask for
your partnership and support.
In order to best craft solutions, it is essential to
definitively understand the problems. Mr. DeLena, it is great
to be with you, and I wanted to ask you--you have seen how
these issues affect communities like my district in New
Hampshire, and the DEA has worked to prevent shipment through
the postal system and crack down on chemists overseas as you
describe--what is the top way that fentanyl enters the country,
and where should congressional efforts be focused to complement
your agency's work?
Mr. DeLena. Congresswoman, thank you for the question and
for your work when it comes to fentanyl.
A majority of the fentanyl that is coming into our
communities crosses the southwest border, predominantly through
the ports of entry, but they use any possible way to get it
across.
Ms. Kuster. And, Mr. Chester, what role can HIDTAs play in
expanding our surveillance and data collection efforts moving
forward?
Mr. Chester. Our HIDTAs play a vital role because they are
in all 50 States. They cover the vast majority of the
population of the United States, and 99 of 100 major
metropolitan areas. They are the one that can provide us the
bottom's up information of what is actually happening in their
communities, and they provide this information nationwide. They
are an extremely valuable resource.
Ms. Kuster. And is there coordination and sufficient
resources for data collection and surveillance to know--I heard
a reference to a new substance today that I wasn't even aware
of, but to know when they are emerging threats?
Mr. Chester. Yes, ma'am. In fact, the HIDTAs are very
valuable, not only do they work effectively in their own right,
but they are networked together very well, particularly through
their drug intelligence officers, who are able to share that
information, and be able to determine nationwide trends, based
upon the local data that they are seeing from their particular
HIDTAs.
Ms. Kuster. I think that data collection and surveillance
is going to be really important.
Dr. Gandotra, I am going to probably have to leave this
question for the record, but once fentanyl enters our borders,
how does SAMHSA work with first responders to educate on
interacting with fentanyl?
Dr. Gandotra. Thank you for that question. I will point to
our grant program, the First Responders--Comprehensive
Addiction and Recovery Act that educates first responders,
firemen, police officers, on how to administer fentanyl, how to
recognize the signs for overdose, and how to link to care.
Ms. Kuster. Great. Thank you. And with that, I yield back.
Mr. Guthrie. Thank you. The gentlelady yields back.
The Chair recognizes Mr. Bilirakis for 5 minutes.
Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it.
Thanks for convening this hearing today.
I would like to start by briefly sharing a news story from
my district in Florida, the Tampa Bay area, and also the nature
coast.
Just last week, the Citrus County Sheriff's Office
apprehended a long-time drug dealer who, as he attempted to
flee arrest in his vehicle, threw a bag of drugs from his
vehicle.
Having ruptured upon impact, the contents of this baggy
were scattered throughout the grass shoulder. HAZMAT teams were
deployed, and approximately 51 grams of fentanyl was collected,
enough fentanyl to kill more than 25,000 people, believe it or
not.
This, once again, highlights that we are in a crisis
situation that deserves the highest amount of attention and
response at every level of government, starting with the Biden
administration.
It is clear they are not doing enough, and I am
disheartened by the tragedies we are seeing on a daily basis.
Headlines of toddlers, adolescents, young adults that have died
already just 1 month into 2023.
Mr. Chairman, thank you for making this a priority.
Fentanyl coming into the country from Mexican cartels;
fentanyl created with chemicals imported from China and India;
enough fentanyl to kill every American in the country multiple
times over.
Now I know there is no silver bullet as we all know that
will solve this crisis right away, but Republicans on this
committee are taking this threat seriously, and there should be
serious doubts--zero doubts though--zero doubts or opposition
permanently scheduling fentanyl-related substances to the
Schedule I, again permanently.
And thank you for taking this on again, Mr. Chairman.
My question is to Mr. DeLena. You talk about the way these
cartels are aggressively lacing other fake pills and
distributing via social media networks. Can you tell us what
your coordination is with social media companies, if any? How
can you better improve communication to quickly respond to drug
sales on these platforms?
Mr. DeLena. Congressman, thank you for the question. It is
very clear that social media has become a superhighway for
drugs. The role of these drug cartels and the drug trafficking
organizations that work on behalf of them, they are
advertising, actually completing sales and effectuating payment
using these types of applications.
And we know that the social media companies who control the
algorithms, they control the content that is driven to the
users, and they control all of the data therein, can do more
and must do more.
You asked about our interaction with them. We interact with
these companies on a regular basis in terms of the
investigations that we are conducting.
Mr. Bilirakis. How much cooperation are you getting?
Mr. DeLena. These social media companies, Congressman, need
to do more. As I stated, they control all of that content, and
there must be more transparency. There must be efforts for
preservation of evidence.
There is applications that have disappearing stories.
Twenty-four hours, you know, later, all of that information can
be gone. I can tell you firsthand that the men and women of DEA
who are--and our friends in law enforcement who are responding
to these drug poisoning deaths, you know, the first thing they
want to do is take steps to prevent another death from
happening in that community.
And the way they do that is by identifying who that drug
trafficker was that maybe sold those drugs to the decedent. If
that information is gone, if there is no way that we can look
at it, there is no steps that can be taken.
Mr. Bilirakis. Well, we must hold them accountable. In the
spirit of being proactive and keeping pace to address new
concerns on the horizon, I am also interested in addressing the
drug xylazine, a tranquilizer drug with no approved medical use
in humans. It is used for horses. It is used as a sedative and
veterinary medicine, I understand.
Florida has led the way in addressing this by scheduling
xylazine on the State level. It is time that we follow suit and
do this federally since it is being discovered in fentanyl
overdose deaths and has horrifying side effects on the human
body and does not respond to naloxone.
Mr. Chester, what can be done to properly trace and track
the presence of xylazine in our drug supply? How important is
it to accurately pinpoint the drugs that are contributing to
overdose deaths throughout the U.S.?
Mr. Guthrie. Thanks. Can we get that on the record so we
can--can you give your answer on the record, do you mind?
I am sorry, your time is expired, and we are trying to get
two panels through. So the gentleman yields back. The Chair now
recognizes Ms. Kelly from Illinois for 5 minutes.
Ms. Kelly. Thank you so much, and I have one dilemma.
Congratulations to you, Mr. Chair, and I want to thank Chairman
Guthrie and Ranking Member Eshoo for holding a hearing on this
very important topic.
We need to eliminate the racial and ethnic disparities that
plague the overdose epidemic and the broader healthcare system,
and I do believe we all agree on that.
Unfortunately, overdose deaths are beginning to rise even
before the pandemic, and Black and Brown communities are
experiencing the fastest increasing rates of overdose deaths
involving synthetic opioids.
In 2020, drug overdose death rates increased by 44 percent
for Black people, 21 percent for Hispanic people, and 39
percent for American Indian and Alaska Native people.
Moreover, access to opioid and substance use disorder
treatment is lower in Black, Latino, and Asian communities.
We could go on forever in the remainder of this hearing,
highlighting diseases and conditions for which people of color
have higher incidences of illness and less access to
healthcare.
Dr. Gandotra, what is SAMHSA doing to reduce disparities in
substance use and mental health in the United States?
Dr. Gandotra. Thank you for that question, and certainly
SAMHSA has recognized this issue as well. We require all new
grant programs, recipients, to submit a data-driven disparity
impact statement, outlining how they are going to address
behavioral health disparities within their grants.
We also have several programs themselves to address closing
equity gaps. In particular, we have the Tribal Opioid Response
Program, which addresses the public health crisis caused by
escalating opioid and stimulant misuse in Tribal communities.
We also have our Technology Transfer Centers, which
disseminate information, specifically Technology Transfer
Centers dedicated to American Indian and Alaska Native
populations, and a separate one for Hispanic and Latino
populations.
We also have three Centers of Excellence for African
American populations, LGBTQI-plus, as well as older adults.
We also fund the Center of Excellence for historically
black colleges and universities to help expand the workforce
within behavioral health.
We have the minority fellowship program which provides
stipends to increase the number of culturally competent,
behavioral health professionals.
And finally, we fund the National Network to Eliminate
Disparities in Behavioral Health Network, which really does
exchange a lot of information between organizations and provide
networking to advance best practices.
Ms. Kelly. Thank you. I just want to make sure that
Congress is taking a holistic approach by investigating
significantly in prevention treatment and recovery.
And also, as my colleague, Mr. Griffith, had brought
forward, my district is urban, suburban, and rural, and it has
become even more rural in the remapping. I have over 2,000
farms in my district, so I want to make sure that we are paying
attention to the rural areas also.
How are you addressing the social determinants of health
and their impact on human well-being?
Dr. Gandotra. Certainly, social determinants of health can
not only impact treatment outcomes, but they also impact
treatment engagement. SAMHSA understands that not all services
are clinical in nature, and they need to be covered.
Through our Block Grant Program, there are set-asides for
wrap-around services such as case management. We have
partnerships with other entities such as HUD to establish
housing opportunities for those within--who are suffering from
HIV or AIDS.
We have a number of other programs that address the social
determinants of health as well.
Ms. Kelly. And may I ask what other agencies you
collaborate with to address health inequities?
Dr. Gandotra. I would say within HHS, our operational
divisions, we with coordinate with HRSA, the Bureau of Indian
Health Services as well, as well as the Bureau of Prisons. We
work with a number of Federal entities when it comes to
establishing treatment and evidence-based care.
Ms. Kelly. Thank you so much. We must intentionally address
the root causes and the inequities, or else we will never get
out of this situation. Thank you.
Mr. Guthrie. Thank you. The gentlelady yields back.
And I should have pointed out to my colleagues on the other
side earlier, Dr. Larry Bucshon will be vice chair of this
committee, and we look forward to working together with him. So
you will see him in the chair quite often. Just want to make
that aware and that announcement.
But I will now recognize the vice chair of the committee,
Dr. Bucshon, for 5 minutes for questions.
Mr. Bucshon. Thank you, Mr. Chairman, and I apologize, I
have another hearing at the same time, as many of us do, but I
have read through your testimony.
Thank you, Chairman Guthrie, for holding the hearing and
drawing attention to this very important point we so often take
for granted, that all life is precious and valuable.
Each of these bills before us today serves as an important
reminder of that fact. Two of them touch on the issue of
illicit drug trafficking and use which affects each of our
districts.
As the medical community has attempted to deal with
increasing rates of illegal drug use and addiction, we have
developed medication-assisted treatment.
And just so you know, I was a physician before I was in
Congress.
While this can be an important tool, and it is an important
tool in the right circumstances, I have long voiced concerns
about its potential to cause harm without the proper
guardrails.
Furthermore, buprenorphine, the primary medication being
used in medication-assisted treatment for opioid use disorder,
is itself an opioid and is extremely vulnerable for misuse and
diversion.
People who have been on the committee know that I have long
been opposed to the broad expansion of prescribing authority
under the umbrella of expanding the availability of treatment.
In medicine, sometimes we are in these situations where
medications are dangerous potentially, and even though we want
more access, we still have to stick with science and make sure
the proper individuals, who are properly trained, are the only
ones that have the ability to prescribe these medications.
Unfortunately, I haven't been able to convince all my
colleagues of my view on this issue. So we have dramatically
expanded it, and I hope that we don't see problems.
Mr. Gandotra, you spoke to my colleague, Mr. Griffith,
earlier about the potential for buprenorphine diversion and
said that you were not aware of it being used as a street drug.
Is that correct?
Dr. Gandotra. Most cases are of buprenorphine have been
utilized for treatment, or for withdrawal mitigation as far
as----
Mr. Bucshon. Well, just, I mean, as you probably know,
there is multiple peer-reviewed articles and even some NIH and
DOJ intelligence research suggesting that it is a significant
risk, that buprenorphine, being a diverted drug.
So even though it sounds like you think that that is a
small issue--we can agree to disagree--what steps is SAMHSA
taking to combat the possible diversion of buprenorphine?
Dr. Gandotra. Thank you very much for that question.
Certainly we know that education on substance use disorder is
important as practitioners diagnose and treat these conditions.
We are working with professional societies to ensure that
there is appropriate and summative information provided to all
members so that ongoing education and training becomes the
standard. That is irrespective of the ex-waiver itself.
And certainly as far as diversion goes, I could also turn
to my DEA colleague for specific diversion actions.
Mr. Bucshon. Yes, sure.
Mr. DeLena. Congressman, thank you for your question. You
asked about buprenorphine and you asked about potential abuse--
--
Mr. Bucshon. Yes, potential diversion, and I mean, for many
years it has been considered one of the highly vulnerable drugs
to being diverted because it is an opioid itself, and as we
increase access, and as I have previously stated, probably have
people that aren't properly trained prescribing it. So what are
you going to do when we start to see it on the street?
Mr. DeLena. I think the word you used, Congressman,
guardrails, puts it best. While we want to make sure that
people get access to the treatment that they need, it has to be
done in a way that does not contribute to overprescribing,
misprescribing, or diversion of that substance.
And we need to make sure that we educate and make aware our
communities and our law enforcement partners as such.
Mr. Bucshon. Yes, I would agree with that. And I mean, as
probably anyone knows that works in this space--and that is not
my area of expertise, but I was a physician--that ongoing
counseling and therapy is extremely important. You know,
showing up and getting medication-assisted treatment without
proper counseling, follow-up, probably almost for the lifetime
in many cases, doesn't give very good results.
I will save this question for your written response.
Naloxone, it is going to come over the counter. This is for Mr.
Gandotra. Will that change any, or affect any existing work or
grant programs at SAMHSA, and how do you plan to deal with
those changes? If you could submit that for the record, I would
appreciate it.
Dr. Gandotra. Thank you.
Mr. Bucshon. Thank you very much. I yield back.
Mr. Guthrie. Thank you. I appreciate the vice chair for
yielding and now recognize Ms. Barragan from California for 5
minutes for questions.
Ms. Barragan. Thank you, Mr. Chairman.
Mr. DeLena, I am looking at your testimony, and under the
Sinaloa Cartel, you mentioned drug trafficking activity in
various regions in Mexico, particularly along the Pacific
coast. Would that include trafficking through boats across
waters, or is that not included in that?
Mr. DeLena. Thank you for the question, Congresswoman.
Those cartels, the Jalisco Cartel and Sinaloa Cartel, will use
any method possible to get drugs into the United States and
into all of our communities.
Ms. Barragan. So do you work with the Coast Guard for
operations on water?
Mr. DeLena. Thank you. We work with all our Federal
partners. We do work with the Coast Guard, and we work with
State and local law enforcement throughout the country.
Ms. Barragan. Thank you. I was stricken by your testimony.
You, on several occasions, mentioned your top priority--your
operational priority is to defeat these two Mexican cartels
that are responsible for driving the drug poisoning epidemic in
the United States.
You say it once there, and then you go on later to say they
are using cars and trucks and other routes to transport these
drugs from Mexico to the United States. And then you continue
to say it on the crossing points, and you even end with saying,
again, that the cartels are driving drug poisoning and
threatening the safety of our health communities.
And I guess I was struck by the number of times you
mentioned driving, just because there has been a lot of
misinformation sometimes put out there.
My understanding has been since, I think, 2020 about 97
percent of fentanyl seizures have been ports of entry. You
previously testified the majority have been at ports of entry.
Does that 97 percent sound about accurate?
Mr. DeLena. Congresswoman, thank you again for the
question.
I don't have the specifics related to the border and the
points of entry. That is probably a better question for the
Department of Homeland Security and the entities therein.
Ms. Barragan. OK. Well, thank you.
I think your testimony about the majority is important. It
is also, I think, why Democrats have prioritized making sure
there was more than $400 million in nonintrusive inspection
systems at the southwest land border, because we know the
majority of this is coming over through the ports of entry.
Democrats also funded additional staffing for CBP points of
entry in the fiscal 2023 omnibus because it historically has
been understaffed. These are the officers that are doing the
interdicting drug attempts to enter our communities. And so we
are going to continue to work on that as one of the tools. I
think in your testimony you mentioned there has to be an
entire--a lot of tools that are necessary for that.
So I just want to thank you for the efforts that you are
doing, and we certainly want to be helpful in making sure that
Congress is funding efforts to help in your fight, in the DEA's
fight.
Dr. Gandotra, I would like to now shift a little bit. In
Los Angeles County and across the country, we are seeing the
humanitarian crisis of people experiencing homelessness, and
they are dying from fentanyl overdoses.
Between 2017 and 2019, people experiencing homelessness in
L.A. County were more than 36 times more likely to die of a
drug overdose compared to the general population. Drug overdose
deaths involving fentanyl tripled between 2018 and 2020, and
drug overdoses remains the primary cause of death for people
experiencing homelessness in L.A. County.
