[Senate Hearing 118-252]
[From the U.S. Government Publishing Office]
S. Hrg. 118-252
FENTANYL IN NATIVE COMMUNITIES: NATIVE
PERSPECTIVES ON ADDRESSING THE
GROWING CRISIS
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HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 8, 2023
__________
Printed for the use of the Committee on Indian Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
__________
U.S. GOVERNMENT PUBLISHING OFFICE
55-193 PDF WASHINGTON : 2024
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COMMITTEE ON INDIAN AFFAIRS
BRIAN SCHATZ, Hawaii, Chairman
LISA MURKOWSKI, Alaska, Vice Chairman
MARIA CANTWELL, Washington JOHN HOEVEN, North Dakota
JON TESTER, Montana STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada MARKWAYNE MULLIN, Oklahoma
TINA SMITH, Minnesota MIKE ROUNDS, South Dakota
BEN RAY LUJAN, New Mexico
Jennifer Romero, Majority Staff Director and Chief Counsel
Amber Ebarb, Minority Staff Director
C O N T E N T S
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Page
Hearing held on November 8, 2023................................. 1
Statement of Senator Cantwell.................................... 3
Statement of Senator Cortez Masto................................ 50
Statement of Senator Daines...................................... 47
Statement of Senator Hoeven...................................... 5
Statement of Senator Lujan....................................... 6
Statement of Senator Murkowski................................... 2
Statement of Senator Schatz...................................... 1
Statement of Senator Smith....................................... 52
Statement of Senator Tester...................................... 6
Witnesses
Azure, Hon. Jamie S., Chairman, Turtle Mountain Band of Chippewa
Indians........................................................ 10
Prepared statement........................................... 12
Gettis, Eric M., Senior Vice President of Behavioral Health,
Southeast Alaska Regional Health Consortium; accompanied by
Corey P. Cox, M.D., Clinical Director for Addiction Services... 22
Prepared statement........................................... 24
Hillaire, Hon. Tony, Chairman, Lummi Nation...................... 7
Prepared statement........................................... 8
Kirk, Hon. Bryce, Councilman, Assiniboine and Sioux Tribes of the
Fort Peck Reservation.......................................... 14
Prepared statement........................................... 15
Seabury, A. Aukahi Austin, Ph.D., Executive Director/Licensed
Clinical Psychologist, I Ola Lahui, Inc........................ 19
Prepared statement........................................... 21
Soto, Claradina, Ph.D., Associate Professor, Department of
Population and Public Health Sciences, Keck School of Medicine,
University of Southern California.............................. 25
Prepared statement........................................... 27
Appendix
Lewis, Nickolaus D., Council, Northwest Portland Area Indian
Health Board, prepared statement............................... 64
National Indian Health Board, prepared statement................. 59
Response to written questions submitted by Hon. Ben Ray Lujan to:
Hon. Jamie S. Azure.......................................... 75
Hon. Tony Hillaire........................................... 76
Hon. Bryce Kirk.............................................. 74
Response to written questions submitted by Hon. Brian Schatz to
Hon. Jamie Azure............................................... 75
Response to written questions submitted by Hon. Tina Smith to:
Hon. Tony Hillaire........................................... 77
Claradina Soto, Ph.D......................................... 78
Seneca Nation, prepared statement................................ 66
United South and Eastern Tribes Sovereignty Protection Fund,
prepared statement............................................. 70
FENTANYL IN NATIVE COMMUNITIES: NATIVE PERSPECTIVES ON ADDRESSING THE
GROWING CRISIS
----------
WEDNESDAY, NOVEMBER 8, 2023
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:35 p.m. in room
628, Dirksen Senate Office Building, Hon. Brian Schatz,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. BRIAN SCHATZ,
U.S. SENATOR FROM HAWAII
The Chairman. Good afternoon. I call this oversight hearing
to order.
Today the Committee will hear directly from tribal leaders,
practitioners specializing in Native behavioral health and a
Native public health expert on opioid use disorder about the
devastating impacts of fentanyl in Native communities.
We will also learn about specific culturally based
practices, dedicated facilities and other promising tools
Native communities have developed and tailored to address their
own needs. This is a really important conversation.
Fentanyl, a potent synthetic opioid, is contributing to a
rapid rise in opioid related deaths across the Country. Native
communities are getting hit extra hard. From 2020 to 2021,
American Indians and Alaska Natives experienced an alarming 33
percent rise in drug overdose deaths, the second biggest of all
groups in the United States. Native Hawaiians and Pacific
Islanders saw the largest increase at 47 percent.
These overdose death rates are nothing short of staggering.
In the past year, several tribes issued emergency declarations
over the rate of fentanyl deaths among their members, and
accidental overdoses, where users are unaware their drug of
choice is mixed with fentanyl, also on the rise among American
Indians, Alaska Natives, and Native Hawaiians.
Last August, tribes from across the Country came together
to strategize on solutions and offer policy recommendations to
address the fentanyl crisis in their own communities at the
National Tribal Opioids Summit. White House officials, Federal
and State leaders, members of Congress, including Senator
Cantwell, also participated. I want to thank her for sounding
the alarm and asking for today's hearing.
This growing crisis is rooted in longstanding structural
inequities in Native communities. Lack of affordable housing,
limited access to high quality health care, and underfunded
public safety programs compound fentanyl's impact on Native
communities. Other unique factors, such as checkerboard tribal
lands, which create a jurisdictional maze for law enforcement,
and a lack of available public health data further complicate
our response.
It has been more than five years since we last held a
hearing on the opioid epidemic in Native communities. COVID-19
contributed to a significant increase in substance abuse and
overdoses nationwide. New threats from synthetic opioids,
including fentanyl, have shifted the response paradigm. The
time is now for the Committee to reengage.
Our work doesn't end by simply identifying the problems.
There is no one-size-fits-all solution. We have to listen to
Native leaders and organizations, health care providers and
support Native-led solutions to fight fentanyl in their home
lands and surrounding communities.
I look forward to hearing from all of our witnesses today
and thank them for joining us in this important discussion.
Vice Chair Murkowski, you are recognized for your opening
statement.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman. I do appreciate
the fact that we are having this very important hearing in
front of us today, and Senator Cantwell, thank you for making
sure that it was scheduled here as we hold this hearing.
Hopefully it is the first in a series of how we respond, how we
deal with what we have in front us.
You have cited the statistics. It is just really disturbing
to know that among American Indians and Alaska Native
populations we see the highest drug overdose rates in the
Country for both 2020 and 2021 in terms of population. We have
certainly seen it in Alaska, the significant increase in
overdose and deaths due to fentanyl, due to opioids.
Thanks to ANTHC's epidemiology center, we know that from
2018 to 2022 the annual number of opioid deaths among Alaska
Natives increased by 383 percent. During the COVID pandemic,
opioid overdose mortality rate among Alaska Native people
doubled.
There was a very, very troubling article in our statewide
Anchorage paper, the Anchorage Daily News, on the 6th of
November. Mr. Chairman, I would ask that a full copy of this
article be included as part of the record.
The Chairman. Without objection, so ordered.
Senator Murkowski. It speaks to the situation that we are
seeing in Alaska right now. This involved a drug ring operated
within a prison.
What the article states is during a 15-month period,
members in this ring sent 58.5 kilos of fentanyl, that is
nearly 130 pounds of fentanyl, to Alaskan communities. They
sent it to communities like Savoonga, population 826 people,
like Tyonek, population 415 people, like Good News Bay, New
Stuyahok, Togiak, Ketchikan, Dillingham, Sitka, islanded
communities where the population is so small and predominantly
Native populations.
Why are they doing this? Why are they doing this? Because
they know that they can get ten times more for this lethal
poison that is being sent. The comment that was provided here
was that a dose of fentanyl that might sell in Anchorage for
$15 could be worth $40 in Utqiagvik, $80 in Kodiak, or $100 in
Bethel.
So they are targeting these small, remote, rural,
vulnerable communities. It is the worst predation there can
possibly be.
Last year, the Alaska Federation of Natives approved a
resolution calling for support for increased resources to
combat the drug epidemic that we are seeing in our Alaska
Native communities. It speaks to the lack of resources for
education, for treatment, for preventive services and public
safety in Alaska Native communities. We are working on so many
different levels.
But I think it is so important today to understand from our
witnesses how they are specifically addressing fentanyl,
whether it is tribal law enforcement investigations and
seizures, more opioid treatment centers in rural communities,
how we deal with the stigma that we know is attached.
I have introduced a bill that we call Bruce's Law to
educate the public about the lethality of fentanyl,
particularly with our youth.
And then just last week we introduced the Tele-health
Response for E-Prescribing and Addiction Therapy Services, we
call it the TREATS Act. It seeks to continue access of tele-
health services when prescribing opioid treatment program
medications.
So there is a lot to talk about. I want to welcome our
Alaska witness, Mr. Eric Gettis. He is going to be joined by
Dr. Corey Cox during the question period of the hearing.
Mr. Gettis is the Senior VP for Behavioral Health at SEARHC
in Juneau, and Dr. Cox is a dual board certified family
medicine and addiction medicine physician, also with SEARHC. He
is currently working to expand access to quality addiction
treatment services in rural Southeast Alaska.
I am pleased that they are going to be with us today with
their input.
Again, thank you, Mr. Chairman.
The Chairman. Thank you, Vice Chair.
I will now recognize Senator Cantwell, who has been, as a
lot of members on this Committee, a leader on this particular
challenge. Senator Cantwell was instrumental in making sure
that this hearing happened.
Senator Cantwell?
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Senator Cantwell. Thank you, Chairman Schatz, you and Vice
Chair Murkowski, for holding this very, very important hearing
today to hear directly from Indian Country how they are
fighting this battle, and how they need a better Federal
partner.
I want to take a moment to introduce one of the witnesses,
the Chairman of the Lummi Nation, Anthony Hillaire. I want to
acknowledge the presence of multiple Lummi Nation leaders who
are with us, key staffers, and Council Member Maureen Kinley
and Jim Washington.
In addition, the Lummi National Policy Advisor, Merisa
Jones, Recovery Specialist Tabitha Jefferson, and the Lummi
Nation youth leaders who are here as a delegation. Thank you
all for traveling all this way to make this voice heard, and to
get people to understand the scourge of this crisis.
Your presence here today is a testament to the devastating
impact the fentanyl crisis has had on the Lummi Nation. When I
visited Lummi Nation in October of last year, fentanyl was
already taking its toll. But a year later, the Lummi community
lost five people to fentanyl overdoses within one week.
In 2022, the Centers for Disease Control and Prevention
reported that American Indians and Alaska Natives had the
highest drug overdose rate of any ethnic group for both 2020
and 2021. The rise of this illicit fentanyl is a problem.
We have hosted nine roundtables throughout the State of
Washington and have spoken at many of the organizational
meetings to talk about what are the solutions. In fact, the
National Tribal Opioid Summit was also held in the State. That
was partly organized by the Northwest Portland Indian Health
Board, it happened at Lummi Nation.
We have talked to tribal leaders in Spokane, Colville,
Yakama, Cowlitz, Jamestown, the Puyallups, the Tulalips, and
many people about how their particular communities are being
impacted. What we know is we must increase treatment and
recovery capacity. As one doctor told me, ``We should have
access to recovery be as easy as access to the drug, and at
this point, it is not.''
We need to better educate young people and get them
involved in prevention and recovery. That is why I am glad to
see the youth delegation that is here today, because they can
help us understand how we can better reach out to young people.
The next generation can lead the way in educating their
peers. In August, as I spoke to the National Tribal Opioid
Summit at Tulalip, a key theme raised by many of the officials
gathered at the session was how understanding where illicit
fentanyl is coming from, and how we respond to it is a top
priority. Data is needed and vital to our response in the
pandemic. Adequate resources, whether that is helping them
recognize the crisis or addressing it in responding, is
critical.
But a few examples. The Jamestown S'Klallam opened a
healing clinic which provides addiction and MAT treatment, and
averages 120 patients per day. The Native Project in Spokane is
working to build the youth and child services that will focus
on tribal children's services to stay away from opioids and
fentanyl. And the Lummi Nation opened a new stabilization and
recovery center for their community members, and is currently
working to construct and open a detox and health care center.
So I welcome Chair Hillaire today to share the breadth and
depth of your unique experience. I am so sorry that this is
what the Lummi Nation has had to deal with.
I know that you as a tribal leader and a community council
member in the past know what it is like to deal with these
issues and to prioritize them. Hopefully, we can work better
together as a Federal partner.
I thank you again, Madam Chair, for the opportunity for
this hearing to take place, and hopefully our Committee to come
up with ideas to better help Indian Country and our whole
United States deal with this crisis.
Thank you.
Senator Murkowski. [Presiding.] Thank you, Senator
Cantwell.
Are there other members wishing to make an opening
statement? Senator Hoeven?
STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
Senator Hoeven. Thank you, Ranking Member Murkowski. I want
to thank both you and Chairman Schatz as well as our witnesses
for being here this afternoon. I appreciate the Committee
holding this very important hearing on the impact of fentanyl
in our tribal communities. It is a huge problem for the entire
Country, in essence every State, and the tribe as well has
become a border State or border reservation because of the
fentanyl that is pouring in over the southern border, a lot of
it of course originating in China.
So this is a problem we have to address across the County.
We are seeing record numbers of overdose deaths, and of course,
it is a huge problem on the reservation as well.
And Senator Cantwell, as well, for everyone who said we
need to have a hearing on this problem, they are right. We do,
and we need to find ways to address it. We need to do that now.
Again, I want to welcome all of our witnesses today, and I
would particularly like to take a minute to welcome and
introduce Chairman Azure. Jamie Azure is Chairman of the Turtle
Mountain Band of Chippewa Indians. He attended the University
of Minnesota, and we don't hold that against him in North
Dakota, that is okay.
He earned Bachelor of Science degrees in both business
management and political science. He has served on the tribal
council since December 2016, and has been chairman since 2018.
He continues to build up his community, foster economic
development, and advocate on behalf of both tribal youth and
elders.
He also serves on the United Tribes Technical College board
of directors. He owns the J. Azure Construction Company, and
through his company is involved in community philanthropic
efforts such as dedicating a percentage of the company's
profits to supporting youth organizations. He resides in
Belcourt with his wife, Denise, and their two children.
Again, Chairman Azure, I want to thank you for being here
today, but even more than that for the important work you do as
chairman for your tribes and the good work that you do both
through your company as well as through your leadership as
tribal chairman. Thanks so much.
Thank you, Madam Chair pro tem.
Senator Murkowski. Pro tem. Thank you, Senator Hoeven.
Senator Tester, I know you want to introduce your witness
and maybe make an opening statement.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. I do. I first want to thank you and the
Chairman for hosting this hearing that I think we can all say
is really important. Thank you, Senator Cantwell, for your
leadership.
I want to welcome everybody who is here testifying, the
people who are here in person and the people who are here
virtually. I also want to have a special introduction for
Councilman Bryce Kirk, who is here in the Indian Affairs room I
think for the first time. He is from the Fort Peck Assiniboine
and Sioux Tribes, joining us from that metropolis of Poplar,
Montana, which is incredibly rural.
Chairman Kirk is serving a second term on the tribal
council. He sits on the Law and Justice Committee there, and
also the Tribal Education Committee.
Chairman Kirk knows first-hand the effects of fentanyl in
his community, and he does important work combatting this drug
on the reservation. Bryce, it is an honor to have you here
today to testify to us. When your time comes up, we look
forward to your testimony.
Senator Murkowski. Thank you, Senator Tester.
Senator Lujan, do you care to make any comments?
STATEMENT OF HON. BEN RAY LUJAN,
U.S. SENATOR FROM NEW MEXICO
Senator Lujan. Madam Chair, thank you so much for this
important hearing and the leadership of the Committee, and for
each of you traveling to share these stories, to share your
thoughts and your ideas of what needs to be done, where there
is negligence as well with lack of support or jurisdictions
where there are questions where criminals learn to take
advantage of them as well.
I certainly look forward to your testimony and thank you
all for being here. Thank you, Madam Chair.
Senator Murkowski. Thank you.
We will now turn to our witnesses. Senator Cantwell has
introduced our first witness, Chairman Hillaire, from the Lummi
Nation. He will be followed by Chairman Azure, who has been
introduced by Senator Hoeven, with the Turtle Mountain Band of
Chippewas.
Next, we will turn to Councilman Kirk, who has been
introduced by Senator Tester, from the Fort Peck Reservation. I
understand that Dr. Aukahi Austin Seabury will be virtual with
us. She is the Executive Director and Licensed Clinical
Psychologist at I Ola Lahui, Inc. in Honolulu.
We will also be joined virtually by Mr. Eric Gettis, who is
with Southeast Alaska Regional Health Consortium as introduced
previously. He will be accompanied by Dr. Corey Cox, Clinical
Director for Addiction Services, also there at SEARHC.
Our final witness will be Claradina Soto, Ph.D., Associate
Professor, Department of Population and Public Health Sciences
at the Keck School of Medicine at UCLA.
I want to remind our witnesses that your full written
testimony will be made part of the official record. So we would
ask that you try to keep your comments to no more than five
minutes so members have an opportunity to ask questions. But we
realize that these comments that you make are very important
and the information will gain today is exceptionally important.
So for those of you who have made the trip to be here,
thank you, and for those of you who are giving your time
online, thank you very much.
Chairman Hillaire, if you will proceed, please.
STATEMENT OF HON. TONY HILLAIRE, CHAIRMAN, LUMMI NATION
Mr. Hillaire. Ey'skweyel e ne schaleche si'iam, Tony
Hillaire tse ne sna, Tse Sum Ten tse ne sna, che' xlemi sen. My
dear friends and relatives, my name is Tony Hillaire, my name
is Tse Sum Ten. I come from Lummi. I serve as the Chairman of
the Lummi Indian Business Council.
Good afternoon, Vice Chair Murkowski and Chairman Schatz
and distinguished members of this Committee. Thank you for
having us here today. I am here with my team. Thank you,
Senator, for introducing them. We are traveling from afar, from
Lummi Nation, located in Washington State. We are here on
behalf of our great Lummi Nation, we are here on behalf of our
ancestors, our elders, our children, our fishermen, our
fisherwomen.
But most of all and most importantly, we are here on behalf
of the grieving grandmothers and mothers who are burying their
children to drug overdose. It is becoming way too normalized.
Just yesterday, we had a funeral for a 26-year-old Lummi woman
who passed away from a drug overdose, leaving behind two
children who will grow up now without a mother.
These are not just anyone to us, these are our family,
these are the people we grew up with, these are our future
chairmen and chairwomen, our future cultural leaders, language
speakers, the ones who will carry the torch into the next
generations.
We want to thank you and this Committee for holding this
hearing so we can discuss this important matter, so that we can
change the world for the better for these next generations. And
a special thank you to Senator Cantwell, our dear friend, for
your immediate response when we have five deaths within three
days at Lummi Nation, four of them being drug overdose. Senator
Cantwell helped respond immediately and gave us some
assistance.
In addition to calling this hearing as well as for
introducing the Parity for Tribal Law Enforcement Act, as well
as attending the National Fentanyl Summit hosted at Tulalip
Tribes, thank you for standing with us and for your ongoing
friendship.
I want to start real quick just acknowledging our
resilience as Lummi people. When we talk about these issues and
the drastic scenes of the fentanyl crisis at home, it goes
without saying how resilient we are as a people, and that we
are self-determining, that we want to take care of ourselves
and that we know how to do that.
The impacts of fentanyl and opioids at home have been very
drastic and very overwhelming. I just ask rhetorically to the
Committee, how many funerals have you been to in the last year?
How many have you ben to in the last month, in the last week?
For us, it is pretty much every day. That is not just for
fentanyl overdose, which is completely devastating, but also
all of the health disparities that we see at Lummi Nation that
we are up against.
We don't have time to meet, and I understand that it is
much needed, but right now our people need leadership, they
need hope. That is our responsibility, to ensure that we never
take away hope from our people.
So when we had those deaths, and when I was talking to
Senator Cantwell, we responded immediately. At Lummi Nation, we
declared a state of emergency. We implemented checkpoints to
limit the amount of drugs that were coming onto our
reservation. We got K-9 units, Senator Cantwell helped us get
FBI agents who helped us get drugs off of the street. That was
the first response, was immediate action is the best message to
the mothers who are grieving at Lummi Nation. So we did just
that.
As we continue to intervene, we are learning the need for
better outreach, better treatment services. The more drugs we
get off the street, the more we disrupt the market of drugs.
Our people who struggle with addiction are really needing that
fix.
So we opened up a stabilization center which is an
expansion of services for medication assisted treatment, and is
open 24-7. Since our drug interdiction efforts, the beds have
been completely full.
In addition to that, we have noticed children being in the
homes of where we found drugs and where we shut down drug
homes. That brings up the need for our Lummi Youth Academy,
which is a residential facility next to our Lummi Nation
School, that ensures that our children can be home, that they
can be closely tied to our people, our culture, and our way of
life as a way of ensuring prevention.
Finally, our need for a detox facility is an immediate need
right now. The severity of withdrawals to fentanyl is really
concerning. Right now, we have plans to build a detox facility,
but through the bureaucracy and through the lack of funding
resources, it has been really challenging. We have raised $15
million over the last few years, lobbying for this very issue.
We need $12 million more to finish the project.
There is so much more to this, more time is needed for
really, really grasping and getting into the weeds of what
needs to be done. But those are the three top priorities for
Lummi Nation.
[Phrase in Native tongue.] Thank you.
[The prepared statement of Mr. Hillaire follows:]
Prepared Statement of Hon. Tony Hillaire, Chairman, Lummi Nation
Good afternoon, Chairman Schatz, Vice-Chair Murkowski, and the
distinguished members of this Committee.
Ey'skweyel e ne schaleche si'iam, Tony Hillaire tse ne sna, Tse Sum
Ten tse ne sna, che' xlemi sen.
My name is Tony Hillaire, my name is Tse Sum Ten. I come from
Lummi. I serve as the Chairman of the Lummi Indian Business Council.
I am here today with my fellow council members, my team, our Lummi
Youth Council members, and Community Leaders. And we are here today on
behalf of the great Lummi Nation, our ancestors, our elders, our
children, our fishermen and fisherwomen. But most of all, we are here
today on behalf of our grieving mothers and grandmothers. Burying our
children is a mother's worst nightmare, and this nightmare is becoming
way too normal.
We want to thank you for holding this hearing so we can discuss
this very important matter. So that we can change the world for the
better, for our next generations. A special thank you to Senator
Cantwell, our dear friend, for her immediate support, for calling the
hearing, for introducing the Parity for Tribal Law Enforcement Act, and
for attending the National Fentanyl Summit.
The impacts of the opioid/fentanyl crisis that have hit our
community are devastating, heartbreaking, and personal.
As I give this testimony, I ask that you reflect on how many people
you know that have lost their lives to fentanyl. How many funerals have
you been to this year that were due to fentanyl-related overdoses? The
Lummi Nation has had a total of seven overdose-related deaths in 2023,
with five of those deaths occurring just from September to October.
In the Lummi Nation, we are not only battling fentanyl but have
also come across Carfentanil, a drug 100 times more lethal than
fentanyl and 10,000 times stronger than morphine. Just when we think we
have a grasp on how we are handling this drug epidemic and reducing
harm, a new, more robust version of fentanyl appears and comes back at
us with even deadlier effects. These fentanyl-related deaths have
impacted every area of our lives, as our community is left in constant
grief and sorrow as we are barely able to lay our loved one to rest
before we get word of the next.
In late August this year, we had the opportunity to escort Dr.
Delphin-Rittmon, Assistant Secretary of SAMHSA, to a homeless camp in
Bellingham Whatcom County, Washington. At the time, we had over 70
tribal members who were living in squalor with no sanitation
facilities. The conditions in which these tribal members are living are
like nothing I have seen before, and it truly is heartbreaking. Our
people are sick, and they are all crying and begging for help.
When our nation took action against the drug epidemic and began
shutting down drug homes, we learned that there are children who are
living within these homes. This is when we understood the need for a
safe place for our children living in an unsafe environment.
Previously, we had a facility that did just this that we called the
Lummi Youth Academy, and there are many success stories of children
attending.
The Lummi Youth Academy provided our children with access to
shelter, food, education, and mental health services. There is an
urgent need for funding to help support programs such as this, which is
crucial as it is a form of Youth Prevention that allows them the tools
needed to break the intergenerational traumas they've endured. Unless
we address the root causes of addiction, we will continue in this
cycle.
Another crucial step is Detoxification and treatment. When our
people want help, too often, we must turn them away because we do not
have beds or capacity. The Lummi Nation has accumulated almost $15
million to build a culturally attuned detox center, but we need another
$12 million.
Currently, our tribal members have a deep fear of getting off
fentanyl, as the withdrawal symptoms are unbearable. When a tribal
member seeks assistance in withdrawing, there is only a tiny window of
time, and we must get them into detox before they change their mind.
Sometimes, it can take a few days for a detox bed to open, and by the
time a bed opens, most of them do not return. The Lummi Nation has been
lobbying for the funds to build their own detox center and has the
support of 29 other tribes in the region.
Despite all we have been through, I do want to say that our people
are strong and resilient. We know how to take care of our people, and
our cultural-based recovery programs have shown that we do recover.
We have sought funds from HHS and IHS, and so far, we have been
unsuccessful despite all the evidence we have provided on loss of life
and suffering. We would like to highlight the importance of Congress
passing the opioid supplemental funding request as this includes a
$250M transfer to the Indian Health Service (IHS), representing an
almost 16 percent set aside of the overall amount to help tribes
specifically address the crisis. We hope some of these funds will be
accessible to support us finalize construction of the SWMS, which has
been endorsed by all Portland Area. The longer we struggle to get funds
or wait for resources, the more likely people are to overdose or die
due to overdose-related deaths.
Law enforcement is another critical area. We need more resources
from the BIA, DEA, and FBI. Due to the lack of prosecutions from the
DOJ and local authorities, we also need the ability to prosecute and
hold accountable non-Indian drug dealers who are killing our people
through this drug crisis. The lack of tribal jurisdiction over non-
Indian drug dealers coming onto our reservation undermines our efforts
to combat the drug crisis and protect our community. We urge Congress
to recognize special criminal jurisdiction over non-Indians who
committed drug offenses in our communities.
Lastly, to fully confront this crisis, we must address issues of
poverty, homelessness, and unresolved trauma that are not only
catalysts for addiction but also perpetuate its vicious cycle.
Conclusion
Our plea for assistance is urgent; the loss of even one individual
in our small community not only ends a lineage but also extinguishes
future generations. The pain and sense of loss affects us all. We know
what we need to help heal our people, but we have barriers that keep us
from doing so.
In September of 2023, the Lummi Nation Declared a State of
Emergency in response to the Drug Crisis. This allowed us to remove our
internal barriers and create policies that allowed us to respond in an
urgent manner. We ask that the federal government hear our cries and
declare this a National Emergency. Declaring a National Emergency would
allow us to tear down the barriers and bureaucracy that hinder our
ability to take care of our people. In these times of darkness and
sorrow, our people are looking for hope, and they are looking to
leadership for answers and action.
On behalf of the Lummi Nation, I thank the Committee for convening
this important hearing on the fentanyl crisis. Thank you for listening,
for really hearing us, and for standing with us as we face this
terrible crisis. At this time, I would be happy to answer any questions
that the Committee may have. Thank you.
Senator Murkowski. Thank you, Chairman Hillaire. We so
appreciate your testimony.
We will next turn to Chairman Azure.
STATEMENT OF HON. JAMIE S. AZURE, CHAIRMAN, TURTLE MOUNTAIN
BAND OF CHIPPEWA INDIANS
Mr. Azure. Good afternoon, Vice Chairman Murkowski and
Committee. Thank you for the opportunity to present testimony
at today's hearing entitled Fentanyl in Native Communities:
Native Perspectives on Addressing the Growing Crisis.
My name is Jamie Azure. I am an enrolled member of the
Turtle Mountain Band of Chippewa Indians and Chairman of the
Tribe. It is an honor to be here with you today.
According to the Centers for Disease Control, nationwide
over 150 people die every day from overdoses related to
synthetic opioids like fentanyl. In 2020 alone, there were over
56,000 people who died of a fentanyl overdose. This threat is
real all over the United States and in my home State of North
Dakota.
According to recent statistics from the North Dakota
Department of Health and Human Services, there has also been a
significant increase in overdose deaths. The fentanyl and
opioid overdose death rate has steadily increased from 2019
where one individual per 10,000 died of an opioid or fentanyl
overdose to 2022 where 2 per 10,000 in North Dakota have passed
away.
On average two North Dakotans die each week from opioid and
fentanyl overdoses, with the highest percentages of those
deaths coming from Native Americans. That is right, in North
Dakota, home of five tribes, Native Americans die at a rate of
almost nine individuals per 10,000.
More alarming and closer to our home in Benson County,
North Dakota, we have seen the one of the largest increases of
fentanyl and opioid deaths in the State at almost two times
higher than the State's average. Those numbers continue to tick
upward as we end 2023.
Within the Turtle Mountain Reservation we also have seen
family members perish at the hands of this deadly poison. In
response, we have set up several drug task forces that work
with State and local authorities to stop this drug trafficking
before it reaches our communities.
For example, last year the Turtle Mountain Band of Chippewa
Indians authorized its own tribal Division of Drug Enforcement,
the DDE, with tribal resources. We hired a director, who along
with the Law and Policy Department, formulated policy and
procedures to get the DDE operational. We hired some
experienced staff and became effective in March of 2023.
As of today, we have four staff on this team. Prior to this
we had to rely on BIA-OJS's Drug Unit's agents. At one point we
relied on one agent, among five North Dakota reservations. As
you can imagine, this was ineffective. This was far too large
of an area to assign to one drug agent.
Since March of 2023 we have had four major fentanyl drug
busts. The DDE stopped a large quantity of drugs from reaching
our people. We utilized tribal intelligence and were able to
intercept large shipments before they were on the streets of
the community.
Please understand that these shipments are coming mostly
from the Detroit metropolitan area, and sometimes as far as Las
Vegas. In intercepting these shipments, we coordinated with
State and Federal partners for arrests coming off Amtrak in
Rugby, North Dakota, around 40 miles from the Turtle Mountains.
Please note that all these drug shipments are from non-
Indians delivering to the reservation. We have also learned
through our law enforcement efforts that these drug dealers
often move into our HUD units with promises of wealth from drug
proceeds for our vulnerable populations. These individuals have
significantly disrupted the lives of our children, resulting in
foster parents when the parents are arrested. Also, note that
these drug dealers are also using social media platforms such
as Facebook, TikTok, Instagram, Snapchat, and more.
Because of the effectiveness of the DDE, the drug dealers
are complaining about loss of profits and reduction of supply.
