[Senate Hearing 114-722]
[From the U.S. Government Publishing Office]
S. Hrg. 114-722
AMERICA'S INSATIABLE DEMAND FOR DRUGS
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HEARING
BEFORE THE
COMMITTEE ON
HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
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AMERICA'S INSATIABLE DEMAND FOR DRUGS, APRIL 13, 2016
ASSESSING THE FEDERAL RESPONSE, MAY 17, 2016
EXAMINING ALTERNATIVE APPROACHES, JUNE 15, 2016
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
RON JOHNSON, Wisconsin Chairman
JOHN McCAIN, Arizona THOMAS R. CARPER, Delaware
ROB PORTMAN, Ohio CLAIRE McCASKILL, Missouri
RAND PAUL, Kentucky JON TESTER, Montana
JAMES LANKFORD, Oklahoma TAMMY BALDWIN, Wisconsin
MICHAEL B. ENZI, Wyoming HEIDI HEITKAMP, North Dakota
KELLY AYOTTE, New Hampshire CORY A. BOOKER, New Jersey
JONI ERNST, Iowa GARY C. PETERS, Michigan
BEN SASSE, Nebraska
Christopher R. Hixon, Staff Director
Brooke N. Ericson, Chief Counsel for Homeland Security
Jose J. Bautista, Professional Staff Member
Servando H. Gonzales, U.S. Customs and Border Protection Detailee
Gabrielle A. Batkin, Minority Staff Director
John P. Kilvington, Minority Deputy Staff Director
Holly A. Idelson, Minority Senior Counsel
Stephen R. Vina, Minority Chief Counsel for Homeland Security
Brian F. Papp, Jr., Minority Professional Staff Member
Ellen W. Harrington, Minority Professional Staff Member
Laura W. Kilbride, Chief Clerk
Benjamin C. Grazda, Hearing Clerk
C O N T E N T S
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Page
WEDNESDAY, APRIL 13, 2016
Opening statements:
Senator Johnson.............................................. 1
Senator Carper............................................... 2
Senator Ayotte............................................... 21
Senator Booker............................................... 24
Senator McCaskill............................................ 27
Senator Portman.............................................. 30
Senator McCain............................................... 33
Prepared statements:
Senator Johnson.............................................. 47
Senator Carper............................................... 48
WITNESS
General John F. Kelly, USMC (Retired), Former Commander of the
United States Southern Command (2012-2016)..................... 5
Jonathan P. Caulkins, H. Guyford Stever Professor of Operations
Research and Public Policy, Heinz College, Carnegie Mellon
University..................................................... 7
Cheryl G. Healton, Dean, College of Global Public Health, New
York University................................................ 9
Tony Sgro, Chief Executive Officer, EdVenture Partners........... 12
Robert J. Budsock, President and Chief Executive Officer,
Integrity House, Inc........................................... 14
Alphabetical List of Witnesses
Budsock, Robert J:
Testimony.................................................... 14
Prepared statement........................................... 121
Caulkins, Jonathan P.:
Testimony.................................................... 7
Prepared statement........................................... 70
Healton, Cheryl G.:
Testimony.................................................... 9
Prepared statement........................................... 93
Kelly, General John F.:
Testimony.................................................... 5
Prepared statement........................................... 50
Sgro, Tony:
Testimony.................................................... 12
Prepared statement with attachment........................... 105
APPENDIX
Response to post-hearing questions for the Record:
Mr. Kelly.................................................... 126
Mr. Caulkins................................................. 138
Ms. Healton.................................................. 146
Mr. Sgro..................................................... 155
Mr. Budsock.................................................. 159
TUESDAY, MAY 17, 2016
Opening statements:
Senator Johnson.............................................. 253
Senator Carper............................................... 253
Senator Ayotte............................................... 267
Senator Tester............................................... 272
Prepared statements:
Senator Johnson.............................................. 285
Senator Carper............................................... 286
WITNESS
Hon. Michael P. Botticelli, Director, Office of National Drug
Control Policy................................................. 255
Kana Enomoto, Principal Deputy Administrator, Substance Abuse and
Mental Health Services Administration, U.S. Department of
Health and Human Services...................................... 257
Diana C. Maurer, Director, Homeland Security and Justice, U.S.
Government Accountability Office............................... 259
Alphabetical List of Witnesses
Botticelli, Hon. Michael P.:
Testimony.................................................... 255
Prepared statement........................................... 288
Enomoto, Kana:
Testimony.................................................... 257
Prepared statement........................................... 298
Maurer, Diana C.:
Testimony.................................................... 259
Prepared statement........................................... 308
APPENDIX
Information submitted by Mr. Botticelli.......................... 329
Information submitted by Mr. Botticelli.......................... 330
Information submitted by Mr. Botticelli.......................... 332
Responses to post-hearing questions for the Record
Mr. Botticelli............................................... 333
Ms. Enomoto.................................................. 339
Ms. Maurer................................................... 350
WEDNESDAY, JUNE 15, 2016
Opening statements:
Senator Johnson.............................................. 355
Senator Carper............................................... 356
Senator Portman.............................................. 371
Senator Lankford............................................. 375
WITNESS
D. Scott MacDonald, M.D., Physician Lead, Providence Crosstown
Clinic......................................................... 358
Ethan Nadelmann, Ph.D., Executuve Director, Drug Policy Alliance. 360
David W. Murray, Senior Fellow, Hudson Institute................. 363
Frederick Ryan, Chief of Police, Arlington, Massachusetts........ 367
Alphabetical List of Witnesses
MacDonald, D. Scott, M.D.:
Testimony.................................................... 358
Prepared statement........................................... 403
Murray, David W.:
Testimony.................................................... 363
Prepared statement........................................... 433
Nadelmann Ph.D., Ethan:
Testimony.................................................... 360
Prepared statement with attachment........................... 410
Ryan, Frederick:
Testimony.................................................... 367
Prepared statement........................................... 470
AMERICA'S INSATIABLE DEMAND FOR DRUGS
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WEDNESDAY, APRIL 13, 2016
U.S. Senate,
Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:33 a.m., in
room 342, Dirksen Senate Office Building, Hon. Ron Johnson,
Chairman of the Committee, presiding.
Present: Senators Johnson, McCain, Portman, Ayotte, Ernst,
Carper, McCaskill, Tester, Heitkamp, Booker, and Peters.
OPENING STATEMENT OF CHAIRMAN JOHNSON
Chairman Johnson. Good morning. This hearing will come to
order.
I want to thank all of the witnesses for taking the time,
not only to appear here today, but for taking the time to
submit what I think are just extremely thoughtful testimonies.
I hate to say this, but I am looking forward to this
hearing. It is such a terrible subject. It is such an enormous
problem facing this Nation.
I took a swing through Wisconsin in January. We called it a
``national security tour.'' And, I asked every public--local,
State, and Federal--public safety official that we talked to,
in probably about six different stops, what is the primary
problem you are dealing with in your job. And, without
exception, it was drugs--drug abuse and drug addiction--not
only because of the crime it creates, but also because of the
broken lives and the broken families.
Senator Ayotte has been, certainly, a big leader, in terms
of highlighting the heroin overdoses, which are prevalent in
New Hampshire--but also in Wisconsin. We had a 24-hour period
in Milwaukee, Wisconsin, where there were six overdoses. Just
in the last couple of years, the overdoses have increased
almost fourfold.
I know, Senator McCain--we did a hearing down in Arizona
with his Governor--it is an enormous problem as it relates to
the border. And, that is kind of the second point of my opening
statement here, which, by the way--I have a written statement
which, with consent, can be entered for the record.\1\
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\1\ The prepared statement of Senator Johnson appears in the
Appendix on page 47.
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Senator Carper. Without objection.
Chairman Johnson. This Committee has a mission statement.
It is pretty simple: to enhance the economic and national
security of America. We established four basic priorities for
the issues we are going to look at: border security,
cybersecurity, protecting our critical infrastructure, and
combating Islamic terrorism.
On border security, alone, we have now held 15 hearings to
look at the different aspects of it and have published a more
than 100-page report on our findings. Among many causes,
certainly my conclusion, I think--and a number of Members on
this Committee would agree with me--the primary root cause of
our unsecure border is America's insatiable demand for drugs,
because it has given rise to the drug cartels, who, by and
large, control whatever section of the Mexican side of the
border they want to control--as General Kelly certainly showed
us, in Guatemala, when we were with him--destroying public
institutions throughout Central America and in some South
American countries.
This is an enormous problem and there are no easy
solutions. We have been fighting a war on drugs for many
decades, spending more than $25 billion a year. In testimony,
General Barry McCaffrey, in front of this Committee, said that
we are only interdicting between 5 and 10 percent of the
illegal drugs coming into this country. We are not winning this
war.
So, the good folks, like General Kelly, have been fighting,
heroically, the supply side of this equation. But, it is our
insatiable demand that also has to be fought. I know Nancy
Reagan had her ``Just Say No'' program--and I know there were
mixed results with that. But, the fact of the matter is, we
have been extremely effective as the world's leading
advertising country. We know how to market. We have reduced
tobacco use. We need to put that same type of committed, long-
term effort into doing everything we can to reduce our
insatiable demand for drugs, because it creates so many
problems--so much heartache.
So, again, I just really want to thank the witnesses. I
really am looking forward to a really thorough discussion and
to laying out the reality. We are going to be talking about
different solutions. We are going to be talking about things
that are controversial, probably. This is not black and white.
We have to have a thorough and honest discussion about this,
because we all agree on the end goal. We have to reduce that
insatiable demand for drugs.
So, with that, I will turn it over to Senator Carper.
OPENING STATEMENT OF SENATOR CARPER\1\
Senator Carper. Thank you, Mr. Chairman. Thank you so much
for bringing this together.
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\1\ The prepared statement of Senator Carper appears in the
Appendix on page 48.
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I want to preface my remarks by just saying that General
Kelly is out of uniform for the first time in a long time. We
appreciate your service so much. How many years did you serve
in all?
General Kelly. Forty-five years and 5 months.
Senator Carper. Wow. What? Did you start at about 9 years
old? [Laughter.]
Thank you for every one of those years.
And, Cheryl, it is just great to see you. Cheryl and I
worked together standing up an outfit called the American
Legacy Foundation at the--it came out of the State Attorneys
Generals' (AGs') efforts--50-State tobacco settlement--and just
did great work in deterring young people from smoking. And, we
are very grateful for your efforts there and for all you
continue to do. Thank you so much for joining us.
And, all of the rest of the panel as well. Tony, it is very
nice to see you again. You can teach us all how to pronounce
your last name it is and we will do just fine here. Thank you
for joining us.
But, as the Chairman has said, this is a serious matter and
we are going to focus on America's devastating addiction to
illegal drugs.
I just came back from--last week, in our 2-week recess, I
went to China. I had not been there before. I had been to Hong
Kong a couple of times, but had never been to China. I learned
a lot. They have their problems. They have their share of
problems over there, as you know. But, they also do some things
pretty well that, maybe, we can learn from. They have, pretty
much, intact two-parent families. Drug addiction is not a
problem there. Gambling is illegal. They do some things very
well and, maybe, there is something that we can learn from what
they are doing in this regard. I like to say, ``Find out what
works, do more of that.'' Now, I am saying that we should find
out what does not work and, maybe, learn from that as well.
But, we look forward to hearing from all of you. This is a
difficult issue. It is not only a health emergency in our
country and our States, but it is also a--it contributes to the
security challenges that a number of our Latin American
neighbors continue to face each day. And, those of us who have
been down there know exactly what I am talking about. General
Kelly has been there with us on several occasions and we are
grateful for that.
But, drug abuse--particularly, prescription drug and heroin
abuse--has been a growing problem across our country for a
number of years now. It has led to tragic consequences, not
just for those who are suffering from addiction, but also for
their families and for the communities in which they live.
The Centers for Disease Control and Prevention (CDC) notes
that, between 2002 and 2012, the rate of heroin-related
overdose deaths, nationally, nearly quadrupled. In my home
State of Delaware, there were 189 suspected overdose deaths in
2014 alone. That is a little State--189 people. And, around
3,000 adults sought treatment for heroin in our State's primary
treatment facilities.
American demand for heroin and other drugs also fuels the
violent tactics of the traffickers who move drugs, goods, and
people across our borders. American drug demand is also having
a dramatic effect on--and a deadly effect in South and Central
America. As our Committee has found, much of the corruption and
violence in the Northern Triangle--in Guatemala, Honduras, El
Salvador, and other parts of Central and South America--are
fueled largely by our appetite for illegal drugs. This
corruption and violence are major causes of the surge of
migration from the Northern Triangle to the United States in
recent years, as well as a source of misery to those who do not
flee.
I know that General Kelly will speak to the extremely
damaging impact our drug use has on our security and the
security of our neighbors in the Northern Triangle--not to
mention the lives of the users themselves.
Today, we are going to have the opportunity to discuss ways
to best address the root causes of our demand for drugs. We
will also explore the merits of media campaigns, peer-to-peer
(P2P) outreach, and other educational initiatives that are
aimed at reducing this demand. I am especially pleased, again,
to welcome Cheryl Healton, who has been an instrumental force
behind the successful public health initiatives that I
mentioned earlier aimed at reducing the use of tobacco--
particularly, among young people--and who stood up this
foundation, colleagues, in 2001 and went to work on it. If you
look at the use of tobacco, among young people, between 2001
and 2010, it is really remarkable what happened--and Cheryl and
her team deserve a lot of credit for that. We are going to find
out, today, how some of those lessons might be imparted and
shared with us, as we face addictions to other kinds of
substances.
And, because addiction and substance abuse are medical
conditions that can often be treated effectively, we will also
discuss the role of prevention and treatment--how they can play
an important role in reducing demand.
In sum, these problems that we are facing are complex and
the potential solutions are not easy or quick. We know that.
Getting a handle on drug abuse and the tragic problems that
stem from it will require an ``all hands on deck'' effort, if
we are to be successful in addressing what drives people to use
these harmful substances and to help them overcome their
addictions.
Again, my thanks to my Chairman. My thanks to our
colleagues, particularly, to all of you. And, thank you to our
staffs for bringing us together for this moment. Thank you.
Welcome.
Chairman Johnson. Thank you, Senator Carper.
It is the tradition of this Committee to swear in
witnesses. So, if you will all rise and raise your right hand.
Do you swear the testimony you will give before this
Committee will be the truth, the whole truth, and nothing but
the truth, so help you, God?
General Kelly. I do.
Mr. Caulkins. I do.
Ms. Healton. I do.
Mr. Sgro. I do.
Mr. Budsock. I do.
Chairman Johnson. Thank you. Please be seated.
Our first witness is General John F. Kelly. General Kelly
served as Commander, United States Southern Command (SOUTHCOM),
in Miami, Florida from November 2012 until January 2016. He
retired from active duty after 45 years of service to the
Nation in the United States Marine Corps (USMC), both as an
enlisted infantryman and an infantry officer on February 1,
2016.
General Kelly, again, thank you for your service to this
Nation and thank you for being here.
TESTIMONY OF GENERAL JOHN F. KELLY, USMC (RETIRED),\1\ FORMER
COMMANDER OF THE UNITED STATES SOUTHERN COMMAND (2012-2016)
General Kelly. Thank you, Mr. Chairman. I would like to
start by saying it is a tremendous honor and privilege to be
here this morning and to appear before this Committee to talk
about this very vital topic.
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\1\ The prepared statement of General Kelly appears in the Appendix
on page 50.
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I have submitted what I know is a lengthy written
statement, but I also know how useful that is to the staff--
particularly, to get these kind of insights. And, I will just
be brief and sit, because I think the real, probably, nub of
this whole thing is the queston and answer (Q and A) segment.
But, I would just start by saying that, when I first
assumed
duties in SOUTHCOM, the thing that struck me was the
visibility--the very accurate visibility that that organization
had then, and has now, on the movement of drugs--cocaine,
heroin, methamphetamine (meth) and pharmaceuticals--from along
this incredibly complex network through my zone, through the
Western Hemisphere, up to the Southwest border, and into the
United States. It was very frustrating, because we had such
clarity of the movement and we had such good partners working
with us--particularly, in Colombia--and I cannot underline that
enough. They are heroic in what they do--as are some of the
other countries. But, the Colombians have really dedicated
themselves to getting at this problem and to helping us--as
well as helping themselves.
But, the point is, my Title 10 responsibilities in that
role were the detection--we did that, very well--and the
monitoring of the movement--we did that extremely well--not
interdiction. Interdiction, of course--I was part of the
interdiction team, but, technically, it is a law enforcement
event.
But, that said, very early on, I became very frustrated at,
really, the lack of assets available to interdict drugs in vast
amounts--tons at a time. And, to watch those drugs make it into
Central America. Once they get into Mexico, they enter a whole
other kind of network that makes it, essentially, a given that
these drugs will appear in Boston, Wisconsin, and Idaho--places
like that. It is really unstoppable once it gets ashore. All of
the drugs that I think you are most concerned with are either
trafficked--they are all produced in Latin America--in Central
America, and then, of course, they are all trafficked up
through to the border.
That same network, though, will carry anything. As I say in
my written statement, the people that manage this network do
not check the reasons for coming to the United States, do not
check bags, and do not test for explosive residue on hands. If
you pay the fare, you are in the United States. And, I do not
mean the people that kind of rush the border--the Mexicans, as
an example--that just come--or the unaccompanied minors that
are coming here for economic reasons. These people are coming
here for a reason. They are paying a lot of money to get here
and they are getting in.
So, from a national security standpoint, as I have said,
certainly, in the Senate Armed Services Committee (SASC) and in
the House Armed Services Committee (HASC) the 3-years I was in
the job in SOUTHCOM, I would say that, when there is a major
event in the United States--whether it is a biological attack,
a dirty bomb, or something like that--when we do the forensics,
we will find that those people came here through the network
that comes up through the Southwest border.
But, I will just simply end with the fact that, as I got
more and more frustrated not being able to do more and more, I
realized that the real problem--and all of the problems in the
South--would go away--the network would fall apart, Colombia
would not have to fight this fight, and the Hondurans would not
be on the edge of the abyss, if we would get our arms around
the drug demand.
And, what I would leave you with--and I give you this
example in my written statement--when I was a kid, 70 percent
of Americans--according to CDC figures, 70 percent of Americans
smoked. As a 9-year-old, I was sent down to the corner store to
buy a pack of cigarettes for my mother and my father. Today,
you cannot do any of that. Today, less than 20 percent--
according to CDC numbers--smoke. So, we know how to do behavior
modification, but we just have not done it. With all of the
good things that people have tried to do to combat drugs, there
is no comprehensive plan.
And, I do highlight, in my written statement, what the Drug
Enforcement Administration (DEA) and the Federal Bureau of
Investigation (FBI) have done by producing a very powerful
anti-demand program that they are focusing on grammar school
kids, middle school kids, and high school--teachers, actually,
to try to get them in the fight. And, I have been told many
times, ``Kelly, this is not your concern. This is a law
enforcement concern.'' OK. But, as I say so frequently, people
are not doing it, And, since they are not doing it, the FBI and
the DEA--people like that are, in fact, taking this task on.
We know how to do this. I do not know why we do not do it.
And, it is just killing Americans at kind of a remarkable rate.
So, I will leave it at that, Mr. Chairman. Thank you very
much.
Chairman Johnson. Well, again, thank you, General Kelly.
And, yes, I appreciate--I think most of the witnesses provided
pretty robust statements. They will all be entered into the
record and I appreciate you keeping it short.
Since you left a minute, I just want to give you the kudos.
This hearing is because of you. It was on our helicopter flight
to the border between Guatemala and Mexico that you asked me
the question, because, again, you are battling the supply. And,
you asked me, ``Senator, when is the last time America had a
concerted, national public relations advertising campaign
against the use of drugs?'' And, I said, ``Well, boy, I
remember Nancy Reagan's `Just Say No' campaign and then a
number of years later, I remember that famous egg commercial:
`Here is your brain. Here is your brain on drugs.' '' And, you
said, ``No, that was all part of the same effort. That was back
in 1985. That was 30 years ago.''
And so, I mean, really, the reason we are doing this is
because of that conversation in that helicopter--it was kind of
hard to hear some of it, but I really credit you with bringing
this, certainly, this dimension of the problem to the
forefront. So, thank you.
Our next witness is Jonathan Caulkins. Mr. Caulkins is the
H. Guyford Stever Professor of Operations Research and Public
Policy at Carnegie Mellon University's Heinz College and is a
member of the National Academy of Engineering. Dr. Caulkins
specializes in systems analysis of problems pertaining to
drugs, crime, terror, violence, and prevention--work that has
won him several awards. Issues surrounding marijuana
legalization have been a particular focus of his in recent
years. Dr. Caulkins.
TESTIMONY OF JONATHAN P. CAULKINS,\1\ STEVER PROFESSOR OF
OPERATIONS RESEARCH AND PUBLIC POLICY, HEINZ COLLEGE, CARNEGIE
MELLON UNIVERSITY
Mr. Caulkins. Thank you. It is a privilege to have the
chance to speak.
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\1\ The prepared statement of Mr. Caulkins appears in the Appendix
on page 70.
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You mentioned that, when you were back in your home State,
people were listing this as the largest problem. When I was a
Doctor of Philosophy (Ph.D.) student in engineering at the
Massachusetts Institute of Technology (MIT), in the late 1980s,
the reason I chose to dedicate my life to building quantitative
models of drug traffickers, markets, and policy is exactly
because it was listed, by the public, as the Nation's biggest
problem.
In my written testimony, I tried to, basically, say three
things. The first is to agree--yes, the flows are large--and to
try to put some numbers to them. There are hundreds of metric
tons, per year, of the hard drugs and thousands of metric tons,
per year, of marijuana. And, the value, as it crosses the
border, is probably over $10 billion a year. You may have heard
that $100 billion is the dollar value of the U.S. drug market.
That is at retail. Most of the price increase happens inside of
the country, so the value at the border is lower--but $10
billion is still a lot of money.
In terms of root causes, I will note that the root cause,
at some level, is just because Americans are people. We do
consume more illegal drugs than most of our peer countries, but
we do not actually consume more intoxicants, in total, in the
sense that we consume less alcohol than many of our peer
countries do. This use of intoxicants is sort of part and
parcel of the human condition.
The main part of the testimony was about the fact that,
even if we did everything in the best possible way, in terms of
our drug policies and their conventional programmatic levers,
that would not eliminate the security hole. The hokey metaphor
I used is that it is like we have a two-car garage. Both doors
are open right now, so burglars can enter. If we did everything
right, we might, at the outside, be able to reduce the flow by
half, but that would still leave one door wide open.
I was asked about a couple of particular tactics. Media
campaigns to control illegal drugs have not fared well in
scientific evaluations. It seems like they ought to work. The
people who do them are sincere. But, when evaluated, they do
not evaluate well--and not only here, but also in the
international literature.
I was asked about treatment. The academic consensus is
absolutely in favor of expanding drug treatment, but, mostly,
because of the potential to alleviate the suffering of the
people who have dependence problems--not because that would
quickly reduce the quantity consumed.
It is always important to differentiate between the opioids
and everything else. For opioids, there are pharmacotherapies
that allow us to substitute a legal opioid for the illegal
opioid--and that does help reduce purchases on the illegal
market. But, we do not have any such technologies for the
stimulants, like crack cocaine and methamphetamine.
I was asked about legalization. It is absolutely true that,
if we did legalize, that would essentially solve the border
security problem. This is because legal businesses can out-
compete illegal businesses when it comes to delivering a legal
product. But, we are unlikely to do that for the hard drugs--
and for good reason.
Cannabis legalization seems to be the way the country is
going. If we eliminated that part of the overall flow of
illegal drugs, that would eliminate the majority of the weight,
but only the minority of the value--maybe a quarter of the
dollar value of the smuggled drugs. The marijuana
liberalization we have seen to date is well short of national
legalization--although very substantial--and, I think, it is
better to understand it as part of a large body of
liberalizations that include the medical laws--not just the
State legal recreational regimes that started in 2012.
There is no question that the market share of imports in
the cannabis market has gone down, but the quantity of cannabis
consumed in the United States has doubled. So, the impact of
policy liberalization on the flow across the border is a lot
smaller than you would think if you look only at the market
share. It is a smaller market share of a bigger market. In the
long run, if we do proceed with national legalization, that
would, presumably, largely eliminate the marijuana part of the
overall drug flow.
The one exception to this fairly pessimistic view of how
much the conventional drug policy levers can do is, a very
innovative approach called ``Swift, Certain, and Fair (SCF),''
which uses extremely frequent testing of people under criminal
justice supervision, while they are on community release,
coupled with certain, but very modest, sanctions. South
Dakota's ``24/7 Sobriety'' program is the classic example. Drug
tests are administered literally twice a day. If somebody tests
positive, they are instantly placed in jail--but for only 24
hours.
These programs have had stunning success at reducing drug
use, but there are real barriers to expanding them. They are a
challenge to the conventional approach to treatment because
they are not really treatment. They may be hard, perhaps, to do
in larger jurisdictions. But, if anything is going to
dramatically reduce the use of hard drugs, I think it would be
some version of ``Swift, Certain, and Fair.''
Then, the last point that I try to make is----
Senator McCain. Some version of----
Mr. Caulkins. ``Swift, Certain, and Fair''--is that, in
some other respects, there has been the potential to shrink the
amount of collateral damage caused by drug markets, even if the
volume of drugs in the markets does not go down as much. So,
for instance, we can try to reduce the number of drug-related
homicides committed in the United States per metric ton of
drugs distributed and consumed. I do not know whether or not
that principle could be applied to border security problems,
but that possibly seems, to me, to be worth investigating.
Thank you.
Chairman Johnson. Thank you, Dr. Caulkins.
Our next witness is Cheryl Healton. Ms. Healton is Dean of
the College of Global Public Health (GPH) at New York
University (NYU) and Director of the Global Institute of Public
Health. Prior to this appointment, Dr. Healton served as
President and Chief Executive Officer (CEO) of Legacy, the
leading foundation dedicated to tobacco control. During her
tenure with the foundation, she guided the highly acclaimed
national youth tobacco prevention counter-marketing campaign,
``Truth,'' which has been credited, in part, with reducing the
prevalence of youth smoking to near record lows. Ms. Healton.
TESTIMONY OF CHERYL HEALTON,\1\ DEAN, COLLEGE OF GLOBAL PUBLIC
HEALTH, NEW YORK UNIVERSITY
Ms. Healton. Mr. Chairman and Members of the Committee, I
am privileged to appear before you this morning to testify
about unmarketing illicit drugs to youth before they start
using them as well as how we can work to curb the adult demand
for drugs.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Healton appears in the Appendix
on page 93.
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My name is Dr. Cheryl Healton and I am Dean of the College
of Global Public Health at New York University. Prior to my
appointment at NYU, I worked for 14 years at American Legacy, a
national 501(c)(3) nonprofit charity with a well-respected
history of producing game changing public health initiatives
proven to reduce tobacco use. Best known for its bold counter-
marketing campaign for youth, ``Truth''--now in its 16th year--
the campaign has been a major part of a comprehensive,
national, State, and local tobacco control strategy. Together,
these measures have resulted in remarkable declines in youth
tobacco use prevalence rates, from 23 percent in 2000 to below
7 percent today.
I have also served on the Board of Directors of the Betty
Ford Institute (BFI) and Phoenix House, a large nonprofit drug
and alcohol rehabilitation organization.
Using tobacco as a case study today, it is important to
understand what it took to prompt dramatic social norm change,
which resulted in these shifts in knowledge, beliefs,
attitudes, and behaviors. Public health experts know that four
factors figure prominently in maintaining dramatic declines in
tobacco consumption.
The first factor is bold, highly targeted counter-marketing
public education campaigns.
The second factor is ever-increasing excise taxes on
products at the State and Federal level to prompt cessation
among price-sensitive consumers and to reduce initiation.
The third factor is policy initiatives that restrict access
to tobacco, safeguard the public from secondhand smoke, and
provide access to cessation services for those addicted to
tobacco products.
Cumulatively, these measures combine to change social norms
and save lives. Yet, the unspoken fourth leg of this stool is
critically important: mustering the political will to enact
what we know works--even though it ruffles feathers and annoys
special interests. Public health too often loses out to
corporate profit motives and the associated political
influence, so we fail to do what we know must be done to
achieve the life-extending results we all desire.
While today's discussion focuses on those who peddle
illicit drugs to our most vulnerable populations, the business
models are not dissimilar. Those who profit from selling drugs
to risk-seeking and troubled teens do so to make long-term
customers of them. They care more about the lucrative sales
than health. They attract young customers when their developing
brains are the most vulnerable to risk-taking and addiction.
Then, they reap the long-term profits, as users remain addicted
and age.
The United States cannot be safe from drug-related criminal
activity without, first, reframing the relationship between
drug use and crime and, second, sharply reducing the insatiable
appetite for illicit drugs. This can be accomplished through
the prevention of youth initiation, deglamorizing use by
disruptive and innovative mass media campaigns as well as un-
selling use, and inducing those who are addicted--or teetering
on the verge of addiction--to seek very prompt treatment. It
goes without saying that drug treatment needs to be broadly
available and covered by insurance plans.
I have provided the Committee with key studies which
demonstrate that well-designed and well-executed, paid mass
media campaigns improve health. In the case of the ``Truth''
campaign, youth social norms and behavior shifted, first in
response to a Statewide Florida campaign and, then, a larger,
national campaign. In the national campaign, after the first 4
years, 450,000 youths did not initiate--as a direct result of
the campaign. In an analysis at 2 years, at least 22 percent of
the decline in youth smoking was directly attributable to the
campaign.
Researchers at Johns Hopkins University (JHU) and Columbia
University also concluded that, in 2 years, alone, the campaign
averted $1.9 billion to $5.4 billion in future medical care
costs.
These are key lessons for the primary prevention of illicit
drug use and should be applied as a basis for a new and
improved program at the national level. The same impact on
initiation may be achieved by powerfully hard-hitting, youth-
focused communications--especially, those designed by and for
youth at the highest risk of using drugs. Messages must be
targeted to those most likely to initiate drug use and must
provide compelling reasons to avoid initiation--including the
fact that those profiting from their drug use are using them--
even if that person is a low-level dealer they see as their
friend or their boyfriend or girlfriend.
The Office of National Drug Control Policy (ONDCP)
supported the Partnership for a Drug-Free America's--now called
the Partnership for Drug-Free Kids'--paid advertising campaign,
which was sharply curtailed after a decade of persistent budget
cuts. It is critical to bring it back--but to restructure it,
so that it is truly independent of the kinds of oversight that
can undermine a public education campaign's ability to succeed.
This, specifically, means that the creative development
must come from paid advertising developed and placed at market
rates to ensure that the work is done by the hardest hitting
and best paid agency possible--and to ensure it gets the right
media placements. Youth market research has to be undertaken to
appropriately target the design to subsets of high-risk youth,
which will likely result in bold advertisements that are
exceptionally unpalatable to adults and government Agency
staff. I believe that point is the key reason that the former
campaign failed--and it did fail.
We need vigorous, real-time evaluation to decommission
advertisements that are not resonating with the intended
audiences and to quickly replace them with those that do. This
is essential, as ads have possible boomerang effects and it is
difficult to predict those in advance.
To effectively reach adults, the approach is similar. But,
if we persist in using a moralistic, criminal justice model for
those addicted and at risk, we will miss the opportunity to
turn the tide on an epidemic that the National Institutes of
Health's (NIH's) data suggests we have been achieving some
success with--and that must continue.
In closing, there are proven ways to reach these young,
impressionable audiences--and adults--with successful
messaging. It requires the abandonment of previous, failed
policies in favor of game-changing new ones.
Thank you.
Chairman Johnson. Thank you, Dr. Healton.
I do want to quickly ask a question, because--as long as
you raised it. What is an example of an unpalatable ad?
Ms. Healton. Well, I mean, I will use the ``Truth''
campaign as an example. Our first advertisement piled 1,200
body bags around a tobacco company in New York City--downtown
Manhattan. The first call I got was from the Department of
Health, which had received a call from then--Mayor Rudy
Giuliani's office asking to pull our ability to execute the
advertisement. Luckily, Mayor Giuliani, ultimately, declined
that invitation to pull our ability to shoot the advertisement.
And then, we received lots of push-back about the
advertisement--including from networks that would not play the
advertisement and including networks that actually took our
advertisements, before they aired, and sent them to
PhilipMorris USA. If they did that for Coca-Cola and Pepsi,
they would be in court over it.
Chairman Johnson. OK. I did not want to have that moment
pass without getting an example.
Our next witness is Tony Sgro. Mr. Sgro is the Chief
Executive Officer of EdVenture Partners (EVP). EVP builds
industry-education partnerships with over 800 universities by
connecting students, educators, and industry leaders for
societal changes and brand building purposes. Mr. Sgro has more
than 40 years of experience in marketing, advertising, and
promotion. Mr. Sgro.
TESTIMONY OF TONY SGRO,\1\ CHIEF EXECUTIVE OFFICER, EDVENTURE
PARTNERS
Mr. Sgro. Chairman Johnson, Ranking Member Carper, and
Members of the Senate Homeland Security and Government Affairs
Committee (HSGAC), thank you for allowing me the honor of
speaking with you today.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Sgro appears in the Appendix on
page 105.
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I have been asked to do two things today. First, to
introduce you to ``Peer-to-Peer: Challenging Extremism
(P2P:CE),'' a countering violent extremism (CVE) university
initiative and competition sponsored by the Department of
Homeland Security (DHS), the National Counterterrorism Center
(NCTC), the Department of State (DOS), and the technology
giant, Facebook. ``Peer-to-Peer: CE'' is based upon a simple
premise. Who better to develop alternative-narratives and
counter-narratives to extremist messaging than the very same
audience extremists want to recruit? Government has recognized
it cannot do it, so it makes perfect sense to enlist tech-savvy
youth to be part of the solution to push back on hate, terror,
and extremism.
The second thing I have been asked to do, after introducing
you to ``Peer-to-Peer: Challenging Extremism'', is to
demonstrate how this clay-like model can, similarly, be
utilized to push back on drug demand by enlisting the help of
street smart digital natives, who can play a role in the
substance abuse solution--as they know the drug and social
media culture of their communities better than anyone in this
room.
Briefly, this is how we make ``Peer-to-Peer: Challenging
Extremism'' work on America's college campuses--and, please,
substitute the word ``extremism'' for the words ``drug demand''
when I speak, so you get a sense of the possibilities.
``Peer-to-Peer: Challenging Extremism'' challenges a class
of university students, over the entire semester, while earning
a grade, to develop a social or digital media initiative,
product, or tool to counter extremism in their communities.
They do robust research, brainstorm extremely creative ``Peer-
to-Peer: Challenging Extremism'' campaigns, and, after they
present their campaigns for review, we give the class real
money to spend--a $2,000 budget--and say, ``Now, go bring your
idea to life. Do not just give us a plan about challenging
extremism, go do something.'' When you give students money to
spend to actually do something, it changes the dynamics of
learning. And, they absolutely love taking this class and doing
something positive in their communities.
The results we have seen, on 98 different universities in
over 30 countries, thus far, with ``Peer-to-Peer: Challenging
Extremism'' have been phenomenal. These campaigns are credible,
authentic, and believable, because they were created by youth
for youth.
Here are two brief examples. At Missouri State University
(MSU), the ``Peer-to-Peer: Challenging Extremism'' class
created, amongst other activities, four different oversized,
downloadable posters for seventh and eighth graders, educating
them about social media safety. They also developed a middle
school social media curriculum designed to cover extremist
recruitment prevention, which the Governor has expressed
interest in expanding to middle schools throughout the State.
Or, at Curtin University in Australia, where students
created a mobile application (app) for vulnerable, young
Muslims called ``52 Jumaa,'' which means 52 Fridays. The
``Peer-to-Peer: Challenging Extremism'' program--and the app
they created--was so successful, it changed the behaviors and
lives of self-proclaimed, at-risk Somali youth in Perth. One
student's brother went to Syria and was killed. Another Somali
youth's brother was in jail for gang violence. Parents of these
troubled, college-age young men thanked our faculty
administration profusely for offering ``Peer-to-Peer:
Challenging Extremism.'' These kids were on a similar path to
destruction and, because of ``Peer-to-Peer: Challenging
Extremism,'' they are now looked upon as role models in the
Somali community in Perth.
I could share many more stories, but given time
limitations, I simply cannot. However, I believe you might
recognize the transferability of this peer-to-peer model and
can see it adapted to other social ills, such as tackling
America's drug problem.
This is how it could be done. It could use the same peer-
to-peer model, where a class forms an agency to address program
objectives that read something like this: ``You, class, are
challenged to create and implement a social or digital media
initiative, product, or tool to curb America's insatiable
demand for drugs. Your campaign will promote drug awareness,
abstinence, intervention, prevention, or whatever you identify,
in your communities, that will be most effective in preventing
drug demand and substance abuse.'' We can wordsmith the
objectives, but I think you get the idea.
From a how-to perspective, we would invite faculty that
teach courses in marketing, advertising, and social media as
well as those that teach about youth drug culture, addictive
disorders, drugs in society, and narcoterrorism to see how
these faculty and students attack the drug problem.
Additionally, the top teams come to Washington to present
and compete in a national face-off competition. The ``Peer-to-
Peer Substance Abuse Challenge'' becomes a national campaign
and movement, like it has with ``Peer-to-Peer: Challenging
Extremism.'' And, Generation Y and Generation Z are owning this
community-based, problem solving approach to push back on
substance abuse in their cities and towns.
Finally, let me close with these four short points. First,
the peer-to-peer model is scalable. For example, with ``P2P:
Challenging Extremism,'' our proof of performance pilot was 20
universities. Today, ``Peer-to-Peer: Challenging Extremism''
has 55 colleges participating--and, in the fall semester, 150
universities in 50 countries will be unleashing a social media
tsunami against the Islamic State of Iraq and Syria (ISIS).
Two, peer-to-peer models can be targeted to reach youth in
States where drug demand is growing or already crippling.
EdVenture Partners has worked with over 800 rural, suburban,
and urban campuses throughout the United States for the last 26
years.
Third, the peer-to-peer model becomes a ``Silicon Valley-
like'' incubator of new, fresh ideas to tackle the drug
problem, where the best ones can be grown, scaled, resourced,
and pushed out--similar to what we are doing with ``P2P:
Challenging Extremism.''
And, lastly, the P2P model is cheap--dirt cheap in
government dollars--according to the National Counterterrorism
Center.
However, I like the way the Committee says it best: ``the
peer-to-peer model is high impact, low cost, and easy on U.S.
taxpayer dollars.''
With that said, I would like to thank you for allowing me
to share my thoughts about, potentially, using a peer-to-peer
strategy to confront America's insatiable demand for drugs.
Chairman Johnson. Thank you, Mr. Sgro.
I do kind of wonder what comes after Generation Z.
[Laughter.]
Mr. Sgro. We do not know yet.
Chairman Johnson. OK.
Our next witness is Robert Budsock. Mr. Budsock is
President and CEO of Integrity House, a nonprofit organization
that provides a full range of addiction treatment and recovery
support for individuals diagnosed with substance use disorders.
Mr. Budsock has been with Integrity House since 1984, having
started his career in clinical services. Mr. Budsock.
Senator Booker. Mr. Chairman, he prefers Bob, please.