I believe we need a drug policy aimed at reducing harm
caused by fentanyl, and it must include a holistic public
health approach.
So my question to you is: You know, the last time this
committee came together, it was on a bipartisan basis to pass
the Restoring Help for Mental Health and Well-Being Act, which
reauthorized billions of dollars in programs to address mental
health and substance abuse.
Can you discuss how the Substance Abuse and Mental Health
Services Administration can use these programs to address
social factors, like homelessness, that worsen fentanyl-related
substance overdoses among the more than 500,000 people
experiencing homelessness in our country?
Dr. Gandotra. Thank you for the question.
Certainly, when we try to address substance use disorder
and mental illness, we have to address people where they are.
Through our block grant funding, the Substance Abuse and Mental
Health Services Administration does provide billions of dollars
to each State, where they can identify the interventions that
are best suited for their communities. This may involve
wraparound services, prevention efforts, harm-reduction
efforts, as well as things specifically such as naloxone
administration.
As far as homelessness goes, we also expanded our
educational resources. We recently released our evidence-based
resource guide, ``Expanding Access to and Use of Behavioral
Health Services for People Experiencing Homelessness.'' This
guide has strategies for engagement, retention, as well as
involvement of recovery efforts. We also highlight key
strategies to ensure success and measure that success in terms
of recovery support for both the unsheltered and sheltered
homeless.
Ms. Barragan. Thank you.
My time has expired. I yield back.
Mr. Guthrie. Thank you.
The gentlelady yields back.
The Chair recognizes Dr. Joyce from Pennsylvania for 5
minutes.
Mr. Joyce. Thank you for yielding, Mr. Chairman.
And I further would like to thank our full committee
Chairwoman McMorris Rodgers for holding this hearing today and
for your continued focus on stopping the scourge of the illicit
fentanyl substances and the tragic impact that they have on our
Nation, specifically in my community in Pennsylvania.
Last month, we were able to hear powerful testimony here
from two of my constituents, Ray and Deb Cullen, who tragically
lost their son to fentanyl poisoning just months ago. Their
loss and those who have felt this across the Nation over the
past year underscores how critical it is that we act to
permanently schedule fentanyl-related substances classwide.
It is shocking to hear that in 2022 alone the DEA seized
almost 379 million deadly doses of fentanyl, which is more than
enough to kill every single man, woman, and child in the United
States. And this is just what was seized.
Lack of operational control over our southern border has
allowed the cartels, the drug traffickers, to flood our streets
with these deadly substances, literally placing every community
in America at risk.
Associate Administrator DeLena, the CDC estimates that
illicit fentanyl or fentanyl-related substances are responsible
for most overdose deaths in our country. I firmly believe that
we must empower law enforcement with every tool that is
necessary to stop those who traffic these deadly substances
into our communities.
For this reason, I am troubled by the Biden
administration's insistence that we should exempt certain
fentanyl-related substances scheduled by class from all
quantity-based mandatory minimums.
Associate Administrator DeLena, with this approach of less-
harsh sentencing guidelines for fentanyl-related substances
under the Biden plan, if a drug trafficker would bring, let's
say, this amount of a fentanyl-related substance into the
United States and, in contrast, had this amount of cocaine, the
mandatory minimum sentences would be greater for this in
cocaine than the more deadly fentanyl-related substances, which
potentially could kill everyone in my district.
Wouldn't this incentivize the drug traffickers to bring
fentanyl-related substances, more of them in, causing more
tragedy, more deaths in the United States?
Mr. DeLena. Congressman, thank you for the question.
It is the top legislative priority of DEA for the permanent
classwide scheduling of fentanyl-related substances.
DEA is a law enforcement agency. We conduct investigations
and make arrests. When it comes to the sentencing and
everything that goes along with it, we defer that to the
prosecutors that we work with and the judges.
Mr. Joyce. So the Biden administration does not recommend
decreased or absent mandatory minimum sentences for fentanyl-
related substances?
Mr. DeLena. Congressman, again, thank you. I would have to
defer to those prosecutors and the judges that make those
decisions, is the best answer to that.
As an investigative law enforcement agency, our goal is to
target those cartels and the drug-trafficking organizations
that are doing the most harm and to make those arrests. Then we
move that forward for prosecution, and those decisions are made
by prosecutors and judges.
Mr. Joyce. Would you agree with me that mandatory minimum
sentences for fentanyl-related substances should be equal to
other narcotics that could be introduced into our country?
Mr. DeLena. Thank you, Congressman, for the question.
I would have to defer to the people that make those
decisions. As a law enforcement agency, we are laser focused on
defeating the two cartels and reducing harm in all of our
communities.
Mr. Joyce. And you talk about that harm in our communities.
I think every Member, both sides of the aisle, has witnessed
those harms and has heard those stories in our communities, in
our families, in our neighborhoods.
I think protecting our southern border is utmost important.
And I think those mandatory minimum sentences should not allow
the exemption of fentanyl-related substances.
I think we have to agree that the impact of fentanyl-
related substances and the ability to carry the similar
mandatory sentencing has to stop the cartels from looking at it
as a business decision, which would carry a great amount of
harm throughout the United States.
I thank you for participating.
And I yield the remainder of my time.
Mr. Guthrie. The gentleman yields back.
The Chair now recognizes Ms. Craig from Minnesota for 5
minutes for questions.
Ms. Craig. Thank you so much, Mr. Chairman.
And especially to our witnesses, thank you for being before
us today to address this absolute crisis here across our
country and in Minnesota's Second Congressional District that I
represent.
You know, families across America are suffering unthinkable
losses as a result of these drugs. I know firsthand that our
Nation's public safety and healthcare professionals are on the
front lines of this battle. In November of last year, I was on
a ride-along with the Shakopee Police Department in my
congressional district. Our first call of the night led us to
the scene of a public drug overdose, where I watched Officer
Soto and two of her colleagues literally bring a young man back
to life from the bathroom floor of a family restaurant.
I know that is just another night in the line of work that
they are in, but addiction, mental health, and other challenges
have stretched them thin. We in Congress owe them both the
utmost respect and the conviction to address and fight these
issues, or we face the possibility of losing countless more
lives to this opioid crisis.
We owe the parents, the grandparents, the friends, and
family of all that were not saved the responsibility to address
these issues in a comprehensive way and not use these tragedies
as another political wedge issue.
Look, I know this is complex. Congress doesn't do complex
very well. I have learned that in my first 4 years in Congress.
And I am disappointed this morning that my Republican
colleagues, some of them, have decided to use this hearing as a
partisan pulpit rather than address this as a forum to talk
about bipartisan solutions to this deadly epidemic.
Yes, we have to disrupt the flow of these drugs and their
raw materials into our Nation. Yes, we have to ensure that
Customs and Border Patrol have what they need in order to
detect and seize these drugs at our border. Yes, we must
permanently schedule these drugs as Class I.
And yes, we have to figure out what to do about social
media companies across our Nation that are promoting on
Snapchat and other platforms these drugs to our young people.
And yes, we have to treat addiction across our Nation.
You know, we sit up here this morning and we ask you single
questions in 5 minutes, and none of those individual questions
encapsulates the enormity and complexity of these issues.
So I am just going to start with this, and I only have
about 1 minute for each answer. But, first of all, the legal
ports of entry, what else do you need to keep them from getting
to our Nation in the first place? What do you need from
Congress?
Mr. DeLena or Mr. Chester?
Mr. DeLena. Thank you, Congresswoman, for your question and
for sharing that story of your ride-along and the heroic
actions of the men and women in law enforcement that day. That
is a scene that I have seen play out personally in all of the
communities that I have served. I know that first responders
are doing that same exact duty all day every day, and we are
seeing it in communities throughout the entire United States.
What we need is the permanent classwide scheduling of
fentanyl-related substances. That is a critical step for us as
we move forward.
I would like to thank Congress for the enhancements that
came to our budget last year. That is very important to us.
DEA's operations that I mentioned, Operation Overdrive and One
Pill Can Kill--One Pill Can Kill, not just an enforcement
operation but an actual outreach and awareness program that is
having such impact in all of our communities--and the counter-
threat teams that I talked about.
We need the support of Congress to be able to continue to
move forward. We want to stay ahead of these cartels when it
comes to our infrastructure, our digital and data. We need that
support to be able to stay ahead of those violent, ruthless
drug cartels.
Ms. Craig. Thank you so much.
And just one more time, why do we need to treat this as a
public health topic? Why do we need a public health solution?
Dr. Gandotra. Thank you for that question.
Certainly, it affects all aspects of public health--
communities and schools, as well as employment, the GDP, as
well as crisis services. We would like to address this on
several fronts, as it affects all aspects of our lives.
Ms. Craig. Thank you so much.
And, with that, Mr. Chairman, unfortunately, my time has
expired. I yield back.
Mr. Bucshon [presiding]. The gentlelady yields back.
I now recognize the gentlelady from Tennessee, Mrs.
Harshbarger.
Mrs. Harshbarger. Thank you, Mr. Chairman.
Thank you to the witnesses today.
Mr. Chester, some Members of Congress and a number of State
attorney generals, both Democrat and Republican, support
designating illicit fentanyl analogs and all precursor
chemicals as weapons of mass destruction, whether through
executive branch action or congressional legislation, either
way.
This would increase interagency coordination to stop
fentanyl and would increase resources for technical development
and deployment of sensors to detect fentanyl and analytical,
data-based decisionmaking.
What are your thoughts on the merits of such a policy?
Mr. Chester. Thank you very much for that question.
That issue and the related issue of a foreign terrorist
designation are something that the administration has looked
very, very closely at across the interagency, and we have
examined it from top to bottom.
The fundamental question is, would doing so provide us any
capabilities, authorities, or procedures that we don't already
have and are not already applying to this problem? And the
answer is ``no.''
All of the architecture, the structure, the capability, and
the authorities that we need to be able to deal with this
problem in a comprehensive way we have available and we are
already applying to this particular problem.
Mrs. Harshbarger. OK.
I have another question for you, sir.
The High Intensity Drug Trafficking Areas, the HIDTA,
program that was created back in 1988 is administered by ONDCP
and provides assistance to law enforcement agencies at the
Federal, State, local, and Tribal levels. They are operating in
regions of the United States that have been deemed as critical
drug-trafficking regions.
My district is east Tennessee, and we are part of the
Appalachian HIDTA. And that plays an important role in pursuing
the disruption and dismantlement of drug-trafficking
organizations and drug threats in the Appalachian region. And
we have been inundated, along with southwest Virginia and
eastern Kentucky, with that.
Its activities include multiagency intelligence-sharing and
enforcement initiatives involving investigation, interdiction,
and prosecution, and also drug use prevention and treatment
initiatives.
Over the past several years, Congress has steadily
increased appropriations for this program, funding it at $280
million in fiscal year 2019 to a point most recently for fiscal
year 2023 at $302 million.
My question is, do you believe it is sufficient funding for
HIDTA? And explain your answer as to why or why not.
Mr. Chester. First off, I agree with your characterization
of the HIDTA program. And, particularly, the Appalachia HIDTA
and Vic Brown do an enormous job in that part of the country.
And we appreciate very much the Congress' continued support for
the HIDTA program, and we appreciate the funding that we have
received.
What I can tell you is that every single penny that the
Congress provides the HIDTA program is put in the right place
to do the right work that they need to do to protect our
communities and protect our country. And we thank you for that.
Mrs. Harshbarger. Well, do you think it is sufficient?
Mr. Chester. Yes, ma'am. We appreciate all of the funding
that we have gotten. Thank you.
Mrs. Harshbarger. OK. Very good.
Mr. DeLena, the DEA--I am very familiar with the DEA and a
bunch of other three- and four-letter agencies in my
profession, as a matter of fact.
My question to you is, can you provide us an update on the
status of DEA's two proposed rules addressing controlled-
substance prescribing via telemedicine? And when will they be
released to the public for review and comment?
Mr. DeLena. Thank you, Congresswoman, for your question.
DEA takes telehealth very seriously, and it is something
that we are moving forward towards. My understanding is that we
are very close to making that. Anything beyond that, I could
take it back and try to get back to you with a more accurate
update.
Mrs. Harshbarger. OK. So it is not open for public comment
yet, but you are close.
Does that mean you have put rules on the books to where we
can look at some of the--I mean, I can't give you information
if I don't know what you have talked about.
Mr. DeLena. Thank you. I don't have that exact answer, but
I will get it back to you.
What I can say is, you know, we want to ensure that
Americans have access to telehealth, and it has to be done in a
way that is safe and, you know, has guardrails that prevent
from overprescribing and misprescribing and diversion.
Mrs. Harshbarger. Yes. Absolutely.
With such a short timeframe before the end of COVID, what
is DEA's plan to ensure patients don't lose access to those
controlled substances that they need? And I guess that would
include buprenorphine as medication for opioid use disorder.
And, you know, I look at that in different ways. I have
seen it misused. There are people who take those strips, you
know, heat them up, use them as injectables. There is a lot of
diversion that goes on with that. But you can't just stop
somebody. But you don't try to drag forward a drug either. You
know, there is a lot that goes into that.
I just wondered what your thoughts are on that.
Mr. DeLena. Thank you, Congresswoman.
We are committed--DEA is committed to continued access to
medications for opioid use disorders. When the COVID-19 public
health emergency has ended, we will address that when it
happens, and we will take steps to make sure that everybody
that is seeking medication has access to it.
Mrs. Harshbarger. OK. All right. Thank you, sir.
And, with that, I yield back.
Mr. Bucshon. The gentlelady yields back.
I now recognize Ms. Blunt Rochester from Delaware for her 5
minutes.
Ms. Blunt Rochester. Thank you, Mr. Chairman, for the
recognition, and congratulations.
I also want to thank the Biden administration officials
testifying today for their tireless efforts to disrupt the
global illicit drug-trafficking enterprise as well as your
efforts to address the public health and national security
challenges that this crisis presents.
Fentanyl remains the deadliest drug threat facing the
people of Delaware and America. In 2021, Delaware had the
fourth-highest rate of drug overdose deaths in the country, and
over 80 percent of these deaths involved fentanyl.
That is why addressing the opioid crisis, now driven by
fentanyl, is one of my top priorities in Congress. I am pleased
my colleagues on the other side of the aisle have also
prioritized addressing the fentanyl crisis, because, at over
100,000 overdose deaths per year, this crisis is sparing no
one.
Unfortunately, the legislation we are considering today
misses the mark. The approach we are considering today focuses
almost exclusively on law enforcement solutions, and, as I have
said many times before in this committee, we cannot incarcerate
ourselves out of this public health problem.
I have been working on legislation with Congresswoman
Kuster called the STOP Fentanyl Act to comprehensively address
both supply-side and demand-side drivers of the fentanyl
crisis. I want to run through a few important provisions of
this legislation.
Our bill will help States improve their fentanyl
surveillance and forensic laboratories so that States can
distinguish between fentanyl, fentanyl analogs, and fentanyl-
related substances.
It will improve access to all forms of medication-assisted
treatment, including methadone, which, along with psycho-social
therapies and community-based recovery supports, is the gold
standard for treating those with opioid use disorder.
It will extend the reach of harm-reduction programs so that
they can help keep more people alive long enough to seek
treatment.
And it will support law enforcement agencies in detecting
and handling fentanyl.
And my first question: Dr. Gandotra--make sure I say that
correctly. Is that correct?
Dr. Gandotra. Thank you. That is correct.
Ms. Blunt Rochester. Can you describe SAMHSA's approach to
expanding harm-reduction strategies and evidence-based
treatment? And explain why focusing on those suffering from
substance use disorder is important, why it is important,
focusing there.
Dr. Gandotra. Thank you, Congresswoman, for this question.
This is part of SAMHSA's mission, to not only address
substance use disorder but reduce the harms that are associated
with its use. Harm reduction is an important pathway to ensure
that patients who may not be ready to engage in full treatment
are at least able to mitigate the harms associated with use.
Harm-reduction principles such as overdose mitigation with
naloxone has been shown to be very beneficial, not just in
training providers but also making them sensitive to asking the
right questions. In addition to that, if we don't identify
patients, we are not actually able to get them into treatment.
Of course, medications for opioid use disorder are the gold
standard for preventing overdose mortality. So certainly we
expand that with our substance use block grants as well as our
State opioid response grants, as well, which dedicates billions
of dollars to the States.
Ms. Blunt Rochester. Thank you.
Our legislation focuses heavily on public health
surveillance and data collection, because data is a powerful
tool that can help us target resources to those most in need.
For example, through robust data collection on overdoses in
Delaware, public health officials identified that 23 percent of
overdose deaths in recent years occurred among those working in
the construction industry.