I am hopeful that we can continue to develop effective
partnerships with State and Federal agencies. But let me be
clear: the BIA Office of Justice Services must step up their
job.
As the Committee has been made aware, we have been strapped
with limited BIA law enforcement resources. For example, the
Bureau of Indian Affairs Law Enforcement continues to shift
away resources from Turtle Mountain. In fact, BIA law
enforcement has recently shifted away our Chief of Police to
work elsewhere. I as tribal chairman wasn't even notified. I
found out by a text from the Chief of Police asking if I was
notified.
These decisions have made Turtle Mountain members less
safe. Can you imagine if in a major city such as Detroit or
Chicago law enforcement was suddenly transferred someplace
else? What kind of message would that send?
I want to take a moment to thank Senator Hoeven for looking
into this important matter for us. Hopefully the Senator can
get answers from the Department of Interior before any more
tribal members are victims of crime or drug overdose.
I would also like to take a moment and offer my continued
support for the following. Number one, S. 465-BADGES sponsored
by Senator Cortez Masto and Senator Hoeven. This bill will help
expedite background checks for BIA law enforcement so they can
get hired more expeditiously. Part of the problem of hiring law
enforcement is how long it takes to go through the background
process. It should not take nine to twelve months.
Number two, advance BIA Law Enforcement Training Center at
Camp Grafton, North Dakota. This training center is the only
BIA law enforcement training center located in the Great Plains
region. This training center helps those communities that
cannot send their police officers all the way to New Mexico and
allows for specialized investigation classes to occur such as
drug interdiction classes.
And number three, keeping the Drug Elimination Program in
the Native American Housing Assistance and Self Determination
Act, NAHASDA funding, which is currently in the Senate version
of the National Defense Authorization Act, NDAA. This program
will allow my community to utilize housing dollars to provide
drug treatment services, rehabilitation, education, and relapse
prevention in a cultural manner.
In closing, I want to thank you all for allowing me to
speak to this important subject. I look forward to answering
any questions that may come after.
I would also like to mention that on behalf of the tribal
leadership that is sitting at this table, that is watching,
that is sitting here in support, this Committee needs to
remember that we took a vow to sit in the chairs that we sit
in, in the leadership roles that we have taken on for that next
generation. We are very close to losing a generation to an
opioid, to a synthetic drug. We need to figure out a way that
we can work together to address a lot of these I sues that are
going to be bought up today, and a lot that we don't have time
to get into.
It is not in my nature to read off the paper that I just
read off. But it was important to get the right facts across.
These are our children; these are the next generation. As
Chairman Hillaire had mentioned earlier, these are the next
round of leaders that we are fighting for.
We as tribal leaders refuse to allow a generation to be
lost. I just wanted to get that point across.
Thank you very much.
[The prepared statement of Mr. Azure follows:]
Prepared Statement of Hon. Jamie S. Azure, Chairman, Turtle Mountain
Band of Chippewa Indians
Dear Chairman Schatz and Vice Chairwomen Murkowski:
Thank you for the opportunity to present testimony at today's
hearing entitled, ``Fentanyl in Native Communities: Native Perspectives
on Addressing the Growing Crisis.'' I am Jamie Azure; I am an enrolled
member of the Turtle Mountain Band of Chippewa Indians and Chairman of
the Tribe. Its great to be with you today.
According to the Centers for Disease Control, nationwide over 150
people die every day from overdoses related to synthetic opioids like
fentanyl. In 2020 alone, there were over 56,000 people who died of a
Fentanyl overdose. This threat is real all over the United States and
in my home state of North Dakota.
According to recent statistics from the North Dakota Department of
Health and Human Services, there also been a significant increase in
overdose deaths. The fentanyl and opioid overdose death rate has
steadily increased from 2019 where 1 individual per 10,000 died ofan
opioid or fentanyl overdose to 2022 where 2 per 10,000 in North Dakota
pass away. On average 2 North Dakotans die each week from opioid and
fentany 1 overdoses with the highest percentages of those deaths coming
from Native Americans. That's right, in North Dakota, home of five
tribes, Native Americans die at a rate of almost 9 individuals per
10,000. More alarming and closer our home of Benson Country, North
Dakota has seen the one of the largest increases of fentanyl and opioid
deaths in the State at almost 2 times higher than the States average.
And those numbers continue to tick upward as we end 2023.
Within the Turtle Mountain Reservation we also have seen family
members perish at the hands of this deadly poison. In response, we have
set up several drug task forces that work with state and local
authorities to stop this drug trafficking before it reaches out
communities.
For example, last year the Turtle Mountain Band of Chippewa Indians
authorized its own tribal Division of Drug Enforcement, (DDE), with
tribal resources. We hired a director, who along with the Law and
Policy Department, formulated policy and procedures to get the DDE
operational. We hired some experienced staff and became effective in
March of 2023. Today we have four staff on this team.
Prior to this we had to rely on BIA-OJS 's Drug Unit's agents. At
one point we relied on one agent, among five North Dakota reservations.
As you can imagine, this was ineffective. This was far too large of an
area to assign to one Drug Agent.
Since March of2023 we have had four major fentanyl drug busts. The
DDE stopped a large quantity of drugs from reaching our people. We
utilized tribal intelligence and were able to intercept large shipments
before they were on the streets of the Community. Please understand
that these shipments are coming mostly from the Detroit metropolitan
areas, and sometimes as far as Las Vegas. In intercepting these
shipments, we coordinated with State and Federal partners for arrests
coming off Amtrack in Rugby, North Dakota.
Please note that all these drug shipments are from non-Indians
delivering to the reservation. We have also learned through our law
enforcement efforts, that these drug dealers often move into our HUD
units with promises of wealth from drugs proceeds for our vulnerable
populations. These individuals have significantly disrupted the lives
of our children resulting in foster parents when the parents are
arrested. Also, note that these drug dealers also use social media
platforms such as Facebook, Tic Toc, Instagram, Snapchat, and more.
Because of the effectiveness of our DDE, the drug dealers are
complaining about loss of profits and reduction of supply. I am hopeful
that we can continue and develop effective partnerships with state and
federal agencies but let me be clear the BIA Office of Justice Services
must step up do their job.
As the Committee has been made aware, we have been strapped with
limited BIA law enforcement resources. For example, the Bureau of
Indian Affairs Law Enforcement continues to shift away resources from
Turtle Mountain. In fact, BIA Law Enforcement recently shifted away our
Chief of Police to work elsewhere. These decisions have made Turtle
Mountain members less safe. Can you imagine if a major city such as
Detroit or Chicago law enforcement were suddenly transferred someplace
else? What kind of message would that send? I want to take a moment to
thank Senator Hoeven for looking into this important matter for us.
Hopefully you Senator can get answers from the Department ofinterior
before any more tribal members are victims of crime and drug overdose.
I also want to take a moment and offer my continued support for the
following:
1) S. 465- BADGES sponsored by Senator Cortez Masto and
Senator Hoeven. This bill will help expedite background checks
for BIA Law Enforcement so they can get hired more
expeditiously. Part of the problem of hiring law enforcement is
how long it takes to go through the background process. It
should not take 9-12 months for this.
2) Advance BIA Law Enforcement Training Center at Camp
Grafton, North Dakota. This training center is the only BIA law
enforcement training center located in the Great Plains region.
This training helps those communities that cannot send their
police officers all the way to New Mexico and allows for
specialized investigation classes occur such as drug
interdiction classes.
3) Keeping the Drug Elimination Program in the Native American
Housing Assistance and Self Determination Act ( NAHASDA) which
is currently in the Senate version of the National Defense
Authorization Act (NDAA). This program will allow my community
to utilize housing dollars to provide drug treatment services,
rehabilitation, education, and relapse prevention in a cultural
manner.
Senator Murkowski. Thank you, Chairman Azure.
Mr. Kirk?
STATEMENT OF HON. BRYCE KIRK, COUNCILMAN,
ASSINIBOINE AND SIOUX TRIBES OF THE FORT PECK
RESERVATION
Mr. Kirk. Hi, I am Bryce Kirk, Councilman for the Fort Peck
Assiniboine and Sioux Tribes on the Fort Peck Indian
Reservation. I would like to thank the Committee and Vice Chair
Murkowski, for allowing me to testify on fentanyl in our
communities.
I will start off with a story of a couple brothers that I
have lost because of fentanyl that leave behind, both entail
six kids, a wife, two wives, and kids that continue to lose
their parents. When I was coming in the door, I remembered a
young lady that I coached in seventh and eighth grade in
basketball. Right now, she is a ninth grader, addicted to
fentanyl right now, today.
As we continue to sit here, fentanyl has no boundaries. It
affects men, women, children, and the elderly from all walks of
life. People deal drugs, including suboxone, to pay for their
own habits. They deal, who will buy to feed their habits? Our
people can go to Spokane with $1,000 and bring 1,000 pills back
and make $120,000 off those pills. This is destroying families.
We have higher crime rates and increased violent rapes,
murders, kidnappings. Suicide remains a large leading cause of
death of our people.
Where did we get that it is okay for people to continue to
lose their loved ones from walking in front of trains, that it
is just okay for them to deal with the pain that they have
dealt with their whole lives and stuffing it down with drugs,
deadly drugs, just to feed the pain that they feel growing up,
the abuse, sexually, physically, emotionally, abuse that no
kid, no person should ever go through?
I myself am a recovered addict. I have been clean and sober
for 11 years, and have now been elected to our tribal council
to be able to lead our people and fight for our people. While
the crisis is daunting, it is not hopeless. I am there with
them, but a mentor also. Before I got on the council, I had a
business that actually helped people come off the streets that
were just like myself, to reach down and start reaching our
people that we have an obligation.
In the end of our swearing in ceremony, we say, ``So help
me God.'' As you guys take an oath, we take an oath too. This
isn't just a red or blue issue. This issue is everybody. It
contains our kids. We on Fort Peck have lost a generation of
kids right now. We have grandparents taking care of great-
grandchildren because the grandchildren that they were taking
care of are now lost to the addictions that we face today.
What we need is more law enforcement. We don't need doors
slammed in our face when we try to reach out to our Federal
partners. We need them opened. We need to be able to work
together with information that they have with people coming
onto our reservation.
We need more mental and behavioral health. One of the
biggest things is there is always talk about funding. There can
never be enough funding to catch up where we are. It is sad to
say that it is going to get worse before it gets better.
Without the help of Federal Government and Congress and
acts that we need on reservations to be able to help support
our people, we need the direct funding to come to our tribes,
to come to our reservations, to where we know what it takes us
as leaders, we know what our people need, we know traditional
ways that our people need to go. We could lead our people
there.
We need jobs and training for our people. We need more
housing, we need more community facilities. One of the biggest
things, in conclusion, is my wife and I are a testament to
this, and no matter what happens, we as Indian people are
resilient and will continue to come out of this as we always
have.
But we need additional support from all parts of the
Federal Government, and we need Federal agencies to be true
partners with us in this effort. We don't need bureaucrats in
D.C. telling us how to solve the problem. We already have the
blueprint for how to solve the crisis in the way that is best
for our communities, which is informed by our experiences on
the ground and successes we have already achieved.
What we need is support and tools to grow our efforts and
start helping us reach the people that are already lost, so
that way we don't lose any more grandparents, grandchildren,
moms, dads and kids, kids that haven't even graduated yet.
I thank you for the time. I thank you for everything.
Hopefully we can move forward.
Thank you.
[The prepared statement of Mr. Kirk follows:]
Prepared Statement of Hon. Bryce Kirk, Councilman, Assiniboine and
Sioux Tribes of the Fort Peck Reservation
I am Bryce Kirk, Councilman for the Assiniboine and Sioux Tribes of
the Fort Peck Reservation. I would like to thank the Committee for the
invitation to testify on the impact of fentanyl in Native communities.
The Fort Peck Reservation is in northeast Montana, forty miles west
of the North Dakota border, and fifty miles south of the Canadian
border, with the Missouri River defining its southern border. The
Reservation encompasses over two million acres of land. We have
approximately 12,000 enrolled tribal members, with approximately 7,000
tribal members living on the Reservation. We have a total Reservation
population of approximately 11,000 people.
As I will discuss in greater detail, there is no greater crisis on
the Fort Peck Reservation than addressing the trade and trafficking of
drugs, in particular fentanyl, on the Reservation. I think the Fort
Peck Tribes are as capable a Tribe as any in the country to combat this
crisis, but we need the support of our federal partners. We stand ready
to work with our partners from law enforcement, social service agencies
and health care agencies to do this necessary work.
At Fort Peck, we have long believed that a strong tribal government
is the way to best keep our community safe. So, we have taken action to
maximize our authorities to protect everyone living within our
boundaries. In this regard, the Fort Peck Tribes have provided law
enforcement and correction services on our Reservation since 1996 under
an Indian Self-Determination and Education Assistance Act contract. We
were also one of the first Indian tribes in the nation to enter into a
cross-deputization agreement with state, county and city law
enforcement agencies. Under this agreement, first ratified more than
twenty years ago, tribal officers are deputized to enforce state and
local law on the Reservation and state and local officers are
authorized to enforce tribal law.
For more than fifty years, the Fort Peck Tribes have had an
independent judicial system, including an appellate court. It is
through this system that we provide justice to our victims and our
defendants. Currently, our judicial system includes law-trained judges,
law-trained prosecutors, law-trained public defenders, probation
officers, a published tribal code, and experienced court clerks and
court reporters. Our court's opinions are published and available to
the public. Notwithstanding a strong Tribal government and strong
governmental institutions, we still are facing a crisis of fentanyl use
in our community that threatens every aspect of our Reservation.
This drug has infested every corner of our community, from the
young to the old and without regard to gender or any other demographic.
What we as tribal leaders are the most worried about is our youth. We
fear this drug is robbing us of an entire generation: our very future.
This crisis happened almost overnight. According to the Montana
Attorney General's Office, since 2019, fentanyl seizures in the state
have risen 11,000 percent. See, https://www.kfyrtv.com/2023/02/24/ag-
reports-skyrocketing-fentanyl-crisis-montana. In 2022, the State Task
Force agencies seized 206,955 dosage units of fentanyl, triple the
amount recorded in 2021. Id. Throughout the entire state of Montana,
the fentanyl-related overdose deaths increased by 167 percent from 2016
to 2020. See, https://leg.mt.gov/content/publications/fiscal/2023-
Interim/IBCD/MT_Fentanyl_Trends_2021.pdf. The largest percentage of
these deaths is adults between the ages of 24 and 44. Id. These are the
people who should be the most productive in our communities. These
people are our future leaders. Instead, they are dying. The Montana
Department of Justice Division of Criminal Investigation reports that
10 percent of all high school students in Montana had taken a
prescription drug without a prescription. Id. These children are not
taking Lipitor. They are taking painkillers--opioids. Tragically for
the Tribes in Montana, the opioid overdose death rate for Indian people
is twice that of non-Indians. See, https://www.npr.org/sections/health-
shots/2022/06/01/1101799174/tribal-leaders-sound-thealarm-after-
fentanyl-overdoses-spike-at-blackfeet-nation.
On the Fort Peck Reservation, what our law enforcement officers
report is that an average opioid user's daily dosage is between 10-20
pills. In an urban area, the average cost per pill is $1. On the Fort
Peck Reservation, the average cost per pill is $120. So how does a user
support this habit? He deals. According to our law enforcement, the
average user is selling at least 50 pills a day to pay for his 20-pill
habit.
To put these numbers in context, a single illicit fentanyl pill can
contain a potentially lethal dose. See, Facts about Fentanyl (dea.gov).
In fact, DEA analysis of counterfeit pills found that 42 percent of
pills tested for fentanyl contained a potentially lethal dose. Id. This
means that many in our community--and especially many of our young
people--are gambling their lives 10 or 20 times a day.
The toll that this is having on our community is devastating. I
lost two men I considered my brothers this last year. Now their
children will grow up without a father. We have children as young as
middle school taking fentanyl. Suicide remains extremely high on our
Reservation. Unfortunately, suicide remains a leading cause of death
across all the Reservations in Montana. The crimes against our
children--our babies--are unspeakable.
This drug affects all families from all walks of life on the
Reservation. We had a Tribal law enforcement officer plead guilty to
stealing drugs from our tribal evidence room. This man is a decorated
military veteran. He is the grandson of a former Chairman and son of a
former Councilman. More importantly, he is a husband and father. But he
was suffering from PTSD from his time in the military and from what he
experienced as a law enforcement officer on the Reservation. We are
thankful that he took the opportunity that the arrest presented him to
go to the VA and get the treatment services he needed, and the federal
judge gave him a sentence that recognized he could come back to our
community and be a productive husband and father--opportunities that
not many of our members who battle addiction receive and, as a result,
some people who could be productive members of our Tribe end up in the
federal criminal justice system for their entire productive life.
I battled with addiction myself. But for a man who mentored me and
is still very much like a father to me, I would not be here today. My
children would not have a dad. I never would have been elected to serve
my people. I am thankful every day for my life that I have now.
In March 2023, we had to close our Tribal Court because someone
chose to smoke fentanyl in one of the bathrooms. An officer was
poisoned simply by entering the bathroom in question. The cleaning of
the Court facility and its air systems took time and was costly.
Another indicator of the fentanyl crisis is the increased crime
rate on the Reservation. In September, the Tribal Executive Board
issued a state of emergency due to the severe increase in juvenile
crime. The increase in crime is across all sectors of crime from
property crimes to violent crimes, including sexual assaults,
kidnapping and murders. Men, women and juveniles are the perpetrators.
And virtually every crime can be attributed to fentanyl: Either a
person was high when they perpetrated the crime, or they committed the
crime to secure money to buy drugs, or they committed an act of
violence in retaliation for something related to fentanyl use or
distribution.
While this crisis is daunting, it is not hopeless, and we must
continue to take action to combat it. This is why I appreciate the
Committee's attention to this issue. There is no single solution. We
must look at this problem from every angle. It is a law enforcement
problem, a mental health problem, a social services problem, an
economic development problem and a community development problem. Thus,
we must craft solutions in all these areas so that we are responding to
the cause of the whole sickness and not just the individual symptoms.
In the area of law enforcement, we need the Department of Justice
and Drug Enforcement Agency to remain strong partners in the
investigation and prosecution of drug crimes on the Reservation. I want
to commend our U.S. Attorney's Office for the hard work they do. One
area where we would like more attention is the level at which a U.S.
Attorney is prosecuting a drug trafficking case. It is our
understanding that a person must be in possession of more than fifty
pills, to be prosecuted for possession with the intent to distribute.
As I stated above, many people are possessing 50 to 100 pills simply to
fund their own drug habit--and this is true especially of the young
people. We must stop these transactions before these people become much
larger dealers.
In this regard, we need our federal partners to be true partners.
In one instance, the DEA knew there was a known high level drug dealer
traveling through Fort Belknap, Rocky Boys and Fort Peck and at no time
did DEA share this information with the Tribal law enforcement
agencies. It seems like to us there is a turf battle related to who is
going to bust who, and no one cares about the ultimate victims of these
crimes. They just care about who is going to get the major bust.
While we need strong federal law enforcement, I must acknowledge
that the federal criminal justice system adds additional layers to the
problem. Therefore, we need creative solutions from our federal
partners. The federal criminal system disproportionately impacts Native
people. And due to statutory mandates, federal criminal sentences are
lengthy. Data shows increased incarceration is linked with increased
recidivism. Moreover, there are no federal BOP facilities in Montana,
which means Fort Peck members incarcerated are sent to federal
facilities far away from home, community, and support systems. This
increases the barriers to successful reintegration into our community
after incarceration--thereby aggravating many of the problems that may
have led to substance use and incarceration in the first place. While
the Residential Drug Abuse Program (RDAP) within the BOP system has
proven to be highly effective, it is a lengthy program to complete, and
the wait list to get into the program can be very long. This means that
it may not be available for individuals unless they are incarcerated
for many years and, even then, the program maintains strict eligibility
criteria that disqualify many individuals altogether.
Again, we need our federal partners to explore creative solutions
that can help combat this crisis. What we know is that just arresting
and putting people in prison and letting them out when they have done
their time does little to combat this crisis. We need Federal
prosecutors and the federal court system to expand opportunities for
deferred prosecution and programs that emphasize rehabilitation over
incarceration--especially for nonviolent simple drug offenses--not
major drug dealing. This work must also look to develop programs that
provide culturally appropriate treatment and counseling.
In addition, our law enforcement officers need greater support.
Like every law enforcement agency in the country, we are having
difficulty recruiting and retaining officers. There are several reasons
this problem is exacerbated in in Indian country. These jobs are
dangerous. They frequently involve dealing with the heaviest--even
traumatic--situations and events, which would be difficult to witness
for anyone but may be especially so for officers who are from our
community. Yet, these officers do not have access to adequate benefits
and resources to manage the stress of the job. As my story earlier
indicated, our officers need specific mental health services and a
support system. And they must, at the very least, receive the same
benefits--in particular pensions--as other federal officers. Thus, we
would ask that Congress take up the Tribal Law Enforcement Parity Act,
S. 2695, which would ensure that Tribal Officers operating pursuant to
a Self-Determination Act contract, like ours at Fort Peck, would have
access to the federal pension program as they would if they were BIA
officers.
Another area of greater support is the need for additional K-9
Units in Indian country. We had one K-9 unit from Northern Cheyenne for
a week and it shut down drug trafficking on the Reservation for that
week. We need greater support for the technology that can assist in
this work, whether it is additional cameras and monitoring equipment or
drones. We have too few officers and they cannot be everywhere they
need to be. These tools will help our officers see what is happening on
the Reservation.
In the area of mental health: We need more mental health and
substance abuse treatment services. We remain thankful that Montana
adopted Medicaid expansion as this has allowed for greater access to
mental health services. We are thankful for the Veterans Administration
and its work to provide mental health and treatment services to Native
Veterans.
We urge Congress to continue to fund the Substance Abuse and Mental
Health Administration's programs that allow Tribes to develop treatment
and prevention programs and initiatives that are culturally
appropriate. We urge Congress to fund the $80 million that was
authorized last year specifically to support Native Behavioral Health
and Substance Abuse Disorders within our communities. In addition, we
need greater support within the Indian Health Service for treatment.
Right now, we only have an outpatient treatment facility on our
Reservation. While I acknowledge this is more than many Reservations
have, it is not enough--we do not have the capacity to provide services
to all who need it, and many people on our Reservation need inpatient
treatment. Thus, we need additional facilities to provide inpatient
treatment to people within our communities.
We also voice our support for the President's supplemental funding
request of $250 million for the Indian Health Service (IHS), as part of
a $1.55 billion total investment in the fight against opioids and
addiction in America which was transmitted to Congress on October 25,
2023. This funding is urgently needed to help Tribal communities
address the severe impacts of the opioid and fentanyl crisis. Tribal
nations and Tribal health systems are innovating when it comes to
behavioral health. By focusing on holistic care, traditional healing
practices, and indigenous ways of knowing, we have seen remarkable
results in Tribal communities for treatment of opioid use. This
investment of $250 million will build on these important successes and
will save lives for generations to come. We call upon Congress to
swiftly enact this funding.
In addition, we need the Indian Health Service to better support
self-determination on the Reservation. For the last 14 months, the Fort
Peck Tribes have sought to assume the Dental and Public Health Nursing
programs on the Reservation, and we have encountered nothing but
resistance from the Fort Peck Service Unit. It is as if the Indian
Health Service wants the Tribes to fail. By assuming the operation of
both programs, we will improve the health status on the Reservation,
and thereby combat one factor that leads to addiction. We can't do this
if the Indian Health Service continues to put up barriers to our
assumption of these programs.
In the area of social services: We need more foster homes on the
Reservation. Far too often when someone loses their children, we have
no other option but to place the child in non-Indian homes off the
Reservation. This simply continues the cycle of trauma for our
children. We also need a real mentorship program on the Reservation. As
I said, it was a mentor who made the difference in my life. If we had a
sustained, intentional program that matched people with others willing
to serve as mentors, I believe this could make a difference. We think
the Tiwahe Program within the BIA must be expanded to all Reservations
to be able to provide these kinds of services. This program is intended
to provide full wrap around support services to families, which is what
is needed for families in recovery.
In the area of economic development: We need jobs and job training
for our people. A job gives a person the means to support their family;
it also gives them a sense of purpose and fulfillment, which helps
their mental health, as well as the physical and mental health of those
in their household. My wife operates a coffee shop on the Reservation.
She has made it her mission to provide hope through employment for our
youth and now adults are coming to her asking for the opportunity to
work. She is making a difference for our people and is an important
asset in battling this crisis on the Reservation. Thus, supporting more
job training and workforce development programs and entrepreneurs like
my wife is critical to this effort. The Department of Labor's Indian
Employment and Training Program must be better funded and streamlined
to provide better services throughout Indian country.
Finally, community development: We need more housing on the
Reservation. I want to thank Senator Schatz for his work to reauthorize
the Native Housing Assistance and Self-Determination Act. People are
living in overcrowded homes, which adds to stress and contributes to
addictions. But also, as we learned with the incident at the Tribal
Court, fentanyl can easily contaminate a space which places every
person living in a home with a user at risk of being poisoned. We need
transitional housing for people who have received treatment so that
they are not forced back into the same environment that led them into
addiction. We also need community facilities that are safe for our
children, whether it is more recreational opportunities like our skate
park or additional Head Start facilities to lay a strong educational
foundation. These facilities are needed across Indian country.
My community is resilient--my wife and I are a testament to this.
We will survive this latest crisis, but we need additional support from
all parts of the federal government, and we need federal agencies to be
true partners with us in this effort. We do not need bureaucrats in
D.C. telling us how to solve the problem. We already have the blueprint
for how to solve this crisis in the way that is best for our
communities, which is informed by our experiences on the ground and the
successes we have already achieved. What we need is the support and
tools to grow our efforts.
Thank you for the opportunity to testify on the vitally important
issue of addressing this crisis that is facing our communities. I would
be pleased to answer any questions and to provide any additional
information that may assist the Committee.
The Chairman. [Presiding.] Thank you very much, Mr. Kirk.
Next, I am pleased to introduce and welcome online Dr. A.
Aukahi Austin Seabury, Ph.D., Executive Director and Licensed
Clinical Psychologist, I Ola Lahui, Inc. in Honolulu, Hawaii.
Welcome, Dr. Seabury.
STATEMENT OF A. AUKAHI AUSTIN SEABURY, Ph.D.,
EXECUTIVE DIRECTOR/LICENSED CLINICAL PSYCHOLOGIST, I OLA LAHUI,
INC.
Ms. Seabury. Aloha mai kakou.
The Chairman. Aloha.
Ms. Seabury. Mahalo nui loa, thank you so much for this
welcome. In Hawaii, we have a saying about health as being
contained in [phrase in Native tongue] the four corners of the
body, speaking about the two shoulders and the two sides of the
hips as holding the most vital organs. So if this convening is
about all of America and the continent, then Hawaii represents
the right hip. And so welcome and greetings from that part of
the vital organs of the Country.
Aloha. It is a pleasure to speak with you. I feel a lot of
gratitude for the time today, to be among my brothers, sisters,
and cousins throughout the Country who are coming to speak
today about the First Nations people. We are in a important
time when all of us are being together to speak about the needs
of our specific communities is very critical to this moment,
especially as the people performing the sharing because of how
important it is that we contribute the ways in which our
specific traditional wisdom has been a promising factor in
recovery for people in healing and well-being.
The solutions that come from our traditional cultural
practices and well-being have been shown to be so vital to how
this is all going to work. So Native-led, Native voices is the
sort of resounding call from across all of these parts of the
world. So I am appreciative to be able to join the voices in
that way.
A little bit about the porch that I am speaking from. I am
a licensed clinical psychologist by training and run a non-
profit behavioral health organization whose focus is on
culturally minded, evidence-based behavioral health services
for Native Hawaiian, medically underserved, and rural
communities. I have spent my career in the service of my people
as a therapist, as a healer, specifically as an advocate and
program builder, and someone who builds and maintains
relationships as a Hawaiian health leader.
What I share today is informed by my patients that I serve,
the communities that I have listened to and been a part of, and
the community partners that I have maintained and their sharing
of their experience of this.
The parts I probably don't need to spend too much time on
is that there are similar factors that affect the First Nations
peoples across the world, such as cultural and historical
trauma, systemic bias and marginalization that is going on
currently, and of course the social determinants that directly
impact all of our health outcomes, including economics and
housing.
In Hawaii specifically we have a really big housing crisis
occurring at the moment as well as very significant impacts and
threats to our freshwater sources. All of those things being
factors that predict the higher rates of substance use and
misuse in the Native community here probably in some ways
probably parallel what occurs in other First Nations.
And those trends tend to be over time. If fentanyl follows
the same path as opioids have and meth have before that, then
what we tend to see is that we follow behind the continent a
few years. So where everyone else is at what I am hoping is at
the peak of the fentanyl, the impacts that you are at that sort
of crisis state, in Hawaii we are seeing that increasing and
rising trend. I don't believe that we are yet at the peak that
we will see for this particular substance.
So if we are to believe that it is going to follow the same
path, that is what we can predict, because we saw cases
initially among individuals who have acquired fentanyl for
prescriptive purposes, but then it was part of their care plan,
and that misuse and that was following along with a lack of
information about the risks of its use, and then of course,
into that sort of misuse category.
And then seeing fentanyl as mixed in with other substances
as a street drug, that is following behind but not reached its
sort of influx, at least in my experience in the communities
that I work in. It is not yet at that peak, widely accessible
utilization component just yet. So we are not seeing as many.
Now, we are seeing opioid deaths, of course. But the rise,
we are still on that increasing arc at this time. So my hope is
that participating in this conversation today, we are talking
in two categories. One of course is about preventive strategies
to help us not follow the way that each of the other substances
has followed across the Country from the continent to us in
Hawaii, to prevent that and sort of stave it off. Because as
you can imagine, our health system is finite, we are an
isolated island nation, and in that way that we have the
substance services that are available; they are all that exist.
So it is vital for us.
So with respect to prevention and intervention, there are
some very specific things that I will focus on. Those are that
for some of our communities, standard, evidence-based western
practices work fine. But for everybody else, that something
else seems to give real promise in the use of cultural practice
as part of healing and recovery. Those programs that have
emphasized those things seem to have really wonderful outcomes.
We even have some third party insurers that have been
experimenting with models for how to fund it.
So with respect to an ask of this Committee, it is to
support those initiatives that find ways to fund through
Medicare, Medicaid funding, because our third party insurers
tend to follow those of the leaders, that they fund those
mechanisms for funding traditional cultural practices as a
vital aspect of healing for our communities.