Chairman Johnson. OK. Bob.
TESTIMONY OF ROBERT BUDSOCK,\1\ PRESIDENT AND CHIEF EXECUTIVE
OFFICER, INTEGRITY HOUSE, INC.
Mr. Budsock. Chairman Johnson, Ranking Member Carper, and
Members of the Committee, it is an honor to be here today with
you and the other leaders that are testifying.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Budsock appears in the Appendix
on page 121.
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As Senator Johnson said, I am Robert Budsock. I am the
President and CEO of Integrity House, and we are a nonprofit
addiction treatment program providing services in the State of
New Jersey. Integrity House was founded in 1968 and our mission
is to provide comprehensive addiction and recovery support to
help individuals reclaim their lives.
Addressing the demand for illegal drugs is one of our
Nation's greatest challenges. The consequences of drug use for
individuals include: drug dependency and addiction, involvement
with the criminal justice system, chronic health issues,
overdose, and, in many cases, death.
Many of the challenges faced by this Committee are linked
to the demand for drugs. The consequences of the demand for
drugs include: drug trafficking and violence, billions of
dollars in costs in our criminal justice and public health
systems, and compromises to our border security.
Through science and research, we know that drug addiction
is a brain disease that can be treated effectively.
I would like to present some facts about the insatiable
demand for illegal drugs that we are experiencing in America.
Illicit drug use in the United States has been increasing at a
frightening rate. The annual National Survey on Drug Use and
Health (NSDUH), conducted by the Substance Abuse and Mental
Health Services Administration (SAMHSA), estimated that 24.6
million Americans age 12 and older had used an illicit drug in
the past month. That is 9.4 percent of the entire population.
One of the factors that has led us to categorize the
current crisis, in the United States, as an epidemic is the
huge increase in the number of overdose deaths. Accidental
death from the use of drugs recently surpassed motor vehicle
accidents as the number one cause of death for young people in
our Nation.
According to the CDC, in 2014, there were 47,055 overdose
deaths and, approximately, 129 Americans, on average, died from
an overdose every day. Tragically, overdose deaths are
increasing in every State, in rural areas, cities, and suburbs
alike--among all segments of our population.
Drug addiction is a complex disorder that can involve,
virtually, every aspect of an individual's ability to
function--in the family, at work, and at school. Because of the
complexity and pervasive consequences of addiction, treatment,
typically, must involve many components. Some of those
components focus directly on the individual's drug use. Others,
like employment training, focus on restoring the addicted
individual to productive membership in the family and in
society, enabling him or her to experience the rewards
associated with abstinence.
Like other chronic diseases, addiction can be managed
successfully. Treatment enables people to counteract
addiction's powerful, disruptive effects on the brain and
behavior as well as to regain control of their lives. But, the
chronic nature of the disease means that relapsing back to drug
use is not only possible, but also likely, with symptom
reoccurrence rates similar to those for other well-
characterized chronic medical diseases--such as diabetes,
hypertension, and asthma--that also have psychological and
behavioral components.
Based on scientific research conducted by the National
Institute on Drug Abuse (NIDA) over the past 40 years, I would
like to highlight five key principles that form the basis of
effective treatment. Addiction is a complex--but treatable--
disease that affects brain function and behavior. No single
treatment is right for everyone. People need to have quick and
ready access to treatment. Effective treatment addresses all of
the patient's needs--not just his or her drug use. There is a
correlation between length of stay and the effectiveness of
treatment. Staying in treatment long enough is critical. Short-
term programs or interventions are just not effective for
everyone.
It has been known for many years that the treatment gap is
massive. That means, despite the large and growing number of
those who need substance abuse treatment, few receive it. I
cannot name another disease or chronic health condition where
this is tolerated or allowed to perpetuate.
One barrier that I would like to discuss is that, if you
get your health insurance through Medicaid--it is barred from
paying for community-based residential treatment at a facility
of 16 beds or more. This happens under something called the
Medicaid Institutions of Mental Diseases (IMDs) exclusion,
which originated in the 1960s as part of a national effort to
deinstitutionalize large psychiatric hospitals. Though
community-based residential treatment programs for substance
use disorders did not exist when the IMD exclusion was
established, addiction treatment programs are considered IMDs
in the eyes of Medicare and Medicaid--thus disqualifying
reimbursement for care at a program like Integrity House and
hundreds of other similar programs around the country.
Integrity House is a longtime and active member of
Treatment Communities of America, a national association of
nonprofit addiction treatment programs, who has advocated for
years for expanding access to treatment by eliminating the IMD
exclusion.
Thank you.
Chairman Johnson. Thank you, Bob.
I realize this hearing is about the insatiable demand for
drugs, but, General Kelly, I want to go to you because you have
been on the front lines of the war against the supply of drugs.
And, I just want to kind of get your input, in terms of where
we are on that.
When we were down in Guatemala and Honduras and we talked
to, not only you, but also other people on the front lines--
people just incredibly dedicated to try and do that work--one
of the comments that really stuck in my mind was from somebody,
who had been battling this a long time, about how we are really
not looking at stopping the flow. We are just talking about
redirecting it out of the country they are operating in. I
mean, we had the drug flow from Colombia through the Caribbean
Islands up into Miami. And, that got redirected through Central
America.
So, just kind of speak to that basic dynamic--what we are
really dealing with--because, the fact of the matter is,
heroin--the cost of heroin in 1981 was over $3,000 a gram. We
are going to do a field hearing outside of Milwaukee on Friday
and research for that shows that, in some places in Milwaukee,
that is down to $100 per gram--about $10 a hit, which is why
you are seeing heroin take the place of opiates, in terms of
addiction.
So, just talk about the fact that we are not--well, I do
not want to put words in your mouth. Talk about how we are
doing with interdicting the supply.
General Kelly. Thank you, Mr. Chairman. I would just
comment that the demand signal, from the United States, has
many thousands of very bad people responding to that demand. At
the higher levels of the cartels, these guys are international
businessmen and they control the network. They control the
price. They control the flow--not only up through the Western
Hemisphere into our own country, but around the world,
frankly--I am speaking right now about cocaine.
Back in the 1980s, when the flow of cocaine and other drugs
went up the Caribbean Islands into, primarily, Miami--the old
``Cocaine Cowboy'' days--the vast majority, as I understand it,
of the heroin consumed in the United States--and it was a lot--
not as much as today, but a lot--was coming from Asia and,
essentially, Afghanistan. That no longer is the case, because,
as the cartels saw the increase in demand for that particular
drug, they just started to produce it--primarily, today, in
Mexico, but also a little bit in Guatemala. They grow the
poppies, they have the factories, and they make the heroin that
comes in.
For methamphetamines, a lot of legislation and a lot of
very good law enforcement activity in the United States shut
down the many thousands of small meth labs operating in the
United States. And, again, these international businessmen--
cartel leaders--saw the demand and, now, most of the
methamphetamine consumed in the United States is produced in
industrial quantities, in Mexico, using precursors that are now
either illegal in the United States--because, again, of what
Congress has done--or are very hard to get. They just import it
in from China and other parts of Asia.
So, no matter what we do to try to interdict it, it will
come, so long as there is the demand.
Chairman Johnson. Talk about the brutality of the cartels,
because, when we were down in Central America, you were kind of
describing how they are, basically, untouchable because they
are so brutal. Central America is battling two things:
corruption and impunity. That last one kind of surprised me--
impunity. Well, impunity because the drug cartels operate with
impunity and then that transfers over to the other parts of
society, where you have the extortionists murdering people if
they do not get bribes. Just speak to how our insatiable demand
for drugs has destroyed--or is destroying--public institutions
in Central America.
General Kelly. Well, due to the immense profits that come
out of our country and are available to the cartels, to the
network of people, and to the criminals, they have an unlimited
amount of money to bribe--or an unlimited amount of money to
kill. In my opinion, no legislator, prosecutor, police officer,
or police chief in his right mind would do anything to stop the
flow of drugs----
Chairman Johnson. Because what happens to those individuals
who try?
General Kelly. Because they are either--well, the example I
would give you--in a Latin American country or a Central
American country, when I was talking to a Minister of the
Interior--kind of like our AG or FBI Director, he said, ``Look,
I will not take their money.'' I think I have told you and
Senator Carper this story. ``I will not take their money and
they know it. And, I will continue to go after them.'' This was
what he said when he first got in office.
But then, he just received a computer disc (CD) in the mail
and the first sequence of the CD had his two little girls
leaving the house in the morning, bouncing down the street on
their way to school. And, the next sequence had him, his wife,
and the two little girls on Sunday morning, walking out of the
house and going down to Sunday mass. And, there was a third and
a fourth. And, as he said, ``No way. I will not take their
money, but I am not going to go after them.'' And, that is the
intimidation factor.
And, their brutal tactics are as bad as anything ISIS and
the rest of the extremists use. They have no laws. They have no
regulations. They have no morals. They have no limits to what
they will do. And, they hold many of these countries,
particularly the Central American countries, in really a grip
of fear.
Chairman Johnson. I often hear--we often hear that taking
drugs is a victimless crime. When we were in Guatemala, we did
visit a shelter for sex trafficked little girls. And, again, it
is the drug cartels that are run by business people and they
expand their product lines into human trafficking--sex
trafficking. By the way, those little girls were ages 11 to 16.
There were also little cribs there, because they become
pregnant. I think the average age was 14.
Can you just speak to what these drug cartels--how do they
expand their business and really cause the mayhem and the
broken lives down in Central America?
General Kelly. Again, think about businessmen. If there is
a need and they detect a need, then they will provide the need.
Again, when pharmaceuticals were getting more and more
expensive--pills were getting more and more expensive in the
United States--and, because of legislation and some other
factors, pills became very expensive and less available--then
the businessmen--the cartel members--went into business and
started producing pharmaceuticals. It is the same thing with
heroin--we have already talked about that--and
methamphetamines. It was good news up here, but so it moved
down to Mexico.
But, in terms of other needs, Latin American and Caribbean
citizens will tell you--and their law enforcement people--that
the movement of guns is, primarily, from our country to the
South. And, many of the guns used to commit crimes in Central
America, Mexico, and the Caribbean are trafficked, by the same
traffickers, into those places.
Anything that we demand in this country, they will provide.
I think the United Nations (U.N.) figures tell us that 18,000
or so young women--mostly adolescents--young girls--are
trafficked into our country every year as sex workers. I do not
think they know they are coming here to become sex workers, but
they come here every year--some little boys, as well, to
provide the same services.
So, they will respond to what the demand is. And so, we
have to, in all of these cases--in my view--reduce the demand,
significantly, and keep up the pressure on the networks.
I am told that this network is really mostly about drugs--
which it is--and mostly about profit--which it is--and that it
is not in the interest of the traffickers to allow other
things--like, say, a terrorist--to come into the country. But,
I will go back to what I said in my written statement--and I
say it all of the time. These people that control the networks
do not check passports. They do not check bags. They do not
care why you are coming, as long as you can pay the freight.
And, you will get in. You will get in. Or, it will get in--
depending on what you want to get here.
Chairman Johnson. They are some of the most evil people on
the planet.
So, again, I am looking for kind of a one-word answer. As
somebody who has been on the front lines for years and in
command of others--of heroic efforts to try to win the war on
drugs--the supply side--are we winning that war?
General Kelly. I could give you a one-word answer, but I
will give it to you at the end. I would just simply say that we
think that an unlimited amount of drugs get into this country--
in the hundreds of tons--not even counting marijuana--in the
hundreds of tons of cocaine, heroin, and methamphetamines. It
gets in, no problem. It gets all the way to Portland, Maine as
fast as it gets to San Diego, California.
We know that tens of thousands of people come into this
country--I am not talking about people coming for economic
reasons and people seeking a better life--I am talking about
sex workers and other people. They get here, no problem.
Millions and millions of items--of counterfeit, industrial-
type items--like electronics--get in.
This very question was posed to me in my last SASC hearing
and I gave the same answer. If all of that is getting in, no
problem, then I would argue that our border is not secure.
Chairman Johnson. Thank you, General Kelly. Senator Carper.
Senator Carper. We are glad you came. You have given us a
lot to chew on and we thank you for that.
I have a couple of aphorisms that these guys and gals, on
our Committee, hear me use all of the time. I like to say,
``There are no silver bullets--a lot of `silver BBs.' '' Some
of them are better than others and you have mentioned some of
those ``silver BBs,'' today.
Oftentimes, I say, ``find out what works and do more of
that.'' Several of you have mentioned programs or initiatives
that have worked very well.
I also am a big advocate, as my colleagues know, of root
causes--like, do not just address the symptoms of problems. Let
us go after the root causes.
And, I got hooked on this, with respect to going to the
border. We have all of these tens of thousands of people trying
to get into our country, mostly from Honduras, Guatemala, and
El Salvador. The flow of people between our country--illegal
aliens between our country and Mexico--there are more Mexicans
going back into Mexico, these days, than coming the other way.
So, the folks that are coming here, largely, from these
three countries--we call it the Northern Triangle--so my focus
has been on determining why their lives are so miserable. What
is it about their lives that compels them to try to get here--
to risk life and limb to make that 1,500-mile trip to the U.S.-
Mexican border to get in. It is the violence, which we are
complicit in by virtue of our addiction to these drugs that are
trafficked through the Northern Triangle nations.
What I want each of you to do is to, maybe, think out loud
for us, maybe, for a minute apiece, about a comprehensive
strategy in this country that might be funded to address this
problem. And, while you think about it, I will just say that we
spend a ton of money on law enforcement--arresting people,
prosecuting them, and putting them in jail for drug-related
crimes that are committed. We spend a ton of money, in my State
and in every State that is represented here--State dollars,
local dollars, and Federal dollars--to incarcerate people. And,
we spend a ton of money for treatment.
My gut tells me that there is money out there that, if we
could just take a fraction--just come up with a fraction of
what we are spending in the areas I just described--we could
probably fund a pretty darn good comprehensive strategy.
Let me just start with General Kelly. Just take a minute
and tell us what could be some of the key elements of a
national strategy.
General Kelly. Well, I will start in the North and just
simply say that it is all about demand. So, doing whatever it
takes to reduce demand to the greatest degree that we can. And
then, it is--coming South--then it is law enforcement and it is
the rehabilitation to take care of these sick people--because
they are sick people. As you get further South, down into the
zone that I used to work in, it is doing better with our
partners--because many of our partners are, in fact, willing to
do more for us. They just are limited in certain ways. Then,
you move a little bit further South into the production zones--
same kind of things. Help them get at the poppies, coca, or
whatever and work with the partners more and more and more.
And, again, they are all good partners--some are better than
others in their capabilities.
But, it just came to me that, frankly--I will be a little
bit cynical--it just does not seem to me that the country is
all that interested in reducing the demand. It is, certainly,
not that interested--for a lot of different reasons--in
providing the kind of assets to the SOUTHCOM Commander that are
needed to interdict. And, I cannot say, by the way, enough good
things about the FBI, the DEA, and DHS. They are just the best
of the best. They are superb men and women.
But, it is about finances--the amazing amounts of money
that have to be laundered out of our country--and the billions
and billions and billions of dollars--we think maybe as much as
$100 billion--has to be laundered. So, it has to go into some
banking institution. And, we know--I think--where those banking
institutions are. It would just be great, in my mind, to just
go after those institutions and take that money away, because,
if you go to sleep at night as a drug cartel leader with
billions of dollars in the bank and you wake up the next
morning and it is going--wherever it went, but it is gone--you
are not a drug cartel leader anymore. You are a dead man.
So, that is what I would say. It is very comprehensive.
Senator Carper. Great. That is great. Thank you. Jonathan.
Mr. Caulkins. It is important, whenever we are talking
about drugs, to disaggregate marijuana from the hard drugs. Mr.
Budsock said 24 or 25 million Americans will self-report having
used an illegal drug within the last 30 days. The comparable
number for marijuana, alone, is 22 million.
Marijuana is a mass market drug. There are more than half
as many Americans who use marijuana, on a daily or near daily
basis, as there are Americans who drink alcohol on a daily or
near daily basis. Marijuana use is within a factor of two of
alcohol, in terms of daily or near daily use.
That is a very different situation than for cocaine, crack,
heroin, and meth, where the consumption is enormously
concentrated in a very small number of people. Eighty percent
of the consumption is accounted for by just 20 percent of the
people who use. It is, maybe, three million people.
The majority of the hard drugs are consumed in the United
States. And so, the majority of that flow across the border
comes from people who are, literally, under criminal justice
supervision, in the sense that they are on probation, on
parole, or on pretrial release. If you want to cut the flow of
the hard drugs, you have to focus on that very small number of
people who are living very chaotic lives and are interacting
with the criminal justice system. If you want to affect
marijuana--that is much more of a mass market public health
target.
Senator Carper. Good. Thank you so much. Cheryl.
Ms. Healton. I have just a few points. One, I think we need
to decriminalize--which does not mean legalize.
We need to instill the availability for mass treatment,
particularly, for the opioid epidemic that we now have, which
you will see in my testimony, can be, partially, laid at the
feet of the pharmaceutical industry, sadly, because the pricing
of these drugs is driving people to street heroin.
And, we need to unsell drug use to both users and non-
users--and that, I think, can be done. And, some of the stories
that General Kelly told us, I think, are great starting points
for motivating people to change their behavior. We consume 40
percent of the world's cocaine and 20 percent of the world's
opioids. We are the number one problem in the world, in terms
of drug consumption.
And, I would just make one added point to the points that
Jonathan Caulkins was making. And, that is that the opioid
problem is much more complex, because--it is either 11 or 17
percent--or somewhere in that range--of adolescents who report
using pills. And, the modal pill that they are using are
opioids--often left over from their last dental visit or the
dental visit of a friend. And, that, in turn, leads to a young
adult opiate addiction for a substantial proportion of those
kids, which, as you can see in the tables that are out there,
is producing a very large number of intentional and
unintentional deaths. It has now surpassed traffic accidents in
the United States, which is a startling statistic. As a 35-year
public health professional, if you told me 25 years ago that
drug-related deaths could exceed traffic accidents, I would
look at you as if you were out of your mind.
Senator Carper. My time has expired, but, when we have a
second round, Mr. Sgro and Mr. Budsock, I am going to come back
and ask the same questions of you. But, those are wonderful
answers. Thank you so much for giving us those thoughts.
Chairman Johnson. Senator Ayotte.
OPENING STATEMENT OF SENATOR AYOTTE
Senator Ayotte. I want to thank you, Chairman. And, I want
to thank all of you for being here.
General Kelly, I wanted to follow up, because this is a
topic that you and I have talked about, in the past, when you
were SOUTHCOM Commander. And, one of the things that struck me
is that I have been working on the demand side with people,
like Senator Portman, and we have worked, for several years, on
what is called the Comprehensive Addiction and Recovery Act
(CARA) that was passed in the Senate in the last few weeks. And
so, it has a prevention piece, a treatment piece, and some
support, in terms of the relationship between prescription
drugs and heroin.
But, I want to get to this interdiction issue too, because
these drug cartels have been particularly clever. They have
flooded this market and driven down the price of heroin, going
to rural areas in New Hampshire, Ohio, and other places in this
country. And so, I actually think that, for the demand side, we
have to do all we can to get at--but we also need to drive the
price up on the supply side.
And, when you were SOUTHCOM Commander, I remember you
testifying about--and I think your written testimony today
reflects that--we see a lot of these drugs coming over, but we
are not putting as much teeth into the interdiction piece as we
possibly could. In fact, what you said is that the effort to
get at our drug demand begins--or should begin--on the cartel's
end of the field, with much greater effort. And, the U.S.
military is almost absent in the effort, due to an almost total
lack of Naval forces.
So, as someone who serves jointly on the Senate Armed
Services Committee, I want to know what we can do to help on
that end, working with our partners--obviously, Customs and
Border Protection (CBP), the Coast Guard, and law enforcement--
that could give more assets to what we need to do, while we are
working on the demand side--because I think this is an
important piece as well.
General Kelly. We need a bigger Navy. That is the answer. I
mean, last year in SOUTHCOM--joint effort--and again, law
enforcement is as important to me down there--or was as
important to me down there, as Naval forces and the Coast
Guard.
But, 70 percent of the 191 metric tons of cocaine that we
took out of the flow--and this is in one-ton to two-ton--
generally speaking--one-ton to two-ton loads--70 percent would
not have been taken had it not been for the occasional Canadian
ship that showed up down there--or the Dutch buoy tender, the
Coast Guard, or the occasional French or British ship. Seventy
percent.
Our Navy is absent for a lot of different reasons. There
are a lot of things going on around the world and the Coast
Guard Commandant, when he first came in, decided to double the
number of cutters----
Senator Ayotte. Right.
General Kelly [continuing]. That is good, but that is only
three or four. And, the way to get at this cocaine problem is
to get it when it is on the high seas, when it is still moving,
and before it makes landfall.
Methamphetamines and heroin produced in Mexico--that does
not move through the transit zone, so to speak, so that really
does become a question of how closely we can work with the
Mexicans to get vast quantities of those drugs. Their best
counter-drug organization down there is the Mexican Marines.
They do very well. And, there are a lot of reasons for that.
But, they do take a lot of drugs in movement.
But, if you are not getting a lot of it to drive up the
price--one of the things that I think I learned from the DEA,
here on Capitol Hill, to buy an illegal Oxycontin or something
like that--Percocet or something like that--a single pill will
cost you about $90. The same amount of heroin to get you to the
same place is $6.
Senator Ayotte. Right.
General Kelly. And, that is why they move to heroin. And,
unless you can do something about inhibiting the flow--and I do
not believe that is entirely a Southwest border issue. I think
it is deep down in Mexico--Sinaloa--places like that. But,
again, our drug demands have turned vast amounts of Mexico into
insurgent-held--if you will--insurgent-held regions that are
dominated by the Joaquin ``El Chapo'' Guzmans of the world--and
not even their army will go in there.
So, the problem is, again, the demand--and, frankly, in my
mind--not to criticize countries like Mexico, Honduras, or
others for not doing enough--because I spent the last 3 years
of my life looking North--not South--and they would tell us,
``Look, we are doing the best we can down there. Why do you not
get your arms around your demand.''
Senator Ayotte. And, that gets me, Dr. Healton, knowing
what has happened with the Legacy Foundation and having been an
Attorney General, myself, before I served in the Senate--I have
two young children. I have an 8-year-old and an 11-year-old. I
have to tell you, their attitude toward smoking is totally
different than attitudes when I was a kid. They, literally, see
someone smoking on the other side of the road--and this is not
something they do because their parents have said to do this--
they will move to the other side of the road.
And so, the notion that we cannot do an ad campaign that
would really focus on this issue--and, especially, I think,
focus on the opioid issue, because the national data shows four
out of five people start with prescription drugs and then go to
heroin. I believe we can do it.
But, something you said is really interesting. And, I think
we are trying to support efforts here to get resources toward
the prevention piece--and that is this. How do we structure
this in a way so that, if we give the Federal resources--along
with combining them with State and local--we put it all
together and we say, ``We are going to go after this and we are
going to get this message out.'' How do we do it in a way so
that it is a sufficient body that does not get the sort of
bureaucracy stifling response of, ``Well, that message is too
troubling'' or so that, when you have a talented advertising
organization that has researched it, collected the data, and
then come up with this--and that was what was so effective. I
remember seeing the guy on the smoking campaign with the
tracheotomy. I mean, you remember that.
But, do you have any thoughts, for us, on how we could
structure something that would give sufficient--the Legacy
Foundation had its support and independence as a nonprofit that
was formed. Obviously, there is an oversight board--many
Attorneys General involved--but you had the sufficient
authority and flexibility to be able to create a really hard
hitting campaign--and that is what we need.
We cannot sugarcoat this with our young people. We cannot
sugarcoat this with adults. Otherwise, we are not going to get
this message through. And, I have met too many families whose
sons, daughters, sisters, brothers, and grandchildren have
died--and it is about not sugarcoating what our families are
experiencing.
So, how do we do this?
Ms. Healton. So, I have two models that I would recommend.
One is driven by the Federal Government and one is a more
private model driven by the States.
In terms of the one driven by the Federal Government, I
would create--I actually think NIDA or SAMHSA would not be a
bad place to rest the bidding. But, I would open it up for a
national bid and I would leave it alone once it is won.
What hurt the ONDCP campaign--and I have pored over their
results for years and have been very disheartened because they
had a fabulous staff--still do--it is now drugfree.org--but
they were not allowed to do what was needed to do the job. And,
I believe the job can be done. I came to Legacy making the
following statement, ``I do not think you can advertise your
way out of an epidemic''--and I believed it at the time.
And, in fact, I was almost going to stop the national
campaign because we were pouring $100 million of money into it,
in the first year, and we did not have any peer-reviewed
literature. And, luckily, in February 2000, a paper came out,
from Florida, that showed a 40-percent decline in middle school
smoking and a 20-percent decline in high school smoking. And
then, in good conscience, I could say, ``Go ahead. Let it go.''
Within 6 months, we were in court. We were in court for 7 years
and $17 million worth of litigation fees were was spent trying
to shut us down.
So, one thing you need to understand is, when you go after
prescription opioids--which are saturating our young people,
saturating adults, and producing the resurgent heroin
epidemic--you will be going up against the pharmaceutical
industry. So, one model is the model I just described.
The second model may be preferable--or, maybe, it is a
parallel model. You do something not unlike what Washington
State did, in terms of Oxycodone and its effects. You do,
basically, a metropolitan statistical area (MSA) focus on the
``unintended''--in
quotes--consequences of pharmaceutical misadventures in pushing
pain analgesics that, in turn, lead to heroin addiction and sow
the seeds in our young kids, who just want to get a root canal,
where the next thing you know--5 years later--they are a heroin
addict. Not a good idea. There are fixes, but it will unleash a
storm of unhappiness on the part of the pharmaceutical
industry.
Senator Ayotte. Well, I have to share with you--first of
all, the storm of unhappiness that we are in right now, with
people who are dying and lost--incredible people who had such
potential--that is the storm of unhappiness. The other storm--
as big as it could be--is minor compared to this storm.
Chairman Johnson. Senator Booker.
OPENING STATEMENT OF SENATOR BOOKER
Senator Booker. Thank you, Mr. Chairman. And, thank you
both to the Chairman and Ranking Member for holding such an
important hearing.
So, really quickly, just, Bob, can you just hit that point,
which is so important, one more time--that we have a law
written that restricts funding for multi-bed facilities when,
now we know--and I know this from being Mayor of Newark--that
the best providers, in my city, who are creating transformative
change, taking people from addiction to recovery and from
criminality to productivity, are being denied funding. It is
such a ridiculous bureaucratic block that is undermining
grassroots efforts to meet this crisis. Could you just make it
plain one more time, so we have it on the record, about the
idiocy of this bureaucracy--and something that we need to
change, in order to see more progress in communities?
Mr. Budsock. Yes, Senator. So, the IMD exclusion was
written into the Medicaid regulations back in the early 1960s.
And, the IMD exclusion means that, in treatment facilities,
such as Integrity House--and there are many other facilities
like Integrity House all across the country--if an individual
comes to us and they have Medicaid as their primary health care
coverage, they are not eligible to access the full continuum of
services that are necessary to treat their disorder. So, they
are able to access certain parts of that continuum, but they
are not able to access the residential services if the facility
has more than 16 beds--and just about 99 percent of the
agencies similar to Integrity House, throughout the United
States, have facilities that are larger than 16 beds.
Senator Booker. So, there are things we can do, right away,
that can make a difference with this issue. And, this is one of
them that is, to me, frustrating that we have not made an
administrative change to fix.
Just to give a larger perspective, having been--I live in
the central ward of Newark, New Jersey. I would imagine that I
am one of the Senators that returns to the poorer Census track
to live. I live up the street from Integrity House and have
been wrestling with the ravages of this reality for my entire
professional career, seeing how we, as a society, would much--
it seems to me, we are much more willing to pay exorbitant
amounts to treat the symptoms of a problem. The law enforcement
costs alone are outrageous, in terms of, again, local
government, jails, police officers, courts, and prisons. But,
that is just one massive cost.
The other massive cost here is hospitals--and what I had to
struggle with are the charity care costs for people being
brought to the emergency room on a continuous basis. And, the
depth--and this is why I appreciated Senator Ayotte's remarks--
the depth of this crisis in our country is astonishing--
especially when you realize how unique America is as a country.
Not only due to the fact that, every day, 1 out of 10
Americans is breaking U.S. drug law--not to mention the fact
that, of the prescription drug consumption--opiate
consumption--I thought it was 50 percent. My staff corrected
me. It is about 80 percent of the globe's pills that are being
consumed by people in this country. The overwhelming majority
of that--of people who consume those pills--or people who get
addicted to heroin--the gateway drug to them are these pills in
which there are--again, we are the mass drivers of that
consumption on the planet Earth--not to mention, Doctor, what
you were talking about when it comes to heroin and the
percentage of this country using it.
But, then, let us even shift to just the antidepressants
being consumed on the planet Earth. There is something going on
here that we, as a Nation, are devouring drugs--prescription
and illegal drugs at rates not seen in humanity--not seen
anyplace else on the planet Earth.
And so, it seems like we are paying for this problem, but
we are not doing anything to get to the root cause. And, that
is why I am so appreciative of this--is that what is causing
us, as a Nation, to turn so dramatically to drugs--legal
prescription and illegal drugs? And, that is what frustrates
me, because I am tired of us spending billions and billions of
dollars--trillions of dollars, as a country--not dealing with
the real root cause of the problem, which is this insatiable
demand for drugs.
And so, I appreciate--we were just talking, when you were
giving your testimony, Doctor, about the effectiveness of the
tobacco campaign and how it really--as Senator Ayotte said--has
changed the consumption patterns in this country. I go to
Europe and you now see what America used to look like. So, we
have done it there, but we are not even chipping away--it is
getting worse in these other areas.
So, I have a minute left. And, maybe, Doctor, I can go with
you and then, Bob--just because you are my neighbor and I have
to go home--and split that time. Doctor, what is going to get
to the root cause of this? Is it just public relations (PR), or
is it something even deeper within our society that we have to
start having an honest conversation about?
Ms. Healton. That is a very difficult question. Why do we
use drugs? Humans have been using mind-altering substances
for----
Senator Booker. But, Doctor, I am sorry--just to interrupt
you----
Ms. Healton. Yes.
Senator Booker. This is not a human problem. It is an
American problem----
Ms. Healton. Yes, it is----
Senator Booker [continuing]. Because you do not see this
going on--at this rate--in other countries.
Ms. Healton. You are right. So, you could come up with lots
of reasons, but the fact is, we have a very substantial profit
motive in our country. Capitalism is our system, so people are
very enterprising. And, people can create markets. Just like
they create markets for the newest T-shirt and the nicest
jeans, they can create markets for drugs. And, when you have
kids who have time on their hands and are bored, they will turn
to that. We do not have the kind of family structure we had in
1950. It is a different world here--the modern world. So, I
would say, it is a combination of drivers like boredom and
poverty--I mean, if I were to pick two drivers.
Senator Booker. Right. And so, Bob, you would say that one
thing we need to do is to increase access to treatment. The
majority of people we incarcerate--you see this, whether it is
Newark--or pick your town--across the country--we are putting
people in jail with addictions and we are not treating that. Is
that what--so, the root cause that you think some of this is
due to?
Mr. Budsock. Yes. Statistics have shown that over 80
percent of individuals that are involved in the criminal
justice system have either a drug-related charge or a charge
that, actually, was brought upon them as a result of their
insatiable demand for illegal drugs.
Do I have a minute to speak?
Senator Booker. No.
Mr. Budsock. No.
Senator Booker. Unfortunately, because I am over my time.
And, I just want to say, Chairman, really quickly, there is
something missing here. In other words, it cannot just be
capitalism, because there are other capitalist countries. We
are different, somehow--and I would love to figure out a way to
get to the root answer of that question, because I just do not
think--I think that all of these people are doing admirable
things to stop it, but there is something that is driving this
that is different than in any other country--and we have
similar economies, similar democracies, and similar free market
systems, but America is unique, globally, in this problem.
Chairman Johnson. Well, again, we are trying to get some of
these answers. I come from a business standpoint. I could not
addict my customers to plastic by giving them a free sample.
You can addict a child to drugs--and that is what really drives
a lot of these markets. Senator McCaskill.
OPENING STATEMENT OF SENATOR MCCASKILL
Senator McCaskill. Thank you.
In 2010, General Kelly, I chaired a hearing on the
Oversight of Government Management Subcommittee, as part of
this Committee, on our counter-narcotics efforts in Latin
America. At that point in time--I mean, it was difficult for us
to get information-- and we were, primarily, looking at the
billions of dollars in contracts that had been given by the
State Department for counter-narcotics efforts in Latin
America.
Six years ago, we had spent $7 billion in Latin America
over the previous 10 years. And, the vast majority of that was
being spent on contractors. Some of them were sole source
contractors--Alaska Native corporations--where there did not
appear to be a good rationale as to why. I mean, this was the
hearing I will remember--never forget, because I discovered
that contractors had prepared the people testifying at the
hearing for the hearing about contractors--and it was one of
those moments that made you think, ``Have we gone down the
rabbit hole so far that we do not realize how silly this has
gotten? ''
So, I would like to ask you, as somebody who has been in
command of SOUTHCOM, what are the metrics we are using for the
massive investment the American taxpayer has made in counter-
narcotics efforts in South America? And, is it still as
dysfunctional as it was in 2010, in terms of the coordination
between the State Department contractors, SOUTHCOM, the DEA,
and all of the other players in the space?
General Kelly. That is truly a great question. On the issue
of money that is managed by the State Department, there is a
lot of money managed by the State Department used to get at
some of these problems. That money does not really touch me
when I----
Senator McCaskill. Should it?
General Kelly. I would tell you, give me that money and I
would be able to fix the problem. I think there is--the
combination of the U.S. military--and I am not trying to
militarize this thing, but there is a military aspect to it--
the combination of the U.S. military down in the zone and our
law enforcement people--to include the FBI, the DEA, and,
frankly, the NSA--they are not law enforcement--but the CIA and
all of the alphabet soup that is inside of DHS--phenomenal men
and women--and we really do bring that together, regionally--we
being SOUTHCOM--through a joint task force that is in Key West,
Florida--a Joint Interagency Task Force (JIATF). It is the
model for tactical--or for intelligence fusion around the
world. In fact, it was replicated years ago in the fight in
Iraq, Afghanistan, and now worldwide against terrorism. It is
very effective.
As I mentioned--I think you were gone--but I can see--we
can see 10 percent--or 90 percent of the production and the
flow, but we could only get at just a small percentage because
we do not have end game authority. I did not have end game
authority--that is, seizure authority. And, I did not,
frankly--even if I had the authority, I did not have the
assets.
The countries that produce drugs in Latin America and the
Caribbean--well, Latin America--are suffering from our drug
demand in a way that is unimaginable in our country. The
violence rates are just off of the page. In the United States,
the U.N. figures go like this: roughly 5 per 100,000 of our
citizens are killed every year. That is how they measure
violence. In Latin America--places like Honduras--it is 91 out
of 100,000. Colombia is down into the 30s now. They have done
that, essentially, by themselves.
But, in the countries that we--this group--this SOUTHCOM
group of interagency actors--where they have spent time and
effort--Colombia, as an example--things have gotten markedly
better. The Colombians, again, have really done it themselves.
We have provided encouragement and advice, but no boots on the
ground.
Senator McCaskill. Well, what is the State Department
doing? I mean, you were there. You had vision. What is the
State Department doing with these billions of dollars?
General Kelly. They--as you have outlined--they invest it
in ways that, perhaps, are acceptable to the State Department,
but are not getting at----
Senator McCaskill. Like, what are they doing?
General Kelly. Well, I mean----
Senator McCaskill. Like, give me an example of the
activities they are paying for with the contractors.
General Kelly. As you point out, they would fund--as an
example--counter-drug or counter-gang violence--counter-gang
participation by young kids in countries--pick a country--
Honduras or somewhere like that.
But, I can remember once sitting and talking to--I would
always meet with the human rights groups when I would travel to
these countries--which was frequently--and I was sitting there
with a very senior person from our country team. And, we were
talking about this kind of topic and I said, ``Well, how about
preventing kids from getting into the gangs,'' which are really
the point of the spear on drug trafficking and all of that--and
drug marketing. And, very quickly, the State Department
representative said, ``We have a very good program for that. In
fact, we spend $10 million a year in this country.'' And, I
said, ``Well, how long has this been going on in this country?
I mean, how long have we been spending the money? '' I was
told, ``Well, 10 years.''
Well, even a Marine infantryman realizes that that is $100
million. So, I asked a question, ``Is the problem of kids going
into the gangs--and by extension into the drug trafficking--is
it better than it was 10 years ago? ''
Senator McCaskill. Or worse?
General Kelly. That would, in my mind, make it a good
investment. Is it the same? In my mind, that would be a bad
investment. That is failure. Or, is it worse? And, he
acknowledged, it is geometrically worse.
So, I would just say that the way that we and the
interagency--the military, certainly--the way we look at
solving a problem is that you set up a program and start to pay
for it. But, every 6 months or 3 months, whatever--we did this
in Iraq and Afghanistan--we do this everywhere--I did it in
SOUTHCOM with the monies that I held. Three months later, we
look--is it getting worse, better, or is it the same? And then,
we make an adjustment.
Senator McCaskill. It is really frustrating. I wish--and I
know that the Chairman is on the Senate Foreign Relations
Committee (SFRC)--and it is frustrating to me, because I think
the State Department means well. It is not that they are not
trying to do things. But, these are legacy efforts without real
metrics. And, as our Chairman likes to say, metrics matter in
business. They ought to matter in government. Metrics matter.
And, the idea that we are spending--just in that one example--
$100 million in Honduras on an anti-gang problem and the
problem has gotten exponentially worse as opposed to better.
Why are we not figuring out a better way--even if it means
moving some of that budget over to some of the players in the
task force in Key West, Florida.
And, I would like us to continue to follow up on this,
because I was stunned at the lack of information that was
available and the lack of metrics that were available for $7
billion in investment--and that was 6 years ago. It has
probably been another $7 billion since then, in terms of
counter-narcotics in Latin America.
And, before my time is up, I want to just briefly talk to
Mr. Budsock. I was, I think, the second prosecutor in the
country to aggressively go after a drug court model. And, I got
a lot of blow-back, politically, from my police department
(PD)--from a lot of people--that this was going to be something
where we were going to bust down a drug house and then going to
give them a bus pass, a job, and a pat on the head. Well, it
was a little more complicated than that, but, as you well
know--and as anybody who works in this field knows--that drug
courts began on the bottom, exponentially grew, and have
remained an incredibly effective way to get at the public
health issue of drugs and crime.
And, I would like--and maybe, Dr. Healton--one of you to
speak to why have we stalled on expanding the drug court model
into things like reentry courts. I mean, we take somebody who
has been in the drug culture for all of their life, we put them
in jail for 18 months, then we give them a bus pass and $20,
and we are shocked that they are back in jail within 6 months.
Why are we not making--since we know drug courts are cheap and
they work--why are we so stubborn about not putting more
resources into this model that has worked so well at turning
folks around and reducing the recidivism rate?
Mr. Budsock. Thank you, Senator. I think one of the major
success factors for the drug courts, is that they are treating
addiction as a chronic disease----
Senator McCaskill. Right.