Through this information grew a partnership between public
health officials and the State's construction industry to
directly distribute Narcan into the hands of workers at risk,
train supervisors on overdoses, and train workers on the stigma
associated with addiction.
Mr. Chester, can you share how Biden administration
agencies currently track fatal and nonfatal overdoses? And do
you have suggestions on how the many different data sources can
be integrated in a way that is more helpful to policymakers?
Mr. Chester. Thank you, Congresswoman. I will be as quick
as I can.
The tracking of fatal overdoses is done by the Centers for
Disease Control and Prevention through the National Center for
Health Statistics. What we were lacking was nonfatal overdose
data, which is a prime indicator for the eventuality of a fatal
overdose.
Just recently, within the last 2 months, ONDCP has launched
a dashboard that works with other agencies to track nonfatal
overdose data, which is incredibly important. And we work
across the interagency in order to track that.
The most important thing that we can do--and I think you
brought this up in your statement--is to use that data and
bring it together to figure out those areas that have the
greatest need, where we can surge resources and make the
greatest effect. And that is principally how we use that data.
Ms. Blunt Rochester. Thank you so much.
I am over time. I will be reaching out to you with a
question about data and DEA.
Thank you, Mr. Chairman, and I yield back.
Mr. Bucshon. The gentlelady yields back.
I now recognize the gentleman from Georgia, Mr. Carter, for
his 5 minutes.
Mr. Carter. Thank you, Mr. Chairman.
And thank all of you for being here.
I think that we would all agree--members of the committee,
witnesses, everyone in America--this is an epidemic. This is
something that has got to be addressed. We all know what is
going on here.
And there are a number of reasons, none that are more
important than the fact that we have to secure our southern
border. I mean, we all know that this is where the vast
majority, if not all, of the fentanyl is coming across, and it
is causing problems. A lot of people look at the border
situation, the crisis that exists down there as being just
illegal immigrants coming across, but we know that it is much
more than that.
And we know that it is infesting all of our communities. In
my district, we--and I represent south Georgia. I represent the
entire coast of Georgia, but I have a lot of rural areas in
south Georgia. We had an incident just last week where we had a
number of people who overdosed in a small community, a small
rural community in south Georgia, and overdosed on fentanyl.
And if it weren't for the heroics of the public safety
personnel in administering Narcan and naloxone, they would have
perished.
And we know what is happening here, and I won't take up my
valuable time with repeating all the numbers. You know, 7
billion--enough fentanyl in this country to kill 7 billion
people, almost 21 times our population. Unbelievable.
You know, I want to share to you a quick story that
happened to me. And, you know, I am a pharmacist, and it
happened to me. I was at a townhall meeting this past August,
and I made a comment about fentanyl addiction, and a mother
rightfully corrected me. She said, ``No, sir. You are wrong.''
She said, ``It is not fentanyl addiction. It is fentanyl
poisoning.'' She said, ``My son took one pill, and he is
dead.''
She was right, and I was wrong. It is fentanyl poisoning.
And we have to do something about it, and we have to address
it. The number-one killer, according to the CDC. It is the
leading cause of death in the U.S. for adults age 18 to 45.
So, enough of that. Mr. Chester, I will start with you and
ask you: In a White House press release dated September the 2nd
of 2021, DEA Administrator Anne Milgram stated, ``The permanent
scheduling of all fentanyl-related substances is critical to
the safety and health of our communities. Class-wide scheduling
provides a vital tool to combat overdose deaths in the United
States.''
Is support for permanent scheduling the official position
of the Biden administration?
Mr. Chester. Yes, Congressman, it is. We support the
scheduling of fentanyl-related substances as a class. We do.
Mr. Carter. I want to remind members of this committee and
everyone here that we are considering the HALT Fentanyl Act,
and that would permanently schedule fentanyl-related substances
and keep them out of our communities, hopefully.
You know, I dealt with this when I was in the Georgia State
legislature and a member of the pharmacy caucus there. We dealt
with this every year when trying to identify the analogs and
trying to--and every time we would identify them one year, they
would come up with different ones the next year. It was just a
vicious cycle.
This is something that has to be done. And I hope that we
will have the administration's support with this, and I hope we
will have everyone on this committee's support.
Mr. DeLena, I want to ask you--and I can't help but bring
up this report that was in The Washington Post recently about
some of the problems that we have had with the DEA agents down
in Mexico. In fact, we had a 6-month time when we were without
personnel down there that we should have had.
And I just need--I need reassurance from you that the
personnel problems that we have had down in Mexico,
particularly with the DEA agents, have been straightened out.
And I think you know what I am talking about. I am talking
about, specifically, the DEA's Mexico office was in turmoil for
more than 6 months, with the Director recalled to Washington
while investigators probed his conduct.
Mr. DeLena. Congressman, thank you for your question.
While I can't comment directly on a personnel matter, what
I can tell you is that DEA's top operational priority is
defeating these Mexican cartels. And the----
Mr. Carter. That is not what I asked you. Come on, now.
Mr. DeLena. The administration----
Mr. Carter. You need to give me confidence that you all got
this straightened out. This is too important. Two hundred
people are dying every day.
Mr. DeLena. Thank you, Congressman.
The Administrator in summer of 2021 ordered a review of all
of our foreign operations to make sure that we have the right
people and that we are most effective in all of the places
where we are situated----
Mr. Carter. This article also indicates that the Mexican
Government is not working with us on this. Can you shine any
light on that with us?
Mr. DeLena. Congressman, thank you.
The Mexican Government needs to do more. We are there in
Mexico laser focused on the cartels and the fentanyl and
methamphetamine that they are producing, but we know that they
need to do more when it comes to collaboration. And----
Mr. Carter. I trust that you all are getting your staff
worked out, straightened out, your situation straightened out.
Two hundred people every day. We don't have time. We don't have
time for this. We have to do something about this right now.
Thank you, Mr. Chairman, and I will yield back.
Mr. Bucshon. The gentleman yields back.
I now recognize the gentlelady from Washington, Ms.
Schrier, for her 5 minutes.
Ms. Schrier. Thank you, Dr. Vice Chair.
And thank you to these excellent witnesses for being here
today. I have learned a lot from this conversation.
In my State of Washington, like every other State, fentanyl
has had profound and devastating impacts. Just months ago, in
my hometown of Sammamish, a Seattle suburb, two parents of a
toddler were buying, using, and dealing fentanyl. They left
pills on their nightstand. Their toddler found them, and the
toddler died from the overdose.
On the other side of my district, in Chelan County, a rural
county in the eastern part of my district, the coroner recently
reported that deaths from fentanyl overdose rose from 6 in 2021
to 20 in 2022.
And, in recent years, local high schoolers have died from
fentanyl overdoses because they did not know that a pill that a
friend gave them or that they got elsewhere or online was laced
with fentanyl.
And I know that every one of us--and we have heard them
today--every one of us has stories just like this from our own
districts.
Mr. DeLena, you noted in your testimony that the Drug
Enforcement Agency investigated more than 129 cases directly
linking the sale of fake pills containing fentanyl to social
media sites, and then alluded to Snapchat just earlier with
links that disappear. And this is where teens are getting these
pills.
So, as a pediatrician, I need to ask, can you talk a little
bit more about what the DEA is doing on this issue to make sure
we don't keep losing our kids? Because they are all on social
media.
Mr. DeLena. Congresswoman, thank you for the question.
And your references to the tragedies that occurred in your
district--at DEA, we have over 4,800 photos of those that have
been lost to fentanyl poisoning in our lobby. The youngest is
17 months, and the oldest is 70 years. So, you know, this drug
does not distinguish.
We are laser focused on the cartels that are pushing this
drug into our country, and we know that those drug cartels and
their entire drug-trafficking organizations are using social
media platforms to try to reach hundreds of millions of
potentially new customers. Because that is truly where
Americans are spending time, is on those social media sites,
particularly young people, which is something that, you know,
is gravely concerning to all of us.
We need to continue with programs like One Pill Can Kill,
where not only are we conducting enforcement and seizing these
pills--50 million pills DEA seized last year--but we are
educating and getting the word out there. We----
Ms. Schrier. In addition to educating parents and students,
what is your interaction with social media sites on this? Do
you get cooperation? And what do you need from Congress to get
those tools?
Mr. DeLena. Thank you, Congresswoman.
We do interact with the social media companies. We do so on
a regular basis, specific to each investigation that we are
conducting. But we know that these social media companies can
and must do more.
They control all of the algorithms. They know how content
is being pushed to all of their hundreds of millions of users.
They control all of the data. And unless we can get a look
inside there, as DEA or, as you said, for Congress to be able
to do something, we can't make those type of recommendations.
So there needs to be more transparency. If they want to fix
this problem, they can fix this problem.
Ms. Schrier. Thank you. This is an area that I look forward
to working with my colleagues on both sides of the aisle to
figure out for a variety of reasons.
I have another question for you. As you may know,
Washington State has many ports. And I have supported
legislation to build up law enforcement capacity to detect
synthetic drugs.
And I appreciate that your testimony also focuses on the
southern border. Can you tell me a little bit about what DEA is
doing to monitor at our seaports?
Mr. DeLena. Thank you, Congresswoman.
First of all, DEA is focused on wherever the threat takes
us and wherever these investigations shall lead. We do work in
all of our communities not only with our other Federal partners
but with our State and local partners as well. I have
personally been involved, in my tenure, particularly in my time
in Florida, with investigations that lead us, you know, to the
sea. And we work hand-in-hand with those that are conducting
those investigations.
And each of it is threat based. If we know that there is a
threat, you know, in your specific area coming in through the
seaport, we are going to be focused on that.
Ms. Schrier. Thank you.
I don't have time to get an answer to this, but, Dr.
Gandotra, I would love it if you could, afterwards, submit
perhaps a list of places that parents can consult so that they
can have conversations with their children about how to not
fall prey to fentanyl poisoning online.
Thank you. I yield back.
Mr. Guthrie [presiding]. Thank you.
The gentlelady yields back.
The Chair recognizes Dr. Miller-Meeks for 5 minutes for the
purpose of asking questions.
Mrs. Miller-Meeks. Thank you very much. And I thank the
Chair and all the witnesses that are here for this
extraordinarily important topic.
And just as an introduction to you, I am a physician, as is
Dr. Schrier. I am the former director of the Iowa Department of
Public Health, under which behavioral health, substance use
disorder was a part. And I also was a State senator and, as a
State senator, passed no preauthorizations for medicated-
assisted treatment, or MAT, for substance use disorder in one
session; also schools as a site of service for behavioral
health, which I think was very forward thinking at the time.
And so my question, Dr. Gandotra: SAMHSA's 2022 report
titled ``National Guidelines for Child and Youth Behavioral
Health Crisis Care'' outlines best practices for implementing
mobile crisis response teams. And we have set these up in Iowa,
when we have set up our child and mental health--or like I
would prefer to call it, brain health--systems. These mobile
crisis teams are typically made up of mental health
professionals, nurses, and peer support providers.
The report recommends that these teams respond to crises
without law enforcement accompaniment unless special
circumstances warrant their inclusion.
And let me also say that in SAMHSA's September 2021 ``Ready
to Respond,'' also on mental health, on page 20, it also notes
shifts away from traditional law enforcement responses in many
cases.
So my question: Is it SAMHSA's position that mobile crisis
teams should respond to calls in lieu of law enforcement?
Dr. Gandotra. Thank you for that question.
Certainly, we understand that, when it comes to crisis
management, providers who are going to deliver the service have
to maintain their safety but also approach this from a trauma-
informed perspective, understanding that sometimes individuals
who have experienced past trauma may be more vulnerable and
more sensitive to the application of law enforcement entities.
Certainly, that has to be balanced with public safety as well
as the information that is given.
And that is really the key, is having the most information,
most up-to-date information, so that the approach can be
tailored and individualized for those purposes, would be my
first and ideal situation. Certainly----
Mrs. Miller-Meeks. So, just to make sure I am
understanding, you are saying it is not in lieu of law
enforcement.
Dr. Gandotra. I am saying it should fit, from the
information, from the clinical perspective, what is best
required for the safety of the patient as well as for the
community provider that is delivering that service, certainly.
Mrs. Miller-Meeks. So, as in an episode we saw--and this
was not a child, but--in subways in New York City where someone
was pushing somebody else off a train track but they are in a
mental health crisis, how do you respond to that then? Because
you may not have that information when a 911 call is made to
know clinically what is the best approach. So, again, is it in
lieu of law enforcement?
And, then, what are the criteria for determining special
circumstances that warrant the involvement of law enforcement?
That perhaps will better answer this question.
Dr. Gandotra. So the strategy that should be employed would
be an evidence-based strategy that would still incorporate
trauma-informed approaches but still maintain safety for the
individual delivering the care as well as the individual
needing the care. We would try to encompass all aspects of the
needs of the provider as well as for the patient.
Mrs. Miller-Meeks. Well, I can certainly see that, perhaps,
if someone is calling a crisis line before there is a crisis.
But when there is an actual incident, as you may see in public,
it could be very difficult to do that.
So thank you so much for the answer, and perhaps you could
elucidate that further in writing.
And I yield back my time.
Mr. Guthrie. The gentlelady yields back.
The Chair now recognizes Mr. Crenshaw from Texas for 5
minutes for asking questions.
Mr. Crenshaw. Thank you, Mr. Chairman.
Thank you all for being here.
I would like to direct most of my questions towards you,
Mr. DeLena. I do have an interest in battling what seems to be
a war with the cartels south of our border.
One of my first questions to you is, you know, you laid out
three strategies the DEA is currently engaged in, but do you
really have enough resources? And do you need more engagement
from other entities, such as the intelligence community and
perhaps the Department of Defense? What else do you need that
would help battle this problem?
Mr. DeLena. Thank you for the question and for your
commitment to this issue, Congressman.
DEA is equipped right now with the resources that have been
allocated to us to focus on these two cartels. Any additional
resources is something, obviously, that, you know, we would be
open to and to discuss, but it would have to be sort of
specific to, you know, maybe what you are talking about.
Mr. Crenshaw. Well, yes, you have certainly been allocated
the resources, and that is what you are working with. I
understand that to be the case. But the question is not that.
It is, is it enough? Are you making an impact against these
cartels?
And if not--clearly not, because they are able to wage a
war against the Mexican Government at will in the state of
Sinaloa just recently, a couple weeks ago. So, obviously, we
are not doing enough. What more is needed?
Mr. DeLena. Congressman, thank you.
I think, you know, with the successes that we talked about,
that DEA seized over 50 million pills last year and 10,000
pounds just of fentanyl and, you know, an exorbitant amount of
methamphetamine as well, you know, our focus right now is to
defeat those two cartels and----
Mr. Crenshaw. OK. OK. What about authorities?
So I have a bill that I am reintroducing today called
Declaring War on the Cartels Act. And what this does is deliver
the same authorities that you would have to go after ISIS
without necessarily labeling them as a terrorist organization.
Would that be helpful? Because that would allow you to go
after their financing. It would allow the U.S. Government to
sanction officials in Mexico that operate with the cartels.
Would that be helpful?
Mr. DeLena. Congressman, thank you.
I can't comment on pending litigation like that. We would
work the interagency process as those things came in.
Mr. Crenshaw. Sure. I imagine it would be helpful if you
had more authority. That is not a trick question. Yes.
All right. What is your cooperation like with the Mexican
Government? Is it good? Is it bad? Has it been better? Does it
mirror at all the longstanding cooperation we have had with,
say, the Government of Colombia during Plan Colombia and the
successes we have had there?
Mr. DeLena. Thank you, Congressman.
This is obviously a fluid and rapidly evolving situation.
We see these cartels in their switch from plant-based drugs to
synthetic-based drugs. This thing continues to evolve every
single day.
We know that the Mexican Government needs to do more. They
need to take steps in their own country, and they need to
assist us additionally than how they are already doing that
right now.
Mr. Crenshaw. OK. So, no, they are not doing enough. They
don't cooperate with you to the extent that you would like.
Do you trust them? If you give them intelligence--like, for
instance, I am assuming that you know where some of these
clandestine labs are that they are making fentanyl that is
killings tens of thousand of Americans a year. I am assuming
you know that. You currently do not have the authority to go
raid that facility in Mexico. The Mexican Government does. If
you tell them about it, will they go take care of it?
Mr. DeLena. Congressman, thank you.
I don't want to get into specifics of investigations, and
that is essentially----
Mr. Crenshaw. I am not asking you to get into specifics. I
am asking you in generalities. You know where a bad guy is. You
tell the Mexican Government to go get them. Will they do it? Do
you even trust them with that information, or do you think they
will tip them off?