I would say that is probably the greatest ask that I would
have of this Committee with respect to different, any other
requests that have already been made with respect to supporting
prevention initiatives that include education or health
providers more generally, both in the risks of inappropriate
use and of course misuse of fentanyl, as well as the value add
and necessity of culturally informed care as well as the use of
traditional cultural practices for healing and well-being as
part of the inclusive health system, instead of as sort of
viewed as marginal the way that it has been historically.
For our community in particular, our folks would much
rather see a traditional healer than a western medical doctor,
especially our men. So in that way that this could be
legitimized and valued in our community we need that training
for our health system and providers alongside support and
funding mechanisms for the programs that are already using
cultural practices as healing.
[The prepared statement of Ms. Seabury follows:]
Prepared Statement of A. Aukahi Austin Seabury, Ph.D., Executive
Director/Licensed Clinical Psychologist, I Ola Lahui, Inc.
Welina me ke aloha mai ke one kaulana o Kakuhihewa.
Greeting with aloha from O`ahu, Hawai`i, the famous sands of the
great chief Kakuhihewa.
It is with great respect that I come before you today to provide
information, insight, and perspective on the impacts of Fentanyl and
other substance use on Native Hawaiians in the communities that I
serve.
A little about the porch that I am speaking from. I am a licensed
clinical psychologist and director of I Ola Lahui, a nonprofit
behavioral health organization that provides culturally-minded,
evidence-based behavioral health services to Native Hawaiian, medically
underserved, and rural communities. I have spent my career in the
service of my people as a therapist, healer, advocate, community
builder, program developer, pilina relationship maintainer, and
Hawaiian health leader. What I share is informed by direct patient
care, community listening and observation, and feedback from other
community health partners.
Due to similar factors affecting other first nations peoples of the
world including cultural and historical trauma, systemic bias and
marginalization, and the social determinants directly impact our health
outcomes including economics and housing, Native Hawaiians experience
high rates of substance use and suffer the more serious consequences of
misuse including judiciary involvement and incarceration, loss of
social support and global impacts on families, and health impacts that
result in poor functioning, heavy reliance on health system resources,
and shortened lifespan.
What we are seeing with respect to Fentanyl seems to follow a
pattern similar to what we have seen with other substances over the
past several decades where the extent of use in Hawai`i tends to lag a
few years behind what is occurring on the continent. Cases of misuse
were initially just seen among individuals who had acquired Fentanyl
initially for a prescription purpose that then changed into misuse,
dependence, and the whole host of known health risks. In the typical
pattern, increased availability and use as a street drug is following,
although use in communities I serve does not seem to have reached the
high rates that are seen elsewhere on the continent yet. The ``yet''
there is the critical note. Access, cost of the drug, and its addiction
potential will likely impact the speed with which this drug will flood
our community.
Looking at this as an opportunity to intervene sooner and reduce
the scope of impact overall, the question of best practices for Native
communities becomes central to the conversation.
It has long been recognized in substance use treatment that
interventions that don't just address substance avoidance, but include
healing, a spiritual component, and support for rebuilding a life are
effective in recovery and relapse prevention. For some portion of our
community, conventional western best practices work fine. For that
portion, access and affordability of care are the main predictors of
success.
I will focus my comments here on the rest of our community, and I
would argue the greater portion, who need something beyond what is
conventionally offered. This ``something beyond'' is the incorporation
of traditional Native Hawaiian cultural practices and worldview. Given
the high occurrence of cultural and historical trauma, Adverse
Childhood Experiences, and current systemic factors, an approach that
focuses on healing and restoration of balance is critical to recovery.
Hawaiian cultural practices provide stability, focus, and growth
opportunities through the learning process that is more easily accepted
than traditional western substance use treatment approaches. They show
a person how to live a life instead of just how to avoid the life they
used to have which was solely focused on substances.
For this type of care to be broadly available requires support in
two areas. The first is prevention. Funding that supports developing
healthy relationship skills, leadership development, and self-efficacy
in youth is a critical deterrent for substance misuse pathways.
Policies and resources that educate prescribing health providers, limit
access to the substance, and make it less available as a street drug
further support this effort.
Looking further upstream, funding and initiatives to address the
desperate housing shortage and affordability, safety of our land,
water, and natural resources, and support for native voices in
leadership will make a significant impact in this and other health
areas for years to come.
The second type of support needed is for intervention. Currently,
traditional native cultural practices are not a universally reimbursed
service as part of Medicare/Medicaid plans. This limits the capacity of
already underfunded substance use programs to provide the healing
services needed by this community. They provide the care when and how
they can, given these constraints, making it very difficult to sustain
and offer more broadly. Some promising efforts are occurring in our
state related to reimbursement for cultural practices that could serve
as a model.
An addition support in this area is needed for health provider
trainings related to knowledge of traditional healing as a valid
treatment approach and the incorporation of Hawaiian worldview and
culture into health services. Increasing the number of providers with
these competencies will improve health and well being outcomes overall
for this and other Native communities.
Mahalo for your time.
The Chairman. Thank you, Dr. Seabury. Mahalo.
Mr. Gettis, please proceed with your testimony.
STATEMENT OF ERIC M. GETTIS, SENIOR VICE PRESIDENT OF
BEHAVIORAL HEALTH, SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM;
ACCOMPANIED BY COREY P. COX, M.D., CLINICAL DIRECTOR FOR
ADDICTION SERVICES
Mr. Gettis. Chairman Schatz, Vice Chair Murkowski, and
members of the Committee, and those who have spoken so expertly
and passionately today, thank you for the opportunity to
testify on the issues of fentanyl, the opioid crisis, and the
impact on Native communities.
My name is Eric Gettis. I serve as Senior Vice President
for Behavioral Health at Southeast Alaska Regional Health
Consortium, known as SEARHC. SEARHC is an Alaska Native-
controlled tribal health organization. We are authorized by the
resolutions of 15 federally recognized Alaska Native tribes to
administer a comprehensive health care delivery for the
Tlingit, Haida, Tsimshian and other residents of Southeast
Alaska.
Founded in 1975, SEARHC is one of the oldest and largest
Native-run health organizations in the Nation with a service
area stretching over 35,000 square miles. SEARHC is accredited
by the Joint Commission and operates two critical access
hospitals, two long-term care facilities, and 22 rural
Community Health Centers.
The decades-long opioid crisis has impacted communities
across the United States and multiple studies, confirmed here
today, show that Alaska Native and American Indian people are
disproportionately impacted by opioid use, opioid related
overdose, and opioid related deaths. The Native Communities of
Southeast Alaska continue to suffer through the heartache and
despair brought about by substance use.
SEARHC has addressed opioid use disorder over the past 10
years by significantly reducing opiate prescriptions, promoting
holistic interventions for pain management, implementing harm
reduction services and activities, and providing buprenorphine
and naltrexone throughout the region. Recognizing more services
were needed, in February 2022 SEARHC opened an Opioid Treatment
Program, or OTP, in Juneau.
OTPs are the only facilities that offer patients all three
forms of medication for opioid use disorder: methadone,
buprenorphine, and naltrexone. No other setting is permitted to
provide methadone. OTPs are critical to reducing overdose
deaths and providing lifesaving addiction treatment.
In the past year, SEARHC added two additional OTPs; in
Sitka and in Klawock. Before these programs opened, those with
opioid use disorder had to physically move hundreds of miles
away, to Anchorage or Seattle, to engage in treatment. Our
programs have dramatically improved people's lives, yet serious
challenges remain.
Fentanyl has rapidly replaced prescription opiates and
heroin as the primary driver of opioid misuse in Southeast
Alaska. Fentanyl is profoundly potent, quickly physically
addictive, easily attainable, and has a very short half-life
leading to escalating quantities of use and lethality. This has
led to yet another widespread wave of opioid use resulting in
more overdoses and preventable deaths.
We consistently find patients developing dependence on
fentanyl over relatively short periods of time. It is essential
that treatment and medication for opioid use disorder be
available and expanded. The COVID pandemic allowed several
long-standing OTP regulations to be eased. These revised rules
improved treatment availability by permitting telemedicine and
allowing prescribers more clinical discretion for some
methadone take-home administration. SEARHC wholeheartedly
supports maintaining these relaxed emergency regulations.
However, there are efforts around the Country seeking to
ease methadone regulations even further. We urge great caution
with these proposals and recommend that methadone remain part
of a comprehensive opioid treatment program.
Access to and availability of harm reduction services and
overdose reversing medications is paramount for saving lives.
Oftentimes these medication supplies are limited. Additionally,
preconceived beliefs about substance use and associated stigma
prevent harm reduction services from being accepted in some
communities.
Changing our words and descriptions, helping communities
reframe beliefs, and realizing that people can and do recover
are all essential components to battle stigma.
Finally, as a nation, we must recognize the necessity of
developing a strong behavioral health workforce. Native
communities across Alaska continually struggle with inadequate
staffing. Behavioral health specialists and peers have long
operated in an under-resourced system that discourages many
from entering or remaining in the field.
Effective treatment requires qualified compassionate
professionals grounded in culturally responsive practices and
relationships. These are the fundamental elements that foster
healing and recovery.
In conclusion, SEARHC truly appreciates the opportunity to
speak before the Committee today on this very important issue.
Thank you.
[The prepared statement of Mr. Gettis follows:]
Prepared Statement of Eric M. Gettis, Senior Vice President of
Behavioral Health, Southeast Alaska Regional Health Consortium
Chairman Schatz, Vice Chair Murkowski, and members of the
Committee, thank you for the opportunity to testify today on the issues
of Fentanyl, the opioid crisis, and the impact on Native communities.
My name is Eric Gettis. I serve as Senior Vice President for Behavioral
Health at Southeast Alaska Regional Health Consortium (SEARHC). SEARHC
is an Alaska Native-controlled tribal health organization. We are
authorized by the resolutions of 15 federally-recognized Alaska Native
tribes to administer a comprehensive health care delivery system for
the Tlingit, Haida, Tsimshian and other residents of Southeast Alaska
under a Self-Governance Compact with the Indian Health Service entered
into pursuant to Title V of the Indian Self-Determination Act.
Founded in 1975, SEARHC is one of the oldest and largest Native-run
health organizations in the Nation with a service area stretching over
35,000 square miles. SEARHC is accredited by the Joint Commission and
operates two critical access hospitals, two long-term care facilities,
and 22 rural Community Health Centers.
The decades long opioid crisis has impacted communities across the
United States and multiple studies have confirmed that Alaska Native
and American Indian populations are disproportionately impacted by
opioid use, opioid related overdose, and opioid related deaths. The
Native Communities of Southeast Alaska continue to suffer through the
heartache and despair brought about by substance use.
SEARHC has addressed opioid use disorder over the past 10 years by
significantly reducing opiate prescriptions, promoting holistic
interventions for pain management, implementing harm reduction
activities, and providing buprenorphine and naltrexone throughout the
region.
Recognizing more services were needed, in February 2022 SEARHC
opened an Opioid Treatment Program (OTP) in Juneau, Alaska. OTPs are
the only facilities that offer patients all three forms of medication
for opioid use disorder: methadone, buprenorphine, and naltrexone. No
other setting is permitted to provide methadone. OTPs are critical to
reducing overdose deaths and providing lifesaving addiction treatment.
In the past year, SEARHC added two additional OTPs; in Sitka,
Alaska, in March 2023, and in Klawock, Alaska, in October 2023. Before
these programs opened, those with opioid use disorder had to physically
move hundreds of miles away, to Anchorage or Seattle, to engage in
treatment. Our programs have dramatically improved people's lives, yet
serious challenges remain.
Fentanyl has rapidly replaced prescription opiates and heroin in
Southeast Alaska as the primary driver of opioid misuse. Fentanyl is
profoundly potent, quickly physically addictive, easily attainable, and
has a very short half-life leading to escalating quantities of use and
lethality. This has led to another widespread wave of opioid use
resulting in more overdoses and preventable deaths. We consistently
find patients developing dependence on Fentanyl over relatively short
periods of time.
It is essential that treatment and medication for opioid use
disorder be available and expanded. The COVID pandemic allowed several
long-standing OTP regulations to be eased. These revised rules improved
treatment availability by permitting telemedicine and allowing
prescribers more clinical discretion for some methadone take-home
administration. SEARHC wholeheartedly supports maintaining these
relaxed emergency regulations. However, there are efforts around the
country seeking to ease methadone regulations even further. We urge
great caution with these proposals and recommend that methadone remain
part of a comprehensive OTP.
Access to and availability of harm reduction services and overdose
reversing medication is paramount for saving lives. Oftentimes these
medication supplies are limited. Additionally, preconceived beliefs
about substance use and associated stigma prevent harm reduction
services from being accepted in some communities. Changing our words
and descriptions, helping communities reframe beliefs, and realizing
that people can and do recover are all essential components to battle
stigma.
Finally, as a nation, we must recognize the necessity of developing
a strong behavioral health workforce. Native communities across Alaska
continually struggle with inadequate staffing. Behavioral health
specialists and peers have long operated in an under resourced system
that discourages many from entering or remaining in the field.
Effective treatment requires qualified compassionate professionals
grounded in culturally responsive practices and relationships. These
are the fundamental elements that foster healing and recovery.
In conclusion, SEARHC truly appreciates the opportunity to speak
before the Committee today. Thank you.
Senator Murkowski. [Presiding.] Thank you, Mr. Gettis.
Our last witness will be Dr. Soto. Thank you for joining
the Committee today.
STATEMENT OF CLARADINA SOTO, Ph.D., ASSOCIATE
PROFESSOR, DEPARTMENT OF POPULATION AND
PUBLIC HEALTH SCIENCES, KECK SCHOOL OF MEDICINE,
UNIVERSITY OF SOUTHERN CALIFORNIA
Ms. Soto. Thank you for having me. Before I begin, I would
like to make a correction that I am from the University of
Southern California. I know it is a rival to UCLA, but that is
okay. Actually, my daughter is there at UCLA.
I am Claradina Toya, or Soto-Toya. I am an urban Indian
born and raised in the east bay area of California. I am Navajo
from my mother's side and Jemez Pueblo from my father's side.
Thank you, Chairman Schatz, Vice Chairman Murkowski, and
all the members of the Senate Committee on Indian Affairs for
this opportunity to address to you today about the fentanyl
crisis that is killing my people.
In my written testimony, I offer information about this
critical issue, the work that we are doing specifically in
California reaching tribal and urban Indian populations, and
several policies that fall within the scope of your Committee's
duty to address the issues affecting our Native people today.
I would like to mention that the work here in California,
our populations are very unique and diverse. We have the
largest American Indian and Alaskan Native population of any
other State. We have 109 federally recognized tribes in
California, as well as numerous State recognized tribes and
non-federally recognized tribes, plus a large urban Indian
population.
Today I would like to discuss how American Indian and
Alaska Native communities face unique challenges and
vulnerabilities that have contributed to the opioid crisis. I
would like to offer four recommendations to the Committee. This
is based on our community engaged research work with community
organizations, tribal governments, Indian health clinics and
our community advisory boards. We understand that effective
change requires a deep understanding of both the challenges
faced by and strengths inherent to our Native communities. I
would like to note, my recommendations may vary by community
and when implementation is considered, it should be decided by
each community.
My first recommendation, and this has been shared by
others, is to increase the accessibility, quality and
sustainability of residential detox and sober living facilities
for tribal and urban Indian populations. We need residential
treatment programs in counties and tribal communities with high
opioid use and overdose deaths. Discussions with our leaders
and stakeholders must immediately happen to expand Native-
specific and culturally centered services, especially among
regions where no recovery services exist.
We must expand medication assisted treatment, MAT, also
known as medication for opioid use disorder. Yes, this is use
of medication, in combination with counseling and behavioral
therapy. That is essential to support and promote opioid use
recovery. So as we think about this critical infrastructure,
this is important in the treatment life cycle for opioid use
disorders. So there is a need for detox and sober living homes
serving our Native community.
One of the critical components missing from the Indian
health care network, particularly here in California, is detox,
that coordinates on a system level with Indian health clinics.
When individuals graduate from residential or other outpatient
treatment programs, sober living and traditional housing for
American Indian and Alaska Natives are critical to providing a
safe culturally centered recovery experience for individuals to
integrate recovery tools into their home and community
settings.
My second recommendation is to integrate cultural
modalities into recovery treatment programs. This includes but
is not limited to healing ceremonies such as prayers, smudging,
sweat lodges, and meeting with traditional healers that offer
safe, sober, and supportive spaces to gather and express
traditional ways of healing. Studies have found that many
Native community members do strongly favor traditional healing
over strict medication use, and I have indicated that healing
begins with culture, and with practices that are grounded in
our traditional way of life.
Access to these approaches and practices and healing for
patient wellness is one of the most critical junctures in the
recovery cycle of change. This is very apparent.
My third recommendation again as also mentioned by others
is to focus on our Native youth in urban and rural areas, with
community based and culturally relevant opioid use prevention
and treatment services. According to CDC, in 2021, Native
adolescents experienced the highest overdose deaths from
fentanyl due to the increased availability of illicit fentanyl,
again highlighting the need for harm reduction education and
greater access to naloxone and mental health services.
Specifically, there is a need for youth rehab programs to
treat and reduce opioid use disorders. We must use family
cohesion, cultural and traditional practices, and culturally
based youth programs as protective factors against our youth
engaging in opioid substance use.
My fourth recommendation, and last, is to address the
challenges of collecting reliable data for our populations to
ensure accurate demographic data and respect the cultural and
ethnic identities of our Native people. All too often, we are
racially misclassified, especially in urban areas, where we are
assumed to belong to another ethnicity based on appearance. We
are not invisible, and we must improve our data collection
methods and collaborate with tribal governments and Native
organizations that are working on these data issues to advocate
for policies that provide data collection and representation of
our Native communities. This will help us determine our impact
in addressing the opioid epidemic in Indian Country.
Thank you so much for your time and this opportunity to
share.
[The prepared statement of Ms. Soto follows:]
Prepared Statement of Claradina Soto, Ph.D., Associate Professor,
Department of Population and Public Health Sciences, Keck School of
Medicine, University of Southern California
Chairman Brian Schatz, Vice Chairman Lisa Murkowski, and all
members of the Senate Committee on Indian Affairs, thank you for the
opportunity to address you today about the fentanyl crisis that is
killing my people.
Fentanyl in the American Indian and Alaska Native (AIAN) community
is a public health crisis. I offer information below about this
critical issue, the work that we are doing, and several policy
recommendations that fall within the scope of your committee's duty to
study the issues affecting the AIAN people and report recommendations
to the Senate.
The Obligation
There are 574 federally recognized Tribal Nations distributed
across Turtle Island; there are also stateonly-recognized Tribes in 16
states, \1\ Tribes without any official recognition, and AIAN people
who are not enrolled members of any Tribal nation. These non-federally
recognized Tribes and individuals do not receive federal benefits or
have the same political status as federally recognized Tribes. Below, I
describe the factors impacting my people as they relate to health
disparities around the opioid crisis, and I explain the federal
responsibility to address these concerns.
Although we once knew how to be healthy, living in balance and
harmony, we have experienced centuries of violence, discrimination, and
disparity resulting from settler colonialism and its associated harms.
Sovereign AIAN nations negotiated treaties with the federal government
over a period of nearly 100 years (1774-1871), \2\ trading ``400
million plus acres of land and our way of life and our very lives for
peace and for the provisions that are provided in the treaties and a
basic human dignity of having basic services for AIAN people.'' \3\
Invaded by European conquerors and ravaged by new diseases such as
smallpox, my people traded their land--their connection to the earth,
their source of wealth, life, food, water, spirituality, and medicine--
in hopes of receiving health and public health services (among other
treaty obligations). In turn, the United States government took upon
itself the federal trust responsibility, ``moral obligations of the
highest responsibility and trust'' \4\ to be provided to the Indian
Nations. Critical aspects of AIAN policy were created and affirmed in
the Marshall Trilogy (early 1800s, identifying Tribes as ``domestic
dependent nations''), the Snyder Act (1921), and the Indian Self
Determination and Education Assistance Act (Public Law 93-638) (1975),
\5\ as well as in more recent executive orders 13175 (2000) and 13647
(2013). \6\
However, access to health care is limited and has been complicated
by federal policies. Congress initially funded Indian health care and
defined the federal government's responsibility in the Snyder Act, \7\
but termination and relocation policies in the 1950s and 1960s impeded
the ability of many to access care by stripping Tribes of their federal
recognition and moving AIANs off of Tribal reservations into urban
areas. \8\ Many Tribes had their federal recognition restored, but
others have not. \9\ The broadening of the Snyder Act under the Indian
Health Care Improvement Act of 1976 ensured the provision of health
care specifically for AIAN individuals. \10\ But although the Indian
Health Service (IHS), an agency within the Department of Health and
Human Services, is intended to provide direct medical and public health
services, access to health care within California can be complicated
because IHS facilities in California are limited. \11\
The federal government has not met its obligations to the Tribes.
Despite the obligations the US government has to provide health
services to members of Tribal nations, IHS is not an entitlement
program like Medicaid, and its spending comes out of discretionary
funding appropriations; IHS is currently funded at 60 percent of need.
\12\ As described in the US Commission on Civil Rights 2018 report,
titled ``Broken Promises: Continuing Federal Funding Shortfall for
Native Americans,'' the Indian Health Service is significantly and
disproportionally underfunded, covering only ``a fraction'' of the
physical and mental health needs of Tribal and Urban Indians and
failing to increase the budget to keep up with population growth and
rising costs; for example, in 2016, IHS allocated only $2834 per person
compared to $9,990 nationwide. \13\
Lastly, in addition to the federal obligations the US government
owes to federally recognized Tribes, I argue that there is a separate
moral responsibility to make restitution to all AIAN communities, which
have been so harmed by federal policies and other forms of
mistreatment, violence, and discrimination. For example, historical and
intergenerational trauma are frequently cited as reasons contributing
to the use of substances; we know that people use harmful substances to
cope with pain and trauma. Since so much of this trauma was inflicted
directly or indirectly by federal policies such as relocation,
termination, and boarding schools, as discussed more in detail below, I
argue that the federal government is directly responsible, at least in
part, for the dire rates of substance use in AIAN communities today.
\14\
The Opioid and Fentanyl Crisis
National data
The United States has been experiencing an opioid and fentanyl
crisis. The Centers for Disease Control and Prevention (CDC) Injury
Center reports that nearly 645,000 people died due to overdoses between
1991-2021, with three waves of overdoses starting respectively in the
1990s, in 2010, and in 2013. \15\ Figure 1 below, from the same source,
depicts how significantly deaths have spiked since 2013 due to both 1.)
all opioid overdoses and 2.) synthetic opioid overdoses specifically.
Table 1 Overdose Death Rates Involving Opioids, by Type, United States
(deaths per 100,000 people)
------------------------------------------------------------------------
Synthetic opioid analgesics
Any opioid Any opioid excluding methadone
------------------------------------------------------------------------
2.9 0.3
1999
5.9 0.9
2006
6.8 1.0
2010
7.4 0.8
2012
9.0 1.8
2014
13.3 6.2
2016
14.6 9.9
2018
21.4 17.8
2020
------------------------------------------------------------------------
Fentanyl is a synthetic opioid up to 100 times stronger than
morphine that can be prescribed pharmaceutically or created illegally;
most overdoses are related to the illegal form, which can be mixed into
other illegal drugs such as heroin and meth, resulting in dangerous
effects due to its strength. \18\ For example, the National Institutes
of Health (NIH) National Institute on Drug Abuse (NIDA) reports that 20
percent of benzodiazepine-related deaths included fentanyl in 2015,
increasing to 70 percent just six years later. \19\ The COVID pandemic
only exacerbated the opioid crisis. While fentanyl resulted in 53,480
preventable deaths in 2020, this increased 26 percent to $67,325 only
one year later, in 2021. \20\
Nationally, AIAN communities face significant disparities in the
opioid crisis. In 2020 and 2021, AIANs experienced the highest death
rates from drug overdoses compared to all other racial and ethnic
groups, as shown in the graphic below, even though rates rose for all
groups in 2021. \21\
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
California data
Fentanyl-related deaths in California have also increased
exponentially between 2016 and 2021, as shown in the figure below from
the California Department of Public Health (CDPH) Substance and
Addiction Prevention Branch. \22\
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Preliminary 2022 data from the California Overdose Surveillance
Dashboard estimates 6,959 deaths related to any opioid overdose and
6,095 specifically related to fentanyl; additionally, 21,316 overdoses
are estimated to have led to an emergency department visit. \23\
According to the California Department of Justice, the 2022 data above
shows a quick and significant rise from 2020, when nearly 4,000 deaths
were estimated to be fentanyl related. \24\ While much of the data
focuses on overdose deaths, it is important to remember that these
numbers show only a fraction of the impact of addiction. Each
individual and their loved ones may struggle with addiction and its
challenges for years before an overdose occurs, if it occurs.
These grim statistics show the terrible consequences of the rise in
fentanyl. To help put this into perspective, more people died in
California in 2021 from fentanyl-related drug overdoses than from all
car accident deaths, with certain groups--men, Black and AIAN racial
groups, and 30-34-year-olds--disproportionally affected. \25\
AIAN health disparities overall
Considering AIAN policies and historical and social factors
described above, it should be unsurprising that AIAN communities face
extensive disparities in a variety of health issues around both
diagnosis and outcome. This section describes the challenges AIAN face
in overall health and how these existing disparities interact with and
lead to OUD/SUD disparities.
According to IHS, the life expectancy of AIAN people is 5.5 years
below the average, and the AIAN community faces disparities in
mortality from many infectious and chronic diseases (e.g., diabetes,
influenza), from violence (e.g., suicide, assault/homicide), and from
drug- and alcohol-induced deaths. \26\ These disparities arise not only
from the underfunded health system but also from a wide range of social
and historical determinants of health, historical trauma and other
forms of trauma, the losses experienced by the AIAN community, factors
such as education level and income, geographic isolation and
technological access challenges, high rates of interpersonal violence
and abuse, health care access challenges, and limited access to
culturally and linguistically appropriate services. Moreover, the
significant underfunding and access to health care issues discussed
above and other inequities (e.g., the reservation system, housing
insecurity, poverty) help perpetuate the cycles of family dysfunction,
such as abuse, domestic violence, and adverse childhood experiences,
that have harmed AIAN families.
Urban Indians
As mentioned above, in the 1950s and 1960s, federal relocation
policies pushed AIAN to move into urban areas. Additionally, many AIANs
also moved to urban areas voluntarily for better economic, educational,
and housing opportunities as well as improved access to health care and
other services. Today, the combination of these factors has led to 87
percent of the AIAN population living in urban areas today as a diverse
and inter-tribal community according to the 2020 census. \27\ Many
Urban Indians have made California cities their new homes; ``1 in 7
American Indians in the United States lives in California and 1 in 9
American Indians in the United States lives in a California city.''
\28\
Although urban areas theoretically offer more geographical access
to healthcare and other services, in fact, Urban Indians have less
access to the IHS and Tribal services they are entitled. \29\ Urban
Indians continue to face disparities in many different areas compared
to other ethnic groups. For example, Urban Indians experience 54
percent higher rates of diabetes, 126 percent higher rates of liver
disease and cirrhosis, and 178 percent higher rates of alcohol-related
deaths compared to general population. \30\ Some small studies have
reported up to 30 percent of all AIAN have depression, with strong
reasons to believe that the number is even higher among AIAN living in
cities. \31\ The unemployment rate of Urban Indians is 11.2 percent
compared to 4.9 percent of non-Hispanic whites in urban areas. \32\
Some cities have reported poverty rates among Urban Indians of 30
percent to 50 percent. \33\ The numerous poor health outcomes, economic
challenges, sense of cultural loss, assimilation, and historical trauma
has led to a much more challenging life experience for Urban Indians
compared to the general population.
AIAN communities: reasons for opioid use
AIAN communities have been and continue to be disproportionately
affected by health disparities related to substance use and the opioid
epidemic. Substances have been used as a ``tool of genocide'' against
the AIAN people since before the United States was a country; as early
as 1749, Benjamin Franklin wrote about the plan and blessing of
``Providence'' to annihilate ``these savages'' with alcohol to get rid
of them so colonists could capture their land. \34\ Many complex
factors go into the high rates of substance use in the AIAN community,
to include historical trauma, lack of resources, lack of opportunity,
isolation, discrimination, loss of culture and land, loss of identity,
feelings of hopelessness, and numerous other factors. Unfortunately,
the use of substances perpetuates this cycle by setting up individuals
and families for further trauma, such as adverse childhood experiences,
which may increase the likelihood of future substance use.
As one of our study participants stated, ``Hopelessness. I mean,
that's pretty much rock bottom. I think that if you have a plan, strong
backing, and a sense of purpose, you will steer clear of those things.
But if you don't, you will fall prey to making bad decisions.'' This
quote summarizes some of the challenges AIAN face that contribute to
OUD/SUD.
The following statistics come directly from our team's original
research, which is discussed further below:
Eight of 19 urban AIAN individuals experiencing homelessness
attributed their substance use to trauma in the form of family
separation or loss. A specific challenge among female
participants with children was navigating child protective
services, losing custody of their children, and coping with
these lifechanging and traumatic situations. Participants
mentioned coping with family loss such as death or separation.
One participant mentioned drinking to cope with their mother's
passing. \35\
Intergenerational trauma was a common theme among the 19
homeless participants. Boarding school was identified as a main
factor for intergenerational trauma among their parents, which
led to substance use in the household growing up and
subsequently their own substance use. Some participants
mentioned they were raised by relatives because their parents
were unable due to their substance use.
National AIAN data
According to recent data from the Centers for Disease Control and
Prevention, AIANs experienced the second highest rate of overdose from
all types of opioid use in 2017 (15.7 deaths/100,000 persons) when
compared to other racial and ethnic groups. \36\ In 2017 and 2018, AIAN
communities experienced a rapid increase in opioid and synthetic opioid
overdose mortality rates. AIAN communities currently have the second
highest rate of opioid overdose when compared to other racial and
ethnic groups. \37\ These disparities have only been magnified by the
COVID-19 pandemic over the last several years. According to the Indian
Health Service (IHS), fentanyl and other synthetic opioids were
associated with increases in opioid overdose deaths among AIANs during
the COVID-19 pandemic. Between January to September 2019 and January to
September 2020, AIAN drug overdose deaths increased disproportionately
compared to deaths among non-Hispanic Whites, Hispanics, and Asians.
\38\ In 2019, 22.3 AIAN overdose deaths were reported per 100,000
persons, and in 2020, reported overdose deaths increased to 29.8 per
100,000; although this number includes overdoses from several drugs,
most of these deaths involved opioids. \39\ Limited access to care and
organizational closures during the COVID-19 pandemic contributed to
these increases, alongside increased stress and disruptions in people's
lives (e.g., work schedules, stay-at-home orders) were also associated
with increases in opioid deaths. \40\
California AIAN data
California has the largest AIAN population in the US, with over
772,394 AIAN individuals (approximately 2 percent of the total
California population). \41\ There are 109 federally recognized Tribes
in California, as well as numerous state-recognized Tribes and non-
federally recognized Tribes. \42\, \43\ Additionally, there are an
estimated 78 state Tribes petitioning for federal recognition \44\.