Mr. Budsock [continuing]. Not as an acute illness. So, what
happens is that, when an individual enters drug court, they
receive a very rigorous schedule, that goes on for a period of
anywhere from 3 to 5 years, where they are reporting to the
drug court once a week on their progress. They are
participating in a treatment program. And, also, their
employment is being monitored and they have realistic and
achievable goals that they must accomplish to progress
throughout the drug court program. And, again, the key is that
addiction is being treated as a chronic disorder.
In New Jersey, we have seen an expansion of drug courts,
specifically, the criminal justice model. However, there are
other areas where drug courts would be effective when it comes
to the family. There is one county in New Jersey that has a
family drug court and we are hoping to see the expansion of
that into other counties. And, anytime that an individual is
involved with the criminal justice system, where there is a
detection of drug use or drug dependency--the model has proven
to be very effective.
Senator McCaskill. Yes. I would just like to see us do it
on the back end. So much of it has been focused on the front
end--and the back end is where recidivism occurs so often.
Chairman Johnson. Senator--let me--because we are 2 minutes
over--but let me just give--there is one metric that we can
use. You might have missed it when I first started questioning
General Kelly.
In 1980, in inflation adjusted dollars, the cost of heroin
was $3,260 per gram. I do not know what it is in St. Louis,
but, in Milwaukee, it is about $100 a gram.
Senator McCaskill. Yes.
Chairman Johnson. So, we are spending $25 billion a year to
interdict the supply of drugs and you want an indication--you
want a metric? Dropping from over $3,000 per gram to $100 per
gram----
Senator McCaskill. I would like a little more granular----
Chairman Johnson. I understand, but that is a pretty
effective macro----
Senator McCaskill [continuing]. Have to tell me where----
Chairman Johnson. Let us put it this way. We are not
winning the war.
Senator McCaskill. Yes.
Chairman Johnson. Senator Portman.
OPENING STATEMENT OF SENATOR PORTMAN
Senator Portman. Thank you, Mr. Chairman. I really
appreciate you and Senator Carper holding the hearing and your
focus on this issue--not just with this hearing, but over the
last couple of years--realizing that we do have an epidemic on
our hands and getting this Committee engaged. In fact, you have
allowed us to have a hearing in Ohio on April 22 to examine the
impact of opioid addiction--and the epidemic we have in
Northern Ohio--and I appreciate that. You guys are focused on
the right thing, in my view.
About 22 or 23 years ago, when I was first elected to the
U.S. House of Representatives, a young mother came to see me
and she wanted to talk about what we were doing on the drug
war, as she called it. Her son had just died of heroin--I am
sorry, of huffing gasoline, of all things, and smoking
marijuana. He just dropped over dead. He was 16 years old. His
name was Jeffrey Gardner. I still have his gold identification
(ID) bracelet.
She came to my office and she said, ``What are you doing?''
And, I was ready for her. It was my first year in Congress. I
said, ``We are spending $15 billion a year on interdicting
drugs, on eradicating drugs in Colombia, and on prosecutions.''
She said, ``How is that helping me?'' I called a meeting of my
church. They were in denial. People said, ``It does not happen
here.'' I called a meeting of the school. They said, ``We
cannot get involved because it will hurt our ratings.'' I
called a meeting of our neighbors. Nobody showed up.
And, I was embarrassed not to have a better answer for
her--and that is what got me involved in this. I was the author
of that ``drug-free media'' campaign in 1998, which had its ups
and downs--and we had some real difficulties with it--but the
fact is, prevention--and General, you are the one that said
it--it is demand.
And, I agree the price of heroin is too low and I agree we
should be doing more to deal with that, to stop the Fentanyl
from coming in, and so on. But, folks, if we do not get at the
demand side, it will be something else next. It was cocaine
back in the 1990s. And, I was the author of the Drug-Free
Communities Act of 1997, which has now helped spawn 2,000
community coalitions. I started one back home. I chaired it for
9 years. I am still very involved with it. And, we have seen
our rates of use by youth going down, Mr. Caulkins--even among
marijuana--which is, as you say, the single biggest drug
abused.
But, we now have this new epidemic and it has hit us hard.
So, I guess my response to the really good question Senator
Carper raised is that it has to be comprehensive, but it has to
focus on demand also. If it does not, you cannot solve the
problem. You cannot build a fence high enough. And, by the way,
methamphetamine can be made in a basement and marijuana can be
grown here--and it is. And, if it does not come from Mexico, it
can come from Afghanistan through Canada--and it does. And,
Fentanyl is coming from China, we are told.
So, I mean, I do not have the answers, clearly, after being
at this for more than two decades. But, I do think this CARA is
a really good step in the right direction. It focuses on
exactly what you all are talking about, today. I know a lot of
you have helped us on it and I thank you for that. But, it does
focus on prevention and education. It does fund these community
coalitions and gets them more involved in the opiate issue,
because that is the crisis we face. We almost have to focus on
the crisis now, including the treatment and the recovery side
of it, because we have so many people who are addicted.
I meet with them almost every week in Ohio. I meet with
recovering addicts and I ask the question, frankly, that was
asked by Senator Booker--a really good question: why? And, a
lot of these kids are suburban kids. So, this notion that it is
all inner city--it is not anymore. In fact, in terms of our
rate of use in Ohio, we think it is biggest per capita in the
rural areas--of prescription drug abuse and heroin addiction.
So, I really think it is the right question. I do not have
the answer, but I do think that CARA is a step in the right
direction, because it is comprehensive. It is broad. It is
about $80 million. Is that enough? No, there should be more
spent, but it is an additional $80 million, over time, if we
can get this done. We passed it in the Senate with a 94 to 1
vote. Do you know what that means? That means that every single
Senator sees it back home now--all of them.
And, it is the number one cause of accidental death--and it
is destroying families and ripping communities apart. I mean, I
talk to my prosecutors back home. They say 80 percent of the
crime is now related to opioid addiction. So, it affects every
emergency room and every firehouse.
I have a couple of quick questions. One--and this is to Dr.
Healton, again--in terms of a broader media campaign--you have
studied this, I know--and, again, the ``drug-free media''
campaign--we started it in the 1990s. We had the Partnership
for a Drug-Free America as our partner--as a private sector
partner. We tried to do something unique in government to bring
the private sector in--the creative people from Madison
Avenue--rather than doing it in-house. It did not work as well
as we intended, in part because government did get involved and
it was not the Madison Avenue, private sector, and hard-impact
advertisements we tried to get. Plus, we lost the money. I
mean, it was hard to keep the money coming.
But, what do you think should be done, in terms of this
broader prevention campaign, as an online or a broadcast media
effort?
Ms. Healton. Well, the ``Truth'' campaign at inception came
at a time where 90 percent of young people were getting their
media through television----
Senator Portman. Yes.
Ms. Healton [continuing]. As did the early days of the
ONDCP. It was a little bit easier. It is more complex now, but
it is doable. And so--I have made the comments before--I would
hand it over with a hands-off approach, because it does get too
complicated. When adults get into the approval process, the
creativity becomes further and further distant from the target.
And, in the case of substance abuse, you are picking the
roughly 40 percent of young people who are open to using
drugs--illicit or otherwise--and they are an interesting and
different subset. You need to design your advertisements,
specifically, for them--this is one of the reasons why the
advertisements are often very hard-hitting.
Also, you are to be commended for all of the work that you
have done. I have been following your career on this issue for
decades and thank you for everything you have done. People have
to step up to this problem--even though the room is empty and
you have been with the problem for a long time.
It is my belief that it is easier to talk young people out
of using tobacco than it is to talk young people out of using
drugs. Drugs are highly mind altering. They are reinforcing in
other ways. Kids have troubled lives. They turn to drugs to
self-medicate. It is a very complex problem. It is not quite as
simple as tobacco.
But, I do think it can be fixed. I think, in the right
hands, we can make a huge impact. And, I think we can know,
quickly, whether we are making an impact and, if we are not,
stop. It is the same reason I said that I almost stopped the
``Truth'' campaign, because $100 million is a lot of money to
spend without any hard evidence that it is likely to work.
Senator Portman. I really appreciate that answer. And, you
are talking about, basically, a request for proposal (RFP),
where you put it out and you have a merit-based process, but
then, you are hands off and allow them to do what they do best.
And, by the way, the good news is that we can target people
more than before, because every company in the private sector
is in marketing and has better--and more--data. In the
political realm, we have more data. And, you can use that data
to be able to target those kids who are the most vulnerable--
who are most susceptible to falling into the grip of addiction.
And, that is why I think it is worth doing.
Again, to Senator Carper's question, we still spend a whole
lot more on the demand side than on the supply side--I am
sorry, on the supply side than on the demand side. And so, you
are talking about $100 million. It is a lot of money. On the
other hand, it is relatively small compared to the billions of
dollars--probably close to 20 billion now--that you would
ascribe to the supply side. Again, I am not saying the law
enforcement--and the supply side--is not important. Of course,
it is. But, ultimately, you are not going to solve it until we
get at the demand side.
My time has expired. Senator McCain is now here and we can
have a chance--he has been a leader on this issue too. But, I
just really appreciate the work you guys are doing in the
trenches every day and we are very eager to get your
perspective--which is more academic, where you can kind of look
at what is really working and what is not working. It is like
we have a fire, though, right now. We have to put out the
fire--and that means better treatment and more treatment
options, better recovery--evidence-based--and helping some of
these people whose lives are just being destroyed by this grip
of addiction--this really difficult grip of opioids--to get
back on their feet.
So, thank you all very much and thank you to the Chairman
and Ranking Member for holding this hearing.
Chairman Johnson. Senator McCain.
OPENING STATEMENT OF SENATOR MCCAIN
Senator McCain. Both Professor Caulkins and Dean Healton
talked about how the ``Just Say No'' efforts to reduce the use
of tobacco have been very effective. Why do we not do that with
drugs?
Mr. Caulkins. It is really important to split drugs up into
their different bins.
Senator McCain. OK. Now we are talking about----
Mr. Caulkins. Marijuana----
Senator McCain. Well, wait a minute. Let us talk about the
major problem right now all over the country, particularly in
the Northeast and the Midwest--and that is manufactured heroin.
Mr. Caulkins. If I might--so, marijuana is sort of similar
to alcohol and tobacco in that it is consumed by a lot of
people. The prescription opioid abuse crisis is absolutely
driven by our policy of making painkillers much more widely
available. For the other bin--the heroin, cocaine, and meth
bin--it is, perhaps, one percent of the country's population
that is completely dominating their consumption and, hence, the
cross-border flows.
Senator McCain. That is not----
Mr. Caulkins. It is hard to reach the one percent with the
media----
Senator McCain. That is not the perception of the Governors
of these States. In fact, Governors in the Northeast and the
Midwest are saying that manufactured heroin has driven the drug
overdose deaths up astronomically. Maybe they are using the
wrong figures, but I do not think so. Go ahead.
Mr. Caulkins. No, it is correct that that use has soared,
but the consumption is still dominated by the small number of
people who use with great frequency. It is only a subset of all
people that have used within the last 12 months that are
driving most of the use--and this is, actually, true not just
of drugs. It would probably be true of plastics too. There are
some high-volume consumers. That is a relatively small number
of people.
There is definitely an opportunity for a media campaign to
change mores and norms around prescription drugs and their
derivatives. I think it is a lot harder to do that for the
three million or so daily and near daily users of cocaine,
crack, meth, and, actually, heroin, who dominate the
consumption that drives the cross-border flow of those drugs.
So, I am trying to differentiate marijuana from the
prescription drugs and to differentiate the prescription drugs
from the classic hard drugs.
Senator McCain. I am trying to address the issue of what is
a, relatively, new threat. And, that is manufactured heroin--
manufactured in Mexico, primarily--right, General Kelly?--that
is now flooding in the view of every Governor--including the
Governors of Wisconsin and Ohio--that is flooding the market--
and people who have been using Oxycontin, which is six times
more expensive--and other painkiller--are now turning to this
manufactured heroin, which has driven up, dramatically, the
deaths from manufactured heroin drug overdoses. Now, that may
be only one percent. I do not know that. But, I do know that
the number of deaths have skyrocketed, which has gotten the
attention of every Governor in America.
Go ahead.
Mr. Caulkins. The question is just--is this the kind of
thing that is best addressed with a broad-based media strategy
or a different strategy? I absolutely agree it is an extremely
important problem. I thought the premise of your question was
why we are not addressing it with something more like a ``Just
Say No'' strategy.
Senator McCain. Why are we not addressing it at all?
Go ahead, Dr. Healton.
Ms. Healton. Well, first of all, I think a lot of the
heroin problem that we are now seeing has its roots in moving
from pills to cheaper heroin because of market forces.
Senator McCain. And, supply.
Ms. Healton. Yes, exactly, and supply, which, of course,
helps to lower the price of heroin--as long as it is getting in
as readily as it is.
But, in France, after they made a drug that is a safe
replacement for an opioid widely available, there was a 79
percent reduction in deadly overdoses. So, there is a treatment
arm that is urgently needed--and, frankly, it is time to get
tough with the pharmaceutical industry. And, I think I did
provide the Committee with some background information----
Senator McCain. I agree with that. I agree about getting
tough with the pharmaceutical industry. But, the fact is--and I
will ask General Kelly--that most of the deaths can be
attributed to manufactured heroin that is coming from Mexico. I
am no friend of the pharmaceutical industry, but the
pharmaceutical industry is not setting up heroin manufacturing
in Mexico. General?
General Kelly. Yes, Senator. As we have discussed--and I
stated a couple of times, today--the heroin--virtually all of
it--97 percent or more--comes from Mexico--and that is a
reaction. It used to come from Afghanistan and the Golden
Triangle--Burma. But, these cartels are run by unbelievably
good businessmen and they see----
Senator McCain. Are they getting into this country fairly
easily? And, why?
General Kelly. Yes. The estimation is that, to feed our
demand, about 45 metric tons of heroin has to get into the
market inside of the United States--about 45 metric tons. You
would fill this room.
So, why does it get in so easily? Because the cartels and
the network--as we have discussed many times--are so
efficient--so good at what they do. It gets in in a relatively
small amount--5, 10, or 15 kilos at a time--and then, it gets
distributed.
A little earlier today, Senator, we were talking about
whether the Southwest border is secure. I would just--as I said
last year and the three previous years in your hearings--all of
the drugs that the demand requires get in. Thousands and
thousands of human beings get in--and all of the rest of it
that comes in through the network. So, I would have to say that
the border is--if not wide open, certainly, open enough to get
inside of the country what the demand requires.
Senator McCain. So, we are talking about a demand and we
are also talking about a supply. And, could I have a quick
recitation of how you can secure the border?
General Kelly. I do not have a lot of experience on the
border, but I would tell you, I think the men and women that
are in law enforcement and at DHS and all, they would--and I
have visited the border--and what they would argue for are
policies--this is them talking--policies that they understand
and can execute--whether it is about drugs or people--and just
more of an effort--whether it is technology or other ways--to
search more vehicles as they cross.
But, really, at the end of the day--and that is a goal line
stand, one day after another. I would argue, in the case of
heroin--as you know, Senator, there are parts of Mexico that
the Mexican authorities will not go. And, that is where this
drug is produced--where the poppies are grown and all of that.
And, I would just argue that we need to help the Mexicans help
themselves and allow them the training and what not to go into
those regions, because it is all--95 percent of it is grown in
Mexico--the poppies--and then, turned into either manufactured
heroin or real heroin--and then, trafficked into our country.
But, it is the demand.
Senator McCain. Mr. Chairman, could I ask your indulgence,
maybe, just if there are any comments our other two witnesses
would like to make?
Chairman Johnson. Sure.
Mr. Sgro. Thank you, Senator. And, I do not claim to have
experience with drug demand. However, as a marketing
communications professional and having taken on the tough
challenge of preventing young people from being recruited by
extremists--that is a tough problem as well. And, what we have
seen with the ``Peer-to-Peer: Challenging Extremism'' program
is that it is a communications issue. It is an awareness issue.
It starts with awareness. And, from a marketing function--and
Doctor, you will know this--you have awareness, interest,
evaluation, trial, and adoption. That is ``marketing 101.''
We need to have really strong education on top of
awareness, because, ultimately, interested people who are
curious are going to come down the funnel and we need
touchpoints with youth all of the way down the funnel to
prevent them from pursuing, trying, and getting addicted to
drugs.
Another point--television does not work with Millennials or
Generation Z. It is social media driven. One of the key
takeaways that we have learned with extremism is that it is who
creates the message that delivers the credibility.
Senator McCain. I can assure you that at least the three of
us are aware of the habits of Millennials--and our attempts to
communicate with them. [Laughter.]
Mr. Sgro. It is almost useless. [Laughter.]
Chairman Johnson. If you could stick around for just a
couple of minutes, I want to kind of go down the same vein--
and, maybe, it can--coming from a marketing background,
myself--because I want to ask this question. Why has the
advertising campaign against tobacco use been so effective and
yet, why did it not work in the war on drugs--and it starts
with the percent of the population that we are targeting?
In 1996, youth smoking peaked at 38 percent of the
population--38 percent as one percent of the population. Now,
it is down to 7 percent. What Dr. Caulkins is talking about is
how we are trying to target one percent--the real problem
users, in terms of driving all of these problems. So, if you
have a broad-based advertising campaign targeted at one
percent, it is not going to be as effective as a broad-based
advertising campaign targeted at 38 percent.
Plus, the difference in the tobacco advertising campaign,
compared to the campaign combatting drugs--tobacco is legal--
and so, you can also increase taxes to reduce the demand. You
can restrict access to restrict the demand.
So, there are some key differences between the campaign
that has been successful with tobacco and the campaign that--
let us face it--has not been successful with drugs. And so, you
have to recognize those differences--and as Mr. Sgro was
talking about too--realize television advertising is not
effective, particularly, when you try and do a broad-based,
expensive broadcasting campaign that is trying to target one
percent of the population--which is the problem.
I mean--just kind of comment. Is that kind of an accurate
evaluation? Dr. Healton.
Ms. Healton. It is 90 percent accurate----
Chairman Johnson. OK.
Ms. Healton [continuing]. But, I want to focus on the 10
percent that is not accurate, because I think it is a very
important 10 percent. The one percent that Jonathan is
describing, that is not the focus of a primary prevention
public education campaign. A primary prevention public
education campaign is targeting those who have never started.
The ``Truth'' campaign was not targeting existing smokers.
As a matter of fact, existing smokers intensely disliked the
``Truth'' campaign. They felt put down by it. They, actually,
did respond positively to it, in the main, in terms of changing
their behavior, but the bulk of the behavior change occurred by
people never starting.
And, the goal of a primary prevention education campaign is
to stop kids from ever starting. And, you have to--you
absolutely must include in this campaign the dangers of using
opioid medication--period. The kids directly have to know it,
because they are being handed it by doctors in sports medicine
clinics, on their college campuses, at their dental offices,
and from their friends for a price.
Chairman Johnson. That is my next question, OK. And, by the
way, you are exactly right. And, I appreciate you pointing that
out.
What is the gateway? We keep hearing that opiate drugs are
the gateway for heroin, but what about the marijuana use? We
are talking about 22 million Americans, in the last month,
using marijuana, as opposed to two million or three million
using the heavier drugs. What is the true gateway here?
Mr. Budsock. I can speak to that.
Chairman Johnson. Sure.
Mr. Budsock. Well, the first thing I would like to cover is
that I was recently participating in a roundtable discussion
with some physicians in the State of New Jersey. They were
talking about changing behaviors in emergency room medicine.
And, one of the physicians asked if you would give heroin to
your 13-year-old daughter. And then, what they did was start to
explain that, chemically, a Percocet or an Oxycodone--
chemically, they are very similar to heroin.
I actually have my 13-year-old daughter with me here,
today. She is a soccer player who has gotten some minor
injuries before. But, I would be terrified if a doctor wanted
to give my daughter a Percocet for an injury because of what I
know--how chemically similar it is to heroin--and also because
I know that different people--addiction is a brain disease--and
everyone's brain is wired a little bit differently.
And, you could go ahead and you could give that Percocet to
10 different people and 10 people may just take it once or
twice and be done with it. But, then the 11th person, maybe,
their brain is a little different and what happens is that they
quickly become addicted and they have that insatiable desire to
just have more and more of that drug. Quickly, they cannot get
the prescription medicine. So, once they find they get cut off
by the doctors, it is very expensive to buy prescriptions on
the street. They quickly go to the low-cost heroin.
Chairman Johnson. Which, by the way, one of the pieces of
legislation we have proposed would make sure the Centers for
Medicare and Medicaid Services (CMS) does not penalize
providers by asking those survey questions--``how did you think
your pain was managed? ''--because that is driving some of
that, along with the other points you are talking about.
Dr. Healton, you had a comment about this.
Ms. Healton. Well, I would just say that, for about 25
years now, there has been a prevailing theory about nicotine
being, actually, a very powerful gateway drug. And, the theory
is--Denise Kandel, recently--I guess about 5 years ago--she,
her husband, Eric Kandel, and Art Levine wrote a paper
reporting on--I would not be a scientist if I did not talk
about mice, but a mouse model in which, if you addict mice to
nicotine and then challenge them with cocaine, they are much
more likely to use the cocaine and to use it at higher levels.
And, they proved it, literally, at the molecular level.
It has not been replicated in humans yet, but there is sort
of a growing body of evidence that nicotine and alcohol, which
are, usually, the first drugs that young people use, are the
most popular two drugs--prior to the big decline in tobacco.
So, they kind of prime the pump for altered states.
Chairman Johnson. I have two other lines of questioning I
need to get at. So, we have begun the experimentation with
marijuana legalization. I have talked to Chiefs of Police, in
Wisconsin, that are involved in national associations and I
just asked them, ``So, what are you hearing? '' And, again,
this is just anecdotal, which you always have to be concerned
about.
The reaction, to me, has been a disaster from a public
safety standpoint. I mean, does anybody want to chime in on--do
you know anything about that? I mean, where are we, in terms of
the experiment, on a State basis, with the legalization of
marijuana? Dr. Healton.
Ms. Healton. Well, I think the jury is out--and there are
studies that are being done--because, really, in the final
analysis, you have to weigh marijuana as a legal drug comapred
to what the situation would be like with marijuana as an
illegal drug. We have not seen an increase in marijuana use
among the teens in the monitoring----
Chairman Johnson. Did you say you have not or you have?
Ms. Healton. Have not.
Chairman Johnson. OK.
Ms. Healton. It is flat. It is still high. I want to say it
is, like, up there in the 30s----
Mr. Caulkins. Use is up in adults.
Ms. Healton. As I said, I am talking about youth. For
youth, it is flat. I would not be surprised if it is up in
adults. Sadly--and many people do not want to talk about this--
but you could think of drug use as kind of a zero-sum game.
People migrate from one to the other. The issue with marijuana
is that it is well known--except for synthetic marijuana, which
is a separate issue--to be, relatively, safer when compared to
other drugs. I think it is socially toxic for young people
because of what it does to motivation--a separate issue. But,
in terms of whether it is going to kill you, it is hard to
find----
Chairman Johnson. What about the potency over the last few
decades?
Ms. Healton. Maybe you want to speak to it?
Mr. Caulkins. Yes. I can----
Ms. Healton. I mean, I could speak to it----
Mr. Caulkins. To be a little bit self-promotional, my
second book on marijuana legalization just came out this month.
So, it is always risky to ask me about this because it is
exactly where my deepest expertise lies.
But, yes, potency has increased--that is the short answer.
The market is bifurcated, including both commercial-grade and
sinsemilla marijuana. The proportion that is the high potency
sinsemilla has gone way up and there are also increases in
potency within each of those bins. Furthermore, there is an
increasing use of extract-based products, like vaping and
dabbing, because, now that there is legal production, it is
economical to extract tetrahydrocannabinol (THC) from parts of
the plant that used to be destroyed.
Chairman Johnson. So, does marijuana move into the
very--again, you are bifurcating it, I am not--but does it move
into more of a status of like heroin, cocaine, or
methamphetamine----
Mr. Caulkins. No. If anything, it is the opposite.
Marijuana use is becoming normalized.
Chairman Johnson. I am talking about, in terms of potency
and the effect on the human brain and health----
Mr. Caulkins. Oh, yes. So--really importantly--even very
high potency marijuana does not stop your heart or your lungs.
It is, behaviorally, a problem. About two to three times as
many ``past month marijuana users'' will self-report that using
it causes them problems at work, at school, and with family, as
compared to the number of ``past-month alcohol users,'' who
will self-report that the alcohol is causing problems in those
areas. So, it interferes with life functioning, but it does not
kill you the way that heroin and opiates do.
Chairman Johnson. My last line of questioning is--we talk
about treatment. First of all, what is the effectiveness of it?
I mean, how effective is treating addiction and what is the
cost? I will look to Bob.
Mr. Budsock. Yes. So, what we have determined is that--or
not we, basically, the field that studies addiction treatment
has definitely determined that there is a correlation between
the length of treatment and success. So, for individuals whose
addiction is treated like an acute disorder, in other words,
they go into a treatment facility for 14 days--for 21 days--and
they just get spun out of that facility without any continuing
care or aftercare--the rate of those individuals going back to
active drug use is very high.
Chairman Johnson. Which is what--90 percent? Ninety five
percent?
Mr. Budsock. You know what, it is very high. I would say--
--
Chairman Johnson. Does anybody have a----
Mr. Budsock. I do not have the statistics in front of me,
but it is at a very high rate. But, that also does not mean
that it is a complete failure.
Chairman Johnson. I understand. When you save one person,
that is wonderful.
What about longer-term treatment, then? What is the
effectiveness?
Mr. Budsock. So, what has been proven is that, with long-
term treatment--when I say long-term treatment, addiction is
treated like a chronic disorder--the same way that you would
treat diabetes, hypertension, or asthma--what is found is that
individuals that have that long-term continuing care have fewer
returns to drug use, more stable employment, and more stable
family situations----
Chairman Johnson. OK. Well, give me--I want stats. I mean,
are we talking--are we 80 percent effective or are we 20
percent effective, even with long-term treatment? Again, I am
trying to get to how----
Mr. Budsock. It depends on, specifically, what you are
measuring. I could tell you, recently, we had a study at
Integrity House. For individuals that completed the residential
component--and after they completed the residential component
they continued in outpatient treatment and upon discharge from
the outpatient treatment--and the outpatient treatment varied
in length anywhere from 3 to 12 months--the day that they
completed that outpatient treatment--which lasted between 3 and
12 months--95 percent of those individuals were abstinent.
Chairman Johnson. And, what does that----
Mr. Budsock. That does not mean----
Chairman Johnson. What does that long-term treatment cost,
per person, per year--just a ballpark amount?
Mr. Budsock. Yes. So, it depends on the intensity. The
intensive, residential treatment, where individuals are
supervised 24 hours a day, is about $100 a day for treatment.
Once the individual completes that intensive residential stay,
they move into a less intense level of care and that cost could
be--if they come back for outpatient three times a week, it
will be approximately $100 for each day that they come back for
treatment.
Chairman Johnson. So, on an annual basis, it would be
$36,000, if it was a daily type of thing. Does that comport
with what other people--again, I am just trying to get some
sort of figure. Dr. Healton.
Ms. Healton. Well, the figures are, generally, correct, but
people are not in treatment, generally speaking, for a full
year. They may be in for 30 days--and the insurers are pushing
that back like crazy.
There is a very well known paper--I can get it for you--
that came out in the New England Journal of Medicine (NEJM)
probably 15 years ago that unequivocally concluded that, for
drug treatment, more is more. The more treatment that you get,
the higher the probability that you will succeed for a longer
period of time.
Drug addiction is very similar to high blood pressure. It
is not going to disappear. It is just--you are going to keep
treating it. And, what you want to do is have the longest
periods of sobriety and abstinence that you can get and have
the safety net there for the person who slips off.
So, if you have someone who is an addict--whatever they are
addicted to--alcohol, pills, or heroin--if, out of 8 years,
they can be drug-free for 6 years, that is a success story.
And, that is how the field is now viewing success. Drug
addiction is a chronic disease.
This is another reason why primary prevention is so cost
effective, because, once someone crosses over, they are at risk
for drug addiction, in a cycle that simply is without end.
Chairman Johnson. OK. I have gone way too long. Senator
Carper.
Senator Carper. Well, as we get close to the end of this
hearing, I had high expectations that we were going to learn a
lot--this was going to be valuable--more so than even I had
hoped--so, we thank you very much for that.
I had asked a question earlier and General Kelly, Mr.
Caulkins, and Dr. Healton took a shot at it. And, that was
about helping us put together some of the elements of a
comprehensive strategy--and I am convinced that we could save a
lot of money here--and treatment is expensive--so are some of
the other things we talked about here--that comprehensive
advertising campaign would be expensive, but, as I always like
to say, ``compared to what? '' I have a friend. If you ask him
how he is doing, he says, ``Well, compared to what? '' So,
compared to what we are already spending, this would probably
be--maybe, not a bargain, but, surely, a deep discount.
Mr. Sgro, I want to come back to you and ask you to go back
to the question that your three compadres there answered for me
earlier. And, I would like for you, and then Mr. Budsock, to
take a shot at the same question.
Mr. Sgro. Yes. Thank you, Senator. I made some comments in
your absence and I will just kind of stick by those. And, that
is that the Millennial-mindset generation and the Generation Z-
mindset are very suspicious of top-down, command messaging.
And, the ability to have young people be a part of the
solution--just given the sheer size of that demographic--is so
important, because the ability to impact behavior exists
between friends. And, not just----
Senator Carper. Say that again. The ability to----
Mr. Sgro. To impact behavior exists amongst friends. They
are not going to be resentful--nor rebellious--with each
other--compared to a top-down command--parents, law
enforcement, or whatever it might be.
Senator Carper. OK.
Mr. Sgro. And, I think another really important issue, when
it comes to the platform of messaging--there is a difference
between what happens in different parts of Los Angeles. Is it
Instagram, WhatsApp, or another social media platform that is
being used? So, things are changing--we have seen--every 15
weeks on social media--and that is how young people
communicate. They may not talk to each other, but they will
text each other. So, the platforms are equally as important as
what, actually, the message is.
Senator Carper. Thank you. Mr. Budsock.
Mr. Budsock. Yes, Senator. So, the first thing I would like
to talk about is cost--and it is important--we came up with a
figure of $36,000 a year--and that would be somebody that is
undergoing intensive services for 12 months. In most cases,
those intensive services probably need to be only for the first
6 months. So, it would probably be $18,000 to treat the
individual for the first 6 months and then, that cost would
decrease for the continuing care.
The other thing that is important----
Senator Carper. The thought comes to mind--I used to know
these numbers better when I was Governor--but we used to say it
cost $20,000 a year to keep an adult incarcerated in the State
of Delaware--and, for youths, it was several times that. So, it
is not far off of that--it is probably closer to $25,000,
$30,000, or $35,000, today, for the incarceration of an adult
for a year.
Mr. Budsock. And, I believe the cost--that is a minimal
cost. That is probably out in very rural areas, like Wyoming. I
know, in New Jersey, it is as expensive as $60,000 to $70,000 a
year to incarcerate someone--and I believe there is a study
that actually has the exact figures for that.
Senator Carper. The thought occurs to me--excuse me for
interrupting. The thought occurs to me, if you have someone who
is incarcerated for a drug-related crime, part of that $100 a
day, if you will, is--if they are incarcerated--for actually
doing a good job on treatment while they are incarcerated, you
actually save some money.
Mr. Budsock. Yes, absolutely.
Senator Carper. Go ahead. I am sorry to keep interrupting.
Mr. Budsock. Well, the other thing is that there are
multiple studies that indicate that, for every dollar invested
into treatment, there is a return to the economy anywhere from
$4 to $7 in associated reduced costs related to crime, inactive
workforce, etc. And, if you factor in the cost for health care
savings, it could be as big of a return as a $12 return for
every $1 invested.
And, the other thing is--going back to your earlier
question----
Senator Carper. I am going to ask you to wrap it up really
quickly, because I have one more question, but just go ahead.
Mr. Budsock. OK.
Senator Carper. Finish your thought.
Mr. Budsock. I will wrap it up quickly. I am trying to put
myself in your seat up there and saying, ``OK, what do I need
to know to actually make sure that we are reducing demand? ''
One piece is prevention--to make sure that we have
effective prevention programs that are teaching kids refusal
skills.
The second is to make sure that treatment is available--
that individuals who need it have quick and ready access to
treatment--and that there is parity--that addiction treatment
is covered in the same way that a physical illness is covered.
And, the final piece is to repeal the IMD exclusion. I
spoke about it earlier. It has been around since 1964 or 1965
and for the current world that we are working in, it is
absolutely an unfair barrier for many people.
Senator Carper. OK. Thank you.
Let me come back to Dr. Caulkins. I think you mentioned--I
think it was a South Dakota program earlier, ``Swift, Certain,
and Fair''--and, I guess, I want to know what possible role
would a program like that, which has apparently been successful
in one State--what possible role could that play on a broader
scale?
Mr. Caulkins. Sure. ``Swift, Certain, and Fair'' is the
broad concept. ``24/7 Sobriety'' is the name of the particular
program in South Dakota. It has now spread to Montana and North
Dakota. Hawaii's Opportunity Probation with Enforcement (HOPE)
is a parallel program.
They have the potential to have a huge impact because of
the fact that today's consumption of the hard drugs is
concentrated in this, relatively, small number of people. And,
these programs have been astonishingly successful at reducing
use, even among that difficult population. So, treatment makes
people better off and, in the long run, it may cut down on
consumption.
But, ``Swift, Certain, and Fair'' regimes are a very
different paradigm. They just test very frequently--in South
Dakota, literally, twice a day--originally, with driving under
the influence (DUI) offenders. They are doing that, now, for
alcohol and for other substances too. And, the remarkable thing
is that an awful lot of people respond when you monitor that
closely and there is an immediate sanction--not a severe
sanction, but an immediate sanction--even if they are dependent
and even if they are not in a traditional treatment program.
One idea is that you can use ``Swift, Certain, and Fair''
as a front end and, maybe, 70 percent of the use can be
addressed by this testing with sanctions--which is a little bit
like a drug court regime--and then, only the folks who fail
``Swift, Certain, and Fair'' would get to the conventional
treatment. And, that would allow conventional treatment to
focus on the smaller subset of people who do not respond to
this incentives-based regime.
Senator Carper. OK. Alright, Mr. Chairman. I have not used
but 32 seconds of my extra time, but could I get another couple
of minutes?
Chairman Johnson. OK.
Senator Carper. Thank you very much. That is what we call
``the Golden Rule.''
Chairman Johnson. I do have to move, so----
Senator Carper. Good. If you need to leave, I would be
happy to stay. I promise not to get in trouble.
Chairman Johnson. I have some questions myself.
Senator Carper. OK. Fair enough.
The other question I have relates to--somebody mentioned
this in your comments--the use of other substances--for
example, opioids. We are using opioids for pain and that kind
of thing. But, there are substances--pharmaceuticals--that can
be prescribed that are not addictive. I know we use other
substances to treat people who are addicted to different types
of drugs. What is the future of that? What is the promise of
that particular approach for folks that might be addicted--
whether it is to meth, cocaine, or heroin? What can be done? Is
there any potential there for success, please?
Mr. Budsock. I can speak, specifically, about opiate
addiction. There is research proving that medication-assisted
treatment (MAT), such as methadone, Suboxone (buprenorphine and
naloxone), and Vivitrol (naltrexone), have all been very
effective in helping the individual--giving the individual time
for their brain to normalize and also to help them avoid the
intense cravings that they are experiencing when they initially
put down the heroin.
What is important is that everyone realizes that it is
medication-assisted treatment. There is no quick fix. If you
just give someone one of these pharmaceuticals, which are
approved by the Food and Drug Administration (FDA) and proven
to be effective by research, the medication, alone, will not
allow the person to actually transform their lives.
Senator Carper. OK. Thank you.
The last thing I would say--Cheryl, I do not know if you
remember, but there was a campaign, in Montana, focused on meth
that I think was very successful for a while. Would you mention
that? And, why did it sort of fade away?
Ms. Healton. Well, there was one evaluation of it that was
done--that I am aware of--and that did show effectiveness. It
was offered to every State in the Union and, in my opinion, the
primary reason that there were only a handful of takers is
because it fell into that category of being objectionable to
adult viewers, in terms of the advertising.
An example--one example was a young man on meth beating his
mother up. Now, this, I am sure, came out of research with meth
addicted kids----
Senator Carper. Right.
Ms. Healton [continuing]. Some in recovery and some not.
They described how they became active in family violence and
they thought that depicting that would turn young people away
from it. That was more than a lot of States were prepared to
air on their dime.
Senator Carper. OK. Thank you all very much.
Chairman Johnson. Thank you, Senator Carper.
I did see that General Kelly wanted to get involved--make
some comment on something, so----
General Kelly. Yes. We talked a lot, obviously, about the
very important topic of addiction and that kind of thing--which
is, to say the least--usually important. I would just make a
pitch. There is another aspect to this and that is--and I think
it, probably, would lend itself to kind of advertising
campaigns or whatever--and that is just the casual use--or the
recreational use--of drugs, particularly, a drug like cocaine.
People that use cocaine or other drugs, recreationally--
that do not get strung out and that do not go down the road of
addiction--they ought to know that their casual, fun use on a
weekend really does end up resulting in the murder of police
officers in Honduras or in the intimidation of families in
Colombia.
And, I think, just appealing to the right side of the
American psyche--and that is understanding that it is not the
same as having a couple of drinks after work because of the way
that it is produced and trafficked into the United States. And,
I have to think that that would--if we did educate--whether it
is college students, young businessmen, Congressional staffers,
or anyone else--that the casual use of these drugs really does
result in terrible things down in the production zone and in
the transit zone. Thank you.
Senator Carper. That is a great point. Thank you.
Chairman Johnson. And, it was the point that I made
earlier. It is not a victimless crime.
So, listen, the beauty of having five people on a panel is
that we get a broad spectrum of views and we get some really
good input. The unfortunate nature of it is that, for a lot of
it, you are sitting there and not being able to answer all of
the questions. So, view this hearing as really just one step in
a series of hearings, because this is such an enormous problem.
You have done a great job of raising our awareness, helping us
to understand this a little better. But, it is incredibly
complex.
So, again, I just want to thank all of you for your time,
your very thoughtful testimonies, and your very thoughtful
answers to our questions. This will continue. We are, actually,
continuing it, in Wisconsin, on Friday. And, we are going to
continue the conversation, more specifically, in terms of the
problems in Wisconsin, but every State in the Union is
suffering under this.
So, with that, the hearing record will remain open for 15
days, until April 28, at 5 p.m., for the submission of
statements and questions for the record.
This hearing is adjourned.
[Whereupon, at 11:48 a.m., the Committee was adjourned.]
A P P E N D I X
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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
ASSESSING THE FEDERAL RESPONSE
----------
TUESDAY, MAY 17, 2016
U.S. Senate,
Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3:33 p.m., in
room SD-342, Dirksen Senate Office Building, Hon. Ron Johnson,
Chairman of the Committee, presiding.
Present: Senators Johnson, Portman, Ayotte, Carper,
McCaskill, Tester, Booker, and Peters.
OPENING STATEMENT OF CHAIRMAN JOHNSON
Chairman Johnson. This hearing will come to order. I do
apologize to the witnesses for the delay. We had a couple of
votes, so I appreciate your indulgence.