Mr. DeLena. Thank you, Congressman.
The Mexican Government needs to do more. They need to seize
those drug labs. They need to disrupt those drug labs. They
need to assist with extradition on the investigations that we
build.
Mr. Crenshaw. All right. You are being very diplomatic, and
that is fine.
Earlier, you mentioned specifically the Jalisco Cartel and
the Sinaloa Cartel. It is worth also naming the leaders of
those cartels and how dangerous these two particular people are
to tens of thousands of Americans. The leader of the Jalisco
Cartel is Nemesio Oseguera Cervantes. They know him as El
Mencho. The leader of the Sinaloa Cartel is Ismael Zambada
Garcia, known as El Mayo.
Everyone should know who these two guys are, because they
are killing tens of thousands of Americans. We all know who
Osama bin Laden is. We started a war just to go after him. And
we should start a war with these cartels, because they are at
war with us. And I would encourage all of my colleagues, across
the aisle, all Republicans, all Democrats, to join with us on
this issue.
I have currently introduced an Authorized Use of Military
Force to go after the cartels specifically with every aspect of
our government's power. I think this needs to be a whole-of-
government approach. And I think we need to be unified, as
Democrats and Republicans, in dealing with this problem.
Thank you.
Mr. Guthrie. Thank you.
The gentleman yields back.
The Chair now recognizes Mrs. Trahan from Massachusetts for
5 minutes to ask questions.
Mrs. Trahan. Thank you, Chairman Guthrie--and I am sorry
the elevator closed on us earlier--Ranking Member Eshoo.
Thank you to the administration witnesses for being here
today.
Based on today's hearing, it is clear that passing policy
solutions to address the fentanyl crisis is top of mind for
Democrats and Republicans alike. And I hope this will be one of
many hearings this subcommittee holds to build on the
bipartisan addiction prevention and treatment policies like the
MAT Act that we passed at the end of last Congress.
The Biden administration's proposal to permanently schedule
FRS within Schedule I includes an important off-ramp to
reschedule an FRS found to have medicinal value, as well as
research provisions which have been adopted by my Republican
colleagues in their HALT Fentanyl bill.
It is important because fentanyl itself has an approved
medical use, and it is possible there are unknown
pharmacological effects and therapeutic potential for the
entire class of substances if studied and regulated properly.
For example, studying FRS may be key to discovering the next
generation of naloxone, commonly known as Narcan, which will
help to save lines.
Our recent trends in overdose deaths show the emergence of
fentanyl adulterated with a powerful animal sedative called
xylazine, which has been talked a lot about today, more
commonly known as ``tranq dope.''
According to the Lowell Sun, the paper in my district,
first responders have already seen this deadly drug make its
way into Lowell, the gateway city where I grew up and I
represent. In fact, the Lowell Police Department has sent out
alerts to residents to inform them of the dangers of this drug.
The city worries that Narcan does not counteract xylazine like
it does with fentanyl. And the FDA issued a similar alert back
in November.
So, Dr. Gandotra, can you please shed light on how naloxone
was discovered and how research into FRS may lead into similar
opioid antagonists?
Dr. Gandotra. Thank you, Congresswoman, for the question.
Certainly, we know naloxone is an important tool for
reversing opioid overdose. It was discovered in the 1960s by a
researcher who was trying to alleviate symptoms of constipation
from chronic opioid use, and it is derived from oxymorphone.
I will also state that it is this property as an opioid
antagonist that makes it incredibly useful as a mono product
for reversing overdoses but also as a combination product with
buprenorphine for Suboxone for opioid treatment and has quite a
different risk profile and diversion profile, making that a
wonderful, evidence-based practice for treating opioid use
disorder.
Mrs. Trahan. Thank you, Doctor. It seems that we do agree
that reforming the research landscape is key to finding new
therapeutic treatments and those lifesaving antidotes.
I am going to attempt to switch gears a bit, because I
would like to focus on access to treatment for opioid disorder.
Since March 2020, the DEA, under authorities associated
with the public health emergency, has allowed registered
clinicians to prescribe some controlled medications after a
telehealth examination for patients suffering from mental
health issues.
The expansion of telehealth services has been vital to
patients across the country who rely on controlled-medication
prescriptions to support their mental health care and aid in
their recovery. And there is broad support across the medical
community for maintaining access to controlled-medication
prescribing through telehealth to ensure patient access to
treatments even if they can't make it into the doctor's office.
I was pleased to see that a very recent study published in
GEMMA Network found that rules permitting doctors to prescribe
buprenorphine via telehealth to treat OUD did not increase
overdose deaths involving the drug.
Congress has directed the DEA to establish a special
registration for providers to prescribe controlled medications
through telehealth. Congresswoman Kuster and I have urged DEA
to release this special registration and maintain access to OUD
treatment via telehealth.
With the public health emergency ending on May 11th of this
year, it is unlikely that the special registration process will
be in place, and patients may lose access to a critical pathway
of treatment.
So, Mr. DeLena, what is the timeline for this special
registration proposed rulemaking? And to avoid a gap in access
to treatment and care, does DEA intend to extend that waiver
allowing clinicians to prescribe controlled medications through
telehealth until the special registration process is in place?
Mr. DeLena. Congresswoman, thank you for the question.
DEA strongly believes that Americans should have access to
telehealth, but it has to be done so in the appropriate way to
avoid overprescribing and misprescribing.
I can't speak to the specific dates and what you are asking
for, but I can certainly take that back and try to get you some
of that information.
Mrs. Trahan. Terrific. Thank you so much.
I have run out of time. I yield back.
Mr. Guthrie. Thank you.
The gentlelady yields back. And that does conclude our
first witness panel.
And I will just say to all three of you: A couple of things
we might have had a difference of opinion on, but I know we are
going to have to all work together. And I respect all of you,
and we look forward to going forward, because this is a crisis.
There are other bills on the agenda as well, but certainly
the fentanyl crisis is first and foremost in everyone's mind.
So hopefully we can find opportunities to move this legislation
forward in a way that we all can support in the end but also be
effective. So we have to have both moving forward.
So thank you very much. Thanks for your patience. Thanks
for being here, and thanks for your answers. And there was a
couple of ``ran out of time, you are going to have to answer on
paper.'' I know we have a record of that, and we look forward
to your timely responses for that.
So the first panel is dismissed, and we will set up for the
second panel.
[Recess.]
Mr. Guthrie. Well, thank you. The subcommittee will come
back to order.
We appreciate all of our witnesses being here today.
This is the beginning of our second panel. And I will
introduce our witnesses, and then we will begin our witness
testimony.
First we have Ms. Kandi Pickard, the president and CEO of
the National Down Syndrome Society.
Then we will hear from Frederick--I-sah-si, is that
correct, because we all want to know how to say your names
correctly--Isasi, the executive director of Families USA.
And then from Molly Cain, a parent advocate who has been
directly impacted by the fentanyl crisis.
And then Dr. Stephen Loyd, the chief medical officer of
Cedar Recovery.
And, finally, we will hear from Dr. Timothy Westlake, an
emergency room physician and former chairman of the Wisconsin
Medical Examining Board as well as former member of the Badger
State's Controlled Substance Board.
So we thank you all for being here and thank you for your
testimony. It is all important to know. Some of you bring in
personal stories.
And some of you haven't testified here before, so I am just
going to explain. You will see the lights in front of you. You
have 5 minutes to do your opening statement. After 4 minutes,
you will see a yellow light to kind of let you know when moving
forward.
But I know you have some stories to tell, so we are not
going to gavel you down too hard. We want to hear your stories.
And so, just relax. And if you are not--people that haven't
testified before, sometimes that can be daunting, but we are
glad to have you here.
And we will begin with Ms. Pickard. You have 5 minutes--you
are recognized for 5 minutes for your opening statement.
STATEMENTS OF KANDI PICKARD, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, NATIONAL DOWN SYNDROME SOCIETY; FREDERICK ISASI,
EXECUTIVE DIRECTOR, FAMILIES USA; MOLLY A. CAIN, PARENT
ADVOCATE; STEPHEN LOYD, M.D., CHIEF MEDICAL OFFICER, CEDAR
RECOVERY; AND TIMOTHY W. WESTLAKE, M.D., EMERGENCY MEDICINE
PHYSICIAN
STATEMENT OF KANDI PICKARD
Ms. Pickard. Thank you.
Chairwoman Rodgers, Chair Guthrie, Ranking Member Eshoo,
and members of the committee, thank you for inviting me here
today to testify on quality-adjusted life year measures, or
QALYs, in combating discrimination against people with
disabilities.
My name is Kandi Pickard, and I proudly serve as the
president and CEO of the National Down Syndrome Society. I am
also the proud parent of four children, including my 10-year-
old son, Mason, who has Down syndrome.
As the leading human rights organization for all
individuals with Down syndrome, NDSS stands in strong support
of a nationwide ban of the use of QALYs and similar measures in
coverage determinations under Federal healthcare programs, like
the one proposed in the Protecting Health Care for All Patients
Act of 2023.
As you know, QALYs place numerical value on the quality of
one's life before and after healthcare treatments and
interventions, and these calculations are then used by Federal
health programs to determine the cost-effectiveness of
treatments and services and, thus, coverage for patients.
Since a substantial number of individuals with disabilities
receive their healthcare through Medicaid, this flawed and
discriminatory metric directly impacts access to necessary
healthcare treatments when they are not deemed cost-effective
enough to administer to individuals with disabilities.
At NDSS, we are very concerned about the use of QALYs and
other value assessments in all instances. And I would like to
share two examples of how these discriminatory practices are
affecting the Down syndrome community.
People with Down syndrome are uniquely situated in the
Alzheimer's landscape because of their extra copy of chromosome
21, which carries the amyloid precursor protein gene that is
strongly associated with Alzheimer's disease.
As a result, individuals with Down syndrome have a higher
than 90 percent lifetime risk for developing Alzheimer's
disease, with the onset of symptoms coming earlier and
progressing faster than the general population. In fact,
Alzheimer's disease is the number-one cause of death for
individuals with Down syndrome.
CMS recently cited several studies that relied on QALYs in
their national coverage decision for Aduhelm, a first-of-its-
kind Alzheimer's treatment.
Access to treatments for this life-altering disease is
paramount for our community, yet value assessments such as
QALYs and other similar one-size-fits-all approaches are
heavily relied upon in coverage decisions. Medicaid coverage
decisions cannot be made based on flawed assessments that
devalue the lives of people with disabilities, especially when
those lives are uniquely at risk, as is the case for our loved
ones with Down syndrome.
Discriminatory metrics and value assessments are also
experienced by individuals with disabilities in the organ
transplant system. A 2019 report from the National Council on
Disability, an independent Federal agency, found that
discrimination against people with disabilities persists in the
organ transplant system, rooted in biased attitudes about the
value of the life of an individual with a disability.
NDSS is proud to champion the bipartisan Charlotte Woodward
Organ Transplant Discrimination Prevention Act, named after
NDSS staff member Charlotte Woodward, who is here with us
today, which prohibits discrimination based solely on
disability in the organ transplant system.
While advocating for the passage of this bill, we remain
vigilant in our responses to other forms of value assessments,
such as QALYs, that persist in many aspects of our healthcare
system and threaten to access nondiscriminatory healthcare for
people with Down syndrome and other disabilities.
Today, alongside a diverse and nonpartisan group of
stakeholders, including the National Council on Disability, the
Consortium for Constituents with Disabilities, and 100 other
disability advocacy groups, I urge you to ban the use of QALYs
in Federal programs.
A person's value is more than what can be determined by a
metric. My son Mason is no less valuable than my other three
children who don't have a disability just because he has Down
syndrome. I see the value in how hard he works at school, the
love of his siblings, and the joy he brings our friends and
family.
It is outright discrimination to deny individuals with
disabilities access to treatment and the care they deserve and
they need because a calculation determines their value.
Congress deals with many challenging and controversial
issues. This should not be one of them. No party condones
discrimination against people with disabilities, and both
Democrats and Republicans are on the record against the use of
QALYs.
I implore you to support this legislation and take the
important step of protecting people like my son from healthcare
discrimination.
Thank you all for inviting me here to speak today. I look
forward to working with the committee on commonsense health
reforms that value patients and people with disabilities.
[The prepared statement of Ms. Pickard follows:]
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Mr. Guthrie. Thank you for your testimony. Let us welcome
Charlotte. Charlotte Woods, did you say? What was her last
name?
Ms. Pickard. Charlotte Woodward.
Mr. Guthrie. Woodward, stand up, and welcome to our
committee. Yes, thank you. Thank you very much. Appreciate you
being here.
So now, Mr. Isasi, you are recognized for 5 minutes for an
opening statement.
STATEMENT OF FREDERICK ISASI
Mr. Isasi. Thank you very much, Chairman Guthrie, Ranking
Member Eshoo, members of the subcommittee. Thank you for the
opportunity to testify today.
I also want to say thank you to Ms. Pickard for the
beautiful testimony you just gave.
For more than 40 years, Families USA has been working to
achieve our mission of a Nation where the best health and
healthcare are equally accessible and affordable to all. We are
very proud to have always been, and will always be, a very
strong partner with the disability community in support of
their healthcare needs.
I know the topic of this hearing is personally very
important to many of us, especially full committee Chair
McMorris Rodgers.
No matter what our ideology, we are all much more alike
than we are different. Everyone struggles with how to care for
a loved one, and so many live with the financial stress of
high-cost medical bills and the unaffordablity of our
healthcare system.
We at Families USA believe that every person in the United
States should have high-quality, affordable healthcare that
prevents illness, allows them to see a doctor, and helps to
keep their family healthy.
Yet almost half of all Americans report having to forego
medical care due to unaffordable costs, and almost the same
number live under the stress and burden of healthcare debt.
For people with disabilities, the situation is considerably
worse. Disabled people are 2\1/2\ more times likely to delay or
to skip or delay healthcare because of cost, and they are
significantly more likely to have unmet medical, dental, and
prescription drug needs.
It is because of our dedication to the needs of all
families, including people with disabilities, that I urge the
subcommittee to oppose the antivalue legislation that is under
consideration.
First, the proposed legislation's prohibition on the use of
quality adjusted years, or such similar measures, is a solution
in search of a problem. The Inflation Reduction Act drug
negotiation provisions already have very specific guardrails
against discrimination from many groups, including people with
disabilities.
Quoting directly from the text of the drug price
negotiation law, it explicitly and unambiguously bars measures
that treat ``extending the life of an elderly, disabled, or
terminally ill individual as of lower value.''
Moreover, similar guardrails exist in other elements of
Federal law, like the Affordable Care Act. In fact, Families
USA, working with our disabled partners, supported inclusion of
these very guardrails in the drug price negotiation law.
So given the explicit Federal protections that already
exist, what is the real effect of the legislation being
considered by the subcommittee today?
This legislation is a giant loophole to allow the greed of
drug companies to continue and would let other elements of our
corporate healthcare sector to continue to price gouge
unchecked, hurting millions of families, employers, taxpayers,
and healthcare costs will continue to soar.
The proposed legislation uses very broad language that drug
company lawyers will argue bans any attempt to develop an
understanding of whether a drug is worth the astronomical price
being charged across pretty much all Federal programs.
We know that terrible pricing abuses and waste are rampant
in our healthcare system, totaling almost a trillion dollars a
year. That is right, almost $1 trillion in healthcare spending
each year is flat-out waste, hurting both the economic security
of families and the U.S. taxpayer.
But we also know that many American families are being hurt
because of low-quality care. Over a quarter of a million people
die each year not from their illness but from the medical
system itself.
Let me say that again. A quarter of a million souls in our
Nation die each year because our healthcare sector is killing
them through low value, poor care, all while we continue to
spend 2 or even 3 times more on healthcare than other Nations.
It is time for this to end, period. It is time for our
Nation to hold our corporate healthcare sector responsible for
providing high-quality care that is affordable.
If Federal policymakers want to live up to our collective
ideals of supporting people with disabilities, we should
refocus our efforts, end the Medicare disability waiting
period, extend Medicaid program in every State, fully fund and
staff Medicaid home and community-based services, and train a
healthcare workforce that will provide high-quality care to
people with disabilities with dignity and without
discrimination.
I urge members of the subcommittee to oppose this ill-
conceived legislation that is simply playing into the hands of
drug companies' greed. Thank you very much.
[The prepared statement of Mr. Isasi follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you for your testimony. I appreciate
that.
Ms. Cain, you are now recognized for 5 minutes for your
opening statement.