AIANs in California, including California Indians and AIANs who
relocated from other states, are dispersed throughout rural and urban
areas around the state, primarily due to federal policies relocating
AIANs from reservations to urban areas. \45\ This data clearly shows
the high need within California's Native communities.
According to the California Rural Indian Health Board, Inc. (CRIHB)
California Tribal Epidemiology Center (TEC), California AIANs
experience the highest rate of opioid overdose deaths and have borne
the greatest burden of suffering from opioid deaths since 2006, but
even these numbers are growing: from 2019 to 2020, there was a 39
percent increase among AIANs opioid-related overdoses nationwide. \46\
For fentanyl-related overdoses specifically, Figure 4 below shows
the rising rates of fentanyl among all California racial and ethnic
groups but highlights that AIANs are the hardest hit, and Figure 5
visually depicts the counties where AIANs have been most greatly
impacted by fentanyl deaths. \47\ However, the same source shows that
both Black and White patients surpass AIAN for fentanyl overdose
emergency department visits and hospitalizations both, perhaps due to
challenges around equal health care access.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Data Challenges
Obtaining comprehensive and accurate data about the AIAN population
is a challenge for many complex reasons. As cited in the California
Consortium for Urban Indian Health's 2020 report, ``A Profile of Data
Availability on American Indians & Alaska Natives in California,''
there is extensive documentation in the literature regarding ``data
capacity issues which under-report health conditions and causes of
death'' among this population. \48\ The report elaborates that AIAN,
are frequently subject to racial misclassification, especially in
California urban areas where they are assumed to belong to another
ethnicity based on appearance; being wrongly classified as non-AIAN 30-
60 percent of the time often renders this group ``invisible,'' for
example, when AIAN data is not reported due to a small sample size.
Compounding this issue is the fact that the AIAN population is already
proportionally small compared to other racial and ethnic groups; as
cited earlier in this document, AIAN make up only around 2 percent of
California. Another consideration is that a full 61 percent of AIAN
individuals reported identifying with multiple racial groups on the
2020 census, the highest rate of any other group, compared to only 13
percent of White, 12 percent of Black, and 17 percent of Asian
respondents. \49\ This is particularly concerning, the same source
elaborates, since individuals of multiple races are often combined into
one category regardless of racial background (i.e., mixed individuals
of any races in combination would also be part of this category),
further rendering the unique needs of the AIAN population invisible.
This is so severe that it has been called a ``data genocide.''
Furthermore, there are challenges collecting reliable data among
AIAN due to unique considerations such as high mobility, variations in
definitions of AIAN groups, residences in extremely rural areas or
without designated addresses, and challenges around question phrasing
and survey completion, among others. \50\
For example, some questions include different definitions (e.g.,
are indigenous Central American populations included?) and terms (e.g.,
``Native American'' vs. ``AIAN'' or ``indigenous'') or ask for specific
Tribal affiliations. Challenges also arise around identity vs. official
Tribal enrollments, eligibilities for membership in varying Tribes, and
the differing political statuses of federally vs. staterecognized or
unrecognized Tribal nations. CCUIH also identifies challenges around
collaboration and data sharing, such as limited access to data among
AIAN organizations and non-Native data not being affirmed by Urban
Indian organizations. \51\ Even though TECs are designated ``public
health authorities,'' \52\ there may be misunderstandings or lack of
knowledge about this that lead to reluctance to share data.
Figure 7 below, from a presentation at the NIHB 2023 Tribal Health
Equity Data Symposium created by the Northwest Portland Area Indian
Health Board, groups these issues into three primary categories: data
access, data collection, and data analysis. \53\ The presentation also
includes a very telling quote that speaks to the cycle of invisibility
from a 2019 journal article published by Michelle Connolly (Blackfeet/
Cree) et al.: ``It is not clear if invisibility results from lack of
data or if lack of data leads to invisibility.'' These challenges are
extremely complicated, and there may be factors even beyond these
mentioned here, such as concerns about data sovereignty, collaboration
challenges, poor relationships, past negative experiences, structural
issues, state vs. federal considerations, and others. Whatever the
specifics, it is clear that accurate data is critical to reliably gain
a picture of AIAN issues and gain the funding and support needed to
address them.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Our Work and Findings
I lead the Initiative for California American Indian Health
Research and Evaluation (I-CAIHRE) at the University of Southern
California (USC). Our mission is to improve the lives of individuals in
California's AIAN communities by conducting high-quality research that
is informed by and responsive to the community's needs and
perspectives. We understand that effective change requires a deep
understanding of both the challenges faced by and strengths inherent to
our Native communities, which can only be achieved through gathering
relevant, community-informed data. Therefore, we are committed to
providing research that incorporates community perspectives and
supports meaningful, sustainable improvements in health and well-being
for AIAN communities in California.
The bulk of I-CAIHRE's work focuses on substance use and commercial
tobacco. Our substance use work is funded by DHCS [contract # 17-
94722], through the California Opioid State Targeted Response (STR) to
the Opioid Crisis Grant from the Substance Abuse and Mental Health
Services Administration (SAMHSA) as part of the state's Tribal
Medication-Assisted Treatment (MAT) Project.
Details about our past and current projects are available on our
website: https://pphs.usc.edu/center/icaihre/with the substance use-
related work falling under the Tribal Medication-Assisted Treatment
(TMAT) sub-section: https://pphs.usc.edu/center/i-caihre/tribal-
medication-assisted-treatment-projects/.
Several highlights and the associated findings and recommendations
are available below.
Addressing the Opioid Crisis in American Indian & Alaska Native
Communities in California: A Statewide Needs Assessment: \54\ This 2019
report publishes research conducted using a participatory action
approach to gather community perspectives from Tribal and Urban Indians
across the state. A total of 279 AIAN individuals (including 83 youth)
participated in key informant interviews or focus groups. They
indicated a high presence of substances in AIAN communities, including
a shift from prescription drugs to heroin. This research found that
youth have access to a wider range of substances than in the past, and
substance use is common within families. Community and individual
stressors were found to be risk factors for opioid use, while
historical and intergenerational trauma drive mental health issues and
substance use. Barriers to treatment were found to include stigma and
structural barriers such as cost, insufficient insurance coverage,
unstable housing, fragmented service delivery, and a lack of
residential treatment facilities. Youth prevention programs and
services were found to be lacking, and recommendations arose around
enhancing prevention and recovery services overall. Another critical
finding was the need for culturally centered activities and treatment/
preventive services to promote whole-person development and maintain
community resiliency.
In summary, this research found that California AIAN communities
have a significant need for OUD/SUD service development and
implementation; furthermore, these services should expand and better
integrate cultural and traditional approaches. This research resulted
in recommendations at the individual, interpersonal, organizational,
community, and policy levels. Policy recommendations include the
following:
Provide funding for and increased access to MAT
Recognize and fund community-defined evidence-based
practices
Remove prior authorization requirements and limits on
coverage, provide financial incentives for medical providers to
become MAT certified, charge a fee on opioid sales to be
deposited into a recovery fund, increase rigor on reporting
requirements to limit access to addictive substances, and adopt
policies supporting more time at patient visits
Allocate funding for AIAN programs specifically and include
Urban Indian Health Programs in federal opioid response dollars
and all federal opioid grants and allowing funding for AIANs
(e.g., through Tribal Opioid Response Grants) to go to Urban
Indian Health Programs as well
Fund further research regarding the impact of homelessness
and housing insecurity
Provide more funding and attention to understand the link
between the opioid crisis and AIAN youth in foster care
Urban American Indians and Alaska Natives Experiencing Homelessness
in California: Strategies for Addressing Housing Insecurities and
Substance Use Disorder: \55\ This 2020 report and published in 2021,
stemmed from a recommendation in the above 2019 report to explore SUD/
OUD issues related to homelessness. Nineteen AIAN adults who were
experiencing homelessness and impacted by SUD/OUD in California's urban
areas were interviewed. The report describes how AIAN individuals
experience disproportionate rates of homelessness and displacement due
to federal policies such as the Indian Removal Act of 1830, the Indian
Relocation Act of 1956, the boarding school policies forced upon AIAN
families, and overcrowding in housing. The report also discusses the
high rates of homelessness in California, the greater risk of SUD among
unhoused individuals (17 percent of homeless individuals experience
chronic substance use), and challenges around access to treatment.
Policy recommendations include the following: \56\
Address individual needs for AIAN individuals experiencing
homelessness, for example supporting and funding California
AIAN Housing First programs (prioritizing housing to provide a
foundation for recovery), AIAN housing education and home
ownership programs, housing cash assistance programs for AIANs,
affordable housing programs for AIANs, meal programs for
homeless AIANs, hotel voucher programs for AIANs, employment
placement programs for homeless AIANs, and emergency shelters
Provide harm reduction services for AIANs
Increase education and awareness of SUD treatment options,
for example offering mentorship programs and service guides
Increase the availability of and access to SUD treatment
services, including transportation support, simplifying intake
and application processes, simplifying communication, and
offering more welcoming, compassionate, and culturally
appropriate staff and environments
Increase the availability of culturally centered recovery
programs, to include increasing program outreach capacities to
target homeless AIANs and offering culturally centered detox
programs for AIANs
Tribal Response to the Opioid Epidemic in California: \57\ This
2020 report presents our evaluation of five programs that received
funding from DHCS's Tribal MAT Program. These programs serve the AIAN
community in California used Tribal MAT funding to increase the
accessibility and use of MAT services with the larger goal of reducing
opioid deaths. Policy recommendations derived from this work include
the following:
Continue and increase funding for Tribal MAT
Advocate for AIAN communities to be included in future
funding opportunities
Provide trainings to community members to empower them to
develop future policies
Outreach to address issues of stigma and trust
Fund community-based navigators to serve as resources for
information; continued funding will also support the
incorporation of traditional healing and recovery approaches
Ensure sustainability, include training that prepares
stakeholders to apply for MAT and OUD funding while retaining
their community workforce
Incorporate increased access to technology in future funding
(e.g., broadband Internet to support telehealth access)
Mapping the Network of Care: Substance Use Treatment and Recovery
Services for American Indians and Alaska Natives in California: \58\
This research, published May 2021, explored another recommendation from
the above 2019 report to increase the availability of detox,
residential, and sober living facilities. During this research, the USC
team gathered and compiled information on available services and
facilities. This research resulted in the following key
recommendations:
Create access to the Drug Medi-Cal Program for AIANs and
Indian Health Providers through an Indian Health Program
Organized Delivery System (DMC IHP-ODS)
Develop a more integrated and collaborative system of care,
to include culturally based service inclusion and the
availability of culturally centered recovery programs such as
healing ceremonies
Increase the availability of AIAN residential treatment
facilities, including those that allow treatment of parents
with children
Increase the availability of AIAN-specific detox treatment
programs
Increase sober living and transitional housing for AIANs
Increase job placement and workforce services for AIANs
Increase youth treatment and recovery programs
Develop permanent sources of funding for community-defined
evidence-based practices
Increase awareness of AIAN-specific community and service
needs
Implementation of Medication for Opioid Use Disorder Treatment in
Indian Health Clinics in California: A Qualitative Evaluation: \59\
This study, published in the Journal of Substance Use and Addiction
Treatment in 2023, explored needs, barriers, and successes related to
implementing medications for opioid use disorder (MOUD)* in Indian
health clinics. Eleven clinics and 29 staff participated in the
interviews. Results found challenges including a lack of education
around MOUD, few clinic resources, and limited provider ability. MOUD
effectiveness was limited by challenges integrating medical and
behavioral care, patient barriers such as geographic isolation, and
limited workforce capacity. Stigma at the clinic level was a barrier to
implementation. Implementation challenges also included insufficient
waivered providers and unmet needs for technical assistance and MOUD
policy and procedure development. MOUD program maintenance was limited
by staff turnover and physical infrastructure limitations.
Recommendations based on this study include the following:
*Note that the terms ``MOUD'' and ``MAT'' are both used to
refer to medications treating addiction. ``MAT'' is used for
much of our work because it is funded by the state ``Tribal
MAT'' project. However, some people are shifting from the term
``MAT'' to other terms like ``MOUD'' because some find the term
``MAT'' to be less preferred or even stigmatizing.
Strengthen clinical infrastructure
Integrate culture into clinical services
Increase AIAN staff to represent the served population
Address stigma at various levels
Consider complex barriers AIAN communities face related to
MOUD implementation and outcomes
Tribal and Urban Indian Community-Defined Best Practices (TUICDBP)
and California Native Medications for Addiction Treatment (NMAT)
Network for Healing and Recovery Projects: \60\ These projects are
currently underway, with our team taking on evaluation and technical
assistance support roles. The TUICDBP grant, acknowledging that culture
is medicine, provides funding for grantees to identify and integrate
traditional cultural healing practices into recovery. The NMAT grant
funds grantees to develop, operationalize, and sustain medications for
addiction treatment services. The current round of funding provides up
to $150,000 for each grantee per project. Preliminary data shows the
critical role of these projects and the importance of incorporating
traditional practices into OUD/SUD treatment and prevention. Current
policy recommendations include the following:
Provide sustained funding to heal disparities through a
return to tradition
Make systemic policy changes that would support continued
funding of cultural practices (e.g., allow reimbursement
through Medicaid/Medi-Cal)
Provide/fund data collection support tailored to AIAN needs
to help address challenges around AIAN data collection
Continue and expand technical assistance
State, Local, and Tribal Collaboration Project: \61\ This project,
also ongoing, conducted a needs assessment around state, local, and
Tribal partnership challenges related to SUD/OUD, with the eventual
goal of addressing some of the identified issues. While this project
focuses on state and local collaboration, which is different from
federal collaboration due to the trust responsibility and federal
agencies responsible for Tribal partnership and services, identified
issues include challenges that likely exist at the federal level as
well: staff turnover, lack of knowledge and awareness about Tribal
considerations, different worldviews, lack of resources, lack of
infrastructure, existing Tribal disparities, poor communication, past
negative experiences, bias, bureaucracy, differences between different
communities and individuals, etc. We recommend including Tribes, Tribal
organizations, Urban Indian organizations, and other AIAN-serving
applicants in federal funding opportunities and encouraging and
facilitating their applications. We recommend including provisions that
states and localities receiving federal funding include Tribal
constituents at a rate that considers not only their population but
also their high level of need. This funding may be offered as pass-
through funding from the state/locality to the Tribes in its area
(which more fully respects Tribal sovereignty and self-determination)
or via state/locality efforts to outreach to AIAN constituents or AIAN
partners; it could also include training for funding recipients around
Tribal considerations.
Substance Use Disorder Policy Advocacy Training Program: \62\ This
current project helps address the need for policy advocates focused on
SUD issues in California's AIAN communities by providing beginner/
intermediate-level training around public and AIAN policy, policy
development, and policy advocacy as well as information about SUD
trends and data. Data from previous training cohorts (2021-2022) show
that participants reported that their knowledge and skills related to
the training program goals were ``greatly improved'' and that
participants found the knowledge, resources, step-by-step guidance, and
peer interaction were the most beneficial aspects. Our team recommends
additional funding for policy training to support AIAN SUD/OUD advocacy
and policy development. Additionally, we recommend federal funding to
provide resources and training or workforce programs for AIAN to
support greater AIAN participation in policy-making processes.
Policy Recommendations
In the section above, we provide recommendations from our projects
and other findings.
In addition, I recommend the following based on my experience and
perspectives:
Provide sufficient funding appropriations for IHS to provide
the support truly needed for all IHSeligible individuals.
Ideally, IHS could be shifted to become an entitlement program
rather than relying on discretionary funding during each budget
period. Regardless of mechanism, the IHS underfunding needs to
be addressed to provide adequate treatment for OUD/SUD and also
support prevention. This includes the provision of OUD/SUD
treatment but also mental health treatment (e.g., for
historical trauma and adverse childhood experiences) that can
help build healthier individuals, families, and communities,
preventing and reducing OUD/SUD rates overall. An adequately
funded system will support lowering OUD/SUD rates beyond simply
funding direct OUD/SUD treatment. For example, better physical
health care may lead to improved mood, greater employability
and thus higher socioeconomic status, less hopelessness,
greater access to care, etc.
Increase enrollment of IHS-eligible AIANs in entitlement
programs like Medicaid as well as other insurance coverage
options. Since IHS is the ``payer of last resort,'' additional
health care payment options save IHS funding (including
purchased referred care) for those who need it most, taking the
burden off IHS and improving access to care, particularly in
urban areas or other areas without IHS services.
Gather input from Tribes, including via Tribal consultations
with federal agencies, in areas regarding relevant policies and
funding around the opioid crisis. Follow best practices for
engagement with Tribal Nations and facilitate participation.
Tribal consultations should be offered consistently and begin
early. Tribal Nations have extremely varying needs, and
participation and decisionmaking should reflect the diversity
of Tribes. Tribal solutions are not ``one size fits all'' and
must consider varying factors like need, size, location,
infrastructure, culture, etc.
Facilitate access to grant funding for Tribes from the
federal government and mandate a reasonable portion of state
funding with federal origins be used to support Tribal
constituents.
Closing Statement
Thank you again, Chairman Brian Schatz, Vice Chairman Lisa
Murkowski, and all members of the Senate Committee on Indian Affairs,
for this opportunity to speak to you and share information about the
AIAN community. I hope that you will consider the great impact of the
opioid crisis on my people and do your part to address these
disparities and remedy the harms done throughout history. I implore you
to use this information to bring about change for one of the most
vulnerable and underserved populations: the first Americans.
I want to thank the following individuals for their assistance in
the written testimony, Mrs. Angelica Al Janabi and Mrs. Ellen
Rippberger, with the University of Southern California Tribal
Medication-Assistant Treatment (TMAT) Project research team.
ENDNOTES
1 National Conference of State Legislatures: https://www.ncsl.org/
research/state-tribal-institute/list-of-federaland-state-recognized-
tribes#State
2 National Archives: https://www.archives.gov/research/native-
americans/treaties
3 Stacy Bohlen, CEO of the National Indian Health Board
4 Department of the Interior, Indian Affairs: https://www.bia.gov/
faqs/what-federal-indian-trust-responsibility
5 National Indian Health Board, Working with Tribal Nations
training: https://www.nihb.org/public_health/wtt/story.html
6 US General Services Administration, Relevant Federal Laws,
Regulations, Executive Orders: https://www.gsa.gov/real-estate/
historic-preservation/historic-preservation-policy-tools/legislation-
policy-andreports/section-106-of-the-national-historic-
preservation-act/native-american-tribal-consultations/relevantfederal-
laws-regulations-executive-orders
7 Warne, D., & Frizzell, L. B. (2014). American Indian Health
Policy: Historical trends and contemporary issues. In American Journal
of Public Health (Vol. 104, Issue SUPPL. 3, pp. S263-S267). American
Public Health Association Inc. https://doi.org/10.2105/AJPH.2013.301682
8 California Rural Indian Health Board: https://crihb.org/about/
history/
9 https://www.kcet.org/shows/tending-the-wild/untold-history-the-
survival-of-californiasindians
10 https://oig.hhs.gov/oei/reports/oai-09-87-00027.pdf
11 Indian Health Service California office: Fiscal Year 2015 Annual
Report. https://www.ihs.gov/california/tasks/sites/default/assets/
assets/File/FY2015IHSCAOAnnualReport.pdf
12 Indian Health Service: https://www.ihs.gov/forpatients/faq/
13 US Commission on Civil Rights, Broken Promises Report: https://
www.usccr.gov/files/pubs/2018/12-2009Broken-Promises.pdf
14FOOTNOTE WAS MISSING
15 Centers for Disease Control and Prevention (CDC): https://
www.cdc.gov/opioids/data/analysis-resources.html
16 CDC: https://www.cdc.gov/drugoverdose/data/OD-death-data.html
17 National Institutes of Health (NIH): https://nida.nih.gov/
research-topics/trends-statistics/overdose-death-rates
18 CDC: https://www.cdc.gov/stopoverdose/fentanyl/index.html
19 NIH: https://nida.nih.gov/research-topics/trends-statistics/
overdose-death-rates
20 NIH: https://injuryfacts.nsc.org/home-and-community/safety-
topics/drugoverdoses/data-details/
21 CDC: https://www.cdc.gov/nchs/products/databriefs/
db457.htm#Key_finding
22 California Department of Public Health: https://www.cdph.ca.gov/
Programs/CCDPHP/sapb/Pages/Fentanyl.aspx
23 California Overdose Surveillance Dashboard: https://
skylab.cdph.ca.gov/ODdash/?tab=Home
24 https://health.ucdavis.edu/blog/cultivating-health/fentanyl-
overdose-facts-signs-and-how-you-can-help
-save-alife/2023/01
25 CAL MATTERS: https://calmatters.org/explainers/california-
opioid-crisis
26 Indian Health Service: https://www.ihs.gov/newsroom/factsheets/
disparities/
27 Office of Minority Health: https://minorityhealth.hhs.gov/
american-indianalaska-native-health
28 California Consortium for Urban Indian Health: https://
ccuih.org/about/about-urban-indians/
29 Office of Minority Health: https://minorityhealth.hhs.gov/
american-indianalaska-native-health
30 National Urban Indian Family Coalition: https://assets.aecf.org/
m/resourcedoc/AECFUrbanIndianAmerica-2008-Full.pdf
31 Urban Indian Health Commission: https://www2.census.gov/cac/nac/
meetings/2015-10-13/invisibletribes.pdf
32 The National Council on Aging. https://www.ncoa.org/article/
american-indians-and-alaska-natives-
keydemographics-and-characteristics
33 New York Times. https://www.nytimes.com/2013/04/14/us/as-
american-indians-move-to-cities-oldand
-new-challenges-follow.html
34 https://nativephilanthropy.candid.org/events/alcohol-as-tool-of-
genocide/
35 https://pphs.usc.edu/wp-content/uploads/2023/04/NAH-Report-
Tribal-MAT.pdf
36 Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G.
(2018). Drug and Opioid-Involved Overdose Deaths--United States, 2013-
2017. MMWR. Morbidity and Mortality Weekly Report, 67(5152), 2013-2017.
https://doi.org/10.15585/mmwr.mm675152e1
37 Wilson, N., Kariisa, M., Seth, P., Smith, H., & Davis, N. L.
(2020). Drug and Opioid-Involved Overdose Deaths_United States, 2017-
2018. MMWR. Morbidity and Mortality Weekly Report, 69(11), 290-297.
https://doi.org/10.15585/mmwr.mm6911a4
38 Kaiser Family Foundation: https://www.kff.org/coronavirus-covid-
19/press-release/drug-overdose-deaths-roseduring-the-covid-19-
pandemic-particularly-among-black-and-american-indian-alaska-native-
people/
39 The Hill: https://thehill.com/changing-america/well-being/
prevention
-cures/3476061-indigenous-americanssee-five-
fold-increase-in-fatal-opioid-overdoses-over-two-decades-study-says/
40 IHS: https://www.ihs.gov/opioids/covid19/
41 US Census Bureau: https://data.census.gov/cedsci/
table?q=S0201&t=009-
AmericanIndianandAlaskaNativealoneorincombinationwithoneormoreotherraces
&g=
0400000US06&tid=ACSSPP1Y2019.S0201
42 Bureau of Indian Affairs: https://www.federalregister.gov/
documents/2014/01/29/2014-01683/indian-entitiesrecognized-and-
eligible-to-receive-services-from-the-united-states-bureau-of-indian
43 http://2010.census.gov/news
44 Judicial Council of California: https://www.courts.ca.gov/
3066.htm
45 Intertribal Friendship House. (2002). Urban Voices: The Bay Area
American Indian Community (S. Lobo (ed.); 1st ed.). University of
Arizona Press.
46 California Rural Indian Health Board: https://
public.tableau.com/app/profile/krista7713/viz/
HealthEquityDashboardOpioids/OpioidsFinal
47 California Overdose Surveillance Dashboard: https://
skylab.cdph.ca.gov/ODdash/?tab=CA
48 California Consortium on Urban Indian Health: https://ccuih.org/
wpcontent/uploads/2021/03/AIANDC_Report_Draft_3_23_Edited.pdf
49 Brookings: https://www.brookings.edu/articles/why-the-federal-
government
-needs-to-change-how-it-collectsdata-on-native-americans/
50 National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC5967841/
51 CCUIH: https://ccuih.org/wp-content/uploads/2021/03/
AIANDC_Report_Draft
_3_23_Edited.pdf
52 https://tribalepicenters.org/
53 https://www.nihb.org/resources/2023DataSymposium/
MondayAfternoonPresentations.pdf
54 https://pphs.usc.edu/wp-content/uploads/2022/11/
USC_AI_Report.pdf
55 https://pphs.usc.edu/wp-content/uploads/2023/04/NAH-Report-
Tribal-MAT.pdf
56 Ramos GG, West AE, Begay C, Telles VM, D'Isabella J, Antony V,
Soto C. Substance use disorder and homelessness among American Indians
and Alaska Natives in California. J Ethn Subst Abuse. 2023 Apr-
Jun;22(2):350-371. doi: 10.1080/15332640.2021.1952125. Epub 2021 Aug 2.
PMID: 34339341
57 https://pphs.usc.edu/wp-content/uploads/2023/04/NAH-Report-
Tribal-MAT.pdf
58 https://pphs.usc.edu/wp-content/uploads/2023/04/Residential-Tx-
Project-Report-for-Community.pdf
59 Soto C, Miller K, Moerner L, Nguyen V, Ramos GG. Implementation
of medication for opioid use disorder treatment in Indian health
clinics in California: A qualitative evaluation. Journal of Substance
Use and Addiction Treatment. 2023 Jul 1:209115
60 https://pphs.usc.edu/research/data-collection-and-analysis-
technical-
assistance-for-tribal-mat-grantees/
61 https://pphs.usc.edu/research/collaboration-improvement-project/
62 https://pphs.usc.edu/research/substance-use-disorder-policy-
advocacy-training-program/
FOLLOW-UP COMMENTS
Chairman Brian Schatz, Vice Chairman Lisa Murkowski, and all
members of the Senate Committee on Indian Affairs, thank you for the
opportunity to present at your recent hearing. I also appreciate the
opportunity to submit follow-up comments regarding the fentanyl crisis
in Indian Country.
During the hearing, I heard discussion around the importance and
effectiveness of culturally relevant care, as well as how this differs
from care that is broadly compassionate and respectful. I would like to
share several thoughts and perspectives for your consideration.
1. Generally, the benefits of cultural competence/cultural
humility and the importance of access to culturally and
linguistically appropriate health care services have been
widely documented without being specific to any one population.
Access to appropriate and relevant care for marginalized groups
is particularly important considering the health disparities
and other disparities faced by many of these populations. The
lack of culturally appropriate, culturally relevant, respectful
care may contribute to and exacerbate these disparities. It is
also widely known that bias and discrimination are embedded in
the current health care system.
Many aspects of modern medical treatment in the US,
particularly around mental/behavioral health, are rooted in
Western worldviews and ideals that may not align with all
cultures. For example, seeing a therapist has helped people
from many backgrounds, but it is closely aligned with a White,
middle-class worldview and workforce, and it may be
inaccessible, unnatural, or uncomfortable for some individuals
or communities. When communities offer alternate solutions,
nothing should stand in the way of their self-determination.
2. When people think of different cultures, many may think of
factors like music, dance, food, and style of dress, but there
are often far deeper considerations. For the American Indian
and Alaska Native (AIAN) population, for example, culture is
``a cognitive map on how to be.'' \1\ In other words, culture
is a way of understanding one's identity, relationships, sense
of purpose, and place/role in the world. While there are many
commonalities across AIAN cultures, specifics may vary (e.g.,
by Tribe or community).
---------------------------------------------------------------------------
\1\ https://pubmed.ncbi.nlm.nih.gov/37085784/
For example, the Swinomish Indian Tribal Community in
Washington State formally developed their own ``Indigenous
Health Indicators,'' reflecting ``non-physiological aspects of
health''; the community identified many indicators that are not
typically considered aspects of health in today's broader US
culture, such as sense of place, the teachings of Elders, and
practice, which includes being ``able to honor proper rituals,
prayers, and thoughtful intentions'' as well as ``able to
satisfy spiritual/cultural needs, e.g., consume foods and
medicines in order to satisfy Spirit's `hunger.''' \2\ Similar
ideas have been repeatedly discussed in indigenous communities.
---------------------------------------------------------------------------
\2\ https://pubmed.ncbi.nlm.nih.gov/27618086/
3. Indigenous communities have raised concerns around the
---------------------------------------------------------------------------
emphasis on ``evidence-based'' treatment.
First, the focus on evidence may not always align with
Native ideas around indigenous ways of knowing or traditional
ecological knowledge; it forces Native peoples to adopt a
Western model of thinking. Native communities may be reluctant
to start from scratch and ``lab test'' practices that have been
carried out in their communities for thousands of years, with
lived experience demonstrating their effectiveness.
Furthermore, the Western, ``evidence based'' model may be
particularly burdensome for Native communities to accommodate
with their often-limited staff and resources. In some cases,
even when Western model testing or evaluation is desired, the
resources and funding may not be there to support, especially
if non-Native individuals and organizations deprioritize Native
practices.
As indigenous conceptions of health are largely much more
holistic than those of Western medicine, providing evidence of
effectiveness can be particularly challenging. For example,
Native communities have repeatedly expressed the importance of
(re)connecting with culture and tradition to build or maintain
the community's health; however, the cause and effect may not
be as immediate and clear as, for example, taking a pill and
seeing tangible, concrete results (e.g., lower blood sugar
levels). Many of these concepts are difficult, if not
impossible, to isolate, randomly assign to participants, and
laboratory test, as may occur in a clinical trial.
Finally, AIAN communities may be reluctant to share their
knowledge for Western testing. This can occur for several
reasons: 1.) the knowledge may be considered sacred or only
considered appropriate for those in the community, and there
may be restrictions on sharing outside the Tribe, in some
cases, even with other Tribal communities, and 2.) the
community may have concerns around exploitation, theft, or
misuse of their knowledge, or they may simply fear that the
knowledge may be disrespected or mocked. These fears are valid
and arise from historical precedent, including several ``'high-
profile' cases of patenting of traditional medicines, without
consent from or compensation to their holders.'' \3\
Unsurprisingly, Native communities may hesitate to turn over
their knowledge, passed down by generations of ancestors and
maintained at great cost due to extensive loss (e.g., of
knowledge keepers, of natural medicine on their traditional
homelands before relocation) and bans on traditional culture to
1.) pharmaceutical companies hoping to sell their sacred wisdom
or take the Tribe's own resources away for profit, potentially
so the Tribal citizens can no longer access it (e.g., due to
limited availability or high cost) or 2.) to a broader society
that has disrespected, harmed, mocked, and exploited them for
centuries.