Because we are short on time, I just have a written
statement that I would ask consent to enter in the record.\1\
---------------------------------------------------------------------------
\1\ The prepared statement of Senator Johnson appears in the
Appendix on page 285.
---------------------------------------------------------------------------
And, I would also like to recognize the fact that it is
National Police Week. There have been 123 law enforcement
officers killed in the line of duty during calendar year 2015,
including two in Wisconsin: Officer Ryan Copeland from
McFarland, Wisconsin and Trooper Trevor John Caspar, who was
killed in Fond du Lac, Wisconsin. So, I would just ask
everybody to bow their heads and take a moment of silence.
[Moment of silence.]
Thank you. The sacrifice of our police officers is really
too large to even express in words, so I appreciate everybody
taking that moment of silence.
With that, Senator Carper.
OPENING STATEMENT OF SENATOR CARPER
Senator Carper. Thank you, Mr. Chairman. Thank you for
pulling this together. To our witnesses, again, we apologize
for the delay. Sometimes, our day jobs get in the way of our
job here on the Committee--and that was voting--voting on the
Senate floor.
I have a statement and I would also like to ask, Mr.
Chairman, unanimous consent that it be included in the
record.\2\ I just want to mention one or two things, if I
could, and then we will get going.
---------------------------------------------------------------------------
\2\ The prepared statement of Senator Carper appears in the
Appendix on page 286.
---------------------------------------------------------------------------
The situation we are in, as a country--there is a large
focus here on the three countries where the most illegal
immigration is coming from in Central America--South America--
and they are: Honduras, Guatemala, and El Salvador. And, the
reason why people are coming up here is that, a lot of times,
young kids--young families live hellacious lives. They live
hellacious lives because we send them money and they send us
drugs. We send money and guns to some of the people that are
just making life miserable for the citizens of those countries.
I am one who always wants to focus on root causes--to find
out what is the root cause of a problem, not just look at the
symptoms of a problem. You have all of these people trying to
get into our country across the border. What is the root cause
of that? The root cause of that is that their lives are
miserable because of our addiction to drugs and the trafficking
of those drugs through those countries.
So, we are doing a couple of things to try to address it,
including investing some money to help enable those countries
to be a better place to live--less horrific--a place they would
want to stay and raise their families. And, the root cause is
our addiction--our addictions to opioids and heroin--that sort
of thing. And, we cannot ignore that.
The last thing I would say is this: We talk in this
Committee, from time to time, about how, in order to be able to
stop human trafficking--in order to be able to stop the
bringing of things that are illegal--including drugs--into this
country, we need to reduce the size of the ``haystack.'' The
``needle in the haystack''--we have to reduce the size of the
``haystack'' if we are going to find those ``needles.'' We have
to be able to--and I am not talking about needles for
addiction--but the key is reducing the size of the
``haystack.'' And, part of that is making sure that the people
living in these countries have a life that is not miserable--
not full of fear, but one for which they would be more inclined
to stay if they could. And, I think they would like to. And,
part of it is on us. Part of that is on us. And, that is why we
are having this hearing today.
We welcome you all. Thank you so much for coming.
Chairman Johnson. Thank you, Senator Carper.
I think this is our 18th hearing on some aspect of the lack
of security on our border. And, certainly, my conclusion--and I
think at least some of the Members here would probably, at
least partially, agree with me--when I have looked at the root
cause of our unsecured border--the primary root cause is our
insatiable demand for drugs--which is why we are having this
hearing. It has given rise to drug cartels who, let us face it,
control whatever portion of the Mexican side of the border they
choose to. It is destroying public institutions in Central
America and parts of Mexico. So, this is an enormous problem
and we just simply have not been winning the ``War on Drugs.''
So, with that, it is the tradition of this Committee to
swear in witnesses. So, if you will all rise and raise your
right hand. Do you swear the testimony you will give before
this Committee will be the truth, the whole truth, and nothing
but the truth, so help you, God?
Mr. Botticelli. I do.
Ms. Enomoto. I do.
Ms. Maurer. I do.
Chairman Johnson. Thank you. Please be seated.
Our first witness is Michael Botticelli. Mr. Botticelli is
Director of the Office of National Drug Control Policy (ONDCP).
Mr. Botticelli has more than two decades of experience
supporting Americans who have been affected by substance abuse
disorders. Prior to joining ONDCP, Mr. Botticelli served as
Director of the Bureau of Substance Abuse Services (BSAS) at
the Massachusetts Department of Public Health (DPH). He is also
in long-term recovery from a substance use disorder,
celebrating more than 25 years of sobriety. We certainly
congratulate you on that. Thank you for your service and we
look forward to your testimony.
TESTIMONY OF HON. MICHAEL P. BOTTICELLI,\1\ DIRECTOR, OFFICE OF
NATIONAL DRUG CONTROL POLICY
Mr. Botticelli. Thank you, Chairman Johnson, Ranking Member
Carper, and Members of the Committee. I want to thank you for
the opportunity to be here today to discuss ONDCP's authorities
along with our collaborative efforts to carry out the
Administration's drug control priorities, including our
response to the opioid epidemic.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Botticelli appears in the
Appendix on page 288.
---------------------------------------------------------------------------
As a component of the Executive Office of the President
(EOP), we establish policies and objectives for the Nation's
drug control programs and ensure that adequate resources are
provided to implement them. We also develop, evaluate,
coordinate, and oversee the international and domestic anti-
drug efforts of Executive Branch Agencies.
We are charged with producing the annual National Drug
Control Strategy, which is the Administration's blueprint for
drug policy along with a national drug control budget.
Let me first start off by saying that the National Drug
Control Strategy has produced results. Particularly important
to us, right now, is that, among youth aged 12 to 17, the
number of current nonmedical users of opioid medication has
declined 29 percent from 2009 to 2014--and 39 percent among
young adults aged 18 to 29. Perhaps most importantly, the
number of new nonmedical users of prescription pain medication
went down 35 percent over this same time period--from 2.2
million in 2009 to 1.4 million in 2014.
Also, between 2009 and 2014, there were reductions in the
use of illicit drugs--other than marijuana--dropping 21 percent
among youth aged 12 to 17 and 20 percent among young adults
aged 18 to 29.
Substantial progress has also been achieved in reducing
alcohol and tobacco use among youth, with a 28-percent decline
in the rate of the lifetime use of alcohol among eighth-grade
students--and 34 percent for cigarettes. These declines exceed
the targets that we established for the 2010 National Drug
Control Strategy.
Despite these achievements, we know that much remains to be
done. And, while we have seen the leveling off of deaths
associated with prescription pain medication, we have seen a
tremendously alarming increase in deaths involving heroin and
illicit fentanyl. These correspond with recent increases in
poppy cultivation and heroin production in Mexico.
With the continued implementation of the Administration's
plan for addressing this crisis, including our engagement with
the government of Mexico, we are hopeful that the Nation will
see renewed declines in the availability of heroin and in
deaths involving opioids.
ONDCP's oversight of the national drug control budget
ensures that the government's efforts are well coordinated and
support the objectives of the National Drug Control Strategy.
ONDCP leads a broad range of interagency groups that support
the National Drug Control Strategy's initiatives. Examples
include interagency working groups on opioid treatment,
prevention, and data as well as the National Heroin
Coordination Group.
ONDCP's funding authorities reflect a balanced demand
reduction and supply reduction approach to drug control,
including continued interdiction and enforcement actions
against criminal drug-trafficking organizations. While the
level of supply reduction funding has remained constant, demand
reduction funding has increased. When the Administration took
office, only 37 percent of Federal drug control resources were
devoted to demand reduction efforts. For fiscal year (FY) 2017,
51 percent has been requested for demand reduction and 49
percent for supply reduction.
The President's 2017 budget control matches the seriousness
of the situation we face as a Nation. It includes $1.1 billion
in new mandatory funding over 2 years to expand access to
treatment and recovery support services for people with opioid
use disorders. This funding will reduce barriers to treatment
and will ensure that every American who wants treatment can
access it and get the help that they need.
Members of the Committee, ONDCP will seek to continue to
find new and effective solutions to address drug use and its
consequences. We remain committed to working with Federal,
State, local, tribal, and private sector partners to develop an
effective drug control strategy and use our budget authority to
develop new programs and expand successful ones.
We know that by working together, we will continue to
reduce the prevalence and consequences of drug use and help
individuals recover from the disease of addiction.
Thank you.
Chairman Johnson. Thank you, Mr. Botticelli.
Our next witness is Kana Enomoto. Ms. Enomoto is Principal
Deputy Administrator of the Substance Abuse and Mental Health
Services Administration (SAMHSA) at the U.S. Department of
Health and Human Services (HHS). SAMHSA is the agency, within
HHS, that leads public health efforts to advance the behavioral
health of the Nation with the mission of reducing the impact of
substance abuse and mental illness on America's communities.
Ms. Enomoto began her tenure at SAMHSA in 1998. Ms. Enomoto.
TESTIMONY OF KANA ENOMOTO,\1\ PRINCIPAL DEPUTY ADMINISTRATOR,
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. Enomoto. Good afternoon, Chairman Johnson, Ranking
Member Carper, and Members of the Committee. I thank all of you
for your leadership to raise awareness and catalyze action to
address addiction in America. It is truly a matter of life or
death.
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\1\ The prepared statement of Ms. Enomoto appears in the Appendix
on page 298.
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Unfortunately, in recent years, overdose deaths have
reached record numbers--and not enough people are getting
treatment. As a Nation, we will not stem the rising tide of
this public health crisis if only one out of 10 people with a
substance use disorder gets the treatment they need. It would
not work for diabetes, it would not work for cancer, and it
will not work for addiction. We must join together to ensure
that every person with a substance use disorder, who seeks
treatment, will find an open door.
Toward this end, SAMHSA is proud to support the President's
National Drug Control Strategy and HHS Secretary Sylvia Mathews
Burwell's Opioid Initiative. The Fiscal Year 2017 President's
budget, as Director Botticelli noted, makes a bold commitment
to face this crisis head on: a $1.1 billion, 2-year investment
in new mandatory funding to build the addiction workforce and
bolster the continuum of services. Of the $1 billion, SAMHSA
proposed $920 million, over 2 years, for State grants to close
the treatment gap for opioid use disorder by making medication-
assisted treatment (MAT), including needed psychosocial
services and recovery supports, affordable and available to
people who are seeking recovery. These funds would support
community prevention, build the workforce, and use technology
to expand the reach of treatment. The initiative also includes
$30 million in new mandatory funding for SAMHSA to evaluate the
effectiveness of MAT programs under real-world conditions.
The fiscal year 2017 budget also includes $50 million of
discretionary funding--an increase of $25 million--to support
23 new State medication-assisted treatment prescription drug
and opioid addiction (MAT-PDOA) grants. MAT-PDOA was created,
in fiscal year 2015, to provide comprehensive care and
evidence-based MAT, including all three medications approved by
the Food and Drug Administration (FDA) to treat opioid use
disorders. In fiscal year 2016, Congress grew this program and
directed SAMHSA to allow medications and services to achieve
and maintain abstinence from all opioids as well as to
prioritize treatment regimens that are less susceptible to
diversion.
One example of MAT-PDOA's success is the Wisconsin Care
Program. Their efforts to expand the availability of
medication-assistant treatment. Originally, there were only two
providers willing to prescribe long-acting injectable
naltrexone in Sauk County, Wisconsin. But, by having a champion
physician present on how effective MAT can be in combating
addiction, that number has already expanded to 12 providers.
That means that 10 more providers are willing to see patients
with substance use disorders that may need life-saving
medications to help them become and stay drug-free.
We must ensure that the substance use workforce is
sufficient to meet the growing demand. Another 2017 proposal to
expand access to MAT is the $10 million Buprenorphine-
Prescribing Authority Demonstration to test the safety and
effectiveness of expanding buprenorphine prescribing to
advanced practice providers, such as nurses and physician
assistants (PAs).
As part of its regulatory responsibility, SAMHSA certifies
the Nation's opioid treatment programs, which provide
monitored, controlled conditions for the safe and effective
treatment of opioid addiction. Finally, SAMHSA is proposing a
new regulation to increase the patient limit for physicians who
have a waiver to prescribe buprenorphine.
Another important program at SAMHSA is the Pregnant and
Postpartum Women's (PPW) initiative. PPW grantees increase
access to family centered residential treatment for pregnant
and parenting women. The evaluation of this program shows great
outcomes. On intake, about two-thirds of these pregnant women
are using alcohol or drugs. At the 6-month follow-up point, 85
percent are alcohol-and drug-free. Healthy babies are being
born and progress is being made.
But, there are still more lives to save. We know that
naloxone can reverse a potentially fatal opioid overdose. But,
it only works if you have it.
In SAMHSA's overdose prevention course for prescribers and
pharmacists, one of the targeted strategies we promote is the
co-prescribing of naloxone with opioid analgesics,
particularly, for patients at high risk of overdose. And, this
month, SAMHSA is accepting applications for State grants to
purchase naloxone and to equip and train first responders. We
appreciate Congress' strong support of this effort.
An underpinning of the Nation's Behavioral Health Safety
Net is the Substance Abuse Prevention and Treatment Block Grant
(SABG). Since 2013, the block grant has grown by $150 million
to $1.9 billion. Further investments like these are crucial
because this program is delivering an impact for the American
people. At discharge, more than 70 percent of individuals who
receive block grant-funded services report no drug use in the
past month. Eighty-four percent report no alcohol use. And, 95
percent report no involvement with the criminal justice system.
Other important components of SAMHSA's treatment and
recovery portfolio include: drug courts and offender reentry
programs,
efforts to combat homelessness, Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), peer
services, and workforce training.
Prevention is another important core element of the
National Drug Control Strategy. SAMHSA's Center for Substance
Abuse Prevention (CSAP) implements the Strategic Prevention
Framework (SPF) grant program, where communities like New
Castle County, Delaware work with their State to focus on using
data and evidence-based strategies to reduce drug abuse and
underage drinking.
In 2016, Congress appropriated $10 million for a new
program, SPF Rx, which will help States to use their
Prescription Drug Monitoring Program (PDMP) data to identify
communities at the highest risk for the diversion and misuse of
prescription drugs.
SAMHSA's prevention efforts also include the administration
of ONDCP's Drug-Free Communities (DFC) Program, which supports
anti-drug coalitions across the country, like Merrimack
Safeguard in New Hampshire, who is implementing evidence-based
programs to increase parental awareness, support parental
responsibility, and reduce easy access to prescription
medications by encouraging responsible and safe storage and
disposal methods.
SAMHSA also implements the Sober Truth on Preventing
Underage Drinking (STOP) Program, so current and former drug-
free communities can focus their efforts to reduce underage
drinking. Thanks to these and other prevention strategies,
national rates of underage drinking among 12-to 20-year-olds
declined by 21 percent from 2004 to 2013.
And, for our tribal communities, SAMHSA's Tribal Behavioral
Health (Native Connections) Grant Program addresses the high
incidence of substance use and suicide among American Indian
and Alaska Native populations. And, we are pleased that, in
fiscal year 2016, across all of its programs, SAMHSA will have
its largest cohort of tribal grantees ever--of 160 grants.
In the area of surveillance and evaluation, many of our
efforts to inform policy and program decisionmaking are made
possible through our Center for Behavioral Health Statistics
and Quality (CBHSQ), which provides critical data to the field
from evaluation and surveillance. CBHSQ's signature programs
include the National Survey on Drug Use and Health (NSDUH), the
Behavioral Health Barometer, and the National Registry of
Evidence-based Programs and Practices (NREPP).
Members of the Committee, thank you for convening this
important hearing. I look forward to working with you to ensure
that we are using our investments strategically, responsibly,
and effectively to deliver a significant impact for the
American people. I am happy to answer any questions.
Chairman Johnson. Thank you, Ms. Enomoto.
Our final witness is Diana Maurer. Ms. Maurer is the
Director of Homeland Security and Justice (HSJ) at the U.S.
Government Accountability Office (GAO). Ms. Maurer's recent
work includes, among other issues, reports and testimonies on
the Federal prison system, Department of Justice (DOJ) grant
programs, nuclear smuggling, national drug control policy, and
Department of Homeland Security (DHS) morale. Ms. Maurer.
TESTIMONY OF DIANA C. MAURER,\1\ DIRECTOR, HOMELAND SECURITY
AND JUSTICE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Maurer. Good afternoon, Chairman Johnson, Ranking
Member Carper, other Members, and staff. I am pleased to be
here today to discuss GAO's perspectives on Federal efforts to
address illicit drug use.
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\1\ The prepared statement of Ms. Maurer appears in the Appendix on
page 308.
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Drug trafficking, drug abuse, and the associated impacts on
public health and safety have been longstanding issues.
Combating these problems is costly. The Administration has
requested more than $31 billion to prevent drug abuse, provide
treatment for substance abuse disorders, support domestic
enforcement of drug laws, interdict drug smuggling, and combat
international drug trafficking.
Now, consider that list of activities for just a second.
Doing all of that involves dozens of very different Federal
Agencies working in the fields of medicine, law enforcement,
intelligence, corrections, and diplomacy. This truly is a
multifaceted effort--and it needs to be, because the problems
from drug abuse in the United States are complex and deep-
seated.
If there is one thing we have learned over the past several
decades, it is that there are no quick or easy fixes. The
Administration's 2017 request is noteworthy because, for the
first time, it has proposed spending more on treatment and
prevention--the so-called ``demand side'' of the problem--than
on law enforcement, interdiction, and international programs--
the so-called ``supply side.''
Over the past several years, spending for supply side
activities has remained roughly the same. Spending today is
roughly comparable--allowing for inflation--to what we spent in
2007. However, spending for the demand side has increased,
especially in recent years. Specifically, since 2013, spending
on treatment programs has increased 67 percent, from $7.9
billion to over $13 billion today. This reflects a growing
emphasis on the increasingly dire public health consequences of
drug abuse, especially of controlled prescription drugs and
heroin.
In 2014, for example, the Center for Disease Control (CDC)
reported nearly 50,000 drug-induced deaths in this country.
That is about 136 Americans every day. To put it another way,
it is also more per day than the total number of Americans
killed, in this country, from terrorist attacks in the nearly
15 years since the attacks on September 11, 2001 (9/11). Given
that bleak fact, ensuring that this money is well spent, that
we are making progress, and that the various agencies are well
coordinated is vital.
ONDCP, to its credit, has focused a great deal of time,
attention, and resources on developing and using performance
measures to assess the progress of Federal drug control
efforts. The 2010 National Drug Control Strategy established a
series of goals with specific outcomes ONDCP hoped to achieve
by last year.
In 2013, we reported that a related set of measures were
generally consistent with effective performance management and
useful for decisionmaking--so, unlike many other Federal
programs, in this area, there is a dashboard with meaningful
indicators of progress and clear targets. So, keep that in mind
when the conversation turns to what these measures tell us.
And, overall, there has been a lack of progress.
According to a report ONDCP issued late last year, none of
the seven goals were achieved. And, in some key areas, the
trend lines moved in the opposite direction. For example, the
percentage of eighth graders who have ever used illicit drugs
increased rather than decreased. The number of drug-related
deaths increased 27 percent rather than decreased 15 percent,
as planned.
We should also recognize some progress in key areas. For
example, the 30-day prevalence of drug use by teenagers has
dropped. There has also been recent progress in Federal drug
abuse prevention and treatment programs. In 2013, we found that
coordination across 76 Federal programs at 15 Agencies was all
too often lacking. Forty percent of the programs at that time
reported no coordination with other Federal agencies. We
recommended that ONDCP take action to reduce the risk of
duplication and improve coordination.
Since our report, ONDCP has done just that. It has
conducted an inventory of the various programs and updated its
budget process and monitoring efforts to enhance coordination.
Mr. Chairman, as Congress considers its options, it is
worth reflecting on the deeply ingrained nature of illicit drug
use in this country. It is an extremely complex problem that
involves millions of people, billions of dollars, and thousands
of communities. There are very real costs in lives and
livelihoods across the United States. Helping reduce these
costs and achieving national drug policy goals will require
effective program implementation, demonstrated results, and
enhanced coordination among the various Federal Agencies.
GAO stands ready to help Congress assess the extent to
which ONDCP and other Federal Agencies achieve these goals and
reduce the impact of drug abuse in this country.
Thank you for the opportunity to testify this afternoon. I
look forward to your questions.
Chairman Johnson. Thank you, Ms. Maurer.
Our clocks are obviously not working here, so we have a
timer, which I will ask staff to put it right there. So, when
we see the little buttons go off, I will know I have run out of
time.
Mr. Botticelli, we have heard a lot of percentages--up and
down. In previous testimony the Committee heard, about 24
million Americans--I think that is correct, somewhere in that
ballpark--use some sort of illegal drug on a monthly basis.
About 3 million are using non-marijuana--in other words,
cocaine, heroin, fentanyl, and those things. Is that pretty
much the number we are talking about here?
Mr. Botticelli. Correct.
Chairman Johnson. How has that changed in the last 10 or 20
years?
Mr. Botticelli. As we have looked at measures--and I want
to thank Ms. Maurer because we actually do have a dashboard of
measures that we track. And, when we look across our measures,
one of the reasons why we have not made progress in many of
these areas, in terms of reducing illicit drug use, has to do
with increasing rates of marijuana use among eighth graders
and, particularly, young adults. And, if you take marijuana out
of the equation, we actually have made significant results with
12-year olds to 17-year-olds in many areas. And, there have
been results among young adults, particularly, in cocaine,
methamphetamine (meth), and prescription drug use issues.
Chairman Johnson. So, rather than look at very narrow
categories, I am just kind of looking at the macro level here.
Three million hard drug users a month--that is about one
percent of the population. Has that held pretty steady? Did it
used to be 2 percent and now it is 1 percent? I mean, has it
always been kind of in that 1-percent range?
Mr. Botticelli. The overall prevalence of drug use has
remained relatively stable over the years. And, we have seen
some--I do think that one of the areas where we have seen a
decrease in prevalence has largely been among youth in the
United States. And, I think this speaks to our overall issues,
because we know that drug use is an issue of early onset. So, I
think as we have seen reductions in, particularly, underage use
rates across the board--with the exception of marijuana--that
it holds promise for seeing a significant decrease in
prevalence overall.
Chairman Johnson. But, in general, the percentage of
Americans using hard drugs has held pretty steady?
Mr. Botticelli. Generally.
Chairman Johnson. So, not much--we have spent billions of
dollars. I do not know what the history is, but we are spending
$30 billion this year. And, prior to that we were spending $20
billion to $25 billion. We spent a lot of money and we really
have not made a dent in this.
Mr. Botticelli. But, I do think, Chairman, if you would
allow me--I think part of the intractability of the issue
speaks to--the fact that, historically, our drug control budget
has been out of balance. While supply reduction and law
enforcement play a critical role, our historic funding around
prevention and treatment efforts----
Chairman Johnson. We will get to those issues.
Mr. Botticelli. OK.
Chairman Johnson. In testimony, General Kelly, former head
of the Southern Command (SOUTHCOM), said that we have
visibility for about 90 percent of the drug flow--and yet, we
just lack the interdiction capability. Do you, basically, agree
with that assessment?
Mr. Botticelli. I do, to some extent. I get quarterly data
on the amount of drugs that are interdicted in the United
States. I have to say that, while we do have operational
awareness, in terms of drugs, I think the U.S. Coast Guard
(USCG) has, significantly, stepped up, in terms of their
interdiction efforts--as well as some of our partner nations.
So, actually, when you look at the amount of, particularly,
cocaine that is interdicted, those numbers are at the highest
level that they have ever been.
Chairman Johnson. But, again, we are talking about narrow
categories. Let us just take a look at another metric that has
come out in testimony--certainly, in briefings. In the early
1980s, the price of a gram of heroin would be, in today's
terms, equivalent to about $3,200. There are reports in
Milwaukee that you can get a gram of heroin for $100. At 10
doses per gram, that is $10 a hit.
Obviously, from the standpoint of interdicting supply, you
would think that, if we were doing a better job, those prices
would remain high. But, they have dropped significantly.
Correct?
Mr. Botticelli. I would say, particularly, in terms of
heroin interdiction, we have a lot more work to do. Part of the
reason that we are seeing such a dramatic increase in heroin
has to do with the dramatic increase in availability and the
lower price in many parts of the United States.
Chairman Johnson. What I am just trying to elicit here is--
we are not making progress on this. I think we are losing the
war.
Ms. Enomoto, all of us would love to believe that we could
treat drug addiction effectively. What is the success rate, in
terms
of--Mr. Botticelli is obviously one of the examples of success.
What is, basically, the success rate?
Ms. Enomoto. I am incredibly optimistic in this space
because we do have science that tells us people can and do
recover. While substance use disorders are chronic neurological
conditions that have the potential for recurrence, they also
have amazing potential for recovery. So, within the SAMHSA
portfolio, we are seeing about two-thirds of people coming out
of our programs at the 6-month follow-up point not using drugs
or alcohol. From our block grants, that number is a little bit
higher. We are seeing that. And, there are other programs, like
our drug court program, where people have a high degree of
motivation. Or, our PPW programs, where we are seeing----
Chairman Johnson. Those results are far higher than what I
have heard in other testimony. For example, in Pewaukee,
Wisconsin, we were being told 5, maybe--at most--10 percent. Do
you dispute that then?
Ms. Enomoto. I do not dispute that that is what those
testimonies were, and----
Chairman Johnson. I understand. Ms. Maurer, have you looked
at any studies on these things?
Ms. Maurer. GAO has not conducted any studies to assess the
effectiveness of treatment or prevention programs. One of the
issues here could be the difference between the number of
people who successfully complete the program compared to the
number of people who go into the program.
I know that one of the indicators that ONDCP is tracking is
trying to get to a 50-percent completion rate for some of the
programs. And, they are close to that mark, but they have not
been able to get to that 50-percent mark. What that says about
people who have completed--as opposed to those who have not
completed, we do not know, from a GAO perspective, but it is a
part of the story.
Chairman Johnson. OK. Mr. Botticelli, do you want to weigh
in?
Mr. Botticelli. So, one of the areas, particularly, with
opioid use disorders, that we see problems with is the fact
that we have three highly effective medications that should be
the standard of care for people with opioid use disorders. Yet,
too few people have access to those for a variety of reasons.
And so, part of our----
Chairman Johnson. Name those reasons.
Mr. Botticelli. So, we have too few physicians who are
prescribing these medications. We have parts of this country
where we actually do not have a physician who is trained to do
that. So, that workforce is important to make sure we do it--
and SAMHSA's grants to promote that.
We also know that we have too few treatment programs that
have incorporated medication-assisted treatment into their
treatment programs--and that has been a focus of both ONDCP and
SAMHSA.
And, we also know--and, again, Congress has taken action on
this--that there was a cap on the number of patients that
physicians treating people with addictions could serve. And,
HHS has proposed increasing that number from 100 to 200 as a
way to increase capacity for opioid use disorders.
Chairman Johnson. OK. Thank you. I am out of time.
I will pass it to you. It is scout's honor, by the way.
Senator Carper. Alright, 6:56. No, I have 9 minutes. OK.
This is good. We only get 7 minutes.
Again, thank you all for joining us today. I started
writing down, while you all were talking--testifying, rather--
and I started writing down the elements of a comprehensive
strategy to deal with these addiction-related problems. And, I
wrote down treatment, I wrote down education--and not just the
education of, particularly, young people--maybe, people not
addicted to anything, but also education for health providers,
particularly doctors, who I think are overprescribing. We have,
in a lot of the Medicaid programs across the country, policies
that are designed to make sure that someone who has a
prescription for opioids can only go to one pharmacy. What do
we call it? ``Lock-out'' or something like that.
Certainly, the stuff that we are doing with drug
interdiction--I used to be a naval flight officer (NFO) and we
used my old Navy P-3 Orion airplanes in the Caribbean--and that
part of the world--to try to interdict folks that are running
drugs in by air. We do it by sea and by land. We do a lot of
law enforcement and so forth.
I want to ask each of you just to, if you could, craft for
us just briefly--take about a minute and a half apiece--and
just describe for us a comprehensive strategy that you think
America would be smart to have. And, Ms. Maurer, if you would
go first and
then--is it ``Enomoto''? OK. And, is it ``Botticelli''? OK. Ms.
Maurer.
Ms. Maurer. Well, thank you. I think the elements of a key
strategy would have to involve many different elements of
national power and many of the elements that you already talked
about. Certainly, there needs to be an approach to reduce the
supply of illicit drugs--and that has to cover both fronts of
that--drugs that are illegal everywhere all of the time--so
heroin, cocaine, and so forth--as well as----
Senator Carper. One of the things we tried to do, I think,
in Afghanistan, was to convince the farmers there--and help the
farmers there to learn how to plant stuff other than poppies
and to make money doing that. Go ahead.
Ms. Maurer. That is right. Exactly. And, that program ran
into some problems as a result. But, that is certainly part of
the overall effort.
In addition to that, we also have to have efforts in place
to put appropriate controls around the prescription medications
that millions of Americans rely on for pain relief, but which
can be misused and abused and----
Senator Carper. Somebody told me--excuse me for
interrupting. Somebody told me they had a daughter that had her
wisdom teeth extracted and they got a month's prescription of
opioids to help her deal with the pain.
Ms. Maurer. That is right. I think, in the most recent
data, there were 12 billion pills produced for U.S. domestic
consumption. That is about 37 pills per American. So, that is a
lot that you have to keep track of. That is on the supply side.
Then, on the demand side, it is really important, like you
said, to have education. It is vital to have treatment and
prevention programs as well because you need to treat the
medical disease of addiction. But, you need to couple that with
programs to try to keep people from getting started and using
drugs illegally and illicitly in the first place.
Senator Carper. We have done that with tobacco quite
successfully through the American Legacy Foundation's--which is
now called the Truth Initiative's--``truth'' campaign.
Ms. Maurer. Absolutely.
Senator Carper. Also, Montana did some very good work years
ago on methamphetamines--the same kind of approach as the
``truth'' campaign. Go ahead.
Ms. Maurer. And, there may be things that we can learn from
those efforts. One thing I would note about the campaigns to
reduce the use of tobacco--as well as the campaign encouraging
people to use seat belts--those are generational changes that
require people to rethink the way they fundamentally approach
things like smoking and driving. It took a while for that to
take hold, but they were successful. There may be things we can
learn from those efforts that we could apply to the drug
problem in this country.
Senator Carper. Alright. Thank you. I have only 8 minutes
left, so, Ms. Enomoto?
Ms. Enomoto. Thank you.
Chairman Johnson. You were never a Boy Scout, were you?
Senator Carper. No. [Laughter.]
I aspired to be, but they would not let me in.
Ms. Enomoto. Thank you very much. It is a great question. I
will leave it to others to address the supply reduction or
interdiction issues, but for us on the demand reduction side,
we think that the President has put forward a very strong and
meaningful strategy, which does encompass prevention,
treatment, and recovery as well as data and public education
initiatives around these issues. And, we are happy to be a part
of that. For the opioid initiative, we are focusing on three
opportunities for high impact, which are: changing prescriber
behavior--as you noted, increasing access to naloxone to reduce
those opioid overdoses, and increasing access to medication-
assisted treatment. And, to do all three of those things, we
need a strong emphasis on data collection, on surveillance, on
evaluation, and on research. And, for all of those, we need to
focus on engaging States and communities as well as expanding
our behavioral health workforce, because, as it stands, when we
only have 1 out of 10 people with an addiction getting
treatment and only 2 out of 10 people with an opioid use
disorder getting treatment--and we still have waitlists and we
still cannot reach all of the people that we need to with our
prevention messaging. We simply do not have the resources--we
do not have the manpower, as it currently stands. And so, it
will require additional investment. And, I think that is what
the President has made clear in his proposals.
Senator Carper. Alright. Thank you.
Mr. Botticelli, you have about 2 minutes. Go ahead.
Mr. Botticelli. First and foremost, if you look at the
structure of our national drug----
Senator Carper. What was the first thing you said? You do
not agree with either of them? Is that what you said?
Mr. Botticelli. Oh, no. I do agree with both of them.
Senator Carper. Thank you.
Mr. Botticelli. I agree that we should take this
comprehensive, multifaceted approach that focuses on
prevention, treatment, and criminal justice reform as well as
looks at our supply reduction efforts, our international
efforts, our interdiction efforts, and our domestic law
enforcement efforts.
I would agree that, particularly with the opioid piece, you
are right on target in saying that reducing the prescribing of
these medications becomes particularly important. So, just to
underscore that, we are now prescribing enough pain medication
to give every adult American their own bottle of pain pills.
And, we know that, with the heroin situation, four out of five
newer users to heroin started by misusing prescription pain
medication.
Senator Carper. Four out of five.
Mr. Botticelli. Four out of five. Four out of five started
misusing. So, this is not a heroin issue that is separate from
our prescription drug issue.
We have been calling for mandatory prescriber education,
saying that we think it is not unreasonable to ask every
prescriber in the United States to take a minimal amount of
education on the topic of safe and effective opioid
prescribing.
Senator Carper. Alright. Thank you all for those responses.
Chairman Johnson. Thank you, Senator Carper.
While we are passing the timer down to Senator Ayotte, I
had a couple seconds left. I just wanted to ask you--one of the
pieces of legislation I have introduced is the Promoting
Responsible Opioid Prescribing (PROP) Act, which is trying to
get rid of the unintended consequences of the surveys being
used, in terms of pain medication. Can you just quickly comment
on that?
Mr. Botticelli. Sure. So, one of the things we have heard--
and, actually, the Department of Health and Human Services is
doing a review. It is called the Hospital Consumer Assessment
Healthcare Providers and Systems (HCAHPS) survey and it links
financial incentives to patient satisfaction around pain. And,
it has gotten reported to us that that could be, actually, a
misaligned incentive and actually promote opioid prescribing.
So, folks at HHS now are looking at that survey and seeing to
what extent those questions have the unintended consequence of
increased opioid prescribing--and if so, changing those
questions to make them more about overall pain management and
not necessarily about opioid prescribing.
Chairman Johnson. Well, if you cannot do it internally--if
you need that law, hopefully, you will support the PROP Act.
Senator Ayotte.
OPENING STATEMENT OF SENATOR AYOTTE
Senator Ayotte. Thank you, Chairman.
Director Botticelli, I wanted to follow up on the issue of
the cap for buprenorphine. I have certainly written--and I know
others here in Congress have also--on this issue. But, do you
know where the decisionmaking process is at for HHS? Right now
the cap still exists, right? And so, as we think about trying
to increase our capacity for medication assisted treatment, how
quickly do you expect the Administration is going to look at
lifting the cap, so that we can increase our capacity there?
Mr. Botticelli. Sure. I believe that is still open for
public comment from now until, I believe, the end of May. I can
check, in terms of HHS' timeline on that. I would suspect,
Senator, that we are going to have a significant number of
comments that we are going to have to work through surrounding
that. But, it is an important priority.
But, we also want to look at other opportunities--through
SAMHSA's grants and through increasing the number of physicians
who can prescribe this. But, increasing capacity is
particularly important.
Senator Ayotte. Right. And, also, I would ask you, Director
and Ms. Enomoto, about the issue of the bed cap. So we have--as
I understand it--a cap of 16, in terms of the number of
residential beds, not only for the treatment of substance use
disorders, but also for mental illness. As we think about--I
know efforts in my own State--and elsewhere--to try to increase
capacity--sometimes it makes sense to increase the existing
capacity of a facility that already has a good treatment
program in place. So, what are your thoughts on that cap? And,
what efforts should be taken to lift that cap as well?
Ms. Enomoto. So, within the Department, the Centers for
Medicare and Medicaid Services (CMS) has the leading role for
the Institute for Mental Disease (IMD) exclusion. And, they
have been working really closely, I think, with States to
promote innovation in this area--and California is an example
of a State with an 1115 waiver that is looking at providing
support to residential treatment providers that have more than
16 beds under their waiver. And so, I think there is a
considerable effort to look at this, both on the mental health
side and on the substance abuse side.
Senator Ayotte. Also, a lot of this is sometimes co-
occurring between these illnesses.
Ms. Enomoto. Right. We also think it is important, though,
to look at expanding options for community-based treatment
because we know that that is important and is an avenue--that
not everyone needs residential treatment and not everyone
requires hospitalization if adequate community-level or
intensive outpatient services and supports are readily
available.
Senator Ayotte. And, as a follow up to that, I have been
one of the lead sponsors of the Improving Treatment for
Pregnant and Postpartum Women Act of 2016. And, a component of
that Act also involves looking at nonresidential treatment
options for pregnant women. And, I wanted to get your thoughts
on that as well.
Ms. Enomoto. In the President's Fiscal Year 2017 budget
proposal, we have proposed a pilot demonstration innovation
program, which would request the ``notwithstanding'' language
for the PPW program because the statute requires that it is,
right now, exclusively for residential treatment. We would like
to have the flexibility to use some of the funding for States
looking at options for multiple pathways to care. So, for some
of the women in those programs--who have other children at home
or who have other job or family responsibilities--to be able to
participate in treatment on an outpatient basis as well and to
see whether or not they achieve similar, comparable outcomes.
Senator Ayotte. Great. Thank you.
Director Botticelli, a lot of the efforts--as I, certainly,
heard in the testimony from Ms. Maurer as well--as we think
about the supply side piece of this--you and I have talked
about this in the past--the heroin and fentanyl are coming over
the Southern border. And, an amendment that I offered to the
National Defense Authorization Act (NDAA), is going to increase
some resources there for the interdiction of heroin and
fentanyl.
But, one of the concerns we have heard before, on this
Committee, is that the precursor chemicals needed to make
fentanyl are actually shipped to Central America from China and
then smuggled into Mexico--or sometimes actually shipped to the
United States and then smuggled into Mexico--and then made into
fentanyl.
So, where do you see our efforts? And, certainly, Ms.
Maurer, if you have any comments on that, in terms of what we
are doing to look at our drug policy. What more can we do to
address the fentanyl interdiction issue? I heard what you had
to say on cocaine and I know that we have seen an increase.
But, this is really the main driver of the drug deaths--as I
see the huge increase in New Hampshire, obviously, with heroin
and prescription drugs. But, when you combine the fentanyl,
that is really the killer.
Mr. Botticelli. Correct. And, actually, the vast majority
of increases that we have seen, in overdose deaths in the
United States, seem to be attributed to either straight
fentanyl or heroin-laced fentanyl--not just in New Hampshire,
but around the country. And, you are right. While we know some
about the fentanyl supply chain, we need to actually amplify
our intelligence around the fentanyl supply chain.
So, we have been working with the intelligence community
(IC) to look at--so, clearly, I think what you have
articulated--of
this being manufactured in China, either shipped directly to
the United States--or through Mexico--and getting into the
supply chain--particularly important areas, but we need to
continue to study that.
But, we have had--China has actually moved to schedule a
number of new chemicals, including acetyl fentanyl, which is
one of the precursors of that--and we continue to work with the
Mexican Government. I was just down there in March meeting with
the Attorney General (AG), focusing on both reducing poppy
cultivation and on increasing their efforts to combat fentanyl
and fentanyl labs.
Senator Ayotte. Good.
I did not know if you wanted to comment on this at all?
Ms. Maurer. We do not have any specific work focused on
fentanyl. We have done work more broadly on supply chain
security and drug control policy.