STATEMENT OF MOLLY A. CAIN
Ms. Cain. Thank you, Chairs Guthrie and Rodgers and Ranking
Members Eshoo and Pallone and members of the committee for
inviting me to come and speak out about fentanyl, how it has
invaded our communities, devastated families, and how it has
become a public health crisis.
My name is Molly Cain, and I lost my beloved 22-year-old
son Carson to fentanyl poisoning on November 27th, 2020. Thank
you for allowing me to share his story.
I would like to begin by painting a story of who Carson
was. Carson had a beautiful soul. He loved deeply and was wise
beyond his years, and his heart was true.
Carson persevered in the face of adversity. When Carson was
6, he was diagnosed with dyslexia; at 7, he was diagnosed with
a familial tremor that progressively worsened, and at 10 years
old, he watched his healthy father be ravaged by and ultimately
succumb to brain cancer.
Carson and his brother took on more responsibility within
our family without being prompted or asked. Carson graduated
high school with both his high school diploma and his AA degree
and went on to Gonzaga University to further his education.
During his college years, Carson was prescribed Xanax for
anxiety. Carson was a genuine and empathetic person who wanted
to better the world around him. He would lend a hand or an
understanding ear to those in need and did not expect anything
in return.
He was the shoulder of strength others leaned on,
especially those friends who had lost a parent. Carson helped
to guide them out of the dark abyss they now faced.
During his college years, Carson would plow snow in the
early-morning hours without request or compensation, would stop
at the parking lot of a local cancer center to clear the lot.
When asked why he made the stop, he replied, ``The patients
going for treatment have enough challenges. They don't need one
more to navigate.'' These actions embodied his compassionate
and devoted spirit.
At 22, Carson was diagnosed with appendix cancer. After a
battery of scans and procedures, it was determined the cancer
had not spread, but a spot found on his lung needed to be
monitored. The anxiety my son had became elevated, and suddenly
COVID hit.
Carson, feeling immense pressure, went to counseling and
was given Xanax again. He told me he felt counseling online was
impersonal, and he was only offered appointments during his
working hours. He stopped going.
On November 26, 2020, Carson came home for Thanksgiving. He
was exhausted. He said he was not sleeping. He had been working
long hours and wasn't able to get the rest he needed. He hugged
me goodbye and thanked me for a wonderful dinner and told me he
loved me.
The next day, after not hearing from him as I usually
would, I called him with no answer. I went to his home, and I
found my beautiful, loving son on his living room floor,
deceased. I cannot put into words the guttural pain of finding
Carson dead and knowing I couldn't save him.
We had to wait almost 3 months for the toxicology report to
find out that fentanyl had killed him. During this waiting
period, we had Carson's phone, and he began to receive
Snapchats with pictures of drugs and emojis from an individual.
We dug into Carson's Cash App account and discovered a
payment to the same individual the night he passed away. For
months, the individual continued to Snapchat pictures of drugs
and emojis.
The DEA did a sting. The individual served less than 24
hours in jail.
I was the one who brought the drug dealer's account to the
attention of Snapchat. Snapchat claims they have filters in
place to monitor for such illicit activity. Then why for 5
months did this individual continue to Snapchat such things if
Snapchat's filters were operational?
In my opinion, Snapchat is the courier, and they provide
the getaway for the traffickers of this poison.
In the months and now years that have ensued, I have
grieved immeasurably. I knew what devastation was after losing
my husband, but losing my child has left a gaping hole within
my being.
The heartache and pain is gripping. My son bought
something, thinking it would ease anxiety, a mistake that cost
him his life. It was not his intent to die. These individuals
who are dying are not overdosing. They are being poisoned.
In the 2 years since Carson's death, tens of thousands of
people have lost their lives to this weapon of mass
destruction. Many victims were unknowing.
We need to be educating our children and families alike
about fentanyl and its lethal effects. It has been published
that in Seattle the fentanyl crisis is so bad the medical
examiner is running low on storage for the dead bodies.
I was told by a DEA agent that we will not see an end to
fentanyl in my lifetime. I find these words exceptionally
chilling. I never thought my son's photo would be hanging on
the DEA's wall as one of the victims of fentanyl.
Heartbreakingly, he is a statistic.
How many lives must be lost before we hold the players in
this hellish nightmare accountable? We must do more to prevent
fentanyl from coming into our country, so one more mother, one
more family, will not have to be brought to their knees in
sorrow. I plead with you to take action.
Thank you for allowing me the opportunity to speak.
[The prepared statement of Ms. Cain follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you for your very moving testimony.
Thank you.
Dr. Loyd, you are recognized for 5 minutes for an opening
statement.
STATEMENT OF STEPHEN LOYD, M.D.
Dr. Loyd. I am so sorry, Ms. Cain.
Good afternoon, Chairman Guthrie, Chairwoman Rodgers,
Ranking Members Eshoo and Pallone, and members of the
committee. I am Stephen Loyd. I am an addiction medicine
physician, and I am in recovery from opioid and benzodiazepine
addiction myself.
Through my work as a physician in Tennessee, I see at least
5,000 patients a year in opioid treatment and recovery, and I
serve as the chief medical officer at Cedar Recovery, which is
an outpatient addiction medicine practice in middle and east
Tennessee.
Also, I am the medical director for an opioid treatment
program in Cocke County, Tennessee, which serves an inmate
population, as well as the medical director at Renewal House, a
Nashville organization, which serves marginalized women with
underlying substance use disorder.
Thank you for the opportunity to appear here today as you
consider these important bills and continue to discuss how to
best address the fentanyl crisis in the United States.
This is something I deal with every day, and I hear stories
like this every day in my work in Tennessee, Kentucky, and
Virginia, in both the patients I treat but also in my role as
Tennessee's opioid czar that has been tasked with figuring out
how to best abate the crisis in our State.
This includes working with our citizens in jails and
prisons as we consider best how to serve their needs along the
needs of other Tennesseans who have been impacted by the opioid
crisis.
Under the Americans with Disabilities Act, those with
substance use disorder are considered to have a disability.
This protects individuals who are in recovery or who have used
drugs in the past, a category that would apply to many
individuals who are incarcerated in the United States.
Under the ADA, as interpreted by the U.S. Department of
Justice, people in recovery but who would be limited in a major
life activity, including activities like communicating, caring
for oneself, and thinking, in absence of treatment of recovery
services are protected.
This extends to inmates within the correctional system who
are prescribed medications for opioid use disorder. In my own
experience, both as someone who has been previously addicted to
opioids and benzodiazepines and was given a second chance, as
well as an addiction treatment doctor, a pathway to recovery is
essential for all individuals, including those who may be
incarcerated on drug-related charges.
I have seen that many, not all, of the individuals who are
incarcerated on drug-related crimes are dealing drugs as a
means to get their own drugs in the midst of their own
substance use disorder.
In those cases, minimum sentencing won't work. If you want
these individuals to stop dealing drugs and reenter society,
you must safely stop their use. This includes not only
medication if needed, but other things like safe housing and
education.
For the past few years, I have been fortunate enough to
work with Judge Duane Slone who runs a drug recovery court in
Tennessee's Fourth Judicial District, which covers four rural
counties. This includes a TN ROCS docket, a program that serves
offenders who have an urgent need for treatment but do not
qualify for drug recovery court.
Judge Slone and myself agree that addressing the social
determinants of health are key to helping offenders with
persistent substance abuse problems break the cycle of their
addiction. This includes access to medical care, as well as
food, steady income, housing, access to transportation and
education opportunities.
While I believe that violent drug offenders should be
appropriately punished under the law, I would argue that those
who were merely engaging in a system that are actively addicted
to the drugs they sell should be afforded the same opportunity
that I was given two decades ago.
I appreciate the opportunity to appear before this
committee, and I look forward to answering any questions you
might have.
[The prepared statement of Dr. Loyd follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you for your testimony, Dr. Loyd, and
the Chair now recognizes Dr. Westlake for 5 minutes for your
opening statement.
STATEMENT OF TIMOTHY W. WESTLAKE, M.D.
Dr. Westlake. Great. Thank you, Chairman Guthrie, Ranking
Member Eshoo, and distinguished members of the subcommittee.
Fentanyl-related substances, or FRSs, are highly active
opioids almost identical to fentanyl except for a tiny
difference in their chemical structure, created by tweaking the
chemical scaffold of fentanyl during synthesis in Chinese and
cartel labs. The result of this chemical tweak is a new potent
opioid with the same deadly effect as fentanyl and which,
before FRS class scheduling was put in place, would have been
legal until causing numerous deaths, raising them on the radar
to be scheduled reactively by DEA.
As an emergency physician telling parents, unimaginably at
times, even friends, that their kids will never come home is
the worst part of my job.
It was shortly after one such conversation with my good
friend Lauri Badura that the idea for fentanyl class scheduling
reform came to mind. Lauri's son Archie was an altar server
with my daughters.
It started with prescription opioids, then snorting heroin,
and, unknowingly, fentanyl. I resuscitated Archie on his
second-to-last overdose. At that time I pulled out a body bag,
laid it down next to him, and warned him that that is where he
would end if he didn't accept help.
He stayed clean for 6 months until illicit fentanyl ended
his life. One of the last things my friend Lauri saw of her son
Archie was him being zipped up into a body bag.
Motivated to act by hundreds of such deaths, FRS scheduling
legislation, which is proactive and not reactive, as had
previously been the case, came together quickly and was enacted
with unanimous vote in the Wisconsin State legislature in 2017.
Almost immediately, DEA adopted it as national policy, but
only temporarily. Before that, scheduling new fentanyls was
like a lethal game of Whac-a-mole. We literally had to wait for
people to die before we could take action.
So why isn't the Wisconsin law permanent Federal law yet?
Some who of oppose FRS scheduling point to the recent spike in
deaths from illicit fentanyl as the proof that it doesn't work.
In reality, they are confabulating and misconstruing the facts.
FRS scheduling does not address illicit fentanyl. Tt was
never designed to do so. Rather, it removes the incentives for
transnational criminal organizations to create new fentanyl-
related substances, thus stopping them from ever existing in
the first place.
It is truly the ultimate form of overdose prevention and
harm reduction. At its core, it is not a law enforcement tool
designed to put criminals in jail. In fact, in the years since
FRS class scheduling has been in place, there have been a total
of eight Federal prosecutions--I will repeat that: eight
Federal prosecutions--in the entire United States under the FRS
scheduling language, half of whom had already known ties to
drug cartels.
As well, there has never been a prosecution for a
nonbioactive fentanyl-related substance because there are no
nonbioactive fentanyl-related substances. All FRSs encountered
in research to date have been found to have potent opioid
activity.
Concerns raised about the potential negative impacts of FRS
scheduling on research are purely theoretical and have already
been addressed by discussions with stakeholders.
These proposed research accommodations that have been
signed off on are supported by the very agencies and
organizations representing academic scientific research in the
U.S., including the National Institutes of Drug Abuse, the
National Institutes of Health, the Department of Health and
Human Services, and the FDA.
These agreed-upon accommodations would significantly loosen
research restrictions into studying all Schedule I substances,
not just FRSs, and would open up wide, promising areas of
research into substance abuse.
Any dampening or restriction of research is purely
theoretical. Fentanyl and its derivatives have been extensively
researched since its discovery in 1960. And since then, not one
fentanyl-based reversal agent or medication-assisted treatment
agent has ever been found.
It has been said that FRS class scheduling would impede
research into life-saving opioid reversal agents, and that
Narcan isn't a strong enough antidote. Take it from me, someone
who sadly uses Narcan to resuscitate fentanyl poisonings far
too often, Narcan works almost miraculously if given in time.
Our kids are dying because they have ingested a lethal dose
of toxic opioids, not because Narcan isn't potent enough.
In conclusion, for 5 years now, FRS scheduling has been
Federal policy, albeit temporary. I can't be more pleased about
that and the big impact my small idea has had.
According to NFLIS, the National Forensic Laboratory
Information System, in a matter of a few short years, the
creation and distribution of new FRSs from China has ground to
a halt, as have the associated deaths.
In the devastating battle we are in against the scourge of
fentanyl, the elimination of related substances that had
previously escaped our scheduling and made their way to
devastate communities across the Nation is surely one bright
spot.
Fentanyls are so toxic and lethal that they can be
classified and actually have been used as chemical weapons. The
lethal dose is 2 milligrams, which is equivalent to 5 grains of
sand. This means that one teaspoon can kill 2,000 people.
That is the amount in this packet of sugar.
Thank you for--I think I ran out of time. Thank you for the
testimony.
[The prepared statement of Dr. Westlake follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you. And after--I will give you a couple
seconds since that was interrupted. But you are completed? All
right. Thank you. So the gentleman yields back.
That concludes testimony. This will begin the question-and-
answer portion of the hearing, and I will begin the questioning
and recognize myself for 5 minutes for such.
Thank you, Ms. Pickard, for being here. You know, if I
would have come into this meeting--so you have already learned
something today--from you, I would have thought the number one
killer was probably heart disease or something such as that,
but it is Alzheimer's. And I just didn't know that at all.
So that gives us--and I was talking with the Democrat
leader, and we said, well, that was a statistic we just didn't
know. So thanks for coming, and sharing testimony is important
when you come here and testify, put it on the record.
I am going to kind of focus on the fentanyl side of it,
but, Ms. Cain, thank you for coming. You are absolutely right,
it is not necessarily people that are addicted or have
addiction issues. There are people that may have prescription
Xanax or Adderall.
I have heard that for some reason they get one, they don't
have their prescription filled, somebody, a friend, has one,
and they use it, thinking they are using it medicinally and it
is laced with fentanyl.
And I tell everybody anywhere I go, if it doesn't come from
a prescription bottle from a pharmacy, don't take it. But you
just don't know that, and that is something that--you being
here is important, and you being here continues--your child
continues to live on that way, and we appreciate you being here
for that.
I just want to talk more with Dr. Westlake, though, on the
bill before us, and, you know, the administration's position
is, we should schedule illicit fentanyl, fentanyl-related
substances, but not make them subject to the mandatory
minimums. And they said because, as they appear, there may be
some medicinal purposes, they may be as harmless as water, as
we heard before, and that just doesn't ring true to me.
One, I don't think there is anything going to be more
harmless. Why would a cartel go to the effort to sell something
as harmless as water? So it doesn't ring true.
But if there is medicinal purposes, if it is trafficking
illegally, like I said before, you know, other diverted
narcotics that are prescription narcotics you can have that are
diverted, are of medical merit, but if they are being diverted
and trafficked illegally, they would still be subject to the
same punishment.
And so, what is your view of--I know you are kind of the
founder of this idea--so what is your view of the
administration's position? I mean, what effect would it have,
if they say, ``OK, we are going schedule them, we are not going
to make them subject to the mandatory minimums like other drugs
are''?
Dr. Westlake. Yes, great question. I think the whole--what
you really have to remember about FRS scheduling is that it is
not about locking people up. It is not a criminal justice bill.
What it is about doing is purely preventing. So it prevents the
existence and creation of these new fentanyl-related
substances----
Mr. Guthrie. Would you say it is not about locking people
up, but if the risk of getting locked up is not there, then it
changes people's behavior?
Dr. Westlake. Absolutely. I mean, the effect is a
preventative effect, but the law enforcement aspect is the key
component to keeping it in place. And the reason that--that it
is important to understand that the research behind structured
activity relationships.
So there is 60 years of research into fentanyl-related
substances and fentanyl, and so there is a wide dearth of
research--if you take a look at my written statement, it goes
into detail about that--a wide--a mountain of literature of
little tiny modifications that you can do to the fentanyl
molecule to make it bioactive.
And that is why the structural language that we used was
targeted specifically for those modifications only. It is not
this--you know, the opposition would say it is this broad-based
thing, and, you know, like you said, it could be water or
something.
And of the 27 substances studied of the 36 that were found
by DEA, all of them have been highly, highly active, bioactive
opioids. One of them is 7,000 more potent than morphine, almost
as potent as carfentanil is.
Mr. Guthrie. So if we were to schedule fentanyl without
subject to mandatory minimums--I am not saying--that is another
debate whether we have a debate on, overall, the program. But
if we were to schedule fentanyl and not subject it to the same
penalties of other similar situation, then it would be a
negative?
Dr. Westlake. Yes. Because then it would take--what it
would do, because right now, the cartels are producing illicit
fentanyl because there is no reason to move to fentanyl-related
substances because they are scheduled, you know, as a class. If
that was removed, then there would be a lot of incentive to go
back to making----
Mr. Guthrie. Which can be more potent or probably more
likely to be more potent and less harmless?
Dr. Westlake. Exactly.