---------------------------------------------------------------------------
\3\ https://pubmed.ncbi.nlm.nih.gov/12821021/
In short, I argue that it is the US government's moral obligation
to listen to our communities and Nations, as the original inhabitants
of this land and as the experts in our people, when we speak. Since
time immemorial, we have known how to keep our bodies, minds, spirits,
and communities healthy, but centuries of trauma and genocide have led
to the disparities we are facing today, including the crisis around
substance use that is another means of destruction and genocide. The
fact that we are still here today is testament to our resilience and
brilliance. Furthermore, we have repeatedly heard that disconnection
from culture is one of the causes of substance use, and that culture,
tradition, and connection are medicine--they are healing for the whole
person, the community, and future generations.
With these considerations in mind, I ask that you consider the
following regarding the fentanyl crisis:
Provide funding to the Tribes and to Tribal organizations to
address these issues, including the 16 percent of funding that
is being considered for this purpose from the larger $1.5
billion SAMHSA Opioid Response funding.
Allow Tribes and Native communities to self-identify needs,
priorities, and solutions, including those that prioritize
culture and may not align with standard Western models of
evaluation or implementation.
Thank you for your time and consideration.
The Chairman. [Presiding.] Senator Cantwell?
Senator Cantwell. Thank you, Mr. Chairman, and thank you
for allowing me to proceed with the questioning.
I want to talk about law enforcement specifically, since
several of the chairmen and council members brought that up. I
want to say that the Opioid Summit held by the Northwest
Portland office at Tulalip, I see some fascinating treatment
work being done by Indian Country, holistic, simplistic, and
certainly responsive to on-reservation focus. I don't want to
diminish that side of the equation.
But what I feel and hear particularly, Mr. Chairman, from
the Lummi is that without adequate tribal law enforcement
resources, I almost feel like Indian Country is being targeted,
that people know that you don't have the law enforcement, that
you don't have the capabilities, and that is where people are
setting up shop.
Consequently, what is happening is the most powerful, the
money is so good everywhere, that the drug is just being made
as quick as possible and as powerful as possible, and people
don't even know the impact of it, and the consequences. You
had, I am not clear if it was four or five deaths, five deaths,
four related to this in one week.
Chairman Azure mentioned the fact that he wants help from
the BIA justice law enforcement, and in your case, we tried to
partner with the FBI. But that was even, I am not saying
kludgey, but there are issues of how you all coordinate and how
we get the FBI to come out and do a bust with you, because you
had to get that product off your reservation. You knew how
deadly it was, and you had to respond.
But who were you calling? Who were you calling to help you
respond to this crisis? I want to know, Senator Mullin and I
have introduced the Parity for Tribal Law Enforcement, a self-
determination contract for Federal law enforcement officers,
making them eligible for benefits as way to try to build
capacity on reservations.
But what are the two or three things we need to do to help
right away with better law enforcement tools for Indian County
to help fight this? If I could hear from each of the three
tribal chairs here.
Mr. Hillaire. Thank you, Senator, and again thank you to
the Committee for holding this hearing.
Yes, law enforcement is a big issue. Not only the severity
of this drug and us being a close-knit community, just one, the
smallest amount is deadly to us. It impacts our future
generations. So it is a really serious problem.
At Lummi Nation, we come against issues that pertain to
jurisdiction, especially when we have a reservation that is a
peninsula, a road that goes, we call it going around the horn
at Lummi Nation, it is surrounded by water. The road has a
right-of-way by the county which is an access road for non-
tribals living on fee land as well as for the Lummi Island
ferry residents, which is not reservation land. So what do we
do when we implement checkpoints and we have somebody who is
non-tribal, and there is no reasonable cause, and they are
bringing drugs on the reservation? It is always an ongoing
issue.
I want to back up just a little bit before I mention a
little bit more on some of the law enforcement thing. This is a
leadership issue. Even just based on everything we have heard
in this short amount of time, we can already see the complexity
of how we are supposed to address it. It is law enforcement, it
is prevention, it is intervention and it is rehabilitation. It
is workforce, it is housing. There is so much to this.
I think a way for us to ensure that we have resources, and
the area of law enforcement being one of them, is that the
United States declare an emergency, a national emergency to
fentanyl. That way we can tear down the barriers, tear down the
bureaucracy, everything that is hindering our ability to take
care of our people, ensure that we don't have to compete with
our brothers and sisters across Indian Country for a grant that
helps us with law enforcement through DOJ or through other
program services, to ensure that we don't have such extensive
reporting systems, to ensure that we have direct funding,
because as you can hear, we know how to take care of ourselves.
But going back to enforcement, I think we definitely need
more resources, BIA, DEA, and the FBI, the lack of prosecutions
from DOJ and local authorities. We also need the ability to
prosecute and hold accountable non-Indian drug dealers who are
murdering our people through this drug, fentanyl and
carfentanil and all the various versions of it. The lack of
tribal jurisdiction over non-Indian drug dealers coming onto
reservation undermines our efforts to combat the drug crisis
and protect our community.
We urge Congress to recognize a special criminal
jurisdiction over non-Indians who commit drug offenses in our
communities. I am sure we will see more through the track that
is being introduced.
Right now, we do everything we can to exert our
sovereignty, to protect our children. We have this very scary
image of carfentanil which seems to be reaching our smaller
communities, which is 100 times stronger than regular fentanyl,
10,000 times stronger than morphine, and if it is sitting on a
coffee table where there are children, then we have to get this
drug off of our reservation. Right now we are doing everything
that we can with the resources that we have.
With the ability of getting the FBI agents to Lummi Nation,
we worked closely with them, we got over 4,500 pills off of the
reservation just within a few days, with the checkpoints and
the K 9 units. So we are going to keep doing, doing everything
we can. But it does come down to a matter of resources, and
brings up what we mentioned earlier, when we go into a drug
interdiction, when we get over 4,500 pills off of the road, our
beds become full at our stabilization center. That is why there
are so many different pieces to this.
But if we start with the highest level possible, that the
United States of America declares this a national emergency, I
believe that we can overcome a lot of the barriers that we are
facing. Thank you.
Senator Cantwell. I know my time is expired, Mr. Chairman,
so I will either take it for the record, or you can give me 30
seconds.
The Chairman. Go ahead.
Senator Cantwell. I didn't know if they wanted to respond
quickly, 30 seconds, I know that is not a lot of time to
respond.
Mr. Azure. Sure, and I want to thank Chairman Hillaire for
hitting the major points. But to break it all down, what we are
asking for are resources that cannot be taken away. I know I
mentioned earlier with the detailing of our law enforcement.
Let's just be honest: in the State of North Dakota we have five
tribes and one FBI agents. We do understand that violent crimes
will take that FBI agent to a different case, and it prolongs
the cases and the investigations.
Right now the Bureau is currently sitting on a mutual aid
agreement that we had brought forward, still sitting on that,
which is why I mentioned earlier that the Turtle Mountains have
moved forward in self-determining our own tribal drug task
force. Because we can't wait any more. I speak on behalf of all
tribes, that we refuse to wait any more, and we will do what we
can to save our next generations.
Thank you.
The Chairman. Mr. Kirk?
Mr. Kirk. One of the things for me is Amtrak. Right now,
Amtrak flows right through reservations in Montana. When do we
become sovereign and be able to inflict that when it comes to
our reservations? I can go, as Jon Tester, to Spokane without
an i.d. and somebody just buys me a ticket and they scan it off
my phone. When are we going to be able to put drug dogs and
enforce those as soon as that Amtrak hits our reservation
boundaries?
As we continue to battle that, the other thing just at the
tip over here, at the BIA formulation, they are bringing data
to the Congress that states that major crimes, rapes, homicides
and everything are down in Indian Country 50 percent. So when
we come for more funding in those aspects, in public safety and
justice, that is why we don't get an increase, because it shows
there is a decrease.
But once you talk to tribal leaders and you talk to people,
we need to get the right data out there that helps us when it
is coming to you guys to be able to help us with the funding
that we need. If there is a decrease, you guys don't see a
reason for an increase. So without numbers and the right
numbers, we are not going to be able to fund and be able to do
the things that my brothers and sisters need on different
reservations and also on ours.
Thank you.
The Chairman. Thank you very much. Vice Chair Murkowski?
Senator Murkowski. [Presiding.] Thank you, Mr. Chairman.
And just to follow up on that point here, we know the numbers,
we know that Native Americans, Alaska Natives as a population
demographically are dying in the past two years of drug
overdoses more than any other populations out there.
We just had a hearing in Appropriations this morning on an
emergency supplemental. This was domestic, we talked about the
border, several of my colleagues were there in Committee, we
talked about fentanyl. There is a significant increase,
significant provision in the supplement to combat fentanyl.
There is $250 million directed to IHS. I am looking at the
situation in Indian Country, I am looking at the situation in
again, communities like Tyonek, Savoonga, Dillingham, tiny
little Native communities that are so far off the grid most
people don't even know that they exist. And yet the drugs are
coming in, and they are killing people.
So we need this data. We need to understand how it is
moving so rapidly. I think we all recognize we have to be doing
more when it comes to treatment. But we are dealing with a drug
the lethality of which is almost incomprehensible for most
people. So when we talk about treatment facilities, you just
can't take your standard five-week treatment facility and get
somebody who is addicted to fentanyl and somebody who got
addicted in less than a month and think that in five weeks you
are going to flip this, and you are going to have somebody that
is now clean.
We have a challenge that is so big and so enormous, it is
going to take exactly what you all are doing in Lummi Nation,
Chairman, with saying as a community, we have to wrap our arms
around it, we pretty much have to figure out how we do this
from within. So I know that resources will be a challenge.
I would ask the three of you as tribal leaders, knowing
that IHS is going to be receiving a specific increment to go
toward these services, where would you specifically direct
that? Give that to us in writing. I think that would be helpful
for us.
I want to ask Mr. Gettis about what you have been able to
do. You have established these three different opioid treatment
programs. You have them in Juneau, in Sitka, now in Klawock. We
know that for far too many of our communities, whether you are
islanded like you are in Southeast, or in many parts of Indian
Country where the distances are just so great that tele-health
is really one way where we can make a difference.
Can you describe how the tele-health authority has helped
to improve treatment for patients who aren't able to get to it,
but also speak to the stigma part of it? I am hearing more and
more and more that people, they don't want to go into the
behavioral health clinic, because they are going to get tagged
as, that guy has a problem, we all know what it is, don't want
to even be seen in there. But through tele-health, it gives you
that level of anonymity that might help address this stigma.
Mr. Gettis, can you speak to that, please?
Mr. Gettis. Thank you, Senator Murkowski. Yes, as you
pointed out, Southeast Alaska is a group of islands that span
600 miles, very, very small Native communities throughout the
region, and much of Alaska is the same way.
With the advancement and availability of tele-health
services we were able to create follow-up after-care programs,
because once you enter into a service and maybe work on
sobriety or abstaining, then you need to return home. Because
people need to be part of their communities, they need to be
part of their families. They need to have that family kinship.
Being able to return home and participate in an after-care
program is just essential. Tele-health has been a big component
of that. Not only has it allowed people to enter by phone or by
a Teams meeting or some sort of venue like this, but you can
then do that without stepping into sometimes that stigmatizing
treatment facility that doesn't fit for everyone.
So we have been able to see significant gains with tele-
health access. It is particularly valuable here throughout our
region We have seasonal workers who need to go fishing, who
need to go hunting, who need to be out, and then with tele-
health, we can bring that in.
We have also seen, and I don't want this lost, I have heard
from communities across Alaska, about elders also having
improved ability for any sort of tele-health access. It
improves health care, it improves and reduces disparities. I
strongly support improving and keeping tele-health
opportunities as available as possible.
Senator Murkowski. Thank you.
Just to our panelists, know that we have been in a series
of votes, so when you see us popping up and down, it is not
because we are not being attentive. Because we do have to go
over and vote. That is where the Chairman is now and that is
where I will be going when he comes back. But not for lack of
attention.
Senator Tester?
Senator Tester. Thank you, Vice Chair Murkowski, and thanks
for having this hearing. I want to thank everybody who
testified.
Councilman Kirk, let's say that a non-Native is selling
drugs on your reservation. Does the tribal justice system have
the ability to arrest and prosecute them?
Mr. Kirk. No.
Senator Tester. So to further clarify, you can't arrest
them?
Mr. Kirk. We can work with our cross-deputization that we
do have with the county. The county then, if they have beds
available, can hold them. But we cannot prosecute non-Natives
in tribal court on reservations.
Senator Tester. So what happens to a drug dealer that is
peddling dope, peddling fentanyl on your reservation and they
get caught? What happens to them? Where do they go? Anything?
Mr. Kirk. Hopefully if the county has enough room, they are
able to house them there.
Senator Tester. But if the county does not, do you let them
loose?
Mr. Kirk. Have to let them loose or try to find the nearest
county that has a bed for them.
Senator Tester. So let's just talk about that problem,
because that indeed is a problem. What can we do about that? Is
it simply prison space, or is it a jurisdictional space?
Mr. Kirk. Give us the criminal jurisdiction to be able to
charge them in tribal court, so we are able to hold them in our
jails.
Senator Tester. Okay. Is that done, let's say somebody
murders somebody, and it is a non-Native, do you have the
ability to arrest them?
Mr. Kirk. Now, pertaining to kids and police officers, and
with the VAWA, we are able to.
Senator Tester. So there is a precedent that has been set
here.
Mr. Kirk. Yes.
Senator Tester. So we need to tweak it a little bit on our
end.
I know that Senator Cantwell talked about law enforcement.
What are the barriers for you right now, the major barriers on
the ground when it comes to law enforcement? Is it FBI? Because
I think we are in the same both North Dakota is in, by the way.
Is it lack of BIA personnel? Is it a lack of tribal
enforcement? I don't know if you guys do your own law
enforcement up there or not in Fort Peck. You do?
Mr. Kirk. Yes, we are a 638 through the BIA, and we control
our own.
Senator Tester. Do you get the money from the BIA to be
able to hire the officers you need, or are you understaffed?
Mr. Kirk. Yes, but we are also understaffed because our
people start out at $20 an hour, and nobody wants to come live
in northeastern Montana for $20 an hour.
Senator Tester. So how much do you think it would take?
Mr. Kirk. Right now, we can use another 100 officers, but
we will never get it. Right now we are trying to get our pay up
to $27 an hour, so that way we are able to bring more interest
to our reservation.
Senator Tester. Do you have the funding to do that, or does
that mean you have to limit the number of officers you hire?
Mr. Kirk. For the lack of people that we have had there,
and with the carry-over that we had, making $27 sustainable, is
it's going to sustain itself for long, just using carry-over
from the previous years that we are able to use.
Senator Tester. I got you. If you were sitting on this side
of the rostrum, what would you do?
Mr. Kirk. I would properly fund BIA to be able to help
Indian Country. Because I would want that for every part of the
Nation, to be able to give them the right, adequate stuff to
fight this and stop this from killing our people.
Senator Tester. So your number one priority would be
funding for law enforcement?
Mr. Kirk. Yes.
Senator Tester. Thank you very much for your testimony. I
appreciate it. I yield to the Senator from Montana.
Senator Murkowski. Senator Daines?
STATEMENT OF HON. STEVE DAINES,
U.S. SENATOR FROM MONTANA
Senator Daines. Thank you, Senator Tester, and to Chairman
Schatz and Vice Chairman Murkowski, thanks for this important
hearing. Councilman Kirk, you have come a long way. When you
come from northeast Montana, there is no quick and easy way to
get here. Thanks for coming all the way for Poplar, no less, to
be here.
I know first-hand that the Fort Peck Reservation has been
hit hard by massive amounts of fentanyl coming into the
Country. A few years ago I was down on the southern border, in
fact, I spent the night from about 10:00 p.m. to 6:00 a.m. with
border patrol, doing a ride-along in their pickups. We would
get out, we literally were apprehending illegals coming into
the Country.
That was on a Monday when I did that. I went back to
Washington, D.C. and then came back to Montana Thursday night,
and was out in Wolf Point Friday morning of that same week. I
was talking to the folks in Wolf Point, their law enforcement.
I asked the officer there, so, I was on the border Monday
night, drugs were coming across the border Monday night on the
southern border between Texas and Mexico, when did those drugs
get here to Wolf Point, do you think? He said, sir, those drugs
got here before you did.
The ongoing fentanyl crisis is devastating. It is
destroying communities, families, lives. And the Montana tribal
communities are ground zero for this destruction. The Montana
crime lab has reported a 1,000 percent increase in fentanyl-
related overdoses since 2017. Native Americans are suffering
the highest overdose death rate by a massive margin. It is not
even close.
In fact, in Montana, Native Americans are twice as likely
to die over an overdose than any other Montanan. The Blackfeet
Nation recently had to declare a state of emergency because of
the staggering number of overdoses they are seeing. Fentanyl
seizures at the border are up 18 percent since 2019. The drugs
that aren't stopped are making their way to Montana.
Here is a staggering stat. Montana Highway Patrol, in the
first half of 20213, seized enough fentanyl to kill 300,000
people. That is nearly a third of our entire State. This is the
human cost of the open border catastrophe that is going on
right now on our southern border.
The crisis at the border is not a funding problem. It is
not a funding problem. I was down there again just three weeks
ago with Border Patrol. They will tell you, we don't need more
money. They will take some money and turn it into some more
personnel, they would like to get the wall built, put in other
video camera surveillance systems and so forth. That would be
needed. But they say the most important thing you can do is to
slow the flow of the flood of people coming across the border.
It is policies, policies that President Biden reversed that
were working in the prior Administration. This is not a
political statement, it is just a fact.
Law enforcement solutions are needed to combat this
problem. The consequences of fentanyl bleed into every part of
our communities. When you have the flood of encounters, some 8
million since the President took office, plus $1.6 million
known got-aways. Known got-aways means Border Patrol seized the
people coming across either physically or through a video
camera, but they were not able to apprehend. We don't know who
these people are.
On top of that, there is probably another 500,000 that come
across, we have no idea. It is a massive problem. And by
flooding the zone with all the encounters, our Border Patrol is
stretched, and they can't stop the drugs coming across. It is a
zero sum situation.
Councilman Kirk, I know this issue is deeply personal to
you. We spoke this morning at Montana Coffee. I would like to
give you a moment to speak on how this crisis has affected you,
the tribe. You told me that just in the last 24 hours, we have
had more deaths to fentanyl. Councilman Kirk?
Mr. Kirk. Yes, most definitely. It seems like without
Narcan, we would have one every hour. There are people
overdosing even right now at the moment. But the Narcan is what
is saving them.
As we discussed this morning, talking to one of the agents
that goes throughout Indian Country for us, lives on our
reservation, I went in and I was like, okay, I want to learn
more. What do we do? What do we do to be able to subside
everything that we are going to do?
I never thought I would hear it from anybody, and the first
thing he said was, shut the border down. Give us a chance. Give
us a chance to stop the flow of whatever is going on here.
Because how does it make it all the way from down there to a
little tiny place in northeastern Montana? How do we get that
there, or in Turtle Mountain, or up in Lummi, or up in Alaska?
All these places are devastated with this.
So again, it is just being able to work together to find
the right answers and the right things for us to do, so that
way we don't lose any more parents, mothers, daughters,
grandchildren, grandparents. We need to work together to be
able to make this happen. Thank you.
Senator Daines. Thank you. I am out of time, but I just
hope we can come together, there is a chance right now to
actually get a bipartisan solution, we are dealing with Israel,
Ukraine, Taiwan and the Pacific challenges as well as the
border. This is a moment we can do something to change the
policies and slow the flow. We don't need to put more money
into processing people through faster. We need to put money
toward actually slowing the flow.
Councilman Kirk, then I am done.
Mr. Kirk. We see that in Indian Country, we see all these
billion dollar packages going to Ukraine and going to Israel.
When is Indian Country going to matter? When are the treaties
and obligations and trust obligations going to matter to us?
When is one of those bills going to reach us so that we are
able to adequately take care of our people?
If packages and bills can be like that, but we have been
underfunded all these years on everything, when is a package
going to come so we can start fighting for our people the right
way? Thank you so much.
Senator Daines. Thanks, Councilman.
The Chairman. [Presiding.] Thank you, Senator Daines.
Before moving on, I wanted to address your point. First of
all, I want to acknowledge your point. Generations of
disinvestment, disenfranchisement, disintermediation of culture
and language and land, and water, all of it. So I don't mean to
diminish the point you are making. I do think it is worth
pointing out that this Committee, both through IIJA, through
the various COVID relief bills and through IRA, made the
biggest investment in Indian Country and Native communities in
American history.
So both things are true, that we did that, and also that it
is not nearly enough. But I did think it was worth pointing out
that we have made a down payment in a way that is historically
unusual. Again, it doesn't solve anything, but it is the first,
most important step in the right direction.
Senator Cortez Masto?
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Thank you. Thank you, Mr. Chairman.
I too agree, I think we have to do an all-of-the-above
approach to address fentanyl that is not only coming into all
of our communities, but our tribal communities, and address the
needs there. I think it is important.
And I want to talk about one of them, the law enforcement
piece of it. I see it in my tribal communities.
But before I do, I have to address some of the conversation
here from some of my colleagues. There is a comprehensive
approach, we can work in a bipartisan way to address what is
happening at the southern border, it is something I worked on
as attorney general, to address the drug trafficking. What I
hear from those on the border is additional funds to help that
drug trafficking.
That is why the current President, in his supplemental, has
actually requested from Congress $849 million for the
procurement of non-intrusive inspection systems to make sure
that cars and trucks are being scanned and can counter illicit
drug activity, including that fentanyl, and human trafficking.
The President is also requesting $4.4 billion for Customers and
Border Patrol to be able to hire additional agents and officers
to make sure that the criminals and traffickers can't get into
the Country.
There is additional funding he has also put in to address
the migrant flow, to really focus on this issue. This is part
of what I think is the all-of-the-above approach. I am here to
tell you, as somebody who worked to fight these transnational
criminal cartels, you can shut down the border, but those drugs
are going to find it here another way, ports of entry, other
ways in.
Unless we are doing an all-of-the-above approach, we are
really not going to make a dent in this. I support HIDA, I
support law enforcement, I support our tribal communities
helping them really address the gaps that I see in some of the
cross-jurisdictional issues that we have. I see in my own
tribes, I was just with Fort McDermott Paiute Shoshone Tribe,
which is on the Nevada-Oregon border. They don't have enough
resources to even hire tribal police. We know that. Some of our
communities don't even have tribal police, so they have to rely
on BIA.
Well, that one BIA agent has to cover a region the size of
Nevada and other territory. And there is only one or two of
them, let alone one FBI agent and maybe one AUSA to prosecute
at a Federal level. That is ridiculous.
That is where we come in as well. I think at a Federal
level it is important for us to really focus on how we address
the BIA issue, to support and supplement what our tribes
already, if they have the ability to hire tribal police, but
those that don't, we actually have adequate law enforcement in
this communities.
That is where we really have to come together in this
Committee to focus on what is necessary.
I will tell you, there are 28 tribal communities in Nevada.
As a former attorney general, I worked with them. One of the
things that we did was enter into memoranda of understanding
between Federal, State, and local law enforcement, because of
the cross-jurisdictional issues, because of the lack of law
enforcement in some of our tribal communities.
I understand, Councilman Kirk, you have done something
similar with the cross-deputization. What are the benefits that
you see of that cross-deputization? If you would talk a little
bit about that, if that helps address some of the gaps and
services until we fix those?
Mr. Kirk. Most definitely. The cross-deputization is with
the county, the Montana Highway Patrol and also the City of
Wolf Point. It works really great to have more boots on the
ground to be able to combat more, to be able to have other
people fighting. Right now, our tribal cops are in the major
cities like Poplar and Wolf Point. And on the outer communities
we also have an MOU with Valley County, also. So they are able
to cover, Valley County covers our west end, and also Roosevelt
County covers our east end.
So we are able to implement different things, but also
implement a security program back home to be able to help us
alleviate different parts of it.
Senator Cortez Masto. Thank you. I am going to ask Chairman
Azure, talk about some of the challenges people don't realize.
I think if you have maybe three or four BIA officers, that is
going to be enough. But they forget that there is a large
territory to cover, places like Nevada and in the west, there
is a lot of coverage, travel time between some cities where
unfortunately a lot of illicit activity can occur. If you want
to hide somewhere, you are able to do it because of the lack of
coverage.
Do you see that in your area, in your State and in your
community and your tribal Nation, as you are working with the
State and Feds as well? I am curious if that is a part of a
barrier that we need to deal with as well.
Mr. Azure. In the Turtle Mountains, we are a unique
demographic. We are a smaller land base, but we have a large
population. They call it The Old Six by Twelve, on our land
base back home. But we have over 14,000 people living on or
right off that Six by Twelve on our reservation. Sometimes that
is where the frustration with the details come into play.
Sometimes we are down to two officers on the weekends.
And that is a major misconception with people, where they
think that the bad guys aren't very smart. Bad guys are smart,
and that is why they prey on reservations, because they know
the red tape, they know the bureaucracy, they know that if they
make a phone call saying that there is an issue on the
southeastern side of our reservation, while the drugs are being
transferred onto the northwest side of it, there are how many
people in that 45-minute drive that they are driving by, or how
many phone calls are coming in. So they know what they are
doing.
And it is another major misconception that this is only
happening on tribes. It isn't. It is happening in small town
America. There is a microscope over the top of our tribes
because of who we are. They know the red tape and they know how
to get away with things. As an attorney general, you know that
there is a number some of the States have where you have to hit
$50,000 to prosecute on a drug charge. Forty thousand and
ninety-nine dollars is what people will be caught with.
So there are so many issues. That is why it needs to be a
joint partnership of everybody working together and taking down
the bureaucracy and taking that red tape down and figuring out
a way of how are we going to protect that next generation. Not
only tribes, but citizens of this great Country.
Senator Cortez Masto. Yes, thank you. I know my time is up,
but I am hopeful, Mr. Chairman, I think when I first got here,
we may have had a conversation around this. It is time for us
to have another conversation about how we fund BIA along with
our U.S. attorneys and FBI as they coordinate as partners with
our tribal communities and our local communities as well. I
don't think we are doing a service here to really address what
we are hearing that is happening in our communities right now.
I think it is time for us to revisit that conversation.
Thank you.
The Chairman. Thank you very much, Senator Cortez Masto.
Senator Smith?
STATEMENT OF HON. TINA SMITH,
U.S. SENATOR FROM MINNESOTA
Senator Smith. Thanks, Mr. Chair, and thank you, Senator
Cortez Masto, for those great questions.
Thanks to all of you for being here. I am so glad to be
with you.
As I was listening to all of this, I want to talk mostly
about the criminal problems that we have around drug
trafficking. I also want to acknowledge that we also have a
severe mental health crisis, behavioral health crisis that we
need to be looking at as well. To my mind, substance use
disorder is a disease. The fact that you have that is a health
challenge that needs to be addressed.
I want to note that there are just far too few resources
and tools available to address that, and to address it in the
context of the generational trauma that we know is driving so
much of that.
There is a very important piece of legislation that we
passed called the Native Behavioral Access Improvement Act.
This is legislation that is built on something that we passed,
which is the Special Diabetes program. Modeled on that Special
Diabetes program is this behavioral health program that would
allow for tribes to be able to use their best knowledge and
their sovereignty to be able to understand how to put together
programs that are going to be able to address that mental
health challenge.
I want to draw attention to that, because I think it is
important.
But this crisis is also, as we have been hearing from many
of you, a result of this legal quagmire where drug traffickers
exploit, as you are saying, to keep opioids flowing into tribal
communities without any accountability. Take the Red Lake
Nation in northern Minnesota, Minnesota is a Public Law 280
States. Red Lake Nation is not under Public Law 280, so it is a
closed reservation.
What happens there is that they repeatedly pick up the same
drug traffickers who are not Native, they then take those folks
to the border, those folks are then picked up by county or
Federal law enforcement and a week later, those folks are right
back there again doing exactly the same crime. It is a
revolving door that there is no end to, and no accountability
for.
So this question of how to address the need for criminal
jurisdiction on tribal lands is important. It has gotten a lot
more complicated following some of these Supreme Court
decisions that we are dealing with. As you have been saying,
those complications have been exploited by these criminal
networks that are trafficking fentanyl and other drugs.
I am going to ask this question to you, Chair Hillaire,
because I think Senator Cantwell was getting at this a little
bit. If you think about what we accomplished with that special
criminal jurisdiction for missing and murdered indigenous
people on reservations, so that you had that special criminal
jurisdiction, can you speak to how that has been working, what
you see as the strengths of that, and anything we can learn for
what we could do if we were able to extend it to drug
trafficking, for example?
Mr. Hillaire. Yes, absolutely, I think that is a great
idea. I want to add on to some of the things you mentioned. We
were reminded by some of our elders that this mental health
crisis and fentanyl crisis is one and the same. So it is a
holistic, comprehensive approach that is needed to address it.
Also, you mentioned two weeks, that somebody is taken to
the border, handed over to other jurisdictions, and then you
see them two weeks later. For us, try two hours later. We are a
sovereign nation and we have to do what is in the best
interests of our people.
So when we go to a known drug home where there is known
drug activity, known drug dealing, and we get them off the
reservation, I do want to mention we also have MOA with our
county as well, which allows us to at least enforce, but then
we hand them over to the county authorities, and then two hours
later, they are hitchhiking back onto the reservation. It is an
ongoing issue.
I think that would be an absolutely great idea, along with
our ability to, if there is a way we can have special
prosecutors that we can prosecute ourselves, because that is
another big barriers, again, we prosecute them federally, but
who is going to take up a case for something that could be seen
as a small crime compared to the vast amount of crime that can
happen in this world.
We would be fully supportive of something like that. It
would just be a matter of narrowing down the details of how
that would work with VAWA.
Senator Smith. Yes. I really appreciate that. We are
working on legislation to accomplish that. I think the feedback
you are giving us, which is we need resources to be able to do
the accountability, but we also need jurisdiction, as we have
learned from VAWA, we have learned from the extensions we did
in VAWA how that can work. I think we should put that learning
into action. Thank you.
Thank you, Mr. Chair.
The Chairman. Thank you, Senator Smith. Senator Lujan?
Senator Lujan. Thank you, Mr. Chairman. I want to thank
everyone for being here today.