Senator Ayotte. OK.
Ms. Maurer. But, nothing specific to fentanyl yet.
Senator Ayotte. Well, I think we are going to, probably,
have you engaged on that, too--just because this is a huge,
growing issue.
Ms. Maurer. Fantastic.
Senator Ayotte. Thank you.
I have one final question. We have been seeing these
reports about the increased price of naloxone and having been
working on this issue with you. Having been in my State doing
ride-alongs with our police and fire departments--with Narcan,
which is the brand name for naloxone, we are saving so many
lives. Our numbers of drug deaths would be so much higher
without access to the life-saving drug. And, that is a key
component of CARA. But, the reports that I have been seeing--at
least in the news--is an increase in this drug price. And, do
you know what is happening with this? Anyone who would like to
jump in and comment on this--the increases in naloxone prices--
why these price increases are occurring--please do. And, should
we be concerned that some manufacturers looking to profit off
of this epidemic? I just think it is important that we
highlight this and understand it.
Mr. Botticelli. I wish I could give you the reasons why the
manufacturer has decided to increase the price of this. My gut
tells me the same thing that yours does--that there are some
opportunistic issues----
Senator Ayotte. I do not like what my gut is telling me.
That is why I am raising this.
Mr. Botticelli. No, I think you are absolutely right. I
think what we have been trying to do by acknowledging the price
increase around naloxone, is to look at, one--through CARA and
other vehicles--how we can get increased access. There has been
a purchasing collaborative set up through the National
Governors Association (NGA) and the U.S. Conference of Mayors
to harness their purchasing authority to do it--and SAMHSA is
giving guidance to States, through their block grant, about
using naloxone purchased. But, it is particularly disturbing
that the cost has gone up, dramatically, at the time that we
need it the most.
Senator Ayotte. I just think, as we think about this
issue--we are in this very public hearing--I hope that those
who are hiking up these prices take notice that we notice. And,
we are going to be focusing on this, because the last thing
that we want as we increase access, is for the price to
increase--so that we can actually save fewer people.
Chairman Johnson. Senator Portman.
Senator Portman. Thank you, Mr. Chairman. And, thank you
for having this hearing on an incredibly important issue. We
have an epidemic in our country right now. And, obviously, I am
concerned by some of the testimony this morning, because, as we
heard from Ms. Maurer, at a time when we have had a huge
increase in opioid addictions, overdoses, and deaths, that, of
the goals that were set out in the 2010 strategy, not a single
one has been achieved. And, Mr. Botticelli said, ``Well, that
is because we are not taking into account the increase in
marijuana use--it is not other things.'' And, one of the things
you talked about was overdose deaths going from--instead of a
15-percent reduction--a 27-percent increase. That is not
marijuana, is it?
Mr. Botticelli. No. That is, typically, other drugs.
Senator Portman. OK. So, I mean, I think I understand, from
the Administration's point of view, why you want to put a good
face on it and say things are going great. They are not going
great. They are going terribly. And, we have had, since March
10th, when CARA passed the U.S. Senate--we believe there are
about 7,000 Americans who have died of an overdose. We spent a
lot of time today talking about the Zika virus, which is a huge
problem. I think one American has died so far--and I support
more efforts on Zika. But, my gosh, we have a crisis and an
epidemic going on right now--and it is right in front of our
eyes.
I was at another treatment center yesterday. I appreciate
what both of you do every day. I do. And, I really appreciate
your testimony to the Senate Judiciary Committee, where you
talked about the need for CARA to provide a more comprehensive
response. And, I would just say everything we have talked about
today is touched on in CARA. The House bill, I think, improves
CARA with regard to the limitation on the number of patients
that a buprenorphine-prescribing doctor can handle. That is
going to be part of the final conference report. On the
increased number of beds, we kicked it to GAO because we did
not have a consensus on that. But, you are going to be working
on that issue, I hope, very soon.
On naloxone--as you know, thanks to your help, we do a lot
more on naloxone, in terms of funding the grants. But, also
significantly, we put some more contours around it to target it
more and to encourage people to provide folks with treatment
options, which, when I went--as I did--to one of our major drug
store pharmacy companies recently to talk about over-the-
counter Narcan--I, of course, support that--and strongly--but I
also support having a consultation, so that the people who are
getting this naloxone--or Narcan--to be able to help a loved
one or a friend can also know where the treatment centers are
in the area and can get these people into treatment. The
solution, alone, is not more Narcan--the treatment is Narcan to
save lives--but also getting people into treatment.
So, I appreciate both of you and what you do every day, but
I think we have to have a little bit of a different attitude
about this. It has to be a crisis mentality, in order for us to
do what needs to be done. And, as you know, the House, on
Friday, passed 18 different bills and put them into one bill--
into the CARA legislation. We have our CARA legislation. The
difference is, I have put down here--and I am happy to provide
this to you today--we would love your help in getting us
through this conference as quickly as possible, because we
cannot wait. And, there are people now talking about adding new
elements to it that have to do with other important issues. We
have to focus on this issue--the opioid crisis that we face.
So, I would ask you today, are you willing to work with us,
as you did in the Senate Judiciary Committee? And, both of your
testimonies were, actually, very helpful. And, as you know,
there are many groups--130 groups at last count--around the
country, who are with us on this to try to get through a
process with the House and the Senate where we take the best of
both and can be sure that we do not weaken the Senate bill.
I know you care a lot about funding. So do I. But, let us
be honest. We did increase the funding in the omnibus for this
year. We have to do it again for next year. The $82 million
that is authorized every year going forward, in the additional
funding in CARA, has to be held and not taken from programs
that may not have an authorization anymore, but that are
appropriated every year. For instance, with the Drug Monitoring
Program, I saw the House used that for some of their funding.
That has to continue to be used for drug monitoring.
So, anyway, any thoughts on that, Director Botticelli?
Mr. Botticelli. So, first of all, I really appreciated your
leadership on this important issue and on CARA. I think you
know that many of the elements of CARA are very important to
the Administration here.
I think we also understand, though, that this issue needs
to be resourced. As I travel the country, in Ohio and other
places, the biggest issue that I hear is the number of people
who want treatment who cannot get it. And, despite everything
that we have done, I think, in previous--and with the support
of Congress and by increasing capacity--we still have too many
people who are not able to access treatment when they need it.
And, I think we need to work with Congress on additional
funding for this issue, because having long waiting lists of
people who cannot get in is a tremendously important issue. We
have parts of the country that do not have a treatment program
that people can access.
So, we know we need a comprehensive response to this, but
it also really needs to include a robust increase in treatment
funding in the United States.
Senator Portman. Yes. Well, this is an authorization bill
and it does authorize additional funding. And then, we need,
every year, of course, to fight for that appropriation. And, it
is not just for one year. It is an authorization going forward.
And, the way these authorization bills work around here is
that, once you get it authorized, it tends to continue. And so,
it is $800 million--$820 million, over 10 years, of additional
funding. And, most of it does go into treatment--not all of it.
But, it is for prevention. One of the things I want to fight
for, in the conference, is a prevention program, because I do
think that is part of the answer, as Ms. Maurer talked about.
So, we need your help on this because we can keep talking
about how we want more of this and we want more of that, but
nothing is going to happen. And then, in our communities we are
going to continue to see families torn apart, communities
devastated,
people dying, and people not being able to fulfill their
purpose in life--their God-given purpose. And, that is where we
are now--and where we will continue to be if we continue to
disagree.
So, let us figure out how to come together. And, again, you
all were very constructive and helpful in the Senate Judiciary
Committee. I do not think we would have gotten a unanimous
vote--or a 94-1 vote--on the floor of the Senate without your
help--and I appreciate that. But, it has some--as I mentioned,
those four items that we have talked about today, they are all
addressed in here. And, of course, treatment is addressed.
Finally, I just want to say--I cannot really figure this
out. OK. I really appreciate the additional emphasis on the
demand side. As you know, I am the author of the Drug-Free
Communities Act of 1997, I started my own coalition back home,
and I am still very involved with that. We just had our 20th
anniversary, by the way. But, we have to make that shift--and
continue to make it. So, I do not disagree with my colleagues
who talk about the need for us to have better border
enforcement. Of course. But, I will just, I guess, stipulate
that, if it is not coming from Mexico, it is coming from your
basement. And, if it is not coming across the border, it is
coming across on a ship. And, as long as the demand is strong
here, there will be ways that it will be filled--whether it is
a return to methamphetamines, which we finally started to make
progress on, or whether it is other drugs that can be produced
by chemists--by the way, that is the case with regard to
fentanyl. It is a form of synthetic heroin. It is produced by
chemists. So, we have to continue to focus on the prevention
side and the treatment and recovery side. And, if we do not, we
will never be able to turn the tide.
So, Ms. Enomoto, do you have any thoughts?
Ms. Enomoto. I just want to express my absolute willingness
to work with you on a package that moves forward. And, to
emphasize your point about the prevention piece of CARA, we
must make sure that we have robust prevention programming in
this country with the resources to match it as well as the
recovery support piece and the peer piece. These are both very
important to helping people achieve and maintain their
recovery.
Senator Portman. Yes. Thank you.
Thank you, Mr. Chairman.
Chairman Johnson. Senator Tester.
OPENING STATEMENT OF SENATOR TESTER
Senator Tester. Thank you, Mr. Chairman. I want to thank
the panelists for being here today.
We hear a lot about the health effects of drugs, about
incarceration for minor drug offenses, and about the rates of
drug abuse among minors. I want to talk a little bit about the
effect of drugs on Federal hiring practices. Right now, four
States and the District of Columbia have legalized marijuana
and a number of States have passed medical marijuana laws that
allow for limited use of cannabis. Mr. Botticelli, have you
seen any evidence that marijuana laws in these States have
affected the hiring decisions for Federal positions?
Mr. Botticelli. I was actually just looking at workplace
drug testing data this morning. The data shows significant
increases in overall general workplace testing--and we have
seen the rates of positive marijuana tests go up dramatically.
I will go back and ask my staff to see if they have specific
data, as it relates to Federal hiring practices.\1\
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\1\ The information submitted by Mr. Botticelli appears in the
Appendix on page 329.
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What we do know is that there was actually an interesting
article in the New York Times this morning that said that many
employers with available jobs are having difficulty hiring
folks because they cannot pass a drug test.
Senator Tester. I would also like to know if you have seen
an increase within the four States that have legalized it--or
if you have seen a problem in the hiring practices of the
Federal Government. If you can pare those out, that would be
good.
Mr. Botticelli. Great. I am happy to do that.
Senator Tester. You said that there has been a significant
increase. Since when?
Mr. Botticelli. I believe this goes back over the past 5
years. Particularly, over the past 3 years, we have seen a
significant increase in people who are testing positive for
marijuana use as a part of their workplace testing.
Senator Tester. Did you do any other testing for substances
other than marijuana?
Mr. Botticelli. This is actually an independent--yes, it
did. So, we have seen actually--and here is where it is
challenging, because some of the--we have seen increases in
positive amphetamine results, but the tests do not show us
whether a result is due to a misuse or because of a
prescription. We have actually seen decreases in positive
prescription pain medication test results as well as for
methamphetamine and cocaine.
Senator Tester. You have seen decreases in those?
Mr. Botticelli. Correct.
Senator Tester. OK. But, increases in amphetamine?
Mr. Botticelli. Yes.
Senator Tester. But, you do not know if it is because of
prescription drugs or----
Mr. Botticelli. Correct. So, for instance, we know that
there are a lot of people who are on Attention Deficit
Hyperactivity Disorder (ADHD) medications, which could be a
part of it. The test does not differentiate between those who
are testing positive because of misuse and those who have a
legitimate prescription. Obviously, marijuana is not in that
category.
Senator Tester. OK. Do any of you have metrics, as far as
that goes, or metrics on the connection to poverty and drug
abuse?
Mr. Botticelli. So, we have known for a long time that
people's economic circumstances can significantly contribute to
drug use rates. We have seen this in recent studies that looked
at the dramatic increase in mortality rates among 44-year-old
to 54-year-old men and women in some areas of particularly
significant poverty in the United States. So, we have known
that there is a correlation there. And, there have been a
number of interesting studies that looked at the intersection
of poverty and increased mortality, particularly around liver
disease, which is associated with alcoholism, suicide, and drug
overdoses.
Senator Tester. OK, So, last weekend I did a little sweep
around the western part of Montana and I was up near the
Salish-Kootenai reservation. A hospital in a little town up
there said that somewhere between 70 to 80 percent of the
pregnancies they saw resulted in children born drug-addicted.
Although it is not the economically worst-off reservation in
the State of Montana, poverty is high. In fact, it is probably
the economically best-off reservation, but poverty is still
very high.
Are these the kinds of rates you are seeing in poor urban
areas, too?
Mr. Botticelli. I do not know if it is that high, in terms
of that. I mean, we have known for a long time that substance
use, among Native Americans, is very high in many of our tribal
communities. And, I know Ms. Enomoto can talk about this, but
part of our efforts have been to increase our efforts--our
prevention and treatment. We have seen a higher-than-normal
overdose rate among Native Americans as a result of this
epidemic.
Senator Tester. You are going to increase your prevention
and treatments efforts in Indian country? Is that what you
meant?
Mr. Botticelli. Correct.
Senator Tester. So, how are you doing that? Are you working
through the Bureau of Indian Affairs (BIA)? How are you doing
it?
Mr. Botticelli. So, one effort is through our Drug-Free
Communities Program grants. We are actually reaching out to
tribes.
Senator Tester. And, is that being utilized by the tribes?
Mr. Botticelli. It has been underutilized. And, we think,
in terms of----
Senator Tester. So, who are you reaching out to in the
tribes?
Mr. Botticelli. We can get you their information, because
we have done a number of technical assistance visits to
tribes.\1\
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\1\ The information submitted by Mr. Botticelli appears in the
Appendix on page 330.
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Senator Tester. That would be really good because, who you
reach out to is going to make a difference, in terms of what
the take-up rate is.
Mr. Botticelli. We also worked with the Bureau of Indian
Affairs and the Indian Health Service (IHS) to actually start
equipping tribal law enforcement with naloxone. We have seen a
dramatic increase in overdoses among Native American tribes.
Senator Tester. How about education in the schools? Are
there any efforts being done by--and I do not care if it is in
poverty-stricken areas or not. It would seem to me that
poverty-stricken areas should be the focus, but is there any
education being done in the schools?
Ms. Enomoto. We are really excited that, this year, we are
issuing $25 million--$30 million in grants under our Tribal
Behavioral Health Grant Programs.
Senator Tester. OK.
Ms. Enomoto. We will have over 100 new tribal grantees
focusing on substance abuse prevention, suicide prevention, and
emotional wellness among tribal youth, including doing
activities in the schools and to educate youth. And, also
working----
Senator Tester. Once again, is this money granted out or
how----
Ms. Enomoto. These are grants.
Senator Tester. So, it is a competitive grant?
Ms. Enomoto. It is a competitive grant, yes.
Senator Tester. OK. Go ahead.
Mr. Botticelli. Are there particular tribes, actually, that
you would like to----
Senator Tester. I mean, all that I am telling you is that I
think you can look at the tribes who have high instances of
poverty--most of which are non-gaming tribes--and you can see
they have issues. They have issues with domestic violence. They
have issues with drug use. They have issues with housing. They
have issues--pick a topic, truthfully.
The point is that you cannot do it from this level. You
need to have partners on the local level to do it--whether it
is education for kids, whether it is prevention for adults, or
whatever it might be. If you do not have those partners, we are
going to be throwing money out of the window. And, those
partners have to be held accountable, too, by the way. So, it
is a hell of a circle. But, when I am told that 70 to 80
percent of the kids that are born on that reservation--and
these figures could be wrong because I did not fact-check them.
But, they came from somewhere. Those kids are born drug-
addicted--holy mackerel. I mean, in the world we live in, I
mean, talk about being put in the hole right out of the chute.
Holy mackerel.
So, go ahead. You were going to say something.
Ms. Enomoto. I do not think those numbers are completely
unexpected for some tribal communities. I think we have also
seen five-time increases for the American Academy of
Neurology's (AAN's) statistics on overdoses. So, while we talk
about this--often people talk about this overdose as a white
middle-class
problem--it is striking Indian country very hard. And, on
average, of American pregnant women, about 30 percent are
getting prescriptions for opioids during pregnancy. So, that
rate for women in Indian country is very high.
I wanted to let you know that we are about to release a
Tribal Behavioral Health Agenda (TBHA)--a National Tribal
Behavioral Health Agenda. We have worked very closely across
the country with the National Indian Health Board, which we
have consulted, in many communities, to identify, across our
Federal partners, local partners, and national organizations--
we talked about what the priorities are for tribal behavioral
health and how can we agree to move forward together. We are
all rowing in the same direction, giving communities a
blueprint for working toward better behavioral health for all
of their young people, including--as well as the adult
populations in their communities.
Senator Tester. OK. My light is flashing, so you can cut me
off here, Mr. Chairman. But, I do have one more question.
Chairman Johnson. OK. Well, I am just a little concerned
about that thing going off.
Senator Tester. Will it buzz?
Chairman Johnson. I am not sure.
Senator Tester. I cannot wait.
Chairman Johnson. Go ahead.
Senator Tester. I will just hold it next to the microphone
so that everybody can hear it. [Laughter.]
This is the last one. Mr. Botticelli, you talked about a
significant increase over the last 5 years--and, especially,
the last 3 years. Has anybody asked why? Why are we seeing a
significant increase in drug abuse over the last 3 years? Why
now?
Mr. Botticelli. I do not mean to sound overly simplistic,
but I think----
Senator Tester. The simpler, the better.
Mr. Botticelli. The simpler, the better. It is the
overprescribing of prescription pain medication in the United
States. We have never had an epidemic like we are currently
facing, in terms of addictions to prescription pain medication
and the overdoses----
Senator Tester. So, are we working with the American
Medical Association (AMA)?
Mr. Botticelli. I will tell you that the AMA has stepped
forward, in terms of voluntary training. I know that they have,
historically, opposed mandatory training. Also, the AMA has
issued a policy statement urging physicians to check
prescription drug monitoring programs. But, at this point, they
see it as a totally voluntary issue. But, we think, at this
time in the epidemic, asking these things to be mandatory is
not unreasonable.
Senator Tester. OK. I am going to give you just a really
quick little story. I had some veterans' listening sessions a
few years ago--I have had some since then, too. But, a few
years ago, one of the people stood up and said--and these were
back-to-back, honest to God. One stood up and said, ``I needed
pain pills for my back and the Department of Veterans Affairs
(VA) would not give me the pain medication.'' The very next
person stood up and said, ``The VA killed my son because of
overmedication.''
There has to be some education done here on what the right
line is, because this is insanity.
Mr. Botticelli. Let me respond to that. As part of the
Federal Government, the President felt it to be so important
that we model this for the medical community, that every
Federal prescriber--including the VA--has to go through
mandatory training and education.
Senator Tester. Yes. Thank you all very much.
Chairman Johnson. The bottom line is, there are no easy
solutions. You may want to take a look at the PROP Act. That,
to a certain extent, addresses some of the unintended
consequences in our law.
I want to go back to treatment metrics. What percentage of
those 3 million hard drug users ever seeks treatment in a given
year? Mr. Botticelli, you were talking about how you hear
consistently that there is no funding for treatment. What
percentage actually seeks treatment?
Mr. Botticelli. So, we know from the National Survey on
Drug Use and Health, which SAMHSA administers, that only a very
small percentage of people who actually meet diagnostic
criteria for a substance use disorder get care and treatment--
and that number is usually between 10 and 20 percent. And, if I
can give you some--substance use disorders have roughly the
prevalence of diabetes. Yet, the treatment rate for diabetes is
about 80 to 85 percent. And, we know some of the reasons why
people do not get care and treatment. One is that they either
do not have insurance or that their insurance does not
appropriately cover it. Stigma also still plays a huge role--
that people are afraid to ask for help. So, part of our effort
here has been to kind of destigmatize people with addiction.
And, we have seen great efforts, I think, across this country,
to encourage people in recovery to stand up.
But, that is part of what fuels our demand--what fuels some
of the negative consequences--this huge treatment gap that we
have in the United States. And, that is why the President
really kind of stepped forward and said that, despite all of
the insurance and expansion that we have done, we still have
too large of a treatment gap in the United States.
Chairman Johnson. What percentage of alcoholics seek
treatment in a given year?
Mr. Botticelli. It depends. And, I can give you the exact
number, depending on the diagnosis. I think that the number is
slightly higher for people with alcohol use disorders--and,
Kana, you may know these numbers better than I do. But, we can
get you those. But, it is not much higher than 20 percent for
alcohol use disorders.\1\
---------------------------------------------------------------------------
\1\ The information submitted by Mr. Botticelli appears in the
Appendix on page 332.
---------------------------------------------------------------------------
Chairman Johnson. So, my point is that you have things,
like Alcoholics Anonymous (AA) for alcohol--that type of thing.
If you do not have a significantly higher percentage of people
seeking treatment there, what would make us expect that there
would be a higher percentage--even if there was more funding--
for treatment? How many addicts just want to keep using drugs
and really do not desire treatment?
Mr. Botticelli. I think that there is a significant number
of people who do. First of all, I have some experience with
this and I think that most people who are addicted to drugs--
particularly, to opioids--want to stop using. And, the hallmark
of addiction is that people keep using.
We have to do a better job with intervening. One of the
reasons why we have done a great job with tobacco is that,
every time you go to the doctor, if you are smoking, the doctor
offers you an intervention. And, we need to do the same thing
for people with substance use disorders. And, unfortunately, we
often wait until they get to their most acute stage--and,
often, that is an intersection with the criminal justice
system, where we do then leverage people into treatment. Our
drug courts--and other programs--do a fabulous job, but we wait
far too long while people are developing these disorders and we
need to do a better job at systemically intervening before
people even reach that acute stage.
We would have better treatment outcomes if we intervened
earlier in people's disease progression as opposed to how we
wait now until basic--you have heard the expression ``hitting
bottom.'' It is crazy that we expect people to hit bottom
before we give them care and treatment.
Chairman Johnson. The best solution would be trying to
convince people never to even try a drug, so they do not become
addicted. We have been successful--we had a hearing on it. This
strategy has been really very successful, in terms of reducing
the use of tobacco through a very concerted, long-term effort--
through education and a public relations campaign. Does anybody
want to express an opinion as to why, for example, our
education efforts with drugs have not worked? Ms. Maurer.
Ms. Maurer. I think, in many respects, the challenge is
much more difficult. We issued some reports early in the decade
that looked at some of the education campaigns that were
implemented in the late 1990s. We found that, for those
particular programs, many did not have any discernible impact--
and, in a few cases, it actually worked in the opposite
direction. So, in other words, in some groups, when teenagers
were exposed to the anti-drug message, they actually used drugs
more frequently. That is an issue with the----
Chairman Johnson. That is not very effective education.
Ms. Maurer. It is not. And, it really goes back to the idea
that you need to have good program design and implementation
for these things to be successful.
I think that, in many respects, the problem we are trying
to address here--while there may be lessons learned from seat
belts and smoking--it is a much more difficult problem, because
it is associated with particular kinds of behaviors and
particular kinds of medical conditions. It is intertwined with
poverty and a bunch of other issues as well. It is tougher to
crack, absolutely.
Chairman Johnson. Ms. Enomoto, in your testimony--and now I
want to try and name these drugs--naltrexone, methadone,
and--what is it?--buprenorphine? Whatever. Can you describe the
difference in those drugs--those treatment drugs--and how they
really work? What are the differences? Or are they all the
same?
Ms. Enomoto. I am not a physician. So, I am happy to get
you a more expert description of the pharmacology of those
different medications. But, from my perspective, the two drugs
methadone and buprenorphine are often referred to as ``agonist
medications'' because they have some opioid qualities. But,
they do not lead to the euphoric state that people get when
they are using drugs, like heroin or oxycodone. And, they
minimize the cravings that people will have for illicit drugs.
And, people are able to initiate the use of those drugs while
they are still in a state of active addiction, so that they can
taper off of the drugs that they are using with the medication-
assisted treatment and work toward their recovery without
maintaining illicit drug use. Those go along with behavioral
services and supports to get the best outcomes. Methadone is a
dispensed drug. It is a prescribed drug for pain relief, but,
for addiction treatment, it is a dispensed drug. Buprenorphine
is available as a prescription in office-based treatment.
Naltrexone is available in two formulations, both an oral
form and an injectable, long-acting form. The oral form is a
pill and the other one is an injection. Those can be prescribed
by any physician, so they are not Schedule II drugs, like
buprenorphine and methadone. And, to use the long-acting
naltrexone--people need to be detoxed from their opioid.
Naltrexone also works on alcohol as well, so that, once people
are through detox and they can get the naltrexone--it is an
antagonist medication, so it actually completely blocks the
opioid receptors. So, if you are taking any other--if you take
alcohol or if you take an opioid, then you will not feel the
effects of those drugs. I think often people refer to it as a
relapse prevention intervention. So, they have different
actions--mechanisms of action--and, maybe, they are preferable
by different--one patient may prefer one over the other. I
think it is a decision between a patient and their physician
about what is the best avenue for them and for their particular
condition.
Chairman Johnson. So, they reduce the craving. Is that kind
of a simple way of putting it?
Ms. Enomoto. Yes.
Chairman Johnson. Can somebody describe for me the
difference between heroin and the other opioids?
Mr. Botticelli. The difference from the medication?
Chairman Johnson. Yes, I mean like OxyContin, is that a
synthetic opioid?
Mr. Botticelli. Again, while I often pretend to be a
doctor, I am not.
Chairman Johnson. We will stipulate that.
Mr. Botticelli. No, but they have very similar properties,
in terms of how they interact on the brain. And so, that is why
people often turn from opiate pain medication to heroin.
Chairman Johnson. But, are those synthetic drugs or are
those also grown from--where are they sourced from?
Mr. Botticelli. So, the others are manufactured
medications. Heroin, which is an illicit--it is a grown----
Chairman Johnson. It is a plant.
Mr. Botticelli. It is a plant.
Chairman Johnson. Whereas the others are the result of some
manufacturing process?
Mr. Botticelli. They are manufactured.
Chairman Johnson. Like fentanyl, for example?. Fentanyl is
a synthetic compound?
Mr. Botticelli. Yes.
Chairman Johnson. OK. Interesting. Senator Carper.
Senator Carper. Thank you, Mr. Chairman.
A little more than a month ago, I was part of an Aspen
Institute seminar in China. And, I had learned some things
about China, but never really spent any time there to speak of.
And, I learned a lot of things. One of the things I learned
about China is that they now have a two-child policy--not a
one-child policy, but a two-child policy that they are kind of
moving toward. I learned that a lot of the kids that grow up
there grow up in intact, two-parent families, which I was
pleased to see. I learned that folks are not much into
gambling, lotteries, or stuff like that. And, I learned that
drug abuse is not really a problem to speak of in their
society.
And, yet, we hear that they ship us materials that are used
for fentanyl and stuff like that--and we have had problems
before with the Chinese using cyber theft to steal our
intellectual property and to use that to create economic
opportunity for themselves at our expense.
I do not know that we have ever said to the Chinese--that
our President said to President Xi Jinping, last September,
with respect to cyber theft, to, basically, ``knock it off.''
And, the Chinese always say, ``Well, we do not do that.'' And,
he said, ``Knock it off,'' just not in so many words. And, they
said, ``We do not really do that.'' And, our President,
basically, said--just not in so many words, ``If you continue
to use cyber theft to steal our intellectual property, you know
what we did to Iran with economic sanctions? We are your
biggest customer. We could do that to you.'' And, we have seen,
since that time, literally, a significant reduction in the
instances of cyber theft going on with intellectual property.
Have you ever heard, in terms of whether it is China--or
some other country--that is providing these kinds of
substances--have you ever heard of how we can use direct
contact, leader to leader and agency to agency, to get them to
stop?
Mr. Botticelli. I can talk about that a little bit. So, I
do not know if President Obama has had a direct conversation,
in terms of the fentanyl issue.
Senator Carper. Not that I know of.
Mr. Botticelli. I know he has with President Enrique Pena
Nieto, in terms of the heroin and fentanyl issue--around that--
and trying to get his commitment to work government to
government.
Senator Carper. Any luck on that?
Mr. Botticelli. We have been having very productive
conversations with the Mexican Government at the working level.
Senator Carper. Good.
Mr. Botticelli. I met with the Mexican Attorney General,
who is spearheading their efforts around it. I think they have
come up with a plan. I think what we would like to see, is for
that to translate into actionable work that they are able to
do, in terms of reducing poppy cultivation, going after labs,
and looking at the fentanyl situation.
Senator Carper. OK.
Mr. Botticelli. I know, at the working level, both the
State Department and I have had a number of conversations with
our colleagues in the Chinese Government, particularly around
the fentanyl issue. We are somewhat optimistic. They have moved
to reschedule a number of the drugs that they are producing. I
think what we would like to see next, is incredibly more robust
enforcement action, on their part, to go after--I mean, they
have a huge industry there, but we would like to see more
oversight and see them going after some of these producers.
This is where, I think, being able to have better intelligence,
in terms of knowing directly where these substances might be
coming from and how they are being shipped, becomes very
important for us.
Senator Carper. Thank you.
Could I ask you another question, Mr. Botticelli? While I
am asking this question, I want the other witnesses just to--I
have been in and out of the hearing today. I apologize for
that. We had to start late--not our fault--not the Chairman's
fault, but it is because of the series of votes on the floor.
So, I missed part of what you said--and, Ms. Maurer--and I am
going to ask Ms. Enomoto to just share with me like one great
takeaway from this hearing, as we think of this issue and how
to deal with it--this challenge and how to deal with it,
please.
Here is my question, Mr. Botticelli, while they are
thinking of that. I was pleased to see--we only have three
counties in Delaware. The northernmost county is called New
Castle County and it is right up along the Pennsylvania border,
as you may know. And, I was pleased to see that New Castle
County was added to the Philadelphia-Camden regional High
Intensity Drug Trafficking Area (HIDTA) program last year.
Could you just take a moment and share with us some
insights on why the work of HIDTAs is so critical to the
success of your office, overall, please?
Mr. Botticelli. So, we were glad to be able to have the
resources from Congress to be able to do that, first of all.
But, I will say two things about why I think HIDTAs are very
successful--or three reasons.
One, I think they do a very accurate assessment of what the
drug threat looks like in any given county in a community and
they are able to target resources against that.
I think, second, as we talked about, that coordination is
key. They are able to really coordinate law enforcement efforts
at the Federal, State, and local level. And, they involve local
law enforcement, in terms of their work, to be able to do that.
I think the third thing is that they understand that law
enforcement is only part of the problem and they actually work
with public health officials to really make sure that we are
having that balanced strategy--that we are not just focusing on
law enforcement, but we are also focusing on demand reduction,
too.
So, I think that is, from my perspective, why the HIDTAs do
a very good job at the local level.
Senator Carper. OK, good. Alright. Ms. Maurer.
Ms. Maurer. I think the one key takeaway from today's
hearing would be that, I think, we are in a unique time right
now, where there is an appreciation that addressing this
problem is going to involve many different aspects of the
Federal Government and involve working with State and local
authorities. We have not always----
Senator Carper. And, the nonprofits.
Ms. Maurer. And, nonprofits.
Senator Carper. The health community, schools, etc.
Ms. Maurer. Absolutely. So, we have not, for example,
always seen this emphasis--or almost an equal emphasis--on the
demand side and the supply side--because both are equally
important for addressing the problem.
I will put in a plug for GAO. There are a lot of programs
at a lot of different Federal Agencies. We could play a role in
helping to assist Congress with its oversight responsibilities
to make sure these programs are being implemented effectively
and efficiently.
Senator Carper. OK. Thank you. Ms. Enomoto.
Ms. Enomoto. So, I have a couple of points and some of them
go back to questions that Senator Johnson asked.
Senator Carper. OK.
Ms. Enomoto. And, I did not get a chance to jump in, but I
think they are relevant.
One of the questions that had been asked is, ``Why are
people saying that only a small fraction of people who go to
treatment get better? ''
Senator Carper. That is a very good question.
Ms. Enomoto. And, what I would say, is that not all
treatment is created equal. Director Botticelli referenced
medication-assisted treatment, which we know is a standard of
care for opioid use disorders. Not all treatment providers are
equipped or adequately resourced to provide evidence-based
services and the interventions and supports that we know yield
the best outcomes. And, that is why, when you ask the question
about why more resources would make a difference--how do we
know that more resources are going to help--first of all, it is
because we know that not all providers are able to really
provide that wrap-around, science-based level of care that we
know can create recovery for the majority of people.
The other thing is that, in our surveys--and I am happy to
get you this data--we actually do not ask people, ``Do you
think you have a disorder?'' We ask people what their behaviors
and their symptoms are--and then, we can generate that
deduction. And then, we ask them: ``Did you seek treatment? Did
you get treatment? If you did not get treatment, why did you
not get treatment? Or, did you not seek treatment at all? If
you did not seek treatment, why was that? ''
For opioid use disorders, we know that there are about half
a million people who wanted treatment, but had different
reasons for not being able to get that treatment. Often it is
because they did not know where to go, their insurance was not
adequate, or they did not have the insurance to pay for it.
So, it is not an insignificant number of people--half a
million people--who need treatment and who are ready to get
treatment, but who do not have a way to pay for it or to get
there. So, I think that is a tremendous opportunity.
And, in terms of public campaigns, I know that GAO had a
look at campaigns and whether or not they were making a
difference. This is something that Madison Avenue figured out a
long time ago. There is a science to this. I think people who
run campaigns also know that there is a science to how many
impressions over a given period of time you need to have to
raise awareness, how many impressions over a given period of
time you need to change belief, and then, even further, how
many you need to change behavior.
Our campaigns are often significantly underresourced, so it
is sort of like, ``Well, we gave you a $10 kit to build a
potato clock, how come you did not get to the moon with that,
when your neighbor, the National Aeronautics and Space
Administration (NASA), was able to get to the moon? Well, we
had a $10 potato clock kit, so that is why we did not get to
the moon. But, with our $10 potato clock, we actually did some
amazing work.''
And so, for example, with our $1 million STOP Act campaign
to combat underage drinking, we are generating $54 million of
donated media. That is a lot. We are getting millions and
millions of impressions.
That being said, we may not be rising to the level that we
know--that the science would tell us--that you need to get to
in order to change knowledge, behavior, and action over time.
And so, I think that is the conversation that needs to be had.
Senator Carper. Great. Those are great answers. Thank you,
Mr. Chairman. And, our thanks to all of you. I am sorry we were
in and out this afternoon, but thank you for bearing with us
and for your testimonies.
Chairman Johnson. Thank you, Senator Carper.
I want to thank the witnesses again for your time, your
testimonies, your answers to our questions, and, really, for
all of your work and efforts in this area. This is a crisis. It
is an enormously difficult challenge--a very complex problem.
So, again, thank you all.
The hearing record will remain open for 15 days until June
1, at 5 p.m., for the submission of statements and questions
for the record.
This hearing is adjourned.
[Whereupon, at 4:56 p.m., the Committee was adjourned.]
A P P E N D I X
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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
ROUNDTABLE: EXAMINING ALTERNATIVE APPROACHES
----------
WEDNESDAY, JUNE 15, 2016
U.S. Senate,
Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:02 a.m., in
room SD-342, Dirksen Senate Office Building, Hon. Ron Johnson,
Chairman of the Committee, presiding.
Present: Senators Johnson, Portman, Lankford, Ayotte,
Sasse, Carper, Tester, and Peters.
OPENING STATEMENT OF CHAIRMAN JOHNSON
Chairman Johnson. Good morning. This roundtable will begin.
The reason we are having this roundtable, of course, is
that the scourge of drug abuse is an incredibly serious, but
also an incredibly difficult problem. There is a somewhat
unusual path that really led to today. When I took over the
Chairmanship, working with Ranking Member Carper, the first
thing we did was develop a mission statement for the Committee:
to enhance the economic and national security of America. And,
then we laid out some priorities.
On the homeland security side, the prorities are: border
security, cybersecurity, protecting our critical
infrastructure, and countering Islamic terror. We have really
focused an awful lot on border security. We have held 18
hearings on different aspects of it and published an
approximately 100-page report.
I think, Senator Carper, you are at least sympathetic to
what I have come up with as the primary reason--the primary
root cause--of our unsecured border: America's insatiable
demand for drugs.
Now, trust me, I did not go into those hearings thinking
that would be my conclusion. Again, there are many causes, but
this is a primary cause.
I did a national security swing through Wisconsin in early
January. Every public safety official I talked to--whether it
was State, local, or Federal--I always asked them the question,
``What is the biggest problem you are dealing with here in your
communities?'' Communities large and small--without exception--
said that the biggest problem was drug abuse, because of the
crime it creates, the broken families, the broken lives, and
the overdoses that we are seeing.
And so, if you take a look at the nexus of so many problems
facing this Nation, our unsecured border--which is a problem,
not only in terms of us being able to try and figure out how to
solve the immigration problem, but also for public health and
safety as well as for national security. And then, you take a
look at how, in every city--certainly in Wisconsin's cities--I
will say in America, it is true--and I think it is probably
pretty universally true--that the number one issue that public
safety officials are grappling with is drug abuse. That is a
big problem.
Now, we are going to have a pretty broad spectrum of ideas
and different approaches as to how to address this unbelievably
difficult problem. I will just finish with a little story here
and then I will turn it over to Senator Carper.
This never came up when I was running in 2010--what my
thoughts are on the legalization of marijuana--or the
decriminalization of marijuana. It never came up during the
campaign. About 2 years into my term, I was in front of a group
of a couple hundred seventh grade kids. And, one of these
seventh graders stood up and said, ``Senator Johnson, would you
support the legalization of marijuana?''
We are holding this hearing because this is a very complex
issue. And, like Prohibition, which fueled the gangs back then,
what we are doing right now is fueling the drug cartels, which
is the reason why we have an unsecured border.
So, I am sympathetic to the broad spectrum of arguments
here, but, at that moment, while I could have punted--I could
have kicked the can down the road--I could have dodged the
question, but I decided to make a decision in front of that
audience. I said, ``No, because of the terrible signal it would
send to kids your age.'' And, there is the dilemma.
So, again, I am looking forward to a good discussion here
to laying out the realities. I talked a little bit before I
struck the gavel here. Let us talk about the significant
problem. Let us talk about what the reality of the situation is
and let us try and move forward with some approaches that make
some sense.
With that, I will turn it over to Senator Carper.
OPENING STATEMENT OF SENATOR CARPER
Senator Carper. Thank you, Mr. Chairman. We are delighted
to see you all. Thank you so much for coming. Thank you for
what you do with your lives.
I come at this issue with a variety of hats on. I am a
retired Navy captain and I spent a long time in the military.
