[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

                              ----------                              
                                                                   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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \2\ https://www.cdc.gov/nchs/products/databriefs/
db457.htm#Key_finding
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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 
---------------------------------------------------------------------------
        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\
---------------------------------------------------------------------------
    \1\ For more information, please contact Karol Dixon, NPAIHB, 
Director of Government Affairs/Health Policy.
---------------------------------------------------------------------------
                                 ______
                                 
                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.
---------------------------------------------------------------------------
    \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).
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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.
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   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.
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    \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)
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    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.
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    \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]
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    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.
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    \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]
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    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.
                                 ______
                                 

        *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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