One issue, Mr. Chairman, I want to raise before I get to my
questions, in New Mexico, thousands of tribal members over the
last couple of years have fallen victim to extensive sober home
Medicaid fraud schemes, where people were being kidnapped and
driven hundreds of miles away into the State of Arizona under
the false promise of treatment, and left there without means to
return home, left homeless, when they were at their most
vulnerable state.
While this has been tragic not just to the families, but to
everyone who has paid attention to this, to the entire
community, it also highlighted the extreme need in communities
to have more treatment. I very much appreciate the
conversations we have had today in all spaces, especially the
line of questioning coming from Senator Cortez Masto and
Senator Smith. I certainly agree with their assessments.
Now, Councilman Kirk, it is my understanding that there is
a presence of a treatment facility on your tribal lands to help
reduce overdose deaths and overall substance use disorder. Is
that facility making a difference?
Mr. Kirk. Right now, with the facility, we are waiting on
sprinkler systems, and also with it being an old residential
place, we have to do commercial water, commercial sewer. So
that continues to back up. There are 12 beds now at the bottom
of it.
So right now what is going on in Montana is throughout the
region, the Rocky Mountain region, tribes that cover Montana,
Idaho, and Wyoming, there is a regional healing center right
now that is going right now that we are starting from the
ground up and working on it. We are trying to get a 62-bed
facility.
Right now I believe it is about $28 million to get it
going. But that is for all the tribes. So if we are able to get
funding with that and also bring the holistic healing and
everything that needs to happen with that, that would be great.
But as for the facility back home, it has not been going for
the past five years.
Senator Lujan. So that facility needs help.
Mr. Kirk. Yes.
Senator Lujan. So let me ask the question differently,
Councilman, will more treatment facilities closer to home make
a difference?
Mr. Kirk. Yes. Because we are also all the way in
northeastern Montana, we are victims that are being left down
in Arizona, and we are still continuing to fly them back. As of
yesterday we got a woman back, and paying for her luggage and
everything to get back home. So we are also subject to that.
Senator Lujan. I appreciate that, Councilman.
Dr. Soto, in your written testimony you discussed a study
you authored on medications for opioid use disorders in Indian
health clinics. Were these IHS clinics Urban Indian
Organizations or tribally run clinics?
Ms. Soto. Can you repeat the question, please?
Senator Lujan. In your written question, you discussed a
study you authored on medications for opioid use disorders in
Indian health clinics. Were these IHS clinics Urban Indian
Organizations or tribally run clinics?
Ms. Soto. Yes, they were Urban Indian health clinics.
Tribal health programs and Urban Indian health clinics as well
throughout the State of California. California does have over
50 Indian health clinics in the State.
Senator Lujan. From your research, how available is
culturally competent treatment for American Indians and Alaska
Natives in the IHS system and the UIO system, or in other
clinical systems?
Ms. Soto. It is offered, and I really want to advocate for
the need for more culture being integrated into our programs. I
can't stress it enough. I am a behavioral health scientist
working with our tribal communities. I have just learned in
engaging and talking with them that culture really is the
foundation of our Native people. It has been there before
colonization, and it is still strong and alive today. It really
is what has kept our people resilient against systemic racism,
structural violence, all the things that we are talking about.
It is really essential to be able to help our communities
recover. So it is good for prevention as well as recovery,
because without this, people in recovery need these cultural
ways to heal. There is so much grief, and there is so much
healing in our communities, I have heard many say today. There
is a lot of unintended grief. We need more of that healing.
So having our traditional ways, and that may be very
different for many of our different communities, drumming,
dancing, song, traditional ceremonies, bringing in our
community, our elders. One of the other things that we have
learned is it would be great if they are advocating to approve
reimbursements by tribal clinics for the cost of traditional
healing services, healers themselves, or these services to help
bring them into these programs.
So they have them, but it takes a lot of resources, it
takes a lot of time. But to have those would really help
support. Culture is essential. As many have said, culture is
prevention and culture is the way of life.
Senator Lujan. Dr. Soto, the data that I have seen shows
that this works. I think that it is something I fully support,
and I have seen work, especially with lessons I have learned
from leaders on the Navajo Nation. So I am hopeful we can find
a path forward there.
If I may, Mr. Chairman, I do have one question that is
technical for Dr. Soto. It is about purchase-referred care
coverage for AIAN patients living outside their service area.
Does that present an obstacle to accessing medication assisted
treatment, MAT?
Ms. Soto. I guess it depends on who has it, but that
purchase-referred care is additional funding, it is never
enough. Sometimes one person can take that entire cost, as they
may need that to help support their travel or support their
rehab, to support the service that they need that may not be
offered at that clinic. Every clinic is obviously very
different. Some of them specialize in certain services.
So that is really important for us to think about. I really
appreciate that comment, because more funding needs to go
within that as well. It is not quite reaching all of our
communities or individuals when support is needed.
Senator Lujan. Thank you very much.
Mr. Chairman, I have other questions, I will submit them
into the record. But just to reiterate what Senator Smith and
Senator Cortez Masto said, associated with resources to the
Bureau of Indian Affairs, to be more supportive as well in
planning and jurisdictional questions.
I hope that there can be time for us to have a conversation
about cross-commissioning and MOUs. In New Mexico, I constantly
hear that liability is an issue where there is an unwillingness
sometimes to enter into these agreements. I don't understand
that.
But if that is an impediment, then what can be done through
the Bureau of Indian Affairs or others, so that we have more
eyes, more ears, more people on the ground to keep us safer? I
always felt safer when there were more patrols through where I
lived as opposed to fewer patrols. Living adjacent to Nambe
Pueblo and Pojoaque Pueblo and the communities where I live and
where I have the honor of visiting, those constraints are
making it less safe for people as opposed to more safe, not
supporting that.
Then lastly, with the Bureau of Indian Affairs, as more
conversations are taking place specific to law enforcement, I
certainly hope that we can gather and have a much larger
conversation about the Bureau of Indian Affairs being
supportive of sovereign nations as opposed to punitive in many
areas. I think the times have definitely grown and moved and
matured from the inception of the Bureau of Indian Affairs as
we look to what that could become to provide more support to
our sovereign nations and to our brothers and sisters.
Thank you, Mr. Chairman, and thank you all again for being
here today. I really appreciate it.
The Chairman. Thank you, Senator Lujan. Just on the
particular line of questioning you had around fraud, I would be
happy to work with your staff on anything that we can do to
follow up and make sure there is accountability but also
prevent it going forward. Thank you for that.
My first question is for Dr. Seabury. I guess it is a bit
of a broad one. I am always cautious not to use words that
people outside of the hearing room might not understand. I want
to put a fine point on what do we mean by culturally competent
care? I think I know. But I want to describe it both as a
concept, but also maybe, Dr. Seabury, you can give me an
example in the Native Hawaiian community of what that actually
looks like.
Ms. Seabury. Mahalo for the question. It is actually a
favorite opening conversation for me. I usually use the words
culturally mindful care, instead of competent. Competent sounds
like you take a class and you get certified and we check off
and you have your papers. When it comes to being relevant and
responsive to a Native community, like the Native Hawaiian
community, the needs are dynamic.
So in this moment in time, we are talking about 2023
culturally mindful or culturally competent care, there are
probably sort of two domains of knowledge. So if you are
talking about a regular health provider, like a primary care
physician or a behavioral health provider, then the aspects of
what they would need to know to be culturally competent or
relevant for working with a Native person might include
specifics such as an awareness of what are the contemporary
issues facing our community today.
So why, related to our review, and our emphasis on our
connection to land and water, for example, why are we having so
many conversations about water use and access? What are the
current stressors and coming issues that face this community
right now related to housing and water, relevant to their
history and situation currently socially.
So I would say part of cultural competence is really about
contemporary issues.
Then the second piece, which is more foundational, is an
understanding of how our shared history as a people and values
show up in the way that we engage in the world. For example,
there is a lot of research that shows that in primary care
situations, health providers interrupt their patients after
about 15 seconds of saying what is wrong. When they look at
cultural understandings of that, we see, Native Hawaiians, like
many other Native people across the Country and other
represented groups, they wait until they are sicker before they
come, because they have had more experiences where they are
bouncing off of the health system, feeling that they were not
seen, but they were criticized or scolded, that assumptions
were made about them because of the group they belong to, that
they don't care about their health, for example.
The Chairman. Doctor, let me interrupt, because I have a
very specific question here. How does that differ from just
being kind and nice and respectful? I do think it differs, but
I want you to put a find point on it. What you are describing
is someone who interrupts their patient, which should be bad in
any context.
Ms. Seabury. Yes, so specifically, in general good western
care is great. Here is the thing. It is not just that part. It
has to do specifically with assumptions that are made about the
person and what are the aspects of their life that are helpful.
So there is discrimination that we can talk specifically about,
assumptions about income, where you live, biases about your
diet and what you might be doing that affect the quality of the
care that they are then provided.
So yes, when we are talking about patient engagement, we
are not just talking about being warm, receptive, sort of
general trauma-informed approach, although that is very
helpful. We are talking specifically about recognizing that
every instance of engaging with the health system without these
modifications of cultural competence and awareness can re-
traumatize members of the Native Hawaiian community because of
the assumptions that are made about them that then make them
not want to seek help in the future.
So they are not able to access it. And when they do, the
assumptions that are made about them impact the quality of the
care they then receive. That is the issue with respect with
competence, in my opinion.
The Chairman. And the assumptions are, I don't want to
repeat a bunch of stereotypes with the microphone on, but the
assumptions are some series of assumptions that it is their
fault?
Ms. Seabury. Yes. That means behaviors are their fault,
that they must come from a violent family, for example, or that
they are unemployed or don't have secure housing because of a
lack of effort, knowledge, education or wisdom on their part.
Those are also assumptions that are made.
And so in many ways I think the sort of lack of recognition
of what are the current systemic factors that impact health far
beyond whether or not you took the medication I told you to
take is vital when we are talking about Native communities,
because 90 percent of health has nothing to do with the health
system. Access to safe sidewalks, street lights matter, law
enforcement in your community, how many fast food joints and
liquor stores are in your community versus libraries and
farmer's markets.
Those things affect health in ways that then the individual
person seeking help bears the responsibility for in the bias of
the provider. So their assumption is that they are not eating
healthy foods because they don't want to, rather than because
they don't have access.
The Chairman. Thank you so much for that.
Just one final request to all the testifiers. It is not
mandatory, because some of you may have access to data and some
may not. I do think it is important that this hearing establish
a record of the efficacy of culturally mindful care. Because
part of what we have to do, this is what we had to do with
Native Hawaiian education and health and what we have had to do
with immersion schools, is that we had to prove that meeting
people where they are culturally actually gets you better
outcomes, even if you have entirely western metrics. You are
still going to get better test scores, attendance rates,
graduation rates, medical outcomes, if you meet people where
they are.
I think there is a tendency in the medical establishment,
in the executive branch of various Federal and State
administrations, that this stuff is not backed up by hard
science. I think that is wrong. But it would be great if we can
be at least a little bit of a repository of the record that
demonstrates, this is the most efficacious way for us to
deliver care, so that we can translate some of that cultural
competency into the kind of western analysis that basically
enables us to get more money for the projects.
I appreciate all of your work. I appreciate the challenges
in front of us together in fighting fentanyl, but also just
generally in trying to keep our communities safe and healthy.
If there are no more question for our witnesses, members
may also submit follow-up written questions for the record. The
hearing record will be open for two weeks.
I want to thank all the witnesses, both online and in
person, for their time and their testimony. This hearing is
adjourned.
[Whereupon, at 4:20 p.m., the hearing was adjourned.]
A P P E N D I X
Prepared Statement of the National Indian Health Board
Members of the Senate Committee on Indian Affairs, on behalf of the
National Indian Health Board (NIHB) and the 574 sovereign federally
recognized American Indian and Alaska Native (AI/AN) Tribal nations we
serve, thank you for the opportunity to provide testimony.
Introduction
The United States recently experienced what some have called a
once-in-a-generation crisis. The COVID-19 pandemic reshaped the very
fabric of our economy, society, culture, relationships and our personal
livelihood. Tribal Nations stood up, when the federal government would
not, to protect our people from this devastating pandemic. As a result,
AI/AN people had a life expectancy at birth of 65.2 years in 2021--
equal to the life expectancy of the total U.S. population in 1944. AI/
AN life expectancy has declined 6.6 years from 2019 to 2021, according
to the 2021 Report of the Centers for Disease Control and Prevention
(CDC). \1\ To date, there has been no response to this crisis of the
loss of life expectancy.
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\1\ U.S. Department of Health and Human Services, Centers for
Disease Prevention and Control, Provisional Life Expectancy Estimates
for 2021 (hereinafter, ``Provisional Life Expectancy Estimates''),
Report No. 23, August 2022, available at: https://www.cdc.gov/nchs/
data/vsrr/vsrr023.pdf, accessed on: March 20, 2023 (total for All races
and origins minus non-Hispanic American Indian or Alaska Native).
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Now, two short years later, our Tribal Nations are facing another
pandemic. This pandemic looks different than that of COVID-19, but has
the potential to shift the very fabric of our communities in the same
profound way. Fentanyl and opioids are spreading through our
communities like an uncontained, unchecked virus. Every day, Tribal
communities across the country grapple with the lives that are being
cut short by this plague. While we wish we could provide some glaring
statistics that would awaken a sense of urgency, such data does not
exist, and what data that does exist is grossly out of date or
inaccurate. Like during the COVID-19 pandemic, the federal government
has an opportunity to take swift action to protect our communities. We
hope Congress will not wait until it's too late.
Today, our nation is confronted by the fentanyl and opioid pandemic
that continues to disproportionately ravage the most marginalized among
us, and Indian Country has been ground zero. In order to understand how
to address and overcome these challenges and realize the opportunity
for transformation before us, we must first insist on an honest
reckoning of our history.
The challenges we face today--most recently evidenced through the
impacts of COVID-19 on Tribal communities--are the fruits of
colonization. This system of exploitation, violence and opportunism is
the foundation on which this Nation was constructed. Despite the poor
social determinants of health most frequently found in the Indigenous
and other communities of color--circumstances that proceed from
hundreds of years of colonization--we are often blamed for our poor
circumstances. What our communities are experiencing from the rise of
fentanyl and opioid overdoses is simply the expected outcome of this
historical truth.
Centuries of genocide, oppression, and simultaneously ignoring our
appeals while persecuting Our People and our ways of life persist and
are now manifest in the vast health and socioeconomic inequities we
face. The historical and intergenerational trauma our families endure,
all rooted in colonization, are the underpinnings of our vulnerability
to substance use disorders. Indeed, we tell our stories of treaties,
Trust responsibility and sovereignty--over and over--and it often
appears the listeners are numb to our historic and current truths. But
the truth does not change: that is the ground we stand on. The
underpinnings of colonization may finally be loosening as a consequence
of the exposed neglect, abuse, bad faith and inequities AI/AN People
have experienced during the COVID-19 pandemic. But it did not start
with COVID-19. We hope that Indian country is not once again ground
zero for another once-in-a-generation pandemic.
Opioid Crisis in Indian Country
Opioids are the latest face of a mental health and substance use
crisis in America that is disproportionately impacting our Tribal
communities. AI/ANs experience some of the highest rates of substance
use issues as compared to other racial and ethnic groups, which has
been attributed--in significant part--to the ongoing impacts of
historical trauma. The high rates of substance use naturally lead to
high rates of overdose from illicit substances, like fentanyl.
According to the CDC, \2\ AI/ANs have experienced the highest age-
adjusted overdose death rates of any group for the past decade, with
many of those deaths resulting from opioid use, including fentanyl and
fentanyl-laced substances.
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\2\ https://www.cdc.gov/nchs/products/databriefs/
db457.htm#Key_finding
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In the past year, several Tribes issued emergency declarations over
the rate of fentanyl deaths among their members. Accidental overdoses--
where a person using drugs is unaware that a substance is mixed with
fentanyl--are also on the rise among American Indians and Alaska
Natives. CDC reports that AI/ANs had the highest overdose rate of any
ethnic group for both 2020 and 2021, driven by a 33 percent rise in
drug overdose deaths during the same period. \3\ The Alaska Native
Tribal Health Consortium's (ANTHC) Alaska Native Epidemiology Center
reported that the annual number of opioid deaths among Alaska Natives
increased by 383 percent between 2018 and 2022, with the rate of opioid
overdose mortality doubling during the COVID-19 pandemic. \4\ AI/AN
adolescents experienced the highest overdose deaths from fentanyl in
2021. \5\ Those numbers are gravely concerning, and if we do not do
more to prevent substance use among our children, then our culture,
heritage, and way of life are at risk. It is up to all of us to ensure
that our children can carry on our traditions into the next generation.
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\3\ Spencer MR, Minino AM, Warner M. Drug overdose deaths in the
United States, 2001-2021. NCHS Data Brief, no 457. Hyattsville, MD:
National Center for Health Statistics. 2022. DOI: https://dx.doi.org/
10.15620/cdc:122556
\4\ Senate Committee on Indian Affairs Hearing on ``Fentanyl in
Native Communities: Native Perspectives on Addressing the Growing
Crisis.'' (2023). Testimony of the Record. Washington, DC: U.S. Senate
Committee on Indian Affairs. https://www.indian.senate.gov/hearings/
oversight-hearing-titled-fentanyl-in-native-communities-
nativeperspectives-on-addressing-the-growing-crisis/
\5\ Friedman J, Godvin M, Shover CL, Gone JP, Hansen H, Schriger
DL. Trends in Drug Overdose Deaths Among US Adolescents, January 2010
to June 2021. JAMA. 2022 Apr 12;327(14):1398-1400. doi: 10.1001/
jama.2022.2847. PMID: 35412573; PMCID: PMC9006103.
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Social injustices, perpetuated over multiple generations, have had
enduring consequences for many American Indian and Alaska Native
individuals, families and communities. Research documents massacres,
genocidal policies, pandemics from the effects of introduced diseases,
forced relocations, forced removal of children through boarding school
policies, and prohibition of spiritual and cultural practices
(including the prohibition of the use of Native languages \6\). \7\
This ongoing and pervasive historical trauma has contributed to the
high rates of opioid and fentanyl use in AI/AN communities. The
symptoms and long-term effects of historical trauma include
psychological distress, poor overall physical and mental health, and
unmet medical and psychological needs, evidenced by increased exposure
to trauma, depressive symptoms, substance misuse, and suicidal thoughts
and attempts. \8\
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\6\ Stannard, D.E. (1992). American Holocaust: The Conquest of the
New World. New York, NY: Oxford University Press.
\7\ Thornton, R. (1987). American Indian holocaust and survival: A
population history since 1492. Norman, OK: University of Oklahoma
Press.
\8\ Tribal Behavioral Health Agenda. (2016). Available at: https://
www.nihb.org/docs/12052016/FINAL%20TBHA%2012-4-16.pdf
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Tribal leaders and federal partners must work together to protect
our Tribal communities with effective and well-funded policy solutions
to address the opioid crisis. Tribes are targeted by those in the drug
trade because it is not a secret that Tribes lack the resources (and
sometimes jurisdictional sovereignty) to adequately police their
communities. As a result, it is difficult for Tribes to stop illicit
opioids from entering and being distributed through their communities.
Legislative solutions are needed to address the targeting that Tribes
are experiencing. Senators Hoeven and Cortez Masto introduced S. 465,
the ``Bridging Agency Data Gaps & Ensuring Safety (BADGES) for Native
Communities Act.'' The bipartisan legislation would expedite background
checks for those seeking employment as law enforcement with the Bureau
of Indian Affairs (BIA), thereby reducing what is currently a 12-month
process. Senators Cantwell and Mullin introduced S. 2695, the ``Parity
for Tribal Law Enforcement Act.'' The bipartisan legislation would
allow Tribal law enforcement to be cross-deputized as federal law
enforcement, thereby shrinking the divide between Tribal and federal
law enforcement partners and granting Tribal law enforcement access to
federal benefits. We appreciate the efforts that Congress is putting
toward addressing policing shortages in our communities, but more can
be done and must be done to address this opioid crisis.
Supplemental Funding Request
Tribes must see a substantial increase in funding to address the
opioid crisis. NIHB and Tribal nations were glad to see the President's
recognition of this crisis through the inclusion of funding in his
recent supplemental budget request to Congress. The President's
proposal to address the crisis would provide $1.55 billion in
additional funding to the Substance Abuse and Mental Health Services
Administration (SAMHSA), including $250 million that would be
transferred to the IHS and made available for two years. Despite the
clear need in Indian Country, few federal dollars have been solely
dedicated for this purpose to Tribal nations. For example, in FY 2023,
State Opioid Response (SOR) funding was $1.575 billion, and the Tribal
Opioid Response (TOR) Grants were $55 million, which is roughly 3
percent of the total. Given the impact of the opioid crisis in Indian
Country, $250 million will be a long overdue investment that will save
lives for generations to come.
Policy Recommendations
The opioid crisis has created serious and complex issues across
Indian Country. Despite these serious challenges, Tribal nations and
Tribal health systems are innovating when it comes to behavioral
health. By focusing on holistic care, traditional healing practices,
and Indigenous ways of knowing, we have seen remarkable results in
Tribal communities for the treatment of opioid use. Tribes have
combined culturally centered prevention, treatment, and recovery
services with the implementation of key evidenced-based practices,
including medications for Opioid Use Disorder (OUD); syringe service
programs; training, administration, and distribution of the lifesaving
overdose reversal medication naloxone; peer recovery support services;
outpatient therapy and behavioral health integration. Nearly 50 years
of self-determination and self-governance policy have clearly
demonstrated that empowering Tribes works and results in better
outcomes at the same dollar-for-dollar investment. In simple terms,
good governance. Additional funding through the supplemental will allow
Tribes to improve and expand this programming that we know is
effective.
Any policies or initiatives designed to improve Tribal behavioral
health must be grounded in culture, tradition, language, and Native
ways of knowing. To that end, in order to reduce AI/AN behavioral
health inequity and improve health outcomes, Congress should pursue the
following priorities:
Advance Comprehensive Tribal Prevention, Treatment, and
Recovery Services to Address the Opioid, Fentanyl, and Suicide
Crises in Indian Country. The lived experiences of AI/AN
historical trauma and adversity have contemporary descriptions
and diagnoses: adverse childhood experiences (ACEs), substance
use disorders (SUDs), and suicidal ideation--all of which
intersect and have accompanying strategies for prevention,
treatment, and recovery. Following an intervention, services
should provide ongoing, comprehensive support for an
established continuum of care. Congress should work to
strengthen and assess the availability of critical services,
gaps in services, and opportunities for improvement to meet
community needs related to the opioid and fentanyl crisis.
Improve Federal Standards for Data Collection and Reporting
to Improve AI/AN Visibility and Better Measure Health
Inequities. High-quality, meaningful AI/AN health data is
essential for identifying disparities, setting priorities,
designing strategies, and highlighting successes related to
health equity. However, racial misclassification, missing data,
and other quality issues impede the representation of AI/ANs in
many data sets. With AI/AN people and communities so often
missing from the data, this becomes one more form of erasure of
AI/ANs--our experiences are not represented, our needs are not
heard, and our very existence becomes invisible. In addition,
the way federal data is reported often excludes the many AI/ANs
who identify as Hispanic or with multiple racial identities.
Reframing the data away from focusing on race and instead
focusing on ``AI/AN'' as a political status is a more
effective, empowering, strengths-based approach supporting
Tribal self-determination. Congress must improve data practices
as this is a crucial step to undo the centuries of AI/AN
erasure contributing to the ongoing health inequities in Tribal
communities, including the opioid and fentanyl crisis.
Elevate a Tribal Perspective in Federal Health Equity Plans
and Initiatives that Honor Trust and Treaty Obligations to
Tribal Nations. Effective efforts for health equity in Indian
Country must approach health equity plans through the lens of
Tribal sovereignty, the nation-to-nation relationship, and the
federal trust responsibility. In addition, these plans must
conceptualize this work around understanding AI/ANs as a group
with a unique political status, not as a racial minority.
Health programs and initiatives need to prioritize Tribal self-
determination and supporting connection to culture and
community. Tribes know their people, communities, social and
historical context, needs, and strengths best--Tribes are the
experts in charting a path to health equity for their people.
In addition, achieving health equity requires recognizing and
rectifying historical injustices and providing resources
according to need.
Create and Invest in an Indigenous Model of Social and
Structural Determinants of Health. Decades of research have
documented health inequities experienced by AI/ANs--including
those inequities around SUD and OUD--and the powerful role
played by underlying social and structural determinants of
health. However, these determinants that drive health
inequities for AI/ANs are often distinct and require a unique
perspective and customized approach to address. Current
research on social determinants of health is missing this
Indigenous perspective. Health equity for AI/ANs will advance
with a Tribally created and Indigenous model of social and
structural determinants of health that will identify root
causes of inequities and priorities for intervention. In July
2023, the 76th World Health Assembly (WHA) adopted a resolution
prioritizing the health of Indigenous Peoples around the World,
including developing a global action plan by 2026. We call on
the United States to invest in, adopt and advance these
priorities as a Tribally-informed path toward achieving health
equity and end crises like the opioid and fentanyl crisis in
our communities.
Address Housing and Homelessness in Indian Country. All
Tribal members should have access to stable, safe, sanitary,
and affordable housing. Individuals cannot have access to
recovery or treatment services without first having safe,
adequate and secure housing. Tribal housing issues and
challenges exacerbate health disparities and lower health
status experienced by AI/AN individuals and communities.
Congress must reauthorize the ``Native American Housing
Assistance and Self- Determination Act of 1996'' (NAHASDA) and
advocate for additional resources for Tribal housing needs.
Housing policies should focus on ``housing first'' before
individuals may be able to live in recovery.
Address Historical and Intergenerational Trauma. SUDs are
among the many health problems worsened by discrimination and
oppression, both historical and current. Research has directly
linked historical trauma, colonization and its methods to
substance use among AI/AN Peoples. Traumatic events experienced
by American Indians and Alaska Natives are not confined to a
single catastrophic period in the past, nor are they confined
to a single event but from many sources; they are ongoing and
present in modern times. Additionally, the detrimental,
intergenerational harm from boarding school policies is
associated with increased SUDs, mental illness, and numerous
chronic health conditions. As we examine our past, we must
continue to look toward the future to identify and address
these policies' impact on our communities, our cultural
integrity including tradition-informed ways of being healthy.
One of the most insidious aspects of historical trauma is its
heritability. It is passed down through families and
communities--most often unknowingly--exposing future
generations to centuries-old sorrow and trauma. Opportunities
to intervene in this process are often overlooked or not
identified, and so the cycle continues. An important way to
actively promote healing is to break this cycle and interrupt
the passing down of messages that contribute to trauma. Trauma
should be proactively addressed in informed ways by the
appropriate tribal (e.g., family members, teachers, leaders,
traditional practitioners, behavioral health professionals) and
non-tribal parties. \9\
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\9\ Ibid.
Promote Culturally Centered and Tribally Driven Behavioral
Health Policy and Programs. AI/AN cultures serve as key
protective factors and primary prevention of many mental health
and substance use disorders. Historically, traditional healing
and culturally centered ways of living provided holistic mental
wellness. Forced assimilation policies and programs harmed
Tribes and created behavioral health disparities and negative
health outcomes. Just as federal policy and programs once
sought to eradicate AI/AN identity, there must be an equally
vigorous contemporary response that assists in reconnection and
revitalization of identity. Cultural restoration is an
essential aspect to the needed approach to these programs.
Support for traditional healing practices and modalities and
investment in community restoration are essential if we are
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going to recover from the many policies of colonization.
To that end, Congress must provide that the funding for these
programs be available through self-governance contracts and
compacts, and tribally driven, and informed. Too often, federal
policies seek to fit support to tribal communities in a system
that was originally designed without their input, and in many
cases, designed to eradicate our people. Instead, programs
serving Tribal communities should focus on culture, healing,
and traditional ways of knowing. Without federal policy
supporting the restoration of culture, community and
traditional knowledge, we will not be able to heal from the
trauma of colonization.
All prevention and treatment programs are not designed to meet
the diverse needs of differing communities, nor are they
designed to readily incorporate traditional American Indian and
Alaska Native worldviews that promote health and healing.
Tribal communities must have the flexibility, support, and
resources to implement prevention, treatment, and recovery
programming that meet the needs of their populations. Congress
should:
Create and support culturally and spiritually based
programming and healing that aligns with the diversity and
needs of the local Tribal population and engages communities in
the development of diversion and reentry programs.
Support and coordinate reentry programming across service
sectors and programming for incarcerated persons and their
families, especially their children.
Support and promote Tribal Healing to Wellness Courts,
Veterans Courts (or the VA Diversion Courts Peer-to-Peer
Support Program), and other courts that support recovery
Formulate and implement long-term, communitywide engagement
and mobilization strategies that emphasize community ownership
of their issues and solutions.
Support and train community members to serve as peer
counselors. \10\
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\10\ Ibid.
Strengthen Tribal Behavioral Health Systems. Many barriers
impact access, quality, and availability of health, behavioral
health, and related services for AI/AN people. These issues
include provider and personnel shortages, limited resources,
and obtaining services without traveling great distances.
Additionally, there are concerns related to funding, such as
amounts, distribution mechanisms, allocations, sufficiency, and
reporting requirements. Congress must invest in adequate
resources to address the chronic behavioral health needs of
Indian Country. This includes providing funding at the full
authorized amount for the newly enacted the Behavioral Health
and Substance Use Disorder Resources for Native Americans
located at SAMHSA. Congress should also enact legislation to
expand the use of contracts and compacts under the ``Indian
Self-Determination and Education Assistance Act'' (ISDEAA) for
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programs outside of the IHS.
We believe that one of the ways to do strengthen behavioral
health systems is to follow other effective programs. One of
the most successful models for addressing chronic health issues
is the Special Diabetes Program for Indians. This program
provides funding to over 300 grantees to treat and prevent type
2 diabetes through approaches that are culturallydriven and
tailored to local community needs. Data shows the program being
remarkably successful with type 2 diabetes onset and
complications for AI/ANs decreasing year after year. Congress
should enact a similar program for behavioral health challenges
that would focus on local needs, and cultural practices.
Conclusion
For centuries, AI/AN people have endured genocide, destruction of
culture, poverty, removal, forced assimilation, and countless traumas
that have all contributed the crisis of OUD and SUD that we see in
Tribal communities today. Addressing the opioid and fentanyl crisis is
a complex issue that involves all sectors including health, public
safety and justice, child welfare, economic opportunity, and many
others. While there is not one policy answer that will eradicate the
impacts of opioids and fentanyl in our communities, we do know that the
core of this answer is restoration of culture.