Mr. Guthrie. So, Dr. Loyd, in your practice, what do you
see as the number one thing that Congress needs to be doing? We
are going to look at--I know it is not before--better look at
the SUPPORT Act as we move forward.
I only have about a half a minute left, but what do you
think--because we need to do the enforcement side, but we also
need to the recovery side.
Dr. Loyd. Thank you, Chairman. The recovery side is
extremely important. The number one thing is something we all
have control over, and that is stigma, how we look at people
with substance use disorder and allow them to step out and ask
for treatment.
But when that happens, the treatment has to be there, and
it has to be evidence based, meeting people where they are.
I heard the definition of ``harm reduction'' in the last
panel, and I would argue that harm reduction is keeping people
alive. I haven't figured out how to treat dead people, and so
we got to keep them alive and then set up a system of recovery
that allows them to succeed like the one I stepped into.
Mr. Guthrie. Thank you. Well, my time is expired, so I will
yield back the time and recognize the ranking Democrat leader
of the subcommittee, Ms. Eshoo from California.
Ms. Eshoo. Thank you, Mr. Chairman, and thank you to each
one of the witnesses. Thank you for your patience in waiting to
reach the witness table. To the two mothers at the witness
table, thank you. I can't--I don't think that there can be a
greater sorrow than burying one's own child.
And, you know, our work here is--what you come and share
with us is a source of inspiration to us, because this is
really what all of the work is about. So thank you to each one
of you.
I want to say something about fentanyl. I know that it is
going to be ongoing because we have legislation that is being
proposed. You know what, I am struck by--and I am for the
legislation, I think it should be scheduled, but I think that
we are, in a way, deluding ourselves, because when I look at
what has taken place over the last 5 years with fentanyl being
scheduled, Schedule I, deaths have not been reduced in the
country. They have gone up.
I don't think it is a result of their being Schedule I that
it has gone up. I just don't think scheduling--I think
scheduling is a whole other issue when it comes to law
enforcement, what tools they have, et cetera, et cetera.
And I also think there is a 10-billion-pound gorilla in the
middle of the room, and that is that sadly, tragically, the
United States of America is the most extraordinary market for
drugs. We have an insatiable appetite for drugs in our country.
And then look at all the things that we are dealing with--
the grief, the sorrow, the wrecking of families, of human life,
dealing with addiction, and all the things that we need to do
to help people. So I just wanted to place those words on the
table.
On QALYs, for those that are tuned in and don't know, have
never heard this word before, it stands for quality adjusted
life years. And they may still not understand it, but that is
what it stands for. And these are measures to determine the
value of drugs or treatments.
I think that QALY measures are discriminatory, period. They
are discriminatory because they don't give equal weight to the
lives of people with chronic disease or disabilities, as they
do to the lives of healthy people.
And as my beautiful mother used to say, God never created
any junk. Each one is precious. Each one is precious.
Now, maybe some legislators know this, others may not. It
is why the Affordable Care Act banned their use in Medicare.
That is very important. So this has not been lost on at least
some of us.
I welcome the legislation, but there is something in this
that refers to the legislation we are considering, where it
refers to similar measures. I don't know what ``similar
measures'' are.
Now, Mr. Isasi, I think that is what you were referencing
in your testimony.
Mr. Isasi. Yes.
Ms. Eshoo. Is that term anywhere in the law today?
Mr. Isasi. So that term is in aspects of the law, but very
importantly, as you are pointing out, the legislation that is
proposed is about one thing: It is about price. It is about
similar measures being applied to price, and it applies----
Ms. Eshoo. Well, that is what QALYs are, aren't they?
Mr. Isasi. Right. So it is not just about----
Ms. Eshoo. I mean, the end result is discriminatory?
Mr. Isasi. That is right. But the problem here is, you
know, as we know, in--so this is all about one thing. The
pharmaceutical companies are trying to create a legal loophole
so that we cannot actually negotiate fair prices with them.
And in this case, they are trying to drive a huge hole
through the drug negotiation law by saying any measures to try
to measure value, any measures that are based on any
assessments, would be barred from being used to set a price. So
it is just a gaping hole.
We are 100 percent with the disability community that they
cannot be discriminatory. As I pointed out in my testimony, the
law already says those prices cannot be set using metrics that
are discriminatory against people with disabilities, against
the elderly, against people who are terminally ill.
So the law has the protections already in place. This is
about giving lawyers for the pharmaceutical companies a giant
loophole to fight against fair prices for American families.
Ms. Eshoo. Well, I think that all of us, including the
disabilities community, would rise up against what you just
described.
We are going to have to get this straight now, Mr.
Chairman, because I think that there is full support on the
issue of QALYs. We know it is discriminatory, but--and we need
to get that done, but we are going to have to address this
other language. Thank you, and I yield back.
Mr. Guthrie. Thank you. I thank the gentlelady for yielding
back. And the Chair now recognizes the chairman of the full
committee, Mrs. McMorris Rodgers, for 5 minutes to ask
questions.
Mrs. Rodgers. Thank you, Mr. Chairman, and I think I will
just start with a little follow-up to Mr. Isasi, because I saw
in your testimony that you say, quote, ``IRA already includes
explicit disability (and other) safeguards.'' So why shouldn't
we apply similar prohibitions and protections to all Federal
health payers? Why would that be a problem?
Mr. Isasi. So, in this case, the proposed negotiation goes
much, much further. It doesn't just ban discrimination, it bans
in setting a price. And it is really important to say that.
This is only about one thing in the legislation. It is
about the price that is being set in drug negotiation, and it
is saying clearly that any measure--and the language is so
broad and so vague that a lawyer for the pharmaceutical
industry will drive a truck through it and say you are trying
to assess value----
Mrs. Rodgers. OK. Thank you. We are going to work on this.
Mr. Isasi. You bet.
Mrs. Rodgers. And I do want to work with the ranking member
to figure out how we can get this language where we need it to
be, to make it clear.
Mr. Isasi. And we are one----
Mrs. Rodgers. OK. Thank you. I am sorry.
Mr. Isasi. Sure.
Mrs. Rodgers. OK. Ms. Cain, I understand you gave pretty
compelling testimony, and we have had the chance to sit down
before, and I greatly appreciate you making the trip to be
here. Carson should be here. Carson should be here today.
And, you know, we have been, especially on our side of the
aisle, the Republicans have been sounding the alarm on fentanyl
and the need for Congress to act. Just last week, we held a
roundtable that was more focused on fentanyl and what is going
on on social media platforms that are making it so available
and platforms that are not taking their responsibility to
moderate illegal activity on their platforms seriously enough.
I just wanted to ask, from your perspective, how can
lawmakers make the most impact, to spread awareness, and curb
the buying and selling of illicit fentanyl? What do you think
that we can do that would be most effective?
Ms. Cain. I think that we need to begin by educating--
educating. Education is a huge thing. I think that I can only
speak to Carson's case. The individual who sold him the pill
served no time for my son's death because of these social media
companies and Snapchat especially.
Once that chat is open, the evidence is gone. And because
they said that--I believe they said that they hold them for 90
days in their server. It was already gone by the time we got
the toxicology report.
In my opinion, which I am sure many will disagree with, I
do think that we need to hold these people accountable. We need
to have tougher laws. In this day and age, when we know that it
is a poison, they are being poisoned, and, again, not all of
these individuals are--many of them are taking it unknowingly.
And we shouldn't be holding them accountable. I think we need
to be, as Dr. Loyd said, we need to be looking at this through
a different lens.
Mrs. Rodgers. Yes. Thank you, thank you for speaking out,
thank you for being here. I will go back and listen to your
testimony. I am sorry I had to step out.
Ms. Cain. Thank you very much.
Mrs. Rodgers. Ms. Pickard, I appreciate you being here
also, and as you know, our son Cole was born with that extra
21st chromosome that people know as Down syndrome. And I
remember when he was born and just the doctors telling us, you
know, what to expect. And in so many of the cases, they got it
wrong. They got it wrong.
He is a freshman in high school now, a 15-year-old, has big
dreams. He wants to go to college. He wants to play football.
You know, he is going to be in a band, he plays the drums. He
is going to do it all.
And, you know, he just reminds me every day as to the
potential of every life. So, you know, I have heard some
statements today about the QALY bill, and I am not sure that it
is fair or conveys the full truth about QALYs.
For example, it has been asserted that banning QALYs is not
necessary in Medicaid, for example, because States are already
required to cover all drugs. However, we know that States have
limited drugs for muscular dystrophy to those who can walk
rather than those who can't, because it is not necessarily seen
as worth the cost of paying for it.
So my question is, what would you like to say about QALYs
in 6 seconds?
Ms. Pickard. Myself?
Mrs. Rodgers. Yes.
Ms. Pickard. Thank you, thank you. So it sounds like Cole
is just like every other 15-year-old young man. And I have to
say, in the healthcare system, I can tell you that children and
adults with Down syndrome regularly face deficiencies in care,
including access.
Doctors who specialize in care for patients in our
community are scarce. There are only 16 adult clinics that
specifically serve individuals with Down syndrome in the
country, leaving patients in States such as Kentucky or New
Jersey without access to specialized care.
And in the moment of greatest need, discriminatory policies
can even restrict individuals with Down syndrome from receiving
those life-saving organ transplants.
Banning QALYs is a step in the right direction, but so much
more needs to be done, and I look forward to working with the
committee to address these important issues. Thank you for
being here.
Mrs. Rodgers. I yield back.
Mr. Guthrie. The gentlelady yields back.
We are trying to--are we going to have time for one more,
we think? Are we going to have time for one more?
Mr. Cardenas. I am willing to risk it.
Mr. Guthrie. Mr. Cardenas of California is recognized for 5
minutes.
Mr. Cardenas. Thank you so much, Mr. Chairman, and thank
you for all your testimony and your important information that
you are sharing with us as policymakers for our country. Thank
you, Molly and Dr. Loyd. You inspired me to call my son.
I want to apologize to my staff who wrote my questions, but
I created my own after talking to my son.
I am one of the lucky ones. My son is in AA. He goes every
day. Thank God.
So I asked him, what should I say? What should we talk
about? What's the answers, et cetera? He doesn't have them all,
but he did give me some advice.
He says, you know, one of the things that I was taught when
I go to this group, there is a boulevard in my district called
Sepulveda. Two people end up in jail because they were buying
drugs on Sepulveda. One has a drug problem. He wakes up in
jail, ``Never going to do that again.'' Maybe he stops taking
drugs.
The person who has an addiction, they wake up in jail and
go, ``Where am I, what is going on, I am never going to buy
drugs on Sepulveda Boulevard.'' They are going to do it again.
So my first question to you, Dr. Loyd, is this: On a per-
person basis, based on your testimony, what you provided for
us, do you think that punitive incarceration answers is more or
less expensive, in all aspects, than prevention, intervention,
and support like you have been describing to us?
Dr. Loyd. Thank you, Congressman Cardenas, and I am glad
about your son. It is the best news. I am here to bring hope
today. My son is in this audience today, watching me sit before
my Congress and my country. It is because I got quality help.
I am talking about people with addiction. I am not talking
about cartels. I am talking about those suffering from the
disease of addiction. Incarceration won't help them. It won't
cure them, because they will do exactly what your son said they
will do, and I would have done it too, and I am a practicing
physician, and I was a practicing physician when I was
addicted.
Our money is much more better spent on prevention,
education, and treatment. Carson didn't know he was getting
fentanyl. He didn't know it. It shouldn't be a death sentence.
And so I think we have to understand as a body and as human
beings that the disease of addiction is not a moral failure. It
is a chronic, treatable disease of the brain, and it is driven
by cravings.
And when you have somebody sitting in there--me, today, I
would look at it and go, ``I am not going to do that again,
period.'' But in the throes of addiction, the response that
your son gave to his friend is exactly right, and it is exactly
what will happen. And the case I always made: If that worked,
nobody would go back to jail a second time.
Mr. Cardenas. Yes. Doctor, you are blessed and fortunate
you are still with us.
Dr. Loyd. Yes.
Mr. Cardenas. Molly, your son isn't. You are not one of the
lucky ones. If we make good policy here, we are going to create
more lucky ones, right, if we do it right.
But if we do it wrong, people are going to continue to die
in the United States of America in a way that no one should
ever leave us.
Is there any other advice you would like to give us, Molly?
Ms. Cain. As I said, we--I can't speak to--I know that
Carson's last year was a perfect storm. I can't speak to--I
know that he was prescribed Xanax, and I know that he wasn't
sleeping.
I have heard from people on social media criticizing the
parents and the people who have used, and that is so
detrimental to the healing. We need to be addressing this
problem.
It is not a problem that just affects--fentanyl is
indiscriminate. It affects all walks of life, every party.
I am not a lawmaker. I came to share my son's story. I am
asking of you to please make some sort of change so another
mother can look across the dinner table, can celebrate her
child's birthday with them.
The only thing I can think of is, we have to educate and we
have to educate young. I think about the Mothers Against Drunk
Driving and how that started. And maybe this is something that
we need to do.
Mr. Cardenas. Thank you so much. My time having expired, I
yield back.
Ms. Cain. Thank you.
Mr. Bucshon [presiding]. The gentleman yields back.
I recognize the gentleman for Texas, Dr. Burgess, for his 5
minutes.
Mr. Burgess. Thank you, Mr. Chairman, and I want to thank
our witnesses for being here today.
Ms. Cain, I will just tell you, we have worked on this
problem of opiate dependence and addiction up here for a long
time, but until our chairwoman, Mrs. McMorris Rodgers, did a
roundtable last week, I had no idea about the Snapchat focus.
And clearly that has--when I talked to the previous panel,
really concerned about fentanyl, because a lot of the work we
have done has been more geared toward, oh, a dentist who
prescribed too many Percodan after a wisdom tooth extraction
and someone took it inappropriately.
Fentanyl is a different disease. It is so much more deadly
than anything that could be contained in a diverted
prescription.
And then Snapchat has added yet another dimension to this
and, quite honestly, one that I had not appreciated, as I say,
until we had done the roundtable up here.
So, as painful as it is, I appreciate you coming and
sharing your story, because we have to focus on these delivery
modules that weren't even in existence when I started on this
committee many, many years ago.
I am up against a vote. I just want to ask, Ms. Pickard,
briefly--thank you for your work that you have done for
National Down Syndrome. We heard from our ranking member, Mr.
Pallone, and I think we have seen in written testimony that
this QALY legislation is a solution in search of a problem.
Would you agree with that characterization?
Ms. Pickard. I believe--thank you for the question. I
believe that more research is needed. I think there is more
research needed to really further develop and test those
alternative methods and frameworks for determining the value of
healthcare treatments.
And we must ensure that individuals with disabilities,
their voices, are included in this conversation.
Mr. Burgess. Well, I wanted to ask unanimous consent to
include two articles in the record. One is by three authors,
one of whom is well known to this committee, Ezekiel Emanuel,
and this is from The Lancet, ``Principles for allocation of
scarce medical interventions.''
And as frightened as I am about QALYs, he also talked about
disability adjusted life years, and clearly that is a focus
that I think will be exceedingly pernicious, and I do want us
to focus on that.
And then the other is from early in the pandemic from an
article that was published in ProPublica that was from the
Arizona Daily Star, dealing with the problem of scarce or
limited resources when we thought we needed more ventilators
than we turned out to need, and who gets to go on the
ventilator and those questions that came up.
ProPublica--I can't believe I am saying this--ProPublica
actually did a very fair report on this, and, Mr. Chairman, I
would just like to add these two articles for the record.
Mr. Bucshon. Without objection.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. And then I have got to go vote. Thank you very
much. I will yield back.
Mr. Bucshon. At this time, we are going to take a brief
recess, probably for about 15 minutes, so Members can vote, and
we will come back right after that. The subcommittee stands in
recess.
[Recess.]
Mr. Bucshon [presiding]. The subcommittee will come to
order. We will restart with questioning, and I recognize the
gentlewoman from Washington, Dr. Schrier, for her questions, 5
minutes.
Ms. Schrier. I should change this. I could take a new
title.
Thank you, Mr. Chairman, and I especially want to thank
you, Ms. Cain, for coming out from Washington State today to
share your son Carson's tragic story, and from one mom to
another mom, I can only imagine your heartbreak. And I think
about this frequently, as I have a 14-year-old boy. And your
account makes so clear why we need to crack down on social
media companies, the avenue by which so many teens get access
to these deadly drugs, poisons.
I am in the process of working on legislation to bring some
of these issues to light and to make sure families have the
tools to keep their children safe. And thank you for sharing
your story, because it helps parents and the rest of this
country and world understand how to keep others safe.