And, we focused a good deal, in those years, on drugs and
trying to make sure that the folks that are serving us--in my
case, in airplanes--were not using drugs that are illegal. And,
if they were, we had a policy that basically said that, if you
are doing drugs, you are out of here. So, I come at this as a
recovering Governor, who focused a fair amount on trying to
make sure that kids were born to parents who were ready to
raise them and to be good parents with high expectations
involved in the education of their children--and that kids had
good role models, mentors and stuff like that. So, I think one
of the reasons why people end up using drugs--and I spent
plenty of time in prison--just as a visitor--but I have been to
every prison in Delaware and talked to inmates. And, I asked
every one of them, ``How did you end up here?'' For the most
part, their stories are similar: ``I was born and I never knew
my dad. My mom was young when I was born. I started school
behind. I started kindergarten behind everybody else who could
read. They knew letters, I did not. And, I just fell further
and further behind and ended up dropping out of school. And, I
cannot support''--they would say, ``I want to be happy. I want
to feel good about myself. How do I do that? I got involved
with drugs. I got caught and I went to prison.'' Again and
again and again, that is the way it happens in my State.
People serve their time, they get out, and they go through,
maybe, work release. Eventually, they are back in their
communities and back in their neighborhoods, with the same
influences, and then, the same problems. So, it is a familiar
story. And, it is not just in Delaware. It is across the
country.
I have taken a special interest in three countries in
Central America: Honduras, Guatemala, and El Salvador. Some of
us have been down there together. The Chairman and I have been
to at least a couple of those countries together. And, I
started focusing on them when I would go to the border to see
what was going on, with respect to all of these tens of
thousands of folks coming into our country illegally. And, what
do we need to do to keep them out? And, we have built walls and
we have built fences. We have over 20,000 U.S. Customs and
Border Patrol (CBP) agents arrayed along the border. We have
drones in the air. We have aerostats--tethered aerostats. We
have P-3 airplanes, we have helicopters, and we have boats. You
name it. We have spent a quarter of $1 trillion to keep people
out over the last 10 years--to keep them from coming, mostly,
from those three countries into the United States. A quarter of
$1 trillion. We spent less than 1 percent of that in order to
address the root causes of their misery, which we are complicit
in creating.
So, for me, a root cause was really addressing the lack of
rule of law in these countries, the lack of opportunity, the
lack of entrepreneurial spirit, and the lack of a workforce. So
my focus was: How do we address those countries, kind of like a
Plan Colombia, if you will, for those three countries? And,
they created something for themselves called the ``Alliance for
Prosperity.'' It is being funded, rather significantly, with
our support and the support of the President and the Vice
President.
But, as the Chairman suggests, that is not really the root
cause. The root cause is our insatiable appetite for drugs. So,
we are complicit in their misery. How do we reduce that
complicity? We do that by reducing our demand for the drugs
that travel through those countries.
So, this is something we all have--everybody on this
Committee has thought a lot about it and we are interested in
finding out what works and doing more of that--and what does
not work, doing less of that.
Thank you so much for being here today and for being an
important part of this conversation.
Chairman Johnson. Thank you, Senator Carper.
One thing I missed in my opening statement--I just wanted
to lay out a couple of facts. The United States has spent an
estimated $1 trillion on the War on Drugs over the last 40
years. There are, roughly, 27 million illegal drug users in the
United States. In 2014, there were 47,000 drug overdoses--an
average of 129 people per day. So, that gives you kind of a
sense of the magnitude of the problem. On an annual basis, we
probably spend about $31 trillion on the War on Drugs. And,
certainly, my conclusion would be that we are not winning that
war. So, this is really about looking at different approaches.
I had a nephew die of a fentanyl overdose in January. So, this
affects every community in America.
With that, again, I want to thank the witnesses. I know
this has been kind of an on-again, off-again process. I know,
Dr. MacDonald, you probably had a pretty fun flight. I love
those red-eye flights myself. I truly appreciate you doing
that. We will start off with Dr. MacDonald. We would like to
give you guys about 5 minutes to do an opening statement, then
we will kind of get into a free-flowing discussion.
Our first witness is Dr. Scott MacDonald. He is a lead
physician at the Providence Crosstown Clinic in downtown
Vancouver, British Columbia. Crosstown is the only clinic in
North America that provides opiate-assisted treatment for
people with severe opiate use disorders. Dr. MacDonald.
Senator Carper. Did you fly in this morning?
TESTIMONY OF D. SCOTT MACDONALD, M.D.,\1\ PHYSICIAN LEAD,
PROVIDENCE CROSSTOWN CLINIC
Dr. MacDonald. Yes, I flew in this morning.
---------------------------------------------------------------------------
\1\ The prepared statement of Dr. MacDonald appears in the Appendix
on page 403.
---------------------------------------------------------------------------
At Providence Crosstown Clinic, 140 people are receiving
daily treatment with injectable opioids, an intensified form of
medication-assisted treatment (MAT). And, I want to thank the
Government of British Columbia for supporting our clinic and
making the delivery of this treatment possible in Vancouver.
About half of the patients are receiving treatment with
hydromorphone, a widely available licensed pain medication. The
remainder receive diacetylmorphine.
Our patients can come up to three times a day for
treatment. Half come twice per day and the other half come
three times a day. About a third take a small dose of methadone
with their last session at night. All of these patients have a
chronic disease--a medical condition for life that can be
successfully managed. Treatment prevents withdrawal and
stabilizes their lives. Here, they have an opportunity to deal
with underlying psychological and mental health issues. In
time, some will step down to less intensive treatments or
gradually wean themselves off.
These patients were all participants in the Study to Assess
Long-term Opioid Medication Effectiveness (SALOME). SALOME was
a follow-up to the North American Opioid Medication Initiative
(NAOMI), which showed that diacetylmorphine, or prescription
heroin, is superior to methadone in that group of patients that
continue to use illicit heroin despite attempts at the standard
treatments. A small group of NAOMI folks received hydromorphone
and, in a surprise finding, these experienced drug users could
not distinguish which treatment they received--and the
beneficial treatment effect was preserved in the hydromorphone
arm.
Some people suffering from severe opioid use disorder need
an intensified treatment like this. While methadone and
buprenorphine are effective treatments for many people and
should remain the first-line responses, no single treatment is
effective for all individuals. Every person left untreated is
at high risk for serious illness and premature death.
Despite the positive results for diacetylmorphine, as
published in the New England Journal of Medicine (NEJM), only
Denmark acted on these results and incorporated prescription
heroin into their health system.
But, it did lead to our follow-up study and testing of
hydromorphone, or Dilaudid, as a potential treatment. And,
hydromorphone has the advantage, over diacetylmorphine, of
already being a licensed pharmaceutical.
The SALOME group underwent stringent testing and controls
to show the need for treatment. For them, the standard
treatments, Suboxone and methadone, had not worked and most had
multiple prior attempts at treatment. They had used injectable
opioids for at least 5 years and, on average, for 15 years.
They had medical and psychological health problems. They had
nearly universal involvement in the criminal justice system. In
short, we were able to recruit the appropriate patients for an
intensified treatment like this.
At the start of the study, they were using illicit opioids
every day. By 6 months, their use was down to just 3 to 5 days
per month. Nearly 80 percent were retained in care and that
high rate continues to this day. At the outset, they were
engaged in illegal activities, on average, 14 days per month.
With treatment that reduced to less than 4 days. This study was
published this past April in the Journal of the American
Medical Association (JAMA) Psychiatry and I would like to
acknowledge Health Canada for allowing us to investigate this
important scientific question and for allowing a number of our
patients to continue on diacetylmorphine, those who need it, on
a compassionate0use basis.
Supervised use of injectable hydromorphone is indicated for
the treatment of severe opioid use disorder. And, we are using
injectable hydromorphone as a medication-assisted treatment, an
intensified medical intervention as a part of the treatment
continuum. Severe opioid use disorder is a chronic disease that
needs to be managed long term, just like Type 2 diabetes or
hypertension. Without our treatment, this group's only option
would be illicit opioids through the narco-capitalist networks.
We still have people who use drugs on the street in
Vancouver, but we have another option, in addition to needle
exchanges: supervised consumption rooms or injection sites.
These are legally protected places where drug users consume
pre-obtained illicit drugs in a safe, nonjudgmental
environment. Vancouver has two such sites. These sites provide
an important entry point for people into medical care and
substance use treatment. They also provide value over needle
exchanges, alone, as needles and equipment are all contained
onsite and needles will not end up in playgrounds or
schoolyards, where they could cause injury.
To contrast with these harm-reduction interventions, at our
clinic, Crosstown, we are providing a medical treatment.
Providing injectable medication in a specialized opioid clinic,
under the supervision of medical professionals who are not only
ensuring the safety of the patients and the community, but are
also providing comprehensive care.
We are able to use hydromorphone ``off-label'' in Canada
for the treatment of substance use disorders, but some
jurisdictions restrict its use to pain. I have seen remarkable
transformations in our patients. Some of our patients have
already returned to work or school.
Supervised injectable hydromorphone is safe, effective, and
cost-effective. It is a useful tool when the standard
treatments are not effective. Treatments are dispensed within
our opioid treatment clinic and prescribed on a ``dispensing
basis'' onsite. In this setting, hydromorphone is not
susceptible to diversion and an exemption for its use could be
considered in jurisdictions where its use to treat substance
use disorders is prohibited by law.
In British Columbia, we need every tool in the toolkit to
rise to the challenge of the opioid epidemic. Injectable
opioid-assisted treatment in supervised clinics is one
effective approach. Supervised consumption rooms, like Insite,
in Vancouver, are valuable for public health. Of course, we
would like to see an end to people's dependence on heroin but,
for those already suffering, it is essential to provide care--
and care based on evidence.
Chairman Johnson. Thank you, Dr. MacDonald.
Our next witness is Dr. Ethan Nadelmann. Dr. Nadelmann is
the founder and executive director of the Drug Policy Alliance
(DPA), the leading organization in the United States promoting
alternatives to the War on Drugs. Dr. Nadelmann.
TESTIMONY OF ETHAN NADELMANN, PH.D.,\1\ EXECUTIVE DIRECTOR,
DRUG POLICY ALLIANCE
Mr. Nadelmann. Thank you, Senator Johnson, for initiating
this roundtable and for inviting me. I have been waiting a long
time for the opportunity to share some of my thoughts with
members of the U.S. Senate.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Nadelmann appears in the Appendix
on page 410.
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Let me just be frank. I fundamentally believe that the War
on Drugs, in this country and around the world, has been a
monumental disaster. It has been a disaster in public health
terms. It has been a disaster in public safety terms. It has
been a disaster in fiscal terms. And, it has been a disaster in
human rights terms.
I appreciate you bringing up the analogy to alcohol
prohibition before because, if you look back at alcohol
prohibition, some of what led the Nation to embrace the 18th
Amendment, back then, was the notion that alcohol was a
horrific drug that was causing immense devastation in this
country and what have you. And, people embarked upon the
experiment of national Prohibition. What happened? We saw Al
Capone and rising levels of organized crime. We saw all sorts
of violence and bootleggers at the borders with Canada and
Mexico--and all around the country. We saw overflowing jail
cells and courthouses. We saw hundreds of thousands of
Americans being blinded, poisoned, and killed by bad bootleg
liquor--liquor that was more dangerous because it was illegal.
We saw people talking about nullifying elements of the Bill of
Rights to the U.S. Constitution. We saw levels of corruption
that were unparalleled, in many parts of the country. We saw
Chicago and other towns essentially taken over by the narco-
traffickers of the day--the alcohol bootleggers. And, we saw a
rising level of cynicism and disregard for the law.
Do you know what else we saw? We did not see any reduction
in alcohol consumption. At the beginning, it looked like it was
going to drive down alcohol use, but, by the end of alcohol
prohibition, alcohol use was as high as it had been at the
beginning. And, the major switch was that people had shifted
from beer and wine to hard liquor--oftentimes underground hard
liquor that was more dangerous. That is when the country came
to its senses and said, ``Enough of this. We are repealing
alcohol Prohibition.''
At the same time, many countries in Europe that were
flirting with Prohibition, they looked at us--they saw Al
Capone, they saw all of the money going down the drain, they
saw all of the failures, and they saw all of the hypocrisy.
They said, ``We are not going to do that. We are going to crack
down on booze with higher taxes, tougher licensing
restrictions, and public education campaigns.'' Do you know
what happened in Europe with that? Without prohibiting alcohol,
they drove alcohol use and alcohol abuse down further than we
did at the beginning of alcohol Prohibition in the United
States. And, rather than putting billions of pounds or
guilders--or whatever it might be--into the hands of
traffickers and gangsters, they put it into government
treasuries. It seems to me, that was the better approach then.
There is a lot to be learned.
Fast forward to right now. Drug prohibition has been a
monumental disaster. You mentioned what is going on in Mexico
and places like that--in Afghanistan--what is going down in
Colombia and parts of Central America. They are like Al Capone
and Chicago times 50. It is the result of a failed
Prohibitionist policy.
Then, you look at what is happening in American prisons.
What are we, less than 5 percent of the world's population?
But, we are almost 25 percent of the world's incarcerated
populations--the highest rate of incarceration in the history
of a democratic society--a rate of incarcerating black people,
in this country, that puts South Africa--during apartheid--or
the Soviet gulags to shame. It is nothing to be proud of and it
turned out to be remarkably ineffective in dealing with the
problems of drug abuse.
Then, you look at the public health side. When human
immunodeficiency virus (HIV) started to spread among injecting
drug users back in the 1980s, those countries--not just
Australia and the Netherlands, but Prime Minister Margaret
Thatcher's Britain--decided that needle exchange programs were
the right thing to do. They succeeded in keeping their HIV
rates among injecting drug users to under 5 percent. In
America, we said, ``No way, no way, no way.'' And, we ended up
killing 100,000 to 200,000 people in this country--not just
injecting drug users but their lovers and their kids as well.
That was a disaster as well.
So, I think that this ``War on Drugs'' has just served this
country so poorly. I think what happened is that we developed
an addiction. It was an addiction to ``drug-war'' thinking,
``drug-war'' ideology, and ``drug-war'' policies. And, right
now, finally, thankfully--the country is finally in recovery
from the ``drug-war'' addiction of our past.
Now, that said, in making the analogy to alcohol
prohibition, I think it applies mightily to the issue of
marijuana prohibition. And, if I had been coaching that student
who asked you that question the day that you spoke in that
school, I would have said, ``Senator, let me tell you
something. Marijuana--I do not see any evidence that the
marijuana laws are preventing young people from getting it or
any evidence that they are preventing older people from getting
it. All that I see is evidence that it is putting a lot of
people in jail and costing the government a lot of money. Do
you still support a marijuana prohibition policy, knowing that
it has been totally ineffective?''
But, with the other drugs, I think this is the way to think
about it--and I am going to conclude my comments with this: I
think what the best drug policy tries to do is it starts with
the understanding that there has never been a drug-free
society, more or less, in human history--and there is never
going to be a drug-free society. If anything, we are going to
see more drugs--legal, illegal, in between, and gray market--in
the future--from pharmaceutical companies and underground
manufacturers--you name it. Therefore, our challenge is not to
try to keep drugs at bay or to build a wall or a moat between
this country and others--between our schools and what have you.
That has failed. The evidence is in.
What we have to do is to accept the fact, sadly, that drugs
are here to stay and that our great challenge is to learn how
to live with this so that they cause the least amount of harm
possible--and, in some cases, the greatest possible good.
Therefore, we need to think about drug policy in the following
two ways:
First, the optimal drug policy should try to do two things:
It should seek to reduce the negative consequences of drug
use--the death, the disease, the crime, the suffering, and the
devastation of families, individuals, and communities. It
should seek to reduce the harms of drugs. And, second, it must
seek to reduce the harms of government policies, reduce the
mass incarceration, reduce the drug gangs abroad, reduce all of
the negative health consequences, and reduce violations of
civil and human rights. The optimal drug policy is the one that
most successfully reduces both the harms of drugs and the harms
of government policies.
And, the second frame--and I will finish with this--I think
it is helpful, because all change, essentially, is incremental
in these areas--and most others--to think about our options as
arrayed along the spectrum, from the most punitive drug
policies, on the one hand, as in Saudi Arabia, Singapore, and
Malaysia--cut off your hands, execute you, lock you up, drug
test you without cause, and throw you into what are called
``treatment camps'' that are really prisons--all of the way
down to the most free-market, ``Milton Friedman-esque,''
policies with no restrictions, except to keep kids away.
The way that we need to think about drug policy is by
moving down this spectrum, from the highly punitive
overreliance on criminal law and criminal justice institutions,
moving incrementally, step-by-step, down this spectrum, but
stopping short at the point at which going any further would
actually entail real risks to public health or public safety.
And, it means being driven by the type of evidence that Dr.
MacDonald just made reference to.
When the evidence shows that mandatory minimum sentences
are not having an effective deterrent impact, then it is time
to reform and repeal those.
When the evidence shows that marijuana has useful medical
purposes, it is time to acknowledge that.
When the evidence shows that providing sterile syringes to
injecting drug users, through pharmacies and needle exchange
programs, reduces the spread of Human Immunodeficiency Virus/
Acquired Immunodeficiency Syndrome (HIV/AIDS) as well as
hepatitis C--without increasing drug use, it is time to do
that.
When the evidence shows that methadone maintenance and
buprenorphine maintenance are successful in reducing the harms
of addiction and in helping people get their lives together, it
is time to do that.
When the evidence shows that heroin maintenance and safe
injection sites reduce all sorts of harms and produce a net
benefit, it is time to do that.
With marijuana legalization, we will see. My judgment is
that the net benefits of moving in the direction of the
sensible regulation of marijuana exceed the risks. That is a
judgment and we will see how that works out. But, I think that
the evidence, overwhelmingly, suggests it is the right way to
go. With the other drugs, we need to move toward the
decriminalization and public health approach, focusing--and
this is what I will do in my comments later--on reducing the
demand and the magnitude for the demand of these drugs. So long
as there is a demand, there will be a supply. Pouring money
into supply just pushes it from one place to another--like
trying to bang down on mercury or step down on a balloon. It is
about reducing demand in ways that are driven by the evidence
and a respect for basic human decency.
Thank you.
Chairman Johnson. Thank you, Dr. Nadelmann.
Now for a slightly different perspective, Dr. David Murray
served for nearly 13 years in President Bush's and President
Obama's Administrations as Chief Scientist and Associate
Director of Supply Reduction in the White House Office of
National Drug Control Policy (ONDCP). He is currently Senior
Fellow at the Hudson Institute. Dr. Murray.
TESTIMONY OF DAVID W. MURRAY,\1\ SENIOR FELLOW, HUDSON
INSTITUTE
Mr. Murray. Thank you, Senator. I, certainly, want to take
a moment to give my appreciation for each of you that is
persisting in this issue and this problem. It is an urgent
issue and it does not get the attention it deserves. And, I
want to commend you Senators, who have persisted in careful
attention to this issue and are probing for answers for what
is, as you identified, the cause of 47,000 deaths of Americans
a year--and overwhelming morbidity that is an additional toll.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Murray appears in the Appendix on
page 433.
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My perspective, from having worked inside of the government
and having looked at the biomedical literature, is that we need
to approach drug policy somewhat differently than we have most
recently--but, that it can work--that we can save lives and
that we can, effectively, transition people into more secure
and better lives. The underlying role of substance abuse--of
drug use--in driving American pathologies is extraordinary.
From homelessness to domestic violence to law enforcement
difficulties to national security risks to education failure to
the death of our beloved fellow citizens and family members,
this is an extraordinary cancer that has been eating at us for
a long time.
You will hear arguments--and have heard some of them
already--I will probably be an outlier--a resister with regard
to certain claims. It is not so much that I do not share the
goals of lower amounts of drug use or of a safer, healthier
society. It is that I am not convinced that the evidence is as
strong as it is sometimes portrayed as, for these methodologies
that are sometimes referred to as ``harm reduction.''
There are claims made about impact that, when you look more
carefully, the evidence is actually very weak and relies on
self-report and on methodological studies that are very
difficult to validate--very difficult to see the actual
replicability of them. The evidence is much weaker than you
might anticipate, with regard to moving in the direction that
has been counseled.
I would point out that we have moved in this direction, in
the last 7\1/2\ years, under this Administration. It is a
direction that has not strongly applied the strategic lessons
of a balanced drug strategy approach and that has weakened and
undermined the very office responsible for setting that
strategy--and that has moved us down a pathway that approaches
harm reduction mentalities. It has led to the enabling of legal
marijuana. It has led to discussions about the distribution of
harm reduction activities, including supervised injection
facilities (SIFs). And, I think we can say that the results
that we are seeing are before us and are really quite
appalling. The results are disaster, epidemic, and tragedy.
Does the ``War on Drugs'' work? Well, I would say that that
is contingent on two things.
First, you have to define what is success. And, when you
have roughly between a tenth and a sixth of the prevalence
rates of illicit substances, such as marijuana--the most widely
used--compared to alcohol or tobacco--that is a form of
success. You are reducing the disease and its morbidity as well
as its impact. When you have one-sixth to one-tenth the
prevalence rate, among young people and adults, of the use of a
substance, part of that is attributable to the fact that there
are social norms against its use and law enforcement sanctions
against its use--and that law enforcement can be a powerful
partner in referring people into treatment and recovery. And,
when we decriminalize or move toward a model of deregulation
and so forth, this really does not suffice. It does not answer
our needs. It undermines the most effective partner for
referring people to treatment. It undermines our hold on
prevention, on the norms of non-using of drugs, and,
ultimately, it weakens our approach, I believe.
The second contingency is this: drug policy, where it has
been effective--and there are models of where it has been
highly effective. Reducing the youth use rates of marijuana 25
percent, in the period from 2001 to 2008--that was an
achievement. Reducing the use of major drugs, including
methamphetamine (meth) and heroin, during that same time
period, were major achievements. And, they are almost always
attributable to having a bipartisan approach that crosses the
aisle, so that it is a unified American understanding of
American lives and American risk. At the same time, you cannot
be--and my famous story of this, which strikes me as so
compelling, is Penelope of Ithaca, the wife of Ulysses. He is
sailing for 20 years and she must marry a suitor when she
finally finishes a tapestry in front of her. And, when that
figure in the tapestry is done, she will be forced to make a
decision. But, what does she do every night as she waits for
Ulysses? She unravels it, because she does not want it to come
to an end.
That is a positive model. But, unfortunately, we have taken
the worst of that. We unravel our drug policy almost every 4 or
8 years. We make gains and we have effective strategies. And
then, we spend the next period of time reversing ourselves.
Under that model, you cannot achieve long-range, sustained
goals. We need to get back to that model of a sustained,
bipartisan approach.
So, what am I recommending? We have to acknowledge a couple
of things. The urgency before us, at the moment, is opioid
overdose deaths. But, we cannot let that drive all of our
understanding. It is a, relatively, unique situation because we
have, for opioids, methadone-assisted or medication-assisted
treatment of various types. We have naloxone, an overdose
reversal drug. We have the capacity to do things, like
injection facilities, if we move in that direction. I would
counsel against it.
These are not available tools for drugs like
methamphetamine, cocaine, or cannabis. We do not have the
medications. We do not have the methodologies of approach. A
comprehensive drug strategy cannot simply focus on the one
urgent thing before us.
The second issue is that we have overwhelmingly focused, in
the last little while in this discussion today and in the
Administration's perspective on the consequences of the opioid
epidemic, on those who have the disease--those who need
treatment. Those who are suffering already--how are we going to
help them? Compassion requires that we do so, but we have to
address the principal urgency, if you are thinking medically,
thinking epidemiologically, or thinking in terms of sound
public policy. You have to shut off the entry into that state
by protection--prevention. You have to find the mechanisms of
preventing people from falling into the state of addiction and
dependency, where we then need to try to rescue them from
overdose constantly with naloxone and within treatment
facilities. This is too late. We can do things for them.
Recovery is possible. But, if we are not urgently addressing
the underlying mechanisms that are driving people into this, we
are missing our policy opportunity and we are committing a
tragedy.
What must we do? Well, one thing would be to not enable the
legalization, the normative acceptance, and the reduction in
perception of risk regarding drugs. And, that is what
legalization precisely does. It undermines the fabric of
resistance and the capacity to prevent. And, I would offer--and
we will have time to discuss, so I will not put all of the
cards on the table at this point. But, I would say that there
is a superior means of approaching this and it is the one piece
of public policy that was, actually, eliminated--or neglected--
in the last 7 years. We have to focus on the drug supply--the
availability of the drugs, themselves. The Administration
recognizes this, with regard to prescription opiates, which are
the number two drug problem in America, in terms of prevalence
rates--behind marijuana--which should tell you, by the way,
that regulation, legalization, and medical practice are not
sufficient to make the problem go away, because we have an
enormous problem with regulated, formerly acceptable medical
practice prescription opiates. They are killing 18,000 people a
year, according to the last count. So, that is not sufficient,
somehow.
At the same time, we have seen the supply, as it is being
reduced from medical practice, showing up, as this rate is
starting to slow. What about cocaine? Cocaine from South
America--from Colombia--was reduced 76 percent between around
2003 through around 2010 2011. The consequences were major in
the United States. People got better. People got into recovery.
Overdose deaths from cocaine dropped significantly.
Well, guess what has happened in the last 2 years in
Colombia? Cocaine is taking off again and it is coming right
back at us. And, it will soon be right back at our throats. As
the supply increased, overdose deaths are starting to climb
once again.
And, the third example--and the one I think that we are not
sufficiently paying attention to--is heroin--the illicit
opiate. Twenty-six metric tons were produced out of Mexico--our
primary source--back in 2013. The assumed need for the use of
heroin in the United States was never more than 18 metric tons.
What were they doing with this abundance? A year later, it rose
to 40 metric tons. That is an extraordinary amount of a deadly
substance that is being manufactured and sent across the
border. And, as of 2015, it has now skyrocketed up to 70 metric
tons. Where is it going? Who is it infecting? Why are we not
doing more with international partnerships, interdiction, and
border protection? If you are thinking epidemiologically--and
this is a disease--you have to drive down the presence of the
pathogen--the thing that infects people. It is a behavioral
disease and the pathogen, in this instance, is the illicit
market of heroin that killed 10,500 people in 2014.
And, now, I hate to make a worse statement, but there is
worse. We are not done yet. The deaths that we have seen, which
have driven the news coverage and have driven our urgencies and
concerns are based on 2013 and 2014 production. It has already
surpassed that. It is already coming now at a 170 percent
increase and it is being added to by synthetic opioids. Look
out. Hang on to your hat. They are going to kill many more.
The fentanyl seizures at the border--fentanyl is measured
in micrograms for a dose. When first responders open a package,
they are at risk for dying. It is that potent--that lethal.
And, it is growing in the tens to hundreds of pounds, which are
now showing up at our border as illicitly manufactured and it
is being laced into heroin. I am sorry to say this, but next
year's death toll will probably be worse--and the year after,
because we have not sufficiently applied the measures that are
absolutely requisite to shut off this pathogen that is killing
many Americans. We need a balanced strategy. We need to have
treatment and recovery. We need to have prevention in our
schools for young people. But, we have to address the sheer
magnitude of the deadly supply that
is driving this engine. And, I would argue--and I will end with
this--when we do approach supply and reduce its capacity to
entangle us, we thereby give power to treatment and recovery as
well as to prevention. We make them more possible and
stronger--and in the presence of law enforcement and drug
courts and referrals to treatment, we have a powerful
partnership that we unfortunately let slip through our grasp--
and we are now paying the price.
Chairman Johnson. Thank you, Dr. Murray.
Our final witness is Chief Frederick Ryan. Chief Ryan has
been a police officer since 1984 and has served as Chief of
Police in Arlington, Massachusetts since 1999. Thank you for
your service and thank you for coming here.
TESTIMONY OF FREDERICK RYAN,\1\ CHIEF OF POLICE, ARLINGTON,
MASSACHUSETTS
Chief Ryan. Good morning, Senator and honorable Members of
the Committee. Thank you for having me. Again, my name is
Frederick Ryan. I am Chief of Police in Arlington,
Massachusetts. I also serve as the vice president of the
Massachusetts Major City Chiefs of Police Association (MMCC),
and I am on the board of the Police Assisted Addiction Recovery
Initiative (PAARI), which was founded out of Gloucester,
Massachusetts.
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\1\ The prepared statement of Mr. Ryan appears in the Appendix on
page 470.
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I am here to talk about the opiate epidemic that has swept
across America. But, before I get into my prepared comments, I
wanted to share with the Committee a text message that I got
this morning, while I was in the other room changing into this
lovely uniform that I am wearing. That message was from a young
man, who our officers had arrested many times for crimes
associated with his drug addiction. After affiliating with the
Police Assisted Addiction Recovery Initiative, we referred this
young man into treatment, rather than to the criminal justice
system. He is now coming up on a year of sobriety. And, he
texted me to thank me for helping him and for coming here today
to speak before this Committee. I think that really illustrates
what I am going to talk about, in terms of police referral to
recovery.
My views are shaped by what I have seen and done as a
police officer on the streets of the Commonwealth of
Massachusetts for more than 30 years and by what I have learned
from individuals suffering from the disease of addiction. I
will summarize my points as follows:
We, as law enforcement, cannot solve this problem alone--
and we must stop telling America that, with just some more
resources, we can do so. In fact, a strategy that relies
largely on law enforcement and arrest, especially aimed at low-
end users, only fuels the epidemic and complicates the chances
for long-term recovery.
Every dealer we arrest and take off of the streets is
quickly replaced by one or more rivals who sometimes compete
for that territory by cutting their prices, increasing the
supply, and marketing new and even more dangerous products,
such as fentanyl-laced heroin. This often makes the situation
worse than it was before the arrest.
Every person with a substance abuse problem that I have
talked to has said that arrest and prosecution has never been a
deterrent. The physical and psychological need for the
substance was far stronger than any seemingly rational
deterrent that the police and the criminal justice system
posed.
Those suffering from substance use disorders are not our
enemies. They are our sons, our daughters, our neighbors, and
our nephews. And, this notion that we are at war with them must
be abandoned.
The solution to the epidemic relies on reducing the demand
for opiates and other substances. This epidemic was built one
drug-dependent victim at a time. And, the solution, while
complex and multidisciplinary, needs to be heavily based on
modern evidence-based treatment options. There are really only
two choices here: long term treatment or death.
Police officers and Chiefs of Police, throughout our
country, are stepping forward to call for change. Through the
leadership of my dear friend and colleague, Chief Campanello up
in Gloucester, Massachusetts and businessman John Rosenthal,
from Boston, the Police Assisted Addiction Recovery Initiative
was founded as a private nonprofit.
And, by the way, as an aside, after it was founded by
businessman John Rosenthal, he lost a nephew to the epidemic as
well.
To date, we have more than 120 police departments that have
affiliated with PAARI. And, we have treatment providers, in 28
States, that are offering scholarships to those suffering from
substance use disorders. These police departments, and many
others, are joining PAARI every day and have stopped arresting
and criminalizing addiction and incarcerating people merely
because they suffer from a substance use disorder.
I want to tell you how and why I came to these conclusions.
You probably expect that a 30-year cop might have a different
perspective on these matters. Simply stated, we are not at war
with our communities--nor should we be.
The epiphany, for me, that we had to have a philosophical
change, came when I was being briefed by our crime analyst on
trending overdose fatalities in our jurisdiction. She displayed
it on a spreadsheet for us. One very young lady, who, by all
standards of measure, was an American success story--college
educated--her mom a school teacher and her dad a firefighter--
overdosed on heroin. Police and emergency medical services
(EMS) responded, reversed the overdose with nasal naloxone, and
she was transported to a Boston hospital. One week later, the
same young lady overdosed--a 911 call, police and EMS response,
naloxone reversal and transportation to a Boston area hospital.
Seven hours later, she overdosed. Fatality. If that does not
illustrate that these deaths are not only predictable, but also
preventable, nothing does. This overdose death was predictable
and, therefore, preventable. And, it highlighted the fact that
we, the police department, possess the identities of those at
the highest risk of a fatal overdose--those who have previously
overdosed--and that, with every non-fatal overdose, there is an
opportunity to do an inventory, to get individuals into
recovery, and to get the family and their loved ones the
resources they need to ensure survival.
Further, this death depicted the real fact that many
emergency rooms (ERs) in America do not have the desire or the
capacity to treat overdose victims in any meaningful way.
Medical and substance use disorder treatment programs cannot be
allowed to continue discharging, to the street, sick people at
risk of immediate death. We would not tolerate this for any
other chronic disease, such as cancer, heart disease, or
diabetes.
This experience led the Arlington Police Department to be
the first in the Nation to affiliate with PAARI. What was a
desperate response to an epidemic threat in two distinct
communities in Massachusetts--Gloucester way up on the north
shore and Arlington in the metropolitan Boston area--resonated
swiftly and broadly across the region and, indeed, the Nation.
And, legislation is moving rapidly through many State
legislatures, empowering police-assisted recovery initiatives
and focusing on reducing the demand for opiates by increasing
access to treatment and prevention.
Essentially, there are two models: the Gloucester and the
Arlington model. The Gloucester model invites those suffering
into the police department. And, they connect them with a
volunteer ``angel'' that helps them navigate the system in
recovery. The Arlington model--we have a social worker who does
outreach to the known population of people suffering from
substance use disorders and works with them and their loved
ones to put in place an intervention plan to plan for the next
overdose, so that we can prevent it from being a fatality. And,
I will talk, in a minute, about the early data trending.
In 2014 and early 2015, in our jurisdiction, we were
averaging one fatality per month on heroin overdoses--many more
non-fatal overdoses and reversals. Following the implementation
of our program, on July 1, 2015, we went 8 months with only one
fatal overdose. Sadly, while I was preparing the testimony that
I am speaking about today, in my office on Sunday morning, the
radio call went out and our officers responded to an overdose,
while I was typing this testimony. And, I listened to the radio
carefully and, at that scene, a family member had dispensed
nasal naloxone and saved their family member. Likely, the
naloxone was dispensed by the Arlington Police Department.
Through the Boston University (BU) School of Public Health,
we are tracking all of our program participants. And, although
it is early, we are seeing significantly lower relapse rates
among the participants in our pre-arrest diversion programs,
both in Gloucester and Arlington.
The Arlington and the other police-assisted recovery
initiatives are only a year old--and it is far too early to
draw conclusions. After all, the disease of addiction is a
chronic condition that often involves relapsing. I think,
maybe, we will talk later about what success looks like, but we
have to prepare for relapse. Nevertheless, there are important
markers that demonstrate we are on the right course:
We are saving lives and we are reducing crime--crimes that
are often associated with drug addiction--burglary,
shoplifting, and other quality-of-life crimes. Some
jurisdictions are reporting as much as a 25-percent reduction
for those crimes.
Our new approach is restoring and building the community's
trust in police--and this is of critical importance to your
Committee. In this very challenging time in the history of
policing in America, where the trust has been lost in many
jurisdictions, programs, such as the one I am speaking of, have
been incredibly valuable at rebuilding the trust in the
community and its police department--and many residents are
shaking their head, saying, ``Finally, the cops got it.'' We
have to stop arresting people because they have an addiction.
Stigma and shame inhibit patients and their families from
seeking treatment and support. The fact that law enforcement is
recognizing this as a disease that needs to be treated into
remission, rather than a crime that requires arrest and
incarceration, has had a positive impact in communities
throughout America.
To that end, I do not, personally, respond to fatal
overdoses. We had the brother of one of our police officers
fatally overdose. I went out to the scene to offer my
condolences to his mom and the family. The young man was,
literally, dead on the other side of the wall and his mom
looked at me and told me, ``Thank you for what you are doing
around addiction in the community. We were just too ashamed to
reach out for help.'' And, it is that shame and that stigma,
which is killing people, that we have to set aside.
You will notice that, in my testimony, I never labeled
those suffering from substance use disorders as ``junkies'' or
``addicts.'' And, I otherwise refrained from labeling these
people--these members of our community. The very real stigma
associated with addiction is among the greatest barriers to
success and it has inhibited the power and the might of the
U.S. Government from bringing a real sense of urgency to the
opioid addiction epidemic and from adopting meaningful and
effective policy changes to address the demand side of this
public health crisis.
Today, in Massachusetts, we lose an average of four people
a day to opiate overdoses--and it is projected that more people
will die this year from overdoses than from automobile
accidents. It is time that we bring a true sense of urgency to
this public health epidemic and that we unleash the might of
our government to address the demand side of the opiate crisis.
And, municipal police departments and PAARI partners across
this country are willing partners in that solution. As I stated
earlier, there are only two choices: long-term treatment or
death. Clearly, we all know the answer that we want. I look
forward to getting started on this work with the Committee,
today. And, I thank you for the invitation to speak here,
today.
Thank you, Senator.
Chairman Johnson. Thank you, Chief Ryan.
Obviously, we have some effective advocates for the various
positions here. And, I truly appreciate the excellent testimony
here.
I am going to be here for the entire roundtable, so I guess
what I would like to do is to turn it over to my colleagues.
And, we can do it--again, I want this to be a free-flowing
discussion. I do want to keep answers relatively short. It
looks like all of us--our witnesses can, certainly, again, be
effective advocates, but let us keep the conversation and
discussion relatively short. Let us keep the answers clipped--
and the questions as well.
We will start with Senator Portman.
OPENING STATEMENT OF SENATOR PORTMAN
Senator Portman. Thank you. And, first, thank you for
having the roundtable. And, to all four of you, thank you for
your important work in this field. As you know, the Senate has
been grappling with this. We spent 2\1/2\ weeks on the floor
with this legislation, called the Comprehensive Addiction and
Recovery Act (CARA). We spent 3 years putting it together. We
had five conferences here, in Washington. Some of you
participated in those. We brought in experts, in various areas,
to try to figure out how to get at the very issues you are
talking about--dealing with this, not as a drug problem, but as
a public health problem, acknowledging that this is an illness,
this is to be treated as a disease--trying to take away the
stigma, which, Chief Ryan, you have talked about--which I agree
with you is part of the reason people are not seeking
treatment. There are other reasons as well.
I am someone who is frustrated, because I have been at this
a long time. Twenty-two years ago, a constituent came to me,
when I was in the House of Represenatives, and said, ``My son
just died. What are you going to do about it?'' And, I was
fully armed with all of the statistics--$15 billion a year on
interdiction and eradication of drugs as well as on
prosecutions and incarceration. And, she said, ``What are you
doing for me in my neighborhood?'' And, that led to a whole
series of thinking and, frankly, to a different position on my
part, in terms of focusing more on the demand side. And, we did
pass a number of bills, the Drug-Free Workplace Act of 1988,
the Drug-Free Media Campaign which I was proud to be the author
of--but also the Drug-Free Communities Act of 1997. We sent out
$1.3 billion, supplying 2,000 community coalitions around our
country, including one I chaired in my hometown for 9 years--
and, which I was on the board of before I ran for this job. I
am still very involved with it.
I think CARA addresses much of what you are talking about.
It will not solve the problem. Washington is not going to solve
this problem. But, it does focus on, primarily, four things.
One is the notion of placing much more emphasis on prevention
and education. And, David, you talked a little about that--the
importance of not taking your eye off of the ball--and, I
think, that is one of the problems we have had. When we solve a
problem--we had cocaine solved, you will recall, back in the
1980s. And, thanks to a basketball player at the University of
Maryland (UMD), everybody thought, ``Cocaine is the issue, we
are going to focus on this.'' When Len Bias died, there was a
lot of emphasis and focus. As soon as you take your eye off of
the ball, it is something else.
You mentioned methamphetamines here today. You mentioned
cocaine coming back. I would tell you that overdoses in my home
State of Ohio, we are starting to see more cocaine, we are
starting to see more meth coming back. And, we thought we had
sort of turned the corner there. So, every time you take your
eye off the ball--I agree with what was said here today--
something will crop back up again.