Restoring Tribal culture, honoring tribal sovereignty, and
supporting self-determination will ensure that Tribal nations have the
tools available to support their communities. This includes enacting
policy that is focused on individualized communities, and does not
force our communities to fit in to the boxes determined by federal
officials. We know what to do. We know how to heal. We need support to
achieve it. This includes investments in behavioral health facilities
are necessary to ensure that those who suffer from opioid use disorders
and the detrimental effects of illicit fentanyl can seek the treatment
they need. We must have investments in housing support, employment, and
public safety. But most of all, cultural and traditional healing
practices that protect AI/AN communities should be a priority and fully
funded through self-governance. There is no quick fix to this crisis,
but adequate funding for Indian country is the first step in preventing
more overdoses and treating those with addiction.
______
Prepared Statement of Nickolaus D. Lewis, Council, Northwest Portland
Area Indian Health Board
Greetings Chairman Schatz and Vice Chairman Murkowski, and Members
of the Committee. My name is Nickolaus D. Lewis, and I serve as Council
on the Lummi Indian Business Council, and as Chair of the Northwest
Portland Area Indian Health Board (NPAIHB or Board). I thank the
Committee for the opportunity to provide testimony on ``Fentanyl in
Native Communities: Native Perspectives on Addressing the Growing
Crisis.''
NPAIHB was established in 1972 and is a tribal organization under
the Indian Self-Determination and Education Assistance Act (ISDEAA),
P.L. 93-638. The Board advocates on specific health care issues in
support of the 43 federally-recognized Indian tribes in Idaho, Oregon,
and Washington (Northwest or Portland Area). The Board's mission is to
eliminate health disparities and improve the quality of life for
American Indians and Alaska Natives (AI/AN) by supporting Northwest
Tribes in the delivery of culturally-appropriate, high-quality health
care. ``Wellness for the seventh generation'' is the Board's vision. We
thank the Subcommittee for their continued support in improving the
delivery of healthcare services in Indian Country.
I provide the following testimony on the fentanyl crisis in the
Northwest:
Opioid and Fentanyl Epidemic in the Northwest
AI/AN people in the Northwest are facing a devastating opioid and
fentanyl epidemic with increased overdoses and deaths. The rate of drug
overdose deaths, specifically for opioid and fentanyl deaths, are
disproportionately higher among AI/ANs in the U.S. compared to other
racial groups. But, the death rate from drug overdose among AI/ANs in
Washington state is almost three (3) times higher than the national AI/
AN rate and the Washington state average. Alarmingly, the overdose
death rate among AI/AN in Oregon has more than doubled from 2015 to
2020. While the national and state averages have also increased during
this timeframe, the rate among AI/AN in Oregon has increased more--a
158.5 percent increase.
The COVID-19 pandemic caused isolation from familial, social, and
cultural activities, increased anxiety and depression, significant
deaths, economic instability, and barriers accessing mental health
services and substance use treatment. As a consequence, the pandemic
precipitated this devastating opioid and fentanyl epidemic and
Northwest Tribes are experiencing significantly poor mental health and
substance use outcomes. This opioid and fentanyl epidemic is
overwhelming tribal programs and services, including health care,
public safety and tribal justice systems, child welfare, housing,
social services and elder care programs.
The Northwest Tribal Leaders advocated for a convening of Tribes
nationally to develop policy priorities and strategic action items to
address this crisis. In August, the NPAIHB hosted the National Tribal
Opioid Summit which convened over 1,000 tribal leaders, frontline
workers, and federal and state policymakers in Tulalip, Washington to
develop solutions, collaboration, and policy recommendations to
directly address the devastating impacts of fentanyl and opioid drug
abuse in tribal communities. The National Tribal Opioid Summit (NTOS)
Resource Hub, available at https://www.npaihb.org/national-tribal-
opioid-summit/, houses all ongoing resources and materials related to
the Summit, including a draft set of policy recommendations and
Executive Summary. A NTOS Report will be forthcoming and posted to the
Resource Hub webpage.
Based upon the NTOS and NPAIHB priorities, we make the following
recommendations to the Committee to address the fentanyl crisis:
Declare a National Emergency for the Opioid Epidemic
We request the Committee calls upon the President to declare a
national emergency for the opioid epidemic devastating Tribal
communities under the National Emergencies Act, 50 U.S.C. 1601 et.
seq., the Robert T. Stafford Disaster Relief and Emergency Assistance
Act, 42 U.S.C. 5121 et. seq., and Public Health Service Act, 42
U.S.C. 247d. We also request that the Administration utilize all
authorities under the Stafford Act, National Emergencies Act, and
Public Health Service Act to:
allow Medicaid and Medicare reimbursement at the Indian
Health Service (IHS) encounter rate for traditional healing and
tribal based practices and all services furnished by behavioral
health providers;
facilitate access to community wide harm reduction training
and access to supplies, including Narcan and fentanyl test
strips, from the Strategic National Stockpile and the Indian
Health Service's National Service Supply Center;
fully fund tribally operated treatment facilities, wrap
around services, and medically assisted treatment programs;
streamline certification requirements for treatment
facilities and Opioid Treatment Programs; and
provide flexibility for Tribes to incorporate and fund
tribal and cultural practices and to address social
determinants of health, including addressing safe housing, food
security, and training and workforce opportunities.
Expand the use of ISDEAA Self-Determination Contracts and Self-
Governance
Compacts
Northwest Tribes have had longstanding requests to the IHS and
Health and Human Services (HHS) to move away from grant funding and
allow tribes the option to receive funds through their contracts and
compacts. Self-determination and Self-governance contracts and compacts
honor tribal sovereignty and the government-to-government relationship
and authorize Tribes to rapidly deploy programs and services to meet
the needs of their communities. IHS and other HHS agencies continue to
provide funding through grant programs. Grant programs result in
significant administrative costs to operate the grant program that are
not reimbursable. We need HHS funding to be flexible and allow us to
address the mental health and substance use needs within our
communities as the needs arise and without restrictions. This Committee
must support an option for tribally-operated facilities to receive all
HHS grant funds through their ISDEAA contracts and compacts.
In addition, HHS agencies have previously allocated funding to IHS
that was distributed to tribes through existing formulas and ISDEAA
contracts and compacts (e.g., Centers for Disease Control and
Prevention). This process successfully allowed tribes to receive funds
quickly from CDC and to use those funds to best meet the needs in their
communities. All HHS funding should be allocated to Tribes through this
mechanism. This Committee must support legislation expanding ISDEAA
contracting and compacting to HHS and its agencies.
Support for Increased Funding to Address Opioid Response
The President is proposing to provide $1.55 billion in additional
funding to the Substance Abuse and Mental Health Services
Administration (SAMHSA) to address the opioid crisis, including $250
million that would be transferred to the IHS and made available for two
years. We support this long overdue investment to tribal opioid
response but request that IHS is directed to provide those funds to
Tribes and Tribal organizations through their existing ISDEAA contracts
and compacts. We also request support for increased funding to
construct facilities for detox and treatment and to address housing
shortages for individuals in recovery and their families.
Improve Opioid Treatment Program (OTP) Service Delivery
Currently, it's an onerous process to open an opioid treatment
program (OTP) due to the number of inspections, reviews, policies, and
procedures necessary to be in place prior to opening. Under 42 C.F.R.
8.2, the medical director of an OTP is defined as ``a physician,
licensed to practice medicine in the jurisdiction of the location of
the OTP.'' However, there are numerous medically trained providers such
as ARNPs or PA-Cs working for tribes who have the experience and
knowledge to serve in the medical director role. By limiting the
credentials of who can be an OTP medical director, tribes are paying
exorbitant salaries to people who may not be the best fit for the
tribe's needs. We request this Committee to urge SAMHSA to initiate
rulemaking to streamline the certification and accreditation process
for OTPs and to give Tribes the flexibility to choose other medically
trained providers to serve as medical director.
Expand the Community Health Aide Program (CHAP) in the Lower 48
Tribal Leaders in the Portland Area support long term sustainable
solutions that build up our communities, create opportunities for our
youth and tribal citizens, educate our healers and train the next
generation of work force. Lack of behavioral health providers is a
significant issue and need in the Portland Area. The Community Health
Aide Program (CHAP) is a program that was designed and implemented by
the Alaska Native Health system over 60 years ago. In nationalizing it
to the rest of the country, tribes everywhere have an important
opportunity to tackle social determinants of health while improving
healthcare workforce and retention especially focused on behavioral
health workforce. CHAP is unique because it not only increases access
to care, but creates access points to health education so that tribal
citizens can become health care providers with professional wage jobs
on reservations and in tribal health programs throughout the country.
Thus, CHAP is critical to addressing poverty and supporting economic
viability in Tribal communities. The education programs associated with
CHAP are the foundation of the program.
In the Northwest, we have established a Dental Therapy Education
Program, two Behavioral Health Aide Education Programs, and in the
process of developing the Community Health Aide Education programs. We
have also worked with the Portland Area IHS Office to standup a CHAP
Certification Board to certify our Portland Area CHAP providers.
Portland Area Tribes and NPAIHB have been innovative and creative in
securing funding for CHAP expansion despite only receiving one IHS
grant of $1 million (of the $20 million appropriated to IHS for the
expansion of CHAP in the lower 48). This Committee must consider this
crucial opportunity to address workforce shortages in Tribal
communities and further support increased access to behavioral health
services.
Support the National Tribal Opioid Summit (NTOS) Recommendations
The NTOS Policy Recommendations and Final Report are being reviewed
and finalized by Tribal Leaders. The Policy Recommendations and Final
Report will be available on the NTOS Resource Hub available at https://
www.npaihb.org/national-tribal-opioid-summit/. We urge the Committee to
support the NTOS Recommendations in order to address this devastating
epidemic affecting Indian Country.
During the NTOS, Tribal Leaders and other Summit attendees
participated in a policy survey that requested their input on how
Congress and the President could address the fentanyl crisis. The
policy survey results are being compiled and will be posted on the NTOS
Resource Hub. We encourage the Committee to review the policy results
when posted.
Conclusion
Thank you for this opportunity to provide testimony on the fentanyl
crisis in the Northwest. As evidenced by our testimony, Tribes need
resources now to save lives from this devastating epidemic. I invite
you to visit the Northwest to learn more about the fentanyl crisis in
our Area. I look forward to working with the Committee on our requests.
\1\
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\1\ For more information, please contact Karol Dixon, NPAIHB,
Director of Government Affairs/Health Policy.
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______
Prepared Statement of the Seneca Nation
Chairman Brian Schatz, Vice Chair Lisa Murkowski, and Members of
the Committee, these comments are being submitted on behalf of the
Seneca Nation in response to the two recent hearings the Committee held
regarding the epidemic of fentanyl use in Native American communities.
The Seneca Nation appreciates the Committee holding two hearings on
this public health crisis in such a short time, and we request you
continue to hold additional hearings and roundtables on the matter
throughout 2024. After monitoring both hearings and reviewing the
written statements of the witnesses, we think it is critical that the
Committee continue to shine a light on this matter through formal
hearings (including field hearings) and roundtable discussions for the
following reasons:
1. Effectively combatting the fentanyl crisis is a multi-
government effort and will require resources from the federal
and state governments along with Native Nation governments. The
Seneca Nation and other Native Nations need to be at the table
and need to be a part of the dialogue about potential solutions
and information sharing regarding the fentanyl crisis. The
federal government has a treaty obligation to help us respond
to this epidemic, and federal partnership is necessary to make
any effective progress in this fight. Holding additional
hearings and roundtable discussions ensures that our Native
voices are heard and creates transparency and accountability
for making meaningful progress on this matter; and
2. In addition to ensuring that we are at the table and are a
part of the discussions, hearings improve the level of
information sharing between governments and communities. The
recent hearings shared useful information about the public
health crisis experienced in other parts of Indian Country.
This information helps guide strategies for combatting the
surge of fentanyl use in our own community. The Seneca Nation
submits these comments to ensure our experiences are placed on
the record to inform the federal government and other Native
Nations about what we are doing to combat fentanyl and its root
causes within our community. One thing that is clear from the
hearings is that Congress and federal agencies are taking too
long to adopt protective laws and policies and to develop best
practices. Fighting the scourge of fentanyl cannot wait for
changes in laws and policies, and sharing information is vital
for those of us who are not getting the same level of outreach
and support from our local federal and state government
entities. The Seneca Nation cannot wait for federal laws and
policies to change. We are taking an active role in addressing
our growing fentanyl crisis. This is why we created our own
Opioid Taskforce, compromised of Seneca Nation leadership and
community members, committing our own resources to develop an
action strategy to combat the root causes of the fentanyl
crisis. Despite committing our own resources, it is still the
federal government's responsibility to aid us and provide
additional funding.
The Seneca Nation is one of the largest of the six Native Nations
from the historic Iroquois Confederacy, a democratic government that
predates the formation of the United States. We are located in what is
now called Western New York State. We have over 8,500 enrolled members,
most of whom reside on or within fifty miles of our multiple non-
contiguous territories. Our territories span four counties: Erie,
Cattaraugus, Chautauqua, and Niagara. Our judicial system is comprised
of a Peacemakers Court that focuses on civil matters, a Surrogates
Court that oversees probate matters, and a Court of Appeals. The
primary enforcers of Seneca Nation laws are the Seneca Nation Marshals
and Conservation Officers. The Nation does not have its own criminal
code or criminal laws and, therefore, the Nation's law enforcement
officers do not enforce any criminal laws and the Nation's Courts do
not process any criminal complaints. Federal and state law enforcement
officials share authority under federal law to exercise criminal
jurisdiction over the Nation's territories, but their limited resources
and competing interests often mean that the enforcement of criminal
laws on Nation territories may not receive the same attention as
neighboring off-territory communities.
Like other Native Nations, the Seneca Nation experiences drug-
related challenges and a surge in opioid abuse and fentanyl related
overdoses and deaths. No family in our Nation has been spared from this
heartache, and we all know someone who is suffering from the fentanyl
crisis. We have had instances where babies are born addicted to opioids
and our community must watch these babies go through the detox process.
Many of our children have lost their parents due to overdose, and many
more watch their parents struggle with active addiction. These
situations place additional burdens on extended families and our foster
care system who must now care for these children. A spiritual person in
our community had a dream in which an elder Seneca woman on the other
side came back to our community and expressed concern about all the
Seneca children without parents. This woman delivered a message that we
need to do more for these children who have lost their parents to
opioids.
We have seen some of our young adults overdose on opioids,
including fentanyl, and discarded on the street instead of rushed to a
hospital where they might have a chance to survive. In one case, a 24-
year-old Seneca man was discarded only several houses away from his
mother's house. Worse is that these stories have become so frequent
that our people are becoming numb and desensitized to the crisis and
long-term trauma it is causing.
The effects of addiction and loss ripple through our community.
Like other Native Nations, our community feels like an extended family,
and we are all connected. Thus, deaths affect all of us-neighbors,
friends, and family. Over the past 10 years, the number of funerals in
our community has increased tremendously and the devastation that
untimely and unnecessary deaths leave behind is often unbearable.
Between 2015-2020 alone, there were 110 documented overdoses on two of
our territories. There have been so many funerals within our community
over the past year that a group of Senecas formed a grass roots
organization to help grieving families. It is the custom and tradition
of Seneca people to bring the bodies of our loved ones home when they
pass away so that our community may care for them with traditional
ceremonies. This can involve hundreds of people coming to a home to
participate in the ceremonies and grieving process. Since most homes
cannot fit this many people, large canopies, tables, and chairs are set
up outside the home to accommodate the number of mourners who visit
throughout the day and night. Given the increased number of funerals in
our community, the grass roots organization also provides resources to
Seneca families for the mourning process and provides grief support.
The opioid epidemic, particularly fentanyl, is our number one
priority, which is why we are so grateful that the Committee held two
hearings on the matter. Fentanyl is such an important issue to us that
the Seneca Nation representative attending the annual White House
Tribal Nations Summit left the Summit to attend the Committee's hearing
on December 6th. These hearings allow for much information to be shared
and conveyed on the record and highlight why it is so important for the
Committee to continue holding additional hearings and shed more light
on this critical issue that impacts all Native Nations. There are three
key things we took away from the two hearings held by the Committee:
1. There is a significant need for more data collection and
data sharing to help combat this crisis;
2. The experiences of Native Nations across the country with
respect to fentanyl and access to federal and state resources
varies greatly; and
3. More federal and state resources are needed now, and needed
quickly, for Native Nations to effectively combat fentanyl.
The hearings highlighted the disparity in data collection and
sharing across the country and how better data can help each community
develop targeted action items. Councilman Bryce Kirk from the
Assiniboine and Sioux Tribes of the Fort Peck Reservation provided very
good data collected by his government, in combination with data that
was shared by the state government. This data allowed the Assiniboine
and Sioux Tribes' government to develop concrete recommendations for
what is needed to combat the fentanyl crisis on their reservation. The
Seneca Nation has been collecting data but we also have encountered
barriers to accessing data collected by local governments. For
instance, we know from our own data that the use of Narcan has helped
prevent deaths from opioid overdoses. Our Seneca Emergency Management
Services tracks the number of calls for dispatch and how many get
cancelled and for what reason. We have had a number of cancelled calls
over the past few months because Narcan was successfully administered.
From this data, we know that increasing the availability of Narcan and
educating people on how to use it reduces the number of overdoses in
our community.
We also know from data collected by Erie County that Senecas are
disproportionately impacted by fentanyl and overdoses. Over one-third
of the Seneca population resides in Erie County and data from the
County government indicates that overdoses among Native Americans is
triple that of other groups. However, data from Cattaraugus County,
where many Seneca people also live, is lacking because of discrepancies
in the data collection methods and available funding. In Cattaraugus
County, the specific cause of death for many opioid overdoses is listed
as heart attacks because the County only has a coroner, not a medical
examiner. Not having the financial resources to hire a medical examiner
means that Cattauragus County is unable to adequately collect the data
surrounding deaths related to fentanyl overdose. Thus, we do not have
an acurate picture of the impact on our people in Cattauragus County.
The hearings also highlighted the disparities in the level of
interactions between the Bureau of Indian Affairs (BIA) and Department
of Justice with various Native Nations across the country. The Director
of the BIA's Office of Justice Services shared valuable information
about some of the threats of opioids in Indian Country. However, the
information also highlighted what the BIA fails to know, such as the
impacts on each Native Nation's community, government and social
services. Additionally, very few, if any, Native Nations in the
Northeast have a BIA presence in our territories. The Eastern Region
Office of the BIA is located in Nashville, Tennessee, and serves 34
Native Nations located in 12 states East of the Mississippi River. BIA
law enforcement officers have a very limited presence in any Native
Nations in the Eastern Region, with field offices only in three Native
communities and all of those are in the Southeast. The Director of the
BIA's Office of Justice Services provided the Penobscot Nation's
Healing to Wellness Court as an example of a Native Nation combatting
the fentanyl crisis even though the BIA has no presence on the
Penobscot Reservation. The New York Field Office formerly located in
Syracuse, NY no longer exists and is temporally located in Cherokee,
North Carolina. The hearings show how the BIA's Office of Justice
Services needs additional resources to offer any real assistance to
Native Nations across the country.
The same is true with regards to the various entities within the
U.S. Department of Justice. We were surprised to hear the testimony of
U.S. Attorney Vanessa Waldrefin which she conveyed very detailed data
about fentanyl in Eastern Washington State, the level of coordination
between her office, Native Nations in the district, the FBI, the BIA,
and the DEA. Also surprising was the number of consultations her office
convenes with Native Nations, the Safe Trails Task Force, and the DEA's
Operation Engage, which focuses on prevention and education. Our
interactions in Western New York are far different from what U.S.
Attorney Waldref describes as occurring in Eastern Washington. There
has been only limited outreach in recent years to us from the U.S.
Attorney for the Western District of New York, and even less from the
BIA or FBI. We are impressed with the level of coordination and
outreach that U.S. Attorney Waldref described in her testimony and
believe that the U.S. Department of Justice could increase its
effectiveness if similar levels of coordination and outreach were
performed throughout Indian Country.
The Seneca Nation shares many of the same experiences as those
Native Nations in Eastern Washington. Our lands are in rural areas, our
people suffer from intergenerational trauma, and our communities and
government are still recovering from broken treaties and promises made
by the United States. We believe that our territories and people are
being specifically targeted by drug cartels and dealers for the same
jurisdictional complexities and lack ofresources that U.S. Attorney
Waldreftestified about for Eastern Washington. Our territories border
the State of Pennsylvania and are close to the Canadian border, and we
are positioned in a main corridor to access New York City. Thus, drug
dealers seeking to smuggle drugs into New York City often target the
Seneca Nation territories as places to set up shop for strategic
access. Yet, the amount of interaction and information we are receiving
from the federal government and State of New York is far less than what
U.S. Attorney Waldref describes as occurring in Eastern Washington.
Finally, the hearings highlighted that additional resources are
needed in Indian Country to combat the fentanyl crisis. All the data
shared during the hearings point to how Native Americans and our
communities are disproportionately impacted by opioid abuse and are
targeted by drug dealers and smugglers because of complex
jurisdictional issues and a lack of information sharing and
coordination with the federal and state governments. Yet, we receive no
additional resources to mitigate these disproportionate impacts. We
need more resources, and we need them now! We need more financial
resources, more information and consultation, and more flexibility and
less red tape from the federal government on how we use our federal
funding so we can address this crisis with the flexibility it requires.
As several of the Native Nation leaders testified during the
hearings, there is no single solution to the fentanyl crisis, and we
must take a holistic approach to solving the problem and its root
causes. A holistic approach means that we need to focus on supporting
cultural practices, mental health, detoxification, and treatment, in
addition to law enforcement. Like other Native Nations, our people lack
access to detox treatment and adequate mental health services. We need
federal funding to address these issues and the flexibility to develop
comprehensive communitybased programs in a culturally relevant manner.
Many states receive federal funding for addiction services and support
services, but this federal funding is not making its way to Native
Nations even though we are disproportionately impacted by the fentanyl
crisis. New York State has an Office of Addiction Services and Support,
but the Seneca Nation receives no funding or assistance from this
office. We need direct funding from the federal Substance Abuse and
Mental Health Services Administration (SAMHSA) rather than relying
solely on State resources. And, we should not have to compete with
other Native Nations for such vital funding; every Native Nation should
receive fundin to address mental health issues and intergenerational
trauma. As a part of the Seneca Nation's commitment to take an active
role in addressing fentanyl abuse and its root causes, we are hosting
the World Indigenous Suicide Prevention Conference in the summer of
2024. This will be the first time the Conference will be held in the
United States and held on Indigenous lands. Yet, we are not receiving
any federal funding to host the Conference even though opioid and
fentanyl use is directly related to suicides in Native American
communities. Our hope is the Department of Health and Human Services
and the Indian Health Service will become partners with us on this
Conference.
In addition to increased federal funding, Native Nations need far
more flexibility in how we can use federal funding so that we can
quickly take actions targeted towards various health crises, such as
fentanyl, without having to wait for Congress to make changes to
existing laws or agencies to revise policies and regulations. We
appreciate President Biden issuing Executive Order 14112 To Promote the
Next Era of Tribal Self Determination. This Executive Order is intended
to make federal funding more accessible, flexible, and equitable for
Native Nations by reducing red tape and allowing Native Nations to
exercise more autonomy over how we use federal funds. Additionally, the
Executive Order creates a one-stop-shop website for Native Nations to
research the federal funding available to us and requires the federal
government to better assess its unmet obligations to Native Nations. It
sounds like good progress, but how long will it take to implement this
Executive Order, and specifically what can be done now pursuant to the
Executive Order to help the Seneca Nation and other Native Nations to
combat the fentanyl crisis in our communities? We need the Committee to
push for the Executive Branch to answer these questions and to provide
answers quickly versus a year from now.
In closing, the Seneca Nation again thanks the Committee for
holding its two recent hearings on the fentanyl crisis, and we ask that
the Committee continue to hold hearings on this important issue in
2024.
______
Prepared Statement of the United South and Eastern Tribes Sovereignty
Protection Fund
As the Committee well knows, the opioid crisis has had a
devastating effect on USET SPF Tribal Nations and Tribal Nations across
the country who continue to experience the destructive effects of
opioid addiction at rates higher than non-Indian communities. According
to the Centers for Disease Control and Prevention (CDC), American
Indians and Alaskan Natives (AI/ANs) experienced the highest rates of
opioid overdose deaths of any racial or ethnic group in both 2020 and
2021. Between 2020 and 2021 alone, Tribal communities experienced a
staggering 33 percent rise in overdose deaths, \1\ the vast majority of
which are the result of opioids, particularly synthetic opioids like
fentanyl. Despite the disproportionate impact opioid use has had in
Indian Country, Tribal Nations continue to lack access to sufficient,
critical resources to address the damaging effects of opioid abuse in
our communities. USET SPF offers the following comments and
recommendations to the Committee to underscore the need for
Congressional action, in accordance with trust and treaty obligations,
to ensure Tribal Nations have the resources necessary to address this
epidemic.
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\1\ ``Drug Overdose Deaths in the United States, 2001-2021,''
Centers of Disease Control and Prevention
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USET SPF is a non-profit, inter-tribal organization advocating on
behalf of thirty-three (33) federally recognized Tribal Nations from
the Northeastern Woodlands to the Everglades and across the Gulf of
Mexico. \2\ USET SPF is dedicated to promoting, protecting, and
advancing the inherent sovereign rights and authorities of Tribal
Nations and in assisting its membership in dealing effectively with
public policy issues.
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\2\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian
Nation (SC), Cayuga Nation (NY), Chickahominy Indian Tribe (VA),
Chickahominy Indian Tribe-Eastern Division (VA), Chitimacha Tribe of
Louisiana (LA), Coushatta Tribe of Louisiana (LA), Eastern Band of
Cherokee Indians (NC), Houlton Band of Maliseet Indians (ME), Jena Band
of Choctaw Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee
Wampanoag Tribe (MA), Miccosukee Tribe of Indians of Florida (FL),
Mississippi Band of Choctaw Indians (MS), Mohegan Tribe of Indians of
Connecticut (CT), Monacan Indian Nation (VA), Nansemond Indian Nation
(VA), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),
Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian Township
(ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot Indian
Nation (ME), Poarch Band of Creek Indians (AL), Rappahannock Tribe
(VA), Saint Regis Mohawk Tribe (NY), Seminole Tribe of Florida (FL),
Seneca Nation of Indians (NY), Shinnecock Indian Nation (NY), Tunica-
Biloxi Tribe of Louisiana (LA), Upper Mattaponi Indian Tribe (VA) and
the Wampanoag Tribe of Gay Head (Aquinnah) (MA).
---------------------------------------------------------------------------
Data Collection and Access Challenges Result in Insufficient Resources
It is unquestionable that opioid abuse, deaths, and trafficking
have reached epidemic levels in the United States, but particularly in
Indian Country. Available statistics already show that AI/AN peoplehad
the highest rates of drug related deaths in recent years, and
information from the Indian Health Service (IHS) indicates that AIANs
are more likely than any other race/ethnicity to have an illicit drug
use disorder. According to the National Institutes of Health (NIH),
opioid mortality rates for AI/AN populations have risen almost
continuously for nearly two decades.
However, USET SPF suspects that rates of AI/AN opioid overdose and
addiction among Tribal Nations are likely much higher than even
national statistics and current data reveal. Per the CDC,
misclassification of race on death certificates ``results in the
underestimation of death rates by as much as 34%'' for AI/AN people.
Further, currently available data fails to fully illustrate the impacts
opioids are having in Tribal communities, as data access within the
Indian Health System is limited and often incomplete. To assess the
full scope of impacts opioids are having in our communities, Tribal
Nations require strengthened data collection activities at all levels.
However, no funding is currently available to Tribal Nations to create
data systems that could more adequately and appropriately illustrate
the impacts of the opioid crisis, and access to necessary federal data
sets.
As we have testified in the past, an overall lack of data
surrounding the opioid crisis, as well as barriers to data collection
and dissemination within the Indian Health System, has not only impeded
Tribal Nation prevention and treatment efforts, but also efforts to
secure increased federal funding. In the absence of robust,
comprehensive data demonstrating the disproportionate effects of opioid
use in Indian Country, effort to expand treatment and prevention
services are greatly hampered.
To remedy this, Congress must provide direct funding to Tribal
Nations and Tribal Epidemiology Centers (TECs) in order to improve
opioid data collection. Without access to critical data, direct
funding, or Congressional champions when strategies are being
developed, Tribal Nations will continue to feel the impacts of the
opioid epidemic for generations. USET SPF urges the Committee to
prioritize addressing this shortfall by working to ensure Tribal
Nations have access to direct funding to improve opioid data and
provide for the treatment and prevention of substance abuse.
Moreover, Tribal Nations and Tribal Epidemiology Centers (TECs)
continue to experience frequent challenges in accessing not just public
health data on both the federal and state level, but Tribal data as
well, which often is not reported back to the Tribal Nation when
collected by other jurisdictions. Despite being designated as Public
Health Authorities, a Government Accountability Office Report, and
Congressional oversight measures, both Tribal Nations and TECs continue
to experience frequent challenges in accessing data on both the federal
and state level--on top of the consistent lack of investment in TECs
and Tribal public health capacity. As Public Health Authorities, TECs
provide invaluable Tribal Nation-specific public health data and
information to Tribal leaders, health directors and public health
professionals in Indian Country. TECs continue to petition both the CDC
and state public health departments for this vital information but have
only received state data where there are positive Tribal-state
relationships.
Congress must remedy this problem, including through compelling the
CDC and states to share all relevant data sets with Tribal Nations and
TECs. CDC must ensure that TECs have access to critical public health
data from federal and state governments. Both should be statutorily
required to share all available public health data with TECs and Tribal
Nations. This should be made a requirement of state cooperative
agreements with CDC. CDC must also take steps to improve the quality of
public health data shared with TECs and Tribal Nations. This includes
requiring states work with Tribal Nations to correct racial
misclassification.
Increased, Direct Funding for the Indian Health System
The federal government has trust and treaty obligations to ensure
Tribal Nations have access to resources, financial and otherwise, to
combat the opioid epidemic. The federal government has affirmed many
times over its requirement to ``provide all resources necessary'' to
ensure ``the highest possible health status'' for Tribal Nations and
citizens. This necessarily includes flexible and substantial funding to
create programs and services that are responsive to the challenges
facing our communities. Though the data on this issue is incomplete,
that which is available shows that Indian Country is being
disproportionately and significantly affected by the opioid crisis. And
yet, we remain without access to critical resources, particularly
direct federal dollars. USET SPF urges the Committee to prioritize
addressing this shortfall by working to ensure Tribal governments have
access to direct funding.