Fentanyl has had profound, devastating impacts in my State
of Washington. And parents want to engage with their children.
Sometimes they don't know how. Just this morning, I met with
the Enumclaw Youth Empowered coalition from my district, and
their focus is on reaching families early to prevent drug use,
experimentation, anything that gets their kids even close.
Given the importance of educating kids and schools and
prescribers and patients, I was wondering, Dr. Loyd, if you
could highlight some of the ways that parents can find guidance
on having these conversations.
Dr. Loyd. Thank you for the question, and it is very
difficult. You know, today is a different world than I grew up
in with social media and what Molly shared with us. But it is
also the world of ``take one pill and you die.'' And that is
the message that is very, very hard.
So when I talk with parents, it is always about being open
and not thinking that you know everything. I see parents make
mistakes all the time--``Oh, I know what is going on inside my
house and I know''--and the truth is, Congresswoman, we don't
have near as much control as we think we do.
And so these opportunities to talk with our children and be
open and honest, most of us have some kind of experience with
things in our past that maybe we could have handled better, and
we are not perfect, and our kids need to see that.
And so my son, I told you, is in this room, and so he was 9
when I got into recovery, and I started sharing my stuff with
both him and my daughter at that time. So I think, for parents,
it is important to realize that it is not the world that we
grew up in, and now, not that anything is OK, but it is a one-
time thing and you can literally die this afternoon.
And that is the part, if you don't know where it came from,
you know, please don't take it, because it will look just like
what comes out of somewhere.
And the other thing I see, Congresswoman, is this. Just
because it comes out of a bottle that a doctor wrote a
prescription for, it is not OK. And I think a lot of times that
kids will look at that, and, well, ``A doctor wrote this, this
is OK''--I have seen it with numerous teenagers--and it is
absolutely not. Those are the places I would start.
Ms. Schrier. I think those are great points, and I will
tell you, even as a pediatrician, it is challenging to have
these conversations, but just last night I had the conversation
again with my 14-year-old because he can't--I am just speaking
to parents out there--you can't have this conversation enough,
and reminding teenagers, who are, by their very nature,
impulsive and experimental and trust their friends sometimes
more than their parents, that anything anybody hands you--
whether they tell you it is an ibuprofen or somebody is trying
to hand you an Adderall, telling you it can help you focus
better--that that could be the pill that ends your life. And so
thank you for bringing this to the forefront, and I will yield
back my time.
Mr. Bucshon. The gentlelady yields back. I now yield 5
minutes to the gentleman from Florida, Dr. Dunn.
Mr. Dunn. Thank you very much, Mr. Chair. So we have an
important opportunity today to advance legislation that will
protect all Americans, including the most vulnerable, the ones
that Dr. Schrier mentioned, the children who are susceptible to
accidental fentanyl exposure and experimentation with street
drugs. So I am proud to support the bills before us today.
Importantly, the HALT Fentanyl Act will permanently place
all fentanyl-related substances into Schedule I. This bill
addresses a failure of the administration and represents an
important step towards getting these deadly fentanyl analogs
off our streets.
However, I believe that to wholly address the fentanyl
crisis, we need to do some other things. We need to designate
the entire class weapons of mass destruction.
That is not a frivolous proposal. It empowers the DHS to
help us with this effort. It also makes international policing
substantially easier.
We also have to better educate our youth again and again
about the dangers of drug use. There is no street drug that is
safe. There is no pusher who can be trusted. Everything could
be laced with fentanyl.
We also have to work to address recidivism in our
communities and, frankly, fix the broken families. An example
of that, one of the counties in my district that was hardest
hit by fentanyl poisonings has 40,000 citizens. Of those
40,000, 22,000 of them have spent time in the county jail. If
we can address some of these root challenges that these
communities face, we can decrease the demand for all street
drugs.
Another important bill we are going to discuss today is the
use of QALYs, quality adjusted life years, by government
insurance programs.
I am a doctor. I think the entire concept of QALYs is
contrary to the American values that set our free society apart
from socialist healthcare systems that restrict care and choose
for you and your family what life is worth.
It is disappointing to me that we have to legislate to
prevent such tactics from driving our Federal healthcare
policy. Our Nation supports some of the greatest biomedical
research in the world. Regardless of one's ability or
disability, all Americans should have the right to choose their
care.
Ms. Pickard, can you give us some examples of how QALYs are
used internationally--where they are used, how they limit
access to care--and how are they used in the United States?
Ms. Pickard. Thank you, Congressman. Many countries,
including our friends in the U.K. and Canada, heavily rely on
QALYs. They help determine who is worth treating and who is too
expensive, thus determining which medicines or treatments are
available to patients.
For example, from 2016 to 2019, the U.K. used QALYs to
restrict access to the first-ever approved treatment for cystic
fibrosis. Unfortunately, it is important to note that these
metrics are not here, you know, used here in the United States
as well.
As you asked about examples about the U.S., most recently
CMS relied on a report from ICER, the Institute for Clinical
and Economic Review, that used QALYs and similar one-size-fits-
all metrics in its national coverage determination for Aduhelm,
the first treatment approved for Alzheimer's disease.
The initial coverage determination excluded individuals
with disabilities. This was particularly concerning, as
individuals with Down syndrome have that heightened lifetime
risk, higher than 90 percent, of developing Alzheimer's
disease.
Access to treatments for this debilitating disease is
paramount to our community, and we will continue to work with
Members of Congress and this committee to ensure individuals
with disabilities are not left out of this conversation.
Mr. Dunn. You know, I think my professors from med school
would be rolling over in their graves if they heard us having
this conversation. It defies belief.
Dr. Westlake, as a fellow physician, I agree with you
regarding the importance of permanently scheduling the
fentanyl-related substances into Schedule I. We all know this
is a crisis. What the heck is the challenge here? We have been
working on this for years. What is the head wind?
Dr. Westlake. Yes, you and my wife have both the same
question. I first testified at a hearing for House Judiciary 5
years ago on this topic and brought this up. I don't know. I
don't know if it is politics, if, you know, there is advantage
in trying to, you know, access criminal justice reform.
I think there is confusion between what this bill, you
know, what the fentanyl-related scheduling does. You know, it
is not going to stop all fentanyl deaths. It is going to stop
fentanyl-related substance creation and fentanyl-related
substance deaths, which it has.
So I really don't--it is very simple to me, but I think it
gets cloudy when you involve what happens in Washington.
Mr. Dunn. I don't know, honestly, for the life of me, I
have never come to one of these hearings and heard somebody
say, ``Fentanyl is pretty good stuff. We ought to have more of
it or push it out on the streets.'' Nobody says that. In China,
it is Schedule I.
Dr. Westlake. Yes. The last thing we need is another
fentanyl.
Mr. Dunn. This is crazy. Well, thank you. My time is
elapsed, and I will yield back to the chairman.
Mr. Bucshon. The gentleman yields back.
I now yield to the gentlelady from Tennessee, Mrs.
Harshbarger.
Mrs. Harshbarger. Well, thank you, Mr. Chairman, and thank
the witnesses. And, Ms. Cain, I am sorry about the loss of your
son. I guarantee that there is not one person in this room who
has not been touched by either the loss of a family member or
friend to some type of drug overdose.
You know, I have been a pharmacist 36 years, so I have
dealt with a lot of this. And, Mr. Loyd, I have dealt with a
lot of impaired physicians, a lot of impaired pharmacists, you
know, employed some to give them a chance to get their hours so
they can practice again. So it is not anything that is new to
me.
And I am telling you, I visited a lot of rehab clinics in
the district, and I read that you have--you know, you are doing
the incarcerated gentlemen at Cocke County in my district. And
Judge Slone, I have met with Judge Slone, I have talked with
him, and he walks the walk because, if I am not mistaken, he
even adopted a child from a mom who was addicted to drugs.
So, you know, these are the kind of judges we need on the
bench in these drug courts, and I have talked to numerous drug
court judges and heard the stories. And he has offered to come
let me sit in with them as they go through that process, and I
said, ``Absolutely, I will come. I want to hear that.''
You know, when I visited some of those rehab clinics and
talked to some of the physicians, you know, they have a
multistep approach. It is not just giving them a drug to get
off of a drug, because that is a problem. They can take those
drugs--I have said this in the last session--they can heat
those foils up. They can inject them. They can abuse that drug.
But what they do, they have the counselors, they have the
group sessions, you know, and there's limiting factors. And one
of the pharmacists left Walgreen's to do a pharmacy there at
one of the rehab centers because he said these guys don't have
a place to go.
A limiting factor is having a bed, having a home, and to
get them back as contributing citizens to society, there's
things that you have to address.
So I guess with all that said, and as an ER physician, you
see this. They come to me, years ago, we would have to come up
with modalities as a compounding pharmacist. We would have to
help them with different drugs. They used to use clonidine to
get them off the drugs.
There's so many things they do. Used to do things for
patients with special needs or Down syndrome, you know, when
you couldn't get specific products. We still do that. My son is
a pharmacist now.
But I guess my question is, you know, sometimes insurance
won't cover them. I know Blue Cross Blue Shield dropped a lot
of the clinics, and they would not cover that, you know, the
drugs that they needed to rehab them.
I guess my question is, what do you believe are the most
important things Congress and/or the FDA or other Federal
agencies can do this year to help us conquer this addiction?
I am saying close the borders for one thing, hold those
people who are selling these narcotics accountable, make those
laws to where--if it were up to me, I would probably label the
cartel as a terrorist organization, but, you know, they
probably don't want me to talk about that. But go ahead,
anybody can answer that.
Dr. Loyd. Thank you, Representative Harshbarger. You are
actually the Representative from my boyhood home district. I am
from Jonesborough, Tennessee.
Mrs. Harshbarger. Jonesborough?
Dr. Loyd. Yes, ma'am.
Mrs. Harshbarger. For heaven's sake, who knew.
Dr. Loyd. So thank you, and I am very familiar with that
area, it is my home, the foothills of the Appalachians. So the
things that we can do as a society I have already talked about
it, is decrease stigma.
As a legislative body, the areas that move the needle the
most in our country, in my opinion, is the criminal justice
system and emergency departments, because these are the places
that our patients are showing up being overdosed.
And the system of care needs to be designed to, one, allow
them to stay alive. And you are exactly right, medication will
allow them to stay alive, but that is a pretty low bar.
If I stop one of my young pregnant women from, you know,
using a needle and putting drugs in her body, that is a good
thing. But if I am sending her back to the environment where
she is getting abused at night, that is a pretty low bar.
So we have to have a system set up that allows us to
reimburse for care, to help people with physical, sexual, and
emotional abuse, which a lot of times are the underlying
drivers of addiction.
And until we can do that and support things like safe
housing, I don't know how all of us would be here today if we
slept on the street last night. Probably not in very good
shape.
And so our system needs to be designed as a comprehensive
level of care to help people find what is right for them.
And a lot of times we judge people on medication, and we
have to stop doing that. Sometimes it is the only thing keeping
them alive.
And I really appreciate the plug for our drug court, and I
invite everybody to come. It is good for your soul.
Mrs. Harshbarger. Yes, it is.
And, Ms. Cain, I just had a dear friend, she went up to
wake her 17-year-old son up, and he was dead. It is the same
thing, it only takes one pill. And people need to be aware of
that. Two grains of sand is all it takes to kill you, and
fentanyl is showing up in everything, and I have talked to a
multitude of people about that.
So we have a problem, we need to fix it, and you can't fix
it if you don't understand it. So I appreciate you being here.
And with that, I yield back.
Mr. Bucshon. The gentlelady yields back.
I now recognize the gentlelady from Iowa, Dr. Miller-Meeks,
for 5 minutes.
Mrs. Miller-Meeks. Thank you very much, Mr. Chair, and
again, I thank our witnesses for their patience throughout this
and then throughout the brief recess as we voted.
I am a physician. I am the former director of the Iowa
Department of Public Health, as I had mentioned earlier, and
then also as a State senator. And it is a very timely topic.
As a State senator, I successfully passed--I can't speak,
but passed in one session no preauthorization for Medicaid-
assisted treatment through our programs, including Medicaid.
I was also able to get behavioral health treatment as a
side of service at schools, so for those individuals who either
don't have transportation or can't get to their providers, so
that we make sure there is a continuum of care.
And, Dr. Westlake, as you referenced in your testimony,
what can Congress do, and you mentioned the HALT Fentanyl Act.
I am an original cosponsor of that, and I agree that there is a
lot of misinformation about that.
And I am also interested, so we are kind of sisters, I am
Iowa, you are Wisconsin, and Wisconsin has a program, but in
Iowa we have the Billion Pledge Program which is another one of
Iowa's leading opioid prevention initiatives.
Specifically, this program aims to remove 1 billion opioid
bills from the medicine cabinets, using evidence-based
protocols, peer-to-peer education, nurse support, and also
preparation for surgery, because as we know, a lot of opioid
addiction has started through postoperative care and pain
management, pain relief.
As part of this, they have a tool kit that has an ice-heat
pack, a nurse responsive, or someone that they can call in
addition to their regular provider. It has a nutritional water
supplement, which gets to the NPO, or nothing by mouth, for,
you know, hours before surgery, which leads to increased pain
afterward. And then a regimen of alternating ibuprofen and
Tylenol.
So I think this program is a critical program that, you
know, looking at their results and statistics, probably should
be replicated. And I know that your experience is largely in
the emergency room setting, but you were very instrumental in
setting up Wisconsin's programs.
So I would like to ask if you have knowledge or information
about what can be done regarding post-op monitoring to reduce
the number of Americans that come away from a surgery with an
opioid addiction and whether you have experience with enhanced
recovery after surgery guided care.
Dr. Westlake. Yes. Thank you for the question.
I think that education is key. You know, I led the
prescription reform efforts in Wisconsin starting 8 or 9 years
ago, 10 years ago, and educating the physicians about
prescribing. But I think we also need to continue to educate
the public.
And, you know, one of the things is--there is a study out
of Michigan that, you know, 1 out of 16 kids that gets exposed
to Vicodin for wisdom tooth extraction becomes addicted to it.
And so it is stopping the initial exposure. And I think as
a society we have to understand that there are going to be
things that are painful. I tell people when they have a broken
wrist: It is going to hurt. You can take Tylenol, you can take
ibuprofen, you do ice. You know, take this tramadol or
hydrocodone only if you have to, at night, and realize that if
you take it there is a potential you could be addicted to it.
I think education is out there, though. I think we are
moving forward significantly on that respect. I think
prescription drugs are not nearly the problem they were 10
years ago.
Mrs. Miller-Meeks. Thank you for that.
We also have increased access to harm-reduction tools, and
we have mentioned that. And I remember going through these as
director of the Public Health Department. And as beneficial as
they are, I just want to also mention that, in my meetings with
both public health and with law enforcement, that we now also
have, you know, individuals who are abusing those very same
tools that we are using to save lives. So, when I am speaking
with individuals in recovery and in law enforcement, mentioning
the use of Narcan--overdosing on medication, knowing that there
is Narcan available. So I think it is an extremely important
tool, but we also have to be cautious and be mindful of that.
There have been significant efforts at the Federal and
State levels to increase access to naloxone, but I want to ask
you, Dr. Westlake, in the little time I have, what more can be
done to ensure individuals, families, EMS, first responders,
emergency departments have the tools they need to give
individuals who have overdosed another chance at recovery?
Dr. Westlake. Yes, I think that is key. I think, you know,
making it over the counter would be ideal. There is no reason
that you would need a prescription for it. There are no side
effects to it, other than it stops opioids from, you know,
affecting the nerve. And so there is really no downside to it.
I think that would be a huge step, and then it could just
be--you know, it could be widespread much more easily.
Mrs. Miller-Meeks. Thank you.
And, Dr. Loyd, my time has expired, but if you had
comments, please feel free to submit those in writing to us
afterwards.
Thank you. I yield back.
Mr. Bucshon. The gentlelady yields back.
I now recognize the gentleman from Florida, Mr. Bilirakis,
for 5 minutes.
Mr. Bilirakis. Thank you, Doctor. I appreciate it very
much.
Ms. Pickard, thank you for sharing your story with regard
to Mason. Your words provide insights into the joy he brings to
you and your family.
The topic of the quality-adjusted life year can get highly
technical. Can you share with us the real-world implications
for the use of QALYs in decisionmaking, particularly for people
living with rare or chronic conditions, such as veterans?
Ms. Pickard. Thank you for the question.
Mr. Bilirakis. My pleasure.
Ms. Pickard. Well, I cannot speak directly to the rare
patient disease community. I can imagine that they encounter
very similar problems as the disability does in regards to the
utilization of QALYs in all of our Federal healthcare programs,
specifically access to those necessary and at times lifesaving
treatments.