So, I think there is a growing consensus around this issue
of treating addiction like a disease--removing the stigma, so
people get treatment--and focusing more on demand, rather than
just focusing on the supply side. And, by the way, look at
where the money has gone. The Drug-Free Communities Act of 1997
is part of this, but there has been more money placed on the
demand side. I would say that it is still not enough, because I
think this will--unfortunately, it is not going to be solved at
the border. If it is not, in my view--and I am not,
necessarily, speaking for my colleagues here, on either side of
the aisle, but we are not going to be able to solve this
problem by building a bigger wall or by stopping it at the
border--because methamphetamines can be made in the basement--
by the way, so can fentanyl. Fentanyl is a synthetic form of
heroin that can be made by a chemist--and is.
So, I have three questions for you. One is with regard to
medication-assisted treatment. It sounds like, Dr. MacDonald,
you have had some success in, essentially, using synthetic
heroin to keep people stabilized--and they have gone back to
work. You did not mention what your percentage is. I would love
to hear that. You did say that, by dealing with the underlying
psychological and mental health issues, some will step down to
less intensive treatments and gradually wean themselves off.
And, some are back at work and back with their families--and, I
assume, into a life where the drugs are not everything. Can you
give us some sense of what the percentage is there? And then,
also my question to you all is: What are some other potential
medical breakthroughs, here? The one that we are using a lot in
Ohio--we have 12 pilots right now--is Vivitrol. And, the notion
is that you have this blocking of the craving, rather than a
synthetic form of an opioid--or an opioid, in the case of
methadone or Suboxone. What else do you see out there? And,
what do you think about Vivitrol or the other drugs coming on?
And then, finally, how about pain medications? Four out of
the five heroin addicts, in Ohio, started on prescription
drugs. And, prescription drugs, as was said by all of you, are
legal, prescribed drugs. I could not agree more with what David
Murray said about the perception of harm. All of the evidence
shows this. If you show there is a perception of harm, you will
have fewer, particularly young people, getting into this. But,
what is the perception of harm when a doctor gives you 80
Percocets after you get your wisdom teeth taken out? And, I
know two parents back home--two parents who lost their child,
because a child went in, as a teenager, to get their wisdom
teeth taken out and ended up getting addicted to prescription
drugs--and they moved to heroin and overdosed.
So, how about pain medication? When was the last time there
was a new pain medication to come on the market? Why are we
using prescription narcotic drugs to deal with things like the
extraction of a wisdom tooth or even a sports injury, when
there has to be much more targeted ways in which to deal with
that pain--and pain management in general?
So, those are the questions I have. And, I would open it up
to everybody.
Dr. MacDonald. We have only had a treatment program, in
Vancouver, for about 2 years. So, it is in the early days. We
are still learning and still studying our patients. Our
patients that are working or that have found work are a small
number. It is, probably, about 5 percent. That is still
significant and, hopefully, it will grow.
The other side of that equation is, our patients have been
using illicit heroin for 15 years, on average--or longer.
Ideally, I would like to engage those folks earlier--not wait
15 years before we intensify their treatment.
With regard to pain medications, I think there is overuse
of opioids for pain medication. And that needs to be reduced.
But, when it comes to people with severe opioid use disorders,
that need to access care, we need to increase access to opioids
and to treatment for them. So, there are two sides to that
solution.
Mr. Nadelmann. If I could just add to that, Senator
Portman--and I also want to thank you for your leadership on
CARA. I think that there are many elements in there, especially
expanding access to methadone and buprenorphine, making
naloxone easier to get, and opening up the possibility for
funding more diversion programs by law enforcement. They are
really wonderful elements and really an important part of the
solution to this.
Let me just say, with respect to what Dr. MacDonald talked
about--about heroin maintenance--it did not start in Vancouver.
It started in Switzerland, back in the early 1990s. First, it
was on an experimental basis. And, once the results were found
to be successful, it was then implemented, first city by city,
and then, on a national basis. It is now a part of Swiss
national drug policy.
Then, the Dutch did the same, and then the Germans did the
same, and then the British did the same, and then Montreal and
Vancouver proceeded. And then, Denmark was considering doing
experiments--trials, with respect to heroin maintenance--and
they looked at the extensive research that had already been
published. They realized that most of the people in Denmark,
who were addicted to heroin, were no different from people
elsewhere in Europe. And, they just proceeded right to go ahead
and start implementing these programs as well.
So, I think you should be aware there is now 20 years of
research, including research published in the New England
Journal of Medicine, and all of the top European journals,
showing that prescribing heroin to those people, who have tried
every other form of treatment--drug-free, in jail, methadone,
and buprenorphine--that it, actually, reduces their illicit
heroin use. It pulls them out of the illicit drug markets and
thereby reduces their other illicit drug use. It reduces their
risk of contracting HIV and hepatitis C. It results in fewer
arrests, less crime, and more people reuniting with family,
because, keep in mind, when you have been using heroin for 10
years or 15 years, you are not getting so high anymore when you
use it. You are, basically, using it to keep from getting sick,
right? And, the fact of the matter is, heroin addicts--unlike
being an alcoholic, where you are still getting drunk or
cocaine users, where it is still messing you up in different
ways--when you have stabilized, whether it is on methadone,
buprenorphine, or--Germany used to have codeine maintenance--
or, for that matter, heroin maintenance, you actually can hold
a job. You can operate as a normal human being. It is hard for
people to believe that, but that is what the evidence shows.
I think your other question about the pain medicine--it is
a great question. Let me say a few things about that.
There are a few things that I think are really seriously
missing here. The first one is more of an understanding of what
is going on with all of these people getting in trouble with
pain medicine and heroin and overdosing and all of this sort of
stuff. What I would recommend is, if you are looking at the
budget of the National Institute on Drug Abuse (NIDA), it is
all well and good that they are doing all of this brain disease
stuff--and I am sure something will come of it--but I would
encourage you to do a more rigorous analysis of what has really
come of the multi-billion-dollar investment in that. But, I
would hire an army--an army of ethnographers and other
researchers to hit the ground and find out what is going on.
Whether it is the kid who got addicted to it from a football
injury going in, or whether it is somebody struggling with
mental illness or with depression, what is going on with each
one of these things? Why are people using these drugs? How are
they using them? What do they know and what do they not know?
When the word hits the streets that there is some dope that
is laced with fentanyl, does that make people want to search it
out or run away? And, if so, why?
With respect to the people dealing, as responders to this
thing, what do they know? Do they know that, for example, a
fentanyl overdose may require a higher level of naloxone? Do
they know how to administer it?
One of my greatest frustrations is that, if you look at the
majority of overdose fatalities in this country, you know what
you find. The majority of them did not solely involve the use
of heroin or a pharmaceutical opiate. Right? The majority
involved the use of opiates with alcohol or sometimes
tranquilizer drugs--benzodiazepines. The fact that using
opiates and alcohol is, oftentimes are most of what--called
overdoses are, in fact, fatal drug combinations. And, I think
that information is not known--not known by young people, not
known by active drug users, and not known by all sorts of
people.
The other thing I would say is that what we are really
dealing with here is an epidemic of pain in this country. It is
physical pain, it is psychological pain, it is emotional pain,
and it is existential pain. And, we then try to deal with all
of this, with opiates, in a way that is incredibly
inappropriate.
The ``New York Times'' had an amazing story, a few days
ago, on the front page. It was about a hospital--an emergency
room at St. Joseph's Hospital, in Paterson, New Jersey, that
has reduced its use of prescriptions and use of opioids in the
emergency room by almost 40 percent since last year. Now, what
are they doing? They are trying whatever works--from new-agey
alternative stuff to feedback to using ketamine for a pain
issue--whatever it might be. You have to be innovative on this
stuff. But, I think finding out the research really truly
committing to the research--do not act and do not put on new
criminal penalties before we really know what is going on.
I will conclude with this: I actually think that, when Len
Bias died 30 years ago, if, somehow, there had been a
prohibition on Congress and State legislatures adding in any
new criminal laws and any new criminal penalties as well as a
simple requirement that every dollar that you wanted to spend
on law enforcement had to be spent on treating drug addiction
and drug use as a health issue--if we had been obliged to spend
those hundreds of billions of dollars, in recent years--or the
$1 trillion on public health, instead of on law enforcement--I
think the evidence, overwhelmingly, indicates that our drug
problems in America would be dramatically less than they are
today--that the number of people alive would be far greater.
Chairman Johnson. OK. Again, I would like to kind of----
Mr. Nadelmann. I apologize.
Chairman Johnson. That is fine. I want a free-flowing
discussion. And, by the way, when we are on a particular topic,
you
do not have to sit and wait for your turn. OK? But, let us go
on to--Senator Lankford came in next, but, again, I want this
to be a discussion and to have a little bit shorter answers--a
little bit shorter questions.
OPENING STATEMENT OF SENATOR LANKFORD
Senator Lankford. There has been a lot of conversation
about the demand side of this--and the supply side as well. You
need me to get a little closer?
Chairman Johnson. Yes.
Senator Lankford. OK. The supply side and the demand side.
Mr. Murray, your conversation as well--about the normalization,
somewhat--the more that we talk about decriminalizing and the
more that we try to make sure people do not feel the stigma,
does it create an environment where people actually feel like,
``OK, there is not a real problem and there is not a real
threat.'' I would like to talk about that a little bit more.
And, in the interdiction of drugs, actually, coming into the
country, when you deal with heroin and the amount of heroin
that is coming in, from Mexico, in particular--and the dramatic
increase there. Poppy fields are not something you hide in the
jungle, like marijuana. They are obvious from the air. They are
obvious from a satellite. They can be known. So, some of the
interdiction conversations.
Finally, I would say that--just as a statement to be able
to throw this out as well--I am concerned that we spend a
tremendous amount of time talking about decriminalizing
marijuana. And, it sends the wrong message, to people around
the country, that drugs are no longer an issue. And, people
just transition that from one drug to another and say, ``Well,
drugs are not the problem if marijuana is not the problem.''
And so, any comments on that? And, Mr. Murray, I would be
interested in your comments.
Mr. Murray. Thank you, Senator. And, again, it is
impressive that you are attending and working on this issue. It
is deeply appreciated. This has needed leadership for a long
time.
Quickly--it is good news that prescription use--opiate
misuse--started going down in 2006. It is gradual, but it is
going down. Effective interventions,the medical practice
changing, and prescriber education--they are taking hold here.
And, more responsibility is being shown. The rising ones are
heroin and fentanyl now. And, fentanyl presents the new threat
of the synthetics--the poppy fields. We used to image, by
national technical means, the estimates we would make for
production. That is over. Fentanyl and synthetics that are
coming along--including new versions that are even more potent
than fentanyl--are being made in labs--in urban settings very
often. Chemicals coming from China and manufactured,
distributed, and arranged in Mexico, are put into the United
States as an adulterant to heroin. They have to be--they cannot
be perceived, in terms of overhead technology. They cannot be
estimated production-wise. It is the methamphetamine model. We
have to go after the precursor chemicals. And, it is not just
border control. You cannot sit here, without defense in-depth,
and think we are going to intercept this, as it comes through
the tunnels. What you must do is be forward-leaning into
source-country partnerships. You have to work effectively, with
leverage, with Mexico and with China. You have to have
effective international programs. Budget data shows that this
Administration has reduced funding for international drug
control programs by the amount of $952 million, since 2009.
That is the wrong direction--the wrong answer. We need to be,
effectively, more engaged with reducing the production
capacity--the chemicals, in the case of the synthetics, the
opiates, in terms of the cultigens, cocaine, and the rest--they
have to be done in international partnerships. We have lost our
moral leadership in international partnerships. Every
international body tells this to us when we allow--enabled
highly potent marijuana--and highly potent marijuana, now legal
and recreationally available--is, itself, linked to the opiate
epidemic. There is a priming gateway dimension to this. An
opiate or heroin user is very commonly--the great majority of
them use at least three drugs at the same time--the polydrug
use. Epidemiologically, it starts with a gateway access--
alcohol, tobacco, or marijuana. These lead into the
accessibility and the vulnerability for subsequent--being
captured in more intense drug use as they grow. That is always
a concern.
Fentanyl divert--OK. The data that we can see, at the
moment, overdose deaths from prescription opiates were
dropping, and then, suddenly, in this last year--2014--
unfortunately, we do not have good data--up to date--spiked
again. That was fentanyl. It was attributed to prescription
overdose problems. It was, probably, rogue illicit production.
It caused 5,500 deaths, on top of what had been a declining----
There are now indications that fentanyl is also being
insinuated into counterfeit pills, so that people are
purchasing what they think to be a medication. It has gotten
micrograms--and the analogy that has been used is, if you are
making chocolate chip cookies and you are putting chocolate
chips in, one cookie has four chips and one cookie has three.
That is the difference between life and death--when it is
micrograms of fentanyl. It is that small. And, the people
making this--the rogue pharmacists and the rogue chemists--do
not have that degree of concern. And, therefore, the
vulnerability, from these new synthetics, is extraordinary.
Naloxone is a terrific response. It does revive people.
Naloxone is not enough, if you are not reducing the supply of
this pathogen. It gives you a 20-minute bridge to get people
into an emergency room. The power of the new synthetics is so
great--it occupies the receptors so strongly--that naloxone is
losing its effectiveness, in terms of the capacity to overcome
these. And, the condition will return.
Media campaigns, Senator Portman--we missed that. My
impression was that--sure, prevention happens in the home, in
the church, in the synagogue, in the school, and in the
community. That has to be done at the local level. But, the
government could help with the incredible media outpouring of
support for drug use and the pathology, thereof, if there is no
counter. We have lost that counter--and my impression is, we
really are missing that role.
Chairman Johnson. Let me interject here. One of the
reasons--and, again, I want to drive this process, because I
want to come out with areas of agreement. The only way we are
going to kind of come together and find out where we agree is
if we kind of stick to specific issues--specific questions--
without broadening--I am being serious about this. The way you
solve problems is to find areas of agreement. So, again, I just
want to have everybody involved in this discussion. Let us
address specific issues and give, relatively, short answers.
And, again, I kind of like the nodding of the heads, going,
``We all agree on that.'' And then, where we disagree, I think
it will just be a little bit more helpful, in terms of the
discussion. Does it make sense? Yes, that is--and, again, I
would like to--as long as we are on a particular subject, let
us stay on it, until we kind of fully discuss it, figure out
where we agree, and figure out where we disagree. And then, we
can move on to the next one.
Senator Ayotte. Well, I have been really proud to work with
Rob on CARA, so I am hoping that we get to this conference and
get this legislation passed.
I wanted to follow up on the prevention idea. We have had a
lot of discussion, in this Committee, about what we have done
on smoking. So, I get that, whether it is Drug-Free Community
grants, like we have in CARA or local prevention efforts, which
are a piece of it. We also have a national campaign. And, it
seems to me that we have an opportunity also, in combination
with local education efforts--whether it is in schools,
churches, or local community organizations that are engaged in
this to do that on a very personal level. But, I think we are
pretty understanding that, if we were to put our might behind
it, on the national level, too, we could change this dialogue
on stigma. We could change the dialogue on exactly whether it
is connection--the understanding of prescription drugs and
heroin--and the devastating impact that this has on people.
So, I would like to get your take on the prevention side--
not only local efforts, but could there be something
nationally? If we did it, it has to be, obviously, tested and
done right. But, we have seen it work in other contexts.
Mr. Nadelmann. Well, if I could just say that the Centers
for Disease Control (CDC) just came out, last month, with its
report on trends and the prevalence of drug use--and it was an
analysis of the National Youth Risk Behavior Survey (YRBS),
from 1991 to 2015. What they found--this is U.S. Government
data--was that the prevalence of marijuana use, by high school
students, decreased between 1999 and 2015. And, there was no
change in prevalence between 2013 and 2015. OK? This is the
period, by the way, during which we went from having half a
dozen States with legal medical marijuana to now, with half of
the States having legal medical marijuana.
Senator Ayotte. How does this get, though, to my question
of----
Mr. Nadelmann. Well, the point I am making is that, at this
point----
Chairman Johnson. Let me just quickly stop you, because you
are quoting a statistic and I am seeing David shake his head.
Is that disputed, what he is saying?
Mr. Murray. Yes, it is highly misleading to characterize it
that way. You have a timeframe and you can ``data slice'' it in
terms of what is up and what is down from the 1990s. What
happened was, we had a steep decline in youth use and in
overall drug use between 2001 and 2008. And then, we had a
reversal beginning in 2009, that took it back up again. So, if
you draw a straight line from the 1990s across, yes, it is down
just a little bit. But, that trajectory is made up of two
movements----
Mr. Nadelmann. But, then again----
Mr. Murray [continuing]. One down and one back up--the
policies were reversed.
Mr. Nadelmann. David, the same period you are picking up on
was a period of massive increase in methamphetamine addiction
and things----
Senator Ayotte. I do not want to interrupt, but I want to
ask a question----
What can we do? We are supporting the CARA efforts, which I
think we need to expand treatment--and the demand side. But,
Chief, I do not know what your thoughts----
Chief Ryan. Yes, in Massachusetts, under Governor Charlie
Baker's leadership, we have the ``State Without StigMA''
campaign, which has been incredibly effective. One of our
treatment providers is the face of the ``State Without StigMA''
campaign, coming from the Governor's office. That messaging was
huge, in terms of us going out and having a dialogue at
community meetings--and people saying, ``Hey, this is coming
from the Governor's office. This is important stuff.'' And, it
further----
Senator Ayotte. Let me say that I admire Governor Baker's
leadership on this.
Chief Ryan. I do, too. He has been incredibly effective.
And, he invited Chief Campanello and me when he signed the
legislation. But, we cannot keep drugs out of our prisons. If
we think we are going to keep it off of the streets of America
through heavily-weighted enforcement priorities, we have simply
got it wrong. And so, it speaks to the need for treatment and
prevention. And, I have learned a lot during this process.
And, the other notion--that we need to have a bed for
everybody--that goes with the stigma, too: ``I need to be in
some bed, somewhere, in some institution, because I have this
substance use disorder.''
Senator Ayotte. Do you have a lot of medication-assisted
treatment?
Chief Ryan. And, that is where I was going with this. And,
the physicians can speak to this better than I can. But, as I
understand it, the one addiction that is the most likely to
respond to medication-assisted treatment is an opiate
addiction. And, we have seen, with Vivitrol--like the Senator
mentioned-incredible effectiveness--and we have partnered with
a Vivitrol clinic. One of the challenges there and one of the
things your Committee might be able to look at is, it is
incredibly expensive.
And so, we have patients that we have gotten into a
Vivitrol clinic, and they go for many months and they are over
the physical addiction. Now, it has become sort of a bit of a
crutch. And, weaning them back off of Vivitrol is becoming
challenging as well.
Senator Ayotte. We also have caps on certain forms of
treatment.
Chief Ryan. Right.
Senator Ayotte. I just want to make sure that, as I look to
your point, Dr. Murray--1 gram of fentanyl is the equivalent,
according to the CDC, of 7,000 street doses of heroin. So,
this, obviously, is a very powerful synthetic drug. The drug
deaths, in my State, are being driven by fentanyl. I mean, that
is where we have seen a market--losing a person a day by
fentanyl. And, as we talk about increasing the efforts on
treatment--and, obviously, I would not have led the effort on
CARA with great people like Rob--and prevention, which I think
is key--and we have not invested enough in that. We need to
invest more.
Chief, I know you want that to be your emphasis--and I am
with you. And, I have my local Chief, Nick Willard, who is the
Chief in our largest city, Manchester, who is a great guy--and
he will say the same thing to me.
But, also, he would say to me, ``I do not want you to
totally give up on the demand.'' And so, whether it is the
fentanyl piece or--so I hope we are not saying that we are not
going to totally abandon our demand efforts--but we need to
focus more on the treatment. I just want to make sure we
clarify that.
Chief Ryan. Yes, thank you, Senator. And, thank you for
putting me in the hot seat on that issue. Absolutely, it is
about proportion, right?
Senator Ayotte. Right.
Chief Ryan. And so, we have drug control officers, but we
can be smarter about our enforcement as well.
Senator Ayotte. And, who we are going after, right? The
high-level folks.
Chief Ryan. Right. I will give you an example. We had two
fatalities and we, quickly put together a case. The drug agents
and drug cops do great, courageous work out there and we need
to recognize that. And, in this instance, they put together a
very good Federal case in a short period of time. And, when I
was briefed on the search warrant, the arrest warrant, the
tactical briefing, and outstanding law enforcement work--but, I
asked two very simple questions after the briefing: ``Tomorrow,
when we take this major supplier out of the loop----
Senator Ayotte. Who comes next?
Chief Ryan [continuing]. ``Do we know who his customers
are?'' The answer was yes.
Then, my follow-up question: ``What are we doing
tomorrow''----
Senator Ayotte. To get them into treatment.
Chief Ryan [continuing]. ``To get them into treatment and
to deal with the public health crisis that we are unwittingly
creating in our own community?'' We can be smarter about our
enforcement. And so, now, any tactical plan, in my
jurisdiction, comes with a parallel social service----
Senator Ayotte. And, you also like drug courts? That is a
piece of ours--alternative sentence----
Chief Ryan. The challenge there, Senator, is when you push
the button for the criminal justice system, it is incredibly
complex and difficult to reverse. And, when you take somebody
suffering from a substance use disorder and put them into a
complex criminal justice system, we are finding it creates even
more challenges.
Mr. Nadelmann. Senator, can I just also say that I agree
with everything the chief just said there. Canada is dealing
with a fentanyl crisis right now as well. Mostly, it is stuff
being imported illegally from China and then pressed into
pills. And, it is across the country--Ontario, Alberta, British
Columbia. And, I was just looking at this last night. I saw
that just recently the Chief Medical Officer (CMO) of British
Columbia, Perry Kendall, issued a public health emergency--it
is very rare for somebody to do that. But, it is what you do if
there is a huge epidemic of a new disease.
Senator Ayotte. Right.
Mr. Nadelmann. And, what he said is that the number one
thing this means for British Columbia is, we are going to treat
this as we would have with what happened with Ebola--or
something else. We are going to find out every single thing we
can find about what is going on in this. Where are people
getting this thing? Why are they using it? What is the drug?
His emphasis was, first and foremost, on research--on finding
out what is going on, what is going on, what is going on.
My fear here is that we are engaging in interventions
without knowing what is really going on. If somehow CARA, or
something else, could allocate money for an army of researchers
to hit the streets to find out what is really going on, I think
policy would be so much better informed.
Senator Portman. I am going to go to the floor to speak on
this very issue and to talk about what Senator Ayotte was just
talking about--how do we get this [inaudible]. But, one thing
about CARA is, there is money in there for research,
specifically [inaudible]--look at some of these issues that you
are addressing. And, I think you are right. We need to have
better information, including on the newest threat of fentanyl
and how we deal with that. And, David, I was asking you about
whether it is produced in America, because it can be and will
be----
Mr. Murray. Pharmaceutically, yes.
Senator Ayotte. We saw it with methamphetamine.
Mr. Murray. Right.
Senator Portman. This is not going to go away. And, Chief,
God bless you. Thank you for what you are doing.
Chief Ryan. Thank you, Senator.
Senator Portman. You are a leader on this. And, by the way,
your Governor came to testify on CARA and helped us put
together the legislation. Charlie Baker did a great job.
Chief Ryan. Thank you, Senator.
Mr. Nadelmann. And, Senator, thank you for your leadership
on CARA.
Mr. Murray. Senator, could I just make one comment about
something you put on the table a minute ago, which we never
quite followed up on? Tobacco is an analogy, because it has
been successful. The youth-use rates have gone down fairly
dramatically. There are different profiles--not a drug cartel--
but, notice what we----
Senator Ayotte. Different physical impact, too, obviously.
Mr. Murray. It is, but the rates dropped. I do not want to
be the guy making a case for stigma. Stigma stands in the way
of our capacity to get people into treatment and recovery.
Senator Portman. The perception of risk.
Mr. Murray. Recovery is----
Senator Ayotte. It is the perception of risk, exactly.
Mr. Murray [continuing]. Rescue.
Senator Ayotte. Stigma.
Mr. Murray. The Titanic is sinking. OK. Stigma can be
used--perception of risk--medical risk--was a major factor in
driving down tobacco use and norms of social disapproval:
``Losers do this. What are you doing this for?'' And, making it
stigmatize people, on the loading dock, out in the rain. But,
they also--it was not regulation and taxation that did it.
Those were high and present when tobacco use was high. It did
not change.
Senator Ayotte. Well, I also think----
Mr. Murray. The perception of risk, the stigma, and the
driving down its acceptability were useful. Can we borrow some
of those tools with regard to drugs?
Senator Ayotte. Well, I think that what we decide to focus
on, nationally, sets the tone, right? So, to the research
point, whatever our national campaign is, let us make sure that
we are thoughtful about it--that we research and figure out
what are the most effective ways to get this message to,
obviously, reduce consumption and the number of people who
start, in the first instance. I am not an expert on this. I do
not know the answer. But, I know we are pretty smart people.
And, we are also a very media-centric society--whether we like
it or not.
So, it seems to me that there is a role in this. CARA,
basically, puts in place the opportunity to do this. It does
not say how to do it. It says it has to be evidence-based
research--and to the point of what your Governor did. Here is
where we are, at a national level, in terms of what tone we are
going to set here.
Chairman Johnson. We held a hearing--and we actually
addressed the difference between the success we had in tobacco
and why the media campaign has not been particularly
successful, in terms of drug demand. One of the conclusions--
one of the statements was that we have not been graphic enough,
in terms of communicating that this is squalor. There is
nothing glamorous about it.
Senator Ayotte. But, also, the other conclusion that came
out of that is that the tobacco campaign was not a totally
government-centric model. You actually engaged--because, if you
look at the tobacco settlement, it was really done from a
separate organization. Sometimes, the government-driven model
is going to put you in a box. What we want to do is have the
right media campaign that is actually evidence-based--what
needs to be done--but is not having all of these--it gets
complicated, as you know, with bureaucracy.
Mr. Nadelmann. Yes, I think you are right about the public-
private partnership. Also, just a few other things about the
tobacco thing.
First of all, unfortunately, the evidence actually shows
that the single most effective way of decreasing adolescent
tobacco use is through higher taxation. The other factors that
David mentioned are also variable.
But, I want to just make two other points here. The other
thing we can say about tobacco--nicotine in the cigarettes--
smokable particle matter--is, essentially, there is no other
substance on Earth which is simultaneously so addictive and so
deadly. Right? We know that if you smoke cigarettes for a month
or so, you have a very good chance of becoming addicted to it.
And, if you smoke cigarettes for years, you have what?--a 30-
percent chance of dying prematurely, by 7 to 10 years. It is
serious. And, we know that the harms associated with
cigarettes--not nicotine, in the form of vaping. That is a very
different situation that dramatically reduces the risk. Butm
cigarettes are incredibly [inaudible].
The second thing we know about cigarettes is also very
interesting. All of the studies--when you interview heroin
addicts and you ask them, ``What is the toughest drug to
quit?'', do you know what the majority of heroin addicts say?
Senator Carper. Cigarettes.
Mr. Nadelmann. Cigarettes. Exactly.
Now, it is also worth noting that we have actually cut
cigarette addiction--cigarette use in America by over 50
percent. It has been one of the greatest drug abuse prevention
successes in American history. And, you know what? We did it
entirely without threatening anybody with jail, incarceration,
tobacco courts, or anything like that. We did it through
education, through prevention, and through the provision of
real information to young people and adults. Stigmatization did
play a role. Higher taxation played a role. But, understand,
our single greatest success in America, in reducing addiction
to a deadly drug, was done entirely without reliance on the
criminal justice system.
Chairman Johnson. Yes.
Mr. Murray. Which makes it perverse that we are enabling
more marijuana----
Senator Carper. Let me just----
Mr. Murray [continuing]. More widely available, the
pathogen.
Senator Carper. Let me just jump in, if I can.
Chairman Johnson. Sure.
Senator Carper. I apologize for being in and out. One of
our former colleagues, George Voinovich, a great Governor and a
great Senator, has passed away. I am trying to figure out how
to get my wife and I to the funeral Friday morning, so I
apologize for being in and out.
When George Voinovich and I were Governors together, I was
asked to be the founding Vice Chairman of something called the
``American Legacy Foundation,'' which focused on how we
convince young people who are smoking to stop and how to
convince young people who are not smoking not to start. And, we
used a multilayered approach, but a big part of it was working
with young people, throughout the country, to develop a message
to take to folks who were smoking already--young people who
were already smoking or were thinking about it, and some of the
success you talked about, I think, is directly attributable to
the ``American Legacy Foundation.'' We got 41 billion out of
the tobacco settlement money, between the States--50 States--
and the tobacco industry--and with the help of some great
advertising agencies, a lot of kids, and the States, we
developed a multilayered media campaign called ``The Truth
Campaign.'' Hard-hitting. Very hard-hitting. If you have ever
seen these commercials, you remember them: a woman talking
through a hole in her throat; huge trucks--tractor-trailers
pulling up in front of tobacco headquarters, and people are
pulling out hundreds of body bags and laying them out; and
bullhorns talking to the tobacco industry people inside of the
building. Very hard-hitting and very effective.
The woman who helped us put that together, Cheryl Healton,
who is now a dean, I think, at New York University (NYU) and
doing good work again--we have involved them, and her folks, to
help us on another truth campaign--and this is with regards to
potential immigrants coming in from Honduras, Guatemala, and El
Salvador--as they look, it is not everything it is painted to
be--getting here, the United States, is not going to be easy.
So, we are using that variation as well. We are creating,
through the Department of Homeland Security (DHS), a somewhat
similar campaign to counter violent extremism (CVE), by
creating a partnership with the Muslim community across the
country, and asking young Muslims to help us develop the same
kind of truth campaign.
If you look at the meth campaign, in Montana, which had
success for a while--I think, maybe, it stopped, and that is
why it did not continue. But, talk to us about this kind of
approach, particularly, for young people who are thinking of
trying heroin or are thinking of trying opioids--to have that
countermessage. What role is there for this approach in this
multilayered approach, which includes prevention and a whole
lot of other things?
Mr. Nadelmann. Senator, I do not want to--I am skeptical. I
think that a basic message for young people about the risks of
these drugs--and remember the old days--the Partnership for a
Drug-Free America, they were sort of obsessed with the
marijuana issue--and that was not the real problem. Alcohol was
a major problem--and tobacco. Alcohol and tobacco--the much
bigger problems. Now, we have the problem of diverted
pharmaceutical drugs--huge numbers of young boys are being
prescribed Ritalin and are sharing it with one another. In many
communities in America, more young people are going to use
Ritalin--either prescribed or diverted--than are actually going
to be using marijuana.
The other thing we found is that even as marijuana use went
up and down and up and down over the last 30 years among
adolescents, when the question was asked, ``Is marijuana easy
to get,'' 80 percent, consistently, throughout the last 30
years, said that it is easy to get.
So, I think that, on the drug prevention education thing,
we need to focus on the bottom line of keeping kids safe. The
message ``Do not use, do not use, do not use--abstinence
only,'' that is a good starting spot. My message to teenagers
is, first, ``Do not do drugs.'' My second message is, ``Do not
do drugs.'' My third message is: ``But, if you do do drugs,
there are some things I want you to know, because my bottom
line, as your parent, who loves you to death, ultimately, is
not did you or did you not. My bottom line is: Are you going to
come home safely at the end of the night, grow up and make me
healthy grandkids. That is my bottom line.''
So, I am focusing on safety. One of the things about
marijuana--none of us want our kids----
Senator Carper. I am going to ask you to stop. I appreciate
everything you are saying, but I want to make sure I hear
from----
Mr. Nadelmann. I am sorry. OK.
Senator Carper. Thank you. I appreciate your passion.
Chief Ryan. Senator, if I may--and I wish I had the
Wheaties he had this morning.
I agree, but, we have to fold the medical profession into
this conversation in a meaningful way. We are looking at people
in our PAARI program. About 80 percent started with a
prescribed opiate, following a traumatic injury. And, here is
the pathway that we are seeing in metropolitan Boston.
Opiates--a 30 milligram (mg), or 80 mg tablet, with a 90-day
prescription. After 90 days, they are buying them on the
street. A 30 mg tablet goes for $30, and an 80 mg tablet goes
for $80. Quickly, they have a $400-, $500-, or $600-a-day
habit. For somebody, who, before, would never have put an
injectable narcotic into their arm, now it becomes a matter of
economics. A $15 bag of heroin, or $500 worth of pills. They go
to heroin.
Chairman Johnson. Let me just interrupt quickly. Is that an
agreement that this is really 80 percent started by----
Mr. Nadelmann. I do not know. I do not know if it is 80
percent. I know that is a growing issue and that people are
trying to manage pain with other forms of it, but I do not----
Chief Ryan. In the population we are serving, that is
what--and there is self--I would agree. You mentioned this
earlier, Dave. This is self-reported.
Mr. Murray. The CDC's most recent----
Chairman Johnson. Again, I really want to get to him, but
just very quickly.
Mr. Murray. Certainly. I am sorry. The issue is about who
initiated with either heroin or prescription opiates. And,
historically, people who are heroin users, initiated with
heroin, but are poly-drug users and are at 15-times greater
risk if they were adolescent marijuana users. But, today, the
most recent initiation numbers--not all of those are heroin
users--those who are starting are inclined to start with
prescription opiates. That is the three out of four. The last
few years, those who have initiated have a tendency to start
with prescription opiates first.
Chairman Johnson. That is the new phenomenon. OK.
Chief Ryan. So, the point is--and we are starting to see--
the University of Massachusetts Medical School invited me to
speak at their in-service training for their physicians--a cop
talking to physicians in their in-service training. So, I think
it is some of those things. And, we are starting to fold in the
medical profession, in a meaningful way, around prescribing of
opiate painkillers.
Dr. MacDonald. Looking at the demographics at our clinic,
we have selected a population that has developed an entrenched,
long-term street heroin dependency. It is the separation from
family at a young age that is appallingly common. So, I am not
sure how you are going to prevent----
Chairman Johnson. I actually want to start asking
questions. I have not done so. I am going to ask questions, OK?
No statements. Questions.
I remember watching a documentary on heroin addicts and,
although the words were different, when they asked the
question, ``Do you remember the first time you ever took
heroin?''--the expression on their faces were almost identical.
It was just kind of, ``Oh, yes. It was like I finally belonged
or I was finally loved.'' According to testimony, there are
about 3 million Americans--about 1 percent of our population--
doing the hard drugs in some shape or form. There are 27
million people doing illegal drugs--that is a little less than
10 percent of our population. Has that changed one iota in 30
years, 40 years, or 50 years--I mean, significantly? Or has
that just been pretty constant? Just respond really quickly.
Mr. Nadelmann. Yes, I mean, it appears to be fairly
constant. It varies, somewhat, by drug. I will just say this:
With alcohol--right?--roughly 10 percent of alcohol consumers
consume over half of the alcohol----
Chairman Johnson. Again, I am talking about drugs, right
now.
Mr. Nadelmann. No, I am making an analogy, here. The same
thing is, probably, true of most other drugs as well--that it
is the minority of each of the drug users who consume the
majority of the drugs.
Chairman Johnson. Again, 1 percent of the population is
doing hard stuff and a little under 10 percent is doing
marijuana and--is that----
Mr. Murray. Taking a historical look, one of the problems
is that the data sets do not go back far enough to tell us
about continuity. We can go back to the mid-1970s--and that was
the highest point of drug use in America--in 1979 through 1985.
Compared to that period, we are down at least 35 percent, so
there has been a major gain, over time, with respect to youth
use that then was carried as a lifetime pattern. We have made a
difference. It proceeds by sharp decreases and then, gradually,
starts picking back up. We forget that it is intergenerational.
We turn off the switch, and a new generation comes in, and it
comes back at us. We have to continue--it is like using an
antibiotic. You have to continue in a sustained fashion.
We have made major gains. We have seen periods when it has
been sharply reduced, and we look for the mechanisms that we
had--the tools. Media campaigns were part of it. Supply
reduction was part of it. Normative participation by American
communities was part of it--and we made a difference.
Chairman Johnson. So, again, let me ask----
Mr. Murray. The answer is yes, we can do it.
Chairman Johnson. Do you agree that we have gone up and
down and that there have been gains made, for whatever reason--
and then, it has kind of come back?
Mr. Nadelmann. Yes, Senator--it depends what you are
measuring, right? I mean, 1980 was the high point of the number
of Americans who said they had used an illegal drug. Then
again, by 1990, the total number of Americans saying that they
had used an illegal drug had dropped by half--so you would say
that was a success.
On the other hand, in 1980, nobody had ever heard of crack
cocaine. By 1990, it was a national epidemic. In 1980, there
were no cases of drug-related AIDS. By 1990, hundreds of
thousands were infected. In 1980, we had 50,000 people behind
bars. In 1990, a quarter of a million people--or close to
that--were behind bars. So, it really depends on what you are
measuring. And, I think that focusing on the number of
Americans who say yes to a pollster--saying ``I used an illegal
drug last year,'' is far less important than looking at the
cumulative harms associated with that drug.
Chairman Johnson. Again, my point is--again, as----
Mr. Nadelmann. You are going somewhere----
Chairman Johnson. No, as a business guy, in manufacturing,
you have to solve a lot of problems. So, you have to, first,
understand what is the truth, what is the reality, and what are
the numbers. Because I have a sense that we have spent $1
trillion on the ``War on Drugs,'' and we are just not winning
it.
Mr. Murray. Right.
Chairman Johnson. And, we are funneling tens of billions of
dollars to some of the most evil people on the planet, in these
drug cartels--and I am not sure that is, necessarily, a good
thing.
I think it is interesting--the way you are saying we need
research. My point of that little story about the heroin
addicts--those 3 million Americans--are they treating their own
depression in some way, shape, or form? I mean, do we have any
sense of--yes, once you are addicted, you are addicted and you
are going back to the heroin, or whatever, to feed that
addiction. Why are they first starting it? Do we have some
sense of that? Is it, literally, treating depression? You
talked about alienation from family. Well, that leads to
depression as well. Do we have any kind of research--any kind
of sense of why people first take it when--let us face it:
people do realize drugs are dangerous, right? Although, in the
media, sometimes, it is viewed as pretty glamorous.
Mr. Nadelmann. Well, Senator, you realize that, for many
people, the first time they take heroin, it is, ``Yuck.'' They
throw up and they do not like it--whatever. There is a
percentage----
Chairman Johnson. Which was different than that
documentary.
Mr. Nadelmann. No, but for people who end up getting
addicted to heroin, those are, oftentimes, the ones who liked
it that first time. Then the question is: Why? Right? We have a
sort of myth underlying the notion of a drug-free society,
which is that all of us emerge as perfectly balanced chemical
creatures from our mothers' wombs. That is not true. Some of us
may emerge with an undersupply of endorphins--our own
biological natural opioids--and that may incline us to drug
addiction later on.
Chairman Johnson. I had a spinal tap--and, I think, it was
Vicodin. I took one and, literally, woke up kind of gasping for
air. I never took another one. But, other people, then--what
you are saying is, other people take--what is Vicodin, anyway?
Is that an opiate?
Mr. Murray. It is hydrocodone.
Chairman Johnson. So, that is an opiate.