Access to funding for federal opioid grant programs is also
important for Tribal Nations and communities. Programs like the Tribal
Opioid Response (TOR) Grant Program at the Substance Abuse and Mental
Health Services Administration (SAMHSA) are valuable tools in fighting
the opioid epidemic in Indian Country. USET SPF urges Congress to
increase funding for this program, as well as appropriate dedicated
funding for the $80 million Behavioral Health and Substance Use
Disorder Program for Native Americans authorized (but not funded) at
SAMHSA last year. In addition, USET SPF continues to support and urge
the immediate passage of The Native Behavioral Health Access
Improvement Act, legislation authored by Senator Tina Smith that would
establish and provide substantial funding for a Special Behavioral
Health Program for Indians, with dollars eligible for receipt through
self-governance compacting and self-determination contracting.
Further, USET SPF supports the adoption of the President's
supplemental funding request to combat the opioid epidemic. This $1.55
billion request includes a $250 million transfer to the IHS via the
State Opioid Response (SOR) grant program. However, it is yet unclear
how the funding would be disbursed from the IHS. USET SPF asserts our
expectation that these funds will be eligible for self-governance
contracting and compacting so that Tribal Nations can directly access
these dollars and determine how best to utilize them in our
communities.
It is important to note that while existing federal programs have
been valuable tools in the fight against the opioid epidemic so far,
there remain significant issues with the provision of funding to Indian
Country through grants and other mechanisms that do not uphold Tribal
sovereignty and self-determination. Many federal grant programs require
funding to pass through the states before it can be delivered to Tribal
Nations if it is delivered at all. Further, when applying for these
grants, states will often include Tribal population and prevalence
numbers in the overall state data used to determine each state's award.
Yet, Tribal Nations are not provided with outreach for these programs
and are left with minimal resources to address the opioid crisis in
their communities. Even when grant programs are specifically provided
for Tribal Nations and organizations, the grant funding is often
extremely limited, and the sheer nature of competitive grants often
excludes many Tribal Nations that would benefit from the programs.
Tribal Nations must not be made to compete with one another for these
limited resources, as funding to Tribal Nations is provided in
fulfillment of federal trust and treaty obligations--not in response to
relative ``need'' or circumstances. To force Tribal Nations to compete
for limited resources through competitive grants is an abrogation of
the trust responsibility and an affront to Tribal sovereignty.
To ensure that Tribal Nations are able to access federal funds
fully and meaningfully in the future, USET SPF recommends the Committee
and Congress:
Pass and implement ``The Native Behavioral Health Access
Improvement Act'' legislation and provide substantial funding
for a Special Behavioral Health Program for Indians, with
dollars eligible for receipt through self-governance compacting
and self-determination contracting.
Fully fund and implement programs such as the Behavioral
Health and Substance Use Disorder Resources for Native
Americans Program at SAMHSA;
Expand language within grant funding programs to
specifically include Tribal Nations such that states cannot
exclude us in grant funding disbursements and are held
accountable by the federal government for delivering funds
directly to Tribal Nations; and
Enact delivery of all federal dollars, including opioid
funding, to Tribal Nations via self-governance contracting and
compacting in recognition of Tribal sovereignty and self-
determination.
Telehealth and Medication Assisted Treatment
Well before the COVID-19 pandemic increased the prevalence and
availability of telehealth services, USET SPF advocated for expanded
telehealth services in Indian Country to combat the rising substance
abuse crisis. Existing telehealth programs within Indian Country have
made significant improvements in their communities when it comes to
access to care, diagnosis, and treatment. In response to the COVID-19
pandemic, the federal government eased several long-standing
regulations regarding opioid treatment programs. For example, prior to
2020, people suffering from opioid use disorder were required to meet
in-person with a health care provider to start medication assisted
treatment. During the COVID-19 pandemic, the federal government
implemented flexibilities that allowed practitioners to prescribe
medications like buprenorphine remotely to new patients via telehealth.
They also allowed for expanded payment for telehealth services and
flexibility on accepted communication technologies (like audio-only
services) to deliver care for substance use disorders via telehealth.
Expanding the use of telehealth for treating substance use disorders is
a vital component in efforts to address the opioid epidemic in Tribal
communities. A study by the National Institutes of Health (NIH)
demonstrates that opioid use disorder treatment via telehealth was
associated with an increased likelihood of staying in treatment, as
well as an increased in treatment access overall. USET SPF urges the
permanent adoption of these temporary authorities so that expanded
access to services may be maintained.
However, though Tribal telehealth continues to make strides, Indian
Country continues to fall behind in establishing sustainable, standard
telehealth system due to limited, or often, lack of existing
infrastructure and bandwidth. The same NIH study referenced above found
that the ``benefits of telehealth are not reaching all populations
equitably.'' It is crucial that Congress invest not only in opioid
addiction telehealth services within Tribal Nations and communities,
but also in infrastructure and bandwidth capabilities. Telehealth
funding and expanded authorities will not be beneficial if barriers to
access, such as infrastructure and bandwidth issues, are not addressed.
Increased Law Enforcement Resources
In addition to health and treatment resources, USET SPF member
Tribal Nations require adequate law enforcement infrastructure to
combat the opioid epidemic. Opioid trafficking is a persistent and
growing problem in Indian Country, as several witnesses noted, and the
USET region is not an exception. In order sufficiently address the
growing opioid abuse and trafficking within our Tribal Nations, our BIA
Drug Enforcement Region needs additional resources, including human
capital.
Tribal Nation law enforcement agencies, much like other entities
operating in Indian Country, face chronic underfunding, understaffing
and other challenges due to inadequate federal appropriations.
Additional resources must be made available to Tribal Nations when it
comes to critical drug enforcement investigations. These services are
conducted primarily by specialized units or task forces on
departmental, statewide and federal levels and involve enhanced
intelligence gathering, information sharing, controlled buys,
surveillances and other factors. As the Committee approaches this
crisis, it must not forget the importance of stopping the supply of
opioids on Tribal lands through well-equipped law enforcement.
In a March 2023 report to Congress (as required under the Tribal
Law and Order Act), the Bureau of Indian Affairs (BIA) indicated that,
``the total estimated costs for public safety and justice programs is
$1.4 billion for law enforcement programs, $247.7 million for existing
detention centers, and $1.2 billion for Tribal courts.'' At
approximately $2.9 billion, this exceeds the entire current BIA budget.
This underscores the chronic underinvestment in law enforcement and
other public safety programs, and the need for this Committee to
support full and mandatory funding for Tribal programs, including
Public Safety & Justice line items.
Culturally Competent Treatment and Services
The incorporation of traditional healing practices and a holistic
approach to health care are fundamental to successful opioid treatment
and aftercare programs in Indian Country. Culturally appropriate care
has had positive, measurable success within Tribal communities, and the
incorporation of traditional healing practices and holistic approaches
to healthcare has become central to many Tribal treatment programs.
Tribal communities have unique treatment needs when it comes to
substance abuse disorders, as AI/ANs experience high levels of
substance abuse disorders, with a strong link to historical trauma.
Opioid addiction treatment in Indian Country, then, must be cognizant
of this trauma, respectful of community factors, and utilize
traditional health care practices. Additionally, opioid addiction
treatment within Tribal communities must include adequate culturally
appropriate aftercare programs to help prevent substance abuse relapse.
These services must be accessible through the Indian Health Care
Delivery System.
Even though culturally competent care has been successful across
Indian Country, treatment options that incorporate cultural healing
aspects are oftentimes not available within or near Tribal communities
due to a lack of resources. However, some USET SPF member Tribal
Nations are engaging in innovative practices that have the potential to
be replicated across Indian Country. For example, one Tribal Nation's
treatment program incorporates a culturally-based recovery model that
has had great success, including in preventing early relapse following
treatment. Other best practices within USET SPF member Tribal Nations
include:
Extended, culturally-based recovery support in a sober
living environment
Trauma informed care training for health and behavioral
health staff
Establishment of innovative, culturally-appropriate Tribal
restorative justice models, such as the Penobscot Nation's
Healing to Wellness Court.
With additional funding and guidance, Tribal Nations could expand
these best practices and incorporate additional practices such as rapid
entry into acute care facilities and additional prevention and control
interventions. USET SPF encourages the Committee to explore how it
might expand these models through legislative action and provide direct
funding to support the best practices that have already been
implemented.
Conclusion
USET SPF appreciates the Committee holding a hearing to hear
specifically from Tribal Nations and leaders as the opioid crisis
continues to disproportionately affect our communities. Opioid
addiction is unquestionably causing devastating effects and suffering
in Indian Country. As Congress considers legislative action on
combatting the opioid crisis nationwide, as well as Fiscal Year 2024
federal funding, it must prioritize Tribal Nation access to all the
resources necessary to address this crisis.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Bryce Kirk
Questions. Councilman Kirk, in your written testimony, you wrote
about the lack of information sharing between the Drug Enforcement
Agency (DEA) and Tribal law enforcement. I have heard similar concerns
from Tribes in New Mexico, including the Navajo Nation. Can you expand
on this? Have you broached this concern with the DEA? What has been the
response?
Lack of prosecutions in the Missing and Murdered Indigenous Peoples
space is an area where I've tried to hold DOJ accountable, and I'm
frustrated that the same problem applies to drug dealers. Are you also
having problems with DOJ and local law enforcement failing to prosecute
non-Indian drug dealers on Tribal lands?
Senator Lujan thank you for the question.
Answer. Our law enforcement officials have let the DEA and the ATF
know our frustration that they were aware of a known drug dealer on our
Reservation and that they failed to inform us or include our law
enforcement in their investigation. The response from the federal
agencies is that they were engaged in an investigation and that they
cannot compromise their investigation by sharing information with the
Tribes' law enforcement agencies. Our sense is that this is almost a
turf war, where one agency wants the big bust and the credit for the
bust, rather than focusing on what should be the objective, which is
removing drug dealers from our communities and working with all
involved law enforcement agencies to accomplish this goal.
We think this can be addressed by supporting multi-agency drug task
forces, which include ATF, DEA, FBI, the Tribal and State law
enforcement agencies. We should all know where the threats are and how
we as cooperative law enforcement agencies are responding to these
threats. Such a task force could report to the Attorney General's
office directly and that way he could ensure that all the agencies
within his purview are working cooperatively.
Regarding your question if we are having problems with DOJ and
local law enforcement failing to prosecute non-Indian drug dealers on
tribal lands, the answer is two-fold.
First our challenge with the Department of Justice is that they
focus on the big drug dealers, transporting pounds of illegal drugs.
However, a significant issue on the Fort Peck Reservation is that there
are people who are dealing 50 pills or less, and the Department of
Justice has no interest in prosecuting these people. As to working with
local agencies, we have a cross-deputization agreement with Roosevelt
County, the State Patrol, the City of Poplar and the City of Wolf Point
where we work to ensure that criminals, including drug dealers, are
properly prosecuted. However, we appreciate that the State of Montana
respects our sovereignty and the proper role of the federal government
to prosecute crimes by non-Indians against Indians. Again, the
challenge for us is that the DOJ does not have the resources to arrest
and prosecute the ``smaller'' drug dealers and thus they are left to
continue to poison our community 20-30 pills at a time.
We would support the federal recognition of the inherent
sovereignty of tribes to prosecute non-Indians engaged in drug dealing
on the Reservation, akin to when Congress recognized the inherent
authority of tribes to prosecute non-Indians who commit domestic
violence crimes and crimes against children on our Reservation.
We look forward to working with you to address this crisis in our
community.
______
Response to Written Questions Submitted by Hon. Brian Schatz to
Hon. Jamie S. Azure
Question. The National High Intensity Drug Trafficking Area (HIDTA)
Program under the Office of National Drug Control Policy partners with
federal, state, local and tribal law enforcement to combat drug
trafficking. Would expansion of the program to include Turtle Mountain
help with your tribe's enforcement efforts?
Answer. Thank you, Chairman Schatz, for the question, the nearest
HIDTA that we could participate is in Kansas City, Missouri for the
Great Plains region. There is a North Dakota Interdiction Trask force
that is headed by the DEA and the North Dakota State Police. Although
we have good relations with the North Dakota State Police, this task
force is primarily a DEA/State oriented task force. However, what's
missing from HIDTA and the most recent 2021 DEA Drug Threat Assessments
is the lack of information or intelligence regarding drugs in Indian
Country. What would be useful would be a requirement that DEA conduct a
separate drug threat assessment focusing on Indian Country especially
where a Federally recognized tribes are within the HIDTA. This
information would be critical for intelligence gathering and resource
deployment.
Turtle Mountain Band (TMB) DDE (Division of Drug Enforcement) Drug
Supervisor Brock Baker worked on several HIDTA task forces throughout
North Dakota over the last 20 years, namely the Grand Forks Narcotics
Task Force and Cass County Drug Task Force. Mr. Baker has a great
working relationship with both task forces. However, many of the
relationships have been formed through previous work relationships he
had with them.
Mr. Baker estimates that 75 percent of their cases come from the
Red River Valley area with the majority coming from Grand Forks and
Fargo metro areas. Both locations have a huge urban Native population
and many drug traffickers use our Native people for entrance or
introduction to tribal members on the reservations.
Mr. Baker spoke with ND BCI Director Lonnie Grabowski, and he and
his Task Force Coordinators in Grand Forks and Fargo, and all are
supportive of placing a tribal officer on one of their task forces to
create a ``liaison'' between the tribe and state HIDTA task forces.
This officer would bridge a state task force and the tribal drug unit.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Jamie S. Azure
Question. What has been your experience in working with the DEA?
Are they good partners?
Answer. Thank you, Senator Lujan, for the question. DEA
traditionally has been a good partner, but the partnership has been
difficult recently due to the DEA being short-staffed and being
detailed out to other areas of the country. One of the areas that the
DEA lacks is a consistent presence in Indian Country to conduct drug
operations and investigations.
Historically, the DEA is known to conduct larger-scale
investigations, such as drug conspiracy cases involving large-scale
dealers who may target Indian Reservations. Many of the cases involving
tribal members mainly involve non-enrolled individuals who conspire
with a tribal member to traffic drugs on or near tribal lands.
DEA did conduct a large arrest operation in the summer/fall of
2022. TMB DDE assisted in the arrest operation.
TMB DDE has attempted to conduct investigative operations with the
DEA RO Fargo office; however, due to that office being short-staffed,
they have had to push back operations several times in 2023 and
canceled an operation set for September 2023.
Mr. Baker, who had previously been assigned to the DEA Task Force
Fargo from 2010 to 2014, inquired about placing a tribal drug
investigator with the DEA Task Force. The DEA Resident Agent in Charge
was very interested, and several meetings were held between Mr. Baker
and the DEA supervisor over the course of 2023 to discuss placing an
officer with DEA Fargo RO.
Although being with the DEA Task Force would be beneficial, having
an officer on a state-run HIDTA task force may provide the most benefit
in connecting street-level drug crimes and larger-scale, multi-
jurisdictional investigations on or near tribal lands.
______
Response to Written Questions Submitted by Hon. Ben Ray Lujan to
Hon. Tony Hillaire
Question 1. The IHS Community Opioid Intervention Pilot Project
awarded 35 grants in 2021 using a little over $16 million in funding
appropriated by Congress, including one to the Albuquerque Area Indian
Health Board in New Mexico and one to the Lummi Nation in Washington.
Chairman Hillaire, what was the impact of these grant funds on the
Lummi Nation?
Answer. We are pleased to report significant progress in our
healthcare services, made possible through the Indian Health Service
Community Opioid Pilot Project. The Lurnmi Nation received $300,000 in
2021. With this grant we have successfully reached and provided
services to over 500 individuals. This milestone is a testament to the
effectiveness of our outreach and support strategies, which have been
crucial in engaging with individuals struggling with addiction and
connecting them with necessary care.
Specifically, our efforts have focused on outreach to homeless
camps, jails, and patients who have left medical facilities against
medical advice. Our staff provided counseling to encourage those who
have disengaged to re-enter treatment and offered guidance on harm
reduction around drug use as well as providing access to overdose
reversal kits, information on clinical care access for health-related
concerns and wound care. By going directly to where the need is
greatest, we have been able to make a tangible difference in the lives
of those most affected by the opioid crisis. Additionally, some of the
funding has been used towards transportation services for patients
being admitted to supports such as clinical, outpatient and in-patient
care. Transportation continues to play a crucial role in our strategy,
ensuring that logistical and geographical challenges do not hinder
individuals from accessing ccntinuous care. This support has been vital
in maintaining treatment adherence and fostering overall health.
healing, and recovery.
Question 1a. And, given that this pilot grant program is not
permanently authorized, wty is it so important that Congress support
the President's domestic supplemental request, including the 16 percent
set-aside for IHS within the $1.55 billion he requested to combat the
fentanyl crisis?
Answer. The President's domestic supplemental request, particularly
the 16 percent set-aside for the Indian Health Service (IHS) within the
$1.55 billion proposed to combat the fentanyl crisis, is of paramount
importance. The Lumrni Nation, like many other Tribal nations, is
facing an acute and escalating crisis due to fentanyl. The potency and
prevalence of this drug have led to a drastic increase in overdoses and
deaths and our Tribe is in urgent need of resources to combat this
crisis effectively. Without adequate funding, the efforts to tackle
this epidemic are significantly hampered.
Currently, our Tribe faces a heartbreaking situation where
individuals seeking help for their addiction are often turned away due
to the lack of resources and treatment capacity. This reality is
devastating. When an individual courageously seeks assistance for
addiction, facing rejection due to lack of available treatment options
can be devastating and potentially fatal. Often, by the time a
treatment bed becomes available, it may already be too late for those
who were previously denied access. Many may have fallen deeper into
their addiction or reached a point where they are unable or unwilling
to seek further help. This creates a pattern of relapse and missed
opportunities for meaningful intervention and recovery.
With sufficient funding, we can significantly expand our treatment
facilities and services. This expansion means more beds for inpatient
care, enhanced outpatient services, and the availability of medically
assisted treatments. Additionally, increased funding can be allocated
to prevention and education programs. By informing our community,
especially the youth, about the dangers of fentanyl and other opioids,
we can prevent addiction before it takes hold. Furthermore, recovery
from addiction is a long-term process. Additional funding would allow
us to provide essential support services, including counseling, job
training, and aftercare programs, to help individuals reintegrate into
the community after treatment.
Question 2. Chairman Hillaire, in your testimony you stated that
due to a lack of prosecutions from the DOJ and local authorities,
Tribal law enforcement is unable to hold accountable non-Indian drug
dealers on Tribal lands. Lack of prosecutions in the Missing and
Murdered Indigenous Peoples space is an area where I've tried to hold
DOJ accountable, and I'm frustrated that the same problem applies to
drug dealers. Can you tell me more about this problem?
Answer. One of the main challenges is the jurisdictional
limitations imposed by federal law. Tribal authorities do not have the
power to prosecute and punish non-Indians for drug trafficking offenses
committed within our reservation. This situation creates a significant
legal loophole that non-Indian drug traffickers exploit. They operate
on tribal lands, knowing that the Tribal government lacks the authority
to prosecute or incarcerate them. This has been a persistent issue,
despite past legislative efforts to enhance tribal authority in
criminal matters.
One of the critical challenges is the categorization of these drug-
related offense, as non-violent crimes. As a result, when state
authorities apprehend non-Indian drug dealers on our reservation, they
are often immediately released due to the non-violent classification of
their offenses. This practice has led to a `'catch and release''
pattern, where offenders are briefly detained but quickly return to
their illicit activities, either on our lands or in the neighboring
non-Indian communities.
Cross-deputization agreements, which allow for shared enforcement
authority between tribal and non-tribal law enforcement agencies, have
been seen as a potential solution. However, in practice, these
agreements often have significant gaps. They may not comprehensively
cover all aspects of law enforcement needs or may not be adequately
supported by the necessary resources. In the context of drugrelated
crimes, these gaps become particularly pronounced.
Over the years, Congress has passed laws to strengthen tribal
authority in certain areas, like the Tribal Law and Order Act of 2010
and the Violence Against Women Act Reauthorization Act of 2022.
However, these measures have not effectively addressed the issue of
drug trafficking by non-Indians on tribal lands.
The lack of effective jurisdictional authority not only allows drug
trafficking to flourish but also contributes to other related crises,
such as the Missing and Murdered Indigenous Peoples issue. Drug
trafficking and its associated violence and exploitation are often
intertwined with these broader social challenges.
A proposed solution is to amend the Indian Civil Rights Act to
explicitly recogrjze the authority of tribal governments to prosecute
non-Indian drug traffickers. This amendment would be a significant step
forward, providing Tribes with the legal framework necessary to address
this critical issue. It could include provisions for incarcerating
convicted offenders in federal prison, thereby offering a more robust
deterrent against drug trafficking in Indian Country.
______
Response to Written Questions Submitted by Hon. Tina Smith to
Hon. Tony Hillaire
Question. Given the high overdose data in urban and rural Native
communities alike, how can Congress support Tribal members living off-
reservation and in urban communities in our response to rising levels
of fentanyl use?
Answer. We are in an opioid crisis of critical proportions, the
likes of which we have never before seen. Drug harms are ravaging for
Native Americans and Alaska Natives (AI/AN) no matter where they reside
across the United States, and across the age spectrum from infants to
Elders \1\, \2\. Even with all the services we need in place right
away, it will take a generation to address even the basic harms of the
opioid crisis. This is a complex and multi-faceted challenging
situation and we must be prepared to mitigate these harms over the
short and long-term utilizing all the resources and flexibilities of
policies and legislation possible to the fullest extent of laws and be
prepared to modify these where necessary. Right now, we urgently need
improvements in law enforcement, health services, prevention, education
and access to culturally attuned, based care. The right approach to
treatment and full access to services is vital. There is a grave lack
of resources provided for infrastructural support for Indian health
care substance use treatment which undermines the availability oflife
saving detox stabilization and withdrawal services. This is one of the
acute needs. This gap represents a barrier to recovery and perpetuates
long standing health disparities especially for those who experience
the disease of addiction in this time of the fentanyl crisis.
---------------------------------------------------------------------------
\1\ Indian Health Service IHS Supports Tribal Communities in
Addressing the Fentanyl Crisis May 2023 Blogs [Accessed 3/7/2024)
\2\ Centers for Disease Control and Prevention Drug Overdose In
Tribal Communities Drug Overdose Prevention in Tribal Communities Drug
Overdose CDC Injury Center [Accessed 3/7/2024)
---------------------------------------------------------------------------
Indian Health Service's (IHS) has no sufficient funds allocated for
the construction of detox facilities despite the fact Tribes have
sounded the alarm and provided data over multiple years which shows all
across the Nation, Tribes are being hit hard by deadly and deadlier
drugs. Despite all the evidence that has been provided to date, which
shows we experience higher levels ofloss and demonstrated an acute and
urgent need; we still have not been able to secure all the funds needed
to build a facility. \3\, \4\ The Lummi Nation has put in requests for
funding assistance through demonstration funds as well as for help from
the Health and Human Services (HHS) Non-Recurring Expense Funds (NEF),
to no avail. On multiple occasions we have met with federal
representatives and leaders to ask for assistance. To date, as far as
funding goes, only the Department of Commerce and Legislators of the
State of Washington have authorized some financial support towards
constructing a detox facility. The facility would be designed to serve
both urban and rural based Tribal members, as well as any others who
are eligible. The need is great, and the facility is supported by the
29 Tribes in our state as well as the Portland IHS Area regional
Tribes. This lack of funding support from our federal trustees for what
is one of the crucial pillars to begin recovery is unfathomable given
the acuity of the situation.
---------------------------------------------------------------------------
\3\ Drug Overdose Deaths in the United States, 2001-2021 NCHS Data
Brief. Number 457. December 2022 (cdc.gov) [Accessed 3/7/2024)
\4\ Opioid Deaths Risen 5-FoldAmong Indigenous Americans Opioid
overdose deaths risen 5-fold among Indigenous Americans BMJ (3/7/2024]
---------------------------------------------------------------------------
One other area of support we seek is to ask that you review the
funding allocated for Indian health care programs especially for
alcohol and substance use services and Public Health. Lummi Nation
receives limited funds for these programs, which does little to provide
the level of services and support staff we actually need given we are
in an emergency. Secretary from HHS, on multiple occasions, has renewed
the opioid public health emergency pursuant to the authorities vested
in his office under section 319 of the Public Health Service Act, 42
U.S.C 247d, \5\ originally determined by Secretary Eric Hargan from
HHS in October 26th 2017 under the Trump Administration. This ongoing
acknowledgment by the Secretary that a public health opioid crisis
exists, flies in the face of reason when funding and resources are not
forthcoming from one of the federal trustee administrations and whose
actions do not match the scale of the problem we are facing.
---------------------------------------------------------------------------
\5\ ASPR Administration for Strategic Preparedness and Response
Renewal of Determination that a Public Health Emergency Exists as a
Result of the Continued Consequences of the Opioid Crisis Affecting our
Nation (hhs.gov) [Accessed 3/7/2024]
---------------------------------------------------------------------------
Fentanyl as well as new types of synthetic opioids cut with deadly
additives such as TRANQ and Carfentanil are now so widely available, we
are seeing a dramatic increase in opioid related health conditions as
well as deaths country wide. We consider what is occurring as a
genocidal and existential threat to our very survival. This crisis is
impacting Tribal members equally in both urban and rural locations,
whole generations and future lineages have been lost.
We have repeatedly requested support from the President to declare
a national emergency. In effect, this would create greater flexibility
for federal resources and assistance to supplement existing state,
tribal and local efforts, and capabilities to save lives, protect
property, as well as bolster public health and safety. In addition,
these measures would contribute significantly to help address gaps and
barriers in addressing treatment, recovery, traditional healing,
housing and rehabilitation, supply and demand and prevention. With all
of these considerations the availability of resources and increased
flexibility will help lessen the catastrophic threat facing tribal
communities, urban and rural and others within the United States. The
opioid crisis is a major national disaster affecting us all and causing
untold damage, loss, hardship, and suffering.
In closing, we want to thank you for this opportunity to provide
testimony and for your ongoing support to help bring this devastating
situation to an end. If you have any further questions regarding this
additional testimony, please contact us.
______
Response to Written Questions Submitted by Hon. Tina Smith to
Claradina Soto, Ph.D.
Question. Given the high overdose data in urban and rural Native
communities alike, how can Congress support Tribal members living off-
reservation and in urban communities in our response to rising levels
of fentanyl use?
Answer. While it is true that fentanyl abuse is a problem for
Native communities who live on designated tribal areas, the profound
disparities faced by American Indian and Alaska Native (AIAN)
communities in off-reservation urban and rural areas regarding the
opioid epidemic is equally urgent. Recent data highlights an alarming
trend where, in both 2020 and 2021, AIANs experienced the highest death
rates from drug overdoses compared to all other racial and ethnic
groups, even as rates surged across the board in 2021. Presently,
approximately 87 percent of the AIAN population resides in urban areas,
constituting a diverse and inter-tribal community, with a significant
concentration in California cities.
Despite the theoretical advantages of urban living, Urban Indians,
constituting 1 in 7 American Indians nationwide and 1 in 9 in
California cities, face substantial barriers to accessing essential
healthcare and tribal services. This reality is exacerbated by
disparaging health statistics, with Urban Indians experiencing higher
rates of diabetes, liver disease, cirrhosis, and alcohol-related deaths
compared to the general population. Congress must take swift and
comprehensive action to address these disparities, ensuring equitable
access to healthcare and addressing the root causes of the opioid
crisis in offreservation AIAN communities.
While opioid treatment services are available to tribal members
through IHS and Tribal Health Programs, rural and urban Indian health
programs serve disproportionally larger AIAN populations with a
fraction of the funding and resources needed to address the crises.
Furthermore, tribal members utilize services such as residential SUD
treatment located off-reservation and rely on these services when their
tribe may not offer them. These recovery services however lack
components that would fill those gaps for a more complete continuum of
care including culturally responsive detox centers, residential
treatment that can accommodate families with children, sober living
facilities both on and off tribal lands, and comprehensive reentry
programs to assist tribal members with reintegration back into their
home communities that sustain their sobriety and foster healthy and
positive contributions to their communities.
Below are 7 steps recommended for Congress to act in addressing the
fentanyl abuse and opioid epidemic for off-reservation, urban, and
rural AIAN communities.
1. Funding for Prevention and Treatment Programs: Congress can
increase allocations of funding specifically earmarked for
urban AIAN and rural off-reservation AIAN communities to
develop and implement prevention and treatment programs
targeting fentanyl and other substance use disorders. This
funding can support culturally appropriate interventions,
outreach efforts, and access to mental health services.
2. Enhanced Law Enforcement Resources: Congress can provide
additional resources to law enforcement agencies to combat
fentanyl trafficking and distribution in off-reservation and
urban areas. This may include funding for specialized training,
equipment, and task forces dedicated to addressing the opioid
crisis in partnership with Urban Indian Health Programs and
AIAN serving agencies.
3. Expansion of Healthcare Services: Congress can support the
expansion of healthcare services in urban AIAN and off-
reservation communities, including access to medication-
assisted treatment (MAT) programs, mental health counseling,
and substance abuse rehabilitation services. This may involve
increasing funding for Indian Health Service (IHS) facilities
and expanding IHS treatment and detox facilities nationally, in
addition to expanding Medicaid coverage for Tribally enrolled
and state recognized Tribal members.
4. Culturally Centered Education and Outreach: Congress can
support initiatives aimed at increasing awareness of the
dangers of fentanyl use within urban AIAN and off-reservation
communities through culturally competent education and outreach
campaigns. This may involve partnering with AIAN leaders,
elders, youth, and community organizations to develop messaging
and materials that resonate with AIAN community members.
5. Data Collection and Research: Congress can allocate funding
for research and data collection efforts to better understand
the scope of fentanyl use among Tribal members living off-
reservation and in urban areas. This data can inform policy
decisions and resource allocation strategies to effectively
address the issue and strengthen University partnerships with
urban AIAN and off-reservation communities.
6. Support for Housing and Economic Development: Congress can
provide support for urban AIAN and off-reservation housing
programs and economic development initiatives to address
underlying social determinants of health that contribute to
substance abuse, including poverty, unemployment, and lack of
stable housing. Primarily, the expansion of sober living and
transitional housing for urban AIAN and offreservation
individuals is a critical need.
7. Collaboration and Coordination: Congress can encourage
collaboration and coordination among urban Indian Health
Programs, federal agencies, state and local governments, and
community organizations to develop comprehensive strategies for
addressing fentanyl use and its associated harms in Tribal
communities.
By taking these steps, Congress can play a critical role in
supporting Tribal members living off-reservation and in urban
communities in their response to rising levels of fentanyl use,
ultimately helping to prevent overdose deaths and improve the health
and well-being of Tribal communities.
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*Responses to the following questions were not available at the
time this hearing went to print*
Written Questions Submitted by Hon. Brian Schatz to
A. Aukahi Austin Seabury, Ph.D.
Question. How is I Ola Lahui using American Rescue Plan funds to
meet the behavioral health needs of rural Native Hawaiian communities?
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