All lives have value, and no one should be discriminated
against based on arbitrary, one-size-fits-all metrics.
Mr. Bilirakis. I agree.
Ms. Cain, I am sorry and saddened to hear about Carson's
story, and I thank you for your bravery and your calls for
action and need for accountability at every level, from Big
Tech companies like Snapchat to the DEA itself.
We are losing this battle. And I agree with your testimony
calling this a weapon of mass destruction. It is completely
appalling that the drug dealer only served in jail for less
than 1 day. Unbelievable.
Can you explain how we can better hold these bad actors and
drug traffickers accountable and why both social media and the
Federal agencies like the DEA need to coordinate better,
please?
Ms. Cain. That is a big question, and I don't know if I am
qualified to answer that, to tell you the truth.
I am a teacher. I believe in education. I believe we need
to be educating, even as young as kindergarten--I am a
kindergarten teacher this year--``Don't touch a pill. Don't--
touch nothing. Take nothing. Ask your parents.''
We need to--as far as Snapchat, I think that they have been
given a free pass, and there is no accountability on their
part. And I think it is time we start holding them accountable.
I would encourage you to go visit the DEA and see the faces
of fentanyl, because it is eye-opening. There are 4,800
pictures hanging in there. There is a family that lost three of
their children. Three. There are children as young as 17
months. You walk around and you look at those faces, and it
hits home. It hits home.
I would encourage you to go do that. They have a thousand
more they haven't hung yet. They don't have the room to keep
hanging them, and they are still coming in.
Mr. Bilirakis. It is affecting all our communities. And,
you know, this committee has made it a priority----
Ms. Cain. I thank you.
Mr. Bilirakis [continuing]. To go after fentanyl.
Ms. Cain. Thank you so much.
Mr. Bilirakis. But, Dr. Westlake--thank you again. I know
it is very difficult, but thanks for your testimony, ma'am.
But, Dr. Westlake, you say in your testimony that fentanyl-
related substance scheduling is preventive, not punitive.
As we see other varieties of substances being laced and
mixed in with fentanyl and other drugs like xylazine becoming
more prevalent, can you explain how we can be more proactive--
we need to be ahead of the game--more proactive and preventive
to stay ahead of the latest drug-trafficking trends?
Dr. Westlake. Yes, I think the first thing that can be done
is to pass the HALT Fentanyl Act. I think that--I mean, just--
the way I look at it, drug use and opioid poisonings are like a
fire hydrant, and there are different nozzles on the fire
hydrant. And you have got illicit fentanyl, which is this big,
and you have got fentanyl-related substances, which is smaller.
But right now it is closed off and it is closed. And to not
permanently enact it is to let it reopen and to start that
spewing again.
It is a huge problem, you know, fentanyl and illicit
fentanyl deaths and poisonings. And Congress--you know, I think
there is always a push to have a legislative solution to do
everything, and I don't know that for a lot of things there is
a legislative solution. I think this is a cultural solution to
the drives for drugs.
But I think this is a legislative solution for FRSes, that
you can stop that, and it doesn't impact, you know, other
things. It is just going to stop the creation of these, and
that is all it does.
Mr. Bilirakis. Thank you very much.
I yield back, Mr. Chairman.
Mr. Bucshon. The gentleman yields back.
I now recognize the gentleman from Pennsylvania, Dr. Joyce,
for 5 minutes.
Mr. Joyce. Thank you for yielding, Mr. Chairman.
And thank you to our second panel for appearing here today,
because you give us that critical insight into the bills that
we are considering.
Dr. Westlake, thank you for turning around and coming back
in to talk to us again.
And during the previous panel, we heard of numerous
concerns regarding the permanent scheduling of fentanyl-related
substances.
First, on the issues of mandatory minimum requirements for
fentanyl-related substances, do you feel these requirements are
necessary to deter the trafficking, to deter the cartels, to
deter the business model, as they continue to bring these
deadly poisons into our communities?
Dr. Westlake. Yes, I think absolutely, without question.
I think that is what makes it prevention-based, is that it
stops the incentive for creating them. If you remove mandatory
minimums, just like you pointed out, you have something that
has less--you know, there is less penalty with it, so that is
where it is going to go, is they are going to start creating
those fentanyl-related substances.
Because if it is easy--there is a lot of literature on
researching fentanyl-related substances and how to make them,
and it is as easy as using just a different reagent. So, if you
want to make methyl fentanyl, all you do is you use methyl
instead of an ethyl group. And so it is literally just one
tweak in a cookbook that is well-delineated in the literature.
That is why the language for the structure is so surgically
targeted, is because it just gets rid of those known pathways.
Mr. Joyce. Dr. Westlake, do you feel that the cartels have
those abilities to make those minor changes to the recipe, to
cook the fentanyl-related products in just a different manner
to allow them to come through and escape those sentencings?
Dr. Westlake. Absolutely. If they can make fentanyl, they
can make any fentanyl-related substance. All they have to do is
look at--there is a Federal sentencing reform testimony that I
put in my testimony that addresses that--Mike Van Linn of DEA,
Ph.D. It is absolutely easy to find in the literature.
Mr. Joyce. We have also heard substantial concerns raised
over a classwide ban and how that could potentially criminalize
harmless substances.
In this case, have there been any fentanyl-related
substances that have been found to be harmless?
Dr. Westlake. No, there have been zero. So there----
Mr. Joyce. Have there been any fentanyl-related products
that have been found to be not addictive?
Dr. Westlake. No, there have been zero.
Mr. Joyce. Have there been any fentanyl-related products
that do not bind to the opioid receptors in the brain?
Dr. Westlake. Zero. All of the substances studied by DEA,
all 27 of them that have been studied, have bioactivity. Again,
one of them is 7,000 times more potent than morphine.
Mr. Joyce. Dr. Westlake, do you feel that all of these
fentanyl-related products are poisons?
Dr. Westlake. Absolutely.
Mr. Joyce. I think that your ability to take your clinical
experience as an emergency room physician, to bring that to
Congress, to take your personal ability to recognize that, as
you put it, all of these fentanyl-related products are deadly
poisons--they are having that impact throughout our country,
making every State a border State, something you have heard us
frequently say but something that you as a physician recognize.
Would you relate personal experiences on what would make
the fentanyl-related products more easily classified, more
educated to those who potentially could see those?
Dr. Westlake. So, again, I think the One Pill Can Kill
idea, the education component of it, of just educating people
that there is no--I have seen marijuana that people smoke that
has fentanyl in it that they die from. I have seen all kinds--
you know, fake Xanax pills.
I mean, I think just the education is key to the component
of how dangerous the substances are.
Mr. Joyce. Given the dangerous nature that we
recognize,that just one pill can kill, if there could be only
one Schedule I drug to have mandatory minimum sentences
attached to it, what would that be?
Dr. Westlake. Absolutely, without a doubt, fentanyl and
fentanyl-related substances. I mean, it is literally--you know,
it is literally a chemical-weapons-grade poison.
You know, it is hard to die overdosing on cocaine. It can
happen, but it does. It is hard to die from heroin, actually,
compared to fentanyl. Fentanyl, I mean, literally 2,000--I
don't have my packet of sugar--2,000 deaths from 1 teaspoon? I
mean, that is insane.
Mr. Joyce. Thank you for your concise presentation.
I thank all of the members of the panel for being here
today.
And I yield the remainder of my time.
Mr. Bucshon. The gentleman yields.
I will now yield 5 minutes to myself for questions.
Dr. Loyd, Cedar Recovery specializes in outpatient care. I
think it is important that we get people care in the least
restrictive setting and that we get them the care early that
they need. This is for substance abuse, of course.
However, we need access to all levels of care, including
residential care and inpatient care, in my opinion. Do you
agree that we should have all settings available to patients?
Dr. Loyd. Thank you for the question, Vice Chairman
Bucshon.
And, yes, I do. I agreed with what you said earlier, and I
am glad we are getting to talk right now, because I do agree
with that. We need to help people find the level of treatment
that is right for them, not the level of treatment that is
right for the person who is providing the treatment. And I see
that all the time.
And there is a difference between access to care and access
to quality care. The patients that we focus on in the
outpatient setting are Medicaid and Medicare as well as State
opioid response patients who don't have resources otherwise.
So all levels of care need to be accessible, but we also
need to look at what may hinder somebody from getting the
necessary level of care. And the example I will give you is the
single mom with two children. The level of care that she may
need is inpatient care. And that is fine and dandy until they
tell her she can't bring her kids with her, and she is the sole
provider for her family.
And so we have to be willing to be flexible and give
patients the level of care that will keep them alive, first,
and then help them find the path to recovery that is right for
them.
Mr. Bucshon. So you must think--there are some Federal
barriers probably, particularly in the Medicare program, like
the IMD exclusion, that maybe we should change or revisit?
Dr. Loyd. Vice Chair, there are a lot of hindrances to
people trying to get care for substance use disorder, and that
would be one I would like to look at.
Mr. Bucshon. Yes, I mean, I think we have talked about that
quite a bit. And I think, personally, we need to just revisit
some of the things we are doing and make sure we are not
limiting access to care in all settings.
Dr. Loyd. Yes, sir.
Mr. Bucshon. Well, Dr. Westlake, I want to ask you again
about naloxone. And you say you are in favor of it going over
the counter.
Dr. Westlake. I am.
Mr. Bucshon. Before we do that--and I am not saying I am
against it. But I was a practicing physician before, a
cardiovascular and thoracic surgeon. So I had a lot of patients
in the ICU that, you know, as you know, sometimes patients
aren't waking up. And you are saying, ``Well, maybe they are
narcotized, so let's try some Narcan and see if it works.'' And
it does frequently.
You know, chronic ICU patients sometimes are given pain
medication even when they are not awake, just with the
assumption that, you know, they are in pain. And that happens.
But then, of course, you know naloxone in that setting and
in other settings is not without some risk. I mean, there are
cardiovascular--potential hypertension, tachycardia,
cardiovascular ramifications. And sometimes people do awake
suddenly and can be combative and have other issues.
So, once we go to over the counter, what type of public
education do you think we should put in place maybe a little
bit before we take that step? Or do you think we--what do you
think we should do?
Dr. Westlake. I see it as--I mean, I think the people that
are going to be using it are not going to be the ones that are
at cardiovascular risk. I think you saw pretty skewed patients
in the ICU that present to the ICU with advanced
cardiovascular----
Mr. Bucshon. I did. That is correct.
Dr. Westlake. So what I am seeing in the E.D. is younger
people, you know, mostly under the age of 40, and if they had
access to it. Someone may have had it at home. Because when it
is given, it works.
And so----
Mr. Bucshon. Absolutely.
Dr. Westlake [continuing]. Definitely education is needed
with it. But I think--and it is the same thing, I think, with
buprenorphine.
Buprenorphine is--I know that there is talk about it being
abused, and I would much rather see buprenorphine abused than
fentanyl or OxyContin or oxycodone. And the people that are
abusing it with substance use disorder are going to be abusing
something, and so that is--it kind of falls into the same
thing, almost like a harm-reduction thing.
Mr. Bucshon. I understand.
Is there any evidence out there that the availability of
naloxone facilitates ongoing illicit narcotics use?
For example, I mean, I have had in some counties, rural
counties, where they have gone to the same house three, four,
five times. And the law enforcement, at least, tell me some of
the suspicion is that the people know that this is available
and, you know, the cavalry is going to show up.
I don't personally believe that, but do you think there is
any evidence of that, that the availability of naloxone could
facilitate further use, or no?
Dr. Westlake. No, I don't think there is.
But do you want to----
Mr. Bucshon. Whoever wants to comment on that.
Dr. Loyd. Thank you, Dr. Westlake.
I don't think there is any evidence to that either. But I
would tell you this: that if it is my son, I hope the cavalry
continues to show up.
Mr. Bucshon. And they do. But they run out. That is the
problem, right? I have counties that are literally--the county
sheriffs, they run out every month before the end of the month.
And then the cavalry may not come.
So, with that, I yield back--oh, Mr. Johnson is here. I
yield back. And I will now recognize the gentleman from Ohio,
Mr. Johnson, for 5 minutes.
Mr. Johnson. Thank you, Mr. Chairman.
I appreciate the panel coming in.
I do have another fentanyl question. Then I will move on.
So let me go quickly to Dr. Westlake.
Higher-dose pills from improperly mixed batches, known as
hotspots, that lead to overdose and death in a given area are
often the way the medical community and law enforcement learn
that fentanyl or an analog has been introduced into a local
drug market, which in turn would beget reactive scheduling in
States.
Dr. Westlake, this helped you--if I understood it right,
this helped lead you to work to target bioactive fentanyls as a
class, in order to remove the incentive that international drug
traffickers had in modifying the drug molecule.
Can you discuss how fentanyl class scheduling is critical
not only for law enforcement but for patient and community
health as well?
Dr. Westlake. Yes. It is critical to leave that spigot
closed so that--you know, again, right now, there are no more
new fentanyl-related substances that are being created, so no
one is dying from new fentanyl-related substances. They are
dying, you know, a lot from illicit fentanyl but not from
fentanyl-related substances.
You know, what Congress can do is to pass a law that will
stop the manufacture and creation of this and remove the
incentive for it. If you take away the mandatory minimums, the
incentive is going to creep back in, and I fear that that would
come back into play.
Mr. Johnson. OK. So, should this scheduling ban expire, is
it realistic to expect that we would see an increase, perhaps
even a sharp increase, in overdose deaths?
Dr. Westlake. So that is a good question. So there is
really not--the fentanyl-related substances are not being
created or researched in America at all. It is all from Chinese
chemical labs and, you know, potentially from Indian chemical
companies if they were to choose to do that. And so the key
thing is to make sure that the Chinese stop, you know, creating
these fentanyl-related substances.
So, yes, I mean, it is critical to get this passed.
Mr. Johnson. OK. All right.
And then I want to pivot to address another piece of
legislation that we are considering today, this, quote,
``quality-adjusted life years.''
This concept is exactly what it sounds like. It is a
calculation, not made by you or your loved ones, that decides
how much, quote, ``quality'' remain in the remaining years of
your life that you might have if you are diagnosed with an
illness or a disability, and that then determines how much cost
and coverage is going to be applied to that.
I mean, another term for that is called rationing
healthcare. That is not what we do in the United States. In
some countries with nationalized healthcare, like the United
Kingdom, the government gets a say in this, when it is time to
consider healthcare treatment options.
And some on the--not everybody, but some on the Democratic
side want to emulate health systems like those in the United
Kingdom. Well, I say, no, thanks, we don't want that here. This
is a dystopian future that neither the people I represent nor I
want any part of.
So, Ms. Pickard, thank you for being here and for your
advocacy on this issue, because the public needs to learn more
about this.
The legislation we are considering today prohibiting using
quality-adjusted life years calculations in Federal programs, I
fully support it. But, in addition, you mentioned other metrics
and value assessments that also contribute to this type of
discrimination or, as I refer to it, rationing.
Can you outline, Ms. Pickard, any other metrics or
assessments here in the United States or overseas that as
policymakers we need to watch out for and work to mitigate the
damage that they may cause?
Ms. Pickard. Thank you for that question.
Yes. I mentioned a little bit earlier that our friends in
the U.K. and in Canada do heavily rely on these QALYs to
determine who is worth treating and who is too expensive to
treat.
I think that, when we look at this, we really want to look
at what is the best for people--in my case, the people with
disabilities--and how do we make sure that we look at
alternatives.
And I think that there has been a number of alternatives
and supplements proposed to replace or improve the QALY, but
there is still more research that needs to be done to determine
what is the best route.
Mr. Johnson. OK. All right.
Mr. Chairman, I see that my time has expired. I yield back.
Mr. Bucshon. The gentleman yields back.
I want to make a personal privilege here, that my wife is
an anesthesiologist, and I have been using the term ``illicit
fentanyl.'' Let me tell you why. Because every day in her job
she uses fentanyl. And she is having patients--this message is
getting out, which is good, that this is a problem in our
country, but it is actually a very useful anesthetic agent that
we use every day legally. So I have been using the term
``illicit fentanyl'' rather than just saying ``fentanyl,'' just
FYI.
At this point, I ask unanimous consent to include in the
record the following items on this list. It is my understanding
these documents have been shared with the minority and approved
by the minority.
Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Bucshon. Seeing there are no further Members wishing to
ask questions, I would like to thank all of our witnesses--it
has been a long day--again for testifying here. Very strong
testimony from all of you. Very much appreciate it.
And, at this point, the committee stands adjourned.
[Whereupon, at 3:01 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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