Mr. Murray. Hydrocodone is a Schedule II opiate----
Chairman Johnson. So, the fact of the matter is, different
people react differently.
Mr. Nadelmann. Exactly--to all drugs--to marijuana, to
alcohol, to opiates, and what have you.
Mr. Murray. There is a body of literature on the risk
predisposing factors for drug use--and it is not a magic
bullet. You cannot say that it is just those people and not
others. Genetic predisposition--yes, it is a big one. And, the
reaction is strikingly more vulnerable if they are presented
with a challenge from the drug itself.
Early childhood experience, including prenatal behavior--
low birth weight children, and children from lower
socioeconomic perspectives--where the mother was a substance
user--they are born at risk--low birth weight, with
extraordinary risk. As they grow up in contexts where they are
challenged by drugs early in life, then the risk skyrockets. If
they can hold off until they are age 20, 22, 23, or 24, they
can be protected for life. There is a study of risk
availability and comorbidity.
Chairman Johnson. In the hearing in Pewaukee, we had some
powerful testimonies. I think one of the most--again, I am not
saying this is fact, but, one of the witnesses said that, on
average, first-drug use, in whatever form, starts somewhere
around the age of 11 or 12?
Mr. Murray. In some communities.
Chief Ryan. And, David, is it not true that, if you can
delay that experimentation----
Mr. Murray. Yes.
Chief Ryan [continuing]. The risk of addiction goes down--
--
Mr. Murray. As the brain matures, if you can hold them
through that window of vulnerability, from, basically, age 11
until age 22, you have a huge capacity to protect them for
life.
Chairman Johnson. In testimony before this Committee, we
had General John Kelly, former head of the U.S. Southern
Command (SOUTHCOM), testify that we have visibility for about
90 percent of drug traffic. We just do not have the
interdiction capability. I think one of you said that, where
there is demand--I agree with this--where there is demand, the
supply is going to meet it.
Further in testimony we heard that in inflated dollars--in
1980, a gram of heroin cost $3,200. In the streets of
Milwaukee, we are hearing reports of $100 a gram or $10 a dose.
And, you talked about that--the difference between the cost of
an OxyContin pill and a heroin addiction.
Mr. Nadelmann. Senator, I think you can find other former
directors of SOUTHCOM who would say that no amount of money we
spend on interdiction is going to keep this stuff from really
coming in. Right? That, whatever we spot, they will find
another way to do it.
Chairman Johnson. When we were down in Central America,
they were talking about--these are the Drug Enforcement
Administration (DEA) guys down there, saying, ``Yes, we
redirected the flow from Colombia, through the Caribbean, up to
Miami, and just, basically, redirected it into Central America.
And, truthfully, I mean, the folks there were also saying that
their goal was to redirect it someplace else.
Mr. Nadelmann. Back to the Caribbean. Assistant Secretary
William Brownfield----
Chairman Johnson. Again, not stopping it, but redirecting
it.
Mr. Nadelmann. Assistant Secretary Brownfield just said,
recently, he said, ``Caribbean, you better watch out,''
because, the more successful we are in pushing it out of
Central America, it is going to push it over there. It is not
going to make any difference for the U.S. addict, who is
suffering, which route it is coming by.
Mr. Murray. Senator, I think that having worked on this,
specifically, for 13 years with the ONDCP's Office of Supply
Reduction, with SOUTHCOM, and with the Joint Interagency Task
Force (JIATF's), there is a narrative of futility: ``Nothing
has ever worked. It is cheaper than ever. And, it just comes
another route--trains, boats, or planes. It gets in here. What
are you going to do?''
Well, there is something you can do. And, you have to have
a chain of interventions that are staged and that work with
each other. And, you begin in the source country, by
eliminating the production. You drive it down 75 percent. At
the same time, you come in with alternative development
strategies, establishing the rule of law, in Colombia----
Chairman Johnson. But, look at what is happening--again,
look at the reality. We do not control Colombia. Look at what
is happening in Colombia. There is different leadership.
Mr. Murray. We went to legalization. And, Colombia and
Mexico both called and said, ``What are you guys doing?'' And,
when people said, ``Well, we are leading out on this. We are
making it recreational,'' they said, ``We have to save
ourselves.''
Mr. Nadelmann. Right. And, now, Canada is about to legalize
marijuana. And, once California votes to legalize it this
November, Mexico is going to open up a significant debate.
President Enrique Pena Nieto was just at the United Nations
(U.N.), talking about----
Mr. Murray. But, interdiction is only part of the----
Mr. Nadelmann. Senator, I have to just say that the
evidence powerfully shows that the overwhelming investment in
interdiction has been money down the drain. And, when you look
at the alternative, which is a focus on the public health
approach and on the demand approach--you look at what Europe
and Australia and other countries have done--where the large
majority of resources have gone into a public health approach--
not into interdiction--and what you see is, they have been,
dramatically, more successful in keeping drug-use rates lower
than us--as well as keeping HIV, hepatitis C, addiction,
overdose, and all of those low.
Chairman Johnson. The fact of the matter is that, now, in
your testimony, we are laying it out. For a couple of decades,
now, different countries and different cities have taken
different approaches. Let us face it: we have an experiment
going on here, in America, with legalization--full legalization
in Colorado, Oregon, and Washington. I was with a group of
Chiefs of Police in Wisconsin, talking about a host of issues.
But, I brought this one up, because they just attended a
national association meeting of Chiefs of Police. I just asked
them, ``Is anybody reporting on this?'' Again, this is just
anecdotal, but the response was that this has been a disaster.
I do not know. Again, that is just a completely anecdotal
comment, but what are you hearing? Are you going to those same
type of national meetings? What are you hearing, in terms of
what is happening in Oregon, Washington, and Colorado, in terms
of legalization and how it is affecting policing?
Chief Ryan. Yes, I mean, there are a lot of anecdotes, out
of Colorado, of people getting their doctor's letter for
athlete's foot to get medical marijuana and these things. But,
you make a valid point. Much of it is anecdotal. I think there
is some research that Ethan talked about--because, what I worry
about is, the quality of life around these marijuana
dispensaries and how the presence of a dispensary will
compromise the quality of life by bringing a demographic into a
neighborhood that would not otherwise come to that
neighborhood.
Mr. Nadelmann. But, there is actually research on that,
showing no increase in crime or any decline in quality of life,
in places where medical marijuana--in this country----
Chief Ryan. I do not know if that is true.
Mr. Nadelmann. By the way, it is also similar with
methadone maintenance clinics. There is a huge ``not in my back
yard'' (NIMBY) fear about having a methadone maintenance
clinic. But, there is extensive research showing, once again,
no diminution in quality of life or any increased criminality.
I would be happy to send the studies about the issues--the
public safety issues around there. And, I think it is
worthwhile mentioning that you have the director of the High
Intensity Drug Trafficking Area (HIDTA) in Colorado, who is,
basically, saying that it is a relatively small number of
crimes--he is quoted as saying that. When you look at overall
crime in Denver, there are so many reasons it rises, and falls.
The ``2016 Colorado Department of Public Safety Report'' notes,
``The total number of industry-related crimes has remained
stable and makes up a very small proportion of overall crime in
Denver.'' The most common problem is burglary. Burglary. And,
that is the issue that Governor John Hickenlooper and others
have asked Congress to fix, because that is that the legal
marijuana industry has to be cash-dependent, because the
marijuana industry is not allowed to engage with federally-
registered banks.
Chairman Johnson. Tom, feel free to hop in.
Senator Carper. Well, thank you.
Chairman Johnson. I had not asked any questions.
Senator Carper. You have not?
Chairman Johnson. I had not.
Senator Carper. I want to come back to the issue of
tobacco. And, the Chairman has heard me say, many times, to
``find out what works, do more of that; find out what does not
work, do less of that.'' But, before I do that, I want to
mention CARA, the legislation that we have been talking about,
here, in this room, in the Senate, and in the House for a good
part of this year.
We have, as you know, in terms of funding programs a two-
step process. We authorize programs and we authorize spending
levels, and then we come back in and we appropriate money. I
have a friend, who is a pastor of a church in Wilmington,
Delaware. And, he likes to say to his congregation, ``It is not
how high we jump up in church on Sunday that matters. It is
what we do when our feet hit the ground.''
It is one thing for us to pass authorizing legislation that
would authorize programs to address this situation--opioids and
opioid addiction. It is another thing to make sure that we have
the resources to fully benefit from the programs we are
authorizing.
One of the meetings I just went out to, in the anteroom,
was with a major insurance company. And, they cover a multi-
State region, here in the Midatlantic. And, I told them what
our discussion was dealing with here. And, they mentioned--they
do business in Pennsylvania. They mentioned that the Governor
of Pennsylvania has called for creating, across the State, 40
different centers for treatment. And, the question is: How do
you pay for that? And, I do not think anybody has figured that
out. But, that was their idea.
In terms of the policies and the coverage that they offer,
it is a lot different, today, with respect to opioids. They
talked about the idea--one of them said, just anecdotally, that
someone that they knew had oral surgery and got a 30-day
prescription for opioids. How crazy can we be?
So, my sense is that--and this conversation, today, sort of
bears it out--there is not any one silver bullet. I like to say
``There are a lot of silver BBs. Some are bigger than others.''
And, this is not just on the Federal Government. This is not
just on State and local governments. This is not just on
insurance companies or on individuals--this is a shared
responsibility. And, part of what our challenge is, is to
figure out what the Federal responsibility is and how we can
use the Federal actions to, maybe, leverage more effective
action on the part of States, local governments, nonprofit
organizations, and the health care delivery system.
I want to come back to tobacco. ``Find out what works, do
more of that.'' And, Dr. Nadelmann, I think you mentioned that
nicotine--tobacco--is among the most addictive substances that
we deal with. Yet, we have had pretty remarkable success in
slowing down the growth of tobacco addiction and, actually, I
think, reducing it--particularly among young people. And, it
has been sustained. It is not like a one-trick pony--one-night
stand. It has been sustained for about 20 years.
Mr. Nadelmann. Yes.
Senator Carper. About 20 years. What can we learn?
Mr. Nadelmann. I think what we learned is that the tobacco
education was remarkably honest and truthful. It reported on
real risks and real dangers, and kids got it. And, they also
knew people who were dying of cancer--and they could see it. I
think they got it.
I think a similar sort of campaign could, potentially, work
with opiates. The difference is that you sometimes need
opiates. Right? So, you do not need tobacco. You just have to
say, ``Do not do it. Do not do it. Do not do it. It can kill
you,'' and what have you.
With opiates, the message has to be more nuanced, which is
sometimes ``this is a useful medication, but, understand: if
you get this for oral surgery, you are going to use it for 3 or
4 days, maybe, and then no longer after that. Understand the
risks. Understand what is going''--so the education has to be
more sophisticated in that respect.
I think the issue with marijuana is that kids look around
and they know 40 percent of their peers are doing it by the
time they are 17-years-old to 18-years-old. They know that some
have a problem. Some are clinical--waking and baking--getting
up in the morning and smoking marijuana and not doing well.
And, they see that those kids are foolish. It is like drinking
and going to school.
But then, they see other kids, who are graduating with
honors--going to good schools. They see adults who are
successful and they understand that the anti-marijuana
fanatical message we had is not truthful. When the government
gives that message----
Senator Carper. Just hold it right there. I just want to
make sure----
Mr. Nadelmann [continuing]. They lose credibility.
Senator Carper [continuing]. We hear from the other
witnesses, please. What can we learn from tobacco?
Mr. Murray. Thank you. I appreciate it. It is a good
question. I would be remiss, if I let this hearing end without
saying what I think is a really critical message. Then I will
address directly the----
Senator Carper. Just do it briefly, please.
Mr. Murray [continuing]. The misinformation that marijuana
is not dangerous and that we have not been confronted with an
enormous onslaught of media support that has, actually, been
totally counterproductive for what youth are experiencing--and
that the risks are very great, which they are--for those
genetically predisposed--catastrophic--and that is a phrase
used by the World Health Organization (WHO) in an article by
the National Institute on Drug Abuse (NIDA), in the New England
Journal of Medicine. ``Catastrophic''--and that the onset in
early adolescence of high-potency marijuana use has the
prospect of triggering a psychic break, depression, and
schizophrenia--prospects that are truly damaging. We are
running an experiment, with our youth--and they are being hurt.
They are being hurt, in Colorado. This is a qualitatively
different drug. Anyone who denies that or who refuses to look
at that evidence is misleading the Nation and misleading
themselves----
Senator Carper. OK. Thank you.
Mr. Murray [continuing]. And, we are sorry. Now, here is
the most critical thing I want to deliver. We have looked
carefully at----
Senator Carper. The most critical thing, for me, is for you
to answer my question.
Mr. Murray. Therefore--oh, I am sorry. Dr. Nadelmann had
suggested that we had offered----
Senator Carper. What can we learn from our success, with
respect to tobacco? That is my question.
Mr. Murray [continuing]. And, he suggested that we had not
offered a calculated risk appreciation--that it was craziness
and reefer madness. I was suggesting that, no, in fact, we
need, precisely, to message the degree of risk and not have
snarky, sarcastic headlines in the ``Washington Post'' about
how using marijuana is like not flossing. No, it is not that.
In fact, it is misleading and irresponsible to make those kinds
of arguments.
Here is the critical thing, though----
Senator Carper. Just be very brief, because I want to hear
from the other witnesses.
Mr. Murray. Yes, Senator, I will. Sorry. The black market
has not withered away. It has not disappeared. All of the
things that we are doing, with regard to recreational, legal
marijuana--and efforts to leverage media, and so forth, on how
to--the black market has gotten stronger. There are people
flooding this country with poisons that are killing Americans.
And, they are stronger, more embedded, richer, more corrupt,
and more penetrating in their reach and scope than any that I
have ever experienced. And, they are getting stronger. They are
running in parallel----
Senator Carper. OK. Mr. Murray, please hold your comments.
Thank you.
Dr. MacDonald, the same question. What can we learn from
our success, with respect to tobacco?
Dr. MacDonald. We have excellent treatments. It works. At
our clinic, 90 percent of the folks smoke. They are also heroin
users. When they come to us, they are interested in having
better health. They are sick because of the severity of their
smoking. They have chronic disease, because of their smoking.
And, in care, we are able to engage them and decrease their
smoking use. Anybody can quit smoking.
Senator Carper. Alright. Thank you. Chief.
Chief Ryan. Just very briefly--David makes a valid point
about using stigma as leverage to try to help address the
opiate issue, as we did with tobacco. My concern there is, if
we had a magic wand, today, and we stopped any new person from
becoming addicted to opiates, we still have a whole generation
of people that have to run the course. And, the stigma is what
is preventing--well, there are a number of things preventing,
but, in my opinion, one of the major factors preventing people
from seeking treatment is the stigma associated with opiate
addiction and heroin addiction.
Senator Carper. Alright. Thank you.
Chief Ryan. I would caution against using stigma as
leverage in this epidemic.
Mr. Nadelmann. I agree. I think stigma did play a positive
role with cigarettes, but it is not just with heroin addiction.
We even have stigma with methadone treatment. One of the
problems you have is that it is so stigmatized that people do
not want to send their kid, who is addicted to opiates, to get
methadone or buprenorphine. I have met people who are on
methadone maintenance, and they are on it for decades. It is
like a diabetic being on insulin. And, they are running a
business, having a family, paying taxes, and doing everything
right. It is methadone. They are not addicted to it. It is just
their daily medication. And, I say, ``Why do you not speak
publicly about this? Be a role model.'' They will say, ``Ethan,
I cannot.'' I say, ``Why not?'' They say, ``Let me tell you
something. If I go to work one morning and I am exhausted,
because my kid was up all last night, and I put my head down on
the table to take a nap, people are going to say, `Oh, poor
boss--poor Joe, he must have been exhausted. Something must
have happened with his kid last night.' If they knew that I was
a methadone maintenance patient, the first thing they would be
thinking is, `He is nodding out.' ''
So, I think we have to fight the stigma--not just with
illicit drugs, but even with the treatments, themselves.
Senator Carper. Alright. Thank you.
Chief Ryan. Another good analogy, Senator, is seat belt
usage.
Senator Carper. Is what?
Chief Ryan. Seat belt usage. Highway safety bureaus, for
many years, were using billboards as well as taking young
ladies and showing scarred faces: ``This is what will happen to
you if you do not wear a seat belt.'' That worked.
Senator Carper. You know what else worked? Convincing
legislators--State legislators--to pass laws that mandated seat
belt usage.
Chief Ryan. Right. But, I would urge caution in this
situation.
Senator Carper. Alright. Thank you.
Chairman Johnson. And then, that kind of gets back to that
point, in our hearing, where we had the one witness talking
about the effectiveness of tobacco and saying that the reason
why it has not been effective with drugs is that we just have
not shown the truth--the graphic nature of this is not good.
I want to talk to the doctor, a little bit, about the
difference in chemistry between these drugs. What is the
difference between a synthetic opioid and heroin?
Dr. MacDonald. They are all opioids. They all have
similarities. And, trying to distinguish one opioid from
another--they all have potential benefits and they all have
ultimately, risk.
Chairman Johnson. My point is, why has one been legal--or a
class of them legal--and another one illegal?
Dr. MacDonald. Well, I will take diacetylmorphine--
prescription heroin--for example. It is used as a pain
medication, in many jurisdictions, in Europe. It does not have
the same stigma that it does in North America.
Chairman Johnson. How close is it, chemically, to natural
heroin?
Dr. MacDonald. It is very close to morphine and
hydromorphone--diacetylmorphine, there is just----
Chairman Johnson. So, we have one form of heroin that is
produced artificially that is, basically, identical to heroin.
That one is legal, because it is medically controlled versus--
--
Mr. Nadelmann. Right. The way to think about this is, both
in Vancouver and also other places, they did a couple of
studies. They took long-term illegal heroin users, and they
tried, in a controlled, double-blind study--this group got
illegal heroin--I mean legal heroin and did not know it. The
other group got morphine. They could tell the difference. This
group got injectable methadone and the other got heroin--they
could tell.
You know what they did? Half of the group got
pharmaceutical heroin. The other half of the group got
pharmaceutical Dilaudid, which is what people get prescribed.
It turns out, long-time heroin users could not tell the
difference, in the effect--how it felt between heroin and
Dilaudid.
Now, what does that mean? It, potentially, means that, if
all of the hundreds of thousands of Americans in hospitals each
year, were being given heroin instead of Dilaudid without
knowing it, it would have the same effects. Nobody would know
the difference. It means, alternatively, that if you would snap
your fingers and all of the people in the world consuming
illegal heroin were suddenly consuming Dilaudid, nobody would
know the difference.
It means if you were to spell heroin D-I-L-A-U-D-I-D or
spell Dilaudid H-E-R-O-I-N, it would, essentially, be the same.
Right? And, I think we need to understand that, part of what
makes heroin what it is that it is called ``heroin.'' The
bottom line is, it is diamorphine. It becomes morphine when it
enters the human body. It is a legitimate painkiller. So, part
of it is the cultural perception of the thing and who is
perceived to use it.
Chairman Johnson. Let me ask about the potency of
marijuana. What has been the trend, from the 1970s to today?
And, can you address the problems associated with the far
greater potency? Doctor, can you speak to that?
Dr. MacDonald. It is certainly not the same drug it was 30
years ago. It is more dangerous.
Chairman Johnson. Which speaks to what Dr. Murray was
talking about.
Mr. Murray. I am still reeling from what we just heard
about diacetylmorphine. I think that that----
Mr. Nadelmann. And, Dilaudid?
Mr. Murray. You asked, specifically, Senator--and I will
try to add hue to this. The potency of marijuana--as best we
can tell from the seizure data from the DEA, in the 1980s--was
around 3 percent Tetrahydrocannabinol (THC), which is the
intoxicating element. It rose, steadily, year after year, about
1 percent a year, until about 2010, when it approached,
nationwide, around 12 percent to 14 percent THC--sinsemilla--a
more potent drug.
Since Colorado--and recreational legalization--the
concentrates and new products--the ``shatter,'' the ``butter,''
and so forth--that are extracts of just THC approach 70 percent
to 90 percent pure THC. And, THC is then embedded in gummy
bears, drinks, and candies being consumed at far higher rates.
The rate of change of that kind of bolus to the brain is so
striking that the risk of dependency and addiction seems to be
elevated. The impact on psychotic breaks seems to be greatly
elevated. And, the exposure, at a relatively early age, to a
drug that is now 70 percent to 90 percent potency--averaging,
nationwide, around 14 percent to 15 percent, for all marijuana
markets combined, together--as opposed to the marijuana that
most people know from previous generations--and, unfortunately,
it is the marijuana that is reflected in the literature that
has taken a longitudinal look at use of those exposed in New
Zealand, in Canada, or in the United States--they were
consuming 3 percent to 4 percent THC at age 17. It is a more
dangerous----
Chairman Johnson. So, is there any dispute about what Dr.
Murray was talking about there, in terms of the potency and the
danger of that?
Mr. Nadelmann. Yes. First, let me agree on two key points.
The potency of marijuana has increased. And, second, when he
refers to something called ``shatter,'' which is a sort of
crack-like version of marijuana, I am also deeply concerned
about consuming marijuana potency that is at 70 percent or 80
percent. That said----
Chairman Johnson. But, it is the truth that that is moving
in that direction--and it is legal.
Mr. Nadelmann. Yes. But, it is important to--well,
``shatter?'' I do not know what is going on with ``shatter.''
Mr. Murray. You call it legal--sir, it is smuggled into
every State in----
Mr. Nadelmann. Yes, smuggled. So, therefore, prohibition
has been a failure, in that case. I think it is important to
understand that doubling or tripling the potency of the THC, in
marijuana, does not double or triple the high. I think it is
also--and let me just be frank here, Senator. I have been an
occasional marijuana consumer, for the last 40 years--since I
was age 18. Right? I remember when I was 18, there were things
called ``Acapulco Gold,'' ``Panama Red,'' and ``Thai Stick,''
where one hit would get you high. There was a lot more low-
quality Mexican marijuana around, but there was high-potency
marijuana back then.
Today, there is other high-potency stuff. Do you know what
you do? You smoke less of it. OK? And, I think that is
important to understand about the relative dangers.
Chairman Johnson. Doctor, can you speak to the medical
reality of those higher potencies?
Dr. MacDonald. I think there is some risk for some
individuals. It is hard to predict--especially with the
edibles. I think those can be a concern. But, I agree with Dr.
Nadelmann that the biggest risk is a criminal record, for
somebody who is using marijuana.
Chairman Johnson. We talked a little bit about the
difference in tobacco. And, you had mentioned that increasing
taxes was effective. I guess, I would argue--I just kind of
want to throw this on the table--because, there really is no
black market, for cigarettes--I mean, there is some black
market, where you have a high-tax State next to a low-tax
State, and there are some cigarette runners, from that
standpoint. But, I mean, the problem you have with marijuana is
that there is a very robust black market. And so, if you try
and approach this, in terms of reducing use, by higher
taxation, I mean, you just fuel the black market.
Mr. Nadelmann. Except, what we are trying to do is to move
it from a world where marijuana was 99 percent or 100 percent
illegal, into a world, like tobacco or alcohol, essentially,
where it is 10 percent or 15 percent illegal--people evading
taxes and smuggling from low tax States, like North Carolina,
to high-tax States, like New York. Or, from New York to Canada,
or something like that. There is a huge benefit in moving this
from an underground, uncontrolled market into a legally
regulated market.
Chairman Johnson. Chief Ryan, you, obviously, are talking
about the opiate and heroin overdoses, and what you are trying
to do there. What are you seeing, in terms of marijuana and the
effects, potentially, the higher potency?
Chief Ryan. Yes, I mean----
Chairman Johnson. And, the trafficking, from the legal
States into States like Massachusetts.
Chief Ryan. Right. And, I remain concerned that the
perception that it is acceptable will have devastating
consequences, in terms of kids experimenting--and then
experimenting at younger ages. And then, that manifesting to
experimentation with other drugs.
Chairman Johnson. You are saying that is a high-level
concern, on your part.
Chief Ryan. It is indeed. And, just--a quick personal
story. I am playing basketball with my daughter, at the end of
my driveway, recently--a 12-year-old girl. It is a Friday
evening. My wife is on the front porch having a glass of wine.
I am having a lovely time with my daughter. A young man pulls
up, and I witness a marijuana deal going down. I went over and
I intervened, as a dad. I never identified myself as a police
officer. I do not want drug deals going on in my neighborhood.
I took action. The kid got flip. I tried to get him to call his
parents. He refused to do so. I called the police.
Where I am going with this, Senator, is, the next day, do
you know what the talk of the neighborhood was? What I did and
how I handled the kid. It was not about the kid's behavior and
the fact that he was in the neighborhood delivering illegal
marijuana.
So, this perception--that marijuana is acceptable and not a
social norm violation--is resulting in kids experimenting
younger. And, what I am seeing on the street--early on--I am
concerned about.
Chairman Johnson. So, the bottom line, going back to my
story about the seventh grade kid, that is a very legitimate
concern in this whole debate: What are we communicating to our
youth?
Chief Ryan. And, how do we manage that? That is the
challenge.
Chairman Johnson. There is the conundrum. So, we have
this----
Chief Ryan. This bad dad stopping----
Chairman Johnson [continuing]. Drug problem, and, because
of the illegal nature of it, we are funneling billions of
dollars to some of the most evil people on the planet. And yet,
you move away from that, and, all of a sudden, you are
communicating, unfortunately, potentially, that this is OK.
Mr. Nadelmann. Senator, I think we communicated a lot of
very good messages to young people about tobacco without making
it illegal for adults and creating a vast black market. I think
we are increasingly communicating effectively about alcohol--
right?--without creating a huge black market.
Chairman Johnson. I am not sure we are very effective about
that.
Mr. Nadelmann. But, actually, binge drinking is going down.
Some of the worse outcomes are actually going down, now. And
so, I think it is important to understand--let us focus on
using good, smart messages to young people about safety and
health, and not getting into drugs and all that. We do not need
to criminalize an entire adult population, spend tens of
billions of dollars on a ``war on marijuana,'' and get 750,000
arrests a year in order to send a message to kids. That is a
very expensive and destructive way of sending a message.
Chairman Johnson. Again, the purpose of this is really to
try and find the areas of agreement. I think that is where you
move forward from, because there is not going to be an
agreement, by Dr. Murray and Dr. Nadelmann, on so many issues.
But, I think there can be complete agreement in what we can do
to communicate--to make sure our young people realize this is
not a good path, this is dangerous, and this is not good for
you to do. I think there would be agreement about that, on this
Committee, as well.
So, it really is about how we, effectively, develop a
national, concerted public relations (PR) and education
campaign to dissuade all Americans from abusing drugs,
particularly our young people--because, it is good to hear that
there are some effective treatments for addiction, but it is a
pretty difficult path. You are better off never having somebody
get addicted.
Mr. Nadelmann. If I could just make two points. First, in
direct response to your question, I just want to caution
against overinvestment on the youth piece. We have done a lot--
we are, actually, doing not so bad. The real investment needs
to be on dealing with people who are really beginning to get in
trouble with opiates at older ages. That is where most of the
death and addiction is. It does not mean you ignore young
people, but understand the great investment needs to be on the
serious addiction.
And, let me just finish----
Chairman Johnson. Let me just comment on that point,
because, again, I just want to ferret out----
Mr. Nadelmann. Senator, if I could just--let me just throw
in one last point.
Chairman Johnson. OK.
Mr. Nadelmann. Because, it goes two ways, in which the
marijuana issue and the opiate issue have overlapped, here--the
opioid overdose issue--and there are three fascinating studies
that have come out, in the last couple of years, that go to the
issue of people dying of overdose. And, what they find is that,
in the States that have the most robust medical marijuana
programs--the ones with the easiest access to marijuana for
medical purposes--in those States, you see lower levels of
opioids being prescribed. And, you see dramatically lower rates
of opioid overdoses. Those studies are published in JAMA's
Internal Medicine, in the prestigious Journal of Pain, and by
the National Bureau of Economic Research (NBER). It is
suggesting that, when you are treating pain, opioids are not
the only thing. Marijuana can also play a positive role. And,
that, for certain types of pain, marijuana may be a more
effective way of dealing with pain than opioids are and a far
less dangerous way.
Chairman Johnson. Dr. Murray.
Mr. Murray. Again, I am just reeling from the amount of
partial truth, misinformation, misdirection, and improper----
Chairman Johnson. Here is your opportunity to----
Mr. Nadelmann. Well, except three studies published in
peer-reviewed journals--top of the line--and I have not heard
the contrary studies quoted, here. So, I rest my case right
there.
Mr. Murray. Dr. Nadelmann----
Chief Ryan. I have my handcuffs with me, gentlemen.
[Laughter.]
Mr. Murray. It would please me to no end to offer you
evidence. I do not anticipate that it would dent you.
That said, I think we are in a battle for the brains of a
new generation--that it is a continuing struggle and it is an
urgent one. ``A battle for the brain,'' that is the phrase a
colleague of mine, at Harvard Medical School, uses--Bertha
Madras, who is a brain researcher, said that the critical issue
here is we are losing these kids and we are losing them,
rapidly. And, we are losing them, first in Colorado, but it is
spreading, nationwide. And, if we do not address that
urgently--because we think it is a soft drug. It has been
called a ``medicine,'' and it is offered as such. It is a joke,
when you read the national media. It is something that we see
on television routinely. There is damage coming. There is
damage that has already been planted into this generation. We
have not seen it yet. It will manifest. And, the damage will
cause us, in shock to think, ``What have we done, experimenting
on this generation, without knowing what price we were going to
pay in broken lives, cognitive impairment, educational failure,
psychotic breaks, schizophrenia, and depression? These are the
sequelae. If you do not believe me, read the New England
Journal of Medicine. Or, you can listen to the World Health
Organization--and they are issuing urgent pleas.
Let me tell you my last story.
Chairman Johnson. Here--I will tell you what. We are going
to give everybody a chance to wrap it up----
Mr. Murray. I can tell my story then.
Chairman Johnson. You can tell your story then. I would
like to give Senator Carper a chance for any further thoughts
or closing questions. And then, we will give you each a chance
to close--and, again, I want to keep it to about a minute. So,
Senator Carper?
Senator Carper. I am going to come back to ``find out what
works, do more of that.'' And, go back to tobacco--highly
addictive. And, among the things that worked that, I think,
were helpful was the ``Truth Campaign,'' particularly for young
people. I think it is still working. Among the other things, it
has worked, with respect to tobacco's--I remember when I was
brand-new to Delaware--right out of the Navy--and I remember
going to the State fair. And, when we walked into the State
fair, they had people actually handing out little packets of
cigarettes--five or six cigarettes in a little packet. That is
how easy it was to get. For many years, if you were a kid--I do
not care if you were 9 years old or 90 years old--you could get
access to tobacco in a vending machine. And, a lot of kids got
access to it--and we made it easy for people. People would go
to drug stores and supermarkets. Kids going in and buying
cigarettes for their parents or whatever--maybe using them for
themselves--maybe taking them to their parents.
We made it more expensive, and we raised taxes, and that
sort of thing. We have a substance that other people can use,
if they are addicted to nicotine, like patches--people can have
gum to chew that reduces the craving for cigarettes.
I think there are lessons there, for us. And, I just want
us to, again, ``Find out what works, do more of that.'' And, I
think there are a number of things that we have done, on the
tobacco side, other than just scaring young people straight.
The other thing that is helpful for me--and, again, thank
you so much--each of you. Some of you have come a long way, and
we are grateful for your being here and for your years of
commitment--your passion for this. Part of what we need to do
is figure out what is the appropriate role for the Federal
Government. And, I said this earlier. What is the appropriate
role for the Federal Government? How do we use limited Federal
resources to leverage, from a whole wide range of
stakeholders--to leverage their contributions and their
participation in things--in approaches that will actually work?
I would just close with that thought, and, again, thank you
all.
Chairman Johnson. Thank you, Senator Carper.
Again, I truly appreciate the time you have spent on very
thoughtful prepared testimonies, coming here, hopping on a red-
eye flight. We will be issuing a report on this. And you can
kind of understand, and by from my background as a
manufacturer, I am pretty data-driven. So, you will all be
given the opportunity to provide the studies--the statistics
that form the basis--the documents behind that report. So, we
will have questions for the record, but we will definitely
afford you that opportunity.
You have heard the discussion. You have seen the
differences. But, I also would encourage you, in what you
supply the Committee for our report, to concentrate on the
areas of agreement. I truly believe we share the same goal.
That is a good place to start. Then, try and find all of the
areas of agreement. And, yes, it will start breaking down
beyond that point, but, in your response to the Committee,
really concentrate on the things we agree on. Hopefully, we can
agree on data. Facts are facts. I realize, sometimes, they are
kind of hard to come by. But, again, I really want you to
continue to help this Committee. I think this has been an
incredibly interesting discussion.
I will turn it over to Dr. MacDonald to kind of start out,
if you have kind of a closing 1-minute comment, here.
Dr. MacDonald. Just to sum up, supervised injectable
hydromorphone--a pharmaceutical agent--can be effective at
engaging the most severely affected heroin users who have not
responded to the standard treatment.
Chairman Johnson. And, I do want to quickly ask you a
question, because I missed it. Your injectable sites, have they
been magnets for--because, there has been some controversy,
``Well, this is going to be a magnet for drug dealers and crime
and that type of thing.''
Dr. MacDonald. There has been no increase in social
instability around the clinics. In fact, they have stabilized.
And, there has been no honeypot effect. So, people have not
come from other jurisdictions seeking the treatment.
Chairman Johnson. Was there any resistance by the
neighborhoods, in terms of establishing those sites?
Dr. MacDonald. With our first study, NAOMI, yes, there was.
But, with people having seen the success and the benefits, both
to the individuals and to the community, I think those have
fallen away now.
Chairman Johnson. Thank you. Dr. Nadelmann.
Mr. Nadelmann. Yes, I think it is almost embarrassing that
the United States has not proceeded with some form of
experiment or policy reform to allow these sorts of safe
injection sites and heroin maintenance programs to happen in
the United States, given the overwhelming evidence, from
outside of the United States, of their efficacy, in all
regards.
But, let me finish with this point--and it is a different
one, in a way. I talked, before, about how valuable it would be
if thousands of ethnographers and other researchers were really
trying to figure out what is going on.
The other part of this is treating pain--and just a couple
of things about that.
First, I think the bravest doctors, in America, are
doctors, who are trying to manage pain in patients, who have
been addicted to opiates, illegally. That population of people,
who have been the junkies--the addicts--whatever you want to
call them--that are dealing with real pain--they are
courageous.
And, second, I tell you, a few months ago, I was talking to
my brother, who is a cardiologist--and his daughters are both
going to medical school. And, I was saying to his daughters,
``I think the single most interesting area of medicine to go
into is pain management.'' Right? It is so interdisciplinary.
It is psychological and it is physical--it is an amazing
subject. And, my brother got angry at me. He said, ``Do not
tell my daughters--your nieces--to do that. Let me tell you, it
is the most''--``You are going to have the DEA looking over
your shoulder. They are looking over your shoulder. You do not
know what is going on. Do not do it.'' But, something to
incentivize medical students and, for that matter, physicians
to learn dramatically more about managing pain, I think, would
be an extraordinarily valuable investment.
Chairman Johnson. And, of course, that was Senator
Portman's point. Dr. Murray.
Mr. Murray. In short order, here, we have heard a great
deal about safe injection, supervised injection facilities, and
giving out heroin to heroin addicts. I will just, in summary
fashion, say that the true test of any good public policy, it
seems to me--it must meet two criteria:
It must be effective. And, the case is not, when you look
at the literature, that these things are effective, as
advertised. They still have many gaps. They do not, actually,
transform the high-risk behavior of the populations. We
continue to lose them, in overdose and HIV transmission. They
continue to inject outside of the facilities. This is not ready
to be an answer to our policy problem, at this point.
The second criterion is, it must be humane. And, I would
say, Senator, that, for the government to step into the role of
officially providing addictive heroin to its citizens, so
transforms the relationship of the citizen to the government
that we should fear it.
And, I will end with my story. I am frustrated by marijuana
legalization advocates, who target children--and they do--and
very effectively. And, they appeal to us by putting suffering
victims--a woman with lupus, where medical marijuana made her
walk again. We have seen this too much.
In particular, I have seen it, recently, regarding another
population that I care a great deal about, because of my
service in the White House. I had the privilege of serving with
the men and women of America's armed services, who occupy our
office and are extraordinary people. And, the issue of Post-
traumatic Stress Disorder (PTSD), in the U.S. veteran
population, is an exceptionally troubling, profound one--many
of them are being treated through, I think, an inadequate
Department of Veterans Affairs (VA) system. I will let others
judge that. And, it has been proposed, here, in this Congress,
and elsewhere, by marijuana advocates, that what veterans
suffering from PTSD most need is high-potency marijuana to
medicate themselves. And, the VA, itself, is not sure about
this and issues equivocal statements about the impact.
But, a recent publication, by a Yale University
psychiatrist indicated that the psychiatrist has studied the
population of veterans who suffer from PTSD. And, he has looked
at those who were given marijuana and the results were totally
counterproductive. It put them at a greater risk of
experiencing psychotic breaks and reduced the effectiveness of
the treatment that they were already having. Many of these
people are being medicated with very powerful psychotropic
medications, already. No one has any idea what the interaction
is, when you add THC to that mix. No one knows about the
outcomes for the young kids in school taking Ritalin at
exorbitant rates--or other antidepressants--interacting with
THC. The potency of the mixtures, the unknown dimension of it,
and to try and enlist veterans as a sympathetic audience--as a
sympathetic profile--to try and sway us toward marijuana, as a
medicine, strikes me as being highly irresponsible.
Chairman Johnson. Thank you, Dr. Murray. We had our own
tragedies at the Tomah VA because of the overprescription of
opiates and drug toxicity.
Chief Ryan, again, you are on the frontline of this. You
are dealing with it on the streets. So, again, we appreciate
your service and appreciate your testimony. Your closing
thought?
Chief Ryan. Thank you, Senator. And, thank you for your
work and the work of your Committee. I would just, briefly,
leave you with a couple of thoughts.
I will never argue that enforcement is not a component to
the global piece of the pie, on this challenge. But, it has to
be proportional. And, we cannot label it a ``war.'' As we try
to roll out community policing and to build trust in our
communities, the last word we want to use--or conduct behavior
like a ``warrior,'' in our communities. We are guardians in our
communities, as law enforcement.
That said, to the extent that you and your Committee can
bring a true sense of urgency to this issue--particularly the
opiate epidemic--and facilitate meaningful dialogue with the
medical profession, law enforcement, and the pharmaceutical
industry--so that, a decade from now, we are in our rocking
chairs, and we can look back and look at our work and our
collaboration--although we may differ--and say that we have
made a positive change in America. And, thank you, Senator.
Chairman Johnson. Well, again, thank you. We all share the
same goal. So, again, we are trying to facilitate a very
honest, very frank discussion. I think that is what we have,
certainly, had here. And, help us build the record, to write a
report that will, hopefully, move that process forward.
So, again, I just thank you all for coming here and for all
of your time. The roundtable record will remain open for 15
days, until June 30, at 5 p.m., for the submission of
statements and questions for the record.
This roundtable is adjourned. Thank you all.
[Whereupon, at 12:18 p.m., the Committee was adjourned.]
A P P E N D I X
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